Parisa Farzanehfar

Towards a Better Treatment Option for Parkinson's Disease: A Review of Adult Neurogenesis.

The motor symptoms of Parkinson’s disease (PD) are caused by degeneration of dopamine (DA) neurons in the substantia nigra pars compacta (SNc) of midbrain. Given the fact that current treatment options are mostly symptomatic and based on increasing DA level in the nigrostriatal system, it is generally believed the most effective and long-lasting treatment for PD motor symptoms will be replacing SNc DA cells, either by endogenous repair (i.e. neurogenesis) or cell transplantation. While cell transplantation is hindered by failure of acquisition and maintenance of the DA phenotype by transplanted cells, hope rests upon non-invasive cell replacement therapy (CRT) with endogenous neural stem cells, which have the potential to give rise to new neurons including DA neurons. Understanding underlying mechanisms and signalling pathways of neurogenesis in the adult brain could shed light on obstacles to achieve effective CRTs and better treatments for PD. This paper first reviews different therapeutic strategies in context of PD along with their advantages and disadvantages followed by an extensive review of adult neurogenesis.

An Ambulatory Tremor Score for Parkinson’s Disease

BACKGROUND While tremor in Parkinsons Disease (PD) can be characterised in the consulting room, its relationship to treatment and fluctuations can be clinically helpful. OBJECTIVE To develop an ambulatory assessment of tremor of PD. METHODS Accelerometry data was collected using the Parkinsons KinetiGraph System (PKG, Global Kinetics). An algorithm was developed, which could successfully distinguish been subjects with a resting or postural tremor that involved the wrist whose frequency was greater than 3 Hz. Percent of time that tremor was present (PTT) between 09 : 00 and 18 : 00 was calculated. RESULTS This algorithm was applied to 85 people with PD who had been assessed clinically for the presence and nature of tremor. The Sensitivity and Selectivity of a PTT ≥0.8% was 92.5% and 92.9% in identifying tremor, providing that the tremor was not a fine kinetic and postural tremor or was not in the upper limb. A PTT >1% provide high likely hood of the presence of clinical meaningful tremor. These cut-offs were retested on a second cohort (n = 87) with a similar outcome. The Sensitivity and Selectivity of the combined group was 88.7% and 89.5% respectively. Using the PTT, 50% of 22 newly diagnosed patients had a PTT >1.0%.The PKGs simultaneous bradykinesia scores was used to find a threshold for the emergence of tremor. Tremor produced artefactual increase in the PKGs dyskinesia score in 1% of this sample. CONCLUSIONS We propose this as a means of assessing the presence of tremor and its relationship to bradykinesia.

Evidence of functional duplicity of Nestin expression in the adult mouse midbrain

Whether or not neurogenesis occurs in the adult substantia nigra pars compacta (SNc) is an important question relevant for developing better treatments for the motor symptoms of Parkinsons disease (PD). Although controversial, it is generally believed that dividing cells here remain undifferentiated or differentiate into glia, not neurons. However, there is a suggestion that Nestin-expressing neural precursor cells (NPCs) in the adult SNc have a propensity to differentiate into neurons, which we sought to confirm in the present study. Adult (>8-weeks old) transgenic NesCreERT2/GtROSA or NesCreERT2/R26eYFP mice were used to permanently label Nestin-expressing cells and their progeny with β-galactosidase (β-gal) or enhanced yellow fluorescent protein (eYFP), respectively. Most β-gal+ or eYFP+ cells were found in the ependymal lining of the midbrain aqueduct (Aq) and in the midline ventral to Aq. Smaller but significant numbers were in the periaqueductal gray (PAG), the ventral tegmental area (VTA), and in SNc. Low-level basal proliferation was evidenced by a modest increase in number of β-gal+ or eYFP+ cells over time, fewer β-gal+ or eYFP+ cells when mice were administered the anti-mitotic agent Cytarabine, and incorporation of the proliferation marker bromodeoxyuridine (BrdU) in a very small number of β-gal+ cells. No evidence of migration was found, including no immunoreactivity against the migration markers doublecortin (DCX) or polysialic acid neural cell adhesion molecule (PSA-NCAM), and no dispersal of β-gal+ or eYFP+ cells through the midbrain parenchyma over time. However, β-gal+ or eYFP+ cells did increase in size and express higher levels of mature neuronal genes over time, indicating growth and neuronal differentiation. In mice whose SNc dopamine neurons had been depleted with 6-hydroxy-dopamine, a model of PD, there were ~2-fold more β-gal+ cells in SNc specifically, although the proportion that were also NeuN+ was not affected. Remarkably, as early as 4days following putative Nestin-expression, many β-gal+ or eYFP+ cells had mature neuronal morphology and were NeuN+. Furthermore, mature neuronal β-gal+ cells were immunoreactive against the self-renewal or pluripotency marker sex determining region Y-box 2 (Sox2). Overall, our data support the notion that some Nestin-expressing, presumably NPCs, have a limited capacity for proliferation, no capacity for migration, and a propensity to generate new neurons within the microenvironment of the adult midbrain. However, our data also suggest that significant numbers of extant midbrain neurons express Nestin and other classical neurogenesis markers in contexts that are presumably not neurogenic. These findings foreshadow duplicitous roles for Nestin and other molecules that are traditionally associated with neurogenesis in the adult midbrain, which should be considered in future PD research.

The use of accelerometry as a tool to measure disturbed nocturnal sleep in Parkinson’s disease

Sleep disturbances are common in Parkinson’s disease (PD). We used the Parkinson’s KinetiGraph (PKG), an objective movement recording system for PD to assess night time sleep in 155 people aged over 60 and without PD (controls), 72 people with PD (PwP) and 46 subjects undergoing a Polysomnogram (PSG: 36 with sleep disorder and 10 with normal sleep). The PKG system uses a wrist worn logger to capture acceleration and derive a bradykinesia score (BKS) every 2 min over 6 days. The BKS ranges from 0–160 with higher scores associated with lesser mobility. Previously we showed that BKS > 80 were associated with day time sleep and used this to produce scores for night time sleep: Efficiency (Percent time with BKS > 80), Fragmentation (Average duration of runs of BKS > 80) and Sleep Quality (BKS > 111 as a representation of atonia). There was a fair association with BKS score and sleep level as judged by PSG. Using these PKG scores, it was possible to distinguish between normal and abnormal PSG studies with good Selectivity (86%) and Sensitivity (80%). The PKG’s sleep scores were significantly different in PD and Controls and correlated with a subject’s self-assessment (PDSS 2) of the quality, wakefulness and restlessness. Using both the PDSS 2 and the PKG, it was apparent that sleep disturbances were apparent early in disease in many PD subjects and that subjects with poor night time sleep were more likely to have day time sleepiness. This system shows promise as a quantitative score for assessing sleep in Parkinson’s disease.Health technologies: Measuring sleep disturbancesA movement recording system reveals the occurrence of sleep disturbances in the early stages of Parkinson’s disease (PD). Malcolm Horne, a movement disorders expert at the University in Melbourne, and colleagues assessed night time sleep in 72 patients with PD using a wrist-worn device that captures movement patterns. The Parkinson’s KinetiGraph (PKG) system derives scores that are associated with sleep stages and correlate with patients’ self-assessment of sleep quality, wakefulness and restlessness. Significant differences between the PKG sleep scores of PD patients and age-matched healthy controls confirmed that night time sleep disturbances and day time sleepiness worsen as the disease progresses. Abnormal PKG scores were found in patients affected by the disease for only 3 years highlighting the extent to which sleep is disrupted in early-stage PD.

Comparative review of adult midbrain and striatum neurogenesis with classical neurogenesis

Parkinsons Disease (PD) motor symptoms are caused by loss of dopamine (DA) neurons in the substantia nigra pars compacta (SNc) of the midbrain. Dopamine cell replacement therapy (DA CRT), either by cell transplantation or endogenous repair, has been a potential treatment to replace dead cells and improve PD motor symptoms. Adult midbrain and striatum have been studied for many years to find evidence of neurogenesis. Although the literature is controversial, recent research has revived the possibility of neurogenesis here. This paper aims to review the process of neurogenesis (by focusing on gene expression patterns) in the adult midbrain/striatum and compare it with classical neurogenesis that occurs in developing midbrain, Sub Ventricular Zone (SVZ) and Sub Granular Zone (SGZ) of the adult brain.

An investigation of gene expression in single cells derived from Nestin-expressing cells in the adult mouse midbrain in vivo

Generation of new dopamine (DA) neurons in the adult midbrain is a controversial issue in development of better treatments for Parkinsons disease (PD). Previous research suggests Nestin-expressing neural precursor cells (NPCs) have a propensity to differentiate into neurons here, including DA neurons. In the present study we sought confirmation of this by studying gene expression in single Nestin-expressing cells and their progeny/ontogeny within the adult mouse midbrain. Cells were identified by administering a pulse of Tamoxifen to adult Nestin-CreERT2×R26eYFP transgenic mice. Samples of cytoplasm were harvested 4 days to 8 months later from individual eYFP+ cells in acutely prepared midbrain slices and analysed by RT-qPCR for gene expression. Remarkably, most eYFP+ cells co-expressed genes associated with mature (including DA) neurons (i.e. NeuN, Gad1, Gad2, vGlut2, TH and/or D2R) and neurogenesis (i.e. Ki67, Dcx, Ncam, Pax6, Ngn2 and/or Msx1), and this was true at all time-points following Tamoxifen. Indeed, cell proliferation genes (Nestin, Ki67) were exclusively expressed by eYFP+ cells with mature neuronal morphology and gene expression, and only at early time-points after Tamoxifen. Expression of proneuronal genes (Pax6, Msx1, Ngn2) was, however, higher in eYFP+ cells with immature morphology compared with mature morphology. Gene expression bore no relationship to cell location indicating that, in contrast to development, Nestin-expressing cells arise throughout the midbrain parenchyma and do not migrate long distances. On the other hand, gene expression did change with time after Tamoxifen, although not in a way consistent with neurogenesis. Overall, our results suggest that Nestin expression in the adult midbrain occurs in mature neurons, casting doubt on the premise of neurogenesis from Nestin+ NPCs here.

Can Valproic Acid Regulate Neurogenesis from Nestin+ Cells in the Adult Midbrain?

Degeneration of dopamine (DA) neurons in the substantia nigra pars compacta (SNc) causes the motor symptoms (e.g. tremor, muscle rigidity, bradykinesia, postural instability) of Parkinson’s disease (PD). It is generally agreed that replacing these neurons will provide better motor symptom relief and fewer side effects than current pharmacotherapies. One potential approach to this is up-regulating endogenous DA neurogenesis in SNc. In the present study, we conducted bioinformatics analyses to identify signalling pathways that control expression of Pax6 and Msx1 genes, which have been identified as potentially important neurogenic regulators in the adult midbrain. From this Valproic acid (VPA) was identified as a regulator of these pathways, and we tested VPA for its ability to regulate midbrain neurogenesis in adult mice. VPA was infused directly into the midbrain of adult NesCreERT2/R26eYFP mice using osmotic pumps attached to implanted cannula. These mice enable permanent eYFP+ labelling of adult Nestin-expressing neural precursor cells and their progeny/ontogeny. VPA did not affect the number of eYFP+ midbrain cells, but significantly reduced the number of Pax6+, Pax6+/NeuN+, eYFP+/NeuN+ and eYFP−/NeuN+ cells. However, this reduction in NeuN expression was probably via VPA’s Histone de-acetylase inhibitory properties rather than reduced neuronal differentiation by eYFP + cells. We conclude that Pax6 and Msx1 are not viable targets for regulating neurogenesis in the adult midbrain.

Evaluation of the Parkinson’s KinetiGraph in monitoring and managing Parkinson’s disease

ABSTRACT Introduction: While objective measurement is routine in clinical care of most conditions, this has not been the case for Parkinson’s Disease. Recent innovations make objective measurement in Parkinson’s Disease possible and its utility and how this should be assessed is discussed here. Areas covered: Whilst therapies are effective in Parkinson’s Disease, symptoms fluctuate in relation to treatment over the course of the day. Objective measurement makes it possible to assess symptom control, whether treatment is required and whether it achieved control. Objective measurement makes it possible to consider targets for therapeutic control and to begin an assessment of the value of improved control. Evidence for the effect of improved measurement on outcomes is only beginning to emerge. As symptom severity relates to quality of life and costs, reducing clinical scores and fluctuations through objective measurement is in the interest of both the patient and the health system. Expert commentary: In broad terms objective measurement should be used to identify patients whose symptoms lie outside the target range and then to assess whether therapy was effective in bringing them into control. While this is relevant to all stages of Parkinson’s Disease specific clinical situations where this had greatest impact are discussed.

Objective measurement in routine care of people with Parkinson’s disease improves outcomes

It is common in medicine to titrate therapy according to target ranges of objectively measured parameters. Objective measurement of motor function is available for Parkinson’s Disease (PD), making it possible to optimise therapy and clinical outcomes. In this study, an accelerometry based measurement and predefined target ranges were used to assess motor function in a Northern Tasmania PD cohort managed by a Movement Disorder clinic. Approximately 40% (n = 103) of the total PD population participated in this study and motor scores were within target in 22%. In the 78% above target, changes in oral therapy were recommended in 74%, Advanced Therapy in 12% and treatment was contraindicated in 9%. Following changes in oral therapy, there was a further objective measurement and clinical consultation to establish whether scores had reached target range: if so subjects left the study, otherwise further changes of therapy were recommended (unless contraindications were present). Seventy-seven cases completed the study, with 48% achieving target (including 22% at outset), Advanced Therapy recommended in 19% and contraindications preventing any change in therapy in 17%. In the 43% of cases in whom oral therapy was changed, total UPDRS improved significantly (effect size = 8) as did the PDQ39 in cases reaching target. NMS Quest and MOCA scores also improved significantly. This study shows that many people in a representative cohort of PD would benefit from objective assessment and treatment of their PD features against a target.Motor symptoms: benefits of treating to a targetMeasuring motor features of patients with Parkinson’s disease (PD) against a target range can guide medication adjustments and improve disease management. An Australian study led by Malcolm Horne at The University of Melbourne used a movement recording system, the Parkinson’s KinetiGraph (PKG), in 103 patients with PD to determine whether their bradykinesia and dyskinesia were within a predefined target range. They showed that adjustments to the oral medication of 14 patients whose PKG scores were outside the target range at the start of the study significantly improved their motor symptoms and brought them within the target range. These findings highlight how objective measurement of motor features can benefit a proportion of patients with PD and contribute to improve the current standard of care based on clinical judgement and patient history.

Measurement of Axial Rigidity and Postural Instability Using Wearable Sensors

Axial Bradykinesia is an important feature of advanced Parkinson’s disease (PD). The purpose of this study is to quantify axial bradykinesia using wearable sensors with the long-term aim of quantifying these movements, while the subject performs routine domestic activities. We measured back movements during common daily activities such as pouring, pointing, walking straight and walking around a chair with a test system engaging a minimal number of Inertial Measurement (IM) based wearable sensors. Participants included controls and PD patients whose rotation and flexion of the back was captured by the time delay between motion signals from sensors attached to the upper and lower back. PD subjects could be distinguished from controls using only two sensors. These findings suggest that a small number of sensors and similar analyses could distinguish between variations in bradykinesia in subjects with measurements performed outside of the laboratory. The subjects could engage in routine activities leading to progressive assessments of therapeutic outcomes.