Zuzana Košutzká

Dynamics of postural control in Parkinson patients with and without symptoms of freezing of gait

BACKGROUND It has been suggested that dynamical measures such as sample entropy may be more appropriate than conventional measures when analyzing time series data such as postural sway. We evaluated conventional and dynamical measures of postural sway in Parkinson disease (PD) patients with and without freezing episodes. METHODS COP (center of pressure) data were recorded during quiet standing with eyes open, eyes closed and while performing a dual task. Data for 16 patients with freezing of gait, 17 patients with no history of freezing and 24 healthy subjects were analyzed. The amount of postural sway was quantified using conventional measures, whereas for the characterization of the temporal structure of the COP data the normalized sway path and sample entropy was calculated. RESULTS Mean radius was higher and sample entropy was lower in patients with freezing symptoms as compared to healthy subjects in all three conditions. Dual-tasking significantly increased sway path length in patients with freezing, while normalized sway path did not change over conditions in this group. CONCLUSIONS Our findings show that postural sway is characterized by a combination of large radius, short normalized sway path and high regularity of the COP only in patients with freezing. This pattern becomes most prominent in a dual-task paradigm. This may explain higher occurrence of gait freezing in dual task situations with subsequent higher risk of falls. Results suggested that dynamic measures may add valuable information for characterizing postural stability in PD patients.

Postural stability under globus pallidus internus stimulation for dystonia

OBJECTIVE Deep brain stimulation of the globus pallidus internus (GPi-DBS) is an efficient and safe treatment for medically refractory dystonia. However, recent studies reported gait problems, falls and bradykinesia in patients after the DBS procedure. The aim of this study was to quantify the effect of GPi-DBS on postural performance in patients with cranio-cervical dystonia. METHODS Thirteen patients with focal/segmental dystonia and GPi-DBS participated in the study. We performed two postural tests (pull test and push and release test) in on- and off-stimulation conditions and recorded the movements of the patients with inertial sensors. RESULTS Under stimulation patients exhibited a higher number of steps (p=0.015), reduced first step length (p=0.011) and lower stepping velocity (p=0.001), compared to off stimulation. We observed a higher number of steps in the push and release test compared to the pull test (p=0.038). The interaction between stimulation condition and test type was significant (p=0.027). CONCLUSIONS The velocity and amplitude of postural reactions are compromised by GPi-DBS in patients with cranio-cervical dystonia. SIGNIFICANCE This information corresponds to patients reports of falls and postural instability after GPi-DBS. Pre-operatively, patients should be informed about the possibility of the occurrence of such phenomena.

Restless legs syndrome in pregnancy is connected with iron deficiency

OBJECTIVE Almost one-third of pregnant women develop symptoms of restless legs syndrome (RLS), which could have a negative impact on quality of life and the course of pregnancy and/or labor. The aim of our study was to determine possible risk factors for developing RLS in pregnant women. METHODS A total of 300 random women in the third trimester of gravidity filled out a simple questionnaire based on the official diagnostic criteria for RLS. Respondents positive for RLS were interviewed to further characterize their symptoms. The parameters of iron metabolism were examined based on blood samples. All data were statistically analyzed. RESULTS We detected significantly lower hemoglobin levels with signs of hypochromic anemia typical of iron deficiency in RLS-positive respondents, although oral iron supplementation was significantly higher in this group. The overall severity of symptoms correlated inversely with hemoglobin level. CONCLUSION According to our results, it appears that serum iron level disturbances play a crucial role in the pathophysiology of secondary RLS in pregnant women.

Tacrolimus-induced parkinsonism in a patient after liver transplantation – case report

BackgroundHepatic encephalopathy may manifest by a wide spectrum of neuropsychiatric symptoms, including cognitive impairment, seizures or extrapyramidal symptoms. The liver transplant can lead to improvement of the signs of encephalopathy but subsequent immunosuppressive treatment might possess pronounced neurotoxicity.Case presentationWe present a case report of a patient with chronic liver disease who developed signs of Parkinsonism after an orthotopic liver transplant, with consecutive immunosuppressant treatment with tacrolimus. Despite the improvement of liver functions due to the cytostatic treatment, a progressive worsening of neuropsychiatric symptoms associated with the presence of tremor was observed. Metabolic as well as endocrine dysfunctions were excluded as the primary causes of this condition. A brain CT did not reveal structural pathology. Signs of severe, symmetric Parkinsonism - with resting tremor, bradykinesia, rigidity and severe postural instability were observed. A brain MRI was performed with the presence of T2- hyperintensities in basal ganglia bilaterally. Tacrolimus blood concentration was elevated; hence the dose was reduced and later switched to less toxic sirolimus. Subsequently, clinical signs markedly improved after treatment modification. Improvement of clinical symptomatology after tacrolimus discontinuation supports the drug-induced etiology of this neurological condition.ConclusionsCytostatic treatment after solid organ transplantation often leads to signs of encephalopathy. If necessary, the dose of cytostatics needs to be reduced, or a less toxic agent must be chosen for the therapy. This modification is usually efficient with no further need for neurological intervention.

A LINK BETWEEN COGNITIVE FUNCTION AND PHYSICAL ACTIVITY: THE IMPACT OF AEROBIC-STRENGTH EXERCISE IN SENIORS WITH MILD COGNITIVE IMPAIRMENT AND/OR IMPAIRED GLUCOSE METABOLISM

was similar between the experimental (n1⁄430, 68%), and control conditions (n1⁄427, 67.5%), but participants in the experimental condition were more likely to return for subsequent evaluations (T11⁄4100%, T21⁄493%) than participants in the control condition (T11⁄480%, T21⁄472%). Across training conditions, global cognition improved following the intervention, t(74)1⁄44.7, p<0.001, with improvements maintained at follow-up, t(73)1⁄43.9, p<0.001. Conclusions:Tailored and adaptive, as well as more generic CCT improved overall cognitive function in older diabetic adults, both in the short term and in the long-term. This suggests that in T2D elderly, cognitive activity in general may have long-term benefits for cognition. The lack of effect on disease management is consistent with prior investigations where no transfer of skills to other domains have been found. Evaluation of secondary outcomes, including specific cognitive domains and self-efficacy, is underway.

Hypometric anticipatory postural adjustments in dystonia are not affected by deep brain stimulation of globus pallidus internus

BACKGROUND Dystonia is a movement disorder with patterned, directional, and often sustained muscle contractions that produce abnormal postures or repetitive movements. Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is an effective and safe treatment for medically refractory dystonia. However, recent studies reported gait problems, gait freezing and falls in patients treated with DBS. Because these symptoms may point to deficient gait initiation processes, we systematically assessed the anticipatory postural adjustments (APAs) prior to stepping in dystonia patients with GPi-DBS. METHODS Thirteen patients with focal/segmental dystonia under GPi-DBS and twelve healthy control subjects were included in the study. Data were collected using pressure sensitive sensors and APAs were studied by centre of pressure measures. We compared APAs of both groups and analysed the influence of GPi-DBS on APAs in patients. RESULTS Medio-lateral and antero-posterior COP displacements, total COP path, maximal APA velocity and 1st step length were all smaller in patients for both ON (p=0.006, p=0.018, p=0.002, p=0.016, p=0.04) and OFF (p=0.001, p=0.01, p=0.001, p=0.03, p=0.024) condition compared to healthy subjects. GPi-DBS did not change APA parameters in patients. CONCLUSIONS Observations that APAs are impaired in dystonia and are at the same time not affected by the stimulation current are compatible with the assumption that APAs and dystonic symptoms may rely on distinct networks, possibly within the same cortical and basal ganglia structures. With no effect of stimulation on APAs it is unlikely that this would be a mechanism of impaired balance in the patients after the surgery.

Prevalent placement error of deep brain stimulation electrode in movement disorders (technical considerations)

BACKGROUND Deep brain stimulation is an effective and safe technique. Displacement of the electrode relative to the optimal stimulation site can lead to insufficient effect and sometimes to the need of operative electrode re-position. OBJECTIVE This study was aimed to analyse targeting accuracy of deep brain stimulation electrode implantation to subthalamic nucleus (STN) and globus pallidus internus (Gpi). It detected possible causes of inaccuracy and prevalent shift to certain direction. METHODS Targeting accuracy was analysed in 47 patients with Parkinson´s disease (PD) and 11 patients with dystonia with bilateral implantation of deep brain stimulation electrodes between years 2009 and 2016. RESULTS A shift of electrode to prevalent direction was observed on the left side to medial and posterior and on the right side to lateral direction. Greater shift was observed on the left side and in a higher angulation of trajectory laterally. Movement of the electrode, because of its traction in anchoring device, was identified as a possible factor for prevalent electrode shift. Calibration of stereotactic coordinates to correct prevalent shift was used. CONCLUSION Targeting inaccuracy is the result of accumulation of errors in individual steps of electrode implantation. Direction of the shift can be random or it can be toward a prevalent direction. A correction of prevalent error can prevent a suboptimal electrode placement (Tab. 3, Fig. 11, Ref. 29).

EFFECTS OF ENDURANCE-STRENGTH TRAINING ON MOTOR FUNCTIONS, COGNITION AND GLUCOSE METABOLISM IN PATIENTS WITH PARKINSON'S DISEASE

P2-021 EFFECTS OF ENDURANCE-STRENGTH TRAINING ON MOTOR FUNCTIONS, COGNITION AND GLUCOSE METABOLISM IN PATIENTS WITH PARKINSON’S DISEASE Jozef Ukropec, Patrik Krumpolec, Lucia Slobodova, Veronika Tirpakova, Matej Vajda, Eva Heckova, Rouyun Ma, Radka Klepochova, Igor Straka, Silvia Vallova, Stanislav Sutovsky, Zuzana Kosutzka, Chia-Liang Tsai, Ming-Chyi Pai, Peter Turcani, Ulrike Dydak, Wolfgang Bogner, Martin Krssak, Peter Valkovic, Milan Sedliak, Barbara Ukropcova, Institute of Experimental Endocrinology Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia; Institute of Experimental Endocrinology, Biomedical Research Center, SAS, Bratislava, Slovakia; Faculty of Medicine, Comenius University, Bratislava, Slovakia; Slovak Medical University, Institute of Sports Medicine, Bratislava, Slovakia; Faculty of Physical Education and Sports, Comenius University, Bratislava, Slovakia; Internal Medicine III, Medical University of Vienna, Vienna, Austria; School of Health Sciences, Purdue University, West Lafayette, IN, USA; Medical University Vienna, Vienna, Austria; Faculty of Medicine, Comenius University & University Hospital Bratislava, Bratislava, Slovakia; Institute of Physical Education, Health and Leisure Studies, National Cheng Kung University, Tainan, Taiwan; National Cheng Kung University Hospital, Tainan, Taiwan; School of Health Sciences, Purdue University, West Lafayette, IN, USA; Medical University of Vienna, Vienna, Austria; Institute of Experimental Endocrinology, Biomedical Research Center, SAS, Bratislava, Slovakia. Contact e-mail: jozef.ukropec@savba.sk