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ABSTRACT: OBJECTIVE: To investigate the ability of the Timed Up and Go test to identify patients with Parkinson's disease at risk for a fall. This study hypothesized that the Timed Up and Go test may be a reliable clinical tool to predict fall risk in Parkinson's disease. DESIGN: Cross-sectional cohort study. SETTING: Sixteen participating National Parkinson's Foundation Centers of Excellence. PARTICIPANTS: A query yielded a total of 2,985 records (1828 men and 1157 women). From these, 884 were excluded because of a lack of crucial information (age, diagnosis, the presence of deep brain stimulation, disease duration, inability of performing the timed up and go without assistance) at the time of testing leaving 2,097 patients included in the analysis. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The primary outcome measure for this study was falls. The chief independent variable was the Timed Up and Go. RESULTS: The initial model examined the prediction of falls from Timed Up and Go, adjusting for all study covariates. The estimated models in the imputed data sets represented a significant improvement above chance (χ2 range (df=17): 531.29 to 542.39, p < .001) suggesting that 74% of participants were accurately classified as a faller or non-faller. The secondary model in which the question of whether the effect of Timed Up and Go was invariant across disease severity demonstrated 75% of participants were accurately classified as a faller or non-faller. Additional analysis revealed a proposed cut score of 11.5 seconds for discrimination of those who did or did not fall. CONCLUSIONS: The findings suggest that the Timed Up and Go test may be an accurate assessments tool to identity those at risk for a fall.
Archives of physical medicine and rehabilitation 03/2013; · 2.18 Impact Factor
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Laura B Zahodne,
Oscar Bernal-Pacheco,
Dawn Bowers,
Herbert Ward,
Genko Oyama,
Natlada Limotai,
Frances Velez-Lago,
Ramon L Rodriguez, Irene Malaty,
Nikolaus R McFarland,
Michael S Okun
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ABSTRACT: Apathy is a common neuropsychiatric feature of Parkinson's disease (PD), but little is known of relationships between apathy and specific medications in PD. Following a retrospective database and chart review of 181 Parkinson's patients, relationships between Apathy Scale scores and use of psychotropic and antiparkinsonian medications were examined with multiple regression. Controlling for age, sex, education, and depression, the use of selective serotonin reuptake inhibitors (SSRIs), but not other antidepressants, was associated with greater apathy. Use of monoamine oxidase B inhibitors was associated with less apathy. Longitudinal studies are needed to evaluate a potential SSRI-induced apathy syndrome in PD.
The Journal of neuropsychiatry and clinical neurosciences 06/2012; 24(3):326-30. · 2.34 Impact Factor
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ABSTRACT: Gait performance is widely evaluated to assess health status in older adult populations. While several investigators have presented normative values for spatiotemporal gait parameters drawn from older adult populations, the literature has been void of large-scale cohort studies, which are needed in order to provide quantitative, normative gait data in persons with Parkinson's disease. The aim of this investigation was to provide reference values for clinically important gait characteristics in a large sample of ambulatory persons with Parkinson's disease to aid both clinicians and researchers in their evaluations and treatments of gait impairment.
Gait performance was collected in 310 individuals with idiopathic Parkinson's disease as they walked across a pressure sensitive walkway. Fourteen quantitative gait parameters were measured and evaluated with respect to Hoehn and Yahr disease staging and gender. Disease duration and age were controlled for in all analyses. Individuals with the greatest Parkinson's disability walked significantly slower with shorter steps and stride lengths than the mild and moderately affected groups. Further, the most affected patients spent more time with both feet on the ground, and walked with a wider base of support than the moderately disabled patients. No differences were detected between the mild and moderate disability groups on any of the gait parameters evaluated.
Reference values for 14 gait parameters in a large cohort of ambulatory patients with Parkinson's disease are provided and these may be highly useful for assessing and interpreting an individual's gait dysfunction. It is important for clinicians and researchers to appreciate the lack of change in quantitative parameters as PD patients move from mild to moderate gait impairment.
PLoS ONE 01/2012; 7(8):e42337. · 4.09 Impact Factor
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ABSTRACT: Apathy is a common feature of Parkinson's disease (PD) that can manifest independently of depression, but little is known about its natural progression in medically managed patients. The present study sought to characterize and compare trajectories of apathy, depression, and motor symptoms in PD over 18 months.
Data from a sample of 186 PD patients (mean disease duration of 8.2 years) followed by the University of Florida Movement Disorders Center were obtained from a clinical research database. Scores on the Unified Parkinson's disease Rating Scale (motor portion), Apathy Scale, and Beck Depression Inventory at three time-points (baseline, 6 months, 18 months) were analyzed in a structural equation modeling framework.
A multivariate growth model controlling for age, sex, education, and disease duration identified linear worsening of both apathy (slope estimate = 0.73; p < .001) and motor symptoms (slope estimate = 1.51; p < .001), and quadratic changes in depression (slope estimate = 1.18; p = .07). All symptoms were positively correlated. Higher education was associated with lower apathy, depression, and motor severity. Advanced age was associated with greater motor and apathy severity. Female sex and longer disease duration were associated with attenuated motor worsening. Antidepressant use was associated only with depression scores.
These longitudinal results support the differentiation of apathy and depression in PD. Like motor progression, apathy progression may be linked at least partially to dopaminergic neurodegeneration. Empirically supported treatments for apathy in PD are needed.
Neuropsychology 12/2011; 26(1):71-80. · 3.82 Impact Factor
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Natlada Limotai,
Criscely Go,
Genko Oyama,
Nelson Hwynn,
Theresa Zesiewicz,
Kelly Foote,
Roongroj Bhidayasiri, Irene Malaty,
Pam Zeilman,
Ramon Rodriguez,
Michael S Okun
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ABSTRACT: The aim of the study is to determine clinical outcomes in patients undergoing Globus Pallidus Internus Deep Brain Stimulation (GPi-DBS) for cranio-facial and cranio-cervical dystonia (Meige) symptoms. A total of 6 patients seen between 2002 and 2010 with cranio-facial and cranio-cervical dystonia symptoms were identified from the University of Florida Institutional Review Board approved database. Patients were videotaped using a standardized protocol, and tapes were randomized and blindly reviewed by a movement disorders neurologist. The Unified Dystonia Rating Scale improved 31.6 ± 23.2% (range: 3.4-63.2%) at 6 months and 63.7 ± 35.3% (range: 6.3-100%) at 12 months. The Burke-Fahn-Marsden Dystonia Rating Scale improved 45.3 ± 29.5% (range: 4.7-75.0%) at 6 months and 61.8 ± 30.9% (range: 16.6-100%) at 12 months. One patient significantly had a very large improvement with little evidence of residual dystonia. Blepharospasm improved in all patients, whereas speech and swallowing did not improve in this cohort. Two patients improved with unilateral GPi-DBS, although one required a contralateral DBS later in the disease course. Two patients were managed with low frequency stimulation (<100 Hz). Two patients had less than 20% benefit. GPi-DBS for cranio-facial and cranio-cervical symptoms is an effective strategy to manage a subset of patients who remain unresponsive to optimized medical management. Unilateral stimulation may be an option for some patients, but it remains unclear whether response to single-sided stimulation will be sustainable. The mixed results of this GPi-DBS case series highlight the need for a careful re-examination of selection criteria, alternative brain targets, and possibly rescue leads for patients who are non-responders to the GPi target.
Journal of Neurology 05/2011; 258(11):2069-74. · 3.47 Impact Factor
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ABSTRACT: Deep brain stimulation (DBS) has been associated with mood sequelae in a subset of patients operated on in either the subthalamic nucleus or the globus pallidus internus for the treatment of Parkinson disease.
To compare mood and motor outcomes in those with and without a presurgical history of depression.
Unilateral subthalamic nucleus or unilateral globus pallidus internus DBS patients followed up for a minimum of 6 months were included. All patients underwent a comprehensive outpatient psychiatric evaluation by a board-certified psychiatrist. Psychiatric diagnoses were based on Diagnostic and Statistical Manual, fourth edition, text revision, nomenclature (American Psychiatric Association, 2000). Motor and mood outcomes were compared.
A total of 110 patients were included. There were no significant differences in baseline variables between the 2 groups. Those with a preoperative history of depression had significantly higher Beck Depression Inventory scores than the nondepression group after DBS (8.97 ± 7.55 vs 5.92 ± 5.71; P = .04). Patients with a depression history had less improvement (11.6%) in pre/post-DBS change when Unified Parkinson Disease Rating Scale motor scores were compared (P = .03) after adjustment for stimulation site and baseline demographic and clinical variables. Patients with a higher levodopa equivalent dose had a worse clinical motor outcome.
Patients with a preoperative depression history had higher Beck Depression Inventory scores after DBS and significantly less (albeit small) improvement in pre/post-DBS change in Unified Parkinson Disease Rating Scale motor scores than patients without a history of depression.
Neurosurgery 03/2011; 69(2):357-60; discussion 360-1. · 2.79 Impact Factor
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ABSTRACT: Parkinson's disease (PD) impacts several domains of functioning, some of which may be neglected when designing treatment or evaluating outcome using current clinical standards. We therefore argue that taking the patients' perspectives of their condition may allow for a more in-depth assessment of patient goals and subsequent tailoring of care.
One hundred and forty-eight patients with idiopathic PD completed a modified version of the Patient-Centered Outcomes Questionnaire (PCOQ-PD), to evaluate treatment success and expectations from the patient's perspective across 10 motor and non-motor functional domains. We also examined patient subgroups based on importance of improvement in various domains.
Patients' ratings suggested there was substantial variation in functional interference that was generally unrelated to demographic variables. On average, across all domains, patients indicated a 50.32% reduction in symptoms would be successful (range = 40.63-58.23%), regardless of treatment experience. Change scores between patients' usual levels of symptom interference and their treatment success levels suggested a greater degree of change was desired in motor versus non-motor domains (p < 0.05). Finally, cluster analyses revealed two patient subgroups based on overall importance of improvement (High vs. Low Importance Endorsement). Notably, the two groups differed in self-reported usual symptom levels despite having similar clinical severity.
We empirically examined treatment success from the PD patient's view as opposed to clinician judgment alone, thereby broadening the set of criteria by which to evaluate outcome. Findings from this exploratory study may guide future treatment emphases and guide patient-provider communication via clarification of patient-defined success.
Parkinsonism & Related Disorders 10/2010; 17(2):89-94. · 3.80 Impact Factor
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Andrew Resnick,
Kelly Foote,
Ramon Rodriguez, Irene Malaty,
Joel Moll,
Donna Carden,
Nolie Krock,
Matthew Medley,
Adam Burdick,
Ihtsham Haq,
Michael Okun
Journal of Neurology 11/2009; · 3.47 Impact Factor
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Andrew S Resnick,
Kelly D Foote,
Ramon L Rodriguez, Irene A Malaty,
Joel L Moll,
Donna L Carden,
Nolie E Krock,
Matthew M Medley,
Adam Burdick,
Ihtsham U Haq,
Michael S Okun
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ABSTRACT: Deep brain stimulation (DBS) has become an increasingly common modality for control of several neurological disorders such as Parkinson's disease, dystonia, essential tremor (ET), and others. Our experience has demonstrated the need for emergency physicians to familiarize themselves with the potential complications of the DBS device as well as the device itself. Therefore, our aim in this paper was to elucidate the number and nature of DBS and non-DBS presentations to the emergency department (ED) and to educate and familiarize ED physicians about DBS devices and their potential complications. We also aimed to devise a simple protocol for DBS management so that all ED physicians would have access to the knowledge or referral capabilities when managing a DBS patient. The objective of the present study was to review the number and nature of ED encounters in patients with deep brain stimulation (DBS) devices implanted for movement and neuropsychiatric disorders. METHODS: The series of encounters reviewed included 215 unique patients with DBS implantation who were identified using an IRB approved database and a paper chart review. Patients in the study included those implanted at University of Florida (UF), as well as those implanted at outside institutions, so long as they were followed at UF. The cohort included n = 215 DBS patients. 25.6% of all 215 patients presented to the ED at least once, with the most common presentation occurring as a result of a decline in mental status when taking into account all visits (6%). Reasons for presentation to the ED included neurological (54.6%), infections/hardware issues (27.9%), orthopedic/focal problems (10.5%), and medical issues (7%). In total, 29 patients arrived at the ED for DBS related issues (23.2%). Of those who presented to the ED (n = 55), the average age was 53.1 (range 10-80 years). Headache was the most common complaint within the neurological category (22.1%), followed by change in mental status (15.1%), and syncope (9.3%). When examining the data by ED diagnosis, change in mental status occurred most commonly in Parkinson's disease (19.6%). Falls were most common in essential tremor (27.2%), and headache occurred most commonly in the dystonia group (52.1%). Across all diseases, mental status change was the most common indication for an ED encounter (6%). Parkinson disease patients most commonly presented with altered mental status (8%), essential tremor patients revealed a high preponderance of falls (6.5%), and dystonia patients tended to present with headache (7.1%). It was concluded that a large number of patients with DBS will present to the ED for many reasons, the majority of which will not be direct complications of their DBS device. Neurological issues were the most common chief complaint, with individual differences depending on the underlying disease. It is important for ED physicians to consider non-DBS related complaints in the presentation of these unique patients since these issues comprise the majority of the ED visits. However, when properly evaluating these patients, management of their DBS device, or referrals to neurosurgery and neurology, if necessary, are imperative. In addition to device management, regular ED standards of care should apply to this special cohort of patients.
Journal of Neurology 10/2009; 257(1):122-31. · 3.47 Impact Factor
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Frandy Susatia, Irene A Malaty,
Kelly D Foote,
Samuel S Wu,
Pamela R Zeilman,
Mitushi Mishra,
Ramon L Rodriguez,
Ihtsham ul Haq,
Charles E Jacobson,
Anqi Sun,
Michael S Okun
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ABSTRACT: The objective of this study was to examine globus pallidus internus deep brain stimulation (GPi-DBS) outcomes in primary and secondary dystonia, derived from blinded ratings using two scales and two raters. Twenty-five patients with variable presentations of dystonia were evaluated with videotaped standardized dystonia rating scales at preoperative baseline and at 6 and 12 months following GPi-DBS implantation. These 75 examination videos were retrospectively evaluated, independently and in random order, by two movement disorder neurologists who were blinded to the treatment status. Both neurologists scored each videotaped evaluation using the Burke-Fahn-Marsden Dystonia Rating Scale-motor part (BFMDRS-M) and the Unified Dystonia Rating Scale (UDRS). A final score for each video was assigned by averaging the raters' scores. An intra-class correlation coefficient was used to calculate inter-rater reliability. A linear mixed model was fitted to investigate the time effect and its interaction with type of dystonia (primary versus secondary) for each rating scale. Inter-rater reliability was excellent. Intraclass correlation coefficients ranged from 0.994 to 0.997 for both scales at baseline, 6 and 12 months. The average motor improvement scores after GPi DBS for the entire heterogeneous group of dystonia patients after 6 and 12 months of stimulation was 21.32% (p = 0.0010) and 28.95% (p = 0.0017), respectively, when the UDRS score was used. Similar levels of improvement 20.46% (p = 0.0055) at 6 months and 27.39% (p = 0.00197) at 12 months were found using the BFMDRS-M score. Analysis using unblinded scores from our database revealed a 32.99 and 37.27% UDRS improvement at 6 and 12 months, and an improvement in UDRS score of 38.5 and 43.7% when the analysis was limited to only primary dystonia. If the data were further segregated to include only cases of DYT-1 primary generalized dystonia, the UDRS benefit increased to 48.24%. Our primary dystonia group was diluted by the presence of both old- and young-onset patients, as well as focal, segmental and generalized dystonia. In conclusion, (1) evaluating motor outcomes of DBS therapy for dystonia using independent, randomized retrospective rating by blinded raters' results in lower improvement scores than when outcomes are rated by unblinded treating neurologists. Blinded methodology may be superior and might produce a more realistic assessment of motor outcomes after DBS in patients with dystonia; (2) outcomes were similar whether the BFMDRS-M or UDRS was utilized; (3) GPi-DBS was effective in treating sustained involuntary motor co-contractions in medication refractory dystonia patients, more so in primary dystonia.
Journal of Neurology 08/2009; 257(1):44-58. · 3.47 Impact Factor
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ABSTRACT: At least one small report has suggested the possibility that limb kinetic apraxia (a deficit in deftness) was not dopamine responsive and independent of bradykinesia and rigidity in PD. Quencer et al. (Neurology 68:150-151, 2007) observed that speed of finger tapping (bradykinesia) in optimally medicated persons with PD was largely comparable to healthy controls, yet their ability to manipulate and rotate a coin (deftness) was impaired. The authors concluded that deftness was independent of parkinsonian features. In this study, we measured tasks of deftness in a more objective way in both the ON and OFF dopaminergic state. Further, we evaluated whether finger-thumb force control was compromised in persons with PD. Eleven PD fluctuators (mean age 68 ± 9 years) and ten healthy age-matched controls (68 ± 8 years) were included. The bradykinesia items in the UPDRS and performance on the large box and block (LBB) tests were used to measure bradykinesia. A small box and block test (SBB), small coin rotation task (SCR) and small lock rotation task (SLR) were used as measures of deftness. Statistical analyses revealed a significant improvement in performance for the LBB, SBB, SLR and the bradykinesia items of the UPDRS following medication. Furthermore, our PD cohort's scores were comparable to controls on tests of bradykinesia and deftness (SLR, SBB and LBB) in the ON state, but they performed statistically worse than controls in the OFF state. On the other hand, analyses of the force control tasks revealed no significant difference between the groups. In summary, the improvement in deftness and bradykinesia in the ON state among our PD cohorts (and their comparable performance in the ON but not OFF state compared to healthy controls) suggests the possibility of a more uniform response of these motor features to dopaminergic therapy in PD.
Journal of Neurology 08/2009; 256(12):2030-5. · 3.47 Impact Factor
