5th International Conference on Parkinson's & Movement Disorders

NEW YORK – One reason to pursue a multimodality strategy to control the symptoms as well as the underlying pathophysiology of Parkinson’s disease (PD) is that a small but substantial proportion of patients with PD-like symptoms have a different diagnosis, according to an expert overview at the International Conference on Parkinson’s Disease and Movement Disorders.

Ted Bosworth/MDedge News

“Fifteen to 20% of patients treated for Parkinson’s disease, even in the most established centers of excellence, do not have Parkinson’s disease on necropsy,” said A.V. Srinivasan, MD, PhD, DSc, of The Tamil Nadu Dr. M.G.R. Medical University, Chennai, India.

This does not preclude benefit from antiparkinson drugs in those patients with PD-like symptoms but a different etiology. Many can benefit from increased dopamine availability, even in the absence of PD, but it emphasizes the complexity of clinical diseases associated with diminished dopamine function, according to Dr. Srinivasan. He characterized this complexity as a reason to avoid a regimented approach to PD management.

“You can just imagine how much this influences our data analysis,” said Dr. Srinivasan, referring to clinical trials designed to generate evidence-based treatment. “We should remember that we should not be too statistically oriented,” he added, citing the adage that “statistics can cause paralysis in your analysis.”

PD is associated with a vast array of neurologic and physical symptoms attributable to PD that overlap with other neurologic disorders, which is the reason that a definitive diagnosis is challenging, according to Dr. Srinivasan. Listing symptoms that should prompt consideration of an alternative diagnosis, Dr. Srinivasan said hallucinations suggest diffuse Lewy body disease, myoclonus suggests corticobasal degeneration, and amyotrophy suggests multiple system atrophy.

“These are only clues, however,” said Dr. Srinivasan, suggesting their presence should prompt consideration of alternative diagnoses, but their absence does not confirm PD.

In some cases, further work-up with one or more of the array of increasingly sophisticated imaging strategies, such as the combination of SPECT and PET, might help clinicians reach a more definitive diagnosis of the underlying pathology, a step that might guide use of dopaminergic therapies. However, effective treatment of PD symptoms does not depend on a definitive diagnosis.

Rather, Dr. Srinivasan advocated an open mind to the management of symptoms, which he indicated are best addressed empirically. As PD or other progressive movement disorders advance, the goal is to keep patients functional and comfortable.

This includes managing patients beyond prescription drugs to address such complications as dysphagia or impaired balance. He advocated practical solutions for causes of impaired quality of life such as soft foods to facilitate swallowing or walkers to keep patients ambulatory. No option that leads to symptom relief should be discounted, including alternative therapies.

“Some clinicians are strongly opposed to nontraditional therapies, such as naturopathy and homeopathy, but these have all been used in Parkinson’s,” Dr. Srinivasan said. Although he did not present data to show efficacy, he indicated that relief of symptoms and improvement of quality of life is the point of any treatment, which should be individualized by response in every patient.

And individualized therapy – in relationship to patient age – is particularly important, according to Dr. Srinivasan. While younger patients typically tolerate relatively aggressive therapies aimed at both PD and its specific symptoms, older patients may accept less ambitious functional improvements to achieve an adequate quality of life.

“After 70 years of age, every additional year is a bonus. After 80 years, every week is a bonus. After 90 years, every minute is a bonus,” said Dr. Srinivasan, in emphasizing an appropriate clinical perspective.

NEW YORK – One reason to pursue a multimodality strategy to control the symptoms as well as the underlying pathophysiology of Parkinson’s disease (PD) is that a small but substantial proportion of patients with PD-like symptoms have a different diagnosis, according to an expert overview at the International Conference on Parkinson’s Disease and Movement Disorders.

Ted Bosworth/MDedge News

“Fifteen to 20% of patients treated for Parkinson’s disease, even in the most established centers of excellence, do not have Parkinson’s disease on necropsy,” said A.V. Srinivasan, MD, PhD, DSc, of The Tamil Nadu Dr. M.G.R. Medical University, Chennai, India.

This does not preclude benefit from antiparkinson drugs in those patients with PD-like symptoms but a different etiology. Many can benefit from increased dopamine availability, even in the absence of PD, but it emphasizes the complexity of clinical diseases associated with diminished dopamine function, according to Dr. Srinivasan. He characterized this complexity as a reason to avoid a regimented approach to PD management.

“You can just imagine how much this influences our data analysis,” said Dr. Srinivasan, referring to clinical trials designed to generate evidence-based treatment. “We should remember that we should not be too statistically oriented,” he added, citing the adage that “statistics can cause paralysis in your analysis.”

PD is associated with a vast array of neurologic and physical symptoms attributable to PD that overlap with other neurologic disorders, which is the reason that a definitive diagnosis is challenging, according to Dr. Srinivasan. Listing symptoms that should prompt consideration of an alternative diagnosis, Dr. Srinivasan said hallucinations suggest diffuse Lewy body disease, myoclonus suggests corticobasal degeneration, and amyotrophy suggests multiple system atrophy.

“These are only clues, however,” said Dr. Srinivasan, suggesting their presence should prompt consideration of alternative diagnoses, but their absence does not confirm PD.

In some cases, further work-up with one or more of the array of increasingly sophisticated imaging strategies, such as the combination of SPECT and PET, might help clinicians reach a more definitive diagnosis of the underlying pathology, a step that might guide use of dopaminergic therapies. However, effective treatment of PD symptoms does not depend on a definitive diagnosis.

Rather, Dr. Srinivasan advocated an open mind to the management of symptoms, which he indicated are best addressed empirically. As PD or other progressive movement disorders advance, the goal is to keep patients functional and comfortable.

This includes managing patients beyond prescription drugs to address such complications as dysphagia or impaired balance. He advocated practical solutions for causes of impaired quality of life such as soft foods to facilitate swallowing or walkers to keep patients ambulatory. No option that leads to symptom relief should be discounted, including alternative therapies.

“Some clinicians are strongly opposed to nontraditional therapies, such as naturopathy and homeopathy, but these have all been used in Parkinson’s,” Dr. Srinivasan said. Although he did not present data to show efficacy, he indicated that relief of symptoms and improvement of quality of life is the point of any treatment, which should be individualized by response in every patient.

And individualized therapy – in relationship to patient age – is particularly important, according to Dr. Srinivasan. While younger patients typically tolerate relatively aggressive therapies aimed at both PD and its specific symptoms, older patients may accept less ambitious functional improvements to achieve an adequate quality of life.

“After 70 years of age, every additional year is a bonus. After 80 years, every week is a bonus. After 90 years, every minute is a bonus,” said Dr. Srinivasan, in emphasizing an appropriate clinical perspective.

NEW YORK – One reason to pursue a multimodality strategy to control the symptoms as well as the underlying pathophysiology of Parkinson’s disease (PD) is that a small but substantial proportion of patients with PD-like symptoms have a different diagnosis, according to an expert overview at the International Conference on Parkinson’s Disease and Movement Disorders.

Ted Bosworth/MDedge News

“Fifteen to 20% of patients treated for Parkinson’s disease, even in the most established centers of excellence, do not have Parkinson’s disease on necropsy,” said A.V. Srinivasan, MD, PhD, DSc, of The Tamil Nadu Dr. M.G.R. Medical University, Chennai, India.

This does not preclude benefit from antiparkinson drugs in those patients with PD-like symptoms but a different etiology. Many can benefit from increased dopamine availability, even in the absence of PD, but it emphasizes the complexity of clinical diseases associated with diminished dopamine function, according to Dr. Srinivasan. He characterized this complexity as a reason to avoid a regimented approach to PD management.

“You can just imagine how much this influences our data analysis,” said Dr. Srinivasan, referring to clinical trials designed to generate evidence-based treatment. “We should remember that we should not be too statistically oriented,” he added, citing the adage that “statistics can cause paralysis in your analysis.”

PD is associated with a vast array of neurologic and physical symptoms attributable to PD that overlap with other neurologic disorders, which is the reason that a definitive diagnosis is challenging, according to Dr. Srinivasan. Listing symptoms that should prompt consideration of an alternative diagnosis, Dr. Srinivasan said hallucinations suggest diffuse Lewy body disease, myoclonus suggests corticobasal degeneration, and amyotrophy suggests multiple system atrophy.

“These are only clues, however,” said Dr. Srinivasan, suggesting their presence should prompt consideration of alternative diagnoses, but their absence does not confirm PD.

In some cases, further work-up with one or more of the array of increasingly sophisticated imaging strategies, such as the combination of SPECT and PET, might help clinicians reach a more definitive diagnosis of the underlying pathology, a step that might guide use of dopaminergic therapies. However, effective treatment of PD symptoms does not depend on a definitive diagnosis.

Rather, Dr. Srinivasan advocated an open mind to the management of symptoms, which he indicated are best addressed empirically. As PD or other progressive movement disorders advance, the goal is to keep patients functional and comfortable.

This includes managing patients beyond prescription drugs to address such complications as dysphagia or impaired balance. He advocated practical solutions for causes of impaired quality of life such as soft foods to facilitate swallowing or walkers to keep patients ambulatory. No option that leads to symptom relief should be discounted, including alternative therapies.

“Some clinicians are strongly opposed to nontraditional therapies, such as naturopathy and homeopathy, but these have all been used in Parkinson’s,” Dr. Srinivasan said. Although he did not present data to show efficacy, he indicated that relief of symptoms and improvement of quality of life is the point of any treatment, which should be individualized by response in every patient.

And individualized therapy – in relationship to patient age – is particularly important, according to Dr. Srinivasan. While younger patients typically tolerate relatively aggressive therapies aimed at both PD and its specific symptoms, older patients may accept less ambitious functional improvements to achieve an adequate quality of life.

“After 70 years of age, every additional year is a bonus. After 80 years, every week is a bonus. After 90 years, every minute is a bonus,” said Dr. Srinivasan, in emphasizing an appropriate clinical perspective.

NEW YORK – Sending sensory feedback upstream to patients with Parkinson’s disease (PD) may offer a low-risk, nonpharmaceutical method to retain and improve motor function. These interventions may be especially helpful in the subpopulation of patients who are intolerant to exercise, with a growing body of evidence showing sustained benefit for newer sensory stimulation techniques.

Kari Oakes/MDedge News

“In a healthy person, movement is the seamless integration of sensory and motor systems,” said Ben Weinstock, DPT, speaking at the International Conference on Parkinson’s Disease and Movement Disorders, pointing out that movement stimulates the senses, and sensory stimulation improves movement.

By contrast, patients with PD experience more than just problems with motor function. Patients with PD and sensory or autonomic dysfunction may find these disturbances contributing to motor dysfunction, said Dr. Weinstock, who treats patients with PD and a variety of complex medical conditions in his private practice.

Some of the hallmark features of PD are movement related: the cogwheel rigidity, bradykinesia, and freezing all contribute to poor balance and a fear of falling. Commonly, PD patients also experience fatigue and alterations in cognition and mood.

However, afferent small-fiber neuropathies and centrally mediated mechanisms in PD can also disturb sensory input: Vestibular function, equilibrium, proprioception, and light and deep touch may all be affected, Dr. Weinstock said.

Autonomic dysfunction can be an underappreciated feature of PD, but such manifestations as orthostatic hypotension and poor thermal regulation can have significant negative impact on quality of life for an individual with PD.

Perhaps the gravest variant of autonomic dysregulation, however, is the cardiac denervation that frequently accompanies PD, said Dr. Weinstock. “Although there is a belief that intensive exercise helps people with PD, many individuals are actually exercise intolerant because of loss of cardiac norepinephrine,” he said (J Neurochem. 2014;131[2]:219-228). “A person with PD who is exercise intolerant is at risk” of syncope, falls, and even serious cardiac events during exercise, he noted.

Cardiovascular dysautonomia in PD has been documented in serial ¹⁸F-dopamine PET scans, showing progressive reduction in uptake over the course of several years in individual patients (Neurobiol Dis. 2012 June;46[3]:572-80). Similarly, studies have shown lower cardiac radiotracer uptake in patients with PD, compared with normal controls, he said (NPJ Parkinsons Dis. 2017. doi: 10.1038/S41531-017-0017-1).

It’s not easy to determine what level of nonmotor dysfunction a given patient has at a particular point in disease progression, said Dr. Weinstock.

“There is no correlation between motor and nonmotor deterioration,” he said. “Somebody might be newly diagnosed with just a mild tremor and still have significant cardiac denervation.”

Weighing how to help an exercise-intolerant patient with PD means taking into consideration the known risks and side effect profile of PD medications, Dr. Weinstock pointed out. Increasing medications, or beginning a new drug therapy, can mean increased risk for unwanted psychiatric side effects and ototoxicity, among other potential ill effects.

Similarly, the decision to implant deep brain stimulation is not to be taken lightly, since depression can begin or worsen, and any surgical procedure carries risks.

For Dr. Weinstock, using strategies to improve sensory input are “a valid option for people with PD.” Such a strategy is safe, and even brief bouts of stimulation “can have significant, beneficial effects,” he said. “The overall goal is to avoid sedentary behavior,” with its accompanying ills, he said.

Dr. Weinstock noted that he uses different strategies to stimulate the various senses, including bright light therapy, which can help regulate circadian rhythms and promote appropriate melatonin secretion, improving sleep and upping daytime wakefulness.

Another visual strategy when working on gait is to use surface lines, a checkerboard pattern, or other targets that provide a visual goal for step length, which typically shortens with PD progression. Though more high-tech options exist, Dr. Weinstock suggested patients begin with just laying lines of masking tape along the floor to mark the target gait length. “Usually the cheap technique is a good test to see if it’s going to work,” he said.

An auditory strategy to improve the gait cycle is use of a metronome or other rhythmic auditory stimulation; music can be helpful in this regard and as a general cognitive and emotional stimulus, said Dr. Weinstock.

“Loss of smell is an early sign of Parkinson’s,” said Dr. Weinstock, and taste also can be dulled. Though offering tasty meals could help reduce risk of malnutrition in PD patients, “It remains to be seen if aromatherapy can lead to neural plasticity and reverse smell loss in PD.”

Vestibular rehabilitation techniques can help not just with balance, but also with helping to lift mood and improve functional activities, according to one study (Arq Neuropsiquiatr 2009;67[2-A]:219-23).

Other ways to provide proprioceptive feedback include the use of orthotics and textured insoles and the use of a weighted vest. Dr. Weinstock also gives consideration to skin taping, which may give patients useful feedback about their bodies’ position in space, he said.

Intriguing results have been seen with acupuncture, acupressure, and electroacupuncture for PD patients, said Dr. Weinstock. In particular, a technique called automated mechanical pressure stimulation uses a bootlike device to provide mechanical stimulation to points at the head of the great toe and on the ball of the foot at the head of the first metatarsal bone.

One functional magnetic resonance imaging (fMRI) study showed acutely increased resting state functional connectivity after such stimulation, in comparison with a sham procedure that also applied pressure, but over a broader area, he said.

After the stimulation procedure used in the study, the patients who received actual stimulation also saw improved ability to initiate voluntary movements, less tremor and rigidity, and less gait freezing (PLoS One. 2015 Oct 15. doi: 10.1371/journal.pone.0137977).

Other studies of the mechanical stimulation device showed similar results, with some showing that repeated sessions helped maintain these and other benefits, such as improved walking velocity, stride length, and Timed Up and Go results – an assessment of fall risk (Int J Rehabil Res. 2015 Sep;38[3]:238-45). Treatment with the device, dubbed Gondola, is most widely available in Italy, where clinical trials are ongoing.

Stimulation to an acupuncture point located on the proximal lateral leg, near the head of the fibula, showed improvements in gait parameters and in fMRI-assessed brain connectivity as well, noted Dr. Weinstock (CNS Neurosci Ther. 2012 Sep;18[9]:781-90).

“There’s a growing amount of evidence that various types of sensory stimulation can have significant benefits for people with Parkinson’s Disease, especially for those who are exercise intolerant,” said Dr. Weinstock.

Dr. Weinstock reported no relevant disclosures.

koakes@mdedge.com

NEW YORK – Sending sensory feedback upstream to patients with Parkinson’s disease (PD) may offer a low-risk, nonpharmaceutical method to retain and improve motor function. These interventions may be especially helpful in the subpopulation of patients who are intolerant to exercise, with a growing body of evidence showing sustained benefit for newer sensory stimulation techniques.

Kari Oakes/MDedge News

“In a healthy person, movement is the seamless integration of sensory and motor systems,” said Ben Weinstock, DPT, speaking at the International Conference on Parkinson’s Disease and Movement Disorders, pointing out that movement stimulates the senses, and sensory stimulation improves movement.

By contrast, patients with PD experience more than just problems with motor function. Patients with PD and sensory or autonomic dysfunction may find these disturbances contributing to motor dysfunction, said Dr. Weinstock, who treats patients with PD and a variety of complex medical conditions in his private practice.

Some of the hallmark features of PD are movement related: the cogwheel rigidity, bradykinesia, and freezing all contribute to poor balance and a fear of falling. Commonly, PD patients also experience fatigue and alterations in cognition and mood.

However, afferent small-fiber neuropathies and centrally mediated mechanisms in PD can also disturb sensory input: Vestibular function, equilibrium, proprioception, and light and deep touch may all be affected, Dr. Weinstock said.

Autonomic dysfunction can be an underappreciated feature of PD, but such manifestations as orthostatic hypotension and poor thermal regulation can have significant negative impact on quality of life for an individual with PD.

Perhaps the gravest variant of autonomic dysregulation, however, is the cardiac denervation that frequently accompanies PD, said Dr. Weinstock. “Although there is a belief that intensive exercise helps people with PD, many individuals are actually exercise intolerant because of loss of cardiac norepinephrine,” he said (J Neurochem. 2014;131[2]:219-228). “A person with PD who is exercise intolerant is at risk” of syncope, falls, and even serious cardiac events during exercise, he noted.

Cardiovascular dysautonomia in PD has been documented in serial ¹⁸F-dopamine PET scans, showing progressive reduction in uptake over the course of several years in individual patients (Neurobiol Dis. 2012 June;46[3]:572-80). Similarly, studies have shown lower cardiac radiotracer uptake in patients with PD, compared with normal controls, he said (NPJ Parkinsons Dis. 2017. doi: 10.1038/S41531-017-0017-1).

It’s not easy to determine what level of nonmotor dysfunction a given patient has at a particular point in disease progression, said Dr. Weinstock.

“There is no correlation between motor and nonmotor deterioration,” he said. “Somebody might be newly diagnosed with just a mild tremor and still have significant cardiac denervation.”

Weighing how to help an exercise-intolerant patient with PD means taking into consideration the known risks and side effect profile of PD medications, Dr. Weinstock pointed out. Increasing medications, or beginning a new drug therapy, can mean increased risk for unwanted psychiatric side effects and ototoxicity, among other potential ill effects.

Similarly, the decision to implant deep brain stimulation is not to be taken lightly, since depression can begin or worsen, and any surgical procedure carries risks.

For Dr. Weinstock, using strategies to improve sensory input are “a valid option for people with PD.” Such a strategy is safe, and even brief bouts of stimulation “can have significant, beneficial effects,” he said. “The overall goal is to avoid sedentary behavior,” with its accompanying ills, he said.

Dr. Weinstock noted that he uses different strategies to stimulate the various senses, including bright light therapy, which can help regulate circadian rhythms and promote appropriate melatonin secretion, improving sleep and upping daytime wakefulness.

Another visual strategy when working on gait is to use surface lines, a checkerboard pattern, or other targets that provide a visual goal for step length, which typically shortens with PD progression. Though more high-tech options exist, Dr. Weinstock suggested patients begin with just laying lines of masking tape along the floor to mark the target gait length. “Usually the cheap technique is a good test to see if it’s going to work,” he said.

An auditory strategy to improve the gait cycle is use of a metronome or other rhythmic auditory stimulation; music can be helpful in this regard and as a general cognitive and emotional stimulus, said Dr. Weinstock.

“Loss of smell is an early sign of Parkinson’s,” said Dr. Weinstock, and taste also can be dulled. Though offering tasty meals could help reduce risk of malnutrition in PD patients, “It remains to be seen if aromatherapy can lead to neural plasticity and reverse smell loss in PD.”

Vestibular rehabilitation techniques can help not just with balance, but also with helping to lift mood and improve functional activities, according to one study (Arq Neuropsiquiatr 2009;67[2-A]:219-23).

Other ways to provide proprioceptive feedback include the use of orthotics and textured insoles and the use of a weighted vest. Dr. Weinstock also gives consideration to skin taping, which may give patients useful feedback about their bodies’ position in space, he said.

Intriguing results have been seen with acupuncture, acupressure, and electroacupuncture for PD patients, said Dr. Weinstock. In particular, a technique called automated mechanical pressure stimulation uses a bootlike device to provide mechanical stimulation to points at the head of the great toe and on the ball of the foot at the head of the first metatarsal bone.

One functional magnetic resonance imaging (fMRI) study showed acutely increased resting state functional connectivity after such stimulation, in comparison with a sham procedure that also applied pressure, but over a broader area, he said.

After the stimulation procedure used in the study, the patients who received actual stimulation also saw improved ability to initiate voluntary movements, less tremor and rigidity, and less gait freezing (PLoS One. 2015 Oct 15. doi: 10.1371/journal.pone.0137977).

Other studies of the mechanical stimulation device showed similar results, with some showing that repeated sessions helped maintain these and other benefits, such as improved walking velocity, stride length, and Timed Up and Go results – an assessment of fall risk (Int J Rehabil Res. 2015 Sep;38[3]:238-45). Treatment with the device, dubbed Gondola, is most widely available in Italy, where clinical trials are ongoing.

Stimulation to an acupuncture point located on the proximal lateral leg, near the head of the fibula, showed improvements in gait parameters and in fMRI-assessed brain connectivity as well, noted Dr. Weinstock (CNS Neurosci Ther. 2012 Sep;18[9]:781-90).

“There’s a growing amount of evidence that various types of sensory stimulation can have significant benefits for people with Parkinson’s Disease, especially for those who are exercise intolerant,” said Dr. Weinstock.

Dr. Weinstock reported no relevant disclosures.

koakes@mdedge.com

NEW YORK – Sending sensory feedback upstream to patients with Parkinson’s disease (PD) may offer a low-risk, nonpharmaceutical method to retain and improve motor function. These interventions may be especially helpful in the subpopulation of patients who are intolerant to exercise, with a growing body of evidence showing sustained benefit for newer sensory stimulation techniques.

Kari Oakes/MDedge News

“In a healthy person, movement is the seamless integration of sensory and motor systems,” said Ben Weinstock, DPT, speaking at the International Conference on Parkinson’s Disease and Movement Disorders, pointing out that movement stimulates the senses, and sensory stimulation improves movement.

By contrast, patients with PD experience more than just problems with motor function. Patients with PD and sensory or autonomic dysfunction may find these disturbances contributing to motor dysfunction, said Dr. Weinstock, who treats patients with PD and a variety of complex medical conditions in his private practice.

Some of the hallmark features of PD are movement related: the cogwheel rigidity, bradykinesia, and freezing all contribute to poor balance and a fear of falling. Commonly, PD patients also experience fatigue and alterations in cognition and mood.

However, afferent small-fiber neuropathies and centrally mediated mechanisms in PD can also disturb sensory input: Vestibular function, equilibrium, proprioception, and light and deep touch may all be affected, Dr. Weinstock said.

Autonomic dysfunction can be an underappreciated feature of PD, but such manifestations as orthostatic hypotension and poor thermal regulation can have significant negative impact on quality of life for an individual with PD.

Perhaps the gravest variant of autonomic dysregulation, however, is the cardiac denervation that frequently accompanies PD, said Dr. Weinstock. “Although there is a belief that intensive exercise helps people with PD, many individuals are actually exercise intolerant because of loss of cardiac norepinephrine,” he said (J Neurochem. 2014;131[2]:219-228). “A person with PD who is exercise intolerant is at risk” of syncope, falls, and even serious cardiac events during exercise, he noted.

Cardiovascular dysautonomia in PD has been documented in serial ¹⁸F-dopamine PET scans, showing progressive reduction in uptake over the course of several years in individual patients (Neurobiol Dis. 2012 June;46[3]:572-80). Similarly, studies have shown lower cardiac radiotracer uptake in patients with PD, compared with normal controls, he said (NPJ Parkinsons Dis. 2017. doi: 10.1038/S41531-017-0017-1).

It’s not easy to determine what level of nonmotor dysfunction a given patient has at a particular point in disease progression, said Dr. Weinstock.

“There is no correlation between motor and nonmotor deterioration,” he said. “Somebody might be newly diagnosed with just a mild tremor and still have significant cardiac denervation.”

Weighing how to help an exercise-intolerant patient with PD means taking into consideration the known risks and side effect profile of PD medications, Dr. Weinstock pointed out. Increasing medications, or beginning a new drug therapy, can mean increased risk for unwanted psychiatric side effects and ototoxicity, among other potential ill effects.

Similarly, the decision to implant deep brain stimulation is not to be taken lightly, since depression can begin or worsen, and any surgical procedure carries risks.

For Dr. Weinstock, using strategies to improve sensory input are “a valid option for people with PD.” Such a strategy is safe, and even brief bouts of stimulation “can have significant, beneficial effects,” he said. “The overall goal is to avoid sedentary behavior,” with its accompanying ills, he said.

Dr. Weinstock noted that he uses different strategies to stimulate the various senses, including bright light therapy, which can help regulate circadian rhythms and promote appropriate melatonin secretion, improving sleep and upping daytime wakefulness.

Another visual strategy when working on gait is to use surface lines, a checkerboard pattern, or other targets that provide a visual goal for step length, which typically shortens with PD progression. Though more high-tech options exist, Dr. Weinstock suggested patients begin with just laying lines of masking tape along the floor to mark the target gait length. “Usually the cheap technique is a good test to see if it’s going to work,” he said.

An auditory strategy to improve the gait cycle is use of a metronome or other rhythmic auditory stimulation; music can be helpful in this regard and as a general cognitive and emotional stimulus, said Dr. Weinstock.

“Loss of smell is an early sign of Parkinson’s,” said Dr. Weinstock, and taste also can be dulled. Though offering tasty meals could help reduce risk of malnutrition in PD patients, “It remains to be seen if aromatherapy can lead to neural plasticity and reverse smell loss in PD.”

Vestibular rehabilitation techniques can help not just with balance, but also with helping to lift mood and improve functional activities, according to one study (Arq Neuropsiquiatr 2009;67[2-A]:219-23).

Other ways to provide proprioceptive feedback include the use of orthotics and textured insoles and the use of a weighted vest. Dr. Weinstock also gives consideration to skin taping, which may give patients useful feedback about their bodies’ position in space, he said.

Intriguing results have been seen with acupuncture, acupressure, and electroacupuncture for PD patients, said Dr. Weinstock. In particular, a technique called automated mechanical pressure stimulation uses a bootlike device to provide mechanical stimulation to points at the head of the great toe and on the ball of the foot at the head of the first metatarsal bone.

One functional magnetic resonance imaging (fMRI) study showed acutely increased resting state functional connectivity after such stimulation, in comparison with a sham procedure that also applied pressure, but over a broader area, he said.

After the stimulation procedure used in the study, the patients who received actual stimulation also saw improved ability to initiate voluntary movements, less tremor and rigidity, and less gait freezing (PLoS One. 2015 Oct 15. doi: 10.1371/journal.pone.0137977).

Other studies of the mechanical stimulation device showed similar results, with some showing that repeated sessions helped maintain these and other benefits, such as improved walking velocity, stride length, and Timed Up and Go results – an assessment of fall risk (Int J Rehabil Res. 2015 Sep;38[3]:238-45). Treatment with the device, dubbed Gondola, is most widely available in Italy, where clinical trials are ongoing.

Stimulation to an acupuncture point located on the proximal lateral leg, near the head of the fibula, showed improvements in gait parameters and in fMRI-assessed brain connectivity as well, noted Dr. Weinstock (CNS Neurosci Ther. 2012 Sep;18[9]:781-90).

“There’s a growing amount of evidence that various types of sensory stimulation can have significant benefits for people with Parkinson’s Disease, especially for those who are exercise intolerant,” said Dr. Weinstock.

Dr. Weinstock reported no relevant disclosures.

koakes@mdedge.com

Exercise classes that focus on boxing movements such as punching a bag may help to improve motor learning patterns in patients with Parkinson’s disease, according to a new pilot study.

When presented with a computerized test in which study participants with Parkinson’s disease had to press buttons corresponding to patterns appearing on a screen, those who had been taking Rock Steady Boxing classes for at least 6 months demonstrated faster reaction time than did those who had never taken the classes, according to Christopher K. McLeod, a second-year medical student at the New York Institute of Technology College of Osteopathic Medicine in Old Westbury, N.Y. Mr. McLeod, who worked with Adena Leder, DO, director of the Parkinson’s Disease Treatment Center at the college, will present his research findings Oct. 20 at the International Conference on Parkinson’s Disease and Movement Disorders in New York.

While the results were not statistically significant, and the number of participants (n = 28) was relatively small, said Mr. McLeod, “We think this is a good pilot study for research going forward, since there really isn’t anything in the literature right now about how procedural memory and learning could be addressed from a therapeutic standpoint in Parkinson’s disease patients.” Procedural learning is a means of acquiring a new skill through repeating the task, like learning to drive a stick shift by doing it.

The investigators used a serial reaction time test to assess procedural memory in 14 patients diagnosed with Parkinson’s disease who had been regularly attending Rock Steady Boxing classes and in 14 patients who did not go to the classes. The test featured a computer screen with four squares that would light up and a box with four corresponding buttons to push as each square lit up. There were seven time blocks in which patients were presented with a series of 10 stimuli. The first pattern was random to get participants accustomed to the task. The second, third, fourth, and fifth blocks had the same sequence, to assess participants’ ability to learn the pattern and respond more quickly. The sixth block again had a random pattern to see if participants slowed down to learn the new pattern, and the seventh block repeated the familiar sequence from the second to fifth blocks.

Experienced boxers generally demonstrated faster reaction time than did nonboxers, the researchers found. Statistical analysis of the four learning blocks (blocks 2-5) revealed a moderate effect (P = .19), indicating that experienced boxers tended to react faster than nonboxers.

Diminished reaction time is a hallmark symptom of Parkinson’s disease, often resulting in patients having to give up the ability drive as the disease progresses, Mr. McLeod said: “Reaction time is something that could eventually lead to falling or not being able to drive, which are huge lifestyle changes that affect these patients emotionally and impact their quality of life.”

The researchers also observed a visible difference in how the two groups tended to respond to the random sequence following the repetitive blocks. Experienced boxers slowed slightly, with a 27.3-ms increase in reaction time, while nonboxers got faster, with a 93.5-ms decrease in reaction time. One possible explanation is that nonboxers simply got better at reacting to the stimuli over time without actually learning the repeated sequence, Mr. McLeod said.

Rock Steady Boxing was founded in Indianapolis by Scott Newman, a former county prosecutor who was diagnosed with Parkinson’s disease at age 40 and experienced significant improvement in his health and agility by engaging in rigorous workouts, such as boxing. Dr. Leder became certified in Rock Steady Boxing and opened a chapter at the New York college in May 2016. The classes include group activities, games, and boxing exercises designed to improve patients’ physical and mental stamina.

Mr. McLeod and Dr. Leder reported no relevant financial disclosures.

Exercise classes that focus on boxing movements such as punching a bag may help to improve motor learning patterns in patients with Parkinson’s disease, according to a new pilot study.

When presented with a computerized test in which study participants with Parkinson’s disease had to press buttons corresponding to patterns appearing on a screen, those who had been taking Rock Steady Boxing classes for at least 6 months demonstrated faster reaction time than did those who had never taken the classes, according to Christopher K. McLeod, a second-year medical student at the New York Institute of Technology College of Osteopathic Medicine in Old Westbury, N.Y. Mr. McLeod, who worked with Adena Leder, DO, director of the Parkinson’s Disease Treatment Center at the college, will present his research findings Oct. 20 at the International Conference on Parkinson’s Disease and Movement Disorders in New York.

While the results were not statistically significant, and the number of participants (n = 28) was relatively small, said Mr. McLeod, “We think this is a good pilot study for research going forward, since there really isn’t anything in the literature right now about how procedural memory and learning could be addressed from a therapeutic standpoint in Parkinson’s disease patients.” Procedural learning is a means of acquiring a new skill through repeating the task, like learning to drive a stick shift by doing it.

The investigators used a serial reaction time test to assess procedural memory in 14 patients diagnosed with Parkinson’s disease who had been regularly attending Rock Steady Boxing classes and in 14 patients who did not go to the classes. The test featured a computer screen with four squares that would light up and a box with four corresponding buttons to push as each square lit up. There were seven time blocks in which patients were presented with a series of 10 stimuli. The first pattern was random to get participants accustomed to the task. The second, third, fourth, and fifth blocks had the same sequence, to assess participants’ ability to learn the pattern and respond more quickly. The sixth block again had a random pattern to see if participants slowed down to learn the new pattern, and the seventh block repeated the familiar sequence from the second to fifth blocks.

Experienced boxers generally demonstrated faster reaction time than did nonboxers, the researchers found. Statistical analysis of the four learning blocks (blocks 2-5) revealed a moderate effect (P = .19), indicating that experienced boxers tended to react faster than nonboxers.

Diminished reaction time is a hallmark symptom of Parkinson’s disease, often resulting in patients having to give up the ability drive as the disease progresses, Mr. McLeod said: “Reaction time is something that could eventually lead to falling or not being able to drive, which are huge lifestyle changes that affect these patients emotionally and impact their quality of life.”

The researchers also observed a visible difference in how the two groups tended to respond to the random sequence following the repetitive blocks. Experienced boxers slowed slightly, with a 27.3-ms increase in reaction time, while nonboxers got faster, with a 93.5-ms decrease in reaction time. One possible explanation is that nonboxers simply got better at reacting to the stimuli over time without actually learning the repeated sequence, Mr. McLeod said.

Rock Steady Boxing was founded in Indianapolis by Scott Newman, a former county prosecutor who was diagnosed with Parkinson’s disease at age 40 and experienced significant improvement in his health and agility by engaging in rigorous workouts, such as boxing. Dr. Leder became certified in Rock Steady Boxing and opened a chapter at the New York college in May 2016. The classes include group activities, games, and boxing exercises designed to improve patients’ physical and mental stamina.

Mr. McLeod and Dr. Leder reported no relevant financial disclosures.

Exercise classes that focus on boxing movements such as punching a bag may help to improve motor learning patterns in patients with Parkinson’s disease, according to a new pilot study.

When presented with a computerized test in which study participants with Parkinson’s disease had to press buttons corresponding to patterns appearing on a screen, those who had been taking Rock Steady Boxing classes for at least 6 months demonstrated faster reaction time than did those who had never taken the classes, according to Christopher K. McLeod, a second-year medical student at the New York Institute of Technology College of Osteopathic Medicine in Old Westbury, N.Y. Mr. McLeod, who worked with Adena Leder, DO, director of the Parkinson’s Disease Treatment Center at the college, will present his research findings Oct. 20 at the International Conference on Parkinson’s Disease and Movement Disorders in New York.

While the results were not statistically significant, and the number of participants (n = 28) was relatively small, said Mr. McLeod, “We think this is a good pilot study for research going forward, since there really isn’t anything in the literature right now about how procedural memory and learning could be addressed from a therapeutic standpoint in Parkinson’s disease patients.” Procedural learning is a means of acquiring a new skill through repeating the task, like learning to drive a stick shift by doing it.

The investigators used a serial reaction time test to assess procedural memory in 14 patients diagnosed with Parkinson’s disease who had been regularly attending Rock Steady Boxing classes and in 14 patients who did not go to the classes. The test featured a computer screen with four squares that would light up and a box with four corresponding buttons to push as each square lit up. There were seven time blocks in which patients were presented with a series of 10 stimuli. The first pattern was random to get participants accustomed to the task. The second, third, fourth, and fifth blocks had the same sequence, to assess participants’ ability to learn the pattern and respond more quickly. The sixth block again had a random pattern to see if participants slowed down to learn the new pattern, and the seventh block repeated the familiar sequence from the second to fifth blocks.

Experienced boxers generally demonstrated faster reaction time than did nonboxers, the researchers found. Statistical analysis of the four learning blocks (blocks 2-5) revealed a moderate effect (P = .19), indicating that experienced boxers tended to react faster than nonboxers.

Diminished reaction time is a hallmark symptom of Parkinson’s disease, often resulting in patients having to give up the ability drive as the disease progresses, Mr. McLeod said: “Reaction time is something that could eventually lead to falling or not being able to drive, which are huge lifestyle changes that affect these patients emotionally and impact their quality of life.”

The researchers also observed a visible difference in how the two groups tended to respond to the random sequence following the repetitive blocks. Experienced boxers slowed slightly, with a 27.3-ms increase in reaction time, while nonboxers got faster, with a 93.5-ms decrease in reaction time. One possible explanation is that nonboxers simply got better at reacting to the stimuli over time without actually learning the repeated sequence, Mr. McLeod said.

Rock Steady Boxing was founded in Indianapolis by Scott Newman, a former county prosecutor who was diagnosed with Parkinson’s disease at age 40 and experienced significant improvement in his health and agility by engaging in rigorous workouts, such as boxing. Dr. Leder became certified in Rock Steady Boxing and opened a chapter at the New York college in May 2016. The classes include group activities, games, and boxing exercises designed to improve patients’ physical and mental stamina.

Mr. McLeod and Dr. Leder reported no relevant financial disclosures.

Sensory receptor stimulation therapy can help certain patients with Parkinson’s disease improve posture and gait issues, according to Ben Weinstock, DPT, who specializes in physical therapy for patients with movement disorders.

Dr. Weinstock will present an update on several physical therapy modalities that can be useful for patients with Parkinson’s disease on Oct. 19 at the International Conference on Parkinson’s Disease and Movement Disorders in New York.

“Up to 70% of people with Parkinson’s disease are exercise intolerant,” Dr. Weinstock said in an interview. “As such, we must provide interventions that can keep them moving and avoid sedentary behavior.”

Manual stimulation of points on the foot can improve freezing of gait as well as normalize stride length, according to research published by Italian investigators in 2015 (Int J Rehabil Res. 2015 Sep. doi: 10.1097/MRR.0000000000000120) while electrical stimulation of acupuncture points on the ear and body assisted with motor and nonmotor Parkinson’s symptoms, based on a 2017 study (Front Hum Neurosci. 2017. doi: 10.3389/fnhum.2017.00338).

Advances in manual pressure therapy as well as using Kinesio taping to improve posture also will be addressed by Dr. Weinstock, who is in private practice in New York.

dfulton@mdege.com

Sensory receptor stimulation therapy can help certain patients with Parkinson’s disease improve posture and gait issues, according to Ben Weinstock, DPT, who specializes in physical therapy for patients with movement disorders.

Dr. Weinstock will present an update on several physical therapy modalities that can be useful for patients with Parkinson’s disease on Oct. 19 at the International Conference on Parkinson’s Disease and Movement Disorders in New York.

“Up to 70% of people with Parkinson’s disease are exercise intolerant,” Dr. Weinstock said in an interview. “As such, we must provide interventions that can keep them moving and avoid sedentary behavior.”

Manual stimulation of points on the foot can improve freezing of gait as well as normalize stride length, according to research published by Italian investigators in 2015 (Int J Rehabil Res. 2015 Sep. doi: 10.1097/MRR.0000000000000120) while electrical stimulation of acupuncture points on the ear and body assisted with motor and nonmotor Parkinson’s symptoms, based on a 2017 study (Front Hum Neurosci. 2017. doi: 10.3389/fnhum.2017.00338).

Advances in manual pressure therapy as well as using Kinesio taping to improve posture also will be addressed by Dr. Weinstock, who is in private practice in New York.

dfulton@mdege.com

Sensory receptor stimulation therapy can help certain patients with Parkinson’s disease improve posture and gait issues, according to Ben Weinstock, DPT, who specializes in physical therapy for patients with movement disorders.

Dr. Weinstock will present an update on several physical therapy modalities that can be useful for patients with Parkinson’s disease on Oct. 19 at the International Conference on Parkinson’s Disease and Movement Disorders in New York.

“Up to 70% of people with Parkinson’s disease are exercise intolerant,” Dr. Weinstock said in an interview. “As such, we must provide interventions that can keep them moving and avoid sedentary behavior.”

Manual stimulation of points on the foot can improve freezing of gait as well as normalize stride length, according to research published by Italian investigators in 2015 (Int J Rehabil Res. 2015 Sep. doi: 10.1097/MRR.0000000000000120) while electrical stimulation of acupuncture points on the ear and body assisted with motor and nonmotor Parkinson’s symptoms, based on a 2017 study (Front Hum Neurosci. 2017. doi: 10.3389/fnhum.2017.00338).

Advances in manual pressure therapy as well as using Kinesio taping to improve posture also will be addressed by Dr. Weinstock, who is in private practice in New York.

dfulton@mdege.com

The development of a 3-D brain organoid that contains all six of the major cell types found in adult human brain cortex will be the featured topic of a presentation at the Young Research Forum of the International Conference on Parkinson’s Disease and Movement Disorders in New York on Oct. 20.

Goodwell Nzou, a doctoral student at Wake Forest University, Winston-Salem, N.C., will give the presentation, titled “The development of a multicellular three dimensional neurovascular unit model with a functional blood-brain barrier” at 1:45 p.m.

In the study that Mr. Nzou and his colleagues at the Wake Forest Institute for Regenerative Medicine published in May in Scientific Reports, they noted that, in addition to the model’s use of all six of the major cell types found in adult human brain cortex (human brain microvascular endothelial cells, pericytes, astrocytes, microglia, oligodendrocytes, and neurons), they found that it also promotes the formation of a blood-brain barrier that mimics normal human anatomy.

The researchers said their 3-D in vitro system could have potential applications in drug discovery, toxicity screening, and disease modeling for neurologic diseases such as Alzheimer’s disease, multiple sclerosis, and amyotrophic lateral sclerosis. They demonstrated the model’s use in toxicity assessment studies for molecules that have the potential to cross or open the blood-brain barrier and also reported establishing a model of the blood-brain barrier during clinical ischemia “showing physiologic responses under hypoxic conditions.”

jevans@mdedge.com

The development of a 3-D brain organoid that contains all six of the major cell types found in adult human brain cortex will be the featured topic of a presentation at the Young Research Forum of the International Conference on Parkinson’s Disease and Movement Disorders in New York on Oct. 20.

Goodwell Nzou, a doctoral student at Wake Forest University, Winston-Salem, N.C., will give the presentation, titled “The development of a multicellular three dimensional neurovascular unit model with a functional blood-brain barrier” at 1:45 p.m.

In the study that Mr. Nzou and his colleagues at the Wake Forest Institute for Regenerative Medicine published in May in Scientific Reports, they noted that, in addition to the model’s use of all six of the major cell types found in adult human brain cortex (human brain microvascular endothelial cells, pericytes, astrocytes, microglia, oligodendrocytes, and neurons), they found that it also promotes the formation of a blood-brain barrier that mimics normal human anatomy.

The researchers said their 3-D in vitro system could have potential applications in drug discovery, toxicity screening, and disease modeling for neurologic diseases such as Alzheimer’s disease, multiple sclerosis, and amyotrophic lateral sclerosis. They demonstrated the model’s use in toxicity assessment studies for molecules that have the potential to cross or open the blood-brain barrier and also reported establishing a model of the blood-brain barrier during clinical ischemia “showing physiologic responses under hypoxic conditions.”

jevans@mdedge.com

The development of a 3-D brain organoid that contains all six of the major cell types found in adult human brain cortex will be the featured topic of a presentation at the Young Research Forum of the International Conference on Parkinson’s Disease and Movement Disorders in New York on Oct. 20.

Goodwell Nzou, a doctoral student at Wake Forest University, Winston-Salem, N.C., will give the presentation, titled “The development of a multicellular three dimensional neurovascular unit model with a functional blood-brain barrier” at 1:45 p.m.

In the study that Mr. Nzou and his colleagues at the Wake Forest Institute for Regenerative Medicine published in May in Scientific Reports, they noted that, in addition to the model’s use of all six of the major cell types found in adult human brain cortex (human brain microvascular endothelial cells, pericytes, astrocytes, microglia, oligodendrocytes, and neurons), they found that it also promotes the formation of a blood-brain barrier that mimics normal human anatomy.

The researchers said their 3-D in vitro system could have potential applications in drug discovery, toxicity screening, and disease modeling for neurologic diseases such as Alzheimer’s disease, multiple sclerosis, and amyotrophic lateral sclerosis. They demonstrated the model’s use in toxicity assessment studies for molecules that have the potential to cross or open the blood-brain barrier and also reported establishing a model of the blood-brain barrier during clinical ischemia “showing physiologic responses under hypoxic conditions.”

jevans@mdedge.com