Utility of the Japanese version of the 9-item Wearing-off Questionnaire

Impact of non-motor fluctuations on QOL in patients with Parkinson's disease

Introduction

Long-term levodopa treatment in patients with Parkinson's disease (PwPD) often causes motor fluctuations, which are known to affect their quality of life (QOL). These motor fluctuations may be accompanied by fluctuations in non-motor symptoms. There is no consensus on how non-motor fluctuations affect QOL.

Methods

This was a single-center, retrospective study and included 375 patients with Parkinson's disease (PwPD) who visited the neurology outpatient department of Fukuoka University Hospital between July 2015 and June 2018. All patients were evaluated for age, sex, disease duration, body weight, and motor symptoms by the Movement Disorder Society-Unified Parkinson's Disease Rating Scale part III, depression scale by the Zung self-rating depression scale, apathy scale, and cognitive function by the Japanese version of The Montreal Cognitive Assessment. A nine-item wearing-off questionnaire (WOQ-9) was used to assess the motor and non-motor fluctuations. QOL in PwPD was investigated using the eight-item Parkinson's Disease Questionnaire (PDQ-8).

Results

In total, 375 PwPD were enrolled and classified into three groups according to the presence or absence of motor and non-motor fluctuations. The first group included 98 (26.1%) patients with non-motor fluctuations (NFL group), the second group included 128 (34.1%) patients who presented with only motor fluctuations (MFL group), and the third group included 149 (39.7%) patients without fluctuations in motor or non-motor symptoms (NoFL group). Among them, the PDQ-8 SUM and SI were significantly higher in the NFL group than in the other groups (p < 0.005), implying that the NFL group had the poorest QOL among groups. Next, multivariable analysis showed that even one non-motor fluctuation was an independent factor that worsened QOL (p < 0.001).

Conclusion

This study showed that PwPD with non-motor fluctuation had a lower QOL than those with no or only motor fluctuation. Moreover, the data showed that PDQ-8 scores were significantly reduced even with only one non-motor fluctuation.

Evaluation of Motor Complications in Parkinson's Disease: Understanding the Perception Gap between Patients and Physicians

Background

Patients with Parkinson's disease (PD) receiving levodopa treatment often report motor complications including wearing-off (WO), dyskinesia, and morning akinesia. As motor complications are associated with a decrease in patients' quality of life (QoL), it is important to identify their occurrence and commence immediate management. This study investigated whether differences in the perception of motor complications exist between patients and their physicians in routine clinical practice.

Methods

After an Internet-based screening survey, questionnaires were distributed to physicians and their patients in Japan. The 9-item Wearing-Off Questionnaire (WOQ-9) was used to objectively assess the presence of WO; patients with WOQ-9 scores ≥2 were considered to have WO. McNemar's test was used to compare physician assessment versus WOQ-9 scores, patient self-awareness versus physician assessment, and patient self-awareness versus WOQ-9, separately. Morning akinesia and dyskinesia were assessed by both physician assessment and patient self-awareness with McNemar's test. QoL was assessed using the 8-item Parkinson's Disease Questionnaire (PDQ-8) with the Wilcoxon rank-sum test.

Results

A total of 235 patients with PD and their 92 physicians participated in this survey. A significant discordance was observed between the WOQ-9 and physician assessment of WO (67.2% vs 46.0%; p < 0.0001). Furthermore, patient self-awareness of WO was 35.3% (p = 0.0004, vs physician). Morning akinesia (patient, 58.7%; physician, 48.9%; p = 0.0032), dyskinesia (patient, 34.0%; physician, 23.4%; p = 0.0006), and bodily discomfort (patient, 25.0; physician, 0.0; p = 0.0102) of QoL were underrecognized by physicians.

Conclusions

This study investigated differences in the perception of WO between patients with PD and their physicians in routine clinical practice and highlighted that patients have a low awareness of the symptoms of WO compared with physician assessments and WOQ-9. Conversely, morning akinesia, dyskinesia, and bodily discomfort were underrecognized by physicians.

The Efficacy of Tai Chi and Stretching Exercises Based on a Smartphone Application for Patients With Parkinson's Disease: A Protocol for a Randomized Controlled Trial

Introduction: Parkinson's disease (PD) is a common neurodegenerative disease that seriously impairs patients' quality of life, and increases the burden of patients and caregivers. Both drugs and exercise can alleviate its motor and non-motor symptoms, improving the quality of life for PD patients. Telehealth, an increasingly popular tool, makes rehabilitation accessible at home, overcoming the inconvenience of traffic and scheduling. Care-PD is a phone application designed for rehabilitation training, which provides Tai Chi and stretching exercises through tutorial videos as well as an online evaluation system. In this protocol, we will explore the efficacy of Tai Chi and stretching exercises as a PD rehabilitation therapy based on the smartphone application Care-PD.

Methods and Analysis: A double-blind, parallel randomized controlled trial will be conducted in this study. The recruitment, intervention, and evaluation processes will be implemented through the Care-PD application. Persons with PD will fill out questionnaires on Activities of Daily Living (ADL), upload the latest case report, and sign the informed consent form in the application. Afterward, doctors and researchers will screen and enroll 180 participants who will be randomly (1:1:1) assigned to Tai Chi group, stretching exercises group, or control group. The subjects will participate in a 1-h exercise session three times per week for 12 weeks, ending with another 4 weeks of follow-up study. Each exercise session includes 10 min of warm-up, 45 min of exercise, and 5 min of cool-down. The primary outcomes are Motor Aspects of Experiences of Daily Living and the 39-item Parkinson's disease Questionnaire. The secondary outcomes include the 9-item Wearing-Off Questionnaire, the Freezing of Gait Questionnaire, the Caregiver Strain Index, Non-motor Experiences of Daily Living, ADL, and Morse Fall Scale. All assessments will be performed at baseline, week 12 and 16.

Discussion: Care-PD integrates subject recruitment, intervention, and evaluation, providing a new perspective on clinical rehabilitation for persons with PD. This study will evaluate the efficacy of Tai Chi and stretching exercises on patients' quality of life and disease progression based on a smartphone application. We aim to provide a new rehabilitation training platform for persons with PD.

Ethics and Dissemination: This study was approved by the Scientific Research Ethics Committee (102772020RT132) of Shanghai University of Sport. Data collection begins after the approval of the ethics committee. The participants must sign an informed consent form before enrollment. The results will be published in relevant journals, seminars, and be disseminated among rehabilitation practitioners and patients with PD.

Clinical Trial Registration: Chinese Clinical Trial Registry, identifier [ChiCTR2100042096]. Registered on January 13, 2021.

Fluctuating pain in Parkinson's disease: Its prevalence and impact on quality of life

Pain is a common non-motor symptom in Parkinson's disease (PD) patients, and the incidence of fluctuating pain may be improved by taking levodopa. There are only a few detailed reports regarding fluctuating pain. In this study, 331 PD patients were classified into three groups: no-pain group (67.4%), non-fluctuating pain group (22.1%), and fluctuating pain group (10.6%). We evaluated patients' background and its impact on the quality of life (QOL) of each group. The pain group exhibited higher levels of depression (p < 0.0001), had a higher frequency of visual hallucinations (p = 0.007), and lower QOL (p < 0.0001) compared with the no-pain group. The fluctuating pain group had a younger onset (p = 0.006), higher Hoehn & Yahr stage (p = 0.018), and higher frequency of wearing-off (p < 0.001) and dyskinesia (p = 0.007) than the other groups. We compared the Parkinson's Disease Questionnaire-8 summary index (PDQ-8 SI) in each pain group to the no-pain group using analysis of variance. As a result, PDQ-8 SI was significantly higher in both the non-fluctuating and fluctuating pain groups (p < 0.0001). Pain is regarded as a non-negligible symptom that affects the QOL of PD patients, and given the unique characteristics, fluctuating pain might be considered as an independent clinical subtype of PD.

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Clinical characteristics of fluctuating pain in Parkinson's disease

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The prevalence of pain in PD was 10.6%, of which 32.4% showed fluctuating pain.

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Fluctuating pain is related to younger age of onset and severity of disease.

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Pain affects the quality of life of patients with Parkinson's disease.

Impact of motor and nonmotor symptoms in Parkinson disease for the quality of life: The Japanese Quality-of-Life Survey of Parkinson Disease (JAQPAD) study

INTRODUCTION

Parkinson's disease (PD) is characterized by a range of classic motor symptoms and heterogeneous nonmotor symptoms that affect patients' quality of life (QoL). Studies have individually reported the effect of either motor or nonmotor symptoms on patients' QoL; however, a thorough assessment of the symptoms that have the greatest influence on QoL is limited. This JAQPAD study examined the effect of both motor and nonmotor symptoms and patient demographics on QoL in a large population of patients with PD in Japan.

METHODS

All members of the Japan Parkinson's Disease Association were invited to participate in the study. Questionnaires assessing wearing-off symptoms (the 9-item Wearing-Off Questionnaire [WOQ-9]), nonmotor symptoms (Non-Motor Symptoms Questionnaire [NMSQ]) and QoL (the 8-item Parkinson's Disease Questionnaire [PDQ-8]) were included. Multiple regression analyses assessed the effect of clinical factors on the PDQ-8 Summary Index (PDQ-8 SI). Spearman rank correlation coefficient (r) estimated the correlation between each subdomain score of nine NMSQ domains and the PDQ-8 SI.

RESULTS

A total of 3022 patients were included in the analysis. The PDQ-8 SI score correlated with off-time, age, duration of PD, work status, and the NMSQ total score and subdomain scores. Memory problems correlated most strongly with the PDQ-8 SI score (r = 0.4419), followed by mood (r = 0.4387) and digestive problems (r = 0.4341; p < 0.0001).

CONCLUSIONS

Physicians tend to focus on motor symptoms, while nonmotor symptoms often go under-recognized in clinical practice. This JAQPAD study highlights the importance of recognition and management of both motor and nonmotor symptoms, which together significantly affect patient QoL.

The Risk Factors for the Wearing-Off Phenomenon in Parkinson's Disease

Introduction: First-line treatment of Parkinson's disease (PD) includes a dopamine analog, levodopa, administered in combination with carbidopa to increase efficacy. Wearing-off (WO) phenomenon is a frequent complication which is defined as a reoccurrence of motor and non-motor symptoms during levodopa free interval, which has a negative impact on the quality of life of patients. Through this study, we aim to determine risk factors that lead to the manifestation of the WO phenomenon among patients presenting in our out-patient department of a tertiary care hospital in Pakistan.

Method: A observational case-control study was conducted from April 2019 to December 2019 in a tertiary care hospital in Pakistan. A total of 101 patients who had PD were included in the study. They were randomized into two groups i.e. patients who had WO phenomenon (59 participants) and patients who did not experience WO (42 participants) phenomena. Patients were evaluated based on a self-administrated questionnaire. A p-value of less than 0.05 was considered significant.

Result: WO was significantly higher in those patients who had earlier onset of Parkinson (59 ± 10 vs. 65 ±8; p<0.002) and had the disease for a longer duration (7.9±5.1 vs. 5.6±3.1, p<0.002). Other findings included, there was more risk of WO in patients on anti-parkinsonian treatment for longer duration (7.2±5.1 vs. 3.9±3.5, p<0.010) and on longer duration on levodopa treatment (6.9±4.9 vs. 3.1±2.8, p<0.0001).

Conclusion: Our study demonstrated several factors which are responsible for the WO phenomenon. This will aid neurologists to consider these risk factors while prescribing different treatment modalities for the disease to improve efficacy and mitigate WO effect among patients, specifically while advising levodopa.

Enhancement of ATP production ameliorates motor and cognitive impairments in a mouse model of MPTP-induced Parkinson's disease

Approximately 30-40% of patients with Parkinson's disease (PD) exhibit cognitive impairments. However, there are currently no clinically effective drugs for the treatment of cognitive impairment in patients with PD. Previous studies have suggested that mitochondrial dysfunction such as decreased adenosine triphosphate (ATP) production triggers dopaminergic neurodegeneration in patients with PD and that mitochondria represent a potential target for the development of novel treatments for preventing PD. Therefore, in the present study, we investigated the cognition-enhancing effects of ethyl pyruvate (EP) and 1-(3,4-dimethoxyphenethyl)-4-(3-phenylpropyl) piperazine dihydrochloride (SA4503) in mice with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced Parkinsonism. PD model mice were generated via treatment with MPTP (25 mg/kg, i.p.) once a day for 5 consecutive days. Twenty-four hours after the final injection of MPTP, mice were intraperitoneally injected with EP (25, 50, 100 mg/kg) or SA4503 (1 mg/kg) once a day for 4 weeks. Chronic administration of EP (100 mg/kg i.p.) or SA4503 (1 mg/kg, i.p.) improved both motor deficits and cognitive impairments in MPTP-treated mice. Furthermore, treatment with EP or SA4503 attenuated decreases in the levels of ATP and tyrosine hydroxylase (TH) in the substantia nigra pars compacta (SNpc)/ventral tegmental area (VTA), striatum, and hippocampal CA1 region. Administration of EP or SA4503 protected the dopaminergic neurons from MPTP-induce toxicity and restored the dopamine levels in the striatum. Elevated 4-hydroxy-2-nonenal- (4-HNE-) and nitrotyrosine-reactive protein levels induced by MPTP-treatment were suppressed by EP or SA4503 treatment in the SNpc-VTA, striatum, and hippocampal CA1 region. These observations suggest that EP and SA4503 attenuate cognitive impairments and motor dysfunction in mice with MPTP-induced PD.

Clinimetrics of the 9- and 19-Item Wearing-Off Questionnaire: A Systematic Review

The treatment of Parkinson's disease (PD) with dopaminergic therapy improves functionality and quality of life. However, as the disease progresses, the wearing-off phenomenon develops, which necessitates complex posology adjustment or adjuvant therapy. This phenomenon may not be well recognized, especially if it is mild or involves nonmotor symptoms. Questionnaires were developed to improve the recognition of the wearing-off phenomenon. The questionnaires consist of a list of symptoms that patients must check if they have and if the symptoms improve with medication. A recent review by the Movement Disorder Society suggested the 19-item (WOQ-19) and 9-item (WOQ-9) questionnaires as screening tools for the wearing-off phenomenon. However, there has not been a systematic review to assess the questionnaires' clinimetric properties, such as sensitivity, specificity, test-retest reliability, and responsiveness. We conducted an extensive search for studies using these two tools. We identified 3 studies using WOQ-19 and 5 studies using WOQ-9. Both questionnaires seem to have good sensitivity (0.81–1). WOQ-19 has variable specificity (0.39–0.8), depending on the number of positive items, while WOQ-9 lacks specificity (0.1–0.69). Only one study using WOQ-19 reported test-retest, and only two studies reported responsiveness. Thus, this report describes the first independent systematic review to exam quantitatively the clinimetric properties of these two questionnaires.

The Risk Factors for the Wearing-off Phenomenon in Parkinson's Disease in Japan: A Cross-sectional, Multicenter Study

Objective Parkinson's disease (PD) is a common, progressive, neurodegenerative disorder. With progression of PD, the wearing-off phenomenon occurs more frequently as a motor complication, decreasing the patient's quality of life. The aim of this study was to investigate the risk factors for the wearing-off phenomenon in Japanese PD patients. Methods All of the study participants were clinically diagnosed as having PD. Each patient was assessed for the wearing-off phenomenon based on the findings of clinical assessments and interviews that were conducted during a single visit. The risk factors for wearing-off were analyzed by univariate and multivariate logistic regression analyses. Results Wearing-off was observed in 101 of the 180 (56.1%) patients who were enrolled in this study. The multivariate logistic regression analysis revealed that the onset of PD at ≥69 years of age (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.05-0.88; p=0.032), female sex (OR, 6.49; 95% CI, 2.34-17.99; p<0.001), catechol-O-methyltransferase (COMT) inhibitor treatment (OR, 19.59; 95% CI, 3.55-108.11; p<0.001) and a high daily levodopa dosage (≥600 mg/day) (OR, 7.69; 95% CI, 1.41-41.84; p=0.018) were independent predictive factors for wearing-off in Japanese PD patients. Conclusion Age at the symptomatic disease onset, female sex, COMT inhibitor treatment, and a high daily levodopa dose were associated with the occurrence of wearing-off in Japanese PD patients. Physicians need to consider the risk factors and carefully choose medications for PD patients to postpone the occurrence of this phenomenon for as long as possible.