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Ohara M, Hirata K, Matsubayashi T, Chen Q, Shimano K, Hanazawa R, Hirakawa A, Yokota T, Hattori T. Circular walking is useful for assessing the risk of falls in early progressive supranuclear palsy. J Neurol 2024; 271:6349-6358. [PMID: 39009736 DOI: 10.1007/s00415-024-12551-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Progressive supranuclear palsy (PSP) is characterized by early onset postural instability and frequent falls. Circular walking necessitates dynamic postural control, which is impaired in patients with PSP. We aimed to explore gait parameters associated with the risk of falls in patients with PSP, focusing on circular walking. METHODS Sixteen drug-naïve patients with PSP, 22 drug-naïve patients with Parkinson's disease (PD), and 23 healthy controls were enrolled. Stride lengths/velocities and their coefficients of variation (CV) during straight and circular walking (walking around a circle of 1-m diameter) were measured under single-task and cognitive dual-task conditions. Correlation analysis was performed between gait parameters and postural instability and gait difficulty (PIGD) motor subscores, representing the risk of falls. RESULTS Patients with PSP had significantly higher CVs of stride lengths/velocities during circular walking than those during straight walking, and the extent of exacerbation of CVs in patients with PSP was larger than that in patients with PD under single-task conditions. Stride lengths/velocities and their CVs were significantly correlated with PIGD motor subscores in patients with PSP only during single-task circular walking. In addition, patients with PSP showed progressive decrements of stride lengths/velocities over steps only during single-task circular walking. CONCLUSIONS Worse gait parameters during circular walking are associated with an increased risk of falls in patients with PSP. Circular walking is a challenging task to demand the compromised motor functions of patients with PSP, unmasking impaired postural control and manifesting sequence effect. Assessing circular walking is useful for evaluating the risk of falls in patients with early PSP.
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Affiliation(s)
- Masahiro Ohara
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kosei Hirata
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Taiki Matsubayashi
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Qingmeng Chen
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kaoru Shimano
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Ryoichi Hanazawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takanori Yokota
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Takaaki Hattori
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
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Quattrone A, Sarica A, Buonocore J, Morelli M, Bianco MG, Calomino C, Aracri F, De Maria M, Vescio B, Vaccaro MG, Quattrone A. Differentiating between common PSP phenotypes using structural MRI: a machine learning study. J Neurol 2023; 270:5502-5515. [PMID: 37507502 PMCID: PMC10576703 DOI: 10.1007/s00415-023-11892-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Differentiating Progressive supranuclear palsy-Richardson's syndrome (PSP-RS) from PSP-Parkinsonism (PSP-P) may be extremely challenging. In this study, we aimed to distinguish these two PSP phenotypes using MRI structural data. METHODS Sixty-two PSP-RS, 40 PSP-P patients and 33 control subjects were enrolled. All patients underwent brain 3 T-MRI; cortical thickness and cortical/subcortical volumes were extracted using Freesurfer on T1-weighted images. We calculated the automated MR Parkinsonism Index (MRPI) and its second version including also the third ventricle width (MRPI 2.0) and tested their classification performance. We also employed a Machine learning (ML) classification approach using two decision tree-based algorithms (eXtreme Gradient Boosting [XGBoost] and Random Forest) with different combinations of structural MRI data in differentiating between PSP phenotypes. RESULTS MRPI and MRPI 2.0 had AUC of 0.88 and 0.81, respectively, in differentiating PSP-RS from PSP-P. ML models demonstrated that the combination of MRPI and volumetric/thickness data was more powerful than each feature alone. The two ML algorithms showed comparable results, and the best ML model in differentiating between PSP phenotypes used XGBoost with a combination of MRPI, cortical thickness and subcortical volumes (AUC 0.93 ± 0.04). Similar performance (AUC 0.93 ± 0.06) was also obtained in a sub-cohort of 59 early PSP patients. CONCLUSION The combined use of MRPI and volumetric/thickness data was more accurate than each MRI feature alone in differentiating between PSP-RS and PSP-P. Our study supports the use of structural MRI to improve the early differential diagnosis between common PSP phenotypes, which may be relevant for prognostic implications and patient inclusion in clinical trials.
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Affiliation(s)
- Andrea Quattrone
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Alessia Sarica
- Department of Medical and Surgical Sciences, Neuroscience Research Center, University "Magna Graecia", Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Jolanda Buonocore
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Maurizio Morelli
- Department of Medical and Surgical Sciences, Institute of Neurology, Magna Graecia University, Catanzaro, Italy
| | - Maria Giovanna Bianco
- Department of Medical and Surgical Sciences, Neuroscience Research Center, University "Magna Graecia", Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Camilla Calomino
- Department of Medical and Surgical Sciences, Neuroscience Research Center, University "Magna Graecia", Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Federica Aracri
- Department of Medical and Surgical Sciences, Neuroscience Research Center, University "Magna Graecia", Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Marida De Maria
- Department of Medical and Surgical Sciences, Neuroscience Research Center, University "Magna Graecia", Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | | | - Maria Grazia Vaccaro
- Department of Medical and Surgical Sciences, Neuroscience Research Center, University "Magna Graecia", Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Aldo Quattrone
- Department of Medical and Surgical Sciences, Neuroscience Research Center, University "Magna Graecia", Viale Europa, Germaneto, 88100, Catanzaro, Italy.
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3
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Calomino C, Quattrone A, Sarica A, Bianco MG, Aracri F, De Maria M, Buonocore J, Vaccaro MG, Vescio B, Quattrone A. Neuroimaging correlates of postural instability in Progressive Supranuclear Palsy. Parkinsonism Relat Disord 2023; 113:105768. [PMID: 37480615 DOI: 10.1016/j.parkreldis.2023.105768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/06/2023] [Accepted: 07/16/2023] [Indexed: 07/24/2023]
Abstract
OBJECTIVE We aimed to identify the brain structures associated with postural instability (PI) in Progressive Supranuclear Palsy (PSP). METHODS Forty-seven PSP patients and 45 control subjects were enrolled in this study. PI was assessed using the items 27 and 28 of the PSP rating scale (postural instability score, PIS). PSP patients were compared with controls using voxel-based morphometry (VBM). In PSP patients, LASSO regression model was used to investigate associations between VBM-based Region-Of-Interest grey matter (GM) volumes and different categories of the PSP rating scale. A whole-brain multi-regression analysis was also used to identify brain areas where GM volumes correlated with the PIS in PSP patients. RESULTS VBM analysis showed widespread GM atrophy (fronto-temporal-parietal-occipital regions, limbic lobes, insula, cerebellum, and basal ganglia) in PSP patients compared with control subjects. In PSP patients, LASSO regression analysis showed associations of the right cerebellar lobules IV-V with ocular motor category score, and the left Rolandic area with bulbar category score, while the right inferior frontal gyrus (IFG) was negatively correlated with the PIS. The whole-brain multi-regression analysis identified the right IFG as the only area significantly associated with the PIS. CONCLUSIONS In our study, two different approaches demonstrated that the IFG volume was associated with PIS in PSP patients, suggesting that this area may play a role in the pathophysiological mechanisms underlying PI. Our findings may have important implications for developing optimal Transcranial Magnetic Stimulation protocols targeting IFG in parkinsonism with postural disorders.
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Affiliation(s)
- Camilla Calomino
- Neuroscience Research Center, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Andrea Quattrone
- Institute of Neurology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Alessia Sarica
- Neuroscience Research Center, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Maria Giovanna Bianco
- Neuroscience Research Center, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Federica Aracri
- Neuroscience Research Center, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Marida De Maria
- Neuroscience Research Center, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Jolanda Buonocore
- Institute of Neurology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Maria Grazia Vaccaro
- Neuroscience Research Center, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | | | - Aldo Quattrone
- Neuroscience Research Center, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.
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Zhu Y, Auer F, Gelnaw H, Davis SN, Hamling KR, May CE, Ahamed H, Ringstad N, Nagel KI, Schoppik D. SAMPL is a high-throughput solution to study unconstrained vertical behavior in small animals. Cell Rep 2023; 42:112573. [PMID: 37267107 PMCID: PMC10592459 DOI: 10.1016/j.celrep.2023.112573] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/27/2023] [Accepted: 05/11/2023] [Indexed: 06/04/2023] Open
Abstract
Balance and movement are impaired in many neurological disorders. Recent advances in behavioral monitoring provide unprecedented access to posture and locomotor kinematics but without the throughput and scalability necessary to screen candidate genes/potential therapeutics. Here, we present a scalable apparatus to measure posture and locomotion (SAMPL). SAMPL includes extensible hardware and open-source software with real-time processing and can acquire data from D. melanogaster, C. elegans, and D. rerio as they move vertically. Using SAMPL, we define how zebrafish balance as they navigate vertically and discover small but systematic variations among kinematic parameters between genetic backgrounds. We demonstrate SAMPL's ability to resolve differences in posture and navigation as a function of effect size and data gathered, providing key data for screens. SAMPL is therefore both a tool to model balance and locomotor disorders and an exemplar of how to scale apparatus to support screens.
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Affiliation(s)
- Yunlu Zhu
- Department of Otolaryngology, New York University Grossman School of Medicine, New York, NY 10016, USA; The Neuroscience Institute, New York University Grossman School of Medicine, New York, NY 10016, USA; Department of Neuroscience & Physiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Franziska Auer
- Department of Otolaryngology, New York University Grossman School of Medicine, New York, NY 10016, USA; The Neuroscience Institute, New York University Grossman School of Medicine, New York, NY 10016, USA; Department of Neuroscience & Physiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Hannah Gelnaw
- Department of Otolaryngology, New York University Grossman School of Medicine, New York, NY 10016, USA; The Neuroscience Institute, New York University Grossman School of Medicine, New York, NY 10016, USA; Department of Neuroscience & Physiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Samantha N Davis
- Department of Otolaryngology, New York University Grossman School of Medicine, New York, NY 10016, USA; The Neuroscience Institute, New York University Grossman School of Medicine, New York, NY 10016, USA; Department of Neuroscience & Physiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Kyla R Hamling
- Department of Otolaryngology, New York University Grossman School of Medicine, New York, NY 10016, USA; The Neuroscience Institute, New York University Grossman School of Medicine, New York, NY 10016, USA; Department of Neuroscience & Physiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Christina E May
- The Neuroscience Institute, New York University Grossman School of Medicine, New York, NY 10016, USA; Department of Neuroscience & Physiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Hassan Ahamed
- Department of Cell Biology, Skirball Institute of Biomolecular Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Niels Ringstad
- Department of Cell Biology, Skirball Institute of Biomolecular Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Katherine I Nagel
- The Neuroscience Institute, New York University Grossman School of Medicine, New York, NY 10016, USA; Department of Neuroscience & Physiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - David Schoppik
- Department of Otolaryngology, New York University Grossman School of Medicine, New York, NY 10016, USA; The Neuroscience Institute, New York University Grossman School of Medicine, New York, NY 10016, USA; Department of Neuroscience & Physiology, New York University Grossman School of Medicine, New York, NY 10016, USA.
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5
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Zhu Y, Auer F, Gelnaw H, Davis SN, Hamling KR, May CE, Ahamed H, Ringstad N, Nagel KI, Schoppik D. Scalable Apparatus to Measure Posture and Locomotion (SAMPL): a high-throughput solution to study unconstrained vertical behavior in small animals. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.07.523102. [PMID: 36712122 PMCID: PMC9881893 DOI: 10.1101/2023.01.07.523102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Balance and movement are impaired in a wide variety of neurological disorders. Recent advances in behavioral monitoring provide unprecedented access to posture and locomotor kinematics, but without the throughput and scalability necessary to screen candidate genes / potential therapeutics. We present a powerful solution: a Scalable Apparatus to Measure Posture and Locomotion (SAMPL). SAMPL includes extensible imaging hardware and low-cost open-source acquisition software with real-time processing. We first demonstrate that SAMPL's hardware and acquisition software can acquire data from from D. melanogaster, C. elegans, and D. rerio as they move vertically. Next, we leverage SAMPL's throughput to rapidly (two weeks) gather a new zebrafish dataset. We use SAMPL's analysis and visualization tools to replicate and extend our current understanding of how zebrafish balance as they navigate through a vertical environment. Next, we discover (1) that key kinematic parameters vary systematically with genetic background, and (2) that such background variation is small relative to the changes that accompany early development. Finally, we simulate SAMPL's ability to resolve differences in posture or vertical navigation as a function of affect size and data gathered -- key data for screens. Taken together, our apparatus, data, and analysis provide a powerful solution for labs using small animals to investigate balance and locomotor disorders at scale. More broadly, SAMPL is both an adaptable resource for labs looking process videographic measures of behavior in real-time, and an exemplar of how to scale hardware to enable the throughput necessary for screening.
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Affiliation(s)
- Yunlu Zhu
- Department. of Otolaryngology, New York University Grossman School of Medicine
- The Neuroscience Institute, New York University Grossman School of Medicine
- Department of Neuroscience & Physiology, New York University Grossman School of Medicine
| | - Franziska Auer
- Department. of Otolaryngology, New York University Grossman School of Medicine
- The Neuroscience Institute, New York University Grossman School of Medicine
- Department of Neuroscience & Physiology, New York University Grossman School of Medicine
| | - Hannah Gelnaw
- Department. of Otolaryngology, New York University Grossman School of Medicine
- The Neuroscience Institute, New York University Grossman School of Medicine
- Department of Neuroscience & Physiology, New York University Grossman School of Medicine
| | - Samantha N. Davis
- Department. of Otolaryngology, New York University Grossman School of Medicine
- The Neuroscience Institute, New York University Grossman School of Medicine
- Department of Neuroscience & Physiology, New York University Grossman School of Medicine
| | - Kyla R. Hamling
- Department. of Otolaryngology, New York University Grossman School of Medicine
- The Neuroscience Institute, New York University Grossman School of Medicine
- Department of Neuroscience & Physiology, New York University Grossman School of Medicine
| | - Christina E. May
- The Neuroscience Institute, New York University Grossman School of Medicine
- Department of Neuroscience & Physiology, New York University Grossman School of Medicine
| | - Hassan Ahamed
- Department of Cell Biology, Skirball Institute of Biomolecular Medicine, New York University Grossman School of Medicine
| | - Niels Ringstad
- Department of Cell Biology, Skirball Institute of Biomolecular Medicine, New York University Grossman School of Medicine
| | - Katherine I. Nagel
- The Neuroscience Institute, New York University Grossman School of Medicine
- Department of Neuroscience & Physiology, New York University Grossman School of Medicine
| | - David Schoppik
- Department. of Otolaryngology, New York University Grossman School of Medicine
- The Neuroscience Institute, New York University Grossman School of Medicine
- Department of Neuroscience & Physiology, New York University Grossman School of Medicine
- Lead Contact
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6
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Sotirakis C, Conway N, Su Z, Villarroel M, Tarassenko L, FitzGerald JJ, Antoniades CA. Longitudinal Monitoring of Progressive Supranuclear Palsy using Body-Worn Movement Sensors. Mov Disord 2022; 37:2263-2271. [PMID: 36054142 DOI: 10.1002/mds.29194] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/15/2022] [Accepted: 07/25/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND We have previously shown that wearable technology and machine learning techniques can accurately discriminate between progressive supranuclear palsy (PSP), Parkinson's disease, and healthy controls. To date these techniques have not been applied in longitudinal studies of disease progression in PSP. OBJECTIVES We aimed to establish whether data collected by a body-worn inertial measurement unit (IMU) network could predict clinical rating scale scores in PSP and whether it could be used to track disease progression. METHODS We studied gait and postural stability in 17 participants with PSP over five visits at 3-month intervals. Participants performed a 2-minute walk and an assessment of postural stability by standing for 30 seconds with their eyes closed, while wearing an array of six IMUs. RESULTS Thirty-two gait and posture features were identified, which progressed significantly with time. A simple linear regression model incorporating the three features with the clearest progression pattern was able to detect statistically significant progression 3 months in advance of the clinical scores. A more complex linear regression and a random forest approach did not improve on this. CONCLUSIONS The reduced variability of the models, in comparison to clinical rating scales, allows a significant change in disease status from baseline to be observed at an earlier stage. The current study sheds light on the individual features that are important in tracking disease progression. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Charalampos Sotirakis
- NeuroMetrology Lab, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Niall Conway
- NeuroMetrology Lab, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Zi Su
- NeuroMetrology Lab, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Mauricio Villarroel
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Lionel Tarassenko
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - James J FitzGerald
- NeuroMetrology Lab, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Chrystalina A Antoniades
- NeuroMetrology Lab, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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7
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Olfati N, Shoeibi A, Litvan I. Clinical Spectrum of Tauopathies. Front Neurol 2022; 13:944806. [PMID: 35911892 PMCID: PMC9329580 DOI: 10.3389/fneur.2022.944806] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/20/2022] [Indexed: 11/20/2022] Open
Abstract
Tauopathies are both clinical and pathological heterogeneous disorders characterized by neuronal and/or glial accumulation of misfolded tau protein. It is now well understood that every pathologic tauopathy may present with various clinical phenotypes based on the primary site of involvement and the spread and distribution of the pathology in the nervous system making clinicopathological correlation more and more challenging. The clinical spectrum of tauopathies includes syndromes with a strong association with an underlying primary tauopathy, including Richardson syndrome (RS), corticobasal syndrome (CBS), non-fluent agrammatic primary progressive aphasia (nfaPPA)/apraxia of speech, pure akinesia with gait freezing (PAGF), and behavioral variant frontotemporal dementia (bvFTD), or weak association with an underlying primary tauopathy, including Parkinsonian syndrome, late-onset cerebellar ataxia, primary lateral sclerosis, semantic variant PPA (svPPA), and amnestic syndrome. Here, we discuss clinical syndromes associated with various primary tauopathies and their distinguishing clinical features and new biomarkers becoming available to improve in vivo diagnosis. Although the typical phenotypic clinical presentations lead us to suspect specific underlying pathologies, it is still challenging to differentiate pathology accurately based on clinical findings due to large phenotypic overlaps. Larger pathology-confirmed studies to validate the use of different biomarkers and prospective longitudinal cohorts evaluating detailed clinical, biofluid, and imaging protocols in subjects presenting with heterogenous phenotypes reflecting a variety of suspected underlying pathologies are fundamental for a better understanding of the clinicopathological correlations.
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Affiliation(s)
- Nahid Olfati
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- UC San Diego Department of Neurosciences, Parkinson and Other Movement Disorder Center, San Diego, CA, United States
| | - Ali Shoeibi
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Irene Litvan
- UC San Diego Department of Neurosciences, Parkinson and Other Movement Disorder Center, San Diego, CA, United States
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8
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He J, He X, Ma Y, Yang L, Fang H, Shang S, Xia H, Lian G, Tang H, Wang Q, Wang J, Lin Z, Wen J, Liu Y, Zhai C, Wang W, Jiang X, Xuan J, Liu M, Lu S, Li X, Wang H, Ouyang C, Cao M, Lin A, Zhang B, Wu D, Chen Y, Xiao C. A comprehensive approach to stool donor screening for faecal microbiota transplantation in China. Microb Cell Fact 2021; 20:216. [PMID: 34838016 PMCID: PMC8626716 DOI: 10.1186/s12934-021-01705-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 11/09/2021] [Indexed: 12/31/2022] Open
Abstract
Background Faecal microbiota transplantation (FMT) is an effective therapy for recurrent Clostridium difficile infections and chronic gastrointestional infections. However, the risks of FMT and the selection process of suitable donors remain insufficiently characterized. The eligibility rate for screening, underlying microbial basis, and core ethical issues of stool donors for FMT are yet to be elucidated in China. Results The potential stool donors were screened from December 2017 to December 2019 with the help of an online survey, clinical assessments, and stool and blood testing. Bioinformatics analyses were performed, and the composition and stability of gut microbiota in stool obtained from eligible donors were dynamically observed using metagenomics. Meanwhile, we build a donor microbial evaluation index (DoMEI) for stool donor screening. In the screening process, we also focused on ethical principles and requirements. Of the 2071 participants, 66 donors were selected via the screening process (3.19% success rate). Although there were significant differences in gut microbiota among donors, we found that the changes in the gut microbiota of the same donor were typically more stable than those between donors over time. Conclusions DoMEI provides a potential reference index for regular stool donor re-evaluation. In this retrospective study, we summarised the donor recruitment and screening procedure ensuring the safety and tolerability for FMT in China. Based on the latest advances in this field, we carried out rigorous recommendation and method which can assist stool bank and clinicians to screen eligible stool donor for FMT. Supplementary Information The online version contains supplementary material available at 10.1186/s12934-021-01705-0.
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Affiliation(s)
- Jianquan He
- School of Medicine, Xiamen University, Xiamen, China
| | - Xingxiang He
- Department of Gastroenterology, The First Affiliated Hospital of Clinical Medicine of Guangdong Pharmaceutical University, Guangzhou, China
| | - Yonghui Ma
- School of Medicine, Xiamen University, Xiamen, China
| | - Luxi Yang
- School of Medicine, Xiamen University, Xiamen, China
| | - Haiming Fang
- Department of Gastroenterology and Hepatology, The Second Hospital of Anhui Medical Univerisity, Hefei, China
| | - Shu Shang
- Department of Gastroenterology, The Fifth People's Hospital of Shenyang, Shenyang, China
| | - Huping Xia
- Anorectal Diagnosis and Treatment Center, The General Hospital of Xinjiang Military Region, Wulumuqi, China
| | - Guanghui Lian
- Department of Gastroenterology, Xiangya Hospital, Changsha, China
| | - Hailing Tang
- Department of Gastroenterology, Xi'an Central Hospital, Xi'an, China
| | - Qizhi Wang
- Department of Gastroenterology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Junping Wang
- Department of Gastroenterology, The Affiliated People's Hospital of Shanxi Medical University, Taiyuan, China
| | - Zhihui Lin
- Department of Gastroenterology, Fujian Provincial Hospital, Fuzhou, China
| | - Jianbo Wen
- Department of Gastroenterology, Pingxiang People's Hospital, Pingxiang, China
| | - Yuedong Liu
- Department of Gastroenterology, The Third Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Chunbao Zhai
- Department of Proctology, The Affiliated People's Hospital of Shanxi Medical University, Taiyuan, China
| | - Wen Wang
- Department of Gastroenterology, 900th Hospital of PLA, Fuzhou, China
| | - Xueliang Jiang
- Department of Gastroenterology, The Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Ji Xuan
- Department of Gastroenterology, Jinling Hospital, Nanjing, China
| | - Morong Liu
- Department of Gastroenterology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shiyun Lu
- Department of Gastroenterology, Fujian Provincial Hospital, Fuzhou, China
| | - Xuejun Li
- Department of Gastroenterology, The Second Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Han Wang
- Xiamen Treatgut Biotechnology Co., Ltd., Xiamen, China
| | - Cong Ouyang
- Xiamen Treatgut Biotechnology Co., Ltd., Xiamen, China
| | - Man Cao
- Xiamen Treatgut Biotechnology Co., Ltd., Xiamen, China
| | - Aiqiang Lin
- Xiamen Treatgut Biotechnology Co., Ltd., Xiamen, China
| | | | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ye Chen
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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9
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Ali F, Loushin SR, Botha H, Josephs KA, Whitwell JL, Kaufman K. Laboratory based assessment of gait and balance impairment in patients with progressive supranuclear palsy. J Neurol Sci 2021; 429:118054. [PMID: 34461552 PMCID: PMC8489851 DOI: 10.1016/j.jns.2021.118054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/27/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Gait and balance abnormalities are a significant source of morbidity and mortality in progressive supranuclear palsy (PSP). Gait impairment in PSP is primarily assessed clinically on exam or with the use of rating scales. Three dimensional video based gait and balance analysis performed in a laboratory setting is a highly accurate method of motion analysis (Wren et al., 2020), however limited data is available in patients with PSP. RESEARCH QUESTION In this study we assess the objective features of postural control, kinematics, kinetic and temporal-spatial gait metrics in PSP, using three-dimensional video motion analysis in a laboratory setting compared to normal controls. METHODS Three-dimensional motion was captured using a 10-camera motion capture system, 41 body markers and ground embedded force plates in 16 patients with PSP patients and compared to motorically normal controls. RESULTS Spatiotemporal, kinematic, and kinetic gait measures effectively differentiated patients with PSP from controls. Patients had slower gait velocity, lower cadence, increased double support time and abnormal antero-posterior sway. Joint kinematics and kinetics were reduced and showed less variation among patients with PSP compared to controls which is suggestive of bradykinesia. Objective gait measures of abnormality correlated with clinical disease severity. Postural sway metrics distinguished PSP from controls and captured gait imbalance. SIGNIFICANCE Objective measures of gait and balance abnormalities in patients with PSP provide an outcome measure that can be potentially used for early disease detection, in clinical trials and to validate portable motion capture devices in the future.
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Affiliation(s)
- Farwa Ali
- Department of Neurology, Rochester, MN, United States of America.
| | - Stacy R Loushin
- Department of Orthopedic Surgery, Rochester, MN, United States of America
| | - Hugo Botha
- Department of Neurology, Rochester, MN, United States of America
| | - Keith A Josephs
- Department of Neurology, Rochester, MN, United States of America
| | - Jennifer L Whitwell
- Department of Radiology, Mayo Clinic Rochester, Rochester, MN, United States of America
| | - Kenton Kaufman
- Department of Orthopedic Surgery, Rochester, MN, United States of America
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10
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Sintini I, Kaufman K, Botha H, Martin PR, Loushin SR, Senjem ML, Reid RI, Schwarz CG, Jack CR, Lowe VJ, Josephs KA, Whitwell JL, Ali F. Neuroimaging correlates of gait abnormalities in progressive supranuclear palsy. Neuroimage Clin 2021; 32:102850. [PMID: 34655905 PMCID: PMC8527041 DOI: 10.1016/j.nicl.2021.102850] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/24/2021] [Accepted: 10/02/2021] [Indexed: 11/20/2022]
Abstract
Progressive supranuclear palsy is a neurodegenerative disorder characterized primarily by tau inclusions and neurodegeneration in the midbrain, basal ganglia, thalamus, premotor and frontal cortex. Neurodegenerative change in progressive supranuclear palsy has been assessed using MRI. Degeneration of white matter tracts is evident with diffusion tensor imaging and PET methods have been used to assess brain metabolism or presence of tau protein deposits. Patients with progressive supranuclear palsy present with a variety of clinical syndromes; however early onset of gait impairments and postural instability are common features. In this study we assessed the relationship between multimodal imaging biomarkers (i.e., MRI atrophy, white matter tracts degeneration, flortaucipir-PET uptake) and laboratory-based measures of gait and balance abnormalities in a cohort of nineteen patients with progressive supranuclear palsy, using univariate and multivariate statistical analyses. The PSP rating scale and its gait midline sub-score were strongly correlated to gait abnormalities but not to postural imbalance. Principal component analysis on gait variables identified velocity, stride length, gait stability ratio, length of gait phases and dynamic stability as the main contributors to the first component, which was associated with diffusion tensor imaging measures in the posterior thalamic radiation, external capsule, superior cerebellar peduncle, superior fronto-occipital fasciculus, body and splenium of the corpus callosum and sagittal stratum, with MRI volumes in frontal and precentral regions and with flortaucipir-PET uptake in the precentral gyrus. The main contributor to the second principal component was cadence, which was higher in patients presenting more abnormalities on mean diffusivity: this unexpected finding might be related to compensatory gait strategies adopted in progressive supranuclear palsy. Postural imbalance was the main contributor to the third principal component, which was related to flortaucipir-PET uptake in the left paracentral lobule and supplementary motor area and white matter disruption in the superior cerebellar peduncle, putamen, pontine crossing tract and corticospinal tract. A partial least square model identified flortaucipir-PET uptake in midbrain, basal ganglia and thalamus as the main correlate of speed and dynamic component of gait in progressive supranuclear palsy. Although causality cannot be established in this analysis, our study sheds light on neurodegeneration of brain regions and white matter tracts that underlies gait and balance impairment in progressive supranuclear palsy.
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Affiliation(s)
- Irene Sintini
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA.
| | - Kenton Kaufman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Hugo Botha
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | - Peter R Martin
- Department of Health Science Research, Mayo Clinic, Rochester, MN 55905, USA
| | - Stacy R Loushin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Matthew L Senjem
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; Department of Information Technology, Mayo Clinic, Rochester MN 55905, USA
| | - Robert I Reid
- Department of Information Technology, Mayo Clinic, Rochester MN 55905, USA
| | | | - Clifford R Jack
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Val J Lowe
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Keith A Josephs
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Farwa Ali
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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11
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Morris ME, Slade SC, Bruce C, McGinley JL, Bloem BR. Enablers to Exercise Participation in Progressive Supranuclear Palsy: Health Professional Perspectives. Front Neurol 2021; 11:635341. [PMID: 33633662 PMCID: PMC7902068 DOI: 10.3389/fneur.2020.635341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/21/2020] [Indexed: 11/20/2022] Open
Abstract
Background: People living with progressive supranuclear palsy (PSP) can experience considerable difficulties with movement, walking, balance, and oculomotor control. The role of exercises and physical activities in mitigating the motor and non-motor symptoms of PSP remains uncertain. Aims: The aim of this study was to identify the perspectives and beliefs of health professionals about the benefits, enablers, and barriers to participation in exercise and physical activity across the course of disease progression of PSP. Methods: Qualitative methods, within a phenomenological framework, were used to obtain nursing and allied health professional perspectives and recommendations. Focus group and in-depth interview questions were derived from a systematic review on exercise for PSP. Expert opinions also guided the interviews, which were audio-recorded, transcribed verbatim, and de-identified. Two researchers independently conducted a thematic analysis. Results: Nineteen health professionals participated from the disciplines of nursing, physiotherapy, occupational therapy, and speech pathology. Four main themes emerged: (i) exercise and physical activities are important for living well with PSP; (ii) provision of information about the benefits of exercise and physical activities facilitates uptake; (iii) interdisciplinary teams work together to improve outcomes; and (iv) care partners can assist with the implementation of exercise and physical activities. Conclusion: Health professionals advocated physical therapies for people living with PSP. The expectation is that structured exercises and physical activities can help to optimize health and well-being, enabling people to continue to participate in social roles. The actual merits of such interventions must now be tested in large-scale controlled clinical trials.
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Affiliation(s)
- Meg E. Morris
- La Trobe Centre for Sport and Exercise Medicine Research, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, VIC, Australia
- Healthscope Academic Research Collaborative in Health (ARCH), Victorian Rehabilitation Centre, Glen Waverley, VIC, Australia
| | - Susan C. Slade
- La Trobe Centre for Sport and Exercise Medicine Research, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, VIC, Australia
- Healthscope Academic Research Collaborative in Health (ARCH), Victorian Rehabilitation Centre, Glen Waverley, VIC, Australia
| | - Christopher Bruce
- Discipline of Occupational Therapy, School of Allied Health, Human Services and Sport, Science, Health and Engineering College, La Trobe University, Bundoora, VIC, Australia
| | | | - Bastiaan R. Bloem
- Radboud University Medical Centre, Nijmegen, Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
- Department of Neurology, Centre of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
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12
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VandeVrede L, Ljubenkov PA, Rojas JC, Welch AE, Boxer AL. Four-Repeat Tauopathies: Current Management and Future Treatments. Neurotherapeutics 2020; 17:1563-1581. [PMID: 32676851 PMCID: PMC7851277 DOI: 10.1007/s13311-020-00888-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Four-repeat tauopathies are a neurodegenerative disease characterized by brain parenchymal accumulation of a specific isoform of the protein tau, which gives rise to a wide breadth of clinical syndromes encompassing diverse symptomatology, with the most common syndromes being progressive supranuclear palsy-Richardson's and corticobasal syndrome. Despite the lack of effective disease-modifying therapies, targeted treatment of symptoms can improve quality of life for patients with 4-repeat tauopathies. However, managing these symptoms can be a daunting task, even for those familiar with the diseases, as they span motor, sensory, cognitive, affective, autonomic, and behavioral domains. This review describes current approaches to symptomatic management of common clinical symptoms in 4-repeat tauopathies with a focus on practical patient management, including pharmacologic and nonpharmacologic strategies, and concludes with a discussion of the history and future of disease-modifying therapeutics and clinical trials in this population.
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Affiliation(s)
- Lawren VandeVrede
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, California, USA.
| | - Peter A Ljubenkov
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Julio C Rojas
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Ariane E Welch
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Adam L Boxer
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, California, USA
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13
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Palmisano C, Todisco M, Marotta G, Volkmann J, Pacchetti C, Frigo CA, Pezzoli G, Isaias IU. Gait initiation in progressive supranuclear palsy: brain metabolic correlates. NEUROIMAGE-CLINICAL 2020; 28:102408. [PMID: 33353609 PMCID: PMC7689404 DOI: 10.1016/j.nicl.2020.102408] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/29/2020] [Accepted: 08/30/2020] [Indexed: 02/07/2023]
Abstract
Dysfunctional gait initiation in progressive supranuclear palsy relates to poor feedforward motor control. Hypometabolism of the caudate nucleus impairs programming of anticipatory postural adjustments. Thalamic hypometabolism correlates with the center of mass kinematic resultants of anticipatory postural adjustments.
The initiation of gait is a highly challenging task for the balance control system, and can be used to investigate the neural control of upright posture maintenance during whole-body movement. Gait initiation is a centrally-mediated motion achieved in a principled, controlled manner, including predictive mechanisms (anticipatory postural adjustments, APA) that destabilize the antigravitary postural set of body segments for the execution of functionally-optimized stepping. Progressive supranuclear palsy (PSP) is a neurodegenerative disease characterized by early impairment of balance and frequent falls. The neural correlates of postural imbalance and falls in PSP are largely unknown. We biomechanically assessed the APA at gait initiation (imbalance, unloading, and stepping phases) of 26 patients with PSP and 14 age-matched healthy controls. Fourteen of 26 enrolled patients were able to perform valid gait initiation trials. The influence of anthropometric and base-of-support measurements on the biomechanical outcome variables was assessed and removed. Biomechanical data were correlated with clinical findings and, in 11 patients, with brain metabolic abnormalities measured using positron emission tomography and 2-deoxy-2-[18F]fluoro-D-glucose. Patients with PSP showed impaired modulation of the center of pressure displacement for a proper setting of the center of mass momentum and subsequent efficient stepping. Biomechanical measurements correlated with “Limb motor” and “Gait and midline” subscores of the Progressive Supranuclear Palsy Rating Scale. Decreased regional glucose uptake in the caudate nucleus correlated with impaired APA programming. Hypometabolism of the caudate nucleus, supplementary motor area, cingulate cortex, thalamus, and midbrain was associated with specific biomechanical resultants of APA. Our findings show that postural instability at gait initiation in patients with PSP correlates with deficient APA production, and is associated with multiple and distinctive dysfunctioning of different areas of the supraspinal locomotor network. Objective biomechanical measures can help to understand fall-related pathophysiological mechanisms and to better monitor disease progression and new interventions.
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Affiliation(s)
- Chiara Palmisano
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany; MBMC Lab, Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Massimiliano Todisco
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany; Parkinson's Disease and Movement Disorders Unit, IRCCS Mondino Foundation, Pavia, Italy; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Giorgio Marotta
- Department of Nuclear Medicine, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Jens Volkmann
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Claudio Pacchetti
- Parkinson's Disease and Movement Disorders Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Carlo A Frigo
- MBMC Lab, Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | | | - Ioannis U Isaias
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany.
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14
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Brown FS, Rowe JB, Passamonti L, Rittman T. Falls in Progressive Supranuclear Palsy. Mov Disord Clin Pract 2019; 7:16-24. [PMID: 31970205 PMCID: PMC6962663 DOI: 10.1002/mdc3.12879] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/16/2019] [Accepted: 11/17/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Despite falls being an almost universal clinical feature and central to the presentation and diagnostic criteria of progressive supranuclear palsy, our understanding of falls is surprisingly limited and there are few effective treatment options. OBJECTIVES To provide an overview of the topic of the impact, assessment, mechanism, and management of falls in progressive supranuclear palsy. METHODS We performed a literature search for "falls" and "progressive supranuclear palsy" and included additional relevant literature known to us. We synthesized this literature with experience from clinical practice. RESULTS We review current understanding of the pathophysiology of falls, highlighting the roles of the indirect pathway and the pedunculopontine nucleus. We go on to identify shortcomings in commonly used assessments to measure falls. We discuss medical and nonmedical fall prevention strategies, and finally we discuss balancing falls risk against promoting independence. CONCLUSION Falls are central to progressive supranuclear palsy presentation and diagnosis. Indirect locomotor and pedunculopontine nucleus dysfunction are thought to be the neural substrate of falls in this condition. Attempts to measure and prevent falls, by medical and nonmedical means, are currently limited. A personalized approach is advocated in the management of falls.
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Affiliation(s)
- Fraser S. Brown
- Department of Clinical NeurosciencesCambridge University HospitalsCambridgeUnited Kingdom
| | - James B. Rowe
- Department of Clinical NeurosciencesUniversity of CambridgeCambridgeUnited Kingdom,Department of NeurologyAddenbrooke's HospitalCambridgeUnited Kingdom
| | - Luca Passamonti
- Department of Clinical NeurosciencesUniversity of CambridgeCambridgeUnited Kingdom,Department of NeurologyAddenbrooke's HospitalCambridgeUnited Kingdom
| | - Timothy Rittman
- Department of Clinical NeurosciencesUniversity of CambridgeCambridgeUnited Kingdom,Department of NeurologyAddenbrooke's HospitalCambridgeUnited Kingdom
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