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Akbar M, Wandy A, Soraya GV, Goysal Y, Lotisna M, Basri MI. Sudomotor dysfunction in diabetic peripheral neuropathy (DPN) and its testing modalities: A literature review. Heliyon 2023; 9:e18184. [PMID: 37539131 PMCID: PMC10393629 DOI: 10.1016/j.heliyon.2023.e18184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 06/04/2023] [Accepted: 07/11/2023] [Indexed: 08/05/2023] Open
Abstract
Long term consequences of diabetes mellitus (DM) may include multi-organ complications such as retinopathy, cardiovascular disease, neuronal, and kidney damage. One of the most prevalent complication is diabetic peripheral neuropathy (DPN), occurring in half of all diabetics, and is the main cause of disability globally with profound impact on a patient's quality of life. Small fiber neuropathy (SFN) can develop in the pre-diabetes stage preceding large fiber damage in DPN. Asymptomatic SFN is difficult to diagnose in early stages, with sudomotor dysfunction considered one of the earliest manifestations of autonomic neuropathy. Early detection is crucial as it can prevent potential cardiovascular events. Although punch skin biopsy is the gold-standard method for SFN diagnosis, implementation as routine screening is hindered due to its invasive, impractical, and time-consuming nature. Other sudomotor testing modalities, most of which evaluate the postganglionic cholinergic sympathetic nervous system, have been developed with varying sensitivity and specificity for SFN diagnosis. Here, we provide an overview on the general mechanism of DPN, the importance of sudomotor assessment for early detection of autonomic dysfunction in DPN, the benefits and disadvantages of current testing modalities, factors that may affect testing, and the importance of future discoveries on sudomotor testing for successful DPN diagnosis.
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Affiliation(s)
- Muhammad Akbar
- Department of Neurology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Alvian Wandy
- Department of Neurology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Gita Vita Soraya
- Department of Neurology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
- Department of Biochemistry, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Yudy Goysal
- Department of Neurology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Mimi Lotisna
- Department of Neurology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Muhammad Iqbal Basri
- Department of Neurology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
- Department of Anatomy, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
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2
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Siepmann T, Arndt M, Sedghi A, Szatmári S, Horváth T, Takáts A, Bereczki D, Moskopp ML, Buchmann S, Skowronek C, Zago W, Woranush W, Lapusca R, Weidemann ML, Gibbons CH, Freeman R, Reichmann H, Puetz V, Barlinn K, Pintér A, Illigens BMW. Two-Year observational study of autonomic skin function in patients with Parkinson's disease compared to healthy individuals. Eur J Neurol 2023; 30:1281-1292. [PMID: 36773001 DOI: 10.1111/ene.15733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND AND PURPOSE We characterized autonomic pilomotor and sudomotor skin function in early Parkinson's disease (PD) longitudinally. METHODS We enrolled PD patients (Hoehn and Yahr 1-2) and healthy controls from movement disorder centers in Germany, Hungary, and the United States. We evaluated axon-reflex responses in adrenergic sympathetic pilomotor nerves and in cholinergic sudomotor nerves and assessed sympathetic skin response (SSR), predominantly parasympathetic neurocardiac function via heart rate variability, and disease-related symptoms at baseline, after 2 weeks, and after 1 and 2 years. CLINICALTRIALS gov: NCT03043768. RESULTS We included 38 participants: 26 PD (60% females, aged 62.4 ± 7.4 years, mean ± SD) and 12 controls (75% females, aged 59.5 ± 5.8 years). Pilomotor function was reduced in PD compared to controls at baseline when quantified via spatial axon-reflex spread (78 [43-143], median [interquartile range] mm2 vs. 175 [68-200] mm2 , p = 0.01) or erect hair follicle count in the axon-reflex region (8 [6-10] vs. 11 [6-16], p = 0.008) and showed reliability absent any changes from baseline to Week 2 (p = not significant [ns]). Between-group differences increased over the course of 2 years (p < 0.05), although no decline was observed within groups (p = ns). Pilomotor impairment in PD correlated with motor symptoms (rho = -0.59, p = 0.017) and was not lateralized (p = ns). Sudomotor axon-reflex and neurocardiac function did not differ between groups (p = ns), but SSR was reduced in PD (p = 0.0001). CONCLUSIONS Impairment of adrenergic sympathetic pilomotor function and SSR in evolving PD is not paralleled by changes to cholinergic sudomotor function and parasympathetic neurocardiac function, suggesting a sympathetic pathophysiology. A pilomotor axon-reflex test might be useful to monitor PD-related pathology.
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Affiliation(s)
- Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Martin Arndt
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Annahita Sedghi
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Tamás Horváth
- Research Center for Sport Physiology, Hungarian University of Sports Science, Budapest, Hungary
| | - Annamária Takáts
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Dániel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Mats Leif Moskopp
- Department of Neurosurgery, Vivantes Klinikum im Friedrichshain, Berlin, Germany.,Institute of Physiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sylvia Buchmann
- Department of Anesthesiology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Cornelia Skowronek
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Wagner Zago
- Prothena Biosciences, South San Francisco, California, USA
| | - Warunya Woranush
- Institute of Physiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Marie Luise Weidemann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christopher H Gibbons
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Heinz Reichmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Alexandra Pintér
- Department of Family Medicine, Semmelweis University, Budapest, Hungary
| | - Ben Min-Woo Illigens
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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3
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Raasing LR, Vogels OJ, Veltkamp M, van Swol CF, Grutters JC. Current View of Diagnosing Small Fiber Neuropathy. J Neuromuscul Dis 2021; 8:185-207. [PMID: 33337383 PMCID: PMC8075405 DOI: 10.3233/jnd-200490] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Small fiber neuropathy (SFN) is a disorder of the small myelinated Aδ-fibers and unmyelinated C-fibers [5, 6]. SFN might affect small sensory fibers, autonomic fibers or both, resulting in sensory changes, autonomic dysfunction or combined symptoms [7]. As a consequence, the symptoms are potentially numerous and have a large impact on quality of life [8]. Since diagnostic methods for SFN are numerous and its pathophysiology complex, this extensive review focusses on categorizing all aspects of SFN as disease and its diagnosis. In this review, sensitivity in combination with specificity of different diagnostic methods are described using the areas under the curve. In the end, a diagnostic work-flow is suggested based on different phenotypes of SFN.
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Affiliation(s)
- Lisette R.M. Raasing
- ILD Center of Excellence, Department of Pulmonology,St Antonius Hospital, CM, Nieuwegein, The Netherlands
| | - Oscar J.M. Vogels
- Department of Neurology, St Antonius Hospital, CM, Nieuwegein, The Netherlands
| | - Marcel Veltkamp
- ILD Center of Excellence, Department of Pulmonology,St Antonius Hospital, CM, Nieuwegein, The Netherlands
- Division of Heart and Lungs, University Medical Center Utrecht, CX, Utrecht, The Netherlands
| | | | - Jan C. Grutters
- ILD Center of Excellence, Department of Pulmonology,St Antonius Hospital, CM, Nieuwegein, The Netherlands
- Division of Heart and Lungs, University Medical Center Utrecht, CX, Utrecht, The Netherlands
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4
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Infante R, Scaglione C, Incensi A, Rizzo G, Liguori R, Donadio V. A Longitudinal Skin Biopsy Study of Phosphorylated Alpha-Synuclein in a Patient With Parkinson Disease and Orthostatic Hypotension. J Neuropathol Exp Neurol 2020; 79:813-816. [PMID: 32529258 DOI: 10.1093/jnen/nlaa048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/24/2019] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
The aim of our study was to assess the distribution of phosphorylated α-synuclein (p-syn) deposits in a patient affected by early stage Parkinson disease and orthostatic hypotension through a longitudinal skin biopsy study. We found widespread p-syn spatial diffusion from deep autonomic dermis nerve bundles to autonomic terminals, suggesting a centrifugal spread of p-syn from ganglia to the innervation target structures. Furthermore, the case suggests the possibility of discriminating synucleinopathies at an early stage of disease by means of skin biopsy. If confirmed, these data support skin biopsy as a useful and promising tool for the diagnosis, longitudinal evaluation, and pathological understanding of Parkinson disease.
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Affiliation(s)
- Rossella Infante
- Department of Biomedical and Neuromotor Sciences, University of Bologna
| | - Cesa Scaglione
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Alex Incensi
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giovanni Rizzo
- Department of Biomedical and Neuromotor Sciences, University of Bologna.,UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Rocco Liguori
- Department of Biomedical and Neuromotor Sciences, University of Bologna.,UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Vincenzo Donadio
- Department of Biomedical and Neuromotor Sciences, University of Bologna
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5
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Merchant KM, Cedarbaum JM, Brundin P, Dave KD, Eberling J, Espay AJ, Hutten SJ, Javidnia M, Luthman J, Maetzler W, Menalled L, Reimer AN, Stoessl AJ, Weiner DM. A Proposed Roadmap for Parkinson's Disease Proof of Concept Clinical Trials Investigating Compounds Targeting Alpha-Synuclein. JOURNAL OF PARKINSONS DISEASE 2020; 9:31-61. [PMID: 30400107 PMCID: PMC6398545 DOI: 10.3233/jpd-181471] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The convergence of human molecular genetics and Lewy pathology of Parkinson's disease (PD) have led to a robust, clinical-stage pipeline of alpha-synuclein (α-syn)-targeted therapies that have the potential to slow or stop the progression of PD and other synucleinopathies. To facilitate the development of these and earlier stage investigational molecules, the Michael J. Fox Foundation for Parkinson's Research convened a group of leaders in the field of PD research from academia and industry, the Alpha-Synuclein Clinical Path Working Group. This group set out to develop recommendations on preclinical and clinical research that can de-risk the development of α-syn targeting therapies. This consensus white paper provides a translational framework, from the selection of animal models and associated end-points to decision-driving biomarkers as well as considerations for the design of clinical proof-of-concept studies. It also identifies current gaps in our biomarker toolkit and the status of the discovery and validation of α-syn-associated biomarkers that could help fill these gaps. Further, it highlights the importance of the emerging digital technology to supplement the capture and monitoring of clinical outcomes. Although the development of disease-modifying therapies targeting α-syn face profound challenges, we remain optimistic that meaningful strides will be made soon toward the identification and approval of disease-modifying therapeutics targeting α-syn.
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Affiliation(s)
- Kalpana M Merchant
- Vincere Biosciences, Inc., and Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Patrik Brundin
- Van Andel Research Institute, Center for Neurodegenerative Science, Grand Rapids, MI, USA
| | - Kuldip D Dave
- The Michael J. Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Jamie Eberling
- The Michael J. Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Alberto J Espay
- UC Gardner Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH, USA
| | - Samantha J Hutten
- The Michael J. Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Monica Javidnia
- Center for Health and Technology, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Walter Maetzler
- Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Liliana Menalled
- The Michael J. Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Alyssa N Reimer
- The Michael J. Fox Foundation for Parkinson's Research, New York, NY, USA
| | - A Jon Stoessl
- Djavad Mowafaghian Centre for Brain Health, Pacific Parkinson's Research Center, University of British Columbia, Vancouver, BC, Canada
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Hijazi MM, Buchmann SJ, Sedghi A, Illigens BM, Reichmann H, Schackert G, Siepmann T. Assessment of cutaneous axon-reflex responses to evaluate functional integrity of autonomic small nerve fibers. Neurol Sci 2020; 41:1685-1696. [PMID: 32125538 PMCID: PMC7359149 DOI: 10.1007/s10072-020-04293-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
Cutaneous autonomic small nerve fibers encompass unmyelinated C-fibers and thinly myelinated Aδ-fibers, which innervate dermal vessels (vasomotor fibers), sweat glands (sudomotor fibers), and hair follicles (pilomotor fibers). Analysis of their integrity can capture early pathology in autonomic neuropathies such as diabetic autonomic neuropathy or peripheral nerve inflammation due to infectious and autoimmune diseases. Furthermore, intraneural deposition of alpha-synuclein in synucleinopathies such as Parkinson’s disease can lead to small fiber damage. Research indicated that detection and quantitative analysis of small fiber pathology might facilitate early diagnosis and initiation of treatment. While autonomic neuropathies show substantial etiopathogenetic heterogeneity, they have in common impaired functional integrity of small nerve fibers. This impairment can be evaluated by quantitative analysis of axonal responses to iontophoretic application of adrenergic or cholinergic agonists to the skin. The axon-reflex can be elicited in cholinergic sudomotor fibers to induce sweating and in cholinergic vasomotor fibers to induce vasodilation. Currently, only few techniques are available to quantify axon-reflex responses, the majority of which is limited by technical demands or lack of validated analysis protocols. Function of vasomotor small fibers can be analyzed using laser Doppler flowmetry, laser Doppler imaging, and laser speckle contrast imaging. Sudomotor function can be assessed using quantitative sudomotor axon-reflex test, silicone imprints, and quantitative direct and indirect testing of sudomotor function. More recent advancements include analysis of piloerection (goose bumps) following stimulation of adrenergic small fibers using pilomotor axon-reflex test. We provide a review of the current literature on axon-reflex tests in cutaneous autonomic small fibers.
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Affiliation(s)
- Mido M Hijazi
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr 74, 01307, Dresden, Germany
| | - Sylvia J Buchmann
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Medicine, Vivantes Klinikum Spandau, Berlin, Germany
| | - Annahita Sedghi
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ben M Illigens
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Heinz Reichmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gabriele Schackert
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr 74, 01307, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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7
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Glatte P, Buchmann SJ, Hijazi MM, Illigens BMW, Siepmann T. Architecture of the Cutaneous Autonomic Nervous System. Front Neurol 2019; 10:970. [PMID: 31551921 PMCID: PMC6746903 DOI: 10.3389/fneur.2019.00970] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 08/23/2019] [Indexed: 12/12/2022] Open
Abstract
The human skin is a highly specialized organ for receiving sensory information but also to preserve the body's homeostasis. These functions are mediated by cutaneous small nerve fibers which display a complex anatomical architecture and are commonly classified into cutaneous A-beta, A-delta and C-fibers based on their diameter, myelinization, and velocity of conduction of action potentials. Knowledge on structure and function of these nerve fibers is relevant as they are selectively targeted by various autonomic neuropathies such as diabetic neuropathy or Parkinson's disease. Functional integrity of autonomic skin nerve fibers can be assessed by quantitative analysis of cutaneous responses to local pharmacological induction of axon reflex responses which result in dilation of cutaneous vessels, sweating, or piloerection depending on the agent used to stimulate this neurogenic response. Sensory fibers can be assessed using quantitative sensory test. Complementing these functional assessments, immunohistochemical staining of superficial skin biopsies allow analysis of structural integrity of cutaneous nerve fibers, a technique which has gained attention due to its capacity of detecting pathogenic depositions of alpha-synuclein in patients with Parkinson's disease. Here, we reviewed the current literature on the anatomy and functional pathways of the cutaneous autonomic nervous system as well as diagnostic techniques to assess its functional and structural integrity.
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Affiliation(s)
- Patrick Glatte
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sylvia J Buchmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Mido Max Hijazi
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ben Min-Woo Illigens
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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8
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Mendoza-Velásquez JJ, Flores-Vázquez JF, Barrón-Velázquez E, Sosa-Ortiz AL, Illigens BMW, Siepmann T. Autonomic Dysfunction in α-Synucleinopathies. Front Neurol 2019; 10:363. [PMID: 31031694 PMCID: PMC6474181 DOI: 10.3389/fneur.2019.00363] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/25/2019] [Indexed: 12/20/2022] Open
Abstract
The α-synucleinopathies are a group of neurodegenerative diseases characterized by abnormal accumulation of insoluble α-synuclein in neurons and glial cells, comprising Parkinson's disease (PD), dementia with Lewy bodies (DLB) and multiple system atrophy (MSA). Although varying in prevalence, symptom patterns, and severity among disorders, all α-synucleinopathies have in common autonomic nervous system dysfunctions, which reduce quality of life. Frequent symptoms among α-synucleinopathies include constipation, urinary and sexual dysfunction, and cardiovascular autonomic symptoms such as orthostatic hypotension, supine hypertension, and reduced heart rate variability. Symptoms due to autonomic dysfunction can appear before motor symptom onset, particularly in MSA and PD, hence, detection and quantitative analysis of these symptoms can enable early diagnosis and initiation of treatment, as well as identification of at-risk populations. While patients with PD, DLB, and MSA show both central and peripheral nervous system involvement of α-synuclein pathology, pure autonomic failure (PAF) is a condition characterized by generalized dysregulation of the autonomic nervous system with neuronal cytoplasmic α-synuclein inclusions in the peripheral autonomic small nerve fibers. Patients with PAF often present with orthostatic hypotension, reduced heart rate variability, anhydrosis, erectile dysfunction, and constipation, without motor or cognitive impairment. These patients also have an increased risk of developing an α-synucleinopathy with central involvement, such as PD, DLB, or MSA in later life, possibly indicating a pathophysiological disease continuum. Pathophysiological aspects, as well as developments in diagnosing and treating dysautonomic symptoms in patients with α-synucleinopathies are discussed in this review.
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Affiliation(s)
- José Javier Mendoza-Velásquez
- Division of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
- Department of Psychiatry and Mental Health, School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Juan Francisco Flores-Vázquez
- Dementia Laboratory, National Institute of Neurology and Neurosurgery, Ciudad de Mexico, Mexico
- Faculty of Medical Sciences, University of Groningen, Groningen, Netherlands
| | - Evalinda Barrón-Velázquez
- Department of Psychiatry and Mental Health, School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Ana Luisa Sosa-Ortiz
- Dementia Laboratory, National Institute of Neurology and Neurosurgery, Ciudad de Mexico, Mexico
| | - Ben-Min Woo Illigens
- Division of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Timo Siepmann
- Division of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Ziemssen T, Siepmann T. The Investigation of the Cardiovascular and Sudomotor Autonomic Nervous System-A Review. Front Neurol 2019; 10:53. [PMID: 30809183 PMCID: PMC6380109 DOI: 10.3389/fneur.2019.00053] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/15/2019] [Indexed: 01/09/2023] Open
Abstract
The autonomic nervous system as operating system of the human organism permeats all organ systems with its pathways permeating that it is involved with virtually all diseases. Anatomically a central part, an afferent part and sympathetic and parasympathetic efferent system can be distinguished. Among the different functional subsystems of the autonomic nervous system, the cardiovascular autonomic nervous system is most frequently examined with easily recordable cardiovascular biosignals as heart rate and blood pressure. Although less widely established, sudomotor tests pose a useful supplement to cardiovascular autonomic assessment as impaired neurogenic sweating belongs to the earliest clinical signs of various autonomic neuropathies as well as neurodegenerative disorders and significantly reduces quality of life. Clinically at first, the autonomic nervous system is assessed with a detailed history of clinical autonomic function and a general clinical examination. As a lof of confounding factors can influence autonomic testing, subjects should be adequately prepared in a standardized way. Autonomic testing is usually performed in that way that the response of the autonomic nervous system to a well-defined challenge is recorded. As no single cardiovascular autonomic test is sufficiently reliable, it is recommended to use a combination of different approaches, an autonomic test battery including test to measure parasympathetic and sympathetic cardiovascular function (deep breathing test, Valsalva maneuver, tilt, or pressor test). More specialized tests include carotid sinus massage, assessment of baroreceptor reflex function, pharmacological tests or cardiac, and regional hemodynamic measurements. Techniques to measure functional integrity of sudomotor nerves include the quantitative sudomotor axon reflex sweat test, analysis of the sympathetic skin response as well as the thermoregulatory sweat test. In addition to these rather established techniques more recent developments have been introduced to reduce technical demands and interindividual variability such as the quantitative direct and indirect axon reflex testing or sudoscan. However, diagnostic accuracy of these tests remains to be determined. We reviewed the current literature on currently available autonomic cardiovascular and sudomotor tests with a focus on their physiological and technical mechanisms as well as their diagnostic value in the scientific and clinical setting.
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Affiliation(s)
- Tjalf Ziemssen
- Autonomic and Neuroendocrinological Functional Laboratory, Center of Clinical Neuroscience, Neurological University Clinic Carl Gustav Carus, Dresden, Germany
| | - Timo Siepmann
- Neurological University Clinic Carl Gustav Carus, Dresden, Germany
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10
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Buchmann SJ, Penzlin AI, Kubasch ML, Illigens BMW, Siepmann T. Assessment of sudomotor function. Clin Auton Res 2018; 29:41-53. [PMID: 29737432 DOI: 10.1007/s10286-018-0530-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 04/27/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE To review the currently available literature on clinical autonomic tests of sudomotor function. METHODS We searched PubMED/MEDLINE for articles on technical principles and clinical applications of sudomotor tests with a focus on their drawbacks and perspectives in order to provide a narrative review. RESULTS The quantitative sudomotor axon reflex sweat test (QSART) is the most widely used test of sudomotor function. The technique captures pathology with low intra- and inter-subject variability but is limited by technical demands. The thermoregulatory sweat test comprises topographic sweat pattern analysis of the ventral skin surface and allows differentiating preganglionic from postganglionic sudomotor damage when combined with a small fiber test such as QSART. The sympathetic skin response also belongs to the more established techniques and is used in lie detection systems due to its high sensitivity for sudomotor responses to emotional stimuli. However, its clinical utility is limited by high variability of measurements, both within and between subjects. Newer and, therefore, less widely established techniques include silicone impressions, quantitative direct and indirect axon reflex testing, sensitive sweat test, and measurement of electrochemical skin conductance. The spoon test does not allow a quantitative assessment of the sweat response but can be used as bedside-screening tool of sudomotor dysfunction. CONCLUSION While new autonomic sudomotor function testings have been developed and studied over the past decades, the most were well-studied and established techniques QSART and TST remain the gold standard of sudomotor assessment. Combining these techniques allows for sophisticated analysis of neurally mediated sudomotor impairment. However, newer techniques display potential to complement gold standard techniques to further improve their precision and diagnostic value.
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Affiliation(s)
- Sylvia J Buchmann
- Department of Neurology, Campus Virchow, Charite University Medicine Berlin, Berlin, Germany
| | | | - Marie Luise Kubasch
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Ben Min-Woo Illigens
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
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11
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Should Skin Biopsies Be Performed in Patients Suspected of Having Parkinson's Disease? PARKINSONS DISEASE 2017; 2017:6064974. [PMID: 29214093 PMCID: PMC5682910 DOI: 10.1155/2017/6064974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 08/30/2017] [Accepted: 09/12/2017] [Indexed: 11/17/2022]
Abstract
In patients with Parkinson's disease (PD), the molecularly misfolded form of α-synuclein was recently identified in cutaneous autonomic nerve fibers which displayed increased accumulation even in early disease stages. However, the underlying mechanisms of synucleinopathic nerve damage and its implication for brain pathology in later life remain to be elucidated. To date, specific diagnostic tools to evaluate small fiber pathology and to discriminate neurodegenerative proteinopathies are rare. Recently, research has indicated that deposition of α-synuclein in cutaneous nerve fibers quantified via immunohistochemistry in superficial skin biopsies might be a valid marker of PD which could facilitate early diagnosis and monitoring of disease progression. However, lack of standardization of techniques to quantify neural α-synuclein deposition limits their utility in clinical practice. Additional challenges include the identification of potential distinct morphological patterns of intraneural α-synuclein deposition among synucleinopathies to facilitate diagnostic discrimination and determining the degree to which structural damage relates to dysfunction of nerve fibers targeted by α-synuclein. Answering these questions might improve our understanding of the pathophysiological role of small fiber neuropathy in Parkinson's disease, help identify new treatment targets, and facilitate assessment of response to neuroprotective treatment.
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