An intensive exercise-based training program reduces prefrontal activity during usual walking in patients with Parkinson’s disease

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Patients with Parkinson’s disease have increased prefrontal activity during usual walking.

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After SIROCCO training, prefrontal activity decreased and gait performance improved in patients.

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An intensive exercise-based training program increased automaticity of gait in patients with PD.

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Findings highlight the potential of neuroplasticity in PD after exercise.

Introduction

Parkinson’s disease (PD) leads to a progressive loss of locomotor automaticity. Consequently, PD patients rely more on executive resources for the control of gait, resulting in increased prefrontal activity while walking. Exercise-based training programs may improve automaticity of walking and reduce prefrontal activity in this population. This study aimed to assess the effect of an intensive multidisciplinary exercise-based training program on prefrontal activity and gait performance during usual walking in PD patients.

Method

Fourteen patients (mean age: 67 ± 9; disease duration: 6 ± 5 years; Hoehn and Yahr score: 1.9 ± 0.6) were included in this study. They were assessed in ON stage at three different times at 5-week intervals: two times before the training program (T0 and T1) and once after the training program (T2). Gait performance (stride time, speed, stride length, cadence, and their respective coefficient of variation) and cortical activity in the dorsolateral prefrontal cortex (DLPFC) using functional near infrared spectroscopy (fNIRS) were measured during usual walking.

Results

Patients had reduced cortical activity of the DLPFC at T2 compared to T1 (p = 0.003). Patients had shorter stride time at T2 compared to T1 (p = 0.025) and tended to have longer stride length at T2 than at T1 (p = 0.056).

Conclusion

The training program led to positive effects on prefrontal activity and gait performance. Reduced prefrontal activity during usual walking after training program suggests that patients may have a greater reserve capacity to face more challenging walking conditions. Further studies will investigate the effect of this training on cortical activity during dual-task walking..

Toward a coherent structuration of disorders of consciousness expertise at a country scale: A proposal for France

Probing consciousness and cognitive abilities in non-communicating patients is one of the most challenging diagnostic issues. A fast growing medical and scientific literature explores the various facets of this challenge, often coined under the generic expression of 'Disorders of Consciousness' (DoC). Crucially, a set of independent converging results demonstrated both (1) the diagnostic and prognostic importance of this expertise, and (2) the need to combine behavioural measures with brain structure and activity data to improve diagnostic and prognostication accuracy as well as potential therapeutic intervention. Thus, probing consciousness in DoC patients appears as a crucial activity rich of human, medical, economic and ethical consequences, but this activity needs to be organized in order to offer this expertise to each concerned patient. More precisely, diagnosis of consciousness differs in difficulty across patients: while a minimal set of data can be sufficient to reach a confident result, some patients need a higher level of expertise that relies on additional behavioural and brain activity and brain structure measures. In order to enable this service on a systematic mode, we present two complementary proposals in the present article. First, we sketch a structuration of DoC expertise at a country-scale, namely France. More precisely, we suggest that a 2-tiers network composed of local (Tier-1) and regional (Tier-2) centers backed by distant electronic databases and algorithmic centers could optimally enable the systematic implementation of DoC expertise in France. Second, we propose to create a national common register of DoC patients in order to better monitor this activity, to improve its performance on the basis of nation-wide collected evidence, and to promote rational decision-making.

[Is there any obstruction other than prostatic obstruction in Idiopathic Parkinson's Disease?]

OBJECTIVE

To highlight the existence of pseudo-dyssynergia in Idiopathic Parkinson's Disease (IPD) constituting a functional bladder outlet obstruction.

MATERIALS AND METHODS

A retrospective study was conducted by including men with a confirmed diagnose of IPD who participated in the SIROCCO rehabilitation program. Patients included clinically exhibited overactive bladder and voiding dysfunction without prostatic hypertrophy ultrasounded. They have been clinically assessed by the Urinary Symptoms Profile (USP) urinary symptom score. Bladder outlet obstruction was assessed by the pressure-flow study. Urodynamic obstruction has been quantified by the bladder obstruction index which depends on detrusor pressure at maximum flow rate and maximum flow rate. It has been defined by a BOOI>40.

RESULTS

The pressure-flow profile was analyzed in 5 patients who met the inclusion criteria. In this group of 5 patients with IPD, the diagnosis was made on average 10.6 years (7-14) before the pressure-flow studies were performed. Our results objectified 4 patients obstructive among 5 and one equivocal patient. A striated pseudo-dyssynergia was found in the 3 obstructive patients and associated with a smooth pseudodyssynergia in one patient.

CONCLUSION

We have observed, in this short series, a pseudo-dyssynergia by subjects suffering from IPD.

LEVEL OF EVIDENCE

3.

Construction and feasibility study of the SOFMER Activity Score (SAS), a new assessment of physical and cognitive activity

OBJECTIVES

For hospitalizations in rehabilitation centers (RCs) in France, the quantification of healthcare givers' activity is based on the dependency of the patients, defined as a total or partial inability to perform activities required for daily living without help. The tools currently used to quantify dependency are not sufficiently precise. Here we describe the construction of a new tool, the SOFMER Activity Score (SAS scoring), which allows for a good description of the level of activity of patients hospitalized in RCs, and a feasibility study of the tool.

METHODS

After a study group proposed the first version of the SAS, the validity of its content was studied by the Delphi consensus method: 26 physicians or healthcare professionals known for their expertise in PMR responded to the first round. The feasibility study was prospective and involved multi-site professionals. Data related to the SAS determined by a multidisciplinary team were collected and compared to the Activité de la Vie Quotidienne (AVQ) scale, which is administered to all patients and included in medical and administrative data.

RESULTS

We included 81 patients in the feasibility study. The mean (SD) time to obtain the SAS was 4.5 (3.3) min. For 97.5% of scorings, the participating professionals judged that the SAS was compatible or fairly compatible with clinical practice. The internal structure of the SAS scale seemed better than that of the AVQ scale, for which the present study confirmed a floor effect for all items.

CONCLUSIONS

The SAS allows for measuring the level of physical and cognitive activity of a patient hospitalized in an RC. If validation studies for the SAS, exploring its reliability, construct validity or criterion validity, confirm the tool's good metrological qualities, the SAS will allow for a good quantification of the burden of care.

Effects of preference and sensory modality on behavioural reaction in patients with disorders of consciousness

BACKGROUND

Reliable evaluation of patients with unresponsive wakefulness syndrome (UWS) or in a minimally conscious state (MCS) remains a major challenge. It has been suggested that the expression of residual cerebral function could be improved by allowing patients to listen to their favourite music. However, the potential effect of music on behavioural responsiveness, as well as the effect of preferred stimuli in other sensory modalities (e.g. olfaction), remain poorly understood.

OBJECTIVE

The aim of our study was to investigate the effect of sensory modality (auditory versus olfactory) and preference (preferred versus neutral) of the test stimuli on patients' subsequent performance on the Coma Recovery Scale-Revised (CRS-R).

RESEARCH DESIGN

Within-subject design because of inter-individual differences between patients.

METHODS AND PROCEDURES

We studied four items from the CRS-R (visual pursuit using a mirror, auditory localization of the own name and two movements to command) in 13 patients (7 MCS; 6 UWS).

MAIN OUTCOMES AND RESULTS

Auditory stimuli triggered higher responsiveness compared to olfactory stimuli, and preferred stimuli were followed by higher scores than did neutral stimuli.

CONCLUSIONS

Findings suggest that preferred auditory stimuli at the bedside contribute to the expression of residual function and could improve the diagnostic assessment.

Drugs for behavior disorders after traumatic brain injury: Systematic review and expert consensus leading to French recommendations for good practice

OBJECTIVE

There are no handbook or recommendations for the use of pharmacological agents to treat neurobehavioral disorders after traumatic brain injury (TBI). This work proposes a systematic review of the literature and a user guide on neuroleptics, antidepressants, beta-blockers, mood stabilizers and other medications for irritability, aggressiveness, agitation, impulsivity, depression, apathy…

METHOD

Steering, working and reading groups (62 people) were formed under the control of the French High Authority for Health (HAS) in collaboration with the SOFMER scientific society (French Society of Physical and Rehabilitation Medicine). Articles were searched by HAS officers in the Medline database from 1990 to 2012, crossing TBI and pharmacological agents. The HAS method to select, read and analyze papers is close to the PRISMA statements.

RESULTS

Out of 772 references, 89 were analyzed, covering a total of 1306 people with TBI. There is insufficient evidence to standardize drug treatments for these disorders. There are however some elements to establish consensus recommendations for good clinical practice. Propranolol can improve aggression (B grade). Carbamazepine and valproate seem effective on agitation and aggression and are recommended as first line treatment (Expert Consensus [EC]). There is no evidence of efficacy for neuroleptics. Their prescription is based on emergency situation for a crisis (loxapine) but not for long-term use (EC). Antidepressants are recommended to treat depression (EC) with a higher standard of proof for Selective Serotonin Reuptake Inhibitors (SSRI, grade B). Other products are described.

CONCLUSION

The choice of treatment depends on the level of evidence, target symptoms, custom objectives, clinical experience and caution strategies.

Behavioral and affective disorders after brain injury: French guidelines for prevention and community supports

OBJECTIVE

The purpose of this study was to elaborate practice guidelines for the prevention of behavioral and affective disorders in adult outpatients after traumatic brain injury (TBI); but also to identify the support systems available for family, caregivers of patients with TBI within the community.

METHODS

The elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement. This involved a systematic and critical review of the literature looking for studies that investigated the impact of programs in community settings directed to behavioral and affective disorders post-TBI. Recommendations were than elaborated by a group of professionals and family representatives.

RESULTS

Only six articles were found comprising 4 studies with a control group. Two studies showed a beneficial effect of personalized behavior management program delivered within natural community settings for persons with brain injury and their caregivers. Two other studies showed the relevance of scheduled telephone interventions to improve depressive symptoms and one study emphasized the usefulness of physical training. One study investigated the relevance of an outreach program; this study showed an improvement of the patients' independence but did not yield any conclusions regarding anxiety and depression.

DISCUSSION AND RECOMMENDATIONS

In addition to the application of care pathways already established by the SOFMER, prevention of behavioral and affective disorders for brain-injured outpatients should involve pain management, as well as development of therapeutic partnerships. It is recommended to inform patients, their family and caregivers regarding the local organization and facilities involved in the management of traumatic brain injury. The relevance of therapeutic education for implementing coping strategies, educating caregivers on behavioral disorder management, follow-up telephone interventions, and holistic therapy seems established. The level of evidence is low and preliminary studies should be confirmed with larger controlled trials.

[Beneficial effect of preferred music on cognitive functions in minimally conscious state patients]

Several studies have shown that music can boost cognitive functions in normal and brain-damaged subjects. A few studies have suggested a beneficial effect of music in patients with a disorder of consciousness but it is difficult to conclude since they did not use quantified measures and a control condition/group. The aim of the present study was to compare the effect of music to that of a continuous sound on the relational behavior of patients in a minimally conscious state (MCS). Behavioral responses of six MCS patients were evaluated using items from the Coma Recovery Scale-Revised. Weekly evaluation sessions were carried out, over four weeks, under two conditions: following the presentation of either the patient's preferred music, or following a continuous sound (control condition). Qualitative and quantitative analyses showed that twelve of the eighteen sessions (66.6%) showed a better result for the music condition than for the control condition. This new protocol suggests that preferred music has a beneficial effect on the cognitive abilities of MCS patients. The results further suggest that cerebral plasticity may be enhanced in autobiographical (emotional and familiar) contexts. These findings should now be further extended with an increased number of patients to further validate the hypothesis of the beneficial effect of music on cognitive recovery.

Does the rectus femoris nerve block improve knee recurvatum in adult stroke patients? A kinematic and electromyographic study

Knee recurvatum (KR) during gait is common in hemiplegic patients. Quadriceps spasticity has been postulated as a cause of KR in this population. The aim of this study was to assess the role of rectus femoris spasticity in KR by using selective motor nerve blocks of the rectus femoris nerve in hemiparetic stroke patients. The data from six adult, post-stroke hemiplegic patients who underwent a rectus femoris nerve block for a stiff-knee gait were retrospectively analyzed. An extensive clinical and functional evaluation was performed and gait was assessed by motion analysis (kinematic, kinetic and electromyographic parameters) before and during the block realized using 2% lidocaine injected under a neurostimulation and ultrasonographic targeting procedure. The main outcome measures were the peak knee extension in stance and peak knee extensor moment obtained during gait analysis. No serious adverse effect of the nerve block was observed. The block allowed a reduction of rectus femoris overactivity in all patients. Peak knee extension and extensor moment in stance did not improve in any patient, but peak knee flexion during the swing phase was significantly higher after block (mean: 31.2° post, 26.4 pre, p < 0.05). Our results provide arguments against the hypothesis that the spasticity of the rectus femoris contributes to KR.

Clinical signs and radiographic evidence of esophageal perforation after tetraplegia

A diagnosis of esophageal perforation at some time after cervical spine surgery is difficult to establish since there exists no clinical picture specific to tetraplegic patients. We carried out a detailed retrospective study of revelatory clinical manifestations and conventional radiographic data in a series of 16 patients hospitalized at Hôpital Henry-Gabrielle (Lyon, France) for rehabilitation purposes between 1983 and 2010 and who presented this complication. The most frequent clinical picture associates cervical pain, fever and dysphagia. Simple front and side X-rays of the cervical spine led in 77% of the cases to a diagnosis of esophageal perforation. The most prevalent radiographic signs of the latter consist in osteosynthesis hardware or instrumentation failure, prevertebral free air next to the cervical esophagus and enlarged prevertebral space. Visualized esophageal X-rays, also known as series, highlight parenchymal opacity next to the posterior wall of the esophagus. A diagnosis of esophageal perforation needs to be carried out in order to facilitate suitable treatment and avoid the compromising of vital functions.

Physical and rehabilitation medicine (PRM) care pathways: adults with severe traumatic brain injury

This document is part of a series of guidelines documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These reference documents focus on a particular pathology (here patients with severe TBI). They describe for each given pathology patients' clinical and social needs, PRM care objectives and necessary human and material resources of the pathology-dedicated pathway. 'Care pathways in PRM' is therefore a short document designed to enable readers (physician, decision-maker, administrator, lawyer, finance manager) to have a global understanding of available therapeutic care structures, organization and economic needs for patients' optimal care and follow-up. After a severe traumatic brain injury, patients might be divided into three categories according to impairment's severity, to early outcomes in the intensive care unit and to functional prognosis. Each category is considered in line with six identical parameters used in the International Classification of Functioning, Disability and Health (World Health Organization), focusing thereafter on personal and environmental factors liable to affect the patients' needs.