Clinical Usefulness of Retropulsion Tests in Persons with Mild to Moderate Parkinson's Disease.

People with Parkinson's disease (PwPD) have an increased risk for falls and near falls. They have particular difficulties with maintaining balance against an external perturbation, and several retropulsion tests exist. The Unified PD Rating Scale item 30 (UPDRS30) is the most common, involving an expected shoulder pull. Others recommend using an unexpected shoulder pull, e.g., the Nutt Retropulsion Test (NRT). We aimed to evaluate the clinical usefulness of these tests for detecting future fallers. By using two different golden standards related to self-reported prospective falls and near falls over 6 months following two different time points with 3.5 years between, we estimated sensitivity/specificity, Youden index, predictive values, and likelihood ratios for each test. The different time points yielded a different prevalence of falls and near falls, as well as different predictive values. When comparing the performance of the NRT and UPDRS30 for detecting future fallers, we found that the NRT consistently performed better than UPDRS30. However, neither test exhibited optimal performance in terms of predictive values and associated likelihood ratios. Our findings speak against using either of these tests as a single assessment for this purpose and support previous recommendations of using a multifactorial approach when targeting balance problems in PwPD.

Outcome on Balance and Gait Following Botulinum Toxin Treatment for Striatal Foot in Parkinson's Disease.

BACKGROUND: Striatal foot deformity can shorten the stance phase of gait and impair the ability to stand and walk. Botulinum neurotoxin type A (BoNT A) is a treatment option. However, no previous study has included clinical balance testing in the evaluation of treatment effects. The aim of this study was to evaluate gait and balance in patients with striatal foot deformities and Parkinson's disease (PD) before and after treatment with BoNT A injections. METHOD: The study included 10 patients with PD and striatal foot deformity who visited a neurological clinic. The mean ± standard deviation age and PD-duration was 62.8 ± 8.8 years and 4.9 ± 3.6 years, respectively. Clinical assessment was made before and 4 and 16 weeks after injection and included 5 clinical gait and balance tests. The intensity of distress due to deformities was investigated with a visual analogue scale. Parkinsonian motor status was assessed with the Unified Parkinson's Disease Rating Scale part III (motor part). Based on ordinary clinical examination, electromyography-guided BoNT A injection was given in affected muscles. Clinically effective doses of BoNT A were used. RESULTS: Improvements were observed regarding functional, dynamic, and standing balance as well as intensity of distress at 4 weeks but not at 16 weeks compared with baseline. CONCLUSIONS: BoNT A injection treatment improved gait and balance in patients with PD and striatal foot deformities. Multicenter trials are needed; and, to achieve increased power, a randomized, double-blind controlled design is needed and should focus on the ability of tests to capture subtle changes in gait and balance.

Practical guidance for CD management involving treatment of botulinum toxin: a consensus statement.

Cervical dystonia is a neurological movement disorder causing abnormal posture of the head. It may be accompanied by involuntary movements which are sometimes tremulous. The condition has marked effects on patients' self-image, and adversely affects quality of life, social relationships and employment. Botulinum neurotoxin (BoNT) is the treatment of choice for CD and its efficacy and safety have been extensively studied in clinical trials. However, current guidelines do not provide enough practical information for physicians who wish to use this valuable treatment in a real-life setting. In addition, patients and physicians may have different perceptions of what successful treatment outcomes should be. Consequently, an international group of expert neurologists, experienced in BoNT treatment, met to review the literature and pool their extensive clinical experience to give practical guidance about treatment of CD with BoNT. Eight topic headings were considered: the place of BoNT within CD treatment options; patient perspectives and desires for treatment; assessment and goal setting; starting treatment with BoNT-A; follow-up sessions; management of side effects; management of non-response; switching between different BoNT products. One rapporteur took responsibility for summarising the current literature for each topic, while the consensus statements were developed by the entire expert group. These statements are presented here along with a discussion of the background information.

[Giant meningioma of the cranial vault and brain: a report of two cases who had not consented for more that 10 years]. / Olbrzymi oponiak sklepienia czaszki i mózgu--opisy przypadków dwóch chorych przez ponad 10 lat niezgadzajacych sie na operacje.

It is extremely rare nowadays to meet the patient with a giant tumour of the skull and brain with deformity of the head and who has not consented for any treatment for many years. We present two rare cases of large tumours. The first case is an example of good prognosis of the surgical procedure despite the extensive size of the tumour. The second shows the natural history of the cranial vault meningioma not treated for more than 30 years. We assume that frontal lobe syndrome was responsible for treatment decisions in both patients.

[Frequency of side effects after botulinum toxin A injections in neurology, rehabilitation and gastroenterology]. / Analiza czestosci wystepowania objawów ubocznych po podaniu toksyny botulinowej typu A w neurologii, rehabilitacji i gastroenterologii.

UNLABELLED: Botulinum toxin type A is one of the most potent biological toxins, recently used clinically (Botox, Dysport) for wide range of indications. THE AIM OF THE STUDY was to assess the frequency and severity of side effects during BTX-A therapy for different indications and underlying possible mechanisms. MATERIAL AND METHODS: Material consisted of 327 patients (F202, M125) who underwent 1043 sessions of BTX-A injections for: cervical dystonia--CD (n=58), blepharospasm--BLP (n=31), hemifacial spasm--HFS (n=39), spasticity due to cerebral palsy--CP (n=96), chronic anal fissure--CAF (n=96), esophageal achalasia--AE (n=7). RESULTS: In CD the following side effects were observed: dysphagia (27% of patients and 7% of sessions), weakness of neck muscles (6.7% and 1.3%), pain during swallowing (5.1% and 1%), flu-like syndrome (3.4%, 0.7%). Dysphagia appeared 8.2 days after injection and lasted 14.9 days on average. In BLP authors noticed: unilateral ptosis (22%, 6.3%), bilateral ptosis (3%, 1.9%), haematoma (3%, 0.6%) and in HFS: excessive weakness resulting in asymmetry of face--mild (28.2% and 20%) and moderate (46% and 26.7%). In spasticity due to CP authors noticed: excessive weakness of lower limbs which lasted 13.8 days on average (6.2% and 1.9%), pain (5.2% and 1.6%), flu-like syndrome (4.1% and 1.3%). In CAF: mild incontinence of the flatus and faeces (9% and 5% of sessions), haematoma (5%), flu-like syndrome (3%), inflammation of external anal varices (2%), epididymitis (1%). In AE: chest pain in 6 (at the day of injection and lasted 2-4 days) and reflux in 2 patients (4-8 weeks after injection, lasted 2-3 weeks) were observed. CONCLUSION: Therapy with BTX-A is a very safe procedure, especially when compared with high rate of effectiveness of injections. The side effects are transient, mostly local and completely reversible.

Side effects of botulinum toxin injection for benign anal disorders.

BACKGROUND: Botulinum toxin A (BT-A) is a powerful biological toxin. Nevertheless, it has proved to be a remarkable therapeutic agent for the treatment of benign anal disorders. Higher doses of BT-A could change the outcome of treatment. It is not known whether doses of BT-A higher than 20 units of Botox (or corresponding doses of Dysport) are as safe for patients as lower doses of BT-A. METHODS: The side effects of BT-A injections in the treatment of chronic anal fissure (105 patients) and functional outlet obstruction (34 patients) were analysed prospectively. The patients received at least 25 units of Botox or 150 units of Dysport. RESULTS: The patients with chronic anal fissure complained of incontinence of flatus (one severe case and eight mild cases), incontinence of faeces (five mild cases), anal haematoma (five cases), flu-like syndrome (three cases), an acute inflammation of external anal varices (two cases), epididymitis (one case) and haemorrhoid prolapse (one case). Patients with anismus suffered from intertrigo (one case); the pain after injection lasted for 2-4 days (four cases). No life-threatening side effects after 181 injections of BT-A were observed. Most of the side effects were only transient symptoms. No significant interdependence between injection methods (injection into one or two sites) and the risk of side effects was found. CONCLUSION: Treatment with BT-A is safe. Despite the application of higher doses of BT-A in the treatment of benign anal disorders so far, no severe side effects were observed.

[Prognostic factors of long-standing improvement in cervical dystonia, treated with botulinum A toxin]. / Czynniki prognostyczne dlugotrwalej poprawy w dystonii szyjnej, leczonej toksyna botulinowa typu A.

The clinical improvement after injections of botulinum toxin A in patients with idiopathic spasmodic torticollis lasts usually about 3 months. Nevertheless in some patients it exceeds several months. The aim of our study was to assess the frequency of prolonged response (arbitrally established as > 6 months) and to find the possible prognostic factors of such longer effect. In the group of 43 patients (F30, M13), average age 43.9 (19-72) years, we observed prolonged effect in 13 (30.2%). In 5 of them remission was repeated in following sessions (two times in four and four times in one). The frequency of spontaneous remissions in spasmodic torticollis (12%) is significantly lower than after botulinum toxin, what means that they are triggered by drug injection in our group of patients with prolonged effect. Within the analysed parameters only the lower average age and the average age at the onset of symptoms statistically significantly differ in both groups. The authors suggest the possibility of other mechanisms responsible for prolonged clinical effect after botulinum toxin: e.g. different time of reinnervation (remodelling of synapses) or the modification of natural course (feed-back mechanisms) of spasmodic torticollis in some patients.