[Functional neuroimaging with SPECT in Parkinson's disease and Parkinsonisms]. / Neuroimagen funcional mediante SPECT en la enfermedad de Parkinson y los parkinsonismos.

INTRODUCTION: The diagnosis of Parkinson's disease and the different Parkinsonian syndromes is currently determined by applying established clinical criteria. Today, different neuroimaging techniques, such as positron emission tomography and single-photon emission computerised tomography (SPECT), are a valuable aid to further our understanding of both the pathophysiology and the diagnosis of the different Parkinsonian pictures. AIM. To examine the usefulness of the different tools utilised to assess the integrity of the nigrostriatal system by visualising the pre-synaptic dopamine transporters and post-synaptic D2 receptors using SPECT techniques; we also sought to determine the role played by the alteration of the cardiac sympathetic innervation using meta-iodobenzylguanidine. DEVELOPMENT: We review the usefulness of the different nuclear medicine techniques for the diagnosis and differential diagnosis of the distinct clinical pictures that are accompanied by Parkinsonian symptoms, and we also discuss the possible future perspectives of said techniques. CONCLUSIONS: A combination of the different nuclear medicine techniques that have been reviewed here is useful in the study and characterisation of Parkinsonian syndromes. In the future they could be used to detect subjects who are possibly at risk of developing Parkinsonism and to be able to assess the effect of therapies that may have a potential modifying effect on the disease.

Neuroimagen funcional mediante SPECT en la enfermedad de Parkinson y los parkinsonismos / Functional neuroimaging with in parkinson’s disease and parkinsonisms

El diagnóstico de la enfermedad de Parkinson y de los diversos síndromes parkinsonianos actualmentese determina mediante la aplicación de criterios clínicos establecidos. Hoy día, las diferentes técnicas de neuroimagen, como la tomografía por emisión de positrones y la tomografía computarizada por emisión de fotón único (SPECT), ayudan en la comprensión tanto de la fisiopatología como del diagnóstico de los diferentes cuadros parkinsonianos. Objetivo. Revisar lautilidad de las diferentes herramientas empleadas en la evaluación de la integridad del sistema nigroestriado mediante la visualización de los transportadores presinápticos de la dopamina y los receptores postsinápticos D2 con técnicas de SPECT,así como el papel de la alteración de la inervación simpática cardíaca mediante el empleo de la metiliodobencilguanidina. Desarrollo. Se revisa la utilidad de las diferentes técnicas de medicina nuclear en el diagnóstico y diagnóstico diferencial delos diversos cuadros que cursan con sintomatología parkinsoniana, y se desarrollan las posibles perspectivas futuras de dichas técnicas. Conclusiones. La combinación de las diversas técnicas de medicina nuclear revisadas es útil en el estudio y lacaracterización de los síndromes parkinsonianos. En un futuro se podrían utilizar para detectar posibles sujetos en riesgo de desarrollar un parkinsonismo y poder evaluar el efecto de posibles terapias modificadoras de la enfermedad

The diagnosis of Parkinson’s disease and the different Parkinsonian syndromes is currently determinedby applying established clinical criteria. Today, different neuroimaging techniques, such as positron emission tomography and single-photon emission computerised tomography (SPECT), are a valuable aid to further our understanding of both the pathophysiology and the diagnosis of the different Parkinsonian pictures. Aim. To examine the usefulness of the different tools utilised to assess the integrity of the nigrostriatal system by visualising the pre-synaptic dopamine transporters and postsynaptic D2 receptors using SPECT techniques; we also sought to determine the role played by the alteration of the cardiac sympathetic innervation using meta-iodobenzylguanidine. Development. We review the usefulness of the different nuclear medicine techniques for the diagnosis and differential diagnosis of the distinct clinical pictures that are accompanied by Parkinsonian symptoms, and we also discuss the possible future perspectives of said techniques. Conclusions. A combination of the different nuclear medicine techniques that have been reviewed here is useful in the study and characterisation of Parkinsonian syndromes. In the future they could be used to detect subjects who are possibly at risk of developing Parkinsonism and to be able to assess the effect of therapies that may have a potential modifying effect on the disease

[Guide to the comprehensive treatment of spasticity]. / Guia del tratamiento integral de la espasticidad.

AIMS AND DEVELOPMENT: Spasticity is an important medical problem with a high rate of incidence both in childhood, mainly as a result of cerebral palsy, and in adults, which is frequently brought about by traumatic brain injuries, strokes and spinal cord injuries. Spasticity is part of upper motoneuron syndrome, which gives rise to important problems, such as limited joint movement, abnormal postures that can produce pain, impaired functional capacity, aesthetic or hygiene disorders, among others. It progresses naturally towards chronicity, accompanied by static phenomena due to alterations affecting the properties of soft tissues (elasticity, plasticity and viscosity). Numerous therapeutic options are available for the treatment of spasticity, including medication, physiotherapy, orthopaedic aid, surgery, and so forth. Moreover, treatment should be individualised and realistic, with goals that have been agreed between the patient or caregiver and the medical team. The aim of the following guide is to further our knowledge of this condition, its causes, epidemiology and progression, as well as to outline an approach that is both rational and global from the point of view of pharmacological, rehabilitation and surgical treatment. CONCLUSIONS: Spasticity is a complex problem that requires specialists (neurologist, rehabilitation doctor, occupational therapist, orthopaedic surgeon, general practitioner, etc.) to work as a team in order to achieve the goals set out when treatment is begun. Early treatment is important to avoid or reduce, as far as possible, the severe complications stemming from this condition.

Guía del tratamiento integral de la espasticidad / Guide to the comprehensive treatment of spasticity

Objetivos y desarrollo. La espasticidad constituye un problema médico de incidencia y trascendencia elevada tanto en la infancia, como consecuencia principalmente de la parálisis cerebral, como en adultos, ocasionada frecuentemente por traumatismos craneoencefálicos, ictus y lesión medular. La espasticidad forma parte del síndrome de motoneurona superior que ocasiona problemas importantes, como son: limitación articular, posturas anómalas que pueden generar dolor, alteraciónde la capacidad funcional, alteraciones estéticas o de higiene, entre otras. Su evolución natural es hacia la cronicidad, acompañada de fenómenos estáticos por alteraciones de las propiedades de los tejidos blandos (elasticidad, plasticidad y viscosidad).Las opciones terapéuticas de la espasticidad son múltiples: fármacos, fisioterapia, ayudas ortopédicas, cirugía, etc.Además, el tratamiento debe ser individualizado y realista, con unos objetivos consensuados entre el paciente o cuidador y el equipo médico. El objetivo de la siguiente guía es profundizar en el conocimiento de esta patología, sus causas, epidemiologíay evolución, así como aportar una forma racional y global de abordaje desde el punto de vista del tratamiento farmacológico, rehabilitador y quirúrgico. Conclusión. La espasticidad es un problema complejo que requiere un trabajo en equipo(neurólogo, rehabilitador, terapeuta ocupacional, cirujano ortopeda, médico de familia, etc.) para conseguir los objetivos que se fijan al principio de su tratamiento. Es importante el tratamiento precoz para evitar o reducir, en la medida de lo posible, las graves complicaciones que conlleva

Aims and development. Spasticity is an important medical problem with a high rate of incidence both in childhood,mainly as a result of cerebral palsy, and in adults, which is frequently brought about by traumatic brain injuries, strokes and spinal cord injuries. Spasticity is part of upper motoneuron syndrome, which gives rise to important problems, such as limitedjoint movement, abnormal postures that can produce pain, impaired functional capacity, aesthetic or hygiene disorders, among others. It progresses naturally towards chronicity, accompanied by static phenomena due to alterations affecting the properties of soft tissues (elasticity, plasticity and viscosity). Numerous therapeutic options are available for the treatment ofspasticity, including medication, physiotherapy, orthopaedic aid, surgery, and so forth. Moreover, treatment should be individualised and realistic, with goals that have been agreed between the patient or caregiver and the medical team. The aimof the following guide is to further our knowledge of this condition, its causes, epidemiology and progression, as well as to outline an approach that is both rational and global from the point of view of pharmacological, rehabilitation and surgicaltreatment. Conclusions. Spasticity is a complex problem that requires specialists (neurologist, rehabilitation doctor, occupational therapist, orthopaedic surgeon, general practitioner, etc.) to work as a team in order to achieve the goals set outwhen treatment is begun. Early treatment is important to avoid or reduce, as far as possible, the severe complications stemming from this condition

[Guidelines for the treatment of child spasticity using botulinum toxin]. / Guía terapéutica de la espasticidad infantil con toxina botulínica.

AIMS: The introduction of botulinum toxin has been a significant step forward in the treatment of spasticity in children and is now considered to be the preferred treatment in focal spasticity. With the aim of optimising this therapeutic resource, a group of Spanish neurologists and specialists in rehabilitation have drawn up these therapeutic guidelines based on the currently available evidence on its use and indications, and on their own experience. DEVELOPMENT: Spasticity in childhood is mainly caused by infantile cerebral palsy. Its natural history is not favourable due to the negative effect of growth and it should be treated before permanent deformities in bones and joints appear. Treatment with botulinum toxin diminishes hyperactivity and muscle tone, and allows the muscle to grow longitudinally, which prevents permanent contractions. The advantages of botulinum toxin are obvious (ease of use and dosing, long-lasting effects, reversibility in case of adverse responses, and so forth) and outnumber by far the few drawbacks it offers. Before it can be used patients, treatment goals and the muscle areas to be treated must all be selected correctly and, at the same time, a tailored rehabilitation scheme must also be developed. The growing body of experience suggests that its early administration is effective in preventing or reducing the severe complications of spasticity. CONCLUSIONS: Botulinum toxin type A is very effective in the treatment of spasticity. These guidelines offer the well-documented experience gained from its use and our knowledge about its indications, effects and safety in clinical practice.

[Quantitative evaluation of 123I-FP-CIT SPECT: validation of a semiautomated method]. / Evaluación cuantitativa del SPET con 123I-FP-CIT: validación de un método semiautomático.

OBJECTIVE: To assess the utility of a quantification of the 123I-FP-CIT uptake by the definition of some reference values, normal range values and interobserver variation. PATIENTS AND METHOD: Fifty patients with a 123I-FP-CIT SPECT: 25 patients had a pathological SPECT with the diagnosis of Parkinson's disease and the remaining had a qualitative normal SPET, with the diagnosis of 14 drug-induced Parkinsonism and 11 with psychogenic Parkinsonism. In the transversal slices, the best central slice that showed the nuclei of the base best was selected and standard ROIs (Region Of Interest) were applied. Specific (caudate and putamen) versus non specific (occipital) and laterality ratios were calculated. A normal statistical analysis for independent quantitative samples was used (mean, standard deviation and range) as well as variation coefficient and correlation coefficient of two observers and the 10th and 90th percentile. RESULTS: The variation coefficient interobserver was 3.24-5.61 and the correlation coefficient was 0.89-0.99. Cut-off values between both populations were established at 2.10 in the right putamen and at 2.05 in the left. Cut-off values definition in caudate were not assessable due to overlapping of ratios of both populations. CONCLUSIONS: This quantification method is highly reproducible. It makes it possible to obtain reference values and to define normal range.

Evaluación cuantitativa del SPET con 123I-FP-CIT: validación de un método semiautomático / Quantitative evaluation of 123I-FP-CIT SPECT: validation of a semiautomated method

Objetivo: Valorar la utilidad de un método de cuantificación de la captación de 123I-FP-CIT mediante la definición de unos valores de referencia, la validación del rango de normalidad y la variación interobservador.Pacientes y método: Se seleccionan 50 pacientes con un SPET con 123I-FP-CIT: 25 patológicos con el diagnóstico clínico de una enfermedad de Parkinson y 25 estudios cualitativamente normales, con el diagnóstico de catorce con un parkinsonismo farmacológico y once con un parkinsonismo psicogénico. En los cortes transversales, se seleccionó el corte central que mejor visualiza los núcleos de la base, y sobre éste se posicionan las áreas de interés (Region Of Interest-ROI) estandarizadas. Se calcularon los índices de captación específica (caudado y putamen) vs no específica (occipital) y las ratios de lateralidad. Se determinaron las variables cuantitativas (media, la desviación estándar y el rango) de ambos grupos, el percentil 10, el percentil 90 y el coeficiente de variación y de correlación entre los resultados de dos observadores. Resultados: Los coeficientes de variación interobservador obtenidos oscilaron entre 3,24 y 5,61. Se obtuvieron unos coeficientes de correlación entre 0,89 y 0,99. El dintel de separación estimado entre ambas poblaciones en el putamen fue en el derecho de 2,10 y en el izquierdo de 2,05. Con respecto a los caudados, existió un solapamiento entre ambas poblaciones que no permitió establecer un límite de separación. Conclusiones: Este método de cuantificación es reproducible, permite definir unos valores de referencia y determinar el límite de la normalidad

Objective: To assess the utility of a quantification of the 123I-FP-CIT uptake by the definition of some reference values, normal range values and interobserver variation. Patients and method: Fifty patients with a 123I-FP-CIT SPECT: 25 patients had a pathological SPECT with the diagnosis of Parkinson's disease and the remaining had a qualitative normal SPET, with the diagnosis of 14 drug-induced Parkinsonism and 11 with psychogenic Parkinsonism. In the transversal slices, the best central slice that showed the nuclei of the base best was selected and standard ROIs (Region Of Interest) were applied. Specific (caudate and putamen) versus non specific (occipital) and laterality ratios were calculated. A normal statistical analysis for independent quantitative samples was used (mean, standard deviation and range) as well as variation coefficient and correlation coefficient of two observers and the 10th and 90th percentile. Results: The variation coefficient interobserver was 3.24-5.61 and the correlation coefficient was 0.89-0.99. Cut-off values between both populations were established at 2.10 in the right putamen and at 2.05 in the left. Cut-off values definition in caudate were not assessable due to overlapping of ratios of both populations. Conclusions: This quantification method is highly reproducible. It makes it possible to obtain reference values and to define normal range

[Guidelines for the treatment of spasticity in adults using Botulinum toxin]. / Guía terapéutica de la espasticidad del adulto con toxina botulínica.

AIMS: The introduction of Botulinum toxin type A (BTA) in the treatment of spasticity in adults was a large step forward in neurology and it is currently seen as the first choice treatment in focal spasticity. In an attempt to achieve the optimisation of this therapeutic resource, different clinical guidelines have been drawn up which include reviews of the evidence available about the indications and use of BTA. Spasticity is characterised by the presence of involuntary muscular hyperactivity that is often associated to pain, deformity and functional disability. From the clinical point of view, the advantages of BTA are obvious (ease of use and dosage determination, long lasting effects, reversibility should the response be inappropriate, etc.) and far outweigh its drawbacks. It can only be used after a proper selection of patients, of the therapeutic aims and of the muscular areas to be treated, and a tailor-made programme of rehabilitation must also be drawn up. Increasing experience in its use suggests that its early administration is effective in preventing or reducing the complications arising from spasticity. CONCLUSIONS: BTA is effective in the treatment of spasticity and plays a significant role if the clinical objectives involve functional aspects. At present a large amount of well-documented experience concerning its indications, effects and safety in clinical practice is already available.

Guía terapéutica de la espasticidad del adulto con toxina botulínica / Guidelines for the treatment of spasticity in adults using botulinum toxin

Objetivos. La introducción de la toxina botulínica A (TBA) en el tratamiento de la espasticidad en los adultos supuso un avance significativo en neurología; en la actualidad, se considera el tratamiento de elección en la espasticidad focal. Para conseguir la optimización de este recurso terapéutico, se han elaborado diferentes guías clínicas en las que se revisa la evidencia disponible sobre las indicaciones y el uso de la TBA. La espasticidad se caracteriza por la presencia de hiperactividad muscular involuntaria que, con frecuencia, se asocia a dolor, deformidad y discapacidad funcional. Las ventajas de la TBA son evidentes desde el punto de vista clínico (facilidad de uso y dosificación, larga duración del efecto, reversibilidad en caso de respuesta inadecuada, etc.) y superan ampliamente sus inconvenientes. Para su empleo se requiere una correcta selección de los pacientes, de los objetivos de tratamiento y de las áreas musculares a tratar y, finalmente, el desarrollo de un plan de rehabilitación personalizado. La creciente experiencia en su uso sugiere que su administración precoz es eficaz para evitar o reducir las complicaciones de la espasticidad. Conclusión. La TBA es efectiva en el tratamiento de la espasticidad y desempeña un papel evidente si los objetivos clínicos son funcionales. Actualmente, existe experiencia bien documentada sobre su uso y se conocen sus indicaciones, efectos y seguridad en la práctica clínica (AU)

Aims. The introduction of Botulinum toxin type A (BTA) in the treatment of spasticity in adults was a large step forward in Neurology and it is currently seen as the first choice treatment in focal spasticity. In an attempt to achieve the optimisation of this therapeutic resource, different clinical guidelines have been drawn up which include reviews of the evidence available about the indications and use of BTA. Spasticity is characterised by the presence of involuntary muscular hyperactivity that is often associated to pain, deformity and functional disability. From the clinical point of view, the advantages of BTA are obvious (ease of use and dosage determination, long lasting effects, reversibility should the response be inappropriate, etc.) and far outweigh its drawbacks. It can only be used after a proper selection of patients, of the therapeutic aims and of the muscular areas to be treated, and a tailor-made programme of rehabilitation must also be drawn up. Increasing experience in its use suggests that its early administration is effective in preventing or reducing the complications arising from spasticity. Conclusions. BTA is effective in the treatment of spasticity and plays a significant role if the clinical objectives involve functional aspects. At present a large amount of well-documented experience concerning its indications, effects and safety in clinical practice is already available (AU)