Three-Dimensional Mesh Recovery from Common 2-Dimensional Pictures for Automated Assessment of Body Posture in Camptocormia.

Background: Three-dimensional (3D) human body estimation from common photographs is an evolving method in the field of computer vision. It has not yet been evaluated on postural disorders. We generated 3D models from 2-dimensional pictures of camptocormia patients to measure the bending angle of the trunk according to recommendations in the literature. Methods: We used the Part Attention Regressor algorithm to generate 3D models from photographs of camptocormia patients' posture and validated the resulting angles against the gold standard. A total of 2 virtual human models with camptocormia were generated to evaluate the performance depending on the camera angle. Results: The bending angle assessment using the 3D mesh correlated highly with the gold standard (R = 0.97, P < 0.05) and is robust to deviations of the camera angle. Conclusions: The generation of 3D models offers a new method for assessing postural disorders. It is automated and robust to nonperfect pictures, and the result offers a comprehensive analysis beyond the bending angle.

Prediction of the effect of deep brain stimulation on gait freezing of Parkinson's disease.

OBJECTIVE: The response of freezing of gait (FOG) to deep brain stimulation of the subthalamic nucleus (STN-DBS) is controversial and depends on many poorly controlled factors. On the other hand, a clinical predictor for the individual patient is needed to counsel the patient regarding this symptom. METHODS: A cohort of 124 patients undergoing STN-DBS was evaluated based on the video-documented Levodopa test at baseline in the OFF- and ON-drug condition and postoperatively in the best condition (ON-drug/ON-stim) and the worst condition (OFF-drug/ON-stim). We compared the freezing item of the Unified Parkinson's disease rating scale (#14), the UPDRS III total score, and FOG severity rated during four provoking situations with regard to its predictive value. RESULTS: We found 'FOG during the turning task' to be the best predictor with an ROC-value of 0.857 compared to 0.603 for the UPDRS Item 14 and 0.583 for the total UPDRS III. An improvement of 1 or 2 grades of the turning item during the preoperative levodopa test predicts an improvement during the worst condition postoperatively of 1 grade or more with an 80% probability. CONCLUSION: This FOG prediction test is simple and clinically useful. The test needs to be studied in a prospective study.

Clinical patterns of gait freezing in Parkinson's disease and their response to interventions: An observer-blinded study.

BACKGROUND: Freezing of gait (FOG) in Parkinson's disease (PD) is provoked by specific situations. The sensitivity of these situations to detect FOG and the relative FOG response to l-dopa and subthalamic nucleus deep brain stimulation (STN-DBS) is unknown. METHODS: Two blinded reviewers analyzed the video recordings of a standardized patient assessment before and 10 months after DBS-implantation of 124 PD patients with positive FOG according to the Unified Parkinson Rating Scale part II item 14. Baseline evaluations were done under 2 conditions (OFF- and ON-drug states). Postoperatively, the patients were evaluated under 4 conditions (OFF-drug/OFF-stim, OFF-drug/ON-stim, ON-drug/OFF-stim, and ON-drug/ON-stim). FOG frequency and its severity was rated during different provoking situations (start, turning, reaching a destination and open space hesitations) during a standardized walking task. Cumulative link mixed models were calculated to investigate the immediate and carry-over effect of medication and stimulation. RESULTS: Eighty-one percent of patients presented FOG at least in one provoking situation on video assessment. During turning, the FOG severity was significantly worse than for the other subtypes (p < 0.0001). Both interventions improve all FOG subtypes similarly. The effect size of l-dopa and STN-DBS on subtypes were similar (p > 0.05), but the combined intervention had a stronger effect on FOG severity (p < 0.0001) compared to each intervention separately. FOG severity was lower at follow-up OFF compared to baseline OFF condition (p < 0.02) demonstrating a carry-over effect of STN-DBS. CONCLUSION: Turning is the most sensitive provoking situation for gait freezing. STN-DBS and l-dopa improve all FOG subtypes similarly, their effect is stronger in combination.

Lack of Accredited Clinical Training in Movement Disorders in Europe, Egypt, and Tunisia.

BACKGROUND: Little information is available on the official postgraduate and subspecialty training programs in movement disorders (MD) in Europe and North Africa. OBJECTIVE: To survey the accessible MD clinical training in these regions. METHODS: We designed a survey on clinical training in MD in different medical fields, at postgraduate and specialized levels. We assessed the characteristics of the participants and the facilities for MD care in their respective countries. We examined whether there are structured, or even accredited postgraduate, or subspecialty MD training programs in neurology, neurosurgery, internal medicine, geriatrics, neuroradiology, neuropediatrics, and general practice. Participants also shared their suggestions and needs. RESULTS: The survey was completed in 31/49 countries. Structured postgraduate MD programs in neurology exist in 20 countries; structured neurology subspecialty training exists in 14 countries and is being developed in two additional countries. Certified neurology subspecialty training was reported to exist in 7 countries. Recommended reading lists, printed books, and other materials are the most popular educational tools, while courses, lectures, webinars, and case presentations are the most popular learning formats. Mandatory activities and skills to be certified were not defined in 15/31 countries. Most participants expressed their need for a mandatory postgraduate MD program and for certified MD sub-specialization programs in neurology. CONCLUSION: Certified postgraduate and subspecialty training exists only in a minority of European countries and was not found in the surveyed Egypt and Tunisia. MD training should be improved in many countries.

Quantitative assessment of posture in healthy controls and patients with Parkinson's disease.

INTRODUCTION: A stooped posture is a main clinical feature of Parkinson's disease (PD). The assessment of posture is important to measure treatment effects. The aim of this study was to investigate the reliability of a standardized postural rating tool, to calculate minimal detectable change scores and to assess the role of gender and age. METHODS: Two independent raters assessed total camptocormia (TCC), upper camptocormia (UCC) and Pisa angles of 192 PD patients and 78 healthy controls (HC) with the free NeuroPostureApp©(http://www.neuroimaging.uni-kiel.de/NeuroPostureApp). Reliabilities and linear models were calculated for different effects. Three subgroups were defined based on two thresholds (mean+2SD of HC and PD): A) normal, B) presumed stooped/lateral bended posture and C) postural disorder. RESULTS: Intraclass correlation coefficients ranged between 0.71 and 0.95 for the interrater and test-retest reliability of the three angles. The minimal detectable change values in the PD patients were 3.7°, 6.7° and 2.1° for the TCC, UCC and Pisa angles, respectively. Men had a more stooped posture than women (p < 0.05). Patients with PD had a worse posture than HC (p < 0.001) in all three angles. For the TCC angle, 39.1% of the patients had a normal posture (<17.4°), 47.9% a presumed stooped posture (>17.4°, <30.2°) and 6.3° had camptocormia (>30.2°). CONCLUSIONS: The NeuroPostureApp© is reliable. Our results confirmed gender differences and the progression of postural deviation in PD patients with age and empirically support the ≥30° TCC angle as a defining criterium for camptocormia. Diagnostic criteria for UCC and Pisa syndrome should be further explored in future studies.

The Effect of Medication and Deep Brain Stimulation on Posture in Parkinson's Disease.

Introduction: Postural abnormalities are common in Parkinson's disease (PD) and increasing with disease progression. While many studies focus on balance and gait, postural alignment is only infrequently studied. Purpose: The aim of the present study was to examine the immediate and long-term effects of medication and deep brain stimulation (DBS) in the subthalamic nucleus on postural alignment in PD. Materials and Methods: PD patients (n = 192) in an advanced stage of disease were videotaped during a standardized l-dopa trial before and after DBS. The patients were tested with and without medication pre-surgical and retested post-surgical (6-24 months) in all treatment combinations of medication and DBS regarding the on and off conditions. The forward bending as total camptocormia (TCC) and upper camptocormia (UCC) angles and lateral bending as Pisa angle were assessed with the free downloadable NeuroPostureApp (http://www.neuroimaging.uni-kiel.de/NeuroPostureApp/). Three subgroups were defined according to normative values of healthy controls and according to clinical criteria: patients with normal posture, with stooped posture, and with postural disorders. Results: A stooped posture was found in 82% of the patients with regard to the TCC angle and in 54% for the UCC angle. Sixty-two percent had an abnormal Pisa angle. Camptocormia was diagnosed in ~7% and a Pisa syndrome in 1% of the patients. Medication and DBS both significantly improved postural alignment in the entire cohort. Female and male patients benefit similarly by medication and stimulation. Subgroup analyses revealed that the effects were also significant for patients with stooped posture, and the effects were strongest for patients with camptocormia: they led to angles below the diagnostical criterion for camptocormia for 13 of 14 patients with TCC and 11 of 26 patients with UCC. DBS had an additional effect to medication over time for the Pisa angle. Conclusion: Medication and DBS both improved postural alignment in PD patients, but effects were small for the entire cohort. Patients with camptocormia according to the TCC angle benefit strongest. The large differences of the treatment effects may indicate distinct pathological mechanisms for stooped posture and postural disorders. The TCC angle was shown to be sensitive to change. The UCC angle was less sensitive but may be a useful assessment tool for a subgroup.

Spin turns in advanced Parkinson's disease: A new clinical gait sign?

OBJECTIVE: Two strategies are known for turning while walking: step turns (the direction change is performed with 3 steps or more) and spin turns (turning on one/both feet simultaneously). It is unknown which strategy patients with Parkinson's disease (PD) choose and if l-dopa and STN-DBS are influencing this strategy. METHODS: Video-recordings of 171 PD patients that completed 180° turns were analyzed by two blinded raters before surgery, both off and on l-dopa, and one year after STN-DBS-implantation. The strategies were classified: 1) spin 2) step and 3) mixed (spin plus step) strategy. The characteristics of the patients with different strategies were compared. RESULTS: Interrater reliability for classification of turning strategy showed high agreement (κ = 0.894). The distribution of the preferred strategy differed significantly between treatment conditions (untreated, treated with l-dopa, l-dopa plus stimulation; X2(4) = 67.2, p < 0.0001). The spin turn was found in 10.5% of patients OFF-drug, 23.5% ON-drug and in 38.8% ON-drug/ON-stim condition. In the three treatment conditions patients with spin turns had significantly lower UPDRS III scores compared to people with step turns (p = 0.017, p = 0.001, p = 0.006, respectively); step turn patients had poorer postural instability and gait disorders (PIGD) scores (p = 0.04, p = 0.002, p = 0.04, respectively). CONCLUSION: The turn strategy can be reliably identified in clinical settings and is a simple motor sign. The spin turn is associated with better motor performance. Since improvements in motor score in patients with fluctuations are also related to behavioral changes, we cannot exclude that the turn strategy also represents a feature of psycho-motor interaction.