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Objective: Prior research suggests that restless leg syndrome (RLS) is prevalent in Parkinson’s disease (PD) with insufficient evidence to support the relationship between RLS, PD, and pain. This study explored the relationship between pain in PD patients and its association with the prevalence and severity of RLS. Method: 127 PD patients were assessed for PD and RLS using the U.K. Brain bank Criteria and the Restless Leg Syndrome diagnostic criteria, respectively. These patients were also assessed for pain perception and interference using the Brief Pain Inventory. Results: The results demonstrated Parkinson’s disease patients who reported pain scored 23 more Restless Leg Syndrome prevalence points ( p < 0.05), and 8.5 counts higher for Restless Leg Syndrome severity ( p < 0.05) compared to the group of Parkinson’s disease patients denying pain. Discussion: The presence of pain in PD patients indicated a higher RLS prevalence and an increased RLS severity. This finding suggests patients suffering from pain interference may experience more severe RLS symptoms. This demonstrates an inextricable link and association between pain in PD patients and RLS. Further robust investigations are required to elucidate any potential causative links, which can inform more holistic treatment principles.

Peripheral neuropathy (PN) is a common neurological problem defined as a dysfunction of sensory, motor, and autonomic nerves. The presence of peripheral neuropathy has recently been noticed in Parkinson's disease (PD) This comorbidity is concerning as it increases the burden on patients whose motor functions are previously compromised. A comprehensive computer-based literature review utilizing multiple peer-reviewed databases (e.g., Embase, PsycINFO, CINAHL, etc.) was conducted. There is evidence for the utility of robust diagnostic criteria to distinguish between large fiber neuropathy (LFN) and small fiber neuropathy (SFN). Some studies have established links between prolonged L-DOPA exposure and prevalence with increased levels of homocysteine (HCY) and methylmalonic acid (MMA) as pathological underlying mechanisms. PN in PD patients with relatively truncated exposure to L-DOPA therapy may have underlying mutations in the Parkin and MHTFR gene or separate mitochondrial disorders. Vitamin B12 and cobalamin deficiencies have also been implicated as drivers of PN. Accumulation of phosphorylated α-synuclein is another central feature in PN and deems urgent exploration via large cohort studies. Importantly, these underlying mechanisms have been linked to peripheral denervation. This review delves into the potential treatments for PN targeting B12 deficiencies and the use of COMT inhibitors along with other novel approaches. Avenues of research with powerful randomized controlled and long-term cohort studies exploring genetic mechanisms and novel treatment pathways is urgently required to alleviate the burden of disease exerted by PN on PD.

Objectives: Although there have been numerous studies conducted to better understand Parkinson’s disease (PD), the epidemiology of its debilitating non-motor symptoms across different ethnicities r...

Among the various non-motor symptoms of Parkinson's disease (PD), pain is often cited as the most common and debilitating feature. Currently, the literature contains gaps in knowledge with respect to the various forms of treatment available, particularly non-pharmacological therapies. Thus, the purpose of this systematic review is to provide an examination of the literature on non-pharmacological therapies for pain in PD. We compared the findings of research articles indexed within various literature databases related to non-pharmacological treatments of pain in PD patients. Our review identified five major non-pharmacological methods of pain therapy in PD: acupuncture, hydrotherapy, massage therapy, neuromodulation, and exercise. Treatments such as exercise therapy found a reduction in pain perception due to various factors, including the analgesic effects of neurotransmitter release during exercise and increased activity leading to a decrease in musculoskeletal rigidity and stiffness. By the same token, hydrotherapy has been shown to reduce pain perception within PD patients, with authors often citing a combined treatment of exercise and hydrotherapy as an effective treatment for pain management. Multiple methods of neurostimulation were also observed, including deep brain stimulation and spinal cord stimulation. Deep brain stimulation showed efficacy in alleviating certain pain types (dystonic and central), while not others (musculoskeletal). Hence, patients may consider deep brain stimulation as an additive procedure for their current treatment protocol. On the other hand, spinal cord stimulation showed significant improvement in reducing VAS scores for pain. Finally, although the literature on massage therapy and acupuncture effectiveness on pain management is limited, both have demonstrated a reduction in pain perception, with common reasons such as tactile stimulation and release of anti-nociceptive molecules in the body. Although literature pertaining to non-pharmacological treatments of pain in PD is sparse, there is copious support for these treatments as beneficial to pain management. Further exploration in the form of clinical trials is warranted to assess the efficacy of such therapies.

Pain is an important non-motor symptom of Parkinson's disease (PD); however, it remains understudied. The purpose of previous studies on the relationship between PD and pain, has been to explore the cause, origin and types of pain. This case control study is designed for clinicians and rehabilitation specialists to effectively identify pain from the patient's point of view. Pain present in PD patients correlates with significant disruption to their daily lives, which was seen by analysing characteristics, frequency, severity and interference of pain.A total of 100 PD patients and 100 control healthy individuals, consisting of 66 males and 34 females were evaluated during routine clinical assessment followed by a neurological exam. The Brief Pain Inventory (BPI) was used to measure chronic pain in terms of pain severity, pain interference and pain frequency between the two groups.It was determined that PD patients had significantly higher pain severity scores compared to controls (p 0.05). PD patients with depressive symptoms had significantly higher pain severity and pain interference scores than controls without depressive symptoms. PD patients reported greater scores on Global BPI pain interference and all components of the pain interference subscale.PD and depression seem to be correlated with higher perceived pain, severity and interference. These findings have not been reported by other case control studies, and warrant further causal research into pain, depression and PD.

Pain, poor sleep quality, restless legs syndrome (RLS), and other symptoms are frequently reported by patients with Parkinson's disease (PD). However, the impact that pain severity and interference has on non-motor symptoms (NMS) has not been extensively studied. The objective of the present study is to explore the relationship between sleep quality in PD to pain and other NMS that affect quality of life.The study included 100 PD patients and 100 age and gender-matched controls assessed for pain severity and pain interference using the Brief Pain Inventory and sleep quality using the Pittsburgh Sleep Quality Index. Participants were also evaluated for their subjective levels of anxiety and depression using the Hospital Anxiety and Depression Scale.PD patients with poor sleep quality had greater pain severity and pain interference than controls and PD patients with good or borderline sleep quality. PD patients with poor sleep quality also had the greatest case-ness and severity for depression and anxiety. However, RLS was not significantly correlated with depression, anxiety or pain.Poor sleep quality in PD patients is related to greater pain severity, pain interference, and more radiating and paresthestic pain that is independent of RLS. There is a higher prevalence of depression and anxiety in PD patients compared to controls, especially in PD patients with poor sleep quality. Our findings suggest a relationship between poor sleep quality in PD with pain, anxiety and depression. Prospective studies are warranted to investigate the causal relationship.

Pain in Parkinson’s disease (PD) is a debilitating symptom with a prevalence of 68%, yet is untreated 50% of the time. What is unclear, however, is which treatment is optimal for minimizing pain severity in PD. Thus, the objective of this systematic review and meta-analysis was to investigate the efficacy of a variety of novel, complimentary, and conventional treatments for pain in PD and elucidate which therapy is the most effective. A systematic search was performed using MEDLINE, PsycINFO, Embase, CINAHL, and CENTRAL databases. To identify additional articles, manual searches of reference lists of included trials were also searched. Major neurology conference proceedings occurring between January 2014 and February 2018 were also searched to identify unpublished studies that may be potentially eligible. Twenty-five randomized controlled trials that encompassed medical, surgical, and complementary therapies met our inclusion criteria and exhibited moderate quality evidence. Two reviewers conducted assessments for study eligibility, risk of bias, data extraction, and quality of evidence rating. A conservative random-effects model was used to pool effect estimates of pain severity. The greatest reductions in pain were found with safinamide (Standardized mean difference = –4.83, 95% CI [–5.07 to –4.59], p < 0.0001), followed by cannabinoids and opioids, multidisciplinary team care, catechol-O-methyltransferase inhibitors, and electrical and Chinese therapies. Moderate effects in reducing pain were in pardoprunox and surgery, while the weakest effects were in dopaminergic agonists and miscellaneous therapies. Safinamide is an important adjunct to standard parkinsonian medication for alleviating pain in PD.

Objective: While much research has been conducted toward understanding the relationship between prevalence of Parkinson's disease (PD) and generalized anxiety, little has been done considering additional influential factors in the relationship by means of a large ethnically diverse sample. Our study strives to fulfill these deficits in the literature as we set out to determine the impact of progression of PD, age, gender, and Hoehn and Yahr (H and Y) staging of PD on generalized anxiety. Methods: A retrospective chart review analysis was performed on PD patients who were regularly examined in a community-based PD and movement disorders center from 2005 to 2010. Results: This study consisted of 310 patients with PD among whom 12% had generalized anxiety. Neither age nor gender was significant onset predictors at P = 0.05. The impact of progression of H and Y Stages 2–3 and 2–4 increased the odds of generalized anxiety disorder (GAD) prevalence though it was statistically insignificant at P = 0.05. Conclusions: Clinicians should not expect the risk of developing anxiety to depend on gender nor change as a function of age though it may increase with symptomatic progression of PD as outlined by H and Y. To the best of our knowledge, this is the largest and most ethnically diverse prevalence study with a focus on generalized anxiety and PD. Significant Outcomes and Limitations: The symptomatic progression of PD, but not age or gender, may be associated with an increased risk for GAD. This study lacked adjustment for potential confounders such as depression and PD medications.

Parkinson's disease (PD) is a neurodegenerative movement disorder characterized by the loss of dopamine containing cells in the substantia nigra, with pain being one of the most common, yet frequently misunderstood symptoms. The prevalence of pain in PD populations ranges from 40-85% and is usually categorized under the following types: i) musculoskeletal pain ii) radicular and neuropathic pain iii) dystonia-related pain iv) akathitic pain and iv) central parkinsonian pain. Areas covered: The aim of this literature review was to document and present the common and uncommon pharmaceutical therapies that treat and/or alleviate these types of pain in PD. The PubMed database was searched with keywords: "Parkinson's disease", "Pain", and "Pharmacological Therapies". Research articles involving randomized, controlled trials were included as well as case studies and qualitative studies. Expert commentary: Given the increased prevalence of pain in PD populations, there is a need for a clear understanding of the types of pain treatments available and how they can be best combined to fit the specific needs of each patient.

Objective: To determine the relationship between resting tremor (RT) and action tremor (AT) in Parkinson’s disease (PD) patients. Methods: A retrospective study of RT and AT severity was conducted in 100 PD patients. The severity rating for each type of tremor in the upper extremities was assessed. The disparity in tremor severity between extremities for each tremor type was compared to that of the other two to identify commonalities in the laterality of the tremor manifestation. Results: Overall, RT is predictive of AT on the same side, but not the opposing side of the body. Patients with less intense resting right upper limb (RRU) tremor and moderately intense RRU tremor were significantly more likely to have an action right upper limb (ARU) tremor (−1.53, P = 0.020; −1.88, P = 0.005, respectively). Similarly, patients with less intense resting left upper limb (RLU) tremor and moderately intense RLU tremors were significantly more likely to have an action left upper limb (ALU) tremor (−3.49, P = 0.000; −1.86, P = 0.017, respectively). In addition, RRU and ALU tremors were associated with an increase in RLU and ARU tremors, respectively. Conclusion: Tremors are common findings in PD patients, and often impair quality of life. By identifying and classifying the relationship between resting and ATs in PD patients, our study sheds light onto the importance of better understanding and future management of this debilitating symptomology.

Pain is common in atypical parkinsonism such as multiple system atrophy (MSA), progressive supranuclear palsy (PSP), corticobasal degeneration (CBD) and dementia with Lewy bodies (LBD). In this study, a systematic review and meta-analysis was conducted and peer-reviewed literature was searched to determine the prevalence and types of pain in four atypical parkinsonism syndromes: MSA, PSP, CBD and LBD. The results show that pain was prevalent mainly in MSA patients in comparison to PSP and CBD patients. Pain was reported at an early stage and was found in females, with limb pain being the most common, followed by neck and back pain. In comparison to PSP, pain locations were similar to MSA patients. CBD patients experienced pain the least in comparison to MSA, PSP and LBD patients.

Objective: Parkinson's disease (PD) patients are known to suffer from pain, anxiety, and depression, but the exact degree of association between the two is unknown. As many PD patients also suffer from physical impairments, this cross-sectional case-control study sets out to compare and determine the case-ness of pain, anxiety and depression in PD patients that suffer with or without symptomatic osteoarthritis (OA). The goal of this study, therefore, was to observe if additional pain associated with comorbid OA in PD patients is correlated with greater depression and anxiety rates. The importance of understanding the burden of pain and increased depression severity of PD and OA patients is so that they may be screened appropriately based on the symptoms, which may increase their overall quality of life. Methods:This cross-sectional case-control study included 3 groups of 34 patients and 78 healthy age and gender-matched control participants. PD patients with symptomatic OA (PD+OA), PD patients without symptomatic OA (PD), patients with symptomatic OA but no PD (OA), and healthy control participants (Control). A PD patient group with Restless Legs Syndrome (PD+RLS) of 27 patients was also included. All participants completed questionnaires to assess for pain, depression, and anxiety. Results:PD+OA and PD patients had worsened depression severity and were more likely to report anxiety and depression case-ness than OA patients. PD+OA patients were more likely to complain about paresthestic and akasthisic pain, but less likely to complain about aching pain compared to PD patients and OA patients. PD+OA patients were more likely to have greater pain severity, and were more likely to report radiating and sharp pain than PD+RLS patients. PD+OA patients were also more likely to report higher depression case-ness than PD+RLS patients. Conclusion:PD with OA seems to be linked with specific pain characteristics (akathisia and paraesthesia) as well as heightened overall pain severity and pain interference in comparison to OA alone, PD alone and PD with RLS. PD is also correlated with depression severity and anxiety case-ness in OA when compared to the OA alone, PD alone and PD with RLS.

The objectives of the study were to analyze the association between Parkinson's disease and restless legs syndrome, and to explore the relationship between mood disorder comorbidity (anxiety and depression), pain, and restless legs syndrome.This study included 123 Parkinson's disease patients and 123 non-Parkinson's disease patients matched for age and gender, and evaluated for anxiety severity, depression severity, pain severity, pain interference, pain disability, and restless legs syndrome prevalence. This was performed using semi-structured interviews and a neurological examination through the restless legs syndrome diagnostic criteria and the following inventories; Hospital Anxiety and Depression Scale, Brief Pain Inventory, and Pain Disability Index.Parkinson's disease patients had significantly greater anxiety severity, depression severity, pain severity, pain interference, pain disability, and restless legs syndrome prevalence in comparison to controls. In addition, Parkinson's disease patients' comorbid for anxiety and depression had significantly greater pain severity, pain interference, and pain disability, but not RLS prevalence, in comparison to Parkinson's disease only, Parkinson's disease anxiety, and Parkinson's disease depression patients.Pain interference, pain severity, and pain disability is greater among Parkinson's disease patients with anxiety and depression, in comparison to Parkinson's disease patients without anxiety and depression. On the contrary, the prevalence of restless legs syndrome was not found to be relevant.

Alkaptonuria (AKU) is considered a rare autosomal recessive condition that results in an accumulation of homogentisic acid in body tissues and causes long-term clinical, neurological and psychological complications. We present a comprehensive evaluation of an atypical 46-year-old Caucasian male who developed all clinical diagnostic symptoms of AKU (ochronotic pigmentations, dark urine and clinical arthritis of major joints including spine) by 25 years of age, well before the typical age mentioned in many reviews. First signs of ochronotic ear pigmentations unexpectedly started appearing as early as 12 years of age. A long “disease-free” period typical in classical AKU patient was also absent. This case report highlights the importance of considering psychological issues in AKU patients. The patient showed symptoms of dysthymia reporting social isolation, diminished interest in pleasurable activities, feeling of worthlessness and irritability as major psychological issues. Early ochronotic pigmentation, advanced spinal myelopathy and arthropathy of major joints suggests aggressive course of the disease. Our patient underwent bilateral shoulder replacement due to AKU-induced arthropathy resulting in restoration of some range of motions. AKU is not fully understood and we recommend treating it as a multidimensional disease with simultaneous physiological, neurological and psychological effects. Early diagnosis, understanding of disease prognosis and emphasis on psychological health is needed to improve the quality of life of AKU patients.

Context: Late onset Parkinson’s disease (LOPD) is a neurodegenerative disorder afflicting individuals of ages 60 and older. However, 5–10% of cases can begin earlier between the ages 20 to 40, and are classified as young onset Parkinson disease (YOPD). Aim: In turn, this study aims to observe the trend in the choice of drug administered to patients with both YOPD and LOPD, with particular emphasis on this trend in its relation to the practice background of the neurologist. Settings and Design: A cross-sectional study was conducted in a community based Parkinson’s disease and movement disorder clinic. Statistical Analysis Used: Using a retrospective chart review data was obtained and analysed. Results: The results showed that 83% of general neurologists prescribed levodopa to their patients with YOPD, whereas movement-disorder specialists took a different approach altogether. They opted not to use levodopa and, in its stead, prescribed a mixture of alternate drugs.

For the interpretation of EEG, the patient’s condition is described, including whether the patient is awake, has eyes closed or open, and is relaxed or tense. Activation methods are also described.

Nerve conduction studies evaluate neuromuscular disease by providing a neurophysiological assessment of peripheral nerves, neuromuscular junctions, muscles, dorsal root ganglion cells, and anterior horn cells. The peripheral nerve is studied with regard to its pathophysiology and its localization.

Patients having EEG studies for a seizure disorder should be studied when awake as well as while asleep in the same record, since interictal epileptiform activity is increased during sleep and when drowsy . Patients are routinely asked to arrive for the examination after having been sleep-deprived the night before to allow for easy transition to drowsiness.

Sensory nerve conduction studies are an essential part of the electrodiagnostic examination, for several reasons. Some peripheral nerve lesions involve only sensory nerves or only the sensory fibers of mixed nerves. Sensory conduction studies are typically more sensitive than their motor counterparts to pathophysiological processes occurring along mixed nerves. For example, in these mixed nerves, sensory conduction typically occurs before or is more severe than the conduction in the motor components, such as in the segmental demyelinating lesions of carpal tunnel syndrome. Sensory conduction amplitudes are more sensitive to axon loss than ?.

The F-wave is an action potential that is evoked intermittently from a muscle by a supramaximal electrical stimulation of the nerve that is caused by the antidromic activation of motor neurons. The F-wave action potential is approximately 1–5 % that of the M-wave and has a variable configuration. Its latency is longer than that of the M-wave and is variable.

Facial neuropathy is the most common cranial neuropathy. The anatomy of the facial nerve is complex, with a long intracranial course. Electrodiagnosis can be helpful in determining prognosis, but such studies are not helpful until several days after the onset of the neuropathy. The clinical presentation shows unilateral weakness of the upper and lower parts of the face, hyperacusis, dysgeusia, and abnormal lacrimation and salivation. Seventy percent of cases are idiopathic, or they can be regarded as Bell’s palsy. Ramsay Hunt syndrome, also known as herpes zoster oticus, is another common cause of facial neuropathy.

Somatosensory evoked potentials (SEPs) are used as an extension of the electrodiagnostic evaluation and nerve conduction tests that are performed in large myelinated sensory fibers of the peripheral and central nervous systems. SEP studies are noninvasive; SEPs are obtained by the repetitive submaximal stimulation of a sensory or mixed sensory/motor peripheral nerve and recording the average responses from electrodes placed over proximal portions of the nerves stimulated in the plexus, spine, and scalp.

Pain is a common problem faced by Parkinson's disease (PD) patients. Despite its impact and disabling effects pain is still frequently overlooked. In this study we analyze a representative sample of peer reviewed literature for the prevalence and types of pain in PD, the impact and significance of pain in the quality of life of the PD patient and the challenges inherent in the diagnosis and management of pain in PD patients. We compared and analyzed the findings of articles indexed in the PubMed database which looked at symptoms reported by large cohorts of PD patients. These articles all reported the incidence, nature and quality of pain in these patients and described the effects of pain on quality of life and generally were cross-sectional, retrospective or case-control studies, though a major pharmacoepidemiological design study was also analyzed. Results of our analysis showed that the pain was prevalent in 59.77% of PD patients. Five different types of pain were reported by PD patients--dystonia, musculoskeletal pain, nerve/nerve root pain, primary/central pain and according to some, akathisia. Patients who reported pain symptoms were also significantly more likely to report associated depression and a decreased quality of life. Many PD patients also reported poor management of pain and lower analgesic use than would be expected. We further discuss some of the possible approaches toward the development of a treatment algorithm regarding the management of pain in PD. We conclude that pain in is an under-recognized and under treated symptom in PD patients. Effective management of pain in PD patients would significantly improve their quality of life. Our analysis is in line with current thinking that identifies PD is much more of a multisystem disease with non-motor symptoms than previously thought.

Young onset Parkinson's disease patients, typically aged 21 to between 40 and 55, have symptomatology similar to regular onset patients. Despite this, we suspect that physicians take longer to diagnose young onset patients since Parkinson's disease is ruled out due to the younger age. The history prior to diagnosis of 14 young onset patients (within 21 to 45 years of age) was compared with an equivalent number of regular onset patients matched by gender, tremor presence, and Hoehn and Yahr stage. Indeed, a longer period of time was taken to diagnose younger patients with an average of additional 15 months (p

Objectives Both visual hallucinations and cognitive dysfunction are experienced by a significant number of patients with Parkinson's disease. There were three main objectives of this study: (1) to determine if there is a difference in the prevalence of dementia in patients with tremor versus non-tremor dominant Parkinson's; (2) to determine if there is a difference of prevalence of visual hallucinations in patients with tremor and non-tremor dominant Parkinson's disease; and (3) to determine if there is a relationship between visual hallucinations and dementia in Parkinson's disease patients. Background Dementia and visual hallucinations are common non-motor symptoms of Parkinson's disease that affect a significant number of patients. Previous research has shown that visual hallucinations may be predictive of future onset of dementia. We wanted to compare the prevalence of these non-motor symptoms in tremor vs. non-tremor dominant Parkinson's disease, although previous research has shown that dementia may be more common in the akinetic rigid variant of Parkinson's disease without tremor. Visual hallucinations have not yet been studied in this way. Methods We performed a retrospective chart analysis on 314 patients with Parkinson's disease in this study. Patients meeting the inclusion criteria were stratified into several categories based on the presence or absence of tremor dominant PD, akinetic rigid dominant PD, dementia and visual hallucinations. Nonparametric tests were used for performing statistical analyses. The Chi Squared test was used for the analysis of categorical variables. Results Patients without tremor had a higher prevalence of dementia (29%) than those with tremor (14%). There was no difference in visual hallucinations in tremor versus non-tremor patients, although there was a significant trend between tremor and visual hallucinations in female patients. A significant correlation was found between dementia and visual hallucinations in the sample, however further investigation showed this was largely associated with female Parkinson's disease patients.

Objective Parkinson’s disease (PD) is a progressively debilitating disorder resulting in reduced quality of life (QoL). Along with the motor symptoms of PD, non-motor symptoms of PD such as pain, restless leg syndrome (RLS) depression also occur. These exacerbate the worsening QoL and must be promptly diagnosed and treated. The objective of this study was to determine the relationship between pain severity, walking, general activity and work (WAW) and rapid eye movements (REM) dimensions of pain interference, and disability with depression and RLS in PD. Patients & methods 120 patients with PD and 120 controls were evaluated for depression using the Hospital Anxiety and Depression Scale (HADS-D). Pain severity and interference was measured using Brief Pain Inventory (BPI). REM and WAW dimensions of pain were also measured. The Pain Disability Index (PDI) was used to assess the disabling effects from chronic pain. Results The study found a statistically significant direct correlation between the BPI, PDI and PD. A significant direct correlation was also found for depression and pain in PD. No association as found between RLS and PD; RLS was not a confounding factor. Conclusions Based on these findings, we conclude that pain interference, severity of pain and disability from pain is directly correlated with depression in PD. We also discern that these symptoms of PD are not independent of each other. We cannot establish a causal relationship between any of these variables. Prompt recognition and treatment of pain and depression is valuable in preserving the quality of life in PD.

Aims: Parkinson's disease is a chronic neurodegenerative disorder characterized by bradykinesia, rigidity, and resting tremor. Dementia, among its non-motor symptoms, is a debilitating complication affecting intellectual functioning. The aim of the present study was to determine the prevalence of dementia in Parkinson's disease and its relation to age, gender and stage of the disease. Methods: A retrospective chart analysis was performed on Parkinson's disease patients seen in a community-based Parkinson's disease and movement disorder clinic between 2005 and 2010. Results: A total of 310 patients were included in this survey, among whom 61 patients (19.7%) with Parkinson's disease met the criteria for dementia. Age was found to be a significant factor in developing dementia, with 90% of patients with dementia aged ≥70. Gender, however, was not correlated with dementia in Parkinson's disease. On analysis of stage at which dementia developed, progression of the disease was positively correlated with prevalence of dementia. Conclusions: As age increases, the chances of developing dementia increase. Dementia, contrarily, is not selective between genders. The likelihood of developing dementia increases as the stage of disease advances. Further research is required in order to understand underlying mechanisms of dementia in Parkinson's disease.

Background Despite being an important non-motor symptom of PD, pain remains largely understudied in PD patients. Experiencing symptoms of pain is highly disruptive of general functioning, as it may hinder both physical prowess and psychological well-being. Although pain is prevalent in the otherwise healthy geriatric population, its increased presence in PD, and the difficulty it poses when combined with other hallmark motor symptoms necessitates further investigation. An improved understanding of factors that aggravate pain, and methods that alleviate discomfort may provide significant insight on the basis of pain in PD. Such information may ultimately allow healthcare professionals to achieve the goal of improved PD patient management. Objective To study the associations between various factors and pain in a Parkinson's disease (PD) patient population. Methods This study investigated 121 PD patients, of which 80 reported to have pain in at least one area of the body. Exclusion criteria included patients suffering from external causes of pain, such as trauma and patients with cognitive impairment whose accounts may not have been reliable. Further inquiry determined the etiology of pain, as well as aggravating and alleviating factors. The efficacies of pharmacological or non-pharmacological therapies were assessed through additional questioning. Individuals were also asked whether their pain was unintentionally affected by other measures, such as prescribed PD medications. Results Multiple linear regression analysis with a Wald test value of 4.070 (p = 0.044) demonstrated a statistically significant relationship between the administration of analgesics in patients with high reported pain and their pain relief. However, patients who experienced moderate pain did not exhibit any statistically significant levels of pain relief with the use of analgesics (Wald = 2.097, p = 0.148). Similarly, non-pharmacological therapies, PD medicine, and comorbidities showed no statistically significant correlations with pain relief. Conclusions Physicians should be aware of the physiological and psychological factors that form major components of pain relief, and that patient education and support are critical to successful treatment programs.

The objective of this study was to determine the prevalence of blepharospasm (BSP), with and without apraxia of eyelid opening (AEO), in patients with parkinsonism, cervical dystonia (CD), and essential tremor (ET). BSP, with or without AEO, is associated with parkinsonism. There have been several reports of BSP in other dystonic conditions, but few looked at the incidence of BSP in ET patients. This study included 659 patients of which 357 had parkinsonism (276 idiopathic Parkinson’s disease (IPD) and 81 atypical parkinsonism (57 progressive supranuclear palsy; 11 multiple system atrophy 13 corticobasal degeneration)), 274 had ET, 22 had CD, and 6 had spinocerebellar ataxia. Our results indicate that BSP (with or without AEO) was more prevalent in atypical parkinsonism (6 out of 81, 7.41%) than IPD (9 out of 276, 3.26%). The study also followed 10 (of the 28) patients with BSP to screen for the development of other movement disorders – of these, 2 developed Parkinson’s disease. We conclude then that BSP is common in parkinsonism and that BSP is more prevalent in atypical parkinsonism. We also conclude that BSP is not a common feature in ET patients (0 out of 274 patients reported BSP symptoms).

Giant cell arteritis (GCA) or Temporal arteritis (TA) is an autoimmune disease and the most common type of vasculitis in the elderly. It causes inflammation of the medium and large arteries in the upper part of the body. GCA is an under-recognized cause of head aches in the elderly, especially when it presents itself with atypical features, resulting in delayed or incorrect diagnosis. Since GCA is a treatable condition, an accurate diagnosis is crucial to prevent the most serious complication of CGA, permanent vision loss. The diagnosis can be further complicated as GCA may present with features of other painful neurological conditions. The present case is an 81-year-old woman diagnosed with GCA, who initially presented with features similar to tension-type headache. Due to overlapping features of these conditions, the diagnosis of GCA was delayed, resulting in irreversible vision loss. Although previous research highlights diagnostic dilemmas featuring GCA and other disease states, this case is exclusive in describing a unique dilemma where tension-type headache mimics GCA.

Delayed enlargement of a traumatic cerebral contusion can occur subsequent to an initial CT scan, and this can lead to neurological deterioration, brain herniation, and death. Herein, we describe the case of a 76-year-old male who experienced an intracerebral hemorrhage subsequent to a fall and whose injury worsened over time. We summarize the current recommendations in the literature for when to initiate follow-up imaging in patients with traumatic head injury, the risk factors for progression, and the role of close clinical monitoring and serial imaging in managing such patients. Finally, we illustrate how these recommendations were applied in our case.

The diagnosis of essential tremor is made if a patient has an action tremor in both upper extremities in the absence of other medical conditions or drugs that cause tremor. In this chapter we point out features that would suggest an alternative diagnosis, and briefly discuss other conditions that might be confused with essential tremor.

Essential tremor (ET) is one of the most common neurological disorders and can affect anyone at any age. Because up to 50 % of ET patients have an affected family member, it is mostly considered a genetic disorder, though the exact genes have not yet been identified. The clinical hallmark of ET is an action (kinetic and postural) tremor of the hands, but the underlying pathophysiology remains unclear. This chapter discusses in more detail the epidemiology, genetics, pathophysiology and clinical features of essential tremor.

Tremor is an involuntary rhythmic oscillation of a body part, mediated by alternating contractions of reciprocally acting muscles. While tremor can be classified in many ways, categorizing tremor based on its positional properties (resting vs. action) is the most clinically helpful. This chapter discusses how to describe patients with different tremors.

In this chapter, we discuss the treatment of essential tremor. Pharmacologically, in addition to propranolol and primidone, there are other medications that can be helpful. There have also been recent advances in non-pharmacologic options. Finally, deep brain stimulation and thalamotomy can be very effective surgical treatments for the appropriate candidates.

Background/Aims: Drooling or sialorrhea is a common non-motor symptom of Parkinson’s disease (PD), and is reported by 35–75% of patients. Drooling is primarily due to impaired swallowing rather than hypersecretion of saliva. In this study, we examined the prevalence of drooling in PD and its relation to various factors such as age, stage of disease, gender and ethnicity. Methods: A retrospective cohort chart analysis of 307 patients with idiopathic PD was conducted. These patients were seen in the Parkinson’s Disease and Movement Disorders Clinic between 2005 and 2010. Results: 123 (40%) patients exhibited drooling. No correlation between age and development of drooling was observed. However, gender was found to be a significant factor in developing sialorrhea. Males are twice as more likely to develop sialorrhea than females. In addition, drooling becomes more prevalent with disease progression; Hoehn and Yahr stage 4 patients being the most at risk. Ethnicity and immigration status have no relationship in developing drooling. Conclusions: Sialorrhea is seen in a significant number of PD patients. This study, to the best of our knowledge, is the most extensive clinical assessment of drooling in PD to date.

Leg pain and discomfort are common complaints in any primary physician’s clinic. Two common causes of pain or discomfort in legs are nocturnal leg cramps (NLC) and restless leg syndrome (RLS). NLC present as painful and sudden contractions mostly in part of the calf. Diagnosis of NLC is mainly clinical and sometimes involves investigations to rule out other mimics. RLS is a condition characterized by the discomfort or urge to move the lower limbs, which occurs at rest or in the evening/night. The similarity of RLS and leg cramps poses the issue of errors in diagnosing and differentiating the two. In this paper we review the pathopysiology of each entity and their diagnosis as well as treatment. The two conditions are then compared to appreciate the differences and similarities. Finally, suggestions are recommended for complete assessment.

Essential tremor (ET) and Parkinson's disease (PD) tremor differ in type, frequency and distribution. Despite being two separate disorders, there have been cases reported of comorbidity for ET-PD. Studies have reported an increase in the incidence of ET in relatives of patients with PD, yet the risk of developing PD in ET patients has not been thoroughly investigated. Our study set out to determine the incidence of precedent ET in PD patients. We conducted a retrospective chart review analysis of 332 idiopathic PD patients to determine how many of them had ET prior to the diagnosis of PD and the percentage of them who were also diagnosed with ET. Our results indicate that the prevalence of precedent ET among a population of idiopathic PD patients was not any higher than the prevalence of ET in a comparable general population. Our results support the notion that ET and PD are mutually independent disorders. Further studies are needed to understand the exact relationship between these two disorders.

The objectives of the study were to analyze the association between Parkinson’s disease and restless legs syndrome, and explore the relationship between mood disorder comorbidity (anxiety and depression), pain, and restless legs syndrome. This study included 123 Parkinson’s disease patients and 123 healthy controls matched for age and gender, and evaluated for anxiety severity, depression severity, pain severity, pain interference, pain disability, and restless legs syndrome prevalence. This was performed using semi-structured interviews and a neurological examination. Restless Legs Syndrome diagnostic criteria and the following inventories were used; Hospital Anxiety and Depression Scale, Brief Pain Inventory, and Pain Disability Index. Parkinson’s disease patients had significantly greater anxiety severity, depression severity, pain severity, pain interference, pain disability, and restless legs syndrome prevalence in comparison to controls. In addition, Parkinson’s disease patients’ comorbid for anxiety and depression had significantly greater pain severity, pain interference, and pain disability, but not RLS prevalence, in comparison to Parkinson’s disease only, Parkinson’s disease anxiety, and Parkinson’s disease depression patients. Pain interference, pain severity, and pain disability is greater among Parkinson’s disease patients with anxiety and depression, in comparison to Parkinson’s disease patients without anxiety and depression. On the contrary, the prevalence of restless legs syndrome was not found to be relevant.

The aim of this review is to assess new, emerging, and experimental treatment options for tardive dyskinesia (TD). The methods to obtain relevant studies for review included a MEDLINE search and a review of studies in English, along with checking reference lists of articles. The leading explanatory models of TD development include dopamine receptor supersensitivity, GABA depletion, cholinergic deficiency, neurotoxicity, oxidative stress, changes in synaptic plasticity, and defective neuroadaptive signaling. As such, a wide range of treatment options are available. To provide a complete summary of choices we review atypical antipsychotics along with resveratrol, botulinum toxin, Ginkgo biloba, tetrabenazine, clonazepam, melatonin, essential fatty acids, zonisamide, levetiracetam, branched-chain amino acids, drug combinations, and invasive surgical treatments. There is currently no US Food and Drug Administration-approved treatment for TD; however, prudent use of atypical antipsychotics with routine monitoring remain the cornerstone of therapy, with experimental treatment options available for further management.

Action tremor (AT) and resting tremor (RT) have been widely cited in many studies with Parkinson's disease (PD) patients, but studies looking at the association between the two tremor types are few and show inconsistent results. This study will look at the prevalence and association of AT and RT in a large sample of idiopathic PD patients, and will put the results into context with the literature.A retrospective chart review analysis of 332 patients with idiopathic PD was performed. Prevalence rates of particular tremor types were noted. The presence of AT was analyzed relative to the presence and severity of RT.Nearly all individuals with AT also had RT. The concurrence of the two tremor types was found to be highly significant by statistical analysis (P0.0001). The severity of RT, measured by its laterality, may also be of importance, albeit to a much smaller extent if at all. Neither presence of tremor nor type of tremor present was influenced by patient gender, age, or Hoehn and Yahr stage of PD.The results indicate that AT has extensive presence in PD. This and its seemingly close relationship to RT suggest that AT may be considered a variant of RT, particularly in PD patients. The degree of association between RT and AT needs to be further analyzed in PD, as well as in essential tremor (ET) and ET-PD.

One of the most common non-motor symptoms in Parkinson's disease (PD) is nocturia. This paper seeks to address the prevalence of nocturia in PD and correlate it to various factors such as gender, Hoehn and Yahr (HY) stage, age, and ethnicities.In particular, 332 PD patients were seen in a community movement disorders clinic and their charts were analyzed from 2005 to 2010. Within this population, more than one-third (34.9%) patients were diagnosed with nocturia.Age, gender, and PD stage were significant predictors of nocturia in PD. With every one-year increase in age, the odds of developing nocturia in PD increases by 3.1% while an increase in HY stage increases the odds of nocturia in PD by 1.645 times. Also, males had greater odds of experiencing nocturia in PD. Ethnicities alone were of no significant importance. However, after performing interaction analyses, Asian and Indian males, especially, were at significantly greater risk than other ethnicities.Future research is indeed required to understand why certain ethnicities are especially at risk. Clinicians must also be aware of the epidemiology of nocturia in PD to prevent and treat this debilitating symptom.

Imaging of the blood vessel lumen can be best achieved by injecting a dye into the vessel and then imaging the dye with Xray, CT, or MR technologies, but a lot of information can be gleaned by measuring flow through the vessels with ultrasound. Because of the increased risk of stroke with conventional angiography, CT angiography or MR angiography is often the first choice of investigation for imaging intracranial arteries, but doppler ultrasound is still frequently used to assess the carotid arteries. Interpreting the results from any modality requires a good knowledge of vessel anatomy. In this chapter we present a quick review of the anatomy of the circle of Willis and provide case examples of vessel stenosis and aneurysms using MRA, CTA, and doppler ultrasound.

Transient ischemic attack (TIA) is defined as a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. A stroke occurs with progression to acute infarction in this context.

Approximately 85 % of patients with multiple sclerosis (MS) present with the relapsing-remitting form of the disease. A high frequency of relapses in the first year after diagnosis is associated with poor prognosis. Exacerbations of multiple sclerosis are characterized by episodes of focal neurological disturbance lasting more than 24 h and preceded by a period of clinical stability lasting 30 days or more. Fluctuations in symptoms with fever, heat, or infection may not be considered true exacerbations since in these contexts previous deficits may be simply “unmasked.” For this reason, screening labs should include a CBC and urinalysis to help exclude intercurrent infection. Contrasted brain MRI is useful to assess any new (typically enhancing) lesions which may be responsible for the acute exacerbation. Lumbar puncture and CSF analysis are not necessary if the diagnosis of multiple sclerosis is already established. However, it may show a variable degree of pleocytosis and increased total protein, myelin basic protein, and oligoclonal bands with an elevated IgG synthesis rate and IgG index. Visual evoked potentials remain abnormal years after an episode of optic neuritis. Somatosensory and brainstem auditory evoked potentials are abnormal in at least one-third to one-half of patients with MS.