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Background and ObjectivesTo systematically review the literature for the most suitable trigger criteria for referral to specialist palliative care services in life-limiting and life-threatening neurologic and neurosurgical conditions.MethodsLiterature searches were conducted in Ovid MEDLINE and EMBASE (1990–December 2020). To be included, studies must have trigger/referral criteria clearly outlined, a ≥75% nononcology neurosciences population, and consensus or guidelines documents regarding palliative neurosciences or trigger/referral criteria. We excluded studies that had an oncologic or non-neurosciences population as the main focus of study, trigger and referral criteria not clearly outlined, and no primary or duplicative data. The protocol was registered with PROSPERO (CRD4202013579), and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The American Academy of NeurologyClinical Practice Guidelines Process Manualwas used to assess for risk of bias.ResultsOur search identified 1,748 publications, of which 22 articles met the eligibility criteria. Studies were considered in 2 main groups: (A) studies designed specifically to identify trigger criteria for referral to specialized neuropalliative care services (n = 9) and (B) studies that retrospectively reported the reason for referral to specialized palliative care or reflected a consensus statement among people with advanced neurologic illness (n = 13). Overall, the results suggest that several published referral triggers for specialized neuropalliative care are based on expert consensus. However, there is a growing body of literature providing evidence-based condition-specific triggers for multiple sclerosis, parkinsonism, amyotrophic lateral sclerosis, and dementia.DiscussionThere is a growing body of research that outlines evidence-based referral triggers for neuropalliative care. The ambiguity of nomenclature surrounding referral triggers in the current literature and field of neuropalliative care was a limitation to this study. We suggest that condition-specific triggers are likely to be the most effective for identifying the appropriate patients and timing for referral to specialist palliative care. (PROSPERO registration number: CRD42020135791,crd.york.ac.uk/prospero)

The advent of wearable tremor suppression de-vices (WTSDs) has provided a promising alternative approach for parkinsonian tremor management, especially for individuals whose tremors are not managed by conventional treatment options. Currently, research in WTSDs has shown successful results with a tremor suppression ratio of up to 99 %; however, the user safety of WTSDs has not been properly considered, especially in the occurrence of unexpected events, such as faults and disturbances. In this study, a fault-tolerant control system was developed and integrated into the control system of a WTSD for the first time. The safety and tremor suppression performance of the proposed system under the influence of a measurement loss fault were tested and evaluated on 18 tremor motion datasets, specifically by quantifying the tremor power suppression ratio and the error when tracking voluntary motion. The experimental evaluation showed that the proposed system could remain functional and safe to use in the existence of the fault, with an average user motion tracking error of 1.5º. It was also found that the proposed system achieved significantly improved performance in both metrics when compared to the system without a fault-tolerant controller. Clinical Relevance-This work improves the safety and robustness of WTSDs making them more suitable for use as an additional treatment for parkinsonian tremor.

The advent of wearable technology has enabled a large number of externally worn mechatronic devices to be developed and tested on people with movement disorders. The complexity of these disorders and the variety of conditions across different patients have resulted in a pressing demand for the incorporation of intelligent control systems, especially for a wearable tremor suppression device (WTSD) that can suppress tremor without impeding the user's voluntary motion. Several devices have been developed to reduce tremor; however, the evaluations of these devices have only been done in a controlled lab setting, while the functionality and ability to avoid user injury under the effect of disturbances during daily use have not been investigated. In this study, the performance of a WTSD was tested with several commonly used tremor suppression control systems, i.e., Weight-frequency Fourier Linear Combiner (WFLC), Bandlimited Multiple Fourier Linear Combiner, and enhanced High-order WFLC-based Kalman Filter, on a bench-top tremor simulator. These systems were also tested under the influence of three simulated disturbances that are commonly seen in real life, i.e., data mutation, sensor drift, and measurement loss. The experimental evaluation showed that none of these systems are safe under the disturbances. The tremor power suppression ratio (67.8%–94.2%) of the WTSD was not significantly lowered by the disturbances; however, the error when tracking voluntary motion significantly increased by 8.8 $^\circ$ –93.6 $^\circ$ , which may present a safety hazard to the users. The results of this study emphasize the importance of integrating safety measures into intelligent WTSDs.

Introduction Parkinsonian tremor has severely impacted the lives of 65% of individuals with Parkinson’s disease, and nearly 25% do not respond to traditional treatments. Although wearable tremor suppression devices (WTSDs) have become a promising alternative approach, this technology is still in the early stages of development, and no studies have reported the stakeholders’ opinions on this technology and their desired design requirements. Methods An online survey was distributed to affected Canadians and Canadian movement disorder specialists (MDS) to acquire information on demographics, the current state of treatments, opinions on the WTSDs, and the desired design requirements of future WTSDs. Results A total of 101 affected individuals and 24 MDS completed the survey. It was found that both groups are generally open to using WTSDs to manage tremor. The most important design requirement to end users is the adaptability to lifestyle, followed by weight and size, accurate motion, comfort, safety, quick response, and cost. Lastly, most of the participants (65%) think that the device should cost under $500. Conclusions The findings from this study can be used as guidelines for the development of future WTSDs, such that the future generations could be evaluated and accepted by the end users.

Alexander disease (AD) is a rare form of leukodystrophy caused by pathogenic variants in the GFAP gene. In young children the condition is fatal, while adults have variable neurological symptoms and prognosis. On magnetic resonance imaging, a pattern of atrophy of the medulla oblongata and cervical spinal cord with a 'tadpole' appearance is highly suggestive of adult-onset Alexander disease (AOAD). GFAP gene sequencing is used to confirm the diagnosis. Pre-mRNA of this gene undergoes alternative splicing resulting in formation of at least 8 different protein isoforms. Most patients with AD described to date have a pathogenic variant in the coding sequence of the main and the most abundant gene isoform, the GFAPα. Recently, two half-siblings with neurological symptoms and radiological signs of AOAD were reported and were not found to have any pathogenic variants in the GFAPα gene while further genetic testing by next generation sequencing revealed a c.1289G>A (p.Arg430His) variant in the alternative exon 7A of the GFAPe isoform. Here we present a case of another patient with symptoms and brain MRI pattern suggestive of AOAD. Similarly to the previously described patients, this patient did not have any pathogenic variants in the main gene isoform and had the same c.1289G>A (p.Arg430His) variant in the GFAPe. This report contributes to evidence of pathogenicity of the c.1289G>A (p.Arg430His) variant in the GFAPe.

Objective: Approximately 25% of individualsliving with parkinsonian tremor do not respond to traditional treatments. Wearable tremor suppression devices (WTSD) provide an alternative approach, however, tremor in the fingers has not been given as much attention as tremor in the elbow and the wrist. Therefore, the objective of this study is to design a wearable tremor suppression glove that can suppress tremor simultaneously, but independently, in multiple hand joints without restricting the user's voluntary motion. Methods: A WTSD was designed for managing tremor in the index finger metacarpophalangeal (MCP) joint, thumb MCP joint, and the wrist. The prototype was tested and assessed on a participant living with parkinsonian tremor. Results: The experimental evaluation showed an overall suppression of 73.1%, 80.7%, and 85.5% in resting tremor, 70.2%, 79.5%, and 81% in postural tremor, and 60.0%, 58.7%, and 65.0% in kinetic tremor in the index finger MCP joint, the thumb MCP joint, and the wrist, respectively. Conclusion: This first assessment of a WTSD for people living with Parkinson's disease provides confirmation of the feasibility of the approach. The next step requires a comprehensive validation on a broader population in order to evaluate the performance of the WTSD. Significance: This study demonstrates the feasibility of using a WTSD to manage hand and finger tremor. The device enriches the field of upper-limb tremor management, as the first WTSD for multiple joints of the hand.

Wearable tremor suppression devices (WTSD) have been considered as a viable solution to manage parkinsonian tremor. WTSDs showed their ability to improve the quality of life of individuals suffering from parkinsonian tremor, by helping them to perform activities of daily living (ADL). Since parkinsonian tremor has been shown to be nonstationary, nonlinear, and stochastic in nature, the performance of the tremor models used by WTSDs is affected by their inability to adapt to the nonlinear behaviour of tremor. Another drawback that the models have is their limitation to estimate or predict one step ahead, which introduces delay when used in real time with WTSDs, which compromises performance. To address these issues, this work proposes a deep neural network model that learns the correlations and nonlinearities of tremor and voluntary motion, and is capable of multi-step prediction with minimal delay. A generalized model that is task and user-independent is presented. The model achieved an average estimation percentage accuracy of 99.2%. The average future voluntary motion prediction percentage accuracy with 10, 20, 50, and 100 steps ahead was 97.0%, 94.0%, 91.6%, and 89.9%, respectively, with prediction time as low as 1.5 ms for 100 steps ahead. The proposed model also achieved an average of 93.8% ± 1.5% in tremor reduction when it was tested in an experimental setup in real time. The tremor reduction showed an improvement of 25% over the Weighted Fourier Linear Combiner (WFLC), an estimator commonly used with WTSDs.

BACKGROUND: Perry syndrome is a rare genetic parkinsonian disorder with TAR DNA binding protein 43 (TDP‐43) pathology clinically presenting with parkinsonism, neuropsychiatric features, weight loss, and central hypoventilation. As respiratory complications are often the cause of death, studies likely show the early stage of the neurodegenerative process. Because of the rarity of this condition, few studies exist, and each case provides insight into pathological findings in this neurodegenerative condition. OBJECTIVE: To study the clinical and pathological correlations of an autopsy case of Perry syndrome. METHODS: The patient was a woman in her 50s with Perry syndrome and a DCTN1 gene mutation. Between October 2016 and July 2019, she underwent postmortem and pathological examination at University Hospital in London, Ontario, Canada. Data were obtained through clinical pathological examination. RESULTS: Microscopy showed significant neuronal loss with pigmentary incontinence and gliosis in the substantia nigra. There was no atrophy elsewhere, including the frontal and cingulate cortex. Intraneuronal cytoplasmic TDP‐43 inclusions and neurites were noticed in a moderate number in the substantia nigra and midbrain and were sparsely noticed in the basal ganglia, thalamus, thoracic motor neuron, posterior nucleus of the hypothalamus, and rostral ventral medulla. β‐Amyloid, Lewy body, and tau pathologies were absent. Rare axonal swelling was identified at the rostral ventrolateral medulla. CONCLUSIONS AND RELEVANCE: This study confirms that Perry syndrome is characterized by TDP‐43 pathology with absent Lewy bodies or tau pathology. These findings support the hypothesis of dysfunctional neurons in the medulla and hypothalamus, which may respectively correlate to the clinical symptoms of hypoventilation and weight loss in Perry syndrome.

Building upon the view of the modes of communication as contextualized communicative genres (Chapter 1, this volume), this chapter explores the development of interpersonal speaking abilities in a world language as the development of students’ understanding of spoken genres. The authors, which include nine teacher candidate contributors, applied their developing knowledge of SFL, genre theory, and genre-based backward design to understand spoken genres in context, analyze those spoken genres, create a schema of a complete orienting basis of action (SCOBA) (Gal’perin, 1992; Fernandez, 2017, Chapter 10; Herazo, 2014) for each spoken genre to make it visible to students, and create assessment criteria that integrate genre theory into the existing performance assessment rubrics for interpersonal speaking. Their work provides a window on an innovative application of genre theory for world language instructional design that can assist world language teachers in addressing performance assessment of the interpersonal mode of communication.

The study of the characteristics and behaviour of tremor for people suffering from Parkinson's disease (PD) is an important first step in developing a new method to predict future tremor signals, their onset and the active tremor instances. The current approaches to detect tremor are limited to tremor estimators that rely on simple tremor models, or on deep brain probing that is invasive in nature. Thus, a new method that is noninvasive and that can capture tremor complexity to predict when tremor is active is needed. In this work, a new approach is presented using neural networks (NNs) and data from inertial measurement units (IMUs) to predict tremor onset and classify the active tremor instances in the wrist and metacarpophalangeal (MCP) joints of the index finger and thumb. The developed model showed an accuracy of 92.9% in predicting and detecting tremor onset, and therefore can be considered a reliable tool that has the potential to be integrated with wearable assistive devices for suppressing tremor.

Parkinson's Disease (PD) is considered to be the second most common age-related neuroegenerative disorder, and it is estimated that seven to ten million people worldwide have PD. One of the symptoms of PD is tremor, and studies have shown that wearable assistive devices have the potential to assist in suppressing it. However, despite the progress in the development of these devices, their performance is limited by the tremor estimators they use. Thus, a need for a tremor model that helps the wearable assistive devices to increase tremor suppression without impeding voluntary motion remains. In this work, a user-independent and task-independent tremor and voluntary motion detection method based on neural networks is proposed. Inertial measurement units (IMUs) were used to measure acceleration and angular velocity from participants with PD, these data were then used to train the neural network. The achieved estimation percentage accuracy of voluntary motion was 99.0%, and the future prediction percentage accuracy was 97.3%, 93.7%, 91.4% and 90.3% for 10 ms, 20 ms, 50 ms and 100 ms ahead, respectively. The root mean squared error (RMSE) achieved for tremor estimation was an average of 0.00087°/s on new unseen data, and the future prediction average RMSE across the different tasks achieved was 0.001°/s, 0.002°/s, 0.020°/s and 0.049°/s for 1 ms, 2 ms, 5 ms, and 10 ms ahead, respectively. Therefore, the proposed method shows promise for use in wearable suppression devices.

Introduction Although it is accepted that individuals with Parkinson’s disease must navigate challenges such as receiving their diagnosis and changing daily occupations, little is known about how they navigate. The purpose of this study is to deepen the current understanding of the experience of living with Parkinson’s disease and its implications for occupation through a narrative visual methodology (photo-elicitation). Method Six individuals with Parkinson’s disease were asked to take photographs and share verbal narrative accounts to illustrate their experience of living with Parkinson’s disease. Findings Results highlight the interrelationship between occupation and identity, as many of the participants’ stories were interpreted as foregrounding the negotiation of occupation, and how such negotiation shaped their sense of identity. Overall, three major themes were identified: (1) Framing the meaning of Parkinson’s disease (accepting the disease as part of who they were); (2) Negotiating engagement in occupation (ongoing deliberation over whether to continue engaging in certain aspects of life as Parkinson’s disease progressed); and (3) Being ready to accept changes that impact personal or social identity (readiness to accept help and to identify as someone with Parkinson’s disease). Conclusion Attending to insights regarding the lived experience of Parkinson’s disease will enhance quality of care through informing an enriched client-centered, occupation-based approach.

Objective: Multiple system atrophy (MSA) is an incurable neurodegenerative illness in which progressive symptoms, including stridor and acute laryngeal obstruction, occur. Advanced care planning and palliative care discussions in people living with MSA are not well defined. The aim of the present study is to evaluate advanced care planning and current practices in palliative care in MSA to identify opportunities for improving quality of care. Methods: The study is a retrospective chart review assessing the focus and timing of palliative care discussions in people living with MSA. Some 22 charts were reviewed. Results: A total of 22 patients were included. The most common symptoms were parkinsonism, orthostatic hypotension, GI/GU dysfunction, ataxia and gait impairment. Six patients had stridor. Of the palliative care discussions that took place, the most common topics were diagnosis, symptoms or symptom management, and prognosis. In the majority of patients who died and who had a do-not-attempt-resuscitation order, discussions surrounding resuscitation and goals of care took place only hours before death. Conclusions: There is no standard approach to advanced care planning and palliative care discussions in people living with MSA. We propose a framework to guide advanced care planning and palliative care discussions in MSA.

Up to 40% of all individuals with Parkinson’s disease (PD) are estimated to experience anxiety that interferes with daily functioning. This article describes research regarding the presentation of anxiety in PD and the influence anxiety has on participation in this population. A scoping review identified 1,635 articles, of which 49 met the inclusion criteria. This review identified that anxiety in PD is often associated with a range of clinical correlates related to demographic and clinical characteristics (age, gender, disease stage, duration, progression), motor symptoms (tremor, bradykinesia, dystonia, freezing of gait, symptom severity), treatment-related complications (on/off fluctuations, on with dyskinesia, unpredictable off), and non-motor symptoms (sleep abnormalities, fatigue, cognitive impairment, depression). These findings can be used to increase clinicians’ awareness toward the specific clinical correlates linked to anxiety in PD so that mental health concerns can be detected and addressed more readily in practice.

© 2019 The Author(s). Background: Currently there are no disease-modifying treatments for Parkinson's disease dementia (PDD), a condition linked to aggregation of the protein α-synuclein in subcortical and cortical brain areas. One of the leading genetic risk factors for Parkinson's disease is being a carrier in the gene for β-Glucocerebrosidase (GCase; gene name GBA1). Studies in cell culture and animal models have shown that raising the levels of GCase can decrease levels of α-synuclein. Ambroxol is a pharmacological chaperone for GCase and is able to raise the levels of GCase and could therefore be a disease-modifying treatment for PDD. The aims of this trial are to determine if Ambroxol is safe and well-tolerated by individuals with PDD and if Ambroxol affects cognitive, biochemical, and neuroimaging measures. Methods: This is a phase II, single-centre, double-blind, randomized placebo-controlled trial involving 75 individuals with mild to moderate PDD. Participants will be randomized into Ambroxol high-dose (1050 mg/day), low-dose (525 mg/day), or placebo treatment arms. Assessments will be undertaken at baseline, 6-months, and 12-months follow up times. Primary outcome measures will be the Alzheimer's disease Assessment Scale-cognitive subscale (ADAS-Cog) and the ADCS Clinician's Global Impression of Change (CGIC). Secondary measures will include the Parkinson's disease Cognitive Rating Scale, Clinical Dementia Rating, Trail Making Test, Stroop Test, Unified Parkinson's disease Rating Scale, Purdue Pegboard, Timed Up and Go, and gait kinematics. Markers of neurodegeneration will include MRI and CSF measures. Pharmacokinetics and pharmacodynamics of Ambroxol will be examined through plasma levels during dose titration phase and evaluation of GCase activity in lymphocytes. Discussion: If found effective and safe, Ambroxol will be one of the first disease-modifying treatments for PDD. Trial registration: ClinicalTrials.gov NCT02914366, 26 Sep 2016/retrospectively registered.

Current treatments for parkinsonian tremor, such as medication and brain surgery, have shown varying levels of effectiveness and carry the risk of significant side effects and complications. Studies on wearable tremor suppression devices have shown positive results in the use of mechanical and electrical suppression on tremor management of the upper limbs. Wearable technology for tremor suppression is a promising solution for patients who do not respond to medication and do not present severe enough symptoms to undergo surgery. Available tremor suppression devices are mainly for elbow and wrist tremor. Devices for finger tremor suppression have not been developed despite the fact that finger tremor is also present. In this study, a wearable tremor suppression glove prototype was designed and validated with recorded tremor data from patients with Parkinson's disease. Two validation experiments were conducted to assess the performance of the proposed device when suppressing tremor motion and following voluntary motion. The tremor suppression assessment showed an overall tremor amplitude reduction of $\pmb{85.0\% \pm 8.1\%}$ , and the power reductions for the Ist, 2nd, and 3rd harmonics are $\pmb{87.9\%\pm .6\%, 92.0\%\pm .4\%}$ , and $\pmb{81.7\% \pm 13.0\%}$ , respectively. Following voluntary motion was possible with a RMSE of $\pmb{14.2\%\pm .5\%}$ and a correlation coefficient of $\pmb{0.97\pm 0.01}$ . Both assessments have shown positive results for the validation of the proposed device; however, further work is needed to improve the performance of the proposed device prior to human trials.

Tremor, being one of the most severe symptoms of Parkinson's disease, has been considered as not only a medical problem but also an engineering problem. Increasingly, wearable technologies are being considered as a viable treatment option. In order to study and control tremor in the field of engineering, the first step often includes modeling and simulation, as access to patients is limited. With the successful realization of a finger tremor simulator, a wearable tremor suppression device could be validated prior to testing on humans. In this study, a tremor simulator was designed and validated with recorded patient tremor data. Two experimental assessments were conducted on the validation of tremor motion reproduction and tremor torque reproduction. The results showed that the proposed simulator has 9%, 82%, and 141% error in the reproduction of the power of the 1st, 2nd and 3rd harmonics of the tremor, and 11.89% mean error on motion reproduction. The tremor torque measured at the index finger metacarpophalangeal joint is $0.02\pm$ 0.02 Nm, and the output torque from the tremor simulator is 0.03 $\pm 0.01$ Nm. Further parameter adjustment of the control system is required to improve performance.

© 2018 Learning associations between stimuli and responses is essential to everyday life. Dorsal striatum (DS) has long been implicated in stimulus-response learning, though recent results challenge this contention. We have proposed that discrepant findings arise because stimulus-response learning methodology generally confounds learning and response selection processes. In 19 patients with Parkinson's disease (PD) and 18 age-matched controls, we found that dopaminergic therapy decreased the efficiency of stimulus-response learning, with corresponding attenuation of ventral striatum (VS) activation. In contrast, exogenous dopamine improved response selection accuracy related to enhanced DS BOLD signal. Contrasts between PD patients and controls fully support these within-subject patterns. These double dissociations in terms of behaviour and neural activity related to VS and DS in PD and in response to dopaminergic therapy, strongly refute the view that DS mediates stimulus-response learning through feedback. Our findings integrate with a growing literature favouring a role for DS in decision making rather than learning, and unite two literature that have been evolving independently.

Recent progress in wearable technology has made wearable tremor suppression devices (WTSDs) for Parkinson’s patients a potentially viable alternative solution for tremor management. So far, in contrast to wrist and elbow tremor, finger tremors have not been studied in depth despite the huge impact that they have on a patient’s daily life. In addition, more evidence has been found showing that the performance of current tremor estimators may be limited by their model order due to the multiple harmonics present in tremor. The aim of this paper is to characterize finger and wrist tremor in both the time and frequency domains, and to propose a high-order tremor estimation algorithm. Tremor magnitudes are reported in the forms of linear acceleration, angular velocity, and angular displacement. The activation of forearm flexor and extensor muscles is also investigated. The frequency analysis shows that Parkinsonian tremors produce oscillations of the hand with pronounced harmonics. At last, a high-order weighted-frequency Fourier linear combiner (WFLC)-based Kalman filter is proposed. The percentage estimation accuracy achieved from the proposed estimator is 96.3 ± 1.7%, showing average improvements of 28.5% and 48.9% over its lower-order counterpart and the WFLC. The proposed estimator shows promise for use in a WTSD.

Although physical activity is generally thought to be beneficial for individuals with Parkinson’s disease (PD), there is limited information regarding current rates of physical activity within this population. In this study, we measured self-reported physical activity levels of individuals with PD and explored factors that affected physical activity engagement. Sixty-one individuals living with PD completed a modified form of the Physical Activity Scale for Individuals With Physical Disabilities. Reported activity was high and exceeds published guidelines for individuals with limited mobility. Major facilitators of physical activity included (a) positive impact on PD-related symptoms, (b) social motivation, and (c) regularity or predictability of the activity. The major barrier to physical activity was PD symptom severity (e.g., lack of balance, gait impairment, tremor, and fatigue).

Aims: To investigate the effect of manipulating the spatial location of a visual cue used to manage gait impairment among individuals with Parkinson's disease. Methods: Six individuals with Parkinson's disease who experience severe freezing of gait were asked to complete the Timed Up and Go test three times in each of the following conditions: no cue, cue presented at the users feet, cue presented at a distance equivalent to step length, and cue presented at a distance equivalent to stride length. Step length, velocity, walker positioning, and time taken to complete a 180 degree turn and the Timed Up and Go test were recorded. Results: Visual cueing led to an improvement in 4/5 outcome measures with magnitude of improvement being dependent upon the spatial location of cue presentation. Conclusions: Findings suggest that visual cueing and the spatial location of cue presentation are highly individualized in terms of managing gait disturbance.

Physical activity is generally thought to be beneficial to individuals with Parkinson’s disease (PD). There is, however, limited information regarding current rates of physical activity among individuals with PD, possibly due to a lack of well-validated measurement tools. In the current study we sampled 63 individuals (31 women) living with PD between the ages of 52 and 87 (M = 70.97 years, SD = 7.53), and evaluated the amount of physical activity in which they engaged over a 7-day period using a modified form of the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD). The PASIPD was demonstrated to be a reliable measure within this population, with three theoretically defensible factors: (1) housework and home-based outdoor activities; (2) recreational and fitness activities; and (3) occupational activities. These results suggest that the PASIPD may be useful for monitoring physical activity involvement among individuals with PD, particularly within large-scale questionnaire-based studies.

In the double-step paradigm, healthy human participants automatically correct reaching movements when targets are displaced. Motor deficits are prominent in Parkinson’s disease (PD) patients. In the lone investigation of online motor correction in PD using the double-step task, a recent study found that PD patients performed unconscious adjustments appropriately but seemed impaired for consciously-perceived modifications. Conscious perception of target movement was achieved by linking displacement to movement onset. PD-related bradykinesia disproportionately prolonged preparatory phases for movements to original target locations for patients, potentially accounting for deficits. Eliminating this confound in a double-step task, we evaluated the effect of conscious awareness of trajectory change on online motor corrections in PD. On and off dopaminergic therapy, PD patients (n= 14) and healthy controls (n= 14) reached to peripheral visual targets that remained stationary or unexpectedly moved during an initial saccade. Saccade latencies in PD are comparable to controls’. Hence, target displacements occurred at equal times across groups. Target jump size affected conscious awareness, confirmed in an independent target displacement judgment task. Small jumps were subliminal, but large target displacements were consciously perceived. Contrary to the previous result, PD patients performed online motor corrections normally and automatically, irrespective of conscious perception. Patients evidenced equivalent movement durations for jump and stay trials, and trajectories for patients and controls were identical, irrespective of conscious perception. Dopaminergic therapy had no effect on performance. In summary, online motor control is intact in PD, unaffected by conscious perceptual awareness. The basal ganglia are not implicated in online corrective responses.

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Background and Purpose: Recently, the Nintendo Wii has emerged as an innovation in rehabilitation. Although research findings to date have contributed to our understanding of the effects of implementing the Wii as a rehabilitation tool, evidence supporting the Wii for improving symptoms in Parkinson's disease (PD) remains limited. The purpose of this study, therefore, was to evaluate the effectiveness of a 12-week home-based exercise program designed around the Wii, in improving balance, balance confidence, and maintaining exercise adherence among individuals with PD. Methods: Fifteen participants were recruited to engage in 30 minutes of Wii activity 3×/week for 12 weeks. Results: Balance and balance confidence improved from baseline to midintervention, but reverted back to near baseline values at postintervention. Exercise adherence was maintained equally throughout the study. Conclusions: The Nintendo Wii has potential to be an effective treatment strategy for improving balance, balance confidence, and fostering programmatic adherence among individuals with PD. Read More: http://informahealthcare.com/doi/abs/10.3109/02703181.2013.814743

Objectives Individuals living with young-onset Parkinson’s disease compose a rare subtype of a disease typically associated with older age. Situated within a large grounded theory study exploring information behavior, this paper describes the core category of the theory, i.e. uncertainty. Methods Data were collected with 39 individuals living with young-onset Parkinson’s disease who took part in in-depth interviews, focus groups and/or an online discussion board. Fourteen autobiographies written by individuals living with young-onset Parkinson’s disease were also used as data sources. Results Through experiencing young-onset Parkinson’s disease, participants were confronted with uncertainty along two main lines. First, they experienced uncertainty with respect to their identities as young- and middle-aged adults, deviating from the idealized age-graded life path marked out within their socio-cultural context. Second, they experienced uncertainty with respect to their functioning, as the heterogeneous nature of Parkinson’s progression meant that it would not be possible to chart how their disease would change over time. This uncertainty was associated with feelings of lost control over their lives and increased grief. Discussion With a deeper appreciation for how uncertainty is experienced in the lives of those with young-onset Parkinson’s disease, health professionals may be better prepared to discuss these issues with patients and provide support and resources.

The study of the mechanical characteristics of tremor for patients suffering from Parkinson's disease (PD) is an important first step to the design of mechanical tremor suppression orthoses. So far, researchers have interpreted tremor characteristics in both the time and the frequency domains. A number of tremor suppression devices have been developed on the basis of these interpretations of tremor. However, most of the studies and devices have only focused on tremor at the wrist and elbow, and have neglected finger tremor despite the huge impact that it has on a patient's daily life. The aim of the present study was to determine the characteristics of finger tremor and wrist tremor, which may be used to provide a reference for the design of tremor suppression devices for the hand. Tremor magnitudes were represented in the forms of linear acceleration, angular velocity and angular displacement. The results show that PD tremors from all joints have a common multiple-frequency pattern and that the second harmonic (6.9–11.5 Hz) makes a large contribution to the tremor that cannot be neglected.

To present a new graphic representation of the international classification of functioning, disability and health (ICF), entitled the ICF-conceptual revision (ICF-CR). The ICF-CR aims to be clearer and more usable tool than the ICF graphic currently used by starting to address criticisms of the ICF raised in the literature, with a focus on positioning quality of life (QoL) in relation to the ICF's other components.This is a conceptual paper based on a review of criticisms of the ICF and related literature published on human functioning.In addition to criticisms of the current graphic, four criticisms of the ICF are discussed in relation to the development of the ICF-CR, including: the lack of development of biopsychosocial theory, the lack of clarity between activities and participation, the language used, and the absence of QoL. General systems theory is used to help construct the new graphic in addressing these criticisms and to position QoL.The ICF-CR is designed to be a more responsive graphic of human functioning; one which enhances the clarity of principles integral to the ICF, including biopsychosocial theory and universalism. It is hoped the ICF-CR will promote continued discussion toward the goal of enhancing the ICF, both visually and conceptually.