May, 2019 | Wisconsin Parkinson Association

Tel Aviv University team studies why patients with Parkinson’s disease have difficulty transitioning from walking to sitting, leading to greater instability and falls

People with Parkinson’s disease — a debilitating degenerative disorder that affects the motor system, causing tremors, shaking and rigidity — are known to have difficulty in turning around and then sitting down.

A new Tel Aviv University study provides an understanding as to why these patients may have difficulty transitioning from walking though turning around to sitting. The results suggest new ways to help improve the rehabilitation of these kind of patients.

“Parkinson’s patients can be challenged when they try to turn as they walk,” said Prof. Jeffrey Hausdorff of Tel Aviv University’s Sackler Faculty of Medicine and the Center for the Study of Movement, Cognition, and Mobility at Tel Aviv Sourasky Medical Center.

While most healthy older adults turn and then sit in a precise sequence that clearly distinguishes the two components of the task, in contrast “we found that most Parkinson’s patients start to sit while they are still turning,” he said.

“We originally speculated that, when transitioning from a walking or standing position to a sitting position, people with Parkinson’s would first turn and then start the process of sitting,” Hausdorff said. “But we found that this wasn’t true.”

The research was led by Hausdorff in collaboration with Prof. Anat Mirelman and Prof. Nir Giladi, also of the university and the Tel Aviv Medical Center, and colleagues at Rush University in Chicago. It was published in January in the journal Gait & Posture.

According to the study, when healthy older adults turn to sit, about 80 percent of them complete the turn before starting to sit, in what the researchers called a “distinct strategy.” But in about 20% of the subjects, part of the turning and sitting take place at the same time, in what the researchers called an “overlapping strategy.”

The researchers evaluated the strategies employed by people with Parkinson’s as they transitioned from standing through turning to sitting. In one experiment, 96 participants with Parkinson’s, assessed both on medication and after its effects wore off, were asked to turn to sit while wearing a body-fixed sensor. The researchers then quantified the turning-to-sitting transition and determined whether the distinct or the overlapping strategy had been employed. The use of the sensor revealed subtle but important distinctions that were previously overlooked based on visual observation alone.

The scientists then stratified the cases, using models adjusted for age, gender, height and weight, to identify the associations with their sitting strategies and with the Parkinsonian characteristics and cognition.

“Interestingly, we found that the individuals who employed the overlapping strategy experienced more severe postural instability compared to those who used the distinct strategy,” Hausdorff said.

They also found that anti-Parkinsonian medications did not affect the strategy choice, “suggesting that the decision may be regulated by networks and brain areas that are less directly affected” by the drugs.

Hausdorff said that it is important for people who suffer from Parkinson’s disease and their physical therapists and others to be aware of this issue.

Based on the study, he said in an emailed comment to The Times of Israel, “one can speculate that some of the rehabilitation and continuous care process should be devoted to teaching people with Parkinson’s that when they are turning to sit down, they should break the process into two separate pieces: first turn, briefly stop, and then sit down.”

“This is the way that healthy young and healthy older adults generally carry out this common task,” and they are much less prone to falls than people with Parkinson’s disease, he said.

Stopping along the turn “may, therefore, be safer and less prone to problems than doing this movement all at once,” he said.

Even so, he added, “it remains to be seen” if interventions designed to make this change in the turning process are indeed effective.

Article from Times of Israel.

Digital Management of Parkinson Disease: Is Technology the Future?

May 1, 2019 Education, Life, Research

With the ever-increasing integration of technology into nearly every aspect of modern life, its applications in medicine continue to expand, including in the area of Parkinson disease (PD).

A recent randomized controlled trial of 195 patients with PD, for example, found that physician care delivered via telemedicine into patients’ homes was as effective as in-person care.1 Additional emerging research supports the benefits of other digital tools in this patient population.

In a review published online in the Journal of Parkinson’s Disease, Clint Hansen, PhD, of the Department of Neurology at Christian-Albrechts-Universität Kiel and the University Hospital Schleswig-Holstein, Campus Kiel in Kiel, Germany, and colleagues explored current and future directions regarding the use of technologies such as the electronic health record (EHR) and wearable sensors in PD management.2

Although many institutions and private practices have replaced paper-based medical records with EHRs, there are often limitations on how these are used in clinical decision making. This is likely to change significantly within the next decade, as most “countries with established health structures will then have nationwide provision of innovative EHRs with cloud storage solutions, and most of these EHRs will be patient-controlled,” Dr Hansen and colleagues noted.

In addition, they wrote, EHRs will “communicate with clinical data warehouses that consolidate hospital- and practice-derived data, with population health analytics databases that will provide information about disease risk and prevention, and with digital technology that is used by… the patient.”2 They also expect that moving forward, data protection laws will become more stringent, thus reducing the risk for privacy violations and increasing patient acceptance of EHRs.

With the growing use of digital devices to provide personalized feedback on measures of health, including those worn on the wrist or contained in shoes, it is conceivable that similar tools could be designed to facilitate the continuous monitoring of disease manifestations in patients with PD. These systems “will most probably be easily and widely used and not [require] an active interaction with the user, will be approved by regulatory authorities and the costs will be covered by health insurances,” noted Dr Hansen and colleauges.2

As a template for such devices intended for application in PD, the authors pointed to continuous subcutaneous glucose monitors that are used in patients with diabetes. Other possibilities include integrated detection systems in hearing aids, glasses, and earphones to allow patient interaction with the environment; analysis of mobility data such as reaction times and multitasking ability; insertable cardiac monitors; use of a smartphone as an accelerometer platform to gauge the treatment efficacy of deep brain stimulation; and remote assessment of autonomic features and gut motility. Many of these systems should be easily individualized to each patient.

In another review published in the same journal issue, the authors propose the use of a sensor-based system to analyze gait and detect falls in patients with PD, which would include decision support based on big data sources.3 One benefit of this type of approach is the “standardization of real-life medical data derived from individual patients into longitudinal multimodal disease trajectories…[which] will allow matching and clustering of different patient trajectories for individualized prediction about the expected treatment efﬁcacy of particular interventions,” wrote Jochen Klucken, MD, of the Department of Molecular Neurology at Friedrich-Alexander University, and colleagues, in the Journal of Parkinson’s Disease. “Ultimately, the growing amount of medical data derived from individualized real-life treatment contexts will enable academic and industrial research to further improve objective outcomes and better tailor individual care.”

To glean further insights pertaining to the use of digital health technology in the realm of PD, Neurology Advisor spoke briefly with Alberto J. Espay, MD, MSc, professor of neurology and director and endowed chair of the James J. and Joan A. Gardner Center for Parkinson’s Disease and Movement Disorders at the University of Cincinnati Academic Health Center. Dr Espay is also chair of the Movement Disorders Society Task Force on Technology, which promotes the development of digital health systems that will achieve the goals mentioned above.4

Neurology Advisor: What is a key example of how digital health technologies could be used to improve PD care?

Dr Espay: Digital health technologies have the capacity of capturing intraday fluctuations with the kind of granularity that no scales, diaries, or questionnaires can.

Neurology Advisor: How can clinicians support these developments?

Dr Espay: Clinicians can stimulate their patients’ participation in a variety of technology-integration projects through many organizations. This is a great time to participate and contribute.

There will be a variety of ongoing studies aimed at developing a new version of the diary in electronic format for the digital age, integrated with mobile health technologies (“e-diary/tracker”). This is being coordinated through the Task Force on Technology of the International Parkinson’s and Movement Disorders Society. Efforts such as these are ongoing or will soon occur in many countries in the world.

Neurology Advisor: What should be next steps in terms of research or development in this area?

Dr Espay: The future development of a unifying platform for integrating and synchronizing the data from multiple technologies, one of the goals of the Movement Disorders Society Technology Task Force, could provide the most comprehensive picture of patients’ function than anything we currently have.

Neurology Advisor: Would you like to note any additional takeaways on the topic?

Dr Espay: Technology offers us the means to improving the ends of health care delivery. In the future it will weave seamlessly into patients’ lives to enhance the capture of data, help anticipate periods in which changes are needed, and empower patients to apply strategies to enhance their quality of life.

References

1. Beck CA, Beran DB, Biglan KM, et al. National randomized controlled trial of virtual house calls for Parkinson disease. Neurology. 2017;89(11):1152-1161.

2. Hansen C, Sanchez-Ferro A, Maetzler W. How mobile health technology and electronic health records will change care of patients with Parkinson’s disease. J Parkinsons Dis. 2018;8(Suppl 1):S41-S45.

3. Klucken J, Krüger R, Schmidt P, Bloem BR. Management of Parkinson’s disease 20 years from now: towards digital health pathways. J Parkinsons Dis. 2018;8(Suppl 1):S85-S94.

4. Espay AJ, Bonato P, Nahab FB, et al. Technology in Parkinson’s disease: challenges and opportunities.Mov Disord. 2016;31(9):1272-1282.

Article from NeurologyAdvisor.

For Caregivers: What is a Parkinson’s Care Partner?

May 1, 2019 Caregivers, Life

Parkinson’s impacts the whole family, especially those most involved in the day-to-day care. As a Parkinson’s care partner, it can be easy to lose sight of your own health and well-being as you care for your loved one living with Parkinson’s. However, taking the time to prioritize your own physical and emotional health will benefit both you and your loved one with Parkinson’s.

In this post, we help you identify important questions to ask regarding your role as a care partner and provide strategies to care for yourself as you care for your loved one.

What is a Care Partner?

A care partner is an essential, active participant with the person with Parkinson’s in their care. While most care partners are spouses, children, siblings, parents and even friends can all be considered care partners. As your loved one living with Parkinson’s becomes less independent and more reliant on your care, your role as a care partner transitions to caregiver.

As a care partner, you are an essential member of the care team supporting the person in your life living with Parkinson’s. Your role as a care partner will evolve over the years and asking questions will help you and your loved one have an ongoing conversation about how to best partner in care to encourage you both to live well.

Here are some important discussion topics to have with your loved one:

Communicate often with your loved one to help them understand and accept your concerns and desire to help and support them. Talk about how much you expect or wish to be involved in care. Care partners typically have the most frequent and ongoing involvement in the lives of people with Parkinson’s. This brings both benefits and challenges as you will often notice effects of Parkinson’s that your loved one may not be aware of. You may find yourself feeling frustrated as you encourage your loved one with Parkinson’s to do activities to help them live well that they may not necessarily want to do, such as exercising, speaking louder or attending an appointment with a healthcare professional.
Talk about how much you expect or wish to be involved in care. Transitioning from spouse, child, parent or even friend to care partner can change your relationship with your loved one with Parkinson’s. It’s important to have discussions with your loved one with Parkinson’s and the rest of the care team about everyone’s expectations about your involvement in your loved one’s care and your relationship outside of serving as a care partner.
Set up rules or even agree on a “catch phrase” that your loved one with Parkinson’s can use to let you know when they feel that your guidance and encouragement may be feeling like nagging or too much pressure.
Speak up during medical appointments. You are both significantly impacted by Parkinson’s and very familiar with the effects it has on your everyday lives. If your typical medical appointments focus only on the person with Parkinson’s, let the Parkinson’s healthcare provider know that you are an active member of the care team and will be contributing during the appointments as well. Writing down the three most important things that you would like your partner’s medical provider to address is another practical step to ensuring your concerns are heard by healthcare providers.

Why is Care Partner Health Important?

Even though you love the person you’re caring for, caring for someone with Parkinson’s brings real physical, emotional and financial challenges.

Care partners can experience more fatigue, depression and sadness than those without the same responsibilities. The increased stress and strain can make regular self-care harder, which can, in turn, cause your physical and emotional health to suffer. Strain can lead to burnout, which occurs when the care partner is at the point of exhaustion.

Overall, care partners are more likely to experience:

Symptoms of depression or anxiety
Chronic medical problems, such as heart disease, obesity, cancer, diabetes or arthritis
Higher levels of strain hormones and/or a weaker immune response
A higher risk for memory problems

As a care partner, you can be proactive about your own wellness, just like you are encouraging your loved one with Parkinson’s to be. Begin by learning more about the stress and strain that can come with being a care partner and take steps to limit or avoid factors that lead to burnout. Continually encourage your partner to take an active role in their own care, as research has shown that when people with Parkinson’s have a greater sense of control over their own life with Parkinson’s, the strain on care partners can lessen and everyone’s well-being improves. Develop your own community of trusted friends, relatives and other care partners who can provide practical as well as emotional support.

You can also consider seeing a social worker or counselor. Social workers and counselors have the expertise and knowledge about community resources to help you address the stress and strain that can come with being a care partner.

How Can I Live Well as a Care Partner?

Your journey of living well as a care partner involves many of the same themes as your loved one who is living with Parkinson’s: taking action, staying connected and being involved. Just as Parkinson’s affects everyone differently, your role as a care partner will affect you in unique ways. It’s important to stay in touch not only with your loved one as you both learn to live well, but with yourself as things change and evolve over time.

Begin by learning more about the stress and strain that can come with being a care partner and take steps to limit or avoid factors that lead to burnout. The American Medical Association provides a caregiver health self-assessment questionnaire with helpful recommendations for starting conversations with healthcare professionals about the impact caring for your loved one may have on your personal health.

Educate yourself about the spectrum of Parkinson’s symptoms and learn which are the most challenging for you and your loved one. Read websites, books and articles as well as watch educational videos, attend support groups and educational events and have conversations with healthcare professionals like your neurologist, nurse or social worker.

Recognizing the importance of maintaining the identity, health and well-being of your loved one with Parkinson’s as well as yourself will bring a better quality of life for you both.

Article from Davis Phinney.

Parkinson’s Awareness Posterboards

May 1, 2019 Awareness, Community Outreach

April was Parkinson Awareness Month, and we were busy!

In addition to TV, RADIO, PODCASTS, we also had BILLBOARDS around southeastern Wisconsin, and POSTERBOARDS at 34 gyms, clinics and YMCAs across the state!

We also received official proclamations declaring April as Parkinson Awareness Month from Governor Evers, and the mayors of Milwaukee, Madison, La Cross, Wausau and Appleton.

Can Imaging Genetics Analysis Effectively Identify Depression In Parkinson Disease?

May 1, 2019 Research

A model using imaging genetics analysis was able to predict and explain the degree of depression in Parkinson disease (PD) with a lower error and higher correlation than other models over a 5-fold cross-validation, according to the results of a study published in PLoS One.

Ji Hye Won, a PhD student from the Department of Electrical and Computer Engineering, Sungkyunkwan University and the Center for Neuroscience Imaging Research, Institute for Basic Science, Suwon, Korea, and colleagues conducted a retrospective analysis of de-identified data. They used diffusion MRI, T1-weighted MRI, and DNA genotyping data obtained from the Parkinson’s Progression Markers Initiative database for 81 patients with PD. Researchers obtained DNA samples genotyped by NeuroX genotyping arrays from the Parkinson’s Progression Markers Initiative and used the least absolute shrinkage and selection operator (LASSO) algorithm to identify regional imaging features that could characterize depression in Parkinson disease. They assessed depression clinically, using the geriatric depression scale.

The investigators identified imaging features that related significantly to the degree of depression, using the LASSO. The selected imaging features correlated strongly with the geriatric depression scale score. Using the LASSO framework, the researchers selected 3 single nucleotide polymorphisms associated with the geriatric depression scale: exm2267347, exm1187499, and exm-rs9303521. The investigators then created a linear regression model with the genetic features from the imaging genetics approach to describe clinical scores suggesting the degree of depression. They constructed other models using imaging and genetic features based on references to validate their models. These models were tested in a 5-fold cross-validation.

The investigators asserted that imaging genetics represents a powerful bottom-up approach to illuminating the mechanisms involved in psychiatric disease. They suggested that imaging genetics could be used to pinpoint neural circuits that translate genetic influences into behavior.

“Our model combining imaging and genetics information could be applied whenever a patient undergoes new imaging and thus could be used for the early prediction of depression. If detected, patients could be directed to many non-drug therapy options that are only available in the early stages of depression,” the researchers concluded.

Article from PsychiatryAdvisor.

Wisconsin Parkinson Magazine | Issue 101

Turn, stop, then sit: A research-based guide for Parkinson’s patients

Tel Aviv University team studies why patients with Parkinson’s disease have difficulty transitioning from walking to sitting, leading to greater instability and falls

Digital Management of Parkinson Disease: Is Technology the Future?

For Caregivers: What is a Parkinson’s Care Partner?

Here are some important discussion topics to have with your loved one:

Overall, care partners are more likely to experience:

Parkinson’s Awareness Posterboards

Can Imaging Genetics Analysis Effectively Identify Depression In Parkinson Disease?

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Can Imaging Genetics Analysis Effectively Identify Depression In Parkinson Disease?