Movement disorders : official journal of the Movement Disorder Society
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Case Reports
Bilateral subthalamic nucleus deep brain stimulation in a patient with cervical dystonia and essential tremor.
The role of subthalamic nucleus (STN) deep brain stimulation (DBS) is well established in Parkinson's disease, but experience with STN DBS in other movement disorders is limited. We report on a patient with medically refractory cervical dystonia and essential tremor resulting in dystonic head tremor and action tremor of the hands who obtained complete tremor suppression and near resolution of her cervical dystonia with bilateral STN stimulation. The results in this case demonstrate that STN DBS can dramatically improve dystonia and tremor in nonparkinsonian movement disorders.
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When medications no longer provide patients with Parkinson's disease a reasonable quality of life due to the presence of levodopa-associated motor fluctuations and dyskinesias, surgical treatment is often pursued. Numerous studies have examined the antiparkinsonian efficacy of procedures currently available, but surprisingly few studies have evaluated their effect on motor response complications in a systematic, controlled manner, using appropriate instruments. Nonetheless, the combined evidence from uncontrolled case series and more recent randomized controlled trials reviewed here indicates that unilateral pallidotomy, bilateral pallidal deep brain stimulation, and bilateral subthalamic deep brain stimulation all substantially alleviate levodopa-induced dyskinesias and, to a lesser extent, motor fluctuations. Incorporation of standardized, validated instruments for the quantification of motor response complications in future surgical study protocols will not only allow more accurate comparison of different interventions but also will help physicians select the most appropriate procedure for their patients.
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Randomized Controlled Trial Clinical Trial
Ropinirole is effective in the treatment of restless legs syndrome. TREAT RLS 2: a 12-week, double-blind, randomized, parallel-group, placebo-controlled study.
Restless legs syndrome (RLS) is a neurological condition with significant impact on sleep and quality of life (QoL). This double-blind, randomized, 12-week, multinational study compared the efficacy and safety of ropinirole and placebo in RLS. In total, 267 outpatients with moderate-to-severe RLS were randomly assigned to ropinirole (0.25-4.0 mg/day) or placebo, 1 to 3 hours before bedtime. ⋯ Improvements were significantly greater for ropinirole than placebo for change in IRLS score at week 12 (-11.2 [SE 0.76] vs. -8.7 [0.75], respectively; adjusted treatment difference -2.5 [95% confidence interval [CI], -4.6, -0.4], P = 0.0197); all key secondary endpoints; sleep and QoL parameters. Adverse events were typical for dopamine agonists; disease augmentation, although not directly assessed, was not reported during treatment. Ropinirole improves symptoms, associated sleep disturbance, and QoL of RLS patients and is generally well tolerated.
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We provide further validation of a Parkinson's disease (PD) home diary and explore implications for practical use in clinical trials. We previously developed and published a home PD diary that includes the categories ASLEEP, off, on without dyskinesia, on with nontroublesome dyskinesia, and on with troublesome dyskinesia [Hauser et al., J Clin Neuropharmacol 2000;23:75-81] and demonstrated that patients generally consider off time and on time with troublesome dyskinesia "bad time" and on time without dyskinesia or with nontroublesome dyskinesia "good time". We suggested that that on time without dyskinesia or with nontroublesome dyskinesia would be an appropriate outcome measure in clinical trials of advanced PD patients. ⋯ The diary appears to be sufficiently simple and feasible. Test-retest reliability was good, and reliability increased with increasing number of diary days but compliance diminished beyond 3 days. Good on time (ONG = on time without dyskinesia or with nontroublesome dyskinesia) most strongly correlated with patients' perceived duration of a good response through the day and is an important outcome variable.
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We aimed to develop and validate a novel rating scale for multiple system atrophy (Unified Multiple System Atrophy Rating Scale-UMSARS). The scale comprises the following components: Part I, historical, 12 items; Part II, motor examination, 14 items; Part III, autonomic examination; and Part IV, global disability scale. For validation purposes, 40 MSA patients were assessed in four centers by 4 raters per center (2 senior and 2 junior raters). ⋯ UMSARS-II correlated well with UPDRS-III and ICARS (rs > 0.8). Depending on the degree of the patient's disability, completion of the entire UMSARS took 30 to 45 minutes. Based on our findings, the UMSARS appears to be a multidimensional, reliable, and valid scale for semiquantitative clinical assessments of MSA patients.