Tag Archives: Symptoms

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Prodromal symptoms, Parkinson’s Disease (PD), and that old song and dance…

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Here’s a few studies that came up in my news feed from  PubMed Central (PMC) or elsewhere for articles recently published on the topics in which I’m interested – namely, prodromal symptoms related to PD, the relationship of REM sleep disorder and depression to PD, and, of course, the use of singing and dance therapies as complementary approaches to dealing with the symptoms of PD.

Prevalence and duration of non-motor symptoms in prodromal Parkinson’s disease

The prevalence and duration of non-motor symptoms (NMS) in prodromal Parkinson’s disease (PD) has not been extensively studied. The aim of this study was to determine the prevalence and duration of prodromal NMS (pNMS) in a cohort of patients with recently diagnosed PD.

…subtracted the duration of the presence of each individual NMS reported from the duration of the earliest motor symptom. NMS whose duration preceded the duration of motor symptoms were considered a pNMS. Individual pNMS were then grouped into relevant pNMS clusters based on the NMSQuest domains. Motor subtypes were defined as tremor dominant, postural instability gait difficulty (PIGD) and indeterminate type according to the Movement Disorder Society Unified Parkinson’s Disease Rating Scale revision.

Results: Prodromal NMS were experienced by 90.3% of patients with PD. … males reporting more sexual dysfunction, forgetfulness and dream re-enactment, whereas females reported more unexplained weight change and anxiety. There was a significant association between any prodromal gastrointestinal symptoms and urinary symptoms  and the PIGD phenotype.[n.b.: phenotype includes inherent traits or characteristics that are observable]. [Emphases added].

Citation:  Durcan R, Wiblin L, Lawson RA, Khoo TK, Yarnall AJ, Duncan GW, Brooks DJ, Pavese N, Burn DJ; ICICLE-PD Study Group. Prevalence and duration of non-motor symptoms in prodromal Parkinson’s disease. Eur J Neurol. 2019 Jul;26(7):979-985. doi: 10.1111/ene.13919. Epub 2019 Mar 1. PMID: 30706593; PMCID: PMC6563450.

Associations of Sleep Disorders With Depressive Symptoms in Early and Prodromal Parkinson’s Disease

Purpose: To explore the effect of sleep disorders, including the probable rapid eye movement (REM) sleep behavior disorder (pRBD) and the daytime sleepiness, on depressive symptoms in patients with early and prodromal PD.

5-year follow-up study showed that sleep disorders, including pRBD and daytime sleepiness, were associated with the increased depressive-related score in individuals with early and prodromal PD.

Conclusion: … Sleep disorders, including pRBD and daytime sleepiness, are associated with depression at baseline and longitudinally, …  partially mediated by the autonomic dysfunction in early and prodromal PD, …  implication that sleep management is of great value for disease surveillance.

Citation: Ma J, Dou K, Liu R, Liao Y, Yuan Z, Xie A. Associations of Sleep Disorders With Depressive Symptoms in Early and Prodromal Parkinson’s Disease. Front Aging Neurosci. 2022 Jun 10;14:898149. doi: 10.3389/fnagi.2022.898149. PMID: 35754965; PMCID: PMC9226450.

Group therapeutic singing improves clinical motor scores in persons with Parkinson’s disease

Abstract
Background Previous reports suggest that group therapeutic singing (GTS) may have a positive effect on motor symptoms in persons with Parkinson’s disease (PD).

Objective To determine the effect of a single session of GTS on clinical motor symptoms.

Methods Clinical motor symptom assessment was completed immediately before and after 1 hour of GTS in 18 participants.

Results A significant decrease in average scores for gait and posture and tremor, but not speech and facial expression or bradykinesia was revealed.

Conclusion These results support the notion that GTS is a beneficial adjuvant therapy for persons with PD that warrants further research.

Citation: Stegemoller E, Forsyth E, Patel B, et al. Group therapeutic singing improves clinical motor scores in persons with Parkinson’s disease BMJ Neurology Open 2022;4:e000286. doi: 10.1136/bmjno-2022-000286

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Sing!

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What research has found its way into the email inbox recently?

Although singing is a nearly universal human behavior, many adults consider themselves poor singers and avoid singing based on self-assessment of pitch matching accuracy during singing (here referred to as singing accuracy), in contrast to the uninhibited singing exhibited by children. In this article, I report results that shed light on how singing accuracy changes across the lifespan, using data from a large online sample, including participants ranging from 6 to 99 years old. Results suggest that singing accuracy improves dramatically from childhood to young adulthood, unperturbed by voice changes during adolescence, and remain at a similarly high level for the remainder of life, exhibiting no strong tendency toward age-related decline. Vocal or instrumental musical training has significant positive effects on singing accuracy, particularly in childhood, though there was no evidence for gender differences. Finally, pitch discrimination varied with age similarly to singing accuracy, in support of views that singing accuracy reflects sensorimotor learning. Taken together, these results are consistent with the view that singing accuracy is a learned motor skill that benefits from engagement and can remain a fruitful endeavor into old age. (emphasis added).

citation: Singing accuracy across the lifespan
Peter Q. Pfordresher preprint  article accessed 6-19-22 at https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.14815

Basically, this says that if you learned how sing accurately when you were young, you can probably sing well into your later years. And, since singing is a learned motor skill, one might assume that it can be learned even as one gets older.

Relevance to folks with Parkinson’s Disease (PD)?

Vocal strength exercises, such as those provided by Power for Parkinson’s as free YouTube video classes, can help with specific Parkinson’s related symptoms:

Many people with PD speak quietly and in one tone; they don’t convey much emotion. Sometimes speech sounds breathy or hoarse. People with Parkinson’s might slur words, mumble or trail off at the end of a sentence. Most people talk slowly, but some speak rapidly, even stuttering or stammering.

Parkinson’s motor symptoms, such as decreased facial expression, slowness and stooped posture, may add to speech problems. These can send incorrect non-verbal cues or impact the ability to show emotion. Source: https://www.michaeljfox.org/news/speech-swallowing-problems accessed June 20, 2022  (emphasis added).

Since our vocal cords are muscles, and singing is a learned motor skill, we can strengthen those muscles and push against the progressive, degenerative symptoms of PD through exercises that:

  • remind us to breathe deeply to sustain vocal volume,
  • improve our posture in order to enable deep breathing,
  • exercise the muscles of the face and mouth
  • to enable crisp diction instead of slurring and mumbling, and that
  • support emotional expression through inflection and singing.

And “Everybody Knows” that if exercise is fun, one is more likely to continue doing it.

Full disclosure: The author has attended Power for Parkinson’s ® vocal exercise classes since their inception in 2016, and co-founded a participant organized singing group (with the late Jeff Berke) in 2015.  Therefore, he might be (definitely is) biased in favor of this modality of treatment for vocal and speech related symptoms of PD.

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Basic human rights

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I don’t have access to the content of this book, but I was struck by the abstract to this chapter:

The right to an education is an important human right and is regulated in considerable detail in Articles 13 and 14 of the International Covenant on Economic, Social and Cultural Rights as well as in Articles 28 and 29 of the UN Convention on the Rights of the Child. With the sole exception of the United States, all United Nations member States have accepted the right to education as a legally binding human right that needs to be implemented in their domestic systems. (emphasis added)

What’s wrong with education in the United States? The U.S.A. hasn’t accepted it as a legally binding human right. No wonder that (well, I won’t go there today).

Chapter: Music Education
Child Development and Human Rights
By Steven J. Holochwost, Elizabeth Stuk

The book citation is:
Fifer, J., Impey, A., Kirchschlaeger, P.G., Nowak, M., & Ulrich, G. (Eds.). (2022). The Routledge Companion to Music and Human Rights (1st ed.). Routledge https://doi.org/10.4324/9781003043478
eBook ISBN 9781003043478

Book Description
The Routledge Companion to Music and Human Rights is a collection of case studies spanning a wide range of concerns about music and human rights in response to intensifying challenges to the well-being of individuals, peoples, and the planet. It brings forward the expertise of academic researchers, lawyers, human rights practitioners, and performing musicians who offer critical reflection on how their work might identify, inform, or advance mutual interests in their respective fields. The book is comprised of 28 chapters, interspersed with 23 ‘voices’ – portraits that focus on individuals’ intimate experiences with music in the defence or advancement of human rights – and explores the following four themes: 1) Fundamentals on music and human rights; 2) Music in pursuit of human rights; 3) Music as a means of violating human rights; 4) Human rights and music: intrinsic resonances.

The book is scheduled for publishing on May 31, 2022. $250 for print, under $50.00 USD for ebook format.

I really gotta look into becoming a student or getting associated with an organization or library that would allow me to access research articles, journals, ans books. It’s the one thing I miss most about IBM: access to technical journals through the library. That, and the IBM Club band, aka the Blue Diamonds Jazz Orchestra (BDJO). 

While not exactly fitting in with music, but maybe under basic human rights (free speech, anyone?), here is an open access article reporting on the results of the Parkinson’s Voice initiative:

Conclusion first:

Sustained vowels may provide an objective, robust and streamlined approach towards informing PwP subtype assignment. The current study’s findings corroborate part of the PD research literature indicating the presence of four PD subtypes having been thoroughly validated on a large PwP cohort and externally validated on two additional PwP cohorts. There are important practical implications of defining PD subtypes using data that is easy to self-collect remotely such as speech signals and in particular sustained vowel /a/ phonations: they enable large-scale investigations and may bring us a step closer towards more personalized medicine approaches and targeted clinical management. The key limitation of the study is that we do not have additional clinical labels (e.g. UPDRS) or other self-reported outcome measures to map the resulting PD subtypes onto something that would be more tangible and comparable to related PD subtype studies. Future work could explore the extent subtypes form useful markers of symptom severity progression and conversely how PD progression might affect subtype membership for individual PwP. Similarly, further work could integrate additional modalities to speech to incorporate longitudinal passively collected modalities and self-reports which could be capturing PD-related symptoms, e.g. via using smartphones and wearables along the lines we have explored for mental disorders [64], [67]–[70]. Collecting additional modalities at scale using increasingly affordable technologies may provide new insights towards understanding PD subtypes which may translate into understanding individual PwP similarities, related PwP symptom trajectories, and ultimately lead to better symptom management strategies.

and from the abstract:

Purpose
People diagnosed with Parkinson’s (PwP) exhibit a diverse manifestation of heterogeneous symptoms which likely reflect different subtypes. However, there is no widely accepted consensus on the criteria for subtype membership assignment. We explored clustering PwP using a data-driven approach mining speech signals.
…
Results
We selected 21 dysphonia measures and found four main clusters which provide tentative insights into different dominating speech-associated characteristics (cophenetic coefficient=0.72, silhouette score=0.67). The cluster findings were consistent across the three PVI cohorts, strongly supporting the generalization of the presented methodology towards PwP subtype assignment, and were independently visually verified in 2D projections with t-SNE.

The citation (and the link to access) this open access article are:

Tsanas, T & Arora, S 2022, ‘Data-driven Subtyping of Parkinson’s using Acoustic Analysis of Sustained Vowels and Cluster Analysis: Findings in the Parkinson’s Voice Initiative Study’, SN Computer Science, vol. 3, 232. https://doi.org/10.1007/s42979-022-01123-y

and that’s all I have for today, folks!

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RBD and other things PD-related

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Diagnosis of PD is often not made until a person is in their 60s. With all the attention that has been focused on the disease(s) in the last 20 years or so, I suspect that more people are getting diagnosed at an earlier age, although most cases of young onset PD are likely to be genetic in origin.

However, an “early” diagnosis may not be a timely diagnosis, as  the title of one opinion piece I read some time ago said (see link below).

It is now becoming apparent that “Parkinson’s”includes several categories of symptoms, not just rigidity, tremors, and gait, as shown in the table below::

Source for the following table, accessed 11/28/2021:  URL=https://www.frontiersin.org/article/10.3389/fneur.2020.00686

The problem is that treatment and diagnosis are often delayed until PD has already reduced Quality of Life for many folks.

Good evidence for the quality-of-life benefits of existing symptomatic treatment supports the argument for earlier diagnosis at a time when symptoms are already present (emphasis added). This argument would be significantly bolstered by the development of disease-modifying treatments. Benefits of early diagnosis and treatment would affect not only the individual (and their families) but also the wider society and the research community. Ultimately, however, shared decision-making and the principles of autonomy, beneficence, and non-maleficence will need to be applied on an individual basis when considering a “timely” diagnosis.

Therefore, the earlier one can predict the probability or inevitability of PD the sooner one can use treatments – whether pharmacological, surgical, nutritional, or lifestyle in nature – that can either reduce, delay, or defer (and possibly reverse?) the symptoms of PD.

Of all the symptoms associated with PD: tremors, bradykinesia, depression & anxiety, posture, gait issues (difficulties walking), REM Sleep Behavior Disorder (RBD), anosmia (loss of ability to smell), cognitive issues, facial masking, and micrographia (small handwriting) – RBD is the one which is most highly predictive of a later PD diagnosis.

The predictive ‘specificity’ is so strong that if someone has RBD, the chance of being diagnosed with Parkinson’s or related conditions over the next 15 years or more is over 80%

If an 18-21 year old person walked into a physician’s office with RBD, essential tremors, and depression as main symptoms, what would happen? In 1970, probably nothing – one might get treated for depression, but essential tremors are also called “benign”tremors, and were ignored, even if the patient reported being able to feel the tremors while resting, though invisible to the external observer. As for RBD, it would probably also be ignored.

By “a physician,” we are talking about a General Practitioner, or “family doctor,” and not s specialist like a  Movement Disorders Specialist who would be trained to identify varied symptoms, including those that are prodromal. And, of course, the identification of prodromal symptoms has only been investigated within the last decade or so, and are identified as for “research only” purposes – not for clinical diagnosis. A recent survey article (not referenced below) indicated that a majority of general practitioners were either unaware of the Movement Disorders Society’s list of prodromal symptoms, or were not using them to make referrals to Movement Disorders Specialists.

But thanks to the dedication and generosity of folks like Michael J. Fox and others, PD has become a respectable disease for which the person who has it has no reason to be apologetic or ashamed, and can hold their head up (and they ought to, since one symptom is to walk with shoulders stooped down) and proudly proclaim that they have Parkinson’s, which is why they walk funny. And so it goes.

Articles that were quoted above or which contributed to this article are found in the links below.

But first:

I See The Signs of PD

Perspective: Current Pitfalls in the Search for Future Treatments and Prevention of Parkinson’s Disease

An early diagnosis is not the same as a timely diagnosis of Parkinson’s disease

Prodromal REM Sleep Behavior Disorder and PD

10 Early Signs of Parkinson’s Disease / Parkinson’s Foundation

REM Sleep Behavior and Motor Findings in Parkinson’s Disease: A Cross-sectional Analysis

Current Update on Clinically Relevant Sleep Issues in Parkinson’s Disease: A Narrative Review

The prodromes of Parkinson’s disease

Exercise-Induced Neuroprotection of the Nigrostriatal Dopamine System in Parkinson’s Disease

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Can Parkinson’s be predicted using Artificial Intelligence (AI)??

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Today we take a look at a review of other papers (a way to get a paper published without having to do any actual research yourself, and the drudge work can be delegated to grad students, someone once told me), but nevertheless, there’s much to be learned from looking at the big picture instead of focusing on individual studies, so we’ll forge ahead. Next article will be on rehabilitation therapies that address motor and cognitive issues in PD.

Interestingly enough, this article comes from Indonesian Journal of Electrical Engineering and Computer Science – not the first place you’d probably look for information n Parkinson’s (PD). And, unless you’re a computer science major or are developing applications using AI, I wouldn’t recommend looking this one up.

Most of the studies reviewed used various techniques to analyze datasets of speech recordings, and tried to differentiate between “healthy”people and people with PD. Some of the approaches were fairly accurate (in the 90% plus range) while others were not that much better than reliance on the four cardinal symptoms to be observed clinically (resting tremor, rigidity, bradykinesia and postural instability). 

This one will either be good reading before going to sleep (unless you’re into neural networks and Bayesian prediction) or a good way to induce a headache. The authors do call for more research (naturally) in this area, especially in regard to developing biomarkers using either neuro-imaging or biofluids. And they note that fine-tuning of biomarkers must be  done, so that there is an acceptable balance between false positives and false negatives in predicting whether a person will likely get PD in the near or distant future.

Citation for this is:

A comparative and comprehensive study of prediction of Parkinson’s Disease, (2021) Pandi, V., et al., Indonesian Journal of Electrical Engineering and Computer Systems, vol. 23, No. 2, September 21, pp. 1748-1760.

It’s an open access article, so if you are interested in computer systems. go ahead and search for it. 

 

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Late Stage Parkinson’s (LSP): Undertreated?

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This paper (or rather a chapter in a thesis) landed in my newsfeed recently. In it, the authors describe a study done to see whether people with Parkinson’s in the later stages are getting adequate treatment and whether they could benefit from more specific treatment. (A link to the PDf file is at the end of this post).

A person in Late Stage Parkinson’s has more than one of the following:

  • Motor symptoms not controlled despite medication.
  • Levadopa-related dyskinesias or dystonia,
  • PD dementia (defined according to MDS Task Force definition (Dubois et al. 2007), and
    not treated with cholinesterase inhibitors,
  • Depression not adequately treated,
  • Neuropsychiatric symptoms, such as agitation/ aggression; anxiety and irritability,
  • Orthostatic hypotension, pain, constipation, urinary symptoms, insomnia or daytime sleepiness (autonomic systems degeneration),
  • Falls on a regular basis,
  • Other symptoms related to risk of choking, speech issues, or producing too much saliva,
  • Inadequate Home environment.

Basically, the study provided a list of recommended activities and treatment on a sheet of paper (the control group) and actually providing the treatments and activities recommended, (the treatment group).

Not surprisingly, the treatment group did better at the end of the study than the controls. The conclusions were that people in late-stage Parkinson’s are often undertreated and could benefit from implementation of movement disorder specialists’ recommendations. (One would hope that the control group would also be provided with the treatments after the study ended. Perhaps, leading to another report)?

I’ve paraphrased the table used to describe late stage Parkinsonism in order not to infringe on their copyright. The title of the entire thesis is “Impairment and Disability in Late Stage Parkinsonism” and the overall author is Danny Hommel. I couldn’t find an email to ask for permission in writing to reproduce anything verbatim.

Other chapters include:

  • The late-stage of parkinsonism’s – motor and non-motor complications
  • The prevalence and determinants of neuropsychiatric symptoms in late-stage parkinsonism
  • Prevalence and prescribed treatments of orthostatic hypotension in institutionalized peoples with Parkinson’s disease (the chapter discussed in this post)
  • Optimizing treatment in undertreated late-stage parkinsonism: a pragmatic randomized trial
  • General discussion/English summary

Published as: ALAJ Hommel, MJ Meinders, NJ Weerkamp, C Richinger,
C Schmotz, S Lorenzl, R Dodel, M Coelho, JJ Ferreira, F Tison, T Boraud,
WG Meissner, K Rosqvist, J Timpka, P Odin, M Wittenberg, BR Bloem,
RT Koopmans, A Schrag and the CLaSP consortium.
Optimizing treatment in undertreated late-stage parkinsonism: a pragmatic
randomized trial.
J Parkinsons Dis. 2020;10(3):1171-1184.

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This is photography on Parkinson’s

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This is photography on Parkinson’s… sometimes. Sometimes you accidentally hit the button due to herky-jerky movements, sometimes you manage to get the shot you envisioned in the viewfinder. Some days your vision is blurred and it’s hard to say whether or not you have the item you want in focus, in focus. More often than not, it’s blurred, and the background or foreground isn’t focused instead. Of course, one can always use autofocus, but that has the same issues as manual focus with blurry vision. The best one can do in that situation is to click the shutter as soon as the screen blinks red, indicating that everything’s in focus. And then, of course, somedays you get the focus right and the shutter speed and it all works. Then again, when life hands you bitter citrus, sometimes you can make a Margarita. Or better yet, KeyLime Pie.

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A review on dance and PD

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Dance classes for Parkinson’s patients was one of the things that got me involved in Power for Parkinson’s© and the Georgetown Area Parkinson’s Support group to begin with. For me, it has helped to improve symptoms and quality of life tremendously.

In this desk review of many studies, the authors came to the following conclusions:

Overall, the reviewed evidence demonstrated that dance can improve motor impairments, specifically balance and motor symptom severity in individuals with mild to moderate PD, and that more research is needed to determine its effects on non-motor symptoms and QOL. RCTs that use a mixed-methods approach and include larger sample sizes will be beneficial in fully characterizing effects and in determining which program elements are most important in bringing about positive, clinically meaningful changes in people with PD.

 Carapellotti AM, Stevenson R, Doumas M (2020) The efficacy of dance for improving motor impairments, non-motor symptoms, and quality of life in Parkinson’s disease: A systematic review and meta-analysis. PLoS ONE 15(8): e0236820. https://doi.org/10.1371/journal.pone.0236820

I have come to the conclusion that every study or review has to include the phrase “more research is needed.” And it is true.

You can read the article in its entirety at the URL in the citation, or download it directly from this link:

The efficacy of dance for improving motor impairments, non-motor symptoms, and quality of life in Parkinson’s disease: A systematic review and meta-analysis

 

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That famous essay

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James Parkinson wrote an essay on “The Shaking Palsy” just over 200 years ago. Although science doesn’t stand still, and folks like Louis Pasteur, Alexander Fleming, and Jonas Salk came along to make important contributions in medical science, the field of Movement Disorders has, until recently, relied almost exclusively on the traits described by Parkinson in his essay to diagnose the disease. French neurologist Jean-Martin Charcot made some advances in making distinctions between some of the symptoms and championed naming the disease after Dr.Parkinson.

Curious about the essay itself? it’s available online as a full access article in The Journal of Neuropsychiatry (downloadable as a PDF file.

An essay on the Shaking Palsy 

An Essay on the Shaking Palsy, by James Parkinson, was originally published as a monograph by Sherwood, Neely, and Jones (London, 1817). Punctuation and spelling follow the original text. Introduction Copyright © 2002 American Psychiatric Publishing, Inc.

 

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Strength training can help with PD symptoms

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A review of studies indicates that strength training can help with mild to moderate Parkinson’s cases. (An earlier blog post here noted that a dance training program increased grey matter volume in the brain versus repetitive strength training. So don’t exclude either from your wellness program, is my [non-medical advice).

Review of strength training in people with Parkinson’s Disease

From the abstract:

Objective: To investigate the evidence on efficacy and limits of strength training in rehabilitation of Parkinson’s disease

Method:A comprehensive search on pubmed, clinical keys database using keywords Parkinson’s disease, physical therapy, strength training ,resistance training. The studies including Randomized controlled trails and systematic reviews published since 2005 are reviewed.

Results:36 studies identified through database searching. 25 studies are excluded due to duplicates, irrelevance, based on titles, outcome diversity. 5 systemic reviews and Meta analysis, 6 RCT are included. Review and analysis of articles is going on

Conclusion : The result of this review suggests that strength training program can be effective in people with mild and moderate parkinson’s disease. It can improve functional independency with increased muscle strength, gait parameters, posture and balance, all of these positive role on participation and quality of life