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Patients should be wary of using non-validated tests to diagnose Lyme Disease, said experts attending an October Science Media Centre briefing on the disease . Consultant microbiologist Matthew Dryden said that an increased, disproportionate public awareness of the rarer side effects of Lyme Disease has led to the spread of misinformation about chronic or ‘post-treatment’ symptoms of Lyme Disease. Consultant in tropical diseases Sarah Logan said that the long-term use of antibiotics by people who believe they have chronic Lyme Disease is more harmful than the effects of the disease itself.
In this observational study, a random sample of 765 patients at neurology outpatient clinics in Shanghai were assessed using questionnaires to see whether a link could be made between neurological symptoms and the occurrence of depression and anxiety . The authors found a correlation between the number of physical symptoms reported and the occurrence of depression and anxiety-related symptoms. More research is required to elucidate any link.
REVIEW: Dizziness demystified—BMJ
This review article covers the latest information about the most common presentations and diagnoses under the ‘dizziness’ umbrella and acts as a guide for diagnosing professionals . The four most common presentations are covered in detail and linked with their possible diagnoses, which include Ménière’s disease, vestibular migraine and cerebellar infarction.
REVIEW: Recent advances in treatment for narcolepsy—Therapeutic advances in Neurological Disorders
An improved understanding of the causes of narcolepsy has led to an increase in the number of available pharmacological treatments for the sleep disorder, which has recently been reclassified into Narcolepsy Type 1 (NT1) and Narcolepsy Type 2 (NT2). Much more is known about the pathophysiology of NT1, with hypocretin/orexin (ORX) neurons being lost through what is thought to be an autoimmune process. This review article gives an overview of the newest pharmacological treatments for narcolepsy, including some new immune-based therapies .
REVIEW: Speech and language therapy approaches to managing primary progressive aphasia—Practical Neurology/BMJ
This article provides an overview of the current state of access to speech and language therapy services in the UK, USA and Australia for people with primary progressive aphasia (PPA) . PPA is a term for a group of neurodegenerative diseases which progressively impair speech and may also cause the development of a motor disorder. The authors conclude that routine referral of people with PPA for speech and language therapy interventions could help to maintain their independence for longer.
REVIEW: Essential tremor: a nuanced approach to the clinical features—Practical Neurology/BMJ
This discussion of the common presentations of essential tremor aims to distinguish the disorder from other commonly comorbid movement and cognitive disorders . These include Parkinson’s disease and dystonia. The article includes discussion of 13 common symptoms and videos of patients undergoing tests for essential tremor.
PROFESSIONAL PERSPECTIVE: Dissociative (non-epileptic) seizures: tackling common challenges after the diagnosis—Practical Neurology/BMJ
Professor Markus Reuber of the Royal Hallamshire Hospital’s Academic Neurology Unit details his approach to patient care following diagnosis of dissociative seizures . He lists some common questions and concerns that his patients have and offers ideas about how to answer them.
REVIEW: Blood pressure and the brain: the neurology of hypertension—Practical Neurology/BMJ
There is an as-yet-unclear pathway between the brain and the occurrence of hypertension . This article gives an overview of the disease and some possible neurological causes and effects of hypertension and advocates early diagnosis, monitoring and treatment to sustain brain health.
REVIEW: Language and language disorders: neuroscience to clinical practice—Practical Neurology/BMJ
This review of language disorders includes an overview of the historic models of understanding of aphasia from the mid-19th century to the modern day . Drawing on this history, the authors present an up-to-date guide to assessment, treatment and rehabilitation of aphasia, before detailing some of the prospects for new approaches to language recovery.
A national campaign to provide greater access to music for people with dementia is collecting information for its ‘music map’ of dementia-focused music therapy services . The map is being launched in response to a perceived lack of centralised information about local musical events and services for people with dementia.
REVIEW: Can you really prevent Parkinson’s?—Medium
Parkinson’s UK research communications manager Dr Beckie Port details and debunks nine commonly-cited preventative measures against Parkinson’s (some evidence-based and others not) . Be sure to read beyond the slightly misleading subheadings—for instance, while point 4 is titled ‘avoid sugar’, the summary reveals that there is ‘little evidence that avoiding sugar completely would prevent the condition’. However, the article is a useful guide to the evidence base for these claims.
GUIDANCE: Parkinson’s and protein—what’s the connection?—Medium
This Parkinson’s UK article responds to a trend towards low-protein and protein-avoidant diets for Parkinson’s disease by explaining how Levodopa transports dopamine across the blood-brain barrier . Protein competes with Levodopa for bloodstream absorption in the small intestine, which has led some to infer that people with Parkinson’s should cut protein out of their diet entirely. Parkinson’s UK recommends against this approach, saying instead that patients should consult their doctors and consider their symptoms before making any changes to their diet.
Providing a comprehensive guide to falls assessment and bone health investigation, this is a useful guide for frontline medical professionals and those involved in the care of people with Parkinson’s disease . People with Parkinson’s disease have an increased risk of osteoporotic fractures, so the authors recommend carrying out blood tests and prescribing bisphosphonates to build up vitamin D and calcium levels.
REVIEW: Non motor symptoms of Parkinson’s disease—GM
As Parkinson’s is a multisystem disease, there are many non-motor symptoms (NMS) of Parkinson’s disease as well as the more commonly-recognised motor symptoms . Here, the authors take us through some of the most common neuropsychiatric, gastrointestinal, sensation-related and sleep-related symptoms, among others.
A common non-motor complication of Parkinson’s disease is mild cognitive impairment (PD-MCI) . However, widely-accepted assessment tools and methods for screening are currently lacking. This guide to PD-MCI provides an overview of its main features and helps to steer medical professionals through diagnosis and management.
A cross-sectional study* of people with a gene mutation known to cause early onset of Parkinson’s disease has found that serotonergic pathology precedes dopaminergic pathology and motor symptoms as an early sign of Parkinson’s progression . They anticipate that molecular imaging of serotonin transporters might therefore be a useful screening tool for those at risk of Parkinson’s disease.
This study of a cohort of 1006 adults and children with epilepsy used data from Italian epilepsy centres to follow each individual for at least 10 years . The authors aimed to identify and describe the long-term prognosis of epilepsy in their cohort, concluding that even long-term remission from seizures did not exclude the possibility of relapse.
STUDY: Cannabis use is both independently associated with and mediates worse psychosocial health in patients with epilepsy—Journal of Neurology, Neurosurgery and Psychiatry/BMJ
This Canada-based cross-sectional study of patients at an epilepsy clinic in Calgary focuses on a supposed relationship between cannabis use and psychosocial health . 337 patients at the clinic reported whether or not they used cannabis and filled out the patient-reported outcome measures (PROMs) questionnaire. Using the data, the authors found a correlation between cannabis use and higher odds of depression, lower quality of life, higher perceived epilepsy disability and lower satisfaction with AEDs among the patients surveyed.
REVIEW: Seizures and movement disorders: phenomenology, diagnostic challenges and therapeutic approaches—Journal of Neurology, Neurosurgery and Psychiatry/BMJ
Seizures and movement disorders are two distinct presentations of epilepsy with overlapping phenomenology but differing pathophysiology . This review aims to inform accurate diagnosis of movement disorders in order to better treat their underlying causes, also offering a guide to treatments and their side-effects.
REVIEW: Progressive multiple sclerosis: latest therapeutic developments and future directions—Therapeutic Advances in Neurological Disorders
Here, the latest developments in treatments for progressive MS are detailed . These include B-cell- and S1P receptor-targeted medications, and medications which restore the immune system and promote remyelination. The article also lists some experimental trials of treatments for progressive MS.
STUDY: Symptomatology and symptomatic treatment in multiple sclerosis: Results from a nationwide MS registry—Multiple Sclerosis Journal
Using data from the German MS Registry on 35,755 patients from 148 MS centres, the authors analysed data on MS symptoms, disease progression and disease course to find links to neuropsychological symptoms . Nearly a third of patients reported fatigue within the first two years of disease, a symptom that the authors claim is currently poorly-treated in people with MS. They also found that sexual dysfunctions were underreported among their cohort.
STUDY: Psychological resilience is linked to motor strength and gait endurance in early multiple sclerosis—Multiple Sclerosis Journal
This case-control study of the effects of psychological resilience in early MS compared 185 patients with early MS to 50 matched healthy controls . The goal was to assess whether psychological resilience, as determined on the Connors-Davidson Resilience Scale (CDRS-10), could explain differential cognitive and motor function in early MS. The authors found an association between high psychological resilience and better motor performance on the Multiple Sclerosis Functional Composite (MSFC) measure in the group with MS, but this was also observed in the healthy controls, suggesting that the link between psychological resilience and motor function is non-disease-related.
STUDY: A randomised double-blind placebo-controlled feasibility trial of flavonoid-rich cocoa for fatigue in people with relapsing and remitting multiple sclerosis—Journal of Neurology, Neurosurgery and Psychiatry/BMJ
The effects of flavonoid-rich cocoa drink on fatigue in people with MS were measured in this feasibility study for a larger trial . However, this being a feasibility study, the small sample size means that the results do not reach statistical significance and further research would be required to establish a causal link between flavonoid-rich cocoa and fatigue relief in MS.
STUDY: Dissociable cognitive patterns related to depression and anxiety in multiple sclerosis—Multiple Sclerosis Journal
Anxiety and depression are much more common in people with MS than in the general population . This cross-sectional study used data on 255 people with relapsing-remitting MS from two cohorts (RADIEMS and MEM CONNECT) to measure the incidence of different MS symptoms against incidence of anxiety and depression. The authors found that lower anxiety was associated with better nonverbal memory and lower depression was related to better attention and processing speed in both cohorts. The study is limited by its cross-sectional design; however, the authors aim to conduct a longitudinal study based on ongoing data collection from the two cohorts.
REVIEW: Cannabis and multiple sclerosis—Practical Neurology/BMJ
The use of medical cannabis has been in the press since the home office licensed its use in the UK in 2018. As of November 2019, only 18 prescriptions had been made since legalisation. However, with larger-scale trials of medical cannabis for chronic pain in the pipeline, doctors and prescribing professionals are likely to need a wider knowledge of the subject in the coming years. This article explores some of the more common medicinal forms of the drug and their interactions with common MS symptoms, and recommends further research .
A retrospective cohort study* focusing on neurodegenerative disorders in former Scottish football (soccer) players has revealed a significantly increased rate of mortality from neurodegenerative diseases when compared to the general population . The study matched 7676 former players with 23,028 controls from the Community Health Index (CHI), which holds health and demographic data on the Scottish population.
*Study link: Neurodegenerative Disease Mortality among Former Professional Soccer Players—New England Journal of Medicine
REVIEW: Understanding neurodegeneration after traumatic brain injury: from mechanisms to clinical trials in dementia—Journal of Neurology, Neurosurgery and Psychiatry/BMJ
Roughly five percent of all dementia cases may have their root in traumatic brain injury (TBI) . TBI is also associated with an increased risk of neurodegenerative diseases including Alzheimer’s and Parkinson’s disease among others. The authors detail the ways in which TBI triggers neurodegeneration, giving advice on investigation and common clinical features. They hope that phase II and phase III clinical trials studying the biomarkers of neurodegeneration will help to find treatments for the condition.
REVIEW: Neuropsychological outcomes following traumatic brain injury—Practical Neurology/BMJ
The exaggeration of TBI in patient records and false attribution of neuropsychological symptoms to TBI can lead to a ‘significant detrimental impact’ on individuals’ recovery, claim the authors of this article . Many factors contribute to recovery post-TBI, not all of them related to the injury itself; therefore the speed of recovery does not always indicate the severity of the injury. This article advocates determination of TBI outcomes based on pathoanatomic classification using neuroimaging.
This longitudinal study* of patients at stroke units in the North West of England has found a high incidence and point prevalence of visual problems among acute stroke survivors . Over a one-year period, 1295 people were admitted to the units, with around half of these undergoing assessment of visual function. Incidence of new onset visual sequelae due to stroke occurred in nearly half of all admissions, and 60% of stroke survivors.
PROFESSIONAL PERSPECTIVE: Post-traumatic benign paroxysmal positional vertigo—Practical Neurology/BMJ
After a minor head injury due to a skiing accident, clinical neurologist Dr Colin Mumford began to experience severe rotational vertigo and nausea . His symptoms were indicative of trauma-induced benign paroxysmal positional vertigo (BPPV), and after being assessed and treated by two of his colleagues, his nausea was replaced by a visual disturbance. Here, he describes his experience of BPPV and shares his understanding of the symptomology.
REVIEW: Managing cluster headache—Practical Neurology/BMJ
There are a number of existing treatments prescribed for management and prevention of cluster headaches, with more on the horizon . This article gives advice regarding diagnosis and examines the evidence base for the most common treatments, as well as listing some of the newer developments in cluster headache treatment.
REVIEW: Medication-overuse headache—BMJ review—Practical Neurology/BMJ
Medication-overuse headache is a complex condition to diagnose and treat. Overuse of triptans and opioids appears to be a common risk factor for the condition, but overuse of any analgesic can cause headache onset . This article is intended as a guide for doctors through the common features, diagnosis, prevention and treatment of medication-overuse headache, including patient-focused advice on drug withdrawal.
SYSTEMATIC REVIEW: Non-invasive neuromodulation for migraine and cluster headache: a systematic review of clinical trials—Journal of Neurology, Neurosurgery and Psychiatry/BMJ
This systematic review assesses the design of 71 clinical trials of non-invasive neuromodulation devices for migraine and cluster headache . The authors measure the design of each trial against the guidelines outlined by the International Headache Society (IHS) and conclude that the designs of clinical trials of non-invasive vagus nerve stimulation are generally better than those of other non-invasive neuromodulation treatments. However, because of the heterogeneity of the trial designs, the reviewers were unable to collate the positive and negative findings from each trial.
STUDY: Effects of onabotulinumtoxinA treatment for chronic migraine on common comorbidities including depression and anxiety—Journal of Neurology, Neurosurgery and Psychiatry/BMJ
This analysis of trial data from the COMPEL trial of onabotulinumtoxinA for chronic migraine has found that trial participants with depression and anxiety reported a decrease in depression and anxiety-related symptoms over the course of the trial . This was determined by analysing data from questionnaires answered by participants five times over 108 weeks. This analysis is limited by its post-hoc design, the non-clinical definitions of depression and anxiety used and the non-randomisation of the original trial. However, it provides some grounds for further research.
STUDY: Onset of efficacy and duration of response of galcanezumab for the prevention of episodic migraine: a post-hoc analysis—Journal of Neurology, Neurosurgery and Psychiatry/BMJ
Before NICE began its technology appraisal of galcanezumab for migraine prevention last year, Eli Lilly sponsored this post-hoc analysis of the speed with which people with episodic migraine respond to the drug . They found signs that onset of efficacy occurs within one week of injection. However, this analysis is limited by the fact that it was not included within the design of the original trial.
PROFESSIONAL PERSPECTIVE: Intense rehabilitation therapy produces very large gains in chronic stroke—Journal of Neurology, Neurosurgery and Psychiatry/BMJ
Researchers found large clinical improvements in upper limb impairment and activity in stroke patients in a single-service observational study of therapy interventions for stroke . Patients admitted for stroke at UCLH’s National Hospital for Neurology and Neurology underwent physiotherapy and occupational therapy over a 90-hour programme. The authors recommend that further, more extensive clinical trials be undertaken to elucidate the link between therapy interventions and upper limb rehabilitation post-stroke.
NEWS FROM NICE
CLINICAL KNOWLEDGE SUMMARY: Migraine: Clinical Knowledge Summary—NICE
NICE reviewed their migraine Clinical Knowledge Summary back in April last year, updating the document with new guidelines and references to key clinical trials . There has also been minor changes to the recommendations based on updated NICE guidance from 2015. The next review is planned for 2024.
CLINICAL KNOWLEDGE SUMMARY: Sleep disorders – shift work and jet lag: Clinical Knowledge Summary—NICE
A similar review has been conducted for the shift work disorder (SWD) and jet lag disorder (JLD) Clinical Knowledge Summary . The next review is planned for 2024.
QUALITY STANDARD: NICE quality standard on dementia—NICE
This quality standard replaces the earlier 2010 and 2013 quality standards on dementia, and reduces the number of quality statements from ten to seven . Among the new statements are recommendations that people with dementia have a single practitioner to oversee their care and that before being given treatment for distress they should be properly assessed to ascertain the cause(s) of distress.
GUIDELINE: NICE guideline: Suspected neurological conditions: recognition and referral—NICE
NICE first published this guideline in May 2019 . It constitutes comprehensive recognition and referral guidance for a range of symptoms where neurological causes are suspected. These include but are not limited to blackouts, dizziness, cognitive deterioration and speech problems. The guideline has separate sections for adults and children.
Doctors should feel confident in diagnosing Lyme whenever a characteristic bull’s eye rash is present, says NICE’s quality standard on Lyme disease . Waiting for blood test results unnecessarily delays treatment, with Lyme disease antibodies appearing six to eight weeks after a bite.
MOTOR NEURONE DISEASE
Nabiximols, a cannabis extract, has been shown to have a positive effect on spasticity in motor neurone disease in a phase II, proof-of-concept trial . The two-year trial* involved 60 participants (30 receiving nabiximols and 30 placebo) and tested the botanical drug for efficacy and tolerability. No severe adverse effects were recorded during the trial and a positive improvement was registered on the Modified Ashworth Scale (MAD) measure of spasticity when compared to placebo. This is, the authors claim, the first randomised controlled trial of a pharmacological treatment for spasticity in motor neurone disease.
*Clinical trials link: https://bit.ly/38rU4aI
ABSTRACT: Reducing length of stay for patients with Motor Neurone Disease admitted to a Specialist Ventilation Unit—European Respiratory Journal
This abstract retrospectively measures the effects of a service evaluation on hospital stay length for MND patients at a specialist ventilation unit . The authors claim that by reducing transfers from other hospitals and facilitating admissions direct from home, they were able to reduce median stay length from five days to three. Only the abstract is available, so a fuller examination of the claims and methodology is not possible.
STUDY: Patients’ perspectives of multidisciplinary home-based e-Health service delivery for motor neurone disease—Disability and Rehabilitation: Assistive Technology
MND multidisciplinary clinics do not routinely offer telehealth care options to patients . This small-scale study of twelve patients with MND shows that most participants had access to IT and regularly used IT to communicate with family and friends. Over 90 percent owned a phone and had an email account. A study with a larger sample size is necessary before any conclusions can be made about the possible effect of telehealth services on MND care.
ABSTRACT: Experiences of being diagnosed with motor neuron disease: “I just want to know”—Collegian
An interview-based assessment of people’s experiences of living with MND found that four themes emerged in the answers given . Interviewees were concerned with: Barriers to early diagnosis; their humane treatment; regaining control of their lives; and support. Only the abstract is available for this paper.
To download the full set of references mentioned throughout the news articles click here.
Written by Chris Jutting, freelance journalist, for Neurodigest.
Posted March 2020