Alfonso Fasano, MD, PhD

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Abstract: Deep brain stimulation has become widely accepted as a treatment for Parkinson's disease (PD), dystonia and tremor, and as an off-label treatment for many other movement disorders. In recent years, new official indications have been approved: obsessive-compulsive disorder and focal epilepsy with secondary generalization. This field is expanding exponentially in two not mutually exclusive fields: clinical and technological. Clinically, we have achieved a deeper understanding of outcomes, thus facilitating the process of target and patient selection. In fact, we have gained a better understanding of established indications, particularly with respect to the debate on whether subthalamus or globus pallidus pars interna should be the target of choice for PD. In addition, the role of DBS for treating dystonia has been further defined in terms of patient selection and surgical outcome. Other established (e.g. essential tremor, epilepsy) and novel indications (e.g. Tourette syndrome) have been addressed as well. Finally, recent technological advantages in neuromodulation have opened new avenues towards new targets and indications.

Key Words: Deep brain stimulation, movement disorders, Parkinson's disease, tremor, dystonia.

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Deep brain stimulation (DBS) is an established neuromodulation technique made possible by the neurosurgical placement of electrodes which deliver a mild electrical current to stimulate areas in the deep brain.

DBS has become widely accepted as a treatment for Parkinson's disease (PD), dystonia and tremor, and as an off-label treatment for many other movement disorders.

We have gained a better understanding of established indications, particularly with respect to the debate on whether subthalamus or globus pallidus pars interna should be the target of choice for PD.

In recent years, new official indications have been approved: obsessive-compulsive disorder and focal epilepsy with secondary generalization.

The advance of neuromodulation technologies has provided clinicians with new tools making targeting, programming, and overall management easier.

Nevertheless, we still fail to have reliable methods predicting the surgical outcome even in established indications, such as epilepsy or dystonia. In fact, the surgical outcome always relies on patient selection, which is mainly driven by the trade off between surgical risk and expected benefits.

DBS cannot cure or change the progression of the disease but it can help relieve symptoms and improve quality of life.

In PD, DBS can help symptoms that respond to levodopa with two exceptions: speech responds to levodopa, but does not usually improve with DBS (and might get worse) whereas tremor not responding to levodopa improves with DBS.

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Kaitlyn Roland, MSc, Research Assistant, Interdisciplinary Graduate Studies, The University of British Columbia, Kelowna, BC.
Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Mary E. Jenkins, BSc(PT), BEd, MD, FRCPC, Associate Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.

Abstract
Burden is a psychological concept, a subjective interpretation by caregivers of the extent to which the caregiving experience impacts on one's health, social life, or financial status. In this article, we examine some of the predictors of caregiver burden, and look specifically at the burden experienced by caregivers of individuals with Parkinson's disease.
Keywords: Parkinson's disease, psychological health, physical health, caregiver burden

Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario,
London, ON.
H. Christopher Hyson, MD, FRCPC, Assistant Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.
Kaitlyn P. Roland, MSc, Research Assistant, Interdisciplinary Graduate Studies, The University of British Columbia Okanagan, Kelowna, BC.

Abstract
Although Parkinson’s disease is primarily considered to be a motor disorder, it has inarguable effects on cognition and personality. The cluster of neuropsychiatric sequelae known as impulse-control disorders has been of particular interest in recent years, perhaps owing to the potentially disastrous effects that such behaviors can have on individuals and families. Research has suggested that impulse control disorders are significantly more prevalent among individuals with Parkinson’s disease, particularly with regards to pathological gambling and hypersexuality, and has further suggested that these disorders are significantly and substantively affected by the use of dopamine agonists. Treatment options for impulse control disorders tend to revolve around dopamine agonist dose reduction or cessation. The use of psychosocial strategies, or deep-brain stimulation of the subthalamic nucleus may also be considered in the management of patients with impulse control disorders.
Keywords: Impulse control disorders, Parkinson’s disease, dopamine agonists service use.

Shen-Yang Lim, MBBS, FRACP, Movement Disorder Centre, University of Toronto, Toronto Western Hospital, Toronto, ON.
Susan H. Fox, MRCP (UK), PhD, Movement Disorder Centre, University of Toronto, Toronto Western Hospital, Toronto, ON.

Parkinson’s disease (PD) is characterized by the presence of bradykinesia, rigidity, and rest tremor. Nonmotor symptoms are also very common in PD and may result in significant disability. Many approaches are available to reduce symptoms. In this article we provide an update on the management of PD. We also discuss the limitations of current treatments.
Key words: Parkinson’s disease, treatment, motor response complications, nonmotor, nondopaminergic.

Weerasak Muangpaisan, MD, FRCPT, Assistant Professor, Department of Preventive and Social Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand; visiting fellow, Harris Manchester College, University of Oxford, Oxford, U.K.

Cases of dementia are increasing due to longer life expectancy of the world population. Physicians should be able to recognize common dementia syndromes. After excluding reversible causes of dementia, there are four common dementia syndromes, which are Alzheimer’s disease, vascular dementia, dementia with Lewy body, and frontotemporal dementia. The key points of clinical differences of these dementia syndromes are summarized in this article.
Key words: Alzheimer’s disease, vascular dementia, dementia with Lewy body, frontotemporal dementia, Parkinson’s disease.

A.M. Johnson, PhD, Assistant Professor, Faculty of Health Sciences, University of Western Ontario, London, ON.
Q.J. Almeida, PhD, Director, Movement Disorders Research & Rehabilitation Centre, Wilfrid Laurier University, Waterloo, ON.

Although medication therapy is generally effective in the clinical management of Parkinson’s disease (PD), additional improvement of some gross motor symptoms may be achieved through the use of nonpharmacological treatments, such as physical therapy and exercise rehabilitation. Despite the fact that PD is a neurological disorder, successful rehabilitation has been demonstrated with treatments that combine cognitive and physical approaches. While the exact mechanism through which these therapies obtain successful outcomes is still largely unknown, it is worthwhile to explore these adjunctive approaches to treating the motor output symptoms of PD.
Key words: Parkinson’s disease, movement disorders, exercise rehabilitation, physical therapy, motor control.

AM Johnson, PhD, Assistant Professor, School of Communication Sciences and Disorders, the University of Western Ontario, London, ON.
SG Adams, PhD, Associate Professor, School of Communication Sciences and Disorders, the University of Western Ontario, London, ON.

In addition to its widely recognized effects on gait, posture, balance, and upper limb coordination, Parkinson’s disease (PD) can have a profound effect on speech and voice, within a cluster of speech characteristics termed hypokinetic dysarthria. Although dopaminergic therapy produces significant benefits in the early stages of PD, speech symptoms may show selective resistance to pharmaceutical therapy in patients with a disease history of more than 10 years. This article discusses the pathophysiology of PD as it relates to speech disorders and considers nonpharmaceutical therapeutic options for hypokinetic dysarthria.
Key words: Parkinson’s disease, speech pathology, dysarthria, treatment.

Steven E. Lo, MD, The Neurological Institute, Columbia University Medical Center, New York, NY, USA.
Steven J. Frucht, MD, The Neurological Institute, Columbia University Medical Center, New York, NY, USA.

Parkinson’s disease (PD) is a neurodegenerative disorder that can significantly impact older patients’ quality of life. Although there are many pharmacologic options to treat PD, the clinician needs to know the indications and potential adverse effects of new medications in the older patient population. Carbidopa/levodopa remains the gold standard for treatment, and new formulations and levodopa-extenders fill specific niches. This article reviews the pros and cons of these medications in older PD patients, and demonstrates therapeutic strategies through case presentations.
Key words: Parkinson’s disease, treatment, levodopa, COMT inhibitor, aging.

David F. Tang-Wai, MDCM, Department of Medicine (Neurology), University of
Toronto, University Health Network, Toronto, ON.

Keith A. Josephs, MST MD, Department of Neurology, Mayo Clinic, Rochester, MN, USA

Neurodegenerative diseases commonly affect cortical and subcortical structures, resulting in clinical features of mixed dementia and parkinsonism. Dementia, albeit an uncommon presenting feature of Parkinson’s disease, may become a complication with disease progression. In this review we discuss the relationship of dementia and parkinsonism. We outline a clinical approach to the diagnosis and management of dementia with Lewy bodies and emphasize the importance of understanding the complexity of the disease, for which in-depth knowledge of medication side-effect profiles is a must if treatment is to be undertaken. We also briefly discuss progressive supranuclear palsy, corticobasal syndrome, and vascular dementia with parkinsonism.

Key words: Parkinson’s disease, dementia with Lewy bodies, visual hallucinations, fluctuations, acetylcholinesterase inhibitors.

K.H.O. Deane, BSc, PhD and C.E. Clarke, BSc, MD, FRCP, Department of Neurosciences, The University of Birmingham and City Hospital, Birmingham, UK.

Many clinicians, therapists and patients support the use of rehabilitation in the treatment of Parkinson's disease. However, systematic reviews reveal a lack of conclusive evidence to support the use of common forms of rehabilitation therapy in this movement disorder. Lack of evidence of efficacy is not proof of lack of effect. Large pragmatic randomized controlled trials are required to determine the effectiveness and safety of rehabilitation therapies for people with Parkinson's disease.
Key words: Parkinson's disease, occupational therapy, physiotherapy, speech therapy, rehabilitation.