Pre-operative psychological assessment is commonly used to assess patients for spinal cord stimulation (SCS). Though often times mandated by insurance, its value is frequently questioned.
We review ...the literature on the predictive value of psychological testing prior to SCS and retrospectively examine our prospective database of SCS patients. We examine associations of Minnesota Multiphasic Personality Inventory (MMPI), Beck Depression Inventory (BDI), and Pain Catastrophizing Scale (PCS) findings and outcomes on the visual analog scale (VAS), McGill Pain Questionnaire - Short Form (MPQ), and Oswestry Disability Index (ODI) at 6 and 12 months post-implantation.
The nine studies examining psychological predictors of SCS outcomes collectively showed that substance abuse or feelings of demoralization or less joy correlated with worse outcomes. Though not statistically significant, our data show that at one year follow-up, patients without psychiatric disorders improved 1.5 times as much on ODI and 2.4 times as much on PCS as compared to patients with psychiatric disorders. Further, depressed patients concurrently treated with anti-depressants had greater improvement in BDI than non-medicated depressed patients (p = 0.009). We develop a tool for pain psychologists based on the existing literature to aid in identifying possible concerns and treating these patients peri-operatively.
The predictive value of psychological testing depends on which psychiatric factors are used and which outcomes are measured. The predictive capacity of psychological indications can be used to holistically treat patients, specifically to recommend psychiatric medication and consulting to supplement SCS treatment as needed.
•Rats underwent a dopaminergic unilateral lesion or sham surgery.•All rats underwent place conditioning to either a low or high dose of apomorphine.•Lesioned rats preferred low dose apomorphine while ...shams did not.•Lesioned rats were divided on preferring high dose apomorphine; shams preferred it.•Increased apomorphine side-effects negatively correlated with place conditioning.
One potential complication of treating Parkinson's Disease (PD) with dopaminergic drugs is dopamine dysregulation syndrome, an addiction-like response to the drug therapy. Here, we assessed whether rats given parkinsonian-like symptoms with a unilateral injection of 6-hydroxydopamine into the medial forebrain bundle (6-OHDA-MFB), exhibit similar behavior. To examine this, we injected these rats or sham-lesioned rats subcutaneously (sc) with apomorphine (APO) at low (0.05mg/kg) and high (1mg/kg) dosage and monitored their conditioned place preference Saline was administered on alternating days. After 4 and 8 conditioned pairings, both rat groups underwent post-conditioning tests in a drug-free state 6-OHDA rats exhibited positive place conditioning to the low dose of APO after 4 and 8 pairings whereas sham-lesioned rats did not (p<0.01). At the high APO dose, sham-lesioned rats showed consistent positive place conditioning, but preferences in 6-OHDA rats were more variable although they all exhibited rotation behavior. Upon further inspection, we noted that contraversive rotation increased over time and this negatively correlated with place conditioning scores. While the absolute number of rotations did not negatively affect preference for the APO-paired chamber, an increase in rotation numbers between pairings did (r=−0.634, p=0.027). Taken together, 6-OHDA rats were more sensitive to the rewarding aspects of APO, but the adverse consequence of rotation diminished this response This model may be ideal to study addiction-like responses in PD.
Abstract Introduction Agitation has significant consequences for patients and staff. When verbal techniques fail, expert guidelines recommend the use of second-generation antipsychotics (SGAs). ...Perhaps out of familiarity with haloperidol and benzodiazepines, emergency department (ED) clinicians often pair SGAs with benzodiazepines as well. Use of SGAs such as olanzapine in alcohol-intoxicated (ETOH+) patients or with benzodiazepines is not well studied and may be associated with vital sign abnormalities. Methods This is a structured chart review of all patient visits who received either oral or intramuscular (IM) olanzapine in an academic ED from 2004 to 2010 and who had systolic blood pressure, heart rate, and oxygen saturation documented before medication administration and within 4 hours afterwards. Results Four hundred eighty-two patient visits received olanzapine; 275 patient visits (225 oral, 50 IM) had vital signs documented. Neither route of administration, concurrent benzodiazepines, nor ingestion of ETOH were associated with significant decreases in systolic BP or heart rate ( P = ns for all comparisons). Decreases in oxygen saturations, however, were significantly larger in ETOH+ patients who received IM olanzapine or IM olanzapine + benzodiazepines. Route of administration, concurrent benzodiazepines, nor ingestion of ETOH was associated with significant decreases in systolic blood pressure or heart rate ( p = ns for all comparisons). Decreases in oxygen saturations, however, were significantly larger in ETOH+ patients who received IM olanzapine or IM olanzapine + benzodiazepines. Conclusions Oral olanzapine was not associated with significant vital sign changes in ED patients. Intramuscular olanzapine also was not associated with vital sign changes in ETOH− patients. In ETOH+ patients, IM olanzapine was associated with significant oxygen desaturations. In ETOH+ ED patients, oral olanzapine (with or without benzodiazepines) or haloperidol may be safer choices. ETOH+ patients may have differential effects with the use of IM SGAs such as olanzapine and should be studied separately in drug trials.
INTRODUCTIONObsessive-compulsive disorder (OCD) is clinically and pathologically heterogenous, with symptoms often refractory to first-line treatments. Deep brain stimulation (DBS) for the treatment ...of refractory OCD provides an opportunity to adjust and individualize neuromodulation targeting aberrant circuitry underlying OCD. The tailoring of DBS therapy may allow precision in symptom control based on patient-specific pathology. Progress has been made in understanding the potential targets for DBS intervention; however, a consensus on an optimal target has not been agreed upon.AREAS COVEREDA literature review of DBS for OCD was performed by querying the PubMed database. The following topics were covered: the evolution of DBS targeting in OCD, the concept of an underlying unified connectomic network, current DBS targets, challenges facing the field, and future directions which could advance personalized DBS in this challenging population.EXPERT OPINIONTo continue the increasing efficacy of DBS for OCD, we must further explore the optimal DBS response across clinical profiles and neuropsychiatric domains of OCD as well as how interventions targeting multiple points in an aberrant circuit, multiple aberrant circuits, or a connectivity hub impact clinical response. Additionally, biomarkers would be invaluable in programming adjustments and creating a closed-loop paradigm to address symptom fluctuation in daily life.
Chronic pain is a major complaint for up to 85% of Parkinson's disease patients; however, it often not identified as a symptom of Parkinson's disease. Adequate treatment of motor symptoms often ...provides analgesic effects in Parkinson's patients but how this occurs remains unclear. Studies have shown both Parkinson's patients and 6‐hydroxydopamine‐lesioned rats exhibit decreased sensory thresholds. In humans, some show improvements in these deficits after subthalamic deep brain stimulation, while others report no change. Differing methods of testing and response criteria may explain these varying results. We examined this effect in 6‐hydroxydopamine‐lesioned rats. Sprague–Dawley rats were unilaterally implanted with subthalamic stimulating electrodes in the lesioned right hemisphere and sensory thresholds were tested using von Frey, tail‐flick and hot‐plate tests. Tests were done during and off subthalamic stimulation at 50 and 150 Hz to assess its effects on sensory thresholds. The 6‐hydroxydopamine‐lesioned animals exhibited lower mechanical (left paw, P < 0.01) and thermal thresholds than shams (hot plate, P < 0.05). Both 50 and 150 Hz increased mechanical (left paw; P < 0.01) and thermal thresholds in 6‐hydroxydopamine‐lesioned rats (hot‐plate test: 150 Hz, P < 0.05, 50 Hz, P < 0.01). Interestingly, during von Frey testing, low‐frequency stimulation provided a more robust improvement in some 6OHDA lesioned rats, while in others, the magnitude of improvement on high‐frequency stimulation was greater. This study shows that subthalamic deep brain stimulation improves mechanical allodynia and thermal hyperalgesia in 6‐hydroxydopamine‐lesioned animals at both high and low frequencies. Furthermore, we suggest considering using low‐frequency stimulation when treating Parkinson's patients where pain remains the predominant complaint.
Thermal and mechanical sensory thresholds are reduced in 6‐hydroxydopamine lesioned parkinsonian rats compared to sham controls. Subthalamic deep brain stimulation at both 150 and 50 Hz improves thermal and mechanical thresholds in parkinsonian rats. Our results suggest that low frequency stimulation could be considered a treatment option for patients with Parkinson's disease with chronic pain as a predominant complaint.
Valosin-containing protein (VCP) associated multisystem proteinopathy (MSP) is a rare inherited disorder that may result in multisystem involvement of varying phenotypes including inclusion body ...myopathy, Paget's disease of bone (PDB), frontotemporal dementia (FTD), parkinsonism, and amyotrophic lateral sclerosis (ALS), among others. An international multidisciplinary consortium of 40+ experts in neuromuscular disease, dementia, movement disorders, psychology, cardiology, pulmonology, physical therapy, occupational therapy, speech and language pathology, nutrition, genetics, integrative medicine, and endocrinology were convened by the patient advocacy organization, Cure VCP Disease, in December 2020 to develop a standard of care for this heterogeneous and under-diagnosed disease. To achieve this goal, working groups collaborated to generate expert consensus recommendations in 10 key areas: genetic diagnosis, myopathy, FTD, PDB, ALS, Charcot Marie Tooth disease (CMT), parkinsonism, cardiomyopathy, pulmonology, supportive therapies, nutrition and supplements, and mental health. In April 2021, facilitated discussion of each working group's conclusions with consensus building techniques enabled final agreement on the proposed standard of care for VCP patients. Timely referral to a specialty neuromuscular center is recommended to aid in efficient diagnosis of VCP MSP via single-gene testing in the case of a known familial VCP variant, or multi-gene panel sequencing in undifferentiated cases. Additionally, regular and ongoing multidisciplinary team follow up is essential for proactive screening and management of secondary complications. The goal of our consortium is to raise awareness of VCP MSP, expedite the time to accurate diagnosis, define gaps and inequities in patient care, initiate appropriate pharmacotherapies and supportive therapies for optimal management, and elevate the recommended best practices guidelines for multidisciplinary care internationally.
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