Overactive bladder (OAB) symptoms in Parkinson disease (PD) are burdensome, and the adverse effects of drug treatment can worsen PD-associated morbidity. Drug adverse effects are avoided with pelvic floor muscle exercise–based behavioral therapy. To assess the noninferiority of behavioral compared with solifenacin drug therapy for OAB symptoms in persons with PD. This 12-week randomized noninferiority trial of behavioral therapy compared with solifenacin was conducted between 2018 and 2023 within 4 US Veterans Affairs health care systems. Eligible participants were diagnosed with PD by a movement disorder neurologist and had an International Consultation on Incontinence Questionnaire OAB module (ICIQ-OAB) symptom score of 7 or higher (range, 0-16; higher score indicates worse symptoms) and Montreal Cognitive Assessment (MOCA) score of 18 or higher (range, 0-30). Participants were randomized 1:1 after stratification by sex, recruitment site, OAB severity, and PD motor symptom severity. Analyses were conducted from October 2023 to April 2024. Behavioral therapy was implemented by a nurse practitioner and included pelvic floor muscle training and urge suppression strategies. Solifenacin therapy started at 5 mg daily, with titration to 10 mg daily if needed. The primary outcome was the 12-week ICIQ-OAB score across groups within a 15% noninferiority margin. Adverse events were assessed every 2 weeks for 8 weeks and again at 12 weeks. A total of 77 persons with PD (65 [84%] male; mean [SD] age, 71.3 [8.9] years; mean [SD] years with PD, 6.6 [5.8]) were randomized to behavioral (n = 36) or drug therapy (n = 41). Seventy-three participants completed the study (4 dropped out in drug group). Baseline characteristics were balanced across groups, including MOCA score (mean [SD], drug, 23.9 [3.1]; behavioral, 24.8 [3.3]) and ICIQ-OAB score (mean [SD], drug, 9.1 [1.7]; behavioral, 8.5 [1.4]). At 12 weeks postrandomization, ICIQ-OAB scores across groups indicated clinically significant improvement and were within the a priori noninferiority margin of 15% (mean [SD] score, drug, 5.8 [2.4]; behavioral, 5.5 [2.0]; P = .02). Dry mouth and falls were reported more frequently in the drug compared with the behavioral group. Results of this randomized noninferiority trial suggest that behavioral therapy is noninferior to drug therapy in improving OAB symptoms in PD. These findings may inform clinical guidelines for urinary symptoms in PD to consider behavioral therapy as an initial treatment option. ClinicalTrials.gov Identifier: NCT03149809

Importance Overactive bladder (OAB) symptoms in Parkinson disease (PD) are burdensome, and the adverse effects of drug treatment can worsen PD-associated morbidity. Drug adverse effects are avoided with pelvic floor muscle exercise-based behavioral therapy. Objective To assess the noninferiority of behavioral compared with solifenacin drug therapy for OAB symptoms in persons with PD. Design, Setting, and Participants This 12-week randomized noninferiority trial of behavioral therapy compared with solifenacin was conducted between 2018 and 2023 within 4 US Veterans Affairs health care systems. Eligible participants were diagnosed with PD by a movement disorder neurologist and had an International Consultation on Incontinence Questionnaire OAB module (ICIQ-OAB) symptom score of 7 or higher (range, 0-16; higher score indicates worse symptoms) and Montreal Cognitive Assessment (MOCA) score of 18 or higher (range, 0-30). Participants were randomized 1:1 after stratification by sex, recruitment site, OAB severity, and PD motor symptom severity. Analyses were conducted from October 2023 to April 2024. Interventions Behavioral therapy was implemented by a nurse practitioner and included pelvic floor muscle training and urge suppression strategies. Solifenacin therapy started at 5 mg daily, with titration to 10 mg daily if needed. Main Outcome and Measures The primary outcome was the 12-week ICIQ-OAB score across groups within a 15% noninferiority margin. Adverse events were assessed every 2 weeks for 8 weeks and again at 12 weeks. Results A total of 77 persons with PD (65 [84%] male; mean [SD] age, 71.3 [8.9] years; mean [SD] years with PD, 6.6 [5.8]) were randomized to behavioral (n = 36) or drug therapy (n = 41). Seventy-three participants completed the study (4 dropped out in drug group). Baseline characteristics were balanced across groups, including MOCA score (mean [SD], drug, 23.9 [3.1]; behavioral, 24.8 [3.3]) and ICIQ-OAB score (mean [SD], drug, 9.1 [1.7]; behavioral, 8.5 [1.4]). At 12 weeks postrandomization, ICIQ-OAB scores across groups indicated clinically significant improvement and were within the a priori noninferiority margin of 15% (mean [SD] score, drug, 5.8 [2.4]; behavioral, 5.5 [2.0]; P = .02). Dry mouth and falls were reported more frequently in the drug compared with the behavioral group. Conclusions and Relevance Results of this randomized noninferiority trial suggest that behavioral therapy is noninferior to drug therapy in improving OAB symptoms in PD. These findings may inform clinical guidelines for urinary symptoms in PD to consider behavioral therapy as an initial treatment option.

Restoring function to damaged neural pathways, or promoting compensatory strategies to overcome dysfunctional neural pathways have been topics of inquiry within motor rehabilitation. This study considers these topics in Parkinsons disease (PD), where disruption within the striatal-thalamic-cortical (STC) circuits can cause impairment in internally guided (IG) movements. A related, but separate externally guided (EG) movement network, recruits the intact cerebellar-thalamic-cortical (CTC) loop to facilitate movement in response to sensory cues, and is effective in remediating motor function. Partnered dance with leading and following roles may be used as proxies for training IG and EG strategies respectively, in PD and can test which strategy is more effective in remediating effects of PD. Leaders determine variables associated with IG and communicate step amplitude, timing, and direction to the follower. Followers use an EG strategy to sense and interpret directional pressure cues from the leader and then enact an appropriate movement response. This study examines how IG and EG training strategy affects STC and CTC circuits and their behavioral outcomes to examine whether compensatory or direct entrainment of neural pathways is more effective in PD. Fifty-eight participants were recruited with mild-moderate PD (stages 1-3) and randomly assigned to EG, IG or non-dance education control group and assessed before and after 12 weeks of biweekly interventions. Participants were assessed with standard cognitive and motor behavioral measures and lay in a Magnetic Resonance Imaging (MRI) scanner while they tapped their foot under two conditions: internal (tapping a learned rhythm: IT) and external (participant taps in response to an assistants felt tap on the participants hand: ET) guidance. The foot-tapping data collected with an accelerometer were evaluated by analyzing the frequency spectrum to calculate amplitude and timing of the foot taps. The functional (fMRI) data were pre-processed (AFNI), registered (MNI), and analyzed for changes in activation using a general linear model in SAS and AFNI. Postintervention, both the EG and the IG groups showed clinically significant changes on disease severity, but the EG group showed improvements on cognitive, motor, and mood variables. The EG group also outperformed the IG group in the in-scanner task performance measured by the foot accelerometer. Imaging data revealed a significant increase in the EG group in the primary motor cortex lower limb region and the parts of the cerebellar circuits, particularly right Cerebellar Lobule VIIIa. The control group showed an increase in activity in the putamen compared to the IG and EG groups that could be due to a different compensatory pathway. All findings were corroborated using a region of interest approach examining the same pathways according to an atlas. Our results indicate that the most effective strategy for the PD participants involved external cues that increased activity in the compensatory CTC pathway, the primary motor region, and significant improvements on almost all behavioral measurements.

Parkinson's disease (PD), an intractable condition impairing motor and cognitive function, is imperfectly treated by drugs and surgery. Two priority issues for many people with PD are OFF-time and cognitive impairment. Even under best medical management, three-fourths of people with PD experience "OFF-time" related to medication-related motor fluctuations, which severely impacts both quality of life and cognition. Cognitive deficits are found even in newly diagnosed people with PD and are often intractable. Our data suggest that partnered dance aerobic exercise (PDAE) reduces OFF-time on the Movement Disorders Society Unified Parkinson Disease Rating Scale-IV (MDS-UPDRS-IV) and ameliorates other disease features, which motivate the PAIRED trial. PDAE provides AE during an improvisational, cognitively engaging rehabilitative physical activity. Although exercise benefits motor and cognitive symptoms and may be neuroprotective for PD, studies using robust biomarkers of neuroprotection in humans are rare. We propose to perform a randomized, controlled trial in individuals with diagnosed mild-moderate PD to compare the efficacy of PDAE vs. walking aerobic exercise (WALK) for OFF-time, cognition, and neuroprotection. We will assess neuroprotection with neuromelanin-sensitive MRI (NM-MRI) and iron-sensitive (R2*) MRI sequences to quantify neuromelanin loss and iron accumulation in substantia nigra pars compacta (SNc). We will use these biomarkers, neuromelanin loss, and iron accumulation, as tools to chart the course of neurodegeneration in patients with PD who have undergone long-term (16 months) intervention. We will randomly assign 102 individuals with mild-moderate PD to 16 months of PDAE or WALK. The 16-month intervention period will consist of Training (3 months of biweekly sessions) and Maintenance (13 months of weekly sessions) phases. We will assess participants at baseline, 3 months (immediately post-Training), and 16 months (immediately post-Maintenance) for OFF-time and behaviorally and physiologically measured cognition. We will acquire NM-MRI and R2* imaging data at baseline and 16 months to assess neuroprotection. We will (1) examine effects of Training and Maintenance phases of PDAE vs. WALK on OFF-time, (2) compare PDAE vs. WALK at 3 and 16 months on behavioral and functional MRI (fMRI) measures of spatial cognition, and (3) compare PDAE vs. WALK for effects on rates of neurodegeneration.

Background: Externally guided (EG) and internally guided (IG) movements are postulated to recruit two parallel neural circuits, in which motor cortical neurons interact with either the cerebellum or striatum via distinct thalamic nuclei. Research suggests EG movements rely more heavily on the cerebello-thalamo-cortical circuit, whereas IG movements rely more on the striato-pallido-thalamo-cortical circuit (1). Because Parkinson's (PD) involves striatal dysfunction, individuals with PD have difficulty generating IG movements (2). Objectives: Determine whether individuals with PD would employ a compensatory mechanism favoring the cerebellum over the striatum during IG lower limb movements. Methods: 22 older adults with mild-moderate PD, who had abstained at least 12 h from anti-PD medications, and 19 age-matched controls performed EG and IG rhythmic foot-tapping during functional magnetic resonance imaging. Participants with PD tapped with their right (more affected) foot. External guidance was paced by a researcher tapping participants' ipsilateral 3rd metacarpal in a pattern with 0.5 to 1 s intervals, while internal guidance was based on pre-scan training in the same pattern. BOLD activation was compared between tasks (EG vs. IG) and groups (PD vs. control). Results: Both groups recruited the putamen and cerebellar regions. The PD group demonstrated less activation in the striatum and motor cortex than controls. A task (EG vs. IG) by group (PD vs. control) interaction was observed in the cerebellum with increased activation for the IG condition in the PD group. Conclusions: These findings support the hypothesized compensatory shift in which the dysfunctional striatum is assisted by the less affected cerebellum to accomplish IG lower limb movement in individuals with mild-moderate PD. These findings are of relevance for temporal gait dysfunction and freezing of gait problems frequently noted in many people with PD and may have implications for future therapeutic application.

Objective: To report 24-week outcomes of an open-label trial of daxibotulinumtoxinA for injection (RT002) in cervical dystonia (CD).

mucoid, or mixed populations), the lung lobes in which these variants are found, and regional proinflammatory cytokine production. METHODS/ STUDY POPULATION: We performed BAL on 16 CF patients with clinically stable disease. For each patient, we obtained BAL fluid from the right upper lobe, right middle lobe, right lower lobe, left upper lobe, lingula, and left lower lobe. We plated BAL fluid on nonselective and P.a.-selective medium to quantitate bacteria and to identify P.a. colony subtypes (nonmucoid, mucoid, or mixed). We further used a V-PLEX human cytokine array to quantitate inflammatory cytokine concentrations (IL-1β, TNF-α, IL-6, IL-8, and IL-10) within BAL fluid specimens. Our specimen collection was approved by the local IRB with informed consent and assent obtained from patient volunteers. RESULTS/ANTICIPATED RESULTS: Based on microbiological analysis, each lobar BAL specimen was classified as uninfected with P. a. or infected with nonmucoid, mucoid, or mixed (both nonmucoid and mucoid) P.a. variants. There was no observed propensity of mucoid or nonmucoid variants to be confined to certain lung lobes in our cohort. However, infection with mucoid P.a. variants was associated with higher concentrations of IL-1β (p< 0.001), TNF-α (p< 0.001), IL-8 (p< 0.001), and IL-10 (p< 0.001) within lobar BAL fluid compared with P.a.-free specimens. Specimens with mucoid variants also had greater concentrations of TNF-α (p< 0.01), IL-8 (p< 0.001), and IL-10 (p< 0.05) compared with specimens with only nonmucoid P.a. variants. Patients infected with mixed mucoid and nonmucoid variants showed higher concentrations of TNF-α and IL-10 (p< 0.05) as well as nonsignificant trends for higher concentrations of IL-1β and IL-6 compared to P.a.-free samples. Interestingly, the presence of nonmucoid P.a. variants was inversely correlated with IL-6 (p< 0.05). Total bacterial burden (both P.a. and non-P. a. species) within BAL fluids was positively correlated with higher proinflammatory cytokine concentrations. Additionally, independent of bacterial colonization, the upper lobes (right upper lobe and left upper lobe) of the lungs showed trends towards higher proinflammatory cytokine concentrations compared with the lower lobes (right lower lobe and left lower lobe). DISCUSSION/SIGNIFICANCE OF IMPACT: Our results demonstrate that P.a. variants (mucoid or nonmucoid) appear not to be geographically restricted in ability to colonize any lobe of the CF lung. Moreover, infection with mucoid P.a. (either alone or in mixed populations with nonmucoid variants) is associated with higher inflammatory cytokine concentrations in the CF lung. Given that infection with mucoid P.a. predicts deterioration in pulmonary function, this study provides a rationale for further investigation of cytokines as diagnostic/prognostic correlates of infection and lung disease in CF.

OBJECTIVES/SPECIFIC AIMS: Parkinson’s disease (PD) is a condition that affects over a million Americans, and despite current medical therapies, the progression of the disease results in impaired generation of internally timed or guided (IG) movements. To address this loss of motor function, previous rehabilitation therapies have focused on remediating the affected striatal-thalamic-cortical circuits (STC), primarily thought to be responsible in generating timed motor patterns. However, given the disease leads to the cell death of dopaminergic cells that are essential for proper STC function, we propose a motor therapy aimed at utilizing a compensatory parallel cerebellar-thalamic-cortical (CTC) pathway, recruited to perform externally guided (EG) movements, in which gait initiation is driven from sensory input. Our previous study has shown efficacy in our novel argentine tango therapy and improves behavioral measures above the relevant MCID threshold, but it has not been established that the CTC are in the causal pathway that are responsible for these changes. Using neural measures from task fMRI, we have begun to characterize networks that have changed and quantify any associations with behavioral metrics. METHODS/STUDY POPULATION: Patients were randomly assigned to an IG (n=18), EG (n=18), or education contact control (n=14). Participants were assessed preintervention and postintervention for behavioral motor and cognitive measures and neurophysiologically with task based fMRI. In the task, participants performed a foot tapping task under both IG (tap their foot in previously learned rhythm) or EG (tap immediately after receiving a tactile cue on their hand) conditions. The fMRI data were preprocessed using AFNI and registered to MNI standard space. The brainnetome atlas was applied and the average time series of each region of interest (ROI) was used to increase the signal to noise ratio. The activation of these ROI with respect to the stimulus was modeled using GLM, and we estimated the area under the curve during the task blocks. A 1-way ANOVA analysis on these betas were performed between the pre and the post intervention time points and the ROIs that were above a significance of 0.95 were identified and corrected for multiple comparisons. The change in beta in all ROIs for each individual were calculated and then correlated with the changes in the behavioral data, to see which changes in ROI areas matched the best with the behavioral changes. RESULTS/ANTICIPATED RESULTS: The EG group showed significant changes only in the EG task in 2 areas—inferior frontal gyrus and inferior temporal sulcus. Correlating to the cognitive behavioral measures show reduced error from the Inferior frontal gyrus (corr>0.5) best reflect changes in observed. There were no changes to either the STC or the CTC pathways. The IG group showed no changes behaviorally and showed no changes neurally as well. The control group showed no changes behaviorally, but neuronally certain DMN nodes, such as the precuneus and inferior temporal regions showed a significant change for both tasks. DISCUSSION/SIGNIFICANCE OF IMPACT: Addressing the damaged STC pathway directly through IG therapy may not be effective. The EG therapy may not be able to enhance the STC pathway. However, the therapy appears to utilize new areas in the frontal regions and correlates with positively with changes in spatial memory and balance tasks. Contrary to our hypothesis the CTC circuit was not upregulated for performance of the IG or EG task, but therapy may have enhanced recruitment of other cognitively engaged areas. The educational control group interestingly showed changes in the DMN network, which has been shown to be linked to attention during tasks blocks.

Injectable daxibotulinumtoxinA (an investigational botulinum toxin, RT002) may offer a more prolonged duration of response—and therefore less frequent dosing—than onabotulinumtoxinA.

To report outcomes of DaxibotulinumtoxinA for Injection (RT002) for the treatment of isolated cervical dystonia (CD).

Objective: To evaluate the association between the genetic variants in CACNA1C, which encodes the α1 subunit of the L-type voltage-sensitive calcium channel (LVSCC) and Parkinson disease (PD) while accounting for interactions with vitamin D concentration. Methods: Two independent case-control data sets (478 cases and 431 controls; 482 cases and 412 controls) were used. Joint effects of single nucleotide polymorphisms (SNPs) and SNP-vitamin D interaction were analyzed by comparing models containing vitamin D deficiency, SNP genotypes, SNP-vitamin D interaction, and covariates to a restricted model with only vitamin D deficiency and covariates. Meta-analysis was used to combine the joint effects in the 2 data sets. Analysis was stratified by vitamin D deficiency to demonstrate the pattern of SNP-vitamin D interaction. Results: Vitamin D deficiency was associated with PD in both data sets (odds ratio [OR] = 1.9–2.7, p ≤ 0.009). SNP rs34621387 demonstrated a significant joint effect (meta-analysis, p = 7.5 × 10−5; Bonferroni corrected, p = 0.02). The G allele at rs34621387 is associated with PD in vitamin D-deficient individuals in both data sets (OR = 2.0–2.1, confidence interval = 1.3–3.5, p = 0.002) but is not associated with PD in vitamin D–nondeficient individuals (p > 0.8 in both data sets). Conclusions: Previous studies suggest that vitamin D deficiency is associated with PD and sustained opening of LVSCC contributes to the selective vulnerability of dopaminergic neurons in PD. Our data demonstrate that the association between genetic variations in CACNA1C and PD depends on vitamin D deficiency, providing one potential mechanism underlying the association between vitamin D deficiency and PD.

Botulinum toxin (BoNT) is highly effective in the treatment of cervical dystonia (CD), yet a significant proportion of patients report low levels of satisfaction following treatment and fail to follow up for repeated treatments. The goal of this study was to determine the reasons that some patients have unsatisfactory responses. A total of 35 subjects who came to our center requesting alternative treatments due to unsatisfactory responses following BoNT treatment for CD were evaluated. Included were 26 women and 9 men with an average age of 57.1 years (range 25–82 years), and an average duration of illness of 12.5 years (range 1–55 years). Details of unsatisfactory BoNT treatments were methodically collected by a movement specialist using a standardized intake form, including provider subspecialty, product used, the number of satisfactory or unsatisfactory trials, doses given, specific muscles treated, the use of electromyographic guidance, side effects, and tests of resistance. The specialist then provided repeat treatments if indicated, and followed each case until the reasons for unsatisfactory outcomes could be determined. Multiple reasons for unsatisfactory outcomes were found. They included suboptimal BoNT doses, suboptimal muscle targeting, intolerable side effects, complex movement patterns, discordant perceptions, and incorrect diagnoses. Only one patient was functionally resistant to BoNT. Of 32 subjects who received repeat BoNT treatments, 25 (78 %) achieved satisfactory responses after revision of the original treatment plan. These results indicate that the majority of unsatisfactory responses to BoNT treatment of CD were caused by correctible factors and imply a need for improved education regarding optimal treatment methods.