Aim: The aim of this study was to investigate the quality and availability of physiotherapy for patients with Parkinson's disease. Materials and methods: Questionnaire inspired by previously published studies was sent to 368 Parkinson's disease patients who met the inclusion criteria (at least one visit in the Movement Disorders Center of the General University Hospital in Prague within the last 2 years; Parkinson's disease, Hoehn & Yahr stage < 5; residence in Prague). The questionnaire consisted of items concerning limitations in six core areas for physiotherapy (gait, transfers, manual dexterity, balance/falls, posture, and physical capacity), limitation in daily living activities, utilization of physiotherapy, patients' satisfaction and other characteristics of the therapy. Results: Questionnaires were returned by 248 patients. Prescription rate in patients with a relevant problem (limitation in a core area and motivation to improve in it) in one of the six core areas ranged from 15% (manual dexterity) to 22% (gait). Most patients (79%) were satisfied with physiotherapy and the over all effect lasted > 3 months in 42/64 patients who answered this question. In total, 10% of the patients changed their physiotherapist due to dissatisfaction. Conclusion: Because of the very low physiotherapy prescription rate, reorganization of Parkinson's disease-related health care is needed in the Czech Republic. An efficient model of health care tested abroad could be ParkinsonNet.

Treatment efficacy of pallidal stimulation (GPi DBS) in dystonia varies and the benefit increases slowly, suggesting induction of slow plastic processes in regions involved with motor control. We examined 19 patients (mean age 48 ± (SD)18 years) with cervical (N = 7) or generalized dystonia (N = 12) of various origin by chronic GPi DBS for 57 ± 28 months. Voxel-based morphometry of postoperative T1-weighted images was calculated for gray matter (GM) density in every patient and compared with 20 matched controls. Paired TMS was applied to the motor cortex to elicit short-latency intracortical inhibition (SICI) of the motor evoked potential. The clinical effect of GPi DBS was expressed as a change in the dystonic score (BFMDS or TWSTRS) between actual GPi DBS ON condition and the preoperative state. Dystonia patients showed increased GM density in the SMA and middle cingulate in comparison with healthy controls (p < 0.05 corrected). The SICI was lower in patients than in controls regardless of the ON and OFF conditions (p < 0.001) and its mean amplitude correlated with GM density in both cerebellar hemispheres (p < 0.05 corrected). Brain changes of chronically GPi DBS treated patients possibly reflect “hardwire” rebuilding of motor regions associated with functional improvement. Supported by the grant GAČR 16-13323S.

Pallidal stimulation (GPi DBS) is an effective treatment of dystonic syndromes with a relatively high variability of clinical benefit. As patients with dystonia typically have a lower ability to suppress unwanted movements, we expected a decreased intracortical inhibition of motor cortex, which can be potentially reversed by GPi DBS. To distinguish between patients with dystonia according to the clinical outcome of GPi DBS using short-latency intracortical inhibition (SICI) of the motor cortex assessed by paired transcranial magnetic stimulation (TMS). We examined 22 patients (mean age 51 ± 17 years) with dystonia of various distribution and origin treated by GPi DBS in different time intervals from implantation. Paired TMS with subthreshold conditioning stimulus followed by a supratreshold testing stimulus 2.5 ms later were applied to the motor cortex to elicit SICI in GPi DBS ON and GPi DBS OFF condition two hours later. The clinical effect (CE) was expressed as a change in the dystonic score (Burke-Fahn-Marsden Dystonia rating Scale or Toronto Western Spasmodic Torticollis Scale) between actual GPi DBS ON condition and the preoperative state. The SICI was less effective in patients than in controls regardless of the ON and OFF conditions (p < 0.001) (Fig. 1aDownload : Download high-res image (206KB)Download : Download full-size image). Non-responders (n = 9; <25% CE) showed abnormally low SICI, partial responders (n = 5; 25%–50% CE) showed higher SICI and the highest SICI was in responders (n = 8; >50% CE, p < 0.05) (Fig. 1b). The MEP onset latency was shorter in patients in GPi DBS ON than in OFF condition (p < 0.001) (Download : Download high-res image (225KB)Download : Download full-size imageFig. 2a) and in addition, the shortest MEP onset latency was observed in non-responders (p < 0.001) (Fig. 2b). There was no correlation of the SICI or MEP onset latency with the position of the distal contact of the electrodes. Our results suggest that the best responders to GPi DBS treatment exhibited a similar level of SICI as in healthy controls. On the contrary, non-responders were unable to increase their reduced cortical inhibition and effectively suppressed dystonic symptoms. We speculate that decreased intracortical inhibition with abnormally fast transmission volley is underpinned by the poor complexity of the motor network. Supported by the grant IGA MZ ČR NT12282-5/2011.