Movement Disorder

Since the emergence of articles by GE Alexander and his colleagues on basal ganglia-thalamacortical circuits in 90's, there has been a series of work discussing the roles of cortico-striato-thalamo-cortico circuits in different cognitive, motor processes and in emotional behaviours [1-6]. There are also some works investigating the role of cortico-striato-thalamo-cortico circuits especially for conscious behaviour and even discussing the functions of neural correlates in perceiving the one's own movements [7-9].

Sandals have become an increasingly popular choice of footwear due to their comfort and convenience, particularly in casual and warm-weather environments. However, differences in gait patterns between sandals and sneakers may have biomechanical implications. This study aimed to compare lower-limb muscle activation during walking in sandals versus sneakers. Twenty-eight healthy participants in their twenties (12 men and 16 women) participated in this study. Each individual walked a 10-meter distance while wearing both types of footwear, with surface electromyography (EMG) sensors attached to their lower limbs. Muscle activation was recorded for eight muscles: gluteus maximus, gluteus medius, biceps femoris, rectus femoris, medial gastrocnemius, lateral gastrocnemius, tibialis anterior, and soleus. Results indicated significantly lower muscle activity in the lateral gastrocnemius and tibialis anterior when walking in sandals compared to sneakers (p < 0.05), while rectus femoris activation significantly increased (p < 0.05). No significant differences were observed in walking speed between the two conditions (p > 0.05). These findings suggest that sandals alter lower-limb muscle activation patterns, potentially reducing walking efficiency and dynamic stability. Such changes could have implications for long-term musculoskeletal health, especially in populations with pre-existing gait impairments or balance issues. A key limitation of this study is the relatively homogenous sample of young, healthy adults, which may restrict generalizability to older or clinical populations. Further research should investigate long-term adaptations to different footwear types and their potential influence on joint loading, balance control, and injury risk across diverse populations.

Background: In spite of advances in psychotherapy and pharmacotherapy, there are still a significant number of patients with depression and obsessive-compulsive disorder that are not aided by either intervention. Although still in the experimental stage, deep brain stimulation (DBS) offers many advantages over other physically-invasive procedures as a treatment for these psychiatric disorders. The purpose of this study is to systematically review reports on clinical trials of DBS for obsessive-compulsive disorder (OCD) and treatment-resistant depression (TRD). Locations for stimulation, success rates and effects of the stimulation on brain metabolism are noted when available. The first observation of the effects of DBS on OCD and TRD came in the course of using DBS to treat movement disorders. Reports of changes in OCD and depression during such studies are reviewed with particular attention to electrode locations and associated adverse events; although these reports were adventitious observations rather than planned. Subsequent studies have been guided by more precise theories of structures involved in DBS and OICD. This study suggests stimulation sites and prognostic indicators for DBS. We also briefly review tractography, a relatively new procedure that holds great promise for the further development of DBS. Methods: Articles were retrieved from MEDLINE via PubMed. Relevant references in retrieved articles were followed up. We included all articles reporting on studies of patients selected for having OCD or TRD. Adequacy of the selected studies was evaluated by the Jadad scale. Evaluation criteria included: number of patients, use of recognized psychiatric rating scales, and use of brain blood flow measurements. Success rates classified as "improved" or "recovered" were recorded. Studies of DBS for movement disorders were included if they reported coincidental relief of depression or reduction in OCD. Most of the studies involved small numbers of subjects so individual studies were reviewed. Results: While the number of cases was small, these were extremely treatment-resistant patients. While not everyone responded, about half the patients did show dramatic improvement. Associated adverse events were generally trivial in younger psychiatric patients but often severe in older movement disorder patients. The procedures differed from study to study, and the numbers of patients was usually too small to do meaningful statistics or make valid inferences as to who will respond to treatment. Conclusions: DBS is considered a promising technique for OCD and TRD. Outstanding questions about patient selection and electrode placement can probably be resolved by (a) larger studies, (b) genetic studies and (c) imaging studies (MRI, fMRI, PET, and tractography).

Lethargic mutant mice carry a mutation in the CCHB4 gene, which encodes the ␤4 subunit of voltage-regulated calcium channels. These mutants have been shown to display a complex neurobehavioral phenotype that includes EEG discharges suggestive of absence epilepsy, chronic ataxia, and hypoactivity. The current studies demonstrate a fourth element of their phenotype, consisting of transient attacks of severe dyskinetic motor behavior. These attacks can be triggered by specific environmental and chemical influences, particularly those that stimulate locomotor activity. Behavioral and EEG analyses indicate that the attacks do not reflect motor epilepsy, but instead resemble a paroxysmal dyskinesia. The lethargic mutants provide additional evidence that calcium channelopathies can produce paroxysmal dyskinesias and provide a novel model for studying this unusual movement disorder.

Highlights d Human neuromuscular junctions (NMJs) are morphologically distinct from rodent NMJs d Human NMJs are remarkably stable across the adult lifespan d Active zone proteins, including SNAP25, are differentially localized in human NMJs d Significant divergence between the synaptic proteome of human and mouse NMJs

This article deals with applied psychology of handwriting, in particular with the use of graphology. In addition to a basic summary of contemporary approaches in the area, selected researches and foreign studies are evaluated. The article also presents results of the PORP research (Projection of Personality Traits in Handwriting, University of South Bohemia 2007) aimed at the evaluation of psychodiagnostic potential of handwriting analysis using 5-factor personality model (Big Five) and comments upon graphological methodology PORP-GRAF and possibilities of further development of the method within psychodiagnostical disciplines.

Background SilvereRussell syndrome (SRS) is characterised by intrauterine growth restriction, poor postnatal growth, relative macrocephaly, triangular face and asymmetry. Maternal uniparental disomy (mUPD) of chromosome 7 and hypomethylation of the imprinting control region (ICR) 1 on chromosome 11p15 are found in 5e10% and up to 60% of patients with SRS, respectively. As many features are non-specific, diagnosis of SRS remains difficult. Studies of patients in whom the molecular diagnosis is confirmed therefore provide valuable clinical information on the condition. Methods A detailed, prospective study of 64 patients with mUPD7 (n¼20) or ICR1 hypomethylation (n¼44) was undertaken. The considerable overlap in clinical phenotype makes it difficult to distinguish these two molecular subgroups reliably. ICR1 hypomethylation was more likely to be scored as 'classical' SRS. Asymmetry, fifth finger clinodactyly and congenital anomalies were more commonly seen with ICR1 hypomethylation, whereas learning difficulties and referral for speech therapy were more likely with mUPD7. Myoclonus-dystonia has been reported previously in one mUPD7 patient. The authors report mild movement disorders in three further cases. No correlation was found between clinical severity and level of ICR1 hypomethylation. Use of assisted reproductive technology in association with ICR1 hypomethylation seems increased compared with the general population. ICR1 hypomethylation was also observed in affected siblings, although recurrence risk remains low in the majority of cases. Overall, a wide range of severity was observed, particularly with ICR1 hypomethylation. A low threshold for investigation of patients with features suggestive, but not typical, of SRS is therefore recommended.

Objective. Advanced complex regional pain syndrome (CRPS) remains very difficult to treat. While subanesthetic low-dose ketamine has shown promise in early localized CRPS, its use in advanced CRPS has not been as effective. Since ketamine's analgesic potency and duration of effect in neuropathic pain are directly dose-dependant, we investigated the efficacy of ketamine in anesthetic dosage in refractory CRPS patients that had failed available standard therapies. Methods. Twenty ASA I-III patients suffering from refractory CRPS received ketamine in anesthetic dosage over 5 days. Outcome criteria were pain relief, effect on the movement disorder, quality of life, and ability to work at baseline and up to 6 months following treatment. Results. Significant pain relief was observed at 1, 3, and 6 months following treatment (93.5 Ϯ 11.1%, 89.4 Ϯ 17.0%, 79.3 Ϯ 25.3%; P < 0.001). Complete remission from CRPS was observed at 1 month in all patients, at 3 months in 17, and at 6 months in 16 patients. If relapse occurred, significant pain relief was still attained at 3 and 6 months (59.0 Ϯ 14.7%, P < 0.004; 50.2 Ϯ 10.6%, P < 0.002). Quality of life, the associated movement disorder, and the ability to work significantly improved in the majority of patients at 3 and 6 months. Conclusions. This open-label trial suggests benefit in pain reduction, associated CRPS symptoms, improved quality of life and ability to work following anesthetic ketamine in previously refractory CRPS patients. However, a randomized controlled trial will be necessary to prove its efficacy.

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation technique that modulates neural activity through repeated magnetic pulses applied to targeted cortical regions. Clinically, rTMS has gained approval for treatment-resistant depression and is increasingly explored for neurological disorders such as post-stroke rehabilitation and mild cognitive impairment (MCI). This overview summarizes its mechanism, current clinical applications, supporting evidence, and patient considerations from a neurologist’s perspective.

Brain creatine (Cr) deficiencies (BCr-d) are rare disorders of creatine biosynthesis and transport. We performed consecutive measures of total Cr (tCr) and of its phosphorylated fraction, phosphocreatine (PCr), in the brains of children affected by Cr synthesis defects during a long period of therapy. The aim was to identify the optimal treatment strategy for these disorders. MATERIALS AND METHODS: Two patients with guanidinoacetate methyltransferase defect (GAMT-d) were treated with different amounts of Cr and with diet restrictions aimed at reducing endogenous guanidinoacetate (GAA) synthesis. Three patients with arginine:glycine amidinotransferase defect (AGAT-d) were treated with different Cr intakes. The patients' treatments were monitored by means of 1 H-and 31 P-MR spectroscopy. RESULTS: Cr and PCr replenishment was lower in GAMT-d than in AGAT-d even when GAMT-d therapy was carried out with a very high Cr intake. Cr and especially PCr replenishment became more efficient only when GAA blood values were reduced. Adenosine triphosphate (ATP) was increased in the baseline phosphorous spectrum of GAMT-d, and it returned to a normal value with treatment. Brain pH and brain P i showed no significant change in the AGAT-d syndrome and at any Cr intake. However, 1 of the 2 GAMT-d patients manifested a lower brain pH level while consuming the GAA-lowering diet. CONCLUSIONS: AGAT-d treatment needs lower Cr intake than GAMT-d. Cr supplementation in GAMT-d treatment should include diet restrictions aimed at reducing GAA concentration in body fluids. 1 H-and especially 31 P-MR spectroscopy are the ideal tools for monitoring the therapy response to these disorders. B rain creatine (Cr) deficiencies (BCr-d) are inborn disor- ders of Cr biosynthesis and Cr transport discovered over the last 10 years and first revealed by proton spectroscopy ( 1 H-MR spectroscopy [ 1 H-MRS]). 1 Following the metabolic pathway of creatine (Fig 1), 2 different groups of disorders may result in the brain creatine depletion: disorders deriving from de novo Cr biosynthesis defect and disorders of Cr transport at the level of the blood-brain barrier. The first group includes the enzymatic defects of arginine: glycine amidinotransferase (AGAT-d) 2,3 and of guanidinoacetate methyltransferase (GAMT-d), 1,4-10 which are the first 2 steps in Cr synthesis. These patients have a systemic depletion of Cr, but in GAMT-d, there is a concomitant endogenous overproduction of guanidinoacetate (GAA), a guanidine compound known for its neurotoxic action 11 and its epileptogenic potential. On the other hand, patients with Cr transport disorder (CT1-d) have normal Cr levels in the body fluids accompanied by an increased creatine-creatinine urinary excretion. The common clinical aspect of BCr-d is developmental delay, mental retardation, and a prominent distur-bance of cognitive and expressive speech. Some patients with GAMT-d may have intractable epilepsy and extrapyramidal movement disorders, probably related to GAA accumulation in tissues and body fluids. MR imaging of the brain in GAMT-d reveals either pallidum hyperintensity on T2weighted images, 1,6,8 myelination delay, 9 or no MR imaging changes 9,10 ; posterior periventricular white matter T2weighted hyperintensity or brain atrophy are described in some CT1-d cases whereas MR imaging is normal in children with AGAT-d. Inheritance of AGAT-d and of GAMT-d is autosomal recessive, 2,22 whereas CT1-d is X-linked. Consecutive 1 H-MRS studies have demonstrated that Cr depletion, under Cr oral administration, is reversible in GAMT-d and AGAT-d but irreversible in CT1-d. In the index case of a male patient with GAMT-d, therapy was monitored over 26 months; the authors demonstrated a 75%-90% replenishment of Cr in the brain with a biphasic trend. Then, 2 sisters with AGAT-d were monitored for 16 months, and a progressive increase in brain Cr, up to 90%-100% of the normal brain Cr concentration, was measured. The brain and muscle metabolism is characterized by a high and fluctuating energy demand, where phosphocreatine (PCr) plays the important role of a temporal and spatial buffer for ATP cellular homeostasis. Therefore, the metabolic and clinical improvement recorded in these patients with Cr assumption is most likely related to the degree of PCr recovery. Brain PCr can be measured in vivo only by 31 P-MRS; so far, no studies have been carried out to determine how substitution therapy of BCr-d increases the Cr pool stored in the form of PCr through the creatine kinase (CK) system reaction. In this study, we measured, by 1 H-and 31 P-spectroscopy, the time-course of brain total Cr (tCr) and PCr restoration in

Background: Parkinson's disease is a neurological condition that worsens over time. Parkinson's disease primarily affects dopaminergic neurons in the substantia nigra of the midbrain. Parkinson's disease is commonly associated with walking difficulties such as postural instability and a shuffling gait. Physiotherapy interventions such as Tai Chi, strength training, body weight support treadmill training, visual cueing, and dual task training are few of the techniques that are frequently used for gait training and to enhance balance. Most often employed strategies for improving walking ability are dual tasking and visual cueing. Many studies showed the advantages of visual cueing and dual-task training for enhancing gait in Parkinson's disease, but there are no research studies done to directly evaluate the efficacy of these two therapeutic modalities alongside standard physiotherapy in individuals with early-stage Parkinson's disease.This study compares the impact of dual-task workouts and visual cueing on enhancing walking abilities in individuals with early-stage Parkinson's disease. Methods: A quasi experimental study design, out of 64 subjects, sixty subjects who satisfied the inclusion criteria were split into two groups: thirty in Group A (visual cueing) and thirty in Group B (dual tasking) with mean age of 50-65 years. Interventions were administered in both groups, five days in a week for six weeks. Outcome measures were analyzedusing ink footprint analysis, gait parameters such as step length, stride length, velocity, and cadence were observed. Result: The results were analyzed using paired T-test to measure pre and post test results within group. When comparing between groups, the analysis of variance (ANOVA) showed a substantial improvement in group B (dual tasking) when compared toGroup A (visual cueing) p<0.01. Conclusion: The findings of this study suggest that walking ability significantly improved after 6 weeks of dual task training and visual cueing exercises along with traditional physiotherapy. However, when compared between groups, it was found that dual tasking exercises is more effective in improving walking ability than visual cueing exercises.

The cooccurrence of rest and postural tremor (mixed tremor) as the predominant clinical manifestation in patients who do not fulfill diagnostic established criteria for essential tremor (ET) or Parkinson's disease (PD) poses a clinical diagnostic challenge. Twenty-two patients with mixed tremor and additional mild extrapyramidal features, such as bradykinesia and rigidity, 20 patients with probable PD, 10 patients with probable ET, and 18 controls were investigated through the combined use of dopamine transporter 123 I-FP-CIT-single-photon emission tomography (DAT-SPECT) and cardiac 123 metaiodobenzylguanidine (MIGB) scintigraphy. Six of the 22 mixed-tremor patients had normal DAT-SPECT, a condition usually found in patients with ET, whereas 16 patients showed damage to the nigrostriatal system. Cardiac MIBG allowed further differentiation between these 16 patients because eight of them had decreased tracer uptakes (heart/mediastinum [H/M] ratio in delayed image, H/M ratio delayed: 1.16 6 0.11, P < 0.001 vs controls), indicating a PD, whereas the remaining eight had normal cardiac tracer uptakes, a finding suggestive of a parkinsonian syndrome (H/M ratio delayed: 1.90 6 0.13). Both DAT-SPECT and cardiac MIBG scintigraphies were abnormal in the 20 patients with probable PD, whereas these were normal in both the patients with probable ET as well as in the controls. Our study suggests that the combined use of both DAT-SPECT and MIBG scintigraphy in mixed tremors with additional extrapyramidal features can help distinguish patients with ET from those with PD and parkinsonism.

The cooccurrence of rest and postural tremor (mixed tremor) as the predominant clinical manifestation in patients who do not fulfill diagnostic established criteria for essential tremor (ET) or Parkinson&#39;s disease (PD) poses a clinical diagnostic challenge. Twenty‐two patients with mixed tremor and additional mild extrapyramidal features, such as bradykinesia and rigidity, 20 patients with probable PD, 10 patients with probable ET, and 18 controls were investigated through the combined use of dopamine transporter 123I‐FP‐CIT‐single‐photon emission tomography (DAT‐SPECT) and cardiac 123metaiodobenzylguanidine (MIGB) scintigraphy. Six of the 22 mixed‐tremor patients had normal DAT‐SPECT, a condition usually found in patients with ET, whereas 16 patients showed damage to the nigrostriatal system. Cardiac MIBG allowed further differentiation between these 16 patients because eight of them had decreased tracer uptakes (heart/mediastinum [H/M] ratio in delayed image, H/M ratio delayed...

Background Cerebral palsy (CP) is an upper motor neuron disease that results in a progressive movement disorder. Secondary to the neurological insult, muscles from CP patients often become spastic. Spastic muscle is characterized by an increased resistance to stretch, but often develops the further complication of contracture which represents a prominent disability in children with CP. This study&#39;s purpose is to characterize alterations of spastic muscle on the transcriptional level. Increased knowledge of spastic muscle may lead to novel therapies to improve the quality of life for children with CP. Method The transcriptional profile of spastic muscles were defined in children with cerebral palsy and compared to control patients using Affymetrix U133A chips. Expression data were verified using quantitative-PCR (QPCR) and validated with SDS-PAGE for select genes. Significant genes were determined using a 2 × 2 ANOVA and results required congruence between 3 preprocessing algorit...

A 14-year-old girl presented with Complex Regional Pain Syndrome, Type I (CRPS-1) of the left ankle after a remote history of sprain. Allodynia, pain, temperature and color changes, and swelling were successfully treated with physical therapy, transcutaneous electrical nerve stimulation (TENS), gabapentin, amitriptyline, and tramadol. Five weeks later, she presented with a continuous, involuntary, intermittent coarse tremor of the left foot causing increased pain. The electromyogram showed rhythmic discharges of 3 Hz frequency lasting 20-80 milliseconds in the left tibialis, peroneus and gastrocnemius, suggestive of either basal ganglia or spinal origin. Tremor and pain were controlled with epidural bupivacaine, but the tremor reappeared after discontinuing epidural blockade. Carbidopa/levodopa 25/100 (Sinemet ® ) was started and the tremor disappeared after two days. With continued physical therapy, pain and swelling resolved within two months and carbidopa/ levodopa was discontinued after five weeks with no recurrence of the tremor. Our success in the treatment of CRPS-associated tremor in this young girl with carbidopa/levodopa suggests that this patient may have had underlying movement disorder which was unmasked by the peripheral injury.

A 14-year-old girl presented with Complex Regional Pain Syndrome, Type I (CRPS-1) of the left ankle after a remote history of sprain. Allodynia, pain, temperature and color changes, and swelling were successfully treated with physical therapy, transcutaneous electrical nerve stimulation (TENS), gabapentin, amitriptyline, and tramadol. Five weeks later, she presented with a continuous, involuntary, intermittent coarse tremor of the left foot causing increased pain. The electromyogram showed rhythmic discharges of 3 Hz frequency lasting 20-80 milliseconds in the left tibialis, peroneus and gastrocnemius, suggestive of either basal ganglia or spinal origin. Tremor and pain were controlled with epidural bupivacaine, but the tremor reappeared after discontinuing epidural blockade. Carbidopa/levodopa 25/100 (Sinemet ® ) was started and the tremor disappeared after two days. With continued physical therapy, pain and swelling resolved within two months and carbidopa/ levodopa was discontinued after five weeks with no recurrence of the tremor. Our success in the treatment of CRPS-associated tremor in this young girl with carbidopa/levodopa suggests that this patient may have had underlying movement disorder which was unmasked by the peripheral injury.

An individual with ataxia has a significant impairment in their ability to perform voluntary movements due to a lack of muscle coordination, which is a neurological disorder. The etiology, clinical presentation, diagnostic methods, and treatment interventions of ataxia are all thoroughly covered in this review. We examine a wide range of conditions that contribute to this complex neurological syndrome, delving into the molecular and cellular mechanisms underlying ataxia. To further address the difficulties presented by ataxic disorders, we also highlight current research developments and possible treatment approaches.

In this double-blind study, patients with an acute exacerbation of schizophrenia or schizoaffective disorder were randomized to receive either ziprasidone 80 mg/day ( n ϭ 106) or 160 mg/day ( n ϭ 104) or placebo ( n ϭ 92), for 6 weeks. Both doses of ziprasidone were statistically significantly more effective than placebo in improving the PANSS total, BPRS total, BPRS core items, CGI-S, and PANSS negative subscale scores ( p Ͻ .05). Ziprasidone 160 mg/day significantly improved depressive symptoms in patients with clinically significant depression at baseline (MADRS у 14, over-all mean 23.5) ( p Ͻ .05) as compared with placebo. The percentage of patients experiencing adverse events was similar in each treatment group, and resultant discontinuation was rare. The most frequent adverse events associated with ziprasidone were generally mild dyspepsia, nausea, dizziness, and transient somnolence. Ziprasidone was shown to have a very low liability for inducing movement disorders and weight gain. The results indicate that ziprasidone is effective and well tolerated in the treatment of the positive, negative, and depressive symptoms of an acute exacerbation of schizophrenia or schizoaffective disorder.

Alien hand syndrome (AHS) is a sensation of foreignness between the patient and one of his or her hands, where the affected hand is observed to perform autonomic purposive behaviors that are interpreted as spontaneous movements of the limb that have an alien origin. 1 Recent studies have found that anatomical lesions leading to uncontrolled limb movement and a feeling of estrangement were predominantly located in the corpus callosum and/or supplementary motor area. 2 In contrast to the well-known sequelae of anterior frontocallosal lesions, posterior AHS is a very rare clinical condition, and the pathophysiology underlying this phenomenon is still unclear. 2 Object affordance theory suggest the role of the right parietal area and its connections with other areas in regulating object affordance primed by the environment. This theory further shows that exaggerated object affordance effects may lead to abnormal hand behaviors in AHS that are related to the balance of objectevoked automatic motor activation and the suppression of these automatically evoked responses. 3 Here we describe a 63-year-old right-handed male patient who was presented with spontaneous movements and estrangement of the left hand. A neurological examination revealed mild hemiparesis and extensor plantar responses on the left side. Involuntary movements of the left upper limb, predominantly of the wrist and the hand, were prominent. The patient did not feel when the extravolitional activity was initiating, and was not able control the behavior of the hand, describing this action as if someone else was controlling the arm from outside. " The findings of a neuropsychological examination were normal except for left-side hemineglect and visuoconstructive impairment shown on tests of spontaneous drawing or copying. In the light of previous findings suggesting the significant role of the corpus callosum and frontal lobe in anterior AHS, we aimed to show that the metabolic impairment does not extend to the well-known anterior brain regions through diachysis. As opposed to frontal and callosal cases of alien hand, in which ipsilateral motor plans and callosal transfer to the opposite hemisphere are regulated abnormally, our patient had a complicated sensory disorder with self-stimulation from the neglected side. In addition to MRI indicating a right-side hemorrhagically transformed ischemic area, FDG-PET scanning revealed significantly reduced glucose uptake in the right parietotemporal cortical region compared to the contralateral hemispheric region (more than 2 standard deviations below the mean of the asymptomatic control group; version 3.5, NeuroQ, Syntermed, Atlanta, GA, USA) (Fig. ), with this difference being most pronounced in the sensorimotor area. Based on a recent report, 4 the present case is exceptional in showing that an isolated cerebrovascular lesion located structurally and metabolically purely in the posterior region can lead to AHS. The present findings indicate that due to the rare presentation of the posterior subtype of AHS and the often-transient nature of the symptoms, functional neuroimaging combined with stimulus-based neuropsychological tasks might provide more information

Parkinson's disease (PD) is a common neurodegenerative disease whose motor and non-motor complications significantly affect a person's quality of life (QoL). This study aimed to investigate the QoL of these patients using the PD questionnaire (PDQ)-39 and identify the prognostic factors associated with their QoL. Methods: In this case-control study, the QoL of two groups (211 controls and 211 cases) was investigated and compared using the PDQ-39 questionnaire. Prognostic factors associated with QoL were determined using multivariate logistic regression analyses. Results: Several 422 patients with a mean age of 59.8±13.7 years were included in the study. The mean PDQ-39 score in the case group was significantly higher in all subscales, except for social support, compared to the control group. The mean score of PDQ-39 was significantly higher in the patients with non-deep brain stimulation (DBS) (53.9±21.1 (than those with DBS (42.22±18.1), especially in the sub-scales of mobility, activities of daily living, cognition, and communication. As the stage of the disease increased, the mean PDQ-39 score in these patients increased significantly. The results of the multivariate analysis showed that sex, patient age, smoking, education level, duration of disease, patient stage, and intervention with DBS were significantly related to patients' QoL (P<0.05). Conclusion: This study highlights the significant impact of DBS on PD patients' QoL, especially in sub-scales of mobility, daily activities, emotional well-being, and cognition. Moreover, identifying the main prognostic factors of QoL (sex, age, smoking status, educational level, disease duration, and stage) can lead to avenues for improving the lives of these patients.

Postural instability is one of the most incapacitating factors in Parkinson's disease (PD). The underlying de®cits and the effects of treatment are still not well understood. The aims of the present study were: (i) to identify abnormalities of postural control in PD patients during unperturbed stance and externally perturbed stance (anterior±posterior tilts of the support surface and of the visual scene); (ii) to assess the effects of L-dopa medication and subthalamic nucleus (STN) stimulation on posture control; and (iii) to characterize potential differential or additive effects of both treatments. Eight PD patients under chronic STN stimulation were investigated and compared with 10 normal controls. The assessment was performed in a crossover design (T STN stimulation, T L-dopa). During unperturbed stance, we recorded measures of spontaneous sway in terms of displacement, velocity and frequency of the centre of pressure (COP), lower body (LB) and upper body (UB) excursions. In addition, inter-segmental UB± LB coupling was investigated as a measure of axial stiffness. All these measures were abnormally large in patients OFF treatment. Under L-dopa treatment, the velocity, frequency and coupling measures were reduced, whereas sway amplitude increased. Very similar effects were obtained under STN stimulation, and these effects became more pronounced in the combined treatment condition. In these data, reduction of intersegmental coupling correlated with increase in sway amplitude. The ®nding suggests that axial stiffness reduction under treatment revealed a treatmentresistant de®cit in the sensorimotor postural control loop. However, these two effects did not correlate with the motor subscores of the uni®ed Parkinson's disease rating scale (UPDRS), which indicates that they are of minor functional relevance for posture control. A frequency peak in the COP excursions at 0.7±1.1 Hz, which we take to indicate a resonance behaviour of the postural control loop, became reduced under therapy. The reduction of this peak did correlate with most improvements in the UPDRS under therapy. Support surface tilt revealed that an UB righting on the LB segment, which is present in normal controls, is missing in the patients. The postural responses to visual tilt were abnormally large in patients, independent of whether the support was stable or slightly moving, while the control subjects clearly pro®ted from a stable support. This ®nding suggests that PD patients lack the ability of normal subjects to use sensory or cognitive information when suppressing the destabilizing effect of visual tilt. These abnormal tilt reactions of the patients were resistant to treatment with L-dopa, STN stimulation and a combination of the two. Overall, the effects of STN stimulation on posture control essentially paralleled those of L-dopa during both unperturbed and externally perturbed stance.

Introduction: Fragile X Syndrome (FXS) is the second most dominant cause of lifelong learning disability and the most common inherited cause of autism. While FXS is explicitly diagnosed in males, females show mild features thus early diagnosis is complicated in areas with no access to genetic testing and molecular diagnosis. Here, we report a case of FXS in a female patient with a rare manifestation of DKA. Case presentation: This case was a 16-year-old female admitted with unconsciousness and hyperglycemia diagnosed with DKA. Additional physical examination showed signs typical for FXS such as long face, narrow brow, large ears, and connective tissue dysfunction in the form of flat foot and joint hypermobility. Due to limited resources molecular testing was not done, but clinical index of suspicion for FXS was high given the family history and physical examination. Discussion: This case portrays the key signs and symptoms in diagnosing FXS in females as most of these signs are likely to be mild. This form of presentation with DKA is not usual in patients diagnosed with FXS and should serve as a reminder that there may be rare association. The absence of genetic testing in low income areas exacerbates the problem of diagnosis. Conclusion: This case demonstrates that, despite the absence of genetic confirmation, symptoms of this condition can be identified in a patient early enough, and the results can be improved. Family history and the physical examination should be emphasized in these situations.

Autism Spectrum disorder is defined as the global developmental disorder characterized by difficulty in social interaction and communication. It is manifested as repetitive patterns of thoughts and behavior. Toe walking is one of the most common initial signs exhibited by autism children and is mostly unilateral. The aim of this study was to identify the effect of Conventional Exercises and Sensorimotor Exercises in reducing the toe-walk in autism children. The study was a randomized control trial that included children of both sex between age group 2 & 5 years with a history of recent toe-walk. The subjects without a history of Tendo Achilles contracture and with a good hip flexibility were included. Subjects with a long time history of toe walking and with TA contracture and associated surgical corrections were excluded. Any subject with a diagnosis of Cerebral palsy and Asperger syndrome were excluded. A total of 40 subjects were included in the study who underwent assessment of Foot alignment through photographs, Plantar Foot Pressure through Foot Posture Index-6 and range of motion at ankle through Goniometer. Group A received Conventional exercises and Group B received Sensorimotor exercises for a period of 4 days a week for 8 weeks. At the end of 8 th week a post test was done for all the standard tests used in the study. The result of the study shows that the experimental group (Group B) who received sensorimotor exercises showed significant improvement in Foot Alignment and range of motion of both plantar flexion and dorsiflexion while the Control group (Group A) showed improvement only in passive range of motion of dorsiflexion alone. The study helps to conclude that the group which received Sensorimotor exercises improved well. Hence it can be considered as the best of treatment to inhibit toe-walk in autistic children.

Background: Antiphospholipid syndrome (APS) is a systemic disorder characterizes by recurrent arterial and venous thrombosis and/or pregnancy miscarriages and positive test for antiphospholipid antibodies. Case: Here we report a 31 year-old female whose main complain was symmetrical motor polyneuropathy and hand muscular weakness over a long period of time. Her clinical picture became more complex by Mitral valve regurgitation and renal dysfunction. Finally with the diagnosis of APS glucocorticoid therapy was started and her renal dysfunction improved profoundly, however her cardiac valvular involvement and peripheral neuropathy remained. Conclusions: APS is a disease with wide clinical presentations and it continues to confound the clinicians.

Self-induced masticatory trauma is an unfortunate complication of a variety of neurologic disorders, including epileptic seizures, cerebral palsy, mental retardation, psychiatric disease, and brain trauma, in addition to other described etiologies. While single or occasional occurrences of tongue biting are relatively benign, recurrent self-injury can pose major issues and predispose a patient to chronic, severe complications. To prevent the complications associated with ongoing trauma to the tongue, steps must be taken to protect individuals from chronic self-injurious behavior. Often, these interventions cause significant morbidity to the patient, such as elective removal of the dentition or complications in gaining access to the oral cavity/airway associated with maxillomandibular fixation. In the neurologically impaired patient, immobilization of the jaws is frequently associated with higher rates of agitation, aspiration, or development of complicating infections of the gingiva...

Hemiballismus-hemichorea associated with lesions related to the subthalamic nucleus or its connections. Hemiballismushemichorea have also been reported in pallidus, caudate core, putamen, thalamus, corona radiata, substantia nigra, premotor and motor cortex lesions. Ballismus is a very large amplitude korean movement that involves the proximal part of the extremities.It is usually unilateral.This condition, which is defined as hemiballismus, is associated with lesions related to the subtalamic nucleus or connections of the contralateral side .Choreic and ballistic movements have been reported in the lesions that cut the afferent and efferent subtalamopallidal pathways of the basal ganglil. In this article we report a 54-year-old woman with hemiballismus-hemichorea who developed after acute ischemia in the globus pallidus.

Deep brain stimulation (DBS) represents a major advance in the treatment of various severe movement disorders or neuropsychiatric diseases. Our understanding of the mechanism of action of this surgical treatment has greatly benefited from functional imaging studies. Most of these studies have been conducted in patients with Parkinson's disease (PD) treated by bilateral subthalamic nucleus (STN) stimulation. These studies have notably underlined the fact that STN stimulation influences motor, limbic, or associative cortical-subcortical loops in various (sometimes contradictory) ways. We present an up-to-date review of the information provided by functional imaging studies in surgery for PD, dystonia, tremor, as well as in psychiatric disorders such as depression or obsessive-compulsive disorder. On the basis of this information, proposed mechanisms of action of DBS are discussed, as well as the need for additional approaches such as improved anatomical localization of the contact used for stimulation or a better understanding of the electrical distribution around the electrode.

Background: Creutzfeldt-Jakob disease (CJD) is a rare neuro degenerative disease that is mainly characterized by rapidly progressive dementia along with a varying combination of myoclonus, visual, cerebellar, pyramidal/extrapyramidal and akinetic mutism. Several movement disorders phenomenologies can occurs either at onset, as presenting symptom or during the course of illness. Present study aims to characterize the clinical, radiological features and the outcome of patients with CJD with movement disorders as the forthcoming manifestation. Methods: Chart review of patients with CJD with movement disorders. Demographic, clinical and radiological details of the patients were reviewed. Results: 25 patients (13 males) of sCJD with median age at presentation of 58 years and median duration of illness of 5 months were included in the study. According to revised CDC diagnostic criteria 1 patient was classified as definite sCJD, 20 as probable and 2 as possible CJD. Myoclonus, ataxia and parkinsonism were the most common movement disorder and chorea was the least common. Magnetic resonance imaging of brain was performed in all and basal ganglia abnormality and cortical ribboning was seen in more than two-third of cases. Electroencephalographic abnormality was noted in 21 patients with triphasic waves and periodic sharp waves seen in 7 and 6 patients respectively. Cerebrospinal fluid 14-3-3 assay was abnormal in 2 out of 4 patients. Atypical presentations were noted in the form of ataxic presentation, CBS like presentation and choreiform presentation. Myoclonus, ataxia and parkinsonism are the most frequent movement disorders phenomenology observed in patients with sCJD.

Introduction: Niemann-Pick disease type C (NPC) is an autosomal recessive neurovisceral lipid storage disorder caused by mutations in theNPC 1or2genes. Movement disorders can occur as the first symptom and as predominant symptom mainly in juvenile-onset. The frequency and heterogeneity of movement disorders in NPC are not well described. We studied the frequency and spectrum of movement disorders in patients with NPC of different age of onset.Methods: Retrospective chart review of patients with NPC diagnosed based on the Suspicion Index tool and demonstration of foamy macrophages/sea-blue histiocytes in bone marrow aspirate.Results: We report 9 cases of NPC with 2 patients of late-infantile, 4 juvenile-onset and 3 of adult-onset. The mean age at onset of symptoms was 11.7 ± 10.4 (range 4–38 years) and the median duration of illness was 4 years. Vertical supranuclear gaze palsy (VSGP) was noted in 8 patients and VSGP with slowing of saccade in 1 patient. Splenomegaly was seen in 5 pa...

ObjectiveaaThe novel coronavirus disease (COVID-19) pandemic and public health measures to control it have resulted in unique challenges in the management of patients with deep brain stimulation (DBS). We report our experience with the management of acute worsening of symptoms due to battery exhaustion in 3 patients with DBS. MethodsaaPatients with DBS for movement disorders who visited the emergency room due to battery exhaustion during the nationwide lockdown from April to May 2020 were included. ResultsaaTwo patients with subthalamic nucleus-DBS for Parkinson's disease (PD) and one with globus pallidus interna-DBS for generalized dystonia presented with acute worsening of symptoms due to battery exhaustion. Urgent battery replacement was performed in both patients with PD. The patient with generalized dystonia was managed with medication adjustment as he chose to defer battery replacement. ConclusionaaDBS battery replacement can be an emergency. Decisions regarding DBS battery replacement should be individualized during this COVID-19 pandemic.

Cognition has been reported to be involved in patients with multiple system atrophy (MSA), although initially it was considered an exclusion in the diagnosis of MSA. We assessed cognition in these patients and compared it with age and education matched healthy controls and correlated with the gray matter volume using voxel-based morphometry (VBM). This was a prospective, case-control, single-center study. Thirty patients with MSA (20 MSA-C (cerebellar variant) and 10 MSA-P (Parkinsonian variant)) and 25 age-and educational level-matched healthy controls were included. All the patients and controls underwent detailed neuropsychological tests and MRI brain. A battery of neuropsychological tests like Stroop test, digit span forward and backward, digit symbol substitution time test, animal naming test, color trail test and auditory verbal learning test were used to assess the various domain of cognition, which include mainly attention, executive function, memory, new learning, mental and motor speed. The gray matter volume was determined using VBM and correlated with neuropsychological scores. Attention, execution, verbal and visual memory, verbal fluency, and new learning were impaired in patients with MSA. MSA-P had more impairment in motor and mental speed, working memory, executive functions, and focused attention compared to MSA-C. Patients with MSA-C had more impairment in new learning, immediate recall, verbal fluency, and sustained attention compared to MSA-P. However, it was not statistically significant. There was a significant correlation between the various cognitive domains and atrophy of frontotemporal cortical areas, insula, caudate, thalamus, and cerebellum. Cognition is impaired in patients with MSA-C and MSA-P and is likely due to the neurodegenerative process involving the cortical and subcortical structures. Long-term follow-up studies are required to find out the progression of these cognitive changes.

Objective Joubert syndrome (JS) is a rare syndrome characterized by ataxia and the molar tooth sign (MTS) on imaging. The present study aims to explore the clinical and radiological features in a cohort of patients with JS.Methods This was a retrospective chart review of patients with JS evaluated by movement disorder specialists.Results Nine patients were included in the study. All patients had facial dysmorphism and ocular abnormalities, and 4 patients had dystonia. Ocular tilt reaction and alternate skew deviation (66%) were the most common ocular abnormalities. Horizontally aligned superior cerebellar peduncles were observed in all four patients with diffusion tensor imaging, with a lack of decussation in three. Exome sequencing performed in four patients revealed novel variants in the MKS1, CPLANE1, and PIBF1 genes.Conclusion Facial dysmorphism, ocular abnormalities and classical imaging findings were observed in all patients with JS. Apart from ataxia, dystonia and myoclonus a...

Background: Psychogenic movement disorders (PMD) is a group of disorders that cannot be attributed to any structural or biochemical abnormality, but has an underlying psychiatric illness. The profile of PMD varies according to country and socioeconomic factors. Methods: The present study reports the clinical profile of patients with PMD from India. Seventy-three patients with documented or clinically established PMD were seen over a period of 14 years with detailed neurological and psychiatric examinations. Results: The mean age at presentation was 29.1 ± 15.1 years (women, 51%). Approximately 30% were ≤18 years of age (boys, 63.6%). The onset of symptoms was abrupt in 61.6% and the initial body part most often affected was right upper limb (adults, 29.4%; children, 31.8%). Tremor was observed in 31.4% of adults and 9% of children, whereas myoclonus was more common in children (36.4%). Tremors were more often seen in women (42.3%) than in men (20%), whereas myoclonus was almost equally prevalent in girls (37.5%) and boys (35.7%). Depression was the most common psychiatric comorbidity (men, 16%; women, 15.4%). About 42.5% required hospital admission and 57.5% had significant reduction or complete cessation of PMD after counseling, antidepressants, and/ or placebo. Conclusions: PMD was equally prevalent among women and men. Tremor was most often observed in adults, whereas myoclonus was most often observed in children. Electrophysiology and placebo were useful supplementary tools for diagnosing PMD. RÉSUMÉ: Déterminants des sujets présentant des troubles psychogènes du mouvement selon le sexe et l'âge: profil clinique de 73 patients. Contexte: Les troubles psychogènes du mouvement (TPM) constituent un groupe de problèmes de santé qui ne peuvent être attribués à aucune anomalie structurale ou biochimique et qui sont dus à une maladie psychiatrique sous-jacente. Le profil des TPM varie selon le pays et les facteurs socio-économiques des patients. Méthode: Nous rapportons le profil de patients présentant des TPM en Inde. Soixante-treize patients présentant des TPM documentés ou établis cliniquement ont subi des examens neurologiques et psychiatriques détaillés au cours d'une période de 14 ans. Résultats: L'âge moyen des patients au moment de la consultation initiale était de 29,1 ± 15.1 ans et 51% étaient des femmes. À peu près 30% étaient âgés de 18 ans ou moins et parmi eux, 63,6% étaient des garçons. Le début des symptômes avait été soudain chez 61,6% et la partie du corps initialement touchée était le plus souvent le membre supérieur droit (29,4% chez les adultes, 31,8% chez les enfants). Chez les adultes, 31,4% avaient du tremblement ainsi que 9% des enfants. La myoclonie était plus fréquente chez les enfants (36,4%). Les tremblements étaient plus fréquemment observés chez les femmes (42,3%) que chez les hommes (20%). La myoclonie était presqu'aussi fréquente chez les filles (37,5%) que chez les garçons (35,7%). La dépression était la comorbidité psychiatrique la plus fréquente tant chez les hommes (16%) que chez les femmes (15,4%). Environ 42,5% des sujets ont dû être hospitalisés et 57,5% présentaient une diminution significative ou un arrêt complet des TPM suite à une prise en charge psychologique, la prescription d'antidépresseurs et/ou de placebo. Conclusions: La prévalence des TPM était égale chez les femmes et chez les hommes. Le tremblement était le plus souvent observé chez les adultes, alors que la myoclonie était plus souvent observée chez les enfants. L'électrophysiologie et le placebo se sont avéré des outils supplémentaires utiles pour poser un diagnostic de TPM.

Gabapentin is a structural analogue of gamma-aminobutyric acid (GABA) that has emerged as a versatile pharmacologic agent since its introduction in the 1990s. Originally developed as an antispasmodic, gabapentin demonstrated efficacy as an adjunctive anticonvulsant and has since expanded into the management of diverse conditions, including neuropathic pain, restless legs syndrome, fibromyalgia, and certain psychiatric disorders. Its unique mechanism of action—binding to the α2δ-1 subunit of voltage-gated calcium channels rather than GABA receptors—attenuates excitatory neurotransmission and neuronal hyperexcitability. Gabapentin displays nonlinear pharmacokinetics with saturable absorption, minimal metabolism, and renal excretion, necessitating dose adjustments in renal impairment. Although well tolerated, gabapentin is associated with a spectrum of adverse effects, from mild dizziness and sedation to rare but serious conditions such as Stevens–Johnson syndrome, anaphylaxis, and respiratory depression, particularly when combined with opioids. Monitoring, gradual tapering, and interprofessional collaboration are essential to minimize risks and maximize benefits. This review synthesizes the pharmacology, clinical indications, safety profile, and strategies for optimizing gabapentin therapy. A detailed clinical scenario illustrates its practical application in an interprofessional care setting.

Objective: Assessment of movement disorders in patients with multiple sclerosis (MS) is difficult because of the complex nature of the movement disorders. The aim of this study was to determine the reliability of Fahn's Tremor Rating Scale (FTRS) in assessing movement disorders in patients with MS. Method: Videos were made of 10 patients with MS showing their rest, postural, action/intention, and goal-related movement disorders as well as their performance of spirometry, a volumetric task, and timed functional tasks. Ratings of tremor were carried out by one rater on two occasions 3 months apart and by 8 raters on one occasion using FTRS. Results: Intrarater reliability was generally very good, with no significant "drift" in ratings over time. Interrater reliability was generally good, with some variation in interpretation of scoring criteria that may reflect raters' backgrounds. Conclusion: The FTRS is a reliable and potentially useful tool with which to assess movement disorders in patients with MS. 0 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation T REMOR AND OTHER movement disorders are recog- nized features of multiple sclerosis (MS) and can be both distressing and disabling. In their series of 656 patients, Kraft and colleagues1 reported tremor in 27%, in half of whom it was associated with difficulties in performing activities of daily living. Various treatments for tremor have been described, including oral medication, the use of weights' applied to the wrists, and stereotactic surgery.2,3 Descriptions of such therapies have used a range of ad hoc scales to measure tremor response, but at present no validated scale is available.3 This partly is in contrast to experience with both essential and Parkinsonian tremor, for which standardized scales exist,4-7 and reflects the complexity of the movement disorders associated with MS. As part of a prospective study of thalamic deep brain stimulation as a treatment for movement disorders in MS, we decided to use a modification of the Fahn Tremor Rating Scale (FTRS) as a measure of the tremor. To evaluate the applicability From the

Background: Negative myoclonus is rarely seen in the clinical setting. It can be involved in some central nervous system pathologies. It has also been observed after antipsychotic treatment. Case Reports: In this article, we will present 3 cases diagnosed with negative myoclonus in a 120-bed university-affiliated hospital within the past 7 years. Based on our clinical experience, it was observed that myoclonic jerk was a rare condition that started with suddenly dose changes. Patients showed good improvement in response to dose reduction. Conclusions: Since the number of reported cases on negative myoclonus is limited, there is still a lack of well-established consensus on the management of this disease. It can be concluded that myoclonic jerk may be dosedependent, sudden dose changes may be effective, anticonvulsants are not effective in all cases, and treatment can be achieved by reducing the dose.

A 77-year old woman presented with a history of falls. Known health problems included biopsy-proven collagenous colitis treated with bismuth subsalicylate. On examination, in addition to impaired balance and gait, she was found to have tremors and cognitive deficits. Investigations revealed a markedly elevated urinary bismuth level. Withdrawal of bismuth subsalicylate led to marked cognitive and physical improvement.

Deficits in postural control are one of the hallmarks of disability in children with cerebral palsy. Yet, much remains unknown regarding the etiology of postural deficits in these children. Here we evaluated postural control at a simplified task level by measuring head stability during quiet sitting while systematically manipulating the level of trunk support and vision in 15 children with CP (6-16 years), 26 typically developing (TD) children (4-14 years), and 11 adults. While TD children did not differ significantly from adults, children with CP had greater head movement than adults in both the sagittal and frontal planes under all conditions except frontal plane movement with Torso Support. Vision did not affect head stability in the sagittal plane for any group while it had differential effects on head stability in the frontal plane. Lack of vision improved head stability in adults and older TD children while destabilizing the head in young children (TD and CP) during the most unstable sitting position. Moreover, vision affected children with CP differently depending on their movement disorder. Children with spastic CP performed worse with eyes closed while those with dyskinetic CP had improved head stability with eyes closed. Our results demonstrate that children with mild to moderate CP have deficits in head stability even during quiet sitting.

Purpose: Design a protocol for probing the plastic nature of the epileptic networks. Methods: We selected 3 patients with pharmaco-resistant epilepsy that were explored in the SEEG method. Single pulse electrical stimulations (SPES) (biphasic, 3 ms, 0.25-5 mA) were applied to adjacent contacts. We calculated the early responses in the 10-110 ms interval and considered only connections between contacts having a RMS value within the 3rd quartile of all the responses in an individual patient, correlated with the stimulation current (Spearman's rho >0.5, p < 0.05). Sublobar anatomical structures projecting to SOZ (inbound connections), as well as SOZ's projections to other structures (outbound connections) were systematically assessed and named generically ''epileptome". SOZ's contacts were also stimulated in various relevant clinical situations (first, second patient-interictal awake vs. sleep vs. postictal, third-on medication vs. off) to understand the dynamics of the outbound analysis. Results: Lack of medication or sleep activated SOZ's network (mean increase in RMS 6%, 28% to baseline) and introduced new structures in the epileptome (hippocampus in one patient, contralateral basal temporal and precuneus in another). Post-seizure, SOZ lost some nearby connections and gained distant ones, not present interictally. Conclusions: Intra-individually the epileptic focus engages in an evolving network configuration that can be accurately described.

Status dystonicus (SD) is a medical emergency leading to a significant morbidity and mortality. It can affect either patients with primary or secondary dystonia. SD is characterized by episodes of generalized muscle contraction sustained and refractory to medical treatment. Usually is possible to identify triggers as fever, infections or abrupt discontinuation of treatment. From a therapeutic point of view there are no evidence-based management guidelines in SD. OBJECTIVE: we report on four patients with status dystonicus describing their clinical manifestations, treatments and evolution. MATERIALS AND METHODS: we reviewed medical records of patients admitted to our department with a diagnosis of status dystonicus from January 2009 to June 2012. RESULTS: we present four male patients with secondary dystonia with usual drug treatment. Range of age at diagnosis was 4-13 years. Fever was the most frequent trigger. Three patients required intravenous benzodiazepines without mechanical ventilation needed; two of which showed unfavorable response, and required implementation of baclofen intrathecal infusion pump, achieving the resolution of the SD and decline in basic medication. Only one patient was managed optimizing oral medication. CONCLUSION: Status dystonicus is a very difficult therapeutic management condition. Early use of surgical techniques, such as baclofen intrathecal infusion pump should be considered before treatment failure or relapse with intravenous benzodiazepines. We emphasize the importance of preventing and controlling triggers. There is an urgent need to develop evidence-based treatment guidelines.

Several articles have described the electromyographic (EMG) patterns underlying cerebellar hypermetria. However, the description of the EMG associated with hypermetria is not consistent between studies. It is hypothesized that the reason for this concerns the criteria used to define and describe the antagonist latency. Several studies on neurologically normal individuals have shown that there are two components to the antagonist EMG: an early component and a late component. However, many studies have