rTMS (repetitive brain transcranial magnetic stimulation) to cure major depression disorder (MDD)

In our center (www.neurolacote.ch) we perform brain rTMS, which is an already a well-known treatment for major depression.
This technique is able to modulate the electrical cortical potentials by the mean of a coil (placed on the head, FIg 1) which provides a repetitive electromagnetic induction of the brain. Low frequency stimulation (<= 1 Hz) reduces the neuronal excitability, whereas high-frequency stimulation (>= 5Hz) enhances it. The dorso-prefrontal-lateral cortex (DLPFC) of the brain is crucial for the emotional control.
Based on a great number of clinical studies (especially with patients with post-stroke depression), the valence hypothesis posits that the DLPFC of the right hemisphere is dominant for processing negative emotions whereas the DLPFC of the left hemisphere elaborates the positive emotions. In case of the patients with major depression the left DLPFC activity would be decreased while the right DLPFC function increased. Thus, rTMS can modify the DLPFC activity in patients with MDD (by reducing right DLPFC activity or by increasing left DLPFC excitability).
More then 40 studies indicated that rTMS can lead to long-term and sustained remission of treatment-resistant MDD and improve the quality of life. 50% of the patients respond positively to the treatment and 32% have a complete remission of the depressive symptoms. The rTMS is also known to improve the antidepressant effects of psychotherapy or drugs such as paroxetine or escitalopram. rTMS could be performed even for pregnant patients. Side effets are mild (generally mild discomfort at the stimulus site of the scalp). rTMS is contraindicated in patients with a history of seizures although the incidence of such complication is quite low (<0.1%). Different protocols of rTMS (as outpatient) are possible for depression over 3-6 weeks. Many patient needs a unique traitement. However, for some of them it is possible to repeat the treatment (every 4 or 6 months). The psychiatrist should contact us (www.neurolacote.ch) to introduce his patient with MDD. The rTMS is a valid alternative for patients having sides effects of antidepressant drugs or resistant to common pharmacological thérapie.

Publié dans Psychiatry, rTMS | Laisser un commentaire

Hyperventilation syndrome (HVS)

Extrait de "Anxiety" Edward Münch 1894
Extrait +Anxiety » Edward Münch 1894

HVS consists of a multitude of somatic symptoms (dizziness, discomfort, difficulty breathing, tingling, stiffness of the tongue and mouth, impaired vision, loss of consciousness or presyncope, tremors, palpitations, bloating of the stomach, hand cramps) induced by hyperventilation (of which the patient is not generally aware) and reproducible at least partially by voluntary hyperventilation.

It is a common syndrome, often associated with a mood disorder (anxiety). The HVS is frequent in general medicine, neurology, pneumology and cardiology. Often patients with HVS consult the neurologist with the fear of a brain disease such as multiple sclerosis (after searching on the internet a cause for their symptoms)

The diagnosis is clinical using specific questionnaires (Nijmegen) and the hyperventilation test, as well as a detailed somatic and psychic history. Neurological examination is normal.

Benzodiazepines and SSRI drugs can be effective, but temporarily, and there are not the final solution. Breathing in a plastic bag is no more recommended.

The education of the patient who should learn exactly what she/he has and the mechanisms involved is fundamental and probably the most effective therapeutic act. Learning breathing techniques without or with feedback (reducing the respiratory rate and promoting relaxation) is important and it is the most appropriate therapeutic approach together with psychotherapy. Any other (non-pharmacological) approach to controlling anxiety and promoting relaxation should be encouraged (yoga, acupuncture, manual medicine, meditation, mindfulness).

Publié dans Psychiatry | Laisser un commentaire

Brain and spirituality

A fascinating scientific question concerns the functioning of the brain for spirituality. It is difficult to provide an empirical definition of spirituality because it is an entirely subjective dimension. Here, I refer to spirituality as the perception of a God or a divine entity in general.
Our brain is certainly programmed for spirituality because it has been part of human life for 40,000 years and manifests itself in all cultures with proportions greater than atheism. Is the brain programmed to believe in an entity that actually exists or is it a kind of representation as in dreams?
Does spirituality only give an advantage for the evolution of the human species?
Why are the experiences of people next to death (during resuscitation) almost always spiritual and stereotyped?
Direct stimulation of certain brain regions (during neurosurgery procedures) can produce spiritual sensations. Some patients experience divine experience during epileptic seizures. At the current stage of research, the neural networks that generate spirituality have too broad distribution in the brain to be easily located.
We would be interested in researches on spirituality with experiments of priming or implicit memory.

Publié dans Cognition and Behavior, Neurologic mysteries | Laisser un commentaire

Constipation and Parkinson’s disease (PD).

 

 

 

 

 

 

 

 

 

Constipation is one of the most frequent non-motor symptoms of PD (40-90% of the patients). It frequently precedes (even several years before) the beginning of tremor and rigidity. PD related constipation is actually the results of neurodegenerative changes in the vegetative centers of the brain and in the peripheral intestinal neurons (the enteric nervous system). Another mechanism is probably the dysregulation of the gut microbiota (the intestinal bacteria ecosystem) in PD.
Constipation can be invalidating and also diminishes the absorption of the dopaminergic drugs and aggravates the other symptoms of PD.
Furthermore, to confirm that constipation and PD are related, it is necessary to exclude any other medical condition (such as colon cancer, irritable bowel syndrome and so on) or the effects of other drugs and medicaments.
Fluid and dietary fibers intake and increasing gait endurance and physical activities is the general approach. Psyllium and stool bulk agents can be useful, but they require good hydration. Osmotic laxatives should be used with caution in case of renal and cardiac dysfunction. Several other pharmacological treatments exist. Restoration of normal gut macrobiota in PD patients could be a future promising therapy.

Publié dans Movement disorders | Laisser un commentaire

Stimulate the brain to treat obesity

Obesity is a pathology that is already pandemic.
At the origin of an excessive consumption of food there are the cerebral circuits of hedonism, those which bring to eat for the pleasure beyond satiety. These are possibly the same brain regions involved in the consumption of tobacco, alcohol and drugs.
These neural systems (which contain dopamine) include the nucleus accumbens, the dorsal striatum, the ventral tegmental area and the orbitofrontal cortex. The dorsolateral prefrontal cortex (DLPFC), which is connected with the aforementioned regions, exerts a cognitive control (reappraisal) on pleasure-oriented behaviors. Direct stimulation of DLPFC by transcranial repetitive magnetic stimulation (rTMS) can reduce impulsive behavior which are food-oriented. The rTMS has very few contraindications and almost no side effects (see our website www.neurolacote.ch for more information). There are already several studies that show that rTMS stimulation of the DLPFC suppresses appetite in comparison to controls that undergo phantom stimulation (placebo). Several rTMS sessions should lead to a stable reduction of appetite and weight. We can perform rTMS treatment in our center if the patient already has a specialized medical follow-up for obesity.

References
Lowe CJ et al. Neuroimage 2018, 177,45-48.
Kim SH et al. Brain Stimulations 2018, 528-535.

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Neurology versus Psychiatry? Hallucinations, Delusions, and Confabulations.

Carota A, Bogousslavsky J

in Front Neurol Neurosci. 2019;44:127-140. doi: 10.1159/000494960. Epub 2019 Apr 30.

 

Abstract
Hallucinations, delusions, and confabulations are common symptoms between neurology and psychiatry. The neurological diseases manifesting with such symptoms (dementia, epilepsy, Korsakoff’s disease, brain tumors, Parkinson’s disease, migraine, right hemisphere stroke and others) would be the key to understand their biological mechanisms, while the cognitive sciences, neuropharmacology and functional neuroimaging would be the tools of such researches. It is possible to understand the perceptive rules of the mind and the mechanisms of the human consciousness based on these symptoms. However, hallucinations and delusions manifest with extraordinary vehemence with psychiatric disorders such as psychosis and schizophrenia, with which there is no evidence of brain lesions. Furthermore, they are subjective symptoms, and they do not have biological markers. Hence, they are prone to high inter-individual variability and depend on other variables (such as education, history of trauma), and are therefore difficult to reduce to unequivocal constructs. Causative mechanisms are probably multiple. For understanding these symptoms, a common framework between neurology and psychiatry is still missing. The psychopathology of French alienists over the 19th century, of S. Freud, and of Henry Ey over the 20th century gave way, in the second half of the 20th century, to the adoption of the DSM and neurosciences, to pursue a pure neurological perspective. However, although psychodynamic models seem nowadays (in a technological era) less influential, detailed clinical evaluations focusing on emotional-cognitive paradigms are probably the only way to lead to new neurobiological researches.

Publié dans Cognition and Behavior, Neurologic mysteries, Psychiatry, visual disorders | Laisser un commentaire

Icepick headache

Icepick headache (or stabbing headache”) is a sudden pain on the scalp, such as a stab, sometimes excruciating and disabling but very short lasting (seconds or one minute). This pain occurs without alert ten or hundred times a day, on variable locations of the skull. It is freaking! This is generally a primary headache. The migraine patient seems more likely to present this type of pain. If it is possible to reproduce the pain with a moderate pressure on the scalp. If there are no other signs at the neurological examination, a brain MRI is not necessary. The diagnosis of icepick headache is clinical. Several triggers are described: stress; disturbances in sleep patterns or routine, red wine, hormonal changes. The cause remains unknown and we assume the role of peripheral (nerve endings of the scalp) and central (reverberation in brain circuits of pain) factors. The pain of the icepick headache is so short that there is no time for analgesic drugs. If the pain is frequent, consider taking drugs such as indomethacin or pregabalin. In conclusion, ice-headed headache is a benign primary headache. However, imagine yourself being hit regularly by an icepick on your head! Patients can be extremely worried. In our center we treat stabbing headache with mesotherapy.

 

 

Publié dans Headache | Laisser un commentaire

Anosognosia and Neurobehavioral assessment

The neurobehavioral assessment consists of a battery of standardized tests and questionnaires and has a variable duration of 2-3 hours. Knowing the exact reason for the assessment (in our cabinet it is often the suspicion of dementia) helps in order to determine the strategy of the assessment.
The clinical history is the most critical source of data and very often requires an informant who knows the patient well. If the informant reports deficits (memory for example) of which the patient is unaware and a memory deficit is objectified by the tests, the patient has anosognosia (a term that derives from the ancient Greek and literally means “lack of knowledge of a disease”). The presence of anosognosia suggests the existence of a neurodegenerative pathology (the Alzheimer’s disease is the most common disorder). The opposite situation is the case of patients (usually younger) who report a greater burden of cognitive symptoms than a reliable informant, and cognitive tests are more in line with the assessment of the latter. This profile is more likely to be associated with anxiety, stress or depression. The neurobehavioral examination investigates anosognosia of the patient but also his emotions (catastrophic reactions, emotional lability, athymhormia), his mood (depression, anxiety) and the neuropsychiatric symptoms (confabulations, delusions, apathy, mania, dissociative symptoms)
Neurobehavioral assessment investigates memory, psychomotor speed, reaction times, cognitive flexibility, reasoning, visuoperceptive skills and language, and provides performance indices (expressed on percentage scales). which are compared to norms of a health control group of the same age and cultural level. The examination inquires the function of the patient in the real life too. The goal is to arrive at a diagnosis, determine treatment, safety measures, risks of driving, finalize patient-centered care strategies, and the education and support of caregivers.
A change in behavior, mood, cognitive functions and memory states clearly the indication to perform the neurobehavioral examination in our center, all the patients more or less aged.

Publié dans Alzheimer, Cognition and Behavior, Memory | Laisser un commentaire

The Mystery of chronic tension headache

This is the most common form of chronic headache (about 4 % of the world’s population), with, often, a negative impact on health and work.
Unlike migraine, this headache affects equally women and men. It consists of (according to the neurological definition) a headache that has a frequency ≥ 15 days a month, for at least 3 months, typically bilateral, with the quality of pressure (often the patient compares it to a helmet or to a headband that squeezes), with mild or moderate intensity (differently than migraine), the duration of hours or days or continuous. Sometimes it associates with nausea and photophobia.
The distinction with chronic migraine and drug overuse headache can be difficult, also because, often, the 3 conditions coexist.
The causes of chronic tension headache are mysterious and they are probably multiple. Probably, nervous and muscle peripheral mechanisms play a primary role with further sensitization of the brain centers of pain. The muscles of these patients become more rigid, which is the physical sign predominant for the clinical examination. The association with anxiety and depression is constant and stress is the most important trigger factor.
Although it is probably the most common headache in the world, tension headache remains a mystery, for the specialist too.
The complexity of mechanisms and causes explains the difficulty of treatment.
The effect of preventive pharmacological treatments (Amitryptiline or Mirtazapine) is often insufficient. The relaxation of cervical muscle and scalp is the primary objective and non-pharmacological treatments (massages, relaxation training, tens, cognitive-behavioral therapy for stress) can be indicated.
I propose mesotherapy.

Publié dans Headache, Pain syndromes, Peripheral Nervous System | Laisser un commentaire

Chess, brain and Alzheimer’s disease

The modern version of chess spread in Europe, Asia and Russia during the 10th century. It is a table game of extraordinary beauty and power and it will follow the human race forever. It is a democratic game and all, men and women, poor and rich can play at the same level. There is only one prerequisite: having a brain.
The game demands concentration, spatial and sustained attention, planning, reasoning, strategy, decision making, imagination (creativity), defense, patience, self-control, depth of calculation, resistance, courage and manipulation and mental flexibility. All types of memory are involved: immediate memory, episodic, prospective, spatial (pattern recognition), work, semantic memory (theoretical knowledge). The game develops the « mentalizing » because it is necessary to continually start thinking with the brain of the opponent to prevent his plans of attack or defense. Chess is a war game, and war is like love (you need to struggle and defense to arrive to the king or the queen).
The brain is the organ of the human body that consumes more glucose. Two-hours playing consumes calories as one-hour walking. Finally, chess play, is fitness!
As far as neurology is concerned, the chess game activates the left (logical and verbal thought) and the right hemispheres (spatial attention), the frontal lobes, the fusiform gyrus, the secondary and tertiary areas of the temporo-parietal junction at work. occipital and the caudate nucleus.
Several functional MRI studies have shown that the brains of chess masters differ from controls in the more intense activation of brain regions involved in working memory, spatial memory, and spatial navigation.
Scientific data has already shown that staying mentally active prevents Alzheimer’s disease.
Activities that stimulate the brain increase the number of neuronal synaptic connections and dendrites. The chess could therefore increase one’s own « cognitive reserve », increase neural connections and prevent Alzheimer’s disease.
There are very few scientific studies on this subject. It’s time to start studying and playing!

Publié dans Alzheimer, Cognition and Behavior | Laisser un commentaire

Catamenial or menstrual migraine


For many migraine sufferers (from 20% to 60%), although there are crises outside the cycle, menstruation is a trigger for migraine attacks.
For other migraine sufferers, the migraine crisis occurs exclusively between the day 2 before and the day 3 after the menstruation onset. The is the catamenial migraine (CM) or « menstrual migraine ».
The headache of CD is more severe, more disabling, longer and less responsive to treatment than usual migraine. Some of the women with MC are terrified by the occurrence of the menstrual period and lose, every month, 3-5 days of work or social life.
MC is due to the physiological decline of estradiol before the onset of menses. It can also occur with the combined estroprogestative contraceptive treatment at the time of the window.
These women often do not know who can help because the neurologist is the expert of the headache but not of hormones and the gynecologist vice versa. Now we are in the field of the neuro-gynecology !!!
For MC a specific preventive treatment with a low dose estrogen patch may be proposed.
The patch is applied 48 hours before menstruation and continued for 7 days. In the case of MC during the window of interruption of combined pills it would be useful switching to the lowest dose estrogen pills with a shorter or without interruption (with abolition of the menses).

Publié dans Headache | Laisser un commentaire

The challenges of Parkinson’s disease

The first challenge for the healthcare professionals is to preserve as long as possible the autonomy of the patients in the daily life.
The disability of  Parkinson’s disease has a high social impact and an important economic cost.
To preserve the patients’ autonomy, the neurologist has to identify and treat not only the « motor » but also the « non motor » symptoms (mood disorders, sleep, low blood pressure, pain, constipation and so on).
Another challenge is defining the mechanisms which cause the onset of the disease and its progress in time. The research focuses on the biomarkers, which can be identified 10 or 20 years before the onset of the first symptoms. Probably, the cure will be possible only in the prodromal phase of the disease. In the advanced phases the intent would be stabilizing the disease or avoiding its progression.
On a clinical perspective, we have to focus on the early « non motor » symptoms of the disease (taste and olfaction reduction, depression and anxiety, the sleep REM phase behavioral disorder, cognitive trouble, constipation and so on.). By better defining these early symptoms we can individuate the patients at risk to develop the disease and obtain an early diagnosis by means of biomarkers or functional imaging.
The hereditary cases of Parkinson’s disease are not so rare (10%) and, for them, the first symptoms appear before the age of 40 or 50. Now, we know the mutations of several genes which are determinant for these cases. The study of these genes can suggest some mechanisms of the sporadic disease.
Another challenge is the treatment of those  symptoms of Parkinson’s disease (dysarthria, gait and equilibrium dysfonction), which are less improved by pharmacological treatments. We need further treatments for the motor fluctuations of the advanced phase of the disease.

Publié dans Movement disorders, Parkinson Disease | Laisser un commentaire

Small revolution against migraine.

In Switzerland, there is a million of people suffering from migraine.
Now, in our center in Gland (www.neurolacote.ch), we can prescribe the Erenumab, a new preventive drug for the episodic (less than 15 days of crises a month) or chronic (more than 15 days of crisis a month during more than 3 months) migraine.
Erenumab is a monoclonal antibody which blocks the protein associated with the calcitonin gene (CGRP-R) and which acts exclusively on the vascular meningeal sites where the migraine pain starts. Thus, this is, for the first time, a biological action which is very specific for migraine and that is different from the one of other painkillers or preventive drugs.
The treatment is supplied in the form of a pen injection. The injection is subcutaneous and should be done once a month. Several clinical trials demonstrated that Erenumab reduced (for about 3000 migrainous patients), at least of a half the monthly number of days of migraines to 40 to 50 % of the patients. According to these studies 25% of the patients with migraine could become free of crises.
Actually, the drug has almost no side effects. Too good to be true? The dark side of the moon is the high price of the drug (about 600 CHF/month). The Swiss health insurances refund the 90% of the cost of the drug, but it is necessary asking for the authorization for each patient.

Publié dans Headache | Laisser un commentaire

rTMS (repetitive transcranial magnetic stimulation) for major depression disease (MDD)

In our center (www.neurolacote.ch) we perform rTMS of the brain, which is a treatment for major depression.
This technique is able to modulate the electrical brain cortical function by a coil which provides repetitive electromagnetic induction on the skull. Low frequency stimulation (<= 1 Hz) reduces the neuronal excitability, whereas high-frequency stimulation (>= 5Hz) enhances it. The dorso-prefrontal-lateral cortex (DLPFC) of the brain regulates emotional control.
Based on a great number of neuroimaging studies and clinical data (especially for patients with post-stroke depression), the valence hypothesis posits that the DLPFC of the right hemisphere is dominant for processing negative emotions whereas the DLPFC of the left hemisphere elaborates the positive emotions. In patients with major depression the left DLPFC activity is decreased while the right DLPFC function is increased. Thus, rTMS can modify the activity of the DLPFC in patients with major depression (by reducing right DLPFC activity or by increasing left DLPFC excitability).
Several studies indicated that rTMS can lead to long-term and sustained remission of treatment-resistant MDD (as showed by standard depression questionnaires), improving the quality of life and functional status of patients. rTMS is also known to improve the antidepressant effect of psychotherapy commonly prescribed drugs (such as paroxetine or escitalopram). rTMS could be also preformed in pregnant patients. Side effets are mild (generally mild discomfort at the stimulus site of the scalp). Different protocols of rTMS (on outpatient basis) are possible for depression over 2 or 4 weeks.
rTMS is contraindicated in patients with a history of seizures although the incidence rate is relatively low (<0.1%).
The psychiatrist of the patient with MDD should contact us (www.neurolacote.ch ; 0041 22 9959744) to discuss about the rTMS treatment

References
Richieri R. et al. Predictive value of dorso-lateral prefrontal connectivity for rTMS response in treatment-resistant depression: A brain perfusion SPECT study.Brain Stimul. 2018 Sep – Oct;11(5):1093-1097.
Donse L. Simultaneous rTMS and psychotherapy in major depressive disorder: Clinical outcomes and predictors from a large naturalistic study.Brain Stimul. 2018 Mar – Apr;11(2):337-345.
Berlim MT et al. Response, remission and drop-out rates following high-frequency repetitive transcranial magnetic stimulation (rTMS) for treating major depression: a systematic review and meta-analysis of randomized, double-blind and sham-controlled trials. Psychol Med. 2014 Jan;44(2):225-39.
Gaynes BN et al. Repetitive transcranial magnetic stimulation for treatment-resistant depression: a systematic review and meta-analysis. J Clin Psychiatry. 2014 May;75(5):477-89.
Kaster TS et al. Efficacy, tolerability, and cognitive effects of deep transcranial magnetic stimulation for late-life depression: a prospective randomized controlled trial. Neuropsychopharmacology. 2018 Jun 18.
Felipe RM et al.Transcranial magnetic stimulation for treatment of major depression during pregnancy: a review.
Trends Psychiatry Psychother. 2016 Oct-Dec;38(4):190-197.

Publié dans Psychiatry, rTMS | Laisser un commentaire

Do not forget the visual evoked potentials (PEV)


A flash of light, which is projected on the retina, produces an electrical response on the visual cortex of the occipital lobe, a phenomenon known since a century. A chessboard that reverses its white and black pattern also produces a cortical response that is measurable (visual evoked potentials or PEV). The PEV are performed with the patient sitting 70-100 cm in front of a screen with a visual angle of 30 seconds of arc; the chessboard changes the color pattern at a frequency of 1-2 Hz (every 500 milliseconds) and 200 responses are recorded for each eye by electrodes applied to the occipital region of the scalp. The examination consists of stimulating one eye at a time (after measuring the visual acuity) and can show if there is a delay of the nerve conduction (from the retina up to the occipital lobe, through the optic nerve , the optic chiasma, the lateral geniculate body and the optical radiations up to the area 17 of the visual cortex). This examination is particularly useful for identifying a pathology of the optic nerve even when the visual function is good, and there is no evidence of abnormalities of the ocular fundus or the visual fields. The examination is therefore needed for detecting demyelinating lesions in case of multiple sclerosis when the diagnosis is uncertain. In this case there is a delay of the P100 wave. The PEV would be useful for investigating all the optic neuritis (toxic causes, ischemic neuropathy, hereditary Leber neuropathy) and also for glaucoma in search of a concomitant impairment of the optic nerve. The normality of the PEV suggests, in the case of blindness, a psychogenic origin.
Although MRI examination can easily demonstrate the existence of lesions on the visual pathways, the PEVs are still a very useful test for measuring the optic nerve function and should be used to monitor the evolution of the optic neuritis. We perform the PEV in our neurology center (http://www.neurolacote.ch). The examen is refunded by the health insurance.

Publié dans Uncategorized | Laisser un commentaire

The mystery of moving toes without or with pain

This rare syndrome is still a mystery. Suddenly, the toes of one or both feet begin to move continuously. Different types of movements are described.
The movements are often irregular and consist of flexion / extension, adduction / abduction, spacing or circular toe movements with sustained contraction from time to time . The patient can interrupt only for a short period of time these movements with a voluntary movement of the foot and toes. The toes do not move during the sleep.
The moving toes are often preceded or accompanied by disabling pain (legs and feet). Hence, the name of the syndrome  » painful legs and moving toes ». This syndrome was first described in the 70’s’. In some cases the syndrome is related to pathologies of the peripheral nerves (polyneuropathy, herniated disc) or spine disease (attached spinal cord syndrome, myelitis). A few cases have been associated with Parkinson’s disease or neuroleptic treatment, chemotherapy, brain tumors, stroke, Wilson’s disease, trauma and thyroid disease.
Most of the time, any cause is detected. The idiopathic form (without apparent causes) affects usually women around the age of 50.
The origin of this syndrome is among the many mysteries of neurology. Is this the resurgence of ancient movements in phylogenesis (type fishes’ fins and gills)?
The evolution can be in the sense of spontaneous remission, stability or progression. Pharmacological treatments (antiepileptics) are partially effective. Treatment with Botox infiltrations can be considered.

Publié dans Neurologic mysteries, Pain syndromes, Peripheral Nervous System, Uncategorized | Laisser un commentaire

The locomotive syndrome

This syndrome was first described in 2007 by the Japanese Orthopedic Association in order to define a new concept causing gait disorders in a considerable number of very elderly patients. This is the locomotive that doesn’t pushes the train forward. The neurologist often meets these patients.
The locomotive syndrome is the consequence of pathologies on 3 levels: bone (osteoporosis), articulations and vertebral discs (spondylosis and spondyloarthritis at the cervical and lumbar level, shoulders, hips and knee arthritis), muscles and peripheral nerves. Finally the locomotive syndrome brings together several pathologies that are related to each other. The symptoms are pain, limitation of mobility, difficulties of balance and walking.
The consequence of this syndrome is a decrease of the functional autonomy for the activities of daily living, a decrease in social life and quality of life. There is a 25-item questionnaire (Geriatric Locomotive Function Scale – GLFS-25) that can help to establish the diagnosis. Other measures can be used to better define the functional state such as the handgrip strength, the on one leg time standing, and the 6 m walking time The syndrome is common for elderly patients. While the term « frailty syndrome » is intended in case several organs are typo-functioning (cognition dysfunction is included), the term locomotive syndrome applies to multiple inter related musculoskeletal problems.
Osteoporosis is an important component of the locomotive syndrome and its prevention is fundamental. Finally, to prevent the locomotive syndrome of the geriatric age, the most important thing to do is to let patients moving. Favor mobility by all means. Assessment and treatments are provided by a multidisciplinary team. Thus, do not forget the neurologist.

Publié dans Neurorehabilitation | Laisser un commentaire

Migraine and sleep

We know, as neurologists, that there is an association between migraine and poor sleep. Sleeping poorly (non-restorative sleep, insomnia) increases migraine attacks and worsens comorbidities (depression and anxiety).
It is known that the brain of the patients with migraine is more sensitive to environmental stimuli (only one example: the light) and that their visceral-vegetative system is more active. There is scientific evidence that migraine patients need more sleep than others. Poor sleep decreases the pain tolerance of migraine sufferers, but also of patients with tension headache.
On the other hand, improving sleep can turn a chronic migraine into an episodic one.
Sleeping pills may be helpful initially, but it is not a valid long-term solution for migraine.
Some tips for migraine sufferers to improve sleep:
⁃ Behavioral cognitive therapy targeted at sleep, especially in cases of depression or anxiety
⁃ No coffee after 1 pm
⁃ No alcohol at night
⁃ No exercising in the 5 hours before bedtime
⁃ Shower (not too hot) before bedtime
⁃ No fluids within 2 hours before bedtime
⁃ Interval of at least 4 hours between dinner and bedtime
⁃ No lights in the bedroom during the night
⁃ The alarm clock must not be visible (turn it)
⁃ Switch-off smartphones and tablets
⁃ No television in bed
⁃ The bed is only for sleeping (or for couple intimacy)
⁃ Listen, if necessary, to music that facilitates sleep (reiki, Marconi Union https://www.youtube.com/watch?v=vm_h0VWj2dk…), without words
⁃ Go to bed when you know you could fall asleep in 20 minutes
⁃ To sleep at least 8 hours every day included weekend (to avoid the migraine of the weekend)
⁃ Get up every day at the same time (to avoid the migraine of the weekend)
⁃ Do not nap during the day

Do you have other tips? Please share with us your experiences.

Publié dans Headache, Sleep, Uncategorized | Laisser un commentaire

Misidentification syndromes at the interface of neurology and psychiatry

As neurologists, sometimes we deal with special « delusions ».
Misidentification syndromes are rare neurologic conditions in which the patient attributes a wrong identity (a sort of hypo-identification) to people (Capgras syndrome or doubles’ illusion), to places (reduplicative amnesia), or believes that the physical appearance of a person changed into that of another (Fregoli syndrome), this last condition corresponds to a sort of hyper-identification. A parallelism can be traced between the Capgras syndrome and somatoparaphrenia (a right hemisphere syndrome). The patient with somatoparaphrenia believes that his or her paralyzed left arm belongs to another person.
The patient with the Capgras syndrome believes that his spouse has been replaced by another person or an alien. So, even if her physical aspect is the usual, inside there is an impostor.
Despite all plausible evidence, there is no way to persuade him that he is wrong. This situation well reminds the 1957 American science fiction horror movie « the invasion of the body snatchers », a cornerstone of extraterrestrial invasions in movies. The patient does not understand that no-one believes him on the false identities of people.
The patient with reduplicative amnesia believes that his house, despite a normal aspect, has been replaced by another location.
More types of misidentification can coexist in the same patient.
All these conditions are at the interface between neurology and psychiatry as they can manifest either with neurologic disease (stroke, subdural hematoma, Alzheimer’s disease, Lewy-body disease, drug intoxication, brain trauma, Parkinson’s disease, Fahr’ disease, levodopa-induced psychosis, epilepsy) or psychiatric disease without brain lesions (such as paranoia, schizophrenia, mania, and dissociative disorders).
Capgras syndrome and reduplicative amnesia manifest after frontal parietal, occipito-parietal, and thalamic lesions. The neural mechanisms underlying the dissociation between appearance and identity of the bodies remain speculative. However, it points to the existence of different cognitive and emotional networks for recognition (or memory) of faces and bodi, networks having different neural substrates or hemispheric dominance.
If you think that your spouse has been replaced by an alien or that your house is another place consult us as something could be wrong in specific regions of your brain.

Publié dans Cognition and Behavior, Lewy Body Disease, Parkinson Disease, Psychiatry | Laisser un commentaire

Fibromyalgia and repetitive transcranial magnetic stimulation (rTMS)

We provide in our centre brain neruomodulation with rTMS in order to treat patients with fibromyalgia. Fibromyalgia is a very common chronic painful musculoskeletal condition affecting about 1-3% of the population world wide. Main clinical features are widespread muscular pain and tenderness, commonly associated with fatigue, sleep disturbances, memory and attention deficits and mood disorders (anxiety and depression). Diagnosis is made according to the American College of Rheumatology criteria (Wolfe et al. 2010 and 2016). A rheumatologist should provide the diagnosis.
The aetiology of the disorder is unknown and there is no a definite cure. Pharmacological interventions (anticonvulsants, antidepressants, AINS and opioid-like substances) have limited efficacy and often side effects. Psychotherapies and physiotherapy have partial success.
Several experimental studies on fibromyalgia suggested the key role of chemical, structural and physiological changes of the central nervous system for pain maintenance. An increased neuronal excitability is installed in brain areas processing physical, emotional and cognitive attributes of pain, probably mediated by glutamate activity on the NMDA receptors.
Repetitive transcranial magnetic stimulation (rTMS) is a safe and non-invasive procedure that uses a magnetic field to modulate the activity of cortical brain areas and their networks and to reduce glutamate activity.
Contraindications for TMS are epilepsy or history of seizure, pacemakers and other implantable medical devices, serious head injury, pregnancy. rTMS treatment can be easily performed on outpatients.
Even if there are only weak recommendations provided by meta-analytic studies and further clinical research is needed, several studies demonstrated the effectiveness of rTMS excitatory modulation on the fronto-dorso-lateral cortex over several weeks. There is expected a minimum 30% of pain improvement and a similar significant chance of fatigue reduction and improvement in sleep and quality of life.

REFERENCES

Fitzgibbon BM et al. Evidence for the improvement of fatigue in fibromyalgia: a 4-week left dorsolateral prefrontal cortex repetitive magnetic stimulation randomized-controlled trial. Eur J Pain 2018 (epub ahead of print).

Hou WH et al. The effects of add-on non-invasive brain stimulation in fibromyalgia : a meta-analysis and meta-regression of randomized controlled trial. Rheumatology (Oxford)2016.55(8):1507-17.

Boyer L. et al. rTMS in fibromyalgia: a randomized trial evaluating QoL and its brain metabolic substrate. Neurology 2014.82(14):1231-8.

Lee SJ et al. The effect of repetitive transcranial magnetic stimulation on fibromyalgia: a randomized sham-controlled trial with 1-mo follow-up. Am J Phys Med Rehabil 2012.91(12): 1077-85.

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