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Psychosis is a common and often debilitating non-motor symptom of Parkinson’s disease (PD). It typically manifests in the form of well-formed visual hallucinations and minor hallucinations, and, at times, can present with delusions and nonvisual hallucinations. Psychosis is associated with many adverse outcomes in PD, and for that reason, it is essential to recognize and treat the symptoms early. The objective of this review article is to highlight the phenomenology, diagnosis, and pathophysiology of PD-associated psychosis (PD-P) and discuss a step-by-step approach to its management. One of the critical steps in managing PD-P is the identification of potential non-PD causes of psychosis, which often require conservative measures. If no secondary causes are identified, pharmacotherapy should be considered. Role of several drugs including pimavanserin (the only FDA-approved agent for the treatment of PD-P), atypical antipsychotics such as quetiapine and clozapine, and cholinesterase inhibitors such as rivastigmine and donepezil are discussed in this review. In addition, we also highlight the potential role of noninvasive brain stimulation (electroconvulsive therapy and transcranial magnetic stimulation) for the treatment of medication-refractory psychosis.

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Spinocerebellar ataxia type 12 (SCA12) is a progressive neurological disorder with a unique prevalence in North Indian population. Trinucleotide CAG repeat expansion beyond certain threshold (>43 repeats) in the upstream region of PPP2R2B gene is associated with cerebello-cortical atrophy in disease affected individuals. Patients with SCA12 predominantly manifest unique distinguishable feature of early slow and progressive action tremor in upper extremities followed by other variable symptoms such as mild to moderate gait ataxia, speech disturbances with tremulous voice, head tremor, and autonomic abnormalities. At present, there is no definite treatment available to cure this disease and the underlying disease mechanism at molecular level largely remains undetermined. This review focuses on epidemiology, clinico-genetic advancements, and therapeutics interventions emerged over the time in this field.

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BACKGROUND: Gait instability is one of the disabling clinical features of majority of patients suffering from Parkinson’s disease (PD). It is partially responsive to dopamine replacement therapy. Precise evaluation of distinct l-DOPA-sensitive and l-DOPA-resistant gait profiles might help in planning therapy of PD patients with gait disorder.METHOD: In this cross-sectional analytical study, we measured the gait parameters of 70 patients and 37 healthy participants using a 6.1-m long electronic walkway containing thousands of pressure sensors embedded in a carpet. The patients were evaluated in their OFF and ON phases of l-DOPA medication, and the data were compared with age- and gender-matched healthy controls.RESULTS: Except for the cadence, most gait parameters including velocity, stride length, and step length were deranged in PD patients. The mean velocity was significantly higher among healthy volunteers (99.19cm/s) compared to PD patients (73.90cm/s, P value 0.0001). However, the mean cadence was comparable between healthy and patient groups (103.29 vs. 103.39, P value 0.966). Certain temporal parameters (cadence, cycle time, and swing time) were nonresponsive to the dopaminergic therapy.CONCLUSION: On the basis of the findings, we propose that l-DOPA treatment improves most of the spatiotemporal gait parameters but cannot completely eliminate the risk of fall.

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A scale is critical for an objective and standardized process in which the purpose involves measuring differences between various individuals and determining priorities such as primary treatment goals. The aim of this study was to describe and analyze the most common Parkinson’s disease (PD) scales already used for research and clinical practice. We searched three databases in an attempt to locate existing scales about PD published until 2017 in electronic form, only the articles in English, Spanish, and Portuguese were reviewed. In sum, 114 scales were evaluated and divided into 6 types representing a general evaluation, such as staging, health-related quality of life, evaluation of the impact on activities of daily living, loss of functionality aimed at evaluation of the signs and symptoms of the disease, evaluation of functioning and disability loss, and other specific evaluations. Other specific evaluations include the following: fear of falling, depression, psychosis, sleep, apathy and anhedonia, anxiety, dysautonomia, dyskinesia, fatigue, motor fluctuations, psychosocial problems, secondary levodopa effects, Scales for Outcomes in Parkinson’s disease (SCOPA) studies, and cognitive impairment screening. When required, more specific characteristics of each scale were included: time to apply, the number of items, advantage, and disadvantage. In the literature, there are a large number of scales, but the majority of them were created for other diseases and only later studied for PD. Also, more than half have only a small number of studies with psychometric evaluation and others can be used for only a specific portion of the general population due to their specific feature assessment or language availability.

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Bupropion (BPP) was originally an antidepressant, but now it is also used for seasonal affective disorder and smoking cessation. The aim of this systematic review was to evaluate the clinical epidemiological profile, pathological mechanisms, and management of BPP-associated movement disorders. Relevant reports in six databases were identified and assessed by two reviewers without language restriction. A total of 63 reports of 710 cases from 16 countries were assessed. The movement disorders associated with BPP found clearly defined were: dyskinesia (8), dystonia (7), parkinsonism (7), myoclonus (6), tic (6), stuttering (3), rapid eye movement sleep disorders (2), and ballism (1); the not clearly defined cases included 488 tremors, 80 slurred speech, 48 ataxia, 20 abnormal movements, 19 falls, 4 akathisia, 3 dyskinesia, 2 hyperkinesia, 2 poor coordination, and the rest was only reported once (dystonia, myoclonus, motor tic, and rigidity). The mean age was 46 years (7–85 years). The male was predominant sex (52.77%). The mean BPP dose was 248.38 mg, and the most common indication was a major depressive disorder (73.68%). The average time of onset was 3.47 weeks and of recovery was 2.71 weeks. The most common management was BPP withdrawal. In the literature, the majority of the cases did not clearly report the clinical neurological examination and lacked electrodiagnostic studies. Future studies about adverse effects with BPP should describe at least the clinical characteristics and the physical exam of the individuals, especially when fall and slurred speech are observed.

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Syphilis is a well-known “great simulator/mimicker” of other diseases. Over the last decades, the clinical features of neurosyphilis have changed with an increasing percentage of atypical manifestations. In this context, movement disorders caused by neurosyphilis are rare and challenging to diagnose. This literature review aimed to evaluate the clinical epidemiological profile, pathological mechanisms, and historical features of neurosyphilis-associated movement disorders. Relevant reports in six databases were identified and assessed by two reviewers without language restriction. A total of 84 reports containing 168 cases who developed a movement disorder related to neurosyphilis were reported. The mean and the median reported ages were 40.50 (standard deviation [SD], 20.30) and 43 years (2.5–72.5 years). The predominant sex was male (79.16%). Argyll Robertson pupils were found in 54.90% of the individuals. The movement disorders reported were tremor, chorea, parkinsonism, ataxia, myoclonus, dystonia, athetosis, and ballism. In the literature, we have a large number of reports about movement disorder associated with neurosyphilis. But, in the majority of them, the individuals had the syphilitic diagnosis based on unspecific methods, electrodiagnostic studies were not performed, or penicillin therapy was unavailable. Also, we believe that any patient presenting with a movement disorder should have a thorough neurological examination of pupillary reflex, and if any abnormality is present, syphilitic laboratorial tests should be done.

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Hashimoto’s encephalopathy (HE) commonly presents with two types of neurological presentation: recurrent stroke-like episodes or seizures and progressive cognitive decline. Being a treatable disorder, one cannot afford to miss the diagnosis. We report a female with HE who presented with a history of recurrent episodes of catatonia, recovering completely with steroids. The diagnosis of the primary disease got delayed for 5 months. HE presenting as catatonia has been reported rarely. A high degree of suspicion in appropriate clinical settings, resulting in early diagnosis, is rewarding as HE usually show good response to corticosteroids.

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INTRODUCTION: Ataxia telangiectasia (AT) is an autosomal-recessive disease, characterized by progressive cerebellar degeneration, mucocutaneous telangiectasia, immunodeficiency, recurrent sinopulmonary infections, sensitivity to radiation, and increased risk of malignancy. The objective of this study was to report the clinical profile of a large cohort of patients with AT seen in a tertiary care referral center. METHODS: This study was a chart review of 100 patients with AT seen by the department of neurology at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India, which is a tertiary care referral center. Detailed demographic, clinical, laboratory, and electrophysiological data were collected from the case records. RESULTS: The mean age of presentation was 9.04 ± 3.52 years. Females (n = 40) had earlier age of presentation (8.87 ± 3.09 years) when compared to males (9.15 ± 3.80 years). The mean age for onset of illness was 3.9 ± 2.84 years, and the mean duration of illness was 4.81 ± 3.30 years. A positive family history was obtained in 20% and consanguinity in 60%. Oculomotor abnormalities included impaired pursuit and slow saccades in 60%, oculomotor apraxia in 84%, and nystagmus in 23%. All the patients had cerebellar ataxia. Extrapyramidal features such as dystonia, choreoathetosis, tremors, and myoclonus were observed in 31% of patients. CONCLUSION: Progressive cerebellar ataxia and telangiectasias were the consistent findings observed in all our patients. Dystonia and chorea were the other extrapyramidal features observed. Owing to increased risk of malignancies, screening should be an integral part of management.

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Parkinson’s disease is a common progressive neurodegenerative disease. Apart from pharmacological treatment, nonpharmacological management in the form of rehabilitation, counselling, and supportive care is an equally important therapeutic pillar. A MEDLINE search strategy using the following terms (1998–2019) was adopted for this review. Limits of “Human” and “English” were applied. Search terms included “Parkinson’s Disease” AND “rehabilitation,” “physical therapy,” “exercise therapy,” “physiotherapy,” and “dance.” Review articles, practice parameters, guidelines, systematic reviews, meta-analyses, randomized controlled trials, and cohort studies were included. Rehabilitation strategies in the management of Parkinson’s disease form a vital component of therapy. There is mounting evidence to support physical therapy in these patients. Rehabilitation should be offered to these patients right from the start to encourage an active lifestyle and to improve quality of life.

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DRPLA (dentatorubral–pallidoluysian atrophy) is a neurodegenerative disorder caused by cytosine-adenine-guanine (CAG) trinucleotide repeat expansion (>48) in ATN1 gene at 12p13.31 locus inherited in an autosomal-dominant manner. The key clinical manifestations of DRPLA are ataxia, dementia, and myoclonic epilepsy and have variable association with intellectual disability, behavioral changes, epileptic seizures, and choreoathetosis. It is most commonly reported in Japanese population with a prevalence of 0.2–0.7/100,000. Here we report a three-generation first Indian family identified to carry a pathogenic CAG expansion in ATN1 and clinical features conformed to its key manifestations.

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Hypoglycemia is associated with adrenergic and various neurological symptoms including hemiparesis. Though not common, movement disorders such as chorea and ballism have been reported in hypoglycemia. This case was of an elderly lady, a known diabetic, who developed two episodes of hemiparesis and single episode of jerky head movement with preserved sensorium lasting for few seconds, associated with hypoglycemia on different occasions, 1 week after increasing the dosage of oral hypoglycemic agent with complete recovery each time with correction of sugar levels. Magnetic resonance imaging showed transient bilateral diffusion restriction in posterior limb of internal capsule.

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Type III GM1 gangliosidosis is the adult or chronic variant of a lysosomal storage disorder, which occurs secondary to deficiency of β-galactosidase. The wishbone pattern of iron deposition which involves the medial and latter parts of the globus pallidus is pathognomonic of this disease. The diagnosis of type III GM1 gangliosidosis should be considered in patient with young onset, progressive generalized dystonia with prominent facial dystonia, and a wishbone pattern of iron deposition.

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BACKGROUND: Non-motor symptoms (NMSs) were a real burden in Parkinson’s disease (PD) and contributed to severe disability, impaired quality of life (QoL), and shortened life expectancy. AIM: The aim of this study was to investigate the prevalence of NMSs in PD and their correlation of NMS with disease duration, severity, and Unified Parkinson's Disease Rating Scale (UPDRS) motor score and their impact on patient’s QoL. MATERIALS AND METHODS: This was a prospective cross-sectional study. Sixty-four patients who were diagnosed by United Kingdom Parkinson's Disease Brain Bank criteria were studied. Non-motor symptom scale (NMSS) analyzed NMS, and motor dysfunction was assessed by the UPDRS II and III during OFF condition and QoL by Parkinson’s Disease Questionnaire-39 (PDQ-39) questionnaire. RESULTS: The prevalence of NMS was 93.75% (n = 60). Most frequent NMS was difficulty in falling asleep (54.7%), urinary urgency (39%), and memory impairment (37.5%). Most disabling symptoms are difficulty in falling asleep (3.34 ± 4.1) and fatigue (2.48 ± 4.2). The total NMSS scores were correlated with Hoehn and Yahr stage, and Movement Disorder Society UPDRS and PDQ-39 scores, but not with duration of disease. Correlation between NMSS and PDQ-39 scores was stronger as compared to the relationship between UPDRS and PDQ-39 scores (r = 0.71 and 0.58, respectively, P = 0.00). CONCLUSION: This study showed the high prevalence of NMSs and value of NMS as predictors of QoL in patients with PD. Therefore, understanding the pathophysiology of these NMSs should be placed at the forefront to develop new therapeutic approaches by improving the QoL of patients with PD.

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OBJECTIVES: To compare the sleep profiles of genetically proven cases of Huntington’s disease (HD) with healthy controls and to correlate the results of various sleep-related parameters with disease severity, duration, and length of cytosine–adenine–guanosine repeats.METHODS: This prospective study was conducted at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India, which included 31 genetically confirmed patients with HD and 50 controls. All the subjects were evaluated for sleep disturbances using standardized sleep questionnaires (Pittsburgh Sleep Quality Index [PSQI] and Epworth Sleepiness Scale [ESS]).RESULTS: The mean age of the patients during the first consultation was 46.0±12.7 years (range: 28–80). The mean age at onset of symptoms was 40.5±13.8 years. Nineteen patients (61.2%) gave history of sleep disturbances. Symptom suggestive of rapid eye movement sleep behavior disorder was present in 8 patients (25.8%). Difficulty in falling asleep was the most common sleep-related disturbance reported by 16 patients (51.6%). The mean ESS score of the patients was 6.22±2.89 and that of the control population was 3.00±2.8 (P value < 0.001). The mean PSQI score of the patients was 8.90±3.50 and that of the control population was 3.3±2.9 (P value < 0.001).CONCLUSIONS: This study demonstrates sleep disturbances in patients with HD compared to healthy controls and the sleep disturbances correlated significantly with the disease duration, severity, and coexistent anxiety and depression.

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Objective: The aim was to assess the opinion of the movement disorder society of India members regarding the uses of botulinum toxin in clinical practice. Methods: We developed an online questionnaire covering different aspects of botulinum toxin uses. The questionnaire was sent by email to all members of the movement disorder society of India. Results: A total of 50 members completed the survey (20%) representing different regions of the country. The average doses of botulinum toxin conform to those mentioned in the literature. Only type A botulinum toxin is available in India. Electromyography was used by 72% of the respondents, however, only 12% of respondents used ultrasonography for muscle localization during botulinum toxin injection. 72% of respondents were using an assessment scale for different types of movement disorders. 76% of the respondents reported adverse effects in their clinical practice, with weakness (69.11%) being the most common. 56% of the respondents reported challenges during the injections with the cost of botulinum toxin being the most common (36%) followed by difficulty in localization of muscles (30%). Conclusion: Our results seem to show that in India, the routine use of botulinum toxin in clinics is far from standardized. Low uses of USG, difficulty in muscle localization and cost of the toxin were important limitations highlighted by the respondents.

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Movement disorders following stroke is a well known phenomena both during acute stage as well as in later phases. The type of movement depends on the site of involvement, it is however not uncommon to have more than one type of movement disorder following a stroke. We present a patient with combined dystonia and asterixis following a unilateral thalamic infarct, whose dystonia persisted on follow up while the asterixis faded away with time.

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Mirtazapine (MTZ) is an atypical antidepressant frequently prescribed for the management of major depressive disorder. It has multiple mechanisms of action, which probably contribute to the several side effects encountered with this medication. Hyperkinetic movement disorders induced by MTZ have been rarely reported in the literature. To the best of authors’ knowledge, there are five cases of dystonia (DTN) secondary to MTZ use, but this study reports the youngest individual in a nonpsychiatric MTZ indication. We report a case of an adult woman who presented with axial and cervical DTN-type laterocollis after 5 days of MTZ use, which was indicated for hot flashes. A comprehensive review of the cases and a mechanism assumption are performed.

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The objective of this paper was to report on a case of steroid-responsive chorea in a patient with κ light-chain monoclonal gammopathy. In addition to subacute-onset generalized chorea, evidence of peripheral neuropathy in this elderly gentleman led us to investigate for paraproteinemia. We treated the patient with intravenous steroids in view of elevated κ light-chain assay and bone marrow biopsy, suggestive of monoclonal gammopathy of undetermined significance. There was a remarkable improvement of paresthesias and chorea at 6 months follow-up with no evidence of evolution to malignancy at 1 year. Autoimmune chorea is a treatable condition if identified and treated timely.

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AIM: Premotor phase in Parkinson’s disease (PD) begins many years before the onset of motor symptoms. Despite advancement in the understanding of this common neurodegenerative disease, clinical diagnosis is still the gold standard. Various fluid- and tissue-based biomarkers have been postulated to play a role in the pathogenesis of PD. We aimed to study the role of serum DJ-1 and apolipoprotein A1 (Apo A1) in PD. SETTINGS AND DESIGN: A cross-sectional observational study was conducted in the Department of Neurology, in collaboration with the Department of Pharmacology. Cases of PD and healthy controls were recruited over 1 year with written informed consent from all the participants. The study was approved by the institutional ethics committee. SUBJECTS AND METHODS: All cases underwent detailed neurological examination, Hoehn and Yahr staging, and MDS-UPDRS (MDS-UPDRS (Movement Disorders Society–Unified Parkinson Disease Rating Scale) scoring. Serum of all the cases and controls were collected for the estimation of DJ-1 and Apo A1 by enzyme-linked immunosorbent assay. STATISTICAL ANALYSIS: Serum DJ-1 and Apo A1 levels were compared between cases and controls using Mann–Whitney test. Correlation of characteristics was carried out using Spearman correlation coefficient. RESULTS: The study cohort included 77 cases of PD and 69 healthy controls. Serum DJ-1 and Apo A1 levels were found to be significantly lower in cases compared to controls (P < 0.001). However, no correlation was found with age of onset, duration of disease, and severity of illness. A negative correlation was observed between DJ-1 levels and cognitive impairment and bladder dysfunction. CONCLUSION: Low levels of DJ-1 and Apo A1 are found in patients with PD of Indian origin. However, correlation of these biomarkers with progression and severity is needed to be explored in future randomized controlled trials with a large sample size.

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BACKGROUND: There is an emerging role of various non-pharmacological strategies in the management of motor and non-motor symptoms of Parkinson’s disease (PD). OBJECTIVE: The aim of the study was to examine the effectiveness of Tai chi and Qigong on cognitive and motor functions, emotions, and quality of life in patients with PD. SUBJECTS AND METHODS: Seven subjects with mean age of 50.2 years, education of 11.71 years, and duration of PD of 6.03 years underwent four-week training of Qigong and Tai chi. They received one session per week under supervision and daily two 45-min practice sessions at home following instructions from the manual. Participants were assessed before and after intervention on neuropsychological tests, Unified Parkinson’s Disease Rating Scale (motor section), Hamilton Anxiety Rating Scale (HAM-A), Hamilton Depression Rating Scale (HAM-D), Epworth Sleepiness Scale (ESS), and Parkinson’s Disease Questionnaire (PDQ-39). RESULTS: There was a significant improvement in executive functions, verbal memory, and reduced scores on clinical scales (UPDRS III, HAM-A, PDQ-39). CONCLUSION: Combined practice of Tai chi and Qigong improves motor and non-motor symptoms of PD. However, well-designed randomized controlled trials and longitudinal studies are required to understand its full potential.

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Gene therapy has proven its potential in treatment of several human diseases. Most recent method in a long line of genome-editing techniques is Clustered Regularly Interspaced Short Palindromic Repeat (CRISPR)/CRISPR-associated protein 9 (Cas9) system. This CRISPR–Cas9 technology uses a ribonucleic acid (RNA)-guided deoxyribonucleic acid (DNA) endonuclease, Cas9, which induces double-strand breaks (DSBs) in target site. These DSBs are repaired by various cellular DNA repair mechanisms leading to changes in target sites. This revolutionary technique has unraveled several mysteries not only in pathogenesis of several human diseases but also proved its high potential in developing disease models ranging from cell lines to large animals. The number of neurodegenerative disorders linked with mutations has been increasing every day. Several such monogenic disorders provide opportunities for gene therapy using CRISPR–Cas9 method. Translational gap toward developing highly precise and personalized medicine for several neurodegenerative disorders has been reduced by CRISPR–Cas9 technology. Recent advancements in this technique have reduced the adverse effects on targets also. In this review, we have summarized recent achievements of CRISPR–Cas9 technology in common neurological disorders aiming clinicians to understand the technology.

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Mirror movements are involuntary movements that accompany the voluntary movement of the contralateral homologous body part. Etiologically, these movements could be broadly divided into two main groups: congenital and acquired mirror movements. The pathogenesis of mirror movements is different in both these groups. Minor physiological mirroring is seen in normal healthy individuals and can occur during normal childhood development, whereas apparent mirroring in adults can be present in many movement disorders. Interestingly in these neurological disorders, mirror movements are seen in a particular limb at a particular time course of the disease. This may help in making an early diagnosis and could help in the differentiation between the various movement disorders. The coordinative behavior of the central nervous system is an inherent need for an adult to work with both hands, interruption of which makes a person unable to do the coordinated task with hands. Examination of mirror movements also contributes to our understanding of movement disorders, their clinical clues, and associated pathophysiology.

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