The Editors have – together with the Scientific Committee – decided that new guideline papers will be presented in the Forum of NEUROPENEWS. In the January issue of the European Journal of Neurology the EFNS/MDS-ES/ENS Recommendations for the Diagnosis of Parkinson’s disease and the Summary of the recommendations of the EFNS/MDS-ES review on therapeutic management of Parkinson’s disease on behalf of the EFNS/MDS-ES Scientist Panel on Movement disorders are published, and we highlight these important articles by offering you the abstracts. We also asked the corresponding author, Alfredo Berardelli, for a short statement. The article EFNS/MDS-ES/ENS Recommendations for the Diagnosis of Parkinson’s disease is also available for CME on the EFNS website for registered users.
EFNS/MDS-ES/ENS recommendations for the diagnosis of Parkinson’s Disease:
A Task Force was convened by the EFNS/MDS-ES/ENS Scientist Panel on Parkinson’s disease and other Movement Disorders to systemically review relevant publications on the diagnosis of Parkinson`s disease (PD). Following the EFNS instruction for the preparation of neurological diagnostic guidelines, recommendation levels have been generated for diagnostic criteria and investigations. For the clinical diagnosis, we recommend the use of the Queen Square Brain Bank criteria (level B). Genetic testing for specific mutations is recommended on an individual basis (level B), taking into account specific features (i.e. family history and age of onset). We recommend olfactory testing to differentiate PD from other parkinsonian disorders including recessive forms (Level A). Screening for pre-motor PD with olfactory testing requires additional tests due to limited specificity. Drug challenge tests are not recommended for the diagnosis in de novo parkinsonian patients. There is an insufficient evidence to support their role in the differential diagnosis between PD and other parkinsonian syndromes. We recommend an assessment of cognition and a screening for RBD, psychotic manifestations and severe depression in the initial evaluation of suspected PD cases (Level A). Transcranial sonography (TCS) is recommended for the differentiation of PD from atypical and secondary parkinsonian disorders (Level A), for the early diagnosis of PD, and in the detection of subjects at risk for PD (Level A), although the technique is so far not universally used and requires some expertise. Because specificity of TCS for the development of PD is limited, TCS should be used in conjunction with other screening tests. Conventional MRT and DWI at 1.5T are recommended as neuroimaging tools that can support a diagnosis of MSA or PSP versus PD on the basis of regional atrophy and signal change as well as diffusivity patterns (Level A). DAT Scan SPECT is registered in Europe and US for the differential diagnosis between degenerative parkinsonisms and essential tremor (Level A). More specifically DATSCAN is indicated in presence of significant diagnostic uncertainty such as parkinsonism associated with neuroleptic exposure and atypical tremor manifestations such as isolated unilateral postural tremor. Studies of [123I]MIBG/SPECT cardiac uptake may be used to identify PD patients vs. controls and MSA patients (Level A). All other SPECT imaging studies do not fulfill registration standards and cannot be recommended for routine clinical use. At present, no conclusion can be drawn as to diagnostic efficacy of autonomic function tests (AFTs), neurophysiological tests and PET imaging in PD.
A. Berardelli, G. Wenning, A. Antonini, D. Berg, B. R. Bloem, V. Bonifati, D. Brooks, D. Burn, C. Colosimo, A. Fanciulli, J. Ferreira, T. Gasser, F. Grandas, P. Kanovsky, V. Kostic, J. Kulisevsky, W. Oertel, W. Poewe, J.-P. Reese, M. Relja, E. Ruzicka, A. Schapira, A. Schrag, K. Seppi, P. Taba and M. Vidailhet; European Journal of Neurology, Vol. 20, Issue 1, pages 16-34, January 2013
Introduction by Alfredo Berardelli and Carlo Colosimo:
The idea of having new European recommendations on Parkinson’s disease (PD) came mainly from the observation that the diagnosis of PD is still based on the UK Brain Bank diagnostic criteria, which were a milestone in this field but are dating back to 1988 and did not include most of the recent technological advances in the field.
A Task Force was convened by the EFNS/Movement Disorder Society-European Section Scientist Panel on PD and other movement disorders to systemically review relevant publications on the diagnosis of PD. The main conclusion coming from the panel of 26 experts is that , while the core clinical criteria for identifying a subject with a parkinsonian disorder should still remain those proposed by Gibb and Lees 25 years ago, there is a need to add complementary investigations in order to increase the sensitivity and specificity of the clinical judgment. When and which tests are needed in a single case depends on the clinical answer we are looking for (is this a case of true parkinsonism or something else? If yes, are we dealing with the common PD or with a secondary case? Or could it be an atypical case?).
Interestingly, some of these laboratory tests (e.g smell tests, SPECT with dopamine transporter tracers [DaTscan], transcranial sonography of the midbrain) can be effectively used in the attempt to identify people in the preclinical phase of the disease. As a matter of fact some of these investigations have already been used in ongoing population studies in Europe and North America, showing preliminary satisfactory results as possible screening tools.
Summary of the recommendations of the EFNS/MDS-ES review on therapeutic management of Parkinson’s disease:
Objective: To summarise the 2010 EFNS/MDS-ES evidence-based treatment recommendations for the management of Parkinson’s disease (PD). This summary includes the treatment recommendations for early and late PD.
Methods: For the 2010 publication, a literature search was undertaken for articles published up to September 2009. For this summary an additional literature search was taken on upto December 2010. Classification of scientific evidence and the rating of recommendations were made according to the EFNS guidance. In cases where there was insufficient scientific evidence, a consensus statement (‘good practice point’) was made.
Results: For each clinical indication, a list of therapeutic interventions is provided, including classification of evidence.
J. Ferreira, R. Katzenschlager, B. R. Bloem, U. Bonuccelli, D. Burn, G. Deuschl, E. Dietrichs, G. Fabbrini, A. Friedman, P. Kanovsky, V. Kostic, A. Nieuwboer, P. Odin, W. Poewe, O. Rascol, C. Sampaio, M. Schüpbach, E. Tolosa, C. Trenkwalder, A. Schapira, A. Berardelli and W. Oertel; European Journal of Neurology, Vol. 20, Issue 1, pages 5-15, January 2013
Introduction by Alfredo Berardelli and Giovanni Fabbrini:
A neurologist needs to take several important decisions when treating patients with Parkinson’s disease. Common problems include: a) which is the best time to start pharmacological treatment; b) how to start pharmacological treatment; c) the availability of drugs capable in delaying disease progression; d) how to deal with motor complications and dyskinesias; e) which is the role of therapies in the advanced phases of the disease; f) how to advise patients regarding physiotherapy and other forms of allied health disciplines; g) therapeutic approaches for non-motor symptoms. The authors of this review tried to answer these and other questions summarizing the key points of the modern management of Parkinson’s disease. The recommendations come from a careful revision of papers dealing with the treatment of both early and advanced phases of Parkinson’s disease. Papers were only selected for review when there was an established rating scale or objective outcome measurement of endpoints; included a minimum of 20 subjects treated for a minimum duration of 4 weeks, and were reported in full-paper format in English. Classifications of evidence and ratings of efficacy were made according to EFNS guidance. A consensus “good practice point” suggestion was reached when evidence from the literature was insufficient to answer the specific question. In summary this review paper is a useful instrument for the correct approach to the treatment of Parkinson’s disease.
Alfredo Berardelli is Professor of Neurology at the University of Rome “La Sapienza”, Department of Neurological Sciences and corresponding author of the Task Forces, which developed the above guideline papers. Carlo Colosimo and Giovanni Fabbrini are Professors of Neurology at the University of Rome “La Sapienza”, Department of Neurology and co-authors of the guidelines on which they have commented.