Abstract
The current best evidence in Parkinson’s disease, Essential Tremor, and Primary Dystonia is reviewed. Clinical questions regarding the epidemiology, diagnosis, and treatment of these disorders are presented. Using evidence-based approach, the literature is searched for the best-available evidence. These articles are critically appraised and an in-depth discussion is presented. Finally, Clinical Bottom Lines are highlighted summarizing the key clinical points for each disorder.
This chapter serves as a reference for medical students, residents, fellows, and practicing neurologists.
Keywords
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Search Strategies
Search Strategies
Parkinson’s Disease
Epidemiology
MEDLINE database was searched since its inception to January of 2009. Medical Subject Heading (MeSH) terms and text words Parkinson’s disease, epidemiology, and (etiology OR risk factors OR prevalence OR incidence) were combined with the Boolean “AND”. Limits of “human,” “English,” “meta-analysis,” and “practice guidelines” were applied. This resulted in 85 citations. The citations and abstracts of these were reviewed for relevance and 14 articles were chosen for review. Reference lists of review articles were also screened for any relevant articles.
Six meta-analyses and one case-control study dealing with incidence, prevalence, and risk factors were included as they represented the highest level of evidence.
Diagnosis
MEDLINE database was searched since its inception to January of 2009. MeSH terms and text words Parkinson’s disease and diagnosis were searched and combined using the Boolean “AND.” After limiting the retrieval to “English,” “human,” and “practice guidelines” a final set of 16 citations were obtained. From this search, all citations and abstracts were searched for relevance to the clinical question revealing four articles. All four articles were reviewed and included if they met the following criteria: address a focused clinical question, contain a thorough search of the literature, and assess the validity of the studies.
A second search was conducted using the MeSH terms and text words Parkinson’s disease and diagnosis and (sensitivity OR specificity) and (physical examination OR magnetic resonance imaging OR positron-emission tomography OR ultrasonography OR olfactory OR SPECT OR growth hormone OR cardiac MIBG OR physical examination OR diagnostic tests) and combined using the Boolean “AND.” After limiting the retrieval to “English” and “human” a final set of 470 citations were obtained, of which 63 articles were selected and reviewed; they were included if they contributed new information not reported in the meta-analysis or systematic practice guidelines, and if they met the following criteria: appropriate spectrum of patients included, presence of a defined gold standard (autopsy or the surrogate marker of clinical diagnosis), diagnostic test was compared to the gold standard in a blinded fashion, and greater than ten participants in the each cohort.
Cochrane Database was searched from inception to January 2009 for the term Parkinson’s disease and diagnosis revealing no additional reviews.
One practice parameter, two systematic reviews, one critically appraised topic, and eleven additional cohort or case-control studies fulfilled criteria.
Treatment
MEDLINE database was searched since its inception to January of 2009. MeSH terms and text words Parkinson’s disease and (therapy OR therapeutics) were searched and combined using the Boolean “AND.” After limiting the retrieval to “English,” “human,” and (“meta-analysis” OR “practice guidelines”) a final set of 77 citations were obtained. From this search, all citations and abstracts were searched for relevance to the clinical question revealing 35 articles. All 35 articles were reviewed and included if they met the following criteria: addressed a focused clinical question, contained a thorough search of the literature, and assessed the validity of the studies.
The same search using the limit “randomized controlled trial” and “the last 5 years” was searched to reveal any new therapy studies that may have been published since the most recent meta-analysis and practice guidelines. This search revealing 285 citations that were reviewed and 70 citations were chosen from this group. The abstracts of these articles were reviewed for relevance. Thirty five articles were chosen for formal review and included if they contributed new information not reported in the meta-analysis or systematic practice guidelines, and if they met the following criteria: concealed randomization, blinding of outcomes, patient losses less than 20%, and at least 20 participants.
Cochrane Database was searched from inception to January 2009 for the term Parkinson’s disease revealing an additional four reviews.
For medication treatment in the early stages of PD, three Cochrane systematic reviews, one meta-analysis, and three well-designed practice parameters fulfilled criteria for inclusion. For medication treatment of the motor fluctuations and dyskinesias in PD, two Cochrane systematic reviews and two practice parameters fulfilled criteria. For surgical treatment of motor fluctuations and dyskinesias, two practice parameters, one meta-analysis, and three recent RCT fulfilled criteria. For treatment of depression, psychosis, and dementia in PD, one practice parameter, three meta-analyses, and one recent RCT met criteria.
Essential Tremor
Epidemiology
MEDLINE database was searched since its inception to January of 2009. MeSH and text words essential tremor, epidemiology, and (etiology OR risk factors OR prevalence OR incidence) was combined with the Boolean “AND.” Limits of “human” and “English” were applied. This resulted in 180 citations. The citations and abstracts of these were reviewed for relevance and 73 articles were chosen for review. Reference lists of review articles were also screened for any relevant articles.
One meta-analysis and 13 case-control or cohort studies were included as they represented the highest level of evidence.
Diagnosis
MEDLINE database was searched since its inception to January of 2009. MeSH terms and text words essential tremor and diagnosis were searched and combined using the Boolean “AND.” The search limits “English,” “human,” and “practice guidelines” were included. No citations were found.
A second search was conducted using the MeSH terms and text words essential tremor, diagnosis, diagnostic tests, and (sensitivity OR specificity) and combined using the Boolean “AND.” After limiting the retrieval to “English” and “human,” a final set of 57 citations were obtained. From this search, all citations and abstracts were searched for relevance to the clinical question revealing 13 articles. All 13 articles were reviewed and included if they met the following criteria: appropriate spectrum of patients included, presence of a defined gold standard (autopsy or the surrogate marker of clinical diagnosis), diagnostic test was compared to the gold standard in a blinded fashion, and greater than ten participants in each cohort.
A third search using the term accuracy in place of diagnostic tests, sensitivity, and specificity was conducted. Two additional articles were found and reviewed.
Cochrane Database was searched from inception to January 2009 for the term tremor and diagnosis revealing no additional reviews.
One retrospective study and two double-blind, prospective trials fulfilled criteria for inclusion.
Treatment
MEDLINE database was searched since its inception to January of 2009. MeSH terms and text words (tremor OR essential tremor) and (therapy OR therapeutics) were searched and combined using the Boolean “AND.” After limiting the retrieval to “English,” “human,” and (“meta-analysis” OR “practice guidelines”) a final set of three citations were obtained. From this search, all citations and abstracts were searched for relevance to the clinical question revealing two practice parameters. These two systematic reviews were included as they met the following criteria: address a focused clinical question, contain a thorough search of the literature, and assess the validity of the studies.
The same search using the limits “randomized controlled trial” and “the last 10 years” was searched to reveal any new therapy studies that may have been published since the most recent practice guidelines. This search revealing 167 citations that were reviewed for relevance to the clinical question; 30 citations were chosen from this group. The abstracts of these articles were reviewed for relevance. Twenty one articles were chosen for formal review and included if they contributed new information not reported in the systematic practice guidelines, and if they met the following criteria: concealed randomization, blinding of outcomes, patient lost to follow-up less than 20%, and at least 20 participants.
Cochrane Database was searched from inception to January 2009 for the term tremor revealing no additional reviews.
Two well-designed practice parameters and eight randomized controlled trials fulfilled criteria for inclusion.
Dystonia
Epidemiology
MEDLINE database was searched since its inception to January of 2009. MeSH and text words (primary dystonia OR dystonic disorders), epidemiology, (etiology OR risk factors OR prevalence OR incidence) was combined with the Boolean “AND.” Limits of “human” and “English” were applied. This resulted in 217 citations. The citations and abstracts were reviewed for relevance and 44 articles chosen for review. Reference lists of review articles were also screened for relevant articles.
One meta-analysis plus eight case-control and cohort studies were included as they represented the highest level of evidence.
Diagnosis
MEDLINE database was searched since its inception to January of 2009. MeSH terms and text words (primary dystonia OR dystonic disorders) and diagnosis were searched and combined using the Boolean “AND.” The search limits “English” and “human” and “practice guidelines” were included. One citation was found.
A second search was conducted using the MeSH terms and text words (primary dystonia OR dystonic disorders), diagnosis, and (diagnostic tests OR sensitivity OR specificity) combined using the Boolean “AND.” After limiting the retrieval to “English” and “human” a final set of 71 citations were obtained. All citations and abstracts were searched for relevance to the clinical question revealing five articles. All five articles were reviewed and included if they met the following criteria: appropriate spectrum of patients included, presence of a defined gold standard (autopsy or the surrogate marker of clinical diagnosis), diagnostic test was compared to the gold standard in a blinded fashion, and greater than ten participants in the each cohort.
A third search using the term accuracy in place of (diagnostic tests OR sensitivity OR specificity) was conducted. No additional articles were found.
Cochrane Database was searched from inception to January 2009 for the term primary dystonia and diagnosis revealing no additional reviews.
One practice guideline and two case-control studies fulfilled criteria for inclusion.
Treatment
MEDLINE database was searched since its inception to January of 2009. MeSH terms and text words (dystonic disorders OR primary dystonia) and (therapy OR therapeutics) were searched and combined using the Boolean “AND.” After limiting the retrieval to “English,” “human,” and (meta-analysis OR practice guidelines), a final set of 13 citations were obtained. From this search, all citations and abstracts were searched for relevance to the clinical question revealing one practice parameter and three meta-analyses. These four systematic reviews were included as they met the following criteria: address a focused clinical question, contain a thorough search of the literature, and assess the validity of the studies.
The same search using the limits (randomized controlled trial OR clinical trial) instead of (meta-analysis OR practice guidelines) was conducted to reveal any new therapeutic studies that may have been published since the most recent practice guidelines and meta-analysis. This search revealed 208 citations, which were reviewed for relevance to the clinical question; 53 citations were chosen from this group. The abstracts of these articles were reviewed for relevance. Nineteen articles were chosen for formal review and included if they contributed new information not reported in the systematic reviews and if they met the following criteria: concealed randomization, blinding of outcomes, patient lost to follow-up less than 20%, and at least 20 participants.
Cochrane Database was searched from inception to January 2009 for the term primary dystonia revealing three additional reviews.
One well-designed practice parameter, six meta-analyses and ten controlled trials fulfilled criteria for inclusion.
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Jenkins, M.E., Miyasaki, J.M., Suchowersky, O. (2012). Movement Disorders. In: Burneo, J., Demaerschalk, B., Jenkins, M. (eds) Neurology. Springer, New York, NY. https://doi.org/10.1007/978-0-387-88555-1_7
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