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Friday, December 2, 2016

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BY FRAN KRITZ

Doctors at this year's annual meeting of the American Academy of Pediatrics (AAP) in September heard some striking statistics about kids and headaches during one research presentation: The number of children and teens brought to the emergency room (ER) for headache pain doubled from 2 percent to 4 percent from 2007 to 2014 at the Children's Hospital of Pittsburgh. The researchers, who plan to publish their study next year, were concerned about the increase both because of the cost and because some parents are taking kids to the ER when perhaps they should be treated by their own doctor.

Survey Says Parents Are Unsure How to Handle Concussions

At least one report suggests parents could use some help when it comes to understanding whether a child's head pain is urgent or not. A survey of more than 500 parents and coaches presented at the 2015 AAP annual meeting found that more than 40 percent of coaches and 50 percent of parents said they would feel comfortable sending a young athlete who'd been hit in the head back into the game without a doctor's approval—a decision contrary to both AAP and American Academy of Neurology (AAN) guidelines.

When young athletes return to play, "symptoms requiring emergency room treatment would not receive urgent attention 25 to 50 percent of the time," says Edward J. Haas, PhD, the survey's lead researcher and director of research and outcomes at the Nemours Center for Children's Health Media in Wilmington, DE. And while parents in the survey acknowledged their children experienced dizziness, headache, and vision problems, they didn't realize those symptoms were possible indications of a concussion.

How to Know When to Go to the ER

Pain is not necessarily a gauge for when to take a child who complains of a headache to the ER, says Bruce H. Cohen, MD, FAAN, a pediatric neurologist and director of the NeuroDevelopmental Science Center at the Akron Children's Hospital in Ohio. "Migraines can cause terrible pain but are not life-threatening, while the [pain of a] brain tumor headache can be rather mild." Non-severe headache pain that persists or doesn't respond to over-the-counter pain relievers should be evaluated by the child's physician, he adds.

The most acute severe headache is a ruptured aneurysm, which is life threatening, but very rare in childhood, says Dr. Cohen. "Since a patient or parent cannot be expected to tell the difference between a first severe migraine and a ruptured aneurysm, new severe headache pain is a situation where the child should be evaluated at the ER."

Generally speaking, says Dr. Cohen, an immediate trip to the ER is warranted for:

  • A first, painful headache
  • A headache accompanied by a stiff neck or vomiting
  • A headache that begins after a head injury, or includes neurologic symptoms such as numbness, weakness, change in vision, speech disturbance, seizure, or a change in behavior 

For more information about pediatric concussions, read a fact sheet from the CDC at bit.ly/ConcussionFactSheet or the AAN concussion guidelines for patients and their families at bit.ly/ConcussionToolkit​.


Thursday, December 1, 2016

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Credit: 9comeback

B​Y SARAH OWENS

Could you identify the scent of pineapple even if you couldn't see it? And if you smelled 10 or more other scents right after, would you remember having smelled the pineapple? A simple scent test designed to answer questions like these may be used to detect Alzheimer's disease early, even in people who do not have symptoms, according to a new study published online on November 23 in the journal Annals of Neurology.

The Scent-Brain Link

People who have dementia often say they have a diminished sense of smell, even before memory problems begin to appear. And research has shown that the same brain areas that process odors—the entorhinal cortex and the olfactory bulb—are vulnerable to Alzheimer's disease. That's why researchers at Massachusetts General Hospital decided to investigate whether a simple smell identification test could accurately predict which older adults would develop Alzheimer's disease. To that end, they developed the three-part The Precepts of Odor Episodic Memory (POEM) test.

Developing a Scent Test

In the first part of the POEM test, participants sniff 10 common scents for two seconds each: menthol, clove, leather, strawberry, lilac, pineapple, smoke, soap, grape, and lemon. Without receiving any visual or verbal clues, they are asked to answer, "Is this odor familiar to you?" They are then given four words and asked to identify the word that fits the scent best.

In the second part, participants sniff 20 scents: the 10 they have already sniffed and 10 new ones. After smelling each scent, they are asked if the odor is familiar and if they smelled the scent before or if it was a new one.

In the third part, participants sniff two scents in a row and are asked whether the scents are the same or different.

Testing for Cognitive Health

The researchers administered the POEM test to 183 adults who were at least 65 years old. Seventy participants had normal cognitive health, 74 had concerns about their cognitive health but had normal cognitive health on tests, and 29 had been diagnosed with mild cognitive impairment, a condition associated with thinking and memory problems that may be a precursor to dementia. Ten participants had possible or probable Alzheimer's disease.

Participants were also given a variety of tests to measure their cognitive health, including a neurologic exam during which doctors tested the participants' memory, orientation, and problem solving skills. Doctors also asked about the participants' hobbies, personal care activities, and participation in their communities. Each participant also underwent MRI and PET scans, which measured structural changes in the brain.

Interpreting the Results                                                            

Participants who scored worse on the scent test were more likely to have scans that showed changes in brain structure that are linked with Alzheimer's disease, including a smaller hippocampus and a thinner entorhinal cortex. They were also more likely to perform worse on the memory tests they took during their neurologic examination.

Participants who scored poorly on the POEM test were also more likely to have the APOE e4 gene, which is associated with an increased risk of Alzheimer's disease.

The Importance of Early Diagnosis

The findings may help researchers develop a simple, quick, and inexpensive test to detect possible Alzheimer's disease even in people who have no problems with thinking or memory, the study authors concluded.

"There is increasing evidence that the neurodegeneration behind Alzheimer's disease starts at least 10 years before the onset of memory symptoms," said Mark Albers, MD, PhD, the study's lead investigator, in a press release accompanying the study. "This sort of inexpensive, noninvasive screening could help us identify the best candidates for [new] therapies to prevent" the disease, he said.​


Thursday, November 17, 2016

BY SARAH OWENS

People with multifocal motor neuropathy (MMN), a painful nerve condition, report that nerve pain in the hands and arms interferes with day-to-day life. They also report that an early, accurate diagnosis and regular treatment can make a difference. Those are the results of a new survey of 214 people in the US and UK by the Neuropathy Action Foundation (NAF).

A Rare Neurologic Condition

MMN, which affects about 0.6 of every 100,000 individuals worldwide, occurs when the immune system attacks multiple nerves in the extremities, resulting in weak and wasting muscles. The condition often starts in one limb, usually a hand, and worsens as time passes. People affected by the condition have dysfunctional movements and are moderately to severely disabled.

Difficulty with Diagnosis

Because MMN may affect only a single nerve at first and cause a slight amount of weakness in one limb, it can be hard to diagnose. To date, doctors diagnose the disorder using a conductive block test, which applies pressure to the affected muscle and then to an area above the muscle to determine if the nerve signal is blocked between the two places. According to the survey, though, just over half (52 percent) of participants were diagnosed based on the results of the test. The other 48 percent were misdiagnosed or diagnosed later, resulting in prolonged pain.

"It is clear we need to do a better job at accurately diagnosing [MMN]," said Jonathan Katz, MD, chief of neuromuscular services at California Pacific Medical Center in San Francisco and one of the survey's lead authors, in a press release about the survey.  "The sooner we can identify MMN, the sooner we can start individuals on the proper therapy, alleviate their symptoms, and improve their lives."

Quality of Life

A significant number of survey respondents reported that MMN affected their quality of life, including their participation in daily activities, their physical health, and their mental health.

Many said they had limited independence. For example, only 62 percent said they could shop and run errands by themselves; 26 percent said they could run errands, but with difficulty, and 12 percent could not run errands at all.

Even simply standing and moving around the home could be hard; 36 percent of respondents had difficulty standing for a period of time, and 8 percent could not do so at all. The patients also reported trouble walking for at least 15 minutes and climbing stairs.

MMN also affected mental and emotional well-being. Nearly half of respondents—46 percent—were depressed, and almost a third (28 percent) said they felt hopeless at times. More than half of the respondents said MMN limited their participation in fun activities and family gatherings.

Treatment Makes a Difference

The survey also showed that treatment, especially when administered early after a diagnosis, improves outcomes.

Ninety one percent of respondents said they were prescribed intravenous immunoglobulin (IVIG) every four to six weeks to treat their MMN. Antibodies in immunoglobulin help prevent the immune system from attacking nerves, thereby lessening nerve pain. Of the patients who received IVIG, 36 percent said their symptoms improved as early as one week after their initial treatment. They felt stronger, their balance improved, and they had less pain and cramping.

However, some patients reported being denied therapy by insurance companies that deemed it unnecessary or too expensive.

The results of the survey "illustrate the complexity of MMN and the impact it can have on people's lives," says Dominick Spatafora, the president of the NAF. "The good news is that the data also show that treatment clearly helps these individuals."​

To browse the complete collection of Neurology Now articles on nerve pain, visit http://bit.ly/NN-Neuropathy.


Monday, November 14, 2016

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BY SARAH OWENS

Seniors who want to lower their risk for dementia, or at least sharpen their mind, may want to head to the gym. So suggest findings from a new study published in the Journal of the American Geriatrics Society.

Study Design

For the Study of Mental and Resistance Training (SMART) trial, researchers at the University of Sydney in Australia enrolled 100 adults aged 55 and older who had mild cognitive impairment (MCI), which refers to memory problems not associated with age or education that do not interfere with daily functioning. MCI sometimes (but not always) precedes progression to dementia.

The participants were randomly assigned to four different activities: resistance training, cognitive training, and two sham activities, in which participants engaged in "dummy" versions of either weight or cognitive training. In the sham cognitive training group, participants watched documentary videos and were asked simple questions about them afterwards. In the sham exercise group, the participants did mild stretches and exercises that didn't increase their strength or heart rate. Each group met two or three times a week for 60- to 100-minute sessions over six months.

Weight and Cognitive Training              

People in the resistance training group engaged in high-intensity, repetitive weightlifting exercises under the guidance of a trainer. The researchers measured the participants' peak aerobic capacity (the ability of their body to use more oxygen during exercise) and their peak strength (measured as the maximum amount lifted during one repetition).

People in the cognitive training group used a computer program that included cognitive exercises to test memory, attention, and how quickly they could process new information.

Stronger Muscles, Stronger Mind

At the beginning and end of the study, the researchers assessed the participants' cognitive health using an Alzheimer's disease assessment scale that measures memory, language, attention, and other brain skills. Higher scores indicate greater cognitive dysfunction.

In the weight training group, researchers found an association between increased upper and whole body strength and better scores on the assessment scale compared to both sham groups. There was no association between improved aerobic capacity and better cognitive scores.

"The stronger people became, the greater the benefit for their brain," the lead study author, Yorgi Mavros, said in a university press release for the study. The researchers hope further study will reveal the physiological mechanism behind the link between improved strength and improved cognition and whether exercise can reduce dementia itself.

To learn more about how exercise benefits brain health, read our story "The Exercise Effect": http://bit.ly/Exercise-Effect. And to learn more about how people with neurologic conditions can adapt exercise to suit their limitations, read our story "Exercise for Everyone": http://bit.ly/Exercise-Everyone.


Friday, November 11, 2016

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​Credit: radnatt​

BY SARAH OWENS

To improve symptoms of autism in kids over the long term, teach the parents, not the children. That's according to a new study of children with severe autism in the United Kingdom, published October 25 in The Lancet, a British medical journal.

Autism Is Expensive

About 1 percent of children and young people have autism spectrum disorder, which can cause behavioral problems and affect their ability to communicate and socialize. The total costs of managing the disorder over a lifetime, including health, education, and social care, can be enormous, so treating kids early can make a big difference over the long term.

Some early-intervention approaches have led to short-term improvement in symptoms. For instance, after working with a therapist, a child may temporarily use more words and appear more interested in interacting with others. But evidence of sustained, long-term improvement is scarce, the study authors noted. For their study, the authors wanted to see what happened if parents of children with autism, not the children themselves, were the subjects of therapy.

Using Video to Teach Parents

For the Preschool Autism Communication Trial (PACT), researchers in the United Kingdom enrolled 152 children between ages 2 and 4 who'd been diagnosed with autism. Most of the children had severe symptoms: they used few, if any, words, rarely made eye contact, and had few facial expressions. Researchers randomly placed 77 of the children in a parent-intervention group, and 75 in a control, or non-intervention, group.

For one year, the parents and children in the intervention group met with a therapist for an instructional session; 12 times for the first six months and six times for the last six months. Each session was divided into two parts: playtime and feedback time.

During playtime, parents would engage in 10 minutes of play with their children, using toys designed to encourage interaction, while being videotaped. During the feedback session, the parents would watch the videotape with a therapist, who would point out any subtle communication attempts by the child that might have been missed during play, like a brief glance or a change in body orientation. The therapist would also highlight moments when the parents were most engaged with the child and explain what the parents were doing that worked.

"For example, [the parents] may have momentarily slowed the pace of play, or may have changed from directing the play to just joining in with what the child was doing," explains Kathy Leadbitter, PhD, research associate at the University of Manchester and one of the study's lead authors.

After each session, the parents were instructed to take what they'd learned and make two or three goals for future interactions—and gradually apply those goals to future play sessions. Eventually, the parents would apply what they learned to 20- and 30-minute play sessions at home and then into other activities such as meals and when getting ready to go out, says Dr. Leadbitter.

Interpreting the Results

Six years after the trial ended, the researchers used clinical tests to judge whether the children's symptoms had improved, including whether they used more words and longer sentences, were more eager to interact with others, and were less insistent on doing the same activity repeatedly. They found that children in the intervention group improved significantly in symptoms of autism compared to children in the control group.

For example, one child who'd had severe autism at the beginning of the study went from being very shy and speaking few words to using full sentences and voluntarily joining conversations and even sharing personal experiences, Dr. Leadbitter says.

At the end of the study, only 46 percent of the children whose parents received training still had severe symptoms of autism, compared to 63 percent of children in the control group. And, the improvements were sustained over six years, making this the first study to show improvements for such a long period of time.

Win-Win

Having a therapist intervene with the parents rather than with the child, the researchers wrote, allows parents to incorporate what they learn into everyday life, where most social learning takes place. This type of treatment could become self-sustaining, the researchers say, which could reduce the need for costly therapy and improve the child's productivity and social success over the course of his or her lifetime.