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We spend a third of our lives asleep –that can be a long time of fitful rest for someone who experiences sleep problems. Disruptions in this state of rest can lead to a decline in one’s overall quality of life. Most patients with sleep problems first seek medical help from their primary care physician.

Sleep in the Primary Care Setting:

Poor quality of sleep tends to accompany common illnesses, and life stressors (including family and social structure changes); thus, patients tend to visit their primary care physician who has a complete knowledge of the factors that are related with their sleep problems. Obstructive Sleep Apnea occurs at a high frequency in the primary care practice setting. An estimated 18 million Americans suffer from OSA; yet, despite the volume of sleep complaints to the primary care physicians, they often go unaddressed.

Common OSA facts and its associated health risks

• OSA is more common in men, and those over the age of 40.
• Snoring (Sleep Disordered Breathing) can be a sign of sleep apnea.
• Adult OSA has a long-standing and unambiguous correlation with obesity and daytime sleepiness. The National Sleep Foundation Sleep in America poll found that 77% of obese adults report having sleep problems. ¹ Sleep specialists say that weight gain, especially in the trunk and neck area, increases the risk of sleep-disordered breathing due to compromised respiratory function.¹ Research shows that sleep problems, like sleep apnea, also result in weight gain which can lead to additional health problems.¹
• Epidemiologic studies have linked sleep apnea with potential, long-term cardiovascular risk.
• Other studies have noted the consistent and strong association between OSA and hypertension.

Diagnosis and Management of OSA

Patients normally go to a sleep lab for OSA diagnosis & evaluation. Often, this causes the primary care physician to loose direct view of his/her patient’s sleep condition. An alternative to sending patients to a sleep lab test is to begin the diagnosis and management process within the primary care setting, by utilizing newer technology that makes sleep diagnosis portable and more readily accessible. Today, diagnosis and therapy of OSA should be considered as part of the health plan to manage diabetes, hypertension, and congestive heart failure — which are all core aspects of primary care medicine.

In conclusion, with training in sleep and an understanding of appropriate testing procedures, primary care physicians can use current evidence based information in the field to provide high-quality sleep medicine in the primary care setting.

While tremor is often the most visible symptom of Parkinson’s disease, bradykinesia can be the most impairing to the patient. The term "bradykinesia" literally means "slowed movements"; however, in the literature, the "bradykinesia" is often used synonymously with the terms "akinesia" and "hypokinesia." Technically, "bradykinesia" only refers to slowness of movement; however, lack of spontaneous movement (akinesia) and smaller than desired movements (hypokinesia) are often grouped together as "bradykinesia." This misuse in terminology can result in widespread variability in clinical ratings.

The standard clinical method for evaluating bradykinesia is qualitative assessment by a clinician and score assignment (0 – 4) based on the Unified Parkinson’s Disease Rating Scale (UPDRS). This score is assigned while the subject completes repetitive tasks of finger-tapping, hand opening-closing, and pronation-supination. Evaluators are instructed to account for a wide array of factors such as speed, amplitude, fatiguing, hesitations, arrests in movement, and how these variables change during the task. This is challenging to even the most experienced movement disorder specialist. A given patient could be scored a 2 on the UPDRS finger-tapping task due to slow and large amplitude movements or fast and small amplitude movements. It is difficult to gauge weights that specific clinicians place on different bradykinesia manifestations.

The inconsistency among raters may have implications beyond symptom severity assessments. Recent data have shown that speed and amplitude respond differentially to dopaminergic medication ^[1]. Furthermore, it is unknown if the underlying neural mechanisms that cause the various bradykinesia manifestations are the same. A quantitative understanding of different bradykinesia features could ultimately lead to the development of more targeted treatments for specific patients with Parkinson’s disease.

One of the most difficult aspects of monitoring Parkinson’s disease (PD) motor symptoms, is that the severity of tremor and bradykinesia (slowed movements) greatly fluctuates throughout the day.

When medication is at its peak effectiveness, the patient is said to be “On.” Similarly, when medication has completely worn off, the subject is said to be “Off.” Symptoms are often worst first thing in morning, but improve after the first dose of medication. However, as the medication wears off, symptoms return mid-day. These cycles of waxing and waning motor symptoms continue throughout the day. Controlling these “On” and “Off” cycles can be difficult, as patients with PD are typically evaluated in the neurologists’ office, which only allows the physician to capture a snapshot of motor symptoms. Furthermore, patients typically are instructed to refrain from taking medication the night prior to the office visit. A state of anxiety in this condition may amplify PD symptoms during motor evaluation. Monitoring motor symptoms at home would provide clinicians with improved tracking of these complex motor fluctuations and in-turn optimize medication dose to improve patient quality of life.

Kinesia is a compact wireless system developed by CleveMed to quantify movement disorder symptoms. In clinical trials, Kinesia objectively quantified tremor and bradykinesia in PD patients in the clinic. Objective symptom ratings output by the Kinesia system were highly correlated to clinician ratings. CleveMed has recently begun a clinical study in which the Kinesia system is being used throughout the day, at home, by patients with PD. Preliminary results demonstrate that Kinesia can capture the “On” and “Off” motor symptom fluctuations in a subject’s home. Monitoring PD symptoms on a more continuous basis at a patient’s home should improve clinical outcomes and decrease costs especially for disparate patient populations in areas not in close proximity to movement disorder specialists.