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St George RJ, Carlson-Kuhta P, King LA, Burchiel KJ, Horak FB. Compensatory stepping in Parkinson's disease is still a problem after deep brain stimulation randomized to STN or GPi. J Neurophysiol 2015; 114:1417-23. [PMID: 26108960 DOI: 10.1152/jn.01052.2014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 06/19/2015] [Indexed: 11/22/2022] Open
Abstract
The effects of deep brain stimulation (DBS) on balance in people with Parkinson's disease (PD) are not well established. This study examined whether DBS randomized to the subthalamic nucleus (STN; n = 11) or globus pallidus interna (GPi; n = 10) improved compensatory stepping to recover balance after a perturbation. The standing surface translated backward, forcing subjects to take compensatory steps forward. Kinematic and kinetic responses were recorded. PD-DBS subjects were tested off and on their levodopa medication before bilateral DBS surgery and retested 6 mo later off and on DBS, combined with off and on levodopa medication. Responses were compared with PD-control subjects (n = 8) tested over the same timescale and 17 healthy control subjects. Neither DBS nor levodopa improved the stepping response. Compensatory stepping in the best-treated state after surgery (DBS+DOPA) was similar to the best-treated state before surgery (DOPA) for the PD-GPi group and the PD-control group. For the PD-STN group, there were more lateral weight shifts, a delayed foot-off, and a greater number of steps required to recover balance in DBS+DOPA after surgery compared with DOPA before surgery. Within the STN group five subjects who did not fall during the experiment before surgery fell at least once after surgery, whereas the number of falls in the GPi and PD-control groups were unchanged. DBS did not improve the compensatory step response needed to recover from balance perturbations in the GPi group and caused delays in the preparation phase of the step in the STN group.
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Affiliation(s)
- R J St George
- Department of Neurology, Oregon Health and Science University, Beaverton, Oregon; Human Motor Control Laboratory, School of Medicine, University of Tasmania, Hobart, Australia
| | - P Carlson-Kuhta
- Department of Neurology, Oregon Health and Science University, Beaverton, Oregon
| | - L A King
- Department of Neurology, Oregon Health and Science University, Beaverton, Oregon
| | - K J Burchiel
- Department of Neurosurgery, Oregon Health and Science University, Beaverton, Oregon
| | - F B Horak
- Department of Neurology, Oregon Health and Science University, Beaverton, Oregon; Department of Veterans Affairs Portland Health Care System, Portland, Oregon; and
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Bonora G, Carpinella I, Cattaneo D, Chiari L, Ferrarin M. A new instrumented method for the evaluation of gait initiation and step climbing based on inertial sensors: a pilot application in Parkinson's disease. J Neuroeng Rehabil 2015; 12:45. [PMID: 25940457 PMCID: PMC4419387 DOI: 10.1186/s12984-015-0038-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 04/22/2015] [Indexed: 01/19/2023] Open
Abstract
Background Step climbing is a demanding task required for personal autonomy in daily living. Anticipatory Postural Adjustments (APAs) preceding gait initiation have been widely investigated revealing to be hypometric in Parkinson’s disease (PD) with consequences in movement initiation. However, only few studies focused on APAs prior to step climbing. In this work, a novel method based on wearable inertial sensors for the analysis of APAs preceding gait initiation and step climbing was developed to further understand dynamic balance control. Validity and sensitivity of the method have been evaluated. Methods Eleven PD and 20 healthy subjects were asked to perform two transitional tasks from quiet standing to level walking, and to step climbing respectively. All the participants wore two inertial sensors, placed on the trunk (L2-L4) and laterally on the shank. In addition, a validation group composed of healthy subjects and 5 PD patients performed the tasks on two force platforms. Correlation between parameters from wearable sensors and force platforms was evaluated. Temporal parameters and trunk acceleration from PD and healthy subjects were analyzed. Results Significant correlation was found for the validation group between temporal parameters extracted from wearable sensors and force platforms and between medio-lateral component of trunk acceleration and correspondent COP displacement. These results support the validity of the method for evaluating APAs prior to both gait initiation and step climbing. Comparison between PD subjects and a subgroup of healthy controls confirms a reduction in PD of the medio-lateral acceleration of the trunk during the imbalance phase in the gait initiation task and shows similar trends during the imbalance and unloading phase of the step climbing task. Interestingly, PD subjects presented difficulties in adapting the medio-lateral amplitude of the imbalance phase to the specific task needs. Conclusions Validity of the method was confirmed by the significant correlation between parameters extracted from wearable sensors and force platforms. Sensitivity was proved by the capability to discriminate PD subjects from healthy controls. Our findings support the applicability of the method to subjects of different age. This method could be a possible valid instrument for a better understanding of feed-forward anticipatory strategies.
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Affiliation(s)
- Gianluca Bonora
- Biomedical Technology Department, Found. Don C. Gnocchi Onlus, IRCCS, Via Capecelatro 66, 20148, Milan, Italy.
| | - Ilaria Carpinella
- Biomedical Technology Department, Found. Don C. Gnocchi Onlus, IRCCS, Via Capecelatro 66, 20148, Milan, Italy.
| | - Davide Cattaneo
- LaRiCe: Gait and Balance Disorders Laboratory, Department of Neurorehabilitation, Found. Don C. Gnocchi Onlus, IRCCS, Via Capecelatro 66, 20148, Milan, Italy.
| | - Lorenzo Chiari
- Department of Electrical, Electronic, and Information Engineering - Guglielmo Marconi (DEI), University of Bologna, Viale Risorgimento 2, 40136, Bologna, Italy.
| | - Maurizio Ferrarin
- Biomedical Technology Department, Found. Don C. Gnocchi Onlus, IRCCS, Via Capecelatro 66, 20148, Milan, Italy.
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Johnson L, Rodrigues J, Teo WP, Walters S, Stell R, Thickbroom G, Mastaglia F. Interactive effects of GPI stimulation and levodopa on postural control in Parkinson's disease. Gait Posture 2015; 41:929-34. [PMID: 25861706 DOI: 10.1016/j.gaitpost.2015.03.346] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 03/13/2015] [Accepted: 03/29/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Postural instability is a major source of disability in idiopathic Parkinson's disease (IPD). Deep brain stimulation of the globus pallidus internus (GPI-DBS) improves clinician-rated balance control but there have been few quantitative studies of its interactive effects with levodopa (L-DOPA). The purpose of this study was to compare the short-term and interactive effects of GPI-DBS and L-DOPA on objective measures of postural stability in patients with longstanding IPD. METHODS Static and dynamic posturography during a whole-body leaning task were performed in 10 IPD patients with bilateral GPI stimulators under the following conditions: untreated (OFF); L-DOPA alone; DBS alone; DBS+L-DOPA, and in 9 healthy Control subjects. Clinical status was assessed using the UPDRS and AIMS Dyskinesia Scale. RESULTS Static sway was greater in IPD patients in the OFF state compared to the Control subjects and was further increased by L-DOPA and reduced by GPI-DBS. In the dynamic task, L-DOPA had a greater effect than GPI-DBS on improving Start Time, but reduced the spatial accuracy and directional control of the task. When the two therapies were combined, GPI-DBS prevented the L-DOPA induced increase in static sway and improved the accuracy of the dynamic task. CONCLUSION The findings demonstrate GPI-DBS and L-DOPA have differential effects on temporal and spatial aspects of postural control in IPD and that GPI-DBS counteracts some of the adverse effects of L-DOPA. Further studies on larger numbers of patients with GPI stimulators are required to confirm these findings and to clarify the contribution of dyskinesias to impaired dynamic postural control.
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Affiliation(s)
- Liam Johnson
- Western Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia; Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Victoria, Australia; The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.
| | - Julian Rodrigues
- Western Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia
| | - Wei-Peng Teo
- Western Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia; Centre for Physical Activity and Nutrition Research, Deakin University, Burwood, Victoria, Australia
| | - Susan Walters
- Western Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia
| | - Rick Stell
- Western Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia
| | - Gary Thickbroom
- Western Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia
| | - Frank Mastaglia
- Institute of Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
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Machado FA, Reppold CT. The effect of deep brain stimulation on motor and cognitive symptoms of Parkinson's disease: A literature review. Dement Neuropsychol 2015; 9:24-31. [PMID: 29213938 PMCID: PMC5618988 DOI: 10.1590/s1980-57642015dn91000005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Deep brain stimulator (DBS) implant surgery is considered a breakthrough in the
treatment of Parkinson's disease, especially in cases where motor symptoms
cannot be controlled through conventional drug treatment. Its benefits have been
studied extensively in the literature, particularly in relation to motor
symptoms. However, the disease's cognitive aspects have been studied to a lesser
extent.
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Affiliation(s)
- Flavia Amaral Machado
- Physiotherapist, Master's Student of Master's Program of Rehabilitation Sciences - Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil
| | - Caroline Tozzi Reppold
- PhD, Psychologist, Neuropsychological Assessment Unit, Master's Program of Rehabilitation Sciences and Health Sciences. Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil
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Abstract
PURPOSE OF REVIEW Later stage Parkinson's disease, sometimes referred to as advanced disease, has been characterized by motor complication, as well as by the potential emergence of nonlevodopa responsive motor and nonmotor symptoms. The management of advanced stage Parkinson's disease can be complex. This review summarizes the currently available treatment strategies for addressing advanced Parkinson's disease. RECENT FINDINGS We will discuss the latest pharmacological strategies (e.g., inhibitors of dopamine-metabolizing enzymes, dopamine agonists, and extended release dopamine formulations) for addressing motor dysfunction. We will summarize the risks and benefits of current invasive treatments. Finally, we will address the current evidence supporting the treatment of nonmotor symptoms in the advanced Parkinson's disease patient. We will conclude by detailing the potential nonpharmacological and multidisciplinary approaches for advanced stage Parkinson's disease. SUMMARY The optimization of levodopa is, in most cases, the most powerful therapeutic option available; however, medication optimization requires an advanced understanding of Parkinson's disease. Failure of conventional pharmacotherapy should precipitate a discussion of the potential risks and benefits of more invasive treatments. Currently, there are no comparative studies of invasive treatment. Among the invasive treatments, deep brain stimulation has the largest amount of existing evidence, but also has the highest individual per patient risk. Nonmotor symptoms will affect quality of life more than the motor Parkinson's disease symptoms, and these nonmotor symptoms should be aggressively treated. Many advanced Parkinson's disease patients will likely benefit from multi and interdisciplinary Parkinson's disease teams with multiple professionals collaborating to develop a collective and tailored strategy for an individual patient.
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Fasano A, Aquino CC, Krauss JK, Honey CR, Bloem BR. Axial disability and deep brain stimulation in patients with Parkinson disease. NATURE REVIEWS. NEUROLOGY 2015. [PMID: 25582445 DOI: 10.1038/nrneurol.2014.252.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Axial motor signs-including gait impairment, postural instability and postural abnormalities-are common and debilitating symptoms in patients with advanced Parkinson disease. Dopamine replacement therapy and physiotherapy provide, at best, partial relief from axial motor symptoms. In carefully selected candidates, deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus internus is an established treatment for 'appendicular' motor signs (limb tremor, bradykinesia and rigidity). However, the effects of DBS on axial signs are much less clear, presumably because motor control of axial and appendicular functions is mediated by different anatomical-functional pathways. Here, we discuss the successes and failures of DBS in managing axial motor signs. We systematically address a series of common clinical questions associated with the preoperative phase, during which patients presenting with prominent axial signs are considered for DBS implantation surgery, and the postoperative phase, in particular, the management of axial motor signs that newly develop as postoperative complications, either acutely or with a delay. We also address the possible merits of new targets-including the pedunculopontine nucleus area, zona incerta and substantia nigra pars reticulata-to specifically alleviate axial symptoms. Supported by a rapidly growing body of evidence, this practically oriented Review aims to support decision-making in the management of axial symptoms.
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Affiliation(s)
- Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Toronto Western Hospital, UHN, University of Toronto, 399 Bathurst Street, 7 Mc412, Toronto, ON M5T 2S8, Canada
| | - Camila C Aquino
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Toronto Western Hospital, UHN, University of Toronto, 399 Bathurst Street, 7 Mc412, Toronto, ON M5T 2S8, Canada
| | - Joachim K Krauss
- Department of Neurosurgery, Medical School Hannover, Carl-Neuberg Straße 1, 30625 Hannover, Germany
| | - Christopher R Honey
- Division of Neurosurgery at the University of British Columbia, 8105-2775 Laurel Street, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Bastiaan R Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, PO Box 9101, 6500 HB Nijmegen, Netherlands
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Abstract
Axial motor signs-including gait impairment, postural instability and postural abnormalities-are common and debilitating symptoms in patients with advanced Parkinson disease. Dopamine replacement therapy and physiotherapy provide, at best, partial relief from axial motor symptoms. In carefully selected candidates, deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus internus is an established treatment for 'appendicular' motor signs (limb tremor, bradykinesia and rigidity). However, the effects of DBS on axial signs are much less clear, presumably because motor control of axial and appendicular functions is mediated by different anatomical-functional pathways. Here, we discuss the successes and failures of DBS in managing axial motor signs. We systematically address a series of common clinical questions associated with the preoperative phase, during which patients presenting with prominent axial signs are considered for DBS implantation surgery, and the postoperative phase, in particular, the management of axial motor signs that newly develop as postoperative complications, either acutely or with a delay. We also address the possible merits of new targets-including the pedunculopontine nucleus area, zona incerta and substantia nigra pars reticulata-to specifically alleviate axial symptoms. Supported by a rapidly growing body of evidence, this practically oriented Review aims to support decision-making in the management of axial symptoms.
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Toosizadeh N, Lei H, Schwenk M, Sherman SJ, Sternberg E, Mohler J, Najafi B. Does integrative medicine enhance balance in aging adults? Proof of concept for the benefit of electroacupuncture therapy in Parkinson's disease. Gerontology 2014; 61:3-14. [PMID: 25341431 DOI: 10.1159/000363442] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 05/07/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postural balance and potentially fall risk increases among older adults living with neurological diseases, especially Parkinson's disease (PD). Since conventional therapies such as levodopa or deep brain stimulation may fail to alleviate or may even worsen balance, interest is growing in evaluating alternative PD therapies. OBJECTIVE The purpose of the current study was to assess improvement in postural balance in PD patients following electroacupuncture (EA) as an alternative therapy. METHODS 15 aging adults (71.2 ± 6.3 years) with idiopathic PD and 44 healthy age-matched participants (74.6 ± 6.5 years) were recruited. The PD participants were randomly assigned (at a ratio of 2:1) to an intervention (n = 10) or to a control group (n = 5). The intervention group received a 30-min EA treatment on a weekly basis for 3 weeks, while the control group received a sham treatment. Outcomes were assessed at baseline and after the final therapy. Measurements included balance assessment, specifically the ratio of medial-lateral (ML) center-of-gravity (COG) sway to anterior-posterior (AP) sway (COGML/AP) and ankle/hip sway during eyes-open, eyes-closed, and eyes-open dual-task trials, the Unified Parkinson's Disease Rating Scale (UPDRS), as well as quality of life, concerns for fall, and pain questionnaires. RESULTS No difference was observed for the assessed parameters between the intervention and the control group at baseline. After treatment, an improvement in balance performance was observed in the intervention group. Compared with the healthy population, PD patients prior to treatment had larger COGML/AP sway with more dependency on upper-body movements for maintaining balance. Following EA therapy, COGML/AP sway was reduced by 31% and ankle/hip sway increased by 46% in the different conditions (p = 0.02 for the dual-task condition). The clinical rating revealed an overall improvement (p < 0.01) in mentation, behavior, and mood (UPDRS part I, 49%), activities of daily living (UPDRS part II, 46%), and motor examination (UPDRS part III, 40%). There was a significant reduction (p < 0.02) in the specific items regarding UPDRS fall status (67%) and rigidity (48%). Changes were small and nonsignificant in the controls (p > 0.29). CONCLUSIONS This pilot study demonstrates improvement in rigidity and balance following EA. These preliminary results suggest EA could be a promising alternative treatment for balance disturbance in PD.
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Affiliation(s)
- Nima Toosizadeh
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP) and Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona, Tucson, Ariz., USA
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Delval A, Moreau C, Bleuse S, Tard C, Ryckewaert G, Devos D, Defebvre L. Auditory cueing of gait initiation in Parkinson’s disease patients with freezing of gait. Clin Neurophysiol 2014; 125:1675-81. [DOI: 10.1016/j.clinph.2013.12.101] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 11/04/2013] [Accepted: 12/17/2013] [Indexed: 01/05/2023]
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Liu Y, Li W, Tan C, Liu X, Wang X, Gui Y, Qin L, Deng F, Hu C, Chen L. Meta-analysis comparing deep brain stimulation of the globus pallidus and subthalamic nucleus to treat advanced Parkinson disease. J Neurosurg 2014; 121:709-18. [PMID: 24905564 DOI: 10.3171/2014.4.jns131711] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECT Deep brain stimulation (DBS) is the surgical procedure of choice for patients with advanced Parkinson disease (PD). The globus pallidus internus (GPi) and the subthalamic nucleus (STN) are commonly targeted by this procedure. The purpose of this meta-analysis was to compare the efficacy of DBS in each region. METHODS MEDLINE/PubMed, EMBASE, Web of Knowledge, and the Cochrane Library were searched for English-language studies published before April 2013. RESULTS of studies investigating the efficacy and clinical outcomes of DBS of the GPi and STN for PD were analyzed. RESULTS Six eligible trials containing a total of 563 patients were included in the analysis. Deep brain stimulation of the GPi or STN equally improved motor function, measured by the Unified Parkinson's Disease Rating Scale Section III (UPDRSIII) (motor section, for patients in on- and off-medication phases), within 1 year postsurgery. The change score for the on-medication phase was 0.68 (95% CI - 2.12 to 3.47, p > 0.05; 5 studies, 518 patients) and for the off-medication phase was 1.83 (95% CI - 3.12 to 6.77, p > 0.05; 5 studies, 518 patients). The UPDRS Section II (activities of daily living) scores for patients on medication improved equally in both DBS groups (p = 0.97). STN DBS allowed medication dosages to be reduced more than GPi DBS (95% CI 129.27-316.64, p < 0.00001; 5 studies, 540 patients). Psychiatric symptoms, measured by Beck Depression Inventory, 2nd edition scores, showed greater improvement from baseline after GPi DBS than after STN DBS (standardized mean difference -2.28, 95% CI -3.73 to -0.84, p = 0.002; 3 studies, 382 patients). CONCLUSIONS GPi and STN DBS improve motor function and activities of daily living for PD patients. Differences in therapeutic efficacy for PD were not observed between the 2 procedures. STN DBS allowed greater reduction in medication for patients, whereas GPi DBS provided greater relief from psychiatric symptoms. An understanding of other symptomatic aspects of targeting each region and long-term observations on therapeutic effects are needed.
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Affiliation(s)
- Yi Liu
- Department of Neurology, the Second Affiliated Hospital of Chong Qing Medical University, YuZhong, Chong Qing, China
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Horak FB, Mancini M. Objective biomarkers of balance and gait for Parkinson's disease using body-worn sensors. Mov Disord 2014; 28:1544-51. [PMID: 24132842 DOI: 10.1002/mds.25684] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 08/09/2013] [Accepted: 08/22/2013] [Indexed: 01/18/2023] Open
Abstract
Balance and gait impairments characterize the progression of Parkinson's disease (PD), predict the risk of falling, and are important contributors to reduced quality of life. Advances in technology of small, body-worn, inertial sensors have made it possible to develop quick, objective measures of balance and gait impairments in the clinic for research trials and clinical practice. Objective balance and gait metrics may eventually provide useful biomarkers for PD. In fact, objective balance and gait measures are already being used as surrogate endpoints for demonstrating clinical efficacy of new treatments, in place of counting falls from diaries, using stop-watch measures of gait speed, or clinical balance rating scales. This review summarizes the types of objective measures available from body-worn sensors. The metrics are organized based on the neural control system for mobility affected by PD: postural stability in stance, postural responses, gait initiation, gait (temporal-spatial lower and upper body coordination and dynamic equilibrium), postural transitions, and freezing of gait. However, the explosion of metrics derived by wearable sensors during prescribed balance and gait tasks, which are abnormal in individuals with PD, do not yet qualify as behavioral biomarkers, because many balance and gait impairments observed in PD are not specific to the disease, nor have they been related to specific pathophysiologic biomarkers. In the future, the most useful balance and gait biomarkers for PD will be those that are sensitive and specific for early PD and are related to the underlying disease process.
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Affiliation(s)
- Fay B Horak
- Department of Neurology, Oregon Health & Science University, Portland, Oregon
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Williams NR, Foote KD, Okun MS. STN vs. GPi Deep Brain Stimulation: Translating the Rematch into Clinical Practice. Mov Disord Clin Pract 2014; 1:24-35. [PMID: 24779023 DOI: 10.1002/mdc3.12004] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
When formulating a deep brain stimulation (DBS) treatment plan for a patient with Parkinson's disease (PD), two critical questions should be addressed: 1- Which brain target should be chosen to optimize this patient's outcome? and 2- Should this patient's DBS operation be unilateral or bilateral? Over the past two decades, two targets have emerged as leading contenders for PD DBS; the subthalamic nucleus (STN) and the globus pallidus internus (GPi). While the GPi target does have a following, most centers have uniformly employed bilateral STN DBS for all Parkinson's disease cases (Figure 1). This bilateral STN "one-size-fits-all" approach was challenged by an editorial entitled "STN vs. GPi: The Rematch," which appeared in the Archives of Neurology in 2005. Since 2005, a series of well designed clinical trials and follow-up studies have addressed the question as to whether a more tailored approach to DBS therapy might improve overall outcomes. Such a tailored approach would include the options of targeting the GPi, or choosing a unilateral operation. The results of the STN vs. GPi 'rematch' studies support the conclusion that bilateral STN DBS may not be the best option for every Parkinson's disease surgical patient. Off period motor symptoms and tremor improve in both targets, and with either unilateral or bilateral stimulation. Advantages of the STN target include more medication reduction, less frequent battery changes, and a more favorable economic profile. Advantages of GPi include more robust dyskinesia suppression, easier programming, and greater flexibility in adjusting medications. In cases where unilateral stimulation is anticipated, the data favor GPi DBS. This review summarizes the accumulated evidence regarding the use of bilateral vs. unilateral DBS and the selection of STN vs. GPi DBS, including definite and possible advantages of different targets and approaches. Based on this evidence, a more patient-tailored, symptom specific approach will be proposed to optimize outcomes of PD DBS therapy. Finally, the importance of an interdisciplinary care team for screening and effective management of DBS patients will be reaffirmed. Interdisciplinary teams can facilitate the proposed patient-specific DBS treatment planning and provide a more thorough analysis of the risk-benefit ratio for each patient.
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Affiliation(s)
- Nolan R Williams
- Department of Psychiatry, Medical University of South Carolina, Charleston SC ; Department of Neurosciences, Medical University of South Carolina, Charleston SC
| | - Kelly D Foote
- Departments of Neurology and Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration and the McKnight Brain Institute, UF Health College of Medicine, Gainesville FL
| | - Michael S Okun
- Departments of Neurology and Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration and the McKnight Brain Institute, UF Health College of Medicine, Gainesville FL
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Troche MS, Brandimore AE, Foote KD, Morishita T, Chen D, Hegland KW, Okun MS. Swallowing outcomes following unilateral STN vs. GPi surgery: a retrospective analysis. Dysphagia 2014; 29:425-31. [PMID: 24652582 DOI: 10.1007/s00455-014-9522-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 02/27/2014] [Indexed: 12/16/2022]
Abstract
The adverse effects of deep brain stimulation (DBS) surgery on swallowing could potentially exacerbate the natural deterioration of airway protection associated with Parkinson's disease (PD) degeneration and increase the incidence of aspiration pneumonia and associated death. There are no studies that compare swallowing outcomes associated with subthalamic nucleus (STN) versus globus pallidus interna (GPi) DBS surgery; therefore, we completed a retrospective study comparing swallowing outcomes in a cohort of patients with PD who underwent unilateral DBS surgery in either the STN or GPi. A chart review was completed to identify all patients with a diagnosis of PD who received videofluoroscopic swallowing evaluations before DBS and after unilateral DBS in the STN or GPi. The retrospective search yielded 33 patients (STN = 14, GPi = 19) with idiopathic PD who met the inclusion criteria. Mean penetration-aspiration (PA) scores did not change significantly for participants who underwent GPi surgery (z = -.181, p = .857), but mean PA scores significantly worsened for participants who underwent STN DBS (z = -2.682, p = .007). There was a significant improvement in Unified PD Rating Scale (UPDRS) scores off medication before surgery, to off medication and on stimulation after surgery for both groups (F = 23.667, p < .001). Despite the limitations of a retrospective analysis, this preliminary study suggests that unilateral STN DBS may have an adverse effect on swallowing function, while unilateral GPi DBS does not appear to have a similar deleterious effect. This study and other future studies should help to elucidate the mechanisms underpinning the effects of DBS on swallowing function.
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Affiliation(s)
- Michelle S Troche
- Department of Speech, Language, and Hearing Sciences, University of Florida, PO Box 117420, Gainesville, FL, 32611, USA,
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St George RJ, Carlson-Kuhta P, Nutt JG, Hogarth P, Burchiel KJ, Horak FB. The effect of deep brain stimulation randomized by site on balance in Parkinson's disease. Mov Disord 2014; 29:949-53. [PMID: 24532106 DOI: 10.1002/mds.25831] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 01/06/2014] [Accepted: 01/12/2014] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The effect of the surgical site of DBS on balance and gait in Parkinson's Disease (PD) is uncertain. This is the first double-blind study of subjects randomized to either the STN (N = 14) or GPi (N = 14) who were assessed on a range of clinical balance measures. METHODS Balance testing occurred before and 6 months postsurgery. A control PD group was tested over the same period without surgery (N = 9). All subjects were tested on and off medication and DBS subjects were also tested on and off DBS. The Postural Instability and Gait Disability items of the UPDRS and additional functional tests, which we call the Balance and Gait scale, were assessed. Activities of Balance Confidence and Activities of Daily Living questionnaires were also recorded. RESULTS Balance was not different between the best-treated states before and after DBS surgery for both sites. Switching DBS on improved balance scores, and scores further improved with medication, compared to the off state. The GPi group showed improved performance in the postsurgery off state and better ratings of balance confidence after surgery, compared to the STN group. CONCLUSIONS Clinical measures of balance function for both the STN and GPi sites showed that balance did not improve beyond the best medically treated state before surgery. Both clinical balance testing in the off/off state and self-reported balance confidence after surgery showed better performance in the GPi than the STN group.
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Affiliation(s)
- Rebecca J St George
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
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Kalia SK, Sankar T, Lozano AM. Deep brain stimulation for Parkinson's disease and other movement disorders. Curr Opin Neurol 2014; 26:374-80. [PMID: 23817213 DOI: 10.1097/wco.0b013e3283632d08] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Deep brain stimulation (DBS) is now widely used in the treatment of Parkinson's disease, tremor, and dystonia. This review examines recent developments in the application of DBS to the management of movement disorders. RECENT FINDINGS In Parkinson's disease, recent work has demonstrated that early DBS may have a significant benefit on quality of life and motor symptoms while permitting a decrease in levodopa equivalent dosage. Thalamic DBS continues to be a well established target for the treatment of tremor, although recent work suggests that alternative targets such as the posterior subthalamic area may be similarly efficacious. The treatment of primary dystonia with DBS has been established in multiple recent trials, demonstrating prolonged symptomatic benefit. SUMMARY DBS is now an established symptomatic treatment modality for Parkinson's disease and other movement disorders. Future work will undoubtedly involve establishing new indications and targets in the treatment of movement disorders with further refinements to existing technology. Ultimately, these methods combined with biologically based therapies may catalyze a shift from symptomatic treatment to actually modifying the natural history of neurodegenerative diseases such as Parkinson's disease.
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Affiliation(s)
- Suneil K Kalia
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Delval A, Tard C, Defebvre L. Why we should study gait initiation in Parkinson's disease. Neurophysiol Clin 2013; 44:69-76. [PMID: 24502907 DOI: 10.1016/j.neucli.2013.10.127] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 10/14/2013] [Accepted: 10/14/2013] [Indexed: 11/28/2022] Open
Abstract
The gait initiation process is of particular interest in Parkinson's disease because it combines motor and cognitive components of movement preparation (referred to as anticipatory postural adjustments) and movement execution (the step by itself). Moreover, gait initiation in Parkinson's disease is often affected by motor blocks (a subtype of the "freezing of gait" phenomenon). Gait initiation disturbances in Parkinson's disease include delayed release of anticipatory postural adjustments, hypokinetic anticipatory postural adjustments (reduced scaling) and bradykinetic anticipatory postural adjustments (abnormal timing). The most extreme form is freezing of gait with sometimes the absence of anticipatory postural adjustments. Other phenomena can be also described in some freezing patients (such as multiple anticipatory postural adjustments, described clinically as "knee trembling"). The fact that emotion, attention, external triggers and dopaminergic drugs can all modify this motor program suggests the existence of a complex pathophysiological mechanism that involves not only locomotor networks but also cortical areas and the basal ganglia system. Abnormal coupling between standing posture and anticipatory postural adjustments and between the latter and step execution appears to be a crucial part of the pathophysiological mechanism. Although external cueing appears to be of interest, few studies have provided evidence of the efficacy of various rehabilitation methods in routine care.
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Affiliation(s)
- A Delval
- Université Lille Nord de France, UDSL, Lille, France; Laboratoire de Neurosciences Fonctionnelles et Pathologies, EA 4559, Lille 2, Lille, France; Clinical Neurophysiology Department, Lille University Medical Center, Lille, France.
| | - C Tard
- Université Lille Nord de France, UDSL, Lille, France; Laboratoire de Neurosciences Fonctionnelles et Pathologies, EA 4559, Lille 2, Lille, France; Neurology and Movement Disorders Department, Lille University Medical Center, Lille, France
| | - L Defebvre
- Université Lille Nord de France, UDSL, Lille, France; Laboratoire de Neurosciences Fonctionnelles et Pathologies, EA 4559, Lille 2, Lille, France; Neurology and Movement Disorders Department, Lille University Medical Center, Lille, France
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Nieuwboer A, Giladi N. Characterizing freezing of gait in Parkinson's disease: Models of an episodic phenomenon. Mov Disord 2013; 28:1509-19. [DOI: 10.1002/mds.25683] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 08/13/2013] [Accepted: 08/22/2013] [Indexed: 11/06/2022] Open
Affiliation(s)
- Alice Nieuwboer
- Department of Rehabilitation Sciences; KU Leuven Leuven Belgium
| | - Nir Giladi
- Movement Disorders Unit, Department of Neurology; Tel-Aviv Medical Center, Sackler School of Medicine; Sagol School of Neuroscience; Tel-Aviv University; Tel-Aviv Israel
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Schoneburg B, Mancini M, Horak F, Nutt JG. Framework for understanding balance dysfunction in Parkinson's disease. Mov Disord 2013; 28:1474-82. [PMID: 23925954 PMCID: PMC4001822 DOI: 10.1002/mds.25613] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/06/2013] [Accepted: 06/25/2013] [Indexed: 12/23/2022] Open
Abstract
People with Parkinson's disease (PD) suffer from progressive impairment in their mobility. Locomotor and balance dysfunction that impairs mobility in PD is an important cause of physical and psychosocial disability. The recognition and evaluation of balance dysfunction by the clinician are an essential component of managing PD. In this review, we describe a framework for understanding balance dysfunction in PD to help clinicians recognize patients who are at risk for falling and impaired mobility.
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Affiliation(s)
| | | | - Fay Horak
- Dept. of Neurology, Oregon Health & Science University
| | - John G. Nutt
- Dept. of Neurology, Oregon Health & Science University
- Portland VA Medical Center
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Luca CC, Singer C. Can 4-aminopyridine modulate dysfunctional gait networks in Parkinson's disease? Parkinsonism Relat Disord 2013; 19:777-82. [DOI: 10.1016/j.parkreldis.2013.04.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/23/2013] [Accepted: 04/25/2013] [Indexed: 11/28/2022]
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