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Aquino CHD, Moscovich M, Marinho MM, Barcelos LB, Felício AC, Halverson M, Hamani C, Ferraz HB, Munhoz RP. Fundamentals of deep brain stimulation for Parkinson's disease in clinical practice: part 1. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-9. [PMID: 38653485 PMCID: PMC11039067 DOI: 10.1055/s-0044-1786026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 02/22/2024] [Indexed: 04/25/2024]
Abstract
Deep brain stimulation (DBS) is recognized as an established therapy for Parkinson's disease (PD) and other movement disorders in the light of the developments seen over the past three decades. Long-term efficacy is established for PD with documented improvement in the cardinal motor symptoms of PD and levodopa-induced complications, such as motor fluctuations and dyskinesias. Timing of patient selection is crucial to obtain optimal benefits from DBS therapy, before PD complications become irreversible. The objective of this first part review is to examine the fundamental concepts of DBS for PD in clinical practice, discussing the historical aspects, patient selection, potential effects of DBS on motor and non-motor symptoms, and the practical management of patients after surgery.
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Affiliation(s)
- Camila Henriques de Aquino
- University of Calgary, Cumming School of Medicine, Department of Clinical Neurosciences, Calgary, AB, Canada.
- University of Calgary, Hotchkiss Brain Institute, Calgary, AB, Canada.
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
| | - Mariana Moscovich
- Christian-Albrechts University, Department of Neurology, Kiel, Germany.
| | - Murilo Martinez Marinho
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
| | - Lorena Broseghini Barcelos
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
| | | | - Matthew Halverson
- University of Utah, Department of Neurology, Salt Lake City, Utah, United States.
| | - Clement Hamani
- University of Toronto, Sunnybrook Hospital, Toronto, ON, Canada.
| | - Henrique Ballalai Ferraz
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
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Cavallieri F, Campanini I, Gessani A, Budriesi C, Fioravanti V, Di Rauso G, Feletti A, Damiano B, Scaltriti S, Guagnano N, Bardi E, Corni MG, Rossi J, Antonelli F, Cavalleri F, Molinari MA, Contardi S, Menozzi E, Puzzolante A, Vannozzi G, Bergamini E, Pavesi G, Meoni S, Fraix V, Fraternali A, Versari A, Lusuardi M, Biagini G, Merlo A, Moro E, Valzania F. Long-term effects of bilateral subthalamic nucleus deep brain stimulation on gait disorders in Parkinson's disease: a clinical-instrumental study. J Neurol 2023; 270:4342-4353. [PMID: 37208527 DOI: 10.1007/s00415-023-11780-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/21/2023] [Accepted: 05/12/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To assess the long-term effects of bilateral subthalamic nucleus deep brain stimulation (STN-DBS) on gait in a cohort of advanced Parkinson's Disease (PD) patients. METHODS This observational study included consecutive PD patients treated with bilateral STN-DBS. Different stimulation and drug treatment conditions were assessed: on-stimulation/off-medication, off-stimulation/off-medication, and on-stimulation/on-medication. Each patient performed the instrumented Timed Up and Go test (iTUG). The instrumental evaluation of walking ability was carried out with a wearable inertial sensor containing a three-dimensional (3D) accelerometer, gyroscope, and magnetometer. This device could provide 3D linear acceleration, angular velocity, and magnetic field vector. Disease motor severity was evaluated with the total score and subscores of the Unified Parkinson Disease Rating Scale part III. RESULTS Twenty-five PD patients with a 5-years median follow-up after surgery (range 3-7) were included (18 men; mean disease duration at surgery 10.44 ± 4.62 years; mean age at surgery 58.40 ± 5.73 years). Both stimulation and medication reduced the total duration of the iTUG and most of its different phases, suggesting a long-term beneficial effect on gait after surgery. However, comparing the two treatments, dopaminergic therapy had a more marked effect in all test phases. STN-DBS alone reduced total iTUG duration, sit-to-stand, and second turn phases duration, while it had a lower effect on stand-to-sit, first turn, forward walking, and walking backward phases duration. CONCLUSIONS This study highlighted that in the long-term after surgery, STN-DBS may contribute to gait and postural control improvement when used together with dopamine replacement therapy, which still shows a substantial beneficial effect.
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Affiliation(s)
- Francesco Cavallieri
- Neuromotor and Rehabilitation Department, Neurology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Isabella Campanini
- LAM-Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS Di Reggio Emilia, S. Sebastiano Hospital, Correggio, Italy.
| | - Annalisa Gessani
- Department of Neuroscience, Neurology Unit, S. Agostino Estense Hospital, AziendaOspedaliero-Universitaria di Modena, Modena, Italy
| | - Carla Budriesi
- Department of Neuroscience, Neurology Unit, S. Agostino Estense Hospital, AziendaOspedaliero-Universitaria di Modena, Modena, Italy
| | - Valentina Fioravanti
- Neuromotor and Rehabilitation Department, Neurology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giulia Di Rauso
- Neuromotor and Rehabilitation Department, Neurology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Department of Neuroscience, Neurology Unit, S. Agostino Estense Hospital, AziendaOspedaliero-Universitaria di Modena, Modena, Italy
| | - Alberto Feletti
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona, Italy
- Neurosurgery Unit, Azienda Ospedaliero-Universitaria of Modena, Ospedale Civile Baggiovara (OCB) Hospital, Modena, Italy
| | - Benedetta Damiano
- LAM-Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS Di Reggio Emilia, S. Sebastiano Hospital, Correggio, Italy
| | - Sara Scaltriti
- LAM-Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS Di Reggio Emilia, S. Sebastiano Hospital, Correggio, Italy
| | - Noemi Guagnano
- LAM-Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS Di Reggio Emilia, S. Sebastiano Hospital, Correggio, Italy
| | - Elisa Bardi
- Department of Neuroscience, Neurology Unit, S. Agostino Estense Hospital, AziendaOspedaliero-Universitaria di Modena, Modena, Italy
| | - Maria Giulia Corni
- Department of Neuroscience, Neurology Unit, S. Agostino Estense Hospital, AziendaOspedaliero-Universitaria di Modena, Modena, Italy
| | - Jessica Rossi
- Neuromotor and Rehabilitation Department, Neurology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Francesca Antonelli
- Department of Neuroscience, Neurology Unit, S. Agostino Estense Hospital, AziendaOspedaliero-Universitaria di Modena, Modena, Italy
| | - Francesca Cavalleri
- Division of Neuroradiology, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino Estense, Modena, Italy
| | - Maria Angela Molinari
- Department of Neuroscience, Neurology Unit, S. Agostino Estense Hospital, AziendaOspedaliero-Universitaria di Modena, Modena, Italy
| | - Sara Contardi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Elisa Menozzi
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Annette Puzzolante
- Neurosurgery Unit, Azienda Ospedaliero-Universitaria of Modena, Ospedale Civile Baggiovara (OCB) Hospital, Modena, Italy
| | - Giuseppe Vannozzi
- Laboratory of Bioengineering and Neuromechanics, Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
| | - Elena Bergamini
- Laboratory of Bioengineering and Neuromechanics, Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
| | - Giacomo Pavesi
- Neurosurgery Unit, Azienda Ospedaliero-Universitaria of Modena, Ospedale Civile Baggiovara (OCB) Hospital, Modena, Italy
| | - Sara Meoni
- Division of Neurology, Grenoble Alpes University, Centre HospitalierUniversitaire de Grenoble, Grenoble Institute of Neuroscience, Grenoble, France
| | - Valérie Fraix
- Division of Neurology, Grenoble Alpes University, Centre HospitalierUniversitaire de Grenoble, Grenoble Institute of Neuroscience, Grenoble, France
| | | | - Annibale Versari
- Nuclear Medicine Unit, Azienda Unità Sanitaria Locale IRCCS, Reggio Emilia, Italy
| | - Mirco Lusuardi
- Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42015, Reggio Emilia, Italy
| | - Giuseppe Biagini
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Merlo
- LAM-Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS Di Reggio Emilia, S. Sebastiano Hospital, Correggio, Italy
| | - Elena Moro
- Division of Neurology, Grenoble Alpes University, Centre HospitalierUniversitaire de Grenoble, Grenoble Institute of Neuroscience, Grenoble, France
| | - Franco Valzania
- Neuromotor and Rehabilitation Department, Neurology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Su ZH, Patel S, Gavine B, Buchanan T, Bogdanovic M, Sarangmat N, Green AL, Bloem BR, FitzGerald JJ, Antoniades CA. Deep Brain Stimulation and Levodopa Affect Gait Variability in Parkinson Disease Differently. Neuromodulation 2023; 26:382-393. [PMID: 35562261 DOI: 10.1016/j.neurom.2022.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/07/2022] [Accepted: 02/06/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Both dopaminergic medication and subthalamic nucleus (STN) deep brain stimulation (DBS) can improve the amplitude and speed of gait in Parkinson disease (PD), but relatively little is known about their comparative effects on gait variability. Gait irregularity has been linked to the degeneration of cholinergic neurons in the pedunculopontine nucleus (PPN). OBJECTIVES The STN and PPN have reciprocal connections, and we hypothesized that STN DBS might improve gait variability by modulating PPN function. Dopaminergic medication should not do this, and we therefore sought to compare the effects of medication and STN DBS on gait variability. MATERIALS AND METHODS We studied 11 patients with STN DBS systems on and off with no alteration to their medication, and 15 patients with PD without DBS systems on and off medication. Participants walked for two minutes in each state, wearing six inertial measurement units. Variability has previously often been expressed in terms of SD or coefficient of variation over a testing session, but these measures conflate long-term variability (eg, gradual slowing, which is not necessarily pathological) with short-term variability (true irregularity). We used Poincaré analysis to separate the short- and long-term variability. RESULTS DBS decreased short-term variability in lower limb gait parameters, whereas medication did not have this effect. In contrast, STN DBS had no effect on arm swing and trunk motion variability, whereas medication increased them, without obvious dyskinesia. CONCLUSIONS Our results suggest that STN DBS acts through a nondopaminergic mechanism to reduce gait variability. We believe that the most likely explanation is the retrograde activation of cholinergic PPN projection neurons.
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Affiliation(s)
- Zi H Su
- NeuroMetrology Lab, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Salil Patel
- NeuroMetrology Lab, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Bronwyn Gavine
- NeuroMetrology Lab, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Marko Bogdanovic
- Oxford Functional Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | | | - Alexander L Green
- Oxford Functional Neurosurgery, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Bastiaan R Bloem
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - James J FitzGerald
- NeuroMetrology Lab, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Oxford Functional Neurosurgery, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Chrystalina A Antoniades
- NeuroMetrology Lab, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
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Freezing of Gait in Parkinson’s Disease Patients Treated with Bilateral Subthalamic Nucleus Deep Brain Stimulation: A Long-Term Overview. Biomedicines 2022; 10:biomedicines10092214. [PMID: 36140318 PMCID: PMC9496255 DOI: 10.3390/biomedicines10092214] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/01/2022] [Accepted: 09/03/2022] [Indexed: 11/16/2022] Open
Abstract
Bilateral subthalamic nucleus deep brain stimulation (STN-DBS) is an effective treatment in advanced Parkinson’s Disease (PD). However, the effects of STN-DBS on freezing of gait (FOG) are still debated, particularly in the long-term follow-up (≥5-years). The main aim of the current study is to evaluate the long-term effects of STN-DBS on FOG. Twenty STN-DBS treated PD patients were included. Each patient was assessed before surgery through a detailed neurological evaluation, including FOG score, and revaluated in the long-term (median follow-up: 5-years) in different stimulation and drug conditions. In the long term follow-up, FOG score significantly worsened in the off-stimulation/off-medication condition compared with the pre-operative off-medication assessment (z = −1.930; p = 0.05) but not in the on-stimulation/off-medication (z = −0.357; p = 0.721). There was also a significant improvement of FOG at long-term assessment by comparing on-stimulation/off-medication and off-stimulation/off-medication conditions (z = −2.944; p = 0.003). These results highlight the possible beneficial long-term effects of STN-DBS on FOG.
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Pozzi NG, Palmisano C, Reich MM, Capetian P, Pacchetti C, Volkmann J, Isaias IU. Troubleshooting Gait Disturbances in Parkinson's Disease With Deep Brain Stimulation. Front Hum Neurosci 2022; 16:806513. [PMID: 35652005 PMCID: PMC9148971 DOI: 10.3389/fnhum.2022.806513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 03/16/2022] [Indexed: 01/08/2023] Open
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus or the globus pallidus is an established treatment for Parkinson's disease (PD) that yields a marked and lasting improvement of motor symptoms. Yet, DBS benefit on gait disturbances in PD is still debated and can be a source of dissatisfaction and poor quality of life. Gait disturbances in PD encompass a variety of clinical manifestations and rely on different pathophysiological bases. While gait disturbances arising years after DBS surgery can be related to disease progression, early impairment of gait may be secondary to treatable causes and benefits from DBS reprogramming. In this review, we tackle the issue of gait disturbances in PD patients with DBS by discussing their neurophysiological basis, providing a detailed clinical characterization, and proposing a pragmatic programming approach to support their management.
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Affiliation(s)
- Nicoló G. Pozzi
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Chiara Palmisano
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Martin M. Reich
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Philip Capetian
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Claudio Pacchetti
- Parkinson’s Disease and Movement Disorders Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Jens Volkmann
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Ioannis U. Isaias
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
- Parkinson Institute Milan, ASST Gaetano Pini-CTO, Milan, Italy
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Schott FP, Gulberti A, Pinnschmidt HO, Gerloff C, Moll CKE, Schaper M, Koeppen JA, Hamel W, Pötter-Nerger M. Subthalamic Deep Brain Stimulation Lead Asymmetry Impacts the Parkinsonian Gait Disorder. Front Hum Neurosci 2022; 16:788200. [PMID: 35418844 PMCID: PMC8995434 DOI: 10.3389/fnhum.2022.788200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe preferable position of Deep Brain Stimulation (DBS) electrodes is proposed to be located in the dorsolateral subthalamic nucleus (STN) to improve general motor performance. The optimal DBS electrode localization for the post-operative improvement of balance and gait is unknown.MethodsIn this single-center, retrospective analyses, 66 Parkinson’s disease (PD) patients (24 female, age 63 ± 7 years) were assessed pre- and post-operatively (8.45 ± 4.2 months after surgery) by using MDS-UPDRS, freezing of gait (FoG) score, Giladi’s gait and falls questionnaire and Berg balance scale. The clinical outcome was related to the DBS electrode coordinates in x, y, z plane as revealed by image-based reconstruction (SureTune™). Binomial generalized linear mixed models with fixed-effect variables electrode asymmetry, parkinsonian subtype, medication, age class and clinical DBS induced changes were analyzed.ResultsSubthalamic nucleus-deep brain stimulation improved all motor, balance and FoG scores in MED OFF condition, however there were heterogeneous results in MED ON condition. DBS electrode reconstructed coordinates impacted the responsiveness of axial symptoms. FoG and balance responders showed slightly more medially located STN electrode coordinates and less medio-lateral asymmetry of the electrode reconstructed coordinates across hemispheres compared to non-responders.ConclusionDeep brain stimulation electrode reconstructed coordinates, particularly electrode asymmetry on the medio-lateral axis affected the post-operative responsiveness of balance and FoG symptoms in PD patients.
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Affiliation(s)
- Frederik P. Schott
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandro Gulberti
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O. Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian K. E. Moll
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miriam Schaper
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes A. Koeppen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Hamel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Monika Pötter-Nerger,
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Chen T, Lin F, Cai G. Comparison of the Efficacy of Deep Brain Stimulation in Different Targets in Improving Gait in Parkinson's Disease: A Systematic Review and Bayesian Network Meta-Analysis. Front Hum Neurosci 2021; 15:749722. [PMID: 34744665 PMCID: PMC8568957 DOI: 10.3389/fnhum.2021.749722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/02/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Although a variety of targets for deep brain stimulation (DBS) have been found to be effective in Parkinson's disease (PD), it remains unclear which target for DBS leads to the best improvement in gait disorders in patients with PD. The purpose of this network meta-analysis (NMA) is to compare the efficacy of subthalamic nucleus (STN)-DBS, internal globus pallidus (GPi)-DBS, and pedunculopontine nucleus (PPN)-DBS, in improving gait disorders in patients with PD. Methods: We searched the PubMed database for articles published from January 1990 to December 2020. We used various languages to search for relevant documents to reduce language bias. A Bayesian NMA and systematic review of randomized and non-randomized controlled trials were conducted to explore the effects of different targets for DBS on gait damage. Result: In the 34 included studies, 538 patients with PD met the inclusion criteria. The NMA results of the effect of the DBS “on and off” on the mean change of the gait of the patients in medication-off show that GPi-DBS, STN-DBS, and PPN-DBS are significantly better than the baseline [GPi-DBS: –0.79(–1.2, –0.41), STN-DBS: –0.97(–1.1, –0.81), and PPN-DBS: –0.56(–1.1, –0.021)]. According to the surface under the cumulative ranking (SUCRA) score, the STN-DBS (SUCRA = 74.15%) ranked first, followed by the GPi-DBS (SUCRA = 48.30%), and the PPN-DBS (SUCRA = 27.20%) ranked last. The NMA results of the effect of the DBS “on and off” on the mean change of the gait of the patients in medication-on show that, compared with baseline, GPi-DBS and STN-DBS proved to be significantly effective [GPi-DBS: –0.53 (–1.0, –0.088) and STN-DBS: –0.47(–0.66, –0.29)]. The GPi-DBS ranked first (SUCRA = 59.00%), followed by STN-DBS(SUCRA = 51.70%), and PPN-DBS(SUCRA = 35.93%) ranked last. Conclusion: The meta-analysis results show that both the STN-DBS and GPi-DBS can affect certain aspects of PD gait disorder.
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Affiliation(s)
- Tianyi Chen
- School of Mathematics, Shandong University, Jinan, China
| | - Fabin Lin
- Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Key Laboratory of Molecular Neurology, Institute of Clinical Neurology, Institute of Neuroscience, Fujian Medical University, Fuzhou, China
| | - Guoen Cai
- Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Key Laboratory of Molecular Neurology, Institute of Clinical Neurology, Institute of Neuroscience, Fujian Medical University, Fuzhou, China
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Brozova H, Barnaure I, Ruzicka E, Stochl J, Alterman R, Tagliati M. Short- and Long-Term Effects of DBS on Gait in Parkinson's Disease. Front Neurol 2021; 12:688760. [PMID: 34690908 PMCID: PMC8531078 DOI: 10.3389/fneur.2021.688760] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/11/2021] [Indexed: 12/18/2022] Open
Abstract
The aim was to compare the short and long-term effects of subthalamic nucleus (STN) deep brain stimulation (DBS) on gait dysfunction and other cardinal symptoms of Parkinson's disease (PD). Two groups of patients were studied. The first group (short-term DBS, n = 8) included patients recently implanted with STN DBS (mean time since DBS 15.8 months, mean age 58.8 years, PD duration 13 years); the second group (long-term DBS, n = 10) included patients with at least 5 years of DBS therapy (mean time since DBS 67.6 months, mean age 61.7 years, PD duration 17.1 years). Both groups were examined using the Unified Parkinson's Disease Rating Scale (UPDRS) and Gait and Balance scale (GABS) during four stimulation/medication states (ON/OFF; OFF/OFF; OFF/ON; ON/ON). Data were analyzed using repeated measures ANOVA with time since implantation (years) between groups and medication or DBS effect (ON, OFF) within groups. In the short-term DBS group, stimulation improved all UPDRS subscores similar to dopaminergic medications. In particular, average gait improvement was over 40% (p = 0.01), as measured by the UPDRS item 29 and GABS II. In the long-term DBS group, stimulation consistently improved all clinical subscores with the exception of gait and postural instability. In these patients, the effect of levodopa on gait was partially preserved. Short-term improvement of gait abnormalities appears to significantly decline after 5 years of STN DBS in PD patients, while effectiveness for other symptoms remains stable. Progressive non-dopaminergic (non-DBS responsive) mechanisms or deleterious effects of high frequency STN stimulation on gait function may play a role.
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Affiliation(s)
- Hana Brozova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Isabelle Barnaure
- Department of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Evzen Ruzicka
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Jan Stochl
- Department of Kinanthropology, Charles University in Prague, Prague, Czechia.,Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Ron Alterman
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Michele Tagliati
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Deep Brain Stimulation Selection Criteria for Parkinson's Disease: Time to Go beyond CAPSIT-PD. J Clin Med 2020; 9:jcm9123931. [PMID: 33291579 PMCID: PMC7761824 DOI: 10.3390/jcm9123931] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 11/24/2020] [Accepted: 12/02/2020] [Indexed: 12/13/2022] Open
Abstract
Despite being introduced in clinical practice more than 20 years ago, selection criteria for deep brain stimulation (DBS) in Parkinson's disease (PD) rely on a document published in 1999 called 'Core Assessment Program for Surgical Interventional Therapies in Parkinson's Disease'. These criteria are useful in supporting the selection of candidates. However, they are both restrictive and out-of-date, because the knowledge on PD progression and phenotyping has massively evolved. Advances in understanding the heterogeneity of PD presentation, courses, phenotypes, and genotypes, render a better identification of good DBS outcome predictors a research priority. Additionally, DBS invasiveness, cost, and the possibility of serious adverse events make it mandatory to predict as accurately as possible the clinical outcome when informing the patients about their suitability for surgery. In this viewpoint, we analyzed the pre-surgical assessment according to the following topics: early versus delayed DBS; the evolution of the levodopa challenge test; and the relevance of axial symptoms; patient-centered outcome measures; non-motor symptoms; and genetics. Based on the literature, we encourage rethinking of the selection process for DBS in PD, which should move toward a broad clinical and instrumental assessment of non-motor symptoms, quantitative measurement of gait, posture, and balance, and in-depth genotypic and phenotypic characterization.
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Navratilova D, Krobot A, Otruba P, Nevrly M, Krahulik D, Kolar P, Kolarova B, Kaiserova M, Mensikova K, Vastik M, Kurcova S, Kanovsky P. Deep Brain Stimulation Effects on Gait Pattern in Advanced Parkinson's Disease Patients. Front Neurosci 2020; 14:814. [PMID: 32922256 PMCID: PMC7456806 DOI: 10.3389/fnins.2020.00814] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 07/10/2020] [Indexed: 12/12/2022] Open
Abstract
Background Gait disturbance accompanies many neurodegenerative diseases; it is characteristic for Parkinson’s disease (PD). Treatment of advanced PD often includes deep brain stimulation (DBS) of the subthalamic nucleus. Regarding gait, previous studies have reported non-significant or conflicting results, possibly related to methodological limitations. Objective The objective of this prospective study was to assess the effects of DBS on biomechanical parameters of gait in patients with PD. Methods Twenty-one patients with advanced PD participated in this prospective study. Gait was examined in all patients using the Zebris FDM-T pressure-sensitive treadmill (Isny, Germany) before DBS implantation and after surgery immediately, further immediately after the start of neurostimulation, and 3 months after neurostimulator activation. We assessed spontaneous gait on a moving treadmill at different speeds. Step length, stance phase of both lower limbs, double-stance phase, and cadence were evaluated. Results In this study, step length increased, allowing the cadence to decrease. Double-stance phase duration, that is, the most sensitive parameter of gait quality and unsteadiness, was reduced, in gait at a speed of 4.5 km/h and in the narrow-based gaits at 1 km/h (tandem gait), which demonstrates improvement. Conclusion This study suggests positive effects of DBS treatment on gait in PD patients. Improvement was observed in several biomechanical parameters of gait.
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Affiliation(s)
- Daniela Navratilova
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Alois Krobot
- Department of Rehabilitation, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Pavel Otruba
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Martin Nevrly
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - David Krahulik
- Department of Neurosurgery, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Petr Kolar
- Department of Rehabilitation, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Barbora Kolarova
- Department of Rehabilitation, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Michaela Kaiserova
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Katerina Mensikova
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Miroslav Vastik
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Sandra Kurcova
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Petr Kanovsky
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
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Vaugoyeau M, Cignetti F, Eusebio A, Azulay JP. Subthalamic Deep Brain Stimulation Modulates Proprioceptive Integration in Parkinson's Disease During a Postural Task. Neuroscience 2020; 437:207-214. [PMID: 32339627 DOI: 10.1016/j.neuroscience.2020.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 01/15/2023]
Abstract
Defective proprioceptive integration may play a role in the pathophysiology of motor symptoms in Parkinson's disease (PD). Dysfunction related to proprioceptively-evoked postural reactions in PD patients is still a controversial issue, with only a limited number of studies to date and mostly discordant results. The aims of the present study were (1) to determine whether or not the proprioceptive defect in PD underlies postural impairment and (2) whether or not deep brain stimulation of the subthalamic nucleus (STN-DBS) affects proprioceptive integration. We examined proprioceptive integration during a postural task in 13 PD patients and 12 age-matched control subjects, using a muscle-tendon vibration paradigm. Analysis of the center of pressure displacement and kinematic data indicates a greater degree of postural destabilization and a reduced ability to maintain a vertical orientation in PD. We found a significant positive effect of STN-DBS on these postural features. Our findings indicate that Parkinson patients, even in the absence of any clinical evidence of instability, falls, or freezing, use proprioceptive information for postural control less efficiently than healthy subjects. Furthermore, STN-DBS was found to improve proprioceptive integration, with positive impacts on postural orientation and balance.
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Affiliation(s)
- M Vaugoyeau
- CNRS, Aix Marseille Univ, LNC UMR 7291, Marseille, France; CNRS, Aix Marseille Univ, Fédération 3C FR 3512, Marseille, France.
| | - F Cignetti
- Univ. Grenoble Alpes, CNRS, TIMC-IMAG, F-38000 Grenoble, France
| | - A Eusebio
- CNRS, Aix Marseille Univ, UMR 7289, Aix Marseille Université, CNRS, 13385, Marseille, France; Aix Marseille Univ, APHM, CHU Timone, Department of Neurology and Movement Disorders, Marseille, France
| | - J P Azulay
- CNRS, Aix Marseille Univ, LNC UMR 7291, Marseille, France; CNRS, Aix Marseille Univ, Fédération 3C FR 3512, Marseille, France; Aix Marseille Univ, APHM, CHU Timone, Department of Neurology and Movement Disorders, Marseille, France
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Szlufik S, Kloda M, Friedman A, Potrzebowska I, Gregier K, Mandat T, Przybyszewski A, Dutkiewicz J, Figura M, Habela P, Koziorowski D. The Neuromodulatory Impact of Subthalamic Nucleus Deep Brain Stimulation on Gait and Postural Instability in Parkinson's Disease Patients: A Prospective Case Controlled Study. Front Neurol 2018; 9:906. [PMID: 30429820 PMCID: PMC6220087 DOI: 10.3389/fneur.2018.00906] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/08/2018] [Indexed: 01/20/2023] Open
Abstract
Background: Subthalamic nucleus deep brain stimulation (STN-DBS) has been an established method in improvement of motor disabilities in Parkinson's disease (PD) patients. It has been also claimed to have an impact on balance and gait disorders in PD patients, but the previous results are conflicting. Objective: The aim of this prospective controlled study was to evaluate the impact of STN-DBS on balance disorders in PD patients in comparison with Best-Medical-Therapy (BMT) and Long-term-Post-Operative (POP) group. Methods: DBS-group consisted of 20 PD patients (8F, 12M) who underwent bilateral STN DBS. POP-group consisted of 14 post-DBS patients (6F, 8M) in median 30 months-time after surgery. Control group (BMT-group) consisted of 20 patients (11F, 9M) who did not undergo surgical intervention. UPDRS III scale and balance tests (Up And Go Test, Dual Task- Timed Up And Go Test, Tandem Walk Test) and posturography parameters were measured during 3 visits in 9 ± 2months periods (V1, V2, V3) 4 phases of treatment (BMT-ON/OFF, DBS-ON/OFF). Results: We have observed the slowdown of gait and postural instability progression in first 9 post-operative months followed by co-existent enhancement of balance disorders in next 9-months evaluation (p < 0.05) in balance tests (Up and Go, TWT) and in posturography examination parameters (p < 0.05). The effect was not observed neither in BMT-group nor POP-group (p > 0.05): these groups revealed constant progression of static and dynamic instability (p > 0.05). Conclusions: STN-DBS can have modulatory effect on static and dynamic instability in PD patients: it can temporarily improve balance disorders. mainly during first 9 post-operative months, but with possible following deterioration of the symptoms in next post-operative months.
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Affiliation(s)
- Stanislaw Szlufik
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
| | - Maria Kloda
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland.,Department of Rehabilitation, II Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Friedman
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
| | - Iwona Potrzebowska
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland.,Department of Rehabilitation, II Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Kacper Gregier
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Mandat
- Department of Neurosurgery, Maria Sklodowska Curie Memorial Oncology Center, Warsaw, Warsaw, Poland
| | - Andrzej Przybyszewski
- Department of Informatics, Polish Japanese Academy of Information Technology, Warsaw, Poland
| | - Justyna Dutkiewicz
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
| | - Monika Figura
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Habela
- Department of Informatics, Polish Japanese Academy of Information Technology, Warsaw, Poland
| | - Dariusz Koziorowski
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
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Debû B, De Oliveira Godeiro C, Lino JC, Moro E. Managing Gait, Balance, and Posture in Parkinson's Disease. Curr Neurol Neurosci Rep 2018; 18:23. [PMID: 29623455 DOI: 10.1007/s11910-018-0828-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Postural instability and gait difficulties inexorably worsen with Parkinson's disease (PD) progression and become treatment resistant, with a severe impact on autonomy and quality of life. We review the main characteristics of balance instability, gait disabilities, and static postural alterations in advanced PD, and the available treatment strategies. RECENT FINDINGS It remains very difficult to satisfactorily alleviate gait and postural disturbances in advanced PD. Medical and surgical interventions often fail to provide satisfactory or durable alleviation of these axial symptoms, that may actually call for differential treatments. Exercise and adapted physical activity programs can contribute to improving the patients' condition. Gait, balance, and postural disabilities are often lumped together under the Postural Instability and Gait Difficulties umbrella term. This may lead to sub-optimal patients' management as data suggest that postural, balance, and gait problems might depend on distinct underlying mechanisms. We advocate for a multidisciplinary approach from the day of diagnosis.
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Affiliation(s)
- Bettina Debû
- University Grenoble Alpes, Grenoble, France.
- INSERM U1216, Grenoble, France.
| | - Clecio De Oliveira Godeiro
- INSERM U1216, Grenoble, France
- Movement Disorders Unit, Division of Neurology, CHU Grenoble Alpes, Grenoble, France
- Division of Neurology, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Jarbas Correa Lino
- INSERM U1216, Grenoble, France
- Movement Disorders Unit, Division of Neurology, CHU Grenoble Alpes, Grenoble, France
- Division of Neurology, CHU Amiens, Amiens, France
| | - Elena Moro
- University Grenoble Alpes, Grenoble, France
- INSERM U1216, Grenoble, France
- Movement Disorders Unit, Division of Neurology, CHU Grenoble Alpes, Grenoble, France
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Neuromodulatory procedures for gait disorders in Parkinson's disease. Acta Neurol Belg 2018; 118:13-19. [PMID: 29139079 DOI: 10.1007/s13760-017-0862-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 11/08/2017] [Indexed: 01/25/2023]
Abstract
The neurophysiology of gait is complex and involves numerous structures in the central nervous system. Gait disorders occur frequently in Parkinson's disease (PD), and their management may become cumbersome, especially in the more advanced stages. Neuromodulatory treatments, including deep brain stimulation, cortical stimulation and spinal cord stimulation, are reviewed with respect to their effectiveness to improve gait in PD patients. Although positive effects have been reported for all of these procedures, many issues remain in view of methodological heterogeneity, variability in outcome measures and sample size. Gait in PD remains a difficult issue with a tremendous impact on quality of life, for which future research is badly needed.
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A meta-analysis of the pedunculopontine nucleus deep-brain stimulation effects on Parkinson's disease. Neuroreport 2018; 27:1336-1344. [PMID: 27779555 DOI: 10.1097/wnr.0000000000000697] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postural instability and gait disturbance (PIGD) are common symptoms in patients with advanced Parkinson's disease (PD). The deep-brain stimulation (DBS) of the pedunculopontine nucleus (PPN) shows a promising effect on PIGD. However, the quantitative effects of PPN DBS for PD, especially for PIGD, and the efficacy of PPN DBS combined with levodopa are controversial and ambiguous to clinical practice. We carried out a meta-analysis of original researches on PPN to PIGD/PD from the electronic databases MEDLINE and EMBASE. The scores of united Parkinson's disease rating scores (UPDRS) III were used to evaluate the improvement in motor function and the scores of UPDRS III subitems 27-30 were used to evaluate the improvement in PIGD. The outcome was expressed as the mean difference and the percentage change between the scores of baseline and end point. The quality of studies was assessed using the 'assessing risk of bias' table. Overall, 909 articles were screened and seven studies were included with a total of 45 patients. The improvement in PIGD was significant, but there were no such effects on motor function. All the differences in PIGD scores were greater in the OFF medicine state rather than the ON medicine state, especially in the comparison between postsurgery ON stimulation and presurgery. PPN DBS indeed improved PIGD in advanced PD patients. This result could inspire more researchers to focus on its clinical application.
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De la Casa-Fages B, Alonso-Frech F, Grandas F. Effect of subthalamic nucleus deep brain stimulation on balance in Parkinson's disease: A static posturographic analysis. Gait Posture 2017; 52:374-380. [PMID: 28061431 DOI: 10.1016/j.gaitpost.2016.12.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 12/17/2016] [Accepted: 12/20/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The effect of subthalamic deep brain stimulation on balance in Parkinson's disease remains unclear. OBJECTIVE To evaluate the effect of subthalamic nucleus stimulation on balance in Parkinson's disease using posturography. METHODS 16 patients (9 women) who underwent subthalamic deep brain stimulation [mean age 59.6 years (46-70); mean disease duration 15.6 years (7-25); mean duration of subthalamic stimulation 32.1 months (3.0-69.6)] and 13 healthy age-matched controls were evaluated using a static posturography analysis. Patients were assessed under four conditions: 1) off medication/off stimulation; 2) off medication/on stimulation; 3) on medication/off stimulation and 4) on medication/on stimulation in ten experimental paradigms, some reproducing common situations of daily living. The displacement of the centre of pressure was analyzed using 14 posturographic parameters. The Mann-Whitney test was used to compare patients with controls. The Wilcoxon signed rank test was used to compare patients under different clinical conditions. RESULTS Patients off medication/off stimulation showed larger and more rapid displacements of the centre of pressure than controls in most paradigms (p<0.05), particularly when performing a dual task. Subthalamic stimulation alone reduced the lateral excursion and anterior-posterior velocity of the centre of pressure in quite stance paradigms (p<0.05). Subthalamic stimulation combined with antiparkinsonian medication did not induce statistically significant changes in posturagraphic measures in any experimental paradigm. CONCLUSIONS Although subthalamic stimulation alone may induce some positive effect on balance, subthalamic stimulation in addition to antiparkinsonian medication, which is the usual treatment in clinical practice, did not modify balance as assessed by static posturography in patients with Parkinson's disease.
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Affiliation(s)
- Beatriz De la Casa-Fages
- Movement Disorders Unit, Neurology Department, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo n°46, 28007, Madrid, Spain.
| | - Fernando Alonso-Frech
- Movement Disorders Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Calle del Prof Martín Lagos, s/n, 28040, Madrid, Spain.
| | - Francisco Grandas
- Movement Disorders Unit, Neurology Department, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo n°46, 28007, Madrid, Spain.
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Cole MH, Naughton GA, Silburn PA. Neuromuscular Impairments Are Associated With Impaired Head and Trunk Stability During Gait in Parkinson Fallers. Neurorehabil Neural Repair 2016; 31:34-47. [PMID: 27354398 DOI: 10.1177/1545968316656057] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The trunk plays a critical role in attenuating movement-related forces that threaten to challenge the body's postural control system. For people with Parkinson's disease (PD), disease progression often leads to dopamine-resistant axial symptoms, which impair trunk control and increase falls risk. Objective This prospective study aimed to evaluate the relationship between impaired trunk muscle function, segmental coordination, and future falls in people with PD. Methods Seventy-nine PD patients and 82 age-matched controls completed clinical assessments and questionnaires to establish their medical history, symptom severity, balance confidence, and falls history. Gait characteristics and trunk muscle activity were assessed using 3-dimensional motion analysis and surface electromyography. The incidence, cause, and consequence of any falls experienced over the next 12 months were recorded and indicated that 48 PD and 29 control participants fell at least once during this time. Results PD fallers had greater peak and baseline lumbar multifidus (LMF) and thoracic erector spinae (TES) activations than control fallers and nonfallers. Analysis of covariance indicated that the higher LMF activity was attributable to the stooped posture adopted by PD fallers, but TES activity was independent of medication use, symptom severity, and trunk orientation. Furthermore, greater LMF and TES baseline activity contributed to increasing lateral head, trunk, and pelvis movements in PD fallers but not nonfallers or controls. Conclusions The results provide evidence of neuromuscular deficits for PD fallers that are independent of medications, symptom severity, and posture and contribute to impaired head, trunk, and pelvis control associated with falls in this population.
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Affiliation(s)
- Michael H Cole
- Australian Catholic University, Banyo, Queensland, Australia
| | | | - Peter A Silburn
- The University of Queensland, Brisbane, Queensland, Australia
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18
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Effects of deep brain stimulation on balance and gait in patients with Parkinson's disease: A systematic neurophysiological review. Neurophysiol Clin 2015; 45:371-88. [DOI: 10.1016/j.neucli.2015.07.001] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 06/23/2015] [Accepted: 07/16/2015] [Indexed: 12/17/2022] Open
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Psychological Benefits of Nonpharmacological Methods Aimed for Improving Balance in Parkinson's Disease: A Systematic Review. Behav Neurol 2015; 2015:620674. [PMID: 26236107 PMCID: PMC4508472 DOI: 10.1155/2015/620674] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 06/07/2015] [Accepted: 06/10/2015] [Indexed: 01/20/2023] Open
Abstract
Parkinson's disease (PD) is a serious condition with a major negative impact on patient's physical and mental health. Postural instability is one of the cardinal difficulties reported by patients to deal with. Neuroanatomical, animal, and clinical studies on nonparkinsonian and parkinsonian subjects suggest an important correlation between the presence of balance dysfunction and multiple mood disorders, such as anxiety, depression, and apathy. Considering that balance dysfunction is a very common symptom in PD, we can presume that by its management we could positively influence patient's state of mind too. This review is an analysis of nonpharmacological methods shown to be effective and successful for improving balance in patients suffering from PD. Strategies such as general exercise, robotic assisted training, Tai Chi, Qi Gong, Yoga, dance (such as tango or ballet), box, virtual reality-based, or neurofeedback-based techniques and so forth can significantly improve the stability in these patients. Beside this physical outcome, many methods have also shown effect on quality of life, depression level, enjoyment, and motivation to continue in practicing the method independently. The purpose of this review is to provide information about practical and creative methods designed to improve balance in PD and highlight their positive impact on patient's psychology.
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Wu T, Hallett M, Chan P. Motor automaticity in Parkinson's disease. Neurobiol Dis 2015; 82:226-234. [PMID: 26102020 DOI: 10.1016/j.nbd.2015.06.014] [Citation(s) in RCA: 204] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 06/15/2015] [Accepted: 06/17/2015] [Indexed: 10/23/2022] Open
Abstract
Bradykinesia is the most important feature contributing to motor difficulties in Parkinson's disease (PD). However, the pathophysiology underlying bradykinesia is not fully understood. One important aspect is that PD patients have difficulty in performing learned motor skills automatically, but this problem has been generally overlooked. Here we review motor automaticity associated motor deficits in PD, such as reduced arm swing, decreased stride length, freezing of gait, micrographia and reduced facial expression. Recent neuroimaging studies have revealed some neural mechanisms underlying impaired motor automaticity in PD, including less efficient neural coding of movement, failure to shift automated motor skills to the sensorimotor striatum, instability of the automatic mode within the striatum, and use of attentional control and/or compensatory efforts to execute movements usually performed automatically in healthy people. PD patients lose previously acquired automatic skills due to their impaired sensorimotor striatum, and have difficulty in acquiring new automatic skills or restoring lost motor skills. More investigations on the pathophysiology of motor automaticity, the effect of L-dopa or surgical treatments on automaticity, and the potential role of using measures of automaticity in early diagnosis of PD would be valuable.
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Affiliation(s)
- Tao Wu
- Department of Neurobiology, Key Laboratory on Neurodegenerative Disorders of Ministry of Education, Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory on Parkinson's Disease, Parkinson Disease Center of Beijing Institute for Brain Disorders, Beijing, China.
| | - Mark Hallett
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Piu Chan
- Department of Neurobiology, Key Laboratory on Neurodegenerative Disorders of Ministry of Education, Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory on Parkinson's Disease, Parkinson Disease Center of Beijing Institute for Brain Disorders, Beijing, China
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Nonnekes J, Snijders AH, Nutt JG, Deuschl G, Giladi N, Bloem BR. Freezing of gait: a practical approach to management. Lancet Neurol 2015; 14:768-78. [PMID: 26018593 DOI: 10.1016/s1474-4422(15)00041-1] [Citation(s) in RCA: 232] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/22/2015] [Accepted: 03/30/2015] [Indexed: 01/09/2023]
Abstract
Freezing of gait is a common and disabling symptom in patients with parkinsonism, characterised by sudden and brief episodes of inability to produce effective forward stepping. These episodes typically occur during gait initiation or turning. Treatment is important because freezing of gait is a major risk factor for falls in parkinsonism, and a source of disability to patients. Various treatment approaches exist, including pharmacological and surgical options, as well as physiotherapy and occupational therapy, but evidence is inconclusive for many approaches, and clear treatment protocols are not available. To address this gap, we review medical and non-medical treatment strategies for freezing of gait and present a practical algorithm for the management of this disorder, based on a combination of evidence, when available, and clinical experience of the authors. Further research is needed to formally establish the merits of our proposed treatment protocol.
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Affiliation(s)
- Jorik Nonnekes
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Anke H Snijders
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - John G Nutt
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Günter Deuschl
- Department of Neurology, Christian-Albrechts University, Kiel, Germany
| | - Nir Giladi
- Sagol School for Neuroscience, Movement Disorders Unit, Department of Neurology, Tel-Aviv Medical Centre, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Bastiaan R Bloem
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands.
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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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Lilleeng B, Gjerstad M, Baardsen R, Dalen I, Larsen JP. Motor symptoms after deep brain stimulation of the subthalamic nucleus. Acta Neurol Scand 2015; 131:298-304. [PMID: 25346142 DOI: 10.1111/ane.12342] [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] [Accepted: 10/01/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Stimulation of the subthalamic nucleus (STN-DBS) is an established treatment with long-term beneficial effects on motor symptoms in patients with Parkinson's disease (PD). The efficacy of STN-DBS on non-dopaminergic motor symptoms remains less elucidated. In this study, we have examined short- and long-term impacts of STN-DBS on the development of the postural instability and gait difficulties (PIGD) phenotype, freezing of gait (FOG), and falls. MATERIALS AND METHODS We collected data from a prospectively followed cohort of patients that had been operated with STN-DBS 6-9 years before final examination and compared our findings to the longitudinal development of the same symptoms in a non-operated, historical reference population. RESULTS During short-term follow-up after surgery, we observed a marked improvement in mean UPDRS-motor score from 27 to 18. We also found clear improvements in tremor, bradykinesia, rigidity, and PIGD scores. However, 6-9 years after surgery, all patients had a dominating PIGD pattern of parkinsonism and 50% of the patients had developed FOG and/or had become recurrent fallers. The disease development in a group of patients with PD from the presurgery period had a similar trajectory as among the operated patients. In addition, mean annual change of both bradykinesia and PIGD scores was nearly identical in both study groups while tremor and rigidity had a significant better development in the operated patients. CONCLUSIONS We found that STN-DBS induces an acute improvement of PIGD symptoms. The following long-term development was however characterized by a marked progression of non-dopaminergic symptoms.
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Affiliation(s)
- B. Lilleeng
- The Norwegian Centre for Movement Disorders; Stavanger University Hospital; Stavanger Norway
| | - M. Gjerstad
- The Norwegian Centre for Movement Disorders; Stavanger University Hospital; Stavanger Norway
| | - R. Baardsen
- The Norwegian Centre for Movement Disorders; Stavanger University Hospital; Stavanger Norway
| | - I. Dalen
- The Norwegian Centre for Movement Disorders; Stavanger University Hospital; Stavanger Norway
| | - J. P. Larsen
- The Norwegian Centre for Movement Disorders; Stavanger University Hospital; Stavanger Norway
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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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Diab KS, Hale LA, Waters DL, Skinner MA. Factors contributing to postural instability in patients with idiopathic Parkinson’s disease. PHYSICAL THERAPY REVIEWS 2014. [DOI: 10.1179/1743288x14y.0000000148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Altuğ F, Acar F, Acar G, Cavlak U. The effects of brain stimulation of subthalamic nucleus surgery on gait and balance performance in Parkinson disease. A pilot study. Arch Med Sci 2014; 10:733-8. [PMID: 25276158 PMCID: PMC4175774 DOI: 10.5114/aoms.2012.31371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 03/12/2012] [Accepted: 05/11/2012] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Parkinson's disease (PD) is a progressive neurodegenerative disorder characterized by tremor, rigidity and bradykinesia. Gait and postural difficulties supersede tremor, rigidity and bradykinesia as drivers of disease burden in patients with advanced PD. The aim of this study was to describe the effects of deep brain stimulation of the subthalamic nucleus on gait ability and balance performance in patients with PD. MATERIAL AND METHODS We studied 19 consecutive patients who underwent bilateral stimulation of the subthalamic nucleus. Patients were evaluated preoperatively and at the 5(th) day and 6(th) month after surgery. Timed Up and Go Test, 12 m Walking Test, Chair Stand Test and Berg Balance Scale (BBS) were used to assess mobility and balance performance. Unified Parkinson's Disease Rating Scale (UPDRS III) and Hoehn and Yahr Scale were also used. RESULTS All the patients' mobility ability and balance performance improved after surgery (p < 0.05). At the 6th month after surgery, the Timed Up and Go Test scores were decreased from 56.05 ±42.52 to 21.47 ±20.36, the 12 m Walking Test scores were decreased from 100.44 ±66.44 to 28.84 ±19.79, the Chair Stand Test scores were increased from 4.00 ±4.66 to 11.68 ±4.43 and the BBS score was increased from 12.84 ±6.89 to 38.89 ±8.79. UPDRS total scores were significantly improved 6 months after surgery (p < 0.001). UPDRS total scores were decreased from 98.26 ±37.69 to 39.36 ±18.85. The Hoehn and Yahr Scale score was significantly decreased after surgery (p < 0.05). CONCLUSIONS Surgical therapy is an effective treatment to improve gait ability and balance performance in Parkinson's patients.
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Affiliation(s)
- Filiz Altuğ
- School of Physical Therapy and Rehabilitation, Pamukkale University, Denizli, Turkey
| | - Feridun Acar
- Department of Neurosurgery, Pamukkale University, Denizli, Turkey
| | - Göksemin Acar
- Department of Neurology, Pamukkale University, Denizli, Turkey
| | - Uğur Cavlak
- School of Physical Therapy and Rehabilitation, Pamukkale University, Denizli, Turkey
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Pötter-Nerger M, Volkmann J. Deep brain stimulation for gait and postural symptoms in Parkinson's disease. Mov Disord 2014; 28:1609-15. [PMID: 24132849 DOI: 10.1002/mds.25677] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 08/16/2013] [Indexed: 11/06/2022] Open
Abstract
In patients with Parkinson's disease, gait and balance difficulties have emerged as some of the main therapeutic concerns. During earlier stages of the disease, the dopamine-responsive aspects of gait disorder can be treated initially with dopaminergic drugs or deep brain stimulation. However, certain temporal aspects of parkinsonian gait disorder remain therapeutically resistant in both the short term and the long term. In this review, we summarize the effects of deep brain stimulation on gait and postural symptoms in the five currently available targets (subthalamic nucleus, globus pallidus, ventralis intermedius thalamic nucleus, pedunculopontine nucleus, and substantia nigra) and describe programming strategies for patients who are mainly disabled by gait problems.
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Maetzler W, Nieuwhof F, Hasmann SE, Bloem BR. Emerging therapies for gait disability and balance impairment: promises and pitfalls. Mov Disord 2014; 28:1576-86. [PMID: 24132846 DOI: 10.1002/mds.25682] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 08/13/2013] [Accepted: 08/13/2013] [Indexed: 12/31/2022] Open
Abstract
Therapeutic management of gait and balance impairment during aging and neurodegeneration has long been a neglected topic. This has changed considerably during recent years, for several reasons: (1) an increasing recognition that gait and balance deficits are among the most relevant determinants of an impaired quality of life and increased mortality for affected individuals; (2) the arrival of new technology, which has allowed for new insights into the anatomy and functional (dis)integrity of gait and balance circuits; and (3) based in part on these improved insights, the development of new, more specific treatment strategies in the field of pharmacotherapy, deep brain surgery, and physiotherapy. The initial experience with these emerging treatments is encouraging, although much work remains to be done. The objective of this narrative review is to discuss several promising developments in the field of gait and balance treatment. We also address several pitfalls that can potentially hinder a fast and efficient continuation of this vital progress. Important issues that should be considered in future research include a clear differentiation between gait and balance as two distinctive targets for treatment and recognition of compensatory mechanisms as a separate target for therapeutic intervention.
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Affiliation(s)
- Walter Maetzler
- Hertie Institute for Clinical Brain Research, Department of Neurodegeneration, Center of Neurology, University of Tübingen, Tübingen, Germany; German Center for Neurodegenerative Diseases (DNZE), Tübingen, Germany
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van der Marck MA, Klok MP, Okun MS, Giladi N, Munneke M, Bloem BR. Consensus-based clinical practice recommendations for the examination and management of falls in patients with Parkinson's disease. Parkinsonism Relat Disord 2014; 20:360-9. [DOI: 10.1016/j.parkreldis.2013.10.030] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 09/13/2013] [Accepted: 10/02/2013] [Indexed: 11/27/2022]
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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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Advanced Parkinson's disease: Clinical characteristics and treatment. Part II. NEUROLOGÍA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.nrleng.2013.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Enfermedad de Parkinson avanzada. Características clínicas y tratamiento. Parte II. Neurologia 2013; 28:558-83. [DOI: 10.1016/j.nrl.2013.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 04/16/2013] [Accepted: 05/02/2013] [Indexed: 01/24/2023] Open
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Sidiropoulos C, Walsh R, Meaney C, Poon YY, Fallis M, Moro E. Low-frequency subthalamic nucleus deep brain stimulation for axial symptoms in advanced Parkinson’s disease. J Neurol 2013; 260:2306-11. [DOI: 10.1007/s00415-013-6983-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 05/22/2013] [Accepted: 05/25/2013] [Indexed: 12/22/2022]
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Abstract
Deep brain stimulation is one of the most effective treatments of Parkinson's disease (PD). This report summarizes the state of the art as at January 2013. Stimulation of the subthalamic nucleus is the most commonly used approach. It improves the core motor symptoms better than medication in patients with advanced disease. It also improves the majority of nonmotor symptoms, such as mood, impulse control disorders, sleep, and some autonomic dysfunctions. Quality of life (QoL) is improved significantly more than with medication. Long-term data show that the treatment is effective for up to 10 years, but the late appearance of l-dopa-resistant symptoms is seemingly not influenced. Internal globus pallidus (GPi) stimulation is less well studied but seems to have similar short-term efficacy. Importantly l-dopa use cannot be reduced with GPi DBS, which is a major disadvantage for patients suffering from medication side-effects, although gait may be influenced more positively. Although short-term QoL improvement seems to be similar to that for subthalamic nucleus (STN) DBS - gait and speech may be better improved - long-term data are rare for GPi DBS. Thalamic stimulation in the ventral intermediate nucleus (VIM) is applied only in tremor-dominant elderly patients. The treatment improves the dopa-sensitive symptoms and effectively reduces fluctuations leading to an overall QoL improvement. Although most of the controlled studies have been on advanced PD, the recently published EARLYSTIM study suggests that even patients with a very short duration of their fluctuations and dyskinesia are doing significantly better with neurostimulation in terms of QoL and all major motor outcome parameters.
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Fasano A, Deuschl G. Patients and DBS targets: Is there any rationale for selecting them? ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.baga.2012.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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ISway: a sensitive, valid and reliable measure of postural control. J Neuroeng Rehabil 2012; 9:59. [PMID: 22913719 PMCID: PMC3481400 DOI: 10.1186/1743-0003-9-59] [Citation(s) in RCA: 313] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 08/15/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinicians need a practical, objective test of postural control that is sensitive to mild neurological disease, shows experimental and clinical validity, and has good test-retest reliability. We developed an instrumented test of postural sway (ISway) using a body-worn accelerometer to offer an objective and practical measure of postural control. METHODS We conducted two separate studies with two groups of subjects. Study I: sensitivity and experimental concurrent validity. Thirteen subjects with early, untreated Parkinson's disease (PD) and 12 age-matched control subjects (CTR) were tested in the laboratory, to compare sway from force-plate COP and inertial sensors. Study II: test-retest reliability and clinical concurrent validity. A different set of 17 early-to-moderate, treated PD (tested ON medication), and 17 age-matched CTR subjects were tested in the clinic to compare clinical balance tests with sway from inertial sensors. For reliability, the sensor was removed, subjects rested for 30 min, and the protocol was repeated. Thirteen sway measures (7 time-domain, 5 frequency-domain measures, and JERK) were computed from the 2D time series acceleration (ACC) data to determine the best metrics for a clinical balance test. RESULTS Both center of pressure (COP) and ACC measures differentiated sway between CTR and untreated PD. JERK and time-domain measures showed the best test-retest reliability (JERK ICC was 0.86 in PD and 0.87 in CTR; time-domain measures ICC ranged from 0.55 to 0.84 in PD and from 0.60 to 0.89 in CTR). JERK, all but one time-domain measure, and one frequency measure were significantly correlated with the clinical postural stability score (r ranged from 0.50 to 0.63, 0.01 < p < 0.05). CONCLUSIONS Based on these results, we recommend a subset of the most sensitive, reliable, and valid ISway measures to characterize posture control in PD: 1) JERK, 2) RMS amplitude and mean velocity from the time-domain measures, and 3) centroidal frequency as the best frequency measure, as valid and reliable measures of balance control from ISway.
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Treatment of motor and non-motor features of Parkinson's disease with deep brain stimulation. Lancet Neurol 2012; 11:429-42. [DOI: 10.1016/s1474-4422(12)70049-2] [Citation(s) in RCA: 266] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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St George RJ, Carlson-Kuhta P, Burchiel KJ, Hogarth P, Frank N, Horak FB. The effects of subthalamic and pallidal deep brain stimulation on postural responses in patients with Parkinson disease. J Neurosurg 2012; 116:1347-56. [PMID: 22424564 DOI: 10.3171/2012.2.jns11847] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The effect of deep brain stimulation (DBS) for Parkinson disease (PD) on balance is unclear. The goal of this study was to investigate how automatic postural responses (APRs) were affected in patients randomized to either subthalamic nucleus (STN) or globus pallidus internus (GPi) surgery. METHODS The authors tested 24 patients with PD who underwent bilateral DBS, 9 control patients with PD who did not undergo DBS, and 17 age-matched control volunteers. The electrode placement site was randomized and blinded to the patients and to the experimenters. Kinematic, kinetic, and electromyographic recordings of postural responses to backward disequilibrium via forward translations of the standing surface were recorded in the week prior to surgery while the patients were off (OFF) and on (ON) antiparkinsonian medication (levodopa), and then 6 months after surgery in 4 conditions: 1) off medication with DBS switched off (OFF/OFF); 2) off medication with DBS on (DBS); 3) on medication with DBS off (DOPA); and 4) with both medication and DBS on (DBS+DOPA). Stability of the automatic postural response (APR) was measured as the difference between the displacement of the center of pressure and the projected location of the center of body mass. RESULTS Patients with PD had worse APR stability than controls. Turning the DBS on at either site improved APR stability compared with the postoperative OFF condition by lengthening the tibialis response, whereas medication did not show an appreciable effect. The STN group had worse APR stability in their best functional state (DBS+DOPA) 6 months after the DBS procedure compared with their best functional state (ON levodopa) before the DBS procedure. In contrast, the GPi group and the PD control group showed no change over 6 months. The APR stability impairment in the STN group was associated with smaller tibialis response amplitudes, but there was no change in response latency or coactivation with gastrocnemius. CONCLUSIONS Turning the DBS current on improved APR stability for both STN and GPi sites. However, there was a detrimental DBS procedural effect for the STN group, and this effect was greater than the benefit of the stimulating current, making overall APR stability functionally worse after surgery for 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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Subthalamic nucleus versus pedunculopontine nucleus stimulation in Parkinson disease: synergy or antagonism? J Neural Transm (Vienna) 2011; 118:1469-75. [PMID: 21695419 DOI: 10.1007/s00702-011-0673-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 06/05/2011] [Indexed: 01/07/2023]
Abstract
Stimulation of the subthalamic nucleus (STN) improves the cardinal features of Parkinson disease (PD). However, its efficacy on gait disorders is less satisfying in the long term. In recent years, the pedunculopontine (PPN) nucleus has emerged as a possible promising deep brain stimulation target for gait disorders in PD. In this review, we examine whether STN and PPN act synergistically or antagonistically. Results suggest that the combination of STN and PPN stimulations leads to a significant further improvement in gait as compared with STN stimulation alone, but additive effects on the classical motor triad are questionable. Thus, they highlight the specificity of STN stimulation over PPN's for the PD cardinal features and the specificity of PPN stimulation over STN for gait disorders. In addition, low-frequency stimulation of the PPN may improve alertness. The additive rather than potentiating effects of STN and PPN stimulations suggest that they may be mediated by distinct pathways. Nevertheless, considering the inconsistencies in published results regarding the influence of PPN stimulation on gait disorders, work is still needed before one can know whether it will convert into a standard surgical treatment and to decipher its place beside STN stimulation.
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Nutt JG, Horak FB, Bloem BR. Milestones in gait, balance, and falling. Mov Disord 2011; 26:1166-74. [DOI: 10.1002/mds.23588] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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The effect of real and virtual visual cues on walking in Parkinson’s disease. J Neurol 2011; 258:991-1000. [DOI: 10.1007/s00415-010-5866-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 11/09/2010] [Accepted: 12/03/2010] [Indexed: 11/25/2022]
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St George RJ, Nutt JG, Burchiel KJ, Horak FB. A meta-regression of the long-term effects of deep brain stimulation on balance and gait in PD. Neurology 2010; 75:1292-9. [PMID: 20921515 DOI: 10.1212/wnl.0b013e3181f61329] [Citation(s) in RCA: 200] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Deep brain stimulation (DBS) alleviates the cardinal Parkinson disease (PD) symptoms of tremor, rigidity, and bradykinesia. However, its effects on postural instability and gait disability (PIGD) are uncertain. Contradictory findings may be due to differences the in stimulation site and the length of time since DBS surgery. This prompted us to conduct the first meta-regression of long-term studies of bilateral DBS in the subthalamic nucleus (STN) and globus pallidus interna (GPi). RESULTS Eleven articles reported a breakdown of the Unified Parkinson's Disease Rating Scale score before and beyond 3 years postsurgery (mean 4.5 years). Random effects meta-regression revealed that DBS initially improved PIGD compared to the OFF medicated state before surgery, but performance declined over time and extrapolation showed subjects would reach presurgery levels 9 years postsurgery. ON medication, DBS improved PIGD over and above the effect of medication before surgery. Nevertheless, for the STN group, PIGD progressively declined and was worse than presurgery function within 2 years. In contrast, GPi patients showed no significant long-term decline in PIGD in the medicated state. Improvements in cardinal signs with DBS at both sites were maintained across 5 years in the OFF and ON medication states. CONCLUSIONS DBS alone does not offer the same improvement to PIGD as it does to the cardinal symptoms, suggesting axial and distal control are differentially affected by DBS. GPi DBS in combination with levodopa seemed to preserve PIGD better than did STN DBS, although more studies of GPi DBS and randomized controls are needed.
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Affiliation(s)
- R J St George
- Department of Neurology, Oregon Health & Sciences University, 505 NW 185 Avenue, Beaverton, OR 97006, USA.
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Kelly VE, Israel SM, Samii A, Slimp JC, Goodkin R, Shumway-Cook A. Assessing the effects of subthalamic nucleus stimulation on gait and mobility in people with Parkinson disease. Disabil Rehabil 2010; 32:929-36. [PMID: 19874214 DOI: 10.3109/09638280903374139] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To determine the effects of unilateral and bilateral subthalamic nucleus (STN) stimulation on gait and mobility in persons with Parkinson disease (PD). METHOD We examined eight individuals with advanced PD who underwent staged stimulator implantation surgeries. Gait and mobility were assessed in the medication-on state with a variety of clinical and laboratory measures (Unified Parkinson Disease Rating Scale items, Timed Up and Go Test, gait speed) at three time points: prior to surgery, after the first surgery (unilateral stimulation) and after the second surgery (bilateral stimulation). RESULTS Despite overall improvements in motor function and reduction of dyskinesia, there were no significant group effects of unilateral or bilateral stimulation on gait and mobility compared to pre-surgical function. However, there were clinically meaningful changes, both improvements and declines, at the individual level. CONCLUSIONS Because of the consequences of gait deficits and mobility limitations for people with PD, future research should examine the effects of STN stimulation on gait in the medication-on state using sensitive and specific measures such as gait speed. Accurate assessment of gait changes is necessary to improve the evaluation of STN effects and the prediction of individuals in need of rehabilitation services to manage gait and mobility deficits.
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Affiliation(s)
- Valerie E Kelly
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington 98195-6490, USA.
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Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools. Med Biol Eng Comput 2010; 48:611-24. [DOI: 10.1007/s11517-010-0633-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 05/05/2010] [Indexed: 10/19/2022]
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Johnsen EL, Sunde N, Mogensen PH, Ostergaard K. MRI verified STN stimulation site--gait improvement and clinical outcome. Eur J Neurol 2010; 17:746-53. [PMID: 20345927 DOI: 10.1111/j.1468-1331.2010.02962.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is effective in alleviating Parkinson's disease (PD) symptoms (tremor, rigidity and bradykinesia) and may improve gait and postural impairment associated with the disease. However, improvement of gait is not always as predictable as the clinical outcome. This may relate to the type of gait impairment or localization of the active DBS contact. METHODS The active contact was visualized on peri-operative magnetic resonance imaging in 22 patients with idiopathic PD, consecutively treated with bilateral STN DBS. Stimulation site was grouped as either in the dorsal/ventral STN or medial/lateral hereof and anterior/posterior STN or medial/lateral hereof. The localization was compared with relative improvement of clinical outcome (UPDRS-III). In 10 patients, quantitative gait analyses were performed, and the improvement in gait performance was compared with stimulation site in the STN. RESULTS Of 44 active contacts, 77% were inside the nucleus, 23% were medial hereof. Stimulation of the dorsal half improved UPDRS-III significantly more than ventral STN DBS (P = 0.02). However, there were no differences between anterior and posterior stimulation in the dorsal STN. Step velocity and length improved significantly more with dorsal stimulation compared with ventral stimulation (P = 0.03 and P = 0.02). Balance during gait was also more improved with dorsal stimulation compared with ventral stimulation. CONCLUSIONS Deep brain stimulation of the dorsal STN is superior to stimulation of the ventral STN. Possible different effects of stimulation inside the nucleus underline the need for exact knowledge of the active stimulation site position to target the most effective area.
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Affiliation(s)
- E L Johnsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.
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[Deep brain stimulation and gait disorders in Parkinson disease]. Rev Neurol (Paris) 2009; 166:178-87. [PMID: 19815246 DOI: 10.1016/j.neurol.2009.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 07/01/2009] [Accepted: 07/16/2009] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Gait disorders and freezing of gait (FOG) are seen in most patients with advanced Parkinson disease. Response to levodopa and deep brain stimulation is variable across patients. STATE OF ART Thalamic stimulation is ineffective on gait and can even worsen balance when bilaterally applied. Pallidal stimulation moderately improves gait disorders and FOG although this effect tends to wane after three to five years. Stimulation of the subthalamic nucleus (STN) improves levodopa-responsive gait disorders and FOG. However, some patients worsen after STN stimulation and others are better improved under levodopa than under STN stimulation. Synergistic effects of the two treatments have been reported. As for pallidal stimulation, there is a failure of long-term STN stimulation to improve gait, probably due to the involvement of non-dopaminergic pathways as the disease progresses. Levodopa-resistant gait disorders and FOG do not usually benefit from STN stimulation. In the rare cases of levodopa-induced FOG, STN stimulation may be indirectly effective, as it enables reduction or arrest of the levodopa treatment. PERSPECTIVES Pedunculopontine nucleus stimulation has recently been performed in small groups of patients with disabling gait disorders and FOG. Although encouraging, the first results need to be confirmed by controlled studies involving larger series of patients. CONCLUSIONS Overall, gait disorders remain a motor PD symptom that is little improved, or only temporarily, by current pharmacological and surgical treatments. Patient management is complex.
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Johnsen EL, Mogensen PH, Sunde NA, Østergaard K. Improved asymmetry of gait in Parkinson's disease with DBS: gait and postural instability in Parkinson's disease treated with bilateral deep brain stimulation in the subthalamic nucleus. Mov Disord 2009; 24:590-7. [PMID: 19097189 DOI: 10.1002/mds.22419] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Postural instability is a sign of progression of Parkinson's disease (PD) and often resistant to levodopa treatment. To explore the effect of bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN) on postural stability and gait, full body gait analyses were performed without medication, OFF and ON DBS in eight PD patients and 12 healthy age-matched controls. DBS setting was changed at least 3 hours before gait analysis. To describe asymmetry most and least affected sides (MAS and LAS) were rated with the Unified Parkinson's Disease Rating Scale, motor part and quantitative gait analysis with the Vicon 612 gait analysis system. Stride length and gait velocity but not cadence improved ON DBS. The distances between the heel markers and center of mass (COM) were asymmetric and reduced OFF DBS. STN DBS increased the distances significantly and reduced asymmetry. The improvement in heel to COM distance was larger on the MAS compared with the LAS. OFF DBS knee momentum asymmetry was inversed so that LAS was more impaired than MAS. ON DBS asymmetry improved. PD patients OFF DBS place the heel too close to COM. The most affected body side has the most impaired swing and the result is a smaller knee moment on the opposite and least affected body side and an asymmetric gait pattern with disturbed balance OFF STN DBS. The asymmetry OFF DBS improved ON DBS. We suggest that DBS facilitates symmetric gait and thereby improves balance during gait.
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Affiliation(s)
- Erik L Johnsen
- Department of Neurology, Aarhus University Hospital, 8000 Aarhus C, Denmark.
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Ferraye MU, Debû B, Pollak P. Deep brain stimulation effect on freezing of gait. Mov Disord 2008; 23 Suppl 2:S489-94. [PMID: 18668617 DOI: 10.1002/mds.21975] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The majority of patients with Parkinson's disease suffer from freezing of gait (FOG), which responds more or less to levodopa. Thalamic stimulation, mainly used in the treatment of tremor dominant Parkinson's disease is ineffective in FOG. GPi stimulation moderately improves FOG, but this effect may abate in the long term. STN stimulation was reported to improve levodopa-responsive FOG. In some patients, the benefit from levodopa is greater than that from STN stimulation, and levodopa and STN stimulation can have additive effects. On the contrary, STN stimulation is ineffective on levodopa-resistant FOG. In the few cases of levodopa-induced FOG, STN stimulation can indirectly be effective, thanks to a great decrease or arrest of levodopa. Stimulation of the pedunculopontine nucleus has recently been performed in small groups of patients suffering from both off- and on-levodopa gait impairments. The first results appear encouraging, but they need to be confirmed by controlled studies in larger series of patients.
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