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Honkanen EA, Korpela J, Pekkonen E, Kaasinen V, Reich MM, Joutsa J. Reappearance of Symptoms after GPi-DBS Discontinuation in Cervical Dystonia. Mov Disord Clin Pract 2021; 8:406-411. [PMID: 33816670 PMCID: PMC8015900 DOI: 10.1002/mdc3.13162] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/11/2021] [Accepted: 01/24/2021] [Indexed: 11/11/2022] Open
Abstract
Background Deep brain stimulation of the globus pallidus interna (GPi‐DBS) is a highly efficacious treatment for cervical dystonia. Typically, the treatment response is delayed, appearing and increasing even months after implantation. However, it is not known how fast the symptoms reappear and whether there is a long‐term therapeutic effect after the stimulation is discontinued. Objectives To study symptom reappearance after switching GPi‐DBS off in cervical dystonia. Methods Twelve patients with bilateral GPi‐DBS were included in the study. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) was evaluated during the study with DBS stimulation on, after switching the stimulation off and 2 days after the stimulation was switched off. Presurgical symptom severity and best postsurgical response were extracted from the hospital records. Results At the time of the investigation, GPi‐DBS was associated with 67 (SD 39)% symptom improvement of presurgical symptoms severity (P = 0.001). Symptom improvement decreased to 27 (53)% (P = 0.046) (n = 12) acutely after switching the stimulation off and was further reduced to 4 (56)% 2 days after discontinuation (P = 0.01) (n = 11), reaching the presurgical level (P = 0.42). In descriptive analyses, older age was associated with faster worsening of symptoms (P < 0.05). Presurgical symptoms severity, stimulation parameters or magnitude of treatment response did not predict symptom worsening. All but one patient tolerated 2 days DBS switched off. Conclusions The results provide novel information about the time frame and severity of symptom worsening after discontinuing GPi‐DBS in cervical dystonia. Symptoms partially reappear immediately after discontinuing GPi‐DBS and full presurgical symptom severity is reached within 2 days.
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Affiliation(s)
- Emma A Honkanen
- Clinical Neurosciences University of Turku Turku Finland.,Division of Clinical Neurosciences Turku University Hospital Turku Finland.,Department of Neurology Satasairaala Central Hospital Pori Finland.,Turku PET Centre Turku University Hospital Turku Finland
| | - Jaana Korpela
- Clinical Neurosciences University of Turku Turku Finland.,Division of Clinical Neurosciences Turku University Hospital Turku Finland
| | - Eero Pekkonen
- Department of Neurology, Helsinki University Hospital and Department of Clinical Neurosciences (Neurology) University of Helsinki Helsinki Finland
| | - Valtteri Kaasinen
- Clinical Neurosciences University of Turku Turku Finland.,Division of Clinical Neurosciences Turku University Hospital Turku Finland
| | - Martin M Reich
- Department of Neurology University Hospital and Julius Maximilian University Würzburg Germany
| | - Juho Joutsa
- Clinical Neurosciences University of Turku Turku Finland.,Division of Clinical Neurosciences Turku University Hospital Turku Finland.,Turku PET Centre Turku University Hospital Turku Finland.,Turku Brain and Mind Center University of Turku Turku Finland
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Koeglsperger T, Palleis C, Hell F, Mehrkens JH, Bötzel K. Deep Brain Stimulation Programming for Movement Disorders: Current Concepts and Evidence-Based Strategies. Front Neurol 2019; 10:410. [PMID: 31231293 PMCID: PMC6558426 DOI: 10.3389/fneur.2019.00410] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/04/2019] [Indexed: 11/16/2022] Open
Abstract
Deep brain stimulation (DBS) has become the treatment of choice for advanced stages of Parkinson's disease, medically intractable essential tremor, and complicated segmental and generalized dystonia. In addition to accurate electrode placement in the target area, effective programming of DBS devices is considered the most important factor for the individual outcome after DBS. Programming of the implanted pulse generator (IPG) is the only modifiable factor once DBS leads have been implanted and it becomes even more relevant in cases in which the electrodes are located at the border of the intended target structure and when side effects become challenging. At present, adjusting stimulation parameters depends to a large extent on personal experience. Based on a comprehensive literature search, we here summarize previous studies that examined the significance of distinct stimulation strategies for ameliorating disease signs and symptoms. We assess the effect of adjusting the stimulus amplitude (A), frequency (f), and pulse width (pw) on clinical symptoms and examine more recent techniques for modulating neuronal elements by electrical stimulation, such as interleaving (Medtronic®) or directional current steering (Boston Scientific®, Abbott®). We thus provide an evidence-based strategy for achieving the best clinical effect with different disorders and avoiding adverse effects in DBS of the subthalamic nucleus (STN), the ventro-intermedius nucleus (VIM), and the globus pallidus internus (GPi).
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Affiliation(s)
- Thomas Koeglsperger
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Carla Palleis
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Franz Hell
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität München, Martinsried, Germany
| | - Jan H Mehrkens
- Department of Neurosurgery, Ludwig Maximilians University, Munich, Germany
| | - Kai Bötzel
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
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3
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Abstract
BACKGROUND Dystonia is a painful and disabling disorder, characterised by painful, involuntary posturing of the affected body region(s). Deep brain stimulation is an intervention typically reserved for severe and drug-refractory cases, although uncertainty exists regarding its efficacy, safety, and tolerability. OBJECTIVES To compare the efficacy, safety, and tolerability of deep brain stimulation (DBS) versus placebo, sham intervention, or best medical care, including botulinum toxin and resective or lesional surgery, in adults with dystonia. SEARCH METHODS We identified studies by searching the CENTRAL, MEDLINE, Embase, three other databases, four clinical trial registries, four grey literature databases, and reference lists of included articles. We ran the last search of all elements of the search strategy, with no language restrictions, on 29 May 2018. SELECTION CRITERIA Double-blind, parallel, randomised, controlled trials (RCTs) comparing DBS with sham stimulation, best medical care, or placebo in adults with dystonia. DATA COLLECTION AND ANALYSIS Two independent review authors assessed records, selected included studies, extracted data onto a standardised (or prespecified) data extraction form, and evaluated the risk of bias. We resolved disagreements by consensus or by consulting a third review author. We conducted meta-analyses using a random-effects model, to estimate pooled effects and corresponding 95% confidence intervals (95% CI). We assessed the quality of the evidence with GRADE methods. The primary efficacy outcome was symptom improvement on any validated symptomatic rating scale, and the primary safety outcome was adverse events. MAIN RESULTS We included two RCTs, enrolling a total of 102 participants. Both trials evaluated the effect of DBS on the internal globus pallidus nucleus, and assessed outcomes after three and six months of stimulation. One of the studies included participants with generalised and segmental dystonia; the other included participants with focal (cervical) dystonia. We assessed both studies at high risk for performance and for-profit bias. One study was retrospectively registered with a clinical trial register, we judged the second at high risk of detection bias.Low-quality evidence suggests that DBS of the internal globus pallidus nucleus may improve overall cervical dystonia-related symptoms (mean difference (MD) 9.8 units, 95% CI 3.52 to 16.08 units; 1 RCT, 59 participants), cervical dystonia-related functional capacity (MD 3.8 units, 95% CI 1.41 to 6.19; 1 RCT, 61 participants), and mood at three months (MD 3.1 units, 95% CI 0.73 to 5.47; 1 RCT, 61 participants).Low-quality evidence suggests that In people with cervical dystonia, DBS may slightly improve the overall clinical status (MD 2.3 units, 95% CI 1.15 to 3.45; 1 RCT, 61 participants). We are uncertain whether DBS improves quality of life in cervical dystonia (MD 3 units, 95% CI -7.71 to 13.71; 1 RCT, 57 participants; very low-quality evidence), or emotional state (MD 2.4 units, 95% CI -6.2 to 11.00; 1 RCT, 56 participants; very low-quality evidence).Low-quality evidence suggests that DBS of the internal globus pallidus nucleus may improve generalised or segmental dystonia-related symptoms (MD 14.4 units, 95% CI 8.0 to 20.8; 1 RCT, 40 participants), overall clinical status (MD 3.5 units, 95% CI 2.33 to 4.67; 1 RCT, 37 participants), physical functioning-related quality of life (MD 6.3 units, 95% CI 1.06 to 11.54; 1 RCT, 33 participants), and overall dystonia-related functional capacity at three months (MD 3.1 units, 95% CI 1.71 to 4.48; 1 RCT, 39 participants). We are uncertain whether DBS improves physical functioning-related quality of life (MD 5.0 units, 95% CI -2.14 to 12.14, 1 RCT, 33 participants; very low-quality evidence), or mental health-related quality of life (MD -4.6 units, 95% CI -11.26 to 2.06; 1 RCT, 30 participants; very low-quality evidence) in generalised or segmental dystonia.We pooled outcomes related to safety and tolerability, since both trials used the same intervention and comparison. We found very low-quality evidence of inconclusive results for risk of adverse events (relative risk (RR) 1.58, 95% 0.98 to 2.54; 2 RCTs, 102 participants), and tolerability (RR 1.86, 95% CI 0.16 to 21.57; 2 RCTs,102 participants). AUTHORS' CONCLUSIONS DBS of the internal globus pallidus nucleus may reduce symptom severity and improve functional capacity in adults with cervical, segmental or generalised moderate to severe dystonia (low-quality evidence), and may improve quality of life in adults with generalised or segmental dystonia (low-quality evidence). We are uncertain whether the procedure improves quality of life in cervical dystonia (very low-quality evidence). We are also uncertain about the safety and tolerability of the procedure in adults with either cervical and generalised, or segmental dystonia (very-low quality evidence).We could draw no conclusions for other populations with dystonia (i.e. children and adolescents, and adults with other types of dystonia), or for other DBS protocols (i.e. other target nuclei or stimulation paradigms). Further research is needed to establish the long-term efficacy and safety of DBS of the internal globus pallidus nucleus.
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Affiliation(s)
- Filipe B Rodrigues
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal, 1649-028
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4
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Hanci I, Kamm C, Scholten M, Roncoroni LP, Weber Y, Krüger R, Plewnia C, Gharabaghi A, Weiss D. Long-Term Effect of GPi-DBS in a Patient With Generalized Dystonia Due to GLUT1 Deficiency Syndrome. Front Neurol 2018; 9:381. [PMID: 29899725 PMCID: PMC5988881 DOI: 10.3389/fneur.2018.00381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/11/2018] [Indexed: 12/25/2022] Open
Abstract
Treatment outcomes from pallidal deep brain stimulation are highly heterogeneous reflecting the phenotypic and etiologic spectrum of dystonia. Treatment stratification to neurostimulation therapy primarily relies on the phenotypic motor presentation; however, etiology including genetic factors are increasingly recognized as modifiers of treatment outcomes. Here, we describe a 53 year-old female patient with a progressive generalized dystonia since age 25. The patient underwent deep brain stimulation of the globus pallidus internus (GPi-DBS) at age 44. Since the clinical phenotype included mobile choreo-dystonic features, we expected favorable therapeutic outcome from GPi-DBS. Although mobile dystonia components were slightly improved in the long-term outcome from GPi-DBS the overall therapeutic response 9 years from implantation was limited when comparing “stimulation off” and “stimulation on” despite of proper electrode localization and sufficient stimulation programming. In order to further understand the reason for this limited motor symptom response, we aimed to clarify the etiology of generalized dystonia in this patient. Genetic testing identified a novel heterozygous pathogenic SLC2A1 mutation as cause of glucose transporter type 1 deficiency syndrome (GLUT1-DS). This case report presents the first outcome of GPi-DBS in a patient with GLUT1-DS, and suggests that genotype relations may increasingly complement phenotype-based therapy stratification of GPi-DBS in dystonia.
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Affiliation(s)
- Idil Hanci
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Centre of Neurodegenerative Diseases, University of Tübingen, Tübingen, Germany.,Centre for Integrative Neuroscience, University of Tübingen, Tübingen, Germany
| | - Christoph Kamm
- Department of Neurology, University of Rostock, Rostock, Germany
| | - Marlieke Scholten
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Centre of Neurodegenerative Diseases, University of Tübingen, Tübingen, Germany.,Centre for Integrative Neuroscience, University of Tübingen, Tübingen, Germany.,Graduate School of Neural and Behavioral Sciences, International Max Planck Research School, University of Tübingen, Tübingen, Germany
| | - Lorenzo P Roncoroni
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Centre of Neurodegenerative Diseases, University of Tübingen, Tübingen, Germany.,Centre for Integrative Neuroscience, University of Tübingen, Tübingen, Germany
| | - Yvonne Weber
- Centre for Integrative Neuroscience, University of Tübingen, Tübingen, Germany.,Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Rejko Krüger
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Centre of Neurodegenerative Diseases, University of Tübingen, Tübingen, Germany.,Centre for Integrative Neuroscience, University of Tübingen, Tübingen, Germany.,Clinical and Experimental Neuroscience, Luxembourg Centre for Systems Biomedicine, Centre Hospitalier de Luxembourg, University of Luxembourg, Luxembourg, Luxembourg
| | - Christian Plewnia
- Centre for Integrative Neuroscience, University of Tübingen, Tübingen, Germany.,Department of Psychiatry and Psychotherapy, Neurophysiology and Interventional Neuropsychiatry, University of Tübingen, Tübingen, Germany
| | - Alireza Gharabaghi
- Centre for Integrative Neuroscience, University of Tübingen, Tübingen, Germany.,Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Daniel Weiss
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Centre of Neurodegenerative Diseases, University of Tübingen, Tübingen, Germany.,Centre for Integrative Neuroscience, University of Tübingen, Tübingen, Germany
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Ellermeyer T, Otte K, Heinrich F, Mansow-Model S, Kayser B, Lipp A, Seidel A, Krause P, Lauritsch K, Gusho E, Paul F, Kühn AA, Brandt AU, Schmitz-Hübsch T. Ranking of Dystonia Severity by Pairwise Video Comparison. Mov Disord Clin Pract 2016; 3:587-595. [PMID: 30363467 DOI: 10.1002/mdc3.12340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 12/29/2015] [Accepted: 01/16/2016] [Indexed: 11/06/2022] Open
Abstract
Background Reviewers of dystonia rating scales agree on the need to assess symptoms more comprehensively. During the development of a quantitative dystonia assessment by video-perceptive computing, we devised a video-based severity ranking as a procedure to create a validation standard without the use of clinical scales. Methods Thirty-four patients with dystonia (17 with dystonic tremor) and 2 controls were assessed with clinical scales and video-recordings of 24 short movement tasks. Two to 4 raters compared multiple permutations of videos from 22 subjects, including 2 healthy controls, until a complete rank order was achieved. Inter-rater agreement was expressed as normalized Kendall tau distance. Spearman correlations of video rank order with clinical scales and self-rating were repeated for tremor/nontremor subgroups. Results Normalized Kendall tau distances were <0.3 for 15 items. The video rank order for sitting and head movements correlated with clinical scales for the whole group (rho 0.52-0.87) and in the subgroup without tremor. In the tremor subgroup such correlation was perceived in the 2 items involving sitting. Video rank order correlated with quality of life self-rating only in 1 item (arms held in front, palm down). Conclusions The agreement of video rankings between raters is remarkable. The lack of correlation in the tremor subgroup in several items may be interpreted as tremor being considered in video comparisons but not in clinical scales. This supports video-based ranking as a more comprehensive rating of dystonia and as a possible validation instrument applicable in situations in which no reference standard is available.
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Affiliation(s)
| | | | - Felix Heinrich
- Department of Neurology Charité-Universitätsmedizin Berlin Germany
| | | | | | - Axel Lipp
- Department of Neurology Charité-Universitätsmedizin Berlin Germany
| | - Adrian Seidel
- Department of Neurology Charité-Universitätsmedizin Berlin Germany
| | - Patricia Krause
- Department of Neurology Charité-Universitätsmedizin Berlin Germany
| | | | - Elona Gusho
- NeuroCure Clinical Research Center Charité-Universitätsmedizin Berlin Germany
| | - Friedemann Paul
- Department of Neurology Charité-Universitätsmedizin Berlin Germany.,NeuroCure Clinical Research Center Charité-Universitätsmedizin Berlin Germany
| | - Andrea A Kühn
- Department of Neurology Charité-Universitätsmedizin Berlin Germany.,NeuroCure Clinical Research Center Charité-Universitätsmedizin Berlin Germany
| | - Alexander U Brandt
- Motognosis UG Berlin Germany.,NeuroCure Clinical Research Center Charité-Universitätsmedizin Berlin Germany
| | - Tanja Schmitz-Hübsch
- Department of Neurology Charité-Universitätsmedizin Berlin Germany.,NeuroCure Clinical Research Center Charité-Universitätsmedizin Berlin Germany
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Risch V, Staiger A, Ziegler W, Ott K, Schölderle T, Pelykh O, Bötzel K. How Does GPi-DBS Affect Speech in Primary Dystonia? Brain Stimul 2015; 8:875-80. [PMID: 26002621 DOI: 10.1016/j.brs.2015.04.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/16/2015] [Accepted: 04/20/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Globus pallidus internus deep brain stimulation (GPi-DBS) can be an effective treatment for primary dystonia. However, speech disorders have previously been reported as a common possible side effect of the treatment. OBJECTIVES To study possible deterioration of speech after GPi-DBS and describe this in different dimensions. METHODS Speech was systematically evaluated in 15 patients with predominant torticollis and GPi-DBS. Each patient was tested twice within one day in two stimulation conditions: ON-DBS vs. OFF-DBS. Speech analyses comprised both function-oriented (perceptual scales, acoustic analyses) and communication-related measures (intelligibility, naturalness). A control sample of 15 healthy speakers underwent the same speech assessment. RESULTS On the group level, patients with dystonia showed mild but significant impairment on the overall dysarthria scale, the intelligibility score, and the naturalness ratings in both stimulation conditions (Mann-Whitney, P < .05). No stimulation-induced deterioration was found. A slight increase in articulation rate was measured in the ON condition. On the single-case level, effects of GPi-DBS on speech were heterogenous. In one patient we observed a deterioration of speech (dysarthria), in a second patient with a history of childhood stuttering we found an aggravation of dysfluency. Impressive benefits could be documented in another patient who also suffered from spasmodic dysphonia. CONCLUSIONS The study provides evidence that speech impairment is not a necessary side-effect of GPi-DBS in primary dystonia. Both, recurring of stuttering and a worsening of dysarthria may be seen in individual patients. The positive effects of GPi-DBS on the symptoms of spasmodic dysphonia merits further research as DBS is not commonly applied in this population.
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Affiliation(s)
- Verena Risch
- Clinical Neuropsychology Research Group (EKN), Städtisches Klinikum München GmbH, Klinikum Schwabing (Haus 19, 2. Stock), Kölner Platz 1, 80804 München, Germany(1)
| | - Anja Staiger
- Clinical Neuropsychology Research Group (EKN), Städtisches Klinikum München GmbH, Klinikum Schwabing (Haus 19, 2. Stock), Kölner Platz 1, 80804 München, Germany(1)
| | - Wolfram Ziegler
- Clinical Neuropsychology Research Group (EKN), Städtisches Klinikum München GmbH, Klinikum Schwabing (Haus 19, 2. Stock), Kölner Platz 1, 80804 München, Germany(1)
| | - Katharina Ott
- Department of Neurology, Ludwig-Maximilians-University Munich, Klinikum Großhadern, Marchioninistrasse 15, 81366 Munich, Germany(2)
| | - Theresa Schölderle
- Clinical Neuropsychology Research Group (EKN), Städtisches Klinikum München GmbH, Klinikum Schwabing (Haus 19, 2. Stock), Kölner Platz 1, 80804 München, Germany(1)
| | - Olena Pelykh
- Department of Orthopedics, Ludwig-Maximilians-University Munich, Klinikum Großhadern, Marchioninistrasse 15, 81366 Munich, Germany(3)
| | - Kai Bötzel
- Department of Neurology, Ludwig-Maximilians-University Munich, Klinikum Großhadern, Marchioninistrasse 15, 81366 Munich, Germany(2).
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Postural stability under globus pallidus internus stimulation for dystonia. Clin Neurophysiol 2015; 126:2299-305. [PMID: 25771176 DOI: 10.1016/j.clinph.2015.01.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 12/22/2014] [Accepted: 01/22/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Deep brain stimulation of the globus pallidus internus (GPi-DBS) is an efficient and safe treatment for medically refractory dystonia. However, recent studies reported gait problems, falls and bradykinesia in patients after the DBS procedure. The aim of this study was to quantify the effect of GPi-DBS on postural performance in patients with cranio-cervical dystonia. METHODS Thirteen patients with focal/segmental dystonia and GPi-DBS participated in the study. We performed two postural tests (pull test and push and release test) in on- and off-stimulation conditions and recorded the movements of the patients with inertial sensors. RESULTS Under stimulation patients exhibited a higher number of steps (p=0.015), reduced first step length (p=0.011) and lower stepping velocity (p=0.001), compared to off stimulation. We observed a higher number of steps in the push and release test compared to the pull test (p=0.038). The interaction between stimulation condition and test type was significant (p=0.027). CONCLUSIONS The velocity and amplitude of postural reactions are compromised by GPi-DBS in patients with cranio-cervical dystonia. SIGNIFICANCE This information corresponds to patient's reports of falls and postural instability after GPi-DBS. Pre-operatively, patients should be informed about the possibility of the occurrence of such phenomena.
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