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Cox E, Wade R, Hodgson R, Fulbright H, Phung TH, Meader N, Walker S, Rothery C, Simmonds M. Devices for remote continuous monitoring of people with Parkinson's disease: a systematic review and cost-effectiveness analysis. Health Technol Assess 2024; 28:1-187. [PMID: 39021200 PMCID: PMC11331379 DOI: 10.3310/ydsl3294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024] Open
Abstract
Background Parkinson's disease is a brain condition causing a progressive loss of co ordination and movement problems. Around 145,500 people have Parkinson's disease in the United Kingdom. Levodopa is the most prescribed treatment for managing motor symptoms in the early stages. Patients should be monitored by a specialist every 6-12 months for disease progression and treatment of adverse effects. Wearable devices may provide a novel approach to management by directly monitoring patients for bradykinesia, dyskinesia, tremor and other symptoms. They are intended to be used alongside clinical judgement. Objectives To determine the clinical and cost-effectiveness of five devices for monitoring Parkinson's disease: Personal KinetiGraph, Kinesia 360, KinesiaU, PDMonitor and STAT-ON. Methods We performed systematic reviews of all evidence on the five devices, outcomes included: diagnostic accuracy, impact on decision-making, clinical outcomes, patient and clinician opinions and economic outcomes. We searched MEDLINE and 12 other databases/trial registries to February 2022. Risk of bias was assessed. Narrative synthesis was used to summarise all identified evidence, as the evidence was insufficient for meta-analysis. One included trial provided individual-level data, which was re-analysed. A de novo decision-analytic model was developed to estimate the cost-effectiveness of Personal KinetiGraph and Kinesia 360 compared to standard of care in the UK NHS over a 5-year time horizon. The base-case analysis considered two alternative monitoring strategies: one-time use and routine use of the device. Results Fifty-seven studies of Personal KinetiGraph, 15 of STAT-ON, 3 of Kinesia 360, 1 of KinesiaU and 1 of PDMonitor were included. There was some evidence to suggest that Personal KinetiGraph can accurately measure bradykinesia and dyskinesia, leading to treatment modification in some patients, and a possible improvement in clinical outcomes when measured using the Unified Parkinson's Disease Rating Scale. The evidence for STAT-ON suggested it may be of value for diagnosing symptoms, but there is currently no evidence on its clinical impact. The evidence for Kinesia 360, KinesiaU and PDMonitor is insufficient to draw any conclusions on their value in clinical practice. The base-case results for Personal KinetiGraph compared to standard of care for one-time and routine use resulted in incremental cost-effectiveness ratios of £67,856 and £57,877 per quality-adjusted life-year gained, respectively, with a beneficial impact of the Personal KinetiGraph on Unified Parkinson's Disease Rating Scale domains III and IV. The incremental cost-effectiveness ratio results for Kinesia 360 compared to standard of care for one-time and routine use were £38,828 and £67,203 per quality-adjusted life-year gained, respectively. Limitations The evidence was limited in extent and often low quality. For all devices, except Personal KinetiGraph, there was little to no evidence on the clinical impact of the technology. Conclusions Personal KinetiGraph could reasonably be used in practice to monitor patient symptoms and modify treatment where required. There is too little evidence on STAT-ON, Kinesia 360, KinesiaU or PDMonitor to be confident that they are clinically useful. The cost-effectiveness of remote monitoring appears to be largely unfavourable with incremental cost-effectiveness ratios in excess of £30,000 per quality-adjusted life-year across a range of alternative assumptions. The main driver of cost-effectiveness was the durability of improvements in patient symptoms. Study registration This study is registered as PROSPERO CRD42022308597. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR135437) and is published in full in Health Technology Assessment; Vol. 28, No. 30. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Edward Cox
- CHE Technology Assessment Group, University of York, York, UK
| | - Ros Wade
- CRD Technology Assessment Group, University of York, York, UK
| | - Robert Hodgson
- CRD Technology Assessment Group, University of York, York, UK
| | - Helen Fulbright
- CRD Technology Assessment Group, University of York, York, UK
| | - Thai Han Phung
- CHE Technology Assessment Group, University of York, York, UK
| | - Nicholas Meader
- CRD Technology Assessment Group, University of York, York, UK
| | - Simon Walker
- CHE Technology Assessment Group, University of York, York, UK
| | - Claire Rothery
- CHE Technology Assessment Group, University of York, York, UK
| | - Mark Simmonds
- CRD Technology Assessment Group, University of York, York, UK
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Theyer C, Beliveau V, Krismer F, Peball M, Mair K, Heim B, Djamshidian A, Kiechl S, Eisner W, Eschlböck S, Wenning GK, Willeit P, Seppi K, Poewe W, Mahlknecht P. Long-Term Medication Profiles in Parkinson's Disease under Subthalamic Deep Brain Stimulation: A Controlled Study. Mov Disord Clin Pract 2024; 11:855-860. [PMID: 38715209 PMCID: PMC11233929 DOI: 10.1002/mdc3.14065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 04/08/2024] [Accepted: 04/18/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Subthalamic deep brain stimulation (STN-DBS) reduces antiparkinsonian medications in Parkinson's disease (PD) compared with the preoperative state. Longitudinal and comparative studies on this effect are lacking. OBJECTIVE To compare longitudinal trajectories of antiparkinsonian medication in STN-DBS treated patients to non-surgically treated control patients. METHODS We collected retrospective information on antiparkinsonian medication from PD patients that underwent subthalamic DBS between 1999 and 2010 and control PD patients similar in age at onset and baseline, sex-distribution, and comorbidities. RESULTS In 74 DBS patients levodopa-equivalent daily dose (LEDD) were reduced by 33.9-56.0% in relation to the preoperative baseline over the 14-year observational period. In 61 control patients LEDDs increased over approximately 10 years, causing a significant divergence between groups. The largest difference amongst single drug-classes was observed for dopamine agonists. CONCLUSION In PD patients, chronic STN-DBS was associated with a lower LEDD compared with control patients over 14 years.
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Affiliation(s)
- Christoph Theyer
- Department of NeurologyInnsbruck Medical UniversityInnsbruckAustria
| | - Vincent Beliveau
- Department of NeurologyInnsbruck Medical UniversityInnsbruckAustria
| | - Florian Krismer
- Department of NeurologyInnsbruck Medical UniversityInnsbruckAustria
| | - Marina Peball
- Department of NeurologyInnsbruck Medical UniversityInnsbruckAustria
| | - Katherina Mair
- Department of NeurologyInnsbruck Medical UniversityInnsbruckAustria
| | - Beatrice Heim
- Department of NeurologyInnsbruck Medical UniversityInnsbruckAustria
| | | | - Stefan Kiechl
- Department of NeurologyInnsbruck Medical UniversityInnsbruckAustria
| | - Wilhelm Eisner
- Department of NeurosurgeryInnsbruck Medical UniversityInnsbruckAustria
| | - Sabine Eschlböck
- Department of NeurologyInnsbruck Medical UniversityInnsbruckAustria
| | | | - Peter Willeit
- Department of Medical Statistics, Informatics and Health EconomicsMedical University of InnsbruckInnsbruckAustria
- Department of Public Health and Primary CareUniversity of CambridgeCambridgeUnited Kingdom
| | - Klaus Seppi
- Department of NeurologyInnsbruck Medical UniversityInnsbruckAustria
| | - Werner Poewe
- Department of NeurologyInnsbruck Medical UniversityInnsbruckAustria
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Nair SS, Chakravarthy S. A Computational Model of Deep Brain Stimulation for Parkinson's Disease Tremor and Bradykinesia. Brain Sci 2024; 14:620. [PMID: 38928620 PMCID: PMC11201485 DOI: 10.3390/brainsci14060620] [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: 04/29/2024] [Revised: 06/05/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Parkinson's disease (PD) is a progressive neurological disorder that is typically characterized by a range of motor dysfunctions, and its impact extends beyond physical abnormalities into emotional well-being and cognitive symptoms. The loss of dopaminergic neurons in the substantia nigra pars compacta (SNc) leads to an array of dysfunctions in the functioning of the basal ganglia (BG) circuitry that manifests into PD. While active research is being carried out to find the root cause of SNc cell death, various therapeutic techniques are used to manage the symptoms of PD. The most common approach in managing the symptoms is replenishing the lost dopamine in the form of taking dopaminergic medications such as levodopa, despite its long-term complications. Another commonly used intervention for PD is deep brain stimulation (DBS). DBS is most commonly used when levodopa medication efficacy is reduced, and, in combination with levodopa medication, it helps reduce the required dosage of medication, prolonging the therapeutic effect. DBS is also a first choice option when motor complications such as dyskinesia emerge as a side effect of medication. Several studies have also reported that though DBS is found to be effective in suppressing severe motor symptoms such as tremors and rigidity, it has an adverse effect on cognitive capabilities. Henceforth, it is important to understand the exact mechanism of DBS in alleviating motor symptoms. A computational model of DBS stimulation for motor symptoms will offer great insights into understanding the mechanisms underlying DBS, and, along this line, in our current study, we modeled a cortico-basal ganglia circuitry of arm reaching, where we simulated healthy control (HC) and PD symptoms as well as the DBS effect on PD tremor and bradykinesia. Our modeling results reveal that PD tremors are more correlated with the theta band, while bradykinesia is more correlated with the beta band of the frequency spectrum of the local field potential (LFP) of the subthalamic nucleus (STN) neurons. With a DBS current of 220 pA, 130 Hz, and a 100 microsecond pulse-width, we could found the maximum therapeutic effect for the pathological dynamics simulated using our model using a set of parameter values. However, the exact DBS characteristics vary from patient to patient, and this can be further studied by exploring the model parameter space. This model can be extended to study different DBS targets and accommodate cognitive dynamics in the future to study the impact of DBS on cognitive symptoms and thereby optimize the parameters to produce optimal performance effects across modalities. Combining DBS with rehabilitation is another frontier where DBS can reduce symptoms such as tremors and rigidity, enabling patients to participate in their therapy. With DBS providing instant relief to patients, a combination of DBS and rehabilitation can enhance neural plasticity. One of the key motivations behind combining DBS with rehabilitation is to expect comparable results in motor performance even with milder DBS currents.
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Affiliation(s)
| | - Srinivasa Chakravarthy
- Department of Biotechnology, Bhupat and Mehta Jyoti School of Biosciences, Chennai 600036, India;
- Department of Medical Science and Technology, Indian Institute of Technology Madras, Sardar Patel Road, Adyar, Chennai 600036, India
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Liu W, Nie P, Zhang J, Zhou D, Zhang J, Chen J. Clinical and Economic Insights into Parkinson's Disease Hospitalization: A Comprehensive Study of 19,719 Inpatient Cases in Hubei Province, China. Neuroepidemiology 2024; 58:237-246. [PMID: 38290491 PMCID: PMC11302739 DOI: 10.1159/000536525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/23/2024] [Indexed: 02/01/2024] Open
Abstract
OBJECTIVE Parkinson's disease (PD) is a profoundly incapacitating neurodegenerative disorder, which presents a substantial challenge to the economic sustainability of the global healthcare system. The present study seeks to clarify the factors that contribute to the costs associated with PD hospitalization and analyze the economic burden it imposes. METHODS We examined data of 19,719 patients with a primary diagnosis of PD who were admitted to hospitals in Hubei Province, China, during the study period. Healthcare data were obtained from the database of electronic medical records. The study presents a comprehensive analysis of the demographic characteristics and investigates the factors that affect their healthcare expenditure. RESULTS The cohort consisted of 10,442 (53.0%) males and 9,277 (47.0%) females. The age-group of 66-70 years experienced the highest incidence of hospitalization among PD patients, with a mortality rate of 0.76‰. The average length of stay for patients was 9.9 ± 8.6 days and the average cost per patient was USD 1,759.9 ± 4,787.7. Surgical interventions were conducted on a mere 2.0% of the total inpatient population. The primary cost component for these interventions was material expenses, accounting for 70.1% of the total. Non-surgical patients primarily incurred expenses related to diagnosis and medication. Notably, surgical patients faced a substantial out-of-pocket rate, reaching up to 90.6%. Surgery was identified as the most influential factor that negatively affected both length of stay and hospitalization costs. Inpatients exhibited significant associations with prolonged length of stay and increased medical expenditure as age increased. Male patients had significantly longer hospital stays and higher medical costs than did females. Additionally, patient's occupation and type of medical insurance exerted significant effects on both length of stay and medical expense. CONCLUSION Age significantly affects PD hospitalization costs. Given the prevailing demographic shift toward an aging population, the government's medical insurance burden related to PD will continue to escalate. Meanwhile, high treatment expenses and out-of-pocket rates impose substantial financial burdens on patients, limiting surgical intervention access to a small fraction of patients. Addressing these issues is of utmost importance in order to ensure comprehensive disease management for the majority of individuals affected by PD.
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Affiliation(s)
- Wen Liu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Brain Research Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Pan Nie
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Brain Research Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jibo Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Brain Research Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Da Zhou
- Center for Health Information and Statistics of Hubei, Wuhan, China
| | - Jie Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Brain Research Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Brain Research Center, Zhongnan Hospital of Wuhan University, Wuhan, China
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Diao Y, Hu T, Xie H, Fan H, Meng F, Yang A, Bai Y, Zhang J. Premature drug reduction after subthalamic nucleus deep brain stimulation leading to worse depression in patients with Parkinson's disease. Front Neurol 2023; 14:1270746. [PMID: 37928164 PMCID: PMC10620523 DOI: 10.3389/fneur.2023.1270746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/26/2023] [Indexed: 11/07/2023] Open
Abstract
Background Reduction of medication in Parkinson's disease (PD) following subthalamic nucleus deep brain stimulation (STN-DBS) has been recognized, but the optimal timing for medication adjustments remains unclear, posing challenges in postoperative patient management. Objective This study aimed to provide evidence for the timing of medication reduction post-DBS using propensity score matching (PSM). Methods In this study, initial programming and observation sessions were conducted over 1 week for patients 4-6 weeks postoperatively. Patients were subsequently categorized into medication reduction or non-reduction groups based on their dyskinesia evaluation using the 4.2-item score from the MDS-UPDRS-IV. PSM was employed to maintain baseline comparability. Short-term motor and neuropsychiatric symptom assessments for both groups were conducted 3-6 months postoperatively. Results A total of 123 PD patients were included. Baseline balance in motor and non-motor scores was achieved between the two groups based on PSM. Short-term efficacy revealed a significant reduction in depression scores within the non-reduction group compared to baseline (P < 0.001) and a significant reduction compared to the reduction group (P = 0.037). No significant differences were observed in UPDRS-III and HAMA scores between the two groups. Within-group analysis showed improvements in motor symptoms, depression, anxiety, and subdomains in the non-reduction group, while the reduction group exhibited improvements only in motor symptoms. Conclusion This study provides evidence for the timing of medication reduction following DBS. Our findings suggest that early maintenance of medication stability is more favorable for improving neuropsychiatric symptoms.
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Affiliation(s)
- Yu Diao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tianqi Hu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hutao Xie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Houyou Fan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fangang Meng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Anchao Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yutong Bai
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
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Soileau MJ, Pagan FL, Fasano A, Rodriguez-Cruz R, Yan CH, Gupta NR, Teigland CL, Pulungan Z, Schinkel JK, Kandukuri PL, Ladhani OA, Siddiqui MS. Comparative Effectiveness of Carbidopa/Levodopa Enteral Suspension and Deep Brain Stimulation on Pill Burden Reduction in Medicare Fee-for-Service Patients with Advanced Parkinson's Disease. Neurol Ther 2023; 12:459-478. [PMID: 36652111 PMCID: PMC10043089 DOI: 10.1007/s40120-022-00433-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/08/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Complex polypharmacy regimens to manage persistent motor fluctuations result in significant pill burden for patients with advanced Parkinson's disease (APD). This study evaluated the effectiveness of carbidopa/levodopa enteral suspension (CLES) and deep brain stimulation (DBS) on reducing pill burden in APD patients. METHODS We utilized 100% Medicare fee-for-service claims from 2014 to 2018 linked to CLES Patient Support Program (PSP) data. CLES initiators (CLES-I) were propensity matched 1:1 with patients enrolled in PSP who did not initiate treatment (CLES-NI) (N = 188) or undergo DBS, and 1:3 with patients who received DBS (N = 204, N = 612). Average daily pill burden and levodopa equivalent daily dosage (LEDD) were measured at baseline, 0-6 months and 7-12 months follow-up. RESULTS CLES-I and CLES-NI had higher pill burden than DBS patients at baseline. However, at 6 months post-treatment, CLES-I had significantly fewer pills/day than CLES-NI (4.7 versus 11.4, p < 0.05) and DBS (4.8 versus 7.4, p < 0.05). A significant reduction in pill burden was observed at 0-6 months (46.3%) and 7-12 months (68.3%) follow-up for CLES-I (p < 0.001) versus increased burden for CLES-NI (+10.5%, p < 0.05 and +8.2%, p > 0.05) and insignificant reductions for DBS (-3.9% and -6.1%, p > 0.05). Mean adjusted pill burden showed 57.3% fewer pills at 0-6 months and 74.1% at 7-12 months among CLES-I compared with CLES-NI, and 49.6% and 70.1% reduction compared with DBS. CLES-I showed a decrease in LEDD at 7-12 months compared with baseline (935 to 237 mg) and to CLES-NI (237 mg versus 1112 mg) and DBS patients (236 mg versus 594 mg). CONCLUSION CLES led to a significant reduction in pill burden and oral LEDD compared with CLES-NI and DBS patients. Pill burden reduction could be considered a treatment goal for patients with APD challenged by complex polypharmacy regimens that interfere with activities of daily living and quality of life.
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Affiliation(s)
- Michael J Soileau
- Texas Movement Disorder Specialists, 204 S. Interstate 35, Suite 103, Georgetown, TX, 78628, USA.
| | - Fernando L Pagan
- Georgetown University Hospital, 3800 Reservoir Rd, NW 7 PHC, Washington, DC, 20007, USA
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.,Division of Neurology, University of Toronto, Toronto, ON, Canada.,Krembil Brain Institute, Toronto, ON, Canada
| | | | - Connie H Yan
- AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Niodita R Gupta
- AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | | | | | - Jill K Schinkel
- Inovalon Insights, 4321 Collington Rd, Bowie, MD, 20716, USA
| | | | - Omar A Ladhani
- AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Mustafa S Siddiqui
- Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC, USA
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Hacker M, Cannard G, Turchan M, Meystedt J, Davis T, Phibbs F, Hedera P, Konrad P, Charles D. Early subthalamic nucleus deep brain stimulation in Parkinson's disease reduces long-term medication costs. Clin Neurol Neurosurg 2021; 210:106976. [PMID: 34666273 DOI: 10.1016/j.clineuro.2021.106976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/20/2021] [Accepted: 09/21/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Subthalamic nucleus (STN) deep brain stimulation (DBS) is recognized as a safe and effective treatment in mid- and advanced-staged Parkinson's disease (PD) that decreases the need for PD medications and their associated costs. This study reports medication costs from the only clinical trial to evaluate DBS in patients with early-stage PD and projects costs through advanced-stage disease. METHODS The DBS in early-stage PD pilot was a prospective, single-blind clinical trial that randomized 30 patients with early-stage PD 1:1 to receive bilateral STN-DBS plus optimal drug therapy (ODT) or ODT alone. Subjects who completed the trial participated in an observational follow-up study and were evaluated annually for five years after randomization. PD medication data collected at each study visit were used to calculate and project medication costs (n = 28). RESULTS Five-year cumulative medication cost reduction with early DBS+ODT was $28,246. Mean annual medication cost for early DBS+ODT subjects was 2.4 times lower than early ODT subjects (β = 2.4, 95%CI:1.5-3.7, p = 0.0004). Early DBS+ODT is projected to reduce cumulative medication costs by $104,958 over 15 years of disease duration. CONCLUSION DBS in early-stage PD may provide long-term medication cost reduction compared to standard care.
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Affiliation(s)
- Mallory Hacker
- Department of Neurology, Vanderbilt University Medical Center, A-0118 Medical Center North, Nashville, TN 37232, United States; Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, 2201 Children's Way Suite 1221, Nashville, TN 37212.
| | - Grace Cannard
- Department of Neurology, Vanderbilt University Medical Center, A-0118 Medical Center North, Nashville, TN 37232, United States.
| | - Maxim Turchan
- Department of Neurology, Vanderbilt University Medical Center, A-0118 Medical Center North, Nashville, TN 37232, United States.
| | - Jacqueline Meystedt
- Department of Neurology, Vanderbilt University Medical Center, A-0118 Medical Center North, Nashville, TN 37232, United States.
| | - Thomas Davis
- Department of Neurology, Vanderbilt University Medical Center, A-0118 Medical Center North, Nashville, TN 37232, United States.
| | - Fenna Phibbs
- Department of Neurology, Vanderbilt University Medical Center, A-0118 Medical Center North, Nashville, TN 37232, United States.
| | - Peter Hedera
- Department of Neurology, Vanderbilt University Medical Center, A-0118 Medical Center North, Nashville, TN 37232, United States; Department of Neurology, University of Louisville, Academic Offices, 500 South Preston St., HSC-A Bldg. Suite 113, Louisville, KY 40202, United States.
| | - Peter Konrad
- Department of Neurosurgery, Vanderbilt University Medical Center, 1161 21st Ave. So., T4224 Medical Center North, Nashville, TN 37232-2380, United States; Department of Neurosurgery, West Virginia University, Room 4300 HSS, Morgantown, WV 26506, United States.
| | - David Charles
- Department of Neurology, Vanderbilt University Medical Center, A-0118 Medical Center North, Nashville, TN 37232, United States.
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