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Lange F, Steigerwald F, Malzacher T, Brandt GA, Odorfer TM, Roothans J, Reich MM, Fricke P, Volkmann J, Matthies C, Capetian PD. Reduced Programming Time and Strong Symptom Control Even in Chronic Course Through Imaging-Based DBS Programming. Front Neurol 2021; 12:785529. [PMID: 34819915 PMCID: PMC8606823 DOI: 10.3389/fneur.2021.785529] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Deep brain stimulation (DBS) programming is based on clinical response testing. Our clinical pilot trial assessed the feasibility of image-guided programing using software depicting the lead location in a patient-specific anatomical model. Methods: Parkinson's disease patients with subthalamic nucleus-DBS were randomly assigned to standard clinical-based programming (CBP) or anatomical-based (imaging-guided) programming (ABP) in an 8-week crossover trial. Programming characteristics and clinical outcomes were evaluated. Results: In 10 patients, both programs led to similar motor symptom control (MDS-UPDRS III) after 4 weeks (medicationOFF/stimulationON; CPB: 18.27 ± 9.23; ABP: 18.37 ± 6.66). Stimulation settings were not significantly different, apart from higher frequency in the baseline program than CBP (p = 0.01) or ABP (p = 0.003). Time spent in a program was not significantly different (CBP: 86.1 ± 29.82%, ABP: 88.6 ± 29.0%). Programing time was significantly shorter (p = 0.039) with ABP (19.78 ± 5.86 min) than CBP (45.22 ± 18.32). Conclusion: Image-guided DBS programming in PD patients drastically reduces programming time without compromising symptom control and patient satisfaction in this small feasibility trial.
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Affiliation(s)
- Florian Lange
- Department of Neurology, University Hospital and Julius-Maximilians-University, Wuerzburg, Germany
| | - Frank Steigerwald
- Department of Neurology, University Hospital and Julius-Maximilians-University, Wuerzburg, Germany
| | - Tobias Malzacher
- Department of Neurology, University Hospital and Julius-Maximilians-University, Wuerzburg, Germany
| | - Gregor Alexander Brandt
- Department of Neurology, University Hospital and Julius-Maximilians-University, Wuerzburg, Germany
| | - Thorsten Michael Odorfer
- Department of Neurology, University Hospital and Julius-Maximilians-University, Wuerzburg, Germany
| | - Jonas Roothans
- Department of Neurology, University Hospital and Julius-Maximilians-University, Wuerzburg, Germany
| | - Martin M Reich
- Department of Neurology, University Hospital and Julius-Maximilians-University, Wuerzburg, Germany
| | - Patrick Fricke
- Department of Neurosurgery, University Hospital and Julius-Maximilians-University, Wuerzburg, Germany
| | - Jens Volkmann
- Department of Neurology, University Hospital and Julius-Maximilians-University, Wuerzburg, Germany
| | - Cordula Matthies
- Department of Neurosurgery, University Hospital and Julius-Maximilians-University, Wuerzburg, Germany
| | - Philipp D Capetian
- Department of Neurology, University Hospital and Julius-Maximilians-University, Wuerzburg, Germany
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Lee KS, Yordanov S, Stubbs D, Edlmann E, Joannides A, Davies B. Integrated care pathways in neurosurgery: A systematic review. PLoS One 2021; 16:e0255628. [PMID: 34339465 PMCID: PMC8328336 DOI: 10.1371/journal.pone.0255628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/20/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction Integrated care pathways (ICPs) are a pre-defined framework of evidence based, multidisciplinary practice for specific patients. They have the potential to enhance continuity of care, patient safety, patient satisfaction, efficiency gains, teamwork and staff education. In order to inform the development of neurosurgical ICPs in the future, we performed a systematic review to aggregate examples of neurosurgical ICP, to consider their impact and design features that may be associated with their success. Methods Electronic databases MEDLINE, EMBASE, and CENTRAL were searched for relevant literature published from date of inception to July 2020. Primary studies reporting details of neurosurgical ICPs, across all pathologies and age groups were eligible for inclusion. Patient outcomes in each case were also recorded. Results Twenty-four studies were included in our final dataset, from the United States, United Kingdom, Italy, China, Korea, France, Netherlands and Switzerland, and a number of sub-specialties. 3 for cerebrospinal fluid diversion, 1 functional, 2 neurovascular, 1 neuro-oncology, 2 paediatric, 2 skull base, 10 spine, 1 for trauma, 2 miscellaneous (other craniotomies). All were single centre studies with no regional or national examples. Thirteen were cohort studies while 11 were case series which lacked a control group. Effectiveness was typically evaluated using hospital or professional performance metrics, such as length of stay (n = 11, 45.8%) or adverse events (n = 17, 70.8%) including readmission, surgical complications and mortality. Patient reported outcomes, including satisfaction, were evaluated infrequently (n = 3, 12.5%). All studies reported a positive impact. No study reported how the design of the ICP was informed by published literature or other methods Conclusions ICPs have been successfully developed across numerous neurosurgical sub-specialities. However, there is often a lack of clarity over their design and weaknesses in their evaluation, including an underrepresentation of the patient’s perspective.
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Affiliation(s)
- Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- * E-mail: (KSL); (BD)
| | - Stefan Yordanov
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Daniel Stubbs
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ellie Edlmann
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Alexis Joannides
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Benjamin Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- * E-mail: (KSL); (BD)
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Aubignat M, Lefranc M, Tir M, Krystkowiak P. Deep brain stimulation programming in Parkinson's disease: Introduction of current issues and perspectives. Rev Neurol (Paris) 2020; 176:770-779. [DOI: 10.1016/j.neurol.2020.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 01/28/2020] [Accepted: 02/12/2020] [Indexed: 12/11/2022]
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Rajan R, Brennan L, Bloem BR, Dahodwala N, Gardner J, Goldman JG, Grimes DA, Iansek R, Kovács N, McGinley J, Parashos SA, Piemonte ME, Eggers C. Integrated Care in Parkinson's Disease: A Systematic Review and
Meta‐Analysis. Mov Disord 2020; 35:1509-1531. [DOI: 10.1002/mds.28097] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- Roopa Rajan
- All India Institute of Medical Sciences New Delhi India
| | | | - Bastiaan R. Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders Nijmegen The Netherlands
| | - Nabila Dahodwala
- Department of Neurology, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Joan Gardner
- Struthers Parkinson's Center, Park Nicollet Health Services Golden Valley Minnesota USA
| | - Jennifer G. Goldman
- Parkinson's Disease and Movement Disorders, Shirley Ryan Abilitylab; Department of Physical Medicine & Rehabilitation and Neurology Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - David A. Grimes
- Ottawa Hospital, University of Ottawa Brain and Mind Research Institute Ottawa Ontario Canada
| | - Robert Iansek
- Clinical Research Centre for Movement Disorders and Gait, Comprehensive Parkinson Care Program, Parkinson Foundation Centre of Excellence, Kington Centre Monash Health Cheltenham Victoria Australia
- Department of Clinical Sciences Monash University Clayton Victoria Australia
| | - Norbert Kovács
- Department of Neurology Universityof Pécs Pécs Hungary
- MTA‐PTE Clinical Neuroscience MR Research Group Pécs Hungary
| | - Jennifer McGinley
- Physiotherapy Department The University of Melbourne Melbourne Australia
| | - Sotirios A. Parashos
- Struthers Parkinson's Center, Park Nicollet Health Services Golden Valley Minnesota USA
| | - Maria E.P. Piemonte
- University of Sao Paulo, Medical School, Physical Therapy, Speech Therapy and Occupational Therapy Department Sao Paulo Brazil
| | - Carsten Eggers
- Department of Neurology, University Hospital Marburg; Center for Mind, Brain and Behavior Universities Gießen & Marburg Marburg Germany
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DBS Programming: An Evolving Approach for Patients with Parkinson's Disease. PARKINSONS DISEASE 2017; 2017:8492619. [PMID: 29147598 PMCID: PMC5632902 DOI: 10.1155/2017/8492619] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/03/2017] [Accepted: 07/19/2017] [Indexed: 11/18/2022]
Abstract
Deep brain stimulation (DBS) surgery is a well-established therapy for control of motor symptoms in Parkinson's disease. Despite an appropriate targeting and an accurate placement of DBS lead, a thorough and efficient programming is critical for a successful clinical outcome. DBS programming is a time consuming and laborious manual process. The current approach involves use of general guidelines involving determination of the lead type, electrode configuration, impedance check, and battery check. However there are no validated and well-established programming protocols. In this review, we will discuss the current practice and the recent advances in DBS programming including the use of interleaving, fractionated current, directional steering of current, and the use of novel DBS pulses. These technological improvements are focused on achieving a more efficient control of clinical symptoms with the least possible side effects. Other promising advances include the introduction of computer guided programming which will likely impact the efficiency of programming for the clinicians and the possibility of remote Internet based programming which will improve access to DBS care for the patients.
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Picillo M, Lozano AM, Kou N, Puppi Munhoz R, Fasano A. Programming Deep Brain Stimulation for Parkinson's Disease: The Toronto Western Hospital Algorithms. Brain Stimul 2016; 9:425-437. [DOI: 10.1016/j.brs.2016.02.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/02/2016] [Accepted: 02/03/2016] [Indexed: 12/19/2022] Open
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Pourfar MH, Mogilner AY, Farris S, Giroux M, Gillego M, Zhao Y, Blum D, Bokil H, Pierre MC. Model-Based Deep Brain Stimulation Programming for Parkinson's Disease: The GUIDE Pilot Study. Stereotact Funct Neurosurg 2015; 93:231-9. [DOI: 10.1159/000375172] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 01/13/2015] [Indexed: 11/19/2022]
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Bendersky D, Ajler P, Yampolsky C. [The use of neuromodulation for the treatment of tremor]. Surg Neurol Int 2014; 5:S232-46. [PMID: 25165613 PMCID: PMC4138824 DOI: 10.4103/2152-7806.137944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 11/29/2012] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Tremor may be a disabling disorder and pharmacologic treatment is the first-line therapy for these patients. Nevertheless, this treatment may lead to a satisfactory tremor reduction in only 50% of patients with essential tremor. Thalamotomy was the treatment of choice for tremor refractory to medical therapy until deep brain stimulation (DBS) of the ventral intermedius nucleus (Vim) of the thalamus has started being used. Nowadays, thalamotomy is rarely performed. METHODS This article is a non-systematic review of the indications, results, programming parameters and surgical technique of DBS of the Vim for the treatment of tremor. RESULTS In spite of the fact that it is possible to achieve similar clinical results using thalamotomy or DBS of the Vim, the former causes more adverse effects than the latter. Furthermore, DBS can be used bilaterally, whereas thalamotomy has a high risk of causing disartria when it is performed in both sides. DBS of the Vim achieved an adequate tremor improvement in several series of patients with tremor caused by essential tremor, Parkinson's disease or multiple sclerosis. Besides the Vim, there are other targets, which are being used by some authors, such as the zona incerta and the prelemniscal radiations. CONCLUSION DBS of the Vim is a useful treatment for disabling tremor refractory to medical therapy. It is essential to carry out an accurate patient selection as well as to use a proper surgical technique. The best stereotactic target for tremor is still unknown, although the Vim is the most used one.
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Affiliation(s)
- Damián Bendersky
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Pablo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Claudio Yampolsky
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Bell E, Racine E. Ethics guidance for neurological and psychiatric deep brain stimulation. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:313-25. [DOI: 10.1016/b978-0-444-53497-2.00026-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Bell E, Maxwell B, McAndrews MP, Sadikot A, Racine E. Deep brain stimulation and ethics: perspectives from a multisite qualitative study of Canadian neurosurgical centers. World Neurosurg 2012; 76:537-47. [PMID: 22251502 DOI: 10.1016/j.wneu.2011.05.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 03/18/2011] [Accepted: 05/13/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is an approved neurosurgical intervention for motor disorders such as Parkinson disease. The emergence of psychiatric uses for DBS combined with the fact that it is an invasive and expensive procedure creates important ethical and social challenges in the delivery of care that need further examination. We endeavored to examine health care provider perspectives on ethical and social challenges encountered in DBS. METHODS Health care providers working in Canadian DBS surgery programs participated in a semistructured interview to identify and characterize ethical and social challenges of DBS. A content analysis of the interviews was conducted. RESULTS Several key ethical issues, such as patient screening and resource allocation, were identified by members of neurosurgical teams. Providers described challenges in selecting patients for DBS on the basis of unclear evidence-based guidance regarding behavioral issues or cognitive criteria. Varied contexts of resource allocation, including some very challenging schemas, were also reported. In addition, the management of patients in the community was highlighted as a source of ethical and clinical complexity, given the need for coordinated long-term care. CONCLUSIONS This study provides insights into the complexity of ethical challenges that providers face in the use of DBS across different neurosurgical centers. We propose actions for health care providers for the long-term care and postoperative monitoring of patients with DBS. More data on patient perspectives in DBS would complement the understanding of key challenges, as well as contribute to best practices, for patient selection, management, and resource allocation.
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Affiliation(s)
- Emily Bell
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
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Do co-morbidities and cognition impact functional change and discharge needs in Parkinson disease? Am J Phys Med Rehabil 2011; 90:272-80. [PMID: 21765244 DOI: 10.1097/phm.0b013e31820b15a2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess the impact of cognition, baseline motor function, and co-morbid medical conditions on functional change, discharge destination, and discharge needs in patients admitted to acute rehabilitation for Parkinson-related impairments. DESIGN This retrospective chart review study evaluated the records of patients admitted to acute rehabilitation over a 5-yr period with a primary impairment category of parkinsonism. Functional status was measured at admission and discharge; 3-mo follow-up function was also collected in a sample of discharged patients. RESULTS Eighty-nine patients (mean age, 74.26 yrs) were admitted over the 5-yr time frame. A more complicated Medicare tier diagnosis (tier 2) was associated with lower total and motor score Functional Independence Measure gains compared with tier 3 (P = 0.009 and P = 0.016, respectively). Cognitive scores at admission were not related to need for caregivers upon discharge. Overall Functional Independence Measure gain (adjusted R(2) = 0.073, P = 0.006) and Functional Independence Measure gain efficiency (adjusted R(2) = 0.142, P < 0.001) inversely correlated with age. At the 3-mo follow-up, a random sample (38%) of patients contacted postdischarge demonstrated continued improvements. CONCLUSIONS Significant improvement may be seen after acute rehabilitation in patients with Parkinson disease, irrespective of cognitive impairment. More complicated medical tier diagnoses result in less Functional Independence Measure gain, and older individuals with Parkinson disease are more likely to show less functional change. However, functional improvements are still statistically significant.
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Bell E, Maxwell B, McAndrews MP, Sadikot AF, Racine E. A review of social and relational aspects of deep brain stimulation in Parkinson's disease informed by healthcare provider experiences. PARKINSONS DISEASE 2011; 2011:871874. [PMID: 21822472 PMCID: PMC3132670 DOI: 10.4061/2011/871874] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 02/15/2011] [Indexed: 11/20/2022]
Abstract
Background. Although the clinical effectiveness of deep brain stimulation (DBS) in Parkinson's disease is established, there has been less examination of its social aspects. Methods and Results. Building on qualitative comments provided by healthcare providers, we present four different social and relational issues (need for social support, changes in relationships (with self and partner) and challenges with regards to occupation and the social system). We review the literature from multiple disciplines on each issue. We comment on their ethical implications and conclude by establishing the future prospects for research with the possible expansion of DBS for psychiatric indications. Conclusions. Our review demonstrates that there are varied social issues involved in DBS. These issues may have significant impacts on the perceived outcome of DBS by patients. Moreover, the fact that the social impact of DBS is still not well understood in emerging psychiatric indications presents an important area for future examination.
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Affiliation(s)
- Emily Bell
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal (IRCM), Montréal, QC, Canada H2W lR7
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Allert N, Dohle C, Horn J, Kelm S, Kirsch H, Nolte P, Weirich W, Karbe H. Rehabilitation von Parkinson-Patienten mit Tiefenhirnstimulation. DER NERVENARZT 2010; 82:462-7. [DOI: 10.1007/s00115-010-3092-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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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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Tassorelli C, Buscone S, Sandrini G, Pacchetti C, Furnari A, Zangaglia R, Bartolo M, Nappi G, Martignoni E. The role of rehabilitation in deep brain stimulation of the subthalamic nucleus for Parkinson's disease: a pilot study. Parkinsonism Relat Disord 2009; 15:675-81. [PMID: 19398215 DOI: 10.1016/j.parkreldis.2009.03.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Revised: 03/01/2009] [Accepted: 03/25/2009] [Indexed: 10/20/2022]
Abstract
Bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an efficacious therapeutic option in the treatment of advanced Parkinson's disease (PD). The procedure may be however associated with functional impairment of different types and intensity. In this paper we describe the functional impairments detected in a group of 34 subjects with PD who were submitted to DBS. These patients belonged to a cohort of 75 consecutive PD patients who underwent the surgical procedure. The rehabilitation program included physiotherapy exercises for recovery/maintenance of the range of motion, active exercises, exercises for coordination and proprioception, and walking training based on the use of sensory cues, with daily sessions for a period of 4-8 weeks. The motor examination section of unified Parkinson's disease rating scale (UPDRS-ME) and the functional independence measure (FIM) scores showed a consistent and significant improvement in the patients' motor performances. The reported findings suggest that rehabilitation may play an important role in the correction of specific functional impairments caused by or associated with DBS in PD.
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Affiliation(s)
- Cristina Tassorelli
- Department of Neurological Sciences, Interdepartmental Centre of Research on Parkinson's Disease (ICRPD), IRCCS C. Mondino Institute of Neurology Foundation, University of Pavia, Via Mondino 2, 27100 Pavia, Italy.
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