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Heß T, Themann P, Oehlwein C, Milani TL. Does Impaired Plantar Cutaneous Vibration Perception Contribute to Axial Motor Symptoms in Parkinson's Disease? Effects of Medication and Subthalamic Nucleus Deep Brain Stimulation. Brain Sci 2023; 13:1681. [PMID: 38137129 PMCID: PMC10742284 DOI: 10.3390/brainsci13121681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 11/28/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVE To investigate whether impaired plantar cutaneous vibration perception contributes to axial motor symptoms in Parkinson's disease (PD) and whether anti-parkinsonian medication and subthalamic nucleus deep brain stimulation (STN-DBS) show different effects. METHODS Three groups were evaluated: PD patients in the medication "on" state (PD-MED), PD patients in the medication "on" state and additionally "on" STN-DBS (PD-MED-DBS), as well as healthy subjects (HS) as reference. Motor performance was analyzed using a pressure distribution platform. Plantar cutaneous vibration perception thresholds (VPT) were investigated using a customized vibration exciter at 30 Hz. RESULTS Motor performance of PD-MED and PD-MED-DBS was characterized by greater postural sway, smaller limits of stability ranges, and slower gait due to shorter strides, fewer steps per minute, and broader stride widths compared to HS. Comparing patient groups, PD-MED-DBS showed better overall motor performance than PD-MED, particularly for the functional limits of stability and gait. VPTs were significantly higher for PD-MED compared to those of HS, which suggests impaired plantar cutaneous vibration perception in PD. However, PD-MED-DBS showed less impaired cutaneous vibration perception than PD-MED. CONCLUSIONS PD patients suffer from poor motor performance compared to healthy subjects. Anti-parkinsonian medication in tandem with STN-DBS seems to be superior for normalizing axial motor symptoms compared to medication alone. Plantar cutaneous vibration perception is impaired in PD patients, whereas anti-parkinsonian medication together with STN-DBS is superior for normalizing tactile cutaneous perception compared to medication alone. Consequently, based on our results and the findings of the literature, impaired plantar cutaneous vibration perception might contribute to axial motor symptoms in PD.
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Affiliation(s)
- Tobias Heß
- Department of Human Locomotion, Chemnitz University of Technology, 09126 Chemnitz, Germany
| | - Peter Themann
- Department of Neurology and Parkinson, Clinic at Tharandter Forest, 09633 Halsbruecke, Germany
| | - Christian Oehlwein
- Neurological Outpatient Clinic for Parkinson Disease and Deep Brain Stimulation, 07551 Gera, Germany
| | - Thomas L. Milani
- Department of Human Locomotion, Chemnitz University of Technology, 09126 Chemnitz, Germany
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Flouty O, Yamamoto K, Germann J, Harmsen IE, Jung HH, Cheyuo C, Zemmar A, Milano V, Sarica C, Lozano AM. Idiopathic Parkinson's disease and chronic pain in the era of deep brain stimulation: a systematic review and meta-analysis. J Neurosurg 2022; 137:1821-1830. [PMID: 35535836 DOI: 10.3171/2022.2.jns212561] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pain is the most common nonmotor symptom of Parkinson's disease (PD) and is often undertreated. Deep brain stimulation (DBS) effectively mitigates the motor symptoms of this multisystem neurodegenerative disease; however, its therapeutic effect on nonmotor symptoms, especially pain, remains inconclusive. While there is a critical need to help this large PD patient population, guidelines for managing this significant disease burden are absent. Herein, the authors systematically reviewed the literature and conducted a meta-analysis to study the influence of traditional (subthalamic nucleus [STN] and globus pallidus internus [GPi]) DBS on chronic pain in patients with PD. METHODS The authors performed a systematic review of the literature and a meta-analysis following PRISMA guidelines. Risk of bias was assessed using the levels of evidence established by the Oxford Centre for Evidence-Based Medicine. Inclusion criteria were articles written in English, published in a peer-reviewed scholarly journal, and about studies conducting an intervention for PD-related pain in no fewer than 5 subjects. RESULTS Twenty-six studies were identified and included in this meta-analysis. Significant interstudy heterogeneity was detected (Cochran's Q test p < 0.05), supporting the use of the random-effects model. The random-effects model estimated the effect size of DBS for the treatment of idiopathic pain as 1.31 (95% CI 0.84-1.79). The DBS-on intervention improved pain scores by 40% as compared to the control state (preoperative baseline or DBS off). CONCLUSIONS The results indicated that traditional STN and GPi DBS can have a favorable impact on pain control and improve pain scores by 40% from baseline in PD patients experiencing chronic pain. Further trials are needed to identify the subtype of PD patients whose pain benefits from DBS and to identify the mechanisms by which DBS improves pain in PD patients.
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Affiliation(s)
- Oliver Flouty
- 1Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Kazuaki Yamamoto
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jurgen Germann
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Irene E Harmsen
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Hyun Ho Jung
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,3Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Cletus Cheyuo
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ajmal Zemmar
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,4Department of Neurosurgery, University of Louisville, School of Medicine, Louisville, Kentucky; and.,5Department of Neurosurgery, Henan Provincial People's Hospital, Henan University People's Hospital, Henan University School of Medicine, Zhengzhou, China
| | - Vanessa Milano
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Can Sarica
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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3
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Kaiserova M, Kastelikova A, Grambalova Z, Otruba P, Zapletalova J, Mensikova K, Rosales R, Kanovsky P. Temperature sensation in Parkinson's disease measured by quantitative sensory testing: a single-center, case-control study. Int J Neurosci 2021:1-6. [PMID: 34666599 DOI: 10.1080/00207454.2021.1991922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The pathophysiology of abnormal temperature sensation in Parkinson's disease (PD) remains unclear. Abnormal thermal detection does not seem to depend on the dopaminergic deficit, suggesting that other systems play a role in these changes, probably both central and peripheral. METHODS We measured thermal detection thresholds (TDT) using quantitative sensory testing (QST) in 28 patients with PD and compared them with 15 healthy controls. RESULTS Of 28 patients, 21% had increased TDT according to the normative data. TDT were higher on the dominant side. No correlation between TDT and disease duration, severity of motor impairment, and dopaminergic therapy was observed. 50% of the patients had difficulty differentiating between warm and cold stimuli, as TDT were within the normal range in most of these patients. CONCLUSIONS Twenty-one percent of the patients in our study had increased TDT according to the normative data. Abnormal thermal detection was more pronounced on the dominant side. Abnormal differentiation between the thermal stimuli suggest impaired central processing of thermal information.
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Affiliation(s)
- Michaela Kaiserova
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University and University Hospital, Olomouc, Czech Republic
| | - Anetta Kastelikova
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University and University Hospital, Olomouc, Czech Republic
| | - Zuzana Grambalova
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University and University Hospital, Olomouc, Czech Republic
| | - Pavel Otruba
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University and University Hospital, Olomouc, Czech Republic
| | - Jana Zapletalova
- Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacky University and University Hospital, Olomouc, Czech Republic
| | - Katerina Mensikova
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University and University Hospital, Olomouc, Czech Republic
| | - Raymond Rosales
- The Neuroscience Institute, Department of Neurology and Psychiatry, University of Santo Tomas University Hospital, Manila, Philippines
| | - Petr Kanovsky
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University and University Hospital, Olomouc, Czech Republic
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4
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Mostofi A, Morgante F, Edwards MJ, Brown P, Pereira EAC. Pain in Parkinson's disease and the role of the subthalamic nucleus. Brain 2021; 144:1342-1350. [PMID: 34037696 DOI: 10.1093/brain/awab001] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/07/2020] [Accepted: 10/22/2020] [Indexed: 11/14/2022] Open
Abstract
Pain is a frequent and poorly treated symptom of Parkinson's disease, mainly due to scarce knowledge of its basic mechanisms. In Parkinson's disease, deep brain stimulation of the subthalamic nucleus is a successful treatment of motor symptoms, but also might be effective in treating pain. However, it has been unclear which type of pain may benefit and how neurostimulation of the subthalamic nucleus might interfere with pain processing in Parkinson's disease. We hypothesized that the subthalamic nucleus may be an effective access point for modulation of neural systems subserving pain perception and processing in Parkinson's disease. To explore this, we discuss data from human neurophysiological and psychophysical investigations. We review studies demonstrating the clinical efficacy of deep brain stimulation of the subthalamic nucleus for pain relief in Parkinson's disease. Finally, we present some of the key insights from investigations in animal models, healthy humans and Parkinson's disease patients into the aberrant neurobiology of pain processing and consider their implications for the pain-relieving effects of subthalamic nucleus neuromodulation. The evidence from clinical and experimental studies supports the hypothesis that altered central processing is critical for pain generation in Parkinson's disease and that the subthalamic nucleus is a key structure in pain perception and modulation. Future preclinical and clinical research should consider the subthalamic nucleus as an entry point to modulate different types of pain, not only in Parkinson's disease but also in other neurological conditions associated with abnormal pain processing.
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Affiliation(s)
- Abteen Mostofi
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, SW17 0RE, London, UK
| | - Francesca Morgante
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, SW17 0RE, London, UK
- Department of Experimental and Clinical Medicine, University of Messina, 98125, Messina, Italy
| | - Mark J Edwards
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, SW17 0RE, London, UK
| | - Peter Brown
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, OX1 3TH, Oxford, UK
| | - Erlick A C Pereira
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, SW17 0RE, London, UK
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5
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Atsumi H, Matsumae M. Fusing of Preoperative Magnetic Resonance and Intraoperative O-arm Images in Deep Brain Stimulation Enhance Intuitive Surgical Planning and Increase Accuracy of Lead Placement. Neurol Med Chir (Tokyo) 2021; 61:341-346. [PMID: 33790132 PMCID: PMC8120096 DOI: 10.2176/nmc.tn.2020-0317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Intraoperative fluoroscopy and microelectrode recording (MER) are useful techniques for guiding lead placement in deep brain stimulation (DBS). Recent advances in magnetic resonance imaging (MRI) have enabled information on the location of the basal ganglia, as the target of DBS, to be obtained preoperatively. However, intraoperative images with few artifacts are required to enable accurate fusion of preoperative imaging data with intraoperative lead position data. With our method, we first fuse preoperative MRI and pre-frame fixed computed tomography (CT) images, then fuse the CT images exactly after mounting the frame, using this fusion image as a platform image. Compared with before and after frame fixation, the pre-frame fixed CT has less artifacts, facilitating the identification of soft tissues such as the ventricles and cortical surface on pre-frame fixed CT images. By fusing the structural information for these soft tissues between pre-frame fixed CT and MR images, this fusion process can provide improved accuracy that is intuitively understood by the surgeon. Using platform images, surgical planning and intraoperative lead positioning can then be evaluated on the same coordinate axis. Positional data on the lead acquired as three-dimensional (3D) data are then added to the platform image. The proposed surgical steps permit the acquisition of accurate lead position data.
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Affiliation(s)
- Hideki Atsumi
- Department of Neurosurgery, Tokai University School of Medicine
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6
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Sabourin S, Khazen O, DiMarzio M, Staudt MD, Williams L, Gillogly M, Durphy J, Hanspal EK, Adam OR, Pilitsis JG. Effect of Directional Deep Brain Stimulation on Sensory Thresholds in Parkinson's Disease. Front Hum Neurosci 2020; 14:217. [PMID: 32581755 PMCID: PMC7296062 DOI: 10.3389/fnhum.2020.00217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 05/14/2020] [Indexed: 11/17/2022] Open
Abstract
Objective Previous studies showed that deep brain stimulation (DBS) relieves pain symptoms in Parkinson disease (PD) patients when programmed for motor-symptom relief. One factor involved in pain processing is sensory perception of stimuli. With the advent of directional leads, we explore whether directional DBS affects quantitative sensory testing (QST) metrics acutely. Methods PD patients with subthalamic (STN) DBS and directional leads were tested in 5 settings (DBS-OFF, DBS-ON with omnidirectional stimulation, and DBS-ON) for each of three directional segments of contact used for clinical programming. The Unified Parkinson’s Disease Rating Scale (UPDRS-III) assessed patient’s motor skills at time of study visit at clinical contact and at contact which produced optimal sensory threshold (defined by the greatest tolerance to mechanical stimuli). Correlation analyses were performed between stimulation parameters [amplitude, frequency, pulse width (PW), total electrical energy delivered (TEED)] and outcome metrics. Results Sensory thresholds were obtained in nine patients. Directional stimulation did not significantly alter patient perceptions of sensory stimulus [cold pain (p = 0.69), warm pain (p = 0.99), Von frey fibers (p = 0.09), pin-prick (p = 0.88), vibration (p = 0.40), pressure (p = 0.98)]. With correlation analysis, increasing PW at the posterior contact increased pin prick and vibration sensitivity (p < 0.001). Additionally, an increase in TEED caused a decrease in sensitivity to warm detection when using the anterior (p = 0.04), lateral (p = 0.02), and medial contacts (p = 0.03), and also caused a decrease in sensitivity to cold detection when using the medial contact (p = 0.03). UPDRS-III remained stable during testing. Conclusion Motor benefit can be acutely maintained at directional contacts, whereas directional stimulation can modulate thermal and mechanical sensitivity. Further investigation will determine whether these changes are maintained chronically or can be improved with optimized programming.
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Affiliation(s)
- Shelby Sabourin
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Olga Khazen
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Marisa DiMarzio
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Michael D Staudt
- Department of Neurosurgery, Albany Medical College, Albany, NY, United States
| | - Lucian Williams
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Michael Gillogly
- Department of Neurosurgery, Albany Medical College, Albany, NY, United States
| | - Jennifer Durphy
- Department of Neurology, Albany Medical College, Albany, NY, United States
| | - Era K Hanspal
- Department of Neurology, Albany Medical College, Albany, NY, United States
| | - Octavian R Adam
- Department of Neurology, Albany Medical College, Albany, NY, United States
| | - Julie G Pilitsis
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States.,Department of Neurosurgery, Albany Medical College, Albany, NY, United States
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7
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Fründt O, Grashorn W, Buhmann C, Forkmann K, Mainka T, Bingel U, Schmidt K. Quantitative Sensory Testing (QST) in Drug-Naïve Patients with Parkinson's Disease. JOURNAL OF PARKINSONS DISEASE 2020; 9:369-378. [PMID: 30829618 DOI: 10.3233/jpd-181513] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pain is highly prevalent in patients with Parkinson's disease (PD), but underlying pathophysiological mechanisms are largely unclear. Alterations in somatosensory processing might contribute to sensory abnormalities in PD. OBJECTIVE This study investigated sensory processing in PD patients. METHODS We used the standardized "Quantitative Sensory Testing" (QST) protocol (German Research Network on Neuropathic Pain) to investigate 13 somatosensory parameters in 19 PD patients naïve to dopaminergic medication and 19 healthy controls matched for age, gender, and handedness. We tested for differences in sensory parameters between i) drug-naïve PD patients and healthy controls, ii) patients' more and less affected body side, and iii) for an association of somatosensory parameters with disease-specific factors. RESULTS We did not observe any significant group differences in somatosensory parameters between PD patients and healthy subjects. In PD patients, QST mean z-scores did not differ between the predominantly and the less affected body side, PD patients with and without PD-specific chronic pain or between different PD subtypes. Age, but not PD disease severity, was associated with a greater loss of function in thermal and mechanical detection thresholds. CONCLUSIONS Somatosensory processing, as assessed with the well-established QST protocol, was normal in drug-naïve PD patients. Thus, somatosensory abnormalities previously reported in medicated PD patients might rather be a result of dopaminergic medication, or may occur later in the course of the disease or with increasing age.
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Affiliation(s)
- Odette Fründt
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wiebke Grashorn
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katarina Forkmann
- Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Tina Mainka
- Department of Neurology, Charité Berlin, Berlin
| | - Ulrike Bingel
- Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Erwin L. Hahn Institute for magnetic resonance imaging, Essen, Germany
| | - Katharina Schmidt
- Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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8
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Sung S, Vijiaratnam N, Chan DWC, Farrell M, Evans AH. Parkinson disease: A systemic review of pain sensitivities and its association with clinical pain and response to dopaminergic stimulation. J Neurol Sci 2018; 395:172-206. [PMID: 30401469 DOI: 10.1016/j.jns.2018.10.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/15/2018] [Accepted: 10/11/2018] [Indexed: 10/28/2022]
Abstract
Patients with Parkinson disease (PD) experience hyperalgesia on evoked pain sensitivity testing, although the relationship of this with persistent pain in PD is less certain. Studies examining this have generated contradictory findings. Further, the role of dopaminergic deficiency as an underlying substrate for hyperalgesia is controversial. We report the results of meta-analyses of the PD pain sensitivity literature in an attempt to answer these questions. We identified 429 records, of which ten articles compared pain sensitivity between PD patients that experienced clinical pain (PDP) to those who did not (PDNP), and twenty studies that examined the effect of dopaminergic medications on pain sensitivity in PD patients. PDP patients experienced a moderate increase in pain sensitivity, had more severe disease, required higher dosages of medication, and were more likely to be female when compared to those PDNP patients. PD patients also had reduced pain sensitivity when tested on dopaminergic medications compared to when they were not on medications. Overall, the results of this systematic review and meta-analysis supports the hypothesis that hyperalgesia contributes to clinical pain in PD, and that the underlying mechanism may be dopaminergically driven.
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Affiliation(s)
- Simon Sung
- Movement Disorders Service, Department of Neurology, the Royal Melbourne Hospital, Grattan St Parkville 3050, Australia; Department of Neurology, Sunshine Hospital, 176 Furlong Road, St Albans, VIC 3021, Australia
| | - Nirosen Vijiaratnam
- Department of Neurology, Sunshine Hospital, 176 Furlong Road, St Albans, VIC 3021, Australia
| | - Daniela Wan Chi Chan
- Department of Endocrinology, Barwon Health, Bellerine St, Geelong, VIC 3220, Australia
| | - Michael Farrell
- Department of Medical Imaging and Radiation Sciences, School of Biomedical Sciences, Faculty of Medicine, Nursing and Health Sciences, 10 Chancellors Walk, Clayton Campus, VIC 3800, Australia
| | - Andrew H Evans
- Movement Disorders Service, Department of Neurology, the Royal Melbourne Hospital, Grattan St Parkville 3050, Australia.
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9
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Cortical Potentials Evoked by Subthalamic Stimulation Demonstrate a Short Latency Hyperdirect Pathway in Humans. J Neurosci 2018; 38:9129-9141. [PMID: 30201770 DOI: 10.1523/jneurosci.1327-18.2018] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 11/21/2022] Open
Abstract
A monosynaptic projection from the cortex to the subthalamic nucleus is thought to have an important role in basal ganglia function and in the mechanism of therapeutic subthalamic deep-brain stimulation, but in humans the evidence for its existence is limited. We sought physiological confirmation of the cortico-subthalamic hyperdirect pathway using invasive recording techniques in patients with Parkinson's disease (9 men, 1 woman). We measured sensorimotor cortical evoked potentials using a temporary subdural strip electrode in response to low-frequency deep-brain stimulation in patients undergoing awake subthalamic or pallidal lead implantations. Evoked potentials were grouped into very short latency (<2 ms), short latency (2-10 ms), and long latency (10-100 ms) from the onset of the stimulus pulse. Subthalamic and pallidal stimulation resulted in very short-latency evoked potentials at 1.5 ms in the primary motor cortex accompanied by EMG-evoked potentials consistent with corticospinal tract activation. Subthalamic, but not pallidal stimulation, resulted in three short-latency evoked potentials at 2.8, 5.8, and 7.7 ms in a widespread cortical distribution, consistent with antidromic activation of the hyperdirect pathway. Long-latency potentials were evoked by both targets, with subthalamic responses lagging pallidal responses by 10-20 ms, consistent with orthodromic activation of the thalamocortical pathway. The amplitude of the first short-latency evoked potential was predictive of the chronic therapeutic stimulation contact.SIGNIFICANCE STATEMENT This is the first physiological demonstration of the corticosubthalamic hyperdirect pathway and its topography at high spatial resolution in humans. We studied cortical potentials evoked by deep-brain stimulation in patients with Parkinson's disease undergoing awake lead implantation surgery. Subthalamic stimulation resulted in multiple short-latency responses consistent with activation of hyperdirect pathway, whereas no such response was present during pallidal stimulation. We contrast these findings with very short latency, direct corticospinal tract activations, and long-latency responses evoked through polysynaptic orthodromic projections. These findings underscore the importance of incorporating the hyperdirect pathway into models of human basal ganglia function.
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10
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DiMarzio M, Pilitsis JG, Gee L, Peng S, Prusik J, Durphy J, Ramirez-Zamora A, Hanspal E, Molho E, McCallum SE. King's Parkinson's Disease Pain Scale for Assessment of Pain Relief Following Deep Brain Stimulation for Parkinson's Disease. Neuromodulation 2018; 21:617-622. [PMID: 29608802 DOI: 10.1111/ner.12778] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/08/2018] [Accepted: 02/20/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Pain is a prevalent and debilitating nonmotor symptom of Parkinson's disease (PD) that is often inadequately managed. Deep brain stimulation (DBS) has been shown to relieve pain in PD but an effective method of identifying which types of PD pain respond to DBS has not been established. We examine the effects of DBS on different types of PD pain using the King's Parkinson's disease pain scale (KPDPS), the only validated scale of PD pain. METHODS We prospectively followed 18 PD patients undergoing subthalamic nucleus (STN) or Globus pallidus interna (GPi) DBS. Subjects completed the KPDPS, low back disability index (LBDI), and McGill pain questionnaire (MPQ), preoperatively and at six months postoperatively. Subjects underwent the unified Parkinson's disease rating scale-III (UPDRS-III) with preoperative scores ON medication and postoperative scores ON medication/DBS stimulation. RESULTS Of the 18 patients, a total of 12 subjects had STN DBS and 6 had GPi DBS. As a group, subjects showed improvement in total KPDPS score at six-month postoperative follow-up (p = 0.004). Fluctuation and nocturnal pain were most significantly improved (p = 0.006, 0.01, respectively). Significant improvements were found in fluctuation-related pain domain following GPi DBS. CONCLUSIONS In this pilot study, we are the first group to employ KPDPS to monitor pain relief following DBS in PD patients. We demonstrate that fluctuation-related pain and nocturnal pain significantly improve with DBS. Use of the KPDPS in the future will allow better understanding of how STN and GPi DBS treat PD pain over time.
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Affiliation(s)
- Marisa DiMarzio
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | - Julie G Pilitsis
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA.,Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Lucy Gee
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA.,Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Sophia Peng
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Julia Prusik
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA.,Department of Neurosurgery, Albany Medical Center, Albany, NY, USA.,Department of Neurology, Albany Medical Center, Albany, NY, USA
| | - Jennifer Durphy
- Department of Neurology, Albany Medical Center, Albany, NY, USA
| | | | - Era Hanspal
- Department of Neurology, Albany Medical Center, Albany, NY, USA
| | - Eric Molho
- Department of Neurology, Albany Medical Center, Albany, NY, USA
| | - Sarah E McCallum
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA
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11
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Sung S, Vijiaratnam N, Chan DWC, Farrell M, Evans AH. Pain sensitivity in Parkinson's disease: Systematic review and meta-analysis. Parkinsonism Relat Disord 2017; 48:17-27. [PMID: 29398491 DOI: 10.1016/j.parkreldis.2017.12.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/22/2017] [Accepted: 12/25/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pain is a common and disabling non-motor symptom of Idiopathic Parkinson's disease (PD) but its underlying pathophysiological mechanisms are not well understood. There is evidence to suggest that altered pain sensitivity may contribute to the experience of pain in PD patients, but clinical studies investigating this have yielded inconsistent results. OBJECTIVES To examine whether pain thresholds are altered in PD patients compared to normal healthy controls (HC), via the use of systematic review and meta-analysis. DATA SOURCES A systematic search of the MEDLINE and EMBASE library from 1966 to April 2015. STUDY SELECTION Studies that compared pain thresholds in PD patients versus HC were included in the systematic review. Additionally, data comparing PD patients off dopaminergic medications (PDMoff) to HC off medications (HCMoff) were pooled for meta-analysis by pain modality. MAIN OUTCOMES Heat pain threshold, cold pain threshold, electrical pain threshold, nociceptive withdrawal reflex threshold, pressure pain threshold, and pain ratings. RESULTS 22 studies were reviewed, comprising of 616 PD and 451 HC. In the comparison of PDMoff versus HCMoff, a large majority of trials (15/19) found reduced pain thresholds (increased pain sensitivity) in PD patients. Meta-analysis of these trials revealed significantly reduced pain thresholds, of moderate to large effect size, in PD patients across all pain modalities. Results were much more heterogenous when PD patients on medications were compared with HC off medications, with most trials reporting no significant difference in pain thresholds between groups. No significant differences were found in pain thresholds for trials that compared PD patients on medications and HC on medications. CONCLUSION PD patients are more sensitive to noxious stimuli compared to HC when tested in the off medication state. This increase in pain sensitivity is observed across all modalities, but is not as apparent when PD patients are administered Levodopa, suggesting that dopamine deficient states may contribute to hyperalgesia. However, it remains to be seen whether or not increased pain sensitivity translates clinically into increased prevalence of pain. Similarly, it is unclear if dopaminergic medications influence pain sensitivity. Performing a meta-analysis on studies comparing pain thresholds in PD patients with and without pain, and on and off dopaminergic medications, may draw more definitive conclusions in this regard.
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Affiliation(s)
- Simon Sung
- Movement Disorders Service, Department of Neurology, The Royal Melbourne Hospital, Grattan, St Parkville, 3050, Australia; Department of Neurology, Sunshine Hospital, 176 Furlong Road, St Albans, VIC, 3021, Australia.
| | - Nirosen Vijiaratnam
- Department of Neurology, Sunshine Hospital, 176 Furlong Road, St Albans, VIC, 3021, Australia
| | - Daniela Wan Chi Chan
- Department of Endocrinology, Barwon Health, Bellerine St, Geelong, VIC, 3220, Australia
| | - Michael Farrell
- Department of Medical Imaging and Radiation Sciences, School of Biomedical Sciences, Faculty of Medicine, Nursing and Health Sciences, 10 Chancellors Walk, Clayton Campus, Victoria 3800, Australia
| | - Andrew H Evans
- Movement Disorders Service, Department of Neurology, The Royal Melbourne Hospital, Grattan, St Parkville, 3050, Australia
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Somatosensory function is impaired in patients with idiopathic REM sleep behaviour disorder. Sleep Med 2017; 42:83-89. [PMID: 29458751 DOI: 10.1016/j.sleep.2017.09.035] [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: 06/29/2017] [Revised: 09/01/2017] [Accepted: 09/28/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Idiopathic REM sleep behaviour disorder (iRBD) has been recognised as a significant biomarker for developing a neurodegenerative alpha-synucleinopathy, which is why iRBD is considered to be a prodromal state for alpha-synucleinopathies including Parkinson's disease (PD). Many patients with PD suffer from complaints of pain and present impaired somatosensory function. We hypothesized that pain perception and somatosensory function could be altered already in a preclinical stage of PD including iRBD. Hence, the objective of this study was to investigate pain perception and somatosensory function in patients with iRBD. METHODS Quantitative sensory testing (QST), laser evoked potentials (LEPs), and conditioned pain modulation (CPM) testing were performed in 13 iRBD patients without any clinical signs of PD or narcolepsy (11 males, 2 females, mean age 65.2 years) and 15 gender- and age-matched healthy control subjects (12 males, 3 females, mean age 65.8 years). RESULTS Thermal detection thresholds were higher in the iRBD group compared with the control group (cold detection threshold (CDT) p = 0.020, thermal sensory limen (TSL) p = 0.001), indicating an impaired temperature sensation in iRBD patients. The N2/P2 LEPs amplitude was smaller in iRBD patients than controls, but not statistically significant (p = 0.053). CONCLUSIONS This study found an impaired somatosensory function in iRBD patients, suggesting that somatosensory impairment might be an early feature in the neurodegenerative process of PD.
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Gandolfi M, Geroin C, Antonini A, Smania N, Tinazzi M. Understanding and Treating Pain Syndromes in Parkinson's Disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 134:827-858. [PMID: 28805585 DOI: 10.1016/bs.irn.2017.05.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pain affects many people with Parkinson's disease (PD) and diminishes their quality of life. Different types of pain have been described, but their related pathophysiological mechanisms remain unclear. The aim of this chapter is to provide movement disorders specialists an update about the pathophysiology of pain and a practical guide for the management of pain syndromes in clinical practice. This chapter reviews current knowledge on the pathophysiological mechanisms of sensory changes and pain in PD, as well as assessment and treatment procedures to manage these symptoms. In summary, changes in peripheral and central pain processing have been demonstrated in PD patients. A decrease in pain threshold and tolerance to several stimuli, a reduced nociceptive withdrawal reflex, a reduced pain threshold, and abnormal pain-induced activation in cortical pain-related areas have been reported. There is no direct association between improvement of motor symptoms and sensory/pain changes, suggesting that motor and nonmotor symptoms do not inevitably share the same mechanisms. Special care in pain assessment in PD is warranted by the specific pathophysiological aspects and the complexity of motor and nonmotor symptoms associated with pain symptoms. Rehabilitation may represent a valid option to manage pain syndromes in PD. However, further research in this field is needed. An integrated approach to pain involving a multidisciplinary team of medical specialists and rehabilitation experts should allow a comprehensive approach to pain in PD.
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Affiliation(s)
- Marialuisa Gandolfi
- Neuromotor and Cognitive Rehabilitation Research Center (CRRNC), University of Verona, Verona, Italy; Neurorehabilitation Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Christian Geroin
- Neuromotor and Cognitive Rehabilitation Research Center (CRRNC), University of Verona, Verona, Italy
| | - Angelo Antonini
- University of Padua and Hospital San Camillo IRCCS, Venice, Italy
| | - Nicola Smania
- Neuromotor and Cognitive Rehabilitation Research Center (CRRNC), University of Verona, Verona, Italy; Neurorehabilitation Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Michele Tinazzi
- Neurology Unit, Movement Disorders Division, University of Verona, Verona, Italy.
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Thompson T, Gallop K, Correll CU, Carvalho AF, Veronese N, Wright E, Stubbs B. Pain perception in Parkinson's disease: A systematic review and meta-analysis of experimental studies. Ageing Res Rev 2017; 35:74-86. [PMID: 28179128 DOI: 10.1016/j.arr.2017.01.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 01/05/2023]
Abstract
While hyperalgesia (increased pain sensitivity) has been suggested to contribute to the increased prevalence of clinical pain in Parkinson's disease (PD), experimental research is equivocal and mechanisms are poorly understood. We conducted a meta-analysis of studies comparing PD patients to healthy controls (HCs) in their response to experimental pain stimuli. Articles were acquired through systematic searches of major databases from inception until 10/2016. Twenty-six studies met inclusion criteria, comprising 1292 participants (PD=739, HCs=553). Random effects meta-analysis of standardized mean differences (SMD) revealed lower pain threshold (indicating hyperalgesia) in PD patients during unmedicated OFF states (SMD=0.51) which was attenuated during dopamine-medicated ON states (SMD=0.23), but unaffected by age, PD duration or PD severity. Analysis of 6 studies employing suprathreshold stimulation paradigms indicated greater pain in PD patients, just failing to reach significance (SMD=0.30, p=0.06). These findings (a) support the existence of hyperalgesia in PD, which could contribute to the onset/intensity of clinical pain, and (b) implicate dopamine deficiency as a potential underlying mechanism, which may present opportunities for the development of novel analgesic strategies.
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Botulinum Toxin Therapy for Nonmotor Aspects of Parkinson's Disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 134:1111-1142. [DOI: 10.1016/bs.irn.2017.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Hogg E, Wertheimer J, Graner S, Tagliati M. Deep Brain Stimulation and Nonmotor Symptoms. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 134:1045-1089. [DOI: 10.1016/bs.irn.2017.05.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Wang XH, Zhang L, Sperry L, Olichney J, Farias ST, Shahlaie K, Chang NM, Liu Y, Wang SP, Wang C. Target Selection Recommendations Based on Impact of Deep Brain Stimulation Surgeries on Nonmotor Symptoms of Parkinson's Disease. Chin Med J (Engl) 2016; 128:3371-80. [PMID: 26668154 PMCID: PMC4797515 DOI: 10.4103/0366-6999.171464] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE This review examines the evidence that deep brain stimulation (DBS) has extensive impact on nonmotor symptoms (NMSs) of patients with Parkinson's disease (PD). DATA SOURCES We retrieved information from the PubMed database up to September, 2015, using various search terms and their combinations including PD, NMSs, DBS, globus pallidus internus (GPi), subthalamic nucleus (STN), and ventral intermediate thalamic nucleus. STUDY SELECTION We included data from peer-reviewed journals on impacts of DBS on neuropsychological profiles, sensory function, autonomic symptoms, weight changes, and sleep disturbances. For psychological symptoms and cognitive impairment, we tried to use more reliable proofs: Random, control, multicenter, large sample sizes, and long period follow-up clinical studies. We categorized the NMSs into four groups: those that would improve definitively following DBS; those that are not significantly affected by DBS; those that remain controversial on their surgical benefit; and those that can be worsened by DBS. RESULTS In general, it seems to be an overall beneficial effect of DBS on NMSs, such as sensory, sleep, gastrointestinal, sweating, cardiovascular, odor, urological symptoms, and sexual dysfunction, GPi-DBS may produce similar results; Both STN and Gpi-DBS are safe with regard to cognition and psychology over long-term follow-up, though verbal fluency decline is related to DBS; The impact of DBS on behavioral addictions and dysphagia is still uncertain. CONCLUSIONS As the motor effects of STN-DBS and GPi-DBS are similar, NMSs may determine the target choice in surgery of future patients.
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Affiliation(s)
- Xiao-Hong Wang
- Department of Neurology, Dalian Municipal Central Hospital, Dalian, Liaoning 116033, China
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Subthalamic deep brain stimulation modulates conscious perception of sensory function in Parkinson's disease. Pain 2016; 157:2758-2765. [DOI: 10.1097/j.pain.0000000000000697] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Gee LE, Walling I, Ramirez-Zamora A, Shin DS, Pilitsis JG. Subthalamic deep brain stimulation alters neuronal firing in canonical pain nuclei in a 6-hydroxydopamine lesioned rat model of Parkinson's disease. Exp Neurol 2016; 283:298-307. [PMID: 27373204 DOI: 10.1016/j.expneurol.2016.06.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/18/2016] [Accepted: 06/28/2016] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Chronic pain is one of the most common non-motor symptoms of Parkinson's disease (PD) affecting up to 85% of patients. Previous studies have established that reduced mechanical and thermal thresholds occur in both idiopathic PD patients and animal models of PD, suggesting that changes may occur in sensory processing circuits. Improvements in sensory thresholds are achieved using subthalamic nucleus (STN) deep brain stimulation (DBS), however the mechanism by which this occurs remains unresolved. MATERIALS AND METHODS We examined unilateral medial forebrain bundle 6-hydroxydopamine (6OHDA) rat model of PD to determine whether STN DBS alters neuronal firing rates in brain areas involved in ascending and descending pain processing. Specifically, single unit in vivo recordings were conducted in the anterior cingulate cortex (ACC), the periaqueductal grey (PAG), and the ventral posteriolateral nucleus of the thalamus (VPL), before, during and after stimulation was applied to the STN at 50 or 150Hz. RESULTS Sham and 6OHDA lesioned animals have similar neuronal firing activity in the VPL, ACC and PAG before stimulation was applied (p>0.05). In 6OHDA lesioned rats, both low frequency stimulation (LFS) (p<0.01) and high frequency stimulation (HFS) (p<0.05) attenuated firing frequency in the ACC. In shams, only LFS decreased firing frequency. A subset of neurons in the PAG was significantly attenuated in both sham and 6OHDA lesioned animals during HFS and LFS (p<0.05), while another subset of PAG neuronal activity significantly increased in 6OHDA lesioned rats during HFS (p<0.05). Finally, low or high frequency STN DBS did not alter neuronal firing frequencies in the VPL. CONCLUSIONS Our results suggest that STN DBS alters neuronal firing in descending pain circuits. We hypothesize that STN DBS attenuates excitatory projections from the ACC to the PAG in 6OHDA lesioned rats. Following this, neurons in the PAG respond by either increasing (during HFS only) or decreasing (during both LFS and HFS), which may modulate descending facilitation or inhibition at the level of the spinal cord. Future work should address specific neuronal changes in the ACC and PAG that occur in a freely moving parkinsonian animal during a pain stimulus treated with STN DBS.
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Affiliation(s)
- Lucy E Gee
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States; Department of Neurosurgery, Albany Medical Center, Albany, NY, United States
| | - Ian Walling
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States; Department of Neurosurgery, Albany Medical Center, Albany, NY, United States
| | | | - Damian S Shin
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Julie G Pilitsis
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States; Department of Neurosurgery, Albany Medical Center, Albany, NY, United States.
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Belasen A, Rizvi K, Gee LE, Yeung P, Prusik J, Ramirez-Zamora A, Hanspal E, Paiva P, Durphy J, Argoff CE, Pilitsis JG. Effect of low-frequency deep brain stimulation on sensory thresholds in Parkinson's disease. J Neurosurg 2016; 126:397-403. [PMID: 27104841 DOI: 10.3171/2016.2.jns152231] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chronic pain is a major distressing symptom of Parkinson's disease (PD) that is often undertreated. Subthalamic nucleus (STN) deep brain stimulation (DBS) delivers high-frequency stimulation (HFS) to patients with PD and has been effective in pain relief in a subset of these patients. However, up to 74% of patients develop new pain concerns while receiving STN DBS. Here the authors explore whether altering the frequency of STN DBS changes pain perception as measured through quantitative sensory testing (QST). METHODS Using QST, the authors measured thermal and mechanical detection and pain thresholds in 19 patients undergoing DBS via HFS, low-frequency stimulation (LFS), and off conditions in a randomized order. Testing was performed in the region of the body with the most pain and in the lower back in patients without chronic pain. RESULTS In the patients with chronic pain, LFS significantly reduced heat detection thresholds as compared with thresholds following HFS (p = 0.029) and in the off state (p = 0.010). Moreover, LFS resulted in increased detection thresholds for mechanical pressure (p = 0.020) and vibration (p = 0.040) compared with these thresholds following HFS. Neither LFS nor HFS led to changes in other mechanical thresholds. In patients without chronic pain, LFS significantly increased mechanical pain thresholds in response to the 40-g pinprick compared with thresholds following HFS (p = 0.032). CONCLUSIONS Recent literature has suggested that STN LFS can be useful in treating nonmotor symptoms of PD. Here the authors demonstrated that LFS modulates thermal and mechanical detection to a greater extent than HFS. Low-frequency stimulation is an innovative means of modulating chronic pain in PD patients receiving STN DBS. The authors suggest that STN LFS may be a future option to consider when treating Parkinson's patients in whom pain remains the predominant complaint.
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Affiliation(s)
| | | | - Lucy E Gee
- Departments of 1 Neurosurgery and.,Center for Neuroscience and Neuropharmacology, Albany Medical College, Albany, New York
| | | | | | | | | | | | | | | | - Julie G Pilitsis
- Departments of 1 Neurosurgery and.,Center for Neuroscience and Neuropharmacology, Albany Medical College, Albany, New York
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Lin CH, Chao CC, Wu SW, Hsieh PC, Feng FP, Lin YH, Chen YM, Wu RM, Hsieh ST. Pathophysiology of Small-Fiber Sensory System in Parkinson's Disease: Skin Innervation and Contact Heat Evoked Potential. Medicine (Baltimore) 2016; 95:e3058. [PMID: 26962835 PMCID: PMC4998916 DOI: 10.1097/md.0000000000003058] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Sensory symptoms are frequent nonmotor complaints in patients with Parkinson's disease (PD). However, few investigations integrally explored the physiology and pathology of the thermonociceptive pathway in PD. We aim to investigate the involvement of the thermonociceptive pathway in PD.Twenty-eight PD patients (16 men, with a mean age and standard deviation of 65.6 ± 10.7 years) free of neuropathic symptoms and systemic disorders were recruited for the study and compared to 23 age- and gender-matched control subjects (12 men, with a mean age and standard deviation of 65.1 ± 9.9 years). We performed skin biopsy, contact heat-evoked potential (CHEP), and quantitative sensory tests (QST) to study the involvement of the thermonociceptive pathway in PD.The duration of PD was 7.1 ± 3.2 (range 2-17 years) years and the UPDRS part III score was 25.6 ± 9.7 (range 10-48) during the off period. Compared to control subjects, PD patients had reduced intra-epidermal nerve fiber (IENF) density (2.48 ± 1.65 vs 6.36 ± 3.19 fibers/mm, P < 0.001) and CHEP amplitude (18.02 ± 10.23 vs 33.28 ± 10.48 μV, P < 0.001). Twenty-three patients (82.1%) had abnormal IENF densities and 18 (64.3%) had abnormal CHEP. Nine patients (32.1%) had abnormal thermal thresholds in the feet. In total 27 patients (96.4%) had at least 1 abnormality in IENF, CHEP, or thermal thresholds of the foot, indicating dysfunctions in the small-fiber nerve system. In control subjects, CHEP amplitude linearly correlated with IENF density (P < 0.001). In contrast, this relationship disappeared in PD (P = 0.312) and CHEP amplitude was negatively correlated with motor severity of PD independent of age, gender, and anti-PD medication dose (P = 0.036), suggesting the influences of central components on thermonociceptive systems in addition to peripheral small-fiber nerves in PD.The present study suggested impairment of small-fiber sensory system at both peripheral and central levels is an intrinsic feature of PD, and skin biopsy, CHEP, and QST provided an integral approach for assessing such dysfunctions.
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Affiliation(s)
- Chin-Hsien Lin
- From the Department of Neurology (C-HL, C-CC, S-WW, F-PF, Y-HL, S-TH), National Taiwan University Hospital; the Department of Pathology (P-CH), Far Eastern Memorial Hospital; Institute of Health Policy and Management (Y-MC), National Taiwan University, Taipei, Taiwan; and Department of Anatomy and Cell Biology (S-TH), Graduate Institute of Brain and Mind Sciences, and Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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Gee LE, Chen N, Ramirez-Zamora A, Shin DS, Pilitsis JG. The effects of subthalamic deep brain stimulation on mechanical and thermal thresholds in 6OHDA-lesioned rats. Eur J Neurosci 2015; 42:2061-9. [PMID: 26082992 DOI: 10.1111/ejn.12992] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/08/2015] [Accepted: 06/11/2015] [Indexed: 12/21/2022]
Abstract
Chronic pain is a major complaint for up to 85% of Parkinson's disease patients; however, it often not identified as a symptom of Parkinson's disease. Adequate treatment of motor symptoms often provides analgesic effects in Parkinson's patients but how this occurs remains unclear. Studies have shown both Parkinson's patients and 6-hydroxydopamine-lesioned rats exhibit decreased sensory thresholds. In humans, some show improvements in these deficits after subthalamic deep brain stimulation, while others report no change. Differing methods of testing and response criteria may explain these varying results. We examined this effect in 6-hydroxydopamine-lesioned rats. Sprague-Dawley rats were unilaterally implanted with subthalamic stimulating electrodes in the lesioned right hemisphere and sensory thresholds were tested using von Frey, tail-flick and hot-plate tests. Tests were done during and off subthalamic stimulation at 50 and 150 Hz to assess its effects on sensory thresholds. The 6-hydroxydopamine-lesioned animals exhibited lower mechanical (left paw, P < 0.01) and thermal thresholds than shams (hot plate, P < 0.05). Both 50 and 150 Hz increased mechanical (left paw; P < 0.01) and thermal thresholds in 6-hydroxydopamine-lesioned rats (hot-plate test: 150 Hz, P < 0.05, 50 Hz, P < 0.01). Interestingly, during von Frey testing, low-frequency stimulation provided a more robust improvement in some 6OHDA lesioned rats, while in others, the magnitude of improvement on high-frequency stimulation was greater. This study shows that subthalamic deep brain stimulation improves mechanical allodynia and thermal hyperalgesia in 6-hydroxydopamine-lesioned animals at both high and low frequencies. Furthermore, we suggest considering using low-frequency stimulation when treating Parkinson's patients where pain remains the predominant complaint.
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Affiliation(s)
- Lucy E Gee
- Center for Neuroscience and Neuropharmacology, Albany Medical College, Albany, NY, USA.,Department of Neurosurgery, AMC Neurosurgery Group, Albany Medical Center, 47 New Scotland Ave, MC 10, Physicians Pavilion, 1st Floor, Albany, NY, 12208, USA
| | - Nita Chen
- Center for Neuroscience and Neuropharmacology, Albany Medical College, Albany, NY, USA
| | | | - Damian S Shin
- Center for Neuroscience and Neuropharmacology, Albany Medical College, Albany, NY, USA
| | - Julie G Pilitsis
- Center for Neuroscience and Neuropharmacology, Albany Medical College, Albany, NY, USA.,Department of Neurosurgery, AMC Neurosurgery Group, Albany Medical Center, 47 New Scotland Ave, MC 10, Physicians Pavilion, 1st Floor, Albany, NY, 12208, USA
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Cury R, Galhardoni R, Fonoff E, Perez Lloret S, dos Santos Ghilardi M, Barbosa E, Teixeira M, Ciampi de Andrade D. Sensory abnormalities and pain in Parkinson disease and its modulation by treatment of motor symptoms. Eur J Pain 2015; 20:151-65. [DOI: 10.1002/ejp.745] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2015] [Indexed: 01/07/2023]
Affiliation(s)
- R.G. Cury
- Pain Center; Department of Neurology; University of São Paulo; São Paulo Brazil
- Pain Center; Instituto do Câncer do Estado de São Paulo; São Paulo Brazil
- Movement Disorders Group; Department of Neurology; University of São Paulo; São Paulo Brazil
| | - R. Galhardoni
- Pain Center; Department of Neurology; University of São Paulo; São Paulo Brazil
| | - E.T. Fonoff
- Pain Center; Department of Neurology; University of São Paulo; São Paulo Brazil
- Transcranial Magnetic Stimulation Laboratory; Psychiatry Institute; University of São Paulo; São Paulo Brazil
- Neurosurgery Division; Department of Neurology; University of São Paulo; São Paulo Brazil
| | - S. Perez Lloret
- Laboratory of Clinical Pharmacology and Epidemiology; Catholic University; Buenos Aires Argentina
| | | | - E.R. Barbosa
- Movement Disorders Group; Department of Neurology; University of São Paulo; São Paulo Brazil
| | - M.J. Teixeira
- Pain Center; Department of Neurology; University of São Paulo; São Paulo Brazil
- Pain Center; Instituto do Câncer do Estado de São Paulo; São Paulo Brazil
- Movement Disorders Group; Department of Neurology; University of São Paulo; São Paulo Brazil
- Transcranial Magnetic Stimulation Laboratory; Psychiatry Institute; University of São Paulo; São Paulo Brazil
- Neurosurgery Division; Department of Neurology; University of São Paulo; São Paulo Brazil
| | - D. Ciampi de Andrade
- Pain Center; Department of Neurology; University of São Paulo; São Paulo Brazil
- Pain Center; Instituto do Câncer do Estado de São Paulo; São Paulo Brazil
- Transcranial Magnetic Stimulation Laboratory; Psychiatry Institute; University of São Paulo; São Paulo Brazil
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Smith H, Gee L, Kumar V, Ramirez-Zamora A, Durphy J, Hanspal E, Barba A, Molho E, Shin D, Pilitsis JG. Deep brain stimulation significantly decreases disability from low back pain in patients with advanced Parkinson's disease. Stereotact Funct Neurosurg 2015; 93:206-11. [PMID: 25895600 DOI: 10.1159/000380827] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 02/10/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Up to 60% of Parkinson's disease (PD) patients suffer from low back pain (LBP) during the course of their disease. How LBP affects daily functional status and how to manage this aspect of PD has not been adequately explored. METHODS We examined 16 patients undergoing bilateral subthalamic nucleus deep brain stimulation (STN DBS) who met the inclusion criteria for moderate disability from LBP, as classified by the Oswestry Low Back Pain Disability Index (OLBPD). RESULTS Thirteen of 16 patients had attempted additional treatments for LBP, including medical management, massage, chiropractic, epidural steroid injections and/or surgery, with minimal relief. Following DBS, there was a significant improvement in the OLBPD at both the 6-month and 1-year time points (p < 0.02, p < 0.005, respectively). A mean improvement of 31.7% on the OLBPD score was noted. The Visual Analogue Scale (VAS) similarly decreased significantly at 1 year (p = 0.015). There was no correlation between the OLBPD score and other measures, including the Unified Parkinson's Disease Rating Scale (UPDRS), age and other nonmotor symptoms. CONCLUSION Given the prevalent yet undertreated disability associated with LBP in PD, these results are novel in that they show that STN DBS has a significant positive effect on disability associated with LBP.
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Affiliation(s)
- Heather Smith
- Department of Neurosurgery, Albany Medical College, Albany, N.Y., USA
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Altered Brain Activation in Early Drug-Naive Parkinson's Disease during Heat Pain Stimuli: An fMRI Study. PARKINSONS DISEASE 2015; 2015:273019. [PMID: 25628915 PMCID: PMC4299805 DOI: 10.1155/2015/273019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 12/15/2014] [Accepted: 12/16/2014] [Indexed: 02/05/2023]
Abstract
Parkinson's disease (PD) is a progressive neurodegenerative disease characterized by motor and nonmotor signs and symptoms. To date, many studies of PD have focused on its cardinal motor symptoms. To study the nonmotor signs of early PD, we investigated the reactions solicited by heat pain stimuli in early untreated PD patients without pain using fMRI. The activation patterns of contact heat stimuli (51°C) were assessed in 14 patients and 17 age- and sex-matched healthy controls. Patients with PD showed significant decreases in activation of the superior temporal gyrus (STG) and insula compared with controls. In addition, a significant relationship between activation of the insula and STG and the pain scores was observed in healthy controls but not in PD. This study provided further support that the insula and STG are important parts of the somatosensory circuitry recruited during the period of pain. The hypoactivity of the STG and insula in PD implied that functions including affective, cognitive, and sensory-discriminative processes, which are associated with the insula and STG, were disturbed. This finding supports the view that leaving early PD untreated could be tied directly to central nervous system dysfunction.
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Doty RL, Gandhi SS, Osman A, Hurtig HI, Pawasarat I, Beals E, Chung I, Dubroff J, Newberg A, Ying GS, Leon-Sarmiento FE. Point pressure sensitivity in early stage Parkinson's disease. Physiol Behav 2014; 138:21-7. [PMID: 25447476 DOI: 10.1016/j.physbeh.2014.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/03/2014] [Accepted: 09/30/2014] [Indexed: 01/22/2023]
Abstract
A number of sensory changes occur in the earliest stages of Parkinson's disease (PD), some of which precede the expression of the classic motor phenotype by years (e.g., olfactory dysfunction). Whether point pressure sensitivity (PPS), a cutaneous measure of light touch mediated by myelinated Aβ fibers, is altered in early PD is not clear. Prior studies on this point are contradictory and are based on non-forced-choice threshold tests that confound the sensitivity measure with the response criterion. While α-synuclein pathology, a defining feature of PD, is present in the skin of PD patients, it is restricted to unmyelinated nerve fibers, suggesting PPS may be spared in this disease. We determined PPS thresholds using a state-of-the-art forced-choice staircase threshold test paradigm in 29 early stage PD patients and 29 matched controls at 11 body sites: the center of the forehead and the left and right forearms, index fingers, palms, medial soles of the feet, and plantar halluces. The patients were tested, in counterbalanced sessions, both on and off dopamine-related medications (DRMs). PPS was not influenced by PD and did not correlate with DRM l-DOPA equivalents, scores on the Unified Parkinson's Disease Rating Scale, side of the major motor disturbances, or SPECT imaging of the striatal dopamine transporter, as measured by technetium-99m TRODAT. However, PPS thresholds were lower on the left than on the right side of the body (p=0.008) and on the upper extremities relative to the toes and feet (ps<0.0001). Positive correlations were evident among the thresholds obtained across all body sectors, even though disparate regions of the body differed in terms of absolute sensitivity. This study indicates that PPS is not influenced in early stage PD regardless of whether patients are on or off DRMs.
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Affiliation(s)
- Richard L Doty
- Smell and Taste Center, Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Shifa S Gandhi
- Smell and Taste Center, Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Allen Osman
- Smell and Taste Center, Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Howard I Hurtig
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ian Pawasarat
- Smell and Taste Center, Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Evan Beals
- Smell and Taste Center, Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Inna Chung
- Smell and Taste Center, Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacob Dubroff
- Department of Radiology, Division of Nuclear Medicine and Clinical Molecular Imaging, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew Newberg
- Myrna Brind Center of Integrative Medicine, Thomas Jefferson University, Philadelphia, PA USA
| | - Gui-Shang Ying
- Department of Ophthalmology and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fidias E Leon-Sarmiento
- Smell and Taste Center, Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Hasan M, Whiteley J, Bresnahan R, MacIver K, Sacco P, Das K, Nurmikko T. Somatosensory Change and Pain Relief Induced by Repetitive Transcranial Magnetic Stimulation in Patients With Central Poststroke Pain. Neuromodulation 2014; 17:731-6; discussion 736. [DOI: 10.1111/ner.12198] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 02/14/2014] [Accepted: 04/18/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Mohammad Hasan
- Pain Research Institute; Clinical Sciences Centre; Liverpool UK
| | | | - Rebecca Bresnahan
- Pain Research Institute; Clinical Sciences Centre; Liverpool UK
- Radiology; The Walton Centre NHS Foundation Trust; Liverpool UK
| | - Kate MacIver
- Pain Research Institute; Clinical Sciences Centre; Liverpool UK
- Radiology; The Walton Centre NHS Foundation Trust; Liverpool UK
| | - Paul Sacco
- Pain Research Institute; Clinical Sciences Centre; Liverpool UK
- Radiology; The Walton Centre NHS Foundation Trust; Liverpool UK
| | - Kumar Das
- Pain Research Institute; Clinical Sciences Centre; Liverpool UK
| | - Turo Nurmikko
- Pain Research Institute; Clinical Sciences Centre; Liverpool UK
- Radiology; The Walton Centre NHS Foundation Trust; Liverpool UK
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Mismatch negativity-like potential (MMN-like) in the subthalamic nuclei in Parkinson's disease patients. J Neural Transm (Vienna) 2014; 121:1507-22. [PMID: 24809684 DOI: 10.1007/s00702-014-1221-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 04/11/2014] [Indexed: 10/25/2022]
Abstract
An infrequent change to an otherwise repetitive sequence of stimuli leads to the generation of mismatch negativity (MMN), even in the absence of attention. This evoked negative response occurs in the scalp-recorded electroencephalogram (EEG) over the temporal and frontal cortices, 100-250 ms after onset of the deviant stimulus. The MMN is used to detect sensory information processing. The aim of our study was to investigate whether MMN can be recorded in the subthalamic nuclei (STN) as evidence of auditory information processing on an unconscious level within this structure. To our knowledge, MMN has never been recorded in the human STN. We recorded intracerebral EEG using a MMN paradigm in five patients with Parkinson's disease (PD) who were implanted with depth electrodes in the subthalamic nuclei (STN). We found far-field MMN when intracerebral contacts were connected to an extracranial reference electrode. In all five PD patients (and nine of ten intracerebral electrodes), we also found near-field MMN-like potentials when intracerebral contacts were referenced to one another, and in some electrodes, we observed phase reversals in these potentials. The mean time-to-peak latency of the intracerebral MMN-like potentials was 214 ± 38 ms (median 219 ms). We reveal MMN-like potentials in bilateral STN. This finding provides evidence that STN receives sensory (auditory) information from other structures. The question for further research is whether STN receives such signals through a previously described hyperdirect pathway between STN and frontal cortex (a known generator of the MMN potential) and if the STN contributes to sensorimotor integration.
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Maruo T, Hosomi K, Shimokawa T, Kishima H, Oshino S, Morris S, Kageyama Y, Yokoe M, Yoshimine T, Saitoh Y. High-frequency repetitive transcranial magnetic stimulation over the primary foot motor area in Parkinson's disease. Brain Stimul 2013; 6:884-91. [PMID: 23769414 DOI: 10.1016/j.brs.2013.05.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 04/30/2013] [Accepted: 05/03/2013] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) has been reported to be clinically effective for treating motor symptoms in Parkinson's disease (PD). Few studies have been performed reporting the effects of rTMS on non-motor symptoms such as depression and apathy in PD. OBJECTIVE We assessed the effects of high-frequency (HF) rTMS over the primary motor (M1) foot area on motor symptoms, depression and apathy scales, and sensory symptoms in PD. METHODS We investigated the efficacy of 3 consecutive days of HF-rTMS over the M1 foot area in 21 patients with PD using a randomized, double-blind cross-over trial compared with sham stimulation. Motor effects were evaluated using the Unified Parkinson's Disease Rating Scale part III (UPDRS-III), the self-assessment motor score, the visual analog scale (VAS), the 10-m walking test, and finger tapping. Non-motor effects were analyzed using the Montgomery Asberg Depression Rating Scale, the Apathy Scale, and quantitative sensory testing. RESULTS HF-rTMS significantly improved UPDRS-III (P < 0.001), VAS (P < 0.001), the walking test (P = 0.014), self-assessment motor score (P = 0.010), and finger tapping measurement (P < 0.05) compared to sham stimulation. In contrast, no significant improvement was observed in depression and apathy scales. Consecutive days of rTMS did not significantly increase the improvement in motor symptoms. There were no adverse effects following rTMS on patients with PD. CONCLUSIONS We confirmed that HF-rTMS over the M1 foot area significantly improved motor symptoms in patients with PD. In addition, daily repeated stimulation was not significantly more effective than a single session of stimulation, but may be effective for maintaining the improvement in motor symptoms in patients with PD.
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Affiliation(s)
- Tomoyuki Maruo
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan; Department of Neuromodulation and Neurosurgery, Office for University-Industry Collaboration, Osaka University, Osaka, Japan
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Abstract
Parkinson's disease (PD) is the second most common neurodegenerative disorder that affects approximately 1 % of people over the age of 60 years. Accurate diagnosis and individualized assessment of the risks and benefits of available antiparkinsonian medications as well as specific clinical features and the phase of disease should guide treatment for patients with PD. Levodopa still remains the gold standard for the treatment of motor symptoms of PD but dopamine agonists (DAs), catechol-O-methyltransferase (COMT) inhibitors and monoamine oxidase B (MAO-B) inhibitors have also been developed to provide more continuous oral delivery of dopaminergic stimulation in order to improve motor outcomes and decrease the risk of levodopa-induced motor complications. Deep-brain stimulation as well as other invasive therapies can be used for the treatment of drug-refractory levodopa-induced motor complications. Despite all of the therapeutic advances achieved within the last 20 years, PD continues to be a progressive disorder leading to severe disability caused by motor and non-motor symptoms. To date, neuroprotective interventions able to modify PD progression are not available. This review focuses on medical and invasive treatment strategies for early and advanced stages of PD as well as on the treatment of PD non-motor symptoms such as mood and behavioural disorders, cognitive and autonomic dysfunction, and sleep disorders, which can antedate PD motor symptoms for years.
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Affiliation(s)
- Fabienne Sprenger
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria.
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Oono Y, Wang K, Atiş ES, Arendt-Nielsen L. Thermal application modulates orofacial somatosensory perception in healthy men and women. Clin Neurophysiol 2013; 124:581-8. [DOI: 10.1016/j.clinph.2012.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 08/24/2012] [Accepted: 08/30/2012] [Indexed: 10/27/2022]
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Abstract
Pain is a common symptom in Parkinson's disease (PD) and accounts for substantial morbidity in up to 80 % of patients. Despite contributing to disease-related discomfort and disability, pain in PD frequently goes underacknowledged and undertreated in clinical practice. Although the exact underlying neurophysiology is unclear, there is increasing understanding of the role of the basal ganglia in somatosensory processing, as well as involvement of additional brainstem structures and non-dopaminergic pathways; appreciation of these mechanisms has implications for treatment strategies. Categorizing painful symptoms based on their clinical description into musculoskeletal, dystonic, radicular-peripheral neuropathic and central pain categories provides a useful framework for management. Importantly, these symptoms should be evaluated in relation to motor symptoms and dopaminergic therapy. A multi-disciplinary approach is recommended as follows: physical therapy, liaison with pain management and consultations to rheumatological, orthopaedic and neurosurgical services should be considered.
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Affiliation(s)
- Munazza Sophie
- Department of Neurology, Columbia University, New York, NY, USA
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Borgohain R, Kandadai RM, Jabeen A, Kannikannan MA. Nonmotor outcomes in Parkinson's disease: is deep brain stimulation better than dopamine replacement therapy? Ther Adv Neurol Disord 2012; 5:23-41. [PMID: 22276074 DOI: 10.1177/1756285611423412] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Nonmotor symptoms are an integral part of Parkinson's disease and cause significant morbidity. Pharmacological therapy helps alleviate the disease but produces nonmotor manifestations. While deep brain stimulation (DBS) has emerged as the treatment of choice for motor dysfunction, the effect on nonmotor symptoms is not well known. Compared with pharmacological therapy, bilateral subthalamic nucleus (STN)-DBS or globus pallidum interna (GPi)-DBS has significant beneficial effects on pain, sleep, gastrointestinal and urological symptoms. STN-DBS is associated with a mild worsening in verbal fluency while GPi-DBS has no effect on cognition. STN-DBS may improve cardiovascular autonomic disturbances by reducing the dose of dopaminergic drugs. Because the motor effects of STN-DBS and GPi-DBS appear to be similar, nonmotor symptoms may determine the target choice in surgery of future patients.
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de Andrade DC, Lefaucheur JP, Galhardoni R, Ferreira KSL, Paiva ARB, Bor-Seng-Shu E, Alvarenga L, Myczkowski ML, Marcolin MA, de Siqueira SRDT, Fonoff E, Barbosa ER, Teixeira MJ. Subthalamic deep brain stimulation modulates small fiber-dependent sensory thresholds in Parkinson's disease. Pain 2012; 153:1107-1113. [PMID: 22456108 DOI: 10.1016/j.pain.2012.02.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 01/16/2012] [Accepted: 02/14/2012] [Indexed: 11/25/2022]
Abstract
The effects of deep brain stimulation of the subthalamic nucleus on nonmotor symptoms of Parkinson's disease (PD) rarely have been investigated. Among these, sensory disturbances, including chronic pain (CP), are frequent in these patients. The aim of this study was to evaluate the changes induced by deep brain stimulation in the perception of sensory stimuli, either noxious or innocuous, mediated by small or large nerve fibers. Sensory detection and pain thresholds were assessed in 25 PD patients all in the off-medication condition with the stimulator turned on or off (on- and off-stimulation conditions, respectively). The relationship between the changes induced by surgery on quantitative sensory testing, spontaneous CP, and motor abilities were studied. Quantitative sensory test results obtained in PD patients were compared with those of age-matched healthy subjects. Chronic pain was present in 72% of patients before vs 36% after surgery (P=.019). Compared with healthy subjects, PD patients had an increased sensitivity to innocuous thermal stimuli and mechanical pain, but a reduced sensitivity to innocuous mechanical stimuli. In addition, they had an increased pain rating when painful thermal stimuli were applied, particularly in the off-stimulation condition. In the on-stimulation condition, there was an increased sensitivity to innocuous thermal stimuli but a reduced sensitivity to mechanical or thermal pain. Pain provoked by thermal stimuli was reduced when the stimulator was turned on. Motor improvement positively correlated with changes in warm detection and heat pain thresholds. Subthalamic nucleus deep brain stimulation contributes to relieve pain associated with PD and specifically modulates small fiber-mediated sensations.
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Affiliation(s)
- Daniel Ciampi de Andrade
- Pain Center, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, Brazil Pain Center, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil Neurology Division, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil EA 4391, Faculté de Médecine, Université Paris Est Créteil, Créteil, France Service de Physiologie - Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris, Créteil, France Transcranial Magnetic Stimulation Laboratories, Psychiatry Institute, University of São Paulo, São Paulo, Brazil
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Pain in Parkinson's disease. Mov Disord 2011; 27:485-91. [DOI: 10.1002/mds.23959] [Citation(s) in RCA: 148] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 08/22/2011] [Accepted: 08/25/2011] [Indexed: 11/07/2022] Open
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