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Jia F, Shukla AW, Hu W, Ma Y, Zhang J, Almeida L, Kao C, Guo Y, Zhang S, Tao Y, Ling Z, Xu X, Yang Z, Meng FG, Wan X, Liu H, Konard PE, Li L. Variable frequency deep brain stimulation of subthalamic nucleus to improve freezing of gait in Parkinson's disease. Natl Sci Rev 2024; 11:nwae187. [PMID: 38948151 PMCID: PMC11214434 DOI: 10.1093/nsr/nwae187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 07/02/2024] Open
Affiliation(s)
- Fumin Jia
- National Engineering Laboratory for Neuromodulation, Tsinghua University, China
| | - Aparna Wagle Shukla
- University of Florida Center for Movement Disorders and Neurorestoration, USA
| | - Wei Hu
- University of Florida Center for Movement Disorders and Neurorestoration, USA
| | - Yu Ma
- Tsinghua University Yuquan Hospital, China
| | - Jianguo Zhang
- Beijing Tiantan Hospital, Capital Medical University, China
| | - Leonardo Almeida
- University of Florida Center for Movement Disorders and Neurorestoration, USA
| | - Chris Kao
- School of Medicine, Vanderbilt University, USA
| | - Yi Guo
- Peking Union Medical College Hospital, China
| | | | - Yingqun Tao
- The General Hospital of Shenyang Military, China
| | | | - Xin Xu
- Chinese PLA General Hospital, China
| | - Zhiquan Yang
- Xiangya Hospital Central South University, China
| | - Fan-gang Meng
- Beijing Neurosurgical Institute, Capital Medical University, China
| | - Xinhua Wan
- Peking Union Medical College Hospital, China
| | - Hesheng Liu
- Athinoula A. Martinos Center for Biomedical Imaging, Harvard Medical School, USA
| | | | - Luming Li
- National Engineering Laboratory for Neuromodulation, Tsinghua University, China
- Precision Medicine & Healthcare Research Center, Tsinghua-Berkeley Shenzhen Institute, China
- Man-Machine-Environment Engineering Institute, School of Aerospace Engineering, Tsinghua University, China
- Center of Epilepsy, Beijing Institute for Brain Disorders, China
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2
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Swinnen BEKS, Lotfalla V, Scholten MN, Prins RHN, Goes KM, de Vries S, Geytenbeek JJM, Dijk JM, Odekerken VJ, Bot M, van den Munckhof P, Schuurman PR, de Bie RMA, Beudel M. Programming Algorithm for the Management of Speech Impairment in Subthalamic Nucleus Deep Brain Stimulation for Parkinson's Disease. Neuromodulation 2024; 27:528-537. [PMID: 37452799 DOI: 10.1016/j.neurom.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/19/2023] [Accepted: 05/28/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES Deep brain stimulation (DBS) of the subthalamic nucleus (STN) for Parkinson's disease (PD) has an ambiguous relation to speech. Speech impairment can be a stimulation-induced side effect, and parkinsonian dysarthria can improve with STN-DBS. Owing to the lack of an up-to-date and evidence-based approach, DBS reprogramming for speech impairment is largely blind and greatly relies on the physician's experience. In this study, we aimed to establish an evidence- and experience-based algorithm for managing speech impairment in patients with PD treated with STN-DBS. MATERIALS AND METHODS We performed a single-center retrospective study to identify patients with STN-DBS and speech impairment. Onset of speech impairment, lead localization, and assessment of DBS-induced nature of speech impairment were collected. When DBS settings were adjusted for improving speech, the magnitude and duration of effect were collected. We also performed a systematic literature review to identify studies describing the effects of parameter adjustments aimed at improving speech impairment in patients with PD receiving STN-DBS. RESULTS In the retrospective study, 245 of 631 patients (38.8%) with STN-DBS had significant speech impairment. The probability of sustained marked improvement upon reprogramming was generally low (27.9%). In the systematic review, 23 of 662 identified studies were included. Only two randomized controlled trials have been performed, providing evidence for interleaving-interlink stimulation only. Considerable methodologic heterogeneity precluded the conduction of a meta-analysis. CONCLUSIONS Speech impairment in STN-DBS for PD is frequent, but high-quality evidence regarding DBS parameter adjustments is scarce, and the probability of sustained improvement is low. To improve this outcome, we propose an evidence- and experience-based approach to address speech impairment in STN-DBS that can be used in clinical practice.
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Affiliation(s)
- Bart E K S Swinnen
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Veronia Lotfalla
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Marije N Scholten
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Rosanne H N Prins
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Kelly M Goes
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Stefanie de Vries
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Joke J M Geytenbeek
- Department of Rehabilitation, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Joke M Dijk
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent J Odekerken
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten Bot
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter R Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Rob M A de Bie
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Martijn Beudel
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands.
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3
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Cheng Y, Zhao G, Chen L, Cui D, Wang C, Feng K, Yin S. Effects of subthalamic nucleus deep brain stimulation using different frequency programming paradigms on axial symptoms in advanced Parkinson's disease. Acta Neurochir (Wien) 2024; 166:124. [PMID: 38457027 DOI: 10.1007/s00701-024-06005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 02/02/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND In advanced Parkinson's disease (PD), axial symptoms are common and can be debilitating. Although deep brain stimulation (DBS) significantly improves motor symptoms, conventional high-frequency stimulation (HFS) has limited effectiveness in improving axial symptoms. In this study, we investigated the effects on multiple axial symptoms after DBS surgery with three different frequency programming paradigms comprising HFS, low-frequency stimulation (LFS), and variable-frequency stimulation (VFS). METHODS This study involved PD patients who had significant preoperative axial symptoms and underwent bilateral subthalamic nucleus (STN) DBS. Axial symptoms, motor symptoms, medications, and quality of life were evaluated preoperatively (baseline). One month after surgery, HFS was applied. At 6 months post-surgery, HFS assessments were performed, and HFS was switched to LFS. A further month later, we conducted LFS assessments and switched LFS to VFS. At 8 months after surgery, VFS assessments were performed. RESULTS Of the 21 PD patients initially enrolled, 16 patients were ultimately included in this study. Regarding HFS, all axial symptoms except for the Berg Balance Scale (p < 0.0001) did not improve compared with the baseline (all p > 0.05). As for LFS and VFS, all axial symptoms improved significantly compared with both the baseline and HFS (all p < 0.05). Moreover, motor symptoms and medications were significantly better than the baseline (all p < 0.05) after using LFS and VFS. Additionally, the quality of life of the PD patients after receiving LFS and VFS was significantly better than at the baseline and with HFS (all p < 0.0001). CONCLUSION Our findings indicate that HFS is ineffective at improving the majority of axial symptoms in advanced PD. However, both the LFS and VFS programming paradigms exhibit significant improvements in various axial symptoms.
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Affiliation(s)
- Yifeng Cheng
- Department of Functional Neurosurgery, Huanhu Hospital, Tianjin University, Tianjin, 300350, China
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, 300350, China
| | - Guangrui Zhao
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, 300350, China
| | - Lei Chen
- Department of Neurology, Huanhu Hospital, Tianjin University, Tianjin, 300350, China
| | - Deqiu Cui
- Department of Functional Neurosurgery, Huanhu Hospital, Tianjin University, Tianjin, 300350, China
| | - Chunjuan Wang
- Department of Functional Neurosurgery, Huanhu Hospital, Tianjin University, Tianjin, 300350, China
| | - Keke Feng
- Department of Functional Neurosurgery, Huanhu Hospital, Tianjin University, Tianjin, 300350, China.
| | - Shaoya Yin
- Department of Functional Neurosurgery, Huanhu Hospital, Tianjin University, Tianjin, 300350, China.
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4
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Fleming JE, Senneff S, Lowery MM. Multivariable closed-loop control of deep brain stimulation for Parkinson's disease. J Neural Eng 2023; 20:056029. [PMID: 37733003 DOI: 10.1088/1741-2552/acfbfa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/21/2023] [Indexed: 09/22/2023]
Abstract
Objective. Closed-loop deep brain stimulation (DBS) methods for Parkinson's disease (PD) to-date modulate either stimulation amplitude or frequency to control a single biomarker. While good performance has been demonstrated for symptoms that are correlated with the chosen biomarker, suboptimal regulation can occur for uncorrelated symptoms or when the relationship between biomarker and symptom varies. Control of stimulation-induced side-effects is typically not considered.Approach.A multivariable control architecture is presented to selectively target suppression of either tremor or subthalamic nucleus beta band oscillations. DBS pulse amplitude and duration are modulated to maintain amplitude below a threshold and avoid stimulation of distal large diameter axons associated with stimulation-induced side effects. A supervisor selects between a bank of controllers which modulate DBS pulse amplitude to control rest tremor or beta activity depending on the level of muscle electromyographic (EMG) activity detected. A secondary controller limits pulse amplitude and modulates pulse duration to target smaller diameter axons lying close to the electrode. The control architecture was investigated in a computational model of the PD motor network which simulated the cortico-basal ganglia network, motoneuron pool, EMG and muscle force signals.Main results.Good control of both rest tremor and beta activity was observed with reduced power delivered when compared with conventional open loop stimulation, The supervisor avoided over- or under-stimulation which occurred when using a single controller tuned to one biomarker. When DBS amplitude was constrained, the secondary controller maintained the efficacy of stimulation by increasing pulse duration to compensate for reduced amplitude. Dual parameter control delivered effective control of the target biomarkers, with additional savings in the power delivered.Significance.Non-linear multivariable control can enable targeted suppression of motor symptoms for PD patients. Moreover, dual parameter control facilitates automatic regulation of the stimulation therapeutic dosage to prevent overstimulation, whilst providing additional power savings.
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Affiliation(s)
- John E Fleming
- Neuromuscular Systems Laboratory, UCD School of Electrical & Electronic Engineering, University College Dublin, Dublin, Ireland
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Mansfield Road, Oxford OX1 3TH, United Kingdom
| | - Sageanne Senneff
- Neuromuscular Systems Laboratory, UCD School of Electrical & Electronic Engineering, University College Dublin, Dublin, Ireland
| | - Madeleine M Lowery
- Neuromuscular Systems Laboratory, UCD School of Electrical & Electronic Engineering, University College Dublin, Dublin, Ireland
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Zuo L, Su A, Shi Y, Li N, Chen S, Yang X. Case report: Spinal cord stimulation in the treatment of pediatric erythromelalgia. Front Neurol 2023; 14:1143241. [PMID: 37273700 PMCID: PMC10233004 DOI: 10.3389/fneur.2023.1143241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/27/2023] [Indexed: 06/06/2023] Open
Abstract
Introduction In children, erythromelalgia is a rare chronic pain syndrome characterized by erythema, severe burning pain, and itching of affected feet. Unfortunately, there is no definitive therapy available currently. Case report Here, we report a case of primary erythromelalgia and the treatment response in a 10-year-old boy, whose genetic findings for mutations in the SCN9A gene were positive and skin biopsy results were diagnosed as small fiber neuropathy, while he has suffered from excruciating burning pain, itching, erythema, and recurrent infections over the past 3 years. He did not respond well to conventional treatment, and the only way to receive minimal relief was to immerse his feet in ice water. After a successful trial of spinal cord stimulation (SCS), the implantable pulse generator (IPG) was successfully implanted without complications, and it proved partial response to therapy. Conclusion There is no specific, efficient treatment for pediatric erythromelalgia currently, but this case demonstrates neuromodulation serves as part of the multimodal regimen to treat pediatric erythromelalgia.
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Chen S, Xu SJ, Li WG, Chen T, Li C, Xu S, Yang N, Liu YM. Remote programming for subthalamic deep brain stimulation in Parkinson's disease. Front Neurol 2022; 13:1061274. [PMID: 36504645 PMCID: PMC9729540 DOI: 10.3389/fneur.2022.1061274] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/10/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is effective for the treatment of Parkinson's disease (PD). Moreover, remote programming is widely used in Mainland China. This necessitates evaluating the ability of remote programming to achieve the ideal postoperative effect. Therefore, we aimed to retrospectively evaluate the effects of different programming modes on the effectiveness of STN-DBS 12 months postoperatively in patients with PD. Methods Clinical data were collected retrospectively, before and 12 months after surgery, in 83 patients with PD. Based on the programming modes voluntarily selected by the patients during 12 months postoperatively, they were divided into three groups, namely remote programming alone, hospital programming alone, and hospital + remote programming. We compared the programming data and the effects of different programming methods on STN-DBS-related improvements 12 months postoperatively among these groups. Furthermore, we analyzed STN-DBS-related improvements at 12 months postoperatively in 76 patients. Results The effectiveness of STN-DBS was not influenced by the three programming modes. The postoperative Movement Disorder Society Unified Parkinson's Disease Rating Scale scores did not reveal statistically significant differences between the remote alone and hospital alone programming groups, except for motor examination. The postoperative decline in the levodopa equivalent daily dose was most apparent in the hospital programming alone group. The programming frequency of the hospital + remote programming group was considerably higher than that of the remaining groups. Seventy-six patients with PD displayed good STN-DBS surgical efficacy. Conclusion Programming modes do not influence the short-term efficacy of STN-DBS, and remote programming can yield a satisfactory surgical effect.
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Sui Y, Yu H, Zhang C, Chen Y, Jiang C, Li L. Deep brain-machine interfaces: sensing and modulating the human deep brain. Natl Sci Rev 2022; 9:nwac212. [PMID: 36644311 PMCID: PMC9834907 DOI: 10.1093/nsr/nwac212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/02/2022] [Accepted: 10/04/2022] [Indexed: 01/18/2023] Open
Abstract
Different from conventional brain-machine interfaces that focus more on decoding the cerebral cortex, deep brain-machine interfaces enable interactions between external machines and deep brain structures. They sense and modulate deep brain neural activities, aiming at function restoration, device control and therapeutic improvements. In this article, we provide an overview of multiple deep brain recording and stimulation techniques that can serve as deep brain-machine interfaces. We highlight two widely used interface technologies, namely deep brain stimulation and stereotactic electroencephalography, for technical trends, clinical applications and brain connectivity research. We discuss the potential to develop closed-loop deep brain-machine interfaces and achieve more effective and applicable systems for the treatment of neurological and psychiatric disorders.
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Affiliation(s)
- Yanan Sui
- National Engineering Research Center of Neuromodulation, Tsinghua University, Beijing 100084, China
| | - Huiling Yu
- National Engineering Research Center of Neuromodulation, Tsinghua University, Beijing 100084, China
| | - Chen Zhang
- National Engineering Research Center of Neuromodulation, Tsinghua University, Beijing 100084, China
| | - Yue Chen
- National Engineering Research Center of Neuromodulation, Tsinghua University, Beijing 100084, China
| | - Changqing Jiang
- National Engineering Research Center of Neuromodulation, Tsinghua University, Beijing 100084, China
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8
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Darbin O, Hatanaka N, Takara S, Kaneko N, Chiken S, Naritoku D, Martino A, Nambu A. Subthalamic nucleus deep brain stimulation driven by primary motor cortex γ2 activity in parkinsonian monkeys. Sci Rep 2022; 12:6493. [PMID: 35444245 PMCID: PMC9021287 DOI: 10.1038/s41598-022-10130-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 03/31/2022] [Indexed: 11/17/2022] Open
Abstract
In parkinsonism, subthalamic nucleus (STN) electrical deep brain stimulation (DBS) improves symptoms, but may be associated with side effects. Adaptive DBS (aDBS), which enables modulation of stimulation, may limit side effects, but limited information is available about clinical effectiveness and efficaciousness. We developed a brain-machine interface for aDBS, which enables modulation of stimulation parameters of STN-DBS in response to γ2 band activity (80-200 Hz) of local field potentials (LFPs) recorded from the primary motor cortex (M1), and tested its effectiveness in parkinsonian monkeys. We trained two monkeys to perform an upper limb reaching task and rendered them parkinsonian with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine. Bipolar intracortical recording electrodes were implanted in the M1, and a recording chamber was attached to access the STN. In aDBS, the M1 LFPs were recorded, filtered into the γ2 band, and discretized into logic pulses by a window discriminator, and the pulses were used to modulate the interval and amplitude of DBS pulses. In constant DBS (cDBS), constant stimulus intervals and amplitudes were used. Reaction and movement times during the task were measured and compared between aDBS and cDBS. The M1-γ2 activities were increased before and during movements in parkinsonian monkeys and these activities modulated the aDBS pulse interval, amplitude, and dispersion. With aDBS and cDBS, reaction and movement times were significantly decreased in comparison to DBS-OFF. The electric charge delivered was lower with aDBS than cDBS. M1-γ2 aDBS in parkinsonian monkeys resulted in clinical benefits that did not exceed those from cDBS. However, M1-γ2 aDBS achieved this magnitude of benefit for only two thirds of the charge delivered by cDBS. In conclusion, M1-γ2 aDBS is an effective therapeutic approach which requires a lower electrical charge delivery than cDBS for comparable clinical benefits.
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Affiliation(s)
- Olivier Darbin
- Division of System Neurophysiology, National Institute for Physiological Sciences, Okazaki, Aichi, Japan. .,Department of Neurology, University South Alabama College of Medicine, 307 University Blvd, Mobile, AL, 36688, USA.
| | - Nobuhiko Hatanaka
- Division of System Neurophysiology, National Institute for Physiological Sciences, Okazaki, Aichi, Japan.,Department of Physiological Sciences, SOKENDAI (Graduate University for Advanced Studies), Okazaki, Aichi, Japan
| | - Sayuki Takara
- Division of System Neurophysiology, National Institute for Physiological Sciences, Okazaki, Aichi, Japan.,Department of Physiological Sciences, SOKENDAI (Graduate University for Advanced Studies), Okazaki, Aichi, Japan.,Department of Physiology, Faculty of Medecine, Kindai University, Osaka-Sayama, Osaka, Japan
| | - Nobuya Kaneko
- Division of System Neurophysiology, National Institute for Physiological Sciences, Okazaki, Aichi, Japan.,Department of Physiological Sciences, SOKENDAI (Graduate University for Advanced Studies), Okazaki, Aichi, Japan
| | - Satomi Chiken
- Division of System Neurophysiology, National Institute for Physiological Sciences, Okazaki, Aichi, Japan.,Department of Physiological Sciences, SOKENDAI (Graduate University for Advanced Studies), Okazaki, Aichi, Japan
| | - Dean Naritoku
- Department of Neurology, University South Alabama College of Medicine, 307 University Blvd, Mobile, AL, 36688, USA
| | - Anthony Martino
- Department of Neurosurgery, University South Alabama College of Medicine, Mobile, AL, USA
| | - Atsushi Nambu
- Division of System Neurophysiology, National Institute for Physiological Sciences, Okazaki, Aichi, Japan. .,Department of Physiological Sciences, SOKENDAI (Graduate University for Advanced Studies), Okazaki, Aichi, Japan.
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9
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Frey J, Cagle J, Johnson KA, Wong JK, Hilliard JD, Butson CR, Okun MS, de Hemptinne C. Past, Present, and Future of Deep Brain Stimulation: Hardware, Software, Imaging, Physiology and Novel Approaches. Front Neurol 2022; 13:825178. [PMID: 35356461 PMCID: PMC8959612 DOI: 10.3389/fneur.2022.825178] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
Deep brain stimulation (DBS) has advanced treatment options for a variety of neurologic and neuropsychiatric conditions. As the technology for DBS continues to progress, treatment efficacy will continue to improve and disease indications will expand. Hardware advances such as longer-lasting batteries will reduce the frequency of battery replacement and segmented leads will facilitate improvements in the effectiveness of stimulation and have the potential to minimize stimulation side effects. Targeting advances such as specialized imaging sequences and "connectomics" will facilitate improved accuracy for lead positioning and trajectory planning. Software advances such as closed-loop stimulation and remote programming will enable DBS to be a more personalized and accessible technology. The future of DBS continues to be promising and holds the potential to further improve quality of life. In this review we will address the past, present and future of DBS.
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Affiliation(s)
- Jessica Frey
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Jackson Cagle
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Kara A. Johnson
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Joshua K. Wong
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Justin D. Hilliard
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Christopher R. Butson
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Michael S. Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Coralie de Hemptinne
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
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10
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Challenges for future theories of Parkinson pathophysiology. Neurosci Res 2021; 177:1-7. [PMID: 34861293 DOI: 10.1016/j.neures.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 11/24/2022]
Abstract
Current theories on the basal ganglia-thalamic-cortical circuitry address the phenomena of hypokinesia and hyperkinesia. In this Perspective, we question whether the current models can address the orchestration of the motor units which is the common final pathway of the motor system. We conclude that the current theories do not to address this orchestration in health and disease. One alternative approach worthy of consideration is nonmonotonic nonlinear dynamics that contrast with a fundamentally linear or monotonic nonlinear approach that are presumed by current theories of basal ganglia-thalamic-cortical system. The purpose here is to make the case that current theories do presuppose a linear or monotonic nonlinear perspective which will be demonstrated as failing to adequately explicate the complex orchestration of motor unit activities in normal movement and in movement disorders. The notion of nonlinear dynamics is not new to neurophysiology; however, it is argued that it is new to the concepts of the physiology and pathophysiology of the basal ganglia-thalamic-cortical system. Providing a wholesale reconceptualization of the basal ganglia-thalamic-cortical system is beyond the scope of this effort. Rather, the contribution of the essay is convincing that there is a need to reconceptualize theories as nonlinear dynamical systems and there are metaphors and analogies from nonlinear science that can be productive in the reconsideration.
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di Biase L, Tinkhauser G, Martin Moraud E, Caminiti ML, Pecoraro PM, Di Lazzaro V. Adaptive, personalized closed-loop therapy for Parkinson's disease: biochemical, neurophysiological, and wearable sensing systems. Expert Rev Neurother 2021; 21:1371-1388. [PMID: 34736368 DOI: 10.1080/14737175.2021.2000392] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Motor complication management is one of the main unmet needs in Parkinson's disease patients. AREAS COVERED Among the most promising emerging approaches for handling motor complications in Parkinson's disease, adaptive deep brain stimulation strategies operating in closed-loop have emerged as pivotal to deliver sustained, near-to-physiological inputs to dysfunctional basal ganglia-cortical circuits over time. Existing sensing systems that can provide feedback signals to close the loop include biochemical-, neurophysiological- or wearable-sensors. Biochemical sensing allows to directly monitor the pharmacokinetic and pharmacodynamic of antiparkinsonian drugs and metabolites. Neurophysiological sensing relies on neurotechnologies to sense cortical or subcortical brain activity and extract real-time correlates of symptom intensity or symptom control during DBS. A more direct representation of the symptom state, particularly the phenomenological differentiation and quantification of motor symptoms, can be realized via wearable sensor technology. EXPERT OPINION Biochemical, neurophysiologic, and wearable-based biomarkers are promising technological tools that either individually or in combination could guide adaptive therapy for Parkinson's disease motor symptoms in the future.
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Affiliation(s)
- Lazzaro di Biase
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico Di Roma, Rome, Italy.,Brain Innovations Lab, Università Campus Bio-Medico Di Roma, Rome, Italy
| | - Gerd Tinkhauser
- Department of Neurology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Eduardo Martin Moraud
- Department of Clinical Neurosciences, Lausanne University Hospital (Chuv) and University of Lausanne (Unil), Lausanne, Switzerland.,Defitech Center for Interventional Neurotherapies (.neurorestore), Lausanne University Hospital and Swiss Federal Institute of Technology (Epfl), Lausanne, Switzerland
| | - Maria Letizia Caminiti
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico Di Roma, Rome, Italy
| | - Pasquale Maria Pecoraro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico Di Roma, Rome, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico Di Roma, Rome, Italy
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12
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Yu N, Liang S, Lu J, Shu Z, Li H, Yu Y, Wu J, Han J. Quantified assessment of deep brain stimulation on Parkinson's patients with task fNIRS measurements and functional connectivity analysis: a pilot study. Chin Neurosurg J 2021; 7:34. [PMID: 34225815 PMCID: PMC8256573 DOI: 10.1186/s41016-021-00251-3] [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] [Received: 11/30/2020] [Accepted: 05/26/2021] [Indexed: 12/02/2022] Open
Abstract
Background Deep brain stimulation (DBS) has proved effective for Parkinson’s disease (PD), but the identification of stimulation parameters relies on doctors’ subjective judgment on patient behavior. Methods Five PD patients performed 10-meter walking tasks under different brain stimulation frequencies. During walking tests, a wearable functional near-infrared spectroscopy (fNIRS) system was used to measure the concentration change of oxygenated hemoglobin (△HbO2) in prefrontal cortex, parietal lobe and occipital lobe. Brain functional connectivity and global efficiency were calculated to quantify the brain activities. Results We discovered that both the global and regional brain efficiency of all patients varied with stimulation parameters, and the DBS pattern enabling the highest brain efficiency was optimal for each patient, in accordance with the clinical assessments and DBS treatment decision made by the doctors. Conclusions Task fNIRS assessments and brain functional connectivity analysis promise a quantified and objective solution for patient-specific optimization of DBS treatment. Trial registration Name: Accurate treatment under the multidisciplinary cooperative diagnosis and treatment model of Parkinson’s disease. Registration number is ChiCTR1900022715. Date of registration is April 23, 2019.
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Affiliation(s)
- Ningbo Yu
- College of Artificial Intelligence, Nankai University, Tianjin, China.,Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin, China
| | - Siquan Liang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Jiewei Lu
- College of Artificial Intelligence, Nankai University, Tianjin, China.,Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin, China
| | - Zhilin Shu
- College of Artificial Intelligence, Nankai University, Tianjin, China.,Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin, China
| | - Haitao Li
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Yang Yu
- Department of Neurorehabilitation, Tianjin Huanhu Hospital, Tianjin, China
| | - Jialing Wu
- Department of Neurorehabilitation, Tianjin Huanhu Hospital, Tianjin, China. .,Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China. .,Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, China.
| | - Jianda Han
- College of Artificial Intelligence, Nankai University, Tianjin, China. .,Tianjin Key Laboratory of Intelligent Robotics, Nankai University, Tianjin, China.
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13
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Wong JK, Hu W, Barmore R, Lopes J, Moore K, Legacy J, Tahafchi P, Jackson Z, Judy JW, Raike RS, Wang A, Tsuboi T, Okun MS, Almeida L. Safety and Tolerability of Burst-Cycling Deep Brain Stimulation for Freezing of Gait in Parkinson's Disease. Front Hum Neurosci 2021; 15:651168. [PMID: 33981207 PMCID: PMC8109241 DOI: 10.3389/fnhum.2021.651168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/31/2021] [Indexed: 02/04/2023] Open
Abstract
Background: Freezing of gait (FOG) is a common symptom in Parkinson’s disease (PD) and can be difficult to treat with dopaminergic medications or with deep brain stimulation (DBS). Novel stimulation paradigms have been proposed to address suboptimal responses to conventional DBS programming methods. Burst-cycling deep brain stimulation (BCDBS) delivers current in various frequencies of bursts (e.g., 4, 10, or 15 Hz), while maintaining an intra-burst frequency identical to conventional DBS. Objective: To evaluate the safety and tolerability of BCDBS in PD patients with FOG. Methods: Ten PD subjects with STN or GPi DBS and complaints of FOG were recruited for this single center, single blinded within-subject crossover study. For each subject, we compared 4, 10, and 15 Hz BCDBS to conventional DBS during the PD medication-OFF state. Results: There were no serious adverse events with BCDBS. It was feasible and straightforward to program BCDBS in the clinic setting. The benefit was comparable to conventional DBS in measures of FOG, functional mobility and in PD motor symptoms. BCDBS had lower battery consumption when compared to conventional DBS. Conclusions: BCDBS was feasible, safe and well tolerated and it has potential to be a viable future DBS programming strategy.
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Affiliation(s)
- Joshua K Wong
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Wei Hu
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Ryan Barmore
- Banner Health Physicians Colorado, Loveland, CO, United States
| | - Janine Lopes
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Kathryn Moore
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Joseph Legacy
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Parisa Tahafchi
- Department of Electrical and Computer Engineering, University of Florida, Gainesville, FL, United States.,Nanoscience Institute for Medical and Engineering Technology, University of Florida, Gainesville, FL, United States
| | - Zachary Jackson
- Department of Electrical and Computer Engineering, University of Florida, Gainesville, FL, United States
| | - Jack W Judy
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States.,Department of Electrical and Computer Engineering, University of Florida, Gainesville, FL, United States.,Nanoscience Institute for Medical and Engineering Technology, University of Florida, Gainesville, FL, United States
| | - Robert S Raike
- Restorative Therapies Group Implantables, Research and Core Technology, Medtronic, Minneapolis, MN, United States
| | - Anson Wang
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Takashi Tsuboi
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States.,Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michael S Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States.,Nanoscience Institute for Medical and Engineering Technology, University of Florida, Gainesville, FL, United States
| | - Leonardo Almeida
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States.,Nanoscience Institute for Medical and Engineering Technology, University of Florida, Gainesville, FL, United States
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14
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Sui Y, Tian Y, Ko WKD, Wang Z, Jia F, Horn A, De Ridder D, Choi KS, Bari AA, Wang S, Hamani C, Baker KB, Machado AG, Aziz TZ, Fonoff ET, Kühn AA, Bergman H, Sanger T, Liu H, Haber SN, Li L. Deep Brain Stimulation Initiative: Toward Innovative Technology, New Disease Indications, and Approaches to Current and Future Clinical Challenges in Neuromodulation Therapy. Front Neurol 2021; 11:597451. [PMID: 33584498 PMCID: PMC7876228 DOI: 10.3389/fneur.2020.597451] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/23/2020] [Indexed: 01/17/2023] Open
Abstract
Deep brain stimulation (DBS) is one of the most important clinical therapies for neurological disorders. DBS also has great potential to become a great tool for clinical neuroscience research. Recently, the National Engineering Laboratory for Neuromodulation at Tsinghua University held an international Deep Brain Stimulation Initiative workshop to discuss the cutting-edge technological achievements and clinical applications of DBS. We specifically addressed new clinical approaches and challenges in DBS for movement disorders (Parkinson's disease and dystonia), clinical application toward neurorehabilitation for stroke, and the progress and challenges toward DBS for neuropsychiatric disorders. This review highlighted key developments in (1) neuroimaging, with advancements in 3-Tesla magnetic resonance imaging DBS compatibility for exploration of brain network mechanisms; (2) novel DBS recording capabilities for uncovering disease pathophysiology; and (3) overcoming global healthcare burdens with online-based DBS programming technology for connecting patient communities. The successful event marks a milestone for global collaborative opportunities in clinical development of neuromodulation to treat major neurological disorders.
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Affiliation(s)
- Yanan Sui
- National Engineering Laboratory for Neuromodulation, Tsinghua University, Beijing, China
| | - Ye Tian
- National Engineering Laboratory for Neuromodulation, Tsinghua University, Beijing, China
| | - Wai Kin Daniel Ko
- National Engineering Laboratory for Neuromodulation, Tsinghua University, Beijing, China
| | - Zhiyan Wang
- National Engineering Laboratory for Neuromodulation, Tsinghua University, Beijing, China
| | - Fumin Jia
- National Engineering Laboratory for Neuromodulation, Tsinghua University, Beijing, China
| | - Andreas Horn
- Charité, Department of Neurology, Movement Disorders and Neuromodulation Unit, University Medicine Berlin, Berlin, Germany
| | - Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ki Sueng Choi
- Department of Psychiatry and Behavioural Science, Emory University, Atlanta, GA, United States.,Department of Radiology, Mount Sinai School of Medicine, New York, NY, United States.,Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, United States
| | - Ausaf A Bari
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, United States
| | - Shouyan Wang
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
| | - Clement Hamani
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Kenneth B Baker
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States.,Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Andre G Machado
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States.,Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Tipu Z Aziz
- Department of Neurosurgery, John Radcliffe Hospital, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Erich Talamoni Fonoff
- Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil.,Hospital Sírio-Libanês and Hospital Albert Einstein, São Paulo, Brazil
| | - Andrea A Kühn
- Charité, Department of Neurology, Movement Disorders and Neuromodulation Unit, University Medicine Berlin, Berlin, Germany
| | - Hagai Bergman
- Department of Medical Neurobiology (Physiology), Institute of Medical Research-Israel-Canada (IMRIC), Faculty of Medicine, Jerusalem, Israel.,The Edmond and Lily Safra Center for Brain Research (ELSC), The Hebrew University and Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Terence Sanger
- University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Hesheng Liu
- Department of Neuroscience, College of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Suzanne N Haber
- Department of Pharmacology and Physiology, University of Rochester School of Medicine & Dentistry, Rochester, NY, United States.,McLean Hospital and Harvard Medical School, Belmont, MA, United States
| | - Luming Li
- National Engineering Laboratory for Neuromodulation, Tsinghua University, Beijing, China
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15
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Lu Y, Xie D, Zhang X, Dong S, Zhang H, Yu B, Wang G, Wang JJ, Li L. Management of Intractable Pain in Patients With Implanted Spinal Cord Stimulation Devices During the COVID-19 Pandemic Using a Remote and Wireless Programming System. Front Neurosci 2020; 14:594696. [PMID: 33363453 PMCID: PMC7753179 DOI: 10.3389/fnins.2020.594696] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/16/2020] [Indexed: 12/23/2022] Open
Abstract
As COVID-19 rampages throughout the world and has a major impact on the healthcare system, non-emergency medical procedures have nearly come to a halt due to appropriate resource reallocation. However, pain never stops, particularly for patients with chronic intractable pain and implanted spinal cord stimulation (SCS) devices. The isolation required to fight this pandemic makes it impossible for such patients to adjust the parameters or configuration of the device on site. Although telemedicine has shown a great effect in many healthcare scenarios, there have been fewer applications of such technology focusing on the interaction with implanted devices. Here, we introduce the first remote and wireless programming system that enables healthcare providers to perform video-based real-time programming and palliative medicine for pain patients with a SCS implant. During the COVID-19 pandemic from January 23, 2020, the date of lockdown of Wuhan, to April 30, 2020, 34 sessions of remote programming were conducted with 16 patients. Thirteen of the 16 patients required programming for parameter optimization. Improvement was achieved with programming adjustment in 12 of 13 (92.3%) cases. Eleven of the 16 (68.8%) patients reported that the system was user-friendly and met their needs. Five patients complained of an unstable connection resulting from the low network speed initially, and three of these patients solved this problem. In summary, we demonstrated that a remote wireless programming system can deliver safe and effective programming operations of implantable SCS device, thereby providing palliative care of value to the most vulnerable chronic pain patients during a pandemic.
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Affiliation(s)
- Yang Lu
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.,National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Duo Xie
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Xiaolei Zhang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Sheng Dong
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Huifang Zhang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Beibei Yu
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Guihuai Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - James Jin Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Luming Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China.,Precision Medicine and Healthcare Research Center, Tsinghua-Berkeley Shenzhen Institute, Tsinghua University, Shenzhen, China.,IDG/McGovern Institute for Brain Research at Tsinghua University, Beijing, China.,Institute of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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16
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Paff M, Loh A, Sarica C, Lozano AM, Fasano A. Update on Current Technologies for Deep Brain Stimulation in Parkinson's Disease. J Mov Disord 2020; 13:185-198. [PMID: 32854482 PMCID: PMC7502302 DOI: 10.14802/jmd.20052] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/22/2020] [Accepted: 07/05/2020] [Indexed: 01/19/2023] Open
Abstract
Deep brain stimulation (DBS) is becoming increasingly central in the treatment of patients with Parkinson's disease and other movement disorders. Recent developments in DBS lead and implantable pulse generator design provide increased flexibility for programming, potentially improving the therapeutic benefit of stimulation. Directional DBS leads may increase the therapeutic window of stimulation by providing a means of avoiding current spread to structures that might give rise to stimulation-related side effects. Similarly, control of current to individual contacts on a DBS lead allows for shaping of the electric field produced between multiple active contacts. The following review aims to describe the recent developments in DBS system technology and the features of each commercially available DBS system. The advantages of each system are reviewed, and general considerations for choosing the most appropriate system are discussed.
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Affiliation(s)
- Michelle Paff
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Canada
| | - Aaron Loh
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Canada
| | - Can Sarica
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Canada
| | - Andres M. Lozano
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson’s Disease, Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, UHN, Division of Neurology, University of Toronto, Toronto, Canada
- Krembil Brain Institute, Toronto, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Canada
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17
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Decreasing battery life in subthalamic deep brain stimulation for Parkinson's disease with repeated replacements: Just a matter of energy delivered? Brain Stimul 2019; 12:845-850. [DOI: 10.1016/j.brs.2019.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 02/07/2019] [Accepted: 02/11/2019] [Indexed: 11/17/2022] Open
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18
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Zhang C, Pan Y, Zhou H, Xie Q, Sun B, Niu CM, Li D. Variable High-Frequency Deep Brain Stimulation of the Subthalamic Nucleus for Speech Disorders in Parkinson's Disease: A Case Report. Front Neurol 2019; 10:379. [PMID: 31040817 PMCID: PMC6477029 DOI: 10.3389/fneur.2019.00379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/28/2019] [Indexed: 11/13/2022] Open
Abstract
Background and Importance: It is known that subthalamic nucleus deep brain stimulation (STN-DBS) at a fixed high frequency (>100 Hz) improves the primary motor symptoms of Parkinson disease (PD), but this stimulation does not improve or may even exacerbate the later-occurring axial symptoms and signs in PD (e.g., problems with gait or speech). Recent evidence suggests that STN-DBS at a fixed lower frequency (< 100 Hz) can improve speech and gait, but may worsen the tremor in PD. Clinical Presentation: The case involved a female patient who developed severe speech problems after 16 years high-frequency STN-DBS for PD. The tremor and dysarthria symptoms were both effectively treated by applying variable-frequency stimulation (VFS) containing only a combination of high frequencies. Conclusion: VFS containing several higher frequencies improved both the tremor and axial signs including speech problems in our patient. This case report suggests that VFS may be of clinical utility in the management of advanced PD, but this should be further verified in larger well-controlled studies.
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Affiliation(s)
- Chencheng Zhang
- Department of Functional Neurosurgery, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yixin Pan
- Department of Functional Neurosurgery, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Haiyan Zhou
- Department of Neurology, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qing Xie
- Department of Rehabilitation Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bomin Sun
- Department of Functional Neurosurgery, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chuanxin M Niu
- Department of Rehabilitation Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China.,Med-X Research Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Dianyou Li
- Department of Functional Neurosurgery, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
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19
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Daneshzand M, Faezipour M, Barkana BD. Robust desynchronization of Parkinson's disease pathological oscillations by frequency modulation of delayed feedback deep brain stimulation. PLoS One 2018; 13:e0207761. [PMID: 30458039 PMCID: PMC6245797 DOI: 10.1371/journal.pone.0207761] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 11/06/2018] [Indexed: 11/30/2022] Open
Abstract
The hyperkinetic symptoms of Parkinson's Disease (PD) are associated with the ensembles of interacting oscillators that cause excess or abnormal synchronous behavior within the Basal Ganglia (BG) circuitry. Delayed feedback stimulation is a closed loop technique shown to suppress this synchronous oscillatory activity. Deep Brain Stimulation (DBS) via delayed feedback is known to destabilize the complex intermittent synchronous states. Computational models of the BG network are often introduced to investigate the effect of delayed feedback high frequency stimulation on partially synchronized dynamics. In this study, we develop a reduced order model of four interacting nuclei of the BG as well as considering the Thalamo-Cortical local effects on the oscillatory dynamics. This model is able to capture the emergence of 34 Hz beta band oscillations seen in the Local Field Potential (LFP) recordings of the PD state. Train of high frequency pulses in a delayed feedback stimulation has shown deficiencies such as strengthening the synchronization in case of highly fluctuating neuronal activities, increasing the energy consumed as well as the incapability of activating all neurons in a large-scale network. To overcome these drawbacks, we propose a new feedback control variable based on the filtered and linearly delayed LFP recordings. The proposed control variable is then used to modulate the frequency of the stimulation signal rather than its amplitude. In strongly coupled networks, oscillations reoccur as soon as the amplitude of the stimulus signal declines. Therefore, we show that maintaining a fixed amplitude and modulating the frequency might ameliorate the desynchronization process, increase the battery lifespan and activate substantial regions of the administered DBS electrode. The charge balanced stimulus pulse itself is embedded with a delay period between its charges to grant robust desynchronization with lower amplitudes needed. The efficiency of the proposed Frequency Adjustment Stimulation (FAS) protocol in a delayed feedback method might contribute to further investigation of DBS modulations aspired to address a wide range of abnormal oscillatory behavior observed in neurological disorders.
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Affiliation(s)
- Mohammad Daneshzand
- D-BEST Lab, Departments of Computer Science and Engineering and Biomedical Engineering, University of Bridgeport, Bridgeport, CT, United States of America
| | - Miad Faezipour
- D-BEST Lab, Departments of Computer Science and Engineering and Biomedical Engineering, University of Bridgeport, Bridgeport, CT, United States of America
| | - Buket D. Barkana
- Department of Electrical Engineering, University of Bridgeport, Bridgeport, CT, United States of America
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20
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Habets JGV, Heijmans M, Kuijf ML, Janssen MLF, Temel Y, Kubben PL. An update on adaptive deep brain stimulation in Parkinson's disease. Mov Disord 2018; 33:1834-1843. [PMID: 30357911 PMCID: PMC6587997 DOI: 10.1002/mds.115] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/26/2018] [Accepted: 07/08/2018] [Indexed: 12/24/2022] Open
Abstract
Advancing conventional open‐loop DBS as a therapy for PD is crucial for overcoming important issues such as the delicate balance between beneficial and adverse effects and limited battery longevity that are currently associated with treatment. Closed‐loop or adaptive DBS aims to overcome these limitations by real‐time adjustment of stimulation parameters based on continuous feedback input signals that are representative of the patient's clinical state. The focus of this update is to discuss the most recent developments regarding potential input signals and possible stimulation parameter modulation for adaptive DBS in PD. Potential input signals for adaptive DBS include basal ganglia local field potentials, cortical recordings (electrocorticography), wearable sensors, and eHealth and mHealth devices. Furthermore, adaptive DBS can be applied with different approaches of stimulation parameter modulation, the feasibility of which can be adapted depending on specific PD phenotypes. Implementation of technological developments like machine learning show potential in the design of such approaches; however, energy consumption deserves further attention. Furthermore, we discuss future considerations regarding the clinical implementation of adaptive DBS in PD. © 2018 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Jeroen G V Habets
- Departments of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands.,School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Margot Heijmans
- Departments of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands.,School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mark L Kuijf
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marcus L F Janssen
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands.,School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Yasin Temel
- Departments of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands.,School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Pieter L Kubben
- Departments of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands.,School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
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21
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Jia F, Wagle Shukla A, Hu W, Almeida L, Holanda V, Zhang J, Meng F, Okun MS, Li L. Deep Brain Stimulation at Variable Frequency to Improve Motor Outcomes in Parkinson's Disease. Mov Disord Clin Pract 2018; 5:538-541. [PMID: 30637270 DOI: 10.1002/mdc3.12658] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 04/02/2018] [Accepted: 04/29/2018] [Indexed: 11/10/2022] Open
Abstract
Introduction Deep brain stimulation (DBS) with high frequency (HFS) is a well-established therapy for Parkinson's disease (PD); however, low frequency DBS (LFS) may control axial symptoms including freezing of gait (FOG). We conducted a pilot safety and feasibility study to examine if a novel DBS paradigm of variable frequency stimulation (VFS) that combined HFS and LFS would capture a broader set of motor symptoms. Methods Four PD patients with bilateral STN DBS and FOG were enrolled. A UPDRS III and 10 m timed up and go (TUG) task were performed off medications-off DBS and then one hour after HFS and one hour after VFS programming. Results The UPDRS III motor score improved by additional 14% during VFS setting when compared to HFS. VFS also increased gait speed (mean change 45%) and reduced the number of freezing episodes (mean change 58%). Conclusions VFS improves UPDRS and FOG in PD when compared to HFS.Copyright © 2018 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Fumin Jia
- National Engineering laboratory for Neuromodulation Tsinghua University Beijing China
| | - Aparna Wagle Shukla
- University of Florida Center for Movement Disorders and Neurorestoration Gainesville FL USA
| | - Wei Hu
- University of Florida Center for Movement Disorders and Neurorestoration Gainesville FL USA
| | - Leonardo Almeida
- University of Florida Center for Movement Disorders and Neurorestoration Gainesville FL USA
| | - Vanessa Holanda
- Department of Neurosurgery University of Florida Gainesville FL USA
| | - Jianguo Zhang
- Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Fangang Meng
- Beijing Neurosurgical Institute Capital Medical University Beijing China
| | - Michael S Okun
- University of Florida Center for Movement Disorders and Neurorestoration Gainesville FL USA
| | - Luming Li
- National Engineering laboratory for Neuromodulation Tsinghua University Beijing China.,Precision Medicine & Healthcare Research Center Tsinghua-Berkeley Shenzhen Institute Shenzhen China.,Man-machine-environment engineering Institute, School of Aerospace Engineering Tsinghua university Beijing China.,Center of Epilepsy Beijing Institute for Brain Disorders Beijing China
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22
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Cai Z, Feng Z, Hu H, Hu N, Wei X. Design of a novel stimulation system with time-varying paradigms for investigating new modes of high frequency stimulation in brain. Biomed Eng Online 2018; 17:90. [PMID: 29929498 PMCID: PMC6013863 DOI: 10.1186/s12938-018-0523-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 06/18/2018] [Indexed: 11/28/2022] Open
Abstract
Background Deep brain stimulation (DBS) has shown wide clinical applications for treating various disorders of central nervous system. High frequency stimulation (HFS) of pulses with a constant intensity and a constant frequency is typically used in DBS. However, new stimulation paradigms with time-varying parameters provide a prospective direction for DBS developments. To meet the research demands for time-varying stimulations, we designed a new stimulation system with a technique of LabVIEW-based virtual instrument. Methods The system included a LabVIEW program, a NI data acquisition card, and an analog stimulus isolator. The output waveforms of the system were measured to verify the time-varying parameters. Preliminary animal experiments were run by delivering the HFS sequences with time-varying parameters to the hippocampal CA1 region of anesthetized rats. Results Verification results showed that the stimulation system was able to generate pulse sequences with ramped intensity and hyperbolic frequency accurately. Application of the time-varying HFS sequences to the axons of pyramidal cells in the hippocampal CA1 region resulted in neuronal responses different from those induced by HFS with constant parameters. The results indicated important modulations of time-varying stimulations to the neuronal activity that could prevent the stimulation from inducing over-synchronized firing of population neurons. Conclusions The stimulation system provides a useful technique for investigating diverse stimulation paradigms for the development of new DBS treatments.
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Affiliation(s)
- Ziyan Cai
- Key Laboratory of Biomedical Engineering of Education Ministry, College of Biomedical Engineering & Instrument Science, Zhejiang University, Hangzhou, 310027, Zhejiang, China
| | - Zhouyan Feng
- Key Laboratory of Biomedical Engineering of Education Ministry, College of Biomedical Engineering & Instrument Science, Zhejiang University, Hangzhou, 310027, Zhejiang, China.
| | - Hanhan Hu
- Key Laboratory of Biomedical Engineering of Education Ministry, College of Biomedical Engineering & Instrument Science, Zhejiang University, Hangzhou, 310027, Zhejiang, China
| | - Na Hu
- Key Laboratory of Biomedical Engineering of Education Ministry, College of Biomedical Engineering & Instrument Science, Zhejiang University, Hangzhou, 310027, Zhejiang, China
| | - Xuefeng Wei
- Department of Biomedical Engineering, The College of New Jersey, Ewing, NJ, 08628, USA
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Daneshzand M, Faezipour M, Barkana BD. Towards frequency adaptation for delayed feedback deep brain stimulations. Neural Regen Res 2018; 13:408-409. [PMID: 29623917 PMCID: PMC5900495 DOI: 10.4103/1673-5374.228715] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Mohammad Daneshzand
- D-BEST Lab, Departments of Computer Science and Engineering and Biomedical Engineering, University of Bridgeport, Bridgeport, CT, USA
| | - Miad Faezipour
- D-BEST Lab, Departments of Computer Science and Engineering and Biomedical Engineering, University of Bridgeport, Bridgeport, CT, USA
| | - Buket D Barkana
- Department of Electrical Engineering, University of Bridgeport, Bridgeport, CT, USA
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24
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Deep brain stimulation for lesion-related tremors: A systematic review and meta-analysis. Parkinsonism Relat Disord 2018; 47:8-14. [DOI: 10.1016/j.parkreldis.2017.12.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 12/10/2017] [Accepted: 12/11/2017] [Indexed: 12/28/2022]
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Ramirez-Zamora A, Giordano JJ, Gunduz A, Brown P, Sanchez JC, Foote KD, Almeida L, Starr PA, Bronte-Stewart HM, Hu W, McIntyre C, Goodman W, Kumsa D, Grill WM, Walker HC, Johnson MD, Vitek JL, Greene D, Rizzuto DS, Song D, Berger TW, Hampson RE, Deadwyler SA, Hochberg LR, Schiff ND, Stypulkowski P, Worrell G, Tiruvadi V, Mayberg HS, Jimenez-Shahed J, Nanda P, Sheth SA, Gross RE, Lempka SF, Li L, Deeb W, Okun MS. Evolving Applications, Technological Challenges and Future Opportunities in Neuromodulation: Proceedings of the Fifth Annual Deep Brain Stimulation Think Tank. Front Neurosci 2018; 11:734. [PMID: 29416498 PMCID: PMC5787550 DOI: 10.3389/fnins.2017.00734] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 12/15/2017] [Indexed: 12/21/2022] Open
Abstract
The annual Deep Brain Stimulation (DBS) Think Tank provides a focal opportunity for a multidisciplinary ensemble of experts in the field of neuromodulation to discuss advancements and forthcoming opportunities and challenges in the field. The proceedings of the fifth Think Tank summarize progress in neuromodulation neurotechnology and techniques for the treatment of a range of neuropsychiatric conditions including Parkinson's disease, dystonia, essential tremor, Tourette syndrome, obsessive compulsive disorder, epilepsy and cognitive, and motor disorders. Each section of this overview of the meeting provides insight to the critical elements of discussion, current challenges, and identified future directions of scientific and technological development and application. The report addresses key issues in developing, and emphasizes major innovations that have occurred during the past year. Specifically, this year's meeting focused on technical developments in DBS, design considerations for DBS electrodes, improved sensors, neuronal signal processing, advancements in development and uses of responsive DBS (closed-loop systems), updates on National Institutes of Health and DARPA DBS programs of the BRAIN initiative, and neuroethical and policy issues arising in and from DBS research and applications in practice.
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Affiliation(s)
- Adolfo Ramirez-Zamora
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States,*Correspondence: Adolfo Ramirez-Zamora
| | - James J. Giordano
- Department of Neurology, Pellegrino Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC, United States
| | - Aysegul Gunduz
- J. Crayton Pruitt Family Department of Biomedical Engineering, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
| | - Peter Brown
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Justin C. Sanchez
- Biological Technologies Office, Defense Advanced Research Projects Agency, Arlington, VA, United States
| | - Kelly D. Foote
- Department of Neurosurgery, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
| | - Leonardo Almeida
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
| | - Philip A. Starr
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Helen M. Bronte-Stewart
- Departments of Neurology and Neurological Sciences and Neurosurgery, Stanford University, Stanford, CA, United States
| | - Wei Hu
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
| | - Cameron McIntyre
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States
| | - Wayne Goodman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States,Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Doe Kumsa
- Division of Biomedical Physics, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, United States Food and Drug Administration, White Oak Federal Research Center, Silver Spring, MD, United States
| | - Warren M. Grill
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
| | - Harrison C. Walker
- Division of Movement Disorders, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States,Department of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Matthew D. Johnson
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, United States
| | - Jerrold L. Vitek
- Department of Neurology, University of Minnesota, Minneapolis, MN, United States
| | - David Greene
- NeuroPace, Inc., Mountain View, CA, United States
| | - Daniel S. Rizzuto
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, United States
| | - Dong Song
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, United States
| | - Theodore W. Berger
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, United States
| | - Robert E. Hampson
- Physiology and Pharmacology, Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, United States
| | - Sam A. Deadwyler
- Physiology and Pharmacology, Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, United States
| | - Leigh R. Hochberg
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, United States,Center for Neurorestoration and Neurotechnology, Rehabilitation R and D Service, Veterans Affairs Medical Center, Providence, RI, United States,School of Engineering and Brown Institute for Brain Science, Brown University, Providence, RI, United States
| | - Nicholas D. Schiff
- Laboratory of Cognitive Neuromodulation, Feil Family Brain Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
| | | | - Greg Worrell
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Vineet Tiruvadi
- Department of Biomedical Engineering, Georgia Institute of Technology, Emory University School of Medicine, Emory University, Atlanta, GA, United States
| | - Helen S. Mayberg
- Departments of Psychiatry, Neurology, and Radiology, Emory University School of Medicine, Emory University, Atlanta, GA, United States
| | - Joohi Jimenez-Shahed
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Pranav Nanda
- Department of Neurological Surgery, The Neurological Institute, Columbia University Herbert and Florence Irving Medical Center, Colombia University, New York, NY, United States
| | - Sameer A. Sheth
- Department of Neurological Surgery, The Neurological Institute, Columbia University Herbert and Florence Irving Medical Center, Colombia University, New York, NY, United States
| | - Robert E. Gross
- Department of Neurosurgery, Emory University, Atlanta, GA, United States
| | - Scott F. Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Luming Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China,Precision Medicine and Healthcare Research Center, Tsinghua-Berkeley Shenzhen Institute, Tsinghua University, Beijing, China,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Wissam Deeb
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
| | - Michael S. Okun
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
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