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Lannon M, Duda T, Mastrolonardo A, Huang E, Martyniuk A, Farrokhyar F, Xie F, Bhandari M, Kalia SK, Sharma S. Economic Evaluations Comparing Deep Brain Stimulation to Best Medical Therapy for Movement Disorders: A Meta-Analysis. PHARMACOECONOMICS 2024; 42:41-68. [PMID: 37751075 DOI: 10.1007/s40273-023-01318-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Movement disorders (Parkinson's disease, essential tremor, primary dystonia) are a debilitating group of conditions that are progressive in nature. The mainstay of treatment is best medical therapy; however, a number of surgical therapies are available, including deep brain stimulation. Economic evaluations are an important aspect of evidence to inform decision makers regarding funding allocated to these therapies. OBJECTIVE This systematic review and meta-analysis evaluated the cost effectiveness of including deep brain stimulation compared with best medical therapy for movement disorder indications in the adult population. METHODS Ovid Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Central Register of Controlled Trials were queried. Only economic evaluations reporting incremental cost-effectiveness ratios for including deep brain stimulation versus best medical therapy for movement disorders were included. Studies were reviewed in duplicate for inclusion and data abstraction. Data were harmonized using the Consumer Price Index and Purchasing Power Parity to standardize values to 2022 US dollars. For inclusion in meta-analyses, studies were required to have sufficient data available to calculate an estimate of the incremental net benefit. Meta-analyses of pooled incremental net benefit based on the time horizon were performed. The study was registered at PROSPERO (CRD42022335436). RESULTS There were 2190 studies reviewed, with 14 economic evaluations included following a title/abstract and full-text review. Only studies considering Parkinson's disease were available for the meta-analysis. Quality of the identified studies was low, with moderate transferability to the American Healthcare System, and certainty of evidence was low. However, studies with a longer time horizon (15 years to lifetime) were found to have significant positive incremental net benefit (indicating cost effectiveness) for including deep brain stimulation with a mean difference of US$40,504.81 (95% confidence interval 2422.42-78,587.19). CONCLUSIONS Deep brain stimulation was cost effective for Parkinson's disease when considered over the course of the patient's remaining life after implantation. TRIAL REGISTRATION Clinical Trial Registration: PROSPERO (CRD42022335436).
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Affiliation(s)
- Melissa Lannon
- Division of Neurosurgery, McMaster University, 237 Barton Street East, Hamilton, ON, Canada.
| | - Taylor Duda
- Division of Neurosurgery, McMaster University, 237 Barton Street East, Hamilton, ON, Canada
| | | | - Ellissa Huang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Amanda Martyniuk
- Division of Neurosurgery, McMaster University, 237 Barton Street East, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Feng Xie
- Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Suneil K Kalia
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, 237 Barton Street East, Hamilton, ON, Canada
- Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
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Helvaci Yilmaz N, Bolluk Kilic B, Zirh TA, Aslan AS, Hanoglu L. Parkinson’s Disease and the COVID-19 Pandemic: Do Quarantine Affect the Motor and Non-Motor Symptoms of Patients with and without Deep Brain Stimulation? HASEKI TIP BÜLTENI 2022. [DOI: 10.4274/haseki.galenos.2022.8225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Mahlknecht P, Foltynie T, Limousin P, Poewe W. How Does Deep Brain Stimulation Change the Course of Parkinson's Disease? Mov Disord 2022; 37:1581-1592. [PMID: 35560443 PMCID: PMC9545904 DOI: 10.1002/mds.29052] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/07/2022] [Accepted: 04/18/2022] [Indexed: 12/14/2022] Open
Abstract
A robust body of evidence from randomized controlled trials has established the efficacy of deep brain stimulation (DBS) in reducing off time and dyskinesias in levodopa‐treated patients with Parkinson's disease (PD). These effects go along with improvements in on period motor function, activities of daily living, and quality of life. In addition, subthalamic DBS is effective in controlling drug‐refractory PD tremor. Here, we review the available data from long‐term observational and controlled follow‐up studies in DBS‐treated patients to re‐examine the persistence of motor and quality of life benefits and evaluate the effects on disease progression, major disability milestones, and survival. Although there is consistent evidence from observational follow‐up studies in DBS‐treated patients over 5–10 years and beyond showing sustained improvement of motor control, the long‐term impact of DBS on overall progression of disability in PD is less clear. Whether DBS reduces or delays the development of later motor and non‐motor disability milestones in comparison to best medical management strategies is difficult to answer by uncontrolled observational follow‐up, but there are signals from controlled long‐term observational studies suggesting that subthalamic DBS may delay some of the late‐stage disability milestones including psychosis, falls, and institutionalization, and also slightly prolongs survival compared with matched medically managed patients. These observations could be attributable to the sustained improvements in motor function and reduction in medication‐induced side effects, whereas there is no clinical evidence of direct effects of DBS on the underlying disease progression. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society
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Affiliation(s)
- Philipp Mahlknecht
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Thomas Foltynie
- Department of Clinical and Movement Neurosciences, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Patricia Limousin
- Department of Clinical and Movement Neurosciences, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Werner Poewe
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
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Brozova H, Barnaure I, Ruzicka E, Stochl J, Alterman R, Tagliati M. Short- and Long-Term Effects of DBS on Gait in Parkinson's Disease. Front Neurol 2021; 12:688760. [PMID: 34690908 PMCID: PMC8531078 DOI: 10.3389/fneur.2021.688760] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/11/2021] [Indexed: 12/18/2022] Open
Abstract
The aim was to compare the short and long-term effects of subthalamic nucleus (STN) deep brain stimulation (DBS) on gait dysfunction and other cardinal symptoms of Parkinson's disease (PD). Two groups of patients were studied. The first group (short-term DBS, n = 8) included patients recently implanted with STN DBS (mean time since DBS 15.8 months, mean age 58.8 years, PD duration 13 years); the second group (long-term DBS, n = 10) included patients with at least 5 years of DBS therapy (mean time since DBS 67.6 months, mean age 61.7 years, PD duration 17.1 years). Both groups were examined using the Unified Parkinson's Disease Rating Scale (UPDRS) and Gait and Balance scale (GABS) during four stimulation/medication states (ON/OFF; OFF/OFF; OFF/ON; ON/ON). Data were analyzed using repeated measures ANOVA with time since implantation (years) between groups and medication or DBS effect (ON, OFF) within groups. In the short-term DBS group, stimulation improved all UPDRS subscores similar to dopaminergic medications. In particular, average gait improvement was over 40% (p = 0.01), as measured by the UPDRS item 29 and GABS II. In the long-term DBS group, stimulation consistently improved all clinical subscores with the exception of gait and postural instability. In these patients, the effect of levodopa on gait was partially preserved. Short-term improvement of gait abnormalities appears to significantly decline after 5 years of STN DBS in PD patients, while effectiveness for other symptoms remains stable. Progressive non-dopaminergic (non-DBS responsive) mechanisms or deleterious effects of high frequency STN stimulation on gait function may play a role.
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Affiliation(s)
- Hana Brozova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Isabelle Barnaure
- Department of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Evzen Ruzicka
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Jan Stochl
- Department of Kinanthropology, Charles University in Prague, Prague, Czechia.,Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Ron Alterman
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Michele Tagliati
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Yen K, Miyasaki JM, Waldron M, Yu L, Sankar T, Ba F. DBS-Edmonton App, a Tool to Manage Patient Expectations of DBS in Parkinson Disease. Neurol Clin Pract 2021; 11:e308-e316. [PMID: 34484906 DOI: 10.1212/cpj.0000000000000962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/14/2020] [Indexed: 12/20/2022]
Abstract
Objective After deep brain stimulation (DBS) for Parkinson disease (PD), patients often do not report the level of satisfaction anticipated. This misalignment can relate to patients' expectations for an invasive treatment and insufficient knowledge of DBS's effectiveness in relieving motor and nonmotor symptoms (NMS). Patient satisfaction depends on expectations and goals for treatment. We hypothesized that improving patient education with a patient-centered shared decision-making tool emphasizing autonomy would improve patient satisfaction and clinical outcome. Methods We developed a computer application (DBS-Edmonton app), allowing patients with PD to input their symptoms and to learn how effective DBS addresses their prioritized symptoms. Sixty-two volunteers referred for DBS used the DBS-Edmonton app. DBS-related knowledge and patient perceptions of the DBS-Edmonton app were assessed with pre- and post-use questionnaires. Fourteen of 24 patients who proceeded to DBS achieved optimization at 6 months. Perceived functional improvement was assessed and compared with 12 control patients with DBS who did not use the DBS-Edmonton app. Results All 62 volunteers considered the DBS-Edmonton app helpful and would recommend it to others. There was improved knowledge about how NMS and axial symptoms respond to DBS. Postoperatively, there was no significant difference in symptoms improvement assessed by standard scales between the groups. Volunteers who used the DBS-Edmonton app had greater satisfaction (p = 0.014). Conclusion This interventional study showed that the DBS-Edmonton app improved DBS-related knowledge and patient satisfaction, independent of the objective motor outcome. It may assist patients in deciding to proceed to DBS and can be easily incorporated into practice to improve patient satisfaction post-DBS.
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Affiliation(s)
- Kevin Yen
- Parkinson and Movement Disorders Program (KY, JMM, MW, FB), Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, School of Public Health (LY), and Division of Neurosurgery (TS), Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Janis M Miyasaki
- Parkinson and Movement Disorders Program (KY, JMM, MW, FB), Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, School of Public Health (LY), and Division of Neurosurgery (TS), Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Michelle Waldron
- Parkinson and Movement Disorders Program (KY, JMM, MW, FB), Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, School of Public Health (LY), and Division of Neurosurgery (TS), Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Lin Yu
- Parkinson and Movement Disorders Program (KY, JMM, MW, FB), Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, School of Public Health (LY), and Division of Neurosurgery (TS), Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Tejas Sankar
- Parkinson and Movement Disorders Program (KY, JMM, MW, FB), Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, School of Public Health (LY), and Division of Neurosurgery (TS), Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Fang Ba
- Parkinson and Movement Disorders Program (KY, JMM, MW, FB), Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, School of Public Health (LY), and Division of Neurosurgery (TS), Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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Prevalence of freezing of gait in Parkinson's disease: a systematic review and meta-analysis. J Neurol 2021; 268:4138-4150. [PMID: 34236501 DOI: 10.1007/s00415-021-10685-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Freezing of gait (FOG) is considered one of the most disturbing and least understood symptoms in Parkinson's disease (PD). The reported prevalence rates of FOG in PD vary widely, ranging from 5 to 85.9%. OBJECTIVE We conducted a systematic review and meta-analysis to provide a reliable estimate of the average point prevalence of FOG in PD, and we further investigated the study characteristics that might have influenced the estimate. METHODS We searched different databases to identify studies that report the prevalence of FOG in PD or include relevant raw data for further calculation. The last inclusion date was February 20, 2020. The modified Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used for the quality assessment, and articles that met the predefined criteria were included in the quantitative analysis. RESULTS Sixty-six studies were selected from 3392 references. A weighted prevalence of 50.6% in 9072 PD patients experienced FOG based on the special questionnaires (the FOG-Q and NFOG-Q), which was about twice as high as that assessed by the specific items of the clinical rating scales (UPDRS item2.14 and MDS-UPDRS item3.11) (23.2%) or simple clinical questions (25.4%). The weighted prevalence was 37.9% for early stage (≤ 5 years) and 64.6% for advanced stage (≥ 9 years). Moreover, a higher prevalence was calculated from the population-based studies than that in multicenter and single-center studies (47.3% vs. 33.5% and 37.1%, respectively). CONCLUSION The result from this systematic review confirms that FOG is very common in PD and its prevalence is usually underestimated in hospital settings. Importantly, a more accurate assessment of FOG in future clinical researches would involve the use of special FOG scale rather than a single item on a scale or a general clinical inquiry.
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Navratilova D, Krobot A, Otruba P, Nevrly M, Krahulik D, Kolar P, Kolarova B, Kaiserova M, Mensikova K, Vastik M, Kurcova S, Kanovsky P. Deep Brain Stimulation Effects on Gait Pattern in Advanced Parkinson's Disease Patients. Front Neurosci 2020; 14:814. [PMID: 32922256 PMCID: PMC7456806 DOI: 10.3389/fnins.2020.00814] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 07/10/2020] [Indexed: 12/12/2022] Open
Abstract
Background Gait disturbance accompanies many neurodegenerative diseases; it is characteristic for Parkinson’s disease (PD). Treatment of advanced PD often includes deep brain stimulation (DBS) of the subthalamic nucleus. Regarding gait, previous studies have reported non-significant or conflicting results, possibly related to methodological limitations. Objective The objective of this prospective study was to assess the effects of DBS on biomechanical parameters of gait in patients with PD. Methods Twenty-one patients with advanced PD participated in this prospective study. Gait was examined in all patients using the Zebris FDM-T pressure-sensitive treadmill (Isny, Germany) before DBS implantation and after surgery immediately, further immediately after the start of neurostimulation, and 3 months after neurostimulator activation. We assessed spontaneous gait on a moving treadmill at different speeds. Step length, stance phase of both lower limbs, double-stance phase, and cadence were evaluated. Results In this study, step length increased, allowing the cadence to decrease. Double-stance phase duration, that is, the most sensitive parameter of gait quality and unsteadiness, was reduced, in gait at a speed of 4.5 km/h and in the narrow-based gaits at 1 km/h (tandem gait), which demonstrates improvement. Conclusion This study suggests positive effects of DBS treatment on gait in PD patients. Improvement was observed in several biomechanical parameters of gait.
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Affiliation(s)
- Daniela Navratilova
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Alois Krobot
- Department of Rehabilitation, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Pavel Otruba
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Martin Nevrly
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - David Krahulik
- Department of Neurosurgery, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Petr Kolar
- Department of Rehabilitation, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Barbora Kolarova
- Department of Rehabilitation, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Michaela Kaiserova
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Katerina Mensikova
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Miroslav Vastik
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Sandra Kurcova
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Petr Kanovsky
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
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Ng JH, See AAQ, Xu Z, King NKK. Longitudinal medication profile and cost savings in Parkinson's disease patients after bilateral subthalamic nucleus deep brain stimulation. J Neurol 2020; 267:2443-2454. [PMID: 32367298 DOI: 10.1007/s00415-020-09741-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Deep brain stimulation of the subthalamic nucleus (STN DBS) has been shown to reduce antiparkinsonian medication in Parkinson's disease. We aimed to investigate the changes in long-term medication profile with STN DBS. METHODS Antiparkinsonian medication data for 56 patients were collected from as early as 3 years before STN DBS up to 10 years after. Cost spending on medication changes was analyzed. Mean levodopa equivalent daily dose (LEDD) was projected 10 years into the future based on preoperative data to create a comparator group wherein the patients did not undergo STN DBS. Use of neuroleptics and antidepressants was also recorded. RESULTS LEDD requirement was significantly reduced by a mean of 31 ± 2% over 10 years after DBS, from 1049 ± 381 mg at pre-DBS baseline, to 713 ± 392 mg at 1 year post-DBS, and 712 ± 385 mg at 10 years post-DBS. This was associated with a mean reduction of 35 ± 3% in medicine cost. Modeled LEDD requirements for not having STN DBS were in the range of 1489 mg to 2721 mg at 10 years post-DBS (109-282% higher than the observed mean LEDD in DBS cohort). The proportion of patients increased from 5% before STN DBS to 14% at 10 year post-DBS for neuroleptics, and 11-23% for antidepressants. CONCLUSION STN DBS led to LEDD reduction and antiparkinsonian medication cost savings in our South-East Asian cohort. Medication reduction with STN DBS in our cohort over the 10-year period was comparable to those reported in Western populations.
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Affiliation(s)
- Jing Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, 21 Lower Kent Ridge Rd, Singapore, 119077, Singapore
| | - Angela An Qi See
- Department of Neurosurgery, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Zheyu Xu
- Department of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Nicolas Kon Kam King
- Department of Neurosurgery, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
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Balance and Gait Improvements of Postoperative Rehabilitation in Patients with Parkinson's Disease Treated with Subthalamic Nucleus Deep Brain Stimulation (STN-DBS). PARKINSONS DISEASE 2019; 2019:7104071. [PMID: 31467660 PMCID: PMC6701295 DOI: 10.1155/2019/7104071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 05/09/2019] [Accepted: 07/09/2019] [Indexed: 11/17/2022]
Abstract
Background Deep brain stimulation of the subthalamic nucleus (STN-DBS) is a surgical treatment to reduce the "off" state motor symptoms of Parkinson's disease (PD). Postural instability is one of the major impairments, which induces disabilities of activities of daily living (ADLs). The effectiveness of STN-DBS for postural instability is unclear, and the effect of rehabilitation following STN-DBS has remained uncertain. Objective The purpose of this study was to examine changes in balance ability, gait function, motor performance, and ADLs following 2 weeks of postoperative rehabilitation in PD patients treated with STN-DBS. Methods Sixteen patients were reviewed retrospectively from February 2016 to March 2017. All patients were tested in their "on" medication state for balance and gait performance using the Mini-Balance Evaluation Systems Test (Mini-BESTest) and the Timed "Up and Go" (TUG) test before the operation, after the operation, and during the discharge period. The UPDRS motor score (UPDRS-III) and Barthel Index (BI) were assessed before the operation and during the discharge period. Rehabilitation focused on muscle strengthening with stretching and proactive balance training. Friedman's test and the post hoc Wilcoxon's signed-rank test were used to analyze the balance assessments, and ANOVA and the post hoc Tukey's test were used to analyze gait performance. The significance level was p < 0.05. Results During the discharge period, the Mini-BESTest and TUG were significantly improved compared with the preoperative and postoperative periods (p < 0.05). There were no differences between preoperative and postoperative periods in the Mini-BESTest (p=0.12) and TUG (p=0.91). The BI and motor sections of the UPDRS did not differ significantly between the preoperative and postoperative periods (p=0.45, p=0.22). Conclusion The results of this study suggest that postoperative rehabilitation improves balance and gait ability in patients with PD treated with STN-DBS.
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Katlowitz K, Ko M, Mogilner AY, Pourfar M. Effect of deep brain simulation on arm, leg, and chin tremor in Parkinson disease. J Neurosurg 2018; 131:1514-1519. [PMID: 30544332 DOI: 10.3171/2018.7.jns18784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The efficacy of deep brain stimulation (DBS) of the subthalamic nucleus (STN) in the treatment of Parkinson disease (PD)-related tremor has been well established. However, the relative impact on arm, leg, and chin tremor has been less clearly elucidated. The authors evaluated the distribution of tremors in a PD cohort undergoing STN DBS and sought to evaluate the differential impact of DBS as a function of tremor location. METHODS A retrospective study of patients with PD with tremor who underwent DBS surgery between 2012 and 2016 was performed to evaluate the impact of STN stimulation on overall and regional tremor scores. RESULTS Across 66 patients the authors found an average of 78% overall reduction in tremor after 6 months. In this cohort, the authors found that tremor reduction was somewhat better for arm than for leg tremors, especially in instances of higher preoperative tremor (84% vs 71% reduction, respectively, for initial tremor scores ≥ 2). No significant difference in response was found between patients with medication-responsive versus medication-nonresponsive tremors. CONCLUSIONS The authors found that although DBS improved tremor in all regions, the improvement was not uniform between chin, arm, and leg-even within the same patient. The reasons behind these differing responses are speculative but suggest that STN DBS may more reliably reduce arm tremors than leg tremors.
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Szlufik S, Kloda M, Friedman A, Potrzebowska I, Gregier K, Mandat T, Przybyszewski A, Dutkiewicz J, Figura M, Habela P, Koziorowski D. The Neuromodulatory Impact of Subthalamic Nucleus Deep Brain Stimulation on Gait and Postural Instability in Parkinson's Disease Patients: A Prospective Case Controlled Study. Front Neurol 2018; 9:906. [PMID: 30429820 PMCID: PMC6220087 DOI: 10.3389/fneur.2018.00906] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/08/2018] [Indexed: 01/20/2023] Open
Abstract
Background: Subthalamic nucleus deep brain stimulation (STN-DBS) has been an established method in improvement of motor disabilities in Parkinson's disease (PD) patients. It has been also claimed to have an impact on balance and gait disorders in PD patients, but the previous results are conflicting. Objective: The aim of this prospective controlled study was to evaluate the impact of STN-DBS on balance disorders in PD patients in comparison with Best-Medical-Therapy (BMT) and Long-term-Post-Operative (POP) group. Methods: DBS-group consisted of 20 PD patients (8F, 12M) who underwent bilateral STN DBS. POP-group consisted of 14 post-DBS patients (6F, 8M) in median 30 months-time after surgery. Control group (BMT-group) consisted of 20 patients (11F, 9M) who did not undergo surgical intervention. UPDRS III scale and balance tests (Up And Go Test, Dual Task- Timed Up And Go Test, Tandem Walk Test) and posturography parameters were measured during 3 visits in 9 ± 2months periods (V1, V2, V3) 4 phases of treatment (BMT-ON/OFF, DBS-ON/OFF). Results: We have observed the slowdown of gait and postural instability progression in first 9 post-operative months followed by co-existent enhancement of balance disorders in next 9-months evaluation (p < 0.05) in balance tests (Up and Go, TWT) and in posturography examination parameters (p < 0.05). The effect was not observed neither in BMT-group nor POP-group (p > 0.05): these groups revealed constant progression of static and dynamic instability (p > 0.05). Conclusions: STN-DBS can have modulatory effect on static and dynamic instability in PD patients: it can temporarily improve balance disorders. mainly during first 9 post-operative months, but with possible following deterioration of the symptoms in next post-operative months.
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Affiliation(s)
- Stanislaw Szlufik
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
| | - Maria Kloda
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland.,Department of Rehabilitation, II Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Friedman
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
| | - Iwona Potrzebowska
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland.,Department of Rehabilitation, II Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Kacper Gregier
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Mandat
- Department of Neurosurgery, Maria Sklodowska Curie Memorial Oncology Center, Warsaw, Warsaw, Poland
| | - Andrzej Przybyszewski
- Department of Informatics, Polish Japanese Academy of Information Technology, Warsaw, Poland
| | - Justyna Dutkiewicz
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
| | - Monika Figura
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Habela
- Department of Informatics, Polish Japanese Academy of Information Technology, Warsaw, Poland
| | - Dariusz Koziorowski
- Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
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Yin Z, Cao Y, Zheng S, Duan J, Zhou D, Xu R, Hong T, Lu G. Persistent adverse effects following different targets and periods after bilateral deep brain stimulation in patients with Parkinson's disease. J Neurol Sci 2018; 393:116-127. [DOI: 10.1016/j.jns.2018.08.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 06/22/2018] [Accepted: 08/14/2018] [Indexed: 02/04/2023]
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14
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Anidi C, O'Day JJ, Anderson RW, Afzal MF, Syrkin-Nikolau J, Velisar A, Bronte-Stewart HM. Neuromodulation targets pathological not physiological beta bursts during gait in Parkinson's disease. Neurobiol Dis 2018; 120:107-117. [PMID: 30196050 DOI: 10.1016/j.nbd.2018.09.004] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/18/2018] [Accepted: 09/04/2018] [Indexed: 11/25/2022] Open
Abstract
Freezing of gait (FOG) is a devastating axial motor symptom in Parkinson's disease (PD) leading to falls, institutionalization, and even death. The response of FOG to dopaminergic medication and deep brain stimulation (DBS) is complex, variable, and yet to be optimized. Fundamental gaps in the knowledge of the underlying neurobiomechanical mechanisms of FOG render this symptom one of the unsolved challenges in the treatment of PD. Subcortical neural mechanisms of gait impairment and FOG in PD are largely unknown due to the challenge of accessing deep brain circuitry and measuring neural signals in real time in freely-moving subjects. Additionally, there is a lack of gait tasks that reliably elicit FOG. Since FOG is episodic, we hypothesized that dynamic features of subthalamic (STN) beta oscillations, or beta bursts, may contribute to the Freezer phenotype in PD during gait tasks that elicit FOG. We also investigated whether STN DBS at 60 Hz or 140 Hz affected beta burst dynamics and gait impairment differently in Freezers and Non-Freezers. Synchronized STN local field potentials, from an implanted, sensing neurostimulator (Activa® PC + S, Medtronic, Inc.), and gait kinematics were recorded in 12 PD subjects, off-medication during forward walking and stepping-in-place tasks under the following randomly presented conditions: NO, 60 Hz, and 140 Hz DBS. Prolonged movement band beta burst durations differentiated Freezers from Non-Freezers, were a pathological neural feature of FOG and were shortened during DBS which improved gait. Normal gait parameters, accompanied by shorter bursts in Non-Freezers, were unchanged during DBS. The difference between the mean burst duration between hemispheres (STNs) of all individuals strongly correlated with the difference in stride time between their legs but there was no correlation between mean burst duration of each STN and stride time of the contralateral leg, suggesting an interaction between hemispheres influences gait. These results suggest that prolonged STN beta burst durations measured during gait is an important biomarker for FOG and that STN DBS modulated long not short burst durations, thereby acting to restore physiological sensorimotor information processing, while improving gait.
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Affiliation(s)
- Chioma Anidi
- Stanford University, Department of Neurology and Neurological Sciences, Rm H3136, SUMC, 300 Pasteur Drive, Stanford, CA 94305, USA.
| | - Johanna J O'Day
- Stanford University, Department of Neurology and Neurological Sciences, Rm H3136, SUMC, 300 Pasteur Drive, Stanford, CA 94305, USA.
| | - Ross W Anderson
- Stanford University, Department of Neurology and Neurological Sciences, Rm H3136, SUMC, 300 Pasteur Drive, Stanford, CA 94305, USA.
| | - Muhammad Furqan Afzal
- Stanford University, Department of Neurology and Neurological Sciences, Rm H3136, SUMC, 300 Pasteur Drive, Stanford, CA 94305, USA.
| | - Judy Syrkin-Nikolau
- Stanford University, Department of Neurology and Neurological Sciences, Rm H3136, SUMC, 300 Pasteur Drive, Stanford, CA 94305, USA.
| | - Anca Velisar
- Stanford University, Department of Neurology and Neurological Sciences, Rm H3136, SUMC, 300 Pasteur Drive, Stanford, CA 94305, USA.
| | - Helen M Bronte-Stewart
- Stanford University, Department of Neurology and Neurological Sciences, Rm H3136, SUMC, 300 Pasteur Drive, Stanford, CA 94305, USA; Stanford University, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Falaki A, Jo HJ, Lewis MM, O'Connell B, De Jesus S, McInerney J, Huang X, Latash ML. Systemic effects of deep brain stimulation on synergic control in Parkinson's disease. Clin Neurophysiol 2018; 129:1320-1332. [PMID: 29573980 PMCID: PMC5938107 DOI: 10.1016/j.clinph.2018.02.126] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 02/08/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE We explored effects of deep brain stimulation (DBS) in patients with Parkinson's disease (PD) on the synergic control of fingers in a multi-finger force production task and of muscles in a task involving vertical posture. METHODS The finger task involved the four fingers of a hand producing accurate total force followed by a targeted quick force pulse. The postural task involved releasing a load from extended arms. The analysis of synergies was performed within the framework of the uncontrolled manifold hypothesis. RESULTS DBS led to no significant changes in indices of stability during steady-state phases. In contrast, DBS improved indices of agility, quantified as anticipatory synergy adjustments that reduced stability of salient performance variables in preparation to their quick change. There were moderate-to-strong correlations between indices of both stability and agility measured in the multi-finger force production and multi-muscle whole-body action. CONCLUSIONS Our results point at systemic changes in synergic control in PD. They show that DBS is effective in improving only one components of synergic control related to agility in performance being relatively ineffective for the stability component. SIGNIFICANCE The results show systemic brain mechanisms of synergies and suggest differential effects of DBS on indices of stability and agility.
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Affiliation(s)
- Ali Falaki
- Department of Kinesiology, The Pennsylvania State University, University Park, PA 16802, USA
| | - Hang Jin Jo
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, Miami, FL 33136, USA
| | - Mechelle M Lewis
- Departments of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Barbara O'Connell
- Departments of Neurosurgery, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Sol De Jesus
- Departments of Neurosurgery, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - James McInerney
- Departments of Neurosurgery, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Xuemei Huang
- Departments of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA 17033, USA; Departments of Pharmacology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA 17033, USA; Departments of Radiology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA 17033, USA; Departments of Neurosurgery, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Mark L Latash
- Department of Kinesiology, The Pennsylvania State University, University Park, PA 16802, USA.
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Xu SH, Yang C, Xian WB, Gu J, Liu JL, Jiang LL, Ye J, Liu YM, Guo QY, Zheng YF, Wu L, Chen WR, Pei Z, Chen L. Voltage adjustment improves rigidity and tremor in Parkinson's disease patients receiving deep brain stimulation. Neural Regen Res 2018; 13:347-352. [PMID: 29557387 PMCID: PMC5879909 DOI: 10.4103/1673-5374.226406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Deep brain stimulation of the subthalamic nucleus is recognized as the most effective treatment for moderate and advanced Parkinson's disease. Programming of the stimulation parameters is important for maintaining the efficacy of deep brain stimulation. Voltage is considered to be the most effective programming parameter. The present study is a retrospective analysis of six patients with Parkinson's disease (four men and two women, aged 37–65 years), who underwent bilateral deep brain stimulation of the subthalamic nucleus at the First Affiliated Hospital of Sun Yat-sen University, China, and who subsequently adjusted only the stimulation voltage. We evaluated motor symptom severity using the Unified Parkinson's Disease Rating Scale Part III, symptom progression using the Hoehn and Yahr scale, and the levodopa equivalent daily dose, before surgery and 1 and 2 years after surgery. The 2-year follow-up results show that rigidity and tremor improved, and clinical symptoms were reduced, while pulse width was maintained at 60 μs and frequency at 130 Hz. Voltage adjustment alone is particularly suitable for patients who cannot tolerate multiparameter program adjustment. Levodopa equivalent daily dose was markedly reduced 1 and 2 years after surgery compared with baseline. Our results confirm that rigidity, tremor and bradykinesia can be best alleviated by voltage adjustment. The trial was registered at ClinicalTrials.gov (identifier: NCT01934881).
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Affiliation(s)
- Shao-Hua Xu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Chao Yang
- Department of Neurosurgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Wen-Biao Xian
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jing Gu
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jin-Long Liu
- Department of Neurosurgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Lu-Lu Jiang
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jing Ye
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province; Department of Neurology, Tangshan Worker's Hospital, Tangshan, Hebei Province, China
| | - Yan-Mei Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Qi-Yu Guo
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Yi-Fan Zheng
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Lei Wu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Wan-Ru Chen
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Zhong Pei
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ling Chen
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
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Jiang LL, Liu JL, Fu XL, Xian WB, Gu J, Liu YM, Ye J, Chen J, Qian H, Xu SH, Pei Z, Chen L. Long-term Efficacy of Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease: A 5-year Follow-up Study in China. Chin Med J (Engl) 2016; 128:2433-8. [PMID: 26365958 PMCID: PMC4725566 DOI: 10.4103/0366-6999.164925] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Subthalamic nucleus deep brain stimulation (STN DBS) is effective against advanced Parkinson's disease (PD), allowing dramatic improvement of Parkinsonism, in addition to a significant reduction in medication. Here we aimed to investigate the long-term effect of STN DBS in Chinese PD patients, which has not been thoroughly studied in China. Methods: Ten PD patients were assessed before DBS and followed up 1, 3, and 5 years later using Unified Parkinson's Disease Rating Scale Part III (UPDRS III), Parkinson's Disease Questionnatire-39, Parkinson's Disease Sleep Scale-Chinese Version, Mini-mental State Examination, Montreal Cognitive Assessment, Hamilton Anxiety Scale and Hamilton Depression Scale. Stimulation parameters and drug dosages were recorded at each follow-up. Data were analyzed using the ANOVA for repeated measures. Results: In the “off” state (off medication), DBS improved UPDRS III scores by 35.87% in 5 years, compared with preoperative baseline (P < 0.001). In the “on” state (on medication), motor scores at 5 years were similar to the results of preoperative levodopa challenge test. The quality of life is improved by 58.18% (P < 0.001) from baseline to 3 years and gradually declined afterward. Sleep, cognition, and emotion were mostly unchanged. Levodopa equivalent daily dose was reduced from 660.4 ± 210.1 mg at baseline to 310.6 ± 158.4 mg at 5 years (by 52.96%, P < 0.001). The average pulse width, frequency and amplitude at 5 years were 75.0 ± 18.21 μs, 138.5 ± 19.34 Hz, and 2.68 ± 0.43 V, respectively. Conclusions: STN DBS is an effective intervention for PD, although associated with a slightly diminished efficacy after 5 years. Compared with other studies, patients in our study required lower voltage and medication for satisfactory symptom control.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Ling Chen
- Department of Neurology, First Affiliated Hospital, Sun Yat-sen University, Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department, National Key Discipline, Guangzhou, Guangdong 510080, China
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