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Tabari F, Berger JI, Flouty O, Copeland B, Greenlee JD, Johari K. Speech, voice, and language outcomes following deep brain stimulation: A systematic review. PLoS One 2024; 19:e0302739. [PMID: 38728329 PMCID: PMC11086900 DOI: 10.1371/journal.pone.0302739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) reliably ameliorates cardinal motor symptoms in Parkinson's disease (PD) and essential tremor (ET). However, the effects of DBS on speech, voice and language have been inconsistent and have not been examined comprehensively in a single study. OBJECTIVE We conducted a systematic analysis of literature by reviewing studies that examined the effects of DBS on speech, voice and language in PD and ET. METHODS A total of 675 publications were retrieved from PubMed, Embase, CINHAL, Web of Science, Cochrane Library and Scopus databases. Based on our selection criteria, 90 papers were included in our analysis. The selected publications were categorized into four subcategories: Fluency, Word production, Articulation and phonology and Voice quality. RESULTS The results suggested a long-term decline in verbal fluency, with more studies reporting deficits in phonemic fluency than semantic fluency following DBS. Additionally, high frequency stimulation, left-sided and bilateral DBS were associated with worse verbal fluency outcomes. Naming improved in the short-term following DBS-ON compared to DBS-OFF, with no long-term differences between the two conditions. Bilateral and low-frequency DBS demonstrated a relative improvement for phonation and articulation. Nonetheless, long-term DBS exacerbated phonation and articulation deficits. The effect of DBS on voice was highly variable, with both improvements and deterioration in different measures of voice. CONCLUSION This was the first study that aimed to combine the outcome of speech, voice, and language following DBS in a single systematic review. The findings revealed a heterogeneous pattern of results for speech, voice, and language across DBS studies, and provided directions for future studies.
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Affiliation(s)
- Fatemeh Tabari
- Human Neurophysiology and Neuromodulation Laboratory, Department of Communication Sciences and Disorders, Louisiana State University, Baton Rouge, LA, United States of America
| | - Joel I. Berger
- Human Brain Research Laboratory, Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, United States of America
| | - Oliver Flouty
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States of America
| | - Brian Copeland
- Department of Neurology, LSU Health Sciences Center, New Orleans, LA, United States of America
| | - Jeremy D. Greenlee
- Human Brain Research Laboratory, Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, United States of America
- Iowa Neuroscience Institute, Iowa City, IA, United States of America
| | - Karim Johari
- Human Neurophysiology and Neuromodulation Laboratory, Department of Communication Sciences and Disorders, Louisiana State University, Baton Rouge, LA, United States of America
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Polat S, Erdem M, Çekinmez M. Comparison of Apathy and Cognitive Symptoms in Pre- and Postoperative Period in Deep Brain Stimulation Surgery. PSYCHIAT CLIN PSYCH 2023; 33:238-245. [PMID: 38765847 PMCID: PMC11037465 DOI: 10.5152/pcp.2023.23621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 07/29/2023] [Indexed: 05/22/2024] Open
Abstract
Background The aim of the study was to investigatie apathy and cognitive functions in Parkinson's disease patients who underwent deep brain stimulation surgery on bilateral subthalamic nuclei. Methods This study included 18 patients with Parkinson's disease who were accommodated in the Parkinson's and Movement Disorders Center of Adana City Training and Research Hospital for treatment in 2022. Patients were evaluated by psychiatry, neurology and neurosurgery specialists with a multidisciplinary approach and found to be surgically appropriate. Standardized Mini-Mental Test and Montreal Cognitive Assessment Scale, Apathy Evaluation Scale, and Hamilton Anxiety and Depression Scale were administered to each patient before the operation and at 6 months after effective stimulation parameters were reached. Results The mean apathy score at the preoperative zeroth month was 47.77 ± 15.83 in patients having deep brain stimulation surgery and 30.83 ± 13.59 in the postoperative sixth month. Statistically that reduction was significant (P = .003) and showed clinical development. The average Hamilton Anxiety Scale scores at the preoperative zeroth month was 11.50 ± 5.14 and 10.22 ± 5.57 at the postoperative sixth month, with no clinical significance (P = .280). The determined value for the Unified Parkinson's Disease Rating Scale, on treatment, was 22.55 ± 7.53 in the preoperative zeroth month and 14.50 ± 6.99 in the postoperative sixth month, with statistical significance (P < .001). The Unified Parkinson's Disease Rating Scale, off treatment, score was revealed to be significant in the preoperative zeroth month (37.44 ± 9.85) in comparison to that of the postoperative sixth month (23.44 ± 7.86; P < .001). Conclusion This study showed that bilateral subthalamic stimulation improves nonmotor and motor symptoms in patients having Parkinson's disease. The mechanism is complex, and we believe that future studies focusing on pharmacological and nonpharmacological treatments involving more patient groups will be useful for clinicians.
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Affiliation(s)
- Selim Polat
- Department of Mental Health and Diseases, Adana City Training and Research Hospital, Adana, Turkey
| | - Miray Erdem
- Department of Neurology, Adana City Training and Research Hospital, Adana, Turkey
| | - Melih Çekinmez
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
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El Ouadih Y, Marques A, Pereira B, Luisoni M, Claise B, Coste J, Sontheimer A, Chaix R, Debilly B, Derost P, Morand D, Durif F, Lemaire JJ. Deep brain stimulation of the subthalamic nucleus in severe Parkinson's disease: relationships between dual-contact topographic setting and 1-year worsening of speech and gait. Acta Neurochir (Wien) 2023; 165:3927-3941. [PMID: 37889334 DOI: 10.1007/s00701-023-05843-9] [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: 01/17/2023] [Accepted: 06/24/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Subthalamic nucleus (STN) deep brain stimulation (DBS) alleviates severe motor fluctuations and dyskinesia in Parkinson's disease, but may result in speech and gait disorders. Among the suspected or demonstrated causes of these adverse effects, we focused on the topography of contact balance (CB; individual, right and left relative dual positions), a scantly studied topic, analyzing the relationships between symmetric or non-symmetric settings, and the worsening of these signs. METHOD An observational monocentric study was conducted on a series of 92 patients after ethical approval. CB was specified by longitudinal and transversal positions and relation to the STN (CB sub-aspects) and totalized at the patient level (patient CB). CB was deemed symmetric when the two contacts were at the same locations relative to the STN. CB was deemed asymmetric when at least one sub-aspect differed in the patient CB. Baseline and 1-year characteristics were routinely collected: (i) general, namely, Unified Parkinson's Disease Rating Scores (UPDRS), II, III motor and IV, daily levodopa equivalent doses, and Parkinson's Disease Questionnaire of Quality of Life (PDQ39) scores; (ii) specific, namely scores for speech (II-5 and III-18) and axial signs (II-14, III-28, III-29, and III-30). Only significant correlations were considered (p < 0.05). RESULTS Baseline characteristics were comparable (symmetric versus asymmetric). CB settings were related to deteriorations of speech and axial signs: communication PDQ39 and UPDRS speech and gait scores worsened exclusively with symmetric settings; the most influential CB sub-aspect was symmetric longitudinal position. CONCLUSION Our findings suggest that avoiding symmetric CB settings, whether by electrode positioning or shaping of electric fields, could reduce worsening of speech and gait.
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Affiliation(s)
- Youssef El Ouadih
- Université Clermont Auvergne, Clermont Auvergne INP, CHU Clermont-Ferrand, CNRS, Institut Pascal, 63000, Clermont-Ferrand, France
- Service de Neurochirurgie, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Ana Marques
- Université Clermont Auvergne, Clermont Auvergne INP, CHU Clermont-Ferrand, CNRS, Institut Pascal, 63000, Clermont-Ferrand, France
- Service de Neurologie, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Bruno Pereira
- Direction de La Recherche Clinique Et de L'Innovation, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Maxime Luisoni
- Université Clermont Auvergne, Clermont Auvergne INP, CHU Clermont-Ferrand, CNRS, Institut Pascal, 63000, Clermont-Ferrand, France
| | - Béatrice Claise
- Service de Radiologie, Unité de Neuroradiologie, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Jérôme Coste
- Université Clermont Auvergne, Clermont Auvergne INP, CHU Clermont-Ferrand, CNRS, Institut Pascal, 63000, Clermont-Ferrand, France
- Service de Neurochirurgie, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Anna Sontheimer
- Université Clermont Auvergne, Clermont Auvergne INP, CHU Clermont-Ferrand, CNRS, Institut Pascal, 63000, Clermont-Ferrand, France
- Service de Neurochirurgie, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Rémi Chaix
- Université Clermont Auvergne, Clermont Auvergne INP, CHU Clermont-Ferrand, CNRS, Institut Pascal, 63000, Clermont-Ferrand, France
- Service de Neurochirurgie, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Bérangère Debilly
- Service de Neurologie, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Philippe Derost
- Service de Neurologie, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Dominique Morand
- Direction de La Recherche Clinique Et de L'Innovation, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Franck Durif
- Université Clermont Auvergne, Clermont Auvergne INP, CHU Clermont-Ferrand, CNRS, Institut Pascal, 63000, Clermont-Ferrand, France
- Service de Neurologie, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Jean-Jacques Lemaire
- Université Clermont Auvergne, Clermont Auvergne INP, CHU Clermont-Ferrand, CNRS, Institut Pascal, 63000, Clermont-Ferrand, France.
- Service de Neurochirurgie, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France.
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Wolke R, Becktepe JS, Paschen S, Helmers A, Kübler‐Weller D, Youn J, Brinker D, Bergman H, Kühn AA, Fasano A, Deuschl G. The Role of Levodopa Challenge in Predicting the Outcome of Subthalamic Deep Brain Stimulation. Mov Disord Clin Pract 2023; 10:1181-1191. [PMID: 37635781 PMCID: PMC10450242 DOI: 10.1002/mdc3.13825] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/14/2023] [Accepted: 06/14/2023] [Indexed: 08/29/2023] Open
Abstract
Background Deep brain stimulation of the subthalamic nucleus (STN-DBS) is an effective and evidence-based treatment for idiopathic Parkinson's disease (iPD). A minority of patients does not sufficiently benefit from STN-DBS. Objective The predictive validity of the levodopa challenge for individual patients is analyzed. Methods Data from patients assessed with a preoperative Levodopa-test and a follow-up examination (mean ± standard deviation: 9.15 months ±3.39) from Kiel (n = 253), Berlin (n = 78) and Toronto (n = 98) were studied. Insufficient DBS outcome was defined as an overall UPDRS-III reduction <33% compared to UPDRS-III in med-off at baseline or alternatively if the minimal clinically important improvement of 5 points was not reached. Single UPDRS-items and sub-scores were dichotomized. Following exploratory analysis, we trained supervised regression- and classification models for outcome prediction. Results Data analysis confirmed significant correlation between the absolute UPDRS-III reduction during Levodopa challenge and after stimulation. But individual improvement was inaccurately predicted with a large range of up to 30 UPDRS III points. Further analysis identified preoperative UPDRS-III/med-off-scores and preoperative Levodopa-improvement as most influential factors. The models for UPDRS-III and sub-scores improvement achieved comparably low accuracy. Conclusions With large prediction intervals, the Levodopa challenge use for patient counseling is limited, though remains important for excluding non-responders to Levodopa. Despite these deficiencies, the current practice of patient selection is highly successful and builds not only on the Levodopa challenge. However, more specific motor tasks and further paraclinical tools for prediction need to be developed.
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Affiliation(s)
- Robin Wolke
- Department of NeurologyUKSH, Christian‐Albrechts University KielKielGermany
| | | | - Steffen Paschen
- Department of NeurologyUKSH, Christian‐Albrechts University KielKielGermany
| | - Ann‐Kristin Helmers
- Department of NeurosurgeryUKSH, Christian‐Albrechts University KielKielGermany
| | - Dorothee Kübler‐Weller
- Movement Disorder and Neuromodulation Unit, Department of NeurologyCharité–UniversitätsmedizinBerlinGermany
| | - Jinyoung Youn
- Department of Neurology, Samsung Medical CenterSchool of medicine Sungkyunkwan UniversitySeoulSouth Korea
| | - Dana Brinker
- Department of NeurologyUKSH, Christian‐Albrechts University KielKielGermany
| | - Hagai Bergman
- The Edmond andLily Safra Center for Brain Sciences (ELSC)The Hebrew UniversityJerusalemIsrael
- Department of Medical Neurobiology (Physiology), Institute of Medical Research‐Israel Canada (IMRIC), Faculty of MedicineThe Hebrew UniversityJerusalemIsrael
- Department of Neurosurgery, Hadassah Medical CenterThe Hebrew UniversityJerusalemIsrael
| | - Andrea A. Kühn
- Movement Disorder and Neuromodulation Unit, Department of NeurologyCharité–UniversitätsmedizinBerlinGermany
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders ClinicToronto Western Hospital, UHNTorontoOntarioCanada
- Division of NeurologyUniversity of TorontoTorontoOntarioCanada
- Krembil Brain InstituteTorontoOntarioCanada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA)TorontoOntarioCanada
| | - Günther Deuschl
- Department of NeurologyUKSH, Christian‐Albrechts University KielKielGermany
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Design and Application of Automated Algorithms for Diagnosis and Treatment Optimization in Neurodegenerative Diseases. Neuroinformatics 2022; 20:765-775. [PMID: 35262881 DOI: 10.1007/s12021-022-09578-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 12/31/2022]
Abstract
Neurodegenerative diseases represent a growing healthcare problem, mainly related to an aging population worldwide and thus their increasing prevalence. In particular, Alzheimer's disease (AD) and Parkinson's disease (PD) are leading neurodegenerative diseases. To aid their diagnosis and optimize treatment, we have developed a classification algorithm for AD to manipulate magnetic resonance images (MRI) stored in a large database of patients, containing 1,200 images. The algorithm can predict whether a patient is healthy, has mild cognitive impairment, or already has AD. We then applied this classification algorithm to therapeutic outcomes in PD after treatment with deep brain stimulation (DBS), to assess which stereotactic variables were the most important to consider when performing surgery in this indication. Here, we describe the stereotactic system used for DBS procedures, and compare different planning methods with the gold standard normally used (i.e., neurophysiological coordinates recorded intraoperatively). We used information collected from database of 72 DBS electrodes implanted in PD patients, and assessed the potentially most beneficial ranges of deviation within planning and neurophysiological coordinates from the operating room, to provide neurosurgeons with additional landmarks that may help to optimize outcomes: we observed that x coordinate deviation within CT scan and gold standard intra-operative neurophysiological coordinates is a robust matric to pre-assess positive therapy outcomes- "good therapy" prediction if deviation is higher than 2.5 mm. When being less than 2.5 mm, adding directly calculated variables deviation (on Y and Z axis) would lead to specific assessment of "very good therapy".
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Shlobin NA, Rosenow JM. Ethical Considerations in the Implantation of Neuromodulatory Devices. Neuromodulation 2022; 25:222-231. [PMID: 35125141 DOI: 10.1111/ner.13357] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/26/2020] [Accepted: 12/21/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Neuromodulatory devices are increasingly used by neurosurgeons to manage a variety of chronic conditions. Given their potential benefits, it is imperative to create clear ethical guidelines for the use of these devices. We present a tiered ethical framework for neurosurgeon recommendations for the use of neuromodulatory devices. MATERIALS AND METHODS We conducted a literature review to identify factors neurosurgeons should consider when choosing to offer a neuromodulatory device to a patient. RESULTS Neurosurgeons must weigh reductions in debilitating symptoms, improved functionality, and preserved quality of life against risks for intraoperative complications and adverse events due to stimulation or the device itself. Neurosurgeons must also evaluate whether patients and families will maintain responsibility for the management of neuromodulatory devices. Consideration of these factors should occur on an axis of resource allocation, ranging from provision of neuromodulatory devices to those with greatest potential benefit in resource-limited settings to provision of neuromodulatory devices to all patients with indications in contexts without resource limitations. Neurosurgeons must also take action to promote device effectiveness throughout the duration of care. CONCLUSIONS Weighing risks and benefits of providing neuromodulatory devices and assessing ability to remain responsible for the devices on the level of the individual patient indicate which patients are most likely to achieve benefit from these devices. Consideration of these factors on an axis of resource allocation will allow for optimal provision of neuromodulatory devices to patients in settings of varied resources. Neurosurgeons play a primary role in promoting the effectiveness of these devices.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
| | - Joshua M Rosenow
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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Lin Z, Zhang C, Li D, Sun B. Preoperative Levodopa Response and Deep Brain Stimulation Effects on Motor Outcomes in Parkinson's Disease: A Systematic Review. Mov Disord Clin Pract 2021; 9:140-155. [PMID: 35146054 DOI: 10.1002/mdc3.13379] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Zhengyu Lin
- Department of Neurosurgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine Shanghai China
- Center for Functional Neurosurgery Ruijin Hospital, Shanghai Jiao Tong University School of Medicine Shanghai China
- Institute of Clinical Neuroscience Ruijin Hospital LuWan Branch, Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Chencheng Zhang
- Department of Neurosurgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine Shanghai China
- Center for Functional Neurosurgery Ruijin Hospital, Shanghai Jiao Tong University School of Medicine Shanghai China
- Institute of Clinical Neuroscience Ruijin Hospital LuWan Branch, Shanghai Jiao Tong University School of Medicine Shanghai China
- Shanghai Research Center for Brain Science and Brain‐Inspired Intelligence Shanghai China
| | - Dianyou Li
- Department of Neurosurgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine Shanghai China
- Center for Functional Neurosurgery Ruijin Hospital, Shanghai Jiao Tong University School of Medicine Shanghai China
- Institute of Clinical Neuroscience Ruijin Hospital LuWan Branch, Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Bomin Sun
- Department of Neurosurgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine Shanghai China
- Center for Functional Neurosurgery Ruijin Hospital, Shanghai Jiao Tong University School of Medicine Shanghai China
- Institute of Clinical Neuroscience Ruijin Hospital LuWan Branch, Shanghai Jiao Tong University School of Medicine Shanghai China
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Lachenmayer ML, Mürset M, Antih N, Debove I, Muellner J, Bompart M, Schlaeppi JA, Nowacki A, You H, Michelis JP, Dransart A, Pollo C, Deuschl G, Krack P. Subthalamic and pallidal deep brain stimulation for Parkinson's disease-meta-analysis of outcomes. NPJ PARKINSONS DISEASE 2021; 7:77. [PMID: 34489472 PMCID: PMC8421387 DOI: 10.1038/s41531-021-00223-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 08/12/2021] [Indexed: 12/26/2022]
Abstract
Although deep brain stimulation (DBS) of the globus pallidus internus (GPi) and the subthalamic nucleus (STN) has become an established treatment for Parkinson’s disease (PD), a recent meta-analysis of outcomes is lacking. To address this gap, we performed a meta-analysis of bilateral STN- and GPi-DBS studies published from 1990-08/2019. Studies with ≥10 subjects reporting Unified Parkinson’s Disease Rating Scale (UPDRS) III motor scores at baseline and 6–12 months follow-up were included. Several outcome variables were analyzed and adverse events (AE) were summarized. 39 STN studies (2035 subjects) and 5 GPi studies (292 subjects) were eligible. UPDRS-II score after surgery in the stimulation-ON/medication-OFF state compared to preoperative medication-OFF state improved by 47% with STN-DBS and 18.5% with GPi-DBS. UPDRS-III score improved by 50.5% with STN-DBS and 29.8% with GPi-DBS. STN-DBS improved dyskinesia by 64%, daily OFF time by 69.1%, and quality of life measured by PDQ-39 by 22.2%, while Levodopa Equivalent Daily Dose (LEDD) was reduced by 50.0%. For GPi-DBS information regarding dyskinesia, OFF time, PDQ-39 and LEDD was insufficient for further analysis. Correlation analysis showed that preoperative L-dopa responsiveness was highly predictive of the STN-DBS motor outcome across all studies. Most common surgery-related AE were infection (5.1%) and intracranial hemorrhage (3.1%). Despite a series of technological advances, outcomes of modern surgery are still comparable with those of the early days of DBS. Recent changes in target selection with a preference of GPi in elderly patients with cognitive deficits and more psychiatric comorbidities require more published data for validation.
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Affiliation(s)
- M Lenard Lachenmayer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Melina Mürset
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Ines Debove
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Julia Muellner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Janine-Ai Schlaeppi
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Nowacki
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hana You
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joan P Michelis
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Claudio Pollo
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Guenther Deuschl
- Department of Neurology, UKSH, Christian-Albrechts-University, Kiel, Germany
| | - Paul Krack
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Benz HL, Caldwell B, Ruiz JP, Saha A, Ho M, Christopher S, Bardot D, Sheehan M, Donnelly A, McLaughlin L, Mange B, Hauber AB, Gwinn K, Heetderks WJ, Sheldon M. Patient-Centered Identification of Meaningful Regulatory Endpoints for Medical Devices to Treat Parkinson's Disease. MDM Policy Pract 2021; 6:23814683211021380. [PMID: 34277950 PMCID: PMC8255597 DOI: 10.1177/23814683211021380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 04/30/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction. A growing literature has developed on identifying outcomes that matter to patients. This study demonstrates an approach involving patient and regulatory perspectives to identify outcomes that are meaningful in the context of medical devices for Parkinson’s disease (PD). Methods. A systematic process was used for specifying relevant regulatory endpoints by synthesizing inputs of various sources and stakeholders. First, a literature review was conducted to identify important benefits, risks, and other considerations for medical devices to treat PD; patient discussion groups (n = 6) were conducted to refine the list of considerations, followed by a survey (n = 29) to prioritize them; and patient and Food and Drug Administration (FDA) reviewers informed specification of the final endpoints. Two FDA clinicians gave clinical and regulatory perspectives at each step. Results. Movement symptoms were ranked as most important (ranked 1 or 2 by 72% of participants) and psychological and cognitive symptoms as the next most important (ranked 1 or 2 by 52% of participants). Within movement symptoms, falls, impaired movement, bradykinesia, resting tremor, stiffness, and rigidity were ranked highly. Overall, nine attributes were identified and prioritized as patient-centric for use in clinical trial design and quantitative patient preference studies. These attributes were benefits and risks related to therapeutics for PD as well as other considerations, including time until a medical device is available for patient use. Discussion. This prospective approach identified meaningful and relevant benefits, risks, and other considerations that may be used for clinical trial design and quantitative patient preference studies. Although PD was the focus of this study, the approach can be used to study patient perspectives about other disease or treatment areas.
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Affiliation(s)
- Heather L Benz
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | - Brittany Caldwell
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | - John P Ruiz
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | - Anindita Saha
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | - Martin Ho
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | | | - Dawn Bardot
- Medical Device Innovation Consortium, Arlington, Virginia
| | - Margaret Sheehan
- The Michael J. Fox Foundation for Parkinson's Research, New York, New York
| | - Anne Donnelly
- The Michael J. Fox Foundation for Parkinson's Research, New York, New York
| | - Lauren McLaughlin
- The Michael J. Fox Foundation for Parkinson's Research, New York, New York
| | - Brennan Mange
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - A Brett Hauber
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - Katrina Gwinn
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | | | - Murray Sheldon
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
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10
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Hanna JA, Scullen T, Kahn L, Mathkour M, Gouveia EE, Garces J, Evans LM, Lea G, Houghton DJ, Biro E, Bui CJ, Sulaiman OA, Smith RD. Comparison of elderly and young patient populations treated with deep brain stimulation for Parkinson's disease: long-term outcomes with up to 7 years of follow-up. J Neurosurg 2019; 131:807-812. [PMID: 30265192 DOI: 10.3171/2018.4.jns171909] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 04/17/2018] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is the procedure of choice for Parkinson's disease (PD). It has been used in PD patients younger than 70 years because of better perceived intra- and postoperative outcomes than in patients 70 years or older. However, previous studies with limited follow-up have demonstrated benefits associated with the treatment of elderly patients. This study aims to evaluate the long-term outcomes in elderly PD patients treated with DBS in comparison with a younger population. METHODS PD patients treated with DBS at the authors' institution from 2008 to 2014 were divided into 2 groups: 1) elderly patients, defined as having an age at surgery ≥ 70 years, and 2) young patients, defined as those < 70 years at surgery. Functional and medical treatment outcomes were evaluated using the Unified Parkinson's Disease Rating Scale part III (UPDRS III), levodopa-equivalent daily dose (LEDD), number of daily doses, and number of anti-PD medications. Study outcomes were compared using univariate analyses, 1-sample paired t-tests, and 2-sample t-tests. RESULTS A total of 151 patients were studied, of whom 24.5% were ≥ 70 years. The most common preoperative Hoehn and Yahr stages for both groups were 2 and 3. On average, elderly patients had more comorbidities at the time of surgery than their younger counterparts (1 vs 0, p = 0.0001) as well as a higher average LEDD (891 mg vs 665 mg, p = 0.008). Both groups experienced significant decreases in LEDD following surgery (elderly 331.38 mg, p = 0.0001; and young 108.6 mg, p = 0.0439), with a more significant decrease seen in elderly patients (young 108.6 mg vs elderly 331.38 mg, p = 0.0153). Elderly patients also experienced more significant reductions in daily doses (young 0.65 vs elderly 3.567, p = 0.0344). Both groups experienced significant improvements in motor function determined by reductions in UPDRS III scores (elderly 16.29 vs young 12.85, p < 0.0001); however, reductions in motor score between groups were not significant. Improvement in motor function was present for a mean follow-up of 3.383 years postsurgery for the young group and 3.51 years for the elderly group. The average follow-up was 40.6 months in the young group and 42.2 months in the elderly group. CONCLUSIONS This study found long-term improvements in motor function and medication requirements in both elderly and young PD patients treated with DBS. These outcomes suggest that DBS can be successfully used in PD patients ≥ 70 years. Further studies will expand on these findings.
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Affiliation(s)
- Joshua A Hanna
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Tyler Scullen
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Lora Kahn
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Mansour Mathkour
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | | | - Juanita Garces
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | | | - Georgia Lea
- 3Movement Disorders, Ochsner Clinic Foundation, New Orleans; and
| | - David J Houghton
- 3Movement Disorders, Ochsner Clinic Foundation, New Orleans; and
| | - Erin Biro
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Cuong J Bui
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Olawale A Sulaiman
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Roger D Smith
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
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11
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Sette A, Seigneuret E, Reymond F, Chabardes S, Castrioto A, Boussat B, Moro E, François P, Fraix V. Battery longevity of neurostimulators in Parkinson disease: A historic cohort study. Brain Stimul 2019; 12:851-857. [DOI: 10.1016/j.brs.2019.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/30/2018] [Accepted: 02/11/2019] [Indexed: 10/27/2022] Open
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12
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Stroupe KT, Smith B, Weaver FM, Gonzalez B, Huo Z, Cao L, Ippolito D, Follett KA. Healthcare Utilization and Costs for Patients With Parkinson's Disease After Deep Brain Stimulation. Mov Disord Clin Pract 2019; 6:369-378. [PMID: 31286006 DOI: 10.1002/mdc3.12765] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/05/2019] [Accepted: 03/15/2019] [Indexed: 11/06/2022] Open
Abstract
Objective To compare the complications, healthcare utilization and costs following DBS or medical management for patients with Parkinson's disease (PD). Methods We examined healthcare utilization and costs for up to 5 years between veterans with DBS and those with medical management for PD. Veterans who received DBS between 2007 and 2013 were matched with veterans who received medical management using propensity score approaches. Healthcare utilization and costs were obtained from national VA and Medicare data sources and compared using procedures to adjust for potential differences in length of follow-up. Results We identified 611 veterans who had received DBS and a matched group of 611 veterans who did not undergo DBS. Among DBS patients, 59% had the electrodes and generator implanted during separate admissions. After 5 years of follow-up, average total healthcare costs, including DBS procedures and complications, were $77,131 (95% confidence interval: $66,095-$88,168; P < 0.001) higher per person for patients who received DBS ($162,489) than patients who received medical management ($85,358). In contrast, excluding the costs of the DBS procedures and complications, average total costs were not significantly different between patients who received DBS and patients who received medical management after 5 years of follow-up. Conclusions Healthcare costs over 5 years were higher for veterans who received DBS. These higher healthcare costs may reflect the costs of DBS procedures and any follow-up required plus greater surveillance by healthcare professionals following DBS as well as unobserved differences in the patients who received medical management or DBS.
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Affiliation(s)
- Kevin T Stroupe
- Center of Innovation for Complex Chronic Healthcare Hines VA Hospital Hines IL.,Loyola University Stritch School of Medicine Maywood IL
| | - Bridget Smith
- Center of Innovation for Complex Chronic Healthcare Hines VA Hospital Hines IL.,Northwestern University Feinberg School of Medicine Chicago IL
| | - Frances M Weaver
- Center of Innovation for Complex Chronic Healthcare Hines VA Hospital Hines IL.,Loyola University Stritch School of Medicine Maywood IL
| | - Beverly Gonzalez
- Center of Innovation for Complex Chronic Healthcare Hines VA Hospital Hines IL
| | - Zhiping Huo
- Center of Innovation for Complex Chronic Healthcare Hines VA Hospital Hines IL
| | - Lishan Cao
- Center of Innovation for Complex Chronic Healthcare Hines VA Hospital Hines IL
| | - Dolores Ippolito
- Center of Innovation for Complex Chronic Healthcare Hines VA Hospital Hines IL
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13
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Razmkon A, Yousefi O, Rezaei R, Salehi S, Petramfar P, Mani A, Rahmati H, Vaidyanathan J, Ilami G, Amirmoezzi Y. Initial Results of Bilateral Subthalamic Nucleus Stimulation for Parkinson Disease in a Newly Established Center in a Developing Country: Shiraz, Southern Iran. World Neurosurg 2018; 121:e129-e135. [PMID: 30236810 DOI: 10.1016/j.wneu.2018.09.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 09/03/2018] [Accepted: 09/05/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To report the establishment of a new center for deep brain stimulation (DBS) as a surgical treatment for Parkinson disease and the surgical outcomes, from 2014 to 2017 in Shiraz, Southern Iran. METHODS A new treatment program was established in Shiraz through a multidisciplinary team in 2014. Thirty-four patients underwent implantation of subthalamic nucleus (STN) electrodes during the last 3 years. Twenty-five patients fulfilled the minimum 6-month follow-up criteria. The baseline Unified Parkinson Disease Rating Scale (UPDRS) was assessed 1 month before surgery in both off-medication and on-medication states by a movement disorder neurologist. To evaluate the outcomes, subscores of the UPDRS were assessed in all patients before surgery and at least 6 months after the operation. RESULTS All 25 patients had advanced Parkinson disease categorized as stage 3 or 4 using the Hoehn and Yahr scale. STN DBS resulted in a dramatic improvement in motor function of most patients. A reduction in dopaminergic medication dosage (average 60% reduction) was observed. The mean improvement was 40% in UPDRS II and 67% in UPDRS III. No surgical or hardware complications were observed. Stimulation-related adverse effects, including increased falling and worsening of speech, occurred in a few patients after surgery. Most of the patients experienced weight gain after surgery. CONCLUSIONS Bilateral STN DBS is a satisfactory and safe treatment for carefully selected patients with advanced Parkinson disease. According to the results, the procedure can be performed safely and with comparable results in developing countries around the world.
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Affiliation(s)
- Ali Razmkon
- Research Center for Neuromodulation and Pain, Kowsar Hospital, Shiraz, Iran.
| | - Omid Yousefi
- Research Center for Neuromodulation and Pain, Kowsar Hospital, Shiraz, Iran
| | - Raziyeh Rezaei
- Research Center for Neuromodulation and Pain, Kowsar Hospital, Shiraz, Iran
| | - Sina Salehi
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Petramfar
- Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arash Mani
- Research Center for Psychiatry and Behavioral Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hashem Rahmati
- Community-based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Ghazal Ilami
- Research Center for Neuromodulation and Pain, Kowsar Hospital, Shiraz, Iran
| | - Yalda Amirmoezzi
- Research Center for Neuromodulation and Pain, Kowsar Hospital, Shiraz, Iran
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14
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Tyulmankov D, Tass PA, Bokil H. Periodic flashing coordinated reset stimulation paradigm reduces sensitivity to ON and OFF period durations. PLoS One 2018; 13:e0203782. [PMID: 30192855 PMCID: PMC6128645 DOI: 10.1371/journal.pone.0203782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 08/27/2018] [Indexed: 11/20/2022] Open
Abstract
Pathological synchronization in the basal ganglia network has been considered an important component of Parkinson’s disease pathophysiology. An established treatment for some patients with Parkinson’s disease is deep brain stimulation, in which a tonic high-frequency pulse train is delivered to target regions of the brain. In recent years, a novel neuromodulation paradigm called coordinated reset stimulation has been proposed, which aims to reverse the pathological synchrony by sequentially delivering short high-frequency bursts to distinct sub-regions of the pathologically synchronized network, with an average intra-burst interval for each sub-region corresponding to period of the pathological oscillation. It has further been proposed that the resultant desynchronization can be enhanced when stimulation is interrupted periodically, and that it is particularly beneficial to precisely tune the stimulation ON and OFF time-windows to the underlying pathological frequency. Pre-clinical and clinical studies of coordinated reset stimulation have relied on these proposals for their stimulation protocols. In this study, we present a modified ON-OFF coordinated reset stimulation paradigm called periodic flashing and study its behavior through computational modeling using the Kuramoto coupled phase oscillator model. We demonstrate that in contrast to conventional coordinated reset stimulation, the periodic flashing variation does not exhibit a need for precise turning of the ON-OFF periods to the pathological frequency, and demonstrates desynchronization for a wide range of ON and OFF periods. We provide a mechanistic explanation for the previously observed sensitivities and demonstrate that they are an artifact of the specific ON-OFF cycling paradigm used. As a practical consequence, the periodic flashing paradigm simplifies the tuning of optimal stimulation parameters by decreasing the dimension of the search space. It also suggests new, more flexible ways of delivering coordinated reset stimulation.
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Affiliation(s)
- Danil Tyulmankov
- Boston Scientific Neuromodulation, Valencia, California, United States of America
| | - Peter A. Tass
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Hemant Bokil
- Boston Scientific Neuromodulation, Valencia, California, United States of America
- * E-mail:
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15
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Polanski WH, Martin KD, Günther S, Schackert G, Klingelhoefer L, Fauser M, Storch A, Sobottka SB. Application of the Six Sigma concept for quality assessment of different strategies in DBS surgery†. Int J Qual Health Care 2018; 30:760-768. [DOI: 10.1093/intqhc/mzy129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 05/28/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Witold H Polanski
- Department of Neurosurgery, University Hospital Carl-Gustav-Carus, Technical University of Dresden, Fetscherstr. 74, Dresden, Germany
| | - K Daniel Martin
- Department of Neurosurgery, University Hospital Carl-Gustav-Carus, Technical University of Dresden, Fetscherstr. 74, Dresden, Germany
| | - Swen Günther
- Faculty of Business Administration, University of applied Science HTW Dresden, Friedrich-List-Platz 1, Dresden, Germany
| | - Gabriele Schackert
- Department of Neurosurgery, University Hospital Carl-Gustav-Carus, Technical University of Dresden, Fetscherstr. 74, Dresden, Germany
| | - Lisa Klingelhoefer
- Division of Neurodegenerative Diseases, Department of Neurology, Technical University of Dresden, Fetscherstr. 74, Dresden, Germany
| | - Mareike Fauser
- Division of Neurodegenerative Diseases, Department of Neurology, Technical University of Dresden, Fetscherstr. 74, Dresden, Germany
| | - Alexander Storch
- Division of Neurodegenerative Diseases, Department of Neurology, Technical University of Dresden, Fetscherstr. 74, Dresden, Germany
- Department of Neurology, University of Rostock, Rostock, Germany
| | - Stephan B Sobottka
- Department of Neurosurgery, University Hospital Carl-Gustav-Carus, Technical University of Dresden, Fetscherstr. 74, Dresden, Germany
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16
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Xu H, Zheng F, Krischek B, Ding W, Xiong C, Wang X, Niu C. Subthalamic nucleus and globus pallidus internus stimulation for the treatment of Parkinson's disease: A systematic review. J Int Med Res 2017; 45:1602-1612. [PMID: 28701061 PMCID: PMC5718722 DOI: 10.1177/0300060517708102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective Deep brain stimulation (DBS) for treatment of advanced Parkinson’s disease (PD) has two anatomical targets: the subthalamic nucleus (STN) and the globus pallidus internus (GPI). The clinical effectiveness of these two stimulation targets was compared in the present study. Methods A systematic review and meta-analysis was performed to evaluated the postoperative changes in the United Parkinson’s Disease Rating Scale (UPDRS) on- and off-phase, on-stimulation motor scores; activities of daily living score (ADLS); and levodopa equivalent dose (LED) after STN and GPI stimulation. Randomized and nonrandomized controlled trials of PD treated by STN and GPI stimulation were considered for inclusion. Results Eight published reports of eligible studies involving 599 patients met the inclusion criteria. No significant differences were observed between the STN and GPI groups in the on-medication, on-stimulation UPDRS motor score [mean difference, 2.15; 95% confidence interval (CI), −0.96–5.27] or ADLS (mean difference, 3.40; 95% CI, 0.95–7.76). Significant differences in favor of STN stimulation were noted in the off-medication, on-stimulation UPDRS motor score (mean difference, 1.67; 95% CI, 0.98–2.37) and LED (mean difference, 130.24; 95% CI, 28.82–231.65). Conclusion The STN may be the preferred target for DBS in consideration of medication reduction, economic efficiency, and motor function improvement in the off phase. However, treatment decisions should be made according to the individual patient’s symptoms and expectations.
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Affiliation(s)
- Hao Xu
- 1 Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, China.,2 Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Zheng
- 3 Department of Cerebrovascular Disease, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China.,4 Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Boris Krischek
- 4 Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Wanhai Ding
- 1 Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Chi Xiong
- 1 Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Xin Wang
- 5 Department of Orthopaedic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Chaoshi Niu
- 1 Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, China
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17
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Thomas NJ, Mertens P, Danaila T, Polo G, Klinger H, Broussolle E, Thobois S. Optimizing the deep brain stimulation care pathway in patients with Parkinson's disease. J Neurol 2017. [PMID: 28631129 DOI: 10.1007/s00415-017-8548-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Management of Parkinson's disease (PD) using deep brain stimulation (DBS) requires complex care in specialized, multidisciplinary centers. A well-organized, efficient patient flow is crucial to ensure that eligible patients can quickly access DBS. Delays or inefficiencies in patient care may impact a center's ability to meet demand, creating a capacity bottleneck. Analysis of the current practices within a center may help identify areas for improvement. After external audit of the DBS workflow of the Lyon Neurological Hospital and comparison with other European centers, manageable steps were suggested to restructure the care pathway. Propositions of the audit comprised, for example: (1) directly admitting referred patients to hospital, without a prior neurological outpatient visit and (2) including the preoperative anesthesia consultation in the hospital stay 1 month before surgery, not separately. This reorganization (between 2013 and 2016) was performed without increases in hospital medical resources or costs. The time from patients' first referral to surgery was reduced (from 22 to 16 months; p = 0.033), as was the number of pre- and postoperative patient visits (11-5; p = 0.025) and the total cumulative length of in-hospital stay (20.5-17.5 nights; p = 0.02). Ultimately, the total number of PD consultations increased (346-498 per year), as did the number of DBS implants per year (32-45 patients). In this single center experience, restructuring the DBS care pathway allowed a higher number of PD patients to benefit from DBS therapy, with a shorter waiting time and without decreasing the quality of care.
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Affiliation(s)
- N J Thomas
- Department of Integrated Health Solutions, Medtronic Trading International Sàrl Europe, Tolochenaz, Switzerland
| | - P Mertens
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Neurochirurgie A, Bron, France.,Faculté de Médecin Lyon Est, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - T Danaila
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Neurologie C, Bron, France
| | - G Polo
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Neurochirurgie A, Bron, France
| | - H Klinger
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Neurologie C, Bron, France
| | - E Broussolle
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Neurologie C, Bron, France.,Faculté de Médecin Lyon Sud Charles Mérieux, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Institut des Sciences Cognitives Marc Jeannerod, Centre de Neurosciences Cognitives, CNRS, UMR 5229, Bron, France
| | - S Thobois
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Neurologie C, Bron, France. .,Faculté de Médecin Lyon Sud Charles Mérieux, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France. .,Institut des Sciences Cognitives Marc Jeannerod, Centre de Neurosciences Cognitives, CNRS, UMR 5229, Bron, France.
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18
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Fox KCR, Fitz NS, Reiner PB. The Multiplicity of Memory Enhancement: Practical and Ethical Implications of the Diverse Neural Substrates Underlying Human Memory Systems. NEUROETHICS-NETH 2016. [DOI: 10.1007/s12152-016-9282-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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19
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Subthalamic beta oscillations are attenuated after withdrawal of chronic high frequency neurostimulation in Parkinson's disease. Neurobiol Dis 2016; 96:22-30. [PMID: 27553876 DOI: 10.1016/j.nbd.2016.08.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 07/27/2016] [Accepted: 08/16/2016] [Indexed: 12/20/2022] Open
Abstract
Subthalamic nucleus (STN) local field potential (LFP) recordings demonstrate beta (13-30Hz) band oscillations in Parkinson's disease (PD) defined as elevations of spectral power. The amount of attenuation of beta band power on therapeutic levels of high frequency (HF) deep brain stimulation (DBS) and/or dopaminergic medication has been correlated with the degree of improvement in bradykinesia and rigidity from the therapy, which has led to the suggestion that elevated beta band power is a marker of PD motor disability. A fundamental question has not been answered: whether there is a prolonged attenuation of beta band power after withdrawal of chronic HF DBS and whether this is related to a lack of progression or even improvement in the underlying motor disability. Until now, in human PD subjects, STN LFP recordings were only attainable in the peri-operative period and after short periods of stimulation. For the first time, using an investigational, implanted sensing neurostimulator (Activa® PC+S, Medtronic, Inc.), STN LFPs and motor disability were recorded/assessed after withdrawal of chronic (6 and 12month) HF DBS in freely moving PD subjects. Beta band power was similar within 14s and 60min after stimulation was withdrawn, suggesting that "off therapy" experiments can be conducted almost immediately after stimulation is turned off. After withdrawal of 6 and 12months of STN DBS, beta band power was significantly lower (P<0.05 at 6 and 12months) and off therapy UPDRS scores were better (P<0.05 at 12months) compared to before DBS was started. The attenuation in beta band power was correlated with improvement in motor disability scores (P<0.05). These findings were supported by evidence of a gradual increase in beta band power in two unstimulated STNs after 24months and could not be explained by changes in lead impedance. This suggests that chronic HF DBS exerts long-term plasticity in the sensorimotor network, which may contribute to a lack of progression in underlying motor disability in PD.
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20
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Xie CL, Shao B, Chen J, Zhou Y, Lin SY, Wang WW. Effects of neurostimulation for advanced Parkinson's disease patients on motor symptoms: A multiple-treatments meta-analysas of randomized controlled trials. Sci Rep 2016; 6:25285. [PMID: 27142183 PMCID: PMC4855136 DOI: 10.1038/srep25285] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 04/14/2016] [Indexed: 11/09/2022] Open
Abstract
Deep brain stimulation (DBS) is the surgical procedure of choice for patients with advanced Parkinson disease (PD). We aim to evaluate the efficacy of GPi (globus pallidus internus), STN (subthalamic nucleus)-DBS and medical therapy for PD. We conducted a systematic review and multiple-treatments meta-analysis to investigate the efficacy of neurostimulation and medical therapy for PD patients. Sixteen eligible studies were included in this analysis. We pooled the whole data and found obvious difference between GPi-DBS versus medical therapy and STN-DBS versus medical therapy in terms of UPDRS scores (Unified Parkinson’s Disease Rating Scale). Meanwhile, we found GPi-DBS had the similar efficacy on the UPDRS scores when compared with STN-DBS. What is more, quality of life, measured by PDQ-39 (Parkinson’s disease Questionnaire) showed greater improvement after GPi-DBS than STN-DBS. Five studies showed STN-DBS was more effective for reduction in medication than GPi-DBS. Overall, either GPi-DBS or STN-DBS was an effective technique to control PD patients’ symptoms and improved their functionality and quality of life. Meanwhile, the UPDRS scores measuring parkinsonian symptoms revealed no significant difference between GPi-DBS and STN-DBS. STN-DBS was more effective for reduction in medication than GPi-DBS. Alternatively, GPi-DBS was more effective for improving the PDQ-39 score than STN-DBS.
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Affiliation(s)
- Cheng-Long Xie
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Bei Shao
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Jie Chen
- The center of Traditional Chinese Medicine, The Second Affiliated Hospital &Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China
| | - Yi Zhou
- The center of Traditional Chinese Medicine, The Second Affiliated Hospital &Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China
| | - Shi-Yi Lin
- The center of Traditional Chinese Medicine, The Second Affiliated Hospital &Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China
| | - Wen-Wen Wang
- The center of Traditional Chinese Medicine, The Second Affiliated Hospital &Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China
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Gardner J, Samuel G, Williams C. Sociology of Low Expectations: Recalibration as Innovation Work in Biomedicine. SCIENCE, TECHNOLOGY & HUMAN VALUES 2015; 40:998-1021. [PMID: 26527846 PMCID: PMC4601077 DOI: 10.1177/0162243915585579] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Social scientists have drawn attention to the role of hype and optimistic visions of the future in providing momentum to biomedical innovation projects by encouraging innovation alliances. In this article, we show how less optimistic, uncertain, and modest visions of the future can also provide innovation projects with momentum. Scholars have highlighted the need for clinicians to carefully manage the expectations of their prospective patients. Using the example of a pioneering clinical team providing deep brain stimulation to children and young people with movement disorders, we show how clinicians confront this requirement by drawing on their professional knowledge and clinical expertise to construct visions of the future with their prospective patients; visions which are personalized, modest, and tainted with uncertainty. We refer to this vision-constructing work as recalibration, and we argue that recalibration enables clinicians to manage the tension between the highly optimistic and hyped visions of the future that surround novel biomedical interventions, and the exigencies of delivering those interventions in a clinical setting. Drawing on work from science and technology studies, we suggest that recalibration enrolls patients in an innovation alliance by creating a shared understanding of how the "effectiveness" of an innovation shall be judged.
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Affiliation(s)
- John Gardner
- University of York, York, UK
- John Gardner, University of York, Heslington, York YO10 5DD, UK.
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Rodríguez-Blázquez C, Forjaz MJ, Lizán L, Paz S, Martínez-Martín P. Estimating the direct and indirect costs associated with Parkinson’s disease. Expert Rev Pharmacoecon Outcomes Res 2015; 15:889-911. [DOI: 10.1586/14737167.2015.1103184] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Genc G, Abboud H, Oravivattanakul S, Alsallom F, Thompson NR, Cooper S, Gostkowski M, Machado A, Fernandez HH. Socioeconomic Status May Impact Functional Outcome of Deep Brain Stimulation Surgery in Parkinson's Disease. Neuromodulation 2015; 19:25-30. [DOI: 10.1111/ner.12324] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 04/24/2015] [Accepted: 05/13/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Gencer Genc
- Cleveland Clinic, Neurological Institute; Center for Neurological Restoration; Cleveland OH USA
- Department of Neurology; Gumussuyu Military Hospital; Istanbul Turkey
| | - Hesham Abboud
- Cleveland Clinic, Neurological Institute; Center for Neurological Restoration; Cleveland OH USA
| | | | - Faisal Alsallom
- Cleveland Clinic, Neurological Institute; Center for Neurological Restoration; Cleveland OH USA
| | - Nicolas R. Thompson
- Cleveland Clinic, Neurological Institute; Center for Outcomes Research and Evaluation; Cleveland OH USA
| | - Scott Cooper
- Cleveland Clinic, Neurological Institute; Center for Neurological Restoration; Cleveland OH USA
| | - Michal Gostkowski
- Cleveland Clinic, Neurological Institute; Center for Neurological Restoration; Cleveland OH USA
| | - Andre Machado
- Cleveland Clinic, Neurological Institute; Center for Neurological Restoration; Cleveland OH USA
| | - Hubert H. Fernandez
- Cleveland Clinic, Neurological Institute; Center for Neurological Restoration; Cleveland OH USA
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Alexoudi A, Shalash A, Knudsen K, Witt K, Mehdorn M, Volkmann J, Deuschl G. The medical treatment of patients with Parkinson's disease receiving subthalamic neurostimulation. Parkinsonism Relat Disord 2015; 21:555-60; discussion 555. [DOI: 10.1016/j.parkreldis.2015.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 03/04/2015] [Accepted: 03/05/2015] [Indexed: 11/28/2022]
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Real life cost and quality of life associated with continuous intraduodenal levodopa infusion compared with oral treatment in Parkinson patients. J Neurol 2014; 261:2438-45. [DOI: 10.1007/s00415-014-7515-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/19/2014] [Accepted: 09/19/2014] [Indexed: 11/25/2022]
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Grahn PJ, Mallory GW, Berry BM, Hachmann JT, Lobel DA, Lujan JL. Restoration of motor function following spinal cord injury via optimal control of intraspinal microstimulation: toward a next generation closed-loop neural prosthesis. Front Neurosci 2014; 8:296. [PMID: 25278830 PMCID: PMC4166363 DOI: 10.3389/fnins.2014.00296] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Accepted: 08/31/2014] [Indexed: 11/13/2022] Open
Abstract
Movement is planned and coordinated by the brain and carried out by contracting muscles acting on specific joints. Motor commands initiated in the brain travel through descending pathways in the spinal cord to effector motor neurons before reaching target muscles. Damage to these pathways by spinal cord injury (SCI) can result in paralysis below the injury level. However, the planning and coordination centers of the brain, as well as peripheral nerves and the muscles that they act upon, remain functional. Neuroprosthetic devices can restore motor function following SCI by direct electrical stimulation of the neuromuscular system. Unfortunately, conventional neuroprosthetic techniques are limited by a myriad of factors that include, but are not limited to, a lack of characterization of non-linear input/output system dynamics, mechanical coupling, limited number of degrees of freedom, high power consumption, large device size, and rapid onset of muscle fatigue. Wireless multi-channel closed-loop neuroprostheses that integrate command signals from the brain with sensor-based feedback from the environment and the system's state offer the possibility of increasing device performance, ultimately improving quality of life for people with SCI. In this manuscript, we review neuroprosthetic technology for improving functional restoration following SCI and describe brain-machine interfaces suitable for control of neuroprosthetic systems with multiple degrees of freedom. Additionally, we discuss novel stimulation paradigms that can improve synergy with higher planning centers and improve fatigue-resistant activation of paralyzed muscles. In the near future, integration of these technologies will provide SCI survivors with versatile closed-loop neuroprosthetic systems for restoring function to paralyzed muscles.
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Affiliation(s)
- Peter J. Grahn
- Mayo Clinic College of Medicine, Mayo ClinicRochester, MN, USA
| | | | | | - Jan T. Hachmann
- Department of Neurologic Surgery, Mayo ClinicRochester, MN, USA
| | | | - J. Luis Lujan
- Department of Neurologic Surgery, Mayo ClinicRochester, MN, USA
- Department of Physiology and Biomedical Engineering, Mayo ClinicRochester, MN, USA
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Stroupe KT, Weaver FM, Cao L, Ippolito D, Barton BR, Burnett-Zeigler IE, Holloway RG, Vickrey BG, Simuni T, Follett KA. Cost of deep brain stimulation for the treatment of Parkinson's disease by surgical stimulation sites. Mov Disord 2014; 29:1666-74. [DOI: 10.1002/mds.26029] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 08/05/2014] [Accepted: 08/25/2014] [Indexed: 02/04/2023] Open
Affiliation(s)
- Kevin T. Stroupe
- Hines VA Hospital, Center for Management of Complex Chronic Healthcare; Hines Illinois USA
- Loyola University Stritch School of Medicine; Maywood Illinois USA
| | - Frances M. Weaver
- Hines VA Hospital, Center for Management of Complex Chronic Healthcare; Hines Illinois USA
- Loyola University Stritch School of Medicine; Maywood Illinois USA
| | - Lishan Cao
- Hines VA Hospital, Center for Management of Complex Chronic Healthcare; Hines Illinois USA
| | - Dolores Ippolito
- Hines VA Hospital, Center for Management of Complex Chronic Healthcare; Hines Illinois USA
| | - Brandon R. Barton
- Rush University Medical Center; Chicago Illinois USA
- Jesse Brown VA Medical Center; Chicago Illinois USA
| | | | | | - Barbara G. Vickrey
- VA Greater Los Angeles Healthcare System, VA Southwest PADRECC; Los Angeles California USA
- UCLA Department of Neurology; Los Angeles California USA
| | - Tanya Simuni
- Northwestern University, Parkinson's Disease and Movement Disorders Center; Chicago Illinois USA
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Grahn PJ, Mallory GW, Khurram OU, Berry BM, Hachmann JT, Bieber AJ, Bennet KE, Min HK, Chang SY, Lee KH, Lujan JL. A neurochemical closed-loop controller for deep brain stimulation: toward individualized smart neuromodulation therapies. Front Neurosci 2014; 8:169. [PMID: 25009455 PMCID: PMC4070176 DOI: 10.3389/fnins.2014.00169] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/02/2014] [Indexed: 01/13/2023] Open
Abstract
Current strategies for optimizing deep brain stimulation (DBS) therapy involve multiple postoperative visits. During each visit, stimulation parameters are adjusted until desired therapeutic effects are achieved and adverse effects are minimized. However, the efficacy of these therapeutic parameters may decline with time due at least in part to disease progression, interactions between the host environment and the electrode, and lead migration. As such, development of closed-loop control systems that can respond to changing neurochemical environments, tailoring DBS therapy to individual patients, is paramount for improving the therapeutic efficacy of DBS. Evidence obtained using electrophysiology and imaging techniques in both animals and humans suggests that DBS works by modulating neural network activity. Recently, animal studies have shown that stimulation-evoked changes in neurotransmitter release that mirror normal physiology are associated with the therapeutic benefits of DBS. Therefore, to fully understand the neurophysiology of DBS and optimize its efficacy, it may be necessary to look beyond conventional electrophysiological analyses and characterize the neurochemical effects of therapeutic and non-therapeutic stimulation. By combining electrochemical monitoring and mathematical modeling techniques, we can potentially replace the trial-and-error process used in clinical programming with deterministic approaches that help attain optimal and stable neurochemical profiles. In this manuscript, we summarize the current understanding of electrophysiological and electrochemical processing for control of neuromodulation therapies. Additionally, we describe a proof-of-principle closed-loop controller that characterizes DBS-evoked dopamine changes to adjust stimulation parameters in a rodent model of DBS. The work described herein represents the initial steps toward achieving a “smart” neuroprosthetic system for treatment of neurologic and psychiatric disorders.
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Affiliation(s)
- Peter J Grahn
- Mayo Clinic College of Medicine, Mayo Clinic Rochester, MN, USA
| | - Grant W Mallory
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA
| | - Obaid U Khurram
- Mayo Clinic College of Medicine, Mayo Clinic Rochester, MN, USA
| | - B Michael Berry
- Mayo Clinic College of Medicine, Mayo Clinic Rochester, MN, USA
| | - Jan T Hachmann
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA
| | - Allan J Bieber
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA ; Department of Neurology, Mayo Clinic Rochester, MN, USA
| | - Kevin E Bennet
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA ; Division of Engineering, Mayo Clinic Rochester, MN, USA
| | - Hoon-Ki Min
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA ; Department of Physiology and Biomedical Engineering, Mayo Clinic Rochester, MN, USA
| | - Su-Youne Chang
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA
| | - Kendall H Lee
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA ; Department of Physiology and Biomedical Engineering, Mayo Clinic Rochester, MN, USA
| | - J L Lujan
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA ; Department of Physiology and Biomedical Engineering, Mayo Clinic Rochester, MN, USA
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Martinez-Martin P, Rodriguez-Blazquez C, Frades-Payo B. Specific patient-reported outcome measures for Parkinson’s disease: analysis and applications. Expert Rev Pharmacoecon Outcomes Res 2014; 8:401-18. [DOI: 10.1586/14737167.8.4.401] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Ponce FA. Advances in Deep Brain Stimulation for Parkinson Disease: Early and “Asleep”? World Neurosurg 2014; 81:6-8. [DOI: 10.1016/j.wneu.2013.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Mehanna R, Lai EC. Deep brain stimulation in Parkinson's disease. Transl Neurodegener 2013; 2:22. [PMID: 24245947 PMCID: PMC4177536 DOI: 10.1186/2047-9158-2-22] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 11/11/2013] [Indexed: 11/10/2022] Open
Abstract
For the last 50 years, levodopa has been the cornerstone of Parkinson's disease management. However, a majority of patients develop motor complications a few years after therapy onset. Deep brain stimulation has been approved by the FDA as an adjunctive treatment in Parkinson disease, especially aimed at controlling these complications. However, the exact mechanism of action of deep brain stimulation, the best nucleus to target as well as the best timing for surgery are still debatable. We here provide an in-depth and critical review of the current literature on this topic.
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Affiliation(s)
| | - Eugene C Lai
- Department of Neurology, Houston Methodist Neurological Institute, 6560 Fannin, Suite 802, Houston 77030, TX, USA.
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Abstract
For the last 50 years, levodopa has been the cornerstone of Parkinson's disease management. However, a majority of patients develop motor complications a few years after therapy onset. Deep brain stimulation has been approved by the FDA as an adjunctive treatment in Parkinson disease, especially aimed at controlling these complications. However, the exact mechanism of action of deep brain stimulation, the best nucleus to target as well as the best timing for surgery are still debatable. We here provide an in-depth and critical review of the current literature on this topic.
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Affiliation(s)
| | - Eugene C Lai
- Department of Neurology, Houston Methodist Neurological Institute, 6560 Fannin, Suite 802, Houston 77030, TX, USA.
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deSouza RM, Moro E, Lang AE, Schapira AHV. Timing of deep brain stimulation in Parkinson disease: a need for reappraisal? Ann Neurol 2013; 73:565-75. [PMID: 23483564 PMCID: PMC4065356 DOI: 10.1002/ana.23890] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 02/28/2013] [Accepted: 03/01/2013] [Indexed: 01/27/2023]
Abstract
We review the current application of deep brain stimulation (DBS) in Parkinson disease (PD) and consider the evidence that earlier use of DBS confers long-term symptomatic benefit for patients compared to best medical therapy. Electronic searches were performed of PubMed, Web of Knowledge, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials to identify all article types relating to the timing of DBS in PD. Current evidence suggests that DBS is typically performed in late stage PD, a mean of 14 to 15 years after diagnosis. Current guidelines recommend that PD patients who are resistant to medical therapies, have significant medication side effects and lengthening off periods, but are otherwise cognitively intact and medically fit for surgery be considered for DBS. If these criteria are rigidly interpreted, it may be that, by the time medical treatment options have been exhausted, the disease has progressed to the point that the patient may no longer be fit for neurosurgical intervention. From the evidence available, we conclude that surgical management of PD alone or in combination with medical therapy results in greater improvement of motor symptoms and quality of life than medical treatment alone. There is evidence to support the use of DBS in less advanced PD and that it may be appropriate for earlier stages of the disease than for which it is currently used. The improving short and long-term safety profile of DBS makes early application a realistic possibility.
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Affiliation(s)
- Ruth-Mary deSouza
- Department of Clinical Neurosciences, Institute of Neurology, University College London, London, United Kingdom
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Gionfriddo MR, Greenberg AJ, Wahegaonkar AL, Lee KH. Pathways of translation: deep brain stimulation. Clin Transl Sci 2013; 6:497-501. [PMID: 24330698 DOI: 10.1111/cts.12055] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Electrical stimulation of the brain has a 2000 year history. Deep brain stimulation (DBS), one form of neurostimulation, is a functional neurosurgical approach in which a high-frequency electrical current stimulates targeted brain structures for therapeutic benefit. It is an effective treatment for certain neuropathologic movement disorders and an emerging therapy for psychiatric conditions and epilepsy. Its translational journey did not follow the typical bench-to-bedside path, but rather reversed the process. The shift from ancient and medieval folkloric remedy to accepted medical practice began with independent discoveries about electricity during the 19th century and was fostered by technological advances of the 20th. In this paper, we review that journey and discuss how the quest to expand its applications and improve outcomes is taking DBS from the bedside back to the bench.
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Affiliation(s)
- Michael R Gionfriddo
- Mayo Graduate School, Mayo Clinic Center for Translational Science Activities, Rochester, Minnesota, USA
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Dams J, Siebert U, Bornschein B, Volkmann J, Deuschl G, Oertel WH, Dodel R, Reese JP. Cost-effectiveness of deep brain stimulation in patients with Parkinson's disease. Mov Disord 2013; 28:763-71. [DOI: 10.1002/mds.25407] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 11/09/2012] [Accepted: 12/26/2012] [Indexed: 11/06/2022] Open
Affiliation(s)
- Judith Dams
- Department of Neurology; Philipps-University Marburg; Marburg Germany
| | - Uwe Siebert
- Department of Public Health and Health Technology Assessment; UMIT-University for Health Sciences, Medical Informatics, and Technology; Hall in Tirol Austria
- Institute for Technology Assessment and Department of Radiology; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts USA
- Department of Health Policy and Management; Harvard School of Public Health; Boston Massachusetts USA
| | - Bernhard Bornschein
- Department of Public Health and Health Technology Assessment; UMIT-University for Health Sciences, Medical Informatics, and Technology; Hall in Tirol Austria
| | - Jens Volkmann
- Department of Neurology; Julius-Maximilians-University; Würzburg Germany
| | - Günther Deuschl
- Department of Neurology; Christian-Albrechts-University; Kiel Germany
| | | | - Richard Dodel
- Department of Neurology; Philipps-University Marburg; Marburg Germany
| | - Jens-Peter Reese
- Department of Neurology; Philipps-University Marburg; Marburg Germany
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Liu HG, Ma Y, Zhang K, Ge M, Meng FG, Feng T, Wan XH, Guo Y, Wang RZ, Yang AC, Hu WH, Guo JZ, Zhang JG. Subthalamic Deep Brain Stimulation With a New Device in Parkinson's Disease: An Open-Label Trial. Neuromodulation 2013; 16:212-8; discussion 218. [DOI: 10.1111/ner.12050] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 01/14/2013] [Accepted: 02/07/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Huan-guang Liu
- Department of Neurology and Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing; China
| | - Yu Ma
- Beijing Neurosurgical Institute; Capital Medical University; Beijing; China
| | - Kai Zhang
- Department of Neurology and Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing; China
| | - Ming Ge
- Department of Neurology and Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing; China
| | - Fan-gang Meng
- Beijing Neurosurgical Institute; Capital Medical University; Beijing; China
| | - Tao Feng
- Department of Neurology and Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing; China
| | - Xin-hua Wan
- Peking Union Medical College Hospital; Beijing; China
| | - Yi Guo
- Peking Union Medical College Hospital; Beijing; China
| | - Ren-zhi Wang
- Peking Union Medical College Hospital; Beijing; China
| | - An-chao Yang
- Department of Neurology and Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing; China
| | - Wen-han Hu
- Beijing Neurosurgical Institute; Capital Medical University; Beijing; China
| | - Jin-zu Guo
- Peking Union Medical College Hospital; Beijing; China
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Selecting deep brain stimulation or infusion therapies in advanced Parkinson's disease: an evidence-based review. J Neurol 2013; 260:2701-14. [PMID: 23287972 PMCID: PMC3825542 DOI: 10.1007/s00415-012-6798-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 12/10/2012] [Indexed: 10/31/2022]
Abstract
Motor complications in Parkinson's disease (PD) result from the short half-life and irregular plasma fluctuations of oral levodopa. When strategies of providing more continuous dopaminergic stimulation by adjusting oral medication fail, patients may be candidates for one of three device-aided therapies: deep brain stimulation (DBS), continuous subcutaneous apomorphine infusion, or continuous duodenal/jejunal levodopa/carbidopa pump infusion (DLI). These therapies differ in their invasiveness, side-effect profile, and the need for nursing care. So far, very few comparative studies have evaluated the efficacy of the three device-aided therapies for specific motor problems in advanced PD. As a result, neurologists currently lack guidance as to which therapy could be most appropriate for a particular PD patient. A group of experts knowledgeable in all three therapies reviewed the currently available literature for each treatment and identified variables of clinical relevance for choosing one of the three options such as type of motor problems, age, and cognitive and psychiatric status. For each scenario, pragmatic and (if available) evidence-based recommendations are provided as to which patients could be candidates for either DBS, DLI, or subcutaneous apomorphine.
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Valldeoriola F, Puig-Junoy J, Puig-Peiró R. Cost analysis of the treatments for patients with advanced Parkinson's disease: SCOPE study. J Med Econ 2013; 16:191-201. [PMID: 23035627 DOI: 10.3111/13696998.2012.737392] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To perform a comparative long-term analysis of the associated healthcare costs for the therapeutic options in advanced Parkinson's Disease (PD): deep brain stimulation (DBS), continuous duodenal levodopa-carbidopa infusion (CDLCI), and continuous subcutaneous apomorphine infusion (CSAI). METHODS Resource use associated with the pre-treatment period, procedure, and follow-up was assessed for the three therapies from the perspective of the Spanish national healthcare system. Resources consumption was measured with a Healthcare Resources Questionnaire (at nine advanced PD centres). Unit costs (Euro-Spain 2010) were applied to measure resource use to obtain the average total cost for each therapy over 5 years. RESULTS Mean cumulative 5-year cost per patient was significantly lower with DBS (€88,014) vs CSAI (€141,393) and CDLCI (€233,986) (p < 0.0001). DBS was associated with the lowest cumulative costs from year 2, with a yearly average cost of €17,603 vs €46,797 for CDLCI (p = 0.001) and €28,279 for CSAI (p = 0.008). For every patient treated annually with CDLCI, two could be treated with DBS (or €29,194 could be saved) and for every patient treated with CSAI, €10,676 could be saved with DBS. The initial DBS investment (32.2% of the total 5-year costs) was offset by decreases in anti-Parkinsonian drugs and follow-up costs. CDLCI and CSAI required constant drug use (i.e., levodopa and carbidopa for CDLCI, apomorphine for CSAI), representing ∼95% of their total 5-year cost. LIMITATIONS All costs were based on a questionnaire, not on actual clinical data. The study is not a cost-effectiveness analysis as there is a lack of comparable outcomes data. An expert panel was used due to the complexity and variability in the treatment of advanced PD. The sample size was relatively small. CONCLUSIONS Overall, DBS requires less use of health resources than CDLCI or CSAI in advanced PD patients, mostly pharmacological. The initial DBS investment was offset at year 2 by reductions in the ongoing consumption of anti-Parkinsonian medication. For every patient treated annually with CDLCI or CSAI, substantial cost savings could be made with DBS.
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Affiliation(s)
- Francesc Valldeoriola
- Neurology Services, Movement Disorders Unit, Hospital Clinic i Provincial, Barcelona, Spain
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Bell E, Racine E. Ethics guidance for neurological and psychiatric deep brain stimulation. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:313-25. [DOI: 10.1016/b978-0-444-53497-2.00026-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Abstract
Proper selection of patients who will reliably benefit from deep brain stimulation (DBS) is critical to its success. This requires careful evaluation that should be delivered by an expert multidisciplinary team involving a movement disorder neurologist, a neurosurgeon, a neuropsychologist, and a psychiatrist. The most suitable candidates for DBS suffer from Parkinson's disease with motor fluctuations and/or dyskinesias that are not adequately controlled with optimized medical therapy, or with medication-refractory tremor. During the best on-motor periods, gait difficulties, instability, and speech problems should be minimal, reflecting an excellent response to levodopa in the ideal candidate. The cognitive, psychiatric, and behavioral status must be normal or minimally affected, with the exception of dopamine agonist drug-induced impulse control disorders, which are usually improved after successful surgery and drug withdrawal. Moreover, the patients have no serious comorbidities. Most patients corresponding to this profile suffer from a relatively young onset of Parkinson's disease, and are aged less than 70 years at the time of surgery. Indeed, most patients fall outside this ideal description, and the medical art is to appreciate for each patient the extent to which the alterations of these features can be accepted. Eventually, patients make their own decision from detailed information of their individualized risks and benefits of DBS. Patient expectations, cooperation, and familial support are also important considerations.
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Rodriguez-Oroz MC, Moro E, Krack P. Long-term outcomes of surgical therapies for Parkinson's disease. Mov Disord 2012. [DOI: 10.1002/mds.25214] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Arai E, Arai M, Uchiyama T, Higuchi Y, Aoyagi K, Yamanaka Y, Yamamoto T, Nagano O, Shiina A, Maruoka D, Matsumura T, Nakagawa T, Katsuno T, Imazeki F, Saeki N, Kuwabara S, Yokosuka O. Subthalamic deep brain stimulation can improve gastric emptying in Parkinson's disease. Brain 2012; 135:1478-85. [PMID: 22522940 DOI: 10.1093/brain/aws086] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
It is established that deep brain stimulation of the subthalamic nucleus improves motor function in advanced Parkinson's disease, but its effects on autonomic function remain to be elucidated. The present study was undertaken to investigate the effects of subthalamic deep brain stimulation on gastric emptying. A total of 16 patients with Parkinson's disease who underwent bilateral subthalamic deep brain stimulation were enrolled. Gastric emptying was expressed as the peak time of (13)CO(2) excretion (T(max)) in the (13)C-acetate breath test and was assessed in patients with and without administration of 100-150 mg levodopa/decarboxylase inhibitor before surgery, and with and without subthalamic deep brain stimulation at 3 months post-surgery. The pattern of (13)CO(2) excretion curve was analysed. To evaluate potential factors related to the effect of subthalamic deep brain stimulation on gastric emptying, we also examined the association between gastric emptying, clinical characteristics, the equivalent dose of levodopa and serum ghrelin levels. The peak time of (13)CO(2) excretion (T(max)) values for gastric emptying in patients without and with levodopa/decarboxylase inhibitor treatment were 45.6 ± 22.7 min and 42.5 ± 13.6 min, respectively (P = not significant), thus demonstrating levodopa resistance. The peak time of (13)CO(2) excretion (T(max)) values without and with subthalamic deep brain stimulation after surgery were 44.0 ± 17.5 min and 30.0 ± 12.5 min (P < 0.001), respectively, which showed that subthalamic deep brain stimulation was effective. Simultaneously, the pattern of the (13)CO(2) excretion curve was also significantly improved relative to surgery with no stimulation (P = 0.002), although the difference with and without levodopa/decarboxylase inhibitor was not significant. The difference in peak time of (13)CO(2) excretion (T(max)) values without levodopa/decarboxylase inhibitor before surgery and without levodopa/decarboxylase inhibitor and subthalamic deep brain stimulation after surgery was not significant, although motor dysfunction improved and the levodopa equivalent dose decreased after surgery. There was little association between changes in ghrelin levels (Δghrelin) and changes in T(max) values (ΔT(max)) in the subthalamic deep brain stimulation trial after surgery (r = -0.20), and no association between changes in other characteristics and ΔT(max) post-surgery in the subthalamic deep brain stimulation trial. These results showed that levodopa/decarboxylase inhibitor did not influence gastric emptying and that subthalamic deep brain stimulation can improve the dysfunction in patients with Parkinson's disease possibly by altering the neural system that controls gastrointestinal function after subthalamic deep brain stimulation. This is the first report to show the effectiveness of subthalamic deep brain stimulation on gastrointestinal dysfunction as a non-motor symptom in Parkinson's disease.
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Affiliation(s)
- Eiji Arai
- Department of Medicine and Clinical Oncology (K1), Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba-City, Japan.
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Reese JP, Dams J, Winter Y, Balzer-Geldsetzer M, Oertel WH, Dodel R. Pharmacoeconomic considerations of treating patients with advanced Parkinson's disease. Expert Opin Pharmacother 2012; 13:939-58. [PMID: 22475391 DOI: 10.1517/14656566.2012.677435] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Parkinson's disease (PD) is one of the most common neurodegenerative diseases. In the later (advanced) stages of PD, the initial treatment of early PD becomes less effective and long-term side effects of dopaminergic treatment become apparent. In advanced PD, motor and non-motor complications occur, which increase treatment costs. Increasing disability and impaired activities of daily living concomitantly raise indirect costs, due to loss in productivity. Hence, the economic burden of advanced PD is substantial for both the society and the patients with their caregivers. AREAS COVERED A systematic literature search was performed involving the databases NHS CRD (National Health Service Centre for Reviews and Dissemination) and PubMed until July 15, 2011. "Parkinson" [Mesh] and "cost" were used as search terms in PubMed and only "Parkinson" in the CRD database. EXPERT OPINION Economic evaluations are scarce and heterogeneous, and their interpretation may be limited due to methodological shortcomings. Dopamine agonists, COMT and MAO-B inhibitors as well levodopa infusion and deep brain stimulation are reported to be cost-effective in the respective decision frameworks. However, these results are heavily dependent on assumptions of drug costs and effect sizes used in the models. More detailed real-life information from long-term clinical trials is needed to feed the economic models, especially for head-to-head comparisons. To date, no economic evaluation has been undertaken for possible neuroprotective/disease modifying effects, and further research is needed for evaluations of interventions for non-motor symptoms.
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Affiliation(s)
- Jens P Reese
- Philipps-University Marburg, Department of Neurology, Baldingerstrasse, 35043 Marburg, Germany
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Schiefer TK, Matsumoto JY, Lee KH. Moving forward: advances in the treatment of movement disorders with deep brain stimulation. Front Integr Neurosci 2011; 5:69. [PMID: 22084629 PMCID: PMC3211039 DOI: 10.3389/fnint.2011.00069] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 10/07/2011] [Indexed: 11/13/2022] Open
Abstract
The modern era of stereotactic and functional neurosurgery has ushered in state of the art technologies for the treatment of movement disorders, particularly Parkinson's disease (PD), tremor, and dystonia. After years of experience with various surgical therapies, the eventual shortcomings of both medical and surgical treatments, and several serendipitous discoveries, deep brain stimulation (DBS) has risen to the forefront as a highly effective, safe, and reversible treatment for these conditions. Idiopathic advanced PD can be treated with thalamic, globus pallidus internus (GPi), or subthalamic nucleus (STN) DBS. Thalamic DBS primarily relieves tremor while GPi and STN DBS alleviate a wide range of Parkinsonian symptoms. Thalamic DBS is also used in the treatment of other types of tremor, particularly essential tremor, with excellent results. Both primary and various types of secondary dystonia can be treated very effectively with GPi DBS. The variety of anatomical targets for these movement disorders is indicative of the network-level dysfunction mediating these movement disturbances. Despite an increasing understanding of the clinical benefits of DBS, little is known about how DBS can create such wide sweeping neuromodulatory effects. The key to improving this therapeutic modality and discovering new ways to treat these and other neurologic conditions lies in better understanding the intricacies of DBS. Here we review the history and pertinent clinical data for DBS treatment of PD, tremor, and dystonia. While multiple regions of the brain have been targeted for DBS in the treatment of these movement disorders, this review article focuses on those that are most commonly used in current clinical practice. Our search criteria for PubMed included combinations of the following terms: DBS, neuromodulation, movement disorders, PD, tremor, dystonia, and history. Dates were not restricted.
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Affiliation(s)
| | | | - Kendall H. Lee
- Department of Neurologic Surgery, Mayo ClinicRochester, MN, USA
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Park YS, Kim JP, Chang WS, Chang JW. Management of a DBS system in patients with traumatic brain injury: case report. Neuromodulation 2011; 14:214-8; discussion 218. [PMID: 21992242 DOI: 10.1111/j.1525-1403.2011.00348.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The use of deep brain stimulation (DBS) is growing. While these patients may suffer from traumatic brain injuries, treatment guidelines for these patients have not yet been reported. This case report demonstrates a strategy for traumatic brain injury after DBS implantation. CLINICAL PRESENTATION A 46-year-old man underwent bilateral DBS in the posterior subthalamic area for essential tremor, which improved both distal and proximal tremor. Two years later, he underwent emergent hematoma evacuation due to a motor vehicle associated injury. A 23-year-old male patient presented with severe Tourette's syndrome characterized by a vocal and self lip biting motor tic. There was a good effect of chronic bilateral thalamic DBS at CM-Pf. Five months later, he had acute subdural hematoma after a motorcycle accident. Instead of removing stimulation electrodes immediately after traumatic brain injury, the patient was reassessed after recovery. Merged preoperative magnetic resonance images and brain computed tomography images, and clinical reassessments were used to plan future treatment. CONCLUSION We recommend removing only the hematoma, leaving the electrodes in position, and then reassessing the electrode position using merged images. The clinical correlation with electrode migration also should be checked. If the patient can tolerate stimulation with a minor displacement, the electrodes should be left in position and the stimulation parameter needs to be adjusted. If not, the stimulation electrodes should be deactivated or repositioned appropriately, depending on the patient's conditions.
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Affiliation(s)
- Young Seok Park
- Department of Neurosurgery, Bundang CHA Hospital, CHA University, Seongnam, Korea
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Elmer L, Hauser RA. Strategies for Parkinson’s disease care: prevention and management of motor fluctuations. Neurodegener Dis Manag 2011. [DOI: 10.2217/nmt.11.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Parkinson’s disease (PD) is characterized clinically by the hallmark motor signs of bradykinesia, rest tremor and rigidity. Current pharmacological management goals include control of motor symptoms as well as prevention and management of motor complications including motor fluctuations and dyskinesias. While the use of levodopa revolutionized the pharmacological management of PD, multiple other agents and strategies have emerged with many demonstrable, albeit sometimes controversial, advantages to a ‘levodopa’ only approach. Despite these developments, the progressive nature of PD requires vigilance and creativity from clinicians as both motor and nonmotor complications grow in number and severity over time.
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Affiliation(s)
- Lawrence Elmer
- University of Toledo College of Medicine, Toledo, OH, USA
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Abstract
OPINION STATEMENT Many important advances for the treatment of Parkinson's disease (PD) have been made over the past decade, and quality of life has improved for most patients. Nonetheless, motor fluctuations in the form of wearing off with the re-emergence of parkinsonian symptoms and hyperkinetic movements (dyskinesias) often arise as a complication of long-term dopaminergic therapy and can be disabling. Because treatment of motor fluctuations is difficult, clinicians should attempt to prevent them by using low doses of dopaminergic drugs in early PD, targeting functionally relevant symptoms. Instead of levodopa, dopamine agonists, amantadine, and rasagiline can be used with the aim of delaying the onset of motor fluctuations. Once motor fluctuations arise, off time can initially be addressed with more frequent dosing of levodopa. Later, adjunctive therapy with a dopamine agonist, COMT-inhibitor, or MAO-B inhibitor becomes necessary. For treatment of dyskinesias, reduction of the levodopa dose should be the first step. If this is not tolerated because of increased off time, then adjunctive therapy with levodopa-sparing agents should be attempted. The addition of amantadine (the only currently available antidyskinetic drug) is another useful strategy but is often only a temporary solution. Once medical attempts at treating motor fluctuations fail, deep brain stimulation (DBS) can be considered. Careful patient selection and skilled placement of DBS electrodes are important determinants of the surgical outcome.
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Affiliation(s)
- Vanessa K Hinson
- Medical University of South Carolina, 326 Calhoun Street, Suite 308, Charleston, SC, 29425, USA,
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Mera T, Vitek JL, Alberts JL, Giuffrida JP. Kinematic optimization of deep brain stimulation across multiple motor symptoms in Parkinson's disease. J Neurosci Methods 2011; 198:280-6. [PMID: 21459111 DOI: 10.1016/j.jneumeth.2011.03.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 03/23/2011] [Accepted: 03/24/2011] [Indexed: 11/25/2022]
Abstract
Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor symptoms including tremor and bradykinesia (slowness of movement). Drug treatment, although capable of controlling these symptoms over a number of years, becomes less effective as the disease progresses and leads to motor complications such as drug-induced dyskinesia (involuntary abnormal movements). Deep brain stimulation (DBS) provides an alternative means of controlling motor symptoms in these patients, and while DBS has been effective in improving motor symptoms, these improvements are largely based on accurate placement of the lead and the ability of medical personnel to adequately program the DBS device following implantation. While guidelines exist for DBS programming, selection of stimulation parameters and patient outcome is greatly dependent on subjective clinical assessments and the experience of the medical personnel performing the programming. The aim of this project was to assess the feasibility of using a quantitative and objective approach to programming. Two subjects underwent standard procedures for DBS programming while wearing a small, compact motion sensor. Kinematic data were collected from subjects as they completed motor tasks to evaluate DBS efficacy. Quantitative variables characterizing tremor and bradykinesia were related to stimulation parameters. Results indicated different stimulation settings might be required for optimal improvement of different motor symptoms. A standardized method of programming DBS parameters utilizing motion analysis may provide an objective method of assessment that the programmer can use to better identify stimulation parameters to achieve optimal improvement across multiple motor symptoms.
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Affiliation(s)
- Thomas Mera
- Division of Movement Disorders, Cleveland Medical Devices, Inc., 4415 Euclid Ave Suite 400, Cleveland, OH 44103, USA.
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The health-related, social, and economic consequences of parkinsonism: a controlled national study. J Neurol 2011; 258:1497-506. [DOI: 10.1007/s00415-011-5969-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Revised: 02/20/2011] [Accepted: 02/21/2011] [Indexed: 10/18/2022]
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Zaidel A, Bergman H, Ritov Y, Israel Z. Levodopa and subthalamic deep brain stimulation responses are not congruent. Mov Disord 2011; 25:2379-86. [PMID: 20824733 DOI: 10.1002/mds.23294] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
There is a consensus that in Parkinson's disease, the extent of preoperative levodopa responsiveness predicts the efficacy of subthalamic nucleus deep brain stimulation (STN DBS). However, this may be the result of statistical methods and primary assumptions. We were able to reproduce previously published correlation results on our data (N = 49 patients). Yet, these same results were demonstrated even after random shuffling of our data. Notably, we did not observe a correlation between STN DBS efficacy and preoperative levodopa responsiveness when using their respective baselines and fractional scores of motor improvement. Furthermore, postoperative responses were not limited by preoperative scores, with tremor demonstrating the greatest discrepancy. We conclude that preoperative levodopa responsiveness does not predict or limit the outcome of STN DBS. These results imply different therapeutic mechanisms for levodopa and STN DBS and therefore question the validity of using substantial preoperative levodopa responsiveness as a selection criterion for STN DBS.
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Affiliation(s)
- Adam Zaidel
- The Interdisciplinary Center for Neural Computation, The Hebrew University of Jerusalem, Israel.
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