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Morton A, Fraser H, Green C, Drovandi A. Effectiveness of Deep Brain Stimulation in Improving Balance in Parkinson's Disease: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 186:242-251.e3. [PMID: 38608807 DOI: 10.1016/j.wneu.2024.04.021] [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: 01/14/2024] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Balance dysfunction is a debilitating feature of advanced Parkinson's disease (PD), potentially improved by deep brain stimulation (DBS). This systematic review and meta-analysis pooled evidence from randomized controlled trials (RCTs) on DBS effectiveness in improving balance in PD. METHODS A systematic search was conducted to identify eligible RCTs investigating the effectiveness of DBS on improving balance in people with PD. Meta-analysis was performed using random effects models and reported as mean difference and 95% confidence intervals. Risk of bias was assessed using Cochrane's ROB-2 tool. RESULTS Seventeen RCTs were eligible (n = 333), utilizing a range of stimulation sites, parameters, reporting tools for balance outcomes, and control/comparator groups, making the identification of clear trends and recommendations difficult. Eleven studies were deemed as having some risk of bias, 4 having low risk of bias and 2 having high risk of bias. One small meta-analysis was conducted and found no significant difference in balance outcomes. Most studies reported no significant improvement in Timed Up-and-Go scores, Berg Balance Scale scores, frequency of falls, and balance-related items of the Movement Disorder Society's Unified Parkinson's Disease Rating Scales. Some studies reported improvements in the Tinetti balance test, posturography readings, and reduction in falls though these were not supported by other studies due to a lack of reporting on these items or conflicting findings. CONCLUSIONS Current research suggests that DBS results in no significant improvement in balance dysfunction for people with PD, though such assertions require larger RCTs with clear reporting methods using validated reporting tools.
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Affiliation(s)
- Amy Morton
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | - Holly Fraser
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | - Chloe Green
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | - Aaron Drovandi
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.
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Bath JE, Wang DD. Unraveling the threads of stability: A review of the neurophysiology of postural control in Parkinson's disease. Neurotherapeutics 2024; 21:e00354. [PMID: 38579454 PMCID: PMC11000188 DOI: 10.1016/j.neurot.2024.e00354] [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: 11/30/2023] [Revised: 03/18/2024] [Accepted: 03/23/2024] [Indexed: 04/07/2024] Open
Abstract
Postural instability is a detrimental and often treatment-refractory symptom of Parkinson's disease. While many existing studies quantify the biomechanical deficits among various postural domains (static, anticipatory, and reactive) in this population, less is known regarding the neural network dysfunctions underlying these phenomena. This review will summarize current studies on the cortical and subcortical neural activities during postural responses in healthy subjects and those with Parkinson's disease. We will also review the effects of current therapies, including neuromodulation and feedback-based wearable devices, on postural instability symptoms. With recent advances in implantable devices that allow chronic, ambulatory neural data collection from patients with Parkinson's disease, combined with sensors that can quantify biomechanical measurements of postural responses, future work using these devices will enable better understanding of the neural mechanisms of postural control. Bridging this knowledge gap will be the critical first step towards developing novel neuromodulatory interventions to enhance the treatment of postural instability in Parkinson's disease.
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Affiliation(s)
- Jessica E Bath
- Department of Physical Therapy & Rehabilitation Science, University of California, San Francisco, USA; Department of Neurological Surgery, University of California, San Francisco, USA
| | - Doris D Wang
- Department of Neurological Surgery, University of California, San Francisco, USA.
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Heß T, Themann P, Oehlwein C, Milani TL. Does Impaired Plantar Cutaneous Vibration Perception Contribute to Axial Motor Symptoms in Parkinson's Disease? Effects of Medication and Subthalamic Nucleus Deep Brain Stimulation. Brain Sci 2023; 13:1681. [PMID: 38137129 PMCID: PMC10742284 DOI: 10.3390/brainsci13121681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 11/28/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVE To investigate whether impaired plantar cutaneous vibration perception contributes to axial motor symptoms in Parkinson's disease (PD) and whether anti-parkinsonian medication and subthalamic nucleus deep brain stimulation (STN-DBS) show different effects. METHODS Three groups were evaluated: PD patients in the medication "on" state (PD-MED), PD patients in the medication "on" state and additionally "on" STN-DBS (PD-MED-DBS), as well as healthy subjects (HS) as reference. Motor performance was analyzed using a pressure distribution platform. Plantar cutaneous vibration perception thresholds (VPT) were investigated using a customized vibration exciter at 30 Hz. RESULTS Motor performance of PD-MED and PD-MED-DBS was characterized by greater postural sway, smaller limits of stability ranges, and slower gait due to shorter strides, fewer steps per minute, and broader stride widths compared to HS. Comparing patient groups, PD-MED-DBS showed better overall motor performance than PD-MED, particularly for the functional limits of stability and gait. VPTs were significantly higher for PD-MED compared to those of HS, which suggests impaired plantar cutaneous vibration perception in PD. However, PD-MED-DBS showed less impaired cutaneous vibration perception than PD-MED. CONCLUSIONS PD patients suffer from poor motor performance compared to healthy subjects. Anti-parkinsonian medication in tandem with STN-DBS seems to be superior for normalizing axial motor symptoms compared to medication alone. Plantar cutaneous vibration perception is impaired in PD patients, whereas anti-parkinsonian medication together with STN-DBS is superior for normalizing tactile cutaneous perception compared to medication alone. Consequently, based on our results and the findings of the literature, impaired plantar cutaneous vibration perception might contribute to axial motor symptoms in PD.
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Affiliation(s)
- Tobias Heß
- Department of Human Locomotion, Chemnitz University of Technology, 09126 Chemnitz, Germany
| | - Peter Themann
- Department of Neurology and Parkinson, Clinic at Tharandter Forest, 09633 Halsbruecke, Germany
| | - Christian Oehlwein
- Neurological Outpatient Clinic for Parkinson Disease and Deep Brain Stimulation, 07551 Gera, Germany
| | - Thomas L. Milani
- Department of Human Locomotion, Chemnitz University of Technology, 09126 Chemnitz, Germany
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Heß T, Oehlwein C, Milani TL. Anticipatory Postural Adjustments and Compensatory Postural Responses to Multidirectional Perturbations-Effects of Medication and Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease. Brain Sci 2023; 13:brainsci13030454. [PMID: 36979264 PMCID: PMC10046463 DOI: 10.3390/brainsci13030454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Postural instability is one of the most restricting motor symptoms for patients with Parkinson's disease (PD). While medication therapy only shows minor effects, it is still unclear whether medication in conjunction with deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves postural stability. Hence, the aim of this study was to investigate whether PD patients treated with medication in conjunction with STN-DBS have superior postural control compared to patients treated with medication alone. METHODS Three study groups were tested: PD patients on medication (PD-MED), PD patients on medication and on STN-DBS (PD-MED-DBS), and healthy elderly subjects (HS) as a reference. Postural performance, including anticipatory postural adjustments (APA) prior to perturbation onset and compensatory postural responses (CPR) following multidirectional horizontal perturbations, was analyzed using force plate and electromyography data. RESULTS Regardless of the treatment condition, both patient groups showed inadequate APA and CPR with early and pronounced antagonistic muscle co-contractions compared to healthy elderly subjects. Comparing the treatment conditions, study group PD-MED-DBS only showed minor advantages over group PD-MED. In particular, group PD-MED-DBS showed faster postural reflexes and tended to have more physiological co-contraction ratios. CONCLUSION medication in conjunction with STN-DBS may have positive effects on the timing and amplitude of postural control.
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Affiliation(s)
- Tobias Heß
- Department of Human Locomotion, Chemnitz University of Technology, 09126 Chemnitz, Germany
| | - Christian Oehlwein
- Neurological Outpatient Clinic for Parkinson Disease and Deep Brain Stimulation, 07551 Gera, Germany
| | - Thomas L Milani
- Department of Human Locomotion, Chemnitz University of Technology, 09126 Chemnitz, Germany
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Short-Term Motor Outcomes in Parkinson’s Disease after Subthalamic Nucleus Deep Brain Stimulation Combined with Post-Operative Rehabilitation: A Pre-Post Comparison Study. PARKINSON'S DISEASE 2022; 2022:8448638. [PMID: 35992727 PMCID: PMC9391177 DOI: 10.1155/2022/8448638] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 06/01/2022] [Accepted: 06/21/2022] [Indexed: 11/27/2022]
Abstract
Background The effects of subthalamic nuclear deep brain stimulation therapy (STN-DBS) and combined postoperative rehabilitation for patients with Parkinson's disease with postural instability have yet to be well reported. This study investigated the effects of short-term postoperative rehabilitation with STN-DBS on physical function in patients with Parkinson's disease. Methods Patients diagnosed with Parkinson's disease who were admitted to our hospital for STN-DBS surgery were included in this study. Data were prospectively collected and retrospectively analyzed. Postoperative rehabilitation consisted of muscle-strengthening exercises, stretching, and balance exercises for 40–60 minutes per day for approximately 14 days. The Mini-Balance Evaluation Systems Test (Mini-BESTest), Timed Up and Go test (TUG) seconds and steps, Trunk Impairment Scale (TIS), seconds for 10 times toe-tapping, lower limb extension torque using StrengthErgo240, and center of pressure sway in the quiet standing posture were evaluated preoperatively, postoperatively, and at discharge. Mini-BESTest changes were also evaluated in the two groups classified by the presence or absence of postural instability. One-way and two-way repeated measures analyses of variance were performed for each of the three periods of change, and paired t-tests with the Bonferroni method were performed as multiple comparison tests. A stepwise multiple regression model was used to identify factors associated with balance improvement. Results A total of 60 patients with Parkinson's disease were included, and there were significant increases in Mini-BESTest, TIS, StrengthErgo240, and postural sway during closed-eye standing compared to pre- and postoperative conditions at discharge (p < 0.05), and they decreased significantly compared to the postoperative period (p < 0.05). On stepwise multiple regression analysis, decreased steps of TUG and improvement of TIS scores were related to improvement of the Mini-BESTest (p < 0.05). In addition, Mini-BESTest scores in both groups with and without postural instability were significantly increased at discharge compared to preoperative and postoperative conditions (p < 0.01). Conclusion Postoperative rehabilitation combined with STN-DBS may provide short-term improvements in physical function compared with the preoperative medicated status. The improvements in gait step length and trunk function may be important factors for obtaining improvement of postoperative postural stability.
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Allen NE, Canning CG, Almeida LRS, Bloem BR, Keus SH, Löfgren N, Nieuwboer A, Verheyden GS, Yamato TP, Sherrington C. Interventions for preventing falls in Parkinson's disease. Cochrane Database Syst Rev 2022; 6:CD011574. [PMID: 35665915 PMCID: PMC9169540 DOI: 10.1002/14651858.cd011574.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Most people with Parkinson's disease (PD) experience at least one fall during the course of their disease. Several interventions designed to reduce falls have been studied. An up-to-date synthesis of evidence for interventions to reduce falls in people with PD will assist with informed decisions regarding fall-prevention interventions for people with PD. OBJECTIVES To assess the effects of interventions designed to reduce falls in people with PD. SEARCH METHODS CENTRAL, MEDLINE, Embase, four other databases and two trials registers were searched on 16 July 2020, together with reference checking, citation searching and contact with study authors to identify additional studies. We also conducted a top-up search on 13 October 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) of interventions that aimed to reduce falls in people with PD and reported the effect on falls. We excluded interventions that aimed to reduce falls due to syncope. DATA COLLECTION AND ANALYSIS We used standard Cochrane Review procedures. Primary outcomes were rate of falls and number of people who fell at least once. Secondary outcomes were the number of people sustaining one or more fall-related fractures, quality of life, adverse events and economic outcomes. The certainty of the evidence was assessed using GRADE. MAIN RESULTS This review includes 32 studies with 3370 participants randomised. We included 25 studies of exercise interventions (2700 participants), three studies of medication interventions (242 participants), one study of fall-prevention education (53 participants) and three studies of exercise plus education (375 participants). Overall, participants in the exercise trials and the exercise plus education trials had mild to moderate PD, while participants in the medication trials included those with more advanced disease. All studies had a high or unclear risk of bias in one or more items. Illustrative risks demonstrating the absolute impact of each intervention are presented in the summary of findings tables. Twelve studies compared exercise (all types) with a control intervention (an intervention not thought to reduce falls, such as usual care or sham exercise) in people with mild to moderate PD. Exercise probably reduces the rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.63 to 0.87; 1456 participants, 12 studies; moderate-certainty evidence). Exercise probably slightly reduces the number of people experiencing one or more falls by 10% (risk ratio (RR) 0.90, 95% CI 0.80 to 1.00; 932 participants, 9 studies; moderate-certainty evidence). We are uncertain whether exercise makes little or no difference to the number of people experiencing one or more fall-related fractures (RR 0.57, 95% CI 0.28 to 1.17; 989 participants, 5 studies; very low-certainty evidence). Exercise may slightly improve health-related quality of life immediately following the intervention (standardised mean difference (SMD) -0.17, 95% CI -0.36 to 0.01; 951 participants, 5 studies; low-certainty evidence). We are uncertain whether exercise has an effect on adverse events or whether exercise is a cost-effective intervention for fall prevention. Three studies trialled a cholinesterase inhibitor (rivastigmine or donepezil). Cholinesterase inhibitors may reduce the rate of falls by 50% (RaR 0.50, 95% CI 0.44 to 0.58; 229 participants, 3 studies; low-certainty evidence). However, we are uncertain if this medication makes little or no difference to the number of people experiencing one or more falls (RR 1.01, 95% CI 0.90 to 1.14230 participants, 3 studies) and to health-related quality of life (EQ5D Thermometer mean difference (MD) 3.00, 95% CI -3.06 to 9.06; very low-certainty evidence). Cholinesterase inhibitors may increase the rate of non fall-related adverse events by 60% (RaR 1.60, 95% CI 1.28 to 2.01; 175 participants, 2 studies; low-certainty evidence). Most adverse events were mild and transient in nature. No data was available regarding the cost-effectiveness of medication for fall prevention. We are uncertain of the effect of education compared to a control intervention on the number of people who fell at least once (RR 10.89, 95% CI 1.26 to 94.03; 53 participants, 1 study; very low-certainty evidence), and no data were available for the other outcomes of interest for this comparisonWe are also uncertain (very low-certainty evidence) whether exercise combined with education makes little or no difference to the number of falls (RaR 0.46, 95% CI 0.12 to 1.85; 320 participants, 2 studies), the number of people sustaining fall-related fractures (RR 1.45, 95% CI 0.40 to 5.32,320 participants, 2 studies), or health-related quality of life (PDQ39 MD 0.05, 95% CI -3.12 to 3.23, 305 participants, 2 studies). Exercise plus education may make little or no difference to the number of people experiencing one or more falls (RR 0.89, 95% CI 0.75 to 1.07; 352 participants, 3 studies; low-certainty evidence). We are uncertain whether exercise combined with education has an effect on adverse events or is a cost-effective intervention for fall prevention. AUTHORS' CONCLUSIONS: Exercise interventions probably reduce the rate of falls, and probably slightly reduce the number of people falling in people with mild to moderate PD. Cholinesterase inhibitors may reduce the rate of falls, but we are uncertain if they have an effect on the number of people falling. The decision to use these medications needs to be balanced against the risk of non fall-related adverse events, though these adverse events were predominantly mild or transient in nature. Further research in the form of large, high-quality RCTs are required to determine the relative impact of different types of exercise and different levels of supervision on falls, and how this could be influenced by disease severity. Further work is also needed to increase the certainty of the effects of medication and further explore falls prevention education interventions both delivered alone and in combination with exercise.
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Affiliation(s)
- Natalie E Allen
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Colleen G Canning
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Lorena Rosa S Almeida
- Movement Disorders and Parkinson's Disease Clinic, Roberto Santos General Hospital, Salvador, Brazil
- Motor Behavior and Neurorehabilitation Research Group, Bahiana School of Medicine and Public Health, Salvador, Brazil
| | - Bastiaan R Bloem
- Raboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, Netherlands
| | - Samyra Hj Keus
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
- Quality and Improvement, OLVG, Amsterdam, Netherlands
| | - Niklas Löfgren
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Department of Women's and Children's Health, Physiotherapy, Uppsala University, Uppsala, Sweden
| | - Alice Nieuwboer
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | | | - Tiê P Yamato
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Pozzi NG, Palmisano C, Reich MM, Capetian P, Pacchetti C, Volkmann J, Isaias IU. Troubleshooting Gait Disturbances in Parkinson's Disease With Deep Brain Stimulation. Front Hum Neurosci 2022; 16:806513. [PMID: 35652005 PMCID: PMC9148971 DOI: 10.3389/fnhum.2022.806513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 03/16/2022] [Indexed: 01/08/2023] Open
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus or the globus pallidus is an established treatment for Parkinson's disease (PD) that yields a marked and lasting improvement of motor symptoms. Yet, DBS benefit on gait disturbances in PD is still debated and can be a source of dissatisfaction and poor quality of life. Gait disturbances in PD encompass a variety of clinical manifestations and rely on different pathophysiological bases. While gait disturbances arising years after DBS surgery can be related to disease progression, early impairment of gait may be secondary to treatable causes and benefits from DBS reprogramming. In this review, we tackle the issue of gait disturbances in PD patients with DBS by discussing their neurophysiological basis, providing a detailed clinical characterization, and proposing a pragmatic programming approach to support their management.
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Affiliation(s)
- Nicoló G. Pozzi
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Chiara Palmisano
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Martin M. Reich
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Philip Capetian
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Claudio Pacchetti
- Parkinson’s Disease and Movement Disorders Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Jens Volkmann
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Ioannis U. Isaias
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
- Parkinson Institute Milan, ASST Gaetano Pini-CTO, Milan, Italy
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Reverse Visually Guided Reaching in Patients with Parkinson’s Disease. PARKINSON'S DISEASE 2022; 2022:8132923. [PMID: 35386952 PMCID: PMC8979744 DOI: 10.1155/2022/8132923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 01/11/2022] [Accepted: 02/22/2022] [Indexed: 11/18/2022]
Abstract
In addition to motor symptoms such as difficulty in movement initiation and bradykinesia, patients with Parkinson’s disease (PD) display nonmotor executive cognitive dysfunction with deficits in inhibitory control. Preoperative psychological assessments are used to screen for impulsivity that may be worsened by deep brain stimulation (DBS) of the subthalamic nucleus (STN). However, it is unclear whether anti-Parkinson’s therapy, such as dopamine replacement therapy (DRT) or DBS, which has beneficial effects on motor function, adversely affects inhibitory control or its domains. The detrimental effects of STN-DBS are more apparent when tasks test the inhibition of habitual prepotent responses or involve complex cognitive loads. Our goal was to use a reverse visually guided reaching (RVGR) task, a hand-based version of the antisaccade task, to simultaneously measure motor performance and response inhibition in subjects with PD. We recruited 55 healthy control subjects, 26 PD subjects receiving treatment with DRTs, and 7 PD subjects receiving treatment with STN-DBS and DRTs. In the RVGR task, a cursor moved opposite to the subject’s hand movement. This was compared to visually guided reaching (VGR) where the cursor moved in the same direction as the subject’s hand movement. Reaction time, mean speed, and direction errors (in RVGR) were assessed. Reaction times were longer, and mean speeds were slower during RVGR compared to VGR in all three groups but worse in untreated subjects with PD. Treatment with DRTs, DBS, or DBS + DRT improved the reaction time and speed on the RVGR task to a greater extent than VGR. Additionally, DBS or DBS + DRT demonstrated an increase in direction errors, which was correlated with decreased reaction time. These results show that the RVGR task quantifies the benefit of STN-DBS on bradykinesia and the concomitant reduction of proactive inhibitory control. The RVGR task has the potential to be used to rapidly screen for preoperative deficits in inhibitory control and to titrate STN-DBS, to maximize the therapeutic benefits on movement, and minimize impaired inhibitory control.
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Coelho DB, de Oliveira CEN, Guimarães MVC, Ribeiro de Souza C, dos Santos ML, de Lima-Pardini AC. A systematic review on the effectiveness of perturbation-based balance training in postural control and gait in Parkinson’s disease. Physiotherapy 2022; 116:58-71. [DOI: 10.1016/j.physio.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 12/29/2021] [Accepted: 02/17/2022] [Indexed: 10/19/2022]
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Au KLK, Wong JK, Tsuboi T, Eisinger RS, Moore K, Lemos Melo Lobo Jofili Lopes J, Holland MT, Holanda VM, Peng-Chen Z, Patterson A, Foote KD, Ramirez-Zamora A, Okun MS, Almeida L. Globus Pallidus Internus (GPi) Deep Brain Stimulation for Parkinson's Disease: Expert Review and Commentary. Neurol Ther 2021; 10:7-30. [PMID: 33140286 PMCID: PMC8140010 DOI: 10.1007/s40120-020-00220-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/08/2020] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION The globus pallidus internus (GPi) region has evolved as a potential target for deep brain stimulation (DBS) in Parkinson's disease (PD). DBS of the GPi (GPi DBS) is an established, safe and effective method for addressing many of the motor symptoms associated with advanced PD. It is important that clinicians fully understand this target when considering GPi DBS for individual patients. METHODS The literature on GPi DBS in PD has been comprehensively reviewed, including the anatomy, physiology and potential pitfalls that may be encountered during surgical targeting and post-operative management. Here, we review and address the implications of lead location on GPi DBS outcomes. Additionally, we provide a summary of randomized controlled clinical trials conducted on DBS in PD, together with expert commentary on potential applications of the GPi as target. Finally, we highlight future technologies that will likely impact GPi DBS, including closed-loop adaptive approaches (e.g. sensing-stimulating capabilities), advanced methods for image-based targeting and advances in DBS programming, including directional leads and pulse shaping. RESULTS There are important disease characteristics and factors to consider prior to selecting the GPi as the DBS target of PD surgery. Prior to and during implantation of the leads it is critical to consider the neuroanatomy, which can be defined through the combination of image-based targeting and intraoperative microelectrode recording strategies. There is an increasing body of literature on GPi DBS in patients with PD suggesting both short- and long-term benefits. Understanding the GPi target can be useful in choosing between the subthalamic (STN), GPi and ventralis intermedius nucleus as lead locations to address the motor symptoms and complications of PD. CONCLUSION GPi DBS can be effectively used in select cases of PD. As the ongoing DBS target debate continues (GPi vs. STN as DBS target), clinicians should keep in mind that GPi DBS has been shown to be an effective treatment strategy for a variety of symptoms, including bradykinesia, rigidity and tremor control. GPi DBS also has an important, direct anti-dyskinetic effect. GPi DBS is easier to program in the outpatient setting and will allow for more flexibility in medication adjustments (e.g. levodopa). Emerging technologies, including GPi closed-loop systems, advanced tractography-based targeting and enhanced programming strategies, will likely be future areas of GPi DBS expansion. We conclude that although the GPi as DBS target may not be appropriate for all PD patients, it has specific clinical advantages.
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Affiliation(s)
- Ka Loong Kelvin Au
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
| | - Joshua K Wong
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Takashi Tsuboi
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Robert S Eisinger
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Kathryn Moore
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | | | - Marshall T Holland
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Vanessa M Holanda
- Center of Neurology and Neurosurgery Associates (CENNA), Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Department of Neurosurgery, Mayo Clinic Jackonsville, Jacksonville, FL, USA
| | - Zhongxing Peng-Chen
- Facultad de Medicina Clínica Alemana, Hospital Padre Hurtado-Universidad del Desarrollo, Santiago, Chile
| | - Addie Patterson
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Kelly D Foote
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Adolfo Ramirez-Zamora
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Leonardo Almeida
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
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Costanza A, Radomska M, Bondolfi G, Zenga F, Amerio A, Aguglia A, Serafini G, Amore M, Berardelli I, Pompili M, Nguyen KD. Suicidality Associated With Deep Brain Stimulation in Extrapyramidal Diseases: A Critical Review and Hypotheses on Neuroanatomical and Neuroimmune Mechanisms. Front Integr Neurosci 2021; 15:632249. [PMID: 33897384 PMCID: PMC8060445 DOI: 10.3389/fnint.2021.632249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 03/15/2021] [Indexed: 12/13/2022] Open
Abstract
Deep brain stimulation (DBS) is a very well-established and effective treatment for patients with extrapyramidal diseases. Despite its generally favorable clinical efficacy, some undesirable outcomes associated with DBS have been reported. Among such complications are incidences of suicidal ideation (SI) and behavior (SB) in patients undergoing this neurosurgical procedure. However, causal associations between DBS and increased suicide risk are not demonstrated and they constitute a debated issue. In light of these observations, the main objective of this work is to provide a comprehensive and unbiased overview of the literature on suicide risk in patients who received subthalamic nucleus (STN) and internal part of globus pallidum (GPi) DBS treatment. Additionally, putative mechanisms that might be involved in the development of SI and SB in these patients as well as caveats associated with these hypotheses are introduced. Finally, we briefly propose some clinical implications, including therapeutic strategies addressing these potential disease mechanisms. While a mechanistic connection between DBS and suicidality remains a controversial topic that requires further investigation, it is of critical importance to consider suicide risk as an integral component of candidate selection and post-operative care in DBS.
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Affiliation(s)
- Alessandra Costanza
- Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland.,Department of Psychiatry, ASO Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Michalina Radomska
- Faculty of Psychology, University of Geneva (UNIGE), Geneva, Switzerland
| | - Guido Bondolfi
- Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland.,Department of Psychiatry, Service of Liaison Psychiatry and Crisis Intervention (SPLIC), Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Francesco Zenga
- Department of Neurosurgery, University and City of Health and Science Hospital, Turin, Italy
| | - Andrea Amerio
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Genova, Italy.,Department of Psychiatry, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Mood Disorders Program, Tufts Medical Center, Boston, MA, United States
| | - Andrea Aguglia
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Genova, Italy.,Department of Psychiatry, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gianluca Serafini
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Genova, Italy.,Department of Psychiatry, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Mario Amore
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Genova, Italy.,Department of Psychiatry, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Isabella Berardelli
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Khoa D Nguyen
- Department of Microbiology and Immunology, Stanford University, Palo Alto, CA, United States.,Tranquis Therapeutics, Palo Alto, CA, United States.,Hong Kong University of Science and Technology, Hong Kong, China
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12
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Azevedo P, Aquino CC, Fasano A. Surgical Management of Parkinson's Disease in the Elderly. Mov Disord Clin Pract 2021; 8:500-509. [PMID: 33981782 DOI: 10.1002/mdc3.13161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/11/2021] [Accepted: 01/19/2021] [Indexed: 11/09/2022] Open
Abstract
Background Deep Brain Stimulation (DBS) is an increasingly popular therapy for Parkinson's Disease (PD). Despite the experience gained over time with DBS of either the subthalamus or the globus pallidus pars interna, there is still no consensus regarding the age limit for DBS indication. Objectives This narrative review of the literature discusses the issues of age and DBS, emphasizing the critical need for good quality evidence to support the surgical management of elderly patients with PD. Methods We searched PubMed using the terms Parkinson's Disease; Parkinson's Disease therapy; deep brain stimulation; antiparkinsonian agents therapeutic use; age factors; aged; aged, 80 and over; middle aged; treatment outcome; and risk assessments. Results We identified several limitations of the available evidence, such as under-representation of older patients in DBS studies, small sample sizes in studies with older participants, heterogeneity of outcomes, and conflicting results. Conclusions Despite preliminary suggestions that age might affect the outcomes of DBS, the evidence to support the hypothesis of age as an independent predictor of DBS outcomes is limited and results are controversial. Ultimately, finding an age-independent biomarker predicting DBS outcome is the final goal to expand this powerful treatment to all patients age in an effective and safe manner.
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Affiliation(s)
- Paula Azevedo
- Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Division of Neurology University of Toronto Toronto Ontario Canada
| | - Camila C Aquino
- Department of Clinical Neurosciences University of Calgary Calgary Alberta Canada.,Hotchkiss Brain Institute, University of Calgary Calgary Alberta Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Division of Neurology University of Toronto Toronto Ontario Canada.,Krembil Brain Institute Toronto Ontario Canada.,CenteR for Advancing Neurotechnological Innovation to Application (CRANIA) Toronto Ontario Canada
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13
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Lu C, Amundsen Huffmaster SL, Louie KH, Lowe R, Abulu R, McGovern R, Vitek JL, MacKinnon CD, Cooper SE. Comparison of forward and backward postural perturbations in mild-to-moderate Parkinson's disease. Gait Posture 2021; 84:205-208. [PMID: 33360643 PMCID: PMC7902457 DOI: 10.1016/j.gaitpost.2020.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Assessing postural stability in Parkinson's disease (PD) often relies on measuring the stepping response to an imposed postural perturbation. The standard clinical technique relies on a brisk backwards pull at the shoulders by the examiner and judgement by a trained rater. In research settings, various quantitative measures and perturbation directions have been tested, but it is unclear which metrics and perturbation direction differ most between people with PD and controls. OBJECTIVES (1) Use standardized forward vs. backward perturbations of a support surface to evaluate reactive stepping performance between PD and control participants. (2) Evaluate the utility of using principal components analysis to capture the dynamics of the reactive response and differences between groups. METHODS Sixty-two individuals participated (40 mild-to-moderate PD, off medication). Standardized rapid translations of the support surface were applied, requiring at least one step, backward or forward, to restore balance. The number of steps taken and the projection of the first principal component (PC1) of the center of pressure (COP) time series were entered in linear repeated-measures mixed effect models. RESULTS Forward falls required significantly fewer steps to recover than backward falls. PC1 captured more than half of the variance in the COP trajectory. Analysis of the PC1 projection revealed a significant interaction effect of group (PD vs. controls) by direction, such that there was a group difference in forward stepping, but not backward. SIGNIFICANCE Forward reactive stepping in PD differed from controls more than backward-stepping. PC1 projections of the COP trajectory capture the dynamics of the postural response and differ between PD and controls.
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Affiliation(s)
- Chiahao Lu
- Department of Neurology, University of Minnesota, 516 Delaware Street SE, Minneapolis, MN 55455, United States
| | | | - Kenneth H. Louie
- Department of Biomedical Engineering, University of Minnesota, 7-105 Hasselmo Hall 312 Church Street SE, Minneapolis, MN 55455, United States
| | - Robert Lowe
- Department of Neurology, University of Minnesota, 516 Delaware Street SE, Minneapolis, MN 55455, United States
| | - Reme Abulu
- Department of Neurology, University of Minnesota, 516 Delaware Street SE, Minneapolis, MN 55455, United States
| | - Robert McGovern
- Department of Neurosurgery, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, United States
| | - Jerrold L. Vitek
- Department of Neurology, University of Minnesota, 516 Delaware Street SE, Minneapolis, MN 55455, United States
| | - Colum D. MacKinnon
- Department of Neurology, University of Minnesota, 516 Delaware Street SE, Minneapolis, MN 55455, United States
| | - Scott E. Cooper
- Department of Neurology, University of Minnesota, 516 Delaware Street SE, Minneapolis, MN 55455, United States
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14
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Hurt CP, Kuhman DJ, Guthrie BL, Lima CR, Wade M, Walker HC. Walking Speed Reliably Measures Clinically Significant Changes in Gait by Directional Deep Brain Stimulation. Front Hum Neurosci 2021; 14:618366. [PMID: 33584227 PMCID: PMC7879982 DOI: 10.3389/fnhum.2020.618366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/17/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction: Although deep brain stimulation (DBS) often improves levodopa-responsive gait symptoms, robust therapies for gait dysfunction from Parkinson's disease (PD) remain a major unmet need. Walking speed could represent a simple, integrated tool to assess DBS efficacy but is often not examined systematically or quantitatively during DBS programming. Here we investigate the reliability and functional significance of changes in gait by directional DBS in the subthalamic nucleus. Methods: Nineteen patients underwent unilateral subthalamic nucleus DBS surgery with an eight-contact directional lead (1-3-3-1 configuration) in the most severely affected hemisphere. They arrived off dopaminergic medications >12 h preoperatively and for device activation 1 month after surgery. We measured a comfortable walking speed using an instrumented walkway with DBS off and at each of 10 stimulation configurations (six directional contacts, two virtual rings, and two circular rings) at the midpoint of the therapeutic window. Repeated measures of ANOVA contrasted preoperative vs. maximum and minimum walking speeds across DBS configurations during device activation. Intraclass correlation coefficients examined walking speed reliability across the four trials within each DBS configuration. We also investigated whether changes in walking speed related to modification of step length vs. cadence with a one-sample t-test. Results: Mean comfortable walking speed improved significantly with DBS on vs. both DBS off and minimum speeds with DBS on (p < 0.001, respectively). Pairwise comparisons showed no significant difference between DBS off and minimum comfortable walking speed with DBS on (p = 1.000). Intraclass correlations were ≥0.949 within each condition. Changes in comfortable walk speed were conferred primarily by changes in step length (p < 0.004). Conclusion: Acute assessment of walking speed is a reliable, clinically meaningful measure of gait function during DBS activation. Directional and circular unilateral subthalamic DBS in appropriate configurations elicit acute and clinically significant improvements in gait dysfunction related to PD. Next-generation directional DBS technologies have significant potential to enhance gait by individually tailoring stimulation parameters to optimize efficacy.
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Affiliation(s)
- Christopher P Hurt
- Rehabilitation Sciences, University of Alabama at Birmingham, Birmingham, AL, United States.,Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Daniel J Kuhman
- Rehabilitation Sciences, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Barton L Guthrie
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Carla R Lima
- Rehabilitation Sciences, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Melissa Wade
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Harrison C Walker
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States.,Department of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL, United States
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15
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Ando S, Kanazawa M, Onodera O. Progressive Supranuclear Palsy with Predominant Cerebellar Ataxia. J Mov Disord 2019; 13:20-26. [PMID: 31847511 PMCID: PMC6987520 DOI: 10.14802/jmd.19061] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/05/2019] [Indexed: 12/11/2022] Open
Abstract
Progressive supranuclear palsy (PSP) is characterized by supranuclear gaze palsy, dystonic rigidity of the neck and upper trunk, frequent falls and mild cognitive impairment. Cerebellar ataxia is one of the exclusion criteria given by the National Institute of Neurological Disorders and Stroke and the Society for Progressive Supranuclear Palsy. As a result, pathologically proven PSP patients exhibiting cerebellar ataxia have often been misdiagnosed with spinocerebellar degeneration, specifically multiple system atrophy with predominant cerebellar ataxia (MSA-C). However, more recently, it has been recognized that patients with PSP can present with truncal and limb ataxia as their initial symptom and/or main manifestation. These patients can be classified as having PSP with predominant cerebellar ataxia (PSP-C), a new subtype of PSP. Since the development of this classification, patients with PSP-C have been identified primarily in Asian countries, and it has been noted that this condition is very rare in Western communities. Furthermore, the clinical features of PSP-C have been identified, enabling it to be distinguished from other subtypes of PSP and MSA-C. In this review, we describe the clinical and neuropathological features of PSP-C. The hypothesized pathophysiology of cerebellar ataxia in PSP-C is also discussed.
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Affiliation(s)
- Shoichiro Ando
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masato Kanazawa
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
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16
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Mao Z, Ling Z, Pan L, Xu X, Cui Z, Liang S, Yu X. Comparison of Efficacy of Deep Brain Stimulation of Different Targets in Parkinson's Disease: A Network Meta-Analysis. Front Aging Neurosci 2019; 11:23. [PMID: 30853908 PMCID: PMC6395396 DOI: 10.3389/fnagi.2019.00023] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/28/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Deep brain stimulation (DBS) is considered an effective treatment option for Parkinson's disease (PD). Several studies have demonstrated the efficacy of neurostimulation in patients with advanced PD. The subthalamic nucleus (STN), the internal globus pallidus (GPi), ventral intermediate nucleus (Vim), and pedunculopontine nucleus (PPN) are reportedly effective DBS targets for control of Parkinsonian tremors. However, there is no consensus on the ideal target for DBS in patients with Parkinson's disease. Only a few studies have directly compared the efficacy of DBS of the Vim, STN, and GPi. Therefore, we searched PubMed, Embase, Cochrane Library, and other databases for observational studies, extracted data on unified Parkinson's disease rating scale (UPDRS) scores and performed a comprehensive network meta-analysis of different strategies of DBS and compared the efficiency of DBS at different targets. Methods: Forest plot was used to examine the overall efficiency of DBS; cumulative probability value was used to rank the strategies under examination. A node-splitting model was employed to assess consistency of reported outcomes inconsistency. A total of 16 studies which focused on UPDRS improvement were included in the network meta-analysis. Results: By comparing the overall efficiency associated with each target, we confirmed the efficacy of DBS therapy in PD. Our findings revealed similar efficacy of DBS targeted at GPi and STN in the on-medication phase [GPi-3.9 (95% CI -7.0 to -0.96); STN-3.1 (-5.9 to -0.38)]; however, in the off-medication phase, Vim-targeted DBS was associated with better improvement in UPDRS scores and could be a choice as a DBS target for tremor-dominant Parkinsonism. Conclusions: Our findings will help improve clinical application of DBS.
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Affiliation(s)
- Zhiqi Mao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Zhipei Ling
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Longsheng Pan
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Zhiqiang Cui
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Shuli Liang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xinguang Yu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
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17
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Mancini M, Horak FB. Potential of APDM mobility lab for the monitoring of the progression of Parkinson's disease. Expert Rev Med Devices 2017; 13:455-62. [PMID: 26872510 DOI: 10.1586/17434440.2016.1153421] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
APDM's Mobility Lab system provides portable, validated, reliable, objective measures of balance and gait that are sensitive to Parkinson's disease (PD). In this review, we describe the potential of objective measures collected with the Mobility Lab system for tracking longitudinal progression of PD. Balance and gait are among the most important motor impairments influencing quality of life for people with PD. Mobility Lab uses body-worn, Opal sensors on the legs, trunk and arms during prescribed tasks, such as the instrumented Get Up and Go test or quiet stance, to quickly quantify the quality of balance and gait in the clinical environment. The same Opal sensors can be sent home with patients to continuously monitor the quality of their daily activities. Objective measures have the potential to monitor progression of mobility impairments in PD throughout its course to improve patient care and accelerate clinical trials.
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Affiliation(s)
- Martina Mancini
- a Veterans Affairs Portland Healthcare System (VAPORHCS) , Portland , OR , USA.,b Department of Neurology , Oregon Health & Science University , Portland , OR , USA
| | - Fay B Horak
- a Veterans Affairs Portland Healthcare System (VAPORHCS) , Portland , OR , USA.,b Department of Neurology , Oregon Health & Science University , Portland , OR , USA
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18
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Schlenstedt C, Shalash A, Muthuraman M, Falk D, Witt K, Deuschl G. Effect of high-frequency subthalamic neurostimulation on gait and freezing of gait in Parkinson's disease: a systematic review and meta-analysis. Eur J Neurol 2016; 24:18-26. [PMID: 27766724 DOI: 10.1111/ene.13167] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/29/2016] [Indexed: 01/18/2023]
Abstract
The aim of this meta-analysis was to summarize the short- and long-term effects of bilateral deep brain stimulation of the subthalamic nucleus (STN-DBS) on gait and freezing of gait (FOG) in Parkinson's disease and to detect predictors of post-stimulation outcome. A comprehensive review of the literature was conducted up to October 2015 using Medline Ovid databases for studies analyzing the effect of bilateral STN-DBS on FOG and/or gait. Sixteen studies with available data for the gait item (no. 29) of the Unified Parkinson's Disease Rating Scale (UPDRS) and six studies with the FOG item (no. 14) were included. Data were summarized for the following follow-up periods: 6-15, 24-48 and >48 months. For the medication (Med)-Off/stimulation(Stim)-On condition compared with baseline Med-Off, STN-DBS significantly improved gait on average from 2.43 to 0.96, 2.53 to 1.31 and 2.56 to 1.40 points at 6-15, 24-48 and >48 months, respectively (P < 0.05). Pre-operative levodopa responsiveness of UPDRS-III and Med-Off severity of gait were the predictors of this beneficial effect. STN-DBS significantly improved FOG for the Med-Off/Stim-On condition compared with baseline on average from 2.26 to 0.82, 2.43 to 1.13 and 2.48 to 1.38 points at 6-15, 24-48 and >48 months, respectively (P < 0.05). There was no significant effect in the Med-On/Stim-On condition. This meta-analysis showed a robust improvement of gait and FOG by STN-DBS for more than 4 years in the Med-Off/Stim-On condition. No beneficial effect was found for the On state of medication. Pre-operative levodopa responsiveness of global motor performance (UPDRS-III) is the strongest predictor of the effect of deep brain stimulation on gait.
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Affiliation(s)
- C Schlenstedt
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | - A Shalash
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany.,Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - M Muthuraman
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany.,Department of Neurology, Johannes Gutenberg University, Mainz, Germany
| | - D Falk
- Department of Neurosurgery, Christian-Albrechts-University, Kiel, Germany
| | - K Witt
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | - G Deuschl
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
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19
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Peterson DS, Horak FB. The Effect of Levodopa on Improvements in Protective Stepping in People With Parkinson's Disease. Neurorehabil Neural Repair 2016; 30:931-940. [PMID: 27162165 DOI: 10.1177/1545968316648669] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The effect of levodopa on postural motor learning in people with Parkinson's disease is poorly understood. In particular, it is unknown whether levodopa affects improvement in protective postural responses after external perturbations such as a slip or trip, a critical aspect of fall prevention. Objective Determine the effect of levodopa on postural motor learning in people with Parkinson's disease. Methods We assessed improvement in protective postural responses in people with Parkinson's disease over short-term (1 day) perturbation training on and off levodopa. We also assessed retention and generalization of improvement. Participants were 22 individuals with Parkinson's disease. The primary outcome was total center of mass (COM) displacement after perturbation. Secondary outcomes assessed first step performance and included margin of stability at first foot contact. Results People with Parkinson's disease improved COM displacement (P = .011) and margin of stability (P = .016) over training. Improvements in these outcomes were more pronounced after training while on levodopa than off levodopa. Levodopa State × Training interactions were not observed for other step performance variables (eg, step latency, length, total number of steps). Improvements were retained for 24 hours, and for margin of stability, retention was more pronounced while on levodopa than off (P = .018). Conclusions Individuals with Parkinson's disease are able to improve protective postural responses through short-term perturbation training, and improvements were more pronounced when on levodopa for some variables. Perturbation training may be more effective if completed while optimally medicated with levodopa.
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Affiliation(s)
- Daniel S Peterson
- Veterans Affairs Portland Health Care System (VAPORHCS), Portland, OR, USA Oregon Health and Science University, Portland, OR, USA University of Utah, Salt Lake City, UT, USA
| | - Fay B Horak
- Veterans Affairs Portland Health Care System (VAPORHCS), Portland, OR, USA Oregon Health and Science University, Portland, OR, USA
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20
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Xu F, Ma W, Huang Y, Qiu Z, Sun L. Deep brain stimulation of pallidal versus subthalamic for patients with Parkinson's disease: a meta-analysis of controlled clinical trials. Neuropsychiatr Dis Treat 2016; 12:1435-44. [PMID: 27382286 PMCID: PMC4922776 DOI: 10.2147/ndt.s105513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Parkinson's disease (PD) is a common neurodegenerative disorder that affects many people every year. Deep brain stimulation (DBS) is an effective nonpharmacological method to treat PD motor symptoms. This meta-analysis was conducted to evaluate the efficacy of subthalamic nucleus (STN)-DBS versus globus pallidus internus (GPi)-DBS in treating advanced PD. METHODS Controlled clinical trials that compared STN-DBS to GPi-DBS for short-term treatment of PD in adults were researched up to November 2015. The primary outcomes were the Unified Parkinson's Disease Rating Scale Section (UPDRS) III score and the levodopa-equivalent dosage (LED) after DBS. The secondary outcomes were the UPDRS II score and the Beck Depression Inventory (BDI) score. RESULTS Totally, 13 studies containing 1,148 PD patients were included in this meta-analysis to compare STN-DBS versus GPi-DBS. During the off-medication state, the pooled weighted mean difference (WMD) of UPDRS III and II scores were -2.18 (95% CI =-5.11 to 0.74) and -1.96 (95% CI =-3.84 to -0.08), respectively. During the on-medication state, the pooled WMD of UPDRS III and II scores were 0.15 (95% CI =-1.14 to 1.44) and 1.01 (95% CI =0.12 to 1.89), respectively. After DBS, the pooled WMD of LED and BDI were -254.48 (95% CI =-341.66) and 2.29 (95% CI =0.83 to 3.75), respectively. CONCLUSION These results indicate that during the off-medication state, the STN-DBS might be superior to GPi-DBS in improving the motor function and activities of daily living for PD patients; but during the on-medication state, the opposite result is observed. Meanwhile, the STN-DBS is superior at reducing the LED, whereas the GPi-DBS shows a significantly greater reduction in BDI score after DBS.
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Affiliation(s)
- Fan Xu
- Interdisciplinary Division of Biomedical Engineering, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, People's Republic of China
| | - Wenbin Ma
- Department of Neurology, Binzhou Medical University Hospital, Binzhou, Shandong, People's Republic of China
| | - Yongmin Huang
- Interdisciplinary Division of Biomedical Engineering, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, People's Republic of China
| | - Zhihai Qiu
- Interdisciplinary Division of Biomedical Engineering, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, People's Republic of China
| | - Lei Sun
- Interdisciplinary Division of Biomedical Engineering, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, People's Republic of China
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