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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Piepjohn P, Bald C, Kuhlenbäumer G, Becktepe JS, Deuschl G, Schmidt G. Real-time classification of movement patterns of tremor patients. BIOMED ENG-BIOMED TE 2022; 67:119-130. [PMID: 35218686 DOI: 10.1515/bmt-2021-0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 01/27/2022] [Indexed: 11/15/2022]
Abstract
The process of diagnosing tremor patients often leads to misdiagnoses. Therefore, existing technical methods for analysing tremor are needed to more effectively distinguish between different diseases. For this purpose, a system has been developed that classifies measured tremor signals in real time. To achieve this, the hand tremor of 561 subjects has been measured in different hand positions. Acceleration and surface electromyography are recorded during the examination. For this study, data from subjects with Parkinson's Disease, Essential Tremor, and physiological tremor are considered. In a first signal analysis feature extraction is performed, and the resulting features are examined for their discriminative value. In a second step, three classification models based on different pattern recognition techniques are developed to classify the subjects with respect to their tremor type. With a trained decision tree, the three tremor types can be classified with a relative diagnostic accuracy of 83.14%. A neural network achieves 84.24% and the combination of both classifiers yields a relative diagnostic accuracy of 85.76%. The approach is promising and involving more features of the recorded time series will improve the discriminative value.
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Affiliation(s)
- Patricia Piepjohn
- Faculty of Engineering, Institute of Electrical and Information Engineering, Digital Signal Processing and System Theory, Kiel University, Kiel, Germany
| | - Christin Bald
- Faculty of Engineering, Institute of Electrical and Information Engineering, Digital Signal Processing and System Theory, Kiel University, Kiel, Germany
| | - Gregor Kuhlenbäumer
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | - Günther Deuschl
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Gerhard Schmidt
- Faculty of Engineering, Institute of Electrical and Information Engineering, Digital Signal Processing and System Theory, Kiel University, Kiel, Germany
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Seuthe J, D'Cruz N, Ginis P, Becktepe JS, Weisser B, Nieuwboer A, Schlenstedt C. The Effect of One Session Split-Belt Treadmill Training on Gait Adaptation in People With Parkinson's Disease and Freezing of Gait. Neurorehabil Neural Repair 2020; 34:954-963. [PMID: 32940131 DOI: 10.1177/1545968320953144] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Freezing of gait (FOG) in Parkinson's disease (PD) is associated with gait asymmetry and switching difficulty. A split-belt treadmill may potentially address those deficits. OBJECTIVE To investigate the immediate and retention effects of one-session split-belt treadmill training (SBT) in contrast to regular tied-belt treadmill training (TBT) on gait asymmetry and adaptation in people with PD and FOG (PD + FOG) and healthy controls (HC). Additionally, to investigate differential effects of 3 SBT protocols and compare different gait adaptation outcomes. METHODS PD + FOG (n = 45) and HC (n = 36) were randomized to 1 of 3 SBT groups (belt speeds' ratio 0.75:1; 0.5:1 or changing ratios) or TBT group. Participants were tested at Pre, Post, and Retention after one treadmill training session. Gait asymmetry was measured during a standardized adaptation test on the split-belt treadmill. RESULTS SBT proved beneficial for gait adaptation in PD + FOG and HC (P < .0001); however, HC improved more. SBT with changing ratios demonstrated significant effects on gait adaptation from Pre to Post in PD + FOG, supported by strong effect sizes (d = 1.14) and improvements being retained for 24 hours. Mean step length asymmetry during initial exposure was lower in HC compared with PD + FOG (P = .035) and differentiated best between the groups. CONCLUSIONS PD + FOG improved gait adaptation after a single SBT session although effects were smaller than in HC. SBT with changing ratios was the most effective to ameliorate gait adaptation in PD + FOG. These promising results warrant future study on whether long-term SBT strengthens adaptation in PD + FOG and has potential to induce a better resilience to FOG. Clinical trial ID: NCT03725215.
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Affiliation(s)
- Jana Seuthe
- University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany.,Christian-Albrechts-University, Kiel, Germany
| | | | | | - Jos Steffen Becktepe
- University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | | | | | - Christian Schlenstedt
- University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
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Rempe T, Becktepe JS, Metz I, Brück W, Stürner KH, Deuschl G, Berg D, Baron R, Zeuner R, Leypoldt F. A case of CLIPPERS syndrome responsive to tocilizumab. Neurol Neuroimmunol Neuroinflamm 2019; 6:e545. [PMID: 30882019 PMCID: PMC6410928 DOI: 10.1212/nxi.0000000000000545] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/08/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Torge Rempe
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Jos Steffen Becktepe
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Imke Metz
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Wolfgang Brück
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Klarissa Hanja Stürner
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Günther Deuschl
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Daniela Berg
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Ralf Baron
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Rainald Zeuner
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Frank Leypoldt
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
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Abstract
Tremor is the most common movement disorder characterized by a rhythmical, involuntary oscillatory movement of a body part. Since distinct diseases can cause similar tremor manifestations and vice-versa, it is challenging to make an accurate diagnosis. This applies particularly for tremor at rest. This entity was only rarely studied in the past, although a multitude of clinical studies on prevalence and clinical features of tremor in Parkinson's disease (PD), essential tremor and dystonia, have been carried out. Monosymptomatic rest tremor has been further separated from tremor-dominated PD. Rest tremor is also found in dystonic tremor, essential tremor with a rest component, Holmes tremor and a few even rarer conditions. Dopamine transporter imaging and several electrophysiological methods provide additional clues for tremor differential diagnosis. New evidence from neuroimaging and electrophysiological studies has broadened our knowledge on the pathophysiology of Parkinsonian and non-Parkinsonian tremor. Large cohort studies are warranted in future to explore the nature course and biological basis of tremor in common tremor related disorders.
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Affiliation(s)
- Wei Chen
- Department of Neurology, Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 200011 Shanghai, China.,Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Christian-Albrechts-University, Rosalind Franklinstr.10, 24105 Kiel, Germany
| | - Franziska Hopfner
- Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Christian-Albrechts-University, Rosalind Franklinstr.10, 24105 Kiel, Germany
| | - Jos Steffen Becktepe
- Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Christian-Albrechts-University, Rosalind Franklinstr.10, 24105 Kiel, Germany
| | - Günther Deuschl
- Department of Neurology, Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 200011 Shanghai, China.,Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Christian-Albrechts-University, Rosalind Franklinstr.10, 24105 Kiel, Germany
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Abstract
Essential tremor is clinically defined but there is increasing evidence that it is not a unique entity. Its pathophysiology has been studied with many methods but may also vary between subtypes. Neurophysiologically, there is strong evidence that a specific cerebello-thalamo-cortical loop is abnormally oscillating. The cause of its uncontrolled oscillation is not yet understood. The clear proof of a degenerative cause is still lacking and abnormal receptors or other causes of altered non-progressive functional disturbance cannot be excluded. Strong evidence supports the major involvement of the cerebellum and there is ample evidence that GABA is the main neurotransmitter involved in the pathophysiology in ET. Genetics have provided so far only a few rare subtypes which are due to specific mutations but there is no doubt that it is mostly a hereditary condition. There is evidence that the large subgroup of late onset tremor is a separate condition and this tremor is an independent risk factor for earlier mortality and comes with signs of premature aging (aging-related tremor). It will be important to improve phenotyping of patients in more detail possibly to include not only features of the tremor itself but also other clinical assessments like force measurements or cognitive testing. Based on these variables, we may be able to better understand the presumably different mechanisms underlying different variants of the disease.
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Affiliation(s)
- F Gövert
- Department of Neurology, Christian-Albrecht University of Kiel, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Schittenhelmstrasse 10, 24105 Kiel, Germany
| | - J S Becktepe
- Department of Neurology, Christian-Albrecht University of Kiel, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Schittenhelmstrasse 10, 24105 Kiel, Germany
| | - G Deuschl
- Department of Neurology, Christian-Albrecht University of Kiel, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Schittenhelmstrasse 10, 24105 Kiel, Germany.
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