Most recent publication – Rapid Assessment of Gait and Speech

Surgical Neurology International

Sierra M. Farris, Monique L. Giroux

August 2, 2016

Rapid Assessment of Gait and Speech after Subthalamic DBS

Background: Describe a rapid assessment for patients with idiopathic Parkinson’s disease (PD) and deep brain stimulation of the subthalamic nucleus reporting worsening speech and/or gait problems.

Methods: We retrospectively reviewed 29 patients that had improvement in gait and/or speech within 30 min after turning stimulation off. Clinical data analyzed include unified PD rating scale motor scores and stimulation parameters before and after adjusting stimulation. All patients received electrode efficacy and side effect threshold testing. Stimulation parameters were adjusted to maximize efficacy, avoid side effects, and maximize battery longevity.

Results: Turning stimulation off revealed reversible speech and/or gait stimulation side effects within 30 min. Focusing on six factors revealed stimulation modifications that improved motor symptoms, eliminated stimulation side effects, and reduced battery drain. Primary stimulation parameters modified were cathode selection and pulse width reduction.

Conclusions: Stimulation-induced side effects impacting gait and speech can be identified within 30 min. A systematic evaluation can distinguish disease progression from reversible stimulation side effects and improve motor outcomes over the long term.

Publication is open access. Link.

Considering DBS Earlier in Parkinson’s

Deep brain stimulation (DBS) improves overall quality of life and social functioning in patients in earlier stages of Parkinson’s disease, according to results of a two-year clinical trial.

The study, led by Günther Deuschl, a professor at Christian-Albrechts-University in Kiel, Germany, and Yves Agid, a professor in neurology and experimental medicine at the Hôpital de la Salpêtrière in Paris, France, is reported online in the New England Journal of Medicine on 14 February 2014. The researchers conclude that DBS was more effective than medical treatment in patients with Parkinson’s disease and early motor complications.

DBS is already established as a treatment for patients with advanced Parkinson’s disease.

It is not a cure, and it does not stop the disease from progressing, but in the right patients, it can significantly improve symptoms, especially tremors, and it can also relieve muscle rigidity. To perform DBS, the neurosurgeon drills a hole in the skull and inserts an electrode about 10 cm into the brain. The electrode delivers mild electrical signals that disrupt and block the brain impulses that cause Parkinson’s symptoms. A wire under the skin connects the electrode to a battery implanted near the collarbone. DBS can be done on one or both sides of the brain. The target areas are usually the thalamus, subthalamic nucleus, and globus pallidus. In this study, the target area was the thalamus.

The Study

The purpose of the 2-year clinical trial, called EARLYSTIM, was to assess the use of DBS in earlier stages of Parkinson’s disease, when “motor complications have just developed and before patients are significantly affected in their social and occupational functioning”. The study recruited 251 patients with early motor complications and randomly assigned them to receive either DBS or best medical treatment. The patients were of average age 52 and had had the condition for an average of 7.5 years. To measure effectiveness of the treatment, the researchers assessed quality of life measures from a questionnaire known as PDQ-39, and social functioning from a short psychosocial questionnaire known as SCOPA-PS. They assessed changes in key areas of motor disability and activities of daily living using the scale UPDRS II. They also assessed any improvements in complications resulting from use of Levodopa, one of the main drugs used to treat Parkinson’s.

Overall Results Show DBS Superior to Medical Therapy

The results showed that patients who received DBS had a 26% improvement in quality of life scores compared with no improvement in the medical treatment group. There was a similar result for social functioning. The results also showed that compared to medical therapy, DBS was significantly superior to medical treatment with respect to motor disability, activities of daily living, levodopa-induced motor complications, and time with good mobility and no dyskinesia.

Among adverse side effects, suicide or attempts at suicide were not very different in the two groups, suggesting the cause lies with the patients rather than the type of treatment, something that is important to take into account in patient counseling, note the authors. Deuschl says in a statement:

“The study showed surprisingly homogeneous results in favor of DBS compared with medical treatment. The most important result is that quality of life of these patients and their social functioning was significantly improved. It is also meaningful that the operation has fewer side effects in this younger population than in advanced disease,” he adds.

Implications

Deuschl suggests that the study has the “potential to change the international guidelines for the treatment of Parkinson’s disease and will put DBS as a treatment option at a much earlier stage of disease severity.” In an accompanying editorial, Caroline Tanner, an epidemiologist who lectures in health research and policy at Stanford University, describes the study as “one of the most rigorously conducted trials of neurostimulation”. However, she warns that the patients in the trial were not typical Parkinson’s patients: they were all under 60 years old when they underwent the surgery, they didn’t have dementia, and on the whole they responded well to the medication. Matthew Stern, Parker Family Professor of Neurology at the University of Pennsylvania, says: “While it is premature to recommend DBS to all patients with motor complications, particularly earlier in the course of PD, it can now be considered a treatment option in this group of individuals.” He says these results “will surely fuel the debate on the impact of DBS on disease progression further and underscores the need for long term follow up of the EARLYSTIM patients”.

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Deep Brain Stimulation Problems & Failures

Deep Brain Stimulation Problems & DBS Failures     Download Post

MANAGING DBS PROBLEMS & FAILURES AFTER DEEP BRAIN STIMULATION SURGERY

Sierra Farris, MA, MPAS, PA-C

Deep brain stimulation (DBS) is a surgical treatment for movement problems associated with Parkinson’s disease, tremor or dystonia. DBS is very effective in controlling many symptoms related to abnormal movement; however dissatisfaction with the therapy can occur at any time after surgery. Expectations for DBS are generally high as is the risks of having brain surgery. Expectations beyond what the therapy can provide are a high source of patient and family dissatisfaction. Adequate pre-surgical counseling is a key step in assuring you and your patient are in agreement about the expected benefit and risks associated with DBS.

When and where to pursue DBS Troubleshooting

Common causes of DBS failures, problems or dissatisfaction:

  • Inadequate or inappropriate adjustment to stimulation
  • Disease progression
  • Damaged DBS hardware or depleted battery
  • Inadequate placement of the implanted electrodes
  • Inadequate medications or expectations
  • Inappropriate diagnosis
  • DBS done too late to achieve optimal benefit

Our DBS Troubleshooting Clinic is a unique multi-day clinic for individuals with DBS seeking a second opinion about programming, determining adequate medication dosing and/or to investigate problems from stimulation or the hardware. Multiple visits with our team may be required to complete the assessment. All visits are tailored to each individual to investigate the cause(s) of dissatisfaction or ineffectiveness of DBS. 

We summarized the results from 50 people seen for troubleshooting below.

Problems ranged (in order of prevalence) from walking/balance, Off time, falls, speech, tremor dyskinesia and no improvement were the most common reasons for troubleshooting. These symptoms are commonly associated with disease progression and may not be investigated after DBS. We have learned from our troubleshooting experience that many symptoms that worsen after DBS can still be improved with careful and meticulous evaluation of the variables that can lead to worsening symptoms. Dr. Monique Giroux and Sierra Farris work together to find solutions to the many problems that can occur months to years after DBS surgery. Some patients will see a physical therapist or speech therapist to help fine tune the stimulation settings for optimal benefit.

Symptoms commonly associated with disease progression can be improved with therapeutic stimulation settings such as speech, walking, stiffness, slowness tremor and balance. Some people did not experience an improvement in symptoms including gait freezing, falls and balance, however, what is obvious in our results is sub-optimal stimulation settings can definitely worsen a person’s symptoms. Some of the patients in this series had DBS for over 5 years but were still improved with reprogramming. We feel that patients should have a thorough evaluation for worsening symptoms no matter how long they have had DBS.

We also believe patients should have confidence that the DBS is working as well as possible to be free of the concerns and stress that can accompany uncertainty. We include an evaluation and discussion about what should be expected from DBS and review the steps if DBS is not performing as expected. Our troubleshooting evaluation includes a medical consultation and structured DBS programming strategies to optimize benefit while avoiding or eliminating stimulation side effects. Surgical consultation is coordinated if indicated.

Read about three incredible individuals living with Parkinson’s disease that were seen in our troubleshooting clinic. Each was determined to find solutions for their unsuccessful DBS surgery and disability from stimulation side effects. You will read about amazing recoveries after proper programming and a new lease on life after revision surgery. Meet Charlene. Meet Dean. Meet Bill.

A pre-appointment consultation is available to patients who would like to discuss their concerns prior to setting up appointments for DBS troubleshooting. Call Celina Romero at 303-781-0511 for special instructions. We require brain imaging and surgical reports prior to scheduling to make sure we optimize Sierra’s time with you during the appointments. Average length of evaluation is 3 days. We have served many patients that live out of state. Learn more about our Comprehensive DBS Services or Sierra Farris, PA-C.