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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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Ramdhani RA, Watts J, Kline M, Fitzpatrick T, Niethammer M, Khojandi A. Differential spatiotemporal gait effects with frequency and dopaminergic modulation in STN-DBS. Front Aging Neurosci 2023; 15:1206533. [PMID: 37842127 PMCID: PMC10570440 DOI: 10.3389/fnagi.2023.1206533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 09/01/2023] [Indexed: 10/17/2023] Open
Abstract
Objective The spatiotemporal gait changes in advanced Parkinson's disease (PD) remain a treatment challenge and have variable responses to L-dopa and subthalamic deep brain stimulation (STN-DBS). The purpose of this study was to determine whether low-frequency STN-DBS (LFS; 60 Hz) elicits a differential response to high-frequency STN-DBS (HFS; 180 Hz) in spatiotemporal gait kinematics. Methods Advanced PD subjects with chronic STN-DBS were evaluated in both the OFF and ON medication states with LFS and HFS stimulation. Randomization of electrode contact pairs and frequency conditions was conducted. Instrumented Stand and Walk assessments were carried out for every stimulation/medication condition. LM-ANOVA was employed for analysis. Results Twenty-two PD subjects participated in the study, with a mean age (SD) of 63.9 years. Significant interactions between frequency (both LFS and HFS) and electrode contact pairs (particularly ventrally located contacts) were observed for both spatial (foot elevation, toe-off angle, stride length) and temporal (foot speed, stance, single limb support (SLS) and foot swing) gait parameters. A synergistic effect was also demonstrated with L-dopa and both HFS and LFS for right SLS, left stance, left foot swing, right toe-off angle, and left arm range of motion. HFS produced significant improvement in trunk and lumbar range of motion compared to LFS. Conclusion The study provides evidence of synergism of L-dopa and STN-DBS on lower limb spatial and temporal measures in advanced PD. HFS and LFS STN-DBS produced equivalent effects among all other tested lower limb gait features. HFS produced significant trunk and lumbar kinematic improvements.
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Affiliation(s)
- Ritesh A. Ramdhani
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Jeremy Watts
- Department of Industrial and Systems Engineering, University of Tennessee, Knoxville, TN, United States
| | - Myriam Kline
- Center for Neurosciences, Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY, United States
| | - Toni Fitzpatrick
- Center for Neurosciences, Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY, United States
| | - Martin Niethammer
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Center for Neurosciences, Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY, United States
| | - Anahita Khojandi
- Department of Industrial and Systems Engineering, University of Tennessee, Knoxville, TN, United States
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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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Langer A, Lucke-Paulig L, Gassner L, Krüger R, Weiss D, Gharabaghi A, Zach H, Maetzler W, Hobert MA. Additive Effect of Dopaminergic Medication on Gait Under Single and Dual-Tasking Is Greater Than of Deep Brain Stimulation in Advanced Parkinson Disease With Long-Duration Deep Brain Stimulation. Neuromodulation 2023; 26:364-373. [PMID: 35227581 DOI: 10.1016/j.neurom.2022.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 12/10/2021] [Accepted: 01/04/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Patients with advanced Parkinson disease (PD) often experience problems with mobility, including walking under single- (ST) and dual-tasking (DT) conditions. The effects of deep brain stimulation in the subthalamic nucleus (DBS) versus dopaminergic medication (Med) on these conditions are not well investigated. MATERIALS AND METHODS We used two ST and two DT-gait paradigms to evaluate the effect of DBS and dopaminergic medication on gait parameters in 14 PD patients (mean age 66 ± 8 years) under DBSOFF/MedON, DBSON/MedOFF, and DBSON/MedON conditions. They performed standardized 20-meter walks with convenient and fast speed. To test DT capabilities, they performed a checking-boxes and a subtraction task during fast-paced walking. Quantitative gait analysis was performed using a tri-axial accelerometer (Dynaport, McRoberts, The Netherlands). Dual-task costs (DTC) of gait parameters and secondary task performance were compared intraindividually between DBSOFF/MedON vs DBSON/MedON, and DBSON/MedOFF vs DBSON/MedON to estimate responsiveness. RESULTS Dopaminergic medication increased gait speed and cadence at convenient speed. It increased cadence and decreased number of steps at fast speed, and improved DTC of cadence during the checking boxes and DTC of cadence and number of steps during the subtraction tasks. DBS only improved DTC of cadence during the checking boxes and DTC of gait speed during the subtraction task. CONCLUSION Dopaminergic medication showed larger additional effects on temporal gait parameters under ST and DT conditions in advanced PD than DBS. These results, after confirmation in independent studies, should be considered in the medical management of advanced PD patients with gait and DT deficits.
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Affiliation(s)
- Agnes Langer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Lara Lucke-Paulig
- Center for Neurology, Hertie Institute for Clinical Brain Research, Department of Neurodegenerative Diseases, University of Tuebingen, Tuebingen, Germany; Department of Endocrinology, Diabetology and Geriatrics, Stuttgart General Hospital, Bad Cannstatt, Germany
| | - Lucia Gassner
- Department of Sport Physiology, Institute of Sports Sciences, University of Vienna, Vienna, Austria; Royal Melbourne Institute of Technology, Melbourne, Australia; HTA Austria - Austrian Institute for Health Technology Assessment GmbH, Vienna, Austria
| | - Rejko Krüger
- Center for Neurology, Hertie Institute for Clinical Brain Research, Department of Neurodegenerative Diseases, University of Tuebingen, Tuebingen, Germany; Luxembourg Institute of Health, Strassen, Luxembourg; Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg; Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Daniel Weiss
- Center for Neurology, Hertie Institute for Clinical Brain Research, Department of Neurodegenerative Diseases, University of Tuebingen, Tuebingen, Germany
| | - Alireza Gharabaghi
- Institute for Neuromodulation and Neurotechnology, Department of Neurosurgery and Neurotechnology, University Hospital Tuebingen, University of Tuebingen, Tuebingen, Germany
| | - Heidemarie Zach
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Walter Maetzler
- Center for Neurology, Hertie Institute for Clinical Brain Research, Department of Neurodegenerative Diseases, University of Tuebingen, Tuebingen, Germany; Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Markus A Hobert
- Center for Neurology, Hertie Institute for Clinical Brain Research, Department of Neurodegenerative Diseases, University of Tuebingen, Tuebingen, Germany; Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Christian-Albrechts-University Kiel, Kiel, Germany.
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Kelemen A, Halász L, Muthuraman M, Erőss L, Barsi P, Zádori D, Laczó B, Kis D, Klivényi P, Fekete G, Bognár L, Bereczki D, Tamás G. Clinical parameters predict the effect of bilateral subthalamic stimulation on dynamic balance parameters during gait in Parkinson's disease. Front Neurol 2022; 13:917187. [PMID: 36226087 PMCID: PMC9549153 DOI: 10.3389/fneur.2022.917187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 08/29/2022] [Indexed: 11/23/2022] Open
Abstract
We investigated the effect of deep brain stimulation on dynamic balance during gait in Parkinson's disease with motion sensor measurements and predicted their values from disease-related factors. We recruited twenty patients with Parkinson's disease treated with bilateral subthalamic stimulation for at least 12 months and 24 healthy controls. Six monitors with three-dimensional gyroscopes and accelerometers were placed on the chest, the lumbar region, the two wrists, and the shins. Patients performed the instrumented Timed Up and Go test in stimulation OFF, stimulation ON, and right- and left-sided stimulation ON conditions. Gait parameters and dynamic balance parameters such as double support, peak turn velocity, and the trunk's range of motion and velocity in three dimensions were analyzed. Age, disease duration, the time elapsed after implantation, the Hoehn-Yahr stage before and after the operation, the levodopa, and stimulation responsiveness were reported. We individually calculated the distance values of stimulation locations from the subthalamic motor center in three dimensions. Sway values of static balance were collected. We compared the gait parameters in the OFF and stimulation ON states and controls. With cluster analysis and a machine-learning-based multiple regression method, we explored the predictive clinical factors for each dynamic balance parameter (with age as a confounder). The arm movements improved the most among gait parameters due to stimulation and the horizontal and sagittal trunk movements. Double support did not change after switching on the stimulation on the group level and did not differ from control values. Individual changes in double support and horizontal range of trunk motion due to stimulation could be predicted from the most disease-related factors and the severity of the disease; the latter also from the stimulation-related changes in the static balance parameters. Physiotherapy should focus on double support and horizontal trunk movements when treating patients with subthalamic deep brain stimulation.
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Affiliation(s)
- Andrea Kelemen
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - László Halász
- National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Muthuraman Muthuraman
- Biomedical Statistics and Multimodal Signal Processing Unit, Department of Neurology, University Medical Center of Johannes Gutenberg University Mainz, Mainz, Germany
| | - Loránd Erőss
- National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Péter Barsi
- Department of Neuroradiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Dénes Zádori
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Bence Laczó
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Dávid Kis
- Department of Neurosurgery, University of Szeged, Szeged, Hungary
| | - Péter Klivényi
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Gábor Fekete
- Department of Neurosurgery, University of Debrecen, Debrecen, Hungary
| | - László Bognár
- Department of Neurosurgery, University of Debrecen, Debrecen, Hungary
| | - Dániel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Gertrúd Tamás
- Department of Neurology, Semmelweis University, Budapest, Hungary
- *Correspondence: Gertrúd Tamás
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Wagner JR, Schaper M, Hamel W, Westphal M, Gerloff C, Engel AK, Moll CKE, Gulberti A, Pötter-Nerger M. Combined Subthalamic and Nigral Stimulation Modulates Temporal Gait Coordination and Cortical Gait-Network Activity in Parkinson’s Disease. Front Hum Neurosci 2022; 16:812954. [PMID: 35295883 PMCID: PMC8919031 DOI: 10.3389/fnhum.2022.812954] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/27/2022] [Indexed: 01/10/2023] Open
Abstract
Background Freezing of gait (FoG) is a disabling burden for Parkinson’s disease (PD) patients with poor response to conventional therapies. Combined deep brain stimulation of the subthalamic nucleus and substantia nigra (STN+SN DBS) moved into focus as a potential therapeutic option to treat the parkinsonian gait disorder and refractory FoG. The mechanisms of action of DBS within the cortical-subcortical-basal ganglia network on gait, particularly at the cortical level, remain unclear. Methods Twelve patients with idiopathic PD and chronically-implanted DBS electrodes were assessed on their regular dopaminergic medication in a standardized stepping in place paradigm. Patients executed the task with DBS switched off (STIM OFF), conventional STN DBS and combined STN+SN DBS and were compared to healthy matched controls. Simultaneous high-density EEG and kinematic measurements were recorded during resting-state, effective stepping, and freezing episodes. Results Clinically, STN+SN DBS was superior to conventional STN DBS in improving temporal stepping variability of the more affected leg. During resting-state and effective stepping, the cortical activity of PD patients in STIM OFF was characterized by excessive over-synchronization in the theta (4–8 Hz), alpha (9–13 Hz), and high-beta (21–30 Hz) band compared to healthy controls. Both active DBS settings similarly decreased resting-state alpha power and reduced pathologically enhanced high-beta activity during resting-state and effective stepping compared to STIM OFF. Freezing episodes during STN DBS and STN+SN DBS showed spectrally and spatially distinct cortical activity patterns when compared to effective stepping. During STN DBS, FoG was associated with an increase in cortical alpha and low-beta activity over central cortical areas, while with STN+SN DBS, an increase in high-beta was prominent over more frontal areas. Conclusions STN+SN DBS improved temporal aspects of parkinsonian gait impairment compared to conventional STN DBS and differentially affected cortical oscillatory patterns during regular locomotion and freezing suggesting a potential modulatory effect on dysfunctional cortical-subcortical communication in PD.
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Affiliation(s)
- Jonas R. Wagner
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miriam Schaper
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Hamel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas K. Engel
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian K. E. Moll
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandro Gulberti
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Monika Pötter-Nerger
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Chen T, Lin F, Cai G. Comparison of the Efficacy of Deep Brain Stimulation in Different Targets in Improving Gait in Parkinson's Disease: A Systematic Review and Bayesian Network Meta-Analysis. Front Hum Neurosci 2021; 15:749722. [PMID: 34744665 PMCID: PMC8568957 DOI: 10.3389/fnhum.2021.749722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/02/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Although a variety of targets for deep brain stimulation (DBS) have been found to be effective in Parkinson's disease (PD), it remains unclear which target for DBS leads to the best improvement in gait disorders in patients with PD. The purpose of this network meta-analysis (NMA) is to compare the efficacy of subthalamic nucleus (STN)-DBS, internal globus pallidus (GPi)-DBS, and pedunculopontine nucleus (PPN)-DBS, in improving gait disorders in patients with PD. Methods: We searched the PubMed database for articles published from January 1990 to December 2020. We used various languages to search for relevant documents to reduce language bias. A Bayesian NMA and systematic review of randomized and non-randomized controlled trials were conducted to explore the effects of different targets for DBS on gait damage. Result: In the 34 included studies, 538 patients with PD met the inclusion criteria. The NMA results of the effect of the DBS “on and off” on the mean change of the gait of the patients in medication-off show that GPi-DBS, STN-DBS, and PPN-DBS are significantly better than the baseline [GPi-DBS: –0.79(–1.2, –0.41), STN-DBS: –0.97(–1.1, –0.81), and PPN-DBS: –0.56(–1.1, –0.021)]. According to the surface under the cumulative ranking (SUCRA) score, the STN-DBS (SUCRA = 74.15%) ranked first, followed by the GPi-DBS (SUCRA = 48.30%), and the PPN-DBS (SUCRA = 27.20%) ranked last. The NMA results of the effect of the DBS “on and off” on the mean change of the gait of the patients in medication-on show that, compared with baseline, GPi-DBS and STN-DBS proved to be significantly effective [GPi-DBS: –0.53 (–1.0, –0.088) and STN-DBS: –0.47(–0.66, –0.29)]. The GPi-DBS ranked first (SUCRA = 59.00%), followed by STN-DBS(SUCRA = 51.70%), and PPN-DBS(SUCRA = 35.93%) ranked last. Conclusion: The meta-analysis results show that both the STN-DBS and GPi-DBS can affect certain aspects of PD gait disorder.
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Affiliation(s)
- Tianyi Chen
- School of Mathematics, Shandong University, Jinan, China
| | - Fabin Lin
- Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Key Laboratory of Molecular Neurology, Institute of Clinical Neurology, Institute of Neuroscience, Fujian Medical University, Fuzhou, China
| | - Guoen Cai
- Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Key Laboratory of Molecular Neurology, Institute of Clinical Neurology, Institute of Neuroscience, Fujian Medical University, Fuzhou, China
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Gera G, Guduru Z, Yamasaki T, Gurwell JA, Chau MJ, Krotinger A, Schmitt FA, Slevin JT, Gerhardt GA, van Horne C, Quintero JE. Gait and Balance Changes with Investigational Peripheral Nerve Cell Therapy during Deep Brain Stimulation in People with Parkinson's Disease. Brain Sci 2021; 11:brainsci11040500. [PMID: 33921079 PMCID: PMC8071359 DOI: 10.3390/brainsci11040500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/25/2021] [Accepted: 04/10/2021] [Indexed: 12/02/2022] Open
Abstract
Background: The efficacy of deep brain stimulation (DBS) and dopaminergic therapy is known to decrease over time. Hence, a new investigational approach combines implanting autologous injury-activated peripheral nerve grafts (APNG) at the time of bilateral DBS surgery to the globus pallidus interna. Objectives: In a study where APNG was unilaterally implanted into the substantia nigra, we explored the effects on clinical gait and balance assessments over two years in 14 individuals with Parkinson’s disease. Methods: Computerized gait and balance evaluations were performed without medication, and stimulation was in the off state for at least 12 h to best assess the role of APNG implantation alone. We hypothesized that APNG might improve gait and balance deficits associated with PD. Results: While people with a degenerative movement disorder typically worsen with time, none of the gait parameters significantly changed across visits in this 24 month study. The postural stability item in the UPDRS did not worsen from baseline to the 24-month follow-up. However, we measured gait and balance improvements in the two most affected individuals, who had moderate PD. In these two individuals, we observed an increase in gait velocity and step length that persisted over 6 and 24 months. Conclusions: Participants did not show worsening of gait and balance performance in the off therapy state two years after surgery, while the two most severely affected participants showed improved performance. Further studies may better address the long-term maintanenace of these results.
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Affiliation(s)
- Geetanjali Gera
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, 204L 900 South Limestone Street, Lexington, KY 40536, USA
- Brain Restoration Center, University of Kentucky, Lexington, KY 40536, USA; (Z.G.); (T.Y.); (J.A.G.); (M.J.C.); (F.A.S.); (J.T.S.); (G.A.G.); (C.v.H.); (J.E.Q.)
- Correspondence: ; Tel.: +1-859-218-0547
| | - Zain Guduru
- Brain Restoration Center, University of Kentucky, Lexington, KY 40536, USA; (Z.G.); (T.Y.); (J.A.G.); (M.J.C.); (F.A.S.); (J.T.S.); (G.A.G.); (C.v.H.); (J.E.Q.)
- Neurology, University of Kentucky, Lexington, KY 40536, USA
| | - Tritia Yamasaki
- Brain Restoration Center, University of Kentucky, Lexington, KY 40536, USA; (Z.G.); (T.Y.); (J.A.G.); (M.J.C.); (F.A.S.); (J.T.S.); (G.A.G.); (C.v.H.); (J.E.Q.)
- Neurology, University of Kentucky, Lexington, KY 40536, USA
- Neuroscience, University of Kentucky, Lexington, KY 40536, USA
- Veterans Affairs Medical Center, Lexington, KY 40502, USA
| | - Julie A. Gurwell
- Brain Restoration Center, University of Kentucky, Lexington, KY 40536, USA; (Z.G.); (T.Y.); (J.A.G.); (M.J.C.); (F.A.S.); (J.T.S.); (G.A.G.); (C.v.H.); (J.E.Q.)
- Neurology, University of Kentucky, Lexington, KY 40536, USA
| | - Monica J. Chau
- Brain Restoration Center, University of Kentucky, Lexington, KY 40536, USA; (Z.G.); (T.Y.); (J.A.G.); (M.J.C.); (F.A.S.); (J.T.S.); (G.A.G.); (C.v.H.); (J.E.Q.)
- Neurosurgery, University of Kentucky, Lexington, KY 40536, USA
| | - Anna Krotinger
- Department of Neuroscience, Wesleyan University, Middletown, CT 06459, USA;
| | - Frederick A. Schmitt
- Brain Restoration Center, University of Kentucky, Lexington, KY 40536, USA; (Z.G.); (T.Y.); (J.A.G.); (M.J.C.); (F.A.S.); (J.T.S.); (G.A.G.); (C.v.H.); (J.E.Q.)
- Neurology, University of Kentucky, Lexington, KY 40536, USA
| | - John T. Slevin
- Brain Restoration Center, University of Kentucky, Lexington, KY 40536, USA; (Z.G.); (T.Y.); (J.A.G.); (M.J.C.); (F.A.S.); (J.T.S.); (G.A.G.); (C.v.H.); (J.E.Q.)
- Neurology, University of Kentucky, Lexington, KY 40536, USA
- Veterans Affairs Medical Center, Lexington, KY 40502, USA
| | - Greg A. Gerhardt
- Brain Restoration Center, University of Kentucky, Lexington, KY 40536, USA; (Z.G.); (T.Y.); (J.A.G.); (M.J.C.); (F.A.S.); (J.T.S.); (G.A.G.); (C.v.H.); (J.E.Q.)
- Neurology, University of Kentucky, Lexington, KY 40536, USA
- Neuroscience, University of Kentucky, Lexington, KY 40536, USA
- Neurosurgery, University of Kentucky, Lexington, KY 40536, USA
| | - Craig van Horne
- Brain Restoration Center, University of Kentucky, Lexington, KY 40536, USA; (Z.G.); (T.Y.); (J.A.G.); (M.J.C.); (F.A.S.); (J.T.S.); (G.A.G.); (C.v.H.); (J.E.Q.)
- Neuroscience, University of Kentucky, Lexington, KY 40536, USA
- Neurosurgery, University of Kentucky, Lexington, KY 40536, USA
| | - Jorge E. Quintero
- Brain Restoration Center, University of Kentucky, Lexington, KY 40536, USA; (Z.G.); (T.Y.); (J.A.G.); (M.J.C.); (F.A.S.); (J.T.S.); (G.A.G.); (C.v.H.); (J.E.Q.)
- Neuroscience, University of Kentucky, Lexington, KY 40536, USA
- Neurosurgery, University of Kentucky, Lexington, KY 40536, USA
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Poláková K, Růžička E, Jech R, Kemlink D, Rusz J, Miletínová E, Brožová H. 3D visual cueing shortens the double support phase of the gait cycle in patients with advanced Parkinson's disease treated with DBS of the STN. PLoS One 2020; 15:e0244676. [PMID: 33382785 PMCID: PMC7774936 DOI: 10.1371/journal.pone.0244676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/14/2020] [Indexed: 11/28/2022] Open
Abstract
Background Gait disturbances have emerged as some of the main therapeutic concerns in late-stage Parkinson’s disease (PD) treated with dopaminergic therapy and deep brain stimulation (DBS). External cues may help to overcome freezing of gait (FOG) and improve some of the gait parameters. Aim To evaluate the effect of 3D visual cues and STN-DBS on gait in PD group. Methods We enrolled 35 PD patients treated with DBS of nucleus subthalamicus (STN-DBS). Twenty-five patients (5 females; mean age 58.9 ±6.3) and 25 sex- and age-matched controls completed the gait examination. The gait in 10 patients deteriorated in OFF state. The severity of PD was evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS) and Hoehn and Yahr (HY). The PD group filled the Falls Efficacy Scale-International (FES) and Freezing of Gait Questionnaire (FOGQ). Gait was examined using the GaitRite Analysis System, placed in the middle of the 10m marked path. The PD group was tested without dopaminergic medication with and without visual cueing together with the DBS switched ON and OFF. The setting of DBS was double-blind and performed in random order. Results The UPDRS was 21.9 ±9.5 in DBS ON state and 41.3 ±13.7 in DBS OFF state. HY was 2.5 ±0.6, FES 12.4 ±4.1 and FOGQ 9.4 ±5.7. In the DBS OFF state, PD group walked more slowly with shorter steps, had greater step length variability and longer duration of the double support phase compared to healthy controls. The walking speed and step length increased in the DBS ON state. The double support phase was reduced with 3D visual cueing and DBS; the combination of both cueing and DBS was even more effective. Conclusion Cueing with 3D visual stimuli shortens the double support phase in PD patients treated with DBS-STN. The DBS is more effective in prolonging step length and increasing gait speed. We conclude that 3D visual cueing can improve walking in patients with DBS.
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Affiliation(s)
- Kamila Poláková
- Department of Neurology and Center of Clinical Neuroscience, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Evžen Růžička
- Department of Neurology and Center of Clinical Neuroscience, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Robert Jech
- Department of Neurology and Center of Clinical Neuroscience, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - David Kemlink
- Department of Neurology and Center of Clinical Neuroscience, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Jan Rusz
- Department of Neurology and Center of Clinical Neuroscience, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
- Department of Circuit Theory, Faculty of Electrical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Eva Miletínová
- Department of Neurology and Center of Clinical Neuroscience, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Hana Brožová
- Department of Neurology and Center of Clinical Neuroscience, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
- * E-mail:
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Effect of Parkinson's disease and two therapeutic interventions on muscle activity during walking: a systematic review. NPJ PARKINSONS DISEASE 2020; 6:22. [PMID: 32964107 PMCID: PMC7481232 DOI: 10.1038/s41531-020-00119-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 07/09/2020] [Indexed: 12/26/2022]
Abstract
Gait deficits are a common feature of Parkinson’s disease (PD) and predictors of future motor and cognitive impairment. Understanding how muscle activity contributes to gait impairment and effects of therapeutic interventions on motor behaviour is crucial for identifying potential biomarkers and developing rehabilitation strategies. This article reviews sixteen studies that investigate the electromyographic (EMG) activity of lower limb muscles in people with PD during walking and reports on their quality. The weight of evidence establishing differences in motor activity between people with PD and healthy older adults (HOAs) is considered. Additionally, the effect of dopaminergic medication and deep brain stimulation (DBS) on modifying motor activity is assessed. Results indicated greater proximal and decreased distal activity of lower limb muscles during walking in individuals with PD compared to HOA. Dopaminergic medication was associated with increased distal lower limb muscle activity whereas subthalamic nucleus DBS increased activity of both proximal and distal lower limb muscles. Tibialis anterior was impacted most by the interventions. Quality of the studies was not strong, with a median score of 61%. Most studies investigated only distal muscles, involved small sample sizes, extracted limited EMG features and lacked rigorous signal processing. Few studies related changes in motor activity with functional gait measures. Understanding mechanisms underpinning gait impairment in PD is essential for development of personalised rehabilitative interventions. Recommendations for future studies include greater participant numbers, recording more functionally diverse muscles, applying multi-muscle analyses, and relating EMG to functional gait measures.
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11
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David FJ, Munoz MJ, Corcos DM. The effect of STN DBS on modulating brain oscillations: consequences for motor and cognitive behavior. Exp Brain Res 2020; 238:1659-1676. [PMID: 32494849 PMCID: PMC7415701 DOI: 10.1007/s00221-020-05834-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/15/2020] [Indexed: 12/11/2022]
Abstract
In this review, we highlight Professor John Rothwell's contribution towards understanding basal ganglia function and dysfunction, as well as the effects of subthalamic nucleus deep brain stimulation (STN DBS). The first section summarizes the rate and oscillatory models of basal ganglia dysfunction with a focus on the oscillation model. The second section summarizes the motor, gait, and cognitive mechanisms of action of STN DBS. In the final section, we summarize the effects of STN DBS on motor and cognitive tasks. The studies reviewed in this section support the conclusion that high-frequency STN DBS improves the motor symptoms of Parkinson's disease. With respect to cognition, STN DBS can be detrimental to performance especially when the task is cognitively demanding. Consolidating findings from many studies, we find that while motor network oscillatory activity is primarily correlated to the beta-band, cognitive network oscillatory activity is not confined to one band but is subserved by activity in multiple frequency bands. Because of these findings, we propose a modified motor and associative/cognitive oscillatory model that can explain the consistent positive motor benefits and the negative and null cognitive effects of STN DBS. This is clinically relevant because STN DBS should enhance oscillatory activity that is related to both motor and cognitive networks to improve both motor and cognitive performance.
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Affiliation(s)
- Fabian J David
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, 645 North Michigan Avenue, Suite 1100, Chicago, IL, 60611, USA.
| | - Miranda J Munoz
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, 645 North Michigan Avenue, Suite 1100, Chicago, IL, 60611, USA
| | - Daniel M Corcos
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, 645 North Michigan Avenue, Suite 1100, Chicago, IL, 60611, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
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12
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Powell DW, Blackmore SE, Puppa M, Lester D, Murray NG, Reed-Jones RJ, Xia RP. Deep brain stimulation enhances movement complexity during gait in individuals with Parkinson's disease. Neurosci Lett 2020; 728:133588. [PMID: 29751070 DOI: 10.1016/j.neulet.2018.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/13/2018] [Accepted: 05/04/2018] [Indexed: 12/11/2022]
Abstract
Deep brain stimulation (DBS) is associated with substantial improvements in motor symptoms of PD. Emerging evidence has suggested that nonlinear measures of complexity may provide greater insight into the efficacy of anti-PD treatments. This study investigated sample entropy and complexity index values in individuals with PD when DBS was OFF compared to ON. Five individuals with PD using DBS performed a four-minute treadmill walking task while 3D kinematics were collected over two periods of 30 s. Participants were tested in the DBS-ON and DBS-OFF conditions. Sample entropy (SE) and complexity index (CI) values were calculated for ankle, knee and hip joint angles. Paired samples t-tests were used to compare mean SE and CI values between the DBS-OFF and DBS-ON conditions, respectively. No differences in SE or CI were observed between the DBS-ON and DBS-OFF conditions at the ankle. At the knee, the DBS-ON was associated with greater SE and CI values than the DBS-OFF condition. At the hip, DBS-ON was associated with greater SE and CI values than the DBS-OFF condition. DBS enhances complexity of movement at the hip and knee joints while complexity at the ankle joint is not significantly altered. Greater complexity of knee and hip joint motion may represent increased adaptability and a greater number of available strategies to complete the gait task.
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Affiliation(s)
- Douglas W Powell
- Exercise Neuroscience Research Laboratory, School of Health Studies, University of Memphis, Memphis, TN, USA.
| | - Sarah E Blackmore
- Exercise Neuroscience Research Laboratory, School of Health Studies, University of Memphis, Memphis, TN, USA
| | - Melissa Puppa
- Exercise Neuroscience Research Laboratory, School of Health Studies, University of Memphis, Memphis, TN, USA
| | - Deranda Lester
- Exercise Neuroscience Research Laboratory, School of Health Studies, University of Memphis, Memphis, TN, USA
| | - Nicholas G Murray
- School of Community Health Sciences, University of Nevada at Reno, Reno, NV, USA
| | - Rebecca J Reed-Jones
- Kinesiology Laboratory, Department of Kinesiology, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Rui-Ping Xia
- Department of Physical Therapy, University of Saint Mary, Leavenworth, KS, USA
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13
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Intestinal Levodopa/Carbidopa Infusion as a Therapeutic Option for Unresponsive Freezing of Gait after Deep Brain Stimulation in Parkinson's Disease. PARKINSONS DISEASE 2020; 2020:1627264. [PMID: 32509261 PMCID: PMC7244984 DOI: 10.1155/2020/1627264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/04/2020] [Accepted: 04/29/2020] [Indexed: 11/18/2022]
Abstract
Background Treatment of freezing of gait (FOG) is always challenging because of its unpredictable nature and multifactorial physiopathology. Intestinal levodopa infusion has been proposed in recent years as a valuable option for its improvement. FOG in Parkinson's disease (PD) can appear after deep brain stimulation in patients who never had gait symptoms. Objective To study the effects of intestinal levodopa/carbidopa infusion in unresponsive-FOG that appears in PD patients treated with subthalamic nucleus deep brain stimulation. Methods We retrospectively collected and analyzed demographic, clinical, and therapeutic data from five PD patients treated with subthalamic nucleus stimulation who developed unresponsive-FOG and received intestinal levodopa/carbidopa infusion as an alternative therapy. FOG was measured based on scores in item 14 of the Unified Parkinson's Disease Rating Scale before and after intestinal levodopa infusion. Results Administration of intestinal levodopa caused improvement of FOG in the “ON” state in four patients (80%) by 2 or more points in item 14 of the Unified Parkinson's Disease Rating Scale. The improvement was maintained for at least 12 months. Conclusions Intestinal levodopa infusion may be a valuable therapeutic option for unresponsive-FOG developed after subthalamic nucleus deep brain stimulation.
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14
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Cebi I, Scholten M, Gharabaghi A, Weiss D. Clinical and Kinematic Correlates of Favorable Gait Outcomes From Subthalamic Stimulation. Front Neurol 2020; 11:212. [PMID: 32431656 PMCID: PMC7213078 DOI: 10.3389/fneur.2020.00212] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/09/2020] [Indexed: 12/16/2022] Open
Abstract
Objective: Gait and freezing of gait (FoG) are highly relevant to the outcomes of subthalamic nucleus deep brain stimulation (STN-DBS) in Parkinson's disease (PD). Previous studies pointed to variable response to combined dopaminergic and STN-DBS treatment. Here, we performed a prospective exploratory study on associations of preoperative clinical and kinematic gait measures with quantitative gait and FoG outcomes after STN-DBS implantation. Methods: We characterized 18 consecutive PD patients (13 freezers) before and after STN-DBS implantation. The patients received preoperative levodopa challenges (MedOff vs. MedOn) and a postoperative reassessment at 6 months from surgery in MedOn/StimOn condition. We correlated the FoG outcome, calculated as improvement of Freezing of Gait Assessment Course (FoG-AC) from baseline MedOff to 6-month follow-up MedOn/StimOn, with the levodopa response of preoperative clinical and kinematic gait measures. We considered measures with significant correlations for a multiple regression model. Results: We found that the postoperative gait and FoG outcomes were associated with the preoperative levodopa response of clinical and kinematic gait measures. In particular, preoperative levodopa sensitivity of FoG showed high correlation with a favorable quantitative FoG outcome. Among kinematic measures, preoperative levodopa response of stride length and range of motion showed high correlation with favorable FoG outcome. In addition, the preoperative levodopa sensitivity of FoG predicted postoperative FoG outcome with high accuracy (R 2 = 0.952; 95% CI: 0.95-1.29; P < 0.001). Conclusions: Preoperative clinical and kinematic measures correlated with favorable postoperative gait and FoG outcomes. The findings should be reproduced in larger and independent cohorts to verify their predictive value.
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Affiliation(s)
- Idil Cebi
- Department of Neurodegenerative Diseases, Centre for Neurology, Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany.,German Centre of Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany.,Tübingen Neuro Campus (TNC), University of Tübingen, Tübingen, Germany.,Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Marlieke Scholten
- Department of Neurodegenerative Diseases, Centre for Neurology, Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany.,German Centre of Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany.,Tübingen Neuro Campus (TNC), University of Tübingen, Tübingen, Germany
| | - Alireza Gharabaghi
- Tübingen Neuro Campus (TNC), University of Tübingen, Tübingen, Germany.,Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Daniel Weiss
- Department of Neurodegenerative Diseases, Centre for Neurology, Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany.,German Centre of Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany.,Tübingen Neuro Campus (TNC), University of Tübingen, Tübingen, Germany
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15
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Arami A, Poulakakis-Daktylidis A, Tai YF, Burdet E. Prediction of Gait Freezing in Parkinsonian Patients: A Binary Classification Augmented With Time Series Prediction. IEEE Trans Neural Syst Rehabil Eng 2019; 27:1909-1919. [PMID: 31398122 DOI: 10.1109/tnsre.2019.2933626] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This paper presents a novel technique to predict freezing of gait in advanced stage Parkinsonian patients using movement data from wearable sensors. A two-class approach is presented which consists of autoregressive predictive models to project the feature time series, followed by machine learning based classifiers to discriminate freezing from nonfreezing based on the predicted features. To implement and validate our technique a set of time domain and frequency domain features were extracted from the 3D acceleration data, which was then analyzed using information theoretic and feature selection approaches to determine the most discriminative features. Predictive models were trained to predict the features from their past values, then fed into binary classifiers based on support vector machines and probabilistic neural networks which were rigorously cross validated. We compared the results of this approach with a three-class classification approach proposed in previous literature, in which a pre-freezing class was introduced and the problem of prediction of the gait freezing incident was reduced to solving a three-class classification problem. The two-class approach resulted in a sensitivity of 93±4%, specificity of 91±6%, with an expected prediction horizon of 1.72 s. Our subject-specific gait freezing prediction algorithm outperformed existing algorithms, yields consistent results across different subjects and is robust against the choice of classifier, with slight variations in the selected features. In addition, we analyzed the merits and limitations of different families of features to predict gait freezing.
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16
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Abstract
Parkinson disease (PD) is a complex, multisystem disorder with both neurologic and systemic nonmotor manifestations. It is neurodegenerative in nature in which disordered balance, gait, and falls are universal problems that can be present at initial diagnosis, and which progress over time. Freezing of gait is a particularly debilitating feature of PD that becomes more prevalent over time with disease progression, being present in approximately 7% after 2 years of disease and 28% after 5 years. Approximately 60% of people with PD fall each year, with around 70% of fallers falling recurrently, and some recurrent fallers falling multiple times per week. Many risk factors for falls in people with PD have been identified; these include a history of falls, freezing of gait, and abnormalities in measures of balance, leg muscle strength, mobility, cognition, and fear of falling. Therapies for improving physical function and mobility include levodopa, cholinesterase inhibitors, methylphenidate, deep-brain stimulation, cuing for freezing of gait, and exercise. This chapter reviews the clinical, pathologic, and physiologic correlates of gait disturbance and falls in PD, as well as the evidence for medical and nonmedical interventions.
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Affiliation(s)
- Samuel D Kim
- Movement Disorders Unit, Department of Neurology, Westmead Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Natalie E Allen
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Colleen G Canning
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Victor S C Fung
- Movement Disorders Unit, Department of Neurology, Westmead Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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17
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Scholten M, Klemt J, Heilbronn M, Plewnia C, Bloem BR, Bunjes F, Krüger R, Gharabaghi A, Weiss D. Effects of Subthalamic and Nigral Stimulation on Gait Kinematics in Parkinson's Disease. Front Neurol 2017; 8:543. [PMID: 29089922 PMCID: PMC5650991 DOI: 10.3389/fneur.2017.00543] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 09/27/2017] [Indexed: 01/24/2023] Open
Abstract
Conventional subthalamic deep brain stimulation for Parkinson's disease (PD) presumably modulates the spatial component of gait. However, temporal dysregulation of gait is one of the factors that is tightly associated with freezing of gait (FOG). Temporal locomotor integration may be modulated differentially at distinct levels of the basal ganglia. Owing to its specific descending brainstem projections, stimulation of the substantia nigra pars reticulata (SNr) area might modulate spatial and temporal parameters of gait differentially compared to standard subthalamic nucleus (STN) stimulation. Here, we aimed to characterize the differential effect of STN or SNr stimulation on kinematic gait parameters. We analyzed biomechanical parameters during unconstrained over ground walking in 12 PD patients with subthalamic deep brain stimulation and FOG. Patients performed walking in three therapeutic conditions: (i) Off stimulation, (ii) STN stimulation (alone), and (iii) SNr stimulation (alone). SNr stimulation was achieved by stimulating the most caudal contact of the electrode. We recorded gait using three sensors (each containing a tri-axial accelerometer, gyroscope, and magnetometer) attached on both left and right ankle, and to the lumbar spine. STN stimulation improved both the spatial features (stride length, stride length variability) and the temporal parameters of gait. SNr stimulation improved temporal parameters of gait (swing time asymmetry). Correlation analysis suggested that patients with more medial localization of the SNr contact associated with a stronger regularization of gait. These results suggest that SNr stimulation might support temporal regularization of gait integration.
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Affiliation(s)
- Marlieke Scholten
- Department of Neurodegenerative Diseases and Hertie Institute for Clinical Brain Research (HIH), University of Tuebingen, Tuebingen, Germany.,German Centre of Neurodegenerative Diseases (DZNE), University of Tuebingen, Tuebingen, Germany.,Centre for Integrative Neuroscience (CIN), University of Tuebingen, Tuebingen, Germany.,Graduate School of Neural & Behavioural Sciences, International Max Planck Research School, University of Tuebingen, Tuebingen, Germany
| | - Johannes Klemt
- Department of Neurodegenerative Diseases and Hertie Institute for Clinical Brain Research (HIH), University of Tuebingen, Tuebingen, Germany.,German Centre of Neurodegenerative Diseases (DZNE), University of Tuebingen, Tuebingen, Germany.,Centre for Integrative Neuroscience (CIN), University of Tuebingen, Tuebingen, Germany
| | - Melanie Heilbronn
- Department of Neurodegenerative Diseases and Hertie Institute for Clinical Brain Research (HIH), University of Tuebingen, Tuebingen, Germany.,German Centre of Neurodegenerative Diseases (DZNE), University of Tuebingen, Tuebingen, Germany.,Centre for Integrative Neuroscience (CIN), University of Tuebingen, Tuebingen, Germany
| | - Christian Plewnia
- Centre for Integrative Neuroscience (CIN), University of Tuebingen, Tuebingen, Germany.,Department of Psychiatry and Psychotherapy, University of Tuebingen, Tuebingen, Germany
| | - Bastiaan R Bloem
- Radboud University Medical Centre, Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Nijmegen, Netherlands
| | - Friedemann Bunjes
- Department of Neurodegenerative Diseases and Hertie Institute for Clinical Brain Research (HIH), University of Tuebingen, Tuebingen, Germany
| | - Rejko Krüger
- Department of Neurodegenerative Diseases and Hertie Institute for Clinical Brain Research (HIH), University of Tuebingen, Tuebingen, Germany.,German Centre of Neurodegenerative Diseases (DZNE), University of Tuebingen, Tuebingen, Germany.,Centre for Integrative Neuroscience (CIN), University of Tuebingen, Tuebingen, Germany.,Clinical and Experimental Neuroscience, Luxembourg Centre for Systems Biomedicine (LCSB), University of Luxembourg Center Hospitalier de Luxembourg (CHL), Luxembourg, Luxembourg
| | - Alireza Gharabaghi
- Centre for Integrative Neuroscience (CIN), University of Tuebingen, Tuebingen, Germany.,Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - Daniel Weiss
- Department of Neurodegenerative Diseases and Hertie Institute for Clinical Brain Research (HIH), University of Tuebingen, Tuebingen, Germany.,German Centre of Neurodegenerative Diseases (DZNE), University of Tuebingen, Tuebingen, Germany.,Centre for Integrative Neuroscience (CIN), University of Tuebingen, Tuebingen, Germany
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18
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Thevathasan W, Debu B, Aziz T, Bloem BR, Blahak C, Butson C, Czernecki V, Foltynie T, Fraix V, Grabli D, Joint C, Lozano AM, Okun MS, Ostrem J, Pavese N, Schrader C, Tai CH, Krauss JK, Moro E. Pedunculopontine nucleus deep brain stimulation in Parkinson's disease: A clinical review. Mov Disord 2017; 33:10-20. [DOI: 10.1002/mds.27098] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 06/08/2017] [Accepted: 06/14/2017] [Indexed: 12/21/2022] Open
Affiliation(s)
- Wesley Thevathasan
- Department of Medicine; Royal Melbourne Hospital, University of Melbourne, Australia and the Bionics Institute of Australia; Melbourne Australia
| | - Bettina Debu
- Movement Disorders Center; Division of Neurology, Centre Hospitalier Universitaire (CHU) Grenoble, Grenoble Alpes University; Grenoble France
| | - Tipu Aziz
- Department of Neurosurgery; John Radcliffe Hospital, University of Oxford; Oxford UK
| | - Bastiaan R. Bloem
- Department of Neurology; Donders Institute for Brain, Cognition and Behaviour, Radboud University; Nijmegen the Netherlands
| | - Christian Blahak
- Department of Neurology; Universitätsmedizin Mannheim, University of Heidelberg; Heidelberg Germany
| | - Christopher Butson
- Department of Bioengineering; Scientific Computing and Imaging Institute, University of Utah; Salt Lake City USA
| | - Virginie Czernecki
- Department of Neurology; Institut de Cerveau et de la Moelle épinière, Sorbonne Universités, University Pierre-and-Marie-Curie (UPMC) Université; Paris France
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience; University College London (UCL) Institute of Neurology; United Kingdom
| | - Valerie Fraix
- Movement Disorders Center; Division of Neurology, Centre Hospitalier Universitaire (CHU) Grenoble, Grenoble Alpes University; Grenoble France
| | - David Grabli
- Department of Neurology; Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtière University Hospital; Paris France
| | - Carole Joint
- Department of Neurosurgery; John Radcliffe Hospital, University of Oxford; Oxford UK
| | - Andres M. Lozano
- Department of Neurosurgery; Toronto Western Hospital, University of Toronto; Toronto Canada
| | - Michael S. Okun
- Departments of Neurology and Neurosurgery; University of Florida Center for Movement Disorders; Gainesville Florida USA
| | - Jill Ostrem
- Department of Neurology; UCSF Movement Disorder and Neuromodulation Center, University of California; San Francisco USA
| | - Nicola Pavese
- Institute of Neuroscience; Newcastle University; Newcastle upon Tyne UK
- Department of Clinical Medicine; Centre for Functionally Integrative Neuroscience, University of Aarhus; Aarhus Denmark
- Department of Neurology; Hannover Medical School; Hannover Germany
| | | | - Chun-Hwei Tai
- Department of Neurology; National Taiwan University Hospital, College of Medicine, National Taiwan University; Taipei Taiwan
| | - Joachim K. Krauss
- Department of Neurosurgery; Hannover Medical School; Hannover Germany
| | - Elena Moro
- Movement Disorders Center; Division of Neurology, Centre Hospitalier Universitaire (CHU) Grenoble, Grenoble Alpes University; Grenoble France
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19
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Buhmann C, Huckhagel T, Engel K, Gulberti A, Hidding U, Poetter-Nerger M, Goerendt I, Ludewig P, Braass H, Choe CU, Krajewski K, Oehlwein C, Mittmann K, Engel AK, Gerloff C, Westphal M, Köppen JA, Moll CKE, Hamel W. Adverse events in deep brain stimulation: A retrospective long-term analysis of neurological, psychiatric and other occurrences. PLoS One 2017; 12:e0178984. [PMID: 28678830 PMCID: PMC5497949 DOI: 10.1371/journal.pone.0178984] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 05/22/2017] [Indexed: 11/18/2022] Open
Abstract
Background and objective The extent to which deep brain stimulation (DBS) can improve quality of life may be perceived as a permanent trade-off between neurological improvements and complications of therapy, comorbidities, and disease progression. Patients and methods We retrospectively investigated 123 consecutive and non-preselected patients. Indications for DBS surgery were Parkinson's disease (82), dystonia (18), tremor of different etiology (21), Huntington's disease (1) and Gilles de la Tourette syndrome (1). AEs were defined as any untoward clinical occurrence, sign or patient complaint or unintended disease if related or unrelated to the surgical procedures, implanted devices or ongoing DBS therapy. Results Over a mean/median follow-up period of 4.7 years (578 patient-years) 433 AEs were recorded in 106 of 123 patients (86.2%). There was no mortality or persistent morbidity from the surgical procedure. All serious adverse events (SAEs) that occurred within 4 weeks of surgery were reversible. Neurological AEs (193 in 85 patients) and psychiatric AEs (78 in 48 patients) were documented most frequently. AEs in 4 patients (suicide under GPI stimulation, weight gain >20 kg, impairment of gait and speech, cognitive decline >2 years following surgery) were severe or worse, at least possibly related to DBS and non reversible. In PD 23.1% of the STN-stimulated patients experienced non-reversible (or unknown reversibility) AEs that were at least possibly related to DBS in the form of impaired speech or gait, depression, weight gain, cognitive disturbances or urinary incontinence (severity was mild or moderate in 15 of 18 patients). Age and Hoehn&Yahr stage of STN-simulated PD patients, but not preoperative motor impairment or response to levodopa, showed a weak correlation (r = 0.24 and 0.22, respectively) with the number of AEs. Conclusions DBS-related AEs that were severe or worse and non-reversible were only observed in PD (4 of 82 patients; 4.9%), but not in other diseases. PD patients exhibited a significant risk for non-severe AEs most of which also represented preexisting and progressive axial and non-motor symptoms of PD. Mild gait and/or speech disturbances were rather frequent complaints under VIM stimulation. GPI stimulation for dystonia could be applied with negligible DBS-related side effects.
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Affiliation(s)
- Carsten Buhmann
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Torge Huckhagel
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Katja Engel
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandro Gulberti
- Institut für Neurophysiologie und Pathophysiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ute Hidding
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Ines Goerendt
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Ludewig
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Hanna Braass
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Chi-un Choe
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Kara Krajewski
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Andreas K. Engel
- Institut für Neurophysiologie und Pathophysiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes A. Köppen
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian K. E. Moll
- Institut für Neurophysiologie und Pathophysiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Hamel
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
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Faggiani E, Benazzouz A. Deep brain stimulation of the subthalamic nucleus in Parkinson’s disease: From history to the interaction with the monoaminergic systems. Prog Neurobiol 2017; 151:139-156. [DOI: 10.1016/j.pneurobio.2016.07.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 07/08/2016] [Indexed: 11/16/2022]
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Chenji G, Wright ML, Chou KL, Seidler RD, Patil PG. Parkinsonian gait improves with bilateral subthalamic nucleus deep brain stimulation during cognitive multi-tasking. Parkinsonism Relat Disord 2017; 38:72-79. [PMID: 28258925 DOI: 10.1016/j.parkreldis.2017.02.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 02/12/2017] [Accepted: 02/21/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Gait impairment in Parkinson's disease reduces mobility and increases fall risk, particularly during cognitive multi-tasking. Studies suggest that bilateral subthalamic deep brain stimulation, a common surgical therapy, degrades motor performance under cognitive dual-task conditions, compared to unilateral stimulation. OBJECTIVE To measure the impact of bilateral versus unilateral subthalamic deep brain stimulation on walking kinematics with and without cognitive dual-tasking. METHODS Gait kinematics of seventeen patients with advanced Parkinson's disease who had undergone bilateral subthalamic deep brain stimulation were examined off medication under three stimulation states (bilateral, unilateral left, unilateral right) with and without a cognitive challenge, using an instrumented walkway system. RESULTS Consistent with earlier studies, gait performance declined for all six measured parameters under cognitive dual-task conditions, independent of stimulation state. However, bilateral stimulation produced greater improvements in step length and double-limb support time than unilateral stimulation, and achieved similar performance for other gait parameters. CONCLUSIONS Contrary to expectations from earlier studies of dual-task motor performance, bilateral subthalamic deep brain stimulation may assist in maintaining temporal and spatial gait performance under cognitive dual-task conditions.
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Affiliation(s)
- Gaurav Chenji
- Surgical Therapies Improving Movement Program, University of Michigan, Ann Arbor, MI, USA; Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Melissa L Wright
- Surgical Therapies Improving Movement Program, University of Michigan, Ann Arbor, MI, USA; School of Kinesiology, University of Michigan, Ann Arbor, MI, USA
| | - Kelvin L Chou
- Surgical Therapies Improving Movement Program, University of Michigan, Ann Arbor, MI, USA; Department of Neurology, University of Michigan, Ann Arbor, MI, USA; Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Rachael D Seidler
- Deparment of Psychology, University of Michigan, Ann Arbor, MI, USA; School of Kinesiology, University of Michigan, Ann Arbor, MI, USA
| | - Parag G Patil
- Surgical Therapies Improving Movement Program, University of Michigan, Ann Arbor, MI, USA; Department of Neurology, University of Michigan, Ann Arbor, MI, USA; Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
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22
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Cossu G, Pau M. Subthalamic nucleus stimulation and gait in Parkinson's Disease: a not always fruitful relationship. Gait Posture 2017; 52:205-210. [PMID: 27915226 DOI: 10.1016/j.gaitpost.2016.11.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 11/19/2016] [Accepted: 11/24/2016] [Indexed: 02/02/2023]
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus (STN) provides efficient treatment for the alleviation of motor signs in patients with advanced Parkinson's disease (PD), but its specific effects on gait is sometimes less successful as it may even lead to an aggravation of freezing of gait. To better understand when axial symptoms can be expected to improve and when they may worsen or be resistant to STN-DBS, we propose here a narrative review that considers the recent literature evidences based on instrumental gait analysis data. Our aim is to report about the efficacy of STN-DBS on PD gait, analyzing the clinical and procedural factors involved, and discussing the strategies for optimizing such effectiveness in patients with advanced PD.
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Affiliation(s)
- Giovanni Cossu
- "G. Brotzu" General Hospital, Department of Neurology, Cagliari, Italy
| | - Massimiliano Pau
- Department of Mechanical, Chemical and Materials Engineering, University of Cagliari, Cagliari, Italy.
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23
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Zeng W, Liu F, Wang Q, Wang Y, Ma L, Zhang Y. Parkinson's disease classification using gait analysis via deterministic learning. Neurosci Lett 2016; 633:268-278. [PMID: 27693437 DOI: 10.1016/j.neulet.2016.09.043] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/12/2016] [Accepted: 09/25/2016] [Indexed: 11/17/2022]
Abstract
Gait analysis plays an important role in maintaining the well-being of human mobility and health care, and is a valuable tool for obtaining quantitative information on motor deficits in Parkinson's disease (PD). In this paper, we propose a method to classify (diagnose) patients with PD and healthy control subjects using gait analysis via deterministic learning theory. The classification approach consists of two phases: a training phase and a classification phase. In the training phase, gait characteristics represented by the gait dynamics are derived from the vertical ground reaction forces under the usual and self-selected paces of the subjects. The gait dynamics underlying gait patterns of healthy controls and PD patients are locally accurately approximated by radial basis function (RBF) neural networks. The obtained knowledge of approximated gait dynamics is stored in constant RBF networks. The gait patterns of healthy controls and PD patients constitute a training set. In the classification phase, a bank of dynamical estimators is constructed for all the training gait patterns. Prior knowledge of gait dynamics represented by the constant RBF networks is embedded in the estimators. By comparing the set of estimators with a test gait pattern of a certain PD patient to be classified (diagnosed), a set of classification errors are generated. The average L1 norms of the errors are taken as the classification measure between the dynamics of the training gait patterns and the dynamics of the test PD gait pattern according to the smallest error principle. When the gait patterns of 93 PD patients and 73 healthy controls are classified with five-fold cross-validation method, the accuracy, sensitivity and specificity of the results are 96.39%, 96.77% and 95.89%, respectively. Based on the results, it may be claimed that the features and the classifiers used in the present study could effectively separate the gait patterns between the groups of PD patients and healthy controls.
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Affiliation(s)
- Wei Zeng
- School of Mechanical & Electrical Engineering, Longyan University, Longyan 364012, PR China.
| | - Fenglin Liu
- School of Mechanical & Electrical Engineering, Longyan University, Longyan 364012, PR China
| | - Qinghui Wang
- School of Mechanical & Electrical Engineering, Longyan University, Longyan 364012, PR China
| | - Ying Wang
- School of Mechanical & Electrical Engineering, Longyan University, Longyan 364012, PR China
| | - Limin Ma
- Department of Orthopaedic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou 510010, PR China
| | - Yu Zhang
- Department of Orthopaedic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou 510010, PR China
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König N, Singh NB, Baumann CR, Taylor WR. Can Gait Signatures Provide Quantitative Measures for Aiding Clinical Decision-Making? A Systematic Meta-Analysis of Gait Variability Behavior in Patients with Parkinson's Disease. Front Hum Neurosci 2016; 10:319. [PMID: 27445759 PMCID: PMC4927578 DOI: 10.3389/fnhum.2016.00319] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 06/13/2016] [Indexed: 12/16/2022] Open
Abstract
A disturbed, inconsistent walking pattern is a common feature of patients with Parkinson's disease (PwPD). Such extreme variability in both temporal and spatial parameters of gait has been associated with unstable walking and an elevated prevalence of falls. However, despite their ability to discretise healthy from pathological function, normative variability values for key gait parameters are still missing. Furthermore, an understanding of each parameter's response to pathology, as well as the inter-parameter relationships, has received little attention. The aim of this systematic literature review and meta-analysis was therefore to define threshold levels for pathological gait variability as well as to investigate whether all gait parameters are equally perturbed in PwPD. Based on a broader systematic literature search that included 13′195 titles, 34 studies addressed Parkinson's disease, presenting 800 PwPD and 854 healthy subjects. Eight gait parameters were compared, of which six showed increased levels of variability during walking in PwPD. The most commonly reported parameter, coefficient of variation of stride time, revealed an upper threshold of 2.4% to discriminate the two groups. Variability of step width, however, was consistently lower in PwPD compared to healthy subjects, and therefore suggests an explicit sensory motor system control mechanism to prioritize balance during walking. The results provide a clear functional threshold for monitoring treatment efficacy in patients with Parkinson's disease. More importantly, however, quantification of specific functional deficits could well provide a basis for locating the source and extent of the neurological damage, and therefore aid clinical decision-making for individualizing therapies.
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Affiliation(s)
- Niklas König
- Department of Health Sciences and Technology, Institute for Biomechanics, Swiss Federal Institute of Technology in Zurich (ETHZ) Zürich, Switzerland
| | - Navrag B Singh
- Department of Health Sciences and Technology, Institute for Biomechanics, Swiss Federal Institute of Technology in Zurich (ETHZ) Zürich, Switzerland
| | - Christian R Baumann
- Department of Neurology, University Hospital Zürich, University of Zürich Zürich, Switzerland
| | - William R Taylor
- Department of Health Sciences and Technology, Institute for Biomechanics, Swiss Federal Institute of Technology in Zurich (ETHZ) Zürich, Switzerland
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25
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Roper JA, Kang N, Ben J, Cauraugh JH, Okun MS, Hass CJ. Deep brain stimulation improves gait velocity in Parkinson’s disease: a systematic review and meta-analysis. J Neurol 2016; 263:1195-203. [DOI: 10.1007/s00415-016-8129-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/09/2016] [Accepted: 04/11/2016] [Indexed: 11/28/2022]
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26
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Effects of deep brain stimulation on balance and gait in patients with Parkinson's disease: A systematic neurophysiological review. Neurophysiol Clin 2015; 45:371-88. [DOI: 10.1016/j.neucli.2015.07.001] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 06/23/2015] [Accepted: 07/16/2015] [Indexed: 12/17/2022] Open
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27
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Defining the clinically meaningful difference in gait speed in persons with Parkinson disease. J Neurol Phys Ther 2015; 38:233-8. [PMID: 25198866 DOI: 10.1097/npt.0000000000000055] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Gait dysfunction is a common target for pharmacological, behavioral, and surgical interventions in persons with Parkinson disease. However, the responsiveness of gait speed, that is, clinically important difference, is not well described in the literature for this population. The purpose of this study was to determine the magnitude of meaningful difference in gait speed using multiple methods of assessment and utilizing a large sample of participants inclusive of various stages of disease severity. METHODS Gait speed was measured using an instrumented walkway in 324 ambulatory persons with idiopathic Parkinson disease. Cross-sectional analysis of the clinically important difference for gait speed was performed using distribution- and anchor-based approaches: disability (Schwab and England Activities of Daily Living Scale), disease stage (Modified Hoehn and Yahr Scale), and severity (Unified Parkinson's Disease Rating Scale). RESULTS Using distribution-based analyses and effect size metrics, the small important difference in gait speed was 0.06 m/s, moderate was 0.14 m/s, and large was 0.22 m/s. Applying previously established cut-points for small, moderate, and large change in the motor scale score, the associated changes in gait speed that might be expected are 0.02, 0.06, and 0.10 m/s. DISCUSSION AND CONCLUSIONS Our data revealed that the clinically important difference in gait speed among persons with Parkinson disease on medication ranged from 0.05 m/s to 0.22 m/s by distribution-based analysis and ranged from 0.02 m/s to 0.18 m/s per level within the anchor-based metrics. These data will aid in evaluating the effectiveness of interventions to improve gait speed in persons with Parkinson disease.Video Abstract available. See video (Supplemental Digital Content 1, http://links.lww.com/JNPT/A77) for more insights from the authors.
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Nonnekes J, Snijders AH, Nutt JG, Deuschl G, Giladi N, Bloem BR. Freezing of gait: a practical approach to management. Lancet Neurol 2015; 14:768-78. [PMID: 26018593 DOI: 10.1016/s1474-4422(15)00041-1] [Citation(s) in RCA: 228] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/22/2015] [Accepted: 03/30/2015] [Indexed: 01/09/2023]
Abstract
Freezing of gait is a common and disabling symptom in patients with parkinsonism, characterised by sudden and brief episodes of inability to produce effective forward stepping. These episodes typically occur during gait initiation or turning. Treatment is important because freezing of gait is a major risk factor for falls in parkinsonism, and a source of disability to patients. Various treatment approaches exist, including pharmacological and surgical options, as well as physiotherapy and occupational therapy, but evidence is inconclusive for many approaches, and clear treatment protocols are not available. To address this gap, we review medical and non-medical treatment strategies for freezing of gait and present a practical algorithm for the management of this disorder, based on a combination of evidence, when available, and clinical experience of the authors. Further research is needed to formally establish the merits of our proposed treatment protocol.
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Affiliation(s)
- Jorik Nonnekes
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Anke H Snijders
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - John G Nutt
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Günter Deuschl
- Department of Neurology, Christian-Albrechts University, Kiel, Germany
| | - Nir Giladi
- Sagol School for Neuroscience, Movement Disorders Unit, Department of Neurology, Tel-Aviv Medical Centre, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Bastiaan R Bloem
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands.
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29
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Fasano A, Aquino CC, Krauss JK, Honey CR, Bloem BR. Axial disability and deep brain stimulation in patients with Parkinson disease. NATURE REVIEWS. NEUROLOGY 2015. [PMID: 25582445 DOI: 10.1038/nrneurol.2014.252.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Axial motor signs-including gait impairment, postural instability and postural abnormalities-are common and debilitating symptoms in patients with advanced Parkinson disease. Dopamine replacement therapy and physiotherapy provide, at best, partial relief from axial motor symptoms. In carefully selected candidates, deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus internus is an established treatment for 'appendicular' motor signs (limb tremor, bradykinesia and rigidity). However, the effects of DBS on axial signs are much less clear, presumably because motor control of axial and appendicular functions is mediated by different anatomical-functional pathways. Here, we discuss the successes and failures of DBS in managing axial motor signs. We systematically address a series of common clinical questions associated with the preoperative phase, during which patients presenting with prominent axial signs are considered for DBS implantation surgery, and the postoperative phase, in particular, the management of axial motor signs that newly develop as postoperative complications, either acutely or with a delay. We also address the possible merits of new targets-including the pedunculopontine nucleus area, zona incerta and substantia nigra pars reticulata-to specifically alleviate axial symptoms. Supported by a rapidly growing body of evidence, this practically oriented Review aims to support decision-making in the management of axial symptoms.
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Affiliation(s)
- Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Toronto Western Hospital, UHN, University of Toronto, 399 Bathurst Street, 7 Mc412, Toronto, ON M5T 2S8, Canada
| | - Camila C Aquino
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Toronto Western Hospital, UHN, University of Toronto, 399 Bathurst Street, 7 Mc412, Toronto, ON M5T 2S8, Canada
| | - Joachim K Krauss
- Department of Neurosurgery, Medical School Hannover, Carl-Neuberg Straße 1, 30625 Hannover, Germany
| | - Christopher R Honey
- Division of Neurosurgery at the University of British Columbia, 8105-2775 Laurel Street, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Bastiaan R Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, PO Box 9101, 6500 HB Nijmegen, Netherlands
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30
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Abstract
Axial motor signs-including gait impairment, postural instability and postural abnormalities-are common and debilitating symptoms in patients with advanced Parkinson disease. Dopamine replacement therapy and physiotherapy provide, at best, partial relief from axial motor symptoms. In carefully selected candidates, deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus internus is an established treatment for 'appendicular' motor signs (limb tremor, bradykinesia and rigidity). However, the effects of DBS on axial signs are much less clear, presumably because motor control of axial and appendicular functions is mediated by different anatomical-functional pathways. Here, we discuss the successes and failures of DBS in managing axial motor signs. We systematically address a series of common clinical questions associated with the preoperative phase, during which patients presenting with prominent axial signs are considered for DBS implantation surgery, and the postoperative phase, in particular, the management of axial motor signs that newly develop as postoperative complications, either acutely or with a delay. We also address the possible merits of new targets-including the pedunculopontine nucleus area, zona incerta and substantia nigra pars reticulata-to specifically alleviate axial symptoms. Supported by a rapidly growing body of evidence, this practically oriented Review aims to support decision-making in the management of axial symptoms.
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31
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Pötter-Nerger M, Volkmann J. Deep brain stimulation for gait and postural symptoms in Parkinson's disease. Mov Disord 2014; 28:1609-15. [PMID: 24132849 DOI: 10.1002/mds.25677] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 08/16/2013] [Indexed: 11/06/2022] Open
Abstract
In patients with Parkinson's disease, gait and balance difficulties have emerged as some of the main therapeutic concerns. During earlier stages of the disease, the dopamine-responsive aspects of gait disorder can be treated initially with dopaminergic drugs or deep brain stimulation. However, certain temporal aspects of parkinsonian gait disorder remain therapeutically resistant in both the short term and the long term. In this review, we summarize the effects of deep brain stimulation on gait and postural symptoms in the five currently available targets (subthalamic nucleus, globus pallidus, ventralis intermedius thalamic nucleus, pedunculopontine nucleus, and substantia nigra) and describe programming strategies for patients who are mainly disabled by gait problems.
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Validation of GDI, GPS and GVS for use in Parkinson's disease through evaluation of effects of subthalamic deep brain stimulation and levodopa. Gait Posture 2014; 39:1142-5. [PMID: 24548797 DOI: 10.1016/j.gaitpost.2014.01.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 01/15/2014] [Accepted: 01/20/2014] [Indexed: 02/02/2023]
Abstract
The Gait Deviation Index (GDI), Gait Profile Score (GPS) and Gait Variable Scores (GVSs) have been proposed as measures of gait quality and validated for use with children with cerebral palsy. The aim of this study was to extend this validation to people with Parkinson's disease by evaluating the effects of subthalamic deep brain stimulation and levodopa on gait. 16 participants had their gait evaluated with stimulation, medication or a combination of both. The Unified Parkinson's Disease Rating Scale (UPDRS) showed statistically significant differences in agreement with previous studies. The GPS and GDI showed similar treatment effects as did GVS for hip and knee flexion/extension, as assessed with Cohen's d where medium or large. Overall the results suggest that these gait indices are sensitive to treatment in this group of patients and that their use in groups other than children with cerebral palsy is valid.
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Pedunculopontine nucleus area oscillations during stance, stepping and freezing in Parkinson's disease. PLoS One 2013; 8:e83919. [PMID: 24386308 PMCID: PMC3875496 DOI: 10.1371/journal.pone.0083919] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Accepted: 11/10/2013] [Indexed: 12/03/2022] Open
Abstract
The pedunculopontine area (PPNa) including the pedunculopontine and cuneiform nuclei, belongs to the mesencephalic locomotor region. Little is known about the oscillatory mechanisms underlying the function of this region in postural and gait control. We examined the modulations of the oscillatory activity of the PPNa and cortex during stepping, a surrogate of gait, and stance in seven Parkinson’s disease patients who received bilateral PPNa implantation for disabling freezing of gait (FOG). In the days following the surgery, we recorded behavioural data together with the local field potentials of the PPNa during sitting, standing and stepping-in-place, under two dopaminergic medication conditions (OFF and ON levodopa). Our results showed that OFF levodopa, all subjects had FOG during step-in-place trials, while ON levodopa, stepping was effective (mean duration of FOG decreasing from 61.7±36.1% to 7.3±10.1% of trial duration). ON levodopa, there was an increase in PPNa alpha (5–12 Hz) oscillatory activity and a decrease in beta (13–35 Hz) and gamma (65–90 Hz) bands activity. PPNa activity was not modulated during quiet standing and sitting. Our results confirm the role of the PPNa in the regulation of gait and suggest that, in Parkinson disease, gait difficulties could be related to an imbalance between low and higher frequencies.
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Wagle Shukla A, Moro E, Gunraj C, Lozano A, Hodaie M, Lang A, Chen R. Long-term subthalamic nucleus stimulation improves sensorimotor integration and proprioception. J Neurol Neurosurg Psychiatry 2013; 84:1020-8. [PMID: 23616568 DOI: 10.1136/jnnp-2012-304102] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Sensorimotor integration is impaired in patients with Parkinson's disease (PD). Short latency afferent inhibition (SAI) and long latency afferent inhibition (LAI) measured with transcranial magnetic stimulation (TMS) can be used to measure sensorimotor integration. Subthalamic nucleus (STN) deep brain stimulation (DBS) has been found to restore these abnormalities, but the time course of these changes is not known. We prospectively evaluated the short-term and long-term effects of STN DBS on SAI, LAI and proprioception. We hypothesised plasticity changes induced by chronic stimulation are necessary to normalise sensorimotor integration and proprioception. METHODS Patients with PD were studied preoperatively, at 1 month and more than 6 months postoperatively. SAI was tested with median nerve stimulation to the wrist preceding TMS pulse to motor cortex by ~20 ms and LAI by 200 ms. Proprioception (distance and spatial errors) in the arm was quantitatively assessed. For postoperative assessments, patients were studied in the medication-off/stimulator-off, medication-off/stimulator-on, medication-on/stimulator-off and medication-on/stimulator-on conditions. RESULTS 11 patients with PD and 10 controls were enrolled. Preoperatively, SAI and proprioception was abnormal during the medication-on conditions and LAI was reduced regardless of the medication status. STN DBS had no significant effect on SAI, LAI and proprioception at 1 month. However, at 6 months SAI, LAI and distance errors were normalised in the medication-on/stimulator-on condition. Spatial error was normalised with DBS on and off. CONCLUSIONS Chronic STN DBS in PD normalises sensorimotor integration and proprioception, likely through long-term plastic changes in the basal ganglia thalamocortical circuit.
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Affiliation(s)
- Aparna Wagle Shukla
- Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Florida, USA
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Winfree KN, Pretzer-Aboff I, Hilgart D, Aggarwal R, Behari M, Agrawal SK. The Effect of Step-Synchronized Vibration on Patients With Parkinson's Disease: Case Studies on Subjects With Freezing of Gait or an Implanted Deep Brain Stimulator. IEEE Trans Neural Syst Rehabil Eng 2013; 21:806-11. [DOI: 10.1109/tnsre.2013.2250308] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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36
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Hill KK, Campbell MC, McNeely ME, Karimi M, Ushe M, Tabbal SD, Hershey T, Flores HP, Hartlein JM, Lugar HM, Revilla FJ, Videen TO, Earhart GM, Perlmutter JS. Cerebral blood flow responses to dorsal and ventral STN DBS correlate with gait and balance responses in Parkinson's disease. Exp Neurol 2013; 241:105-12. [PMID: 23262122 PMCID: PMC3570746 DOI: 10.1016/j.expneurol.2012.12.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 12/03/2012] [Accepted: 12/06/2012] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The effects of subthalamic nucleus (STN) deep brain stimulation (DBS) on gait and balance vary and the underlying mechanisms remain unclear. DBS location may alter motor benefit due to anatomical heterogeneity in STN. The purposes of this study were to (1) compare the effects of DBS of dorsal (D-STN) versus ventral (V-STN) regions on gait, balance and regional cerebral blood flow (rCBF) and (2) examine the relationships between changes in rCBF and changes in gait and balance induced by D-STN or V-STN DBS. METHODS We used a validated atlas registration to locate and stimulate through electrode contacts in D-STN and V-STN regions of 37 people with Parkinson's disease. In a within-subjects, double-blind and counterbalanced design controlled for DBS settings, we measured PET rCBF responses in a priori regions of interest and quantified gait and balance during DBS Off, unilateral D-STN DBS and unilateral V-STN DBS. RESULTS DBS of either site increased stride length without producing significant group-level changes in gait velocity, cadence or balance. Both sites increased rCBF in subcortical regions and produced variable changes in cortical and cerebellar regions. DBS-induced changes in gait velocity are related to premotor cortex rCBF changes during V-STN DBS (r=-0.40, p=0.03) and to rCBF changes in the cerebellum anterior lobe during D-STN DBS (r=-0.43, p=0.02). CONCLUSIONS DBS-induced changes in gait corresponded to rCBF responses in selected cortical and cerebellar regions. These relationships differed during D-STN versus V-STN DBS, suggesting DBS acts through distinct neuronal pathways dependent on DBS location.
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Affiliation(s)
- K K Hill
- Department of Biomedical Engineering, Washington University School of Medicine, St. Louis, MO, USA
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Kim SD, Allen NE, Canning CG, Fung VSC. Postural instability in patients with Parkinson's disease. Epidemiology, pathophysiology and management. CNS Drugs 2013; 27:97-112. [PMID: 23076544 DOI: 10.1007/s40263-012-0012-3] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Postural instability is one of the cardinal signs in Parkinson's disease (PD). It can be present even at diagnosis, but becomes more prevalent and worsens with disease progression. It represents one of the most disabling symptoms in the advanced stages of the disease, as it is associated with increased falls and loss of independence. Clinical and posturographic studies have contributed to significant advances in unravelling the complex pathophysiology of postural instability in patients with PD, but it still remains yet to be fully clarified, partly due to the difficulty in distinguishing between the disease process and the compensatory mechanisms, but also due to the fact that non-standardized techniques are used to measure balance and postural instability. There is increasing evidence that physical therapy, especially highly challenging balance exercises, can improve postural stability and reduce the risk of falls, although the long-term effects of physical therapy interventions on postural stability need to be explored given the progressive nature of PD. Pharmacotherapy with dopaminergic medications can provide significant improvements in postural instability in early- to mid-stage PD but the effects tend to wane with time consistent with spread of the disease process to non-dopaminergic pathways in advanced PD. Donepezil has been associated with a reduced risk of falls and methylphenidate has shown potential benefit against freezing of gait, but the results are yet to be replicated in large randomized studies. Surgical treatments, including lesioning and deep brain stimulation surgery targeting the subthalamic nucleus and the globus pallidus internus, tend to only provide modest benefit for postural instability. New surgical targets such as the pedunculopontine nucleus have emerged as a potential specific therapy for postural instability and gait disorder but remain experimental.
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Affiliation(s)
- Samuel D Kim
- Movement Disorders Unit, Department of Neurology, Westmead Hospital, Darcy Rd, Westmead, NSW, 2145, Australia
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Wang XH, Lu G, Hu X, Tsang KS, Kwong WH, Wu FX, Meng HW, Jiang S, Liu SW, Ng HK, Poon WS. Quantitative assessment of gait and neurochemical correlation in a classical murine model of Parkinson's disease. BMC Neurosci 2012; 13:142. [PMID: 23151254 PMCID: PMC3507899 DOI: 10.1186/1471-2202-13-142] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 09/14/2012] [Indexed: 11/30/2022] Open
Abstract
Background Gait deficits are important clinical symptoms of Parkinson’s disease (PD). However, existing behavioral tests for the detection of motor impairments in rodents with systemic dopamine depletion only measure akinesia and dyskinesia, and data focusing on gait are scarce. We evaluated gait changes in the methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced C57BL/6 murine model of PD by using a computer-assisted CatWalk system. Correlations of gait parameters with tyrosine hydroxylase (TH) protein levels in the substantia nigra (SN) were also investigated. Results The gait readouts, including the walking duration, variation of walking speed, step cycle, duty cycle, stance, initial dual stance, terminal dual stance, three- and four-point supports, and the base of support between hind limbs was noted to increase significantly one week after MPTP injection. In contrast, values of the stride length, cadence, swing speed, and diagonal dual support decreased substantially following MPTP treatment (p < 0.05). All of these changes lasted for three weeks after the last MPTP administration. Except for the stance in the fore limbs and the swing speed in the hind limbs, the gait variability in the PD mice showed a closer correlation with the protein levels of TH in the SN than the walking distances in the conventional open field test. Coordination parameters of the regularity index and step pattern were not affected in mice treated with MPTP. Conclusion Data of the study suggest that the computer-assisted CatWalk system can provide reliable and objective criteria to stratify gait changes arising from MPTP-induced bilateral lesions in C57/BL6 mice. The extent of gait changes was noted to correlate with the expression of the biomarker for dopaminergic neurons. This novel analytical method may hold promise in the study of disease progression and new drug screening in a murine PD model.
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Affiliation(s)
- Xiao Hong Wang
- Research Center for Sectional and Imaging Anatomy, Shandong University School of Medicine, 250012 Jinan, Shandong, China
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Lohnes CA, Earhart GM. Effect of subthalamic deep brain stimulation on turning kinematics and related saccadic eye movements in Parkinson disease. Exp Neurol 2012; 236:389-94. [PMID: 22580213 DOI: 10.1016/j.expneurol.2012.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 04/10/2012] [Accepted: 05/01/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND Persons with Parkinson disease (PD) experience turning difficulty, often leading to freezing of gait and falls. Visual information plays a significant role in locomotion and turning, and while the effects of deep brain stimulation (DBS) on oculomotor function have been well documented, the effects of DBS on oculomotor function during turning and on turning itself have yet to be fully elucidated. OBJECTIVE To determine the effects of STN DBS on turning performance and related oculomotor performance in PD. METHODS Eleven subjects with PD and DBS of the subthalamic nucleus performed a seated voluntary saccade task and standing 180° turns in DBS OFF and DBS ON conditions. Oculomotor data were captured using an infrared eye tracking system while segment rotations were measured using 3-D motion capture. RESULTS During the seated saccade task, DBS did not improve saccade amplitude or latency. DBS also did not improve gait velocity and stride length during forward walking. During turning, DBS improved turn performance (turn duration), reduced the number of saccades performed during the turns, and increased the amplitude and velocity of the saccade initiating the turn. DBS decreased the intersegmental latencies (eye-head, eye-foot, and head-trunk) but this effect was lost for eye-head and eye-foot after controlling for the duration of the first gait cycle. CONCLUSIONS DBS significantly improves turn performance and related oculomotor performance. These findings add to the growing list of therapeutic benefits offered by DBS.
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Affiliation(s)
- Corey A Lohnes
- Program in Physical Therapy, Washington University in St. Louis, St. Louis, MO 63108, USA
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Khan S, Javed S, Mooney L, White P, Plaha P, Whone A, Gill SS. Clinical outcomes from bilateral versus unilateral stimulation of the pedunculopontine nucleus with and without concomitant caudal zona incerta region stimulation in Parkinson's disease. Br J Neurosurg 2012; 26:722-5. [PMID: 22404735 DOI: 10.3109/02688697.2012.659297] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The Pedunculopontine nucleus is a novel target for deep brain stimulation and this may improve postural instability and gait dysfunction in Parkinson's disease. If unilateral Pedunculopontine nucleus stimulation is as efficacious as bilateral stimulation this would lead to less surgical risk. METHODS 5 Parkinson's disease patients with bilateral caudal Zona Incerta region and Pedunculopontine nucleus electrodes were assessed using the motor component of the Unified Parkinson's Disease Rating Scale. Patients were assessed in the on-medication state to determine the optimal combination of stimulation setting for axial symptom control. RESULTS The on-medication composite axial-subscore only showed a statistically significant improvement when bilateral Pedunculopontine nucleus and caudal Zona Incerta region stimulation was used. CONCLUSIONS In the on-medication state bilateral Pedunculopontine nucleus and caudal Zona Incerta region stimulation is required in order to produce a significant change in the motor Unified Parkinson's Disease Rating Scale axial-subscore from baseline.
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Affiliation(s)
- Sadaquate Khan
- Department of Neurosurgery, Institute of Neurosciences, Frenchay Hospital, Bristol
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Khan S, Gill SS, Mooney L, White P, Whone A, Brooks DJ, Pavese N. Combined pedunculopontine-subthalamic stimulation in Parkinson disease. Neurology 2012; 78:1090-5. [PMID: 22402859 DOI: 10.1212/wnl.0b013e31824e8e96] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the effect of deep brain stimulation (DBS) in the pedunculopontine nucleus (PPN) and caudal zona incerta (cZi)-both separately and in combination-on motor symptoms and regional cerebral blood flow (rCBF) in patients with Parkinson disease (PD). METHODS Four patients with bilateral cZi and PPN DBS electrodes were rated with the Unified Parkinson's Disease Rating Scale motor subscale (UPDRS-III) when taking and withdrawn from medication. A block of 16 [(15)O]-H(2)O PET resting measurements of rCBF were performed in 4 different states with patients withdrawn from medication: 1) no stimulation, 2) cZi stimulation alone, 3) PPN stimulation alone, 4) combined PPN/cZi stimulation. RESULTS When patients were medicated, combined PPN/cZi stimulation produced a statistically significant improvement in UPDRS-III score compared to cZi stimulation alone. In the "off" medication state, the clinical effect of combined stimulation was not significantly different from that induced by cZi stimulation alone. Concomitant PPN/cZi stimulation had a cumulative effect on levels of rCBF, effectively combining subcortical and cortical changes induced by stimulation of either target in isolation. CONCLUSIONS These findings suggest that concomitant low frequency stimulation of PPN and cZi regions induces additive brain activation changes and provides improved control of PD symptoms when medicated. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that concomitant low frequency stimulation of PPN and cZI improves motor symptoms in patients with PD on dopamine replacement. It provides Class III evidence that concomitant low frequency stimulation of PPN and cZi induces additive rCBF changes in motor areas of brain.
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Affiliation(s)
- S Khan
- Department of Neurosurgery, Institute of Neurosciences, Frenchay Hospital, Bristol, UK
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Thevathasan W, Cole MH, Graepel CL, Hyam JA, Jenkinson N, Brittain JS, Coyne TJ, Silburn PA, Aziz TZ, Kerr G, Brown P. A spatiotemporal analysis of gait freezing and the impact of pedunculopontine nucleus stimulation. ACTA ACUST UNITED AC 2012; 135:1446-54. [PMID: 22396391 PMCID: PMC3338924 DOI: 10.1093/brain/aws039] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Gait freezing is an episodic arrest of locomotion due to an inability to take normal steps. Pedunculopontine nucleus stimulation is an emerging therapy proposed to improve gait freezing, even where refractory to medication. However, the efficacy and precise effects of pedunculopontine nucleus stimulation on Parkinsonian gait disturbance are not established. The clinical application of this new therapy is controversial and it is unknown if bilateral stimulation is more effective than unilateral. Here, in a double-blinded study using objective spatiotemporal gait analysis, we assessed the impact of unilateral and bilateral pedunculopontine nucleus stimulation on triggered episodes of gait freezing and on background deficits of unconstrained gait in Parkinson’s disease. Under experimental conditions, while OFF medication, Parkinsonian patients with severe gait freezing implanted with pedunculopontine nucleus stimulators below the pontomesencephalic junction were assessed during three conditions; off stimulation, unilateral stimulation and bilateral stimulation. Results were compared to Parkinsonian patients without gait freezing matched for disease severity and healthy controls. Pedunculopontine nucleus stimulation improved objective measures of gait freezing, with bilateral stimulation more effective than unilateral. During unconstrained walking, Parkinsonian patients who experience gait freezing had reduced step length and increased step length variability compared to patients without gait freezing; however, these deficits were unchanged by pedunculopontine nucleus stimulation. Chronic pedunculopontine nucleus stimulation improved Freezing of Gait Questionnaire scores, reflecting a reduction of the freezing encountered in patients’ usual environments and medication states. This study provides objective, double-blinded evidence that in a specific subgroup of Parkinsonian patients, stimulation of a caudal pedunculopontine nucleus region selectively improves gait freezing but not background deficits in step length. Bilateral stimulation was more effective than unilateral.
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Affiliation(s)
- Wesley Thevathasan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
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Rochester L, Chastin SFM, Lord S, Baker K, Burn DJ. Understanding the impact of deep brain stimulation on ambulatory activity in advanced Parkinson’s disease. J Neurol 2011; 259:1081-6. [DOI: 10.1007/s00415-011-6301-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 10/14/2011] [Accepted: 10/19/2011] [Indexed: 11/28/2022]
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A review of dual-task walking deficits in people with Parkinson's disease: motor and cognitive contributions, mechanisms, and clinical implications. PARKINSONS DISEASE 2011; 2012:918719. [PMID: 22135764 PMCID: PMC3205740 DOI: 10.1155/2012/918719] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 08/29/2011] [Accepted: 09/04/2011] [Indexed: 12/20/2022]
Abstract
Gait impairments in Parkinson's disease (PD) are exacerbated under dual-task conditions requiring the simultaneous performance of cognitive or motor tasks. Dual-task walking deficits impact functional mobility, which often requires walking while performing concurrent tasks such as talking or carrying an object. The consequences of gait impairments in PD are significant and include increased disability, increased fall risk, and reduced quality of life. However, effective therapeutic interventions for dual-task walking deficits are limited. The goals of this narrative review are to describe dual-task walking deficits in people with PD, to discuss motor and cognitive factors that may contribute to these deficits, to review potential mechanisms underlying dual-task deficits, and to discuss the effect of therapeutic interventions on dual-task walking deficits in persons with PD.
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Bleuse S, Delval A, Blatt J, Derambure P, Destée A, Defebvre L. Effect of bilateral subthalamic nucleus deep brain stimulation on postural adjustments during arm movement. Clin Neurophysiol 2011; 122:2032-5. [DOI: 10.1016/j.clinph.2011.02.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 02/21/2011] [Accepted: 02/24/2011] [Indexed: 12/01/2022]
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Effect of globus pallidus internus stimulation on neuronal activity in the pedunculopontine tegmental nucleus in the primate model of Parkinson's disease. Exp Neurol 2011; 233:575-80. [PMID: 21821025 DOI: 10.1016/j.expneurol.2011.07.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 07/16/2011] [Indexed: 11/22/2022]
Abstract
The pedunculopontine tegmental nucleus (PPN) is being explored as a site for deep brain stimulation (DBS) for the treatment of patients with medically refractory gait and postural abnormalities (MRGPA) associated with Parkinson's disease (PD). The PPN is involved in initiation and modulation of gait and other stereotyped motor behaviors and is inter-connected with the pallido-thalamo-cortical circuit. Internal segment of the globus pallidus (GPi) DBS is effective at treating the motor signs associated with PD, however its impact on MRGPA is limited and its effect on PPN neuronal activity is unknown. The current work characterizes the effect of therapeutically-effective GPi DBS on PPN neuronal activity in a single rhesus monkey made parkinsonian using 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). A scaled-down, quadripolar DBS lead was implanted into sensorimotor GPi under electrophysiological and stereotactic guidance. Single-neuron activity was recorded from PPN before, during and after DBS. GPi DBS reduced the mean discharge rate of PPN neurons from 16.8 Hz to 12.8 Hz, with 30 (66.7%) neurons showing a decreased mean rate, 3 (6.7%) increased and 12 (26.7%) unchanged. Consistent with known GABAergic projections from GPi to PPN, and with previous observations that stimulation increases output from the stimulated structure, GPi DBS suppressed activity in the PPN. The present observations, together with previous reports of improvement in MRGPA during low frequency stimulation in PPN, suggest that activation of PPN output may be required to improve MRGPA and may account for the lack of improvement in MRGPA typically observed with GPi or subthalamic nucleus (STN) DBS.
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Muniz AMS, Liu H, Lyons KE, Pahwa R, Liu W, Nadal J. Quantitative evaluation of the effects of subthalamic stimulation on gait in Parkinson's disease patients using principal component analysis. Int J Neurosci 2010; 120:609-16. [PMID: 20707636 DOI: 10.3109/00207454.2010.504904] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Principal component analysis (PCA) was applied to the ground reaction force (GRF) for evaluating the deep brain stimulation of the subthalamic nucleus (DBS-STN) effects in Parkinson's disease (PD) subjects with and without medication. METHODS Ten subjects who underwent DBS-STN were evaluated under the following four conditions: without treatment (mof-sof), with stimulation (mof-son), with medication (mon-sof), and with both treatments (mon-son). A control group of 30 subjects was also evaluated. PCA was applied separately on each GRF component. Broken stick criterion selected eight principal components (PC) from vertical GRF and one from each horizontal GRF. A standard distance was calculated using these 10 PCs and the gait speed to measure how far the PD group's gait was from the normal pattern. RESULTS The standard distance allowed classifying normal and PD subjects in the mof-sof condition with 100% accuracy, sensitivity, and specificity. The same distance was calculated for mon-sof, mof-son, and mon-son conditions. The smallest mean standard distance was found in the mon-son condition, which was significantly different from mof-sof (Friedman test with Dunn post-hoc, p < .05). CONCLUSION PCA allowed the quantitative evaluation of treatment effects, indicating that DBS-STN improves the GRF pattern in PD subjects, primarily in the medication on state.
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Affiliation(s)
- A M S Muniz
- Department of Postgraduation, Physical Education College of Brazilian Army, Rio de Janeiro, Brazil
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St George RJ, Nutt JG, Burchiel KJ, Horak FB. A meta-regression of the long-term effects of deep brain stimulation on balance and gait in PD. Neurology 2010; 75:1292-9. [PMID: 20921515 DOI: 10.1212/wnl.0b013e3181f61329] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Deep brain stimulation (DBS) alleviates the cardinal Parkinson disease (PD) symptoms of tremor, rigidity, and bradykinesia. However, its effects on postural instability and gait disability (PIGD) are uncertain. Contradictory findings may be due to differences the in stimulation site and the length of time since DBS surgery. This prompted us to conduct the first meta-regression of long-term studies of bilateral DBS in the subthalamic nucleus (STN) and globus pallidus interna (GPi). RESULTS Eleven articles reported a breakdown of the Unified Parkinson's Disease Rating Scale score before and beyond 3 years postsurgery (mean 4.5 years). Random effects meta-regression revealed that DBS initially improved PIGD compared to the OFF medicated state before surgery, but performance declined over time and extrapolation showed subjects would reach presurgery levels 9 years postsurgery. ON medication, DBS improved PIGD over and above the effect of medication before surgery. Nevertheless, for the STN group, PIGD progressively declined and was worse than presurgery function within 2 years. In contrast, GPi patients showed no significant long-term decline in PIGD in the medicated state. Improvements in cardinal signs with DBS at both sites were maintained across 5 years in the OFF and ON medication states. CONCLUSIONS DBS alone does not offer the same improvement to PIGD as it does to the cardinal symptoms, suggesting axial and distal control are differentially affected by DBS. GPi DBS in combination with levodopa seemed to preserve PIGD better than did STN DBS, although more studies of GPi DBS and randomized controls are needed.
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Affiliation(s)
- R J St George
- Department of Neurology, Oregon Health & Sciences University, 505 NW 185 Avenue, Beaverton, OR 97006, USA.
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Nisenzon AN, Robinson ME, Bowers D, Banou E, Malaty I, Okun MS. Measurement of patient-centered outcomes in Parkinson's disease: what do patients really want from their treatment? Parkinsonism Relat Disord 2010; 17:89-94. [PMID: 20952243 DOI: 10.1016/j.parkreldis.2010.09.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 09/06/2010] [Accepted: 09/16/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND Parkinson's disease (PD) impacts several domains of functioning, some of which may be neglected when designing treatment or evaluating outcome using current clinical standards. We therefore argue that taking the patients' perspectives of their condition may allow for a more in-depth assessment of patient goals and subsequent tailoring of care. METHODS One hundred and forty-eight patients with idiopathic PD completed a modified version of the Patient-Centered Outcomes Questionnaire (PCOQ-PD), to evaluate treatment success and expectations from the patient's perspective across 10 motor and non-motor functional domains. We also examined patient subgroups based on importance of improvement in various domains. RESULTS Patients' ratings suggested there was substantial variation in functional interference that was generally unrelated to demographic variables. On average, across all domains, patients indicated a 50.32% reduction in symptoms would be successful (range = 40.63-58.23%), regardless of treatment experience. Change scores between patients' usual levels of symptom interference and their treatment success levels suggested a greater degree of change was desired in motor versus non-motor domains (p < 0.05). Finally, cluster analyses revealed two patient subgroups based on overall importance of improvement (High vs. Low Importance Endorsement). Notably, the two groups differed in self-reported usual symptom levels despite having similar clinical severity. CONCLUSIONS We empirically examined treatment success from the PD patient's view as opposed to clinician judgment alone, thereby broadening the set of criteria by which to evaluate outcome. Findings from this exploratory study may guide future treatment emphases and guide patient-provider communication via clarification of patient-defined success.
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Affiliation(s)
- Anne N Nisenzon
- Department of Clinical and Health Psychology, University of Florida, Health Science Center, P.O. Box 100165, Gainesville, FL 32610-0165, USA.
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Peppe A, Pierantozzi M, Chiavalon C, Marchetti F, Caltagirone C, Musicco M, Stanzione P, Stefani A. Deep brain stimulation of the pedunculopontine tegmentum and subthalamic nucleus: effects on gait in Parkinson's disease. Gait Posture 2010; 32:512-8. [PMID: 20727761 DOI: 10.1016/j.gaitpost.2010.07.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 07/14/2010] [Accepted: 07/16/2010] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study examines the effects of subthalamic nucleus (STN) deep brain stimulation (DBS) and pedunculopontine tegmentum (PPTg) DBS in advanced Parkinson's disease using gait analysis. METHODS Five people underwent bilateral DBS in both the STN and PPTg. Gait analysis was performed one year after neurosurgery using an optoelectronic system. The effects of DBS (STN, PPTg and STN+PPTg) were studied in two clinical conditions: without (Off) and during (On) antiparkinsonian therapy. RESULTS PPTg and STN DBS were associated with changes in spatio-temporal and kinematics variables. CONCLUSIONS Although experimental data cannot be generalized widely due to the small sample, PPTg DBS appears to affect the neuronal circuits subserving gait.
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Affiliation(s)
- A Peppe
- IRCCS, Santa Lucia Foundation, Via Ardeatina 309, 00179 Rome, Italy.
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