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Stunnenberg BC, Berends J, Griggs RC, Statland J, Drost G, Nikles J, Groenewoud H, van Engelen BGM, Jan van der Wilt G, Raaphorst J. N-of-1 Trials in Neurology: A Systematic Review. Neurology 2021; 98:e174-e185. [PMID: 34675101 DOI: 10.1212/wnl.0000000000012998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 10/14/2021] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo perform a systematic review of published N-of-1 trials (e.g. single patient cross-over trials) in neurological disorders, including an assessment of methodological quality and reporting.MethodsWe searched PubMed, MEDLINE and Embase, from inception date - the first of December 2019, for reports on N-of-1 trials in neurological disorders. Basic trial information on design, disease, intervention, analysis and treatment success was extracted. Strengths and weaknesses of the N-of-1 trials were assessed using the CONSORT extension for N-of-1 trials (CENT) 2015 criteria checklist and the Jadad score as measures of quality and reporting.ResultsWe retrieved 40 reports of N-of-1 trials in neurological disorders (19 individual N-of-1 trials, 21 series of N-of-1 trials). Most N-of-1 trials were performed in neuromuscular and neurodegenerative / movement disorders. Unlike the majority of trials that studied the main symptom(s) of a chronic stable condition, nine N-of-1 trials studied a stable chronic symptom of a progressive or acute neurological disorder. Besides pharmacological interventions, electrical stimulation protocols and nutritional products were studied. A mean total CENT score of 20.88 (SD, 9.10; range 0-43) and mean total Jadad score of 2.90 (SD, 2.15; range 0-5) were found as methodological measures of quality and reporting across all N-of-1 trialsConclusionsN-of-1 trials have been reported in numerous neurological disorders, not only in chronic stable disorders, but also in progressive or acute disorders with a stable symptom. This indicates the emerging therapeutic area of N-of-1 trials in Neurology.Methodological quality and reporting of N-of-1 trials were found suboptimal and can easily be improved in future trials by appropriately describing the methods of blinding and randomization and follow CENT guidelines. As most N-of-1 trials remain unreported in medical literature, this systematic review probably only represent the tip of the iceberg of conducted N-of-1 trials in neurological disorders. In addition to conventional trial designs, N-of-1 trials can help to bridge the gap between research and clinical care by providing an alternative, personalized level 1 evidence-base for suitable treatments.
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Affiliation(s)
- Bas C Stunnenberg
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joost Berends
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert C Griggs
- Department of Neurology, University of Rochester Medical Center, Rochester, USA
| | - Jeffrey Statland
- Department of Neurology, University of Kansas Medical Center, Kansas City, USA
| | - Gea Drost
- University of Groningen, Department of Neurology and Neurosurgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jane Nikles
- The University of Queensland Centre for Clinical Research, The University of Queensland, Herston, Brisbane, Queensland, Australia
| | - Hans Groenewoud
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Baziel G M van Engelen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gert Jan van der Wilt
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joost Raaphorst
- Amsterdam UMC, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, Amsterdam, Netherlands
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Ota HCU, Smith BG, Alamri A, Robertson FC, Marcus H, Hirst A, Broekman M, Hutchinson P, McCulloch P, Kolias A. The IDEAL framework in neurosurgery: a bibliometric analysis. Acta Neurochir (Wien) 2020; 162:2939-2947. [PMID: 32651707 PMCID: PMC7593304 DOI: 10.1007/s00701-020-04477-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/29/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The Idea, Development, Exploration, Assessment and Long-term study (IDEAL) framework was created to provide a structured way for assessing and evaluating novel surgical techniques and devices. OBJECTIVES The aim of this paper was to investigate the utilization of the IDEAL framework within neurosurgery, and to identify factors influencing implementation. METHODS A bibliometric analysis of the 7 key IDEAL papers on Scopus, PubMed, Embase, Web of Science, and Google Scholar databases (2009-2019) was performed. A second journal-specific search then identified additional papers citing the IDEAL framework. Publications identified were screened by two independent reviewers to select neurosurgery-specific articles. RESULTS The citation search identified 1336 articles. The journal search identified another 16 articles. Following deduplication and review, 51 relevant articles remained; 14 primary papers (27%) and 37 secondary papers (73%). Of the primary papers, 5 (36%) papers applied the IDEAL framework to their research correctly; two were aligned to the pre-IDEAL stage, one to the Idea and Development stages, and two to the Exploration stage. Of the secondary papers, 21 (57%) explicitly discussed the IDEAL framework. Eighteen (86%) of these were supportive of implementing the framework, while one was not, and two were neutral. CONCLUSION The adoption of the IDEAL framework in neurosurgery has been slow, particularly for early-stage neurosurgical techniques and inventions. However, the largely positive reviews in secondary literature suggest potential for increased use that may be achieved with education and publicity.
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Affiliation(s)
| | - Brandon G Smith
- Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - Alexander Alamri
- Department of Neurosurgery, The Royal London Hospital, London, UK
| | - Faith C Robertson
- Department. of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hani Marcus
- The Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Allison Hirst
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford and John Radcliffe Hospital, Oxford, UK
| | - Marike Broekman
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford and John Radcliffe Hospital, Oxford, UK
- Department of Neurosurgery, Haaglanden Medical Center/Leiden University Medical Center, The Hague, Netherlands
| | - Peter Hutchinson
- Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - Peter McCulloch
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford and John Radcliffe Hospital, Oxford, UK
| | - Angelos Kolias
- Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK.
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford and John Radcliffe Hospital, Oxford, UK.
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Deng H, Yue JK, Wang DD. Trends in safety and cost of deep brain stimulation for treatment of movement disorders in the United States: 2002-2014. Br J Neurosurg 2020; 35:57-64. [PMID: 32476485 DOI: 10.1080/02688697.2020.1759776] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Deep brain stimulation (DBS) is being increasingly utilized to treat movement disorders including Parkinson's disease (PD), essential tremor (ET), and dystonia. An improved understanding of national trends in safety and cost is necessary. Herein, our objectives are to (1) characterize complication, mortality, and cost profiles of patients undergoing DBS for movement disorders in the United States, (2) identify predictors of morbidity and mortality, and (3) evaluate impact of complications on cost. METHODS DBS surgeries were extracted from the National Inpatient Sample (NIS) 2002-2014 for the clinical indications of PD, ET, and dystonia. Patient characteristics and eight complication categories (hardware malfunction, infection, neurological, other haemorrhagic, thromboembolic, cardiac, pulmonary, and renal/urinary) were reviewed. Outcomes included complications, mortality, hospitalization length, and inflation-adjusted cost. RESULTS There were 44,866 weighted admissions (PD-73.5%, ET-22.7%, dystonia-3.8%). The number of procedures increased 2.22-fold from 2002 to 2014 (N = 2372 in 2002; N = 5260 in 2014). Inpatient cost was $22,802 ± 13,164, remaining stable from 2002 to 2014 ($24,188 ± 15,910, $20,630 ± 11,031, respectively). Four percent experienced complications (dystonia-6.0%, PD-4.4%, ET-3.1%, p < .001). In-hospital mortality was 0.2%. Cost was greater in patients with complications ($36,306 ± 29,263 vs. $22,196 ± 11,560, p < .001). Most common complications were renal/urinary (1.5%), neurological (1.1%), and pulmonary (0.7%). Thromboembolic, pulmonary, and haemorrhagic complications were associated with greatest cost. CONCLUSION Increased DBS utilization for adult movement disorders in the United States from 2002 to 2014 was attributed to rapid adoption by teaching hospitals for PD. DBS remains a safe procedure with low overall complications and stable inpatient costs from 2002 to 2014. Complication risks vary by type of movement disorder, and although rare, multiple complications increase morbidity and cost of care.
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Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Doris D Wang
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Tan H, Debarros J, He S, Pogosyan A, Aziz TZ, Huang Y, Wang S, Timmermann L, Visser-Vandewalle V, Pedrosa DJ, Green AL, Brown P. Decoding voluntary movements and postural tremor based on thalamic LFPs as a basis for closed-loop stimulation for essential tremor. Brain Stimul 2019; 12:858-867. [PMID: 30827864 PMCID: PMC6600875 DOI: 10.1016/j.brs.2019.02.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND High frequency Deep brain stimulation (DBS) targeting motor thalamus is an effective therapy for essential tremor (ET). However, conventional continuous stimulation may deliver unnecessary current to the brain since tremor mainly affects voluntary movements and sustained postures in ET. OBJECTIVE We aim to decode both voluntary movements and the presence of postural tremor from the Local field potentials (LFPs) recorded from the electrode implanted in motor thalamus for stimulation, in order to close the loop for DBS so that stimulation could be delivered on demand, without the need for peripheral sensors or additional invasive electrodes. METHODS LFPs from the motor thalamus, surface electromyographic (EMG) signals and/or behavioural measurements were simultaneously recorded in seven ET patients during temporary lead externalisation 3-5 days after the first surgery for DBS when they performed different voluntary upper limb movements. Nine different patients were recorded during the surgery, when they were asked to lift their arms to trigger postural tremor. A machine learning based binary classifier was used to detect voluntary movements and postural tremor based on features extracted from thalamic LFPs. RESULTS Cross-validation demonstrated that both voluntary movements and postural tremor can be decoded with an average sensitivity of 0.8 and false detection rate of 0.2. Oscillatory activities in the beta frequency bands (13-23 Hz) and the theta frequency bands (4-7 Hz) contributed most to the decoding of movements and postural tremor, respectively, though incorporating features in different frequency bands using a machine learning approach increased the accuracy of decoding.
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Affiliation(s)
- Huiling Tan
- Medical Research Council Brain Network Dynamics Unit at the University of Oxford, OX1 3TH, Oxford, United Kingdom; Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, OX3 9DU, Oxford, United Kingdom.
| | - Jean Debarros
- Medical Research Council Brain Network Dynamics Unit at the University of Oxford, OX1 3TH, Oxford, United Kingdom; Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, OX3 9DU, Oxford, United Kingdom
| | - Shenghong He
- Medical Research Council Brain Network Dynamics Unit at the University of Oxford, OX1 3TH, Oxford, United Kingdom; Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, OX3 9DU, Oxford, United Kingdom
| | - Alek Pogosyan
- Medical Research Council Brain Network Dynamics Unit at the University of Oxford, OX1 3TH, Oxford, United Kingdom; Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, OX3 9DU, Oxford, United Kingdom
| | - Tipu Z Aziz
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Yongzhi Huang
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Shouyan Wang
- Neural and Intelligence Engineering Center, Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
| | - Lars Timmermann
- Department of Neurology, University Hospital of Gießen and Marburg, Marburg, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, University Hospital Cologne, 50924, Cologne, Germany
| | - David J Pedrosa
- Department of Neurology, University Hospital of Gießen and Marburg, Marburg, Germany
| | - Alexander L Green
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Peter Brown
- Medical Research Council Brain Network Dynamics Unit at the University of Oxford, OX1 3TH, Oxford, United Kingdom; Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, OX3 9DU, Oxford, United Kingdom.
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Deep brain stimulation in uncommon tremor disorders: indications, targets, and programming. J Neurol 2018; 265:2473-2493. [PMID: 29511865 DOI: 10.1007/s00415-018-8823-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/01/2018] [Accepted: 03/02/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND In uncommon tremor disorders, clinical efficacy and optimal anatomical targets for deep brain stimulation (DBS) remain inadequately studied and insufficiently quantified. METHODS We performed a systematic review of PubMed.gov and ClinicalTrials.gov. Relevant articles were identified using the following keywords: "tremor", "Holmes tremor", "orthostatic tremor", "multiple sclerosis", "multiple sclerosis tremor", "neuropathy", "neuropathic tremor", "fragile X-associated tremor/ataxia syndrome", and "fragile X." RESULTS We identified a total of 263 cases treated with DBS for uncommon tremor disorders. Of these, 44 had Holmes tremor (HT), 18 orthostatic tremor (OT), 177 multiple sclerosis (MS)-associated tremor, 14 neuropathy-associated tremor, and 10 fragile X-associated tremor/ataxia syndrome (FXTAS). DBS resulted in favorable, albeit partial, clinical improvements in HT cases receiving Vim-DBS alone or in combination with additional targets. A sustained improvement was reported in OT cases treated with bilateral Vim-DBS, while the two cases treated with unilateral Vim-DBS demonstrated only a transient effect. MS-associated tremor responded to dual-target Vim-/VO-DBS, but the inability to account for the progression of MS-associated disability impeded the assessment of its long-term clinical efficacy. Neuropathy-associated tremor substantially improved with Vim-DBS. In FXTAS patients, while Vim-DBS was effective in improving tremor, equivocal results were observed in those with ataxia. CONCLUSIONS DBS of select targets may represent an effective therapeutic strategy for uncommon tremor disorders, although the level of evidence is currently in its incipient form and based on single cases or limited case series. An international registry is, therefore, warranted to clarify selection criteria, long-term results, and optimal surgical targets.
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Abstract
INTRODUCTION Essential tremor is the most common form of pathologic tremor. Surgical therapies disrupt tremorogenic oscillation in the cerebellothalamocortical pathway and are capable of abolishing severe tremor that is refractory to available pharmacotherapies. Surgical methods are raspidly improving and are the subject of this review. Areas covered: A PubMed search on 18 January 2018 using the query essential tremor AND surgery produced 839 abstracts. 379 papers were selected for review of the methods, efficacy, safety and expense of stereotactic deep brain stimulation (DBS), stereotactic radiosurgery (SRS), focused ultrasound (FUS) ablation, and radiofrequency ablation of the cerebellothalamocortical pathway. Expert commentary: DBS and SRS, FUS and radiofrequency ablations are capable of reducing upper extremity tremor by more than 80% and are far more effective than any available drug. The main research questions at this time are: 1) the relative safety, efficacy, and expense of DBS, SRS, and FUS performed unilaterally and bilaterally; 2) the relative safety and efficacy of thalamic versus subthalamic targeting; 3) the relative safety and efficacy of atlas-based versus direct imaging tractography-based anatomical targeting; and 4) the need for intraoperative microelectrode recordings and macroelectrode stimulation in awake patients to identify the optimum anatomical target. Randomized controlled trials are needed.
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Affiliation(s)
- Rodger J Elble
- a Neuroscience Institute , Southern Illinois University School of Medicine , Springfield , Illinois , USA
| | - Ludy Shih
- b Department of Neurology , Beth Israel Deaconess Medical Center, Harvard Medical School , Boston , Massachusetts USA
| | - Jeffrey W Cozzens
- a Neuroscience Institute , Southern Illinois University School of Medicine , Springfield , Illinois , USA
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Ben-Haim S, Falowski SM. Evaluation of Patient Perspectives Toward Awake, Frame-Based Deep-Brain Stimulation Surgery. World Neurosurg 2017; 111:e601-e607. [PMID: 29288853 DOI: 10.1016/j.wneu.2017.12.122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) is an effective therapeutic modality; however, only a percentage of eligible patients undergo the procedure. OBJECTIVES To study patients' perspectives toward DBS surgery. METHODS A survey was sent to 95 consecutive adult patients who underwent DBS surgery for Parkinson disease, essential tremor, or dystonia; the response rate was 73% (69 patients). Post-hoc analyses were performed to evaluate factors that led to favorable outcomes. The average time between surgical procedure to survey completion was 16 months. RESULTS Awake surgery, use of a rigid head frame, and having hair clipped were seldom reported as major deterrents to surgery. Patients retrospectively reported an average comfort level of 8.3 ± 1.8 during surgery. The average comfort level with head frame placement was reported as 5.2 ± 3.15, and patients reporting discomfort with the frame nonetheless reported overall comfort with the procedure (8.7 ± 1.8). An analysis of satisfaction revealed that 90% of patients would recommend the procedure to a family member or friend and that 78% of patients would undergo the procedure again. A post-hoc analysis of patients who were not satisfied with the procedure revealed that this subset reported significantly less overall comfort (6.9 ± 1.7, P = 0.0003) and were less likely to report that the goals and expectations of surgery were clearly discussed before surgery (P = 0.0004). CONCLUSIONS Frame placement, awake surgery, and head shaving did not appear to play a significant role in most patients' decision-making process to undergo DBS, as analyzed in this retrospective cohort. The majority of patients were satisfied with the procedure and reported being comfortable. Managing goals and expectations preoperatively played a significant role in ultimate overall satisfaction.
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Affiliation(s)
- Sharona Ben-Haim
- Department of Neurosurgery, University of California, San Diego, San Diego, California, USA
| | - Steven M Falowski
- Department of Neurosurgery, St. Lukes University Health Network, Bethlehem, Pennsylvania, USA.
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Akbar U, Raike RS, Hack N, Hess CW, Skinner J, Martinez-Ramirez D, DeJesus S, Okun MS. Randomized, Blinded Pilot Testing of Nonconventional Stimulation Patterns and Shapes in Parkinson's Disease and Essential Tremor: Evidence for Further Evaluating Narrow and Biphasic Pulses. Neuromodulation 2016; 19:343-56. [PMID: 27000764 PMCID: PMC4914444 DOI: 10.1111/ner.12397] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/17/2015] [Accepted: 12/21/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Evidence suggests that nonconventional programming may improve deep brain stimulation (DBS) therapy for movement disorders. The primary objective was to assess feasibility of testing the tolerability of several nonconventional settings in Parkinson's disease (PD) and essential tremor (ET) subjects in a single office visit. Secondary objectives were to explore for potential efficacy signals and to assess the energy demand on the implantable pulse-generators (IPGs). MATERIALS AND METHODS A custom firmware (FW) application was developed and acutely uploaded to the IPGs of eight PD and three ET subjects, allowing delivery of several nonconventional DBS settings, including narrow pulse widths, square biphasic pulses, and irregular pulse patterns. Standard clinical rating scales and several objective measures were used to compare motor outcomes with sham, clinically-optimal and nonconventional settings. Blinded and randomized testing was conducted in a traditional office setting. RESULTS Overall, the nonconventional settings were well tolerated. Under these conditions it was also possible to detect clinically-relevant differences in DBS responses using clinical rating scales but not objective measures. Compared to the clinically-optimal settings, some nonconventional settings appeared to offer similar benefit (e.g., narrow pulse widths) and others lesser benefit. Moreover, the results suggest that square biphasic pulses may deliver greater benefit. No unexpected IPG efficiency disadvantages were associated with delivering nonconventional settings. CONCLUSIONS It is feasible to acutely screen nonconventional DBS settings using controlled study designs in traditional office settings. Simple IPG FW upgrades may provide more DBS programming options for optimizing therapy. Potential advantages of narrow and biphasic pulses deserve follow up.
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Affiliation(s)
- Umer Akbar
- University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA.,Department of Neurology, Brown University, Providence, RI, USA
| | - Robert S Raike
- Neuromodulation Global Research, Medtronic Inc., Minneapolis, MN, USA
| | - Nawaz Hack
- University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA.,US Naval Hospital, Okinawa, Japan
| | - Christopher W Hess
- University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Jared Skinner
- University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Daniel Martinez-Ramirez
- University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Sol DeJesus
- University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Michael S Okun
- University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA.,Departments of Neurology and Neurosurgery, University of Florida, Gainesville, FL, USA
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Picillo M, Fasano A. Recent advances in Essential Tremor: Surgical treatment. Parkinsonism Relat Disord 2016; 22 Suppl 1:S171-5. [DOI: 10.1016/j.parkreldis.2015.09.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/02/2015] [Indexed: 11/26/2022]
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