Surgical management dbs and effects on gait posture and falls overview
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Surgical management: DBS and effects on gait, posture and falls overview. Miguel Coelho , MD Neurology Department, Hospital Santa Maria Clinical Pharmacology Unit, IMM, Lisbon Portugal. 25 September 2014. 2nd Annual Allied Health Professional Summer School. Financial Disclosure.

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Surgical management dbs and effects on gait posture and falls overview

Surgical management: DBS and effects on gait, posture and fallsoverview

Miguel Coelho, MD

Neurology Department, Hospital Santa Maria

Clinical Pharmacology Unit, IMM, Lisbon

Portugal

25 September 2014

2nd Annual Allied Health Professional Summer School


Financial disclosure

Financial Disclosure

  • Nothing to declare.


Outline

Outline

  • Indications for DBS in PD.

  • Overall efficacy of DBS for advanced PD.

  • Safety of DBS for advanced PD .

  • DBS effects on gait, posture and falls.


Levodopa induced motor complications

Levodopa-induced motor complications

  • Levodopa-induced motor complications (MC): high incidence in PD patients treated with L-dopa.

  • General rule: ~ 40-50% after 5 yrs of L-dopa.

  • Consist of motor fluctuations & dyskinesias.

  • High impact on disability and QoL.

  • Difficult to manage and complex drug regimens.

Ahlskog & Muenter 01; Schrag & Quinn 00; Marras 04


Indications for dbs in pd

Indications for DBS in PD

  • PD with disabling MC refractory to best medical treatment.

  • Disabling tremor refractory to medical treatment.

  • Off dystonia.

  • Neither curative nor disease-modifying.

  • Benefit on QoL (mostly motor sub-domains; in those ≤ 65 yrs-old)

Bronstein 11; Lang 06; Deuschl 06; Hilker R et al 05; Kleiner-Fisman et al 06; Pahwa et al 06; Derost et al 07


Candidates for dbs in pd

Candidates for DBS in PD

  • 70-75 years.

  • Good response to L-dopa (best predictor).

  • Indepedent on ADL during ON.

  • No or few axial non-LD-responsive motor signs.

Bronstein 11; Lang 06


Candidates for dbs in pd1

Candidates for DBS in PD

  • No Dementia.

  • No severe treatment-resistant depression or other severe psychiatric disorder.

  • Psychosis should be carefully assessed (drug-induced ?).

  • Realistic expectations & good social support.

Bronstein 11; Lang 06


Efficacy of dbs

Efficacy of DBS

  • Superior to best medical therapy (BMT).

  • Overall efficacious and safe on long-term (10 years), except axial signs.

  • Improves QoL.

  • STN or GPi.

Schuepbach 13; Odekerken 13; Castrioto 11; Deuschl 06; Williams 10; Weaver 09; Follett 10;


Efficacy of dbs1

Efficacy of DBS

  • Motor Benefit:

    • Off periods in 30-60%.

    • “On without dyskinesias” in 45%.

    • Disability of dyskinesias in 50-60%.

    • in parkinsonism severity (UPDRS motor off) in 40- 50%.

Odekerken 13; Castrioto 11; Deuschl 06; Williams 10; Weaver 09; Follett 10; Shupbach 07; Anderson 05; Parkinson Study Group 01; Limousin 96;


Efficacy of dbs2

Efficacy of DBS

  • Motor Benefit:

    • ADL (UPDRS II off) in 20-40%.

    • Levodopa Equivalent Dose (LED) in 40-50%.

    • STN > GPi

Odekerken 13; Castrioto 11; Deuschl 06; Williams 10; Weaver 09; ; Follett 10; Krack 03; Kleiner-Fisman et al 06; Pahwa et al 06; Derost et al 07; Shupbach et al 07; Anderson et al 05; Parkinson Study Group 01; Limousin 96;


Surgical management dbs and effects on gait posture and falls overview

Krack 03

Rodriguez-Oroz 05


Safety of dbs

Safety of DBS

  • Safety:

    • High frequency of clinical relevant AEs (11%).

    • Increase concern with safety.

    • Neuropsychiatric side effects.

    • Axial side effects (gait \ balance \ speech)

Videnovic 08; Kleiner-Fisman et al 06; Pahwa et al 06;


Surgical management dbs and effects on gait posture and falls overview

Procedure and hardware-related AEs

Videnovic 08


Stimulation independent disease progression aes

Stimulation independent \ disease progression AEs

Videnovic 08


Dbs on gait posture and falls

DBS on gait, posture and falls

The effects of DBS on balance and gait are difficult to interpret because they are complex behaviors that may or may not be sensitive to LD or DBS, and many postoperative observations are anecdotal.

Aspects of gait and speech that improve with LD therapy improve with DBS; however, these may later worsen with disease progression. There was consensus that STN DBS can worsen speech and gait in some patients whose symptoms may be improved by altering stimulation parameters.

Bronstein 11


Dbs on gait posture and falls1

DBS on gait, posture and falls

  • Does DBS improve gait, posture and falls?

    • Short-term

    • Long-term

    • Compare to what? dopa-sensitive signs?

  • Can DBS deteriorate axial symptoms in the short term?

  • STN vsGpi?


Does dbs improve gait posture and falls

Does DBS improve gait, posture and falls?

Stim ON

Rodriguez-Oroz 05


Surgical management dbs and effects on gait posture and falls overview

Stim on +Med off

Krack 03


Surgical management dbs and effects on gait posture and falls overview

Follett 10

Stim on

med off

med on

Odekerken 13


Surgical management dbs and effects on gait posture and falls overview

Castrioto 11


Can dbs deteriorate axial symptoms in the short term

Can DBS deteriorate axial symptoms in the short term?

Med off

Castrioto 11


Surgical management dbs and effects on gait posture and falls overview

24 months

Schuepbach, Earlystim 13


Surgical management dbs and effects on gait posture and falls overview

Weaver 09

12 months

Williams 10, PD SURG UK


Surgical management dbs and effects on gait posture and falls overview

Rodriguez-Oroz 05


Surgical management dbs and effects on gait posture and falls overview

STN; control with no stimulation till 3 months

Okun, 12


Surgical management dbs and effects on gait posture and falls overview

Adams 11

Ferraye 08


Surgical management dbs and effects on gait posture and falls overview

Umemura 10


Surgical management dbs and effects on gait posture and falls overview

Is there a difference between STN and GPi?

Meta-regression of 11 studies

St. George 10


Surgical management dbs and effects on gait posture and falls overview

Follett 10


Surgical management dbs and effects on gait posture and falls overview

Multicentre study with blinded and unblided assessments at 5-6 yrs FU

N = 51

Moro 10


Surgical management dbs and effects on gait posture and falls overview

Stim on

med off

med on

Odekerken 13

AEs


Surgical management dbs and effects on gait posture and falls overview

STN

Stim ON

GPI

Rodriguez-Oroz 05


Gait posture falls

Gait & Posture & Falls

  • DBS improves gait and balance comparing on\off stimulation in the short and medium-term.

  • DBS effect on these signs < apendicular.

  • But DBS seems to worsen falls compared to baseline in a subset of patients.

  • But DBS seems to worsen gait compared to baseline in a subset of patients.


Gait posture falls1

Gait & Posture & Falls

  • STN might be worse than GPi.

  • Different test conditions (i.e med on\dbs off)

  • Diverse clinical & laboratory outcomes among “axial symptoms umbrella”: different results.


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