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 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

  • Nothing to declare.


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 (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

  • 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

  • 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 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

  • 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 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 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;


Krack 03

Rodriguez-Oroz 05


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;


Procedure and hardware-related AEs

Videnovic 08


Stimulation independent \ disease progression AEs

Videnovic 08


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 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?

Stim ON

Rodriguez-Oroz 05


Stim on +Med off

Krack 03


Follett 10

Stim on

med off

med on

Odekerken 13


Castrioto 11


Can DBS deteriorate axial symptoms in the short term?

Med off

Castrioto 11


24 months

Schuepbach, Earlystim 13


Weaver 09

12 months

Williams 10, PD SURG UK


Rodriguez-Oroz 05


STN; control with no stimulation till 3 months

Okun, 12


Adams 11

Ferraye 08


Umemura 10


Is there a difference between STN and GPi?

Meta-regression of 11 studies

St. George 10


Follett 10


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

N = 51

Moro 10


Stim on

med off

med on

Odekerken 13

AEs


STN

Stim ON

GPI

Rodriguez-Oroz 05


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 & 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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