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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 falls

  • Nothing to declare.


Outline
Outline falls

  • 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 falls

  • 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 falls

  • 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 falls

  • 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 falls

  • 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 falls

  • 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 falls

  • 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 falls

  • 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 falls 03

Rodriguez-Oroz 05


Safety of dbs
Safety of DBS falls

  • 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;




Dbs on gait posture and falls
DBS on gait, posture and falls 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 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? falls

Stim ON

Rodriguez-Oroz 05


Stim falls on +Med off

Krack 03


Follett 10 falls

Stim on

med off

med on

Odekerken 13


Castrioto falls 11



24 months falls

Schuepbach, Earlystim 13


Weaver 09 falls

12 months

Williams 10, PD SURG UK


Rodriguez- fallsOroz 05



Adams 11 falls

Ferraye 08


Umemura falls 10


Is there a difference between STN and fallsGPi?

Meta-regression of 11 studies

St. George 10


Follett 10 falls


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

N = 51

Moro 10


Stim falls on

med off

med on

Odekerken 13

AEs


STN falls

Stim ON

GPI

Rodriguez-Oroz 05


Gait posture falls
Gait & Posture & Falls 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 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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