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Surgical management: DBS and effects on gait, posture and falls overview

This overview discusses the indications, efficacy, safety, and effects of deep brain stimulation (DBS) on gait, posture, and falls in patients with advanced Parkinson's disease (PD).

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Surgical management: DBS and effects on gait, posture and falls overview

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  1. 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

  2. Financial Disclosure • Nothing to declare.

  3. 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.

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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;

  9. 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;

  10. 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;

  11. Krack 03 Rodriguez-Oroz 05

  12. 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;

  13. Procedure and hardware-related AEs Videnovic 08

  14. Stimulation independent \ disease progression AEs Videnovic 08

  15. 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

  16. 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?

  17. Does DBS improve gait, posture and falls? Stim ON Rodriguez-Oroz 05

  18. Stim on +Med off Krack 03

  19. Follett 10 Stim on med off med on Odekerken 13

  20. Castrioto 11

  21. Can DBS deteriorate axial symptoms in the short term? Med off Castrioto 11

  22. 24 months Schuepbach, Earlystim 13

  23. Weaver 09 12 months Williams 10, PD SURG UK

  24. Rodriguez-Oroz 05

  25. STN; control with no stimulation till 3 months Okun, 12

  26. Adams 11 Ferraye 08

  27. Umemura 10

  28. Is there a difference between STN and GPi? Meta-regression of 11 studies St. George 10

  29. Follett 10

  30. Multicentre study with blinded and unblided assessments at 5-6 yrs FU N = 51 Moro 10

  31. Stim on med off med on Odekerken 13 AEs

  32. STN Stim ON GPI Rodriguez-Oroz 05

  33. 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.

  34. 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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