Deep Brain Stimulation Programming for Movement Disorders: Current Concepts and Evidence-Based Strategies

Abstract

Deep brain stimulation (DBS) has become the treatment of choice for advanced stages of Parkinson's disease, medically intractable essential tremor, and complicated segmental and generalized dystonia. In addition to accurate electrode placement in the target area, effective programming of DBS devices is considered the most important factor for the individual outcome after DBS. Programming of the implanted pulse generator (IPG) is the only modifiable factor once DBS leads have been implanted and it becomes even more relevant in cases in which the electrodes are located at the border of the intended target structure and when side effects become challenging. At present, adjusting stimulation parameters depends to a large extent on personal experience. Based on a comprehensive literature search, we here summarize previous studies that examined the significance of distinct stimulation strategies for ameliorating disease signs and symptoms. We assess the effect of adjusting the stimulus amplitude (A), frequency (f), and pulse width (pw) on clinical symptoms and examine more recent techniques for modulating neuronal elements by electrical stimulation, such as interleaving (Medtronic®) or directional current steering (Boston Scientific®, Abbott®). We thus provide an evidence-based strategy for achieving the best clinical effect with different disorders and avoiding adverse effects in DBS of the subthalamic nucleus (STN), the ventro-intermedius nucleus (VIM), and the globus pallidus internus (GPi).

Comparison of 3T and 7T MRI for the visualization of globus pallidus sub-segments

“…For example, stimulation of the dorsal region of the GPi improves signs and symptoms associated with Parkinson’s disease such as hypokinesia and rigidity. By contrast, although stimulation of the posteroventral region of the GPi reduces hyperkinesia induced by increasing the levodopa dose, it may aggravate gait hypokinesia 2,3,7 .…”

“…Deep brain stimulation (DBS) is a stereotactic neurosurgical technique involving the placement of stimulating electrodes to the small subcortical structure 1 . DBS targeting the internal region of Globus Pallidus (GPi-DBS) is the treatment of choice for later stages of Parkinson’s disease and medical refractory generalized and segmented dystonia 2 . The clinical efficiency of GPi-DBS depends on accurate localization of electrodes inside the GPi 3–5 .…”

“…Electrical current may spread into these regions. Thus the proper placement of the electrode and control of electrical current is critical to prevent side effects 2 . More importantly, the stimulation of distinct regions within the GPi causes a different therapeutic outcome.…”

Use of high-density EEG in patients with Parkinson's disease treated with deep brain stimulation

“…While STN DBS alleviates cardinal motor symptoms of PD (namely tremor, rigidity and bradykinesia) and improves the quality of life of PD patients, several reports have shown that this treatment may be related to worsening of cognitive functioning 3,4 . A multidisciplinary team (neurosurgeon, neurologist, neuropsychologist, neuroradiologist) should be involved in decision-making on the indication of the procedure itself 5 . STN DBS may have an impact on cortical functions as shown by its effect on scalp EEG or long-latency evoked potentials 6 .…”

Sinusoidal stimulation on afferent fibers modulates the firing pattern of downstream neurons in rat hippocampus

“…Electrical stimulation of the brain has excellent prospects for treating several neurological and psychiatric disorders such as Parkinson's disease, essential tremor, epilepsy, depression, and so on (Koeglsperger et al, 2019;Lozano et al, 2019). Although pulse stimuli (i.e., square waveforms) are commonly used in the stimulation, other electrical waveforms such as sinusoids have been investigated for improving the therapeutic efficacy and safety, as well as for developing new stimulation paradigms (Foutz and McIntyre, 2010;Jensen and Durand, 2007;Ramirez-Zamora et al, 2018).…”