Subthalamic Nucleus Stimulation: Improvements in Outcome With Reprogramming

Abstract

Background: Deep brain stimulation (DBS) is currently the most effective surgical treatment for advanced Parkinson disease (PD). Even when the electrode is well positioned in the target, the optimization of clinical results depends on careful programming of electrical parameters and changes in antiparkinsonian drug dosages.Objective: To determine whether stable outcomes from subthalamic nucleus DBS for PD can be improved by revising stimulation parameters and drug dosages through "hands-on" involvement of a neurologist expert in both movement disorders and DBS programming.Methods: In 44 consecutive patients with PD with longterm stable response to subthalamic nucleus DBS (mean±SD, 3.5±1.7 years), we compared scores from the Unified Parkinson's Disease Rating Scale parts II through IV obtained immediately before and following a formal reprogramming of their stimulation. The reprogramming was performed by a neurologist expert in both PD and DBS and accompanied by further medication adjust-ments. The patients were subsequently followed up for as long as 14 months.Results: In 24 patients (54.6%), the scores on the Unified Parkinson's Disease Rating Scale parts II and III significantly improved by 15.0% and 25.9%, respectively. Anti-PD drugs were significantly reduced (by 25.9%). No improvement was observed in 16 patients (36.4%), and the conditions of 4 patients (9.1%) worsened.Conclusions: Further improvement of parkinsonian signs can be achieved in the majority of patients even after longterm stable stimulation. Improved patient outcomes from subthalamic nucleus DBS are obtained when postoperative care is personally managed by a neurologist expert in movement disorders and DBS who is directly responsible for stimulation programming and simultaneous drug adjustments based on observed clinical responses to changing stimulation parameters.

Deep Brain Stimulation in Parkinson's Disease: Still Effective After More Than 8 Years

“…An effect of systematic reprogramming has previously been reported also by Moro and colleagues 14 in a younger group 3.5 years after surgery. Of the patients, 89% received a new setting, and a sustained effect was found in more than half of the patients after up to 14 months.…”

Deep Brain Stimulation in Parkinson's Disease: Still Effective After More Than 8 Years

“…An effect of systematic reprogramming has previously been reported also by Moro and colleagues 14 in a younger group 3.5 years after surgery. Of the patients, 89% received a new setting, and a sustained effect was found in more than half of the patients after up to 14 months.…”

Failure of long-term subthalamic nucleus stimulation corrected by additional pallidal stimulation in a patient with Parkinson’s disease

“…In contrast to other reports, the delayed failure in our case cannot be attributed to suboptimal programming of DBS, technical dysfunction, or suboptimal dopaminergic medication [9,10]. Secondly, this is the first time that GPi DBS has been successfully applied to correct STN DBS failure.…”

Fading of Deep Brain Stimulation Efficacy Versus Disease Progression: Untangling a Gordian Knot

“…In keeping with studies with a shorter follow-up, 2,19 the study by Thomsen and colleagues showed that reprogramming DBS settings is beneficial also in the long term, as 83% of cognitively unaffected patients who consented to be reprogrammed improved after settings were changed. Interestingly, reprogramming strategy led to an increase of volume of tissue activated, thus supporting the view that either a tolerance to DBS or underdosed stimulation contributed to a decay of therapeutic efficacy, which could be mistaken instead as medication/stimulation resistance.…”

Deep Brain Stimulation in Parkinson's Disease: Still Effective After More Than 8 Years

“…An effect of systematic reprogramming has previously been reported also by Moro and colleagues 14 in a younger group 3.5 years after surgery. Of the patients, 89% received a new setting, and a sustained effect was found in more than half of the patients after up to 14 months.…”

Failure of long-term subthalamic nucleus stimulation corrected by additional pallidal stimulation in a patient with Parkinson’s disease

“…In contrast to other reports, the delayed failure in our case cannot be attributed to suboptimal programming of DBS, technical dysfunction, or suboptimal dopaminergic medication [9,10]. Secondly, this is the first time that GPi DBS has been successfully applied to correct STN DBS failure.…”

Fading of Deep Brain Stimulation Efficacy Versus Disease Progression: Untangling a Gordian Knot

“…In keeping with studies with a shorter follow-up, 2,19 the study by Thomsen and colleagues showed that reprogramming DBS settings is beneficial also in the long term, as 83% of cognitively unaffected patients who consented to be reprogrammed improved after settings were changed. Interestingly, reprogramming strategy led to an increase of volume of tissue activated, thus supporting the view that either a tolerance to DBS or underdosed stimulation contributed to a decay of therapeutic efficacy, which could be mistaken instead as medication/stimulation resistance.…”

Deep Brain Stimulation in Parkinson's Disease: Still Effective After More Than 8 Years

“…An effect of systematic reprogramming has previously been reported also by Moro and colleagues 14 in a younger group 3.5 years after surgery. Of the patients, 89% received a new setting, and a sustained effect was found in more than half of the patients after up to 14 months.…”

Failure of long-term subthalamic nucleus stimulation corrected by additional pallidal stimulation in a patient with Parkinson’s disease

“…In contrast to other reports, the delayed failure in our case cannot be attributed to suboptimal programming of DBS, technical dysfunction, or suboptimal dopaminergic medication [9,10]. Secondly, this is the first time that GPi DBS has been successfully applied to correct STN DBS failure.…”

Fading of Deep Brain Stimulation Efficacy Versus Disease Progression: Untangling a Gordian Knot

“…In keeping with studies with a shorter follow-up, 2,19 the study by Thomsen and colleagues showed that reprogramming DBS settings is beneficial also in the long term, as 83% of cognitively unaffected patients who consented to be reprogrammed improved after settings were changed. Interestingly, reprogramming strategy led to an increase of volume of tissue activated, thus supporting the view that either a tolerance to DBS or underdosed stimulation contributed to a decay of therapeutic efficacy, which could be mistaken instead as medication/stimulation resistance.…”