Adaptive Deep Brain Stimulation for Movement Disorders: The Long Road to Clinical Therapy

Meidahl, Anders Christian; Tinkhauser, Gerd; Herz, Damian M.; Cagnan, Hayriye; Debarros, Jean; Brown, Peter

doi:10.1002/mds.27022

Cited by 183 publications

(168 citation statements)

References 75 publications

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“…However, there are several reasons why adaptive DBS could improve this therapy. Reduction in stimulation current without loss of therapeutic benefit has the potential to reduce stimulation-induced adverse effects 19 , as well as prolong battery life or allow greater miniaturization of the relatively large pulse generators now in use 20 . Further, some of the PD patients most in need of DBS are also among the most difficult to successfully program: those who alternate between extreme states of dyskinesia and bradykinesia with little in-between time (“brittle fluctuators”) 21,22 .…”

Section: Discussionmentioning

confidence: 99%

Adaptive deep brain stimulation for Parkinson’s disease using motor cortex sensing

et al. 2018

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Objective Contemporary deep brain stimulation for Parkinson’s disease is delivered continuously, and adjustments based on patient’s changing symptoms must be made manually by a trained clinician. Patients may be subjected to energy intensive settings at times when they are not needed, possibly resulting in stimulation-induced adverse effects, such as dyskinesia. One solution is “adaptive” DBS, in which stimulation is modified in real time based on neural signals that co-vary with the severity of motor signs or of stimulation-induced adverse effects. Here we show the feasibility of adaptive DBS using a fully implanted neural prosthesis. Approach We demonstrate adaptive deep brain stimulation in two patients with Parkinson’s disease using a fully implanted neural prosthesis that is enabled to utilize brain sensing to control stimulation amplitude (Activa PC+S). We used a cortical narrowband gamma (60-90 Hz) oscillation related to dyskinesia to decrease stimulation voltage when gamma oscillatory activity is high (indicating dyskinesia) and increase stimulation voltage when it is low. Main Results We demonstrate the feasibility of “adaptive deep brain stimulation” in two patients with Parkinson’s disease. In short term in-clinic testing, energy savings were substantial (38-45%), and therapeutic efficacy was maintained. Significance This is the first demonstration of adaptive DBS in Parkinson’s disease using a fully implanted device and neural sensing. Our approach is distinct from other strategies utilizing basal ganglia signals for feedback control.

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Section: Discussionmentioning

confidence: 99%

Adaptive deep brain stimulation for Parkinson’s disease using motor cortex sensing

et al. 2018

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“…These studies were not included because they did not meet inclusion criteria or have been reported since we concluded the review process. Examples are the assessment of interventions administered on an as‐needed regimen, including the more recently studied octanol and its derivatives, open label assessment of perampanel, customized approach for botulinum toxin administration to improve safety in the treatment of hand tremor, other DBS approaches with assessment of targets such as the Zona Incerta/Posterior Subthalamic area, the STN, use of constant‐current or closed loop stimulation paradigms, and novel MRI‐guided approaches for thalamotomy . These interventions will likely merit assessment in a future MDS‐EBM review on ET.…”

Section: Discussionmentioning

confidence: 99%

MDS evidence‐based review of treatments for essential tremor

et al. 2019

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Background Essential tremor is one of the most prevalent movement disorders. Many treatments for essential tremor have been reported in clinical practice, but it is uncertain which options have the most robust evidence. The International Parkinson and Movement Disorder Society commissioned a task force on tremor to review clinical studies of treatments for essential tremor. Objectives To conduct an evidence‐based review of current pharmacological and surgical treatments for essential tremor, using standardized criteria defined a priori by the International Parkinson and Movement Disorder Society. Methods We followed the recommendations of the International Parkinson and Movement Disorder Society Evidence Based Medicine Committee. Results Sixty‐four studies of pharmacological and surgical interventions were included in the review. Propranolol and primidone were classified as clinically useful, similar to Topiramate, but only for doses higher than 200 mg/day. Alprazolam and botulinum toxin type A were classified as possibly useful. Unilateral Ventralis intermedius thalamic DBS, radiofrequency thalamotomy, and MRI‐guided focused ultrasound thalamotomy were considered possibly useful. All the above recommendations were made for limb tremor in essential tremor. There was insufficient evidence for voice and head tremor as well as for the remaining interventions. Conclusion Propranolol, primidone, and topiramate (>200 mg/day) are the pharmacological interventions in which the data reviewed robustly supported efficacy. Their safety profile and patient preference may guide the prioritization of these interventions in clinical practice. MRI‐guided focused ultrasound thalamotomy was, for the first time, assessed and was considered to be possibly useful. There is a need to improve study design in essential tremor and overcome the limitation of small sample sizes, cross‐over studies, short‐term follow‐up studies, and use of nonvalidated clinical scales. © 2019 International Parkinson and Movement Disorder Society

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“…For example, the relationship with tremor is debated. Although other STN‐LFP signals like theta‐band (3‐8 Hz) activity show promise in relation to tremor, additional input signals to monitor tremor might be needed . Third, the clinical relevance or symptomatic contribution of high‐ versus low‐beta bands is a topic of discussion .…”

Section: Adbs Based On Electrophysiological Recordingsmentioning

confidence: 99%

“…First, a ramping onset, which increases the stimulation voltage from zero toward a predefined amplitude, can be used to overcome paresthesia . Furthermore, ON/OFF AM can be applied in a phase‐dependent manner, in which a stimulus is applied with a fixed latency to an input signal . Phase‐dependent aDBS is hypothesized to have advantages over standard aDBS.…”

Section: Stimulation Parameter Modulation In Adbsmentioning

confidence: 99%

“…Although other STN-LFP signals like theta-band (3-8 Hz) activity show promise in relation to tremor, 14 additional input signals to monitor tremor might be needed. 24,25 Third, the clinical relevance or symptomatic contribution of high-versus low-beta bands is a topic of discussion. 26,27 Last, alpha/betaband activity is influenced by daily life events such as rest tremor, 24 voluntary movements, 28,29 movement artifacts during gait, 30 different vigilance states and sleep, 31 and aDBS itself, 32 which makes the isolation of disease-related signals difficult.…”

Section: Adbs Based On Electrophysiological Recordings Basal Gangliamentioning

confidence: 99%

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An update on adaptive deep brain stimulation in Parkinson's disease

et al. 2018

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Advancing conventional open‐loop DBS as a therapy for PD is crucial for overcoming important issues such as the delicate balance between beneficial and adverse effects and limited battery longevity that are currently associated with treatment. Closed‐loop or adaptive DBS aims to overcome these limitations by real‐time adjustment of stimulation parameters based on continuous feedback input signals that are representative of the patient's clinical state. The focus of this update is to discuss the most recent developments regarding potential input signals and possible stimulation parameter modulation for adaptive DBS in PD. Potential input signals for adaptive DBS include basal ganglia local field potentials, cortical recordings (electrocorticography), wearable sensors, and eHealth and mHealth devices. Furthermore, adaptive DBS can be applied with different approaches of stimulation parameter modulation, the feasibility of which can be adapted depending on specific PD phenotypes. Implementation of technological developments like machine learning show potential in the design of such approaches; however, energy consumption deserves further attention. Furthermore, we discuss future considerations regarding the clinical implementation of adaptive DBS in PD. © 2018 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

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Adaptive Deep Brain Stimulation for Movement Disorders: The Long Road to Clinical Therapy

Cited by 183 publications

References 75 publications

Adaptive deep brain stimulation for Parkinson’s disease using motor cortex sensing

Adaptive deep brain stimulation for Parkinson’s disease using motor cortex sensing

MDS evidence‐based review of treatments for essential tremor

An update on adaptive deep brain stimulation in Parkinson's disease

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