Troubleshooting Gait Disturbances in Parkinson’s Disease With Deep Brain Stimulation

Abstract

Deep brain stimulation (DBS) of the subthalamic nucleus or the globus pallidus is an established treatment for Parkinson’s disease (PD) that yields a marked and lasting improvement of motor symptoms. Yet, DBS benefit on gait disturbances in PD is still debated and can be a source of dissatisfaction and poor quality of life. Gait disturbances in PD encompass a variety of clinical manifestations and rely on different pathophysiological bases. While gait disturbances arising years after DBS surgery can be related to disease progression, early impairment of gait may be secondary to treatable causes and benefits from DBS reprogramming. In this review, we tackle the issue of gait disturbances in PD patients with DBS by discussing their neurophysiological basis, providing a detailed clinical characterization, and proposing a pragmatic programming approach to support their management.

Long-term improvement of gait with adaptive deep brain stimulation in a patient with Parkinson’s disease

“…15 This explains the multifaced properties of parkinsonian gait, the patient-specific electrophysiological alterations, [16][17][18] and the variable and often unsatisfactory response to therapy. 1,19 This is particularly true in patients with STN-DBS, where we directly modulate the activity of an essential node of the supraspinal locomotor network with as-yet unknown impact on local and circuitry activity. Current data about the effect of STN-cDBS on gait are heterogeneous, with only a few studies objectively assessing gait alterations with an instrumental approach.…”

“…Specifically, poorly manageable axial symptoms such as gait derangements and subsequent falls may emerge along with disease progression, adding to global clinical burden and causing significant disability. 1,2 On the whole, the response of gait impairment to DBS is often unsatisfactory and, in some instances, treatment-induced worsening is possible, as DBS can directly interfere with the physiological, integrated functioning of the cortical, subcortical and spinal components of the locomotor network. 3 In particular, the delivery of DBS with constant stimulation parameters (i.e., conventional DBS, cDBS) may alter the dynamic synchronization between cortical areas involved in motor control and the basal ganglia and mesencephalic locomotor regions, thus directly impairing gait adaptation to contextual needs.…”

Gait-related cross-frequency coupling in the subthalamic nucleus of parkinsonian patients

“…The STN is a key node of the supraspinal locomotor network that is directly connected to the supplementary motor and parietal areas and projects to the mesencephalic locomotor region [52,53]. In recent years, technological advances [19] have enabled important information to be obtained about the composite subthalamic dynamics of human locomotion [6,10]. Some studies reporting basal ganglia eld potential recorded from implanted DBS leads in patients with PD showed modulation of beta oscillations during stepping and actual gait [23][24][25][26].…”

“…Much attention has been given to patients with Parkinson's disease (PD), due to the multiple gait problems in these patients [7], their highly disabling impact and reduced quality of life and life expectancy [8,9], and the lack of speci c therapies. Indeed, despite sustained improvement in motor symptoms, the effect of dopaminergic drugs [7] and deep brain stimulation (DBS) on gait impairment in PD remains largely unsatisfactory [10,11]. Over 40% of PD patients with DBS of the subthalamic nucleus (STN) report a subjective worsening of gait performance six months after surgery, despite general motor improvement [12].…”

A Transatlantic Viewpoint on the Role of Pallidal Stimulation for Parkinson's Disease

“…Although the majority of patients respond well to STN DBS, 14 every DBS expert would concur that the potential outcome ranges between the miraculous effect often portrayed by the media, usually young tremordominant patients, and the disappointed patients in whom surgery and/or stimulation had a profound detrimental effect on speech, 15 cognition, 16 gait, and balance. 17 Despite definite improvement in tremor and motor complications, 18 which is generally observed, the impact of these problems on function and quality of life makes these gains less significant. In contrast, the effect of GPi DBS is in our experience somewhat more modest, especially in the longer term, 10 and it rarely comes with the nearly overnight transformation seen in STN DBS.…”