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Programming Deep Brain Stimulation for Tremor and Dystonia: The Toronto Western Hospital Algorithms

  • Marina Picillo
    Affiliations
    Morton and Gloria Shulman Movement Disorders Clinic, The Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada

    Centre for Neurodegenerative Diseases (CEMAND), Department of Medicine and Surgery, Neuroscience Section, University of Salerno, Salerno, Italy
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  • Andres M. Lozano
    Affiliations
    Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Toronto, Canada
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  • Nancy Kou
    Affiliations
    Morton and Gloria Shulman Movement Disorders Clinic, The Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
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  • Renato Puppi Munhoz
    Affiliations
    Morton and Gloria Shulman Movement Disorders Clinic, The Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
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  • Alfonso Fasano
    Correspondence
    Corresponding author. Tel.: +1 (416) 603 5800, ext. 5961; fax +1 (416) 603 5004.
    Affiliations
    Morton and Gloria Shulman Movement Disorders Clinic, The Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
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Published:February 12, 2016DOI:https://doi.org/10.1016/j.brs.2016.02.003

      Highlights

      • Deep brain stimulation is an established and effective treatment for both tremor and dystonia.
      • Post-operative programming is a time-consuming process mainly relying on clinician's personal experience as no evidence-based guidelines are available.
      • We reviewed the literature on initial and follow-up programming procedures.
      • We developed standardized programming protocols tailored to an individualized approach to managing symptoms associated with deep brain stimulation and disease progression in patients with tremor and dystonia.

      Abstract

      Background

      Deep brain stimulation (DBS) is an effective treatment for essential tremor (ET) and dystonia. After surgery, a number of extensive programming sessions are performed, mainly relying on neurologist's personal experience as no programming guidelines have been provided so far, with the exception of recommendations provided by groups of experts. Finally, fewer information is available for the management of DBS in ET and dystonia compared with Parkinson's disease.

      Objective/hypothesis

      Our aim is to review the literature on initial and follow-up DBS programming procedures for ET and dystonia and integrate the results with our current practice at Toronto Western Hospital (TWH) to develop standardized DBS programming protocols.

      Methods

      We conducted a literature search of PubMed from inception to July 2014 with the keywords “balance”, “bradykinesia”, “deep brain stimulation”, “dysarthria”, “dystonia”, “gait disturbances”, “initial programming”, “loss of benefit”, “micrographia”, “speech”, “speech difficulties” and “tremor”. Seventy-six papers were considered for this review.

      Results

      Based on the literature review and our experience at TWH, we refined three algorithms for management of ET, including: (1) initial programming, (2) management of balance and speech issues and (3) loss of stimulation benefit. We also depicted algorithms for the management of dystonia, including: (1) initial programming and (2) management of stimulation-induced hypokinesia (shuffling gait, micrographia and speech impairment).

      Conclusions

      We propose five algorithms tailored to an individualized approach to managing ET and dystonia patients with DBS. We encourage the application of these algorithms to supplement current standards of care in established as well as new DBS centers to test the clinical usefulness of these algorithms in supplementing the current standards of care.

      Abbreviations:

      CCS (current-constant stimulation), CT (computed tomography), DBS (deep brain stimulation), ET (essential tremor), GPi (globus pallidus pars interna), IPG (internal pulse generator), MICC (multiple independent current control), MRI (magnetic resonance imaging), MS (multiple sclerosis), PD (Parkinson's disease), TWH (Toronto Western Hospital), VCS (voltage-constant stimulation), Vim (ventralisintermedius nucleus of the thalamus), VPL (ventro-postero-lateral thalamic nucleus)

      Keywords

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