Rehabilitation von Parkinson-Patienten mit Tiefenhirnstimulation
ABSTRACT HintergrundDie Tiefenhirnstimulation des Nucleus subthalamicus stellt eine wirksame Therapieoption für Patienten mit fortgeschrittener
Parkinson-Krankheit dar. Eine wachsende Zahl von Patienten wird nach der Ersteinstellung stationär rehabilitativ behandelt.
Die Bedeutung einer weiteren Stimulator- und Medikamenteneinstellung für diese Rehabilitationsbehandlung ist unklar.
Patienten und MethodenDiese retrospektive Analyse schloss Parkinson-Patienten ein, die innerhalb von 3 Monaten nach Elektrodenimplantation eine
stationäre Rehabilitationsbehandlung mit systematischem Algorithmus zur Verbesserung der Stimulationswirkung durchliefen.
Untersucht wurden (1) die vorgenommenen Änderungen der Stimulationsparameter und der Medikation sowie (2) der Einfluss auf
die mit dem Barthel-Index bestimmte Alltagskompetenz.
ErgebnisseInsgesamt 95Patienten wurden 20,4±10,7Tage nach der Operation über 29,0±11,2Tage rehabilitativ behandelt. Technische Dysfunktionen
fanden sich bei 3 (3,1%) Patienten und eine Elektrodendislokation bei einer Patientin (1,1%). An 7,3±4,0 Tagen erfolgten teils
mehrfache Änderungen der Stimulationsparameter. Bis zur Entlassung wurden die Stimulationsamplituden signifikant von 2,1±0,8V
auf 3,0±0,8V erhöht. Zudem wurden bei 70 (73,7%) Patienten aktive Stimulationskontakte gegenüber der Aufnahmeeinstellung
geändert. Die mittlere L-Dopa-Äquivalenzdosis sank von 529±290mg/Tag auf 300±277mg/Tag. Der Barthel-Index stieg signifikant
um 10,3±12,4 Punkte.
SchlussfolgerungEine weitere Stimulator- und Medikamenteneinstellung nach der Ersteinstellung im primären Zentrum stellt einen wichtigen Bestandteil
der stationären Rehabilitationsbehandlung von Parkinson-Patienten mit Tiefenhirnstimulation dar.
BackgroundDeep brain stimulation (DBS) of the subthalamic nucleus (STN) has become an important therapeutic option in patients with
advanced Parkinson’s disease (PD). An increasing number of patients are referred for hospital rehabilitation after initial
programming. The role of further DBS and medication adjustments for this rehabilitation therapy is uncertain.
MethodsThis study was a retrospective analysis of a hospital rehabilitation program with a systematic algorithm to improve DBS efficacy
in PD patients referred within 3 months after electrode implantation. This study analyzed (1) changes of stimulation parameters
and medication and (2) changes in the performance of activities of daily living as measured by the Barthel index.
ResultsAfter an average of 20.4±10.7 days following surgery 95 PD patients were hospitalized for an average rehabilitation period
of 29.0±11.2 days. Technical dysfunctions were found in 3 (3.1%) patients and a bilateral electrode dislocation in 1 (1.1%)
patient. Stimulation parameters were adjusted on 7.3±4.0 days, sometimes with several adjustments on the same day. Until discharge
the stimulation amplitude was significantly increased from 2.1±0.8V to 3.0±0.8V. Moreover, in 70 (73.7%) patients active
stimulation contacts were changed. The mean levodopa equivalent dosage decreased from 529±290mg/die to 300±277mg/die. The
Barthel index increased significantly by 10.3±12.4 points.
ConclusionFurther DBS and medication adjustments play an important role for hospital rehabilitation of PD patients after initial DBS
programming in DBS centers.
SchlüsselwörterTiefenhirnstimulation–Nucleus subthalamicus–Morbus Parkinson–Rehabilitation–Alltagskompetenz
KeywordsDeep brain stimulation–Nucleus subthalamicus–Parkinson disease–Rehabilitation–Activities of daily living
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ABSTRACT: To evaluate the effects of the dopamine D2-D3 agonist ropinirole in patients who developed apathy after complete withdrawal from dopaminergic medication following successful subthalamic nucleus (STN) stimulation for advanced Parkinson disease (PD). We assessed apathy (Apathy Scale, Apathy Inventory), mood (Montgomery-Asberg Depression Rating Scale), cognitive functions (Mattis Dementia rating scale, frontal score, executive tests) and motor state (UPDRS-III) in 8 PD patients treated with STN stimulation without dopaminergic treatment and who became apathetic. Assessments were made at baseline and after 6 weeks of ropinirole treatment (7.2 +/- 5.9 mg/d; range 1-18 mg/d). Apathy improved with ropinirole in all but 1 patient (54 +/- 24%; range 0-78%). Mood also improved (75 +/- 31%; range 0-100%), but not in correlation with the change in apathy. Cognitive performance was not modified. Stimulation contacts were located within the STN in all patients except the one who remained apathetic in spite of ropinirole treatment (zona incerta). We suggest that apathy, which was compensated for by an enhancement of D2-D3 receptor stimulation in PD patients with STN stimulation: (1) depends on a dopaminergic deficit in associativo-limbic areas of the brain and (2) can be avoided if a dopaminergic agonist is administered postoperatively.Movement Disorders 06/2008; 23(7):964-9. · 5.63 Impact Factor
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ABSTRACT: Although the short-term benefits of bilateral stimulation of the subthalamic nucleus in patients with advanced Parkinson's disease have been well documented, the long-term outcomes of the procedure are unknown. We conducted a five-year prospective study of the first 49 consecutive patients whom we treated with bilateral stimulation of the subthalamic nucleus. Patients were assessed at one, three, and five years with levodopa (on medication) and without levodopa (off medication), with use of the Unified Parkinson's Disease Rating Scale. Seven patients did not complete the study: three died, and four were lost to follow-up. As compared with base line, the patients' scores at five years for motor function while off medication improved by 54 percent (P<0.001) and those for activities of daily living improved by 49 percent (P<0.001). Speech was the only motor function for which off-medication scores did not improve. The scores for motor function on medication did not improve one year after surgery, except for the dyskinesia scores. On-medication akinesia, speech, postural stability, and freezing of gait worsened between year 1 and year 5 (P<0.001 for all comparisons). At five years, the dose of dopaminergic treatment and the duration and severity of levodopa-induced dyskinesia were reduced, as compared with base line (P<0.001 for each comparison). The average scores for cognitive performance remained unchanged, but dementia developed in three patients after three years. Mean depression scores remained unchanged. Severe adverse events included a large intracerebral hemorrhage in one patient. One patient committed suicide. Patients with advanced Parkinson's disease who were treated with bilateral stimulation of the subthalamic nucleus had marked improvements over five years in motor function while off medication and in dyskinesia while on medication. There was no control group, but worsening of akinesia, speech, postural stability, freezing of gait, and cognitive function between the first and the fifth year is consistent with the natural history of Parkinson's disease.New England Journal of Medicine 11/2003; 349(20):1925-34. · 54.42 Impact Factor
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ABSTRACT: Numerous factors need to be taken into account when managing a patient with Parkinson's disease (PD) after deep brain stimulation (DBS). Questions such as when to begin programming, how to conduct a programming screen, how to assess the effects of programming, and how to titrate stimulation and medication for each of the targeted sites need to be addressed. Follow-up care should be determined, including patient adjustments of stimulation, timing of follow-up visits and telephone contact with the patient, and stimulation and medication conditions during the follow-up assessments. A management plan for problems that can arise after DBS such as weight gain, dyskinesia, axial symptoms, speech dysfunction, muscle contractions, paresthesia, eyelid, ocular and visual disturbances, and behavioral and cognitive problems should be developed. Long-term complications such as infection or erosion, loss of effect, intermittent stimulation, tolerance, and pain or discomfort can develop and need to be managed. Other factors that need consideration are social and job-related factors, development of dementia, general medical issues, and lifestyle changes. This report from the Consensus on Deep Brain Stimulation for Parkinson's Disease, a project commissioned by the Congress of Neurological Surgeons and the Movement Disorder Society, outlines answers to a series of questions developed to address all aspects of DBS postoperative management and decision-making with a systematic overview of the literature (until mid-2004) and by the expert opinion of the authors. The report has been endorsed by the Scientific Issues Committee of the Movement Disorder Society and the American Society of Stereotactic and Functional Neurosurgery.Movement Disorders 07/2006; 21 Suppl 14:S219-37. · 4.56 Impact Factor