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ABSTRACT: Fatigue is a common and disabling nonmotor symptom seen in Parkinson's disease (PD). While deep brain stimulation surgery (DBS) improves motor symptoms, it has also been associated with non-motor side effects. To date no study has utilized standardized instruments to evaluate fatigue following DBS surgery. Our objective was to determine the prevalence of fatigue following DBS surgery in PD its impact on quality of life and explore predictive factors. We recruited 44 PD subjects. At least one year following DBS placement, we administered the Fatigue Severity Scale (FSS), the Parkinson's Disease Questionnaire (PDQ-39), the Beck Depression Inventory, the Beck Anxiety Inventory, the UPDRS, and a neuropsychological battery. Fifty-eight percent of subjects had moderate to severe fatigue. Fatigue was significantly associated with quality of life, depression, and anxiety. Depression preoperatively was the only predictive factor of fatigue. Fatigue is common following DBS surgery and significantly impacts quality of life.
Parkinson's disease. 01/2012; 2012:769506.
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ABSTRACT: It has been observed that low-frequency stimulation (LFS) may be effective for dystonia, and the use of LFS may alleviate the need for frequent battery changes in a subset of patients. The aim of this study was to analyze LFS as a strategy to treat deep brain stimulation (DBS) patients with various dystonias.
Subjects had to receive a minimum of 6 months of clinical follow-up at the University of Florida, and were required to have a minimum of 3 months on a LFS trial. Twenty-seven dystonia DBS patients were retrospectively analyzed from the UF-INFORM database.
Thirteen subjects met inclusion criteria. Of the 13 subjects, all had bilateral internal pallidum (GPi) DBS, and five (38.5%) remained with at least one side on LFS settings at their last follow up (average follow up 24 months, range 6-46 months). Within the first 6 months, six (46%) subjects remained on LFS and seven (54%) were changed to high-frequency stimulation (HFS). Those who remained on LFS settings at 6 months were characterized by shorter disease durations than those on HFS settings. There were no significant differences in dystonia severity (Unified Dystonia Rating Scale and Burke-Fahn-Marsden Dystonia Rating Scale) at baseline between the two settings. The estimated battery life for LFS (79.9±30.5) was significantly longer than for HFS settings (32.2±13.1, p<0.001).
LFS was ultimately chosen for 38.5% of all subjects. Although this study failed to yield solid predictive features, subjects on LFS tended to have shorter disease durations.
Tremor and other hyperkinetic movements (New York, N.Y.). 01/2012; 2.
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ABSTRACT: Impulse control disorders (ICDs) and dopamine dysregulation syndrome (DDS) are important behavioral problems that affect a subpopulation of patients with Parkinson's disease (PD) and typically result in markedly diminished quality of life for patients and their caregivers. We aimed to investigate the effects of subthalamic nucleus (STN) and internal globus pallidus (GPi) deep brain stimulation (DBS) on ICD/DDS frequency and dopaminergic medication usage.
A retrospective chart review was performed on 159 individuals who underwent unilateral or bilateral PD DBS surgery in either STN or GPi. According to published criteria, pre- and post-operative records were reviewed to categorize patients both pre- and post-operatively as having ICD, DDS, both ICD and DDS, or neither ICD nor DDS. Group differences in patient demographics, clinical presentations, levodopa equivalent dose (LED), and change in diagnosis following unilateral/bilateral by brain target (STN or GPi DBS placement) were examined.
28 patients met diagnostic criteria for ICD or DDS pre- or post-operatively. ICD or DDS classification did not differ by GPi or STN target stimulation. There was no change in DDS diagnosis after unilateral or bilateral stimulation. For ICD, diagnosis resolved in 2 of 7 individuals after unilateral or bilateral DBS. Post-operative development of these syndromes was significant; 17 patients developed ICD diagnoses post-operatively with 2 patients with pre-operative ICD developing DDS post-operatively.
Unilateral or bilateral DBS did not significantly treat DDS or ICD in our sample, even though a few cases of ICD resolved post-operatively. Rather, our study provides preliminary evidence that DDS and ICD diagnoses may emerge following DBS surgery.
PLoS ONE 01/2012; 7(1):e29768. · 4.09 Impact Factor
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ABSTRACT: We administered a 7-question survey on drooling to PD patients and age-matched controls. Each subject was assigned a drooling severity score and categorized as a "drooler" or a "non-drooler". The age, disease duration, motor scores, quality of life (PDQ-39), and levodopa equivalent daily dosage (LEDD) were compared between PD droolers vs. PD non-droolers. 58 PD patients and 51 age-matched controls participated. In PD patients, the mean: disease duration was 10.96 years (SD 8.66) and UPDRS on motor score was 30.76 (SD 10.57). The drooling severity score was significantly different between patients vs. controls (3.41 vs. .58; p < .01). 14% of controls vs. 59% of patients were droolers (p < .01). PD droolers scored worse on the ADL subscale of the PDQ-39 (p = .031). Furthermore, PD droolers had significant difficulty speaking (7.27% vs. 0%; p < .01); eating (3.64% vs. 0%; p = .01); and socially interacting (12.73% vs. 0%; p < .01) compared to PD non-droolers. Interestingly, the hallucination component of the UPDRS Part I was significantly correlated with being a drooler (p = .016). None of the other variables have significant effect on drooling severity scores. There is a high prevalence of drooling among PD patients compared to controls. PD droolers had worse quality of life and had more difficulty speaking, eating and socially interacting compared to PD non-droolers. Experiencing hallucinations was the only factor that correlated with being a drooler and it may be confounded by medications.
Parkinsonism & Related Disorders 08/2010; 16(7):475-7. · 3.80 Impact Factor
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ABSTRACT: Adverse event (AE) rates for deep brain stimulation (DBS) are variable, due to various methodologies used for identifying, collecting, and reporting AEs. This lack of a prospective, standardized AE collection method is a shortcoming in the advancement of DBS. In this paper the authors disclose the standardized and prospectively recorded AE data from their institution, correlated with clinical outcome and quality of life (QOL) measures.
All patients who underwent operations at the authors' institution for Parkinson disease (PD), essential tremor, dystonia, other tremor, and obsessive-compulsive disorder were included. Complications occurring intraoperatively or within the first 180 days following surgery were recorded, analyzed, and classified as mild, moderate, or severe, regardless of their perceived relationship to the procedure. The presence, frequency, and severity of AEs were compared with the following outcome measurements: postoperative change in the QOL scales (Medical Outcomes Study 36-Item Short-Form Survey, 39-Item PD Questionnaire); motor scales (Tremor Rating Scale, Unified Dystonia Rating Scale, Unified PD Rating Scale); and Patient Global Impression Scale (PGIS).
Two hundred seventy DBS procedures were performed in 198 patients. Three hundred AEs were recorded in 146 (54.1%) of the 270 procedures, and the AEs were recorded in 119 (60.1%) of 198 patients. Of the 198 patients, the maximum severity of AEs was mild in 28 (14.1%), moderate in 35 (17.7%), and severe in 56 (28.3%). Of the 300 AEs, 102 (34.1%) of 299 were mild, 106 (35.5%) were moderate, and 91 (30.4%) were severe. The AEs were classified as probably not stimulation induced in 10 (3.4%) of 297, probably in 44 (14.9%), unclear for 89 (30%), and not applicable to stimulation in 154 (51.9%). Adverse events were also classified as probably related to surgery in 111 (37.2%) of 298, possibly related in 96 (32.2%), and probably not related to surgery in 91 (30.5%). There was no significant difference (p = 0.22) in QOL outcomes among patients who had no AEs compared with those who experienced mild, moderate, or severe AEs. There was no significant difference in QOL outcomes between patients who did not experience an AE compared with those who experienced any AE. There was no significant difference in the mean General PGIS score between patients without an AE versus those with any AE, as well as on the Symptom-Specific PGIS. Motor function outcomes did not vary between patients with or without AEs. For patients with PD with or without AEs, there was no significant difference in preoperative off-medicine Unified PD Rating Scale score and postoperative 6-month on-medication/on-stimulation change scores (p = 0.59). For patients with tremor there were no differences between those with or without AEs on the Tremor Rating Scale for motor function or activities of daily living. Patients with dystonia with and without AEs showed no differences in the Unified Dystonia Rating Scale.
Prospectively and systematically recording AEs may result in higher AE rates, but this does not correlate with poorer QOL, motor function, or patient-oriented outcome scores.
Neurosurgical FOCUS 08/2010; 29(2):E4. · 2.87 Impact Factor
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Frandy Susatia,
Irene A Malaty,
Kelly D Foote,
Samuel S Wu,
Pamela R Zeilman,
Mitushi Mishra,
Ramon L Rodriguez,
Ihtsham ul Haq, Charles E Jacobson,
Anqi Sun,
Michael S Okun
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ABSTRACT: The objective of this study was to examine globus pallidus internus deep brain stimulation (GPi-DBS) outcomes in primary and secondary dystonia, derived from blinded ratings using two scales and two raters. Twenty-five patients with variable presentations of dystonia were evaluated with videotaped standardized dystonia rating scales at preoperative baseline and at 6 and 12 months following GPi-DBS implantation. These 75 examination videos were retrospectively evaluated, independently and in random order, by two movement disorder neurologists who were blinded to the treatment status. Both neurologists scored each videotaped evaluation using the Burke-Fahn-Marsden Dystonia Rating Scale-motor part (BFMDRS-M) and the Unified Dystonia Rating Scale (UDRS). A final score for each video was assigned by averaging the raters' scores. An intra-class correlation coefficient was used to calculate inter-rater reliability. A linear mixed model was fitted to investigate the time effect and its interaction with type of dystonia (primary versus secondary) for each rating scale. Inter-rater reliability was excellent. Intraclass correlation coefficients ranged from 0.994 to 0.997 for both scales at baseline, 6 and 12 months. The average motor improvement scores after GPi DBS for the entire heterogeneous group of dystonia patients after 6 and 12 months of stimulation was 21.32% (p = 0.0010) and 28.95% (p = 0.0017), respectively, when the UDRS score was used. Similar levels of improvement 20.46% (p = 0.0055) at 6 months and 27.39% (p = 0.00197) at 12 months were found using the BFMDRS-M score. Analysis using unblinded scores from our database revealed a 32.99 and 37.27% UDRS improvement at 6 and 12 months, and an improvement in UDRS score of 38.5 and 43.7% when the analysis was limited to only primary dystonia. If the data were further segregated to include only cases of DYT-1 primary generalized dystonia, the UDRS benefit increased to 48.24%. Our primary dystonia group was diluted by the presence of both old- and young-onset patients, as well as focal, segmental and generalized dystonia. In conclusion, (1) evaluating motor outcomes of DBS therapy for dystonia using independent, randomized retrospective rating by blinded raters' results in lower improvement scores than when outcomes are rated by unblinded treating neurologists. Blinded methodology may be superior and might produce a more realistic assessment of motor outcomes after DBS in patients with dystonia; (2) outcomes were similar whether the BFMDRS-M or UDRS was utilized; (3) GPi-DBS was effective in treating sustained involuntary motor co-contractions in medication refractory dystonia patients, more so in primary dystonia.
Journal of Neurology 08/2009; 257(1):44-58. · 3.47 Impact Factor
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Emily K. Plowman-Prine PhD,
Christine M. Sapienza PhD,
Michael S. Okun MD,
Stephenie L. Pollock BS,
Charles Jacobson BS,
Sam S. Wu PhD,
John C. Rosenbek PhD,
Emily K. Plowman‐Prine,
Christine M. Sapienza,
Michael S. Okun,
Stephenie L. Pollock, Charles Jacobson,
Sam S. Wu,
John C. Rosenbek
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ABSTRACT: Few studies exist in the literature investigating the impact of idiopathic Parkinson's Disease (IPD) on swallow-related quality of life. We therefore aimed in this project to: (1) evaluate swallow-specific quality of life in IPD; (2) delineate potential relationships between IPD duration and severity with swallow-specific quality of life; (3) investigate relationships between swallow-specific quality of life and general health-related quality of life; and (4) investigate relationships between swallow-specific quality of life and depression. Thirty-six patients diagnosed with IPD with and without dysphagia filled out self-report assessments of the SWAL-QOL, Parkinson's Disease Questionnaire-39 (PDQ-39), and Beck Depression Inventory (BDI). A series of Mann Whitney U tests were performed between non-dysphagic and dysphagic groups for the total SWAL-QOL score and the 10 SWAL-QOL domains. Spearman's Rho correlation analyses were performed between the SWAL-QOL and (1) PDQ-39; (2) Hoehn and Yahr stage; (3) PD disease duration; (4) UPDRS “on” score; and (5) the BDI. The dysphagia swallowing group reported significant reductions compared to the non-dysphagic group for the total SWAL-QOL score (P = 0.02), mental health domain score (P = 0.002) and social domain score (P = 0.002). No relationships existed between swallow-specific quality of life and disease duration or severity. Significant relationships existed between swallow-specific quality of life and general health-related quality of life (rs =−0.56, P = 0.000) and depression (rs = −0.48, P = 0.003). These exploratory data highlight the psychosocial sequelae that swallowing impairment can have in those with IPD and suggest a possible association between swallowing, social function, and depression. © 2009 Movement Disorder Society
Movement Disorders 07/2009; 24(9):1352 - 1358. · 4.51 Impact Factor
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ABSTRACT: Few studies exist in the literature investigating the impact of idiopathic Parkinson's Disease (IPD) on swallow-related quality of life. We therefore aimed in this project to: (1) evaluate swallow-specific quality of life in IPD; (2) delineate potential relationships between IPD duration and severity with swallow-specific quality of life; (3) investigate relationships between swallow-specific quality of life and general health-related quality of life; and (4) investigate relationships between swallow-specific quality of life and depression. Thirty-six patients diagnosed with IPD with and without dysphagia filled out self-report assessments of the SWAL-QOL, Parkinson's Disease Questionnaire-39 (PDQ-39), and Beck Depression Inventory (BDI). A series of Mann Whitney U tests were performed between non-dysphagic and dysphagic groups for the total SWAL-QOL score and the 10 SWAL-QOL domains. Spearman's Rho correlation analyses were performed between the SWAL-QOL and (1) PDQ-39; (2) Hoehn and Yahr stage; (3) PD disease duration; (4) UPDRS "on" score; and (5) the BDI. The dysphagia swallowing group reported significant reductions compared to the non-dysphagic group for the total SWAL-QOL score (P = 0.02), mental health domain score (P = 0.002) and social domain score (P = 0.002). No relationships existed between swallow-specific quality of life and disease duration or severity. Significant relationships existed between swallow-specific quality of life and general health-related quality of life (r(s) =-0.56, P = 0.000) and depression (r(s) = -0.48, P = 0.003). These exploratory data highlight the psychosocial sequelae that swallowing impairment can have in those with IPD and suggest a possible association between swallowing, social function, and depression.
Movement Disorders 06/2009; 24(9):1352-8. · 4.51 Impact Factor
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ABSTRACT: Consecutive patients in a Movement Disorders Center with Parkinson disease (PD) were offered to undergo complete neuropsychological testing and to complete the Beck Depression Inventory (BDI), regardless of their cognitive and behavioral status. A total of 82 patients were included in this cross-sectional study and had a mean age of 67.7 years, formal education of 14.8 years, PD duration of 101 months, Unified Parkinson Disease Rating Scale-Motor ''off'' score of 36.96, Mini-Mental State Examination (MMSE) score of 27.8 (range 19-30), and BDI score of 10.23 (SD 8.65). Beck Depression Inventory scores did not correlate with disease duration or motor scores but inversely correlated with the MMSE scores (r = -0.40; P < .001) and total Dementia Rating Scale (DRS) scores (r = -0.33; P < .01). Using a univariate regression analysis controlling for age, gender, education, and total Unified Parkinson Disease Rating Scales (UPDRS) score, the BDI scores had a significant and unique relationship with MMSE scores. However, when the BDI scores were correlated with specific cognitive domains, only the Boston Naming Test and the Hopkins Verbal Learning Test (HVLT) delayed recall remained significant after Bonferroni correction. Similarly, when comparing the cognitive performance of patients with PD who scored >14 on the BDI versus those who scored <14, only the mean score of the Boston Naming Test was different between the 2 groups. Our study shows that while depressive symptoms correlated with global cognitive performance, naming, verbal memory, and language are the most susceptible cognitive domains affected with depressive symptoms.
Journal of Geriatric Psychiatry and Neurology 06/2009; 22(4):223-7. · 3.07 Impact Factor
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ABSTRACT: While deep brain stimulation (DBS) surgery is a well-accepted treatment for Parkinson disease (PD) that improves overall quality of life (QoL), its effects across different domains of QoL are unclear. The study reported here directly compared the effects of unilateral DBS in subthalamic nucleus (STN) or globus pallidus (GPi) on QoL in 42 non-demented patients with medication-refractory PD. Patients were enrolled in the COMPARE trial, a randomized clinical trial of cognitive and mood effects of STN versus GPi DBS conducted at the University of Florida Movement Disorders Center. Patients underwent motor, mood, verbal fluency and QoL (Parkinson disease questionnaire: PDQ-39) measures before and 6 months following surgery. Groups experienced motor and mood improvements that did not differ by target. Patients with STN DBS evidenced a slight decrement on letter fluency. On average, all patients endorsed better overall QoL after surgery. However, despite similar motor and mood improvements, GPi patients improved more than STN patients (38 vs. 14%, respectively; P = 0.03). Patients reported better QoL on subscales of mobility, activities of daily living (ADLs), emotional well-being, stigma, cognition and discomfort, but not on those of social support and communication. Improvements on the mobility, ADLs, stigma and social support subscales were greater amongst GPi patients. In regression analyses, only depression changes independently predicted changes in overall QoL as well as emotional well-being and social support changes. Within the STN group only, declining category fluency scores correlated with poorer QoL on the communication subscale. Unilateral DBS in both STN and GPi improved QoL overall and in disparate domains 6 months after surgery. Patients receiving GPi DBS reported greater improvements that cannot be explained by differential mood or motor effects; however, verbal fluency changes may have partially contributed to lesser QoL improvements amongst STN patients.
Journal of Neurology 05/2009; 256(8):1321-9. · 3.47 Impact Factor
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ABSTRACT: Prior research has demonstrated that dystonia patients may have reductions in numerous measures of quality of life (QOL) when compared to healthy age-matched controls. However, the determinants of QOL in this patient population have not been fully specified. To address this issue, we administered the Medical Outcomes Study Short Form 36 (SF-36) questionnaire along with the Visual Analogue Mood Scale (VAMS), the Beck Depression Inventory (BDI), the Unified Dystonia Rating Scale (UDRS), and the State and Trait Anxiety Index (STAI) to 73 patients diagnosed with primary dystonia. Dystonia patients demonstrated lower QOL on all subscales of the SF-36 compared to normative healthy age-matched data. While the UDRS, a predominantly motor scale, was not significantly correlated with QOL (r = -0.19, P = 0.11), the BDI (r = -0.79, P < 0.0001), the STAI (r = -0.63, P < 0.0001) and multiple subscales of the VAMS revealed significant correlations. The tired subscale was the item most strongly correlated with overall QOL (r = -0.52, P < 0.0001), and particularly QOL related to physical function. The association of tiredness with QOL remained significant even when adjusting for the BDI and STAI scores (P < 0.0001). This study highlights the importance of mood and energy in QOL among a cohort of patients with dystonia. Further studies will be needed to determine the effect of treatment on these associations and whether disturbances in energy are related to sleep disturbances or to primary fatigue issues.
Journal of Neurology 03/2009; 256(6):996-1001. · 3.47 Impact Factor
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ABSTRACT: To review the spectrum of problems that can occur in the DBS patient and to suggest potential troubleshooting tips for identification and management of DBS related issues.
Deep brain stimulation (DBS) has become commonplace for the treatment of medication-refractory neurological disorders. There remains no consensus on the best practices for screening, surgical techniques, and post-operative care. There are few experienced DBS programmers and scarce resources available describing approaches for troubleshooting DBS problems.
We present a case-based review that offers practical tips for the management and troubleshooting of difficult to manage DBS cases. We present 10 cases to demonstrate common issues encountered in DBS management.
There are many important difficulties that may be encountered with DBS devices, and practitioners should be aware of these potential problems, as well as rational management solutions. The following areas should be emphasized as potential causes of difficulties: a non-ideal initial DBS candidate, inadequate multidisciplinary team care, failure of perceived expectations, DBS procedural complication, hardware complication, suboptimal lead placement, programming, access to care, disease progression, and tolerance/habituation.
Neurologists seeing DBS patients should become familiar with issues involved in difficult to manage DBS cases. Many "DBS failures" are currently treatable by appropriate medicine, programming, and surgical approaches.
Parkinsonism & Related Disorders 04/2008; 14(7):532-8. · 3.80 Impact Factor
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ABSTRACT: Deep brain stimulation (DBS) surgery has become the gold standard for treatment of select refractory cases of Parkinson disease and essential tremor. Despite the usefulness of DBS surgery in many cases, there remain situations where lesion therapy (subthalamotomy, pallidotomy or thalamotomy) may provide a reasonable alternative to DBS. We reviewed the University of Florida Institutional Review Board-approved database for movement disorders surgery and identified 286 DBS leads placed in 189 patients as well as 4 additional patients who had lesion therapy. In these 4 cases we reviewed the clinical presentations that resulted in a multidisciplinary team opting for lesion therapy over DBS. Lesion therapy represents a viable alternative and has several important advantages, including a decreased need for access to specialists and clinical follow-up, improved affordability, and a lower infection risk.
Stereotactic and Functional Neurosurgery 02/2008; 86(3):147-52. · 1.85 Impact Factor
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Michael S Okun,
Hubert H Fernandez,
Ramon L Rodriguez,
Janet Romrell,
Michele Suelter,
Sarah Munson,
Elan D Louis,
Thomas Mulligan,
Paul S Foster,
Brian V Shenal,
Sheyan J Armaghani, Charles Jacobson,
Samuel Wu,
Gregory Crucian
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ABSTRACT: Testosterone deficiency has been reported in patients with Parkinson disease (PD), Alzheimer disease, and Huntington disease. It is not known whether testosterone therapy (TT) in men with borderline hypogonadism and neurodegenerative diseases will be of substantial benefit. Previously, we reported that testosterone deficiency is more common in patients with PD compared with age-matched control subjects, and we also reported in 2 small open-label studies that some nonmotor symptoms responded favorably to TT.
To define the effects of TT on nonmotor and motor symptoms in men with PD and probable testosterone deficiency.
Double-masked, placebo-controlled, parallel-group, single-center trial.
Two experimental groups: patients with PD who were receiving either TT or placebo.
Participants received either the study drug by intramuscular injection (200 mg/mL of testosterone enanthate every 2 weeks for 8 weeks) or placebo (isotonic sodium chloride solution injections). In patients in each group, the testosterone serum concentration was obtained at each study visit. During 2 study visits, testosterone levels were blindly evaluated and the intramuscular testosterone dose was increased by 200 mg/mL if the free testosterone value failed to double from the baseline value.
The primary outcome variable was the St Louis Testosterone Deficiency Questionnaire, and secondary outcome measures included measures of mood, cognition, fatigue, motor function, and frequency of adverse events. At the end of the double-blind phase, all patients were offered open-label TT and were followed up after 3 and 6 months.
Fifteen patients in the placebo group (mean age, 69.9 years), receiving a mean total levodopa equivalent dose of 924 mg/d, had a baseline free testosterone level of 47.91 pg/mL, compared with 15 patients in the TT group (mean age, 66.7 years), receiving an average total levodopa equivalent dose of 734 mg/d, who had a baseline free testosterone level of 63.49 pg/mL. Testosterone was generally well tolerated. More subjects in the TT group experienced lower extremity edema (40% vs 20%). In 2 patients, 1 in each group, prostate-specific antigen levels were elevated from baseline. The improvement in the TT group compared with the placebo group (1.7 vs 1.1) on the St Louis Testosterone Deficiency Scale was not statistically significant. In addition, there were no significant differences in motor and nonmotor features of PD between the 2 groups, although a few subscales showed improvements (Hopkins Verbal Learning Test, P<.04; and Backward Visual Span subtrial, P<.03). However, long-term open-label TT resulted in delayed but sustained improvement in subjects in the TT group who continued to receive treatment (n = 6) compared with subjects in the placebo group who elected not to receive TT (n = 3).
Testosterone therapy was generally well tolerated in elderly men with PD and probable testosterone deficiency. While there was no significant difference in the motor and nonmotor scales between the TT and placebo groups at the end of 8 weeks compared with baseline, this may be due to several study limitations, including small sample size, a strong placebo effect with intramuscular therapy, and short follow-up that did not allow measurement of delayed effects of TT in some subjects. Until more definitive studies are reported, practitioners should be particularly cautious in treatment of low testosterone concentrations in men with PD and borderline testosterone deficiency, and careful consideration should be given to the risks vs the benefits of TT.
Archives of Neurology 06/2006; 63(5):729-35. · 7.58 Impact Factor
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ABSTRACT: To report the results of ventralis intermedius nucleus/ventralis oralis posterior nucleus (VIM) plus ventralis oralis anterior (VOA)/ventralis oralis posterior (VOP) thalamic deep brain stimulation (DBS) for the treatment of posttraumatic and multiple sclerosis tremor.
The treatment of posttraumatic tremor and multiple sclerosis tremor, by either medication or surgery, has proven difficult. Lesions and DBS have had mixed and somewhat disappointing results. Previously, we reported the use of two DBS electrodes (one at the VIM/VOP border and one at the VOA/VOP border) as effective for the treatment of posttraumatic tremor in a single patient. In this study, we report the results of this technique on four patients.
Four patients with either posttraumatic tremor (n = 3) or multiple sclerosis tremor (n = 1) underwent placement of two DBS electrodes (one at the VIM/VOP border and one at the VOA/VOP border). Patients underwent preoperative testing and testing at a minimum of 6 months after implantation in four conditions: On VIM DBS/On VOA/VOP DBS; On VIM DBS/Off VOA VOP DBS (5 h DBS washout); Off VIM DBS/Off VOA/VOP DBS (12 h overnight washout); and Off VIM DBS/On VOA/VOP DBS (5 h DBS washout).
Each of the patients showed improvements in all four conditions when compared with the baseline. All of the improvements were maintained with chronic DBS, without tremor rebound. An analysis was performed to determine whether each condition was associated with symptom reduction (percentage change). The percentage reduction was significant for each condition and measure, despite the small number of participants. For the total tremor rating scale score, the Off VIM/Off VOA/VOP condition yielded less symptom reduction than the On VIM condition or the On VOA/VOP condition. The On VIM and On VOA/VOP conditions did not differ significantly from each other in terms of contralateral upper extremity symptoms or total clinical score. Activation of both the VIM and VOA/VOP electrodes was associated with the greatest symptom reduction.
Tremors, such as those examined in this study, that are refractory to medications and have a poor response to VIM DBS monotherapy, may respond favorably to VIM plus VOA/VOP DBS. Two electrodes may be better than one for the treatment of certain disorders; however, more study will be required to confirm this hypothesis.
Neurosurgery 05/2006; 58(4 Suppl 2):ONS-280-5; discussion ONS-285-6. · 2.79 Impact Factor
