Expectation and the placebo effect in Parkinson's disease patients with subthalamic nucleus deep brain stimulation
Rodrigo MercadoConstantine ConstantoyannisTomasz MandatAjit KumarMichael SchulzerA. Jon StoesslChristopher R. Honey
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Abstract To determine whether the degree to which a patient with Parkinson's disease expects therapeutic benefit from subthalamic nucleus–deep brain stimulation (STN‐DBS) influences the magnitude of his or her improved motor response, 10 patients with idiopathic Parkinson's and bilateral STN‐DBS were tested after a 12‐hour period off medication and stimulation. Four consecutive UPDRS III scores were performed in the following conditions: (a) stimulation OFF, patient aware; (b) stimulation OFF, patient blind; (c) stimulation ON, patient aware; and (d) stimulation ON, patient blind. Statistical significance ( P = 0.0001) was observed when comparing main effect ON versus OFF (mean ON: 32.55; mean OFF: 49.15). When the stimulation was OFF, patients aware of this condition had higher UPDRS motor scores than when they were blinded (mean: 50.7 vs. 47.6). With the stimulation ON, UPDRS motor scores were lower when the patients were aware of the stimulation compared with when they were blinded (mean: 30.6 vs. 34.5). The interaction between these levels was significant ( P = 0.049). This variation was important for bradykinesia and was not significant for tremor and rigidity. The authors conclude that the information about the condition of the stimulation enhanced the final clinical effect in opposite directions. The results presented support the role of expectation and placebo effects in STN‐DBS in Parkinson's disease patients. © 2006 Movement Disorder SocietyKeywords:
Subthalamic Nucleus
Motor symptoms
Brain stimulation
ABSTRACT Deep Brain Stimulation (DBS) of the subthalamic nucleus (STN) has shown clinical potential for relieving the motor symptoms of advanced Parkinson’s disease. While accurate localization of the STN is critical for consistent across-patients effective DBS, clear visualization of the STN under standard clinical MR protocols is still challenging. Therefore, intraoperative microelectrode recordings (MER) are incorporated to accurately localize the STN. However, MER require significant neurosurgical expertise and lengthen the surgery time. Recent advances in 7T MR technology facilitate the ability to clearly visualize the STN. The vast majority of centers, however, still do not have 7T MRI systems, and fewer have the ability to collect and analyze the data. This work introduces an automatic STN localization framework based on standard clinical MRIs without additional cost in the current DBS planning protocol. Our approach benefits from a large database of 7T MRI and its clinical MRI pairs. We first model in the 7T database, using efficient machine learning algorithms, the spatial and geometric dependency between the STN and its adjacent structures (predictors). Given a standard clinical MRI, our method automatically computes the predictors and uses the learned information to predict the patient-specific STN. We validate our proposed method on clinical T 2 W MRI of 80 subjects, comparing with experts-segmented STNs from the corresponding 7T MRI pairs. The experimental results show that our framework provides more accurate and robust patient-specific STN localization than using state-of-the-art atlases. We also demonstrate the clinical feasibility of the proposed technique assessing the post-operative electrode active contact locations.
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High-frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN) is now ending its second decade as an established modality for treating Parkinson's disease (PD). Knowledge of the pathophysiology of PD and clinical applications for STN DBS is burgeoning. Despite this, the mechanism of how STN DBS works remains an enigma. Furthermore, motor symptoms have been seen as a focus for improved quality of life after STN DBS yet non-motor symptoms also play an integral role in determining treatment outcome. In this paper, new evidence for the mechanisms of action of STN DBS is discussed and the impact of the therapy on motor and non-motor symptoms of PD is analysed. Future directions of treatment and emerging technologies are also reviewed.
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Introduction and Aim: The targets used in dbs for Parkinson's disease are subthalamic nucleus (STN), globus pallidus interna (GPi), pedunculopontine nucleus and thalamus. The common targets are STN and GPi. The indications for target localisation are drifting from the classical knowledge which was established in the last 2 decades. Material and Methods: A group of 32 Parkinson's Hoehn and Yahr 3-4 patients were randomly assigned to STN and GPi dbs (dep brain stimulation). 16 patients had STN dbs and 16 patients had GPi dbs. Their preoperative and postoperative motor and non-motor scales were compared. Results: There was no significant difference between motor outcomes of STN and GPi dbs. There was a marked difference in weight gain and manic-depressive episodes in STN dbs group. Conclusion: GPi as an old target has similar motor outcomes with STN stimulation. However the limbic stimulation side effects are more prominent in STN stimulation. In this study, these factors and new trends will be discussed and presented.
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The objective of this paper is to review the available literature concerning the effects of subthalamic nucleus deep brain stimulation (STN-DBS) on quality of life (QoL) and motor and depressive symptoms in patients with Parkinson's disease (PD). These studies demonstrate that STN-DBS has an effect on QoL and symptoms in patients with PD. There was a significant improvement in QoL following STN-DBS compared with no improvement after medical therapy. PD patients treated with STN-DBS had a 40–50% improvement in motor function. Nevertheless, depressive symptoms did not reveal consistent change.
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Parkinson’s disease is an age-related neurodegenerative disorder and is characterized by gradual deterioration of motor symptoms. Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is now widely used in neurosurgical therapy, because it markedly improves the Parkinson’s disease symptoms. Tracing studies have shown that the STN is segregated into multiple functional areas. We hypothesize that DBS should be targeted in the area responsible for motor function to reduce unwanted side effects and improve the positive DBS effects. Therefore, we are interested in localization of the functional areas of the STN. In our study, we determine the functional distribution of the synaptic inputs within the STN of anesthetized rats.
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