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The Study of Subthalamic Deep Brain Stimulation for Parkinson Disease

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The Study of Subthalamic Deep Brain Stimulation for Parkinson Disease CLINICAL RESEARCH e-ISSN 1643-3750 © Med Sci Monit, 2020; 26: e919682 DOI: 10.12659/MSM.919682 Received: 2019.08.27 Accepted: 2020.01.15 The Study of Subthalamic Deep Brain Available online: 2020.02.04 Published: 2020.03.29 Stimulation for Parkinson Disease-Associated Camptocormia Authors’ Contribution: ABCDEF 1 Siquan Liang* 1 Department of Neurosurgery, Tianjin Huanhu Hosptial, Tianjin, P.R. China Study Design A ABC 2 Yang Yu* 2 Department of Neurological Rehabilitation, Tianjin Huanhu Hosptial, Tianjin, Data Collection B P.R. China Statistical Analysis C BCD 1 Haitao Li 3 Department of Psychology, Tianjin Huanhu Hosptial, Tianjin, P.R. China Data Interpretation D BCD 2 Yue Wang Manuscript Preparation E CDF 2 Yuanyuan Cheng Literature Search F Funds Collection G DEF 3 Hechao Yang * Siquan Liang and Yang Yu contributed equally and shared co-first authorship Corresponding Authors: Siquan Liang, e-mail: [email protected], Hechao Yang, e-mail: [email protected] Source of support: Departmental sources Background: Camptocormia is an axis symptom of Parkinson disease. It remains uncertain whether treatment with medica- tions and surgery are effective. In this study, we assessed the efficacy of subthalamic nucleus deep brain stim- ulation (STN DBS) in Parkinson disease-associated camptocormia and explored some of its mechanisms. Material/Methods: Parkinson disease-associated camptocormia was diagnosed by the following procedures. All patients under- went bilateral STN DBS. The patents’ camptocormia was rated by degree and MDS Unified Parkinson’s Disease Rating Scale (UPDRS) item 3.13 before and after DBS surgery. Rehabilitation and psychological interventions were used after surgery, in addition to adjustments of medication and stimulus parameters. The treatment ef- fects on camptocormia were assessed comparing medication-off (presurgery) versus stimulation-on (post-sur- gery). Ethical approval for this study was provided through the Center of Human Research Ethics Committee (No. 2019-35). This study trial was registered in Chinese Clinical Trial Registry (No. ChiCTR1900022655). All the participants provided written informed consent. Results: After DBS surgery, all of study patients’ symptoms were improved, with different levels of improvement. The minimum and maximum improvement rates were 20% and 100% respectively. The score of item 3.13 of the MDS-UPDRS III and the degree of camptocormia were found to be obviously improved (P<0.05). Conclusions: STN DBS can improve Parkinson disease-associated camptocormia; STN DBS assisted with rehabilitation and psychological intervention appears to be more effective. MeSH Keywords: Deep Brain Stimulation • Parkinson Disease • Subthalamic Nucleus Full-text PDF: https://www.medscimonit.com/abstract/index/idArt/919682 4110 4 3 68 Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] This work is licensed under Creative Common Attribution- [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) e919682-1 [Chemical Abstracts/CAS] Liang S. et al.: CLINICAL RESEARCH The study of subthalamic deep brain stimulation… © Med Sci Monit, 2020; 26: e919682 Background PD-associated camptocormia that were responsive or unre- sponsive to DBS surgery, and we endeavored to reveal the un- Among progressive neurodegenerative diseases, Parkinson dis- derlying disease mechanisms. ease (PD) is the most common, followed by Alzheimer disease; and PD concern over PD has been increasing [1]. Although trem- ors, rigidity, akinesia, and gait disorders are common symp- Material and Methods toms of PD, abnormal posture is also recognized as a concern because it causes serious inconveniences in the daily life and Patients work of patients with PD. Abnormal postures include camp- tocormia and Pisa syndrome. Pisa syndrome, also known as Between March 2017 and March 2019, 15 patients with PD pleurothotonus, is characterized by tonic lateral flexion, accom- that exhibited camptocormia underwent bilateral STN DBS in panied by a slight rotation of the trunk in the sagittal plane, our hospital. All 15 patients (7 males and 8 females) present- which results in an abnormal posture, reminiscent of the lean- ed with camptocormia in the absence of medications. We de- ing tower of Pisa [2]. Camptocormia is a posture abnormality, fined camptocormia as an involuntary anterior flexion of the described as involuntary flexion of the thoracolumbar spine, thoracolumbar spine greater than 15° or more, when the pa- which worsens when walking, sitting, or standing for long pe- tient was standing or walking, but reversible by lying in a re- riods of time, but completely disappears in the recumbent po- cumbent position [13,14]. sition. “Camptocormia” is from the Greek “kamptein”, which means bend, and “kormos”, which means trunk [3]. All patients had been diagnosed with PD based on the clin- ical diagnostic criteria for PD established by the Movement Most motor symptoms can initially be controlled with levodopa Disorder Society (MDS). Screening for DBS surgery was car- and other dopaminergic drugs. However, after a few years, motor ried out according to MDS guidelines. Patients were consid- fluctuations and dyskinesia typically develop due to progres- ered eligible for DBS treatment when, in levodopa challenge sive motor dysfunction, and quality of life deteriorates as well. tests, they showed a sufficient response to levodopa (i.e., >30% At this stage, deep brain stimulation (DBS) therapy should be improvement) assessed with the Unified PD Rating Scale III considered. The physiological mechanisms that underlie the (UPDRS III). The inclusion criteria for study participation were effectiveness of DBS remain to be clarified [4]. Nevertheless, the following: a substantial reduction in the curative effect of DBS is a highly efficient, evidence-based therapy used for a levodopa or the appearance of a serious movement fluctua- number of neurodegenerative diseases, particularly for move- tion or dyskinesia, which affected quality of life. Exclusion cri- ment disorders such as PD, essential tremors, and dystonia [5]. teria were the following: obvious cognitive impairment, severe anxiety and depression, coagulation disorders, and any other In 2002, DBS of the subthalamic nucleus (STN) and globus pal- severe illness that might affect surgery [15–17]. lidus internus (GPi) were both approved by the US Food and Drug Administration (FDA) as a safe, effective treatment op- To confirm that all camptocormia conditions were related tions for patients with advanced PD. And in 2015, the FDA ap- to PD, we conducted a series of procedures (Figure 1). First, proval the use of deep brain stimulation (DBS) therapy in peo- the stooped posture had to disappear completely in the recum- ple with PD “of at least 4 years duration and with recent onset bent position. Second, it should be ruled out as a medication motor complications, or motor complications of longer-stand- side-effect. Third, primary muscle disease had to be excluded ing duration that are not adequately controlled with medica- with magnetic resonance imaging (MRI) scans and other exam- tion” [6]. Since then, DBS in the STN has been widely applied inations. Next, psychological and cognitive assessments were to improve patient quality of life and the motor and non-mo- conducted to identify psychological elements that should be tor symptoms of PD. However, more difficult issues arise as the managed peri- and intra-operationally [18,19]. Then, after con- condition progresses; these issues are known as the axis symp- firming that the camptocormia was related to PD, it was very toms of PD. Some axis symptoms can be treated with anti-PD important to estimate the duration of camptocormia. For du- medications and DBS surgery. But the effects of most of these rations less than 3 years, STN DBS surgery, followed by med- treatments cannot be predicted with absolute certainty [7–9]. ication and rehabilitation, is considered a good choice. If the durations are more than 3 years, the efficacy of treatment can Camptocormia is an axis symptom of PD. It remains uncer- be obtained only through medication and rehabilitation, some- tain whether treatment with medications and surgery are ef- times plastic surgery is a reluctantly choice [11,20]. When dys- fective; preliminary findings must be confirmed. Some au- tonia is the main cause of camptocormia, either the Gi or STN thors have postulated that camptocormia is responsive to STN should be considered for the DBS target. DBS in some, but not all patients with PD [10–12]. Here, we aimed to explore the clinical characteristics of patients with Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] This work is licensed under Creative Common Attribution- [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) e919682-2 [Chemical Abstracts/CAS] Liang S. et al.: The study of subthalamic deep brain stimulation… CLINICAL RESEARCH © Med Sci Monit, 2020; 26: e919682 Figure 1. Flow diagram shows the procedures Stooped posture associated for diagnosing and treating with PD Parkinson disease-associated camptocormia. PD – Parkinson disease; STN – subthalamic nucleus; Reversible in a recumbent DBS – deep brain stimulation; position GPi – globus pallidus internus; EMG – electromyography; Camptocormia MRI – magnetic resonance imaging. Related to medications Psychological
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