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Improving Outcomes of Deep Brain Stimulation for Essential Tremor with Motion Tracking and Speech Analysis

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Improving Outcomes of Deep Brain Stimulation for Essential Tremor with Motion Tracking and Speech Analysis IETF Grant Proposal: 27 February 2015 Improving Outcomes of Deep Brain Stimulation for Essential Tremor with Motion Tracking and Speech Analysis Brief Summary Deep Brain Stimulation (DBS) is a common form of treatment for medically refractory essential tremor (ET). DBS consists of one or two small electrode arrays that are placed in specific brain targets by a trained neurosurgeon. Controlled electrical pulses are then sent to these electrodes by a neuro- stimulator to modify brain activity and provide therapeutic benefit. The characteristics (duration, amplitude, and frequency) of these pulses must be set to minimize tremor, yet prevent unwanted side- effects such as speech difficulties. Usually, these parameters are set by a neurologist based on their observation of tremor and side-effect. In general, the ventral intermediate nucleus (VIM) of the brain is considered the most appropriate target for stimulation. Recently, however, the posterior subthalamic area (PSA) was also discovered to be an effective stimulation target. Since this discovery, much debate has ensued regarding which is the better target in terms of tremor and side-effect reduction. For each target, the stimulation level must also be considered due to influence on implant battery life. In this study we aim to determine which of the two targets provides the best outcome to the patient using novel methods to quantify tremor and side- effect. The majority of clinical assessments of ET rely on clinical scores based on observation. These are subjective measures influenced by the clinician’s opinion and experience. Unfortunately, the accuracy and sensitivity of such measures can be inadequate. To improve assessment of ET, we have developed our own method of tremor measurement based on electronic motion tracking. This system, with its accompanying software, is able to give us a real-time objective measure of tremor amplitude, velocity, and frequency – with far greater accuracy, sensitivity, and reliability than that of clinical rating scales. Additionally, we will measure side-effect severity using automated speech analysis algorithms. We plan to use novel algorithms to detect side-effects during natural conversations with patients. We believe the inclusion of these objective assessment techniques will help us determine which DBS target gives optimum benefits to each patient. Publications and conference presentations arising from this research will better inform the research community, neurologists, and neurosurgeons about choosing DBS targets for the treatment of ET. Future research will determine if the results we observe in a short-term clinical setting can be verified during long-term stimulation in ET patients using DBS. The present proposal will therefore provide important data that will enable us to seek government grants in the future. 1 Specific aims The primary objective of this research is to compare the efficacy of deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) and posterior subthalamic area (PSA) to treat the symptoms of essential tremor (ET) using measures of tremor severity, stimulation-induced side-effect intensity, vocal tremor, stimulation intensity, and patient quality of life indicators. We aim to use both subjective instruments (clinical rating scales) and objective techniques (motion tracking system and speech analysis algorithms) to compare VIM and PSA targets. Based on past experience and the expert opinion of the principal investigator (Dr Richard Peppard, Neurologist), the hypothesis to be tested is that a greater level of tremor suppression can be achieved without side-effect at lower stimulus amplitudes for PSA stimulation compared to VIM stimulation. Furthermore, we believe that simultaneous stimulation of both the VIM and PSA will show greater benefit than stimulation of any single region alone. 2 Rationale and relevance to essential tremor DBS is a surgical technique currently used to treat some patients with movement disorders and certain psychiatric conditions. It involves the implantation of one or two stimulating electrode arrays which are placed in specific brain regions with the intention to modulate local and connected brain activity, which in turn leads to a reduction or cessation of symptoms. The particular brain region that is targeted depends on the neurological condition; for example, electrodes are usually placed in the subthalamic nucleus for a patient with Parkinson’s disease and in the VIM or the PSA for a patient with ET. The global prevalence of ET ranges from 0.4 – 5% across different populations, and is higher in persons older than 60 years of age (4.6 – 6.3%) [6]. It is estimated that the USA alone has 7 million people living with ET [7]. If not properly treated, ET has detrimental effects on the patient’s quality of life due to social isolation, stress, functional impairment, and embarrassment caused by eating and drinking difficulties among other activities of daily living [9]. ET may also be associated with increased risk of mortality; however, further research is needed to confirm this [11]. DBS is used as a treatment for patients suffering from ET who do not respond to other pharmacological therapies – an estimated 25 - 55% of ET sufferers [8]. The quality-adjusted life year (QALY) is a useful and widely accepted measure of disease burden, including both the duration and the quality of life [12]. Effective DBS, which is contingent upon the optimal selection of stimulation targets, leads to an average QALY gain over 10 years of 2.538 [10] – a significant benefit for the ET population in general. The conventional DBS target for ET patients is the VIM, where long term stimulation has been shown to achieve either a complete or near-complete resolution of the tremor in nearly 80% of patients [1, 2]. However, there is a well-known tolerance to VIM stimulation which occurs over time, and possible stimulation-induced side-effects such as dysarthria (abnormal speech) and gait disturbance are also observed [3, 4]. The need to increase stimulation over time leads to reduced lifetime of the implantable neurostimulator battery, requiring more frequent surgical replacements – a burden on the patient as well as the healthcare economy. Therefore, the VIM may not be the most suitable DBS target for the optimal treatment of ET. An area of the PSA called the zona incerta is a newer DBS target which has shown promise as a better alternative to VIM. Currently, however, there is little or no data to guide target selection [5]. An important requirement of the proposed study is an objective Figure 1 measurement of tremor severity. In a typical clinical setting, tremor is assessed by clinical observation and the application of simple tests such as tracing a spiral on a piece of paper (as shown in Figure 1). We have developed a novel technique to more reliably and accurately measure tremor severity using advances in electromagnetic motion tracking technology and customized software. Up to four different parts of the body can be simultaneously tracked using small, light- weight sensors (Figure 2), with accuracy to within 0.4mm. The custom-designed software we have developed at the Bionics Institute (Figure 3) is able to show tremor severity in real-time, and we have shown that in ET patients it is highly correlated (r2 > 0.90, p < 0.001) with clinical ratings. This system was utilized in a recent clinical study to determine the time-course of DBS therapeutic effect for ET. We found that after DBS application, tremor improved within 10 seconds, however when DBS was disabled, we observed an immediate increase in tremor which peaked after 2 minutes and receded to steady-state approximately 6 minutes post DBS. These ‘wash-in’ and ‘wash-out’ periods must be carefully observed during clinical studies. Our research is clinically significant because at this time no reliable scientific evidence exists to guide neurologists with their decision to target the PSA or VIM since the degree of therapeutic benefit for the patient when stimulating either target is uncertain. Figure 2 Figure 3 3 Research methods and procedures We aim to recruit 20 adults who are using existing DBS therapy to treat ET. These patients have a unique DBS lead trajectory that allows us to stimulate both PSA and VIM targets simply by changing electrode configurations. This provides us with a unique opportunity to study the effectiveness of PSA and VIM stimulation within the same patient. Existing pre-operative MRI and post-operative CT imaging will be used to determine exact electrode location to verify stimulation targets. Informed written consent will be sought from each participant prior to enrolment and we have obtained ethics approval from the Royal Melbourne Hospital and St. Vincent’s Hospital Human Research Ethics Committee to conduct this study. We aim to evaluate and compare the effectiveness of the following stimulation conditions in each patient: 1) PSA stimulation only; 2) VIM stimulation only; and 3) simultaneous VIM and PSA stimulation. These conditions will be randomized to prevent causal bias emerging from effects such as fatigue. Adequate rest periods will be allowed between conditions. Control baseline tremor severity will be recorded with DBS turned off. For each of the three conditions, we will systematically increase DBS amplitude in 0.5V steps, starting at levels which begin to decrease tremor severity, until persistent side- effects become evident or the patient reports discomfort. At least 10 seconds will be allowed between
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