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P2.047 ParkinTune: automated Parkinson's disease motor symptom assessment for deep brain stimulation programming
Poster presentations / Parkinsonism and Related Disorders 15S2 (2009) S29–S199
P2.047 ParkinTune: automated Parkinson’s disease motor symptom assessment for deep brain stimulation programming T. Mera1 , J. Alberts2,3,4 , A. Machado3,5 , J. Vitek3,5 , J. Giuffrida1 . 1 Movement Disorders, Cleveland Medical Devices, 2 Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 3 Center for Neurological Restoration, Cleveland Clinic, 4 Louis Stokes Veterans Affairs Medical Center, 5 Neurosciences, Cleveland Clinic, Cleveland, OH, USA The objective was to design, build, and clinically assess ParkinTune™, an advanced wireless movement disorder monitor technology to augment stimulation programming (tuning) involved in deep brain stimulation (DBS) procedures for Parkinson’s disease (PD). Major PD symptoms that affect quality of life include tremor and bradykinesia. Clinicians lack tools that combine physiological, electrical, and behavioral data to optimize stimulator programming. The current standard in evaluating symptoms during DBS surgery and subsequent outpatient programming sessions is the Unified Parkinson’s Disease Rating Scale (UPDRS), a qualitative ranking system scored by integer values from 0–4. Kinesia™, a compact wireless motion sensor system previously developed by CleveMed to quantify movement disorder motor symptoms, was adapted to objectively assess symptom severity during DBS procedures. To date, four surgery and nine follow-up patients participated in a clinical study. Motion data were collected during tremor and bradykinesia UPDRS tasks using various combinations of DBS contact and amplitude settings. Kinematic signals were processed to output objective motor scores. An algorithm was developed to analyze three-dimensional (contact, amplitude, score) DBS maps to yield the optimized DBS settings defined by minimized score AND amplitude. Results showed that ParkinTune-derived DBS final parameter settings matched clinician assessment and could be achieved with significantly fewer measurements on average. Questionnaire responses demonstrated patient and clinician acceptance of the ParkinTune system during DBS programming procedures. The ParkinTune system should reduce time and costs associated with routine DBS procedures and improve access to optimized programming for patients not in close proximity to movement disorder medical centers. P2.048 Screening and selection process for deep brain stimulation: the Emory experience G.J. Revuelta1 , R.E. Gross1,2 , J. Wuu3 , S. Goyal4 , S.A. Factor1 , K. Mewes1 , S.D. Triche1 , T. Wichmann1 , M.R. DeLong1 , C.D. Esper1 . 1 Division of Movement Disorders, Department of Neurology, 2 Department of Neurosurgery, 3 Department of Neurology, Emory University, School of Medicine, Atlanta, GA, 4 Massachusetts Institute of Technology, School of Science, Department of Brain and Cognitive Science, Cambridge, MA, USA Background: Although the selection criteria for deep brain stimulation (DBS) have been well established, the screening and evaluation process has not been well examined. Objectives: To examine our experience with screening and management of patients referred for DBS. Methods: Retrospective database and record review of all patients referred for DBS from 2002 to 2008. All patients were evaluated by a movement disorders DBS specialist. Variables examined included demographic information, diagnosis, disease duration, geographical distance, referring physician specialty, and reason for deferral of surgery at time of visit. All patients were followed until 2008 to determine if they obtained surgery. Results: The 630 patients (372F, 258M, age 8–90 years) reviewed comprised of 388 with Parkinson’s disease (PD), 73 with essential tremor (ET), 83 with dystonia, 21 with atypical PD and 65 with other diagnoses. Of these 56% were not felt to need or meet criteria for surgery. Suboptimal medical management was the most common
S101
reason (52–84% of PD, ET, dystonia). Of the remaining, other reasons include: symptoms that will not respond to DBS (32%), patient decision (16%), cognitive dysfunction (10%), mild disease that does not warrant DBS (7%), patient lost to follow-up and patient responding well to medications (5% each), and psychiatric reasons (4.1%). Conclusions: The majority of patients screened at our center were found to be sub-optimally treated and, following optimization of therapy did not require surgery within the time frame of the study. Careful screening and active medical management is critical prior to decision making for DBS. P2.049 Benefits and risks of deep brain stimulation (DBS) for Parkinson’s disease (PD) – results from the PD SURG study C. Rick1 , N. Ives1 , S. Patel1 , S. Parsons2 , C. Tomlinson1 , S. Gill3 , T. Varma4 , A. Williams5 , K. Wheatley2 , on behalf of The PD SURG Collaborative Group. 1 BCTU, 2 School of Cancer Studies, University of Birmingham, Birmingham, 3 Neurosurgery, Frenchay Hospital, Bristol, 4 Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool, 5 Neurology, Queen Elizabeth Medical Centre, Birmingham, UK Objective: To understand the potential risks and benefits of DBS relative to medical therapy for PD. Introduction: Results from the 4 randomised controlled trials comparing DBS to best medical therapy have consistently shown a benefit for surgery. Surgery, however, is not without risks which must be considered when deciding on treatment options. Methods: 366 patients were randomised in to the PD SURG trial: to immediate surgery or best medical therapy (surgery deferred for at least one year). Patient Quality of Life (QoL) was measured at baseline and 1 year by PDQ-39 (primary endpoint). Serious Adverse Events (SAEs) causing overnight hospitalisation were reported by the neurosurgical centres or the patients; to assess potential reporting bias, in a sample of patients hospital notes were reviewed and their general practitioner was also asked for SAEs. Results: At one year, the QoL of patients randomised to immediate surgery had significantly improved compared to best medical therapy (PDQ-39 Summary Index: difference −4.7 points; p = 0.001). However, there was also a much greater risk of SAEs, both from the surgery itself and non-surgical events. Serious adverse events (SAEs) SAEs (events)
Surgery related
PD related
Other
Deaths
Total
Surgery Medical therapy
43 2
26 14
30 15
2 1
101 (71 patients) 30 (27 patients)
Conclusion: The benefits of DBS surgery over medical therapy are tempered by increased SAE risk. Identifying patients most likely to benefit from surgery, eg from an individual patient data metaanalysis, may limit exposure to the surgical risks. P2.050 Do pre-existing psychiatric disorders affect quality of life following deep brain stimulation for Parkinson’s disease? B. Robottom1 , K. Anderson2 , P. Fishman1 , H. Eisenberg3 , S. Powell1 , S. Reich1 , W. Weiner1 , L. Shulman1 . 1 Neurology, 2 Psychiatry and Neurology, 3 Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA Objective: To assess the effect of pre-existing psychiatric illness on quality of life (QoL) and motor outcome after deep brain stimulation (STN-DBS) in Parkinson’s disease (PD). Background: Active or untreated psychiatric disease is a contraindication to STN-DBS surgery. It is unclear whether preexisting, stable, treated psychiatric illness affects QoL after STNDBS.
P2.047 ParkinTune: automated Parkinson’s disease motor symptom assessment for deep brain stimulation programming T. Mera1 , J. Alberts2,3,4 , A. Machado3,5 , J. Vitek3,5 , J. Giuffrida1 . 1 Movement Disorders, Cleveland Medical Devices, 2 Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 3 Center for Neurological Restoration, Cleveland Clinic, 4 Louis Stokes Veterans Affairs Medical Center, 5 Neurosciences, Cleveland Clinic, Cleveland, OH, USA The objective was to design, build, and clinically assess ParkinTune™, an advanced wireless movement disorder monitor technology to augment stimulation programming (tuning) involved in deep brain stimulation (DBS) procedures for Parkinson’s disease (PD). Major PD symptoms that affect quality of life include tremor and bradykinesia. Clinicians lack tools that combine physiological, electrical, and behavioral data to optimize stimulator programming. The current standard in evaluating symptoms during DBS surgery and subsequent outpatient programming sessions is the Unified Parkinson’s Disease Rating Scale (UPDRS), a qualitative ranking system scored by integer values from 0–4. Kinesia™, a compact wireless motion sensor system previously developed by CleveMed to quantify movement disorder motor symptoms, was adapted to objectively assess symptom severity during DBS procedures. To date, four surgery and nine follow-up patients participated in a clinical study. Motion data were collected during tremor and bradykinesia UPDRS tasks using various combinations of DBS contact and amplitude settings. Kinematic signals were processed to output objective motor scores. An algorithm was developed to analyze three-dimensional (contact, amplitude, score) DBS maps to yield the optimized DBS settings defined by minimized score AND amplitude. Results showed that ParkinTune-derived DBS final parameter settings matched clinician assessment and could be achieved with significantly fewer measurements on average. Questionnaire responses demonstrated patient and clinician acceptance of the ParkinTune system during DBS programming procedures. The ParkinTune system should reduce time and costs associated with routine DBS procedures and improve access to optimized programming for patients not in close proximity to movement disorder medical centers. P2.048 Screening and selection process for deep brain stimulation: the Emory experience G.J. Revuelta1 , R.E. Gross1,2 , J. Wuu3 , S. Goyal4 , S.A. Factor1 , K. Mewes1 , S.D. Triche1 , T. Wichmann1 , M.R. DeLong1 , C.D. Esper1 . 1 Division of Movement Disorders, Department of Neurology, 2 Department of Neurosurgery, 3 Department of Neurology, Emory University, School of Medicine, Atlanta, GA, 4 Massachusetts Institute of Technology, School of Science, Department of Brain and Cognitive Science, Cambridge, MA, USA Background: Although the selection criteria for deep brain stimulation (DBS) have been well established, the screening and evaluation process has not been well examined. Objectives: To examine our experience with screening and management of patients referred for DBS. Methods: Retrospective database and record review of all patients referred for DBS from 2002 to 2008. All patients were evaluated by a movement disorders DBS specialist. Variables examined included demographic information, diagnosis, disease duration, geographical distance, referring physician specialty, and reason for deferral of surgery at time of visit. All patients were followed until 2008 to determine if they obtained surgery. Results: The 630 patients (372F, 258M, age 8–90 years) reviewed comprised of 388 with Parkinson’s disease (PD), 73 with essential tremor (ET), 83 with dystonia, 21 with atypical PD and 65 with other diagnoses. Of these 56% were not felt to need or meet criteria for surgery. Suboptimal medical management was the most common
S101
reason (52–84% of PD, ET, dystonia). Of the remaining, other reasons include: symptoms that will not respond to DBS (32%), patient decision (16%), cognitive dysfunction (10%), mild disease that does not warrant DBS (7%), patient lost to follow-up and patient responding well to medications (5% each), and psychiatric reasons (4.1%). Conclusions: The majority of patients screened at our center were found to be sub-optimally treated and, following optimization of therapy did not require surgery within the time frame of the study. Careful screening and active medical management is critical prior to decision making for DBS. P2.049 Benefits and risks of deep brain stimulation (DBS) for Parkinson’s disease (PD) – results from the PD SURG study C. Rick1 , N. Ives1 , S. Patel1 , S. Parsons2 , C. Tomlinson1 , S. Gill3 , T. Varma4 , A. Williams5 , K. Wheatley2 , on behalf of The PD SURG Collaborative Group. 1 BCTU, 2 School of Cancer Studies, University of Birmingham, Birmingham, 3 Neurosurgery, Frenchay Hospital, Bristol, 4 Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool, 5 Neurology, Queen Elizabeth Medical Centre, Birmingham, UK Objective: To understand the potential risks and benefits of DBS relative to medical therapy for PD. Introduction: Results from the 4 randomised controlled trials comparing DBS to best medical therapy have consistently shown a benefit for surgery. Surgery, however, is not without risks which must be considered when deciding on treatment options. Methods: 366 patients were randomised in to the PD SURG trial: to immediate surgery or best medical therapy (surgery deferred for at least one year). Patient Quality of Life (QoL) was measured at baseline and 1 year by PDQ-39 (primary endpoint). Serious Adverse Events (SAEs) causing overnight hospitalisation were reported by the neurosurgical centres or the patients; to assess potential reporting bias, in a sample of patients hospital notes were reviewed and their general practitioner was also asked for SAEs. Results: At one year, the QoL of patients randomised to immediate surgery had significantly improved compared to best medical therapy (PDQ-39 Summary Index: difference −4.7 points; p = 0.001). However, there was also a much greater risk of SAEs, both from the surgery itself and non-surgical events. Serious adverse events (SAEs) SAEs (events)
Surgery related
PD related
Other
Deaths
Total
Surgery Medical therapy
43 2
26 14
30 15
2 1
101 (71 patients) 30 (27 patients)
Conclusion: The benefits of DBS surgery over medical therapy are tempered by increased SAE risk. Identifying patients most likely to benefit from surgery, eg from an individual patient data metaanalysis, may limit exposure to the surgical risks. P2.050 Do pre-existing psychiatric disorders affect quality of life following deep brain stimulation for Parkinson’s disease? B. Robottom1 , K. Anderson2 , P. Fishman1 , H. Eisenberg3 , S. Powell1 , S. Reich1 , W. Weiner1 , L. Shulman1 . 1 Neurology, 2 Psychiatry and Neurology, 3 Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA Objective: To assess the effect of pre-existing psychiatric illness on quality of life (QoL) and motor outcome after deep brain stimulation (STN-DBS) in Parkinson’s disease (PD). Background: Active or untreated psychiatric disease is a contraindication to STN-DBS surgery. It is unclear whether preexisting, stable, treated psychiatric illness affects QoL after STNDBS.