Optimizing Deep Brain Stimulation Programming in Parkinson’s Disease
The success of deep brain stimulation (DBS) therapy in Parkinson’s disease (PD), whether the target is subthalamic nucleus (STN), globus pallidus interna (GPi), or ventral intermediate thalamus (VIM), starts prior to DBS surgery. The route to best outcomes is based on the proper screening and patient selection, followed by identifying expected clinical benefits and setting the stage with the patient for realistic expectations for goals of DBS therapy. Important information to obtain prior to proceeding with DBS therapy include: Presence of tremor and response to PD medication; Amount (hours/minutes) and severity of medication off time with respect to doses of medication, and specific motor symptoms (tremor, rigidity, bradykinesia), with localization to side and part of the body; History and details of gait changes with medication wearing off, or if present at peak, response to medications; Dyskinesia as it relates to medications: peak effect, presence when medication worn off (such as upon awakening, prior to first morning dose of PD medications), or biphasic with respect to medication onset of action and wearing off; Motor score in relationship to best response to medication off/on in a person experiencing motor fluctuations; History of levodopa intolerance. These same issues are often useful to reassess at the first visit after DBS therapy has been initiated and kept in mind subsequently, to help identify potential for further improvement with adjustments in DBS parameters and help achieve stimulation optimization.