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The Role of Deep Brain Stimulation (DBS) in the Treatment of Postural Instability and Gait Disorders of Parkinson's Disease

  • Helen Bronte-Stewart
Chapter
Part of the Current Clinical Neurology book series (CCNEU)

Abstract

Postural instability and gait disorders are movement abnormalities commonly associated with advanced Parkinson's disease (PD) that lead to loss of independence. Although the available literature varies in methodology and design, there appears to be consensus among many studies concerning the effect of subthalamic nucleus (STN) or globus pallidus internus (GPi) deep brain stimulation (DBS) on postural stability and gait disorders in PD. In the short term, DBS improves all postural and gait subscores of the UPDRS including freezing in the off-medication state.

Quantitative studies have revealed considerable detail concerning the effect of DBS on postural instability and gait disorders. This is especially the case in the area of postural stability, where medication and DBS both reduce postural tremor as well as the resonant behavior seen in postural sway in quiet stance. However, in both quiet stance and on unstable surfaces medication worsens, whereas STN DBS improves postural sway velocity and the area over which the body sways. Concerning voluntary postural movement, medication and DBS both improve postural bradykinesia, although this has only been only significant for DBS and DBS plus medication. Neither DBS nor medication improve righting responses to external perturbations. From the available data, this may be due to a lack of improvement in postural reaction times and automatic postural reflexes.

By contrast, medication and DBS appear to have similar effects on most aspects of gait. Gait initiation and gait velocity improve on DBS while off medication, mostly due to improvement in stride length. The irregularity in gait parameters and time spent in double stance also improve. Very few studies have examined the effect of DBS on freezing of gait (FOG) but there is consensus that both STN and GPi DBS improve FOG in the off-medication but not the on-medication state. Studies of long-term STN DBS in PD support continued benefit for retropulsion and gait in the off-medication state after 4 to 5 years. In the on medication state, there was worsening of axial scores and FOG after 5 years. Preliminary experience with pedunculopontine nucleus (PPN) DBS indicates a significant short-term benefit of PPN DBS alone on posture and gait scores compared to pre-operative on-medication scores.

This is an exciting time for research and development of new therapies in gait and balance disorders. These previously incapacitating disorders may eventually be treatable in PD and in other forms of parkinsonism, in which gait and postural instability are especially prominent features.

Keywords

postural control postural instability gait Parkinson's disease deep brain stimulation freezing of gait 

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Copyright information

© Humana Press, a part of Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Helen Bronte-Stewart
    • 1
  1. 1.Departments of Neurology and Neurosciences and Neurosurgery, Stanford Movement Disorders CenterStanford UniversityStanfordUSA

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