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Focused-ultrasound Lesion Surgery Can Treat Tremors and Improve Life Quality, Study Says

tremors and surgery

Treating tremor in Parkinson’s patients using non-invasive and focused-ultrasound lesion surgery is associated with better quality of life when compared to deep brain stimulation, although both approaches are equally effective in easing this disease symptom, a review study reports.

The study, “Outcomes in Lesion Surgery versus Deep Brain Stimulation in Patients with Tremor: A Systematic Review and Meta-analysis,” was published in the journal World Neurosurgery.

At least 50 percent of people with Parkinson’s, essential tremor (ET) or multiple sclerosis (MS) given oral medications as a first-line treatment for tremor — defined as an involuntary, uncontrollable muscle contraction; most commonly in the hands — do not tolerate these medications over the long term.

Current alternatives include deep brain stimulation (DBS) and lesion surgery (LS), which induces lesions on targeted areas using a heated electrode or focused ultrasound. Prior comparisons have shown that while the two techniques are equally effective in suppressing tremor, DBS led to a greater improvement in function.

But LS with focused ultrasound is gaining in popularity, and one study suggested that it may significantly improve tremor and quality of life.

Researchers at Harvard Medical School conduced a systematic review and a meta-analysis — a type of statistical study that combines the results of various studies — to determine which strategy is most effective in diminishing tremor severity and improving life quality and function in people with Parkinson’s, ET, or MS.

Three online databases were searched for results of randomized clinical trials published up to Jan. 1, 2018, and that included adults treated with either LS or DBS, or serving as controls. Both DBS and LS studies targeted unilateral or bilateral thalamus, pallidum or subthalamic nucleus, all of which are implicated in motor function.

Thirteen Parkinson’s trials were among the 15 included in this study, and the primary outcome for all but one was change in upper limb tremor severity, as assessed with the unified Parkinson’s disease rating scale (UPDRS) part III. Changes in quality of life, cognitive function and neuropsychiatric function were also assessed with variable measures.

A total of 1, 508 patients (mean age range, 48.4 to 70.8) were included, and in addition to the 13 studies involving only Parkinson’s patients, one study looked at people with Parkinson’s, ET and MS, while the remaining study was in people with severe ET.

Four of the 15 trials — involving 125 patients — directly compared DBS to LS. The others compared either LS or DBS with controls.

Results showed that DBS and LS were not significantly different across all analyzed outcomes, which is in line with current guidelines, the researchers noted. All but one trial showed both these types of surgery eased tremor severity. Quality of life findings showed variability in outcomes, which was driven by disease duration. Specifically, longer disease duration correlated with a greater likelihood of surgery and better quality of life.

A subgroup analysis that looked specifically at LS using focused ultrasound revealed that this approach was associated with a significant improvement in quality of life compared to DNS, although changes in tremor severity were similar.

“Policy makers, healthcare providers, and patients could therefore consider focused-ultrasound [LS] as a potential choice for tremor control, based on currently available evidence,” the researchers wrote.

However, results from more studies directly comparing DBS with focused-ultrasound LS are needed, they advised.

The post Focused-ultrasound Lesion Surgery Can Treat Tremors and Improve Life Quality, Study Says appeared first on Parkinson’s News Today.

DBS Effectively Reduces Tremor in Parkinson’s Patients, Regardless of Stimulated Brain Area, Study Shows

Parkinson's tremor

Deep brain stimulation (DBS) can effectively reduce tremor in people with Parkinson’s disease, regardless of the brain region stimulated, according to a recent review study.

The review, “STN vs. GPi deep brain stimulation for tremor suppression in Parkinson disease: A systematic review and meta-analysis,” was published in the journal Parkinsonism & Related Disorders.

Tremor is a main symptom of Parkinson’s disease, strongly affecting patients’ quality of life. It is estimated that 47-90% of Parkinson’s patients have an action tremor and 76-100% have a resting tremor.

Reduction of tremors is an important goal in Parkinson’s treatment, and could have a significant impact in patients’ well-being and everyday life. However, tremor is difficult to treat and often does not respond to anti-tremor medications.

Deep brain stimulation — electric stimulation in strategic brain areas through surgically implanted thin wires in the brain — is used to treat people with advanced Parkinson’s disease whose motor symptoms, such as tremors, are not reduced with medication.

Several studies have shown that DBS eases motor symptoms, reduces the necessary daily dose of medication, and improves patients’ quality of life.

Currently, the main approved targets for DBS in Parkinson disease are the subthalamic nucleus (STN) and the globus pallidus interna (GPi), areas of the brain involved in motor function.

While recent studies have found no significant differences between the therapeutic effects of the stimulation of both targets, many clinicians maintain an older preference for STN over GPi, due to a supposedly greater reduction in tremors and in medication.

However, evidence supporting STN-DBS superiority in tremor suppression is limited.

Researchers have conducted a systematic review of all randomized clinical studies comparing the therapeutic effects of STN-DBS and GPi-DBS on tremors in Parkinson’s patients, published before March 2017.

Their search identified five suitable longitudinal randomized control trials with five years follow-up data. The data included the two DBS targets, STN and GPi, and tremor sub-scores of the Unified Parkinson’s Disease Rating Scale (UPDRS) before and after DBS, and with or without dopaminergic medication.

Their analysis showed that deep brain stimulation significantly reduced tremor symptoms in Parkinson’s patients, and that these effects were observed regardless of medication status.

When looking at the two targets of deep brain stimulation, researchers found that both methods reduced tremor severity in Parkinson’s patients, with no significant differences between them. These results support that DBS of each target promotes similar long-term benefits on tremor.

However, analysis of therapeutic effects on tremor over the course of five years showed that STN-DBS was more effective to reduce tremors after two and five years than at the first six months. In turn, GPi-DBS showed a more stable degree of effectiveness on tremors over time.

“Although both targets were effective, practitioners should be aware that it is possible one target could appear superior in studies depending on the duration of follow-up,” researchers wrote.

They also noted that when Parkinson’s patients present with tremor as the primary complaint, or as an issue adversely affecting quality of life, selection of deep brain stimulation target should focus on the presence of other problems “such as cognitive impairment, speech difficulties, presence of mood disorders, and presence of impulse control disorders.”

The post DBS Effectively Reduces Tremor in Parkinson’s Patients, Regardless of Stimulated Brain Area, Study Shows appeared first on Parkinson’s News Today.

Source: Parkinson's News Today

Deep Brain Stimulation Seen to Ease Tremors in Patients with Early-stage Disease in Pilot Study

DBS and tremors

Deep brain stimulation (DBS) was seen to slow the progression of “rest tremors”  in patients with early-stage Parkinson’s disease, a pilot study reports.

The study, “Effects of deep brain stimulation on rest tremor progression in early stage Parkinson disease,” was published in Neurology.

“The finding around tremor is truly exceptional,” David Charles, MD,  professor and vice-chair of neurology at Vanderbilt University, in Tennessee, and the study’s senior author, said in a university news article. “Why it is so remarkable is because there are no treatments for Parkinson’s that have been proven to slow the progression of any element of the disease.”

Vanderbilt has been approved to conduct a large-scale, Phase 3 clinical trial looking at the effectiveness of deep brain stimulation in early-stage patients by the U.S. Food and Drug Administration based on this pilot study. It plans to start enrolling about 280 such patients when it opens next year.

This study’s findings point to DBS easing tremors associated with periods of rest — tremors very common in Parkinson’s patients and particularly distressing at early disease stages — but was too small to measure effectiveness or benefit with any significance.

DBS is commonly used to treat patients with advanced Parkinson’s who no longer respond to available medications and are unable to adequately manage their symptoms. The FDA also recently expanded use of DBS — which requires surgery to implant a device to stimulate targeted regions of the brain — to patients with mid-stage disease who also respond poorly to standard medications.

The pilot trial (NCT00282152), which took place at Vanderbilt’s medical center, looked at whether DBS might be safe and tolerable for early-stage patients. It included 28 people, ages 50 to 75, who had been taking Parkinson’s medications for at least six months and up to four years. They had no history of dyskinesia (uncontrolled movement) and stable motor symptoms.

Patients were randomized to receive DBS plus Parkinson’s medication, or medication alone. At baseline (study start) and 6, 12, 18, and 24 months, all agreed to stop all Parkinson’s therapy for one week (medication and/or stimulation). This allowed researchers to evaluate symptom changes and progression.

Results found that patients on medication alone were seven times more likely to again develop rest tremor two years post-treatment, compared to those patients given both DBS and standard therapy.

Analysis also revealed that 86% of the medication-only group developed new motor symptoms in limbs that were initially unaffected. This occurred in 46% of patients in the DBS treatment group.

Seven DBS-treated patients did not develop rest tremors in previously unaffected limbs, and four of these patients showed a lack of tremors in an initially affected limb at the study’s.

“The field of DBS therapy for Parkinson’s disease is moving toward earlier stages of treatment,” Charles said.  The planned Phase 3 study will both  “ensure patient safety and provide the Parkinson’s community with the best possible medical evidence to guide treatment.”

This large-scale trial — expected to begin in 2019 — will likely take place at Vanderbilt’s Nashville campus and at other 17 medical centers across the United States, according to the article.

The post Deep Brain Stimulation Seen to Ease Tremors in Patients with Early-stage Disease in Pilot Study appeared first on Parkinson’s News Today.

Source: Parkinson's News Today