Background High-frequency deep brain stimulation (DBS) with a single electrical source is effective for motor symptom relief in patients with Parkinson's disease. We postulated that a multiple-source, constant-current device that permits well defined distribution of current would lead to motor improvement in patients with Parkinson's disease.Methods We did a prospective, multicentre, non-randomised, open-label intervention study of an implantable DBS device (the VANTAGE study) at six specialist DBS centres at universities in six European countries. Patients were judged eligible if they were aged 21-75 years, had been diagnosed with bilateral idiopathic Parkinson's disease with motor symptoms for more than 5 years, had a Hoehn and Yahr score of 2 or greater, and had a Unified Parkinson's disease rating scale part III (UPDRS III) score in the medication-off state of more than 30, which improved by 33% or more after a levodopa challenge. Participants underwent bilateral implantation in the subthalamic nucleus of a multiple-source, constant-current, eight-contact, rechargeable DBS system, and were assessed 12,26, and 52 weeks after implantation. The primary endpoint was the mean change in UPDRS III scores (assessed by site investigators who were aware of the treatment assignment) from baseline (medication-off state) to 26 weeks after first lead implantation (stimulation-on, medication-off state). This study is registered with ClinicalTrials.gov, number NCT01221948.Findings Of 53 patients enrolled in the study, 40 received a bilateral implant in the subthalamic nucleus and their data contributed to the primary endpoint analysis. Improvement was noted in the UPDRS III motor score 6 months after first lead implantation (mean 13.5 [SD 6.8], 95% CI 11.3-15.7) compared with baseline (37.4 [8.9], 34.5-40.2), with a mean difference of 23.8 (SD 10-6; 95% CI 20-3-27.3; p<0.0001). One patient died of pneumonia 24 weeks after implantation, which was judged to be unrelated to the procedure. 125 adverse events were reported, the most frequent of which were dystonia, speech disorder, and apathy. 18 serious adverse events were recorded, three of which were attributed to the device or procedure (one case each of infection, migration, and respiratory depression). All serious adverse events resolved without residual effects and stimulation remained on during the study.Interpretation The multiple-source, constant-current, eight-contact DBS system suppressed motor symptoms effectively in patients with Parkinson's disease, with an acceptable safety profile. Future trials are needed to investigate systematically the potential benefits of this system on postoperative outcome and its side-effects.

BACKGROUND:Technical devices are becoming more prevalent in society and also in medical care. Older adults need more support to learn new technologies than younger subjects. So far, no research has been done on the usability of patient controllers in deep brain stimulation in an elderly population. The aim of the study was to investigate the factors influencing the performance of elderly DBS patients with respect to usability aspects of Medtronic Access therapy controllers.METHODS:Time, mistakes and frequency of use of the controller were compared in 41 elderly DBS patients who prior to the study had already owned a therapy controller for more than six years. One group (n = 20, mean age = 66.4 years) was watching an instructional video and then completed practical assignments on a model implantable pulse generator (IPG). The other group (n = 21, mean age = 65.9 years) completed the tasks without having seen the video before. Any errors that patients made were documented and also corrected so that all of them received hands-on training. After six months all patients were re-evaluated on the dummy IPG in order to compare the effects of hands-on alone vs. video-based training combined with hands-on.RESULTS:The group that had seen the video before significantly outperformed the control group at both assessments with respect to number of errors. Both groups performed faster after six months compared to baseline and tend to use the controller more often than at baseline.CONCLUSION:Our results indicate that elderly DBS patients who have been using the controller for several years still have various difficulties in operating the device. However, we also showed that age-specific training may improve the performance in older adults. In general, the design of DBS patient controllers should focus on the specific needs of the end-users. But as changes to medical devices take a long time to be implemented, video instructions with age-specific content plus hands-on training may improve learning for older adults.

Wie der Name schon verrät, steht bei der tiefen Hirnstimulation das Gehirn im Mittelpunkt des Interesses. Um das Wirkprinzip der tiefen Hirnstimulation besser verstehen zu können, soll daher zunächst ein kurzer Überblick über Aufbau und Funktion des menschlichen Gehirns gegeben werden.

Die tiefe Hirnstimulation eignet sich nicht nur für die Behandlung der fortgeschrittenen Parkinson-Erkrankung, sondern auch für eine Reihe anderer Bewegungsstörungen.

Die Operation stellt naturgemäß das zentrale Thema in der Behandlung mit der tiefen Hirnstimulation dar. Viele Patienten empfinden den Eingriff als belastend, vor allem wenn er als Wachoperation, das heißt in lokaler Betäubung, durchgeführt wird. In den letzten Jahren hat die Operation allerdings erheblich an Schrecken verloren, da sie aufgrund der verbesserten Planungstechnik bereits in einigen Zentren unter Vollnarkose durchgeführt werden kann.

Die Systeme zur tiefen Hirnstimulation bestehen aus verschiedenen Komponenten: Impulsgeber, Elektroden, Elektrodenverlängerungen, Patientensteuergerät und Programmiergerät des Arztes. Zu den nachladbaren System gehört auch ein Nachladegerät.

Die tiefe Hirnstimulation ist ein chirurgisches Verfahren und wird daher von Neurochirurgen durchgeführt, der Weg zur Operation führt aber zwingend über einen Neurologen. Es gibt heute eine Vielzahl an sehr wirksamen Medikamenten zur Behandlung der Parkinson-Krankheit. Die verschiedenen Substanzklassen der Parkinson-Medikamente werden einzeln und/oder kombiniert eingesetzt, bevor der Schritt zur Operation erfolgt. Auch ist wichtig, dass die Medikamente nicht nur ausprobiert werden, sondern dass sie in ausreichender Dosierung und über eine ausreichende Dauer eingesetzt werden.

Abhängig vom jeweiligen Symptom und der Krankheit werden unterschiedliche Zielpunkte im Gehirn anvisiert. Beinahe alle liegen im Bereich der grauen Substanz des Hirnstamms.

In der ganzheitlichen Nachsorge nehmen neben der medizinischen Versorgung auch psychologische Betreuung, Physiotherapie, Ergotherapie und Logopädie einen wichtigen Stellenwert ein. Ziel ist es, den Betroffenen in der Zeit nach der Operation zu unterstützen sowie die wieder gewonnenen Fähigkeiten richtig einzusetzen und zu verfeinern. Im Zuge der Behandlung mit der tiefen Hirnstimulation müssen für jeden Patienten mit Bewegungsstörungen maßgeschneiderte Einstellungen der Stimulationswerte ermittelt und die Medikamente darauf abgestimmt werden.

Das Buch befasst sich mit sämtlichen Aspekten der tiefen Hirnstimulation. Medizinisches, psychologisches und technisches Hintergrundwissen wird verständlich vermittelt. Es geht aber auch auf alltäglic

Geschichte der operativen Verfahren  Die chirurgische Behandlung der Parkinson-Krankheit ist keine Erfindung der jüngsten Vergangenheit. Ansätze, die Symptome chirurgisch in den Griff zu bekommen, reichen bis in das späte 19. Jahrhundert zurück. Zu einem Zeitpunkt, in dem es noch fast keine medikamentöse Behandlung der Krankheit gab, standen sowohl die Ärzte, als auch die Patienten der Parkinson-Krankheit weitgehend hilflos gegenüber. So verwundert es nicht, dass alle möglichen chirurgischen Versuche unternommen wurden, um die störenden Symptome zu beseitigen. Nervendurchtrennungen wurden ebenso durchgeführt wie Ausschaltungen am Rückenmark oder der Hirnrinde. Auch Eingriffe am vegetativen Nervensystem sowie am Kleinhirn wurden vorgenommen.

Seit 20 Jahren nimmt die Bedeutung der tiefen Hirnstimulation in der chirurgischen Behandlung von Bewegungsstörungen laufend zu. Oft wird dabei aber übersehen, dass es auch andere chirurgische Methoden gibt, mit denen die Krankheitssymptome von Bewegungsstörungen günstig beeinflusst werden können.

Deep brain stimulation is a neurosurgical therapy for patients with advanced movement disorders (e.g., Parkinson’s disease). This therapy involves the use of a patient controller for home-use. So far, there are four different patient controllers available on the European market. However, use and acceptance of the patient controller is relatively low. The main end-user group is patients above the age of 60 years. This article compares the design of the different interfaces, with a special focus on gerotechnological aspects (display, acoustic signals, coloring, lettering, cognitive load and haptics). We suggest strategies to optimize the use and acceptance of these devices, which have already entered the market. Moreover, future directions of deep brain stimulation and the usability of patient controllers are discussed.

ZusammenfassungWenn von Morbus Parkinson die Rede ist, betrifft das immer die idiopathische oder primäre Form. Darunter versteht man die reine Parkinson-Krankheit, die ohne fassbare Ursache entsteht.

Background Deep brain stimulation of the subthalamic nucleus significantly improves motor function in patients with severe Parkinson's disease. However, the effects on nonmotor aspects remain uncertain. The present study investigated the effects of subthalamic nucleus deep brain stimulation on mood and psychosocial functions in 33 patients with advanced Parkinson's disease in a three year follow-up. Methods Self-rating questionnaires were administered to 33 patients prior to surgery as well as three, six, twelve and 36 months after surgery. Results In the long run, motor function significantly improved after surgery. Mood and psychosocial functions transiently improved at one year but returned to baseline at 36 months after surgery. In addition, we performed cluster and discriminant function analyses and revealed four distinct psychosocial profiles, which remained relatively stable in the course of time. Two profiles featured impaired psychosocial functioning while the other two of them were characterized by greater psychosocial stability. Conclusion Compared to baseline no worsening in mood and psychosocial functions was found three years after electrode implantation. Moreover, patients can be assigned to four distinct psychosocial profiles that are relatively stable in the time course. Since these subtypes already exist preoperatively the extent of psychosocial support can be anticipatory adjusted to the patients' needs in order to enhance coping strategies and compliance. This would allow early detection and even prevention of potential psychiatric adverse events after surgery. Given adequate psychosocial support, these findings imply that patients with mild psychiatric disturbances should not be excluded from surgery.