[Nonpharmacological treatment procedures for Parkinson's disease]. / Nichtmedikamentöse Therapieverfahren beim Morbus Parkinson.

Nonpharmacological treatment strategies in Parkinson' disease include heterogeneous treatment modalities, such as physiotherapy, occupational therapy, speech therapy, cognitive training and deep brain stimulation as well as noninvasive brain stimulation strategies. Even in the early stages of Parkinson's disease nonpharmacological interventions, such as active exercise therapy and speech therapy can be indicated taking the individual symptoms of a patient into account. Mild cognitive deficits are frequently detected in the course of the disease and progression of these disorders to dementia in the advanced stages of the disease is not uncommon. The starting point for a cognitive training, training strategy and training frequency is unknown and currently under investigation. Deep brain stimulation is an established treatment modality, which should be considered when motor fluctuations cannot be adequately controlled by pharmacological treatment. This therapeutic option depends on patient-specific needs and has to be managed by a multiprofessional team. Non-invasive neurostimulation techniques, such as transcranial magnetic stimulation and transcranial direct current stimulation are experimental tools and cannot currently be recommended for general use.

German registry of paediatric deep brain stimulation in patients with childhood-onset dystonia (GEPESTIM).

BACKGROUND: Data on paediatric deep brain stimulation (DBS) is limited, especially for long-term outcomes, because of small numbers in single center series and lack of systematic multi-center trials. OBJECTIVES: We seek to systematically evaluate the clinical outcome of paediatric patients undergoing DBS. METHODS: A German registry on paediatric DBS (GEPESTIM) was created to collect data of patients with dystonia undergoing DBS up to the age of 18 years. Patients were divided into three groups according to etiology (group 1 inherited, group 2 acquired, and group 3 idiopathic dystonia). RESULTS: Data of 44 patients with a mean age of 12.8 years at time of operation provided by 6 German centers could be documented in the registry so far (group 1 n = 18, group 2 n = 16, group 3 n = 10). Average absolute improvement after implantation was 15.5 ± 18.0 for 27 patients with pre- and postoperative Burke-Fahn-Marsden Dystonia Rating scale movement scores available (p < 0.001) (group 1: 19.6 ± 19.7, n = 12; group 2: 7.0 ± 8.9, n = 8; group 3: 19.2 ± 20.7, n = 7). Infection was the main reason for hardware removal (n = 6). 20 IPG replacements due to battery expiry were necessary in 15 patients at 3.7 ± 1.8 years after last implantation. DISCUSSION: Pre- and postoperative data on paediatric DBS are very heterogeneous and incomplete but corroborate the positive effects of DBS on inherited and acquired dystonia. Adverse events including relatively frequent IPG replacements due to battery expiry seem to be a prominent feature of children with dystonia undergoing DBS. The registry enables collaborative research on DBS treatment in the paediatric population and to create standardized management algorithms in the future.

[Deep brain stimulation for Parkinson's disease: timing and patient selection]. / Tiefe Hirnstimulation bei Morbus Parkinson: wann und für wen?

Deep brain stimulation (DBS) is an effective and evidence-based treatment option for Parkinson's disease. Studies have shown that DBS has good and long-term effects on motor function and quality of life for patients in an advanced stage of the disease and that it is more effective than medical therapy alone. Moreover, a favorable effect of DBS could also be detected at an earlier stage of the disease. On the other hand, possible risks and side effects of the procedure need to be taken into consideration. These can manifest as procedure-related complications, such as bleeding and infections in addition to stimulation-associated phenomena, such as neuropsychiatric disorders and motor side effects. Despite the good effects of DBS important issues still need to be addressed which will be discussed in this article considering the results of several new randomized and controlled clinical studies. For patients with Parkinson's disease with early fluctuations and dyskinesia, DBS has been found to be superior to the best pharmaceutical treatment; therefore, DBS can be considered as a treatment option in the earlier course of the disease. The diagnostic evaluation and the exclusion of contraindications are crucial for patient selection. The choice of the target should be based on the individual symptoms in patients although the subthalamic nucleus (STN) can be considered the standard target. In every case an individual assessment of chances and risks must be conducted and realistic goals and reasonable expectations must be defined.

Does increased gamma activity in patients suffering from Parkinson's disease counteract the movement inhibiting beta activity?

Akinesia and rigidity are cardinal symptoms of Parkinson's disease (PD). Previous studies analysing event-related desynchronization during movement onset associated both symptoms with pathologically increased oscillations in the beta frequency range. By focusing on the movement onset only, these studies cannot, however, shed light onto the question how oscillatory activity is changed during continuous movements. To investigate this issue, we compared the power of the local field potentials (LFP) within and above the subthalamic nucleus (STN) during rest, an isometric hold condition of the forearm, and a fist flexion and extension task in 13 patients with idiopathic PD during implantation of deep brain stimulation (DBS) electrodes. During fist flexion and extension (relative to rest), significantly increased activity in the low beta (12-18 Hz) and gamma (30-48 Hz) frequency ranges was observed within the STN, while during hold (compared to rest) no significant difference was found. For the regions above the STN the power during fist movements (compared to rest) was significantly higher, i.e. in the range of 18-30 Hz, with no significant changes in the gamma frequency range. Beta activity is claimed to inhibit movement and thereby could render fist movements more exhausting. Therefore, the observed increase in beta activity in the STN during fist movements might result in bradykinesia as experienced by many patients. We hypothesise that in order to enable repetitive fist movement despite increased beta activity, "prokinetic" gamma activity may be increased as a compensatory mechanism.