Ryan Walsh
McHenry County College
Fall 2015

Abstract:

If a patient that has Parkinson's Disease (PD) there is an electrical implant they can receive called Subthalamic Nucleus Deep Brain Stimulation (STN-DBS) that is extremely effective in curing the disabling neurological symptoms, most commonly the debilitating motor symptoms of PD. The reason I'm doing this doing this research is to see the negative outcomes of the surgery. I am looking for any emotional or cognitive consequences that can occur in the long-term or short-term time periods. Through my research, I have found that there are some side effects such as: change in mood and behavior, trouble creating and expressing words and having a hard time recognizing facial expressions. I have also found out that there have been cases that have occurred with no negative long-term or short-term effects. Regarding these possible negative consequences, I personally have worked as a caregiver taking care of multiple people with PD and I have seen the extreme negative consequences with the rigidity of their bodies and the danger they put themselves in when they try to do menial tasks such as trying to go to the bathroom. I feel as if the positive outcomes outweigh the negative consequences with the STN-DBS implant. If I personally had PD, I would wait another 10-15 years until more research is done for the negative consequences.

Annotated Bibliography

Pham, U., Solbakk, A., Skogseid, I., Toft, M., Pripp, A., Konglund, A., . . . Malt, U. (2015). Personality Changes after Deep Brain Stimulation in Parkinson’s Disease. Parkinson's Disease, 1-7. DOI: http://dx.doi.org/10.1155/2015/490507

According to Pham Et. al. (2015), 45 Parkinson's Disease patients with the same degree of the disease were tested and their personality profiles were also examined. The personality profile of the patients was examined by the patients themselves, the relatives of the patients and medical examiners. Relatives and medical examiners did notice a change in impulsiveness of the PD patients. During the self examination of the patients, they did not notice a change in their personalities. There was also a large change is premeditation of movements. Family members also noted that the patients were less thoughtful and didn't think of the repercussions of their actions. It is thought that this can vary with individual patients. Pham stated: "To our knowledge, this is the first study to apply multiple measurements when assessing patients with PD before and after STN-DBS (Subthalamic Nucleus Deep Brain Stimulation)." This information is important because it emphasizes that the treatment of PD could vary with the individual patient. I felt that this was an excellent example of evidence based review because they used the personal profiles of the patients before they had PD and they also had family members analyze their relatives to further the scientific research for the medical examiners.
This article was important because it did aid me in answering my clinical question because it gave insight on how the medical examiners did their research. Papuć, E., Trojanowski, T., Obszańska, K., & Stelmasiak, Z. (2014). Aggressive behavior as a rare side effect of subthalamic stimulation in Parkinson’s disease. Neurocase 2015 Apr; 21 (2): 220-5, 220-225. DOI: http://dx.doi.org/10.1080/13554794.2014.890729

According to Papuc et. Al (2014), when a patient with Parkinson’s Disease (PD) receives a deep brain stimulation (DBS), there is a chance they will acquire behavioral changes. One patients with a 12-year history received bilateral stimulation of the subthalamic nucleus (STN); it was observed that they could develop aggressive behavior. When the STN stimulator was applied in the brain, the patient experienced extreme anger episodes. When the stimulation mode was changed, all anger subsided. It has been hypothesized that the aggression came from the limbic circuit probably within STN and it might affect the surrounding tissue. Papac stated: "Four weeks after surgery STN stimulation was switched on. With increasing the amplitude of stimulation on the right (active contacts 1 and 2) the patient experienced transient episodes of aggression." This furthers the research of the STN network and proves that it does not only have to do with motor function of the ganglia system. This bit of information was important because it made me realize how many things can go wrong with implanting an electrode. This information would be under the fourth tier in the evidence hierarchy because this is a case report; it took one Parkinson's patient with the DBS and focused on his aggressive tendencies.
This was useful in answering my clinical question because this can show the negative consequences of the emotional changes that come with the STN-DBS implant.

Wojtecki, L., Timmermann, L., Groiss, S., Elben, S., Reck, C., Südmeyer, M., . . . Schnitzler, A. (2011). Long-term time course of affective lability after subthalamic deep brain stimulation electrode implantation. Neurocase 2011 Dec; 17 (6): 527-32., 527-532. DOI: http://web.a.ebscohost.com/ehost/detail/detail?vid=14&sid=3322ab6c-e1f4-44ea-92cd-18cefdec3
6da%40sessionmgr4002&hid=4114&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=2011378642&db=c8h

According to Wojtecki et. Al (2011), this study focused on a report from a 53-month followup from a patient with affective Parkinson’s Disease, the surgery strongly influenced mood in the first week after surgery; uncontrollable laughter was observed. Long-term impact up to 37 months was very minor, including: negative emotion and depression, which could possibly be caused by the right electrode stimulating the subthalamic nucleus and other adjacent fiber tracts. It has been concluded that there could be long-term emotional effects of electrode implants in a Parkinson’s patient. This article made clear that there could be further complications down the road. This falls under the fourth tier of evidence hierarchy and is somewhat trustworthy because it was a follow up on a surgery on a singular patient, making this a case report.
This was a useful article in answering my clinical question, because it is shows the long term effects of this surgery.

Jones, H., Kendall, D., Okun, M., Wu, S., Velozo, C., Fernandez, H., . . . Rosenbek, J. (2010). Speech motor program maintenance, but not switching, is enhanced by left-hemispheric deep brain stimulation in Parkinson's disease. Int J Speech Lang Pathol International Journal of Speech-Language Pathology, 385-398. DOI: http://dx.doi.org/10.3109/17549507.2010.491870

According to. Jones et Al. (2010), of 12 PD participants, speech reaction time (SRT) was measured. Two different implants were tested to see which is most effective in speech-language pathology. Subthalamic nucleus (STN) stimulation and globus pallidus pars Interna (GPi). Speech preparation was measured in two speech categories: speech maintenance and switching. Jones stated: "A double blind testing was completed in participants with DBS of globus pallidus pars interna (GPi) or subthalamic nucleus (STN). Speech recognition time (SRT) was significantly faster in the maintenance versus switch task, regardless of DBS state." Whether or not if the medical examiners turned "on" or "off" the DBS mattered only to the maintenance portion of speech, not speech switching. The data suggest that left-hemispheric DBS may have a much different effect on aspects of speech preparation in PD patients. Medical examiners hypothesize that DBS may have little to do with the higher level motor processes such as motor planning. This falls under the case report category of evidence hierarchy.
This was useful for answering my clinical question because it shows me the possible negative speech impairments.

Frost, E., Tripoliti, E., Hariz, M., Pring, T., & Limousin, P. (2010). Self-perception of speech changes in patients with Parkinson's disease following deep brain stimulation of the subthalamic nucleus. Int J Speech Lang Pathol International Journal of Speech-Language Pathology, 399-404. http://dx.doi.org/10.3109/17549507.2010.497560

According to Frost Et. al. (2010), this study was based upon postoperative rating of speech impairments using the Voice Handicap Index (HVI) after the Subthalamic Nucleus Deep Brain Stimulation (STN-DBS) implantation. The goal was to use the VHI to assess how their speech has improved compared to preoperative viewpoints. The researchers individually obtained the patients intelligibility standing. The researchers also had a control group of PD patients that have not undergone STN-DBS. "Correlations between the VHI scores and intelligibility were significant both before and after surgery, suggesting that patients accurately perceive their difficulties. The findings confirm the variability in the speech difficulties of patients following STN-DBS.", says Frost. This would be categorized as a Case Control Study because they used a control group. This could be considered applicable to my clinical question because it is examining possible speech impairments.

Hoffman-Ruddy, B., Schulz, G., Vitek, J., & Evatt, M. (2001). A preliminary study of the effects of subthalamic nucleus (STN) deep brain stimulation (DBS) on voice and speech characteristics in Parkinson's Disease (PD). Clinical Linguistics & Phonetics, 97-101. DOI: http://sirsi.mchenry.edu:2253/ehost/detail/detail?sid=6221c306-ff99-453f-b200-69d55c0b8315@sessionmgr4002&vid=19&hid=4209&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=2001052179&db=ccm

According to Hoffman-Ruddy Et. al. (2001), One male, age 57, with PD for 7 years with the STN-DBS implant. “For the voice and speech protocol, the phonatory tasks included three repetitions of the following: maximum sustained vowel phonations, pitch glides, syllable repetition, short consonant-vowel-consonant words and oral reading of a standardized passage.” says Hoffman-Ruddy. Hoffman-Ruddy also stated “The neurologists’ clinical rating of motor disability for condition 4: on stimulator/on medication revealed the following: (1) only a mild speech impairment that resolved when the participant increased effort; (2) mild impairment in facial expression; (3) no observable tremor; (4) no observable rigidity; (5) no difficulty in tapping; (6) mild difficulty in rapid alternating patting with evidence of dyskinesia on the right side; (7) mild-moderate amount of foot agility; (8) no observed diffculty arising from a seated position; (9) no observed diffculty in postural stability and mild diffculty in gait; (10) the number of steps it took to turn 360 deegree was 1±2 steps and had good stride when required to walk 50 feet.” This is proving that the STN-DBS system does work very well, but it does come with some mild side effects. This was a test on one individual though. It could vary from person to person. This would constitute as a Review Article under the Evidence Hierarchy because it is going over the long term side effects of the STN-DBS implant. This could be applicable to my clinical question because it is reviewing the negative aspects of speech from the STN-DBS system. Although, this information is from 2001 and it is a bit outdated.

Aiello, M., Eleopra, R., Lettieri, C., Mondani, M., D'auria, S., Belgrado, E., . . . Rumiati, R. (2014). Emotion recognition in Parkinson's disease after subthalamic deep brain stimulation: Differential effects of microlesion and STN stimulation. Cortex, 35-45. http://dx.doi.org/10.1016/j.cortex.2013.11.003

According to Aiello Et. al. (2014), While STN-DBS is very effective, it does have some other cognitive and emotional complications down the road. Some patients have had a difficult time recognizing emotions through facial expressions and other emotional cues. “However, it is still unclear whether the STN per se is responsible for such changes or whether others factors like the microlesion produced by the electrode implantation may also play a role. In this study we evaluated facial emotions discrimination and emotions recognition using both facial and prosodic expressions in 12 patients with PD and 13 matched controls. Patients' were tested in four conditions: before surgery, both in on and off medication, and after surgery, respectively few days after STN implantation before turning stimulator on and few months after with stimulation on. We observed that PD patients were impaired in discriminating and recognizing facial emotions, especially disgust, even before DBS implant.” Says Aiello. This means that it is unclear if the small lesion that is created when the STN-DBS implant is implanted, could cause some emotional recognition problems such as disgust recognition. This would constitute as Laboratory Research because they are just analyzing previous data from post operative surgeries. This is very important towards my clinical question because this shows the possibility of not being able to recognize facial expressions.

Gilbert, F. (2012). The burden of normality: From 'chronically ill' to 'symptom free'. New ethical challenges for deep brain stimulation postoperative treatment. Journal of Medical Ethics, 408-412. DOI: http://dx.doi.org/10.1136/medethics-2011-100044

According to Gilbert Et. al. (2012), after curing the symptoms of PD, some patients experience something called the 'Burden of Normality' (BoN) syndrome. BoN is usually overlooked by physicians because they are focusing on the ill side effects of the implant itself, but they don't take into consideration on how the patients feel after being completely treated. Gilbert states “ Most of the discussion about DBS postoperative changes to self is focused on abnormal side effects caused by the intervention (ie, hypersexuality, hypomania, etc). By contrast, relatively little attention is paid to the idea that successfully 'treated' individuals might experience difficulties in adjusting to becoming 'normal'.”. There are multiple things you need to look out for after the surgery is done. Gilbert states “(1) to articulate the postoperative DBS psychosocial adjustment process in terms of the BoN syndrome, (2) to address whether the BoN syndrome illustrates that DBS treatment poses a threat to the patient's identity, and (3) to examine whether the current framework for rehabilitation after DBS procedures should be updated and take into account the BoN syndrome as a postoperative self-change response”. This would fall under the category of Review Article on the Evidence Hierarchy Pyramid because it is going over previously overviewed information. This could be applicable to my clinical question, even though in my opinion it is very opinionated.

Mestre, T., Espay, A., Marras, C., Eckman, M., Pollak, P., & Lang, A. (2014). Subthalamic nucleus-deep brain stimulation for early motor complications in Parkinson's disease-the EARLYSTIM trial: Early is not always better. Movement Disorders Mov Disord., 1751-1756. http://dx.doi.org/10.1002/mds.26024

According to Mestre Et. al. (2014), There is a trial period for PD patients called EARLYSTIM. This treatment option is for PD patients who have been experiencing motor complications for less than 3 years. “STN-DBS significantly improved all primary and secondary outcome measures while best medical therapy failed to provide any improvement at the two-year follow-up time point. On face value these results strongly favor the application of STN-DBS far earlier than is currently applied, when patients are just beginning to experience problems with motor complications. Here we review the application of early DBS and the EARLYSTIM trial from the perspectives of clinical issues, health economics and study design and patient expectation of benefit. We conclude that the most relevant issue is not when to operate but on whom and that early is not always better.” says Mestre. This information is important because it is stating that if you start the STN-DBS system early, it would not make that big of a difference compared to if you did it later in time. This would constitute as a Case Report because it is reviewing a follow up of previously discovered information.

Huang, H., Watts, R., & Montgomery, E. (2014). Effects of deep brain stimulation frequency on bradykinesia of Parkinson's disease. Movement Disorders Mov Disord., 203-206. http://dx.doi.org/10.1002/mds.25773

According to Huang Et. al. (2014), six PD subjects were picked out that are taking very few drugs. They stimulated the STN-DBS system for 10 minutes and observed the motor movements, such as opening and closing their hand. Huang stated: “Multiple frequencies (low and high) resulted in peaks of increased movement amplitudes. Peaks were specific and varied

among individuals. No clear relationship between stimulation frequency and movement frequency was discovered. In light of the findings, a wider range of stimulation frequencies should be examined, particularly lower frequencies. Most current theories of PD pathophysiology and DBS mechanisms of action fail to explain results of the kind demonstrated herein”. This bit of information is very important because it stresses that the frequencies that have been previously used have been too high and they need to test lower frequencies. This would constitute as an Evidence Based Review because it is taking previously unused data and figuring out how this can be used in the future.

References:

Aiello, M., Eleopra, R., Lettieri, C., Mondani, M., D'auria, S., Belgrado, E., . . . Rumiati, R. (2014). Emotion recognition in Parkinson's disease after subthalamic deep brain stimulation: Differential effects of microlesion and STN stimulation. Cortex, 35-45. http://dx.doi.org/10.1016/j.cortex.2013.11.003
Retrieved from EBSCO Host.

Frost, E., Tripoliti, E., Hariz, M., Pring, T., & Limousin, P. (2010). Self-perception of speech changes in patients with Parkinson's disease following deep brain stimulation of the subthalamic nucleus. Int J Speech Lang Pathol International Journal of Speech-Language Pathology, 399-404. http://dx.doi.org/10.3109/17549507.2010.497560
Retrieved from EBSCOHost.

Gilbert, F. (2012). The burden of normality: From 'chronically ill' to 'symptom free'. New ethical challenges for deep brain stimulation postoperative treatment. Journal of Medical Ethics, 408-412. DOI: http://dx.doi.org/10.1136/medethics-2011-100044
Retrieved from EBSCOHost.

Hoffman-Ruddy, B., Schulz, G., Vitek, J., & Evatt, M. (2001). A preliminary study of the effects of subthalamic nucleus (STN) deep brain stimulation (DBS) on voice and speech characteristics in Parkinson's Disease (PD). Clinical Linguistics & Phonetics, 97-101. DOI: http://sirsi.mchenry.edu:2253/ehost/detail/detail?sid=6221c306-ff99-453f-b200-69d55c0b8315@sessionmgr4002&vid=19&hid=4209&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=2001052179&db=ccm
Retrieved from EBSCOHost.

Huang, H., Watts, R., & Montgomery, E. (2014). Effects of deep brain stimulation frequency on bradykinesia of Parkinson's disease. Movement Disorders Mov Disord., 203-206. http://dx.doi.org/10.1002/mds.25773
Retrieved from EBSCOHost.

Jones, H., Kendall, D., Okun, M., Wu, S., Velozo, C., Fernandez, H., . . . Rosenbek, J. (2010). Speech motor program maintenance, but not switching, is enhanced by left-hemispheric deep brain stimulation in Parkinson's disease. Int J Speech Lang Pathol International Journal of Speech-Language Pathology, 385-398. DOI: http://dx.doi.org/10.3109/17549507.2010.491870
Retrieved from EBSCOHost.

Mestre, T., Espay, A., Marras, C., Eckman, M., Pollak, P., & Lang, A. (2014). Subthalamic nucleus-deep brain stimulation for early motor complications in Parkinson's disease-the EARLYSTIM trial: Early is not always better. Movement Disorders Mov Disord., 1751-1756. http://dx.doi.org/10.1002/mds.26024
Retrieved from EBSCOHost.

Papuć, E., Trojanowski, T., Obszańska, K., & Stelmasiak, Z. (2014). Aggressive behavior as a rare side effect of subthalamic stimulation in Parkinson’s disease. Neurocase 2015 Apr; 21 (2): 220-5, 220-225. DOI: http://dx.doi.org/10.1080/13554794.2014.890729
Retrieved from EBSCOHost.

Pham, U., Solbakk, A., Skogseid, I., Toft, M., Pripp, A., Konglund, A., . . . Malt, U. (2015). Personality Changes after Deep Brain Stimulation in Parkinson’s Disease. Parkinson's Disease, 1-7. DOI: http://dx.doi.org/10.1155/2015/490507
Retrieved from EBSCOHost.

Wojtecki, L., Timmermann, L., Groiss, S., Elben, S., Reck, C., Südmeyer, M., . . . Schnitzler, A. (2011). Long-term time course of affective lability after subthalamic deep brain stimulation electrode implantation. Neurocase 2011 Dec; 17 (6): 527-32., 527-532. DOI: http://web.a.ebscohost.com/ehost/detail/detail?vid=14&sid=3322ab6c-e1f4-44ea-92cd-18cefdec3
6da%40sessionmgr4002&hid=4114&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=2011378642&db=c8h
Retrieved from EBSCOHost.