脑深部电刺激PPT课件

成功DBS治疗的关键 正确的病人选择 精确的DBS系统植入 最佳的病人管理： ——最佳的脑起搏器程控 ——与DBS相配合的药物调整 ——手术副作用控制 ——病人教育和支持 The quality of the clinical results associated with deep brain stimulation depends on three major factors: Appropriate patient selection Accurate placement of the leads in the target structures Optimal post-operative patient management (programming, medication adjustment, side-effects management, psychological support, physiotherapy) 正确进行病人选择的重要性 只有正确的病人选择才能保证DBS治疗的最佳效果 既往的经验也证实，只有选择好的病人，才有可能有好的治疗效果。 The primary objective of the selection process is to identify those individuals in whom the expected benefit will outweigh the inherent risks of the surgical procedure. Functional stereotactic surgery strives to improve motor function and to reduce disability by alleviating symptoms of a movement disorder. A number of patients referred for Activa® Therapy are inappropriate candidates. At the same time, an unknown number of patients that are good candidates are not referred for surgical treatment. PD = Parkinson’s disease 帕金森患者接受DBS治疗的 标准 excel标准偏差excel标准偏差函数exl标准差函数国标检验抽样标准表免费下载红头文件格式标准下载 * 确诊为原发性帕金森病 对左旋多巴曾有良好反应，且保持至目前 出现药物调整无法控制的严重症状 运动波动和/或严重异动症 认知能力正常（无痴呆） 合理的手术期望值和良好的家庭支持条件 可进行神经刺激器程控 *被普遍接受的标准 Ideal candidates for Activa® Therapy have idiopathic PD lasting for more than 5 years. They have a good levodopa response (historical and current) but experience side effects from long-term medical treatment such as motor fluctuations or dyskinesias. There should be minimal ‘On-time without dyskinesias’ and substantial disability during ‘Off-periods’, affecting the activities of daily life. Patients must also be cognitively intact. Dementia, acute psychosis, and depression are usually exclusion criteria. The general health condition of the patient needs to be good enough to withstand the operation and to maintain cooperation during prolonged awake stereotactic surgery. The treating physician should be informed about the patient’s personal expectation from surgery and should correct unrealistic perspectives. Finally, the patient needs to understand that the therapeutic benefits of DBS for advanced Parkinson’s disease are not immediately obtained after surgery. Programming the device and adjusting medication may be time consuming and tedious, and the patient must be ready to cooperate during this process. Older patients may respond equally well to surgery, but levodopa-resistant symptoms are more often encountered in this group, surgical adverse events are more frequent, motor rehabilitation is slower, and concomitant diseases (e.g. orthopaedic problems secondary to a Parkinsonian postural or gait disorder) may limit the degree of functional restitution. Volkmann J. "Deep brain stimulation for the treatment of Parkinson's disease." J Clin Neurophysiol 2004;21(1):6–17. PD = Parkinson’s disease 不适合接受DBS治疗帕金森病患者标准 (1) 帕金森患者： 对左旋多巴无反应或反应不良 继发性帕金森并或帕金森综合症 “开”期状态不佳 明显的认知障碍 Mattis痴呆量 表 关于同志近三年现实表现材料材料类招标技术评分表图表与交易pdf视力表打印pdf用图表说话 pdf 无法治疗的抑郁症或其他精神病 不愿或无法配合手术的进行 不愿或无法配合术后随访 *Product technical manual must be reviewed prior to use for detailed disclosure. In patients with PD, Activa® Therapy is not suitable for patients who show a poor response to levodopa. Because the response to levodopa predicts the clinical outcomes, levodopa resistant symptoms such as dysarthria, on-freezing or postural instability may limit the degree of functional improvement after deep brain stimulation and should therefore be considered as relative contraindications. In patients being considered for Activa® Therapy, it is important that the patient is not cognitively impaired so they are able to understand the procedure, appreciate the risks involved and cope with the changes to their life after surgery. Dementia, acute psychosis and acute depression with suicidal ideation are all exclusion criteria for surgery. PD = Parkinson’s disease; ET = essential tremor 不适合接受DBS治疗帕金森病患者标准(2) 整体健康状况不佳 神经外科手术风险大 脑损伤 严重脑萎缩 凝血病 无法控制的高血压 需接受透热疗法 禁忌症： 糖尿病 免疫抑制 已植入心脏起搏器 需反复进行MRI *Product technical manual must be reviewed prior to use for detailed disclosure. In patients with PD, ET or dystonia being considered for Activa® Therapy, the general health condition of the patient needs to be such that they will cope with the operation and be able to maintain cooperation during prolonged awake-surgery. Patients with an abnormal cerebral MRI scan should not be considered for Activa® Therapy. Brain atrophy, coagulopathy, anticoagulation therapy or uncontrolled hypertension increase the risk of bleeding during surgery. Activa® Therapy should not be used in patients that may require diathermy. Other factors that should be taken into consideration (but are not necessarily exclusion criteria) are: diabetes or immunosuppressive therapy, which can increase the risk of infection the presence of a cardiac pacemaker, which may interfere with magnetic resonance imaging and limit the programming options of DBS the need for repeated MRI. Although most MRI procedures can be performed safely with an implanted Activa System, clinicians should carefully weigh the decision to use MRI in patients with an implanted Activa System (refer to Product Information slides). PD = Parkinson’s disease; ET = essential tremor; DBS = deep brain stimulation 原发性帕金森病是DBS治疗前提 确诊为原发性帕金森病是接受DBS治疗最重要的前提 UK脑库的诊断标准 >帕金森病的症状诊断 >帕金森病的排除标准 >帕金森病的支持性诊断标准 1. Ahlskog JE et al, 2001 2. Hubble JP et al, 1989 In PD, within 4–6 years of levodopa therapy, over one third of patients develop motor fluctuations and one third of patients develop dyskinesia. After 10 years of levodopa therapy, up to 80% of patients, and almost 100% of those with young-onset PD, develop motor complications In ET, up to 30% of patients will not respond to treatment with propranolol, and as many as 20% of patients cannot tolerate primidone. Ahlskog JE, Muenter MD. "Frequency of levodopa-related dyskinesias and motor fluctuations as estimated from the cumulative literature." Mov Disord 2001; 16(3): 448–458. Hubble JP, Busenbark KL, Koller WC. "Essential tremor." Clin Neuropharmacol 1989; 12(6): 453–482. PD = Parkinson’s disease; ET = essential tremor 当疾病症状已非单纯药物可以控制时，应当考虑接受DBS手术治疗 接受左旋多巴疗法4-6年（帕金森病） >40%的患者出现运动波动症状1 >40%的患者出现异动症1 接受左旋多巴疗法10年后（帕金森病） >80%的患者出现运动并发症 1. Ahlskog JE et al, 2001 2. Hubble JP et al, 1989 In PD, within 4–6 years of levodopa therapy, over one third of patients develop motor fluctuations and one third of patients develop dyskinesia. After 10 years of levodopa therapy, up to 80% of patients, and almost 100% of those with young-onset PD, develop motor complications In ET, up to 30% of patients will not respond to treatment with propranolol, and as many as 20% of patients cannot tolerate primidone. Ahlskog JE, Muenter MD. "Frequency of levodopa-related dyskinesias and motor fluctuations as estimated from the cumulative literature." Mov Disord 2001; 16(3): 448–458. Hubble JP, Busenbark KL, Koller WC. "Essential tremor." Clin Neuropharmacol 1989; 12(6): 453–482. PD = Parkinson’s disease; ET = essential tremor 当疾病症状已非单纯药物可以控制时，应当考虑接受DBS手术治疗 “严重的运动障碍症状” 一天3或3小时以上 “关” 期 伴随严重的运动症状 和/或 “开” 期伴 异动症 不满意 症状控制 左旋多巴所致“剂末现象” 3 or more hours a day of “off” time with troubling symptoms and/or “on” time with troubling dyskinesias (criterion from NIH/VA Study) 关期伴有 Dissatisfied with symptom control 当疾病症状已非单纯药物可以控制时，应当考虑接受DBS手术治疗 “抗帕金森病药物优化调整后” 5次或以上/日 服用左旋多巴类药物 服药种类 (3种或3种以上) 服用 COMT 抑制剂 无法忍受药物的副作用 3 or more hours a day of “off” time with troubling symptoms and/or “on” time with troubling dyskinesias (criterion from NIH/VA Study) 关期伴有 Dissatisfied with symptom control 患者年龄轻、病程短对DBS治疗效果好 患者年龄轻的患者，其DBS治疗后的效果较年龄大的好。 病程短的患者，其DBS治疗效果较病程长的患者好 选择病人的方法 预期手术是否成功的重要指标是帕金森病的症状必须对左旋多巴敏感 采用左旋多巴试验（超域值剂量）观察症状的改善而预期手术的疗效 尽管采取一种或者多种治疗措施，病人仍有长期应用L-dopa的运动并发症 病人处于严重的“关”阶段，或者异动症阶段。 UPDRS运动评分（III）< 30分 至少一个肢体出现严重的异动，即UPDRS （IV） 或者至少一个肢体有明显的震颤，UPDRS （III）的运动评分的第20和21项 神经外科手术风险和禁忌症 需要衡量病人目前的功能和手术治疗的利弊 左旋多巴冲击试验 有效帕金森病患者术前评估 以左旋多巴替代多巴胺激动剂3-5天 手术前一晚停止服用抗帕金森药物（使患者处于“关”期状态） 第二天上午进行帕金森症状评估 按左旋多巴冲击试验要求给药 在最佳“开”期状态进行帕金森病症状评估 术前“开/关”期评估：UPDRS运动评分至少改善30% 1. Charles PD et al, 2002 The presurgical levodopa test helps to predict the individual response profile of a patient to bilateral STN or GPi stimulation. To ensure a stable off-condition when medication is removed, high doses of medium- to long-acting dopamine agonists are replaced by equivalent amounts of levodopa in the 3–5 days prior to the test. Antiparkinsonian medication is then withdrawn overnight and the symptoms of PD are assessed the following morning (Off-state), using the UPDRS. After scoring the symptoms in the Off-state the patient is given a ‘challenge dose’ of levodopa. This is usually 1.5 times the morning dose of levodopa plus the levodopa equivalent dose of a dopamine agonist taken in the morning. The patient is scored in the ‘best On’ condition usually 30–60 minutes after taking the challenging dose. The patient’s suitability for Activa® Therapy can be determined by comparing these UPDRS scores assessed before and after the challenge levodopa dose. A good response is defined by an improvement of at least 30% of the motor UPDRS. Symptoms other than dyskinesias or tremor, which persist during ‘best On’ after taking a challenging dose of levodopa are less likely to benefit from DBS. Charles, PD, Van Blercom N, et al. “Predictors of effective bilateral subthalamic nucleus stimulation for PD." Neurology 2002; 59(6): 932-934. PD = Parkinson’s disease; UPDRS = Unified Parkinson’s disease Rating Scale L-DA 试验：预估手术效果 DBS治疗效果好的运动症状 剂末运动不能和药效缩短 药物峰值浓度药效理想但药效很快消退 药物峰值浓度药效理想但出现不能预料的关期 开关现象 对多巴治疗有反应的冻结现象 关期异动症；双相异动症 药物达到峰值浓度时，出现舞蹈样异动 DBS治疗效果不确定的症状 对左旋多巴没有反应的吞咽困难 对左旋多巴没有反应的发音困难 性欲问 题 快递公司问题件快递公司问题件货款处理关于圆的周长面积重点题型关于解方程组的题及答案关于南海问题 便秘；尿失禁 认知障碍；抑郁；精神病 睡眠障碍 DBS患者评估流程图 CAPSIT-PD Core Assessment Program for Surgical Interventional Therapies in Parkinson’s Disease， G-L Defer, et al. Mov Disor 1999;14(4):572-584 发病5年以上考虑进行手术 临床症状 MRI检查 对L-dopa反应 符合PD的诊断标准 认知 痴呆 抑郁等 最佳的药物调整 没有变化的药物治疗 临床教育 DBS治疗 6月 12月 24 月 -3月 如果药物调整 临床评估 MRI T-1 3D MRI T-1 3D MRI T-2 认知测试 不符合PD标准 排除手术候选人 MRI T-1 3D 临床评估 临床评估 临床评估 临床评估 认知测试 认知测试 To get maximum benefits from Activa therapy, it is extremely important to choose idiopathic Parkinson’s disease, who response to levodopa therapy or dopaminergic agonists and present improvement of motor functions. What is Parkinsonisim? How does it differ from Parkinsons? A: The term Parkinsonism can be used in two basic ways. It can be used early in the diagnostic procedure to indicate the patient is experiencing symptoms that can be seen as part of Parkinson's disease but the doctor wants to rule out other possible causes before suggesting Parkinson's disease. Or, it can be used further into the progression to indicate that while the person shows different symptoms commonly-seen as part of classical Parkinson's disease, the lack of benefit from the typically-used antiparkinson medications and/or the appearance of other symptoms is now suggesting an alternative diagnosis but even at this point the doctor cannot be more specific. There are a number of disorders that early on produce symptoms very similar to those seen as part "idiopathic" Parkinson's disease. These might include such rare disorders as Progressive Supranuclear Palsy, Shy-Drager Syndrome, OPCA, etc. Each eventually produces symptoms NOT at all common to PD which finally allows the physician to come to a more accurate diagnosis. Often, we hear that due to dementia or depression patient is not candidate for Activa therapy. Please ask your neurologists how severe their dementia or depression by asking scores. For more information on Parkinson’s disease, please read “A Guide for Patients. The forty most-frequently-asked questions about Parkinson’s disease” published by Parkinson’s Disease Foundation. DBS患者核心评估试验 患者日记 每月一周，一周里醒时每30分钟 记录 混凝土 养护记录下载土方回填监理旁站记录免费下载集备记录下载集备记录下载集备记录下载 一次 注意：当跌倒、冻结或肌张力障碍发作时记录 患者居家 检测 工程第三方检测合同工程防雷检测合同植筋拉拔检测方案传感器技术课后答案检测机构通用要求培训 前一天 注意! 晚上8点以前最后服用抗帕金森药物 生活质量评分 SF 36, PDQ-39 在家中填写 实际定义“关”状态 UPDRS Hoehn & Yahr Single-dose L-dopa Test Hand/ arm X 2 Walk X 2 Dyskinesia/ Dystonia RS 检测当天 开状态下的认知试验 MATTIS MADRS Verbal Fluency Pace Auditory Serial Additional Test Odd Man Out Test Modified Brown Peterson Paradigm Rey Auditory Verbal Learning Test Visual Mnesic Battery of Signoret Tower of Hanoi 随机检测 实际定义“开”状态 UPDRS Hoehn & Yahr Single-dose L-dopa Test Hand/ arm X 2 Walk X 2 Dyskinesia/ Dystonia RS CAPSIT-PD Core Assessment Program for Surgical Interventional Therapies in Parkinson’s Disease， G-L Defer, et al. Mov Disor 1999;14(4):572-584 To get maximum benefits from Activa therapy, it is extremely important to choose idiopathic Parkinson’s disease, who response to levodopa therapy or dopaminergic agonists and present improvement of motor functions. What is Parkinsonisim? How does it differ from Parkinsons? A: The term Parkinsonism can be used in two basic ways. It can be used early in the diagnostic procedure to indicate the patient is experiencing symptoms that can be seen as part of Parkinson's disease but the doctor wants to rule out other possible causes before suggesting Parkinson's disease. Or, it can be used further into the progression to indicate that while the person shows different symptoms commonly-seen as part of classical Parkinson's disease, the lack of benefit from the typically-used antiparkinson medications and/or the appearance of other symptoms is now suggesting an alternative diagnosis but even at this point the doctor cannot be more specific. There are a number of disorders that early on produce symptoms very similar to those seen as part "idiopathic" Parkinson's disease. These might include such rare disorders as Progressive Supranuclear Palsy, Shy-Drager Syndrome, OPCA, etc. Each eventually produces symptoms NOT at all common to PD which finally allows the physician to come to a more accurate diagnosis. Often, we hear that due to dementia or depression patient is not candidate for Activa therapy. Please ask your neurologists how severe their dementia or depression by asking scores. For more information on Parkinson’s disease, please read “A Guide for Patients. The forty most-frequently-asked questions about Parkinson’s disease” published by Parkinson’s Disease Foundation. DBS 手术时机 没有很多的资料论述理想的手术时机 目前多数是比较晚期的病人接受脑起搏器治疗 有实验显示DBS有神经保护作用，但尚未有完整的资料证实 目前认为手术的时机：出现主要症状的药物抵抗，预期DBS可以缓解症状，减轻功能障碍 DBS 手术时机 需要考虑的问题： 手术能够缓解的症状是否是引起病人功能障碍的主要原因 确认其他可能的引起功能障碍的原因 预估手术缓解主要症状的可能性 估计个体可能的手术风险和并发症 建立不同水平的手术能达到的功能康复的目标 病人对于手术的期望值 年轻患者出现轻度运动波动，影响其工作的可以考虑相对较早期接受手术治疗 病程长短直接影响到DBS治疗的疗效 疾病进展 疗法 僵直 运动缓慢 震颤 姿势失衡 运动波动 异动症 认知障碍 痴呆 5年 10年 15年 确诊 过早？ 过晚？ 窗口期 The degree of benefit obtained from DBS depends also on the ability for the physician and the patient to seize the “window of opportunity” during the course of Parkinson’s disease. The CAPSIT-PD recommendation is that a patient should have a disease duration of at least 5 years before being considered for inclusion in a neurosurgical protocol, to allow for atypical forms of parkinsonism to become evident.1 Also, by 5 years, the majority of patients will have been exposed to levodopa, facilitating testing and assessment. On the other hand, as the disease progresses, cognitive decline and dementia occur almost inevitably in the late stages of PD. Lang AE, Widner H. “Deep brain stimulation for Parkinson’s disease: patient selection and evaluation." Mov Disord 2002; 17(3): S94-S101. PD = Parkinson’s disease 患者的年龄 50% 0% 100% 20% 出现临床症状 没有临床症状 患者症状的状态 (Hoehn & Yahr) V I II IV III Adapted from E. Mora presentation 平均诊断年龄: 55 to 60 病程长短直接影响到DBS治疗的疗效 特定人群的DBS疗法情况 下列患者群体的DBS手术的有效性和安全性尚未得到证实： 曾接受外科消融术 怀孕 痴呆 凝血病 中重度抑郁症 患者年龄<18岁（帕金森病、特发性震颤）、<7岁（肌张力障碍） 患者年龄>75 岁（帕金森病、肌张力障碍）、>80 years （特发性震颤） Activa® Therapy is currently approved for the treatment of disabling ET, PD and primary dystonia. The efficacy and safety of Activa® Therapy has not yet been established in: patients who have undergone a previous thalamotomy or surgical ablation procedure pregnant women patients with dementia, coagulopathies or moderate-to-severe depression. Activa® Therapy has been shown to be effective, with a favourable safety profile, in patients with dystonia aged as young as 7 years. Data on the efficacy and safety of Activa® Therapy is limited in elderly patients with PD (>75 years), dystonia (>75 years) or ET (>80 years). Older patients may respond equally well to surgery, but surgical adverse events are more frequent, motor rehabilitation is slower, and concomitant diseases may limit the degree of functional restitution. ET = essential tremor; PD = Parkinson’s disease The quality of the clinical results associated with deep brain stimulation depends on three major factors: Appropriate patient selection Accurate placement of the leads in the target structures Optimal post-operative patient management (programming, medication adjustment, side-effects management, psychological support, physiotherapy) The primary objective of the selection process is to identify those individuals in whom the expected benefit will outweigh the inherent risks of the surgical procedure. Functional stereotactic surgery strives to improve motor function and to reduce disability by alleviating symptoms of a movement disorder. A number of patients referred for Activa® Therapy are inappropriate candidates. At the same time, an unknown number of patients that are good candidates are not referred for surgical treatment. PD = Parkinson’s disease Ideal candidates for Activa® Therapy have idiopathic PD lasting for more than 5 years. They have a good levodopa response (historical and current) but experience side effects from long-term medical treatment such as motor fluctuations or dyskinesias. There should be minimal ‘On-time without dyskinesias’ and substantial disability during ‘Off-periods’, affecting the activities of daily life. Patients must also be cognitively intact. Dementia, acute psychosis, and depression are usually exclusion criteria. The general health condition of the patient needs to be good enough to withstand the operation and to maintain cooperation during prolonged awake stereotactic surgery. The treating physician should be informed about the patient’s personal expectation from surgery and should correct unrealistic perspectives. Finally, the patient needs to understand that the therapeutic benefits of DBS for advanced Parkinson’s disease are not immediately obtained after surgery. Programming the device and adjusting medication may be time consuming and tedious, and the patient must be ready to cooperate during this process. Older patients may respond equally well to surgery, but levodopa-resistant symptoms are more often encountered in this group, surgical adverse events are more frequent, motor rehabilitation is slower, and concomitant diseases (e.g. orthopaedic problems secondary to a Parkinsonian postural or gait disorder) may limit the degree of functional restitution. Volkmann J. "Deep brain stimulation for the treatment of Parkinson's disease." J Clin Neurophysiol 2004;21(1):6–17. PD = Parkinson’s disease In patients with PD, Activa® Therapy is not suitable for patients who show a poor response to levodopa. Because the response to levodopa predicts the clinical outcomes, levodopa resistant symptoms such as dysarthria, on-freezing or postural instability may limit the degree of functional improvement after deep brain stimulation and should therefore be considered as relative contraindications. In patients being considered for Activa® Therapy, it is important that the patient is not cognitively impaired so they are able to understand the procedure, appreciate the risks involved and cope with the changes to their life after surgery. Dementia, acute psychosis and acute depression with suicidal ideation are all exclusion criteria for surgery. PD = Parkinson’s disease; ET = essential tremor In patients with PD, ET or dystonia being considered for Activa® Therapy, the general health condition of the patient needs to be such that they will cope with the operation and be able to maintain cooperation during prolonged awake-surgery. Patients with an abnormal cerebral MRI scan should not be considered for Activa® Therapy. Brain atrophy, coagulopathy, anticoagulation therapy or uncontrolled hypertension increase the risk of bleeding during surgery. Activa® Therapy should not be used in patients that may require diathermy. Other factors that should be taken into consideration (but are not necessarily exclusion criteria) are: diabetes or immunosuppressive therapy, which can increase the risk of infection the presence of a cardiac pacemaker, which may interfere with magnetic resonance imaging and limit the programming options of DBS the need for repeated MRI. Although most MRI procedures can be performed safely with an implanted Activa System, clinicians should carefully weigh the decision to use MRI in patients with an implanted Activa System (refer to Product Information slides). PD = Parkinson’s disease; ET = essential tremor; DBS = deep brain stimulation In PD, within 4–6 years of levodopa therapy, over one third of patients develop motor fluctuations and one third of patients develop dyskinesia. After 10 years of levodopa therapy, up to 80% of patients, and almost 100% of those with young-onset PD, develop motor complications In ET, up to 30% of patients will not respond to treatment with propranolol, and as many as 20% of patients cannot tolerate primidone. Ahlskog JE, Muenter MD. "Frequency of levodopa-related dyskinesias and motor fluctuations as estimated from the cumulative literature." Mov Disord 2001; 16(3): 448–458. Hubble JP, Busenbark KL, Koller WC. "Essential tremor." Clin Neuropharmacol 1989; 12(6): 453–482. PD = Parkinson’s disease; ET = essential tremor In PD, within 4–6 years of levodopa therapy, over one third of patients develop motor fluctuations and one third of patients develop dyskinesia. After 10 years of levodopa therapy, up to 80% of patients, and almost 100% of those with young-onset PD, develop motor complications In ET, up to 30% of patients will not respond to treatment with propranolol, and as many as 20% of patients cannot tolerate primidone. Ahlskog JE, Muenter MD. "Frequency of levodopa-related dyskinesias and motor fluctuations as estimated from the cumulative literature." Mov Disord 2001; 16(3): 448–458. Hubble JP, Busenbark KL, Koller WC. "Essential tremor." Clin Neuropharmacol 1989; 12(6): 453–482. PD = Parkinson’s disease; ET = essential tremor 3 or more hours a day of “off” time with troubling symptoms and/or “on” time with troubling dyskinesias (criterion from NIH/VA Study) 关期伴有 Dissatisfied with symptom control 3 or more hours a day of “off” time with troubling symptoms and/or “on” time with troubling dyskinesias (criterion from NIH/VA Study) 关期伴有 Dissatisfied with symptom control The presurgical levodopa test helps to predict the individual response profile of a patient to bilateral STN or GPi stimulation. To ensure a stable off-condition when medication is removed, high doses of medium- to long-acting dopamine agonists are replaced by equivalent amounts of levodopa in the 3–5 days prior to the test. Antiparkinsonian medication is then withdrawn overnight and the symptoms of PD are assessed the following morning (Off-state), using the UPDRS. After scoring the symptoms in the Off-state the patient is given a ‘challenge dose’ of levodopa. This is usually 1.5 times the morning dose of levodopa plus the levodopa equivalent dose of a dopamine agonist taken in the morning. The patient is scored in the ‘best On’ condition usually 30–60 minutes after taking the challenging dose. The patient’s suitability for Activa® Therapy can be determined by comparing these UPDRS scores assessed before and after the challenge levodopa dose. A good response is defined by an improvement of at least 30% of the motor UPDRS. Symptoms other than dyskinesias or tremor, which persist during ‘best On’ after taking a challenging dose of levodopa are less likely to benefit from DBS. Charles, PD, Van Blercom N, et al. “Predictors of effective bilateral subthalamic nucleus stimulation for PD." Neurology 2002; 59(6): 932-934. PD = Parkinson’s disease; UPDRS = Unified Parkinson’s disease Rating Scale To get maximum benefits from Activa therapy, it is extremely important to choose idiopathic Parkinson’s disease, who response to levodopa therapy or dopaminergic agonists and present improvement of motor functions. What is Parkinsonisim? How does it differ from Parkinsons? A: The term Parkinsonism can be used in two basic ways. It can be used early in the diagnostic procedure to indicate the patient is experiencing symptoms that can be seen as part of Parkinson's disease but the doctor wants to rule out other possible causes before suggesting Parkinson's disease. Or, it can be used further into the progression to indicate that while the person shows different symptoms commonly-seen as part of classical Parkinson's disease, the lack of benefit from the typically-used antiparkinson medications and/or the appearance of other symptoms is now suggesting an alternative diagnosis but even at this point the doctor cannot be more specific. There are a number of disorders that early on produce symptoms very similar to those seen as part "idiopathic" Parkinson's disease. These might include such rare disorders as Progressive Supranuclear Palsy, Shy-Drager Syndrome, OPCA, etc. Each eventually produces symptoms NOT at all common to PD which finally allows the physician to come to a more accurate diagnosis. Often, we hear that due to dementia or depression patient is not candidate for Activa therapy. Please ask your neurologists how severe their dementia or depression by asking scores. For more information on Parkinson’s disease, please read “A Guide for Patients. The forty most-frequently-asked questions about Parkinson’s disease” published by Parkinson’s Disease Foundation. To get maximum benefits from Activa therapy, it is extremely important to choose idiopathic Parkinson’s disease, who response to levodopa therapy or dopaminergic agonists and present improvement of motor functions. What is Parkinsonisim? How does it differ from Parkinsons? A: The term Parkinsonism can be used in two basic ways. It can be used early in the diagnostic procedure to indicate the patient is experiencing symptoms that can be seen as part of Parkinson's disease but the doctor wants to rule out other possible causes before suggesting Parkinson's disease. Or, it can be used further into the progression to indicate that while the person shows different symptoms commonly-seen as part of classical Parkinson's disease, the lack of benefit from the typically-used antiparkinson medications and/or the appearance of other symptoms is now suggesting an alternative diagnosis but even at this point the doctor cannot be more specific. There are a number of disorders that early on produce symptoms very similar to those seen as part "idiopathic" Parkinson's disease. These might include such rare disorders as Progressive Supranuclear Palsy, Shy-Drager Syndrome, OPCA, etc. Each eventually produces symptoms NOT at all common to PD which finally allows the physician to come to a more accurate diagnosis. Often, we hear that due to dementia or depression patient is not candidate for Activa therapy. Please ask your neurologists how severe their dementia or depression by asking scores. For more information on Parkinson’s disease, please read “A Guide for Patients. The forty most-frequently-asked questions about Parkinson’s disease” published by Parkinson’s Disease Foundation. The degree of benefit obtained from DBS depends also on the ability for the physician and the patient to seize the “window of opportunity” during the course of Parkinson’s disease. The CAPSIT-PD recommendation is that a patient should have a disease duration of at least 5 years before being considered for inclusion in a neurosurgical protocol, to allow for atypical forms of parkinsonism to become evident.1 Also, by 5 years, the majority of patients will have been exposed to levodopa, facilitating testing and assessment. On the other hand, as the disease progresses, cognitive decline and dementia occur almost inevitably in the late stages of PD. Lang AE, Widner H. “Deep brain stimulation for Parkinson’s disease: patient selection and evaluation." Mov Disord 2002; 17(3): S94-S101. PD = Parkinson’s disease Activa® Therapy is currently approved for the treatment of disabling ET, PD and primary dystonia. The efficacy and safety of Activa® Therapy has not yet been established in: patients who have undergone a previous thalamotomy or surgical ablation procedure pregnant women patients with dementia, coagulopathies or moderate-to-severe depression. Activa® Therapy has been shown to be effective, with a favourable safety profile, in patients with dystonia aged as young as 7 years. Data on the efficacy and safety of Activa® Therapy is limited in elderly patients with PD (>75 years), dystonia (>75 years) or ET (>80 years). Older patients may respond equally well to surgery, but surgical adverse events are more frequent, motor rehabilitation is slower, and concomitant diseases may limit the degree of functional restitution. ET = essential tremor; PD = Parkinson’s disease