Module 05

Advanced Programming — STN, GPi & VIM / DRT

Slides 21–25 | Turning a well-placed lead into clinical benefit

Original lecture slides 21–25 · Module 05 / 10

“IMPLANTATION CREATES THE OPPORTUNITY; PROGRAMMING CREATES THE THERAPY.”

The programming loop

01CLINICAL GOAL
02MONOPOLAR REVIEW
03THERAPEUTIC WINDOW
04OPTIMIZATION
05FOLLOW-UP

Original slide 21 framework. The loop repeats for the lifetime of the therapy.

Learning objectives

By the end of this module you should be able to

01Describe programming as the second operation rather than an afterthought
02Run the five-step programming loop in order
03State a clinical goal in terms the patient would recognize
04Conduct a structured contact-by-contact monopolar review
05Record benefit and side-effect thresholds separately for every contact
06Define and measure the therapeutic window
07Select contacts for maximum useful benefit with the largest safety margin
08Reason about amplitude, pulse width, frequency and configuration independently
09Apply STN programming logic to motor benefit, fluctuation and dyskinesia
10Apply GPi programming logic to dyskinesia, dystonia and motor phenotype
11Approach VIM / DRT tremor programming as a pathway problem
12Recognize stimulation-induced adverse effects and use them to localize the field
13Plan medication reassessment alongside stimulation optimization
14Document programming so a colleague can continue it years later

Original lecture slides

Slides 21–25

The slides below are reproduced exactly as delivered. Everything outside the slide panel is added study material.

Slide 21

Original lecture slide

100%

PROGRAMMING: THE SECOND OPERATION

Turning a well-placed lead into clinical benefit
LEAD — Position fixed
CONTACT — Select
FIELD — Shape
RESPONSE — Test
REFINE — Repeat
THE PROGRAMMING LOOP
1 Clinical goal — Tremor / rigidity / dyskinesia / gait
2 Monopolar review — Contact × amplitude × response
3 Therapeutic window — Benefit threshold vs side-effect threshold
4 Optimization — Amplitude • pulse width • frequency • configuration
5 Follow-up — Symptoms change → settings evolve
KEY MESSAGE • Implantation creates the opportunity; programming creates the therapy.
Dr Vikas Kathuria | MCh Neurosurgery

Why this slide matters

Once the lead is fixed, every remaining degree of freedom is electrical. Programming is where a technically good operation becomes — or fails to become — a treatment.

Core concepts

The lead position is now a constant

ESTABLISHED

Contact, field, response and refinement are the only variables left. That is why lead position had to be right, and why it must be known.

Programming is a loop, not an event

ESTABLISHED

Symptoms change, medication changes and the disease progresses, so settings evolve across years of follow-up.

Start from a clinical goal

ESTABLISHED

A setting can only be judged against a stated goal.

Tremor
Rigidity
Bradykinesia
Dyskinesia
Gait
Function and quality of life

Surgical / clinical pearl

Implantation creates the opportunity; programming creates the therapy.
If nobody wrote down the goal, nobody can say whether the session helped.
Change one variable at a time or the result cannot be interpreted.

Image placeholder

21A PROGRAMMING SESSION — INSERT AUTHENTIC IMAGE

Real clinical image required

Image typeProgramming screenshot

DescriptionAuthentic clinician programmer interface or session photograph with consent; never fabricate device screens.

Clinical purposeSupport programming teaching without fabricating patient data, device screenshots or clinical imaging.

Suggested sourceINSERT AUTHENTIC PUBLISHED / INSTITUTIONAL IMAGE HERE (licensing and consent confirmed)

CaptionTo be written with the final image

AssociationModule 05 · Slide 21

Audience question

AUDIENCE QUESTIONESTABLISHED

What is the first thing you do at a first programming session?

Diagram

The programming loop

01CLINICAL GOAL
02MONOPOLAR REVIEW
03THERAPEUTIC WINDOW
04OPTIMIZATION
05FOLLOW-UP

Original slide framework, reproduced as supplied.

Speaker notes — 12 teaching points (hidden by default)

Open by asking how many in the room programme their own patients — the split shapes the discussion.
Established: a fixed lead means all remaining control is electrical.
Practical implication: book enough time; a rushed first session produces settings nobody can interpret later.
Prevention strategy: record the goal, the baseline examination and the medication state before touching the device.
Diagnostic pitfall: attributing a poor first session to the lead before the programming space has been explored.
Management consideration: agree who owns follow-up programming before the patient leaves.
Evidence limitation: programming protocols vary between centres; the method matters more than the local recipe.
Common misconception: that programming is technical support rather than clinical practice.
Question for fellows: what would you document so a colleague could continue this in five years?
Difficult decision point: a patient with unrealistic expectations at the first session.
Multidisciplinary trigger: involve the specialist nurse or therapist early in the loop.
Close on the original key message.

References

Slide 22

Original lecture slide

100%

MONOPOLAR REVIEW

Find the contact with the best therapeutic window
DBS LEAD
Contact 0
Contact 1
Contact 2
Contact 3
CONTACT-BY-CONTACT TESTING
CONTACT | BENEFIT | SIDE EFFECT | WINDOW
0 | high | high | narrow
1 | good | low | wide
2 | good | moderate | moderate
3 | poor | high | poor
LOOK FOR — Maximum useful benefit with the largest safety margin.
Do not chase the strongest response; chase the most useful response.
Dr Vikas Kathuria | MCh Neurosurgery

Why this slide matters

The monopolar review is the one structured measurement in programming. Skipping it turns the rest of the therapy into guesswork.

Core concepts

Two thresholds per contact

ESTABLISHED

The amplitude at which useful benefit appears, and the amplitude at which a side effect appears. The window is the distance between them.

Reading the original table

ESTABLISHED

The qualitative labels are reproduced exactly as on the original slide. Contact 1 illustrates the teaching point: the best window, not the biggest effect.

Contact 0 — high benefit but high side effect: narrow window
Contact 1 — good benefit with low side effect: wide window
Contact 2 — good benefit with moderate side effect: moderate window
Contact 3 — poor benefit with high side effect: poor window

Document what you tested

ESTABLISHED

Amplitude steps, the symptom examined, the side effect observed and the state of medication. Undocumented programming cannot be continued by anyone else.

Surgical / clinical pearl

Do not chase the strongest response; chase the most useful response.
A narrow window is a warning about lead position, not only about the contact.
Re-test before you commit: a single observation is not a threshold.

Image placeholder

22A MONOPOLAR REVIEW RECORD — INSERT AUTHENTIC IMAGE

Real clinical image required

Image typeProgramming screenshot

DescriptionAuthentic monopolar review record or programmer screen with thresholds documented.

Clinical purposeSupport programming teaching without fabricating patient data, device screenshots or clinical imaging.

Suggested sourceINSERT AUTHENTIC PUBLISHED / INSTITUTIONAL IMAGE HERE (licensing and consent confirmed)

CaptionTo be written with the final image

AssociationModule 05 · Slide 22

Audience question

AUDIENCE QUESTIONESTABLISHED

Which contact would you choose from the original table, and why?

Audience question

CRITICAL THINKINGSUPPORTED

What does a narrow window at every contact tell you?

Monopolar review — original slide data (verbatim)

CONTACT	BENEFIT	SIDE EFFECT	WINDOW
0	high	high	narrow
1	good	low	wide
2	good	moderate	moderate
3	poor	high	poor

LOOK FOR — maximum useful benefit with the largest safety margin.

Monopolar review method (teaching checklist)

A teaching aid, not a protocol. Local practice, device platform and patient tolerance all modify it.

Speaker notes — 12 teaching points (hidden by default)

Open by asking the room to define the therapeutic window in one sentence.
Established: monopolar review is the structured basis of contact selection.
Practical implication: allocate enough time; a rushed review generates unreliable thresholds.
Prevention strategy: consistent examination technique makes thresholds comparable between sessions.
Diagnostic pitfall: recording benefit without recording the medication state.
Management consideration: a narrow window at every contact should trigger lead localization.
Evidence limitation: thresholds vary with examiner, symptom and time of day.
Common misconception: that the contact with the most dramatic effect is the best contact.
Question for fellows: how would you document this review for a colleague in five years?
Difficult decision point: two contacts with similar windows and different side-effect profiles.
Multidisciplinary trigger: speech or gait side effects that need formal assessment.
Close on the original slide line about the most useful response.

References

Slide 23

Original lecture slide

100%

STN PROGRAMMING

Motor benefit, medication strategy, and side-effect control
MOTOR — bradykinesia, rigidity
TREMOR — rest tremor
FLUCTUATION — OFF time
DYSKINESIA — often improves with medication reduction
STN: PRACTICAL PROGRAMMING LOGIC
START — Choose the contact with the best clinical response
AMPLITUDE — Increase gradually while monitoring adverse effects
PULSE WIDTH — Consider shorter PW when side effects limit amplitude
FREQUENCY — Adjust according to symptom phenotype and response
MEDICATION — Reassess dopaminergic therapy after DBS optimization
PEARL — STN programming is a balance between motor benefit and spread into nearby structures.
Dr Vikas Kathuria | MCh Neurosurgery

Why this slide matters

The STN sits among structures that produce recognizable side effects. Those side effects are the map: they tell you which way the field has spread.

Core concepts

Spread has an address

SUPPORTED

Adverse effects are diagnostic information about where the current is going.

Muscle contraction — corticospinal / corticobulbar direction
Paresthesia — medial lemniscus direction
Diplopia / gaze deviation — oculomotor direction
Dysarthria — corticobulbar involvement
Mood or behavioural change — associative / limbic territory

Medication is part of the programme

ESTABLISHED

Dopaminergic therapy is reassessed after stimulation optimization, not before it, and dyskinesia often improves as medication is reduced.

Phenotype directs the parameters

SUPPORTED

Tremor, rigidity, bradykinesia and OFF-time fluctuation do not respond identically to the same adjustment.

Surgical / clinical pearl

STN programming is a balance between motor benefit and spread into nearby structures.
A side effect at low amplitude is a localization statement.
Optimize stimulation first, then reassess medication — not both in the same visit.

Image placeholder

23A STN AND ADJACENT STRUCTURES — INSERT AUTHENTIC IMAGE

Real clinical image required

Image typeSTN anatomy

DescriptionAuthentic anatomical atlas figure or original educational schematic showing the STN and its neighbours.

Clinical purposeSupport programming teaching without fabricating patient data, device screenshots or clinical imaging.

Suggested sourceINSERT AUTHENTIC PUBLISHED / INSTITUTIONAL IMAGE HERE (licensing and consent confirmed)

CaptionTo be written with the final image

AssociationModule 05 · Slide 23

Audience question

AUDIENCE QUESTIONSUPPORTED

A patient develops muscle contraction at low amplitude. What does that tell you?

Audience question

FACULTY DISCUSSIONESTABLISHED

When do you reduce dopaminergic medication after STN DBS?

Deep dive

When side effects limit amplitude

SUPPORTED

Consider a shorter pulse width
Consider a different contact
Consider directional steering if the lead is segmented
Re-examine whether the field is reaching the intended territory

When benefit is incomplete

SUPPORTED

Confirm the symptom is stimulation-responsive
Re-check medication state during testing
Reconsider contact selection
Consider lead localization if the window is narrow everywhere

Diagram

STN practical programming logic

01START
02AMPLITUDE
03PULSE WIDTH
04FREQUENCY
05MEDICATION

Original slide sequence, reproduced as supplied.

Speaker notes — 12 teaching points (hidden by default)

Open by asking what side effect the room most often meets first in STN programming.
Established: STN DBS improves motor fluctuation and allows medication reduction in selected patients.
Practical implication: examine during testing rather than relying on patient report alone.
Prevention strategy: agree the medication reduction plan and its owner before discharge.
Diagnostic pitfall: treating stimulation-induced dysarthria as disease progression.
Management consideration: mood and apathy can emerge during medication reduction.
Evidence limitation: optimal frequency and pulse-width strategy remain individualized rather than fixed.
Common misconception: that maximal amplitude equals maximal benefit.
Question for fellows: which single observation during testing most changes your next step?
Difficult decision point: good motor benefit with emerging behavioural change.
Multidisciplinary trigger: neuropsychiatry input during medication reduction.
Close on the original pearl about benefit versus spread.

References

Volkmann J, Moro E, Pahwa R. Basic algorithms for the programming of deep brain stimulation in Parkinson's disease. Mov Disord. 2006;21(Suppl 14):S284-S289.
Koeglsperger T, Palleis C, Hell F, Mehrkens JH, Bötzel K. Deep brain stimulation programming for movement disorders: current concepts and evidence-based strategies. Front Neurol. 2019;10:410.
Picillo M, Lozano AM, Kou N, Puppi Munhoz R, Fasano A. Programming deep brain stimulation for Parkinson's disease: the Toronto Western Hospital algorithms. Brain Stimul. 2016;9(3):425-437.
Rodriguez-Oroz MC, Obeso JA, Lang AE, et al. Bilateral deep brain stimulation in Parkinson's disease: a multicentre study with 4 years follow-up. Brain. 2005;128(Pt 10):2240-2249.

Slide 24

Original lecture slide

100%

GPi PROGRAMMING

Think dyskinesia, dystonia, and the motor phenotype
GPi
POSTEROVENTRAL / SENSORIMOTOR
PROGRAMMING OBJECTIVES
DYSKINESIA — Reduce troublesome involuntary movement
DYSTONIA — Suppress dystonic posturing
MOTOR — Improve rigidity / bradykinesia
MEDICATION — Reduction is useful—but not the only goal
TARGET-SPECIFIC PEARL • GPi stimulation can provide strong anti-dyskinetic benefit without making medication reduction the primary objective.
Dr Vikas Kathuria | MCh Neurosurgery

Why this slide matters

GPi programming is organized around what the patient is troubled by — involuntary movement, posturing, rigidity — rather than around a medication-reduction target.

Core concepts

Posteroventral sensorimotor territory

ESTABLISHED

The programming objective is the sensorimotor portion of the internal pallidum; the field must reach it without producing capsular or optic-tract effects.

Dystonia takes time

ESTABLISHED

Dystonia responses can evolve over weeks to months, so programming judgements cannot be made on the day in the way they often can for tremor.

Neighbours to respect

SUPPORTED

Internal capsule — muscle contraction, dysarthria
Optic tract — visual phenomena
Pallidal borders — variable benefit and side-effect profile

Surgical / clinical pearl

GPi stimulation can provide strong anti-dyskinetic benefit without making medication reduction the primary objective.
In dystonia, judge the programme over weeks — not in the clinic room.
Visual phenomena during testing point at the optic tract, not at a device fault.

Image placeholder

24A GPi AND ADJACENT STRUCTURES — INSERT AUTHENTIC IMAGE

Real clinical image required

Image typeGPi anatomy

DescriptionAuthentic anatomical atlas figure or original educational schematic of the pallidum, capsule and optic tract.

Clinical purposeSupport programming teaching without fabricating patient data, device screenshots or clinical imaging.

Suggested sourceINSERT AUTHENTIC PUBLISHED / INSTITUTIONAL IMAGE HERE (licensing and consent confirmed)

CaptionTo be written with the final image

AssociationModule 05 · Slide 24

Audience question

AUDIENCE QUESTIONESTABLISHED

Why can GPi programming look disappointing on the day and good three months later?

Deep dive

Programming considerations in dystonia

SUPPORTED

Allow time before judging benefit
Phasic and tonic components may respond differently
Higher energy requirements may affect battery planning
Document a structured baseline for later comparison

Diagram

GPi programming objectives

01DYSKINESIA
02DYSTONIA
03MOTOR
04MEDICATION

Original slide objectives, reproduced as supplied.

Speaker notes — 12 teaching points (hidden by default)

Open by asking how the room judges success in a dystonia programming session.
Established: GPi DBS is effective in selected dystonia and provides anti-dyskinetic benefit in Parkinson disease.
Practical implication: schedule review at a timescale that matches the expected response.
Prevention strategy: structured video and rating-scale baselines before the first programme.
Diagnostic pitfall: declaring failure before the dystonia response has had time to develop.
Management consideration: energy requirements influence battery and device selection.
Evidence limitation: dystonia phenotypes differ widely in expected benefit.
Common misconception: that GPi is only a fallback when STN is contraindicated.
Question for fellows: what would you record so benefit at three months can be demonstrated?
Difficult decision point: partial benefit with significant energy demand.
Multidisciplinary trigger: physiotherapy and occupational therapy in dystonia follow-up.
Close on the original target-specific pearl.

References

Kupsch A, Benecke R, Müller J, et al. Pallidal deep-brain stimulation in primary generalized or segmental dystonia. N Engl J Med. 2006;355(19):1978-1990.
Vidailhet M, Vercueil L, Houeto JL, et al. Bilateral deep-brain stimulation of the globus pallidus in primary generalized dystonia. N Engl J Med. 2005;352(5):459-467.
Follett KA, Weaver FM, Stern M, et al. Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease. N Engl J Med. 2010;362(22):2077-2091.
Volkmann J, Moro E, Pahwa R. Basic algorithms for the programming of deep brain stimulation in Parkinson's disease. Mov Disord. 2006;21(Suppl 14):S284-S289.

Slide 25

Original lecture slide

100%

VIM / DRT PROGRAMMING

Tremor control is a pathway problem
VIM
DRT
CEREBELLUM
PROGRAMMING QUESTIONS
1 Is tremor suppressed?
2 What is the lowest effective amplitude?
3 Is there dysarthria / paresthesia / ataxia?
4 Can directional steering improve the window?
5 Is the clinical target actually the tremor pathway?
KEY IDEA • For tremor, “where the current goes” can matter more than the nominal nucleus name.
Dr Vikas Kathuria | MCh Neurosurgery

Why this slide matters

Tremor programming is where the difference between a nucleus name and a stimulated pathway becomes clinically obvious.

Core concepts

Lowest effective amplitude

SUPPORTED

Tremor can often be suppressed at several settings; the useful setting is the one that suppresses tremor with the least side effect and the least energy.

Recognizable side effects

SUPPORTED

Each localizes the field and guides the next adjustment.

Paresthesia — sensory territory
Dysarthria — corticobulbar involvement
Ataxia / disequilibrium — cerebellar pathway involvement

Habituation and progression

SUPPORTED

Apparent loss of tremor control over time may reflect habituation, disease progression or both, and is assessed rather than assumed.

Nucleus and pathway are not the same statement

ESTABLISHED

VIM is a nuclear target; the DRT is a pathway concept. Keeping them distinct prevents sloppy targeting and sloppy programming arguments.

Surgical / clinical pearl

For tremor, “where the current goes” can matter more than the nominal nucleus name.
Record the lowest effective amplitude — it is the number that predicts battery life and side-effect risk.
Ataxia during testing is a pathway signal, not merely an intolerance.

Image placeholder

25A VIM / DRT ANATOMY — INSERT AUTHENTIC IMAGE

Real clinical image required

Image typePSA / DRTT anatomy

DescriptionAuthentic anatomical figure or original educational schematic; never fabricate tractography output.

Clinical purposeSupport programming teaching without fabricating patient data, device screenshots or clinical imaging.

Suggested sourceINSERT AUTHENTIC PUBLISHED / INSTITUTIONAL IMAGE HERE (licensing and consent confirmed)

CaptionTo be written with the final image

AssociationModule 05 · Slide 25

Audience question

AUDIENCE QUESTIONSUPPORTED

Tremor is controlled but the patient reports dysarthria at the same setting. What next?

Audience question

CRITICAL THINKINGSUPPORTED

Does directional steering guarantee a better outcome?

Deep dive

When the window is narrow

SUPPORTED

Try alternative contacts
Consider directional steering where available
Consider pulse-width reduction
Re-examine lead position relative to the intended territory
Reassess whether the stimulated field reaches the tremor pathway

Diagram

Tremor programming questions

01IS TREMOR SUPPRESSED?
02LOWEST EFFECTIVE AMPLITUDE?
03DYSARTHRIA / PARESTHESIA / ATAXIA?
04CAN STEERING IMPROVE THE WINDOW?
05IS THE TARGET THE TREMOR PATHWAY?

Original slide questions, reproduced as supplied.

Speaker notes — 12 teaching points (hidden by default)

Open by asking the room to distinguish VIM from DRT in one sentence.
Established: VIM stimulation is an effective tremor treatment with long clinical experience.
Practical implication: record the lowest effective amplitude at every review.
Prevention strategy: baseline speech and gait assessment before programming escalation.
Diagnostic pitfall: reading habituation into what is actually disease progression, or the reverse.
Management consideration: energy use and battery planning follow directly from amplitude.
Evidence limitation: pathway-oriented targeting has a smaller long-term evidence base than VIM.
Common misconception: that steering can rescue any lead position.
Question for fellows: how would you separate habituation from progression in clinic?
Difficult decision point: excellent tremor control with unacceptable dysarthria.
Multidisciplinary trigger: speech and language therapy assessment.
Close on the original key idea about where the current goes.

References

Deep study material

Expanded study material

Programming determines clinical outcome in a well-placed lead

ESTABLISHED

Systematic programming with documented thresholds is standard practice in every established DBS centre.

Monopolar review is the accepted structured method

ESTABLISHED

Contact-by-contact testing of benefit and side-effect thresholds underlies contact selection.

Parameter choices shape the field differently

SUPPORTED

Amplitude, pulse width, frequency and electrode configuration alter field size, recruitment and physiological effect; modelling and clinical data support this separation.

Imaging-informed and model-guided programming

EMERGING

Lead reconstruction and field modelling can narrow the programming search space; this is increasingly used but not a universal requirement.

Automated or algorithmic programming selection

EXPERIMENTAL

RESEARCH DIRECTION — decision support, not decision replacement.

Anatomy

Expanded study material for this section is written once the original slides for this module are supplied.

Surgical principles

Expanded study material for this section is written once the original slides for this module are supplied.

Physiology

Expanded study material for this section is written once the original slides for this module are supplied.

Imaging

Expanded study material for this section is written once the original slides for this module are supplied.

Programming

Monopolar review as a structured mapping of benefit and side-effect thresholds

Independent effects of amplitude, pulse width and frequency on the stimulation field

Target-specific expectations for STN, GPi and VIM/DRT

Image placeholders

Images required for this module

Each placeholder states the image type, what is required, why it teaches and where a legitimate source should come from. No clinical image is fabricated.

Image placeholder

PAGE 05 PROGRAMMING WORKFLOW — INSERT AUTHENTIC IMAGE

Real clinical image required

Image typeSchematic / diagram

DescriptionOriginal educational diagram of the full programming workflow from clinical goal to follow-up.

Clinical purposeSupport programming teaching without fabricating patient data, device screenshots or clinical imaging.

Suggested sourceINSERT AUTHENTIC PUBLISHED / INSTITUTIONAL IMAGE HERE (licensing and consent confirmed)

CaptionTo be written with the final image

AssociationModule 05 · Slide 21

THE PROGRAMMING SYSTEM

Clinical goal

Lead knowledge

Monopolar review

Benefit threshold

Side-effect threshold

Therapeutic window

Contact selection

Parameters

Medication

Follow-up

GOAL
REVIEW
WINDOW
CONTACT
PARAMETERS
MEDICATION
FOLLOW-UP
BACK TO GOAL

PROGRAM FOR THE THERAPEUTIC WINDOW, NOT MAXIMAL EFFECT.

Clinical pearls

Implantation creates the opportunity; programming creates the therapy.
Do not chase the strongest response; chase the most useful response.
Two thresholds per contact — benefit and side effect — define the window.
A narrow window at every contact is a localization signal.
STN programming balances motor benefit against spread.
GPi programming is organized around dyskinesia, dystonia and motor phenotype.
In dystonia, judge benefit over weeks, not in the clinic room.
For tremor, where the current goes matters more than the nucleus name.
Optimize stimulation first, then reassess medication.
Undocumented programming cannot be continued by anyone else.

Common errors

Programming without a stated clinical goal.
Skipping the monopolar review and adjusting by trial and error.
Recording benefit without recording the side-effect threshold.
Changing several parameters at once.
Escalating amplitude instead of investigating a narrow window.
Reducing medication and changing stimulation in the same visit.
Judging a dystonia programme on the day it was set.
Assuming directional steering can rescue a malpositioned lead.
Treating stimulation-induced dysarthria as disease progression.
Leaving no documentation for the next clinician.

Case discussion

Cases

Case discussion

CASE — Good benefit, narrow window

Patient profile

Teaching case. No real patient data are used.

Clinical phenotype

STN DBS with useful rigidity benefit, but muscle contraction appears just above the benefit threshold at every contact.

Programming

Monopolar review documents benefit and side-effect thresholds contact by contact; all windows are narrow.

Outcome

A narrow window at every contact is treated as a localization question, not as a reason to escalate amplitude.

Lessons

Windows, not magnitudes, drive contact selection.
Uniformly narrow windows point at lead position or field limitation.
Pulse-width reduction and steering are tried before revision is discussed.

Case discussion

CASE — Tremor controlled, speech worse

Patient profile

Teaching case. No real patient data are used.

Clinical phenotype

VIM DBS with excellent tremor suppression and new dysarthria at the effective setting.

Programming

Alternative contacts, directional steering where available and pulse-width reduction are explored against a documented baseline speech assessment.

Outcome

The goal becomes the widest window that the patient can live with, not the greatest tremor suppression achievable.

Lessons

Record the lowest effective amplitude at every visit.
Speech side effects need a baseline to be interpretable.
Patient-defined tolerability is part of the programming endpoint.

Take-home message

Programming is the second operation.Program for the therapeutic window, not maximal effect.

GOAL
REVIEW
WINDOW
CONTACT
PARAMETERS
FOLLOW-UP

References

Evidence supporting this module

Volkmann J, Moro E, Pahwa R. Basic algorithms for the programming of deep brain stimulation in Parkinson's disease. Mov Disord. 2006;21(Suppl 14):S284-S289.
Moro E, Esselink RJA, Xie J, Hommel M, Benabid AL, Pollak P. The impact on Parkinson's disease of electrical parameter settings in STN stimulation. Neurology. 2002;59(5):706-713.
Picillo M, Lozano AM, Kou N, Puppi Munhoz R, Fasano A. Programming deep brain stimulation for Parkinson's disease: the Toronto Western Hospital algorithms. Brain Stimul. 2016;9(3):425-437.
Picillo M, Lozano AM, Kou N, Munhoz RP, Fasano A. Programming deep brain stimulation for tremor and dystonia: the Toronto Western Hospital algorithms. Brain Stimul. 2016;9(3):438-452.
Koeglsperger T, Palleis C, Hell F, Mehrkens JH, Bötzel K. Deep brain stimulation programming for movement disorders: current concepts and evidence-based strategies. Front Neurol. 2019;10:410.
Rodriguez-Oroz MC, Obeso JA, Lang AE, et al. Bilateral deep brain stimulation in Parkinson's disease: a multicentre study with 4 years follow-up. Brain. 2005;128(Pt 10):2240-2249.
Kupsch A, Benecke R, Müller J, et al. Pallidal deep-brain stimulation in primary generalized or segmental dystonia. N Engl J Med. 2006;355(19):1978-1990.
Vidailhet M, Vercueil L, Houeto JL, et al. Bilateral deep-brain stimulation of the globus pallidus in primary generalized dystonia. N Engl J Med. 2005;352(5):459-467.
Follett KA, Weaver FM, Stern M, et al. Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease. N Engl J Med. 2010;362(22):2077-2091.
Blume J, Schlaier J, Rothenfußer E, et al. Intraoperative clinical testing overestimates the therapeutic window of the permanent DBS electrode in the subthalamic nucleus. Acta Neurochir (Wien). 2017;159(9):1721-1726.
Barbe MT, Reker P, Hamacher S, et al. DBS of the PSA and the VIM in essential tremor: a randomized, double-blind, crossover trial. Neurology. 2018;91(6):e543-e550.
Paschen S, Forstenpointner J, Becktepe J, et al. Long-term efficacy of deep brain stimulation for essential tremor: an observer-blinded study. Neurology. 2019;92(12):e1378-e1386.
Steigerwald F, Matthies C, Volkmann J. Directional deep brain stimulation. Neurotherapeutics. 2019;16(1):100-104.
Pollo C, Kaelin-Lang A, Oertel MF, et al. Directional deep brain stimulation: an intraoperative double-blind pilot study. Brain. 2014;137(Pt 7):2015-2026.

“A WELL-PLACED LEAD IS AN OPPORTUNITY. THE THERAPY IS BUILT AFTERWARDS, CONTACT BY CONTACT, THRESHOLD BY THRESHOLD, VISIT BY VISIT.”

Next module · 06Directional DBS → Therapeutic Window → Long-Term Management