You can find out more about NPF's National Medical Director, Dr. Michael S. Okun, by also visiting the NPF Center of Excellence, University of Florida Center for Movement Disorders & Neurorestoration.
In this month’s issue of the Lancet Neurology, the PD SURG trial results (conducted by a multicenter team of collaborative investigators from all over Britain) are including a one year follow-up of Parkinson’s disease deep brain stimulation (DBS) patients. The trial was randomized, and it compared DBS to best medical therapy. The primary outcome variable was quality of life, and interestingly, patients in the best medical therapy arm had access to apomorphine pumps. Though sites were allowed to use the subthalamic nucleus target, the globus pallidus interna target, and even lesion therapy (e.g. pallidotomy), 174/178 (98%) of patients in the surgery group were implanted with subthalamic nucleus DBS. There was a five point improvement noted in quality of life scores in the surgical compared to medical group. Although compared to other studies the quality of life improvement was less robust, this may have reflected a longer study duration, or potentially even disease progression. There were unmistakable improvements in dyskinesias, and on time in the surgical group, although diaries were not utilized.
Though, not a perfect trial, its large size and use of a medical control group along with unique access to apomorphine made it unique among available DBS publications. The results underscored the powerful influence that DBS can have on motor fluctuations. Additionally, these SURGE investigators plan in the future a long term (9 year) follow-up, and this will surely enlighten the field as to disease progression, and other issues potentially important to DBS cohorts.
One unique and hidden aspect of this trial was the report of the “reasons why patients sought DBS surgery.” Severe off periods, dyskinesia and tremor were far and away the most common indications cited for DBS therapy. As DBS moves into a tailoring phase (the right target and approach for a particular symptom or symptom cluster) this type of information will be very useful to clinicians.
People may criticize the lower total motor change scores reported in PD SURG when comparing pre- and post-operative operative outcomes to other trials, however they must remember that as many randomized blinded DBS trial results emerge from international centers (VA PADRECC study, Cleveland Clinic/Emory Study, UF COMPARE trial), that the open label improvements previously documented will almost certainly be shown to be a study bias. The results of the PD SURG trial may offer a look at what DBS outcomes may realistically look like as the therapy migrates to centers with less expertise (remember they used a multitude of centers all over Britain).
It is fascinating to see that 98% of implants were placed in the subthalamic nucleus in this study, despite the option for surgeons to use a different target. Though the subthalamic target has many strengths, it also has relative weaknesses. Emerging data is now strongly suggestive that the motor outcomes in pallidum and subthalamic nucleus are actually similar, and that targets in the future should be tailored for individual patients and individual symptoms.
In conclusion can we say the PD SURG trial was a surge forward for the PD community? The answer is certainly yes, as the publication of more carefully controlled DBS trials will be important in guiding DBS therapy into the future.
Posted: 5/1/2010 6:10:13 AM by
Browse current and archived What's Hot in PD? articles, the National Parkinson Foundation's monthly blog for people with Parkinson's written by our National Medical Director, Dr. Michael S. Okun.
The Dream of a Pill Free Existence and the Continuous Dopaminergic Pump for the Treatment of Parkinson's Disease
Should I take Inosine to Raise my Uric Acid Levels and Treat my Parkinson’s Disease?
Could Fungus and Mold be an Important Contributor to Parkinson’s Disease?
Pimavanserin and the Hope for a Better Drug for Hallucinations and Psychosis in Parkinson’s Disease
Halting of the Creatine Study
The Importance of Identifying and Treating Caregiver Strain
Putting Parkinson’s Disease Information into the Palm of Your Hand: Parkinson’s Enters the Smartphon
What Parkinson’s Disease Patients Need to Know about H. Pylori Gastrointestinal Infections
A2A Receptor Antagonists and Parkinson’s Disease Treatment
Another Setback for Trophic Factor Treatment in Parkinson's Disease
IPX066 and What Patients Really Want in New Carbidopa/Levodopa (Sinemet) Formulations
The Weather Forecast for Parkinson’s Disease Calls for Worldwide Economic Storm
Defeating the Barriers to Implementing Exercise Regimens in Parkinson’s Disease Patients
When should you start medication therapy for Parkinson’s disease?
Neurologist Care Reduces Hospitalizations in Parkinson's Disease
A Victory in Court for Parkinson's Disease Patients who Require Ongoing Rehabilitative Therapies
Given the recent FDA announcement about Mirapex (pramipexole), should I be worried about dopamine agonists?
What about the new Parkinson’s Disease Vaccine? What should I know?
Caffeine as a Potential Treatment for Parkinson’s Disease
Time to Consider GPi DBS for Parkinson’s Disease: A Shift in the Practice of Patient Selection for DBS
A New Treatment for Parkinson’s Disease-Related Constipation
Too Many Pills: Improving Delivery Systems for Parkinson’s Disease Drugs
Measuring Quality and Assessing Depression in Parkinson's Disease
Watch out for Unexpected Obstacles if You Use a Cueing Strategy to Break Freezing of Gait in Parkinson’s Disease
Pill Color, Generic Medications and Insurance Issues: Important Medication-Related Tips for the Parkinson’s Disease Patient
Are Blood Tests for Parkinson’s Disease on the Horizon?
Placing Stem Cells in Animal Models of Parkinson’s Disease: Another Important Step
Important News for the Parkinson’s Disease Community: More Evidence that Sinemet and Madopar are Not Toxic and do Not Accelerate Disease Progression
The Case for All Parkinson’s Disease Patients to be Co-managed by a Primary Care-Neurologist Team
Scientists say Research on Brain Proteins Involved in Parkinson’s Disease is “Shaping” Up
Who Actually Takes Care of Most of the Parkinson’s Patients Worldwide: The Need for Education and the Parkinson’s Toolkit
If you are Dizzy or Passing Out, it could be Your Parkinson’s Disease or Parkinson’s Disease Medications
How Will Group Visits for Parkinson’s Disease Fit into the Future of Parkinson’s Disease Care?
Why Patients Should be Wary of Chelation Therapy for Parkinson’s Disease
Opening the Door to Gene Therapy in Parkinson’s Disease: The Need for Refinement of the Technology and Approach
Does it Matter if I Can’t Get Brand Sinemet?
Should I get a DaTscan or PET scan to confirm my diagnosis of Parkinson’s disease?
A Critical Reappraisal of the Worst Drugs in Parkinson’s Disease
Environmental Risks for PD: Manganese, Welding, Mining, and Parkinsonism
Calling for the FDA to Revise the Eight Sinemet a Day Rule
Dry Cleaning Solvents and Potential Environmental Risks for Developing Parkinson’s Disease
Maintaining the Balance: Why Parkinson’s Disease Patients Need to Understand Drug Recalls, Withdrawals, and Safety Alerts
Shining a Light on Parkinson’s Disease: Optogenetics Has a Bright Future in Research
Poor Medication Management of Parkinson's Disease During Hospital Admissions: Patients and Families Can Improve Their Hospital-Based Management
Why Are Patches and Continuous Release Technology a Big Deal to Parkinson's?
Is the PD SURG Trial Another Surge Forward for DBS Therapy?
Cycling in PD in Those Who Can’t Walk: Is it Possible?
New iPS Stem Cells for PD: What Does it Mean?
Time for Comprehensive Care Networks for PD
Is Parkinson's Disease a Prion Disease?
Parkinson's Disease Linked to Gaucher's Disease
Brain Cells Keep Time Stamps: Implications for Parkinson's Disease Therapies
Is it Safe to Have an MRI with a DBS in Place?
Take Care of Your Bones as They Are Affected in Parkinson's Disease (Even in Men)
Is it Time to Start Paying Attention to Pain Symptoms in Parkinson's Disease Patients?
Glutathione Fails to Demonstrate Significant Improvement in PD Symptoms
Keeping an Eye on Trials Important to the Parkinson's Disease Patient
Increased Risk of Melanoma in Parkinson's Disease
Finally a DBS Expert Consensus Statement Aimed at Their True Customers: The Patients
Pesticides and Environmental Exposure in Parkinson's disease: Should We Stay Away From the Stink Truck?
Is Exercise Effective Treatment and Protection Against PD?
Why are Transplant Trials Struggling to Succeed in the Treatment of PD?
Are Monoamine Oxidase Inhibitors Disease Modifying or Neuroprotective in PD?
Update on Gene Therapy for Parkinson's Disease