Fixing a Shaky Video to Remotely Program Deep Brain Stimulation

Deep Brain Stimulation (DBS) is an increasingly used therapy to treat refractory tremor in Parkinson’s disease (PD) patients [1]. Recurrent postoperative appointments for programming tuning are fundamental for successful outcomes [2]. In Canada, long distances and difficult weather conditions may restrict the access to DBS-specialized clinics. Novel technologies, particularly remote programming, may overcome these issues [3]. We aimed to describe a new strategy to assess tremor remotely during DBS programming.

We present the case of a 65-year-old female patient with a 7-year-history of tremor-dominant PD. Despite receiving a daily dose equivalent to 1620 mg of levodopa, her tremor improved by <40% during the levodopa challenge, as assessed by the resting tremor items of the Unified Parkinson’s Disease Rating Scale (UPDRS) Part III. A multidisciplinary preoperative evaluation—including Psychiatry, Neuropsychology, Neurology, and Neurosurgery—was conducted. She demonstrated a good response to a supramaximal dose of levodopa, with her overall UPDRS-III score improving from 52 to 28. Given her motor fluctuations and dyskinesias, and in the absence of concerning neuropsychiatric or cognitive symptoms, she was deemed a suitable candidate for bilateral subthalamic nucleus (STN) DBS surgery. The patient underwent successful surgery and was implanted with an Infinity™ implantable pulse generator (IPG) with directional leads, by Abbott (Chicago, IL, USA). As her residence was located 1,500 km from our center, device programming was performed remotely using the Neurosphere™ virtual clinic platform.

Two months after surgery, DBS initial programming session was carried out at our center. After identifying the therapeutic thresholds for each contact in person, the patient settings were fine-tuned remotely on a weekly basis. During the evaluation, the patient was asked to hold her controller in a fixed position until her rest tremor re-emerged, one hand at a time. Once tremor reached the maximum amplitude and was clearly noticeable by a shaking video-frame, we optimized the stimulation parameters by increasing amplitude and frequency, until the frame was still (video 1). The final settings for her left STN were C+11a-11c-, 3.5mA, 60µs, 160Hz. She reported a sustained benefit in the follow-up, and her levodopa equivalent dose was gradually reduced by 60% compared to baseline.

To date, the use of remote care to assess and treat PD patients remains controversial. Although some authors recommend in-person appointments for initial programming after DBS surgery, growing evidence supports that satisfactory outcomes can be reached with telemedicine [4, 5]. Tremor, a core feature of PD, is among the symptoms that can be assessed remotely. However, this can be challenging, as patients may struggle to position themselves appropriately within the camera frame, or image resolution may be insufficient to detect subtle tremors. We propose that this alternative method of assessing upper limb tremor may offer advantages—not only for patients, who are only required to hold the DBS controller, but also for healthcare providers, who could base their adjustments on more visible shakiness. Nevertheless, our report is limited to a single case. A prospective cohort comparing different strategies will be needed to validate our findings.