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Guideline Summary
Guideline Title
Care of the movement disorder patient with deep brain stimulation.
Bibliographic Source(s)
American Association of Neuroscience Nurses. Care of the movement disorder patient with deep brain stimulation. Glenview (IL): American Association of Neuroscience Nurses; 2009. 50 p. [166 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Movement disorders:

  • Parkinson disease (PD)
  • Essential tremor (ET)
  • Dystonia
Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Treatment
Clinical Specialty
Geriatrics
Neurological Surgery
Neurology
Nursing
Intended Users
Advanced Practice Nurses
Hospitals
Nurses
Guideline Objective(s)
  • To help nurses provide consistent, high-quality, current care to patients with movement disorders who have deep brain stimulation (DBS) devices
  • To present basic algorithms for DBS programming for Parkinson disease, essential tremor, and dystonia symptom control, along with pharmacotherapeutic and nonpharmacologic management to increase the likelihood of successful patient outcomes
Target Population

Patients with movement disorders who have or who are candidates for deep brain stimulation devices

Interventions and Practices Considered

Management/Treatment

  1. Pharmacologic treatment
  2. Nonpharmacologic treatment that includes exercise, physical therapy, and occupational therapy
  3. Surgical management that includes deep brain stimulation (DBS) device insertion
    • Patient selection criteria
  4. Preoperative care
    • Screening tests
    • Teaching or patient preparation
  5. Intraoperative care
    • Nursing support
    • Procedure
  6. Postoperative care
    • Monitor pain, side effects, and ongoing care
    • Magnetic resonance imaging (MRI) or computed tomography (CT)
    • Patient and family education
Major Outcomes Considered
  • Relief of symptoms of movement disorder
  • Side effects of treatment
  • Functional status
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

A review of the published literature was conducted using PubMed/MEDLINE and CINAHL databases from 1990 to January 2008 using the following search terms: Parkinson disease, essential tremor, dystonia, and deep brain stimulation, with a second search of the bibliographies of retrieved articles. Materials for these guidelines are derived from journal articles (both research and review), textbooks, reference materials, and monographs. Studies that did not directly pertain to the topic or were not written in English were excluded from further evaluation. In addition, the American Academy of Neurology's (AAN) Practice Parameter: Evaluation and Treatment of Depression, Psychosis, and Dementia in Parkinson Disease (an evidence-based review) published in April 2006 was used.

The AAN's evidence-based practice parameters published in April 2006 are cited in this guideline. These four documents focus on diagnosis of new onset Parkinson disease (PD); treatment of PD with motor fluctuations and dyskinesia; neuroprotective strategies and alternative therapies; and evaluation and treatment of depression, psychosis, and dementia. In addition, AAN's practice parameter for essential tremor therapy was reviewed. The practice parameters are available at www.aan.com External Web Site Policy.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Data Quality Classification

Class I: Randomized controlled trial without significant limitations or meta-analysis

Class II: Randomized controlled trial with important limitations (e.g., methodological flaws, inconsistent results); observational study (e.g., cohort, case control)

Class III: Qualitative study, case study, or series

Class IV: Evidence from reports of expert committees and/or expert opinion of the guideline panel, standards of care, and clinical protocols that have been identified

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Levels of Recommendation

Level 1: Recommendations are supported by class I evidence.

Level 2: Recommendations are supported by class II evidence.

Level 3: Recommendations are supported by class III and class IV evidence.

Cost Analysis

A cost analysis was not performed and reviews of published cost analyses were not included.

Method of Guideline Validation
External Peer Review
Description of Method of Guideline Validation

Prior to publication, the guideline was subjected to double-blinded external peer review by a panel of reviewers representing diverse roles, practice settings, and geographic locations.

Recommendations

Major Recommendations

Parkinson Disease

Medical Management

  1. There is no cure for Parkinson disease (PD) and no known treatment to slow or stop the progression of the disease (Suchowersky et al., 2006).
  2. The treatment goal is to maintain patients' functional status and independence.
  3. Interventions require multidisciplinary collaboration through pharmacotherapy, rehabilitation, deep brain stimulation (DBS) surgery, patient education, and family and social support. Surgical treatment has become a mainstay of midstage PD management, but not all patients are appropriate candidates or can afford treatment.
  4. Adhering to the prescribed medication regimen is important. Lack of compliance may lead to increased morbidities, disease exacerbations, and more office visits and hospitalizations, resulting in higher costs. Research suggests low compliance, with more than 50% of patients missing at least one dose of their medication per week and more than 20% missing three or more doses per week (Leopold, Polansky, & Hurka, 2004).
  5. Refer to Table 3 in the original guideline document for dosing, purpose, action, and common side effects of the antiparkinsonian drug classifications.
  6. Medications to avoid. See the original guideline document for a partial listing of drugs that patients with PD should avoid.
  7. Medications recommended for initial treatment. A PD diagnosis is not necessarily cause to initiate drug therapy. Drug therapy is warranted when symptoms are bothersome or produce disability (Nutt & Wooten, 2005). Efficacious agents for initial therapy include levodopa, dopamine agonists, anticholinergic agents, amantadine, and selective monamine oxidase B (MAO-B) inhibitors (Table 3 in the original guideline document). Guidelines from the American Academy of Neurology (AAN) and a Movement Disorder Society evidence-based review indicate that initiating therapy with levodopa or a dopamine agonist is reasonable (Holloway et al., 2004). It is uncertain whether levodopa therapy or dopamine agonist therapy is the better choice for initial treatment ("Management of Parkinson's," 2002; Miyasaki et al., 2002).
    1. In elderly patients, levodopa is the usual treatment of choice compared to dopamine agonists because of its lower risk for psychiatric complications (Level 1; Abbott et al., 2001; Rascol et al., 2000).
    2. In younger patients, a dopamine agonist may be preferable for a longer treatment horizon and higher tolerance of side effects. In addition, agonists are less likely to provoke motor fluctuations and dyskinesias (Level 1; Rascol et al., 2000).
    3. If depression and anxiety are debilitating symptoms, they usually are targeted for initial therapy.
    4. Nausea frequently is associated with antiparkinson medications, especially levodopa or dopamine receptor agonists. Titrate these drugs slowly or reduce the dose. If nausea is associated with levodopa, additional carbidopa (Lodosyn) can be added to each dose.
    5. Patients taking MAO-Bs should avoid meperidine, dextromethorphan, ephedrine-like drug found in some cold remedies, amphetamines, tricyclic antidepressants, appetite suppressants, cyclobenzaprine, asthmatic drugs, barbiturates, opioids, and others. Those on rasagiline (Azilect) should avoid foods high in tyramine such as broad beans, cheeses, liver, and wine.

Nonpharmacological Treatments (Level 3; Suchowersky et al., 2006)

  1. Exercise and walking for flexibility, strength, and balance
  2. Regular exercise (neuroprotective in PD; Suchowersky et al., 2006)
  3. Physical therapy that incorporates massage, heat, exercise, and balance/gait retraining
  4. Speech therapy, which may improve speech volume (Lee Silverman Voice Treatment; El Sharkawi et al., 2002)
  5. Occupational therapy for assistive devices and in-home needs
  6. Complementary and alternative PD therapy (Ward, 2007)
  7. Optimal care to maximize physical and mental function and health includes a comprehensive combination of drug therapy and physical, occupational, and speech therapies, and holistic approaches, social services, and psychological counseling.

Essential Tremor

Medical Management

  1. Pharmacological therapy reduces tremor by 50% to 60% but may have dose-limiting side effects that can be troublesome for patients (Rajput, Robinson, & Rajput, 2004).
  2. Adverse effects including depression and male impotence should be monitored in patients on propranolol (Zesiewicz et al., 2005).
  3. Botulinum toxin Type A has been used to treat head, hand, and voice tremor in essential tremor (ET). Its use in the treatment of tremor of the upper extremities is limited because it commonly causes weakness. It is more useful in the treatment of head tremor because it often provides benefit without unwanted, troublesome weakness (Level 3; Zesiewicz et al., 2005). Weakness is dose-dependent and a transient side effect of botulinum toxin injections. No studies have evaluated the use of Botulinum toxin Type B for treatment of ET (Zesiewicz et al., 2005) See Table 5 in the original guideline document.

DBS for ET

  1. Patient selection
    1. Careful patient selection is the most important step in considering DBS surgery.
    2. Patients must have benign ET that is pharmaco-resistant. This means that despite adequate medication trials in sufficiently high doses, tremor remains disabling and/or medication side effects are intolerable. Common medications to consider before implanting patients with ET include primidone, propranolol, and one anticonvulsant such as clozapine (Clozaril) (Zesiewicz et al., 2005).
    3. Patients should be carefully assessed for other neurodegenerative disorders such as early PD or medication-induced tremor. There is increasing evidence that some patients with established diagnoses of benign ET may develop symptoms of PD or other atypical tremor disorders up to 10 years later (Benito-Leon & Louis, 2006).
    4. Surgical candidates should have normal brain scans or scans without deficits within the planned surgical region.
  2. DBS outcomes for ET
    1. Patients and family members need to be advised that improvements in ET symptoms after ventralis intermedius (VIM) stimulation demonstrate that limb or distal tremor improves more rapidly than proximal tremor (e.g., shoulder). In addition, postural tremor improves more easily than action tremor. Action tremor of the hand is the most difficult to control (e.g., when brushing teeth or drinking from a cup) (Dowsey-Limousin, 2002).
    2. It has been shown the thalamic VIM DBS target is highly effective for relief of controlling ET (Koller et al., 1997). Although unilateral VIM DBS has been shown to suppress contralateral limb tremor, control of head and voice tremor often requires bilateral DBS (Lyons & Pahwa, 2004). Bilateral VIM DBS is associated with stimulation-induced dysarthria from well-placed leads. Dysarthria is produced by current spreading into adjacent motor or capsular fibers. This can be minimized in some patients by programming adjustments, but sometimes this is not possible and a choice must be made to tolerate dysarthria in exchange for better tremor control. Others may choose to deactivate one implant during speaking engagements and activate both sides for fine-motor tasks. Additionally, control of proximal ataxia or cerebellar symptoms is more difficult to treat (often refractory to VIM stimulation) than distal (hand/wrist) tremor (Hamel et al., 2007). Early studies suggest implanting leads in more inferior thalamic targets (STN/zona incerta) can better control ataxia and intention tremor (Hamel et al., 2007; Herzog et al., 2007).
    3. Additionally, for unclear reasons, some patients with implants develop a type of ataxic gait disorder or trouble with balance after bilateral implants (Koller et al., 1997). It is unclear if this results from the spread of current/stimulation to other regions connecting with the thalamus (cerebellar fibers), or if this is related to a patient's underlying disease progression after implant (Hamel et al., 2007; Herzog et al., 2007). Tremor remains a challenging symptom to manage with DBS. In patients with a clear diagnosis of ET who have well-placed leads, however, VIM DBS has proven effective for long-term control of distal limb tremor (Koller et al., 1997).

Dystonia

DBS for Dystonia

  1. Dystonia does not generally respond to pharmacologic treatment, but has robustly responded in patients implanted with globus pallidus interna (GPi) DBS (Houeto et al., 2007; Kupsch et al., 2006; Starr et al., 2006; Vidailhet et al., 2005). Although there is a lack of large randomized DBS trials, the preliminary results from those undergoing DBS for primary dystonia diagnoses types were so compelling the Food and Drug Administration (FDA) granted approval in 2003 to treat this population under a Humanitarian Device Exemption. Recent experience shows robust DBS outcomes in patients with primary or genetic forms of dystonia and tardive dystonias; however, patients with secondary dystonias such as cerebral palsy and poststroke syndromes respond less predictably to DBS (Starr et al., 2006; Vidailhet & Pollak, 2005; Volkmann & Benecke, 2002).
  2. DBS outcomes for dystonia. Patient and family expectations for surgical improvement in dystonia must be based upon the type of dystonia and the knowledge that responses are variable despite correct positioning of the electrodes (Kupsch et al., 2006; Vidailhet et al., 2005). Generally, primary dystonia responds better than secondary dystonia, and the best results are achieved in patients with generalized, segmental, or hemi-dystonic dystonia (Volkmann & Benecke, 2002). Patients also must be advised that unlike in cases of PD and ET, improvement in dystonia symptoms may be delayed after surgery. Improvements often are progressive and may take up to 6 months (Bittar et al., 2005).
  3. When selecting dystonia candidates for DBS, look for:
    1. Genetically positive dystonia
    2. Primary idiopathic, generalized, or segmental dystonia with disability despite maximum drug and botulinum-toxin therapy
    3. Secondary (tardive) dystonia with stable psychiatric symptoms
    4. Willingness to tolerate the ambiguity of therapy response and multiple programming sessions
    5. Adequate social support
  4. Adverse effects of DBS in dystonia. The most common adverse event for patients with dystonia after DBS is dysarthria. Other common adverse outcomes include weakness on one or both sides of the body and disequilibrium. Paresthesias may occur but typically resolve with programming adjustments. Patients with dystonia are at high risk of DBS lead fracture and migration (Yianni et al., 2004) from traction of the implanted hardware.

Medical Management

  1. Limited literature supports medication adjustment after DBS for dystonia, so medication usually is not changed (Kupsch et al., 2006; Vidailhet et al., 2005). Drug classification for dystonia management is displayed in Table 6 in the original guideline document.
  2. If patients do not respond well to medications or botulinum toxin treatment, surgery may be considered for certain types of dystonia. Some patients use a sensory trick called "geste antagoniste" in which touching the affected or adjacent body part can reduce dystonic contractions (WE MOVE, 2006). Physical therapy aids such as head or neck braces and hand splints also can mimic the sensory trick. Exercises to improve flexibility and range of motion, strengthen underutilized muscles, and promote proper posture are recommended. Identifying activities and movements that exacerbate dystonic symptoms also is recommended.
  3. The benefit of DBS on levodopa-induced dyskinesia and dystonia in PD prompted similar attempts in idiopathic focal and generalized dystonia. As mentioned earlier, the GPi currently is considered the most appropriate target for dystonia. Bilateral DBS is preferred to unilateral DBS given the generalized nature of primary generalized dystonia (PGD). Although the pathophysiology of idiopathic dystonia is unknown, positron emission tomography (PET) imaging reveals dysfunction in the GPi, suggesting secondary pathologic overactivation of thalamo-cortical motor regions. Interruption of this abnormal overactive pathway may be one reason GPi DBS relieves some dystonic symptoms. Additional information about dystonia may be found at www.wemove.org External Web Site Policy and www.dystonia-foundation.org External Web Site Policy.

Surgical Management of Movement Disorders

Surgery is directed at treating motor disability when medical management is exhausted for patients with essential tremor (ET), dystonia, and PD in whom response to antiparkinsonian medications is complicated by severe motor fluctuations and dyskinesia. Careful patient selection is an important factor in evaluating patients for DBS surgery. DBS candidates and criteria may differ depending on the targeted symptom or disorder. Screening parameters for appropriate ET and dystonic surgical candidates have not been established; however, the same interdisciplinary workup conducted for PD is necessary.

Peripheral surgery is a destructive surgical procedure for treating dystonia, and it targets parts of the body other than the brain, such as selected peripheral nerves for cervical dystonias. This also is known as selective peripheral denervation. In both DBS and peripheral procedures, the goal of surgery is to interrupt the faulty communication between the brain and muscles that causes involuntary muscle movements. The purpose of surgery is to treat symptoms and improve function, but it will not cure the underlying condition.

Patient Selection

  1. Appropriate candidates for PD surgery present with these traits (Pahwa et al., 2006; Voon et al., 2006).
    1. Idiopathic PD and continued response to levodopa
    2. Disabling motor symptoms despite optimized medication regimens (dyskinesias, "on-off" motor fluctuations)
    3. Low surgical risk
    4. Intact cognitive function determined by neuropsychological testing
    5. Adequate social support
    6. Depression, if any (treated)
  2. Exclusion criteria for DBS
    1. People with dementia are at greater risk for cognitive decline after surgery (Funkiewiez et al., 2004), and their condition suggests additional neuropathology (Hughes et al., 2001).
    2. Chronological age alone has not been established as an important predictor for DBS benefits. Younger patients with shorter disease duration may experience more improvement than older patients with longer disease durations (Level III; Pahwa et al., 2006). Older patients with borderline cognitive impairment may benefit from a staged implant in which practitioners implant one lead and wait 4 to 6 weeks before performing the second-side implant (Machado et al., 2006).
    3. DBS does not help the following PD symptoms (Lang, Deuschl, & Rezai, 2006):
      1. Symptoms that do not improve with a suprathreshold dose of levodopa
      2. Freezing, backwards falling/imbalance
      3. Flexed neck or posture
      4. Dementia or apathy
      5. Anxiety or depression
      6. Speech problems
      7. Most nonmotor symptoms
    1. Individualized risk-to-benefit analysis is recommended.

Preoperative Care

Involve a movement disorder specialist, neuropsychologist, primary care provider, and neurosurgeon.

Preoperative screening tests include brain imaging, a general medical physical examination (including a Unified Parkinson's Disease Rating Scale [UPDRS] motor rating in an "off" state without PD medications), blood tests, electrocardiogram (ECG), chest X ray, neuropsychological testing, and a review of contraindications to surgery, which could include a medication regimen with anticoagulants.

Include teaching and/or patient preparation by the neuroscience nurse (see Section XV, Education in the original guideline document).

Intraoperative Care

Nursing Support

Routine nursing support is needed, as the circulating and operating nurses in the surgical environment must prep scalps and position patients comfortably throughout the procedure.

Procedure

  1. The DBS system consists of three components: the lead, the extension wire, and the neurostimulator or implantable pulse generator (IPG). The lead is a thin, insulated wire inserted through a quarter-sized burr hole that opens in the skull and is secured in the brain with a fixation device or cap (Figure 3 and Figure 4 in the original guideline document).
  2. The patient is awake, but may be given local anesthetic and intravenous sedation during placement of a stereotactic head frame. The surgeon may use the newer frameless system for targeting purposes. Either approach works and is facility-dependent. Brain magnetic resonance imaging (MRI) or computed tomography (CT) is obtained after the frame or frameless system is applied and surgical coordinates or measurements for the target are made using surgical software systems.
  3. The patient should discontinue PD medications for at least 12 hours before the procedure (this is facility-dependent) because of the need for intraoperative electrophysiological monitoring. In the medication "off" state, the patient's abnormal electrophysiology is apparent and hyperactive, and this facilitates intraoperative identification or mapping of the motor subterritory or each neuron's action potentials to identify the ideal location to place the final electrode (Gross et al., 2006).
  4. The patient is awake during the motor-mapping portion of the surgery to evaluate motor response or to assess side effects and efficacy during macrostimulation. In pediatric patients with dystonia, surgery often is performed under general anesthesia (Gross et al., 2006; Starr et al., 2006).
  5. Mapping the motor subterritory of the target identifies the best region to place the final electrode. Some surgeons use microelectrode recordings to identify the motor subterritory of the desired nucleus. Mapping involves inserting a small microelectrode that monitors the electrical activity or action potentials of each structure as it is advanced toward the target. The physiology of each nucleus is distinct, so the microelectrodes display patterns unique to each structure. The activity is displayed on an oscilloscope and allows the neurosurgeon, neurologist, or neurophysiologist to distinguish the neurons in the various regions of the brain. Brain mapping is an additional confirmatory step to ensure the selected target is accurately reached. After the motor subterritory is identified, the final lead is implanted into this location. This lead is then tested intraoperatively to assess side effects and, for some facilities, efficacy of lead location (Byrd, Marks, & Starr, 2000).
  6. During intraoperative test stimulation, the lead location is assessed with the patient awake so he or she can communicate symptoms and respond to the test stimulation. This is necessary to assess if usual voltages can be used without stimulating adjacent structures that can cause unacceptable side effects. The surgical team observes for adverse reactions such as tingling, eye deviation, weakness, or facial grimacing that, if they occur at too low of a threshold, may signify the need to reposition the lead away from the structure that is producing the side effect.
  7. Patients typically require bilateral electrodes placed for bilateral symptoms (see Figure 5 in the original guideline document) (McIntyre et al., 2004).
  8. It is advisable to check impedances in the operating room before incisions are closed.
  9. After the brain leads (Figure 6 in the original guideline document) are implanted, the patient returns 1 to 2 weeks later (a facility-dependent interval) as an outpatient for the remaining hardware implant surgery. For this aspect of the surgery, the patient is placed under general anesthesia to connect the leads to the extension cable and then to the pulse generator. The extension cable, an insulated wire that is passed under the skin of the head, neck, and shoulder, connects the lead to the neurostimulator.
  10. The neurostimulator is the third component and usually is implanted subcutaneously just below the clavicle, lower in the chest, or in the abdomen, similar to placement of a cardiac pacemaker. It may be done the same day as the lead implant or staged as determined by the surgeon.
  11. Patient symptoms may transiently improve in the first postoperative month, although DBS has not been activated (microlesion effect).
  12. Initial DBS programming may be done during the inpatient phase or on an outpatient basis; it is facility- and/or physician-dependent (Figure 6 in the original guideline document).

Postoperative Care

Early Postoperative Period

  1. Expect an average hospitalization of 1 to 3 days, and longer stays if complications arise.
  2. Monitor and control postoperative pain.
  3. Assess for surgery complications including intracranial edema (which may cause behavioral or mental status changes), bleeding, infection, seizure, and wound dehiscence. DBS has been associated with decline in cognition and psychiatric complications, although the exact mechanism of postoperative personality changes and sustained mood changes are under debate.
  4. Assess PD symptoms.
  5. If DBS programming is done on an inpatient basis, assess for side effects, which generally are mild and reversible, by readjusting DBS settings. They most often include:
    1. Transient paresthesias
    2. Speech problems
    3. Dizziness or lightheadedness
    4. Facial or limb weakness/paresthesias
    5. Dystonia, dyskinesia
    6. Motor incoordination
    7. Worsening of PD symptoms
  6. Resume the preoperative schedule of PD medications unless otherwise determined by individual patient responses.
  7. PD medications need to be administered on time and according to the patient's home routine schedule.
  8. Obtain a postoperative MRI or CT and "merge" with the preoperative MRI to confirm lead placement (Larson et al., 2008). Figure 8 in the original guideline document depicts CT lead/electrode placement.
  9. Provide patient and family education (see Section XV, Education, in the original guideline document).

Posthospital Discharge Period

  1. Monitor specific symptoms exhibited by the patient that are responsive to DBS and target them during programming sessions.
  2. Postoperatively, antiparkinsonian medications may be reduced after programming for patients with STN implants (Deuschl et al., 2006).
  3. Provide patient and family education (see Section XV, Education, in the original guideline document).

Ongoing Care

  1. DBS is activated 1 to 30 days postoperatively and may occur in the hospital or outpatient setting (see Section IX in the original guideline document).
  2. Initial DBS adjustment occurs over the course of weeks to months.
  3. Monitoring the response to DBS programming occurs over hours to days.
  4. PD medication reductions will be based on individual patient responses to DBS.

Practice Pearls

When working with patients with DBS, consider these observations and directives:

  • Collaboration between the neurologist and programmer is fundamental before the physician or advanced practice nurse (APN) can adjust medications.
  • Minimize programming for short-term symptom exacerbations. Patients can experience a placebo effect or benefit from visiting the clinic and programming, then return to baseline or worsen when they return to their home. Patients with advanced disease may have symptom exacerbations due to other medical problems. After a patient has an implant, it is common for practitioners to inappropriately associate new problems with the new implant.
  • Ask the patient to keep a diary during the first 6 months of stimulation to record motoric problems to assess if the problematic symptoms correlate with time of day and time of medication. Have the patient try to assess if symptoms either fluctuate with medication dosing or are constant. Remind patients that stimulation-related problems are constant and medication-related problems fluctuate.
  • The goal of DBS is to maximize benefit, not eliminate PD medications.
  • Rescreen each contact/electrode if evaluating a patient for an initial programming session or if clinical efficacy is questioned. Check the DBS usage counter (should be 99% to 100% for patients with dystonia and PD). Check electrical impedance, especially if there has been loss of efficacy.
  • Remember that each patient and his or her symptoms are different. Accurate lead location, effective programming, and good patient selection all are key factors to therapy success.
  • Medtronic, Inc., offers training courses for developing programming skills and knowledge for providers working with patients with DBS.

Definitions:

Data Quality Classification

Class I: Randomized controlled trial without significant limitations or meta-analysis

Class II: Randomized controlled trial with important limitations (e.g., methodological flaws, inconsistent results); observational study (e.g., cohort, case control)

Class III: Qualitative study, case study, or series

Class IV: Evidence from reports of expert committees and/or expert opinion of the guideline panel, standards of care, and clinical protocols that have been identified

Levels of Recommendation

Level 1: Recommendations are supported by class I evidence.

Level 2: Recommendations are supported by class II evidence.

Level 3: Recommendations are supported by class III and class IV evidence.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Resources and recommendations for practice should promote best practices to enable nurses to provide optimal care to patients with movement disorders who have a deep brain stimulator.

Potential Harms
  • In patients with essential tremor (ET), adverse effects of deep brain stimulation (DBS) generally are mild and correlate with the intensity of stimulation. The most frequent side effect of thalamic stimulation is paresthesias. Other complications include dysarthria, weakness on one or both sides of the body, balance disturbance, and headache.
  • Potential risks of DBS surgery include headache; infection 3% to 5%; stroke, infarct, symptomatic <1% to 2%; hemorrhage, symptomatic <3%; transient postoperative disorientation, cognitive slowness, hallucinations <3%; seizures <2%; death within 1 month of surgery <1%; and hardware malfunction <5%.
  • Disadvantages of DBS include risk of hardware breakage or infection, higher cost than medication therapy, need for battery replacement every 2 to 5 years, and need for periodic reprogramming and limited expert care for programming of the device in some localities.
  • The most common adverse event for patients with dystonia after DBS is dysarthria. Other common adverse outcomes include weakness on one or both sides of the body and disequilibrium. Paresthesias may occur but typically resolve with programming adjustments.
  • Patients with dystonia are at high risk of DBS lead fracture and migration from traction of the implanted hardware.
  • Patients with DBS implants need to take special precautions for magnetic resonance imaging (MRI). MRI can heat the implanted electrodes and leads and burn the surrounding tissue, which can lead to serious injury to the brain or death. Patients with implanted devices should alert the technician before undergoing an MRI procedure. The recommended maximum displayed head-specific absorption rate is 0.1 W/kg, which provides a reasonable thermal safety margin and prevents heating of the internal wires. The MRI must be performed with a head coil and tesla strength of 1.5 or less. Contact Medtronic for current guidelines before performing an MRI of the head.

For more information, refer to Tables 3, 5 and 6 in the original guideline document for common side effects of drug classifications for Parkinson disease, essential tremor, and dystonia.

Contraindications

Contraindications
  • Contraindications to surgery for insertion of a deep brain stimulation (DBS) device could include a medication regimen with anticoagulants.
  • Magnetic resonance imaging (MRI) of any body part other than the head is contraindicated. (See "Potential Harms" for specific precautions recommended for MRI of the head.)
  • Diathermy is contraindicated for all patients with DBS implants. Serious brain injury may be caused by exposure of any part of the implantable pulse generator (IPG) device to diathermy. Diathermy is a type of ultrasound therapy that helps to reduce pain. This therapy involves applying a heat coil to the skin or body, which heats brain electrodes and can cause serious brain injury or death. Diathermy is used by dentists, pain specialists, sports medicine physicians, and physical therapists.

Qualifying Statements

Qualifying Statements
  • The authors, editors, and publisher of this document neither represent nor guarantee that the practices described herein will, if followed, ensure safe and effective patient care. The authors, editors, and publisher further assume no liability or responsibility in connection with any information or recommendations contained in this document. These recommendations reflect the American Association of Neuroscience Nurses' judgment regarding the state of general knowledge and practice in our field as of the date of publication and are subject to change based on the availability of new scientific information.
  • This is a relatively new technology with new indications for use, and information and research in this area is evolving. Accordingly, adherence to these guidelines is voluntary. Practitioners must ultimately determine their application in light of the circumstances presented by individual patients.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Staff Training/Competency Material
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American Association of Neuroscience Nurses. Care of the movement disorder patient with deep brain stimulation. Glenview (IL): American Association of Neuroscience Nurses; 2009. 50 p. [166 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009
Guideline Developer(s)
American Association of Neuroscience Nurses - Professional Association
Source(s) of Funding

American Association of Neuroscience Nurses

This publication was supported by an educational grant from Medtronic, Inc.

Guideline Committee

American Association of Neuroscience Nurses Clinical Practice Guideline Series Editorial Board

Composition of Group That Authored the Guideline

Content Authors: Constance Ward, MSN RN BC CNRN, Chair; Susan Heath, MS RN CNRN; Virginia Janovsky, MN MS RN; Elaine Lanier, MSN RN; Romay Franks, BSN RN; Susan O'Connor, BSN RN

Financial Disclosures/Conflicts of Interest

The American Association of Neuroscience Nurses (AANN) requires that all planners, teachers, and authors involved in CNE make full disclosure indicating whether the individual and/or his/her family have any relevant financial relationships, now or within the 12 months preceding this event, with a commercial interest (e.g., pharmaceutical companies, biomedical device manufacturers, and/or corporations) whose products or services are discussed in the continuing education activity content over which the individual has control. All presenters participating in the AANN sponsored programs must complete this form and return it as indicated. All information disclosed is printed in the program materials.

The authors state no potential conflicts of interest.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the American Association of Neuroscience Nurses Web site External Web Site Policy.

Print copies: Available from the American Association of Neuroscience Nurses, 4700 W. Lake Ave., Glenview, IL 60025.

Availability of Companion Documents

Continuing education (CE) credit in conjunction with the clinical practice guideline is available from the American Association of Neuroscience Nurses Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on July 22, 2010. The information was verified by the guideline developer on August 17, 2010. This summary was updated by ECRI Institute on May 20, 2011 following the U.S. Food and Drug Administration advisory on antipsychotic drugs.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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