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[Preprint]. 2024 Sep 23:2024.09.20.24314037.

doi: 10.1101/2024.09.20.24314037.

Physical therapy in patients with Parkinson's disease treated with Deep Brain Stimulation: a Delphi panel study

M Guidetti¹, S Marceglia¹, T Bocci^{1

2}, R Duncan^{3

4}, A Fasano^{5

6

7

8}, K D Foote^{9

10}, C Hamani^{11

12

13}, J K Krauss¹⁴, A A Kühn^{14

15

16

17

18

19}, F Lena^{20

21}, P Limousin²², A M Lozano^{5

6

23}, N V Maiorana¹, N Modugno²¹, E Moro²⁴, M S Okun^{25

26}, S Oliveri^{1

2}, M Santilli²¹, A Schnitzler^{27

28}, Y Temel²⁹, L Timmermann³⁰, V Visser-Vandewalle³¹, J Volkmann³², A Priori^{1

2}

Affiliations

¹ "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142 Milan, Italy.
² Clinical Neurology Unit, "Azienda Socio-Sanitaria Territoriale Santi Paolo e Carlo", Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142 Milan, Italy.
³ Washington University in St. Louis, School of Medicine, Program in Physical Therapy, St. Louis, MO, USA.
⁴ Washington University in St. Louis, School of Medicine, Department of Neurology, St. Louis, MO, USA.
⁵ Krembil Research Institute, University Health Network, Toronto, ON, Canada.
⁶ CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada.
⁷ KITE, University Health Network, Toronto, ON, Canada.
⁸ Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, ON, Canada.
⁹ Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, 3011 SW Williston Rd, Gainesville, FL 32608, USA.
¹⁰ Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
¹¹ Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, M4N 3M5, ON, Canada.
¹² Harquail Centre for Neuromodulation, 2075 Bayview Avenue, Toronto, M4N 3M5, ON, Canada.
¹³ Department of Surgery, University of Toronto, 149 College Street, Toronto, M5T 1P5, ON, Canada.
¹⁴ Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
¹⁵ Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
¹⁶ Bernstein Center for Computational Neuroscience, Humboldt-Universität, Berlin, Germany.
¹⁷ NeuroCure, Exzellenzcluster, Charité-Universitätsmedizin Berlin, Berlin, Germany.
¹⁸ DZNE, German Center for Neurodegenerative Diseases, Berlin, Germany.
¹⁹ Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany.
²⁰ Department of Medicine and Health, University of Molise, 86100 Campobasso, Italy.
²¹ IRCCS INM Neuromed, 86077 Pozzilli, Italy.
²² Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom.
²³ Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
²⁴ Division of Neurology, CHU of Grenoble, Grenoble Institute of Neurosciences, INSERM U1216, Grenoble Alpes University, Grenoble, France.
²⁵ Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, United States.
²⁶ Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, United States.
²⁷ Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.
²⁸ Department of Neurology, Center for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.
²⁹ Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands.
³⁰ Department of Neurology, University Hospital of Marburg, Marburg, Germany.
³¹ Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
³² Department of Neurology, University Hospital Würzburg, Würzburg, Germany.

PMID: 39399050
PMCID: PMC11469472
DOI: 10.1101/2024.09.20.24314037

Physical therapy in patients with Parkinson's disease treated with Deep Brain Stimulation: a Delphi panel study

M Guidetti et al. medRxiv. 2024.

[Preprint]. 2024 Sep 23:2024.09.20.24314037.

doi: 10.1101/2024.09.20.24314037.

Authors

Affiliations

¹ "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142 Milan, Italy.
² Clinical Neurology Unit, "Azienda Socio-Sanitaria Territoriale Santi Paolo e Carlo", Department of Health Sciences, University of Milan, Via Antonio di Rudinì 8, 20142 Milan, Italy.
³ Washington University in St. Louis, School of Medicine, Program in Physical Therapy, St. Louis, MO, USA.
⁴ Washington University in St. Louis, School of Medicine, Department of Neurology, St. Louis, MO, USA.
⁵ Krembil Research Institute, University Health Network, Toronto, ON, Canada.
⁶ CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada.
⁷ KITE, University Health Network, Toronto, ON, Canada.
⁸ Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, ON, Canada.
⁹ Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, 3011 SW Williston Rd, Gainesville, FL 32608, USA.
¹⁰ Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
¹¹ Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, M4N 3M5, ON, Canada.
¹² Harquail Centre for Neuromodulation, 2075 Bayview Avenue, Toronto, M4N 3M5, ON, Canada.
¹³ Department of Surgery, University of Toronto, 149 College Street, Toronto, M5T 1P5, ON, Canada.
¹⁴ Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
¹⁵ Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
¹⁶ Bernstein Center for Computational Neuroscience, Humboldt-Universität, Berlin, Germany.
¹⁷ NeuroCure, Exzellenzcluster, Charité-Universitätsmedizin Berlin, Berlin, Germany.
¹⁸ DZNE, German Center for Neurodegenerative Diseases, Berlin, Germany.
¹⁹ Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany.
²⁰ Department of Medicine and Health, University of Molise, 86100 Campobasso, Italy.
²¹ IRCCS INM Neuromed, 86077 Pozzilli, Italy.
²² Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom.
²³ Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
²⁴ Division of Neurology, CHU of Grenoble, Grenoble Institute of Neurosciences, INSERM U1216, Grenoble Alpes University, Grenoble, France.
²⁵ Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, United States.
²⁶ Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, United States.
²⁷ Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.
²⁸ Department of Neurology, Center for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.
²⁹ Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands.
³⁰ Department of Neurology, University Hospital of Marburg, Marburg, Germany.
³¹ Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
³² Department of Neurology, University Hospital Würzburg, Würzburg, Germany.

PMID: 39399050
PMCID: PMC11469472
DOI: 10.1101/2024.09.20.24314037

Update in

Is physical therapy recommended for people with parkinson's disease treated with subthalamic deep brain stimulation? a delphi consensus study.
Guidetti M, Marceglia S, Bocci T, Duncan R, Fasano A, Foote KD, Hamani C, Krauss JK, Kühn AA, Lena F, Limousin P, Lozano AM, Maiorana NV, Modugno N, Moro E, Okun MS, Oliveri S, Santilli M, Schnitzler A, Temel Y, Timmermann L, Visser-Vandewalle V, Volkmann J, Priori A. Guidetti M, et al. J Neuroeng Rehabil. 2025 Apr 10;22(1):80. doi: 10.1186/s12984-025-01616-w. J Neuroeng Rehabil. 2025. PMID: 40211348 Free PMC article.

Abstract

Although deep brain stimulation of the subthalamic nucleus (STN-DBS) induces motor benefits in people with Parkinson's disease (PwPD), the size and duration of the effects of STN-DBS on motor axial (e.g., postural instability, trunk posture alterations) and gait impairments (e.g., freezing of gait - FOG) are still ambiguous. Physical therapy (PT) effectively complements pharmacological treatment to improve postural stability, gait performance, and other dopamine-resistant symptoms (e.g. festination, hesitation, axial motor dysfunctions, and FOG) in PwPD who are non-surgically treated. Despite the potential for positive adjuvant effects of PT following STN-DBS surgery, there is a paucity of science available on the topic. In such a scenario, gathering the opinion and expertise of leading investigators worldwide was pursued to study motor rehabilitation in PwPD following STN-DBS. After summarizing the few available findings through a systematic review, we identified clinical and academically experienced DBS clinicians (n=21) to discuss the challenges related to PT following STN-DBS. A 5-point Likert scale questionnaire was used and based on the results of the systematic review along with a Delphi method. Thirty-nine questions were submitted to the panel - half related to general considerations on PT following STN-DBS, half related to PT treatments. Despite the low-to-moderate quality, the few available rehabilitative studies suggested that PT could improve dynamic and static balance, gait performance and posture. Similarly, panellists strongly agreed that PT might help in improving motor symptoms and quality of life, and it may be possibly prescribed to maximize the effects of the stimulation. The experts agreed that physical therapists could be part of the multidisciplinary team taking care of the patients. Also, they agreed on prescribing of conventional PT, but not massage or manual therapy. Our results will inform the rehabilitation and the DBS community to engage, publish and deepen this area of research. Such efforts may spark guidelines for PT following STN-DBS.

Keywords: DBS; Deep Brain Stimulation; Delphi consensus; Motor rehabilitation; Parkinson’s disease; Physical therapy; Physiotherapy; movement disorders; neuromodulation.

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Conflict of interest statement

A.F. has received payments as consultant and/or speaker from Abbott, Boston Scientific, Ceregate, Inbrain Neuroelectronics, Medtronic, Iota and has received research support from Boston Scientific, Medtronic. K.D.F. reports receiving research support and fellowship support from Medtronic and Boston Scientific and research support from Functional Neuromodulation. CRB has received support from the NIH (UH3 NS119844) and has served as a consultant for NeuraModix. J.K.K. is a consultant to Medtronic, Boston Scientific, aleva and Inomed. A.A.K. is a consultant to Medtronic, Boston Scientific and Teva. A.M.L. is a consultant to Abbott, Boston Scientific, Insightec, Medtronic and Functional Neuromodulation (Scientific Director). EM has received an educational grant from Boston Scientific and honoraria from Medtronic and Newronika. M.S.O. serves as Medical Advisor in the Parkinson’s Foundation, and has received research grants from NIH, Parkinson’s Foundation, the Michael J. Fox Foundation, the Parkinson Alliance, Smallwood Foundation, the Bachmann-Strauss Foundation, the Tourette Syndrome Association, and the UF Foundation. M.S.O. ‘s research is supported by: R01 NS131342 NIH R01 NR014852, R01NS096008, UH3NS119844, U01NS119562. M.S.O. is PI of the NIH R25NS108939 Training Grant. M.S.O. has received royalties for publications with Hachette Book Group, Demos, Manson, Amazon, Smashwords, Books4Patients, Perseus, Robert Rose, Oxford and Cambridge (movement disorders books). M.S.O. is an associate editor for New England Journal of Medicine Journal Watch Neurology and JAMA Neurology. M.S.O. has participated in CME and educational activities (past 12–24 months) on movement disorders sponsored by WebMD/Medscape, RMEI Medical Education, American Academy of Neurology, Movement Disorders Society, Mediflix and by Vanderbilt University. The institution and not M.S.O. receives grants from industry. M.S.O. has participated as a site PI and/or co-PI for several NIH, foundation, and industry sponsored trials over the years but has not received honoraria. Research projects at the University of Florida receive device and drug donations. A.S. received consulting fees from Abbott, Zambon, and Abbvie, and speaker honoraria from bsh medical communication, Abbott, Kyowa Kirin, Novartis, Abbvie, and Alexion, GE Healtcare. The institution of AS, not AS personally, received funding by the Deutsche Forschungsgemeinschaft, the Brunhilde Moll Foundation, and Abbott. L.T. received occasional payments as a consultant for Boston Scientific, L.T. received honoraria as a speaker on symposia sponsored by Boston Scientific, AbbVIE, Novartis, Neuraxpharm, Teva, the Movement Disorders Society und DIAPLAN. The institution of L.T., not L.T. personally, received funding by Boston Scientific, the German Research Foundation, the German Ministry of Education and Research, the Otto-Loewi-Foundation and the Deutsche Parkinson Vereinigung. Neither L.T. nor any member of his family holds stocks, stock options, patents or financial interests in any of the above-mentioned companies or their competitors. L.T. serves as the president of the German Neurological Society without any payment or any income. V.V.V. received occasional payments as a consultant or speaker on symposia from Boston Scientific and Medtronic. J.V. reports grants and personal fees from Medtronic, grants and personal fees from Boston Scientific, personal fees from Abbott outside the submitted work. J.V. was supported by the German Research Foundation (DFG, Project-ID424778381, TRR 295) – J.V. received consulting and lecture fees from Boston Scientific, Medtronic and Newronika, research grants from the German Research Foundation, the German Ministry of Research and Education, Boston Scientific and Medtronic, lecture Honoraria from UCB, Zambon, Abbott. A.P. and S.M. are founders and shareholders of Newronika Spa, Italy. All other authors declare no competing interests.

Figures

**Fig.1.**
Flowchart of the scoping review selection process.

**Fig.2.**
Percentage of agreement for the 11 general considerations on physical therapy after subthalamic nucleus deep brain stimulation in patients with Parkinson’s disease (Statement 1–11) among the Delphi Panel members, as result of the first round. No statement reached a consensus (i.e., >80% of the responses fell in the same response label). PD = Parkinson’s disease; STN-DBS = subthalamic nucleus deep brain stimulation; S = statement.

**Fig.3.**
Percentage of agreement for the 11 general considerations on physical therapy after subthalamic nucleus deep brain stimulation in patients with Parkinson’s disease (Statement 1–11) among the Delphi Panel members, as result of the second round. Statement 1, Statement 4 and Statement 11 reached a consensus, i.e., 89% of the responses fell in the response label “strongly agree”. PD = Parkinson’s disease; STN-DBS = subthalamic nucleus deep brain stimulation; S = statement.

**Fig.4.**
Percentage of agreement for the 11 general considerations on physical therapy after subthalamic nucleus deep brain stimulation in patients with Parkinson’s disease (Statement 1–11) among the Delphi Panel members, as result of the third round. Statement 5, Statement 8, Statement 9 and Statement 10 reached a consensus, i.e., respectively, 88%, 94%, 88% and 88% of the responses fell in the response label “strongly agree”. PD = Parkinson’s disease; STN-DBS = subthalamic nucleus deep brain stimulation; S = statement.

**Fig.5.**
Percentage of agreement for the 28 statements on physical therapy treatments after subthalamic nucleus deep brain stimulation in patients with Parkinson’s disease (Statement 12–39) among the Delphi Panel members, as result of the first round. No statement reached a consensus (i.e., >80% of the responses fell in the same response label). PD = Parkinson’s disease; STN-DBS = subthalamic nucleus deep brain stimulation; S = statement.

**Fig.6.**
Percentage of agreement for the 28 statements on physical therapy treatments after subthalamic nucleus deep brain stimulation in patients with Parkinson’s disease (Statement 12–39) among the Delphi Panel members, as result of the second round. No statement reached a consensus (i.e., >80% of the responses fell in the same response label). PD = Parkinson’s disease; STN-DBS = subthalamic nucleus deep brain stimulation; S = statement.

**Fig.7.**
Percentage of agreement for the 28 statements on physical therapy treatments after subthalamic nucleus deep brain stimulation in patients with Parkinson’s disease (Statement 12–39) among the Delphi Panel members, as result of the third round. Statement 12 and Statement 13 reached a consensus, i.e., for both, 81% of the responses fell in the response label “strongly agree”. Statement 17 reached a consensus, i.e., 81% of the responses fell in the response label “disagree”. PD = Parkinson’s disease; STN-DBS = subthalamic nucleus deep brain stimulation; S = statemen

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References

1. Limousin P, Foltynie T. Long-term outcomes of deep brain stimulation in Parkinson disease. Nature Reviews Neurology 2019 15:4. 18 febbraio 2019;15(4):234–42. - PubMed
1. Guidetti M, Marceglia S, Loh A, Harmsen IE, Meoni S, Foffani G, et al. Clinical perspectives of adaptive deep brain stimulation. Brain stimulation. 1 settembre 2021;14(5):1238–47. - PubMed
1. Conway ZJ, Silburn PA, Thevathasan W, Maley KO, Naughton GA, Cole MH. Alternate Subthalamic Nucleus Deep Brain Stimulation Parameters to Manage Motor Symptoms of Parkinson’s Disease: Systematic Review and Meta-analysis. Movement Disorders Clinical Practice. 1 gennaio 2019;6(1):17–26. - PMC - PubMed
1. Fasano A, Aquino CC, Krauss JK, Honey CR, Bloem BR. Axial disability and deep brain stimulation in patients with Parkinson disease. Nat Rev Neurol. febbraio 2015;11(2):98–110. - PubMed
1. Lozano AM, Lipsman N, Bergman H, Brown P, Chabardes S, Chang JW, et al. Deep brain stimulation: current challenges and future directions. Nat Rev Neurol. marzo 2019;15(3):148–60. - PMC - PubMed

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This is a preprint.

Physical therapy in patients with Parkinson's disease treated with Deep Brain Stimulation: a Delphi panel study

Affiliations

Physical therapy in patients with Parkinson's disease treated with Deep Brain Stimulation: a Delphi panel study

Authors

Affiliations

Update in

Abstract

Conflict of interest statement

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