The Effects of Deep Brain Stimulation on Balance in Parkinson's Disease as Measured Using Posturography-A Narrative Review

Abstract

Background: Postural imbalance with falls affects 80% of patients with Parkinson's disease (PD) at 10 years. Standard PD therapies (e.g., levodopa and/or deep brain stimulation-DBS) are poor at improving postural imbalance. Additionally, the mechanistic complexity of interpreting postural control is a major barrier to improving our understanding of treatment effects. In this paper, we review the effects of DBS on balance as measured using posturography. We also critically appraise the quantitative measures and analyses used in these studies.

Methods: A literature search was performed independently by 2 researchers using the PUBMED database. Thirty-eight studies are included in this review, with DBS at the subthalamic nucleus (STN-) (n = 25), globus pallidus internus (GPi-) (n = 6), ventral intermediate nucleus (VIM)/thalamus (n = 2), and pedunculopontine nucleus (PPN) (n = 5).

Results: STN- and GPi-DBS reduce static sway in PD and mitigate the increased sway from levodopa. STN-DBS impairs automatic responses to perturbations, whilst GPi-DBS has a more neutral effect. STN-DBS may promote protective strategies following external perturbations but does not improve adaptation. The evidence regarding the effects on gait initiation is less clear. Insufficient evidence exists to make conclusions regarding VIM- and PPN-DBS.

Conclusions: STN- and GPi-DBS have differing effects on posturography, which suggests site-specific and possibly non-dopaminergic mechanisms. Posturography tests should be utilised to answer specific questions regarding the mechanisms of and effects on postural control following DBS. We recommend standardising posturography measures and test conditions by expert consensus and greater long-term data collection, utilising ongoing DBS registries.

Keywords: Parkinson’s disease; balance; deep brain stimulation; postural instability; posturography.

Figure 1

Dopaminergic and non-dopaminergic supraspinal pathways of postural control in health (A) and in PD (B). ‘+’ denotes overactivity, and ‘dashed line’ denotes underactivity with respect to normal physiology. The number of ‘+’ and ‘dashes’ relates to the degree of over- and underactivity. CN—cuneiform nucleus, GPi—globus pallidus internus, PPNc/r—pedunculopontine nucleus caudal/rostral, SNc/r—substantia nigra pars compacta/reticulata, STN—subthalamic nucleus.

Figure 2

Common static posturography test conditions. Quiet standing sway is usually performed on a force platform, though IMUs can also be used; the graphic shows an example of CoM sway data generated from IMUs, expressed as x vs. y (A); Sensory organisation test (SOT) conditions, which measures sway during combinations of visual, somatosensory and sway-referenced conditions (B). AP—anteroposterior; ML—mediolateral. Created in BioRender. Lonergan, B. (2025). URL: https://BioRender.com/20nvui6 (accessed on 21 March 2025).

Figure 3

Common dynamic posturography test conditions include external perturbations (A), gait initiation (B) and target acquisition with leaning (C). Created in BioRender. Lonergan, B. (2025). URL: https://BioRender.com/dw6gsg6 (accessed on 21 March 2025).

Figure 4

Dopaminergic and non-dopaminergic supraspinal pathways of postural control in health (A) and in PD (B), with proposed mechanisms for GPi- (C) and STN-DBS (D). ‘+’ denotes overactivity, and ‘dashed line’ denotes underactivity with respect to normal physiology. The number of ‘+’ and ‘dashes’ relates to the degree of over- and underactivity. CN—cuneiform nucleus, GPi—globus pallidus internus, PPNc/r—pedunculopontine nucleus caudal/rostral, SNc/r—substantia nigra pars compacta/reticulata, STN—subthalamic nucleus.