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Dr. Okun

Post of the Week: STN DBS Worsens Language Function

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Dr. Okun    409

This recent study from the Vanderbilt COE revealed that STN DBS worsened motor aspects of language and grammatical function (but not the content of language). Patients seeking STN DBS should be aware of this potential impairment. The abstract is provided below:

 

PLoS One. 2012;7(8):e42829. Epub 2012 Aug 7.

Subthalamic nucleus deep brain stimulation impacts language in early Parkinson's disease.

Phillips L, Litcofsky KA, Pelster M, Gelfand M, Ullman MT, Charles PD.

 

Source

Department of Neurology, Vanderbilt University, Nashville, Tennessee, United States of America.

 

Abstract

Although deep brain stimulation (DBS) of the basal ganglia improves motor outcomes in Parkinson's disease (PD), its effects on cognition, including language, remain unclear. This study examined the impact of subthalamic nucleus (STN) DBS on two fundamental capacities of language, grammatical and lexical functions. These functions were tested with the production of regular and irregular past-tenses, which contrast aspects of grammatical (regulars) and lexical (irregulars) processing while controlling for multiple potentially confounding factors. Aspects of the motor system were tested by contrasting the naming of manipulated (motor) and non-manipulated (non-motor) objects. Performance was compared between healthy controls and early-stage PD patients treated with either DBS/medications or medications alone. Patients were assessed on and off treatment, with controls following a parallel testing schedule. STN-DBS improved naming of manipulated (motor) but not non-manipulated (non-motor) objects, as compared to both controls and patients with just medications, who did not differ from each other across assessment sessions. In contrast, STN-DBS led to worse performance at regulars (grammar) but not irregulars (lexicon), as compared to the other two subject groups, who again did not differ. The results suggest that STN-DBS negatively impacts language in early PD, but may be specific in depressing aspects of grammatical and not lexical processing. The finding that STN-DBS affects both motor and grammar (but not lexical) functions strengthens the view that both depend on basal ganglia circuitry, although the mechanisms for its differential impact on the two (improved motor, impaired grammar) remain to be elucidated.

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siak    43

Is there anything that will improve  this deficit once the surgery is done? Is the cognitive deficit reversible ? Do "brain games" help?

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Dr. Okun    409

We don't actually know.  Some people think that cognitive games may help, and some people have used speech therapy and psychology to work on the verbal fluency issues.

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My husband was diagnosed a year ago. He is 39 years old. Recently we met a neurologist who told us about DBS for young patients, everything he said sound wonderful, but I have serious doubts about it. In your opinion is it a good option for a young patient even when meds are working well? Is there an important risk of impairment of cognitive functions such as executive functions? My husband works at an insurance company calculating the risk of accidents and things like that, and be able to judge, organize and plan are critical for the Job. He is really excited about DBS and the doctor talked about minimal risks, all of them reversible, but I have read some articles about serious consequences of DBS in very few cases or about using DBS for later stages of the disease. Wht do you think?

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Dr. Okun    409

In general if the medications are working well and there are no issues with tremor, on-off fluctuations, or dyskinesia I am cautious not to be too hasty to DBS.  It is not a risk free procedure and a complete interdisciplinary evaluation should be performed with a risk-benefit ratio.  If there are no issues and he is still working, I generally do not offer DBS and I watch conservatively and wait for a disabling symptom that would justify the risk-benefit ratio.  There is a study in NEJM on earlier DBS, but if there is no disabling symptom I think most people will not offer DBS.

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janvier    3

Dear Doctor,

The study talks about language difficulties after DBS for early PD patients. Does this mean that patients who had PD for more then 10 or 15 years are lets say less concerned about this problem after DBS.  To your knowledge is there any study in this area. Thanks.

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Dr. Okun    409

So far the concern has been the same for both earlier DBS or later DBS intervention (for speech problems); particularly when leads are implanted on both sides of the brain.

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janvier    3

Dear Doctor,

Thanks for the reply. Two more questions. Are the speech problems reversible? That is if the patient stops the stimulation do they go away? Secondly, you say in case of bilateral stimulation, are there PD patients with unilateral STN? Can any PD patient live for many years with unilateral STN? Thanks.

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Dr. Okun    409

It is totally possible and actually common to only get one STN or one GPi DBS.

 

The speech problems may be irreversible (getting words out of the moth) or reversible (slurring).  There are cases when they are not reversible by turning the DBS off.

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waruna01    44

Are speech problems more common in bilateral STN DBS or bilateral GPi DBS? Does all, if not most, patients who undergo bilateral DBS report these problems with speech? How can this condition be mitigated for patient who underwent bilateral DBS?

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Dr. Okun    409

It is unknown if the speech problems are less with GPi DBS and some groups think so; most think they are less with one lead versus two.  Speech therapy can help post-DBS, but if not consistently applied patients report reverting back to their post-DBS poor speech (need consistency in the speech therapy).  I am unaware of a strategy to completely mitigate the problem.

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