title: Programming Deep Brain Stimulation for Tremor and Dystonia: The Toronto Western Hospital Algorithms.
abstract: Deep brain stimulation (DBS) is an effective treatment for essential tremor (ET) and dystonia. After surgery, a number of extensive programming sessions are performed, mainly relying on neurologist's personal experience as no programming guidelines have been provided so far, with the exception of recommendations provided by groups of experts. Finally, fewer information is available for the management of DBS in ET and dystonia compared with Parkinson's disease.
  
  
  
  Our aim is to review the literature on initial and follow-up DBS programming procedures for ET and dystonia and integrate the results with our current practice at Toronto Western Hospital (TWH) to develop standardized DBS programming protocols.
  
  
  
  We conducted a literature search of PubMed from inception to July 2014 with the keywords "balance", "bradykinesia", "deep brain stimulation", "dysarthria", "dystonia", "gait disturbances", "initial programming", "loss of benefit", "micrographia", "speech", "speech difficulties" and "tremor". Seventy-six papers were considered for this review.
  
  
  
  Based on the literature review and our experience at TWH, we refined three algorithms for management of ET, including: (1) initial programming, (2) management of balance and speech issues and (3) loss of stimulation benefit. We also depicted algorithms for the management of dystonia, including: (1) initial programming and (2) management of stimulation-induced hypokinesia (shuffling gait, micrographia and speech impairment).
  
  
  
  We propose five algorithms tailored to an individualized approach to managing ET and dystonia patients with DBS. We encourage the application of these algorithms to supplement current standards of care in established as well as new DBS centers to test the clinical usefulness of these algorithms in supplementing the current standards of care.
authors.affiliation: Morton and Gloria Shulman Movement Disorders Clinic, The Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Centre for Neurodegenerative Diseases (CEMAND), Department of Medicine and Surgery, Neuroscience Section, University of Salerno, Salerno, Italy.
authors.forename: Marina
authors.initials: M
authors.lastname: Picillo
authors.affiliation: Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Toronto, Canada.
authors.forename: Andres M
authors.initials: AM
authors.lastname: Lozano
authors.affiliation: Morton and Gloria Shulman Movement Disorders Clinic, The Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Nancy
authors.initials: N
authors.lastname: Kou
authors.affiliation: Morton and Gloria Shulman Movement Disorders Clinic, The Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Renato Puppi
authors.initials: RP
authors.lastname: Munhoz
authors.affiliation: Morton and Gloria Shulman Movement Disorders Clinic, The Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada. Electronic address: alfonso.fasano@gmail.com.
authors.forename: Alfonso
authors.initials: A
authors.lastname: Fasano
mesh_terms: D000465:Algorithms; D046690:Deep Brain Stimulation / Q000009:adverse effects / Q000379:methods*; D004421:Dystonia / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D006760:Hospitalization / Q000639:trends; D006801:Humans; D064887:Observational Studies as Topic / Q000379:methods; D010300:Parkinson Disease / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy; D013064:Speech Disorders / Q000175:diagnosis / Q000503:physiopathology; D016896:Treatment Outcome; D014202:Tremor / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*
keywords: Dystonia; Programming; Stimulation; Surgery; Tremor