title: Programming Deep Brain Stimulation for Parkinson's Disease: The Toronto Western Hospital Algorithms.
abstract: Deep brain stimulation (DBS) is an established and effective treatment for Parkinson's disease (PD). After surgery, a number of extensive programming sessions are performed to define the most optimal stimulation parameters. Programming sessions mainly rely only on neurologist's experience. As a result, patients often undergo inconsistent and inefficient stimulation changes, as well as unnecessary visits.
  
  
  
  We reviewed the literature on initial and follow-up DBS programming procedures and integrated our current practice at Toronto Western Hospital (TWH) to develop standardized DBS programming protocols. We propose four algorithms including the initial programming and specific algorithms tailored to symptoms experienced by patients following DBS: speech disturbances, stimulation-induced dyskinesia and gait impairment.
  
  
  
  We conducted a literature search of PubMed from inception to July 2014 with the keywords "deep brain stimulation", "festination", "freezing", "initial programming", "Parkinson's disease", "postural instability", "speech disturbances", and "stimulation induced dyskinesia". Seventy papers were considered for this review.
  
  
  
  Based on the literature review and our experience at TWH, we refined four algorithms for: (1) the initial programming stage, and management of symptoms following DBS, particularly addressing (2) speech disturbances, (3) stimulation-induced dyskinesia, and (4) gait impairment.
  
  
  
  We propose four algorithms tailored to an individualized approach to managing symptoms associated with DBS and disease progression in patients with PD. We encourage 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 and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital and 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, University of Toronto, Toronto Western Hospital/University Health Network, Toronto, Ontario, Canada.
authors.forename: Andres M
authors.initials: AM
authors.lastname: Lozano
authors.affiliation: Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital and 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 and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital and Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Renato
authors.initials: R
authors.lastname: Puppi Munhoz
authors.affiliation: Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital and 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: D000368:Aged; D000465:Algorithms; D046690:Deep Brain Stimulation / Q000009:adverse effects / Q000379:methods*; D020233:Gait Disorders, Neurologic; D006760:Hospitalization / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D064887:Observational Studies as Topic / Q000379:methods; D009864:Ontario; D010300:Parkinson Disease / Q000175:diagnosis / Q000503:physiopathology* / Q000601:surgery*; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D013064:Speech Disorders / Q000175:diagnosis / Q000503:physiopathology; D020531:Subthalamic Nucleus / Q000502:physiology; D016896:Treatment Outcome
keywords: Freezing; Parkinson's disease; Programming; Speech; Stimulation-induced dyskinesia; Surgery