Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> Our objective was to develop parameters for objective ambulatory measurements of levodopa-induced dyskinesias (LID) in patients with Parkinson's disease (PD). Twenty-three PD patients with mild to severe LID were submitted to a standardized protocol of 1-minute recordings during rest, talking, stress, and four activities of daily life (ADL). Patients were simultaneously monitored with portable multi-channel accelerometry (four pairs of bi-axial sensors mounted onto the most affected arm, leg, and at the trunk) and recorded by video. LID severity was assessed with a modified Abnormal Involuntary Movement Scale (m-AIMS). The signals were analyzed, and every 1/8-second interval the amplitude was obtained of the dominant frequency within 1–4 Hz and 4–8 Hz frequency bands (Amp1–4 and Amp4–8). For both measures, convergent validity, reproducibility, and responsiveness were determined. ::: ::: ::: ::: In absence of voluntary movements, a significant relation was found between Amp1–4 and Amp4–8 and m-AIMS. Repeated measurements during rest showed a high reproducibility (intraclass correlation coefficient = 0.90 [Amp1–4] and 0.86[Amp4–8]). The extent to which LID increased with talking and stress correlated significantly (p = 0.02) between the objective and clinical measures (intraclass correlation for differences = 0.67). During ADL, LID occurred in a similar frequency band as voluntary movements and only Amp1–4 and Amp4–8 of the trunk and leg sensor remained highly correlated with m-AIMS. ::: ::: ::: ::: Although objective measures of LID are reliable and responsive, they fail to distinguish LID from voluntary movements. These measures are of value only when obtained during rest (all sensor sites) or during ADL when derived from those body segments that are normally not involved in these ADL tasks (trunk and leg). Mov. Disord. 16:58–61, 2001. © 2001 Movement Disorder Society. <s> BIB001 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> Abstract This study was undertaken to analyse kinetic tremor during a compensatory tracking task performed with the index fingers. Patients with Parkinson's disease (PD) ( n =21) and control subjects ( n =30) were tested using a laser system transducing displacement. All participants underwent a clinical examination. Nine characteristics quantifying the tracking task and tremor were applied to the processed displacement or velocity signal. The discriminating power of each characteristic was evaluated using differences between group means ( p values), maximum percentage discrimination, and number of outliers in the patient group. All nine characteristics showed significant differences between means of the two groups using Welch-modified t -tests for unequal variances. The most discriminating characteristics reflected differences in the frequency distribution of the movement (proportional power in the 3–4 Hz range, harmonicity and median frequency). These differences were rarely visible and did not correlate highly with tremor amplitude or with clinical ratings of tremor. Control subjects had residual spectral power from the tracking oscillations leaking above 3 Hz, while most patients had a small ‘kinetic tremor’ in the 7–12 Hz range. The maximum discrimination was moderate, 63% in the best case. Combining representative information about proportional power during posture (recorded in the same subjects) and tracking gave a much higher discrimination (90%) with respect to the 96.7th percentile of the control group. These results suggest that information coming from postural and kinetic tremors can be combined to isolate a subclinical feature of PD symptomatology. This feature could be used to re-evaluate the classic distinction made between the akineto-rigid and tremulous forms of PD and is independent of tremor amplitude. <s> BIB002 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> We examined the effects of high-frequency deep brain stimulation of the subthalamic nucleus (STN-DBS) on characteristics of electromyographic (EMG) activity of the agonist muscle in 8 patients with Parkinson's disease (PD). Patients were examined during STN-DBS (ON), and 30 minutes after switching off both stimulators (OFF). They were asked to make a ballistic movement in paradigms of simple reaction time (SRT) and choice reaction time (CRT) tasks. Onset of movement (MOVonset) was measured as the latency of the initial displacement from baseline of the signal from an accelerometer attached to the dorsum of the hand. In the associated EMG activity, recorded from wrist extensor muscles, we measured onset latency (EMGonset), size of the first EMG burst (EMGsize), and number of EMG bursts (EMGbursts) counted between EMGonset and task execution. MOVonset and EMGonset were significantly shorter in ON than in OFF conditions in CRT. EMGsize was larger, EMGbursts were reduced, and peak of the acceleration profile was larger in ON compared with OFF conditions in both SRT and CRT. Our results indicate that STN-DBS induces a significant improvement in motor performance of reaction time tasks in PD patients. Such improvement is associated with a change in features of the EMG activity suggesting an increase in the excitability of the motor pathways engaged in ballistic movements. © 2003 Movement Disorder Society <s> BIB003 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> Postural instability and gait disability (PIGD) are disabling signs of Parkinson's disease. Stereotactic surgery aimed at the internal globus pallidus (GPi) or subthalamic nucleus (STN) might improve PIGD, but the precise effects remain unclear. We performed a systematic review of studies that examined the effects of GPi or STN surgery on PIGD. Most studies examined the effects of bilateral GPi stimulation, bilateral STN stimulation, and unilateral pallidotomy; we, therefore, only performed a meta-analysis on these studies. Bilateral GPi stimulation, bilateral STN stimulation, and to a lesser extent, unilateral pallidotomy significantly improved PIGD, and more so during the ON phase than during the OFF phase. <s> BIB004 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> Shortcomings of existing assessment methods in Parkinson disease (PD) have led to the development of continuous ambulatory multichannel accelerometry for the assessment of the core features of PD. Although measures for hypokinesia, bradykinesia, and tremor have been validated in groups of patients with PD, it is unclear whether this method is able to detect "on" with or without dyskinesias, and "off" in individual PD patients. This study therefore addressed the accuracy of objective ambulatory accelerometry in detecting motor complications in 15 PD patients, using a self-assessment scale as gold standard. Measures for hypokinesia, bradykinesia, and tremor showed limited sensitivity (0.60-0.71) and specificity (0.66-0.76) for motor complications in individual PD patients. In the group of PD patients, comparing the "on" with the "off' state yielded statistically significant differences for tremor only. Objective dyskinesia measures correlated with time spent with dyskinesias (r = 0.89). Although validated for the measurement of hypokinesia, bradykinesia, and tremor, continuous ambulatory multichannel accelerometry currently cannot detect "on" and "off" in individual PD patients. <s> BIB005 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has proved to be effective for tremor in Parkinson’s disease (PD). Most of the recent studies used only clinical data to analyse tremor reduction. The objective of our study was to quantify tremor reduction by STN DBS and antiparkinsonian medication in elderly PD patients using an objective measuring system. Amplitude and frequency of resting tremor and re-emergent resting tremor during postural tasks were analysed using an ultrasound-based measuring system and surface electromyography. In a prospective study design nine patients with advanced PD were examined preoperatively off and on medication, and twice postoperatively during four treatment conditions: off treatment, on STN DBS, on medication, and on STN DBS plus medication. While both STN DBS and medication reduced tremor amplitude, STN DBS alone and the combination of medication and STN DBS were significantly superior to pre- and postoperative medication. STN DBS but not medication increased tremor frequency, and off treatment tremor frequency was significantly reduced postoperatively compared to baseline. These findings demonstrate that STN DBS is highly effective in elderly patients with advanced PD and moderate preoperative tremor reduction by medication. Thus, with regard to the advanced impact on the other parkinsonian symptoms, STN DBS can replace thalamic stimulation in this cohort of patients. Nevertheless, medication was still effective postoperatively and may act synergistically. The significantly superior efficacy of STN DBS on tremor amplitude and its impact on tremor frequency in contrast to medication might be explained by the influence of STN DBS on additional neural circuits independent from dopaminergic neurotransmission. <s> BIB006 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> It is widely accepted that patients with Parkinson's disease experience immediate but temporary improvement in motor signs after surgical implantation of subthalamic nucleus (STN) deep brain stimulating electrodes before the electrodes are activated, although this has never been formally studied. Based on anecdotal observations that limb mobility improved just after microelectrode recording (MER) during deep brain stimulation (DBS) procedures, we designed a prospective study to measure upper extremity bradykinesia using a quantitative measure of angular velocity. Measurements were made pre- and post-MER and during intraoperative DBS. Analysis of 98 STN DBS procedures performed on 61 patients showed that MER did not create adverse clinical symptoms despite concerns that MER increases morbidity. Quantitative upper extremity bradykinesia improved after MER alone, and further improvement was seen during intraoperative DBS. Electrophysiological data from each case were then compared to the improvement in bradykinesia post-MER alone and a significant correlation was found between the improvement in arm bradykinesia, the number of passes through the STN with somatosensory driving, and also with the number of arm cells with somatosensory driving in the STN, but not with total number of passes, total number of passes through the STN, or total number of cells with somatosensory driving in the STN. This study demonstrates that there is a significant improvement in upper extremity bradykinesia just after MER, before inserting or activating the DBS electrode in patients with Parkinson's disease who undergo STN DBS. <s> BIB007 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> We developed an algorithm that distinguishes between on and off states in patients with Parkinson's disease during daily life activities. Twenty-three patients were monitored continuously in a home-like situation for approximately 3 hours while they carried out normal daily-life activities. Behavior and comments of patients during the experiment were used to determine the on and off periods by a trained observer. Behavior of the patients was measured using triaxial accelerometers, which were placed at six different positions on the body. Parameters related to hypokinesia (percentage movement), bradykinesia (mean velocity), and tremor (percentage peak frequencies above 4 Hz) were used to distinguish between on and off states. The on-off detection was evaluated using sensitivity and specificity. The performance for each patient was defined as the average of the sensitivity and specificity. The best performance to classify on and off states was obtained by analysis of movements in the frequency domain with a sensitivity of 0.97 and a specificity of 0.97. We conclude that our algorithm can distinguish between on and off states with a sensitivity and specificity near 0.97. This method, together with our previously published method to detect levodopa-induced dyskinesia, can automatically assess the motor state of Parkinson's disease patients and can operate successfully in unsupervised ambulatory conditions. <s> BIB008 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> The present study characterized involuntary movements associated with levodopa-induced dyskinesias (LID) in patients with Parkinson's disease. We used amplitude, proportional energy, frequency dispersion and sample entropy to determine whether LID movement patterns are truly random, as clinical description seems to suggest, or possess some underlying pattern that is not visible to the naked eye. LID was captured using a magnetic tracker system, which provided 3D rendering of whole-body LID. Patients were instructed to maintain a standing position, with arms extended in front of them. We compared the measurements of the dyskinetic PD group (DPD) with 10 patients without dyskinesias (NDPD) and 10 control subjects. In comparison to the other two groups, movement patterns from the DPD group had significantly higher amplitude, confirming the presence of dyskinesias. In addition, higher frequency components in the power spectrum of velocity were detected, suggestive of higher velocity in LID movement. Furthermore, there was a concentration in narrow frequency bands, which suggested stable oscillatory activity. Finally, sample entropy revealed more regularity in the DPD group. Although not statistically significant, we found that the amplitude from the NDPD group had a tendency to be smaller than those of controls. As well, the spectra were often more dispersed for the NDPD group. In conclusion, the present results suggest that LID cannot be considered as purely random movement since they possess some deterministic pattern of motion. This may provide a way for patients to adapt to these involuntary movements while performing voluntary motor acts. <s> BIB009 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> Deep brain stimulation of the thalamus (thalamic DBS) is an established therapy for medically intractable essential tremor and tremor caused by multiple sclerosis. In both disorders, motor disability results from complex interaction between kinetic tremor and accompanying ataxia with voluntary movements. In clinical studies, the efficacy of thalamic DBS has been thoroughly assessed. However, the optimal anatomical target structure for neurostimulation is still debated and has never been analysed in conjunction with objective measurements of the different aspects of motor impairment. In 10 essential tremor and 11 multiple sclerosis patients, we analysed the effect of thalamic DBS through each contact of the quadripolar electrode on the contralateral tremor rating scale, accelerometry and kinematic measures of reach-to-grasp-movements. These measures were correlated with the anatomical position of the stimulating electrode in stereotactic space and in relation to nuclear boundaries derived from intraoperative microrecording. We found a significant impact of the stereotactic z-coordinate of stimulation contacts on the TRS, accelerometry total power and spatial deviation in the deceleration and target period of reach-to-grasp-movements. Most effective contacts clustered within the subthalamic area (STA) covering the posterior Zona incerta and prelemniscal radiation. Stimulation within this region led to a mean reduction of the lateralized tremor rating scale by 15.8 points which was significantly superior to stimulation within the thalamus (P < 0.05, student's t-test). STA stimulation resulted in reduction of the accelerometry total power by 99%, whereas stimulation at the ventral thalamic border (68%) or within the thalamus proper (2.5%) was significantly less effective (P < 0.01). Concomitantly, STA stimulation led to a significantly higher increase of tremor frequency and decrease in EMG synchronization compared to stimulation within the thalamus proper (P < 0.001). In reach-to-grasp movements, STA stimulation reduced the spatial variability of the movement path in the deceleration period by 28.9% and in the target period by 58.4%, whereas stimulation within the thalamus was again significantly less effective (P < 0.05), with a reduction in the deceleration period between 6.5 and 21.8% and in the target period between 1.2 and 11.3%. An analysis of the nuclear boundaries from intraoperative microrecording confirmed the anatomical impression that most effective electrodes were located within the STA. Our data demonstrate a profound effect of deep brain stimulation of the thalamic region on tremor and ataxia in essential tremor and tremor caused by multiple sclerosis. The better efficacy of stimulation within the STA compared to thalamus proper favours the concept of a modulation of cerebello-thalamic projections underlying the improvement of these symptoms. <s> BIB010 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> This study examined the efficacy of subthalamic nucleus (STN), deep brain stimulation (DBS), and medication for resting tremor during performance of secondary tasks. Hand tremor was recorded using accelerometry and electromyography (EMG) from 10 patients with Parkinson’s disease (PD) and ten matched control subjects. The PD subjects were examined off treatment, on STN DBS, on medication, and on STN DBS plus medication. In the first experiment, tremor was recorded in a quiet condition and during a cognitive task designed to enhance tremor. In the second experiment, tremor was recorded in a quiet condition and during isometric finger flexion (motor task) with the contralateral limb at 5% of the maximal voluntary contraction (MVC) that was designed to suppress tremor. Results showed that: (1) STN DBS and medication reduced tremor during a cognitive task that exacerbated tremor, (2) STN DBS normalized tremor frequency in both the quiet and cognitive task conditions, whereas tremor amplitude was only normalized in the quiet condition, (3) a secondary motor task reduced tremor in a similar manner to STN DBS. These findings demonstrate that STN DBS still suppresses tremor in the presence of a cognitive task. Furthermore, a secondary motor task of the opposite limb suppresses tremor to levels comparable to STN DBS. <s> BIB011 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> Summary Introduction Neurophysiological assessment can provide quantitative measures for the selected motor signs that have been targeted for surgery and may be helpful in predicting the therapeutic effects of deep brain stimulation (DBS) on pathological tremor, motor performance, and rigidity. Objective To present a survey and demonstrate the contribution of neurophysiological assessment of side effects and effects on disabling motor symptoms at various steps of DBS surgery, and to confirm its role for optimal target localization, as an adjuvant to anatomic imaging. Material and methods The data result from 192 nuclei in 118 procedures on patients with Parkinson's disease (84), essential tremor (24), Hallenvorder Spatz dystonia (4), multiple sclerosis (4), and Holmes tremor (2). The intraoperative neurophysiological monitoring (IOM) protocol consists of semimicroelectrode recording (for subthalamic nuclei), whereas accelerotransducers and spectral analysis allow assessment of tremor, finger tapping (FT), diadochokinesis (DDK), and determination of the distance between DBS electrodes and internal capsule (IC). Rigidity is assessed by surface EMG recordings in combination with a goniometer. Results The determination of the functional distance between the DBS electrode and the IC is based on the activation functions of axons in the IC. We show the high sensitivity of accelerometers for tremor over a large part of the body, the relationship between clinical scores and spectral frequencies of FT and DDK. Parkinsonian rigidity can be assessed from surface EMG (sEMG) by means of a balance coefficient, which can detect negative rigidity, for low unified Parkinson's disease rating scale (UPDRS) scores (0–2) and quantified EMG when negative rigidity is excluded. Conclusion Accelerometer and sEMG recording have shown their value for intraoperative assessment of disabling motor symptoms and side effects during surgery, to optimize the target position electrodes for DBS. The combination with contemporary signal analyzing techniques permit intraoperative monitoring without a significant delay. IONM improves sensitivity and adds objective neurophysiological data. <s> BIB012 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> Deep brain stimulation (DBS) is an established treatment for Parkinson’s disease. Success of DBS is highly dependent on electrode location and electrical parameter settings. The aim of this study was to develop a general method for setting up patient-specific 3D computer models of DBS, based on magnetic resonance images, and to demonstrate the use of such models for assessing the position of the electrode contacts and the distribution of the electric field in relation to individual patient anatomy. A software tool was developed for creating finite element DBS-models. The electric field generated by DBS was simulated in one patient and the result was visualized with isolevels and glyphs. The result was evaluated and it corresponded well with reported effects and side effects of stimulation. It was demonstrated that patient-specific finite element models and simulations of DBS can be useful for increasing the understanding of the clinical outcome of DBS. <s> BIB013 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> BACKGROUND ::: This study examined changes in the translation of the center of pressure during forward and lateral (90 degrees to the side) gait initiation in two populations of older adults with postural instability. ::: ::: ::: METHODS ::: Twenty-eight older adults transitioning to frailty and 16 persons with Parkinson's disease in the "on medication state" were evaluated during initiation trials. Displacements, velocities, and smoothness of the center of pressure trace were calculated and compared. ::: ::: ::: FINDINGS ::: Both groups produced movements of the center of pressure that on average were reduced compared to healthy populations. Adults transitioning to frailty were able to scale the output of the motor program so forces that propel the body in the intended direction of movement were maximized as evidenced by movements of the center of pressure. The adults transitioning to frailty produced patterns of center of pressure trajectories that were more similar to healthy adults where as individuals with Parkinson's disease produced trajectories that were counterproductive to producing efficient gait initiation in both the forward and lateral direction. ::: ::: ::: INTERPRETATION ::: These findings suggest that persons with Parkinson's disease even when in the medicated state exhibit inefficient postural adjustments during both forward and lateral gait initiation and that these postural adjustments are more susceptible to deterioration from the complex interaction of central and peripheral changes associated with Parkinson's disease than to aging alone. <s> BIB014 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> Increased tremor and postural instability are motor problems commonly associated with Parkinson's disease (PD). Despite the similarity between these oscillatory forms, little is known about the relation between them, especially for individuals with enhanced tremor. This study was designed to examine the nature of any relation between center of pressure (COP) excursions and postural/resting limb tremor of young, older individuals, and Parkinsonian participants in their different medication states. The resting and postural tremor for the PD participants was characterized by a single, prominent peak frequency between 4 and 7 Hz. The postural tremor for young/older participants contained smaller peaks between 1 to 4 and 7 to 12 Hz although no prominent peak was seen in their resting tremor. The AP and ML COP dynamics of all participants was characterized by a major peak between 0.1 and 0.5 Hz. An additional peak was observed in the COP output of the PD participants between 4 and 7 Hz. While no tremor-COP coupling was observed for the young/old groups, coherence analysis revealed a significant degree of coupling between COP motion and tremor between 4 and 7 Hz for PD participants. These results highlight that the amplified tremor in PD can manifest itself in COP dynamics. This finding may have implications for postural stability for this patient group. © 2007 Movement Disorder Society <s> BIB015 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> The frequency of stimulation is one of the primary factors determining the effectiveness of deep brain stimulation (DBS) in relieving tremor. DBS efficacy, however, may depend not only on the average frequency of stimulation, but also on the temporal pattern of stimulation. We conducted intraoperative measurements of the effect of temporally irregular DBS (nonconstant interpulse intervals) on tremor. As the coefficient of variation of irregular high frequency DBS trains increased, they became less effective at reducing tremor (mixed effects regression model, P<0.04). These data provide evidence that the effects of DBS are dependent not only on the average frequency of DBS, but also on the regularity of the temporal spacing of DBS pulses. <s> BIB016 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> Objective:High-frequency subthalamic nucleus deep brain stimulation (STN-DBS) is an established treatment for patients with advanced Parkinson disease (PD). To date, intraoperative monitoring of parkinsonian symptoms, such as tremor and bradykinesia, is largely based on subjective strategies. We conducted a pilot study to evaluate short-term intraoperative outcomes of unilateral macrostimulation of the STN-DBS in PD patients using a neuromotor symptom registration device (CATSYS 2000 System). Methods:We studied 12 consecutive PD patients who received staged unilateral STN-DBS implants and 10 male control subjects free of neurologic deficits using a simple portable system with two sensors: a tremor pen and a touch recording plate. Results revealed excellent test–retest reliability for postural tremor in control subjects. PD patients were evaluated preoperatively during “off” state and intraoperatively for rest, postural tremor intensity, and frequency of finger tapping. Comparisons between premacrostimulation and postmacrostimulation were made using analysis of variance for repeated measures. Results:Electronic rest tremor registration revealed a mean improvement of ×12.5 in tremor intensity measurements in the stimulated/contralateral side (p = 0.002). An overall ×3.8 improvement was registered on the nonstimulated/ipsilateral side. Significant improvements after STN-DBS were also recorded for postural tremor and frequency of finger tapping. Conclusion:Using a noninvasive, simple, and sensitive electronic recording method of intraoperative motor symptom registration, we were able to supplement short-term clinical observation by objectively quantifying the characteristics of tremor and finger tapping in response to subthalamic nucleus deep brain macrostimulation. GLOSSARYDBS = deep brain stimulation; HI = harmonic index; MS = multiple sclerosis; PD = Parkinson disease; STN = subthalamic nucleus; UPDRS = Unified Parkinson’s Disease Rating Scale. <s> BIB017 </s> Stereotactic implantation of deep brain stimulation electrodes: a review of technical systems, methods and emerging tools <s> Movement pattern analysis <s> Abstract Essential Tremor (ET) is characterized by a 4–12-Hz postural and kinetic tremor, most commonly affecting the upper limbs. Deep brain stimulation (DBS) of the thalamus (Vim) has been found to be highly effective in severe/refractory forms of ET. Intra-operative assessment of tremor is performed using clinical methods based on patient and physician perception of tremor intensity. We present for the first time the case of a patient whose tremor was objectively monitored/quantified pre- and intra-operatively using device-based tremor registration to supplement clinical measures. We present the case of a 76-year-old right-handed woman that received unilateral (left-sided) DBS of the ventrointermediate (Vim) nucleus of thalamus (Vim) for medically refractory ET. Tremor was monitored with an accelerometer-based Tremor Pen ® , which is part of a simple portable device (CATSYS 2000 System ® , Danish Product Development Ltd., DK, www.catsys.dk). The patient was asked to perform tasks for tremor evaluation before and during thalamic DBS. Tremor quantification revealed a significant improvement (34.7-fold) in the contralateral (right) limb following macro-stimulation. No significant improvement was registered in the ipsilateral (non-operated) side. Simple electronic tremor registration methods during DBS of the Vim nucleus of the thalamus may supplement the existing methodology that is solely based on subjective measures derived from clinical observations. <s> BIB018
In order to make analysis of Parkinson's disease symptoms (tremor, bradykinesia, rigidity and postural instability) and dyskinesia more objective, several centres have introduced movement pattern analysis to their clinical evaluation procedure. It exists in a variety of laboratory-based systems to quantitatively measure and analyse body movement. This includes systems for movement analysis of dystonia BIB013 [78], tremor BIB002  BIB018 , bradykinesia  BIB003 , gait BIB004 BIB014 BIB015 and levodopa-induced dyskinesias BIB009 BIB005 . A majority of the mentioned papers deal with the quantitative evaluation of Parkinsonian symptoms in general. Still, only some of the mentioned movement analysis studies for Parkinson's disease have been performed in relation to DBS. Just to name some of them: Kumru BIB003 examined the effects of STN-DBS on characteristics of EMG activity of the wrist representative for bradykinesia and akinesia of the agonist muscle; Herzog BIB010 and Fukuda  applied accelerometry to compare between results of thalamic and subthalamic nucleus DBS and to correlate PET imaging (regional cerebral blood flow) with tremor in patients with unilateral Vim-DBS respectively. Sturman BIB011 examined the efficacy of STN-DBS and medication for resting tremor with accelerometery and EMG; Blahak BIB006 and Timmermann  did the same using an ultrasound-based measuring system (Blahak in addition to EMG). Several studies used quantified gait analysis to demonstrate the impact of STN and GPi stimulation on gait and balance BIB004 . Most of these studies concern pre-/postoperative or stimulation ON/OFF evaluations that means during preoperative office visits, hospitalisation for surgery, or postoperative follow-up visits. Intraoperative quantitative measurement of the motor manifestations of Parkinson's disease has rarely been proposed. Some groups intraoperatively used accelerometry and/or surface EMG BIB016 BIB012 , accelerometer-based tremor pens and touch recording plates BIB017 , or gyroscopes BIB007 to try to objectify the assessment of tremor and bradykinesia. Birdno et al. BIB016 used intraoperative accelerometry to demonstrate the influence of the periodicity of DBS on tremor, but did apparently not make it a part of their routine surgical protocol. Journee et al. BIB012 intraoperatively placed two 1D accelerometers on the index finger and analysed amplitude and frequency as tremor parameters. Even if there is no gold standard today for movement pattern analysis, accelerometers seem to be the most frequently used evaluation technique, but this can as well be linked to the fact that tremor is the mostly evaluated Parkinson's disease symptom. Some typical quantitative parameters for tremor and bradykinesia that have been derived from accelerometric measurements in addition to amplitude and frequency BIB012  are mean magnitude BIB001 BIB008 , the duration of tremor  , and poverty of movement  .