INTRODUCTION: Around 1% of adults have Parkinson's disease, with a median time of 9 years between diagnosis and death.
METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments in people with early-stage Parkinson's disease? What are the effects of adding other treatments in people with Parkinson's disease who have motor complications from levodopa? What are the effects of surgery in people with later Parkinson's disease? What are the effects of nursing and rehabilitation treatments in people with Parkinson's disease? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS: We found 59 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: adding a catechol-methyl transferase inhibitor, or dopamine agonist to levodopa; amantadine; dopamine agonists; levodopa (immediate-release, modified-release); monoamine oxidase B inhibitors; occupational therapy; pallidal deep brain stimulation; pallidotomy; Parkinson's disease nurse specialist interventions; physiotherapy; speech and language therapy; subthalamic nucleus deep brain stimulation; subthalamotomy; swallowing therapy; thalamic deep brain stimulation; and thalamotomy.
OBJECTIVE: To determine the effectiveness and adverse effects of deep brain stimulation (DBS) in the treatment of symptoms of idiopathic Parkinson's disease, essential tremor, and primary dystonia and to do an economic analysis if evidence for effectiveness is established.
THE TECHNOLOGY: Deep brain stimulation (DBS) is a surgical procedure indicated in the relief of motor function symptoms of Parkinson's disease, essential tremor and dystonia. It involves the surgical implantation of the DBS device, which include the implantable pulse generator or stimulator, the extension, and the lead. The electric impulse is produced within the stimulator component, and transmitted to the brain site by the extension and the lead(s). DBS surgery can be either unilateral or bilateral. The laterality of the surgery and target area for brain stimulation may vary with the type of symptom or spectrum of symptoms, and such decisions are made on a case-by-case basis. Advantages of DBS over ablative surgery is that it is comparatively less invasive, it is reversible, and it allows for stimulation of both sides of the brain. Ablative surgery, which is not practiced in Ontario, results in a non-reversible lesion and is often not conducted on both sides. Thus far, DBS has been considered as an adjunct to drug therapy.
REVIEW STRATEGY: The standard Medical Advisory Secretariat search strategy was conducted to identify international health technology assessments and English language journal articles published from January 1, 2001 onwards. Documents were reviewed separately for Parkinson's disease, essential tremor and primary dystonia.
SUMMARY OF FINDINGS: There is level 1b evidence that bilateral DBS of the subthalamic nucleus is effective in the short-term control of advanced parkinsonian symptoms, and there is level 3a evidence that the effect is sustained for at least 5 years. There is Level 3a evidence that DBS of the thalamus is effective in the control of tremor in patients with essential tremor and PD for at least 6 years. There is level 3a evidence that bilateral DBS of the globus pallidus is effective in the control of symptoms of primary dystonia for at least 1 year.
CONCLUSION: According to the estimates of prevalence and evidence of effectiveness, there is a shortfall in the numbers of DBS currently done in Ontario for drug-resistant PD, essential tremor, and primary dystonia.Since complication rates are lower if DBS is performed in specialized centres, the number of sites should be limited.The cost per procedure to institutions with the expertise to undertake DBS and the human resource considerations are likely to be limiting factors in the further diffusion of DBS.
Around 1% of adults have Parkinson's disease, with a median time of 9 years between diagnosis and death.
METHODS AND OUTCOMES:
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments in people with early-stage Parkinson's disease? What are the effects of adding other treatments in people with Parkinson's disease who have motor complications from levodopa? What are the effects of surgery in people with later Parkinson's disease? What are the effects of nursing and rehabilitation treatments in people with Parkinson's disease? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS:
We found 59 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS:
In this systematic review we present information relating to the effectiveness and safety of the following interventions: adding a catechol-methyl transferase inhibitor, or dopamine agonist to levodopa; amantadine; dopamine agonists; levodopa (immediate-release, modified-release); monoamine oxidase B inhibitors; occupational therapy; pallidal deep brain stimulation; pallidotomy; Parkinson's disease nurse specialist interventions; physiotherapy; speech and language therapy; subthalamic nucleus deep brain stimulation; subthalamotomy; swallowing therapy; thalamic deep brain stimulation; and thalamotomy.
