Objective: Provide a review of duty-cycle based programming, also referred to as “cycling” (CycPm), and its potential role in DBS for movement disorders.

Background: Continuous DBS is an effective therapy for medication refractory movement disorders. However, a small percentage of patients struggle with the balance of therapy benefit without bothersome side effects or loss of effectiveness. CycPm is an advanced strategy that regulates the duty cycle of stimulation at predefined on and off intervals. One meta-analysis of advanced programming techniques found limited literature on CycPm¹ which currently consists of mostly case reports².

Method: A retrospective chart review and single-center qualitative analysis of patients with DBS who had CycPm was performed. Clinical demographics, DBS programming parameters, and experiences with CycPm were extracted from medical records. We excluded patients with incomplete DBS programming documentation.

Results: A total of 40 patients with at least one CycPm setting programmed were identified. Justification for trying CycPm included suboptimal benefit with cDBS, therapeutic benefit limited by persistent stimulation induced side effects, and loss of therapeutic benefit over time. Of the 40, 24 had Parkinson’s disease (PD), 10 had essential tremor (ET), 4 had dystonia and 2 had post-traumatic brain injury (TBI) related tremor. In the PD cohort, 5 reported benefit and continued using CycPm until at least the next programming session. 19 patients experienced either no benefit or side effects and discontinued CycPm. In the ET cohort, 3 reported benefit while 7 reported no benefit or side effects. Mixed results were found in the dystonia and TBI cohorts. Of the 12 patients who reported benefit, 4 mentioned better tremor control (1 ET, 2 PD, 1 post-TBI). CycPm parameters varied, with stimulation on times ranging from 0.5 seconds to 5 minutes and off times from 0.2 to 10 seconds. For the 12 patients reporting benefit, adjustments to the cycling parameters (increasing stimulation on time, decreasing off time) optimized results in 5 patients.

Conclusion: CycPm is an advanced DBS strategy that may provide benefit in challenging cases, particularly those experiencing benefit wane or attempting better tremor control. Optimization of parameters, such as increasing stimulation on time and reducing off time, improved outcomes for several patients at UF.

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References: 1. Najera RA, Mahavadi AK, Khan AU, Boddeti U, Del Bene VA, Walker HC and Bentley JN (2023) Alternative patterns of deep brain stimulation in neurologic and neuropsychiatric disorders. Front. Neuroinform. 17:1156818. doi: 10.3389/fninf.2023.1156818 https://www.frontiersin.org/journals/neuroinformatics/articles/10.3389/fninf.2023.1156818/full

2. Enatsu R, Kitagawa M, Morishita T, Sasagawa A, Kuribara T, Hirano T, Arihara M, Mikami T, Mikuni N. Effect of Cycling Thalamosubthalamic Stimulation on Tremor Habituation and Rebound in Parkinson Disease. World Neurosurg. 2020 Dec;144:64-67. doi: 10.1016/j.wneu.2020.08.141. Epub 2020 Aug 22. PMID: 32841798. https://www.sciencedirect.com/science/article/pii/S1878875020319100?via%3Dihub

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MDS Abstracts - https://www.mdsabstracts.org/abstract/leveraging-duty-cycle-based-programming-for-deep-brain-stimulation/