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Research paper
Gait worsening and the microlesion effect following deep brain stimulation for essential tremor
  1. Ryan Roemmich1,2,
  2. Jaimie A Roper3,
  3. Robert S Eisinger4,
  4. Jackson N Cagle5,
  5. Lauren Maine5,
  6. Wissam Deeb6,
  7. Aparna Wagle Shukla7,
  8. Christopher W Hess8,
  9. Aysegul Gunduz5,
  10. Kelly D Foote9,
  11. Michael S Okun6,
  12. Chris J Hass10
  1. 1 Center for Movement Studies, Kennedy Krieger Institute, Baltimore, Maryland, USA
  2. 2 Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  3. 3 School of Kinesiology, Auburn University, Auburn, Alabama, USA
  4. 4 Department of Neuroscience, University of Florida, Gainesville, Florida, USA
  5. 5 J. Crayton Pruitt Department of Biomedical Engineering, University of Florida, Gainesville, Florida, USA
  6. 6 Department of Neurology, University of Florida, Gainesville, Florida, USA
  7. 7 Center for Movement Disorders, Gainesville, Florida, USA
  8. 8 Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Florida, USA
  9. 9 Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
  10. 10 Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
  1. Correspondence to Dr Ryan Roemmich, Center for Movement Studies, Kennedy Krieger Institute, Baltimore, MA 21205, USA; rroemmi1{at}


Objective To investigate the effects of unilateral thalamic deep brain stimulation (DBS) on walking in persons with medication-refractory essential tremor (ET).

Methods We performed laboratory-based gait analyses on 24 persons with medication-refractory ET before and after unilateral thalamic DBS implantation. Normal and tandem walking parameters were analysed across sessions (PRE-DBS/DBS OFF/DBS ON) by repeated measures analyses of variance. Pearson’s correlations assessed whether changes in walking after DBS were global (ie, related across gait parameters). Baseline characteristics, lead locations and stimulation parameters were analysed as possible contributors to gait effects.

Results DBS minimally affected gait at the cohort level. However, 25% of participants experienced clinically meaningful gait worsening. Walking speed decreased by >30% in two participants and by >10% in four others. Decreased walking speed correlated with increased gait variability, indicating global gait worsening in affected participants. The worsening persisted even after the stimulation was turned off. Participants with worse baseline tandem walking performance may be more likely to experience post-DBS gait worsening; the percentage of tandem missteps at baseline was nearly three times higher and tandem walking speeds were approximately 30% slower in participants who experienced gait worsening. However, these differences in tandem walking in persons with gait worsening as compared with those without worsening were not statistically significant. Lead locations and stimulation parameters were similar in participants with and without gait worsening.

Conclusion Global gait worsening occurred in 25% of participants with unilateral DBS for medication-refractory ET. The effect was present on and off stimulation, likely indicating a microlesion effect.

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  • MSO and CJH are joint senior authors.

  • Contributors RTR, MSO and CJH designed the study. RTR and JAR collected and analysed gait data. RSE, JNC, LM and AG performed MRI and lead location analyses. RTR and RSE analysed clinical and demographic data. WD, AAWS, CWS and MSO conducted clinical assessments and collected clinical data. KDF performed all surgeries. MSO and CJH oversaw the study. RTR wrote the original draft of the manuscript. JAR, RSE, MSO and CJH edited the manuscript. All authors approved the final manuscript. RTR is guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Institutional Review Board at the University of Florida.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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