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Dear Editor, Three patients with relatively young-onset levodopa-responsive Parkinson’s disease (PD) underwent subthalamic (STN) deep brain stimulation (DBS) surgery for the management of severe motor response complications following oral dopaminergic therapy. All patients experienced a substantial motor function benefit postoperatively but developed a delayed (> 5 years following DBS) deterioration in gait, characterized by freezing of gait (FOG), slowing of gait and lower limb dystonia. The patients reported that gait dysfunction did not fluctuate according to levodopa intake and was refractory to the optimization of the DBS settings and oral medication regimen, including levodopa at doses ≥ 600 mg/day. This study was deemed exempt from formal ethical review by our institution’s Research Ethics Committee (R20180718). All patients gave written informed consent for their data to be published. Patients were started on daytime levodopa-carbidopa intestinal gel (LCIG) infusion via jejunostomy following a nasoduodenal trial of this therapy. Walking and 180-degree turn times in the “on-stimulation/on-medication” state were recorded on video before initiation of LCIG infusion and again after at least 6 months. Baseline (i.e., pre-LCIG) videos were recorded 1–2 hours after the standard morning dose of levodopa. Followup (i.e., post-LCIG) videos were recorded during daytime LCIG infusion at each patient’s prescribed continuous rate. The DBS settings were identical at the pre-LCIG and post-LCIG assessments. Clinical details of the patients are summarized in Table 1. Walking and 180-degree turn times and distances one day before LCIG initiation and at variable times (6–23 months) after LCIG initiation are shown in Table 1. Changes in walking and 180-degree turn times were analyzed by a two-tailed paired t-test. Supplementary Video 1 in the online-only Data Supplement shows the 10 meter walk times (10 meter walk to target, 180-degree turn, then return to origin) of patient 2 recorded one day prior to and six months after commencement of LCIG infusion. There was a mean 28% improvement (range 14-41) in followup walking time relative to the baseline walking time (p = 0.118). There was a mean 36% improvement in the 180-degree turn time (p = 0.057). All patients reported a significant reduction in episodes of FOG while they were on LCIG. Patients reported that the improvement in gait occurred within days or weeks of commencing LCIG and were sustained with long-term use. All patients remain on LCIG at the time of writing and continue to live independently or semi-independently. STN DBS is an effective treatment for a range of motor problems in PD, including cardinal manifestations (tremor, rigidity, and bradykinesia) and medication response complications (motor fluctuations and dyskinesias).1 Improvement in these aspects

journal of movement disorders

Benefits of Levodopa-Carbidopa Intestinal Gel Infusion in Patients with Parkinson’s Disease Experiencing Gait Dysfunction Following Subthalamic Deep Brain Stimulation