Chronic adaptive deep brain stimulation in Parkinson's disease: ADAPT-START findings and programming principles

Deep brain stimulation (DBS) is established for Parkinson's disease (PD), but conventional DBS (cDBS) may yield suboptimal symptom control and side effects, particularly on gait. Adaptive DBS (aDBS), adjusting stimulation to subthalamic beta activity, may offer superior outcomes, though programming remains incompletely defined. Between January and April 2025, we offered dual threshold aDBS to 20 consecutive PD patients with chronic cDBS and a Percept neurostimulator. Nine were eligible; exclusions were due to signal artifacts, absence of a distinct beta peak, or stimulation settings incompatible with aDBS. By July 2025, five remained on chronic aDBS, one reverted to cDBS by preference, and three were still in optimization. In this manuscript, we outline our aDBS programming principles and preliminary clinical efficacy. On unblinded MDS-UPDRS III, aDBS yielded a ~35% greater motor improvement than cDBS, with gait showing the most consistent benefits. Dual threshold aDBS appears clinically advantageous, though current technical and programming constraints may limit widespread adoption.