In Cleveland’s humid summer heat, Michal Gostkowski, DO, doesn’t need a jacket. In fall, perhaps a light coat. As winter’s cold bite creeps in, he’ll be sure to bundle up.

Just like changing outerwear when the weather shifts, the brains of individuals with Parkinson’s disease (PD) sometimes need adjusting throughout the day. That’s the idea behind a newly cleared adaptive deep brain stimulation (aDBS) device now being used to treat PD, said Gostkowski, neurologist at Cleveland Clinic in Cleveland. As the patient’s brain and symptoms fluctuate throughout the day, aDBS adjusts in real time, offering tailored control.

While conventional DBS (cDBS) has been a cornerstone treatment for nearly 30 years, it has clear limitations. cDBS delivers constant, fixed electrical stimulation to targeted brain regions but can’t adjust to symptom fluctuations or the effects of medication. This can result in significant side effects, including dyskinesia.

In contrast, aDBS is a closed-loop system that offers a personalized alternative. By monitoring brain activity in real time and adjusting stimulation dynamically, this next-generation technology delivers greater symptom control with fewer side effects.

Neurologists in North America, Europe, and Asia are adopting the therapy to help preserve patients’ independence and function, offering hope for millions living with the disease.

The response, so far, has been promising. Of Gostkowski’s 75 patients using aDBS, to date, none has discontinued the therapy.

“This has been very advantageous for most patients,” Gostkowski told Medscape Medical News. “It just seems to provide what the body is missing, what the brain’s not doing by itself, and patients really like it.”

A Decade in the Making

In February, manufacturer Medtronic received FDA clearance for BrainSense aDBS and the BrainSense Electrode Identifier system, making it the first and only aDBS system cleared for clinical use in PD.

The approval was the culmination of more than a decade of research into refining aDBS — from determining which brain wave frequencies correlate to Parkinson’s motor symptoms to further identifying which signals were safe and effective enough to drive the aDBS system.

Researchers at Stanford University in Palo Alto, California, were the first to implant a sensing device that could handle aDBS with the fully embedded system.

In 2018, researchers at the University of California, San Francisco (UCSF), first implanted aDBS in two patients with PD, demonstrating that it was as effective at controlling symptoms as cDBS.

The procedure involves inserting electrodes into the brain and implanting a battery-powered pulse generator under the collarbone. The implanted leads are placed deep into the tiniest brain structures including the subthalamic nucleus where they pick up local field potentials. Within these signals, abnormal beta-band frequencies in the 13-30 Hz range activate the aDBS system.

Stimulation then modulates the disrupted beta waves in patients with PD, helping to alleviate certain motor symptoms.

A pivotal clinical trial — ADAPT-PD — led by Helen Bronte-Stewart, MD, MS, professor of neurology at Stanford University, served as the basis for FDA clearance of the technology.

The results of this 2020 multicenter, prospective, single-blind, randomized crossover trial were published in JAMA Neurology this week. Among the study’s 68 participants (70.6% men; mean age, 62.2 years; disease duration, 13.5 years), most had effective “on” time (defined as time when symptoms were well controlled) without experiencing troublesome dyskinesia compared with cDBS.

“More than two thirds of study participants indicated a ‘strong’ or ‘somewhat’ preference for aDBS over their previous cDBS settings for improved motor symptoms or fewer symptom fluctuations,” the investigators wrote.

There needs to be sufficient beta power close to the electrode to drive the system, Bronte-Stewart told Medscape Medical News. “If there isn’t enough of a signal recordable, then adaptive deep brain stimulation won’t work, and that often depends on where the lead is in the brain,” she said.

Realistic Expectations

Selecting patients with realistic expectations is key with aDBS, Gostkowski emphasized. Older patients and those with preexisting gait and speech problems are at a greater risk for stimulation-induced side effects, said Martijn Beudel, MD, PhD, neurologist and associate professor at Amsterdam University Medical Center (UMC) in Amsterdam, Netherlands.

In addition, patients with significant cognitive impairment or dementia are typically ineligible because the surgery itself may pose risks. Nonmotor symptoms of PD — such as swallowing difficulties, drooling, or blood pressure regulation — are not improved with this technology.

Some patients hope for improvements in memory or freezing of gait, Gostkowski noted, but these symptoms are unlikely to respond, which can lead to confusion about what aDBS can, and cannot, achieve. 

Rand Laycock, a 70-year-old music conductor who had been using cDBS to treat his PD, was a good fit for aDBS, Gostkowski said. Since Laycock switched from cDBS to the adaptive system earlier this year, the impact has been profound.

“My tremor is almost all gone, except if I experience extreme anxiety or stress — and my dyskinesia is pretty well under control,” Laycock said in a Cleveland Clinic patient profile. “My symptoms are minimal compared to the way they were, and a lot of that is due to the adaptive deep brain stimulation.”

In fact, aDBS has enabled him to continue his 47-year career on the podium.

Clinical data reinforce such patient-reported outcomes. A recent study led by UCSF researchers showed that aDBS improved symptoms and quality of life in patients with PD while reducing common side effects of cDBS.

Patients like Laycock who transition to aDBS require no further surgery — the Medtronic’s Percept DBS system can be updated via software to activate its adaptive setting.

Global Uptake

Although patients with the Percept device installed can technically update to aDBS, that doesn’t always mean they should.

“It takes a long time to set someone in an adaptive DBS mode, and the juice may not be worth the squeeze for many patients with well-placed DBS leads,” Michael Okun, MD, medical advisor for the Parkinson’s Foundation and author of the book The Parkinson’s Plan, told Medscape Medical News in an email.

Bronte-Stewart chimed a similar note. She cautioned against framing aDBS as a revolutionary alternative that patients must have. Rather, she said, it should be viewed as a personalized biological therapy vs an entirely new treatment.

Worldwide, more than 160,000 patients with PD have DBS implants, though it’s unclear how many are using aDBS. However, Medtronic reports that to date, over 40,000 people globally have the Percept device.

“The exact number of clinics using aDBS is still small. The barriers for implementation include the need for clinician training, the complexity of programming, and insurance reimbursement hurdles,” Okun said.

In the US, the cost of DBS ranges from $70,000 to $100,000. Gostkowski and Brett Youngerman, MD, neurosurgeon and assistant professor of neurological surgery at Columbia University Irving Medical Center in New York City, said that their patients with PD have had no issues getting insurance coverage for the treatment.

Across the pond in Netherlands, Beudel has been busy rolling out aDBS to his patients.

His team began using aDBS in routine clinical practice in 2021, initially through the ADAPT-PD trial, and has since expanded its use to roughly 20 patients this year.

He noted that patients currently require slightly more frequent hospital visits than those with cDBS, primarily for algorithm adjustments. However, in his experience, aDBS offers superior management of stimulation-induced side effects, including dysarthria, dyskinesia, and gait disturbances.

“We have the advantage that we stimulate less than with cDBS, so it’s less prone for side effects. Of course, we need to be very cautious when titrating the aDBS algorithms because we need to make sure that the stimulation is switching on based on a physiological signal that correlates with the symptoms of the patient,” he told Medscape Medical News.

Given the recent rollout of this technology, Beudel stressed the importance of learning from other clinicians and establishing an international registry of centers using aDBS. So far, 26 centers across Europe, the US, and Japan have joined the consortium with the goal of sharing patient outcome data and clinical insights.

Another advantage of aDBS is its longer battery life. Because it doesn’t stimulate the brain continuously, UCSF researchers found that it can conserve about 40% more power than cDBS. The battery requires monthly recharging but retains capacity for roughly 12 years — far outlasting most cell phones.

The Road Ahead

However, there are still key aspects of aDBS that experts believe need further refinement. “The main limitation right now is that it’s limited to a single predefined biomarker primarily focused on beta power,” Youngerman, who also reported beneficial outcomes from aDBS among his 25 patients, told Medscape Medical News.

The current commercial device remains first generation, but future iterations are expected to incorporate more sophisticated algorithms capable of interpreting additional neural signals as scientific understanding advances, said Bronte-Stewart.

aDBS is also being explored as a potential treatment for other neurologic disorders and certain psychiatric conditions.

The next step for aDBS is greater integration of artificial intelligence (AI), which could make the system more autonomous and reduce hospital visits by allowing the stimulation to self-titrate, Beudel said.

Remote monitoring tools are also in development, potentially allowing clinicians to access a patient’s aDBS data remotely and further reduce the need for clinic visits. Postmarket studies are planned, and early registries are being established, though results will likely take a year or more to emerge, Okun noted.

“The next-generation systems with AI-driven algorithms and better user interfaces are on the horizon. I’m excited. However, we must simplify programming and ensure broader access to make it a true game changer for Parkinson’s care,” he said.

But for now, aDBS appears to be making a meaningful difference for patients with PD in the US and abroad. Gostkowski’s patient Rand described the therapy as “a life-changing procedure that allows you to become your own self again.”

Youngerman and Gostkowski reported having no relevant financial disclosures. Beudel reported receiving research funding from the Amsterdam UMC TKI-PPP grant (2021 and 2023 call), the EU Joint Programme-Neurodegenerative Disease Research project (2021 call), Stichting ParkinsonFonds (2023 and 2025 call), and Medtronic (2023-2025), all paid to the institution. Bronte-Stewart and Okun reported having no relevant disclosures.