How Is Deep Brain Stimulation Used To Treat Parkinsons Disease
Deep brain stimulation delivers electrical impulses to a targeted area of the brain that is responsible for the movement symptoms caused by Parkinsons disease. The electrical impulses disrupt the abnormal activity that occurs in the brains circuitry, which is causing the symptoms.
There are three areas in the brain that can be targets for deep brain stimulation in patients with Parkinsons disease. They are the subthalamic nucleus, the globus pallidus internus, and the ventral intermediate nucleus of the thalamus. Each of these areas plays a role in the brains circuitry that is responsible for the control of movement.
The specific area in the brain to target in an individual with Parkinsons disease depends on symptoms that need to be treated. For example, deep brain stimulation of subthalamic nucleus is effective for all major movement symptoms of Parkinsons disease, such as tremor, slowness of movement , stiffness , and problems with walking and balance. Deep brain stimulation of globus pallidus is another effective target for a wide range of Parkinsons symptoms. The thalamic target is sometimes selected for patients with tremor symptoms. The recommended target for each patient is made collaboratively with the neurologist, neurosurgeon and other caregivers involved in the decision making process.
What Did The Research Involve
The researchers recruited 251 people from Germany and France with Parkinson’s disease and early movement problems. To be included, patients had to be between 18 and 60 years, have had Parkinson’s for at least four years, and not have a severe form of the disease.
Patients with major depression or dementia were not included in this study. They were randomly assigned to receive either neurostimulation plus medical therapy , or medical therapy only .
The neurostimulation group underwent surgery to have electrodes implanted into certain parts of the brain and were fitted with a neurostimulator that was connected to the electrodes.
The electrical implant generated small electrical signals to stimulate the brain and was controlled by a handheld device. These electrical signals block abnormal nerve signals, which are thought to trigger the symptoms of Parkinson’s disease.
Medical therapy involved standard drug therapy for Parkinson’s disease. All patients were then assessed at five months, one year and two years.
The primary outcome of the trial was disease-related quality of life at two years, which was assessed using the Parkinson’s disease questionnaire . The PDQ-39 is essentially a scoring system that assesses the extent that the disease has impacted a person’s quality of life. Scores in the questionnaire ranged from 0 to 100, with higher scores indicating worse function.
Other outcomes measured were:
- time with good mobility and no dyskinesia
- adverse events
Resources For More Information
- Surgical option a potential life-changer for patients with OCD: Read and watch Erins story as she, a lively 21-year-old woman, fought her battle with OCD. This article explores how deep brain stimulation gave Erin her life back. The procedure was the first of its kind performed at Albany Medical Center the only facility offering this treatment between New York and Boston. In Erins own words, Now, I can be who I really am and tell people my story and hopefully inspire people and help people along the way.
- Karen and Jims Story: A Shared Journey of Life, Love and DBS: Read about Karen and Jim. They were each diagnosed with Parkinsons before they met. Follow them on their journey as they fall in love after meeting each other from an online support group. See how they embraced each other and DBS.
- Kays Story A Parkinsons Disease Patient: Read about Kay, a 68-year-old woman suffering from Parkinsons disease. The article and video explore how DBS helped her regain her life. In Kays own words, Its like I had been turned on again. It was like a miracle.
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Less Medication More Relief
Medtronic DBS therapy may reduce the need for other Parkinsons medications1 and, consequently, medication-related side effects. DBS delivers therapy 24 hours a day and doesnt wear off while sleeping. Its already working when you wake up.
* Signal may not be present or measurable in all patients. Clinical benefits of brain sensing have not been established.
A Recent Study Reveals That Deep Brain Stimulation Remains Effective In Parkinsons Patients 15 Years After Device Implantation
June 04, 2021 – Deep brain stimulation has sustained benefits for Parkinsons patients fifteen years after device implantation, a recent study published in Neurology reveals. Study participants continue to experience motor function improvement and less dependence on medications to curb symptoms.
Deep brain stimulation benefits seem to last for several years but not enough data have been available to show that these effects are still present more than 15 years after surgery, said study author Elena Moro, MD, PhD, a Fellow of the American Academy of Neurology, in a press release.
We wanted to know if people with Parkinsons disease continue to benefit from this treatment. It is exciting to report that our study found in the long run, deep brain stimulation continues to be effective in people with Parkinsons disease.
Dig Deeper
Researchers studied a cohort of 51 Parkinsons patients who had a deep brain stimulation device implanted. Patients had the device for an average for 17 years. While the average age of diagnosis was 40, the average age of the candidate when they received the implant was 51.
The deep brain stimulation device is implanted surgically under the skin in the patients chest. Electrodes placed strategically on the brain communicate with the device which maintains control of electrical impulses.
- Tagged
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An Important First Step
Also, Dr. Starr explains, Other adaptive deep brain stimulation designs record brain activity from an area adjacent to where the stimulation occurs, in the basal ganglia, which is susceptible to interference from stimulation current.
Instead, he goes on, our device receives feedback from the motor cortex, far from the stimulation source, providing a more reliable signal.
The researchers are excited about the avenues that this feasibility study is opening up in terms of improving Parkinsons therapy, and they are already planning larger trials in order to test the devices long-term effectiveness.
The novel approach taken in this small-scale feasibility study may be an important first step in developing a more refined or personalized way for doctors to reduce the problems patients with Parkinsons disease face every day.
Nick B. Langhals, program director at NINDS
You can watch Dr. Starrs explanation about the innovative brain stimulation devices in the video below.
Planning And Surgical Technique
Prior to surgery the operation is planned on a computer using MRI scans. The surgeon chooses targets in the brain . Usually two electrodes are inserted, one on each side of the head. After selecting each target point, an entry point is chosen where a hole will be drilled in the skull to pass the wire through. The entry point is chosen such that the trajectory path avoids blood vessels, thereby reducing the incidence of bleeding complications.
Caption: The Sacramento, Calif. operating room where Parkinsons disease patient Joel Davis undergoes his deep brain stimulation brain surgery for Parkinsons disease photo reproduced with permission of the photographer
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Stereotactic Dbs Vs Interventional Image
Stereotactic DBS surgery requires the patient to be off their medication. During the procedure, a frame stabilizes the head and provides coordinates to help the surgeons guide the lead to the correct location in the brain. The patient gets local anesthesia to keep them comfortable throughout each step along with a mild sedative to help them relax.
During image-guided DBS surgery, such as with interventional MRI or CT scan, the patient is often asleep under general anesthesia while the surgeon uses images of the brain to guide the lead to its target.
Some advanced centers offer both the stereotactic and iMRI-guided options for DBS surgery. In this case, the doctor and patient will discuss which procedure is better based on a number of factors.
For instance, the doctor may recommend an image-guided procedure for children, patients who have extreme symptoms, those who are especially anxious or fearful or those whose leads are going into certain parts of the brain.
Generally, DBS surgery follows this process:
Exactech Connexion Gxl Hip Implant Liner Recall Sparks Lawsuits
In June 2021, Exactech issued an urgent letter to orthopedic surgeons concerning the high failure rate of its GXL hip implant liners. There have been several articles in the medical literature questioning the early failures of the GXL hip implant liners. Exactech has also sent recall letters to some patients.
In 2019, Exactech removed the GXL liners from the US market in favor of a new product called the XLE liner. The medical literature and reports had shown hip implant patients with the GXL liner that had premature wear of the polyethylene and failure of the liners requiring revision surgery. Exactech sold almost 90,000 of these liners which were implanted in patients before it was removed from the market in 2019.
The GXL liners that have been failing were designed for use with the Exactech Novation, Accumatch and MCS hip implant systems.
Industry standards in the hip implant manufacturing community require that implants have a failure rate of less than one percent per year. That means that after 10 years 90% of implants should still be functional and after 20 years 80% of hip implants should remain functional. The Exactech implant failures with a GXL reported to the company are occurring between three and six years from the initial implant surgery.
If you have had a failure of an Exactech hip implant please contact us so we can review your case and be sure the failure is reported to the FDA.
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Success Rates Of Dental Implant In Patients With Parkinsons Disease
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Introduction of Clinical Question
Background
Parkinsons Disease is one of the most common conditions that present with orofacial dystonia and dyskinesia .
This leads to patients with the disease having trouble performing everyday activities such as eating, speaking and maintaining oral hygiene . Parkinsons Disease is more often seen in men than women and affects every 120 out of 100,000 people. There are two modes of this disease. The first is a genetic form which only consists of 5% of people with Parkinsons and occurs at a young age. The second occurs around the age of 57 and is deemed idiopathic as it has a more complex etiology where there is a familial and environmental component . Secondary Parkinsonism can be drug-induced. Parkinsons disease is caused by the death of dopaminergic neurons in the substantia nigra and locus coruleus. It is caused by the presence of Lewy bodies in the nerve cells in areas as such .
These neurons, which are subsequently destroyed, are necessary for the control of movement and coordination. Patients begin to experience symptoms once there is about a 65% reduction in functioning dopaminergic neurons .
Significance
Purpose
Patients Presentation of Condition or Risk
Data Management Design Inputs
Having the object of accelerating neurophysiological research, a core requirement for a bidirectional IPG acting as a clinical BCI is to store and transmit neural signals. Although chronic data streaming represents a heuristic goal, its practical implementation still needs to overcome important limitations such as high-power demand, consequent fast battery drain, and maintenance of a permanent external receiver link all these features ultimately add unnecessary burdens for patients. For instance, continuous data streaming with an implantable rechargeable device require the use of a transmitter that has to be continuously worn by the patient. Many bidirectional neuromodulation platforms are targeting chronic wireless communication at the preclinical or investigational stage.
Embedding compressed data requires to have an a priori knowledge of what signal features are significant for the specific disease, but because of the exploratory application of clinical BCI, time domain data are necessary to the discovery of new biomarkers and physiological mechanisms of action. Moving from the concept of chronic monitoring to exploratory recording, the requirement of data wireless streaming can be relaxed by limiting it to on-demand and time-constrained streaming sessions that allow for controlled experimental investigations without burdening the patient.
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Who Is A Candidate For Deep Brain Stimulation
DBS is more than just a surgical procedure. It involves a series of evaluations, procedures, and consultations before and after the actual operation, so people interested in being treated with DBS should be prepared to commit time to the process.
For example, those who do not live close to a medical center that offers DBS surgery may need to spend significant time traveling back and forth to appointments.
The procedure, as well as the pre-operative evaluation and post-operative follow-up, can be expensive depending on the persons insurance coverage. DBS surgery is an FDA-approved treatment for Parkinsons disease, and Medicare and most private insurers cover the procedure, but the extent of coverage will depend on each persons individual policy.
Prospective patients should have realistic expectations about DBS results. Although DBS can improve movement symptoms of Parkinsons disease and greatly improve quality of life in properly selected patients, it is not likely to return anyone to perfect health.
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Currently Available Deep Brain Stimulation Devices
At the current time, the U.S Food and Drug Administration has approved several different deep brain stimulation devices from three separate manufacturers. While all DBS systems have the same basic components and work the same way, each device is unique. The differences are not drastic, but they represent innovation and improvement in care and care delivery. Variations, such as rechargeable batteries or electrodes that can deliver stimulation in novel ways or sense and record your brain signals, may lead you and your doctor to pick one over another. Available DBS devices for Parkinsons include:
ABBOTT
Infinity
Abbotts Infinity DBS was FDA-approved for Parkinsons in 2016. Infinitys brain leads allow directional stimulation, which is a potentially increased ability for the clinician to guide electrical stimulation toward areas associated with symptoms and away from side effects. This device operates with Apple iOS software and controllers. It also uses a non-rechargeable battery.
In 2021, Abbott developed a new technology that enables people with these devices to communicate with their clinician and receive DBS adjustments remotely, from their home or other location through WiFi, using the patient controller device.
For some, knowing they can connect with their doctor and adjustments anytime and anywhere makes life with DBS a little easier.
MEDTRONIC
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Major Depression And Obsessive
DBS has been used in a small number of clinical trials to treat people with severe treatment-resistant depression . A number of neuroanatomical targets have been used for DBS for TRD including the subgenual cingulate gyrus, posterior gyrus rectus,nucleus accumbens, ventral capsule/ventral striatum, inferior thalamic peduncle, and the lateral habenula. A recently proposed target of DBS intervention in depression is the superolateral branch of the medial forebrain bundle its stimulation lead to surprisingly rapid antidepressant effects.
The small numbers in the early trials of DBS for TRD currently limit the selection of an optimal neuroanatomical target. Evidence is insufficient to support DBS as a therapeutic modality for depression however, the procedure may be an effective treatment modality in the future. In fact, beneficial results have been documented in the neurosurgical literature, including a few instances in which people who were deeply depressed were provided with portable stimulators for self treatment.
DBS for TRD can be as effective as antidepressants and can have good response and remission rates, but adverse effects and safety must be more fully evaluated. Common side effects include “wound infection, perioperative headache, and worsening/irritable mood increased suicidality”.
What Is Deep Brain Stimulation
In deep brain stimulation, electrodes are placed in a specific area of the brain depending on the symptoms being treated. The electrodes are placed on both the left and right sides of the brain through small holes made at the top of the skull. The electrodes are connected by long wires that travel under the skin and down the neck to a battery-powered stimulator under the skin of the chest . When turned on, the stimulator sends electrical pulses to block the faulty nerve signals causing tremors, rigidity, and other symptoms.
A DBS system has three parts that are implanted inside the body:
- Neurostimulator a programmable battery-powered pacemaker device that creates electric pulses. It is placed under the skin of the chest below the collarbone or in the abdomen.
- Lead a coated wire with a number of electrodes at the tip that deliver electric pulses to the brain tissue. It is placed inside the brain and connects to an extension wire through a small hole in the skull.
- Extension an insulated wire that connects the lead to the neurostimulator. It is placed under the skin and runs from the scalp, behind the ear, down the neck, and to the chest.
DBS is very effective at reducing dyskinesias, the uncontrolled wiggling movements caused by high doses of levadopa medication. Typically, DBS will help make your symptoms less severe so that lower medication doses may be used.
Electrodes can be placed in the following brain areas :
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What Are The Results
Successful DBS is related to 1) appropriate patient selection, 2) appropriate selection of the brain area for stimulation, 3) precise positioning of the electrode during surgery, and 4) experienced programming and medication management.
For Parkinson’s disease, DBS of the subthalamic nucleus improves the symptoms of slowness, tremor, and rigidity in about 70% of patients . Most people are able to reduce their medications and lessen their side effects, including dyskinesias. It has also been shown to be superior in long term management of symptoms than medications .
For essential tremor, DBS of the thalamus may significantly reduce hand tremor in 60 to 90% of patients and may improve head and voice tremor.
DBS of the globus pallidus is most useful in treatment of dyskinesias , dystonias, as well as other tremors. For dystonia, DBS of the GPi may be the only effective treatment for debilitating symptoms. Though recent studies show little difference between GPi-DBS and STN-DBS.
Patients report other benefits of DBS. For example, better sleep, more involvement in physical activity, and improved quality of life.
Recent research in animals suggest that DBS may “protect” or slow the death of dopamine nerve cells . While the scientific data is inconclusive, observation of DBS patients show potential slowing of the disease relative to their pre-DBS condition.