Tuesday, August 2, 2022

What Is Deep Brain Stimulation For Parkinson’s Disease

How Do I Get Ready For Dbs

Deep Brain Stimulation for Parkinson’s Disease

DBS requires a commitment to participate in evaluations, procedures, and consultations before and after the procedure. DBS is usually only available in large medical centers. If you do not live close to a medical center that offers DBS procedures, you may need to spend significant time traveling. The procedure and associated appointments can be expensive. It is also important for you to have realistic expectations. Although DBS can improve symptoms, it will not cure the condition.

Before DBS, you will have assessments to determine whether this is a good option for you. You will need tests to evaluate memory and thinking. A psychiatrist may examine you to determine if you have a condition such as depression or anxiety that requires treatment before the DBS procedure.

Ask your healthcare provider about what you might need to do in the days and weeks before your procedure, such as if there are any special dietary or medicine restrictions.

Current And New Dbs Targets

Chronic degeneration of dopamine neurons in the SNc and consequent striatal dopamine deficiency seems to lead to a cascade of functional changes, which underpin many clinical features of PD . Studies published in the early 1990s using MPTP primate models of parkinsonism support the hypothesis that abnormally increased activity in STN leads to abnormal GPi activity . This seems to lead to excessive inhibition of the thalamocortical and brainstem motor projections .

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:

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What Is Deep Brain Stimulation Or Dbs

Deep brain stimulation, or DBS, is often described as a pacemaker for the brain. It works much like a pacemaker, sending electrical signals to the brain instead of the heart. DBS is primarily utilized for patients who have Parkinsons disease, dystonia, or essential tremor, and who cant adequately control their disease with medication. Before any patient is considered for the surgery, they are evaluated by the U-M interdisciplinary team. That team includes a neurosurgeon, neurologist, clinical neuropsychologist, speech pathologist, social worker, and other team members who ensure that you and your family understand the procedure and discuss your expectations and concerns.

Its important to understand that DBS does not offer a cure for your disease, but a way to manage it more effectively. It can offer many benefits, including the need to take less medication and therefore experience fewer medication side effects.

Is There Anything I Can Do To Slow The Progression Of Parkinsons Symptoms

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Treatment for Parkinsons can help you manage your symptoms. Currently, theres no way to cure or stop the progression of Parkinsons. However, medical professionals have found ways to slow the progression of symptoms with therapies such as medications and deep brain therapy.

Diet and exercise are also known to slow down Parkinsons. Studies have shown that eating a nutritious diet, such as the Mediterranean diet, can help slow down the progression of Parkinsons disease.

Additionally, getting regular exercise has been shown to slow down symptom progression. People with Parkinsons should try to get at least 2.5 hours of exercise each week. A physical therapist or another medical professional can help you develop an exercise routine that meets your needs.

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Conflict Of Interest Statement

PH is the director of the Duke University Parkinson Disease and Movement Disorders fellowship, which receives grant support from Medtronic. MS works for Duke University, and has received consultancy fees from Eli Lilly, Merz, Osmotica, Pfizer, SK Life Sciences, Allergan, Avid, Best Doctors, Biotie, Lundbeck, Neuronova, Novartis Pharma , Saraepta Therapeutics, and Sunovion Pharmaceutics, Inc. Dr. MS has also received grants from the Michael J. Fox Foundation, the NIH, the Parkinson Study Group, and Pharma 2B, royalties from Informa Press for the Handbook of Dystonia and Duke University for the Wearing Off Questionnaire. He has also received payment for development of educational presentations from the University of Kansas, the University of Miami, and the University of Rochester. Dr. MS also received paid travel accommodations from the Cleveland Clinic Neurological Institute, the Movement Disorder Society, and the National Parkinson Foundation.

Overview Of Medical Management Of Pd

The basic approach to PD management begins with the identification of specific symptoms that contribute significantly to disability and also are amenable to therapy. Typically, the cardinal motor symptoms are most responsive to classic PD pharmacotherapy. Great care must be exercised by patients and clinicians to avoid targeting symptoms that are unrelated to PD with PD medications, as well as not to mislead patients by attributing symptoms to PD when they are due to other causes. If the initial target symptoms are of sufficient severity to affect daily activities, anti-PD therapy is generally recommended. Levodopa and its many formulations, synthetic dopamine agonists, inhibitors of monoamine oxidase-type B, anticholinergics, and amantadine can all be used as first-line medications, either alone or in combinations. Inhibitors of catechol-O-methyltransferase are not utilized as monotherapy, but can augment the effect of levodopa formulations as well.

Dyskinesias occur in a majority of medicated PD patients over time, with estimates of 40%50% of PD patients developing dyskinesias within 46 years.5,24 Onset of dyskinesias is most commonly correlated with duration and dose of levodopa as well as disease duration itself.24 A common misconception is that dyskinesias always indicate overdosing of anti-PD medications. In fact, many times, the optimal medication regimen with the least disability and fewest side effects is marked by prominent dyskinesias.

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How Deep Brain Stimulation Works

Exactly how DBS works is not completely understood, but many experts believe it regulates abnormal electrical signaling patterns in the brain. To control normal movement and other functions, brain cells communicate with each other using electrical signals. In Parkinson’s disease, these signals become irregular and uncoordinated, which leads to motor symptoms. DBS may interrupt the irregular signaling patterns so cells can communicate more smoothly and symptoms lessen.

Deep Brain Stimulation For Parkinsons Disease

Deep Brain Stimulation (DBS) for Parkinson’s disease

For people with severe motor symptoms of Parkinsons disease that are not adequately controlled by medication, a treatment called deep brain stimulation may offer some relief.

Deep brain stimulation requires the surgical placement of a small conductor called an electrode in the brain. The electrode delivers electrical stimulation that blocks the nerve signals that cause tremors.

Specialists at NYU Langones Center for Neuromodulation perform more than 100 deep brain stimulation procedures each year. Our neurologists, neurosurgeons, and psychiatrists provide a thorough evaluation to ensure youre a good candidate for the procedure.

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What Benefits Does The Procedure Offer

DBS is not a cure for Parkinsons, but it may help control motor symptoms while allowing a reduction in levodopa dose. This can help reduce dyskinesias and reduce off time. DBS does not usually increase the peak benefits derived from a dose of levodopa the best levodopa response before DBS is a good indicator of the best response after DBS. But it can help extend the amount of on time without dyskinesias, which may significantly increase quality of life.

DBS does not provide most patients benefit for their non-motor symptoms, such as depression, sleep disturbance, or anxiety. DBS also does not usually improve postural instability or walking problems. If a symptom you have does not respond to levodopa, it is not likely to respond to DBS.

The Surgery Involves Electrodes Being Inserted Into The Brain

Manzil Bacchus was diagnosed with Parkinsons disease in 2008. Initially, he was told that there was nothing he could do to stop the progression of the progressive nervous system disorder that affects movement. Manzil and his wife, Sadia, continued to manage the increasingly worrisome symptoms which included tremors and the growing amount of medication that he had to take each day.

After Manzil was diagnosed with colitis, a chronic digestive disease that has been linked to Parkinsons, the family began investigating a new surgical option. In deep brain stimulation , electrodes are inserted in regions of the brain that have been affected by the Parkinsons, with an impulse generator battery also inserted in another area of the body. When turned on, the electrodes send gentle electrical pulses to help improve symptoms like tremors and motor control.

Manzil and Sadia sat down with Healthing to talk about Manzils experience having brain surgery during the COVID-19 pandemic and the difference that deep brain stimulation has made to his quality of life.

When was Manzil diagnosed with Parkinsons?Manzil: Back in 2007, my hands started shaking. I was volunteering at a mosque, helping people to take a pilgrimage in Saudi Arabia, helping with their application for visas and stuff like that. One of the girls noticed my hand shaking and asked why. I thought I was just tired. After that, I also noticed that my left foot was dragging when I walked.

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Why A Doctor May Choose Deep Brain Stimulation

According to the National Parkinson Foundation, the ideal Parkinsons disease candidate for DBS surgery has:

  • PD symptoms that interfere with activities of daily living.

  • Fluctuations in mobility due to PD medications with or without dyskinesia .

  • Continued good response to PD medications, even if the medication effects may wear off sooner than they have in the past.

  • A history of several different combinations of PD medications while under the supervision of a neurologist specializing in movement disorders.

These factors* may make a person a less than ideal candidate for DBS surgery:

  • Difficulty with balance, walking, or freezing as the main disabling symptom.

  • A primary symptom of speech difficulty.

  • Continuous confusion and problems with memory and thinking.

  • A psychiatric condition such as depression or anxiety that has not improved or stabilized with other treatment.

  • Another condition that increases the risk for surgery complications.

*Some of these factors may be treatable. Having one or more does not disqualify a person for future DBS surgery, but the doctor may recommend more aggressive therapy focused on these issues before surgery takes place.

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Manzil and Sadia sat down with Healthing to talk about Manzils experience having brain surgery during the COVID-19 pandemic and the difference that deep brain stimulation has made to his quality of life.

When was Manzil diagnosed with Parkinsons?Manzil: Back in 2007, my hands started shaking. I was volunteering at a mosque, helping people to take a pilgrimage in Saudi Arabia, helping with their application for visas and stuff like that. One of the girls noticed my hand shaking and asked why. I thought I was just tired. After that, I also noticed that my left foot was dragging when I walked.

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Deep Brain Stimulation Program

The Deep Brain Stimulation program at Boston University Medical Campus is a collaborative medical and surgical program offered by the departments of Neurology and Neurosurgery for the treatment of Parkinsons disease, Essential Tremor, and Dystonia. This multidisciplinary program combines the efforts of the departments of neurosurgery, neurology, neuropsychiatry, behavioral medicine, anesthesiology, and nursing. Neurosurgical interventions for Parkinsons disease and tremor have been offered at BUMC since 1996.

A multi-step screening process is used to carefully select patients for this procedure. Some patients who may be candidates for surgery include: 1) patients who do not have good movement control despite optimized medical therapy and 2) patients who have dyskinesia or other side effects which limit the use of Parkinsons medications.

In the selection process patients are referred by their neurologist for a screening neurological consultation by the neurological DBS program team members. Patients are evaluated with a brain MRI, neuropsychological testing and movement testing with videotaping. A meeting is also scheduled with the neurosurgeon who provides information on DBS and determines eligibility for surgery.

After DBS surgery, follow up neurological care and adjustments of medications and DBS neurostimulators is conducted by our team. To learn more about the Deep Brain Stimulation program, .

What Happens After Surgery

After surgery, you may take your regular dose of Parkinson’s medication immediately. You are kept overnight for monitoring and observation. Most patients are discharged home the next day.

During the recovery time after implanting the electrodes, you may feel better than normal. Brain swelling around the electrode tip causes a lesion effect that lasts a couple days to weeks. This temporary effect is a good predictor of your outcome once the stimulator is implanted and programmed.

About a week later, you will return to the hospital for outpatient surgery to implant the stimulator in the chest/abdomen. This surgery is performed under general anesthesia and takes about an hour. Patients go home the same day.

Step 7: implant the stimulator You will be taken to the OR and put to sleep with general anesthesia. A portion of the scalp incision is reopened to access the leads. A small incision is made near the collarbone and the neurostimulator is implanted under the skin. The lead is attached to an extension wire that is passed under the skin of the scalp, down the neck, to the stimulator/battery in the chest or abdomen. The device will be visible as a small bulge under the skin, but it is usually not seen under clothes.

You will have lifting and activity restrictions for 6-8 weeks while the incisions heal. Follow all discharge instructions and the neck exercises provided. Incision pain can be managed with medication.

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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.

What Is Deep Brain Stimulation For Parkinsons Disease

Exploring the Use of Deep Brain Stimulation in Parkinson’s Disease

Deep brain stimulation is a surgical procedure used to treat a variety of disabling neurological symptomsmost commonly the debilitating symptoms of Parkinsons disease , such as tremor, rigidity, stiffness, slowed movement, and walking problems. The procedure is also used to treat essential tremor, a common neurological movement disorder. At present, the procedure is used only for patients whose symptoms cannot be adequately controlled with medications.

DBS uses a surgically implanted, battery-operated medical device called a neurostimulatorsimilar to a heart pacemaker and approximately the size of a stopwatchto deliver electrical stimulation to targeted areas in the brain that control movement, blocking the abnormal nerve signals that cause tremor and PD symptoms.Before the procedure, a neurosurgeon uses magnetic resonance imaging or computed tomography scanning to identify and locate the exact target within the brain where electrical nerve signals generate the PD symptoms.

Some surgeons may use microelectrode recordingwhich involves a small wire that monitors the activity of nerve cells in the target areato more specifically identify the precise brain target that will be stimulated. Generally, these targets are the thalamus, subthalamic nucleus, and globus pallidus.The DBS system consists of three components: the lead, the extension, and the neurostimulator.

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What Are The Benefits Of Dbs

The benefits of DBS vary from person to person. However, most people with PD find that DBS aids them in several ways.

DBS generally eases abnormal movements, muscle stiffness, and tremors. Many studies have found a drop in motor symptoms, especially tremors, after DBS. One study reported improvements in 72.5% of the people with tremors who took part in the research.1-4

DBS often results in a higher standard of living. A decrease in motor symptoms allows people to move better. This helps them to carry out routine tasks more easily. With fewer symptoms, they also have less need for drugs to treat those symptoms, and thus, fewer side effects.1,3,4

Surgery To Implant The Deep Brain Stimulation Device

Deep brain stimulation requires the surgical implantation of an electrical device into the brain. A neurosurgeon uses imaging scans to pinpoint the right spot in the brain for implanting the electrode.

When surgeons have determined the correct location, they create a small opening in the skull and insert a thin, insulated wire, through which they insert the electrode. Surgery to implant the electrode takes about four hours and requires general anesthesia. You may then stay overnight in the hospital for observation.

The next day, doctors perform the second part of the surgery, which involves connecting the insulated wire to a battery-operated pulse generator that is implanted under the skin near the collarbone. Most people can return home after this procedure.

Several days after the surgery, you meet with your neurologist, who programs the pulse generator. Pushing a button on an external remote control sends electrical impulses from the pulse generator to the electrode in the brain.

People who use deep brain stimulation work closely with their neurologist to find the combination of settings that best controls their symptoms. After several visits, they are able to control the strength of the electrical impulses on their own. Following this adjustment period, most people require only occasional maintenance visits.

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Living With A Dbs Device

Batteries most often last three to five years, but this can vary. Rechargeable batteries may last up to 15 years.

There are several precautions related to electrical/magnetic devices that are important, but usually easy to accommodate. Items such as cell phones, computers, and home appliances do not generally interfere with the stimulator. Keep your stimulator identification card handy when you are out and about, in your wallet or purse.

Theft Detectors

Be aware that some devices may cause your transmitter to turn on or off. This includes security monitors that might be found at the library and retail shops.

If this occurs accidentally, it is not usually serious, but may be uncomfortable or result in your symptoms worsening if the stimulator is turned off. When you visit stores with these devices, you can ask to bypass the device by presenting your stimulator identification card.

Home Electronics

Keep the magnet used to activate and deactivate the stimulator at least 12 inches away from televisions, computer disks, and credit cards, as the magnet could potentially damage these items.

Air Travel/Metal Detectors

Talk to TSA personnel when traveling by plane, as the metal in the stimulator may set off the detector. If you are asked to go through additional screening with a detector wand, its important to talk to the person screening you about your stimulator.

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