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Thursday, May 16, 2024
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Dbs For Parkinson’s Disease

Dbs Device Management During A Crisis

Deep Brain Stimulation (DBS) for Parkinson’s disease

Patients who utilize DBS therapy for management of neuropsychiatric disorders require ongoing surgical care and outpatient clinic visits for device management. The implantation of de novo DBS leads is considered an elective procedure and should not be scheduled while pandemic measures are in place.

The necessary maintenance includes routine IPG replacements , infection management, assessment of hardware-related complications, as well as outpatient stimulation adjustments . Limited device programming and management can be handled through telemedicine . The telemedicine visits and telephone consultations are also critical to promptly identify any potential surgical issues.

Surgical procedures can be classified into four categories according to the American College of Surgeons guidelines : elective , time-sensitive , urgent , and emergent . Outpatient clinic visits can be classified more simply as elective or urgent . We define an urgent clinic visit as one that would potentially prevent an emergency department visit, a hospitalization or significant disability. Pandemic measures may permit only emergent/urgent procedures and urgent outpatient visits. Depending on local regulations, virus spread, and available resources some elective and time-sensitive procedures may be liberalized based on need.

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Does Insurance Cover Deep Brain Stimulation

Many insurances will cover DBS, especially if it has official approval to treat that condition. Its important that you contact your insurance company to learn if they cover DBS procedures in any way.

A note from Cleveland Clinic

Deep brain stimulation is a treatment option that can help with a wide range of conditions that affect your brain function and mental health. Its almost always an option after other treatments and methods are unsuccessful. Its most common for conditions like Parkinsons disease and epilepsy, but researchers are also exploring the possibility of using it to treat many other conditions. While it does involve two to three surgeries, its also very effective at helping reduce symptoms and treat conditions that severely affect your quality of life.

Role Of The Funding Source

The sponsor and the participating centres designed and approved the protocol. Medtronic monitored the study and the data were entered into a validated database. A statistician employed by the company performed the statistical analysis based on specific requests of the investigators. Final data were made available to the authors who independent of the sponsor assessed the data analysis as well as the interpretation and writing of the results.

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Modeling Brain Circuits For Movement

Although interest in ablative surgery for PD waned, researchers were learning more about brain circuits for motor control through studies in animal models. In the 1970s, Mahlon DeLong, then a research fellow at NIH working with scientists at NIMH and NINDS, used electrical stimulation to meticulously characterize the functions of neurons in different brain areas as animals performed movements7,8,9,10. Over a period of several years and continuing after DeLong moved to Johns Hopkins University School of Medicine, these NIH and NINDS-supported studies led to a model of basal ganglia circuit organization, with parallel, functionally segregated circuits involved in movement and other complex functions11,12. As part of the movement-related circuit, the subthalamic nucleus modulates the GP, which sends signals through the thalamus to the supplementary motor area , a brain area important for planning and coordinating movement. By this time, researchers knew that the loss of dopamine-producing neurons in the basal ganglia contributed to PD, but how such changes disrupted motor circuit activity and function was still not clear, in part because no animal model of the disease was available.

How Does Dbs Work

Deep Brain Stimulation Dbs Parkinsons Disease Stock Vector (Royalty ...

In DBS surgery, electrodes are inserted into a targeted area of the brain, using MRI and, at times, recordings of brain cell activity during the procedure. A second procedure is performed to implant an impulse generator battery , which is similar to a heart pacemaker and approximately the size of a stopwatch.

The IPG is placed under the collarbone or in the abdomen and delivers an electrical stimulation to targeted areas in the brain that control movement. Those who undergo DBS surgery are given a controller to turn the device on or off and review basic parameters such as battery life.

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Effects On Nonmotor Symptoms

There are several types of nonmotor symptom induced by DBS. The symptoms we should pay attention to are autonomic symptoms, poor sleep quality, and pain.

PD patients often have autonomic symptoms such as orthostatic hypotension, constipation, neurogenic bladder, dyshidrosis, and sexual dysfunction. However, the effects of DBS on autonomic symptoms have not been studied in detail and remain obscure. Changes in blood pressure and heart rate after STN-DBS have been reported.52) Holmberg et al.53) conducted a prospective study and found that there was no significant difference in circulatory autonomic function between the patients with STN-DBS and those treated only with anti-PD drugs. Erola et al.54) compared circulatory autonomic function before STN-DBS with that after 1 year of STN-DBS, and they found no statistically significant difference.

Constipation is a common autonomic symptom in PD patients. It is often recognized from the onset of the disease. The improvement of constipation after STN-DBS is often noted. However, improvement is only partial and usually patients need to take laxative drugs even after STN-DBS. The improvement of constipation appears to be related to the improvement of motor functions. Bladder dysfunction is also frequently noted in PD patients. There are some reports mentioning the direct effect of STN-DBS on bladder dysfunction. However, such an effect remains to be confirmed.

A Systematic Review And Guideline Comparing Subthalamic Nucleus Deep Brain Stimulation To Globus Pallidus Internus Deep Brain Stimulation For The Treatment Of Patients With Pd

  • RughaniA, SchwalbJM, SidiropoulosC, et al. Congress of Neurological Surgeons systematic review and evidence-based guideline on subthalamic nucleus and globus pallidus internus deep brain stimulation for the treatment of patients with Parkinsons disease: executive summary. Neurosurgery. 2018 82:753756..

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What Is The Prognosis

Although most people still need to take medication after undergoing DBS, many people experience considerable reduction of their PD symptoms and can greatly reduce their medications. The amount of reduction varies from person to person. The reduction in dose of medication can lead to decreased risk of side effects such as dyskinesia.

There is a 1 to 3% chance of infection, stroke, bleeding in the brain, or other complications associated with anesthesia. It is best to discuss associated risks with your neurologist and neurosurgeon, as diabetes and heart and lung conditions all may influence these risks and the decision to pursue surgery.

A General Rule Is That Dbs Will Likely Improve Parkinsons Symptoms That Respond To Medication

Deep Brain Stimulation (DBS) for Parkinson’s Disease | Missy’s Story

The Evaluation prior to DBS Surgery

A team of experts, including a movement disorder specialist and a neurosurgeon , conduct an extensive assessment when considering DBS for someone. The evaluation consists of medication and symptom review, examination both on and off Parkinsons drugs, brain imaging, and oftentimes also detailed memory/thinking testing . If DBS is offered, its important to discuss the expected benefits as each persons experience is unique. Its also critical to discuss the potential surgical risks, including bleeding, stroke and infection.

The DBS Procedure and Device Programming

In DBS surgery, thin wires called electrodes are placed into one or both sides of the brain in specific areas that control movement. Usually a person remains awake during surgery so that he or she can answer questions and perform certain tasks to make sure that the electrodes are positioned correctly. However, some medical centers now are using brain imaging to guide the electrodes to the right spot while a person is asleep. Each method has its pros and cons and may not be suitable for everyone or available everywhere.

Once the electrodes are situated, they are connected to a battery-operated device that is typically placed under the skin below the collarbone. This device, called a neurostimulator, delivers continuous electrical pulses through the electrodes to decrease Parkinsons symptoms.

How DBS Works

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Key Issues In Minimizing Risks

The minimization of risks may also be closely associated with target choice and may be associated with whether unilateral or bilateral DBS surgery is chosen for an individual patient.

Hypophonia, dysarthria & swallowing

Concerns over worsening hyophonia, dysarthria and swallowing issues may sway an interdisciplinary team toward unilateral DBS and perhaps GPi as a target, but more data is required to clarify this issue. Dysarthria and hypophonia issues have been reported to occur in the majority of all bilateral STN DBS cases, and therefore, this issue should be thoroughly discussed with each patient . It is important to keep in mind that despite the majority of patients subjectively reporting issues in speech following DBS, several studies show some objective improvement on UPDRS ratings and this issue requires clarity and better outcome measures . It is unknown what the effects of DBS will be on pre-existing swallowing and aspiration problems, but in most centers these patients would be excluded from DBS consideration.

Verbal fluency, cognition & mood

Mood, as measured by self-report indexes, such as the Beck Depression Inventory, has been observed to mildly improve following DBS surgery. However, in the recent VA Cooperative study, bilateral GPi mildly improved mood, and bilateral STN mildly worsened it following 24 months of follow-up.

Levodopa-unresponsive gait issues

Age

Weight gain

Battery changes

Adverse events

Who Is A Candidate

You may be a candidate for DBS if you have:

  • a movement disorder with worsening symptoms and your medications have begun to lose effectiveness.
  • troubling “off” periods when your medication wears off before the next dose can be taken.
  • troubling “on” periods when you develop medication-induced dyskinesias .

DBS may not be an option if you have severe untreated depression, advanced dementia, or if you have symptoms that are not typical for Parkinson’s.

DBS can help treat symptoms caused by:

  • Parkinson’s disease: tremor, rigidity, and slowness of movement caused by the death of dopamine-producing nerve cells responsible for relaying messages that control body movement.
  • Essential tremor: involuntary rhythmic tremors of the hands and arms, occurring both at rest and during purposeful movement. Also may affect the head in a “no-no” motion.
  • Dystonia: involuntary movements and prolonged muscle contraction, resulting in twisting or writhing body motions, tremor, and abnormal posture. May involve the entire body, or only an isolated area. Spasms can often be suppressed by “sensory tricks,” such as touching the face, eyebrows, or hands.

After your evaluation and videotaping is complete, your case will be discussed at a conference with multiple physicians, nurses, and surgeons. The team discusses the best treatment plan for each patient. If the team agrees that you are a good candidate for DBS, you will be contacted to schedule an appointment with a neurosurgeon.

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The Future Could Hold Even Bigger Innovations In Dbs

I hope mostly that we are learning to treat patients better, says Dr Stieglitz. Maybe in the future we could even learn how to do multi-target stimulation. In the future we might have the technology and also the knowledge to influence complex networks in the brain in a more sophisticated way.

But Dr Stieglitz feels the first priority should be making DBS therapy available to more people with Parkinsons disease. I hope that more patients will benefit from deep brain stimulation. This is the first thing not to improve the treatments for a few patients, but to bring the treatments to more people in need, he says. I believe in the future of DBS.

Medtronics Percept PC neurostimulator with BrainSense technology.

Find out more about Medtronic DBS therapy for Parkinsons disease.

At a glance: benefits of the Percept PC neurostimulator

  • It can continuously sense and record brain signals, allowing clinicians to track patient-specific signals and correlate these with patient-recorded events
  • Its the only DBS system that is compatible with 3T full-body MRI scans*, meaning it can be left on with certain stimulation configurations while the scans take place
  • It incorporates low pulse width, providing expanded stimulation options
  • It has improved battery longevity** and a comfortable new shape
  • It has an enhanced Patient Programmer*** through a custom-configured Samsung mobile device, allowing patients to manage their therapy more easily.

Need to know

Footnotes

How Is Deep Brain Stimulation Used To Treat Parkinsons Disease

dbs for parkinson

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.

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How Will My Doctor Test For It

There’s no one test for Parkinson’s. A lot of it’s based on your symptoms and health history, but it could take some time to figure it out. Part of the process is ruling out other conditions that look like Parkinson’s. The docotor may do a DaT scan, which looks for dopamine in the brain. This can aid in a diagnosis.

Because there is no single test, it’s very important to go to a doctor who knows a lot about it, early on. It’s easy to miss.

If you do have it, your doctor might use what’s called the Hoehn and Yahr scale to tell you what stage of the disease you’re in. It ranks how severe your symptoms are from 1 to 5, where 5 is the most serious.

The stage can help you get a better feel for where your symptoms fall and what to expect as the disease gets worse. But keep in mind, some people could take up to 20 years to move from mild to more serious symptoms. For others, the change is much faster.

Should The Timeline For Operating Be Moved Up

Traditionally many expert PD centers have delayed invasive surgical therapy for as long as possible. This purposeful delay has raised the question, how long is too long? DBS has not been shown to have a disease-modifying effect. As DBS is not disease modifying, to proceed to surgical therapy symptoms should, at a minimum, be difficult to manage with medications, and they should have a profound impact on the sufferers quality of life. If patients are still working, and DBS has the potential to keep them working, this should be considered in the decision-making process. To date, studies have not shown any advantage for DBS to keep PD patients at work. These types of studies are, however, very complex to perform, and very complex to interpret , as there are many factors as to why a patient may not return to work.

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The Symptoms That Dbs Treats

Deep brain stimulation is used primarily to treat the motor symptoms of Parkinsons disease, but this can vary somewhat between the different placement sites. Symptoms treated include:

  • Abnormal movements : Dyskinesias are often a side effect of medications for Parkinsons disease and include involuntary movements such as twisting, head bobbing, squirming, and more.

DBS is not usually helpful with walking problems or balance, though improvements in the symptoms above can indirectly affect walking. It also does not provide significant benefits for non-motor symptoms of Parkinsons such as cognitive changes, mood changes , or problems with sleeping.

The benefits of DBS can be estimated by looking at how a person responds to levodopa. Symptoms that respond to levodopa will often respond to DBS . But symptoms that are not changed with levodopa are unlikely to be improved by DBS.

DBS often allows for a reduction in the dosage of levodopa, which in turn can result in fewer involuntary movements and a reduction in off time. The result is often improved quality of life.

Have A Dbs Surgery Evaluation

Deep Brain Stimulation (DBS): Parkinson’s Disease – Mike Robbins

Meet with a neurologist and complete a series of screenings to see if youre a candidate for DBS surgery when the time comes. Screenings may include ON time/OFF time testing, a neuropsychological evaluation, a general health screening, brain imaging, and routine lab work.

People with tremor experience an average of 70% reduction in tremor, depending on its type and location.ยน

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Pallidal Stimulation Versus Subthalamic Stimulation

As mentioned, there are two main anatomic targets for using DBS to treat PD the STN and the GPi. There have been several large randomized studies comparing STN and GPi DBS in PD. It is suggested that both STN DBS and GPi DBS overall equally and successfully improve motor symptom, and are similar in cost-effectiveness. However, although no differences were observed in the on phase between STN DBS and GPi DBS, significant differences were seen in the off phase STN DBS was more effective in terms of motor function improvement in the off phase. There are different opinions in terms of effects of STN DBS and GPi DBS on quality of life. Some authors have found no significant difference between the STN and GPi targets. However, others agree with that greater improvements in quality-of-life measures are achieved in patients with GPi DBS.

GPi DBS can be used for patients with more axial symptoms, gait issues, dyskinesias, depression, and word fluency problems. STN DBS is often favored in reducing medication post surgery, and for patients with greater tremor. STN-DBS has also demonstrated an improvement in the quality of sleep for patients.

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