Deep Brain Stimulation Programming For Movement Disorders: Current Concepts And Evidence
- 1Department of Neurology, Ludwig Maximilians University, Munich, Germany
- 2Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases , Munich, Germany
- 3Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität München, Martinsried, Germany
- 4Department of Neurosurgery, Ludwig Maximilians University, Munich, Germany
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.
Precise Placement During Dbs Surgery
But the procedure would have to wait. The coronavirus pandemic shut down elective surgeries across Colorado, then throttled them back later in 2020. It would be January 2021 until the procedures took place.
Deep-brain stimulation surgery for Craig involved three procedures. During the first and second, doctors implanted the electrodes on the right and left sides of Craigs brain. During the third procedure, the specialists placed the battery under the skin just below the collarbone.
Three subspecialists collaborated prior to and in the operating room for placement of the DBS electrodes: the movement-disorders neurologist , the neurophysiologist who aides in determining the location of the electrode based upon hearing and watching brain cells fire ) and the stereotactic functional neurosurgeon . University of Colorado Hospital is among a select few U.S. medical centers bringing such a comprehensive array of skills to the DBS operating room.
In early April, the Overmans were back at the hospital for Kern to program the DBS device. This was one of the several 330-mile trips he had already made. Programming involves adjusting the amount and location of electrical current flowing to Craigs subthalamic nucleus. Susan took cell phone videos of her husband walking down a hallway before and after the roughly 90-minute session. Before, he shuffles slowly and stiffly with baby steps after, his strides are healthy and his gait appears nearly normal.
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Postoperative Depression Anxiety And Apathy
The risk factors for postoperative depression including a history of preoperative depression, rapid or excessive reduction of dopaminergic drugs, and having difficulty to adapt to life changes . Therefore, for DBS patients with postoperative depression, doctors can consider increasing the equivalent dose of levodopa or using dopamine receptor agonist . When these medical measures prove ineffective, doctors should consider the serotonin reuptake inhibitors and psychotherapy . DBS high frequency stimulation may lead to acute depressive state, which need to be re-programming .
Treatment of postoperative anxiety should be based on the principles for PD with anxiety . Benzodiazepine drugs are commonly used anti-anxiety drugs, which may increase cognitive impairment or fall risk. Selective serotonin reuptake inhibitors can also be used in anxiolytic treatment. The incidence of apathy after DBS was related to preoperative non-motor symptom fluctuations, anxiety, young patients and impulse control disorders . Apathy after DBS can be improved by the use of selective D2/D3 receptor agonists .
Convenience Of Internet And Remote Programming Operation
Our Likert scale showed that all patients who have received remote programming and self-evaluation were appreciative of Internet telemedical technology. However, based on the inclusion and exclusion criteria, 4 patients who were over 70 years old and had no one who could operate the smartphone were excluded. But in general, most patients and their caregivers in China could meet such requirements.
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Prediction Of Optimal Contact Using Ml
Given our finding of differential fMRI response patterns produced as a function of DBS stimulation site and voltage , we next sought to identify the brain regions whose activity would be most informative in predicting clinical benefit. For each patient, normalized mean t-values for activation and deactivation were calculated from the statistical response maps for 16 ROIs corresponding to motor areas and areas corresponding to known side-effects of DBS . Features from these 16 ROIs were used to derive an ML model that classified a given setting as optimal or non-optimal using linear discriminant analysis . Frequency data were excluded from the ML analysis as it was acquired with bilateral, rather than unilateral left DBS stimulation.
Fig. 5: fMRI responses predict optimal DBS parameters.
What Is The Success Rate Of Deep Brain Stimulation
In general, deep brain stimulation is usually successful. The success rate depends on the condition involved. For conditions like epilepsy and Parkinson’s disease, DBS is very effective. More research is necessary for conditions where DBS is experimental before experts know if DBS is likely to help.
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Risks And Side Effects Of Deep Brain Stimulation
Like any surgery, deep brain stimulation can have side effects, and it carries potential risks. Its also important to consider the complications and side effects of medications you take since their dosages can often be reduced following surgery.
While DBS may cause side effects, it may also reduce side effects from medications.
How Does Dbs Work
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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Specific Programming Strategies For Dbs Of The Subthalamic Nucleus
It is thought that adjustment of stimulation parameters is best carried out by trained clinicians and depends to a large extent on personal experience, whereas detailed algorithms for a disease-specific programming strategy are rare, with the exception of expert recommendations .
Assessing the Response to DBS:
Figure 2. The effects of DBS on clinical symptoms are time-dependent. PD signs and symptoms respond to STN-DBS variably. Axial symptoms may take hours or days to improve, whereas tremor typically disappears almost instantly with STN- or VIM-DBS . A similar temporal disparity occurs with dystonia, where phasic dystonic symptoms respond quickly within minutes to GPi-DBS, and tonic dystonic movements may take much longer to resolve . The reappearance of symptoms after discontinuation of DBS exhibits a similar temporal pattern.
Electrode Configuration Adjustment
Stimulation Parameter Selection
Top Patient Complaint About Dbs Device: Ineffective Stimulation
Now, researchers at Vanderbilt University Medical Center, in Tennessee, where the trial took place, reported five-year results regarding medication costs. They also projected such costs through 15 years to reflect the mean time for Parkinsons to progress from early to advanced stages the time when a typical patient may be offered DBS.
Data from motor symptom-targeting medications, collected at each visit, were used to calculate and project medication costs.
The analysis included 28 participants who completed at least one follow-up visit. They had a mean age of 61.1 and had lived with the disease for a mean of 2.1 years at study entry.
The results showed that the mean annual Parkinsons medication cost had increased from $4,941 at the studys start to $14,177 after five years for patients receiving standard medication alone. For the DBS group, the costs increased from $4,507 to $6,636.
This represented a 2.4 times lower annual medication cost and a five-year cumulative cost reduction of $28,246 for patients receiving both DBS and standard medication relative to the control group.
Patients originally assigned to medication alone also were five times more likely to have higher medication costs than those in the DBS group.
In addition, annual medication costs at 15 years using 10% annual cost increases to account for disease progression were projected to reach $30,371 for the control group and $14,216 for the DBS group.
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How Many Years Does The Battery Of Deep Brain Stimulation Last
The best DBS device would have a never-ending battery. But, in real-life the DBS battery does run out after some years.
Each of these devices has two varieties: Non-rechargeable & Rechargeable. The non-rechargeable batteries are cheaper. However, they last for a shorter period.
When the battery runs out, the wires inside the head do not need to be replaced. Only the battery below the chest skin is replaced.
So, the battery replacement surgery is much simpler and quicker than the original surgery.
The estimated average life of each of these batteries is noted below.
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What Happens After Surgery
After surgery, you may take your regular dose of Parkinsons 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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Who May Benefit From Deep Brain Stimulation
A number of criteria can help identify people who are good candidates for deep brain stimulation. This includes people who:
- Have been living with Parkinsons disease for at least five years, though the procedure was approved for early symptoms in 2016 and is now being evaluated to see if it offers benefits for people earlier in the disease
- Have symptoms that are not well controlled on medications
- Are responding to Parkinsons medications : The procedure should only be done for people who are responding to this treatment, but the medication effects fluctuate during the day and the effectiveness of the medication is getting shorter.
- Find that the uncontrolled symptoms are lowering their quality of life
- Are doing relatively well cognitively
At the current time, there is no set age limit for DBS, but the effectiveness may be lower in older people.
What Happens Before Surgery
In the doctors office you will sign consent forms and complete paperwork to inform the surgeon about your medical history, including allergies, medicines, anesthesia reactions, and previous surgeries. Presurgical tests may need to be done several days before surgery. Consult your primary care physician about stopping certain medications and ensure you are cleared for surgery.You may also need clearance from your cardiologist if you have a history of heart conditions.
Stop taking all non-steroidal anti-inflammatory medicines and blood thinners 7 days before surgery. Stop using nicotine and drinking alcohol 1 week before and 2 weeks after surgery to avoid bleeding and healing problems.
You may be asked to wash your skin and hair with Hibiclens or Dial soap before surgery. It kills bacteria and reduces surgical site infections.
No food or drink, including your Parkinsons medication, is permitted after midnight the night before surgery.
Try to get a good nights sleep. The DBS surgery involves multiple steps and lasts most of the day, during which you may be awake and off medication.
Morning of surgery
Arrive at the hospital 2 hours before your scheduled surgery time to complete the necessary paperwork and pre-procedure work-ups. An anesthesiologist will talk with you and explain the effects of anesthesia and its risks.
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Deep Brain Stimulation: Resources
To learn more about Deep Brain Stimulation, Medtronics website contains numerous resources for physicians, including information on acquiring training as well as patient selection. Additionally, the site offers access to peer presentations on DBS, procedure videos, details on reimbursement and prior authorization, as well as patient education resources for both pre- and post-implant care. Physicians can also find guidelines and manuals for various models.
Additionally, in some instances, DBS can offer benefits that medication does not. For example, With tremor, some patients do not respond at all to medication, whereas DBS has shown to be highly effective in this regard. When it comes to drug-induced dyskinesias, we have very few drugs that are effective. According to Dr. DeLong, amantadine is arguably the only one thats really proven to be of significance in this regard.
Regarding adverse events, Dr. DeLong observes that DBS carries a small, but significant risk to patients undergoing this procedure. Overall, there is a one percent risk of bleeding and possible neurologic deficit, resulting from placement of the stimulating electrodes. There is also about a five percent risk of infection involving the pacemaker and leads over the first five years, as well as a small risk of mechanical or lead breakdown, he observes. Therefore, the patient must weigh potential risks versus benefits in deciding on DBS.
Balance Disorders And Gait Disorders
Patients with gait disorders need to increase the drug dose during chronic stimulation period. If the dopaminergic drugs are ineffective, doctors may consider amantadine or other drugs . STN-DBS postoperative, doctors should try interleaved stimulation, LFS, VFS or increase the dose of levodopa when patients with FOG . For the patients with balance disorders, the programmer should pay attention to maintaining the bilateral limb muscle tension symmetry as well as DBS parameters and drugs. The dyskinesia, orthostatic hypotension and other factors affecting the balance of patients with other factors should also be considered . The following options can be recommended. 1) reduction of voltage 2) change in active electrode contacts 3) reduction in frequency 4) application of VFS 5) application of interleaved Stimulation.
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Am I A Good Candidate For Dbs
To determine if you are a good candidate, you:
Page reviewed by Dr. Chauncey Spears, Clinical Assistant Professor and Dr. Amelia Heston, Movement Disorders Fellow at the University of Michigan.
The Accuracy Of The Self
Previous studies have shown that with the software, patients can complete a variety of self-evaluation scales at home . The self-evaluation scale software used in this study was similar to the previous works . The self-evaluation scale mainly focuses on non-motor symptoms. This study focuses on whether the chief complaint of motor symptoms can be improved. The indicators involved are UPDRS-III and the patient’s self-evaluation scale. Among them, UPDRS-III is evaluated by doctors with the certification of UPDRS-III score based on videos on the app, which has high credibility. The autonomous video recording method for motor symptoms evaluation was used for the first time. After training, caregivers could record motor videos according to the requirements of the UPDRS-III at the appropriate time . The self-evaluation scale of patients’ symptoms after programming can reflect the effect of programming to some extent.
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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.
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.
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