How Does Deep Brain Stimulation Work
Electrodes are strategically placed on specific parts of the brain to treat Parkinsonism symptoms.
Tiny holes are drilled on the skull of the patient to insert the electrodes deep within the brain .
Long wires are placed right underneath the skin, to connect these electrodes to a neurostimulator device.
Much like a pacemaker for a cardiac patient, this device is used to employ electric signals to moderate brain activity.
The neurotransmitter is battery-powered, lasting for anywhere between 2 to 6 years before needing to be replaced.
Parkinsons symptoms, such as tremors and muscle rigidity, are caused mainly by faulty nerve signals arising from brain cell damage.
The DBS neurotransmitter, however, will block these signals to reduce these symptoms.
The average reduction in the medication of people who have had DBS is 30% to 40%.
Klaire Purtee’s Main Concern Was Her Daughter Who Needs 24
Retired teacher Klaire Partee has always been an active person. At 55, she entered a 5K obstacle race. She became alarmed while trying to climb a rope apparatus tied between two trees – it seemed as if her brain wasnt telling her legs to move.
I used to be so athletic, she says. So, it was really kind of odd. I thought ‘Well, Im either getting old or something else is going on.’
Three years later, she had a diagnosis: Parkinsons disease. Its a neurological disorder characterized by tremors and stiff movements.
The disease wasnt the only thing at the top of her mind. She wondered who would take care of her daughter, who needs 24-hour care. At this point, she was having trouble holding a cup of coffee or a piece of paper.
Ohio State University Wexner Medical Center neurologists suggested the latest deep brain stimulation device from Medtronic called the SenSight Directional Lead System. She would be the first in Ohio to get it.
The device looks like a pacemaker inserted in a patients chest with leads that are surgically implanted in the brain.
First, I thought, oh gosh, drilling a hole in my head and brain surgery really sound scary. But after about two years I decided to go ahead and get it,” Purtee says. “And it wasnt that bad at all. I went home the next day, so it was really a good thing in the end.
What Is The Device And How Has It Advanced?
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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Research To Improve Deep Brain Stimulation
Researchers are working to improve upon existing DBS devices and methods to help treat more symptoms and more people. Some researchers are putting electrodes in a different area of the brain the pedunculopontine nucleus to treat walking and balance problems that don’t typically improve with present-day DBS. Others are developing a “smart” DBS device that can record a person’s unique brain signals and deliver electrical stimulation only when needed, such as when symptoms return, rather than continuously, as the current systems do. This could help reduce side effects such as numbness and weakness and lengthen the battery life of the neurostimulator, which would result in a longer time between battery replacement procedures.
Scientists also are planning to test deep brain stimulation in the first years after a Parkinson’s diagnosis to see if the therapy may slow or stop disease progression. Testing in Parkinson’s models showed the therapy may help protect brain cells, and a small human trial showed motor symptoms improved after early-stage DBS.
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:
- Stiffness
- 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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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., Onset of dyskinesias is most commonly correlated with duration and dose of levodopa as well as disease duration itself. 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.
Who Is Not A Good Dbs Candidate
You are not a good candidate for DBS if:
- You have Parkinsons plus symptoms or do not have a clear diagnosis of Parkinsons.
- You need full-body MRI scans, or certain head and chest MRI scans.
- You cannot operate the internal pulse generator, also called the stimulator or IPG.
- Test stimulation does not work.
- You have certain brain conditions such as ischemic brain disease, demyelinating brain disease or brain tumors.
- You have significant intellectual or memory impairment.
- You are not healthy enough to have surgery or have other untreated or chronic illnesses.
DBS can work well for certain people. But it can make certain symptoms of Parkinsons worse. People with certain symptoms should not have DBS. These include:
- Having Parkinsons that is not a typical form of the disease.
- Having Parkinsons plus symptoms such as multiple system atrophy, progressive supranuclear palsy or vascular parkinsonism.
- Not functioning well, even with medication for example, not being able to walk even when taking medication.
- Having end-stage Parkinsons.
At OHSU, we are committed to providing the best treatment for everyone with Parkinsons, so our specialists will talk with you about other options if DBS is not right for you.
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How Will Your Research Help To Significantly Advance Research Into Parkinsons Disease
We have found a stimulation pattern that can already be programmed using existing devices that can reduce stimulation time and provide longer-lasting therapeutic effects. We dont yet fully understand why the effects of burst stimulation are so long-lasting, but one exciting possibility is that it is treating underlying circuit dysfunction, rather than simply masking symptoms. This is the research that we are doing now.
We want to study the short-term and long-term effects of burst DBS throughout the motor system. Our hope is that we can use this stimulation to retrain the motor system to function despite the continued absence of dopamine.
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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.
What Is Deep Brain Stimulation And How Does It Work
DBS is a therapy that we have for various neurological conditions, said Dr. Sheth. It’s a system that you can think of like a pacemaker. But rather than being a pacemaker for the heart, it’s for the brain.
Dr. Sheth describes the brain as having many circuits that govern everything we do, including how we move.
If the movement circuit is not working properly, we may have a movement disorder like Parkinson’s, he said. If we can identify the circuit within the brain that is not working properly, we can use this device to reset the rhythms in the brain and restore the balance so that our movements can be better controlled or without a tremor.
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Can You Describe How You Conducted Your Most Recent Research Into Dbs And Parkinsons Disease What Did You Discover
My lab studies how brain cells communicate during movement and why the loss of dopamine, as happens with Parkinsons disease, disrupts their communication. Through this basic research, we observed how different types of neurons responded to electrical stimulation and found a short window, right after stimulation was turned on, where some neurons accelerated and some slowed down. This was the same pattern of neural activity that had produced long-lasting therapeutic effects in a previous study, but that the research was conducted using a technique called optogenetics, which is not possible to use in humans.
However, if we left the stimulation on for more than a few seconds, all neurons began to accelerate and the specificity was lost. This suggested to us that if we patterned our electrical stimulation correctly using short stimulation bursts, rather than continuous stimulation as used during conventional DBS, we could use DBS to drive a specific pattern of neural activity that can induce prolonged therapeutic responses .
When we tested this idea in Parkinsons mice, we found that burst DBS increased movement to the same degree as conventional DBS protocols, but allowed mice to continue moving after stimulation was turned off, whereas mice receiving the conventional DBS protocol, stopped moving as soon as stimulation was turned off.
Image credit: Teeradej / Shutterstock.com
Can I Use Electrical Devices
While you should be able to use most electronic devices, you should be aware that:
- Some devices, such as theft detectors and screening devices, like those found in airports, department stores, and public libraries, can cause your neurotransmitter to switch on or off. Usually, this only causes an uncomfortable sensation. However, your symptoms could get worse suddenly. Always carry the identification card given to you. With this, you may request assistance to bypass those devices.
- You will be able to use home appliances, computers, and cell phones. They do not usually interfere with your implanted stimulator.
- You will be provided with a magnet to activate and deactivate your stimulator. This magnet may damage televisions, credit cards, and computer discs. Always keep it at least 1 foot away from these items.
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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.
Medical Diagnosis and Treatment
Occupational Electromagnetic Concerns
Will It Work For Me
This is largely a personal decision. A typical candidate is one whose symptoms are worsening and require increased medication, either in terms of dose, frequency or the number of medications taken. Our guidance is typically that the risk of doing something ought to be less than doing nothing. For most patients, they know when the time is right for them and proceed with confidence. These are the patients who have outstanding results.
To find out if deep brain stimulation is right for you, please join us at our monthly lunch and learn from noon to 1 p.m. on the second Thursday of each month. Lunch is provided. This is a free event, but registration is required and limited. To register, please call or email .
A treatment called deep brain stimulation, or DBS, has been used for more than a decade at Penn State Hershey to help patients with a range of disorders to control their muscular symptoms. In this story, we meet two brothers who share similar diagnoses and who both underwent DBS with hopes of getting their lives back.
James McInerney, MD discusses deep brain stimulation as a treatment for disabling neurological disorders.
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How Can Parkinsons New Zealand Help
Parkinson’s New Zealand offers information and professional support to people living with Parkinsons. Our team of Parkinsons Community Educators can provide home visits for personalised sessions.
Community Educators work closely with the person with Parkinsons and their carers to develop a medical plan that upholds their health and lifestyle. Community Educators liaise with health professionals that treat Parkinsons in the community, including speech-language therapists, occupational therapists, and physiotherapists.
Parkinsons New Zealand also has support groups for members for sharing their coping strategies, experiences, and is a chance to establish social networks. Programs for people with Parkinsons include exercise, physiotherapy, hydrotherapy, and art or music therapy sessions.
How Should I Care For The Surgical Area Once I Am Home
- Your stitches or staples will be removed 10 to 14 days after surgery.
- Each of the four pin sites should be kept covered with band aids until they are dry. You will be able to wash your head with a damp cloth, avoiding the surgical area.
- You may only shampoo your hair the day after your stitches or staples are removed, but only very gently.
- You should not scratch or irritate the wound areas.
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Treating The Movement Symptoms Of Parkinsons
Deep brain stimulation helps control your movement symptoms when your medications aren’t working as well as they used to. For many people with Parkinson’s, DBS makes a difference when even small tasks have become challenging. DBS has helped some people stay as independent as possible and keep doing the activities they love.