‘brain Pacemaker’ For Parkinson’s Disease Equally Effective In 2 Regions Of Brain
“This is great news for patients”
MAYWOOD, Ill. — Studies have shown that a “brain pacemaker” called deep brain stimulation is an effective treatment for Parkinson’s disease.
But there’s been debate over what region of the brain to stimulate — the globus pallidus interna or the subthalamic nucleus. Now, a major study published in the June 3, 2010 New England Journal of Medicine is showing that stimulating either region resulted in similar improvements in motor function. There were small differences in non-motor effects such as mood and cognitive function.
“Both targets in the brain are viable for improving motor function. This is great news for patients,” said Frances Weaver, PhD, of Edward Hines Jr. VA Hospital and Loyola University Health System. Weaver, one of the study’s lead investigators, is a professor and director of the Program in Health Research at Loyola University Chicago Stritch School of Medicine and director of the Center for Management of Complex Chronic Care at Hines VA Hospital.
DBS is a treatment for Parkinson’s patients who no longer benefit from drugs, or who experience unacceptable side effects. DBS is not a cure, and it does not stop the disease from progressing. But in the right patients, DBS can significantly improve symptoms, especially tremors. DBS also can reduce rigidity.
New England Journal of Medicine
Deep Brain Stimulation For Parkinsons Disease
What is Deep Brain Stimulation?
Deep brain stimulation is a neurosurgical procedure that involves implanting electrodes within certain areas of your brain. These electrodes produce electrical impulses that regulate abnormal impulses. Or the electrical impulses can affect certain cells and chemicals within the brain.
Deep brain stimulation is a type of therapy used to relieve neurological symptoms associated with Parkinsons disease such as:
. Walking problems
. Muscle spasms
DBS will not cure Parkinsons disease or other neurological conditions. But it can lessen symptoms and improve overall quality of life.
The deep brain stimulation system consists of four parts:
. Leads that end in electrodes that are implanted in the brain.
. A small pacemaker-like device, called a pulse generator that creates the electrical pulses.
. Extension leads that carry electrical pulses from the device and are attached to the leads implanted in the brain.
. Hand-held programmer device that adjusts the devices signals and can turn the device off and on.
In deep brain stimulation, electrodes are placed in the targeted areas of the brain. The electrodes are connected by wires to a type of pacemaker device placed under the skin of the chest below the collarbone.
About Iranian Surgery
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Before Deep Brain Stimulation Surgery
Why its done
What kinds of neurologic conditions can be treated with deep brain stimulation?
. Parkinsons disease
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 Parkinsons 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.
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I Need Tremor Control In Both Of My Hands To Perform My Job Can I Have Dbs For Both Hands
If you have Parkinsons disease, you are likely to have bilateral surgery with placement of leads in the subthalamic nucleus or globus pallidus interna and experience tremor control in both hands. If you have essential tremor , lead placement occurs in the ventralis intermedius nucleus of the thalamus, but often only on one side. This is done to see if there is enough benefit with tremor control in one hand. By doing so, the risk is cut in half. It has been our experience that most people can perform most of their activities with tremor control in one hand. If you find that you need both hands to be controlled, it is possible to place a DBS system for the other hand. Keep in mind, however, that those with bilateral VIM leads for ET often describe problems with speech and balance.
How Effective Is Dbs Therapy
Though DBS is considered an alternative, its a well-established, FDA-approved technique that has been used to treat Parkinsons and essential tremor for 30+ years.
Theres been a lot of studies over the years, said Dr. Sheth. Randomized trials have been presented in the top medical journals that show that for the appropriately chosen patient, DBS is more effective than the best medical therapy. So, in that appropriately chosen patient, DBS can be very successful at improving tremor for essential tremor and tremor stiffness, rigidity, and those other motor symptoms of Parkinsons disease.
One patient who has found success with DBS is Rudy Hardy.
Its made a profound difference in my life, said Hardy. A professional sports photographer and professor of criminal justice, Hardys life was controlled by Parkinsons. He tried medication initially, and though it seemed to work for a while, his tremors eventually worsened. Since undergoing DBS, Hardys symptoms are now almost completely undetectable. Watch Hardy talk about his experience with DBS below.
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What Conditions And Symptoms Can Dbs Treat
DBS can treat several conditions that affect your brain, including movement disorders, mental health conditions and epilepsy.
DBS has approval from the U.S. Food and Drug Administration to treat the following conditions:
It’s important to keep in mind that while the above conditions might benefit from DBS, experts still don’t know if this is the case. It usually takes years of research and clinical trials to determine if a medical procedure like DBS is helpful for conditions like these. While researchers are looking into them, DBS surgery to treat these conditions is not common.
A Growing Medical Technology Niche
The generator, a self-contained unit with a battery, sends pulses of electricity through the leads to stimulate areas of the brain, reducing or in some cases even eliminating the most debilitating parts of the disease. A small, cellphone-size remote control can be used to adjust the “dosage” of electricity and can turn the device on and off.
One of the major manufacturers of the device is Medtronic, which has been active in the U.S. market the longest it first received approval for use of its DBS system for advanced Parkinson’s in 2002 the FDA approved it in 2016 for use with patients who have had Parkinson’s for at least four years. Abbott Laboratories acquired the DBS business with its acquisition of St. Jude Medical last year and Boston Scientific, which currently offers its DBS system in Europe, hopes to receive U.S. approval by year-end.
The three companies’ business lines focused on neurology had roughly $1 billion in combined sales in the most recent reported quarter. Medtronic’s brain therapies group is the leader, with $522 million in sales in the most recent quarter, though it does not break out DBS sales specifically. Abbott’s neuromodulation unit had $300 million in global sales, with approximately 10 percent coming from DBS sales, but it says DBS has been growing since launching in the United States last year.
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If The Mechanism Of Dbs Is Not Known Why Should I Consider It
Because it works.
Because it is quite safe.
There are many things for which we dont understand the exact reason. For example, we are still finding out more about the myriad benefits of exercise.
For example How does exercise improve Mood? We dont understand that too well. But it is easy to grasp that exercise is good for you.
This what-you-see-is-true evidence is called Empiric Evidence.
Like A Pacemaker For The Brain
Deep brain stimulation is a surgical treatment sometimes used in Parkinsons and other conditions. In this treatment, small pulses of electrical current are applied to specific locations in the brain through implanted electrodes. These electrodes are connected by wires that run under the skin to a programmable internal pulse generator, which is usually implanted just under the collarbone . It contains a battery and some electronics to generate the pulses, similar to a heart pacemaker. The device delivers electrical stimulation to specific brain areas that are involved in movement control. Electrical stimulation at precise locations in the brain is thought to restore the balance of the circuits that are disrupted in Parkinsons disease.
DBS can alleviate tremor, reduce stiffness, and lessen dyskinesias. It can very effectively smooth out on/off fluctuations.
Prior to the introduction of DBS in the 1990s, the main surgical treatment for Parkinsons disease involved inserting a probe into the brain and heating the tip of the probe to burn a very small region of brain tissue. The burn, known as a lesion, was made at the same targets that we now stimulate. Lesional surgery is still a useful option in some cases where DBS is not possible. Recently it has become possible to create lesions noninvasively using focused ultrasound.
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How Does Dbs Compare To Other Methods Of Treatment For Parkinsons Disease
As in Hardys case, every patients treatment begins with medication until it is determined that they can benefit from DBS. Medications are always tried first. Unfortunately, we can only get so far with medications. Oftentimes, many patients try them, and they may work for a little while, said Dr. Sheth.
But at some point, oftentimes the medications stop working as much because the disorder tends to progress over the years. It could get worse, and the medicines may not be able to keep up. Many of the medicines themselves have their own side effects. So, you get to a point where perhaps the medicines are helping to a degree, but theyre causing their own side effects, and exactly when we get to that point is when we introduce the idea of a surgical therapy like DBS.
Are There Any Alternative Treatments
Some research suggests that a supplement called coenzyme Q10 may help in the early stages of Parkinsons when taken for 16 months or longer. For mild to moderate Parkinsons, the practice of tai chi may help improve balance more than resistance training or stretching.
Other complementary therapies may include:
- massage or meditation for relaxation
- acupuncture for pain reduction
- yoga to improve flexibility and balance
Some dietary or herbal supplements can react with medications, so talk to your doctor before starting any supplements.
The neurostimulator runs on batteries that last three to five years. They can be replaced in an outpatient procedure.
Your doctor will provide you with specific instructions on life with DBS, such as:
- Other screening devices and theft detectors in stores and other public venues can cause your neurostimulator to turn off or on. This may cause a mild, uncomfortable sensation. Show your ID card and ask for assistance in bypassing these devices, if possible.
- Places to avoid include those with large magnetic fields, such as power generators and automobile junkyards. You should also avoid high-voltage or radar machinery, including television and radio transmitters, high-tension wires, electric arc welders, radar installations, and smelting furnaces.
- Its safe to use cellphones,home appliances, and computers, as they wont cause interference.
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What To Expect After Dbs
Surgery to implant the leads generally entails an overnight stay, while the IPG is usually implanted as same-day surgery. During recovery, your surgeon will talk to you about caring for your wounds, when you can shower, and any activity restrictions. Its usually recommended that any heavy lifting be avoided for a few weeks.
After another two to four weeks, youll return to have your device programmed. This process will continue for several weeks to ensure the stimulation settings are optimal to control your symptoms. During these visits, you will be shown how to turn the device on and off with the handheld device and check the battery level.
Once the programming has been completed, you will have regular follow-up visits to check and adjust the stimulation to maintain the most benefit for your symptoms.
Does Insurance Cover The Cost Of Deep Brain Stimulation
DBS is FDA-approved and covered by most health insurance companies. Some insurance companies require prior authorization before having surgery, and some do not fully understand DBS and may initially deny coverage. However, usually with some detailed explanation, the decision is reversed. Denial may be based on the false assumption that DBS is experimental. If your diagnosis is Parkinsons disease, essential tremor, or dystonia, the proposed DBS surgery is approved by the FDA and is not experimental. If the DBS surgery is recommended for a different diagnosis, it may indeed be considered experimental and is at risk for denial of coverage. Experimental DBS surgery will require authorization/approval from your insurance company.
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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.
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The Road To Clinical Trials
As we consider assembling these components into a commercial medical device, we first look for parts of existing cochlear implants that we can adopt. The audio processors that work with todays cochlear implants can be adapted to our purpose well just need to split up the signal into more channels with smaller frequency ranges. The external transmitter and implanted receiver also could be similar to existing technologies, which will make our regulatory pathway that much easier. But the truly novel parts of our systemthe optical stimulator and the gene therapy to deliver the channelrhodopsins to the cochleawill require a good amount of scrutiny.
Cochlear implant surgery is quite mature and typically takes only a couple of hours at most. To keep things simple, we want to keep our procedure as close as possible to existing surgeries. But the key part of the surgery will be quite different: Instead of inserting electrodes into the cochlea, surgeons will first administer viral vectors to deliver the genes for the channelrhodopsin to the cochlear nerve cells, and then implant the light emitter into the cochlea.
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How Does Deep Brain Stimulation Work
Movement-related symptoms of Parkinsons disease and other neurological conditions are caused by disorganized electrical signals in the areas of the brain that control movement. When successful, DBS interrupts the irregular signals that cause tremors and other movement symptoms.
After a series of tests that determines the optimal placement, neurosurgeons implant one or more wires, called leads, inside the brain. The leads are connected with an insulated wire extension to a very small neurostimulator implanted under the persons collarbone, similar to a heart pacemaker. Continuous pulses of electric current from the neurostimulator pass through the leads and into the brain.
A few weeks after the neurostimulator has been in place, the doctor programs it to deliver an electrical signal. This programming process may take more than one visit over a period of weeks or months to ensure the current is properly adjusted and providing effective results. In adjusting the device, the doctor seeks an optimal balance between improving symptom control and limiting side effects.
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‘brain Pacemaker Has Proven Benefits For Patients With Some Movement Disorders
Among the more than 500 patients who have undergone deep brain stimulation the implantation of a brain pacemaker and electrodes to ease symptoms of movement disorders one of the common observations is that they wish they had done it earlier, says Nader Pouratian, MD, director of UCLAs Neurosurgical Movement Disorders Program.
In the United States, an estimated 10-million people have essential tremor and 1 million have Parkinsons disease. While DBS does not cure or change the trajectory of either disease, it is a safe and effective procedure that provides symptomatic relief to many patients, Dr. Pouratian says. The procedure has most recently been approved for two more conditions, dystonia and obsessive-compulsive disorder. It is also being studied for its potential to help in a number of other conditions.
In DBS, electrodes are strategically placed in the brain while a battery-powered generator is implanted in the chest to emit continuous pulses, correcting the abnormal patterns of brain activity for patients with neurological disease.
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Brain ‘pacemaker’ Treats Parkinson’s
Aug. 30, 2006 — New research shows that the surgical procedure known as deep-brain stimulation is a more effective treatment for many patients with Parkinson’s diseaseParkinson’s disease than drug therapy alone.
Patients under the age of 75 who had the surgery were better able to function physically and socially six months later than other patients of similar age — and with similar symptoms — who remained on the drug treatment.
The German study was one of the first to consider quality of life as a treatment end point. Patients treated with deep-brain stimulation plus Parkinson’s medications had quality-of-life scores that were 25% higher six months later than patients treated with drugs alone, researcher Jens Volkmann, MD, PhD, tells WebMD.