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Deep Brain Stimulation for Movement Disorders

Online Health Chat with Darlene Lobel, MD

July 28, 2014

Description

Cleveland Clinic ranks among the world’s leaders in innovative applications of deep brain stimulation (DBS) surgery. Having performed hundreds of DBS surgeries, our physicians and scientists continue to gain knowledge about the circuitry that contributes to the development of movement disorders and other neurological and psychiatric conditions.
 
The Food and Drug Administration (FDA) has approved DBS for the treatment of Parkinson’s disease and essential tremor. It is also approved for dystonia and obsessive compulsive disorder under a Humanitarian Device Exemption.

DBS uses advanced computer technology to pinpoint areas of the patient’s brain where faulty electrical signals are triggering symptoms. Guided by this information, a neurosurgeon makes a small opening in the skull and implants electrodes in targeted areas of the brain. Depending on the patient’s needs, this procedure is done on one or both sides of the body. In order to ensure that the implants are properly placed, the patient may be awake during part of the surgery so that he or she may communicate with the surgical team. Local anesthesia relieves any pain during this wakeful period.

The patient usually goes home two to three days following surgery and returns to the hospital one week later for a second step. At this time, general anesthesia is used as the surgeon implants a battery-powered pulse generator under the patient’s collarbone.

Thin wires placed beneath the skin connect this “brain pacemaker” to the electrodes implanted earlier in the brain. The pulse generator delivers stimulation to these targeted brain areas, blocking the abnormal signals that produce symptoms such as tremor, stiffness and slowed movement.

The patient goes home in less than 24 hours and returns as an outpatient two to four weeks later to turn on and program the pulse generator. Several visits might be necessary to fine-tune the device to control a patient’s particular symptoms. This process is painless. At home, the patient has the ability to switch the stimulation on or off. The device’s batteries generally last three to five years.


About the Speakers

Darlene Lobel, MD, is a Staff Neurosurgeon in the Center for Neurological Restoration in the Neurological Institute. Dr. Lobel performs DBS surgery for patients with Parkinson's disease, tremor, dystonia and psychiatric disorders. She also does procedures for patients with intractable pain syndromes and spasticity.

Dr. Lobel received her medical degree from the Medical College of Georgia in 2000.  She completed her residency in neurological surgery at the same institution in 2006. She then pursued fellowship training in stereotactic neurosurgery and radiosurgery at UCLA, and further training in functional neurosurgery and epilepsy surgery at Emory University, completing her fellowship there in 2007.

Dr. Lobel has many specialty interests including DBS for movement disorders, neuropsychiatric disorders and emerging indications; frameless DBS; stereotactic neurosurgery; spinal cord stimulation for chronic pain disorders; and the surgical management of spasticity.


Let’s Chat About Deep Brain Stimulation for Movement Disorders

Moderator: Welcome to our chat today with Cleveland Clinic neurosurgeon and movement disorder specialist, Darlene Lobel, MD. We are thrilled to have her here with us to share her expertise about deep brain stimulation for movement disorders.

Let's begin with the questions that have been submitted.


DBS ESSENTIALS

felip1983: Are there many locations in the United States that perform deep brain stimulation?

Darlene_Lobel,_MD: Most major medical centers have surgeons who perform DBS. Ideally, you should be evaluated at an academic hospital, where movement disorder neurologists, neurosurgeons and the other team members work together in the same facility. This allows the treatment team to optimize your medical and surgical care.

Cleveland Clinic’s Center for Neurological Restoration is among the first in the world to bring together an interdisciplinary team of renowned neurologists, neurosurgeons, psychiatrists, neuropsychologists, researchers and other specialists who offer the latest medical and surgical treatments for patients with movement disorders. The center is nationally recognized for expertise in medical management and innovations in the surgical treatment of movement disorders (Parkinson’s disease, essential tremor or dystonia) as well as obsessive-compulsive disorders, depression and chronic pain. Patients benefit from the comprehensive, integrated approach to care provided by center staff. The team members collaborate to develop an individualized management and treatment plan.

Bobmckaige: How long does the effect of DBS last?

Darlene_Lobel,_MD: DBS continues to be effective for several years after the surgery. The electrodes in the brain typically do not ever need to be replaced; however, the battery or "pacemaker" that controls the device needs to be replaced every few years. That being said, symptoms of Parkinson's disease worsen over time, so DBS therapy may not appear to be as effective after 10 to 15 years.

Bobmckaige: Is medication still necessary after DBS?

Darlene_Lobel,_MD: Most patients still need to take some medications after DBS. However, we are able to significantly reduce the dosage and frequency of the medications after surgery. On average, my patients reduce medications by 50 percent, and some are able to reduce medications by up to 80 percent.

u775kelly: My friend’s father had a tremor in his left arm that he was unable to control, along with head bobbing. He just had a procedure at Cleveland Clinic called gamma knife, which seems less invasive. How does this procedure differ from DBS? And do you perform gamma knife as well for tremors?
 
Darlene_Lobel,_MD: Gamma knife is a non-invasive procedure that involves creating a lesion in the brain in an area known to cause tremors. Gamma knife is therefore a permanent, non-reversible treatment for tremor. Deep brain stimulation is a reversible therapy. There is no damage to the brain by the electrodes, so a DBS system could be removed in the future, if, for example, a cure is found for Parkinson's disease or essential tremor. We perform DBS and gamma knife here at Cleveland Clinic.

momk: Is DBS normally covered by health insurance  (Medicare, Blue Cross)?

Darlene_Lobel,_MD: DBS is covered by most major insurance carriers, including Medicare, Medicaid and Blue Cross, in the treatment of Parkinson's disease, essential tremor and certain types of dystonia. DBS for other conditions, such as Tourette's syndrome or obsessive-compulsive disorder, may not be covered by most insurance companies.


RECOMMENDATIONS

cyclist: A lady, 84 years old, has symptoms of either Parkinson's disease or Alzheimer’s disease. Other than this, she is in good health. Would this procedure be recommended for her condition and age? If the answer is yes, what are the chances of a complete and safe recovery? Thank you very much for considering my question.
 
Darlene_Lobel,_MD: While there is no age limit per se for consideration of DBS surgery, typically patients in their mid to late 80s are preferably treated with medications to control symptoms of Parkinson's disease, as risks of complications from surgery are higher for older patients. A formal evaluation of the patient's medical history and current physical condition would be needed to fully evaluate the potential benefits of DBS surgery, surgical risk and recovery time. DBS is a well-established therapy for Parkinson's disease and other movement disorders. At this time, DBS is still in the experimental stages for Alzheimer's disease.

Bobmckaige: What are the criteria that you need to meet in order to qualify for DBS? In other words, how do you know it's time to seriously consider this procedure?

Darlene_Lobel,_MD: We typically consider deep brain stimulation as a treatment when medications are no longer controlling the symptoms of disorders such as Parkinson's Disease, essential tremor or dystonia. As Parkinson's disease progresses, patients typically require higher doses of medications, which may result in side effects. Also, as the disease progresses, patients may not respond as well to the medications and may experience periods during the day known as "wearing off" periods. DBS is usually considered at this time, as it helps to control symptoms of Parkinson's throughout the day and allows us to lower the medication doses. There is a thorough evaluation process to assess patients for DBS, which involves evaluation by a neurologist, neurosurgeon and neuropsychologist. Once you are evaluated by this team of physicians, a recommendation will be made whether to proceed with DBS surgery or not.

Indysen: Is there an age that you no longer perform DBS?

Darlene_Lobel,_MD: There is no specific age limit for consideration of DBS. We evaluate the overall health of the patient and determine the surgical risk. We have performed DBS in patients in their 80s.


TREMORS

shakeyguy: I have had tremors in both hands for approximately 16 years. At first, the tremor was very slight but got progressively worse over time. Eventually, I could not write with my right hand so I began to write with my left hand. The tremor worsened and now I cannot write with either hand. In 1997, my tremor was diagnosed as familial tremor and untreatable. In 1998, the tremor was diagnosed as early onset Parkinson's disease. In 2000, the diagnosis was focal dystonia. Various treatments have included Mysoline®, primidone, Neurontin®, Requip®, Klonopin®, Lyrica®, BOTOX® and others that I have forgotten. None of them have relieved the tremors. Do you have any suggestions?

Darlene_Lobel,_MD: First, I recommend that you undergo a formal evaluation by a movement disorder specialist in order to confirm your diagnosis. While you were taking many different medications that are used to treat symptoms of various movement disorders, there are several other medications that may be helpful to treat your symptoms. A movement disorder specialist would be able to make appropriate medication recommendations after completing your evaluation. If these medications are unable to control your symptoms, then deep brain stimulation may be an option to treat your condition.

Also, it is interesting that you were told that "familial tremor." also known as "essential tremor," was untreatable. There are medications that can be used to treat this type of tremor. Additionally, this type of tremor responds very well to deep brain stimulation.

jlp152: I have a familial tremor that I have had since I was 5 years old. I am now 54 and find the tremor definitely worsening. It is sometimes difficult to complete easy tasks due to my shaking. I also have problems with dropping things. I have tried a medication in the past that did help somewhat with the tremor, but I did not like the brain-dead feeling I had, so I discontinued using it. I have been on propranolol XR 80 mg once daily for several years and don't really feel like it is helping, but due to low blood pressure, my dose cannot be increased. Any thoughts on my doing the deep brain stimulation or would you recommend a different approach?

Darlene_Lobel,_MD: Essential tremor, also known as "familial tremor," is a condition that responds very well to deep brain stimulation. DBS can typically reduce symptoms of tremor by up to 90 percent. This allows patients to more easily perform their normal activities and return to their hobbies. The side effects you have experienced with the medications are common. Once DBS is performed, you may no longer need these medications to control symptoms of tremor. I recommend that you undergo a formal evaluation by a movement disorder specialist in order to determine the best treatment options for you.


PARKINSON’S DISEASE

newspaper13: Are there any other options to DBS surgery that would provide relief from the symptoms of Parkinson's disease?
 
Darlene_Lobel,_MD: Typically, symptoms of Parkinson's disease are treated with a variety of medications, particularly in the early stages of the disease. After a number of years taking Parkinson's medications, it is common for patients to experience side effects, particularly with higher medication dosages. It is at this time that we begin to evaluate patients for deep brain stimulation therapy. DBS improves the symptoms of Parkinson's disease and often permits us to lower doses of Parkinson's medications.

While DBS is not a cure for Parkinson's disease, it helps to control the symptoms of Parkinson's disease, including tremor, stiffness and slowness of movement, more consistently throughout the day than medications alone. At this time, there is no known cure for Parkinson's disease, so medications and deep brain stimulation are the best treatment options, outside of experimental therapies.

jsena: Have you seen DBS help to lessen symptoms of Parkinson’s such as stiffness/rigidity in muscles, or does it mainly help only to control tremors?
 
Darlene_Lobel,_MD: In the treatment of Parkinson's disease, DBS controls about 90 percent of tremor, and reduces symptoms of stiffness and slowness of movement by about 70 percent to 80 percent. This effect is durable, meaning that it lasts for a number of years.

clara: My husband found out he has treatable Parkinson disease. He is on L-dopa sp. I assume it will progress. Would he be able to stimulate the brain if and when he gets worse?

Darlene_Lobel,_MD: L-Dopamine, which is typically administered in the form of Sinemet®, is a medication commonly used to treat the symptoms of Parkinson's disease upon initial diagnosis. Sinemet, in combination with other medications, typically controls the symptoms of PD for a number of years. However, Parkinson's is a progressive disease and patients often require higher and higher doses of medications as the disease progresses. This often results in disabling side effects. It is at this point that we consider DBS as a treatment. I recommend that your husband be evaluated by a movement disorder specialist. He may want to also meet with a DBS surgeon in order to obtain more information on the procedure, even if he is not ready to have the surgery at this time.


DIFFERENT DIAGNOSES

SydMaxwell: I have foot drop and cannot control moving my ankle and lifting my foot, perhaps due to the loss of the frontal left lobe. Could any medicine, such as low-dosage epilepsy medicine, cause this? I used to be very athletic, but now I trip a lot. I have tried to use a professionally made leg brace. I ended up having a hammertoe, which
physicians will not operate on because of my limitation in lifting my foot properly. Do you have any suggestions? Are there any exercises that would help?

Darlene_Lobel,_MD: These symptoms could be caused by a variety of medical conditions, but are unlikely to be caused by a movement disorder. I recommend evaluation by a spine specialist who could best evaluate you and refer you for physical therapy or other appropriate treatment.

kitty2828: Has DBS ever helped for para-neoplastic syndrome cerebellar degeneration? Can it help the tremors and/or the ataxia?
 
Darlene_Lobel,_MD: DBS has been performed to treat cerebellar ataxia. The therapy can control the tremor associated with cerebellar ataxia to some extent; however, the response is typically not as good as with treatment for Parkinson's disease or essential tremor. There may be other symptoms associated with para-neoplastic symptoms and cerebellar ataxia, and, unfortunately, DBS has not been proven to be very effective in the treatment of these other symptoms.

loveitaly: Is this innovative treatment also applied to individuals with epilepsy and retractable seizures? How has the success rate of this treatment been? I was reading in the summary that the person stays awake (in the first part of the surgery) so they can communicate with the surgeon. What is done if the surgery is being performed on an individual with developmental delays, who is nonverbal, with some degree of intellectual disabilities but who has these movements or tremors? How different would the procedure be if the patient can't communicate? Thanks for your time and expertise.

Darlene_Lobel,_MD: There is a type of deep brain stimulation that has been moderately successful in the treatment of certain types of epilepsy. Seizures may decrease in frequency by up to 50 percent and may lessen in severity. I would recommend evaluation by an epilepsy surgeon who has experience placing these devices. Regarding the second part of your question, many patients are awake during the surgery; however, for certain patients, it is possible to perform the surgery with the patient asleep, in an intraoperative MRI scanner. We use the MRI during surgery to determine the exact placement of the electrode. While this does not allow us to test the electrode for effectiveness at the time of surgery, the results with this type of DBS surgery have been very successful. It also allows us to perform the surgery in patients that you described – those that are non-verbal, have intellectual disabilities and others, such as those with severe anxiety.

rainbowsandbutterflys: Can this help a person who has multiple issues - chronic pain, achalasia, idiopathic neuropathy pain in extremities, heart disease? I have been 10 years on pain medication and cannot take seizure medications due to hyponatremia.

Darlene_Lobel,_MD: Deep brain stimulation has been used to treat certain types of pain; however, the type of pain you describe, neuropathic pain, may be better treated with other types of therapy, such as spinal cord stimulation.

u775kelly: Have you used DBS to treat dystonia?

Darlene_Lobel,_MD: DBS can successfully treat certain types of dystonia, particularly dystonia associated with a genetic mutation. I have placed DBS systems in several patients with different types of dystonia, with very high success rates.

shakeyguy: Would DBS be appropriate for tremors brought on by exposure to Agent Orange? I am a Vietnam veteran who had significant exposure to the substance in 1968. The Veterans Administration denies any connection to tremors from the chemical. Anecdotally, many of my friends who had similar exposure have tremors similar to mine.

Darlene_Lobel,_MD: Tremors brought on by chemicals, such as Agent Orange, may or may not respond to DBS. There is no published literature on this topic. I would recommend you be evaluated by a movement disorder specialist, who may want to try other medications. If you do not respond to medical therapy, DBS may be option for you.

stormymichele: My symptoms of  ataxia are balance-related, not tremors. Can DBS help?

Darlene_Lobel,_MD: DBS may improve balance in some cases, but generally does not improve balance as much as it improves tremor. I recommend you be evaluated formally by a movement disorder specialist to assess the ability of DBS to help with your condition.

Indysen: I am losing my cognitive ability. Can DBS help slow or stop this?

Darlene_Lobel,_MD: DBS is currently not indicated to treat cognitive disorders. However, there are current clinical trials that are evaluating the effectiveness of DBS to treat Alzheimer's disease and a variety of other disorders, including depression, traumatic brain injury and obesity, to list a few. If you are interested in being considered to participate in a clinical trial, we can provide you with more information.

rainbowsandbutterflys: Would this help to eliminate spasticity and stiffness from anorexic brain injury, where the symptoms have been described by a neurologist as like parkinsonism?

Darlene_Lobel,_MD: DBS for brain injury is experimental at this time. Current research in this area includes studying ways to improve level of consciousness and level of functioning after brain injury. There are other treatment options for spasticity and stiffness, which involve delivering medications directly into the spinal column through a "pump" placed into the patient's abdomen. A neurologist who specializes in spasticity will be able to evaluate you for this type of treatment.

rainbowsandbutterflys: Can this help PTSD when medications fail?

Darlene_Lobel,_MD: DBS for PTSD is experimental at this time. There are several centers studying the efficacy of DBS in the treatment of anxiety in general and anxiety related to PTSD.

CHRISTIANN: Have you done DBS with spasmodic dysphonia? If so, what kind of results have you had?

Darlene_Lobel,_MD: I have not personally performed DBS for spasmodic dysphonia and am not aware of DBS as a treatment option for this disorder.

loveitaly: Due to Meniere's disease and to treatments with gentamicin antibiotic to kill the vertigoes, that side of my body is affected with balance problems. It varies in intensity; sometimes I am better than others. Would DBS be effective for people with balance disorder due to Meniere's and its consequences?

Darlene_Lobel,_MD: DBS can help improve balance in some patients, but there is no current published research in Meniere's patients specifically.


RESEARCH

sylvia82: What current research is being done in the field of DBS?

Darlene_Lobel,_MD: Several centers in the United States and abroad are conducting research in DBS, and it includes studying ways to improve DBS therapy. Currently, DBS delivers a constant level of stimulation to the patient's brain. New research may help us develop a DBS system that "senses" chemical or electrical changes in a patient's brain and only provides stimulation when it is needed. This may improve the effectiveness of DBS therapy and reduce the number of times a patient may need a battery replacement for the system.

newspaper13: You mentioned experimental therapies. Could you tell us more about them?

Darlene_Lobel,_MD: There are ongoing research studies in the United States and abroad that are evaluating the use of stem cells in the treatment of Parkinson's disease. Previous studies have not demonstrated a benefit from stem cells; however, some of these new clinical trials may show promise. This is an important area of research, as such treatments may represent a cure for Parkinson's.

johnbaumer: How do you see the technology of DBS changing in the coming years? Any hope for it being less invasive - fewer wires, longer-lasting and/or no batteries?

Darlene_Lobel,_MD: Currently, researchers are investigating ways to improve DBS therapy and to optimize the electrodes and the batteries that control the systems. Wireless systems, while possible to develop, are currently too expensive for mainstream therapy.


GENERAL INFORMATION

marywies: I was wondering if I could get some more information on movement disorders. The information that I have found online has been enlightening, but I still feel like there is more that I can learn.

Darlene_Lobel,_MD: Cleveland Clinic's Center for Neurological Restoration provides a variety of educational materials for patients to learn more about services, disease information and more. You can find videos, podcasts and downloadable treatment guides, as well as current happenings involving the Neurological Restoration Center here:
http://my.clevelandclinic.org/neurological_institute/center-for-neurological-restoration/patient-education/patient-resources.aspx.

jlp152: You recommended making an appointment with a movement disorder specialist for my familiar tremor. Would I be able to make one with you for it?

Darlene_Lobel,_MD: To schedule an appointment with me or any of the other specialists in Cleveland Clinic’s Center for Neurological Restoration, please call 216.636.5860 or toll-free 866.588.2264. You can also visit us online at http://my.clevelandclinic.org/neurological_restoration/default.aspx.
I will have someone from my office follow up with you directly.

rainbowsandbutterflys: When you are out of town, what group would you need to set up a collaboration with? It is hard to know which physicians to see.

Darlene_Lobel,_MD: There are several centers in the United States where you can be evaluated for DBS therapy. We evaluate several patients at Cleveland Clinic who come in from out of town. We arrange the visits with all the necessary physicians over a two- to three-day period in order to accommodate these patients.


Closing

Moderator: I am sorry to say that our time with Darlene Lobel, MD is now over. Thank you for sharing your expertise and time to answer questions today.

Darlene_Lobel,_MD: Thank you everyone for your questions. This will end our chat time today. Please feel free to contact me if you have other questions


For Appointments

To schedule an appointment with Darlene Lobel, MD, or any of the other specialists in Cleveland Clinic’s Center for Neurological Restoration, please call 216.636.5860 or toll-free 866.588.2264. You can also visit us online at http://my.clevelandclinic.org/neurological_restoration/default.aspx.

For More Information
On Deep Brain Stimulation
There are a number of health articles that may help to clarify some common questions. You may also visit clevelandclinic.org/health.

Parkinson’s Disease: An Overview
http://my.clevelandclinic.org/disorders/parkinsons_disease/hic_parkinsons_disease_an_overview.aspx

Deep Brain Stimulation for Parkinson's Disease Patients
http://my.clevelandclinic.org/services/deep_brain_stimulation_dbs/hic_deep_brain_stimulation_for_parkinsons_disease_patients.aspx

Treatment Guide
Cleveland Clinic's Center for Neurological Restoration provides a variety of educational materials for patients to learn more about services, disease information and more. You can find videos, podcasts, downloadable treatment guides as well as current happenings involving the Neurological Restoration Center here:
http://my.clevelandclinic.org/neurological_institute/center-for-neurological-restoration/patient-education/patient-resources.aspx

On Cleveland Clinic

Cleveland Clinic’s Center for Neurological Restoration is among the first in the world to bring a team of experts, including renowned neurologists, neurosurgeons, researchers and a host of support personnel, to offer the latest proven treatments for people with movement disorders, including Parkinson’s disease, essential tremor and dystonia. Our surgical team is world-renowned for performing deep brain stimulation (DBS) surgeries and has experience with more than 1,200 DBS implants. The group also has expertise in the surgical management of spasticity. Various medication clinical trials as well as gene therapy surgical trial programs are underway. You can also visit us online at http://my.clevelandclinic.org/neurological_institute/center-for-neurological-restoration/default.aspx

On Your Health

MyChart®: Your Personal Health Connection is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 8+\66.915.3383 or send an email to: mychartsupport@ccf.org.

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.


Contact Information

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This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician’s independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2014. The Cleveland Clinic Foundation. All rights reserved.