Selected Podcast
Is Your Patient a Candidate for Deep Brain Stimulation (DBS)
In this panel discussion, Michael Okun, MD, and Kelly Foote, MD, examine Deep Brain Stimulation. They share information for providers on how to decide if your Parkinson’s patient is a candidate for deep brain stimulation.
Featuring:
Learn more about Kelly D. Foote, MD
Michael S. Okun, MD, received his B.A. in History from Florida State University, and his M.D. from the University of Florida where he graduated with Honors. Dr. Okun completed an internship and Neurology residency at the University of Florida. Following residency he was trained at Emory University, one of the world’s leading centers for movement disorders research, in both general movement disorders and in microelectrode recording/surgical treatments.
Learn more about Michael Okun, MD
Kelly Foote, MD | Michael Okun, MD
Kelly D. Foote, MD, is a graduate of the University of Utah, where he completed a BS degree in Materials Engineering as well as his Doctorate of Medicine. The U of U School of Medicine honored him with the Florence M. Strong Award in recognition of his outstanding qualities as a physician dedicated to patients. He did his general surgery internship at the University of Florida, where he also completed his residency in Neurological Surgery, including one year of dedicated training in Stereotactic and Functional Neurosurgery under the mentorship of Dr. William Friedman.Learn more about Kelly D. Foote, MD
Michael S. Okun, MD, received his B.A. in History from Florida State University, and his M.D. from the University of Florida where he graduated with Honors. Dr. Okun completed an internship and Neurology residency at the University of Florida. Following residency he was trained at Emory University, one of the world’s leading centers for movement disorders research, in both general movement disorders and in microelectrode recording/surgical treatments.
Learn more about Michael Okun, MD
Transcription:
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Is your Parkinson’s patient a candidate for deep brain stimulation? Welcome to UF Health Med cast with UF health shands Hospital. In this panel discussion today, we have Dr Michael Okin, MD is a University of Florida chair of neurology; and executive direction of the Norman Fixel Institute for Neurological Diseases at UF Health; and a professor at UF and Dr Kelly Foote, MD is the Co-Director Norman Fixel Institute for Neurological Diseases at UF Health. Gentlemen, I’m so glad to have you join us today. Dr. Okun, I’d like to start with you. What is usually the first line treatment for tremors resulting from movement disorders such as Parkinson’s?
Michael Okun, MD (Guest): Well when we see patients who come to us and they have issues with shaking or with difficulty picking up objects or doing the types of things that they need to do to button buttons, and hand write and all the things you need to do to just get through your everyday life; we typically will do a full evaluation and look to see if there’s anything we can do with adding a medication. We want to see what type of tremor it is. There is actually a whole bunch of different subtypes of tremors. So, not all tremor is one thing and so we want to make sure we get the diagnosis right and once we’re sure we know what we are dealing with; we have a number of different medicines that we can try and we always want to try medications and if there are some behavioral treatments and some exercises and some things that might help that tremor as well, we’ll also prescribe those.
Host: Dr. Foote, based on what Dr. Okun just said, if your patient has not seen positive effects from medication, for other providers, other neurologists that are dealing with patients with Parkinson’s; give us some of the clinical indications for use of deep brain stimulation.
Kelly Foote, MD (Guest): Well, you sort of alluded to the issue there, when the medications are not solving the problem for appropriately selected patients; surgical intervention can actually be very helpful. And in the case of tremor as you brought up before, if it’s an essential tremor, which is very common and not to be confused with Parkinson’s Disease, which is a more complex problem that frequently involves tremor; either of those two problems can be addressed very effectively with deep brain stimulation.
Host: Dr. Okun tell us a little bit about it. What are some of the advantages and what are some of the risks?
Dr. Okun: Well so when we think about should we proceed with a surgical intervention for any individual patient; what we want to do is we want to meet with that patient and that family member and we want to be sure that we understand everything it is that will make their life better and what are the reasons that we may want to do a surgery. I mean even though we do this surgery through a tiny burr hole and we use a lot of computers and fancy devices; it’s still a risk to pass a probe into the brain and to try to stimulate through that probe and change the way in which a lot of these brain regions are talking to each other. And so, the first step is having that conversation with the patient and with the family about expectations and what is it that you want to improve? Is it tremor, is it stiffness, is it slowness? And so, we try to create that nice interaction where we can both be speaking the same language and then once we’ve done the first evaluation and usually patients see a neurologist, if they are being operated on for a neurological disorder or a psychiatrist if it’s a psychiatric disorder or a neuropsychiatric disorder.
Then we proceed with what is called a multidisciplinary workup. And so, that’s where a neurologist and a neurosurgeon and a psychiatrist and all the rehab specialists like physical therapist, occupational therapists and speech and swallow therapists as well as social workers and nutritionists, meet with the patient and then we do something that might sound a little unconventional and that’s that we talk behind the patient’s back and the best type of healthcare that you can hope for in the modern system is when a group of doctors and professionals and healthcare professionals get together and they are actually talking about you. And then once we do that, we can establish what might be the best approach whether surgery is the right approach for the patient. Have we tried everything?
And then if we are going to do surgery, then we want to have that discussion about do you need it on one side of your brain or on two, what brain target might be the best for your individual symptoms and then getting all the way back to that first question. What are your expectations and what expectations based on our experience, so at UF Health Shands Hospital, we’ve done over 2000 leads and so we have a lot of experience and so we can draw on that to try to give patients a sense of what may or may not get better with the operation.
Dr. Foote: I would add from a neurosurgeon’s perspective; that I approach this as a risk benefit analysis. And you might be surprised that the decision making process for deep brain stimulation is much more complex than that say for a patient who comes to me with a brain tumor. Even though the brain tumor is typically a much worse problem to deal with and the operation that your propose carries a substantially higher risk than deep brain stimulation; the decision making is relatively straightforward. Because that is an urgent or emergent operation and deep brain stimulation is sort of special in that it is an elective brain surgery.
Some might argue that elective brain surgery shouldn’t exist. Because any time you do brain surgery; there is the potential for an injury to the brain and of course an injury to the brain could leave you with new problems that may or may not be worse than the problems you came in with. So, we take that very seriously. And that’s what all this infrastructure is about that we’ve developed at UF Health Shands Hospital and the team approach that Dr. Okun described takes some of the pressure off of me in this decision making process.
I really like the way he said what are your expectations. I actually with every single patient when I first meet them, I talk to them about what affects your quality of life and they make a list for me in order of importance to them. These are the symptoms that most impair my quality of life in order of importance to me. And then based on our experiences with a couple of thousand people before them; we can give them realistic expectations and say look, this first thing on your list I think is very likely to respond well to surgery and we’ve found a way to do this operation that addresses that quite nicely. But perhaps this second thing on your list, I can tell you right now, that never gets better and you should know up front that that particular symptom is not something that we figured out a way to solve. The third and fourth things on your list, I’m pretty confident. The fifth thing on your list, sometimes it gets better and sometimes it doesn’t. And we don’t fully understand how to make that happen every time.
But at least, once we’ve finished this conversation, the patients can have very realistic expectations about what we can hope to achieve with this intervention.
Host: Well it certainly is a comprehensive multidisciplinary evaluation and as you say, patient selection criteria is so important for this. Dr. Foote, speak a little bit about the device programming itself. How does it work and tell us a little bit about the surgeon and the movement disorder specialist experience with this procedure.
Dr. Foote: Well, the devices involved – the implantation of in general, a single wire with multiple metal contacts that make contact with the part of the brain that we hope to stimulate in order to address the patient’s symptoms and as you might imagine; the position in the brain that we stimulate anatomically, determines the effect and the success or failure of the operation is completely dependent on delivering the electrical currents exactly where we want to deliver it and perhaps just as importantly, not delivering electrical currents to other structures or other circuitry surrounding the circuitry that we know we can stimulate for the patient’s benefit.
So, a big part of this operation is an investment in making sure that the DBS lead and those electrical contacts end up exactly where they need to be to help the symptoms. If they are a couple of millimeters in one direction or the other; then you may get stimulation induced side effects that are intolerable instead of the relief from your tremor or in the case of Parkinson’s Disease suppression of your dyskinesia or relief from stiffness and slowness and muscle cramping.
So, getting the DBS lead in precisely the right position and then programming to adjust where that current is going and how powerfully it gets there is the process that we use to delivery therapeutic stimulation and have what can be really dramatic effects on people’s symptoms and quality of life.
Host: Well thank you for that answer. Dr. Okun, how have been your outcomes? Have you seen sustained improvement in motor function and a reduction maybe in antiparkinsonian medication? Has that been stable? Have you seen any adverse effects of treatments? Tell us a little bit about your outcomes.
Dr. Okun: So, I think one of the most important lessons of running a really high quality deep brain stimulation program is making sure that you have both the right preoperative screening, that you do the procedure in a very careful way because the real estate in the brain matters. So, it matters whether you are a millimeter or two off can be like the distance between Florida and California. And so, it’s really important to get the leads in the right place but then maybe most important is to make sure you have the right team in place to follow the patients and so the follow up of these patients includes not only programming the device and so everybody thinks about okay you have this really fancy device that you’ve implanted, it’s going to be all about programming. But a lot of these patients have diseases like Parkinson’s Disease and so long term, it’s not just the programming of the device but it’s also management of the medications.
Now when the procedure is done and it’s successful which in most cases, it is and in fact, in almost all cases, it should be successful with low side effects and that’s part of the interdisciplinary screening process. So, part of the process of seeing all these people from different disciplines and assessing the risk and making sure that you are taking the right approach and you have the right follow up for patients ensures that you are going to have success in most of these cases.
Now can you get side effects, and can you get complications from deep brain stimulation? You certainly can and the ones that we worry the most about are bleeds or strokes because remember we might be pushing through a brain region and accidentally or unintentionally hit something that we don’t want to hit, and we worry about infection. Because we are putting a device into somebody and that device doesn’t have a blood supply so if maybe a little bit of dirt gets on that device or a little bit of bacteria gets on there; we don’t have the blood supply that even if we take antibiotics, we can clear that and so those are two of the things that happen less than 5% of the time. So, usually a few percent of the time in most major centers that do a lot of these procedures.
And so we watch out for that. Now in terms of motor benefits; it can be life changing. So, if you’re a Parkinson’s patient; it might capture your tremor and so it’s very good with tremor, it’s very good for another movement disorder called dyskinesia which are these extra dance like movements that you get from taking dopamine replacement therapy called levodopa. It’s very effective at suppressing those extra movements. It also improves the quality of life by doing things like reducing the amount of stiffness that you have and improving your speed of movement or your slowness of movement that happens with Parkinson’s and so you get to be faster and so you can do your activities of daily living in a faster way that you couldn’t do before because the movement was so slow and so labored.
And then many of our Parkinson’s patients, the meds are wearing off after a few hours and coming back on and so we call these fluctuations where the meds are wearing off and then as they wear off you get tremors, stiffness and slowness. And so you can imagine going through cycles of being on your meds and off your meds and one of the great things about deep brain stimulation is it really does smooth out those on and off fluctuations. And so, in summary, we think about improvements in tremor, we think about improvements in that other movement disorder caused by the medicines called dyskinesia and then stiffness and slowness improve and then these fluctuations that go up and done that can really make life difficult for patients.
And then finally, the other thing is that some patients but not all will also have a reduction in the medications that they take.
Dr. Foote: I would add that one sort of nice way to think about it is that deep brain stimulation does not cure Parkinson’s Disease. It doesn’t even necessarily make someone dramatically better than they are when they are at their best on their medications. But what it does quite nicely is get people at or near their best level of functioning and keep them there much more of the time. So, alleviating those motor fluctuations is one of the main indications for deep brain stimulation. And in most cases, as Parkinson’s Disease progresses, it becomes increasingly difficult even for very good movement disorder specialists to adjust the medications well enough to avoid those motor fluctuations because it gets more and more difficult as the disease progresses.
And so at some point, deep brain stimulation can have a beneficial effect in that regard.
Host: Dr. Foote, before we conclude this episode; tell us about some promising new therapies in regards to tremors and deep brain stimulation for other providers. Let them know what’s exciting in your field of neurosurgery and why you think it’s important that they refer to the specialists at UF Health Shands Hospital.
Dr. Foote: Well, there are a couple of different directions I could go with your question. The question about why I think it’s important to send patients to a place like UF Health Shands Hospital has to do with the specialization that is very effective. We talked about that interdisciplinary team approach and I think until you see it in action; it’s hard to appreciate how important that can be in making sure we get the optimal outcome. We have eight different specialists with various areas of expertise who are all let’s say we are dealing with a Parkinson’s patient. Each of these specialists is a Parkinson’s expert but they might be a physical therapist or an occupational therapist or a psychiatrist or a neuropsychologist, but all of these folks are focused on Parkinson’s Disease and know all the nuances of Parkinson’s Disease within their area of expertise.
So, they are Parkinson’s specialists but just as importantly, they are also deep brain stimulation specialists. And each one of them has evaluated hundreds of patients before and after deep brain stimulation and they have this wealth of understanding that they can share with me as we are making decisions. Let me give you an example just to illustrate what I’m talking about. Perhaps the Parkinson’s specialist who is a speech pathologist who focuses on speech and swallowing does her evaluation of a patient prior to surgery and says, you know what, this patient is aspirating. They have a dysfunctional swallow and they don’t even realize that some of their food is getting into their lungs and they are at high risk for getting pneumonia. And one of the possible temporary side effects of deep brain stimulation just from a little swelling in the brain around the DBS, the implanted DBS lead is that it can impair your swallowing function temporarily.
And so if we know that in advance; then the speech pathologist might in our meeting when we are talking about this patient’s case; say, heh you know what, this patient has this issue and in my experience with other patients like this, when we’ve done the deep brain stimulation operation this way, when you stimulate in this target; it turns out better than when you stimulate in this target and it’s a lower risk of having postoperative problems. And by the way, I think as a precaution, immediately after the operation, I want you to call me and I will come evaluate this patient’s swallowing function before you start giving the patient something to eat and drink just to make sure that we don’t cause a pneumonia during the hospitalization.
So, that’s one example. But I could give you 50 different examples of how this interdisciplinary approach can alter – it’s not just making the decision should this patient have a DBS operation. But how should we do the operation for this specific patient in order to maximize the predicted benefit and to minimize all of the risks and all different domains. And that infrastructure, I think is what makes a center like ours special and allows us to as Michael said, we expect essentially every patient who goes through this process of careful patient selection and tailoring the operation to their given needs and their risks; we expect every patient to have a good outcome and the patients who have bad outcomes should be very few and far between.
Host: Dr. Okun, please conclude for us what can a referring physician expect from your team after referral in so far as communication and your team approach. Just kind of summarize for us.
Dr. Okun: Yeah so, after referral to UF Health Shands Hospital, we consider ourselves to be partners with everyone. We see patients from every continent except for Antarctica. We haven’t had a patient from there but we’ve had patients from all over and so, our job is really to help to restore people’s lives and to make things easier for the referring docs and so if they need some help in evaluating a patient for deep brain stimulation and going through the process; we are happy to provide that help if the patient needs surgery and would like to be managed back in his or her community. Whether that’s locally, regionally, across the pond meaning in Europe or Australia or somewhere else; we work with physicians all over the world.
And so, out job is to really try to impact lives and try to help people with symptoms that can be modulated by this really cool and unique therapy and the number of indications for the therapy keep growing and we do a lot of research too. And so, we are involved in a lot of National Institutes of Health and other studies for other indications so not just Parkinson’s and tremor, but we operate on dystonia and obsessive compulsive disorder and Tourette’s Syndrome and so, the expectation from our end is how can we help. We are here to help. The answer is always yes. Not everybody is a surgical candidate but certainly if you can benefit from a surgery; we want to see what we can do to help you. And we also want to return you back to your communities and make it easy for management to happen there locally as well.
And so, we’ve really enjoyed the partnership we’ve had with various physicians and health practitioners all over the world.
Host: Thank you gentlemen for joining us. What a fascinating topic. Thank you so much for sharing your incredible expertise today. And that concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs, please follow us on your social channels. I’m Melanie Cole.
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Is your Parkinson’s patient a candidate for deep brain stimulation? Welcome to UF Health Med cast with UF health shands Hospital. In this panel discussion today, we have Dr Michael Okin, MD is a University of Florida chair of neurology; and executive direction of the Norman Fixel Institute for Neurological Diseases at UF Health; and a professor at UF and Dr Kelly Foote, MD is the Co-Director Norman Fixel Institute for Neurological Diseases at UF Health. Gentlemen, I’m so glad to have you join us today. Dr. Okun, I’d like to start with you. What is usually the first line treatment for tremors resulting from movement disorders such as Parkinson’s?
Michael Okun, MD (Guest): Well when we see patients who come to us and they have issues with shaking or with difficulty picking up objects or doing the types of things that they need to do to button buttons, and hand write and all the things you need to do to just get through your everyday life; we typically will do a full evaluation and look to see if there’s anything we can do with adding a medication. We want to see what type of tremor it is. There is actually a whole bunch of different subtypes of tremors. So, not all tremor is one thing and so we want to make sure we get the diagnosis right and once we’re sure we know what we are dealing with; we have a number of different medicines that we can try and we always want to try medications and if there are some behavioral treatments and some exercises and some things that might help that tremor as well, we’ll also prescribe those.
Host: Dr. Foote, based on what Dr. Okun just said, if your patient has not seen positive effects from medication, for other providers, other neurologists that are dealing with patients with Parkinson’s; give us some of the clinical indications for use of deep brain stimulation.
Kelly Foote, MD (Guest): Well, you sort of alluded to the issue there, when the medications are not solving the problem for appropriately selected patients; surgical intervention can actually be very helpful. And in the case of tremor as you brought up before, if it’s an essential tremor, which is very common and not to be confused with Parkinson’s Disease, which is a more complex problem that frequently involves tremor; either of those two problems can be addressed very effectively with deep brain stimulation.
Host: Dr. Okun tell us a little bit about it. What are some of the advantages and what are some of the risks?
Dr. Okun: Well so when we think about should we proceed with a surgical intervention for any individual patient; what we want to do is we want to meet with that patient and that family member and we want to be sure that we understand everything it is that will make their life better and what are the reasons that we may want to do a surgery. I mean even though we do this surgery through a tiny burr hole and we use a lot of computers and fancy devices; it’s still a risk to pass a probe into the brain and to try to stimulate through that probe and change the way in which a lot of these brain regions are talking to each other. And so, the first step is having that conversation with the patient and with the family about expectations and what is it that you want to improve? Is it tremor, is it stiffness, is it slowness? And so, we try to create that nice interaction where we can both be speaking the same language and then once we’ve done the first evaluation and usually patients see a neurologist, if they are being operated on for a neurological disorder or a psychiatrist if it’s a psychiatric disorder or a neuropsychiatric disorder.
Then we proceed with what is called a multidisciplinary workup. And so, that’s where a neurologist and a neurosurgeon and a psychiatrist and all the rehab specialists like physical therapist, occupational therapists and speech and swallow therapists as well as social workers and nutritionists, meet with the patient and then we do something that might sound a little unconventional and that’s that we talk behind the patient’s back and the best type of healthcare that you can hope for in the modern system is when a group of doctors and professionals and healthcare professionals get together and they are actually talking about you. And then once we do that, we can establish what might be the best approach whether surgery is the right approach for the patient. Have we tried everything?
And then if we are going to do surgery, then we want to have that discussion about do you need it on one side of your brain or on two, what brain target might be the best for your individual symptoms and then getting all the way back to that first question. What are your expectations and what expectations based on our experience, so at UF Health Shands Hospital, we’ve done over 2000 leads and so we have a lot of experience and so we can draw on that to try to give patients a sense of what may or may not get better with the operation.
Dr. Foote: I would add from a neurosurgeon’s perspective; that I approach this as a risk benefit analysis. And you might be surprised that the decision making process for deep brain stimulation is much more complex than that say for a patient who comes to me with a brain tumor. Even though the brain tumor is typically a much worse problem to deal with and the operation that your propose carries a substantially higher risk than deep brain stimulation; the decision making is relatively straightforward. Because that is an urgent or emergent operation and deep brain stimulation is sort of special in that it is an elective brain surgery.
Some might argue that elective brain surgery shouldn’t exist. Because any time you do brain surgery; there is the potential for an injury to the brain and of course an injury to the brain could leave you with new problems that may or may not be worse than the problems you came in with. So, we take that very seriously. And that’s what all this infrastructure is about that we’ve developed at UF Health Shands Hospital and the team approach that Dr. Okun described takes some of the pressure off of me in this decision making process.
I really like the way he said what are your expectations. I actually with every single patient when I first meet them, I talk to them about what affects your quality of life and they make a list for me in order of importance to them. These are the symptoms that most impair my quality of life in order of importance to me. And then based on our experiences with a couple of thousand people before them; we can give them realistic expectations and say look, this first thing on your list I think is very likely to respond well to surgery and we’ve found a way to do this operation that addresses that quite nicely. But perhaps this second thing on your list, I can tell you right now, that never gets better and you should know up front that that particular symptom is not something that we figured out a way to solve. The third and fourth things on your list, I’m pretty confident. The fifth thing on your list, sometimes it gets better and sometimes it doesn’t. And we don’t fully understand how to make that happen every time.
But at least, once we’ve finished this conversation, the patients can have very realistic expectations about what we can hope to achieve with this intervention.
Host: Well it certainly is a comprehensive multidisciplinary evaluation and as you say, patient selection criteria is so important for this. Dr. Foote, speak a little bit about the device programming itself. How does it work and tell us a little bit about the surgeon and the movement disorder specialist experience with this procedure.
Dr. Foote: Well, the devices involved – the implantation of in general, a single wire with multiple metal contacts that make contact with the part of the brain that we hope to stimulate in order to address the patient’s symptoms and as you might imagine; the position in the brain that we stimulate anatomically, determines the effect and the success or failure of the operation is completely dependent on delivering the electrical currents exactly where we want to deliver it and perhaps just as importantly, not delivering electrical currents to other structures or other circuitry surrounding the circuitry that we know we can stimulate for the patient’s benefit.
So, a big part of this operation is an investment in making sure that the DBS lead and those electrical contacts end up exactly where they need to be to help the symptoms. If they are a couple of millimeters in one direction or the other; then you may get stimulation induced side effects that are intolerable instead of the relief from your tremor or in the case of Parkinson’s Disease suppression of your dyskinesia or relief from stiffness and slowness and muscle cramping.
So, getting the DBS lead in precisely the right position and then programming to adjust where that current is going and how powerfully it gets there is the process that we use to delivery therapeutic stimulation and have what can be really dramatic effects on people’s symptoms and quality of life.
Host: Well thank you for that answer. Dr. Okun, how have been your outcomes? Have you seen sustained improvement in motor function and a reduction maybe in antiparkinsonian medication? Has that been stable? Have you seen any adverse effects of treatments? Tell us a little bit about your outcomes.
Dr. Okun: So, I think one of the most important lessons of running a really high quality deep brain stimulation program is making sure that you have both the right preoperative screening, that you do the procedure in a very careful way because the real estate in the brain matters. So, it matters whether you are a millimeter or two off can be like the distance between Florida and California. And so, it’s really important to get the leads in the right place but then maybe most important is to make sure you have the right team in place to follow the patients and so the follow up of these patients includes not only programming the device and so everybody thinks about okay you have this really fancy device that you’ve implanted, it’s going to be all about programming. But a lot of these patients have diseases like Parkinson’s Disease and so long term, it’s not just the programming of the device but it’s also management of the medications.
Now when the procedure is done and it’s successful which in most cases, it is and in fact, in almost all cases, it should be successful with low side effects and that’s part of the interdisciplinary screening process. So, part of the process of seeing all these people from different disciplines and assessing the risk and making sure that you are taking the right approach and you have the right follow up for patients ensures that you are going to have success in most of these cases.
Now can you get side effects, and can you get complications from deep brain stimulation? You certainly can and the ones that we worry the most about are bleeds or strokes because remember we might be pushing through a brain region and accidentally or unintentionally hit something that we don’t want to hit, and we worry about infection. Because we are putting a device into somebody and that device doesn’t have a blood supply so if maybe a little bit of dirt gets on that device or a little bit of bacteria gets on there; we don’t have the blood supply that even if we take antibiotics, we can clear that and so those are two of the things that happen less than 5% of the time. So, usually a few percent of the time in most major centers that do a lot of these procedures.
And so we watch out for that. Now in terms of motor benefits; it can be life changing. So, if you’re a Parkinson’s patient; it might capture your tremor and so it’s very good with tremor, it’s very good for another movement disorder called dyskinesia which are these extra dance like movements that you get from taking dopamine replacement therapy called levodopa. It’s very effective at suppressing those extra movements. It also improves the quality of life by doing things like reducing the amount of stiffness that you have and improving your speed of movement or your slowness of movement that happens with Parkinson’s and so you get to be faster and so you can do your activities of daily living in a faster way that you couldn’t do before because the movement was so slow and so labored.
And then many of our Parkinson’s patients, the meds are wearing off after a few hours and coming back on and so we call these fluctuations where the meds are wearing off and then as they wear off you get tremors, stiffness and slowness. And so you can imagine going through cycles of being on your meds and off your meds and one of the great things about deep brain stimulation is it really does smooth out those on and off fluctuations. And so, in summary, we think about improvements in tremor, we think about improvements in that other movement disorder caused by the medicines called dyskinesia and then stiffness and slowness improve and then these fluctuations that go up and done that can really make life difficult for patients.
And then finally, the other thing is that some patients but not all will also have a reduction in the medications that they take.
Dr. Foote: I would add that one sort of nice way to think about it is that deep brain stimulation does not cure Parkinson’s Disease. It doesn’t even necessarily make someone dramatically better than they are when they are at their best on their medications. But what it does quite nicely is get people at or near their best level of functioning and keep them there much more of the time. So, alleviating those motor fluctuations is one of the main indications for deep brain stimulation. And in most cases, as Parkinson’s Disease progresses, it becomes increasingly difficult even for very good movement disorder specialists to adjust the medications well enough to avoid those motor fluctuations because it gets more and more difficult as the disease progresses.
And so at some point, deep brain stimulation can have a beneficial effect in that regard.
Host: Dr. Foote, before we conclude this episode; tell us about some promising new therapies in regards to tremors and deep brain stimulation for other providers. Let them know what’s exciting in your field of neurosurgery and why you think it’s important that they refer to the specialists at UF Health Shands Hospital.
Dr. Foote: Well, there are a couple of different directions I could go with your question. The question about why I think it’s important to send patients to a place like UF Health Shands Hospital has to do with the specialization that is very effective. We talked about that interdisciplinary team approach and I think until you see it in action; it’s hard to appreciate how important that can be in making sure we get the optimal outcome. We have eight different specialists with various areas of expertise who are all let’s say we are dealing with a Parkinson’s patient. Each of these specialists is a Parkinson’s expert but they might be a physical therapist or an occupational therapist or a psychiatrist or a neuropsychologist, but all of these folks are focused on Parkinson’s Disease and know all the nuances of Parkinson’s Disease within their area of expertise.
So, they are Parkinson’s specialists but just as importantly, they are also deep brain stimulation specialists. And each one of them has evaluated hundreds of patients before and after deep brain stimulation and they have this wealth of understanding that they can share with me as we are making decisions. Let me give you an example just to illustrate what I’m talking about. Perhaps the Parkinson’s specialist who is a speech pathologist who focuses on speech and swallowing does her evaluation of a patient prior to surgery and says, you know what, this patient is aspirating. They have a dysfunctional swallow and they don’t even realize that some of their food is getting into their lungs and they are at high risk for getting pneumonia. And one of the possible temporary side effects of deep brain stimulation just from a little swelling in the brain around the DBS, the implanted DBS lead is that it can impair your swallowing function temporarily.
And so if we know that in advance; then the speech pathologist might in our meeting when we are talking about this patient’s case; say, heh you know what, this patient has this issue and in my experience with other patients like this, when we’ve done the deep brain stimulation operation this way, when you stimulate in this target; it turns out better than when you stimulate in this target and it’s a lower risk of having postoperative problems. And by the way, I think as a precaution, immediately after the operation, I want you to call me and I will come evaluate this patient’s swallowing function before you start giving the patient something to eat and drink just to make sure that we don’t cause a pneumonia during the hospitalization.
So, that’s one example. But I could give you 50 different examples of how this interdisciplinary approach can alter – it’s not just making the decision should this patient have a DBS operation. But how should we do the operation for this specific patient in order to maximize the predicted benefit and to minimize all of the risks and all different domains. And that infrastructure, I think is what makes a center like ours special and allows us to as Michael said, we expect essentially every patient who goes through this process of careful patient selection and tailoring the operation to their given needs and their risks; we expect every patient to have a good outcome and the patients who have bad outcomes should be very few and far between.
Host: Dr. Okun, please conclude for us what can a referring physician expect from your team after referral in so far as communication and your team approach. Just kind of summarize for us.
Dr. Okun: Yeah so, after referral to UF Health Shands Hospital, we consider ourselves to be partners with everyone. We see patients from every continent except for Antarctica. We haven’t had a patient from there but we’ve had patients from all over and so, our job is really to help to restore people’s lives and to make things easier for the referring docs and so if they need some help in evaluating a patient for deep brain stimulation and going through the process; we are happy to provide that help if the patient needs surgery and would like to be managed back in his or her community. Whether that’s locally, regionally, across the pond meaning in Europe or Australia or somewhere else; we work with physicians all over the world.
And so, out job is to really try to impact lives and try to help people with symptoms that can be modulated by this really cool and unique therapy and the number of indications for the therapy keep growing and we do a lot of research too. And so, we are involved in a lot of National Institutes of Health and other studies for other indications so not just Parkinson’s and tremor, but we operate on dystonia and obsessive compulsive disorder and Tourette’s Syndrome and so, the expectation from our end is how can we help. We are here to help. The answer is always yes. Not everybody is a surgical candidate but certainly if you can benefit from a surgery; we want to see what we can do to help you. And we also want to return you back to your communities and make it easy for management to happen there locally as well.
And so, we’ve really enjoyed the partnership we’ve had with various physicians and health practitioners all over the world.
Host: Thank you gentlemen for joining us. What a fascinating topic. Thank you so much for sharing your incredible expertise today. And that concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs, please follow us on your social channels. I’m Melanie Cole.