TECHNOLOGY IN REHABILITATION

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TECHNOLOGY IN REHABILITATION Neuromodulation
Deep Brain Stimulation Overview
Elena Draznin, MD Medical Director , Swedish
Rehabilitation Unit.
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Neuromodulation is a therapeutic alteration of
activity in central, peripheral or autonomic
nervous systems, electrically or
pharmacologically, by means of implanted devices
Spasticity Parkinsons disease, other movement
disorders Cortical stimulation for
stroke Pain Epilepsy Intractable nausea Cochlear
implants
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Idiopathic Parkinsons disease

• Progressive neurodegenerative disorder
• 1.5 million in US
• Slowly progressive
• Asymmetric onset
• Affecting mostly people over 60
• Etiology is unknown.

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Two advocates for research who developed
Parkinson's early Muhammad Ali at age 42 and
Michael J. Fox at age 30.
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What Causes PD?
A small area in the brain stem called the
substantia nigra controls movement. In PD, cells
in the substantia nigra stop producing dopamine,
a chemical that helps nerve cells communicate. As
dopamine-producing cells die, the brain does not
receive the necessary messages about how and when
to move.
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Parkinson's Disease
Brain disorder with a gradual loss of movement
control. Cardinal signs Tremors,
Stiffness, rigidity
Akinesia or bradykinesia.
Postural instability,
impaired balance.
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Symptom Tremor Tremor is an early symptom for
about 70 of people with Parkinson's. It occurs
in a finger or hand at rest, rhythmically,
usually four to six beats per second, or in a
"pill-rolling" manner, as if rolling a pill
between the thumb and index finger.
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TYPES OF TREMOR Essential Tremor- 50
familial Parkinsonism Dystonia Secondary
tremor medicine stroke MS Peripheral
Nerve damage Psychological
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The early signs of Parkinson's disease include
Stiffness or difficulty walking Difficulty
getting out of a chair
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The early signs of Parkinson's disease Stooped
posture A 'masked' face, frozen in a serious
expression
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Symptom Rigidity Rigidity occurs when the
muscles stay stiff and don't relax. The arms may
not swing when a person is walking. There may be
cramping or pain in the muscles.
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Parkinson's disease Small, crowded handwriting
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Parkinsons disease
Cost of drug therapy 1,000- 6,000 per
year Health care cost 2,000- 20,000 per
year Risk of death doubles Referral to
neurologist associated with decreased morbidity/
mortality and SNF placement.
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Moderate to Advance Disease
On-off fluctuations random or EOD
wearing off Dose failures Dyskenesias
Non dopamine responsive symptoms
postural flexion and instability falls
retropulsion and propulsion
freezing, motor initiation speech and
swallowing
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Parkinsons Disease Treatment Continuum of
Interventions
Modified from Giroux, ML and Farris, SF.
Cleveland Clinic Foundation 2005 Cleveland Clinic
Foundation Center for Neurological Restoration
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When Should DBS be Considered?

• When, despite optimized pharmacotherapy, your
  patient experiences troubling motor symptoms,
  which may include
• Wearing off Off periods that contain troubling
  bradykinesia, rigidity, tremor, and/or gait
  difficulty
• Troubling dyskinesia
• Motor fluctuations
• Refractory tremor

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Optimal candidate for DBS

• Presence of on-off fluctuations
• Dyskenesia impairing quality of life
• Medication resistant tremor
• Reasonable cognitive function
• Adequate response to dopaminergic therapy

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DBS When Pharmacotherapy isnt Enough

• As Parkinsons disease progresses, medications
  may fail to provide consistent and adequate
  symptom control
• Medications used at levels required for symptom
  control may produce adverse effects
• Motor complications, such as dyskinesia
• Cognitive and psychiatric problems
• Nausea, hypotension, and other systemic effects

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Approved Indications

• DBS Therapy is approved for the treatment of
  symptoms due to
• Essential Tremor
• FDA approved in 1997
• Parkinsons disease
• FDA approved in 2002
• Dystonia
• FDA approved (HDE) in 2003
• Over 100,000 patients implanted worldwide

Humanitarian Device Authorized by Federal Law
for the use as an aid in the management of
chronic, intractable (drug refractory) primary
dystonia, including generalized and segmental
dystonia, hemidystonia, and cervical dystonia,
for individuals 7 years of age and older.
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Team Screening for DBS

• Neurologist
• Neurosurgeon
• Neuropsychologist
• Physiatrist
• Cost DBS 28,000 -- 50,000
• Programming cost 3,000

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Dopamine dysregulation syndrome

• Impulse control disorder gambling, shopping,
  hypersexuality,
• Behavior disturbances aggressive tendencies,
  fights, psychosis, compulsive eating
• Punding repetition of complex motor behaviors
• Hypomania, mania, dysphoria

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Surgery Deep Brain Stimulation
Uses an implanted electrode to deliver
high-frequency electrical stimulation to
structures involved in the control of movement
This electrical stimulation overrides abnormal
neuronal activity within brain regions to bring
motor controlling circuits into a more normal
state of function, thereby reducing movement
disorder symptoms
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DBS Therapy

• Acts on cells and fibers closest to the
  electrode, changing firing pattern of individual
  neurons in BG
• Triggers neighboring astrocytes to release Ca2
  and neurotransmitters
• Increases blood flow, stimulates neurogenesis

Click screen to play
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Target Sites for DBS
Ventral Intermediate Thalamus Essential Tremor
Subthalamic Nucleus Parkinsons diseaseand
Dystonia
Globus Pallidus Parkinsons diseaseand Dystonia
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DBS for Parkinson Disease
GPi
STN
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Lesion therapy DBS

• Thalamotomy
• Subthalamotomy
• Pallidotomy
• High risk with bilateral lesion

• Programmable
• Bilateral placement
• Reversible effect

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DBS Therapy Steps

• Inpatient admission for lead implant
• Inpatient or outpatient admission for placement
  of implantable pulse generator.
• Follow-up programming of IPG(s)
• Rehabilitation

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Inpatient Rehab Admission Criteria DBS Therapy

• Patients may meet IRF admission criteria due to
  the change in clinical status
• Deep Brain Stimulation changes clinical status
  through symptom relief2
• Presence of ADL deficits is a patient selection
  criteria for DBS Therapy
• Intensive rehabilitation contributes to the
  success of DBS therapy by improving ADL deficits

2 Rehncrona SJohnels BWidner HTornqvist
ALHariz MSydow O. Long-term efficacy of
thalamic deep brain stimulation for tremor
Double-blind assessments.Mov Disord 2003 Feb18
(2) 163-70
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American Academy of Neurology -PD Guidelines

• DBS is included in the AAN PD Guidelines
  (released in April 2006) with the following key
  points
• Ten to 20 of people with Parkinson disease may
  be eligible for surgical treatment.1
• Talk to your neurologist early in your disease
  to discuss the potential for future surgical
  treatment.1

1AAN Guideline Summary for Patients and their
Families Medical and Surgical Treatment for
Motor Fluctuations and Dyskinesia in Parkinson
Disease, 2006
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ON Time Without Dyskinesias Improves from 27
to 74 of a Patients Waking Day
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27
7
49
74
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Before Surgery (n96)
6 Months After SurgeryBilateral STN Activa
Implant (n91)
ON without Dyskinesia
ON with Dyskinesia
OFF
The Deep-Brain Stimulation for Parkinsons
Disease Study Group. Deep-brain stimulation of
the subthalamic nucleus for the pars interna of
the globus pallidus in Parkinsons disease. N Eng
J Med. 2001345956-63.
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Motor Symptoms Improvements Maintained After 5
Years

• In a 5-year study, DBS significantly improved
  OFF-medication assessments of tremor, rigidity,
  and akinesia/bradykinesia

OFF-Medication Motor Score Improvements OFF-Medication Motor Score Improvements OFF-Medication Motor Score Improvements OFF-Medication Motor Score Improvements
6-month 1-year 3 years 5 years
Tremor 79 75 83 75
Rigidity 58 73 74 71
Akinesia 42 63 52 49
Results for STN
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DBS efficacy for ET

• 69 of Essential Tremor patients experience total
  or significant suppression of disabling tremor
• This results in significant reduction in
  disability
• Stimulation-induced adverse effects include
  transient paresthesia, dysarthria, and
  disequilibrium
• Many of the side effects were temporary or
  improved with adjustment of electrical parameters

Data on File. Medtronic, Inc.
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Conclusions In this randomized controlled
trial, deep brain stimulation was more effective
than best medical therapy in alleviating
disability in patients with moderate to severe PD
with motor complications responsive to levodopa
and no significant cognitive impairment.