Cleveland ClinicScience InternshipProgram for Nursing

The Effects of Deep Brain Stimulation on the Motor Symptoms of Parkinson’s Disease

Aaron Mulheren, Kathryn Wilson, MSN, APN, Milind Deogaonkar, MD

Cleveland Clinic

Background• Deep Brain Stimulation surgery involves

surgically placing an electrode(s) into a target in the brain and connecting the electrode(s) to a surgically implanted battery in the chest.

• Common targets for electrode

placement in brain:•Subthalamic Nucleus (STN)•Internal segment of the Globus Pallidus (GPi)•Ventral Intermediate Nucleus of the Thalamus (VIM)

• Deep Brain Stimulation can reduce tremor, bradykinesia, rigidity, and gait impairment – problematic symptoms in Parkinson’s patients.

• Deep Brain Stimulation has also shown improvement in dystonia, Tourette syndrome, and certain disorders such as pain, depression, obsessive compulsive disorder; however, these treatments are not FDA approved and are still being researched

• There is a rigorous screening process to determine if patients are good candidates for DBS.

• Candidacy based on how patient responds to Parkinson’s medications using UPDRS scoring system. Video-taped off and on medications for use at a later Patient Management Meeting.

Background, Continued

• Candidates also go through a psychiatry screening as well as a neuropsychological evaluation.

• A multi-disciplinary team (Patient Management Meeting) ultimately decides on whether the patient is a good candidate.

• In surgery, a hole is drilled into the front of the patient’s skull. An electrode is placed through the frontal lobe, and guided into a structure in the midbrain by a “mapper” – a neurologist who observes brain neurons to ensure the precise placement of the electrode.

• One month after the initial brain surgery, patient undergoes first programming in clinic, during which a clinician tries various settings until symptom control is optimized while avoiding side effects.

Results• Taken from a pool of 30 individuals with Parkinson’s

Disease

• 24 male/6 female

• Targets: 3 GPI / 26 STN / 1 VIM

• Average age: 63.8

• Pre-op off meds: 40.3 (n=28)

• Pre-op on meds: 22.9 (n=30)

• 1 Mo. Post-op on stimulation and meds: 16.3 (n=21)

• 3-6 Mo. Post-op on stimulation and meds: 17.3 (n=19)

• 9-12 Mo. Post-op on stimulation and meds: 16.5 (n=8)

• Average improvement: 59%

• Student T-Test shows P value is less than 0.00

Conclusions

• Deep Brain Stimulation improves the motor symptoms of Parkinson’s Disease more than medication alone, and the improvement lasts through the end of at least the first year.

Recommendations

• Repeat study to ensure maintaining this level of excellence.

• All patients asked to return at one year interval.

• All patients get on stim/off med at the benchmark intervals. (1, 3, 6, 12 months)

DBS Outcomes

40.3

20.4

22.9

17.316.5

0

5

10

15

20

25

30

35

40

45

Pre-op OFF Pre-op ON 1 Mo. ON 3-6 Mo. ON 9-12 Mo. ON

UP

DR

S S

co

res

Purpose of Study

• To determine the percentage of improvement in the motor symptoms of patients with Parkinson’s disease before and after Deep Brain Stimulation surgery.

Methodology

• Data acquired from patient records for those who had the diagnosis of PD and underwent DBS Surgery during a one year period.

• Motor scores were previously documented in the chart using the Unified Parkinson’s Disease Rating Scale (“UPDRS scores”); scores range from 0 (normal) to 108 (wretched). Scores for different time frames were compared.

• Average improvement determined by comparing these scores from pre-operatively to 9-12 months post-operatively.