Parkinson’s Disease (PD) is a disorder in which there is a loss of dopamine-producing cells in the brain. It is estimated to affect 1% of people over the age of 65. PD causes symptoms that vary from person to person and develop slowly over time. Motor (movement) symptoms are often the most noticeable. Common motor symptoms include tremor, bradykinesia (slowness of movements), stiffness, and problems with gait and balance. PD may also cause non-motor symptoms such as problems with sleep, constipation, loss of sense of smell, depression, and changes in memory and thinking.

PD is usually diagnosed by a neurologist after a careful review of your medical history, symptoms, and physical examination. In certain cases, your doctor might order a DAT scan. You may also have an MRI of your brain or blood tests, but these are generally used to rule out other disorders that might cause similar symptoms.

Treatment for PD begins with medications. The mainstay of drug therapy is levodopa (Sinemet), a pill that supplements dopamine in the brain. In time, your doctor may also add a second or third medication. Exercise therapy has also shown excellent benefits in PD.

As PD progresses, you may begin to develop motor complications. For example, you may notice your levodopa wearing off quickly. Patients may develop cycles where they fluctuate rapidly between a state of slowness and tremulousness (being “OFF”) and another state where they are more fluid in their movements (being “ON”) but may have bothersome uncontrollable movements called dyskinesias.

For patients with motor complications of PD, deep brain stimulation (DBS) is a safe and effective procedure that has been used in the US for over 20 years. DBS for Parkinson’s has been supported by multiple randomized controlled trials - the gold standard in medicine. Benefits of DBS include improved motor function, more good ON time during the day, and improved quality of life. Not every PD patient is a good candidate for DBS, so it’s important to discuss with your neurologist and neurosurgeon whether it is the right choice for you.

When considering DBS for a patient with PD, we look for the following criteria:

* A good response to levodopa.

* Presence of motor complications such as rapid wearing off of levodopa, dyskinesias, or medication-resistant tremor.

* Absence of dementia.

If your neurologist thinks it might be time to consider DBS, he or she will refer you to a neurosurgeon like myself who specializes in the procedure. Before or after your neurosurgery appointment, you will need at least two additional evaluations:

* ON/OFF test - Also known as a levodopa challenge test. Your movements will be tested before and after a dose of levodopa.

* Neuropsychological evaluation - A psychologist will conduct a detailed interview with you to screen for thinking or memory problems that might be affected by DBS.

If the above tests suggest you are a good candidate for DBS, I will order a brain MRI to help plan the surgery.

DBS surgery consists of two stages. In the first stage, I insert the DBS wires into the brain. I will wake you up for a short part of this operation to make sure the wire is in the right spot. You will stay overnight in the hospital and go home the following day.

The second stage of DBS surgery is done as an outpatient, meaning you go home on the day of surgery. In this stage, a battery is implanted beneath the skin under the collarbone and connected to the wire that was implanted in the brain. This surgery is less than an hour, and I perform it with you asleep.

For more information about the process of surgery and instructions for patients before and after, please visit my DBS Patient Guide.

The DBS system is turned on in your neurologist’s office 3-4 weeks after being implanted. Your neurologist will perform careful testing to find the right settings for you. You will not be able to feel the electrical pulses, but improvements in movement or tremor can often be noticed right away.

It takes two or three visits to your neurologist to find the best therapy settings for you, so don’t be discouraged if you only notice a little improvement after your first visit or if your improvement is temporary.

DBS is effective for movement symptoms of PD, particularly those that have shown a good response to levodopa. In other words, symptoms of your PD that get better (or used to get better) with levodopa are also likely to improve with DBS. The exception is tremor; DBS tends to be effective for tremor even if the tremor is difficult to treat with medications.

DBS helps smooth out fluctuations in motor function. It provides an average of 4-5 additional hours per day of good ON time, and patients report improved quality of life. Many patients are able to reduce their medication doses. Patients with DBS often describe that their motor abilities feel improved to the point where they were 5 years or so ago. These effects last for years, and because DBS therapy is flexible, the stimulator settings can be modified to fit your symptoms as they progress over time.

Importantly, while DBS can offer dramatic improvements in the motor symptoms of PD, it is not helpful for non-motor symptoms.

First, please request a referral from your neurologist. I prefer a neurology referral over a self-referral because a referral from your neurologist will include records of your Parkinson's care that will help inform our decision about surgery.

At your appointment, I will ask you about your medical history, the movement symptoms of your PD that you find most bothersome, which medications or therapies you have tried, and whether you are experiencing any cognitive problems. I will also perform a physical examination.

It can be helpful for me to see you in your OFF state (i.e. when you are at your worst) so that I can see how bad the tremor, rigidity, and slowness are, but I recognize that this is not always possible. If you plan to take your medication before my appointment, it is very helpful if you bring a video on your phone that a family member has taken when you are in an OFF state.

We will then spend most of the clinic visit reviewing DBS therapy and how it might apply to you.

* Parkinson’s Foundation

* Parkinson Association of the Rockies