Movement Disorders, Parkinson's Disease, Deep Brain Stimulation: Expert Q&A

[MUSIC PLAYING] Today on At The Forefront Live we'll talk about Parkinson's disease, one of the most common movement disorders. It causes impaired or involuntary movements and can affect behavior, mood, and other body functions. When medication can no longer safely control symptoms, experts look for other solutions.

Our experts at UChicago Medicine offer deep brain stimulation to treat patients who have movement disorders. DBS involves placing small electrodes into the brain. Dr. Tao Xie and neurosurgeon Dr. Peter Warnke join us to discuss the diagnosis and management of Parkinson's disease and DBS as a treatment option. Both of our experts will take your questions. That's coming up right now on At the Forefront Live.

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And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Let's start off having each of you introduce yourselves and tell us what you do here at UChicago medicine. And Dr. Warnke we're going to start with you.

Oh, thank you very much, Tim. So I'm the Director of Stereotactic and Functional Neurosurgery at the University of Chicago. And I perform deep brain stimulation for Parkinson's disease, also for other movement disorders, and do all the epilepsy surgery and some deep-seated functional tumors. So overall, all the important functional eloquent areas of the brain are covered by functional neurosurgery.

Hello, everyone. My name is Tao Xie. I'm an Associate Professor of Neurology and Mood Disorder specializing in neurology. I'm the Director of the Mood Disorder Clinic and DBS program. I'm so glad to be here to talk about Parkinson's disease and DBS program.

Great. So Dr. Warnke, I would be remiss in saying that we are obviously in a working medical center. And you're working right now. That's while you're wearing a mask and you have the surgical cap on. We appreciate you making the time. But we also appreciate you always putting patients first. And I know you've been working with patients, even this morning. So thanks for being in here right now.

So let's talk a little bit about Parkinson's in general to start with. And I don't know, either one of you can take this question. But explain to us what is Parkinson's and what does it do to the body.

Dr. Xie.

OK, so Parkinson's disease is a neurodegenerative disease due to the progress test in the specifically dopamine producing neurons in the substantia nigra specific region in the brain, because that neuron produces dopamine. Dopamine is very important for the movement. With the death of this neuron and the lack of a dopamine, that's why patient develop with the symptoms of Parkinson's-- of Parkinsonism syndrome.

Parkinsonism was a cardinal symptom of bradykinesia, which is a slow movement and rigidity, which is kind of stiff stiffness feeling and also tremor. The tremors mainly occur when the patient puts the hand at rest. We call it resting tremor. The symptom usually gradual start. For the majority of patient it start around the age of 55. And some can start up earlier.

And usually it start on one side of the body, most commonly it's the upper body. The most commonly noticed symptom is that the tremor. That's brought up a lot of patient come to see us. The tremor usually affects of the finger or the thumb and then the hand and then that tremor can gradually spread to the same side of the leg or then move to the other side.>

The patient can also have other symptoms, like I mentioned, the stiffness. The stiffness can also focus on the shoulder. And the some patient can be misdiagnosed as frozen shoulder or osteoarthritis. And other symptoms the patient feel slowly movement. And then their facial expressions also become plain. It's lack of facial expression and eye blink is reduced.

And their speech become like monotonic and also softer. Their writing becomes smaller. And also when they are walking, they have reduced their arms swing and they have like a shuffling gait. And also when they're walking, the tremor can also be more noticeable. And they can have like this hunched forward posture.

Besides just the motor symptom, the patient can also have like some non-motor the symptom, like loss of the smell of function and REM behavior, disorder like acting out a dream even before the motor symptom onset. And some also come with constipation.

And as the disease progression, all the symptoms become more prominent, and also the actual symptom like a gait problem, freezing gait, loss of balance, and then difficulty swallowing and the cognitive impairment, all this can become an issue, including anxiety, depression and other non-motor pain and then sleep cycle change, et cetera.

Dr. Xie, do we know what actually causes Parkinson's?

Yeah, pathology wise, it's caused by abnormal accumulation of a protein called alpha-synuclein. Because they kind of fall of order normally and then form certain-- we call it aggression. And then deposit it in the cell body. And the damage of the cell function eventually gradually kill the cells. And then the-- this is the major cause of the protein we've found it. But there's also other proteins that can also damage the cell.

And so far only 10% the patient we find a genetic cause of that. 90% of the patient is sporadic. So we found that young onset people more likely have a genetic cause of it and later onset, age of 50 or above, are less likely to have it at least so far. So overall, we think it's most likely for the majority of patients it's a combination genetics, of course, and environment toxin exposure. Toxin including baseline epidemiological study like pesticides, et cetera.

So Dr. Warnke, there are different types of movement disorders, correct? What are some of the other ones?

So the other ones are essential tremor, which is a clearly genetic disease where the criteria are to have a positive family history. And another criterion is that it is chemical sensitive, so it responds very well to a little bit of alcohol, which some patients then use to mask and cover the tremor. And that's one thing.

Another one is dystonia, which is also genetically caused in some cases, in other cases not. And all of those are amenable to a deep brain stimulation to disrupt the pathological circuits in the brain.

So let's talk a little bit more about deep brain stimulation and what exactly that is. I mentioned it briefly in the introduction on the program. But if you can kind of walk us through that. And Dr. Warnke, we'll start with you. And just tell us what that is and how that works, if you will, please.

Yeah and that's a very good question, because most people are very, I would say, irrationally afraid. This is brain surgery. But it is the most scientifically proven and the most non-invasive brain surgery you can think of. Deep brain stimulation means that computer guided based on an MRI scan, and in our case at the University of Chicago with a pin drop CT scan, we design a target.

And we know exactly, for example on Parkinson's disease, it's in the so called substantiac nucleus. And in a subportion of that, we designed this target, and then calculate with the patient in a stereotactic frame, so the head cannot move. Then we calculate how to get there avoiding vascular structures, vessels, any eloquent areas to most safely get there. And the precision we use is in the range of 0.3 millimeters. So that's how precise you can position your electrodes. And that is needed to get effective treatment.

Having an the intraoperative CT scan makes this an extremely safe procedure, because each step of the way, when we implant the electrode, we know exactly where we are in the brain.

Interesting.

So-- I'm sorry go ahead.

What we also do during this surgery is we test the physiological function of these nerve cells that we want to influence with deep brain stimulation. So we record from individual cells and look for the typical pattern we see in Parkinson's patients. Once we've found that, we know we are exactly in the right spot. Then we implant the therapeutic electrode, which then later is connected to a very small battery under the clavicle. And then we can program this from outside. That's the standard classical procedure, which is established by very good evidence since 20 years.

So you mentioned you put that into the clavicle. And does it-- it provides that's that-- I guess, it's kind of a minor electrical current. Is that correct?

Yes.

That is-- it's a trick--

How often does it do that?

It's permanently stimulating. That's the current situation is for which we have all the data is we permanently stimulate. To elaborate, in the future there will be-- and systems are experimentally available already, to only stimulate when the patient is symptomatic, what's called a closed loop system, which would be perfect. It only stimulates when the patient develops a tremor or has frozen movements. So you don't use battery time and stimulation all the time.

Interesting. So we are getting some questions from viewers. And I want to throw a few of these at you and see what your thoughts are. The first one is from a viewer. Is medical cannabis useful for Parkinson's? And I don't know who wants to take that one. But either one of you.

That's for Dr. Xie.

OK, all right, so again, this is a very good question. We commonly get this question from patients' family. And so far there's no clear evidence from our field to show that has a specific effect on patient with Parkinson's disease and the symptom.

However, anecdotally, the patient's family can often tell me that after they take it, that their tremor become less. I guess it is probably because the medication-- that drug can calm them down. And then because, you know, the anxiety, stress can always affect the tremor, make the tremor worse. So I think that probably there's the indirect effect instead of a direct effect.

Interesting. So Dr. Warnke, when we talk about deep brain stimulation, can you treat other movement disorders with that as well or is this just primarily for Parkinson's? No, this is very effective for its essential tremor, in a different part of the brain, though. But it is very, very effective to suppress the essential tremor, which is important because these patients can't write checks. They can't write letters. They can't use their hand anymore. And as soon as you turn the DBS system on, the tremors almost completely disappears and they get their normal function of life back.

The other disease is dystonia, where it is also very effective. Again, we use a different area. And we can treat dystonia very effective with DBS stimulation in an area called the pallidum.

And I've got to say this, Dr. Warnke, I know you've been in surgery this morning. I think you're joining this probably from the locker room, so we're getting a little noise in the background.

It's from the OR directly.

Oh, OK, from the OR direct. There we go. So that's something we haven't done before. But again, appreciate you doing this. Let's talk a little bit about the criteria that a patient has to meet for surgery. When somebody comes to you and they've got a problem like this, Dr. Warnke or Dr. Xie, I'm not sure who wants to take this, what criteria do they need to meet?

Dr. Xie first, then I'll take a turn.

All right, thank you. So you now in terms of a treatment, usually we start on medication. And all this dopamine medication, whatever the drug is the right choice. Some is dopamine precursor, converter to dopamine-- to compensate for the loss of a dopamine in the brain or we can use a dopamine agonist or we can use a medication to suppress the degradation of a dopamine or other mechanism.

Usually this medication works very well initially. But as the disease progress, some symptoms become very difficult to control, like a motor fluctuation or dyskinesia, which is excessive movement. And then the patient need to take excessive and medication and the medication accumulate, and can cause also medication side effects, such as a hallucination, and blood pressure drop, et cetera.

And some patients even though the kind of symptom Parkinson's disease like slowness in movement and rigidity usually responded very well by tremor may not always respond to any medications. So for the patient responded to medication very well, however the motor frustration dyskinesia cannot be well controlled by medication adjustment. They can consider DBS.

And also for a patient with a medication refractive tremor, the tremor cannot be controlled by medication, they can also consider with the condition that the patient presents with at least four year history of Parkinson's disease. And that would allow you to have a good confidence level for the diagnosis PD. Because you know Parkinson's disease respond to DBS well, but not other Parkinsonisms.

And then also had the patient has to have reasonable cognitive function without significant dementia. And then the patient had to have a good motor steps without uncontrolled depression, anxiety, severe anxiety, or psychosis. And also systematic disease should allow them to tolerate to the surgery very well.

And also the patient should have good family support because after surgery they need to follow up to do the programming. And they should also have a reasonable expectation of what a symptom DBS is aimed for. Is it for tremor, for dyskinesia, or for something else because DBS treats a certain symptom but not all the symptom.

So we have a few more questions coming in from viewers. And one comment. I'm going to do the comment or read the comment first. Then we'll get to some more of the questions. This one is this is aimed at Dr. Xie. It says Dr. Xie has been a real godsend for my husband's condition. So thank you Dr. Xie. That's a very nice comment from one of your patient's spouses.

Question from a viewer. What are toxins, other than pesticides, that might cause Parkinson's? And I have no idea which one of you wants to take that one.

Well there were a couple. I think, but the pesticides we should be a little bit careful. This is very epidemiological data. There's no 100% clear cause effect. One toxin, which is actually a drug, which is MTPT which people doing drug abuse use is very well known and very well established and that can cause Parkinson's. Actually, we use this in experimental Parkinson's models to test new treatments.

So that's proven. The other ones are just on a very large scale if you look at large populations, you see more patients having Parkinson's that are exposed to this. That's for an association. That doesn't prove that this toxin caused the Parkinson's.

Another question from a viewer. And I'm probably going to mispronounce this, so bear with me. Would a patient suffering from tardive dyskinesia, which is a side effect of prolonged exposure to past medicines that and now no longer on those specific meds, benefit from DBS? And is DBS covered by insurance?

Yeah, it's tardive dyskinesia. And yes, definitely DBS is very effective. Again, in the same area where we treat dystonia patients, which is called the pallidum. It's very effective particularly for these neuroleptic induced dyskinesias.

Great. Dr. Xie, are there medications for Parkinson's that don't cause hallucinations?

Oh, yeah, so I think this is a good question, because the hallucinations in Parkinson's patients not necessarily just from medication. It's also from an advanced disease state and with some cognitive impairment. So they all can cause a certain degree the risk of a hallucination. But, you know, the most likely one is dopamine agonist. They're more likely particularly for elderly people.

Dr. Warnke, how is UChicago Medicine unique and in our approach to care for Parkinson's patients compared to other medical centers?

Yes, we have a longstanding interest, and that comes from my work at other places as well, to use biological indications, biological imaging. So part of the diagnostic is to use SPECT scans, PET scans. And what we want to do is refine the indication and predict the outcome to DBS. Not every patient has 100% fantastic outcome. That is clear at all fields of medicine the same.

But we want to find the biological parameters that predict the best outcome, either it be glucose metabolism. Or using functional imaging, we want to stimulate not only some nerve cells, we also want to stimulate some nerve fibers that connect different parts of the brain. And it's these connections which have gone array, to say, in Parkinson's disease.

So we can use more sophisticated imaging. And having a CT scanner in the operating room available, we can fuse those images into our program, into our planning, and target the areas where we think we get the best outcome. So in other words, it's a little bit like in oncology, it's personalized medicine.

Not every Parkinson's patients has the same connections in their brain. We want to find the connections which have gone array and target specifically those.

Great. And Dr. Warnke, final question, is DBS a one time surgery or is that something you have to do periodically?

No, the implantation of the depth electrodes into the brain is a one time procedure. Now things are changing. The batteries now have a much longer life. And we also have batteries that we can record from. But from time to time every 6, 7 years, actually some battery systems last up to 12 years, you have to replace the battery. That, mind you, is a 10 minute outpatient procedure.

Interesting. Well, Dr. Warnke, Dr. Xie, thank you very much for your time today. We're going to take a quick break now. And when we return, we'll visit the UChicago Medicine Blood Donation Center and speak with Dr. Chancey Christenson about the need for donors. That's coming up next.

Thank you.

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And welcome back. We were live in the OR a little bit ago. Now we're going live from our blood donation center with Dr. Chancey Christenson Welcome Dr. Christenson. Thank you for taking time out of your day to talk to us a little bit about blood donations and how critically important that is to what we do here at UChicago Medicine.

Well, thanks for having me. It's always nice to talk about blood.

Yeah. I know you do. And this is a big topic with you, obviously. important are blood donations to our patients and patients in need cross Chicago, particularly in this time of COVID?

Sure, so I think before COVID, there was always a need for blood, right. You know we're the number-- we're the level 1 trauma center for the South Side of Chicago. We have an amazing cancer center. We have these groundbreaking transplants, including double and triple transplants. We have a children's hospital. We have a labor and delivery. So there's always been a need for blood.

You know, your average liver takes 10 units. Your average gunshot wound takes 10 units. Your average car can take 15 to 20 units. So there's always been this back room need for blood. I think COVID really helped demonstrate the critical need for blood during-- really to keep everything running.

So during the height of the surge, there was at the max was a 40% decrease at the national level. So we were getting 60% of the inventory that we would expect from every major supplier. For several months, it was a 75% fulfillment rate. So the only way we're really to keep blood in the hospital was the fact that all of the elective surgeries and all the procedures were canceled. And so the fact that really highlights that having blood helps keep the doors of the hospital open. You know having access to blood really helps the other doctors do their jobs. And so we're really a critical supply.

And I'm so glad you brought that up. And the way you phrased that is so important, because we're back at full capacity in business, right now, maybe not full capacity, but pretty darn close. And we are at a business right now. For business right now, we're taking all kinds of patients in. Obviously, the hospital is a safe place. So you need to be busy. And I think you are pretty busy. But how are we doing right now as far as blood donations?

We're doing really well. Everything has been come back to sort of the normal levels. And certainly, you know, the national suppliers is supplying at the same level. So it's been really helpful. I also want to add that thanks to the generosity of the University of Chicago community during the height of it, during the start of the March, April, May time period, we're able to collect almost five times more in a month than we normally do. And that really helped make up the deficit from the national shortage that we were undergoing. So right now things are looking good.

And you know it's a pretty easy process if you do want to be a donor. It's not painful. It's not a difficult thing to do. And you're in the blood donation center right now, which is pretty neat. Can you show us around a little bit and just kind of tell us what we're looking at here?

Sure so this would be your basic blood donation chair. So you come in, the whole process usually takes about half an hour at the most. So you come in. You get some paperwork done. We have to screen you the day of. We try to make sure that-- we'll do a finger stick and then we'll get-- you'll get your blood drawn. You get a lot of snacks.

We have great friendly staff that always comes by. Additionally, I don't know if you can see it over there, but that white machine is to help for platelets. And so platelets is a little bit longer. They are in a lot more short supply. But what happens is that basically the machine will help only take out the platelets. It will return everything else to you as well.

So platelet donations take about 90 minutes. But, you know, it's always in short supply. The platelets are-- they only last five days. And, you know, one benefit is certainly that people may be squeamish for different reasons about donating blood. And they may feel faint, maybe they feel woozy from times they've donated. If you donate platelets, you don't have that effect because you get your same red blood cells back. We only really take the platelets. And so it really is a lot better for a lot of the patients, a lot of the donors as well.

So what is the difference between just donating regular blood and platelets? I mean, I know what you just said, you get it back. But what is the need for platelets? I guess, that's the more important question.

Sure, so the platelets really help you clot. And so, I mean, they really form the actual clot itself. And so you know, we have a lot of chemotherapy patients. We have a lot of burn patients. We have a lot of major surgeries. So if you think about it, if you give blood, sort of it can be manufactured into three things-- platelets, red cells, and plasma.

If you give platelets then we just get just the platelets alone. The real advantage is also for platelets is that when we make platelets from red blood cells, we have to pool six of them together and then you make one big dose of six combined platelets. Obviously, if we can just get it from one person, which is what the machine can do. The machine the platelet machine can get the equivalent of six platelet donors in one person.

And so there's a lot less infectious risk. There's a lot less that exposure to different donors. So it really is a lot safer for the patients for donating just the one platelet unit.

Let's talk about safety for a minute. But before we get to that, actually do we need to make two comments. You do have snacks there. And you also have TV for people to watch. So you keep them entertained while they're there. And your staff is really, really nice. I've met--

Yeah, they're the best part.

Yeah, I mean, I met several of them. And they're great. They're great people to deal with. So when people come in, they'll feel very welcome. And it's just-- it's really a positive experience.

I think that's sort of the best-- I think that's the best example of what we here at The Blood Donation Center have. You know, I think sometimes you can go to other blood drives. And sometimes you can't be-- you know, you go to a van and maybe they give you like a stale cookie or, you know, they're just trying to rush it through.

I think here we're much more of a mom and pop shop, you know. We don't sell the units anybody. All the units are used in house. So really we try to cultivate it that we're family, that we're a team, that we really work together with all the rest of the hospital. So we really try to make the experience the best we can, because we always want people to come back.

It's very important point that the blood that's donated here stays here and is used for patients here at UChicago Medicine. So Southsiders, if you want to come in and donate, you're helping your neighbors out and potentially yourself even. But it's really-- it's a great place to come.

A couple of quick points that I think we need to make before we go. People are nervous I think a little bit with COVID. You are being very careful in protecting people. Talk to us just a little bit about that if you will, please.

Sure, the safety of our donors is really the most important thing for us. You, know we really try to make sure, you know, because people are willing to take the time and their energy to come and donate and they're also coming to donate blood. So we can't expect them to have more things. And so I think, we try and take every precaution we can.

You know, we try and keep people socially distanced, making them wear a mask. We have rigorous cleaning of the equipment. We try to make people have an appointment to make sure that we have the maximum number of people within the space. And so we really focus on the safety of the donors as much as we can to try and protect against anything.

And if somebody wants to do this, so they just reach out to the medical center and make an appointment? Is that the easiest way?

Sure, so we have the University of Chicago Blood Donation, it's a subset of the web page. And so you can go to that. We have scheduling. You can also call here at 773-702-6247 to schedule an appointment as well. We're working at some other more high tech things. But, you know, right now, we just say call and make an appointment. We have everyone spaced at about half an hour.

We are trying to develop a capability for remote screening similar to, you know, a virtual health visit as well. It's just it's a slightly different process for donors. And so we're still trying to set that up. But that will help as well.

You guys have a lot of exciting things coming and we really, really appreciate you taking the time out of your day to do this, that's fantastic. That's all the time we have for the program. We'll have, of course, another At The Forefront Live coming up next week. Please remember to check out our Facebook page for our schedule of programs coming up in the future.

Also if you want more information about UChicago Medicine, take a look at our website at UChicagoMedicine.org. And as Dr. Christenson just said, you can also find the blood donation page there as well. If you need the appointment, you can us a call at 888-824-0200. And remember you can schedule your video visit by going to the website as well.

Thanks again for being with us today. And I hope you have a great week.

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