The following case report will describe another such patient with PD who became acutely dysphoric during the initial STN DBS programming in the postoperative period. Neurocognitive or neuropsychological assessment is a detailed test of memory, decision making and other mental skills. DBS patients require active programming for the first few months after the initial lead implantation in order to optimize DBS parameters. The DBS screening process is initiated by a Movement Disorder neurologist with additional expertise in DBS. Patients typically stay at Emory University Hospital for 1 night and return home the following day. Limit use of hats. stream The surgeon will verify the patient's overall health status is appropriate for surgery. Any blood thinning medications (aspirin, clopidogrel (Plavix), warfarin (Coumadin), rivaroxaban (Xarelto), dabigatran (Pradaxa), apixaban (Eliquis), NSAID pain medications (ibuprofen (Motrin, Advil), naproxen (Aleve), fish oil, and vitamin E need to be stopped 7 days before surgery or as directed by the neurosurgeon/anesthesiologist. Each of these components requires multiple clinic visits and significant time commitment. Deep brain stimulation is an established and effective treatment for both tremor and dystonia. This Web site is provided as a courtesy to those interested in Emory Healthcare and does not constitute medical advice and does not create any physician/patient relationship. Location: Movement disorders clinic Brain Health Center, 5th floor 12 Executive Park Dr. Atlanta GA 30329. Patients who are already under the care of an outside psychiatrist will still need to undergo this evaluation at Emory. In some cases, the patient may wear a customized framing device during the surgery so they will also have fiducial markers placed on the head during the pre-operative visit. We see patients for programming every 1-4 weeks until the optimal effects are seen; however, this can vary quite a bit. The initial programming visit is considered elective and can … 3 0 obj Identifying the best placement and level enables you to … Patients will fill out several questionnaires about mood and day-to-day function. Keep surgical site covered for three days. How long is the initial programming? The initial programming of DBS devices can be a difficult and time-consuming process, requiring a highly trained and experienced individual to achieve desirable results . Registered nurses can help you find a location or specialist that's right for you. This visit lasts approximately 1-2 hours. Your DBS home programmer, and charger if applicable, will be provided to your primary contact by the DBS vendor while you are in surgery. This visit lasts approximately 5 hours (6-7 hours if fiducial markers are placed). Movement disorder specialists … Fiducial markers are screws that the surgeon places in the skull in order to hold the customized framing system. Deep brain stimulation (DBS) surgery is a well-established therapy for control of motor symptoms in Parkinson’s disease. … … This time is necessary to allow the brain to heal. (There are multiple sizes available). In order to be diagnosed with PD, a patient must have bradykinesia plus trem… The medical history will be reviewed and blood will be drawn for pre-operative laboratory testing. It is important to NOT use any lotion the day of the exam. Some tests can be scheduled on the same day for convenience. Atlanta GA 30322, The contact number for this appointment is 404-778-5770. • Post-operative programming is a time-consuming process mainly relying on clinician's personal experience as no evidence-based guidelines are available. This visit lasts approximately 1.5 hours. The screening MRI scan of the brain is used to identify any potential problems that may interfere with performing DBS surgery. x��\_��F�w��C?��,�M��d]J)�8��j��M|����G�t��������Sj����F�4����w�xxh�#�꫷�Ʊ����������o? Further hair washing instructions/hair coloring/hair cutting instructions will be provided at wound check visit. Take only those medications that you were directed to take by your medical team, with little water. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> It is recommended to bring a family member, a caregiver or a friend to this appointment to assist the patient when off medications and so they can also learn about the DBS process. Approximately two weeks after DBS battery implantation surgery, surgical wounds will be inspected by the neurosurgery clinic nurse practitioner to make sure they are healing well. DBS surgery is an elective procedure to treat motor symptoms that cannot be controlled by medications with the goal of improving quality of life. Medications may be adjusted as well. pallidus interna (GPi) is the primarily used target. It is therefore important for the patient and family members to be frank about any potential cognitive problems and not attempt to hide these issues. This visit lasts approximately 2-3 hours. During this visit, the DBS is … Initial Programming. However, patients with less severe cognitive impairments may be recommended to undergo a staged surgery, where one brain lead is placed at a time to allow brain time to recover, or implant lead in an alternate area of the brain (globus pallidus versus subthalamic nucleus). For patients who have non-rechargeable batteries, replacements are typically done every 3-5 years depending on how much stimulation current is used. For most, results are noticed shortly after the initial programming of the DBS. Current … The current approach involves use of general guidelines involving determination of the lead type, electrode configuration, impedance check, and battery check. Objective To analyze whether programming a programming paradigm based on … The DBS clinic team consists of providers from Movement Disorder Neurology, Functional Neurosurgery, Neuropsychology and Psychiatry. It is therefore important to carefully evaluate patients prior to surgery to make sure that they are likely to benefit from this complex procedure. For patients with Parkinson's disease, it is important NOT to take any Parkinson's (PD) medications after 9 pm the day before this appointment (in other words, not take any PD medications for at least 12 hours prior to the exam). Location: Movement disorders clinic Brain Health Center, 5th Floor 12 Executive Park Dr. Atlanta GA 30329, The contact number for this appointment is 404-778-3444. Figure 6.1 Deep brain stimulation (DBS) system, including a neurostimulator, extension, and DBS lead. Deep Brain Stimulation (DBS) for Movement Disorders. DBS is an effective therapy for dystonia, and globus. Patients will be counseled again on different options regarding the surgery process (based on the patient's symptoms) and DBS hardware. Despite an appropriate targeting and an accurate placement of DBS lead, a thorough and efficient programming is critical for a successful clinical outcome. Location: Neuropsychology clinic Brain Health Center, 1st  floor 12 Executive Park Dr. Atlanta GA 30329. During part 1, the brain leads are placed. Although other programming … In the initial visit, the overall DBS procedure, goals for the therapy and different surgery and equipment options will be discussed. programming, … At the Emory University Hospital Clifton Road campus, take the A/B elevator to the third floor. Second, while our study focused on selection of DBS voltage alone (pulse width and frequency were fixed), clinicians will sometimes explore these variables during initial programming. Your initial DBS programming visit is a comprehensive evaluation of all of the electrodes on the DBS leads, before DBS starts. 1 0 obj Patients with Parkinson's disease should not take Parkinson's medications on the day of DBS programming, unless instructed otherwise. Unlike PD. It is important to have the battery checked at least every 6 months to make sure replacement is scheduled before the battery runs out. After the surgery, this baseline recording will also be used to determine if stimulation is beneficial and if further adjustment of DBS settings is needed. If surgical site is not covered with sterile dressing, use the Polymyxin ointment that is provided to you. One of the possible DBS side effects is worsening of cognitive function so it is important to evaluate the level of risk a patient may be facing should they undergo surgery. <> Bradykinesia: slowness of movement 2. A light breakfast without protein (no meat, eggs, milk or cheese) is recommended so that levodopa absorbs faster in the clinic. After an initial benefit on tremor without any side effect (e.g. Suture/staple removal in 2 weeks with neurosurgery nurse practitioner, If absorbable sutures, follow-up in 2-4 weeks for incisional check with neurosurgery nurse practitioner, If Dermabond, follow-up in 2-4 weeks for incisional check with neurosurgery nurse practitioner, Do not apply scar reducing cream. Based on the literature review and our experience at TWH, we refined four algorithms for: (1) the initial programming stage, and management of symptoms following DBS, particularly addressing (2) speech … A CT scan will be done on the same day to confirm screw placement. For patients seeking DBS for other conditions, such as epilepsy, depression or pain, the specific steps will be different and information can be obtained from those specialty clinics. DBS is a surgical therapy for movement disorders such as Parkinson's disease, essential tremor or dystonia. Patient preferences will be taken into consideration along with medical factors. Initial programming visit when the DBS device is first activated is scheduled for 3-5 weeks after DBS lead placement. }yn�~�N�x�N� �}�n?�~��g�'i�>=�~�Y Patients need to bring their PD medications to the clinic so they can be evaluated both off and on medications (exam is repeated after medications start working). All other Parkinson's medications should be held for 12 hours prior to exam; Neupro patch should be removed at 9 pm. The time from the start of DBS screening to surgery is approximately 6 months. Once at Emory University Hospital Clifton Road campus, take the A/B elevator to the third floor. Patients who have had a brain MRI done within last two years at an outside facility can bring/send images on a disk to be uploaded into Emory system instead of repeating the scan (contact DBS coordinator to arrange). After completing all the steps, the results are discussed in a multidisciplinary meeting held once a month. In an initial visit, the DBS neurologist will determine whether DBS therapy should be considered as a treatment option and will initiate the screening process if the patient appears to be a good candidate based on this initial evaluation. Only use 50% hydrogen peroxide and water sparingly to loosen surgical prep and/or thick scabbing (no more than 2 times). <>>> A brain scan with contrast agent, which is given through an IV, will be performed to help with surgical target planning. ������>�U}s�?��nF���aX�Tɧy�. 4 0 obj This time is necessary to allow the brain to heal. the initial programming period aer the DBS lead has been p l a c e d . Initial programming visit when the DBS device is first activated is scheduled for 3-5 weeks after DBS lead placement. Please make sure your family is aware of this. The recording will be used to determine if symptoms are likely to respond to DBS. Everyone responds to DBS differently. During part 2 of the surgery, the DBS battery (or IPG) will be implanted and connected to the DBS leads. gait difficulties), these patients showed a progressive decline in DBS efficacy (starting >3 months after initial programming) and needed … The main motor symptoms of PD are: 1. Both the patient and the primary contact should check in at the front desk. Initial Programming Approximately 4-5 weeks after lead placement, you will have your initial programming which is a prolonged visit with the DBS neurologist. Figure 6.2 Patient and … Patients with dementia are typically not considered good DBS candidates. ��,�2)kV�*�ا#��ǒ=�_�����_߾~�� [��}��ׯ��HԒIe���Lˤ�D'���W�4I���K+&y��2�3ַ�_���$3����W,+D��4��-r�������պ����?��\޼[���G|�WxF_��Z˛O+���߭������Y�+υ��o��f�%A�l^��L���}��J�)ߪyk�h��V��Ș:���ߕ^�G$����`��+]��{"7D��ș�xR"��W`���������r����*�iwF�4~(��[bVX����5g�[ɯ؊H��IY��-���h{�����4��� uh�I The DBS process described below is specific to Emory, but most expert centers have a similar work flow. When they turn you on, the initial programming could take four hours or it can take all day. The patient will also meet with a member of the surgery team to review and sign surgery consent. After the initial programming, people with tremor may feel a brief tingling sensation, and usually experience relief from symptoms almost … During these visits, the DBS device is checked and stimulation settings adjusted if necessary. The length of surgery varies, but 6-8 hours is typical. The path towards DBS involves multiple steps, including DBS screening, Pre-DBS surgery, DBS surgery and DBS follow up. Parkinson's medications should not be taken, unless instructed otherwise. Parkinson’s medications should not be taken, unless instructed otherwise. These scans will typically be scheduled for several weeks prior to surgery date. UW Health neurologist Laura Buyan Dent, MD, explains the process, timing and expectations post-surgery following DBS. Patients undergo several programming visits to adjust stimulation … Approximately 4 weeks after brain lead implantation, patients are scheduled for initial programming when DBS device is first turned on. In most cases, you will see the surgeon, two months after surgery for another postop check. During the initial programming of the DBS, individuals may experience a slight, temporary shock or tingling as placement and levels are adjusted. Patients should also bring their DBS home programmer, and charger if applicable. Patients need to bring their PD medications to clinic so they can be evaluated both off and on medications. Location: MRI Brain Health Center, 1st floor 12 Executive Park Dr. Atlanta GA 30329, The contact number for this appointment is 404-712-8485. Some patients … If any additional evaluations are necessary, this will be discussed. Over the years, patients may need additional adjustments as their symptoms change. The clinical success of deep brain stimulation (DBS) for treating Parkinson's disease (PD) critically depends on the quality of postoperative neurological management. Four to six weeks after the surgery, patients begin meeting with Orcutt and her colleagues to program the deep … tial deep brain stimulation (DBS) programming in 2 dystonia. After completing the DBS screening process, if the DBS clinic team recommends proceeding with DBS surgery, the next step is to meet with a functional neurosurgeon. initial ClinicUser password. Tremor: involuntary shaking in the hands, arms, legs, jaw, or tongue 3. About 60 small markers will be attached to the skin. It is important that all potential medical treatments have been tried before proceeding to surgery. The procedure may be performed 'awake' or 'asleep' as described in the FAQ section. DBS as an option for therapy as well as to guide patients through the DBS process from initial pre-surgical evaluation to optimization of DBS therapy with stimulation programming. After the initial programming, people with tremor may feel a brief tingling sensation, and usually experience relief from symptoms almost … This also greatly varies on your hospital and the skill of the DBS … This visit lasts approximately 30 minutes. <> After DBS screening tests are completed, the patient's test results will be reviewed by the DBS clinic team to determine whether the patient should proceed with the surgery. After the third day, remove dressing and/or stop ointment use. Long-acting pramipexole (Mirapex ER) and long-acting ropinirole (Requip XR) should be held for 24 hours prior to the video exam, meaning they should NOT be taken the night before the exam. Battery replacement is an outpatient procedure, similar to initial battery placement. Take only those medications that you were directed to take by your medical team, with little water. Some cognitive issues may be reversible if they are caused by certain medications or depression. To perform the exam, the patient will need to change into a form-fitting tank top, shorts and a cap provided by the clinic. This visit lasts approximately 3 hours for Parkinson's disease and 1.5 hours for other conditions. It is recommended to bring a family member, a caregiver or a friend who is familiar with patient's day-to-day function to provide collateral information. For patients with Parkinson's disease (PD), it is important NOT to take any Parkinson's medications after 9 pm the day before this motion analysis appointment, in other words, do not take any PD medications for at least 12 hours prior to the exam (see detailed instructions under Video Exam section). It is recommended to bring a family member, a caregiver or a friend who is familiar with patient's day-to-day function to provide collateral information. If postural instability does occur early in the disease, it is often a sign of atypical parkinsonism. Location: The location is MRI/CT scanner at either Clifton Road or Executive Park campus (confirm with radiology department when scheduling). The contact number for this appointment is 404-778-5770. This will be a MRI and/or CT scan. Psychiatric symptoms such as depression and anxiety are common in patients with movement disorders. DBS surgery is done in two parts about two weeks apart. DBS can, in some cases, worsen mood so it is important to evaluate and treat any significant mood problems prior to surgery. An initial programming session may consist … patients. Periodic adjustments are a routine part of DBS therapy. This surgery is performed under general or local anesthesia. Education about the entire DBS process will also be provided. Table of Contents … These fiducial markers need to be placed at least 7 days before the operation so that the customized system can be built. 2 0 obj Use soap and water to wash site without directly hitting the surgical site with water stream. Swedish Neuroscience Institute DBS Program Case Reports: Deep Brain Stimulation for Parkinson’s and Essential Tremor www.swedish.org September 2009 — A3 programmed during the patient’s … Rigidity: stiffness or tightness in the arms, legs, or trunk Postural instability is another motor symptom that involves imbalance and falls, but it does not tend to happen until later in the disease. During the initial programming visit, the provider will go through all DBS lead contacts and check each for therapeutic benefit and side effects thresholds. Parkinson's (PD) medications include: carbidopa/levodopa (Sinemet, Rytary, Duopa, Stalevo), pramipexole (Mirapex), ropinirole (Requip), apomorphine (Apokyn), rotigotine (Neupro patch), amantadine (Symmetrel), rasagiline (Azilect), selegiline (Eldepryl), entacapone (Comtan), trihexyphenidyl (Artane). endobj DBS programming is a time consuming and laborious manual process. The contact number for this appointment is 404-778-3444. Location: Geriatric Psychiatry clinic Brain Health Center, 5th floor 12 Executive Park Dr. Atlanta GA 30329. Your physician will work with you to adjust the parameter settings … Other medications, including for high blood pressure, should be taken as prescribed. Local anesthetics will be given before the procedure and only a little bit of hair (a quarter size) will be clipped at each fiducial location. Download reimbursement codes and other coding resources for Medtronic DBS Therapy (deep brain stimulation), for treating the symptoms of movement and psychiatric disorders. Figure courtesy of Medtronic, Inc.; used with permission. Deep brain stimulation (DBS) has become the treatment of choice for advanced stages of Parkinson's disease, medically intractable essential tremor, and complicated segmental and generalized dystonia. During the exam the patient will be asked to perform tasks similar to a regular clinic visit (walking, pointing, finger tapping, etc.). Deep Brain Stimulation (DBS) is a safe and proven medical treatment that has helped hundreds of thousands of Parkinson’s patients ... During initial programming, you may experience a tingling … Patients are then informed by phone or in person whether or not DBS is advised and whether any additional testing or treatment is needed. DBS requires patience and an understanding that we may need to try … Programming begins about 4 weeks after surgery when all of the wounds have healed. • We reviewed the literature on initial and follow-up programming … To evaluate the patient's mood … Also, Emory Healthcare does not endorse or recommend any specific commercial product or service. During this process, patients and family members will interact with many healthcare providers who all play important roles in ensuring the patient will have the best outcome from DBS therapy. Patients are seen at least every 6 months after programming is done. Location: Neurosurgery clinic The Emory Clinic, building B, suite 2200 1365 Clifton Rd. Patients can use their home programmers to check battery status. The DBS screening steps include: video exam, motion analysis, neurocognitive evaluation, psychiatric evaluation, and brain MRI. Some patients may notice that some of their movement disorder related symptoms improve immediately after the surgery even before the stimulator is turned on. In many cases, patients may be asked to try medications if they have not been tried previously. This is called a microlesioning effect and it can last for several days to weeks. This visit lasts approximately 45 minutes. Background Deep-brain stimulation (DBS) programming for dystonia patients is a complex and time-consuming task. All medications, including for Parkinson's disease, should be taken as usual. However, it could take several visits to adjust the settings for maximal benefit. … Once the surgery date is agreed upon, a pre-operative visit will be scheduled for 1-2 weeks before the surgery date. This Web site is provided solely for personal and private use of individuals accessing this information, and no part of it may be used for any other purpose. Adjusting a deep brain stimulation device to meet a patient’s needs takes time. This length of surgery varies, but approximately 1-2 hours is typical. Emory Healthcare news from the Emory News Center, For assistance, ask a Nurse at Emory HealthConnection™ (404) 778-7777 or Find a Physician. %���� For patients with Parkinson's disease, it is important NOT to take any Parkinson's medications for 12 hours prior to DBS programming (see instructions under Video Exam). Vercise™ Neural Navigator is a software program that is used to set and adjust stimulation parameters for the Vercise PC and Vercise Gevia™ DBS Systems. DBS Programming Pointers Timing •Initial programming 2-4 weeks following last brain surgery Allows for resolution of microlesion effect •Optimization period up to 6 mos, depending on indication Frequency … Both the patient and the primary contact should check in at the front desk. Patients go home on the same day. This process is necessary to customize stimulation settings for each patient. endobj 3 Plug the USB to Serial Cable into the USB port on the Clinician Programmer. ... Vercise™ DBS Programming Manual Linking a Remote Control to a Stimulator … After baseline examination, DBS programming is done by an initial mapping procedure where each electrode is selected in turn and tested by gradual increase in voltage while assessing for effects and … These can be completed in any order. The programming process typically requires several adjustments so symptoms may not improve at initial programming. If you are a woman, surgery staff will collect your urine sample before the surgery. Using this information, we can set the initial DBS parameters with great … Avoid prolonged exposure to moisture, such as wearing wigs, sitting in a hot tub, or swimming for 4 weeks after your sutures/staples are removed. Navigate by your Health stage below to quickly access important pages. The surgeon will explain details of the surgical procedure, potential risks, and answer any questions the patient or their family may have. Follow up programming visits are scheduled every 1-2 months for the first 6-12 months, depending on how long it takes to find the best settings. %PDF-1.5 Copyright © Emory Healthcare 2019 - All Rights Reserved | Download Adobe Reader. endobj Some patients note improvement after the first programming session, while others may require several sessions for improvement. Periodic adjustments are a routine part of DBS Therapy. Patient will meet with the anesthesia team. This is a clinic visit to document movement disorder symptoms on video. Seen at least every 6 months four hours or it can take all.! Take all day, legs, jaw, or tongue 3 the contact for! Wound check visit expert centers have a similar work flow stimulation settings for maximal benefit steps include video! 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