Parkinsons Symptoms That Respond to DBS Treatment in Mumbai

Which Parkinson’s Symptoms Improve With DBS—and Which May Not?

Deep Brain Stimulation (DBS) can offer meaningful symptom management for appropriate candidates with Parkinson’s disease, but it is important to know that DBS does not address all Parkinson’s symptoms. It is usually most effective for motor symptoms that respond to levodopa and for some intractable symptoms such as tremor. It doesn’t cure Parkinson’s disease or slow the disease from getting worse.

Therefore, an important part of determining when surgery is appropriate is figuring out what DBS is likely—and unlikely—to improve. At Fortis Hospital Mulund, Mumbai, patients being considered for DBS undergo specialist assessment to determine their dominant symptoms, response to medication and realistic treatment goals.

How Does DBS Help Parkinson’s Symptoms?

Deep brain stimulation involves surgically implanting tiny electrodes in targeted areas of the brain that help control movement. Electrodes are attached to a neurostimulator that delivers controlled electrical pulses to help normalize abnormal activity in brain circuits that control movement.

Common DBS targets for Parkinson’s disease include the Subthalamic Nucleus (STN) and Globus Pallidus Internus (GPi). The selection of the target and the stimulation parameters depend on the individual patient’s symptoms and goals of treatment.

DBS is particularly useful in controlling motor symptoms and fluctuations that have become difficult to manage consistently with medication alone.

Parkinson’s symptoms that DBS may improve

1. Tremor/ Shaking - One of the symptoms of Parkinson’s that DBS can help with is tremor. This may be of special interest to patients who still suffer from disabling tremor despite adequate medication.

Some patients find that better tremor control makes it easier for them to do everyday things like eating, drinking, writing, dressing and using a phone.

2. Rigidity or Muscle Stiffness - Parkinson’s disease can cause significant muscle stiffness, making it hard to move and to do everyday activities.

DBS may enhance freedom of movement and reduce rigidity in carefully chosen patients, especially if stiffness has previously responded to dopaminergic medication.

3. Bradykinesia or Slow Movements - Bradykinesia is the hallmark of slowness of movement in Parkinson’s disease. Patients may be slower to stand up, walk, dress or do routine tasks. DBS may alleviate bradykinesia in selected patients, particularly if the symptom improves during the patient’s medication “ON” state.

4. Motor Fluctuations and “OFF” Periods - As Parkinson’s disease progresses, some patients experience a decrease in the length of time each dose of medication is effective. They may go back and forth between a “ON” state, when medication is doing a pretty good job of controlling their symptoms, and a “OFF” state, when stiffness, slowness and tremor return. DBS can reduce troublesome motor fluctuations and improve the consistency of motor symptom control. This is one of the important reasons that otherwise levodopa-responsive Parkinson’s patients may be referred for assessment for DBS.

5. Dyskinesia (Dyskinesia describes involuntary movements that may occur after prolonged dopaminergic treatment. For some patients, controlling Parkinson's symptoms requires doses of medication that also produce troubling dyskinesia. Depending on the DBS target and the specific treatment plan, DBS may play a role in directly reducing dyskinesia or in allowing for medication adjustments. Dr. Sawhney’s overview of DBS also notes that dyskinesia and ON/OFF fluctuations are symptoms that may get better after DBS.

Which Parkinson’s Symptoms Might Not Improve With DBS?

Recognizing its limitations is one of the most important parts of DBS counseling. A technically successful DBS surgery does not mean that all Parkinson's symptoms will go away.

1. Problems with Speech or Speech Difficulties - DBS may not reliably improve speech problems, especially when there is already a substantial speech impairment before surgery. Also in some cases stimulation can affect speech and careful programming is important.
2. Balance and postural instability: In general, DBS is less predictable for advanced balance problems and postural instability, particularly if these are unresponsive to levodopa. Thus, patients whose main problem is repeated falls or severe balance impairment require particularly careful evaluation before DBS.
3. Cognitive Decline - DBS is mainly a treatment for certain motor symptoms, not for cognitive decline. DBS is not expected to improve memory impairment, confusion and dementia. Also, severe cognitive impairment may be a consideration in determining whether a patient is a good surgical candidate. In particular the patient guidance by Dr. Sawhney mentions limited benefit for speech problems, balance difficulties and cognitive symptoms.
4. Fatigue/ tiredness - Tiredness is a frequent and complicated non-motor symptom of Parkinson’s disease. DBS is not usually a primary target symptom of DBS and should not be expected to be resolved by performing DBS. 

A Useful Principle: Levodopa Improves the Symptom?

The most useful indicator during DBS evaluation is the patient’s response of motor symptoms to levodopa.

If the motor symptoms such as stiffness, slowness and other motor symptoms improve significantly when the Parkinson’s medication is working then we often have a better basis for expecting these symptoms to respond to DBS. Tremor may be an exception, with some medication-resistant tremors potentially responding to stimulation.

That’s why patients shouldn’t be chosen for DBS just because they have Parkinson’s disease. The team needs to understand what specific symptoms are causing disability and which symptoms DBS can practically address.

Why It’s So Important to Do a Pre-DBS Evaluation

 -Prior to DBS surgery patients usually undergo a comprehensive assessment which may include:

• Neurological examination, detailed
• Parkinson’s disease progression: a review
• Medical history
• Levodopa response assessment
• Brain scans
• Cognitive or neuropsychological testing
• Speech, gait and balance assessment
• General Medical and Surgical Fitness Examination

The goal is not simply to determine whether DBS can technically be done. The purpose is to determine whether the individual symptom profile of the patient indicates DBS as a suitable treatment.

This also provides an opportunity for the patient and family to set realistic goals before surgery.

DBS Assessment at Fortis Hospital Mulund Mumbai 

Dr Gurneet Singh Sawhney, Director – Stereotactic & Functional Neurosciences and Senior Consultant, Department of Neurosurgery & Spinal Surgery, Fortis Hospital, Mulund, Mumbai, assesses patients with Parkinson’s disease and movement disorders for advanced functional neurosurgical interventions, including DBS.

Dr. Sawhney has done 80+ DBS Surgeries and has advanced fellowship training in Functional Neurosurgery from Tokyo Women’s Medical University, Japan. His clinical interests include Deep Brain Stimulation, Parkinson’s disease, movement disorder surgery, essential tremor, dystonia, stereotactic neurosurgery and neuromodulation. His professional website lists his main clinical services as DBS, Parkinson’s surgery and functional neurosurgery. Patients from Mumbai, Navi Mumbai and other parts of India contemplating DBS should undergo an individualized assessment to understand which symptoms are likely to improve, and which may continue despite surgery.

Managing the right expectations from DBS

DBS can result in substantial improvement in some motor symptoms, but you don’t measure its success by the fact that every symptom of Parkinson’s is gone.

For a suitable candidate the goal might be better control of tremor, stiffness and slowness, less troublesome OFF periods, less dyskinesia and more predictable daily functioning.

Speech problems, serious balance problems, cognitive decline and fatigue may not react the same way.

The key question, then, is not simply, “Does DBS work for Parkinson’s? It is: “Which of this particular patient’s symptoms are likely to respond to DBS?”

A specialist DBS assessment can help answer that question before a patient and family decide on surgery.