Over the years, patients may need additional adjustments as their symptoms change. 2 0 obj Location: Geriatric Psychiatry clinic Brain Health Center, 5th floor 12 Executive Park Dr. Atlanta GA 30329. A brain scan with contrast agent, which is given through an IV, will be performed to help with surgical target planning. The procedure may be performed 'awake' or 'asleep' as described in the FAQ section. initial ClinicUser password. All other Parkinson's medications should be held for 12 hours prior to exam; Neupro patch should be removed at 9 pm. • Post-operative programming is a time-consuming process mainly relying on clinician's personal experience as no evidence-based guidelines are available. These scans will typically be scheduled for several weeks prior to 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. Deep brain stimulation (DBS) surgery is a well-established therapy for control of motor symptoms in Parkinson’s disease. 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. Once the surgery date is agreed upon, a pre-operative visit will be scheduled for 1-2 weeks before the surgery date. Background Deep-brain stimulation (DBS) programming for dystonia patients is a complex and time-consuming task. After completing all the steps, the results are discussed in a multidisciplinary meeting held once a month. pallidus interna (GPi) is the primarily used target. Both the patient and the primary contact should check in at the front desk. 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. Patients will fill out several questionnaires about mood and day-to-day function. These can be completed in any order. Location: Movement disorders clinic Brain Health Center, 5th floor 12 Executive Park Dr. Atlanta GA 30329. Location: Neurosurgery clinic The Emory Clinic, building B, suite 2200 1365 Clifton Rd. How long is the initial programming? Deep brain stimulation is an established and effective treatment for both tremor and dystonia. The DBS screening steps include: video exam, motion analysis, neurocognitive evaluation, psychiatric evaluation, and brain MRI. This visit lasts approximately 45 minutes. Download reimbursement codes and other coding resources for Medtronic DBS Therapy (deep brain stimulation), for treating the symptoms of movement and psychiatric disorders. In order to be diagnosed with PD, a patient must have bradykinesia plus trem… patients. Patients can use their home programmers to check battery status. 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. Take only those medications that you were directed to take by your medical team, with little water. 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). Some patients note improvement after the first programming session, while others may require several sessions for improvement. Some cognitive issues may be reversible if they are caused by certain medications or depression. programming, … During part 1, the brain leads are placed. Atlanta GA 30322, The contact number for this appointment is 404-778-5770. For most, results are noticed shortly after the initial programming of the DBS. Initial programming visit when the DBS device is first activated is scheduled for 3-5 weeks after DBS lead placement. Periodic adjustments are a routine part of DBS therapy. endobj Adjusting a deep brain stimulation device to meet a patient’s needs takes time. After the initial programming, people with tremor may feel a brief tingling sensation, and usually experience relief from symptoms almost … This process is necessary to customize stimulation settings for each patient. Only use 50% hydrogen peroxide and water sparingly to loosen surgical prep and/or thick scabbing (no more than 2 times). Other medications, including for high blood pressure, should be taken as prescribed. The contact number for this appointment is 404-778-5770. 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 … <> To perform the exam, the patient will need to change into a form-fitting tank top, shorts and a cap provided by the clinic. Please make sure your family is aware of this. This surgery is performed under general or local anesthesia. This visit lasts approximately 30 minutes. Table of Contents … 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. Initial Programming Approximately 4-5 weeks after lead placement, you will have your initial programming which is a prolonged visit with the DBS neurologist. 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. 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. 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. It is important that all potential medical treatments have been tried before proceeding to surgery. Some patients … Some patients may notice that some of their movement disorder related symptoms improve immediately after the surgery even before the stimulator is turned on. 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. Current … Neurocognitive or neuropsychological assessment is a detailed test of memory, decision making and other mental skills. 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 … We see patients for programming every 1-4 weeks until the optimal effects are seen; however, this can vary quite a bit. • We reviewed the literature on initial and follow-up programming … Also, Emory Healthcare does not endorse or recommend any specific commercial product or service. 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. 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. The length of surgery varies, but 6-8 hours is typical. Some tests can be scheduled on the same day for convenience. Tremor: involuntary shaking in the hands, arms, legs, jaw, or tongue 3. This length of surgery varies, but approximately 1-2 hours is typical. %PDF-1.5 Emory Healthcare news from the Emory News Center, For assistance, ask a Nurse at Emory HealthConnection™ (404) 778-7777 or Find a Physician. Education about the entire DBS process will also be provided. Patients undergo several programming visits to adjust stimulation … Identifying the best placement and level enables you to … 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. Everyone responds to DBS differently. The initial programming visit is considered elective and can … endobj If postural instability does occur early in the disease, it is often a sign of atypical parkinsonism. Movement disorder specialists … Periodic adjustments are a routine part of DBS Therapy. }yn�~�N�x�N� �}�n?�~��g�'i�>=�~�Y It is therefore important to carefully evaluate patients prior to surgery to make sure that they are likely to benefit from this complex procedure. During this visit, the DBS is … This visit lasts approximately 1-2 hours. Each of these components requires multiple clinic visits and significant time commitment. Initial Programming. 3 0 obj Your initial DBS programming visit is a comprehensive evaluation of all of the electrodes on the DBS leads, before DBS starts. Keep surgical site covered for three days. DBS surgery is done in two parts about two weeks apart. Battery replacement is an outpatient procedure, similar to initial battery placement. gait difficulties), these patients showed a progressive decline in DBS efficacy (starting >3 months after initial programming) and needed … This visit lasts approximately 2-3 hours. The current approach involves use of general guidelines involving determination of the lead type, electrode configuration, impedance check, and battery check. A CT scan will be done on the same day to confirm screw placement. During the initial programming visit, the provider will go through all DBS lead contacts and check each for therapeutic benefit and side effects thresholds. The screening MRI scan of the brain is used to identify any potential problems that may interfere with performing DBS surgery. A light breakfast without protein (no meat, eggs, milk or cheese) is recommended so that levodopa absorbs faster in the clinic. This is a clinic visit to document movement disorder symptoms on video. 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). Patients are seen at least every 6 months after programming is done. If you are a woman, surgery staff will collect your urine sample before the surgery. Patients go home on the same day. ������>�U}s�?��nF���aX�Tɧy�. Patients with Parkinson's disease should not take Parkinson's medications on the day of DBS programming, unless instructed otherwise. After the initial programming, people with tremor may feel a brief tingling sensation, and usually experience relief from symptoms almost … UW Health neurologist Laura Buyan Dent, MD, explains the process, timing and expectations post-surgery following DBS. 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 … An initial programming session may consist … 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. 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. 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. 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 will be a MRI and/or CT scan. Figure 6.2 Patient and … Initial programming visit when the DBS device is first activated is scheduled for 3-5 weeks after DBS lead placement. 3 Plug the USB to Serial Cable into the USB port on the Clinician Programmer. It is important to have the battery checked at least every 6 months to make sure replacement is scheduled before the battery runs out. … Psychiatric symptoms such as depression and anxiety are common in patients with movement disorders. 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). Four to six weeks after the surgery, patients begin meeting with Orcutt and her colleagues to program the deep … DBS is a surgical therapy for movement disorders such as Parkinson's disease, essential tremor or dystonia. Deep Brain Stimulation (DBS) for Movement Disorders. Figure 6.1 Deep brain stimulation (DBS) system, including a neurostimulator, extension, and DBS lead. 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. For patients who have non-rechargeable batteries, replacements are typically done every 3-5 years depending on how much stimulation current is used. The surgeon will explain details of the surgical procedure, potential risks, and answer any questions the patient or their family may have. The DBS clinic team consists of providers from Movement Disorder Neurology, Functional Neurosurgery, Neuropsychology and Psychiatry. DBS is an effective therapy for dystonia, and globus. 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. The programming process typically requires several adjustments so symptoms may not improve at initial programming. The surgeon will verify the patient's overall health status is appropriate for surgery. Unlike PD. Approximately 4 weeks after brain lead implantation, patients are scheduled for initial programming when DBS device is first turned on. 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. During the exam the patient will be asked to perform tasks similar to a regular clinic visit (walking, pointing, finger tapping, etc.). 1 0 obj Patients need to bring their PD medications to clinic so they can be evaluated both off and on medications. Further hair washing instructions/hair coloring/hair cutting instructions will be provided at wound check visit. About 60 small markers will be attached to the skin. Patients will be counseled again on different options regarding the surgery process (based on the patient's symptoms) and DBS hardware. The DBS process described below is specific to Emory, but most expert centers have a similar work flow. The recording will be used to determine if symptoms are likely to respond to DBS. 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. <> Both the patient and the primary contact should check in at the front desk. 4 0 obj It is important to NOT use any lotion the day of the exam. 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. Once at Emory University Hospital Clifton Road campus, take the A/B elevator to the third floor. tial deep brain stimulation (DBS) programming in 2 dystonia. Registered nurses can help you find a location or specialist that's right for you. During the initial programming of the DBS, individuals may experience a slight, temporary shock or tingling as placement and levels are adjusted. This visit lasts approximately 3 hours for Parkinson's disease and 1.5 hours for other conditions. This time is necessary to allow the brain to heal. These fiducial markers need to be placed at least 7 days before the operation so that the customized system can be built. 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). 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. %���� The path towards DBS involves multiple steps, including DBS screening, Pre-DBS surgery, DBS surgery and DBS follow up. DBS requires patience and an understanding that we may need to try … After the third day, remove dressing and/or stop ointment use. When they turn you on, the initial programming could take four hours or it can take all day. DBS surgery is an elective procedure to treat motor symptoms that cannot be controlled by medications with the goal of improving quality of life. The medical history will be reviewed and blood will be drawn for pre-operative laboratory testing. Location: The location is MRI/CT scanner at either Clifton Road or Executive Park campus (confirm with radiology department when scheduling). <>>> 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. Patients with dementia are typically not considered good DBS candidates. All medications, including for Parkinson's disease, should be taken as usual. 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. This visit lasts approximately 5 hours (6-7 hours if fiducial markers are placed). Limit use of hats. During part 2 of the surgery, the DBS battery (or IPG) will be implanted and connected to the DBS leads. Despite an appropriate targeting and an accurate placement of DBS lead, a thorough and efficient programming is critical for a successful clinical outcome. Use soap and water to wash site without directly hitting the surgical site with water stream. Your physician will work with you to adjust the parameter settings … DBS can, in some cases, worsen mood so it is important to evaluate and treat any significant mood problems prior to surgery. Location: MRI Brain Health Center, 1st floor 12 Executive Park Dr. Atlanta GA 30329, The contact number for this appointment is 404-712-8485. The main motor symptoms of PD are: 1. 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. This is called a microlesioning effect and it can last for several days to weeks. During these visits, the DBS device is checked and stimulation settings adjusted if necessary. 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). Take only those medications that you were directed to take by your medical team, with little water. Although other programming … Using this information, we can set the initial DBS parameters with great … 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 … DBS programming is a time consuming and laborious manual process. 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. DBS patients require active programming for the first few months after the initial lead implantation in order to optimize DBS parameters. 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 . Patients who are already under the care of an outside psychiatrist will still need to undergo this evaluation at Emory. 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. If any additional evaluations are necessary, this will be discussed. Parkinson’s medications should not be taken, unless instructed otherwise. To evaluate the patient's mood … … Copyright © Emory Healthcare 2019 - All Rights Reserved | Download Adobe Reader. Patients typically stay at Emory University Hospital for 1 night and return home the following day. At the Emory University Hospital Clifton Road campus, take the A/B elevator to the third floor. ��,�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 x��\_��F�w��C?��,�M��d]J)�8��j��M|����G�t��������Sj����F�4����w�xxh�#�꫷�Ʊ����������o? However, it could take several visits to adjust the settings for maximal benefit. Patients are then informed by phone or in person whether or not DBS is advised and whether any additional testing or treatment is needed. Location: Neuropsychology clinic Brain Health Center, 1st  floor 12 Executive Park Dr. Atlanta GA 30329. After an initial benefit on tremor without any side effect (e.g. 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). Objective To analyze whether programming a programming paradigm based on … Patient preferences will be taken into consideration along with medical factors. Figure courtesy of Medtronic, Inc.; used with permission. In most cases, you will see the surgeon, two months after surgery for another postop check. This time is necessary to allow the brain to heal. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> This visit lasts approximately 1.5 hours. Bradykinesia: slowness of movement 2. If surgical site is not covered with sterile dressing, use the Polymyxin ointment that is provided to you. This also greatly varies on your hospital and the skill of the DBS … endobj stream The contact number for this appointment is 404-778-3444. Navigate by your Health stage below to quickly access important pages. ... Vercise™ DBS Programming Manual Linking a Remote Control to a Stimulator … In the initial visit, the overall DBS procedure, goals for the therapy and different surgery and equipment options will be discussed. The time from the start of DBS screening to surgery is approximately 6 months. Programming begins about 4 weeks after surgery when all of the wounds have healed. 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. 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. The patient will also meet with a member of the surgery team to review and sign surgery consent. Parkinson's medications should not be taken, unless instructed otherwise. … Medications may be adjusted as well. Patient will meet with the anesthesia team. Fiducial markers are screws that the surgeon places in the skull in order to hold the customized framing system. Patients should also bring their DBS home programmer, and charger if applicable. In many cases, patients may be asked to try medications if they have not been tried previously. the initial programming period aer the DBS lead has been p l a c e d . The DBS screening process is initiated by a Movement Disorder neurologist with additional expertise in DBS. 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