For therapists working with patients suffering from movement disorders, what is the most effective treatment regimen for patients after having deep brain stimulation surgery to achieve the best functional outcomes?
Recent advances have shown that treating neurological symptoms with deep brain stimulation (DBS) has been very beneficial in decreasing patient’s symptoms. DBS is a neurosurgical procedure that is used to help treat the symptoms of Parkinson’s disease, dystonia, essential tremor, torticollis, epilepsy, stroke, obsessive-compulsive disorder (OCD), major depression, and most recently traumatic brain injury (TBI). Some patients can control these symptoms with use of oral medications, Botulinum toxin, Baclofen, and surgical management. If symptoms are not controlled with traditional interventions, then DBS is the next step for significantly decreasing these patient symptoms.
According to the Deep Brain Stimulation Patient Resource Guide from the Swedish Neuroscience Institute, DBS involves surgically implanting leads into specific areas of the brain that act on the movement system. Then 7 to 10 days later the leads will be connected to a battery implant (pulse generator or neurostimulator) that is inserted into the chest wall. Three weeks after the battery is inserted, the doctors will activate the neurotransmitter for the first time during the follow-up visit, and the patient will be sent home with a hand-held remote control device. Researchers state that the steady current is what alters the brain activity that is causing the abnormal movement patterns. According to the CRS Clinical Practice Guidelines Manual Deep Brain Stimulation, the Food and Drug Administration (FDA) approved DBS therapy in 2003. It is safe for treating patients as young as seven years of age. Before surgery, the neurosurgeon will use a magnetic resonance imaging (MRI) or computed tomography (CT) scanning to identify the target areas. The target areas for a patient with Parkinson’s disease are the thalamus, subthalamic nucleus (STN) and globus pallidus. (GPi). Preliminary studies for DBS of the subthalamic nucleus (STN-DBS) have reported that after surgery balance, gait, and increased risk of falling may not improve. However, walking speed, rigidity, bradykinesia, and tremor should be enhanced. That is why it is important for the physical therapist to be apart of developing and implementing interventions to advance patient’s quality of life. Unfortunately, at this time, there have been no studies performed that investigate how an individual will respond to physical therapy (PT). That is why it is important to contact the patient’s physician and be aware of what things to avoid.
A study by Duncan, R. from Washington University School of Medicine published phase 1 of their clinical trial, “Physical Therapy and Deep Brain Stimulation in Parkinson Disease.” This study will be a pilot randomized controlled trial and is expected to be completed by January 31, 2019. It is estimated that 34 participants, 30 years of age or older, will be randomly placed in either a physical therapy group or a control group over an 8-week period. Those placed in the physical therapy group will perform therapy for 1-hour two times a week with treatment focusing on balance and gait. Duncan, R. hypothesizes that PT will be safe and efficient for patients undergoing DBS surgery. The number of DBS-procedures being performed each year has increased to 8,000-10,000 individuals. This means that other allied healthcare providers need to be well trained to help reduce further complication and provide the best quality of care possible. Currently, most patients are only being treated with pharmacologic management and consistent follow-up appointments with the doctor. According to Duncan, R. et al., this study will help determine if PT is effective in improving patient posture, stability and gait after having STN-DBS.
According to the Deep Brain Stimulation Patient Resource Guide from the Swedish Neuroscience Institute, physical and occupational therapist (OT) current role is to perform a pre-assessment. This will include videotaping the patient’s current status to be able to compare later on. Then have the patient perform all of the assessments while off of their medication (if applicable) and then administer the same tests while they are on their medication. After surgery, the PT or OT will reevaluate using the same test as before while the patients DBS system is on and off. If a patient qualifies for inpatient rehabilitation after surgery, it is crucial to be working on early mobilization to increase strength, endurance, and flexibility. However, it is important to avoid overhead activates, excessive stretching of the neck, twisting movements, lifting more than 10 pounds, excessive forward reaching, and strenuous exercise because these activates can lead to putting too much stress on the stimulator. About a month after the patient’s last surgery, outpatient rehabilitation is recommended. It is important to repeat the tests used before the surgery. Medtronic DBS Therapy for Parkinson’s disease and Essential Tremor Clinical Summary states that diathermy (deep heat treatment); shortwave diathermy, microwave diathermy, or therapeutic ultrasound diathermy cannot be used with this population at any time. Research has shown that the energy form these modalities can be transferred through the neurotransmitter and lead to severe tissue damage, damage to the neurotransmitter, or death. Swimming is also another thing to avoid until the incision is fully healed because infections can form. Once the incision is healed, one must avoid diving below 10 meters (33 feet) of water due to the increased atmospheric pressure potentially damaging the DBS system. Other things to avoid are skydiving, skiing, sports, games, or hiking in the mountains because the movements involved during these activities are too extensive. On the other hand, diagnostic ultrasound, x-rays and transcranial electrical stimulation are all safe to use with these patients.
Although there are significant limitations of current literature available on this topic, there are excellent clinical guidelines available for other health care provides to use. The clinical guidelines are great resources to use when working with patient’s that have Parkinson’s disease. However, more research needs to be done for the other neurologic pathologies. If research can prove that early therapeutic interventions are safe and efficient for these population, then that can lead to further reducing complication after DBS surgery and optimize the patients quality of life.
References
CRS Clinical Practice Guidelines Manual DEEP BRAIN STIMULATION (2010). https://www.uhccommunityplan.com/content/dam/communityplan/healthcareprofessionals/providerinformation/AZ-Provider-Information/uhcaz-dbs.pdf
Deep Brain Stimulation (2017). Children’s Hospital Colorado. https://www.childrenscolorado.org/doctors-and-departments/departments/neuroscience-institute/programs/deep-brain-stimulation-program/
Deep Brain Stimulation Evaluation Before and After Surgery. University of Wisconsin Hospitals and Clinics (2015)
https://www.uwhealth.org/healthfacts/neuro/7408.pdf
Nora, C. P et al. Deep Brain Stimulation Patient Resource Guide (2011). Swedish Neuroscience Institute. NI-08-07805. Retrieved at https://www.swedish.org/~/media/Images/Swedish/pdf/1_DBS%20Patient%20Resource%20Guide%20pdf.pdf
Duncan, R. Physical Therapy and Deep Brain Stimulation in Parkinson Disease (PTDBS) (2017). https://clinicaltrials.gov/ct2/show/NCTO318282
https://www.youtube.com/watch?v=wZZ4Vf3HinA
https://www.youtube.com/watch?v=gApA-6lvsfE