choroba Parkinsona (en)

TREATMENT OF PARKINSON’S DISEASE, TREMOR AND DYSTONIA

ABOUT PARKINSON’S DISEASE, TREMOR AND DYSTONIA

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Parkinson’s disease

  • 0.5-1% of population aged 40 to 60 . = 70,000 patients in Poland
  • Symptoms:
    • motor
      • associated with dopaminergic transmission (Parkinson’s triad)
      • not associated with DA transmission (gait, speech, posture)
      • late (freezings, falls)
      • medication-related complications (fluctuations, dyskinesias)
    • non-motor (olfactory and tase disorders, vegetative, behavioural and cognitive disorders, sleep disorders)

Tremor

  • Parkinson’s disease: 0.5-1% of population aged 40 to 60 . = 70,000
  • Essential tremor
  • Multiple sclerosis tremors
  • Holmes tremor

Dystonia

  • Dystonia involves the occurrence of involuntary movement causing different body parts to twist and bend, which often results in an unnatural posture.
  • Dystonia is caused by disturbances in the function of neural connections within the so-called  subcortical nuclei.

PARKINSON’S DISEASE COMPREHENSIVE TREATMENT CENTER

CONSULTATION CENTER – qualification procedure

  • Pre-qualification for surgical treatment of Huntington’s chorea – online neurosurgery advice – W. Libionka, MD, PhD.
  • Qualification for further surgical treatment (DBS) and rehabilitation, including consultations:
    • Neurological
    • Neuropsychological
    • Psychiatric
    • Rehabilitation
    • Speech and language therapy
    • Neurosurgical -recommendations for further surgical treatment of Huntington’s disease and/or rehabilitation.
  • Anesthesiology pre-qualification (in case of qualification for the DBS procedure) – anesthesiologic advice online

CONSULTATION CENTER – treatment monitoring

  • Monitoring control – complex (for patients subject to DBS), including consultations:
    • neurological,
    • neuropsychological- assessment of cognitive deficits,
    • speech and language therapy,
    • physiotherapeutic,
    • neurosurgical – always the last, with DBS programming)
  • Monitoring control – limited (for patients subject to DBS), including consultations:
    • neurological,
    • neurosurgical- always the last, with DBS programming)
  • Monitoring control – complex (for non-DBS patients), including consultations:
    • neurological,
    • neuropsychological- assessment of cognitive deficits
    • speech and language therapy
    • physiotherapeutic
  • Monitoring control – limited (for non- DBS patients), neurological in the outpatient clinic or online advice

In order to ensure optimal stimulator operation (DBS), monitoring control visits 3 and 6 months after the date of the procedure are recommended, and at least every 6 months thereafter.

SURGICAL TREATMENT OF HUNTINGTON’S DISEASE – NEUROSTIMULATION (DBS) – hospital stay for about 5 days

  • Verification of the qualification for DBS, including consultations:
    • Anesthesiologic,
    • Neurosurgical,
  • Surgical procedure,
  • Periprocedural rehabilitation (physiotherapy and speech and language therapy),
  • Post-surgical control (free of charge) within a month after the surgical procedure,

REHABILITATION

  • Based on recommendations from the monitoring control – complex, creating an individual patient rehabilitation program,
  • Implementation of the individual rehabilitation program, as a part of 2-3-week rehabilitation courses, with the participation of a physiotherapist, neurologist and neuropsychologist.

PROCEDURAL TREATMENT

Mechanism of deep brain stimulation

  • Direct effects of stimulation: regional depolarization and hyperpolarisation of the cell membrane (axons –the lowest threshold)
  • Indirect (secondary) effects: activation of afferent endings -synaptic effects (stimulation or inhibition of adjacent cells)
  • Cathodic or bipolar stimulation (based on immediate neurostimulation effect in Parkinson’s disease and essential tremor):
    • 120-180 Hz
  • 5-10 Hz –intensifies symptoms
  • 10-50 Hz –no improvement

Stimulator implantation

  • Implantation under the clavicle/in the axillary fossa
  • Method of preparing the microelectrode tip for externalisation
  • Fixing and location of connections

The essence of treatment with neurostimulation

The currently used device looks like a pacemaker – it consists of a battery connected to an electric pulse generator, a cable and an electrode. The entire system is implanted subcutaneously: the pulse generator is usually placed below the clavicle and is connected via a cable to a stimulating electrode, surgically implanted in a selected area of the brain. When the procedure is to have a bilateral effect, bilateral electrode implantation is necessary. Once stimulation is on, the flowing current reversibly modifies the activity of the stimulated area, leading to improvement of the patient’s function. The stimulator’s operation is controlled telemetrically by a programmer. There are models enabling percutaneous battery charging by electromagnetic induction already available in the market. This type of device is used in our hospital.

Boston Scientific stimulator

Vercise Gevia

For the neurostimulation of deep brain structures in Huntington’s disease, we use the Vercise Gevia rechargeable stimulator:

  • Up to 25 years of uninterrupted operation without battery replacement
  • Lower weight and size of the device, the patient experiences less discomfort after implantation
  • MRI examinations may be safely performed
  • Inductive charging every 1 – 3 weeks
  • Wireless remote control for monitoring of the device operation

The use of directional electrodes for electrostimulation of deep brain structures allows for:

  • Lower energy consumption
    • In case of rechargeable stimulators that extends the time of operation between charging
    • In case of non-rechargeable stimulators that extends the time of operation before the necessary replacement
  • Increased effectiveness of electrostimulation by directional (over a sector of 120°) effect on selected structures of the brain.

Replacement of stimulator battery

wymiana baterii

  • The possibility of replacing the old-type, unchargeable stimulator with the most moder, rechargeable one
  • Low surgical risk – neurosurgical access not necessary
  • Certified adapters make it possible to replace previously implanted stimulators by Medtronic, Boston, Abbott

REHABILITATION IN TREATMENT OF HUNTINGTON’S DISEASE

  • Patient rehabilitation is carried out based on recommendations from the monitoring control – complex and the individual rehabilitation program
  • The individual rehabilitation program is offered as part of 2-3-week-long rehabilitation courses with the participation of: a physiotherapist, neurologist and neuropsychologist.
  • Rehabilitation can be introduced at any stage of Huntington’s disease treatment, particularly after the DBS procedure.
  • During rehabilitation, the patient is accommodated in a hotel near the hospital. It is possible to share the room with an accompanying person.

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