A Full Spectrum of Treatment Options
Patients with movement disorders are initially treated with medications designed to stimulate the dopamine system or to mimic its controlling effect on other nerve cells. Management of medications to achieve optimal functioning can often be a complex process that requires expert neurologic consultation. Once conventional drug therapies are no longer effective, patients may benefit from surgical intervention.
The Movement Disorders Program at Cedars-Sinai is a vital resource for individuals with Parkinson's disease or other movement disorders. The program provides comprehensive services and information, including:
- Medication assessment
- Treatment plan evaluation
- Information about surgical alternatives
- Deep Brain Stimulation
Comprehensive Services for Movement Disorders in a Multidisciplinary Center
Movement disorders like dystonia often present complex symptoms and profound effects on cognition, mood and physical appearance. While medical therapy for Parkinson's can be effective for years, the treatment options for dystonia and other movement disorders are limited. A minority of patients with dystonia may respond to dopamine-replacement therapy, and in some cases targeted injections of botulinum neurotoxin can alleviate symptoms.
Movement disorders can affect patients in early childhood, or may be present in adult age; each patient reacts differently to medications. Dr. Michele Tagliati is among the nation's most experienced physicians at recognizing and treating these rare disorders. Our team at Cedars-Sinai can quickly recognize when care strategies need change. In fact, what can be a miracle drug for a young adult, can result in side effects like hallucinations in an elderly patient.
The team's medical management of these often rare, always complex, diseases can include expertise in determining medication dosages, alternative drug-delivery systems and varied drug combinations, all depending on a patient's changing course. Botulinum neurotoxin injections can target problem areas for symptom control. Clinical trials are available to evaluate innovative therapies. Each patient receives counseling to help with lifestyle adjustments, education to understand their treatment and long-term follow-up care, often through consultation with referring physicians.
Botulinum Neurotoxin (BNT) Injections
While the public may be most familiar with Botulinum Neurotoxin (BNT) injections for cosmetic purposes, such treatments have been a mainstay for movement disorders for decades. At Cedars-Sinai, the Movement Disorders Program takes advantage of Dr. Tagliati's expertise in BNT therapy, a topic on which he has published (both in peer-reviewed journals and popular publications) and is called on to teach and to consult with other physicians and medical experts.
Dr. Tagliati employs botulinum neurotoxin (also known by trade names: Botox®, Dysport®, Myobloc®, Xeomin®) using electromyography and needles that can simultaneously record the electrical activity of the muscle and inject the drug. The toxin gets absorbed by nerve terminals and prevents nerves from secreting neurotransmitters. The net effect is the muscles are less stimulated by the nerves and so they calm down.
Precisely placed injections can help control eye spasms, facial spasms, the blinking and chin thrusting of Meige's syndrome, the stiff neck of torticollis, the arm or leg muscle spasms of focal limb dystonia or the muscle contractions of spasticity.
In the vast majority of cases, BNT injections are a highly effective treatment. While most spasm medications are not specific to movement disorders and can have troubling side effects like chronic sleepiness, BNTs can be injected directly into overactive or spasming muscles, rapidly improving patients' lives with few, if any, side effects. The prime indication for BNT injections is dystonia, although they also can help control Parkinson's-related drooling or bladder overactivity.
Surgery: At the Forefront of Deep Brain Stimulation
Interest in neurosurgery for Parkinson's and other movement disorders has been renewed by multiple factors: limits on the efficacy of drug treatments; progress in understanding and targeting sites for stimulation in the basal ganglia; and major advances in imaging technology.The most promising neurosurgery currently available - and approved by the FDA - is Deep Brain Stimulation (DBS), which can be targeted in three areas of the brain: the thalamus for tremors; the globus pallidus internus for Parkinson's disease and dystonia; and the subthalamic nucleus for Parkinson's disease.
In DBS, leads are implanted into specific brain targets, with high accuracy. Neurosurgeon Adam Mamelak adjusts for minute individual differences, meticulously locking the leads into precise locations. A scant millimeter within the brain can mean the difference between symptom relief and an unexpected side effect.
The leads are programmed remotely, an area of expertise for Dr. Tagliati and one he teaches annually at the Academy of Neurology meeting. The electrical stimulation device, along with tailored drug regimens, can provide good control over shaking, stiffness and loss of muscle control, otherwise unresponsive to medications.
In some movement disorders, such as childhood onset dystonia, DBS has the potential to restore patients to full, normal function. Some patients can move rapidly from homebound debilitation to normalcy, from wheelchair to walking, from spoon-fed dependence to playing tennis.
Teamwork and experience, like the close relationship between neurologist Dr. Tagliati and neurosurgeon Dr. Mamelak, are crucial to the success of DBS. Dr. Tagliati often consults in the operating room, observing placement of electrodes. Dr. Mamelak, in turn, studies post-surgical scans with Dr. Tagliati, and observes patients' progress through follow-up programming and medical management. They are in constant communication about each patient before, during and after surgery. This unique team focuses on ensuring each patient's progress.
Success of the procedure, then, depends on precise lead placement, proficient programming, expert medication adjustments, side-effect management and patient education and support. These elements are all interdependent. DBS has proven successful enough in carefully selected Parkinson's patients, that it should be seen not as a last resort, but as an option for those deemed optimal candidates.
The procedure also lends itself to research, important work that both can directly benefit patients and ensure that a much-respected institution like Cedars-Sinai stays at the medical and qualitative fore. Some Parkinson's patients, after DBS implantation, improve in many ways, but a subset of them experience sudden, unexplained falls. By examining all the MRI scans of patients, we are exploring whether altering placement of the lead might reduce falls in patients.
While DBS has become the mainstay surgical treatment for movement disorders, ablative procedures, such as thalamotomy and pallidotomy, also can be useful for some patients who may not be good DBS candidates. And for some, such as frail, elderly patients or those taking blood thinners, for whom surgery is not an option, external treatment with a gamma knife can deliver radiation to targeted areas of the brain.
Click here for more information on Deep Brain Stimulation.