Moving Forward

Moving Forward - Archive

3/30/2009

Deep Brain Stimulation and the Placebo Effect

Post Written by Bradley Hiner, MD

Welcome to our first installment of Moving Forward, the Parkinson’s Disease and Movement Disorders blog. We hope to cover a broad range of topics relating to these conditions, and hope to generate discussion and feedback from our readers.

As this is the first in our series, let’s start off with a bang:

“Deep Brain Stimulation? I think it’s all a placebo effect.”

A reporter for a large local newspaper interviewed various Parkinson specialists about deep brain stimulation (DBS) after a well-designed, well-executed national study found that DBS was superior to the best medical management in selected patients with Parkinson’s. One of the doctors interviewed stated he thought the effects of DBS were “all placebo.”

This is simply wrong.

The whole point of the study was that this is not a placebo effect, in fact just the opposite. These days we call this “evidence-based medicine.” It’s not what I think I know, or what I’ve been told by someone else; it’s what the EVIDENCE shows.

The shame of it is that folks with PD, should they be under the care of a physician like that, will simply not be given the straight story. It will not even be mentioned as an option, which is too bad. While DBS can be associated with side-effects, the study also showed that 99 percent of the side-effects have resolved at the 6 month mark.

Don’t get me wrong — DBS is not for everybody. Our job is to make sure that proper patient selection takes place so we can be confident when we move in that direction. But not offering it at all in this day and age is equivalent to telling a heart patient that he or she shouldn’t have a pacemaker placed because “it’s a placebo effect.”

Your doctor needs to be your advocate. Our job is to stay on top of all the latest research and be able to offer non-biased information so that patients and families can make informed decisions about their health care.

Medicine is a funny thing. What is true at one point in time becomes obsolete with acquisition of new knowledge. In his 1817 publication, “An Essay on the Shaking Palsy,” Dr. James Parkinson not only identified the clinical features of the disorder that now carries his name, but also speculated on the treatment for the disorder. He suggested that blisters be raised on the back of the neck, presumably to let the evil humors out that were causing congestion of the brainstem. We’ve come a long way, and there’s a long way to go yet. But nothing could be more exciting and fast-paced than the field of Parkinson’s and Movement Disorders. We doctors are obligated to keep up with advancements in the field so we can offer you the best opportunities to make informed decisions regarding your health care.

The following is feedback received for this blog:

Thank you for the well written and insightful article you wrote concerning DBS and the Placebo Effect. What Parkinsons patients are good candidates for DBS? I understand that that anyone that can still control Parkinsons effectively with medication would probably not need to choose DBS. What Parkinson characteristics make for a good DBS candidate. While 99% of the side effects are improved when the occur do occur after DBS, how severe is the 1 % that is not improved. How often is the operation not successful (little or no improvement)? Not too long ago I read an article in the Milwaukee Journal in which a Dr. Nauseda from Mount Sinai Hospital stated that DBS was no more effective than medication if the medication is prescribed properly. I have read numerous articles, however, where patients were improved after DBS and some dramatically. Can some patients actually be worse after the operation? Do most insurances advocate and support DBS?

Thanks again for the article.

- Randy Samborski

Thanks for your excellent questions. In a nutshell, DBS is an option for patients whose quality of life is adversely affected by their Parkinson's disease and the medications aren't helping like they used to. A phrase I often use is, "taking more medication with less benefit and more side-effects." That is a pretty broad generalization, and we actually go through a very thorough process to ensure that if the patient goes through with DBS that we can expect good results.

Regarding the statement, "DBS was no more effective than medication if the medication is prescribed properly", the whole point of the recently published study I alluded to (Journal of the American Medical Association, Jan. 7, 2009, pp. 63-73) was that in properly selected patients, DBS is indeed superior to medication. Specifically, after studying 255 patients equally matched and distributed between surgery and medical management, "71% of deep brain stimulation patients and 32% of best medical therapy patients experienced clinically meaningful motor function improvements," resulting in improved quality of life. For you Parkinson patients, this translated to an average gain of 4.6 hours of quality "on" time compared to pills.

Regarding side-effects, the most common is infection (5-10%), which is usually responsive to antibiotics. On occasion we have to remove hardware, usually the battery — which can be replaced later without having to change the DBS lead itself.

Finally, this procedure is approved by Medicare and almost all insurance carriers. I can't think of the last time we had a denial.

Thanks again for your questions, and I'd welcome the opportunity to meet with you or anyone else out there who has questions about DBS.

Brad Hiner, M.D.

Posted 9:08 AM

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Blog post by Dr. Karen Blindauer

We started our blog more than years ago and now are taking a break. We feel honored to have appeared so often on the front page of the Froedtert website. We’ve been able to share information on the illnesses that we treat, but, more importantly, we’ve shared stories about the people who have these illnesses. We’ve talked about patients who dance, sing, create poetry and prose. We’ve shared ways that people are “living well” despite chronic conditions. We have been inspired.

The Parkinson’s and Movement Disorders Program at Froedtert & The Medical College of Wisconsin remains strong, comprehensive, interdisciplinary and continuously growing. We have three fellowship-trained movement disorder neurologists with over 40 years of experience among us. We have nationally renowned experts right here in Milwaukee. Our program offers the most up-to-date care in Parkinson’s disease (PD) including the state-of-the-art Deep Brain Stimulation surgery for PD and other movement disorders. Our nurses and therapists specialize in the treatment of PD and all have had the latest training.

Our Outreach Coordinator connects with all possible sources of information and referral for our patients regarding any psycho/social needs. She facilitates six local support groups and the Living Well with Chronic Conditions Program that we have spoken of so often.

The annual Wisconsin State Huntington Disease Conference meets on Saturday, April 21, at the Country Springs Conference Center in Pewaukee. Our annual Symposium for People with Parkinson’s and Their Families will take place on Saturday, September 15, also at the Country Springs Conference Center. Our annual Moving Forward: Ride/Walk for Parkinson’s event will again be held beside the Glacial Drumlin Trail in Dousman on Sunday, October 7.

We continue to teach medical students, residents and fellows, so the next generation of experts can carry on our legacy. We remain involved in research in Parkinson’s disease and other movement disorders, from the basic sciences to the latest clinical trials. We continue to participate in community lectures to educate our patients about their conditions and treatment options. We remain committed to providing the most comprehensive, state of the art, compassionate, and expert care for our movement disorders patients. We’re just going to take a break from blogging.

Vicki Conte, the Community Outreach Coordinator in the Neurosciences Center is going to begin a blog that will cover topics throughout the neurosciences from ALS, dementia, epilepsy, spine care and stroke. You’ll learn about the roles that our neurologists, neurosurgeons, neuro-psychologists, and physical medicine and rehab staff play. And importantly you’ll hear about the struggles and victories of patients who are cared for here. Tune in to "The Nerve Center" on a regular basis at www.froedtert.com/nervecenter.

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