Essential Tremor: A New Life Through Deep Brain Stimulation

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Approximately 10 million people in the United States have essential tremor (ET), which eventually can interfere with daily activities such as eating, drinking and writing. Yet, most people with ET are never offered a therapy that was FDA approved in 1997.

At the University of Michigan, a program called STIM—Surgical Therapies Improving Movement—is changing the lives of people with ET using this very treatment, called deep brain stimulation (DBS).

Surgical Therapies Improving Movement— changing the lives of people with ET using deep brain stimulation

Surgical Therapies
Improving Movement—
changing the lives of
people with ET using
deep brain stimulation

“I think most people know DBS is a really good and effective therapy for Parkinson’s because two-thirds of our referrals are for Parkinson’s. But fewer people know how good it is for essential tremor. And ET is a much more common disease than Parkinson’s,” says Kelvin Chou, M.D., co-director of STIM and co-director of the Movement Disorders Clinic.

Approximately 10 million people have ET compared with approximately 1 million who have Parkinson’s.

“There’s an incredible unmet clinical need for this therapy. The major barrier to patients getting this quality-of-life-improving therapy is essentially a lack of awareness. That’s why we’re very interested in helping to educate providers and patients about the risks and benefits of DBS for ET,” says Parag Patil, M.D., Ph.D., an assistant professor in U-M’s departments of Neurosurgery, Neurology, Biomedical Engineering and Anesthesiology.

The STIM program treats essential tremor and Parkinson’s primarily, but DBS is also effective for patients with dystonia and a few other neurological disorders.

DBS Device
A DBS device is similar to a pacemaker for the heart, but instead of having electrodes (or electrical wires) implanted in the heart, the electrodes are placed into the thalamus portion of brain. The electrodes carry electrical signals to specific brain locations. These electrical signals cause the brain cells around the DBS electrode to change their activity. By changing the activity of brain cells, DBS can reduce the symptoms of many neurological disorders, depending on where the electrodes are placed.

DBS is not a cure for the disease but a way to manage it more effectively. It can offer many benefits, including the need to take less medication and therefore experience fewer medication side effects.

Patient Evaluation
Before patients are considered for DBS surgery, they are evaluated by the multidisciplinary STIM team, which has extensive training in DBS. The team includes a neurosurgeon, neurologist, clinical neuropsychologist, speech pathologist, social worker and other team members who ensure that the patient and their family understand the procedure and discuss expectations and concerns.

“In our program, a third of patients who are referred for DBS just need to have their medication adjusted. Another third go through the evaluation process, are offered the surgery and choose to defer. They’re not quite ready. So, that leaves one-third who actually have the surgery. And that’s fine, because for us, the emphasis is education, not just operating on people,” Patil says.

 

Endoscopic Skull Base and Pituitary Programs: Pioneering Minimally Invasive Surgeries For Faster Recovery

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The University of Michigan’s Cranial Base and Pituitary programs diagnose and treat benign and malignant tumors involving the cranial base and pituitary regions, cerebrospinal fluid leaks, encephaloceles and traumatic injuries to the face and skull. Endoscopic skull base surgery is an increasingly used technique that does not require facial incisions.

pituitary1

Resection of suprasellar craniopharyngioma

“Minimally invasive endoscopic approaches to the skull base have largely replaced the more invasive transcranial and transfacial approaches that were the mainstay of treatment for decades,” says Stephen E. Sullivan, M.D. Sullivan is director of the minimally invasive skull base program based in the departments of otolaryngology and neurosurgery and the minimally invasive pituitary program.

“We’re able to access most skull base brain tumors endoscopically, just through the nostrils. We actually get better visualization than we could previously in an open operation,” he says. Computer image guidance like a GPS is often used.

This approach causes patient lengths of stays to come down significantly. For the patient, it means no incisions, less pain and quicker recoveries.

“We evaluate patients in a multidisciplinary manner with all of the necessary consultants.  One

Resection of pre-pontine craniopharyngioma

Resection of pre-pontine craniopharyngioma

stop shopping, so to speak,” says Sullivan.

High Volumes and Types of Care
Sullivan’s programs perform about 225 skull base surgeries a year, approximately 120 of which are pituitary surgery. The remaining types of tumors are meningiomas, chordomas, craniopharyngiomas, esthesioneuroblastomas and sinonasal malignancies that involve the skull base.

Sullivan’s clinic takes a multidisciplinary approach in assessing patients by including all the specialists involved, including neurosurgery; ear, nose and throat; neuro-ophthamology and radiology. “Together, we come to joint decisions about care,” Sullivan says.

“We are one of the highest volumes centers in the country, certainly in the Midwest.”

For the Referring Physician
His area also has ongoing research looking at, for example, chordoma treatments and cells lines, and the genetic profile of chordoma cells. “It’s important for patients to participate in clinical trials.

“I want referring physicians to know that, while these are complicated tumors, the treatment paradigms are changing very rapidly right now. What wasn’t possible even a year ago is indeed possible now,” Sullivan says. “We’re happy to field any and all calls.”

Skull Base Program
  • Patients needing surgery can be seen in clinic within 1 or 2 weeks
  • 225 skull base surgeries a year, 120 of which are pituitary surgeries

 Find more information at UofMhealth.org/CranialBase or call M-LINE at 1-800-962-3555.

Concussion: Not an End Game

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The variability of concussion injuries makes experience a critical component to providing quality care.   Michigan NeuroSport sees 2,400-2,500 sport concussion cases every year, in addition to cases of peripheral nerve injury, spinal cord injury, stingers and other neurological injuries. It’s one of the few programs in the country dedicated to the neurological concerns of athletes of all ages.

“We provide a comprehensive neurological approach because we know that not every injury produces the same clinical syndrome or appears at the same time,” says Jeffrey S. Kutcher, M.D., director, Michigan NeuroSport, and associate professor of neurology. “A detailed yet focused history and examination allow us to put a lot of things in perspective like migraine, ADHD and depression. We’re able to sort through those and provide an accurate diagnosis.”end_game

NeuroSport physicians are team physicians for the University of Michigan, Eastern Michigan University and USA Ski-Snowboard, director of NBA concussion program, and consultants for the NFLPA and NHLPA. “Working with the teams, we’re taking care of athletes in real time, understanding the brain in real situations,” Kutcher says.

Customized Treatment
Just as each athlete is unique, so is every concussion. NeuroSport uses a customized, gradual, step-by-step process for safe return to play. This approach is based on elements such as the patient’s history and the nature of their sport.

“From diagnosing and treating thousands of patients and conducting research, we firmly believe that concussions are not a death sentence for athletes. Most of those who are concussed recover fully and can return to playing their sport safely, if they receive the appropriate medical care,” Kutcher says.

“What sets us apart is that we offer athletes neurological care and concussion treatment that is focused in neurology.” He notes that concussion clinics are popping up all over the United States. “They tend to only scratch the surface of the complex care these patients need.”

For Referring Physicians
Kutcher says that NeuroSport physicians can be helpful across the entire spectrum of athlete brain health management—anytime a referring physician feels uncomfortable evaluating a patient or making management decisions, whether it’s concussion, post-concussion syndrome, long-term concerns or other neurological issues.

Michigan NeuroSport Clinic: 734-930-7400

 

Back in the game First patient in state to leave hospital with a total artificial heart

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Going home from the hospital was an important milestone for Stan Larkin, a 24-year-old resident of Ypsilanti, and also for the state of Michigan. When Larkin was discharged on Dec. 23, 2014, from University of Michigan Frankel Cardiovascular Center in time to spend the holidays with his family, he went home without a human heart.

Larkin is the first in the state of Michigan to leave the hospital with a Total Artificial Heart.  Using a device called The Freedom® Driver, a 13-pound power supply that delivers compressed air to pump blood through the body, Larkin’s artificial heart is fueled by a portable driver, rather than the traditional “Big Blue” hospital driver that weighs 418 pounds and is the size of a washing machine.

All in the Family

Stan Larkin and his brother Dominique Larkin, 23, are in a simultaneous battle with heart disease. In 2007, Stan collapsed at a basketball game and tests revealed a condition called right ventricular dysplasia, a leading cause of cardiac arrest.

Stan Larkin, with his father, Eugene, is regaining his health while waiting for a transplant.

Stan Larkin, with his father, Eugene, is regaining his health while waiting for a transplant.

Because the heart condition can be inherited, doctors believed others in his family might be at risk. Just weeks after Stan’s diagnosis, his younger brother Dominique was also found to have familial cardiomyopathy. Some people who have cardiomyopathy — especially those who have hypertrophic cardiomyopathy (HCM) — may live a healthy life with few problems or symptoms. Others may have serious symptoms and complications. As the heart becomes weaker, it is less able to pump blood through the body and maintain a normal electrical rhythm.

Surgeons at the U-M  Frankel Cardiovascular Center implanted a defibrillator to help regulate Stan’s heart rhythm. For a time, the defibrillator kept Stan’s heart beating a regular rate, but he had to limit physical activity. It was not clear just how strong his heart was.

Running out of options

Over time, Stan’s condition worsened and his dysplasia progressed to both ventricles of his heart so neither chamber could collect and pump blood effectively. He became progressively weaker, and his doctors grew more concerned that he wouldn’t survive the wait for a suitable organ for transplant.

In October 2014, Stan was admitted to U-M Frankel Cardiovascular Center and underwent a series of physiological tests to determine if he was a good candidate for an artificial heart. With the test results and the knowledge that his time was running out, this became his best option. On Nov. 7, 2014 doctors removed his failing heart and replaced it with the SynCardia temporary Total Artificial Heart.

With the Total Artificial Heart, there are two tubes that exit the body, and those tubes have to be connected to a machine that can deliver compressed air into the ventricles to allow blood to be pumped through the body.

Prior to the development of the Freedom portable driver, the only FDA-approved driver for the SynCardia temporary Total Artificial Heart was the large Big Blue hospital driver, which confined patients to the hospital for months, even years, waiting for a matching donor heart. The Freedom Driver does the same thing as Big Blue — deliver the compressed air — except it is portable.

First connected to Big Blue, Stan was switched to the Freedom driver, which was approved by the FDA in June 2014 to power the total artificial heart as a bridge to transplant. His care marks two milestones: as the first U-M patient to make the transition to the Freedom Driver and first patient in Michigan to go home with it.

The wait continues at home

“Stan is still listed for a heart transplant and we hope to transplant him as soon as an organ is available. In the meantime he can be at home, CIC_game2he can be functional, and continue to rehabilitate himself so he’s in the best possible shape when his opportunity comes,” says University of Michigan cardiac surgeon Jonathan Haft, M.D.

Stan’s brother, Dominique, also progressed to bi-ventricular dysplasia and ultimately received an artificial heart. Since then, he received a heart transplant and continues to regain his health. Meanwhile, Stan worked with occupational and physical therapists to be well enough to navigate the world with the Freedom Driver.

The Freedom Driver is powered by two lithium–ion batteries that recharge with a standard electrical outlet, and is designed to be worn in a backpack or shoulder bag. Staying close to a power supply, eating low sodium meals and taking a bevy of blood-thinning medications have helped Stan remain healthy as he continues his wait for a transplant.

There’s no denying when he’s around because of the sound of the rhythmic pulses broadcast by the device strapped to his back, but Stan says, “I can honestly say I’ve gotten used to it. This is what’s keeping me going. I can’t wait to get a heart transplant so I can truly feel like myself again.”

A bridge becomes a destination

Ventricular assist devices have been used for well over a decade to improve survival and quality of life as patients wait for a heart transplant. When all other treatment options — including medications, lifestyle changes and heart procedures — have failed, the devices may be used as destination therapy. Unlike bridge therapy, destination therapy keeps patients on an LVAD for the rest of their lives.

The devices are most commonly used to support the left side of the heart, called left ventricular assist devices (LVADs), and others may be used to support the right side of the heart. If both sides of the heart require support, the total artificial heart may be used.

The U-M Ventricular Assist Devices (VAD) Program is one of only a few programs worldwide with access to many investigational and FDA-approved VADs, like the HeartMate II® manufactured by Thoratec Corporation for the REVIVE-IT trial. Specialists on the team work with referring physicians in the evaluation and selection of the most appropriate device based on each patient’s needs.

A team approach

Of the 5.7 million Americans living with heart failure, about 10 percent have advanced heart failure, according to the American Heart Association. Heart failure is considered advanced when patients feel shortness of breath even at rest. Even at an advanced stage, treatment options exist to help the heart pump as best as it can.

The Heart Failure Program at the University of Michigan Frankel Cardiovascular Center focuses on the complex management of advanced heart failure, circulatory support and heart transplantation. The Heart Failure Program team has extensive, high-volume experience in the treatment of patients with acute heart failure.  Heart failure services include a telemanagement team of nurses as well as an inpatient team of nurse practitioners and physician assistants to ensure safe, collaborative, patient and family centered care.

Breathe Deeply Caring for children with complex asthma

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Difficult-to-treat asthma can be a major contributor to school absenteeism, inability to engage in physical activity, and emergency department visits and hospital admissions.  In some cases, what presents itself as recurrent pneumonia or frequent respiratory infections can actually be traced back to an underlying asthma diagnosis.

The C.S. Mott Children’s Hospital Asthma Wellness Program is specifically designed for high-risk pediatric asthma patients.CIC-breathedeeply

“We’ve crafted our program around the needs of children 3 years of age and older who have had at least two emergency room visits or an inpatient admission for asthma,” says Marc Hershenson, MD, chief of the division of pediatric pulmonology at C.S. Mott Children’s Hospital.

The Mott team works closely with the child’s family and primary care providers to manage complex asthma through a robust year-long protocol utilizing intensive education and case management.  Emphasis is focused on decreased emergency department visits and admissions. Each child in the program is seen by a pediatric pulmonologist, nurse educator, respiratory therapist and social worker.

“We take a collaborative, multidisciplinary approach to treating children with complex asthma,” says Dr. Hershenson. “We’ve found that to be the best way to help minimize the complications of asthma for these children.  Causes of poor asthma control can range from failure to use an inhaler correctly to co-morbidities such as gastroesophageal reflux or fungal sensitization.   On the other hand, some referrals for difficult-to-treat asthma turn out to have other diseases like primary ciliary dyskinesia or recurrent aspiration.  Our multidisciplinary model allows us to provide accurate, comprehensive, multi-faceted care for each child.”

COMPREHENSIVE AND CONVENIENT

The U-M pediatric pulmonology team – including 11 pediatric pulmonologists – offers expertise in pulmonary conditions ranging from common breathing disorders to rare conditions:

  • Wheezing
  • Chronic cough
  • Recurrent respiratory infections and pneumonia
  • Asthma
  • Cystic fibrosis
  • Lung diseases of premature infants including bronchopulmonary dysplasia
  • Sleep-disordered breathing including central and obstructive apnea
  • Respiratory insufficiency requiring ventilator assistance
  • Aerodigestive disorders
  • Congenital abnormalities of airway and lung development including tracheobronchomalacia

Functional Wellness Initiative Improving quality of life for brain tumor patients

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This first-of-its kind clinical model brings together both the latest therapies to improve brain tumor survival and the comprehensive portfolio of rehabilitation services that patients need to help them maximize the quality of their lives.

An estimated 90 percent of brain tumor patients must cope with one or more significant functional, cognitive, motor or language impairments as a result of their tumors. The Functional Wellness Initiative identifies and treats both adult and pediatric patients with malignant and benign brain tumors that affect language, motor, psychological and neurocognitive outcomes.CIC-123 singlepage

“Many patients face a complex mix of challenges as a result of their tumors,” Hervey-Jumper says. “In the past, separate evaluations were needed from each discipline before arriving at a treatment strategy. That meant burdening patients with multiple appointments and making it more challenging for providers to coordinate their efforts. Here at Michigan, we bring the experts together for the patient right from the start.” Hervey- Jumper’s clinical and research focus is on brain mapping and functional reorganization.

Patient Visit

During a patient’s first clinic visit, he or she will see a multidisciplinary team of clinicians from neuro-oncology, physical medicine, clinical neuropsychology, speech pathology and neurosurgery. And they will collaborate on an all-inclusive, individualized care plan.

Every aspect of the care plan is based on the unique needs, values and preferences of patients and their families.

“This approach allows us to provide a more individualized care experience,” says Aaron Mammoser, M.D., a neuro-oncologist who specializes in novel therapeutics to improve survival. “Patients discuss their needs and concerns with all of their care providers at one time. By reducing the number of visits needed, we’re saving patients and families time and travel while enhancing their care experience.”

Follow-up Care

The timing and frequency of subsequent visits, treatment, rehabilitation and assessments will depend upon the patient’s individual care plan. These follow-up appointments allow for continued monitoring and support throughout the care process. As needs change, so will the treatment plan, focusing on both length of survival as well as achieving the best possible quality of life.

The Team

In addition to Hervey-Jumper and Mammoser, the team includes:

  • Sean Smith, M.D., a physical medicine and rehabilitation physician specializing in improving the quality of life for patients with cancer
  • Nicolette Gabel, M.D., a clinical neuro-psychologist who specializes in neurocognitive remediation
  • Karen Kluin, S., C.C.C., BC-ANCDS, a speech pathologist who specializes in perioperative language testing.
  • Thomas Ferguson, N.P., clinical coordinator for the program
  • Other faculty of the University of Michigan Brain Tumor Program include Larry Junck, M.D., Oren Sagher, M.D., Jason Heth, M.D. and Daniel Orringer, M.D.

MEET Donell Hall

Donell Hall was driving to work when he experienced another one of the massive headaches that would leave him temporarily unable to speak clearly. he managed to park, get out of his car, and lay on the ground to wait for help. Just able to function enough to call 911 and say a few words that would lead the operator to determine his location, hall remembers police arriving on the scene and then waking up in the hospital.

After a series of tests, doctors told hall he had a massive brain tumor that needed immediate treatment. Hall had been experiencing these headaches since the age of 14, and he had always thought the speech loss was a side effect of a bad migraine headache. As he approached his late 20’s, the head- aches became more frequent, occurring 2-3 times per year.CIC-donnell

Hall first met Dr. Hervey-Jumper and some of the other Functional wellness team members as he was being prepared for surgery to remove the tumor. As a TV/video/broadcast producer and business owner, the ability to speak is critical to Hall’s work and his livelihood.

The team understood this and spent much time discussing how Hall could retain his language skills after surgery. They also anticipated the added complexity of radiation and chemotherapy to shrink the remaining tumor that would not be able to be removed without risking long-term speech loss.

“The team was fantastic. They spent a lot of time prepping me for post-surgery to make sure I would be able to talk like I did before the surgery,” says Hall, who is now 30 years old. “If I can’t speak quickly and have people understand me,  my job is over.”

After his surgery in November 2014 to remove the tumor, hall continued working regularly with a speech pathologist to improve his language skills and his memory. Although less frequently now, he still visits the Functional Wellness Program about once a month and was able to return to work last month. “My language is coming back – I still forget a lot. But I’ve got most of it back. I feel good,” says Hall with a smile.