Deep brain stimulation (DBS) is a surgical treatment for movement problems associated with Parkinson’s disease, tremor or dystonia. DBS is very effective in controlling many symptoms related to abnormal movement, however dissatisfaction with the therapy can occur at any time after surgery. Since 2004, Sierra Farris, PA-C has managed a deep brain stimulation troubleshooting specialty clinic to investigate DBS problems. Over 350 people from across the country and abroad seen to investigate dissatisfaction after DBS. Sierra works with Dr. Monique Giroux, physical therapy and speech therapy to optimize DBS results.
Deep Brain Stimulation Troubleshooting Clinic
When the outcome is not what you expected. The DBS Troubleshooting Clinic is a unique comprehensive multi-day clinic for individuals with DBS seeking a second opinion about programming, determining adequate medication dosing and/or to investigate problems from stimulation or the hardware. Multiple visits with our team may be required to complete the assessment. Visits are tailored to each individual to investigate the cause(s) of dissatisfaction or ineffectiveness of DBS.
- Sierra Farris PA-C and Dr. Monique Giroux conduct specialized neurological evaluations to assess whether DBS is working as expected. Troubleshooting includes a medical consultation, electrode placement assessment, detailed DBS programming, expert programming strategies to optimize benefit and eliminate stimulation side effects, optimize battery longevity and assess the hardware circuit. Disease progression and medications are reviewed. Troubleshooting appointments are customized for each person.
- Physical therapy and/or Speech therapy evaluations by a neuro-specialized therapists if indicated.
- Brain MRI or CT or hardware x-rays can be obtained if hardware safety testing reveals an intact system.
- Surgical consultation with highly skilled surgeons is coordinated if indicated.
- Recommendations and reports are sent to the patient and/or physician upon request.
- Revision surgery work-ups are offered to patients with poor electrode position.
Common causes of Deep Brain Stimulation problems, failures, or dissatisfaction:
- Inadequate stimulation settings
- Stimulation induced side effects
- Damaged DBS hardware
- Depleted DBS battery or rapid battery depletion
- Poor placement of the implanted electrodes
- Inadequate medications or expectations
- Incorrect diagnosis
- Disease progression
- DBS done too late
- DBS done too early
Below are the results from 50 patients seen in our troubleshooting clinic.
Defining the problem – Is DBS a failure?
The graph on the right illustrates the most bothersome symptoms after DBS surgery that led patients to our troubleshooting clinic from across the United States. Problems such as walking, balance, speech and no improvement in On time were the most common reasons for dissatisfaction. Since walking, balance and speech problems are commonly associated with disease progression, worsening symptoms may not be investigated after DBS. We have learned from our troubleshooting experience that many symptoms that worsen after DBS can still improve with careful and meticulous evaluations of the variables that can worsen symptoms. Dr. Monique Giroux and Sierra Farris work together to find solutions to the many problems that can occur months to years after DBS surgery. Some patients will see physical therapy or speech therapy to fine tune the stimulation settings for optimal benefit.
Most people are improved after adjusting their stimulation settings.
The graph on the left shows the results for the 50 patients experiencing problems of mainly walking, balance and speech problems. The first six symptoms listed are measured during the appointment and the remaining symptoms are reported by each patient. As you can see in the graph, symptoms commonly associated with disease progression can be improved with therapeutic stimulation settings (noted in blue). Some people did not experience improvement in symptoms (noted in red), however, what is obvious from our results is sub-optimal stimulation settings can definitely worsen symptoms and can be improved even years after DBS surgery. Some of the patients in this series had DBS for over 5 years but were still improved with reprogramming. We feel that patients should have a thorough evaluation for worsening symptoms no matter how long they have had DBS.
Read about three incredible individuals living with Parkinson’s disease that were seen in our troubleshooting clinic. Both were determined to find solutions for their unsuccessful DBS surgery and disability from stimulation side effects. You will read about an amazing recovery after proper programming and a new lease on life after revision surgery. Meet Charlene. Meet Dean. Meet Bill.
DBS Publications by Sierra Farris and Dr. Monique Giroux
1. Farris, S, Giroux ML. Deep brain stimulation hardware complications: The Role of Electrode Impedance Measurements. Movement Disorders 2008: Vol 23, Issue 5: 755-760.
2. Lee JYK, Machado A, Deogaonkur M, Kubu C, Farris S, Giroux M, Vitek J, Rezai A: Thalamic Deep Brain Stimulation for Tourette’s Syndrome. International Society of Reconstructive Neurosurgery, Seoul, South Korea, September 1-3, 2005.
3. Farris S , Giroux, ML. Gait changes after Deep Brain Stimulation for Parkinson’s Disease in a patient with cervical myelopathy. Neurorehabilitation 2008: Vol 23, No. 3 :263-265.
4. Rueda-Acevedo, M; Farris, S; Senatus, P; Giroux, ML. Controlling dyskinesias in Parkinson’s disease patients with STN DBS. A new programming strategy. American Academy of Neurology 2007.
5. Farris S, Giroux ML. Self-reported change in review of systems post bilateral subthalamic deep brain stimulation. Movement Disorders Conference, Chicago, 2008
6. Farris S, Zylstra A, Giroux ML: Change in exertional O2 saturation with deep brain stimulation in Parkinson’s disease. Movement Disorders Conference, Chicago, 2008
7. Giroux, ML and Farris, SM. Lead Wire Fracture associated with Normal Electrode Impedance Measurements in a Patient with a Kinetra neurostimulator. Neuromodulation Volume 13, Issue 1, pages 65–67, January 2010
8. Farris S, Giroux ML. Deep brain stimulation, A review of the procedure and the complications. Journal of the American Academy of Physician Assistants, Review Article, February 14, 2011
9. Farris S, Gianola F. Ethical issues surrounding deep brain stimulation in Parkinson’s disease, Journal of the American Academy of Physician Assistants, Feature Article, February 19, 2009
10. Widge AS, Agarwal P, Giroux M, Farris S, Hebb AO, Kimmel RJ. “Psychosis from Subthalamic Nucleus Deep Brain Stimulator Lesion Effect.” Surgical Neurology International; 4:7, 2013.
11. Farris S, Giroux ML. Retrospective Review of Factors Leading to Dissatisfaction with STN DBS during Long-term Management. Surgical Neurology International; accepted April 2013 In Press
12. Michael H. Pourfar, Alon Y. Mogilner, Sierra Farris, Monique Giroux, Yufan Zhao, Hemant Bokil, Mark C. Pierre. The Graphical User Interface for DBS Evaluation (GUIDE) study explored whether a visual programming system could help clinicians accurately predetermine the ideal settings for stimulation in patients who received Deep Brian Stimulation (DBS) for management of their Parkinson’s disease. International Parkinson’s and Movement Disorders Congress Abstract 2013
13. Michael H. Pourfar, Alon Y. Mogilner, Maria Gillego, Sierra Farris, Monique Giroux, Yufan Zhao, Hemant Bokil, Mark C. Pierre. Model Based Deep Brain Stimulation Programming for Parkinson’s Disease; The GUIDE Pilot Study, Submitted to Journal of Neurosurgery 2013.
14. Giroux, ML and Farris SM. Chapter 27 Basic aspects of deep brain stimulation programming in Parkinson’s disease. Editor: Mauricio Rueda Acevedo, MD and Luz Jaqueline Ruiz, MD. Assoc Colombiana de Neurologia, Parkinson’s Disease: Update and Review, ISBN: 978-958-99088-2-2;2009.Download Information