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Deep Brain Stimulation: A New Treatment Shows Promise in the Most Difficult Cases

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As a student of bioscience, I find this book to be comprehensive in deep brain stimulation (DBS) topic with a simple, but concise understanding. Deep Brain Stimulation by Jamie Talan takes us to the forefront of brain research with an accessible introduction to a new treatment method for disparate brain diseases such as Parkinson's disease, dystonia, obsessive-compulsive disorder, chronic pain, and even states of long-term unconsciousness. This book provides readers with an inside look on the revolutionary technology by tracking history, presenting latest developments from preeminent scientists, and providing firsthand accounts from patients.

The first part of the book describes of pioneers and histories in the DBS research field with Parkinson's disease. Parkinson's disease is one of the best studied brain disorder by the end of twentieth century and has long history with human life. The book shows us many frontiers and their successful researches such as Rolf Hassler and Lauri Laitinen, who are neurosurgeons and focused on thalamus surgery for treatment of Parkinson's tremor, and Irving S. Cooper, who operated on more than five thousands surgery for Parkinson's patients. Even though the results were unsuccessful, these efforts provided a starting point to understand the disease and moved one step closer to the brain regions that are related to Parkinson's tremor.

After some period of this controversy on the frontiers, George C. Cotzias developed a precursor of dopamine called L-dopa. He shows that L-dopa crossed into the brain broke down to form the dopamine needed to restore levels of the chemical to the basal ganglia. This region was normally rich with dopamine, but in the Parkinson's patients, dopamine was depleted from the cells. Over two decades, patients had been relying on L-dopa to treat their symptoms, but the medicine was proving to have its own problems such as on and off fluctuations, and dopamine cells in the brain continued to die away.

The patients unable to benefit in the long-term from L-dopa, it remained for researchers to produce one more series advances that would open the road to DBS. Those advances would emerge from confluence of neurosurgery and revelations from microrecording of brain cells by Dr. Delong. He and his team are focused on microrecorduing of brain and applied pillidotomy to the basal ganglia. They proved that the surgical lesion in the pallidum worked better than medications, reducing symptoms by 30 percent more than the drugs.

In November 1986, Dr. Benabid found that electrical stimulation with high frequency can stop the patient's tremor. When he applied stimulation on STN based on the results of Dr. Delong, he found at least resting tremors had gone. For more than twenty years since the mid-1980s, pioneering leadership-by DeLong, Laitinene, Benabid, and Vitek most notably-had been setting the landmarks by which deep brain stimulation could begin to advance.

For dystonia, researchers have more hard time to figure out the effects of DBS treatment because responding time of DBS treatment is not same as Parkinson's. When they implanted electrode, they can see the results immediately. However, a few months later after patient had a surgery, the patient starts to respond and the symptoms are reduced by more than 50 percent.

People marvel at the concept of DBS when they see someone with advanced Parkinson's, who is no longer jerking and can walk smoothly, or a young boy out playing basketball again after being unable even to sit in a wheelchair without falling to the ground because of dystonia. But then mention that neurosurgeons and neurologists have teamed up with psychiatrists to tackle obsessive-compulsive disorder (OCD), Tourette syndrome, or depression, and there is a look of consternation."Stimulation the brain to alter behavior and mood?" the researchers start with this sentence and notice that such side effects of DBS had been created changes in mood and behaviors. The OCD patients with DBS had improved almost 65 percent on their symptoms. For the Depression and Tourette symdrome, DBS is still not clear because some of patients are getting better but the orders are not. In addition, the brain regions related to these psychiatric disorders are not clear enough. The researchers think DBS does not only activate the output from stimulated structure but also changes the pattern of neuronal activity from a noisy, chaotic signal to a more regular one. This pattern change may be the key to find out DBS for depression and Tourette syndrome, but notes much remain to be done to understand the effects on the network and how it may change with long-term stimulation.

Finally, the author touches the parameters and risks for DBS treatment. DBS techniques have developed for each condition the benefits always have emerged hand in hand with the side effects and the risks. The problem is that DBS is not just a surgery but a technique that needs to be done just right and sometimes adjusting the parameters of the stimulation can take months, or even longer. The neurosurgeon and neurologist have to keep their eyes wide open and look at patients for best treatment with DBS.

After finishing the book, it seems to deserve at least a four out of five star rating, the amount of information gained on major history of DBS and its effects on Parkinson's disease, dystonia, and psychiatric disorders are satisfying. Although the author offers multiple examples to illustrate his point, it is at a great difficulty to comprehend for non-field related readers. In essence, more than 40,000 patients around the world have undergone DBS. Most have experienced remarkable improvement, and news of successes has been reported widely. Yet between brain and device are ambushes and challenges less often captured, and they are crucial to a clearer understanding of what doctors and scientist mean by breakthrough. I highly recommend this book to those who are interested in brain disorder and new treatment methods.

I found this book inspiration because it gave hope for a treatment option for Parkinson's
disease and other hard to treat disease states where there was often no options. Talan has the gift of describing a scientifically detailed treatment in terms that I could understand and at the same time providing valuable new information for medical professionals. The personalized case studies made the book an even easier and believable read. Talan put Deep Brain Stimulation on the map to the public and medical community as well.

This book goes into the history of developing a way to reduce the Parkinson's pill-rolling, resting tremors and the action/essential tremors, that I have. I found this book to be very helpful and encouraging.

very interesting book people that don't know about dystonia or parkinson's disease should read this book

DEEP BRAIN STIMULATION: A NEW TREATMENT SHOWS PROMISE IN THE MOST DIFFICULT CASES is a pick for any medical collection: it discusses a new technology of electrodes implanted in the brain and attached to a battery that alleviates suffering. Over 40,000 patients around the world have undergone this - both successes and cautions are detailed in a survey of experiments using DBS to treat various disorders.

As one of the first patients to undergo DBS for Dystonia (2001), and was one of the case histories Jamie discussed, I truly enjoyed the book. Talan writes in an easy to read manner, and describes the truly amazing potential, and potential pitfalls, of this novel treatment. As DBS becomes more well publicized, this book will be a go-to reference for the lay person. It is a quick read because it is not overly technical, and is well suited for the non-scientific reader.

If you want to hear her discussion of the book on NPR, you can go to http://www.wnyc.org/flashplayer/player.html#/play/%2Fstream%2Fxspf%2F127486.

Kudos to Jamie Talan for bringing this treatment to the public consciousness.

(NOTE: I am NOT financially involved in this book in any way whatsoever.)

Deep Brain Stimulation: A New Treatment Shows Promise in the Most Difficult Cases by Jamie Talan looks at the discovery and application of Deep Brain Stimulation (DBS) in a variety of neurological and psychological disorders. This novel delves into, not only the history, but also the impact on the patients who underwent the treatment, as well as the ethical choices faced by the doctors. I think this novel would be a good read for anyone interested in learning about the brain, and treatments that impact it.

This book is broken into three parts. The first portion discusses how treatment for Parkinson's disease progressed from brain lesioning, to drug treatment, and finally to DBS. The second portion then explores other diseases for which DBS could be used as a treatment. These disorders include dystonia, obsessive-compulsive disorder, depression, Tourette syndrome, epilepsy, intractable pain, and comatose patients. Lastly the book discusses the ethics behind DBS and how patients should be evaluated and chosen to undergo DBS.

One of the reasons that I enjoyed this book so much was that it was written for individuals with very little background in neuroscience. Talan begins the book by developing some history not only on Parkinson's but also on brain surgery. Most of the first surgeries done to relieve patients of their tremors were lesions of the brain that they believed were causing the tremors. The main region they focused on was the basal ganglia and surrounding structures such as the thalamus. Much of the work these scientists did was trial and error. They either tried an area and it worked, or tried an area and it didn't work as well or at all. Deep brain stimulation was discovered during these surgeries. The surgeons would stimulate areas of the brain to see what they controlled, and to make sure they were not lesioning something important. In one case while stimulating these areas, the surgeons found that if they stimulated the thalamus at a certain frequency the patient's tremors stopped. The surgeons put two and two together, and thus DBS was born. I think it's fascinating that one little "accident" during surgery could provide a whole new treatment for these patients. Stories like this are what kept me constantly wanting to read more of this book.

Although the work with Parkinson's was very important to the discovery and use of DBS, it was interesting to hear how this technology could be applied to other disorders. With dystonia being a movement disorder, it made sense, to me atleast, that it could benefit from treatment with DBS, however the fact that DBS could potentially benefit people with OCD or depression was amazing. As Talan discusses, disorders such as these took not only a neurosurgeon, but also a psychologist to monitor and treat the patient. One specific patient discussed in the book had severe depression, and underwent DBS because nothing else had worked. As they discussed, her treatment was nowhere near an instant cure as, "she still had great difficulty with concentration, memory, and thinking clearly" (89). Just like this patient, many had to undergo a number of adjustments to their device, and only about 50%, in one study, had significantly improved.

As can be shown by this example, and many others discussed by Talan, this treatment is still being refined with every new patient and disorder. I enjoyed the fact that Talan, while celebrating the success stories associated with DBS, also brought up the less successful cases. Because as amazing as the success can be, its important to consider the unsuccessful cases, and see what can be improved. Many of these cases are like the one previously discussed, where it might not be a perfect condition for the treatment. However, Talan also discusses cases in which the doctor was inexperienced in the procedure. I think this is an especially important aspect of the book as a warning for readers to be sure that any doctor they are working with is an expert in the field.

Another important aspect that Talan discussed was the ethics behind DBS. Although many people know that doctors and researchers have criteria for the patients they choose when it comes to experimental procedures, they may not know what it is, or how they make those choices. In the case of DBS, since it is quite a risky surgery, the current criteria include the fact that patients had to have exhausted their options for treatment. This is an important criterion because " if the DBS device is implanted in these patients, they could be worse off than before" (142). I think the most important question about ethicality, however, comes at the very end of the book when Talan asks, "It begins to seem that DBS may one day join a debate similar to that now raging over medications that can also boost mental performance in healthy people: should everyone have the option of strengthening healthy brain networks to feel or to think better than normal?" (158).

I would highly recommend this book to anyone. Even though I only had a pretty basic knowledge of the brain and its functions, I was able to fully appreciate everything presented by Talan in this book. It also gave me a great appreciation for the doctors and researchers who work so hard to try and improve the quality of life for individuals debilitated by disease. In addition, I was in constant awe at the amazing cases of how patients benefited from DBS. I think my only negative thought about this book was that there were not enough of these cases presented throughout. Although learning about the development and use of the treatment was quite interesting, the cases of application to actual patients were inspiring.

Review of Deep Brain Stimulation, A New Treatment Shows Promise In The Most Difficult Cases, by Edgar award-winning author Jamie Talen.

It is misleading to classify this book as "Popular Science/Medicine" the way this work's publishers did: such a designation is inadequate to describe Jamie Talen's comprehensive history of the antecedents to this specialized and seemingly "new" medical treatment and the professional biographies of those performed such surgeries and had enough of a success rate to justify further research and application of related techniques.

"The early pioneers who set out to understand the brain tried structure after structure in the neighborhood of the basal ganglia until they found the ones that would alleviate the symptoms of movement disorders. The neurosurgeons who began operating on these patients in the 1940s were destroying what they hoped was abnormal tissue. But there was scant scientific proof to justify their techniques and treatments, which they developed more or less by accident. Someone tried something, it worked; others began doing it. At the same time, scientists began to study the brain's inner workings systematically. They started the painstaking work of figuring out what exactly was taking place inside this three pound tissue.
In time, and fortunately, neurosurgeons began working alongside neurologists and scientists. Taking a leaf from Wilder Penfield's book, they began using stimulating electrodes to guide them to specific brain tissue. The move to use this tool during surgery was what eventually led surgeons to leave the electrodes in place. (Talen, J., 2009, Deep Brain Stimulation, Dana Press, New York/Washington, D.C., p. 26.)

"Not everyone thought that microelectrode recording was important, however. Some neurologists believed the scans and the stereotactic programming could get them to the same place without risking further problems by threading hair-thin leads in and out of tissue to guide the course. The use of micro-electrode recording is still debated in surgical halls today. No studies have been published comparing patients who have had DBS with such surgical recordings to those who did not have the recordings. Yet Vitek said there is evidence that once the area is mapped with microelectrodes, surgeons often end up placing the lead in a location different from the one they originally targeted. (Talen, J., 2009, Deep Brain Stimulation, Dana Press, New York/Washington, D.C., p. 46.)

The book also describes the spread of DBS to major medical institutions outside the US, ethical considerations, and the "catching up" society and the US government regulatory apparatus had to do in order to allow this treatment to become a part of mainstream medicine and to establish a system of patient selectivity and professional ethics which minimize some of the negative potential both to public image and to individual patients which had accompanied earlier attempts to promote brain surgeries as effective treatments for mood and movement disorders. The "cowboy" approach which had accompanied some of the new varieties of brain surgery in the past would not be acceptable in today's society. New applications for DBS surgeries and devices were quietly approved on a slow trickle of patients over a number of years in the late 1990s and early 2000s.

"Thus, in 1999, Mayberg moved to the University of Toronto ready to devise and test deep brain stimulation in severely depressed patients for whom nothing else was working. In 2002, the team was granted approval to operate on six patients. They brought their first one into the operating room a year later, in 2003. They worked with a whole team of specialists---psychiatrists, psychologists, neurologists, and ethicists---to figure out who should be allowed entry into the study." (Talen, J., 2009, Deep Brain Stimulation, Dana Press, New York/Washington, D.C., p. 82.)

In at least one instance of the experimental application of new DBS surgery, Dr. Donald Richardson, at 74 years of age, successfully implanted a Deep Brain Stimulator device and leads in a Tourette's patient and thus became a living embodiment of the history the new DBS techniques had in the older efforts to minimize symptoms by lesioning or destroying relevant brain tissue.
"To a reporter from the Tulane University Magazine, Richardson explained his embracing of the new DBS technique in the context of his personal history: `I did procedures on Tourette patients years ago, before we had a stimulator. ...What we found is that if we put an electrode in the brain, found the right spot and stimulated it, we could markedly make the patient's Tourette symptoms worse. Then, if we made a small lesion and coagulated the area, the symptoms got much better.' But his technique didn't hold up, he said, and he stopped doing it. Then modern deep brain stimulation came along, and Richardson opened the gate again: `I think the future for deep-brain stimulation is almost limitless. We're just scratching the surface.'"
(Talen, J., 2009, Deep Brain Stimulation, Dana Press, New York/Washington, D.C., p. 102.)

However good the idea of DBS may seem in theory, it is in execution and follow-up that many things can go wrong, and the devices and surgeries not work as intended. The book tells of one man with severe dystonia which DBS helped...up to a point. One of his muscle contractions snapped the leads from the stimulator, which failed to work as effectively afterwards; the problem was only discovered as the man's symptoms got worse and severely affected his life and career. New leads had to be re-implanted. A man with severe OCD had a DBS device which eliminated many symptoms for him...until the batteries on his stimulator had ran low. His OCD symptoms overtook him on the road and resulted in a potentially dangerous encounter with a State trooper.

Some of the leading surgeons in the field have been starting to see human "do-overs" show up at their university and hospital departments for reasons other than the kind of maintenance issues described above. After having given seminars about DBS to doctors far and wide, many doctors who were not specialists in this type of surgery thought they were qualified to do it after having attended these seminars, proving the "cowboy" attitude is still alive and well in the field of medicine. Sometimes this resulted in doctors with little other experience in brain surgery implanting devices and electrodes in the wrong places. Other problems started to arise when DBS started to be done on patients who were less carefully selected for risk/benefit factors. And then there are cases where the area around the device gets infected.

Another potential hazard which could lead to DBS functioning less than optimally is the fact that surgery and implanting the device is only one part and not necessarily the most important part of the therapy: programming the device and assessing its effects on the patient are more often than not out of the hands of the doctor who installs it and are left to nurses, occupational therapists, and others in the "support team" who "lower on the totem pole" some of whom may not have received specialized training with the devices or are familiar with how they are supposed to function.

Recognizing this scenario, one of the major research institutions which performs DBS surgeries recruited a nurse experienced in programming DBS devices and working with patients who had them installed to impart her personal knowledge to others on the support team. Another factor is that only major universities, teaching hospitals, etc. are likely to have the kind of support team which can help assess post-operative functioning of the device, programming adjustments, and follow-up with the patients.

As Medtronics, the firm that pioneered the pacemaker for the heart, expanded into DBS equipment, including leads and electrodes "the thickness of a hair", opportunities for other companies and related devices arose.
"One company, NeuroPace, is developing a novel deep brain stimulation technique built with a microchip sensor, electrode, and microprocessor surgically embedded in the extracellular space within the brain to monitor abnormal electrical activity. Information of an impending seizure is sent to the microprocessor, which turns on the stimulating electrode to stop the seizure activity. The company calls this technology responsive stimulation." (Talen, J., 2009, Deep Brain Stimulation, Dana Press, New York/Washington, D.C., p109.)
"As of 2009, using deep brain stimulation for anything other than movement disorders was still considered experimental. No one knows whether the technique will ultimately help people with obsessive-compulsive disorder or depression or cluster headaches or epilepsy. Studies are only beginning, and it will take years to find out whether the risks outweigh the benefits." ...
And as neuroscientists identify the circuits involved in other brain diseases---passing DBS leads in, around, and through the tissue of the exquisite human brain and identifying effects of that procedure on the wide swath of cognative actvities and emotions---what systems will be put in place to ensure that these techniques are not used for pure human enhancement?" (Talen, J., 2009, Deep Brain Stimulation, Dana Press, New York/Washington, D.C., pp. 157-158.)

I had Deep Brain Stimulation last year and thought this book would be interesting. It was not an easy read - a little too technical for me. It didn't address the questions I had about the surgery.