“This procedure is a game changer for our ability to treat patients with essential tremor and tremor-dominant Parkinson’s disease,” said Abigail J. Rao, M.D., stereotactic and functional neurosurgeon with Norton Neuroscience Institute. “Acquiring this technology advances our mission of giving patients the best possible outcomes, while further establishing Norton Neuroscience Institute as the regional leader in advanced neurological care.”

The treatment is an incisionless surgery, by which several ultrasound beams are focused down to millimeter accuracy, carefully creating a small lesion in a specific part of the brain. The patient lies in an MRI scanner that allows frequent scans to monitor the location, size and temperature of the lesion being created. During that process, the patient wears a helmet-like device filled with cool water that has more than 1,000 ultrasound transmitters, while the surgeon also tests the patient’s tremor and neurologic function. The newly created lesion provides immediate and dramatic relief of hand tremor and other symptoms of movement disorders, allowing for better motor control for life’s daily tasks or hobbies, as well as better quality of life.

The surgery does not require any anesthesia or hospital stay.

“This is truly groundbreaking technology that will allow us to help so many people in new ways,” said Lynnie Meyer, R.N., Ed.D., FAHP, CFRE, senior vice president and chief development officer, Norton Healthcare. “As focused ultrasound progresses, we hope to see its benefit in treating other conditions.”

The focused ultrasound surgery has been approved by the U.S. Food and Drug Administration since 2016 and is backed by years of data, which has shown most patients experience immediate, significant relief from tremor symptoms. The most common side effects include imbalance and numbness, but these usually subside within a few weeks.

To qualify for the treatment, a patient must have a confirmed diagnosis that is not adequately controlled by medication. The patient’s anatomy is carefully studied, and the surgery is planned, with CT and MRI scans taken prior to the day of the procedure. After the procedure, the patient receives a follow-up MRI to evaluate the lesion.

Start Your Journey With a Free Seminar

If you’re interested in learning more about high-intensity focused ultrasound treatment, be sure to join us for a free informational session. During this session, our team will address treatment options tailored specifically to individuals diagnosed with essential tremor and/or Parkinson’s disease.

The post Norton Neuroscience Institute acquires groundbreaking focused ultrasound technology appeared first on Norton Healthcare.

With an implant that interrupts uncontrolled movements, Mike has regained control of his body and can now get postoperative visits and treatments without having to go to his neurologist’s office.

In July, Mike underwent deep brain stimulation (DBS) surgery by Abigail J. Rao, M.D., functional neurosurgeon with Norton Neuroscience Institute. DBS is like a pacemaker for the brain. It delivers gentle stimulation that can change abnormal circuitry, which causes uncontrolled movements. With the surgery, the stimulator is implanted into the brain, with wires running under the skin. Those wires then connect to a battery under the skin of the chest.

A new program called NeuroSphere Virtual Clinic allows Mike’s neurologist to adjust the device remotely so it provides optimal stimulation. Mike can be hundreds of miles away enjoying his new freedom when Justin T. Phillips, M.D., neurologist and director of Norton Neuroscience Institute Cressman Parkinson’s & Movement Disorders Center, tunes his stimulator.

After surgery, Mike and Dr. Phillips met for a virtual visit. Dr. Phillips saw the live video of Mike’s hands having tremors. After pressing a few buttons on a tablet device, Dr. Phillips sent signals to Mike’s DBS implant, using Bluetooth and cloud technology. In a matter of moments, Mike’s tremors stopped.

“Before the visit, I was shaking all over the place, but now that Dr. Phillips got it calibrated … nothing,” Mike said. “It’s amazing.”

According to Dr. Phillips, the virtual clinic gives him more options to support his patients.

“As Parkinson’s progresses, patients have more challenges getting around,” he said. “Being able to help patients in their own homes can make the experience better for them and their families.”

The technology also allows patients, like Mike, to make certain adjustments on their own.

Mike’s ability to get his stimulator programmed remotely is just part of the breakthrough advances provided at Norton Neuroscience Institute.

Dr. Rao was first in the Louisville area to use advanced techniques that don’t require the patient to be awake during DBS surgery. Historically, the surgery required the patient’s brain cells to be sampled and patient movements to be tested during surgery. However, advances in surgical technique and high resolution imaging no longer require this and actually allow for reduced surgical risks with the patient under general anesthesia.

“DBS can help patients regain smoother, more normal movements, less slowness and less excessive movements that can develop as a side effect or consequence of long-term medication use,” Dr. Rao said. “We typically see very positive outcomes.”

While Mike continues to receive treatment for his Parkinson’s disease, he has plenty to look forward to, like hitting the golf course and returning to boxing class. His message to others with Parkinson’s or similar diseases is to ask about DBS.

“I thought it was my best chance at having a normal life,” Mike said. “I’m already noticing a vast improvement.”

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Jason was diagnosed with the progressive nervous system disorder eight years ago at age 40. Parkinson’s causes unintended or uncontrollable movements, such as shaking, as well as stiffness and difficulty with balance and coordination.

Jason said he felt shocked.

“People think it’s an older-generation issue,” he said. “I’m sitting there going, ‘I’m 40. This can’t be true.’”

After his diagnosis, Jason was connected with Parkinson Support Center of Kentuckiana, a Part of Norton Neuroscience Institute Resource Centers. Resources and services provided for patients like Jason are funded by community support through the Norton Healthcare Foundation.

Jason is the director of operations at Against the Grain Brewery in Louisville. When he learned about the center’s annual fundraising event, the Denim & Diamonds Gala Celebration, he knew he had to get involved. Since then, he has been using his 30 years of experience in the restaurant industry and vast network of chef friends to help produce the event and continue to raise awareness about Parkinson’s disease and funding for the center.

Through donations and volunteerism, the Norton Healthcare Foundation provides funding for support groups, exercise programs, equipment, new technologies, clinical research and health education for patients, families, medical staff and the community.

“It takes the support of everyone in the community for us to be able to be here for patients like Jason when they need us,” said Lynnie Meyer, R.N., Ed.D., CFRE, senior vice president and chief development officer, Norton Healthcare. “We are looking forward to a great evening of celebration, and are so grateful for all that Jason has done and is doing to support the work of the center.”

For Jason, the fellowship that happens at Demim & Diamonds is just as important as the fundraising.

“You almost forget about the disease for a day, have some fellowship and support those around you because everyone has to lean on one another,” he said. “We just need to celebrate and raise awareness and raise funds.”

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One of the newest neurologists on staff at Norton Neuroscience Institute, Dr. Crowell grew up watching his grandfather, a long-time physician, care for the members of his small Alabama community. Dr. Crowell saw firsthand, he said, “the relationships my grandfather built with his patients.”

When his grandfather was diagnosed with Parkinson’s, a nervous system disorder that impacts movement and causes tremors, Dr. Crowell was already in school learning about the brain. He decided then to pursue neurology.

“A lot of what I was hearing at the time was secondhand from my aunts and grandmother,” Dr. Crowell said. “It was sad in many ways because he had always been, in our family, the one who had all the medical answers. I just wanted to understand [Parkinson’s] better.”

Dr. Crowell completed medical school at the University of Alabama at Birmingham, where he went on to complete a fellowship in movement disorders after his residency at the University of Virginia, Charlottesville. He especially took an interest in deep brain stimulation, a procedure in which electrodes are implanted in the brain to combat the symptoms of Parkinson’s.

He also wanted to learn more about improving patient care and the delivery of health care, which led him to earn a master’s degree in public administration with a focus on health care policy from the prestigious Harvard Kennedy School in Cambridge, Massachusetts.

All that led to Dr. Crowell arriving at the intersection of medical and scientific curiosity and personal connection.

Norton Healthcare’s need for a second Parkinson’s specialist met Dr. Crowell’s desire to be closer to family in Alabama and Tennessee, and to treat people with the kind of personal care his grandfather demonstrated. His schedule filled out two-plus months before he even set foot in the office. Dr. Crowell said his first few months “have been really gratifying getting people help faster.”

“I try very hard to not treat a lab finding or an exam finding, and instead treat the patient,” he said. “I can prescribe medicines or tests all day, but if I haven’t answered the patient’s questions, have I done anything? I had a mentor who would say, ‘It’s only a good pass if your teammate catches it.’ Sometimes that’s just listening. People come to us with concerns; it’s our job to address them and provide them with reassurance.”

Dr. Crowell’s recently published research

• Rising Drug Costs for Neurologic Diseases
• A crisis in US drug pricing: Consequences for patients with neuromuscular diseases, physicians and society, part 1
• A crisis in US drug pricing: Consequences for patients with neuromuscular diseases, physicians, and society, part 2
• Awake Testing during Deep Brain Stimulation Surgery Predicts Postoperative Stimulation Side Effect Thresholds
• MM1-Type Sporadic Creutzfeldt-Jakob Disease With Early Behavioral Changes and Prolonged Symptom Duration

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First, don’t skip doses or take less than prescribed. Talk to your doctor about cheaper alternatives, ask your pharmacist about options and check for any state or drug industry programs that might help.

“There are times when a less effective, cheaper alternative treatment is the right choice for a patient. Many expensive drugs are unaffordable, while others aren’t worth the cost,” said Jason L. Crowell, M.D., MPA, a neurologist specializing in movement disorders at Norton Neuroscience Institute.

Helping patients understand their options when they can’t afford their medication is a passion for Dr. Crowell. In his practice, it’s common for him to have patients with rare neurological conditions that could be helped by a medication costing thousands of dollars.

He often discusses the price of medication with his patients.

“As a physician, I want to know if the treatments I prescribe are inducing financial toxicity in my patients. I routinely ask patients about side effects of their medicine, and a drug’s cost is often its most significant side effect,” Dr. Crowell said. “It’s important we consider the big picture regarding the tests and treatments we recommend, including how it affects a patient’s mental health, family members and other areas of life. Affordability is a big part of that.”

He encourages patients to talk to their health care providers about the financial challenges their medication or other care may create and what they have to sacrifice. Being open about out-of-pocket expenses at the doctor’s office or pharmacy or for lab work and other tests can open the door to a conversation about alternatives.

Discuss your insurance coverage with your health care provider and seek to find a middle ground that addresses your conditions in an affordable way.

If you can’t afford medication

• Some medications may be cheaper at another pharmacy. If you have health insurance, check with your insurance provider to see if your plan has a preferred pharmacy where your benefit may be better. You also may be able to save money by requesting a 90-day prescription or using a mail-order service.
• Your provider may be able to switch your medication to a generic and/or cheaper alternative.
• Drug discount cards, such as GoodRx, can help you save on prescriptions. You can find discount cards and participating pharmacies online, or ask your pharmacist.
• Manufacturer coupons and copay cards: Some drug companies offer discount coupons to patients with commercial insurance plans. Medicare and Tricare plans are excluded from copay cards.
• Medicare’s Extra Help program: If you have Medicare, you may be eligible for extra help with prescription costs. Call (800) MEDICARE (633-4227) to find out if you qualify.
  • For example, Indiana’s HoosierRx program helps low-income older adults pay their Medicare Part D premiums and the prescription coverage under a Medicare Advantage plan.
• Patient assistance programs: Some drug companies have assistance programs that may offer prescription drugs at little to no cost, depending on eligibility. If you have run out of other options, ask your provider or pharmacist if you qualify for any assistance programs. You may be able to apply through the drug manufacturer’s website.
  • For example, the Kentucky Prescription Assistance Program helps those who qualify find free or reduced-cost prescription drugs through the drug companies’ assistance programs, discount drug programs and discount pharmacy programs.

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Dopamine is a chemical involved in movement, and its decrease in the brain is central to Parkinson’s disease. By the time someone starts experiencing symptoms, dopamine levels in the basal ganglia already have dropped an estimated 50% to 75%.

Walking, movement and tremor can be managed better with Parkinson’s disease medications.

Levodopa, which the brain converts to dopamine through a natural process, is the gold standard for treatment, according to Justin T. Phillips, M.D., medical director of movement disorders at the Norton Neuroscience Institute Cressman Parkinson’s & Movement Disorders Center.

Common misconceptions about levodopa prompt some patients to wait before taking. Some patients worry they will develop a tolerance for the drug and it will stop working, it is only effective for a certain amount of time or that will cause the disease to progress faster.

“All of these are myths,” Dr. Phillips said. “In addition to being the most effective medication, levodopa also tends to have fewer side effects, particularly in the long term.”

Levodopa should be started as soon as troubling symptoms begin, according to Dr. Phillips. It will lessen disability in the long run, though it will require adjustments over time.

While Parkinson’s disease medications address symptoms, there are none yet that slow down or stop the progression of the disease.

Exercise is the only known therapy that can modify the disease itself, according to Dr. Phillips.

Thirty minutes of moderate intensity aerobic exercise at least three days a week has been shown to help people with Parkinson’s disease. According to Dr. Phillips, studies have found yoga, dance, Tai Chi, boxing and music therapy all show benefits, as have occupational, physical, and speech therapy.

Parkinson’s disease medications

In addition to levodopa, other medications that can be used by themselves to treat Parkinson’s disease symptoms include:

• Dopamine agonists. These appear similar enough to dopamine to activate the brain’s dopamine receptors. Dopamine agonists aren’t going to be as effective against symptoms as levodopa, but they last longer and can help smooth out the sometimes off-and-on-again effect of levodopa.
• Monoamine oxidase B (MAO B) inhibitors. These medications help the brain retain dopamine. Monoamine oxidase B is an enzyme that helps break down dopamine in the brain. Blocking the enzyme helps keep dopamine in the brain.
• This drug works on the N-methyl-D-aspartate (NMDA) receptors in the brain and appears to help release dopamine.

As the disease progresses, these Parkinson’s disease medications may need to be used in various combinations as motor fluctuations develop into an on-and-off-again pattern of Parkinson’s symptoms.

The post Parkinson’s disease medications increase or retain dopamine to address symptoms appeared first on Norton Healthcare.

Dr. Rao uses deep brain stimulation (DBS) to help patients with essential tremor, Parkinson’s disease, dystonia and difficult-to-treat epilepsy.

“Deep brain stimulation won’t cure the disorder, but it may help lessen symptoms,” Dr. Rao said. “In many cases, it allows people to reduce their medications and improve their quality of life.”

How deep brain stimulation works

The deep brain stimulation system consists of several components. An electrode is implanted in the targeted area of the brain. Then, an insulated wire is passed under the skin of the head, neck and shoulder, and is connected to a battery implanted near the collarbone.

Once connected and turned on, the system delivers a constant stimulus, or electrical impulse, to the tip of the electrode implanted in the brain. This stimulus interrupts the abnormal circuit in the brain causing the movement disorder. By overriding the abnormal impulses, DBS can help reduce tremors, slowness, stiffness and walking issues.

‘Sleep-through’ DBS surgery

Dr. Rao uses a newer DBS surgery technique in which the patient, instead of being awake, is fully anesthetized. In fact, she performed Louisville’s first “asleep” DBS surgery on a patient with Parkinson’s disease in late 2018.

Dr. Rao said this method has many benefits, including being more comfortable for patients who aren’t comfortable with the idea of being awake during brain surgery.

“Initially surgeons would put the millimeter-sized electrode in the brain and have patients perform movements. Then, they could move the electrode or change the stimulation if they had unintended results, such as numbness in an arm,” Dr. Rao said. “But advancements in technology map the brain in three dimensions, which allows for accurate targeting. This means patients can comfortably sleep through the procedure.”

The technique also can mean a quicker and safer operation, with a lower risk of bleeding.

Deep brain stimulation now being used to treat epilepsy, depression and more

The concept of using electrical current inside the brain has been around for several decades, mostly for movement disorders. Now it’s at least an experimental treatment for conditions such as hypertension (high blood pressure), depression, obsessive-compulsive disorder, chronic pain and dementia, such as that seen in Alzheimer’s disease.

“DBS could have many additional applications in the near future,” Dr. Rao said. “It’s very exciting technology.”

It’s also exciting for her patients.

“I tell my patients it’s not a cure, but it can be transformative for people who say, ‘I can go out with my friends; I can brush my teeth,’” she said. “For them, life is a lot better.”

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Using a method called deep brain stimulation (DBS), Dr. Rao places tiny electrodes inside the brain to quell disabling movement disorders such as essential tremor, Parkinson’s disease or dystonia, where muscles fight each other.

For patients, the improvements to quality of life are nothing short of profound.

“For many patients, the tremor is so bad they can’t cut their food or drink without spilling. So they become dependent on others, they can’t work or write legibly, they don’t go out because they’re embarrassed. It’s very debilitating,” she said. “With DBS, we can often see the condition reduced 50 to 80 percent or even more.”

Deep brain stimulation for Parkinson’s disease, dystonia, essential tremor

Dr. Rao specializes in functional neurosurgery, which works to improve the lives of patients with these disorders. Often, younger patients are able to manage the condition with medication, but as they age the condition becomes severely disabling.

“It’s life-changing and so rewarding to see people with otherwise good health able to function again,” Dr. Rao said.

Dr. Rao moved to Louisville at an exciting time for her field and for Norton Healthcare, which hired her to take on a leadership role in developing DBS and the functional neurosurgery specialty as demand and broader usage increases. She works at Norton Brownsboro Hospital.

More uses for deep brain stimulation: Epilepsy, OCD, pain and more

Physicians have been using electrical current targeted with pinpoint accuracy inside the brain for several decades, mostly to treat movement disorders. It now has new uses and is being tested for a broader array of conditions such as epilepsy, depression, obsessive-compulsive disorder, pain treatment and memory problems that can come with Alzheimer’s disease.

Researchers predict an aging population will lead to a large increase in the number of people with Alzheimer’s and Parkinson’s diseases. A 2014 study found about 100,000 people worldwide have been implanted with DBS systems, most of whom have Parkinson’s disease or essential tremor.

“Functional neurosurgery is very cutting-edge — really the most exciting, up-and-coming part of neurosurgery,” Dr. Rao said.

Specialized training in deep brain stimulation at UCLA fellowship

Dr. Rao grew up on a farm outside of Madison, Wisconsin, and was inspired to practice medicine by her father, who is a busy plastic surgeon. She got interested in neurosurgery as an undergraduate student working in a neuroscience lab and earned her medical degree from Warren Alpert Medical School of Brown University in Providence, Rhode Island. She trained in neurosurgery at Oregon Health & Science University in Portland.

That’s where she met her husband, a neuroscience intensive care unit (ICU) nurse. The two learned they had grown up about an hour apart in Wisconsin and were later married in an Oregon vineyard.

After completing her residency in neurosurgery, Dr. Rao completed a fellowship in functional neurosurgery at University of California – Los Angeles and the VA West Los Angeles Medical Center. There, she obtained specialized training in DBS, epilepsy, surgical management of pain, and peripheral nerve disorders.

During that time, Dr. Rao and her husband enjoyed living near the beach in Santa Monica, and over the years have enjoyed traveling to places such as Thailand, French Polynesia and Botswana for a safari. Dr. Rao said she considered a number of offers but decided that Norton Healthcare had all the elements needed to pursue her advanced work.

She said each DBS operation takes several hours. She implants tiny electrodes in the brain that draw their power from a battery placed under the skin near the shoulder.

New deep brain stimulation technique allows patients to be asleep during surgery

Dr. Rao uses a newer technique where the patient, instead of being awake, is fully anesthetized. She said it has many benefits, including being more comfortable for the patients, who often are understandably uncomfortable with the idea of being awake during brain surgery.

“When the field first started, people thought, ‘How are we going to know we are placing the electrodes exactly where we want them to be?’ So they did the surgery with patients awake,” she said. “They’d put the millimeter-sized electrode in, have patients perform movements and then they could move the electrode or change the stimulation (for the best therapeutic effect) if they had unintended results, such as numbness in an arm.”

But advancements in technology, including intraoperative magnetic resonance imaging (MRI) and computed tomography (CT) scans that map the brain in three dimensions, have allowed for accurate targeting. It also allows for a much quicker procedure — two hours as opposed to most of the day — which means less likelihood that the target area will shift.

Deep brain stimulation is ‘not a cure, but it can be transformative’

Dr. Rao said she realizes families often have misgivings about brain surgeries, including elective surgeries. She emphasizes compassionate care that accompanies her advanced skills, walking them through the process, empowering them with education and stressing the full benefits of DBS might take weeks or months to show up.

“I tell my patients it’s not a cure, but it can be transformative for people who say, ‘I can go out with my friends, I can brush my teeth, and I can not have a seizure at work. Life is a lot better,” she said.

Dr. Rao also performs other types of neurosurgery and said her field’s high-stakes operations means she’s often thinking about patients day and night.

“All neurosurgeons worry a lot, and there are instances every few weeks or months where you might go home but you’re constantly concerned about something. You’ll go back to check on them. Or you’re just chart-stalking them in the computer,” she said. “You’re never really gone from work.”

From disoriented to chatting over a sandwich within days

The challenges and rewards of her work were evident on one of the first surgeries that she was in charge of in Los Angeles. There, Dr. Rao was called for a woman in her 80s who had arrived at the UCLA emergency room with a dangerous blood clot in her brain.

The older woman could barely talk and didn’t know what was happening, Dr. Rao recalled.

“Her family was super sweet. I talked to her daughter and grandkids, explaining things,” she said. “If we don’t do something about this, she will pass from this problem.”

The family decided to proceed with the surgery, and Dr. Rao said she would never forget the results.

“She recovered amazingly. It was so awesome to see,” Dr. Rao said. “Two days later, she’s eating a club sandwich in the ICU, watching TV, she’s chatting and we’re having a whole conversation. She wanted to talk and talk. The family was crying. It was something I’ll always remember.”

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