Alternative treatments for Neurological disorders: TMS vs DBS

Doctors will most commonly prescribe medications to treat neurological disorders, but if medications loose their effect or if they are unable to cross the protective barriers to reach the brain, then medications become a useless treatment.  When this does occur, health care professionals can now use two new techniques as treatments: Transcranial Magnetic Stimulation (TMS) and Deep Brain Stimulation (DBS) to treat neurological and/or psychological disorders.

TMS is a non-invasive and painless treatment that involves the production of a magnetic field in a magnetic stimulator (or capacitor) by creating an electrical current through the magnetic coil that is composed of wire.  Rapid changes in the magnetic field can induce strong enough currents in the form of single or repetitive pulsed electrical currents.  The electrical current that was created in the magnetic stimulator penetrates through the skull and is transferred to deep tissue in the brain.  Deep penetration of brain tissue triggers nerve impulses by temporarily depolarizing the nervous system, and allows new neurological pathways to form, while promoting increased brain plasticity (Nollet et al., 2003).  Nollet et al., (2003) demonstrated that 500J of energy is stored in the magnetic stimulator in the form of electrostatic charge and is transferred to the magnetic coil, where it converts electrostatic energy into magnetic energy in 100μs, the output of the magnetic stimulator averages 3 MegaWatts.  The rapid energy transfer builds up as a magnetic field which induces currents in the tissue that is near the area of stimulation.

On the other hand, DBS is an invasive treatment that involves the implantation of very thin wire with four electrodes into the brain without damaging brain tissue; a kind of brain pacemaker, called a pulse generator, is also implanted in the chest, and delivers continuous stimulation to the brain that is self regulated with a device (Gang, et al., 2005).  DBS is most commonly used to treat movement disorders (such as Parkinson's disease) which are a sub-classification of neurological disorders, but more research is currently being done on the application of DBS to other types of neurological illnesses and psychiatric disorders.  Electrodes are usually implanted in brain regions at the thalamus, basal ganglia, or the subthalamic nucleus and delivers pulses of electrical energy that are sent through a wire from the pulse generator.  The delivery of electrical stimulation can be adjusted to regulate and/or activate neuronal pathways that have been deactivated or that function abnormally by directly stimulating the release of calcium.  The electrical stimulation delivered to the brain by the pacemaker can be easily disrupted by electrical and magnetic energy within the environment (Okun, et al., 2014).

Gang, L., Chao, Y., Ling, L., & Lu, S.  (2005).  Uncovering the mechanism(s) of deep brain stimulation.  J.  Phys.: Conf.  Ser.  Journal of Physics: Conference Series, 13, 336-344.  Retrieved November 29, 2015, from http://iopscience.iop.org/article/10.1088/1742-6596/13/1/078/pdf

Nollet, H., Ham, L., Deprez, P., & Vanderstraeten, G.  (2003).  Transcranial magnetic stimulation: Review of the technique, basic principles and applications.  The Veterinary Journal, 166(1), 28-42.  Retrieved November 19, 2015, from http://www.researchgate.net/publication/10724301_Transcranial_magnetic_stimulation_review_of_the_technique_basic_principles_and_applications._Vet_J

Okun, M.S., Zeilman, R.P.  (2014).  Parkinson’s Disease Deep Brain Stimulation: A Practical Guide for Patients and Families.  The National Parkinson Foundation.  Retieved November 29, 2015, from http://www.parkinson.org/sites/default/files/Guide_to_DBS_Stimulation_Therapy.pdf

Non-invasive diagnostic procedures: MRI and CT scans

Both Magnetic Resonance Images (MRIs) and Computed Tomography (CT) are used as noninvasive diagnostic techniques to understand what may be happening in the brain of a patient.  Because both techniques provide a visual representation of a patient's brain, they can detect brain tumors, degeneration in the brain, and other structural malformations that are identified as characteristics of disease.  These images are frequently used along with neurological tests to help produce a proper diagnosis.

MRIs, technically known as Nuclear Magnetic Resonance Imaging, utilizes the electromagnetic properties of protons to generate tissue images which form an important tool in diagnosing neurological conditions and diseases.  MRI machines emit a pulse in the radio-frequency range which cause [nuclear] protons, primarily within the body's water molecules, to align to the pulse's magnetic field.  When the pulse completes, the protons "relax" to their original alignment, releasing weak electromagnetic energy that is detected to form the image.  Careful calibration of these fields across a gradient (varying the field strength at known points) allows the resulting emissions to be located in three-dimensional space, so that cross-sectional images can be produced (Nave, 2004).

Computed Tomography (CT), sometimes called Computerized Axial Tomography (CAT) is a development of radiography that uses data from a series of X-ray exposures at different angles to calculate a three-dimensional image.  X-rays are high-frequency photons that attenuate (partially reflect or get absorbed) to a different extent depending on the substances that passes through.  Dense materials, such as bone, attenuate the X-ray beam more strongly than fatty tissue, for example.  The strength of the beam received by the detector, on the opposite side of the target from the emitter, is used to determine the radio-opaqueness (represented with shades of color) of matter from each angle. Because each of these exposures lack information about the depth of the attenuating matter, they are computer-processed together to extrapolate a three-dimensional model (Knipe, n.d.).  CT scans are particularly good at detecting abnormalities, including hemorrhaging, tumors, and fractures, but do, on their own, have difficulty displaying soft tissues in good detail, and do involve exposure to small amounts of ionizing radiation (Athale, 2012).  Use of a contrast agent such as iodine, which strongly attenuates X-rays, can show organs and particularly abnormalities clearly (Kennedy, 2015).

 

Athale, S. (2012). A tale of two scans: Which is better - a CT scan or an MRI? The Hanford Sentinel. Retrieved November 28, 2015 from http://hanfordsentinel.com/news/local/a-tale-of-two-scans-which-is-better--/article_82dce24a-0d87-11e2-bb76-0019bb2963f4.html

Kennedy, T., et al. (2015). Neuroradiology Learning Module: Contrast. Department of Radiology, University of Wisconsin School of Medicine and Public Health. Retrieved November 28, 2015 from https://sites.google.com/a/wisc.edu/neuroradiology/image-acquisition/contrast

Knipe, H., Nadrljanski M., et al. (n.d.) Computed Tomography. Radiopaedia.org. Retrieved November 28, 2015 from http://radiopaedia.org/articles/computed-tomography

Nave, R. (2004). Magnetic Resonance Imaging. Hyper Physics. Retrieved November 29, 2015 from http://hyperphysics.phy-astr.gsu.edu/hbase/nuclear/mri.html

Non-invasive brain imaging as a preventative measure

According to (Goldsteen, 2014, pg 142) cerebrovascular disease is within the 10 leading causes of death in the U.S. and the many causes of cerebrovascular disease including: stress, smoking, overweight, high blood pressure, increase amounts of alcohol, and not enough exercise (NHS Choices, 2015).  All of these factors can lead to the most common forms of cerebrovascular disease including: stroke, transient ischemic attack, subarachnoid hemorrhage, and vascular dementia (NHS Choices, 2015). Even though there is currently no cure after cerebrovascular disease occurs, there are current treatments and medications. Additionally, there are important preventive measures that should be considered a priority by healthcare professionals as possible interventions to: prevent, reduce symptoms or severity of disease. One intervention that can be used as a preventative measure, is improving the access to brain imaging. “American Brain,” n.d. lists the different types of brain imaging that are used as diagnostic tools, including: Computed Tomography (CT) scans, Magnetic Resonance Imaging (MRI)s, Functional Magnetic Resonance Imaging (fMRI), and many others. These brain imaging techniques are often used by medical professionals during the diagnosis and treatment process, after symptoms of disease have been noticed. Unfortunately, for cerebrovascular diseases, time can be crucial; research by Longstreth et al., (2002) found that MRI scans that were conducted 5 years after an initial normal MRI scan contained increased amounts of infarcts within the participants. To clarify, after 5 years a new MRI was compared to initial MRI scans which did not show abnormalities; this suggests that abnormalities can develop within 5 years and brain imaging such as an MRI scan can be used to detect any early characteristics that can lead to a severe disease. If medical professionals detect early signs, including infarcts, then treatment can be started immediately to prevent progress of disease. In another study, van der Kolk ( as cited in Gounis et al., 2015) has shown that a combination of MRI and Positron Emission Tomography (PET) can be used to detect inflammation near infarcted areas in the brain; inflammation is also a sign of cell and tissue damage in the central nervous system. Both inflammation and infarcts can be detected before tissue damage or brain injury develops as a result of disease.

Therefore, it is important that brain imaging resources are expanded and used as part of a patient's regular medical routine, because this preventative measure can detect abnormalities in the brain, spinal cord, and nerves as soon as they occur; this will prevent disease and it symptoms.  Improving the access to brain imaging will improve quality of life and will decrease costs in the long run if used on a regular basis (Oliveira, n.d.).

 

Comparing the costs

Preventative measures cost less in the long run compared to when disease has occurred; even if insurance does not cover brain imaging such as CT or MRI scans, the price that patients pay for them would still be less than the price that they would have to pay after cerebrovascular disease occurs. Lets consider the following healthcare costs whether the patient has insurance or not. For example, let's say that in a “perfect world” a patient gets a brain scan once a year and will cost between $50-$5000 annually (Cost of Stroke Treatment - Consumer Information, n.d.). In another scenario, after a brain scan, the doctor notices that a patient has a blood clot, and it needs to be treated immediately. The patient can take medication without being hospitalized; this will cost between $50-$5000 for the brain scan plus $2,200-$5,978 for medication (Cost of Stroke Treatment - Consumer Information, n.d.).

We can compare this with a worst case scenario in which a patient has a stroke because symptoms were not noticed on time. This patient will then need to be hospitalized for a few days; the costs are between $9,100-$19,500 because, they will need to take medications which can cost between $2,200-$5,978 and they will also need regular brain scans to determine: the effects on the brain, progression of disease, or to detect secondary injury; this will cost an additional $50-$5000 for each scan (Cost of Stroke Treatment - Consumer Information, n.d.). In this worst case scenario, the total costs for a patient after having a stroke are between $11,350-$30,478, and it does not include long term post-stroke costs that result from rehabilitation, regular check-ups, or loss of income due to disability (Cost of Stroke Treatment - Consumer Information, n.d.).

Healthcare costs per patient	Preventing stroke with scans estimated costs	Pre-stroke treatment Estimated costs	Post-stroke Estimated costs
Brain imaging	~$50-$5000	~$50-$5000	~$50-$5000
Medications		~$2,200-$5,978	~$2,200-$5,978
Hospitalization			~$9,100-19,500

According to Mozaffarian et al (as cited in Sandberg, 2016) the overall cost of strokes, a cerebrovascular disease, can increase from $71.6 billion to $184.1 billion dollars per year by 2030. Health care professionals need to find a way to reduce the overall costs by implementing more preventative care programs that include brain imaging. Finally, brain imaging is a non-invasive technique that can be used to determine disease in the brain and it should be cost effective to patients.

Citations

American Brain Tumor Association. Types of Brain Scans. (n.d.). Retrieved October 15, 2016, from http://www.abta.org/brain-tumor-information/diagnosis/types-of-brain-scans.html

Cost of Stroke Treatment - Consumer Information. (n.d.). Retrieved October 19, 2016, from http://health.costhelper.com/treating-stroke.cost.html

Goldsteen, R. L., DrPH. (20140717). Introduction to Public Health, Second Edition, 2nd Edition. [VitalSource Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9780826196675/

Goldstein, L. B., Higashida, R. T., Howard, V. J., Johnston, S., Khavjou, O. A., Lackland, D. T., . . . Trogdon, J. G. (2013, May 22). Costs to treat stroke in America may double by 2030. Retrieved October 19, 2016, from http://newsroom.heart.org/news/costs-to-treat-stroke-in-america-may-double-by-2030

Gounis, M. J., Van der Marel, K., Marosfoi, M., Mazzanti, M. L., Clarençon, F., Chueh, J., ... Bogdanov, A. A. (2015,September 08). Imaging Inflammation in Cerebrovascular Disease: Figure. Stroke, 46(10), 2991-2997. doi:10.1161/strokeaha.115.008229. Retrieved October 15, 2016, from http://stroke.ahajournals.org/content/46/10/2991

Longstreth, W. T., Dulberg, C., Manolio, T. A., Lewis, M. R., Beauchamp, N. J., O'leary, D., ... Furberg, C. D. (2002). Incidence, Manifestations, and Predictors of Brain Infarcts Defined by Serial Cranial Magnetic Resonance Imaging in the Elderly: The Cardiovascular Health Study. Stroke, 33(10), 2376-2382. doi:10.1161/01.str.0000032241.58727.49. Retrieved October 15, 2016, from http://stroke.ahajournals.org/content/33/10/2376.long

NHS Choices. Cerebrovascular disease - Risks and prevention. (2015, February 2). Retrieved October 15, 2016, fromhttp://www.nhs.uk/Conditions/Cerebrovascular-disease/Pages/Prevention.aspx

NHS Choices. Cerebrovascular disease - Introduction. (2015, February 2). Retrieved October 15, 2016, from http://www.nhs.uk/conditions/Cerebrovascular-disease/Pages/Definition.aspx

Oliveira Filho, J. (n.d.). Neuroimaging of acute ischemic stroke (S. E. Kasner, E. D. Schwartz, & J. F. Dashe, Eds.). Retrieved October 15, 2016, from http://www.uptodate.com/contents/neuroimaging-of-acute-ischemic-stroke

   Sandberg, J. (2016, February 5). Stroke Fact Sheet. Retrieved October 19, 2016, from http://www.strokeassociation.org/idc/groups/stroke-public/@wcm/@hcm/@sta/documents/downloadable/ucm_485076.docx

The Physics of Gait Associated with Neurology

Fall prevention week is a time to remind health care professionals, patients, and caregivers of the important ways that falls can be avoided.

In my experience while working with the elder population I have witness the consequences of a fall. Even if a patient is healthy, a fall can be detrimental to their overall health, because in many instances a fall can lead to extreme health decline or even death. Therefore, it is important that fall prevention week is taken seriously by the community.

First of all, It is important to identify the characteristics of walking gaits and learn about the physics involved when walking in order to understand the differences in walking patterns between normal individual and individuals suffering with disease.  According to (Dann, n.d.), walking involves pushing the ground with a backward force which will cause a forward reaction force.  This follows Newton's third law which states that when two objects interact, they each exert a force on each other, therefore as the foot exerts a force that pushes on the ground backwards while walking, the ground exerts a force in the form of friction which pushes you forward (Dann, n.d.). A research study by (Lockhart, et al., 2009) demonstrated that individuals suffering from cognitive impairments have lower gait parameters including: slower heel contact velocity with the ground, shorter step lengths, and slower walking velocities, all of which is correlated with a higher required coefficient of friction (RCOF).  The data in this study supported the statistical significant lower gait parameters, while also showing that the demand for friction was higher.  Without an understanding of the physics of walking, quantitative analysis of walking parameters would not be possible.

Some neurological disorders and mental health conditions associated with abnormal gait parameters include Depression, Dementia, Parkinson's disease, cerebral dysfunction or degeneration, Alzheimer's, multiples Sclerosis, and stroke (Salzman, 2010).
While I was shadowing medical doctors and a Physician Assistant (PA) in Neurology, I was able to observed the integration of neurological tests within their diagnostic and treatment practices. Healthcare providers frequently use clinical tests including assessments in their practice to evaluate gait and balance in patients (Salzman, 2010). Other tests, involve measuring the walking gait of individuals suffering with symptoms that are related to cognitive impairments: by analyzing these walking patterns, health care providers can make more specific diagnoses, and apply the most appropriate treatment. Measuring walking gaits are also used to constantly determine the progression of disease; since many neurological disorders including Parkinson's disease and Alzheimer's disease progress at different rates in each patient, it is crucial that individuals undergo these neurological tests on a regular basis in case new symptoms arise or treatments including medications need to be changed.

According to (Salzman, 2010), patients, caregivers and health care professionals can utilize techniques that can reduce fall risks. Health care professionals should use assessments and clinical tests more frequently on patients, especially if they have noticed a change in their health, or if there has been a change in their medication in addition to other treatment plans (Salzman, 2010). Healthcare professionals and caregiver should also be aware of changes in health, medications, treatments, and make sure that patients use any specialize equipment properly and at all times including, walkers, eye glasses, hearing aids, etc. Care givers, or any individuals who spends a lot of time with patients should make notes about their activities of daily living so that they can be able to detect any changes (Salzman, 2010). Caregivers should also make sure that the areas in an individuals living space is clear, and clean to avoid falls or further injury after falling. (Salzman, 2010) emphasize the importance of physical exercise in a patients daily activities, and suggests that they should engage in physical exercise on a regular basis independently, in a group, or with a physical therapist.

Citations:

Dann, D.  (Director). (n.d.). Physics of Walking [Motion picture]. U.S. https://www.youtube.com/watch?v=Ws_sKgGNSFE (no author).  (n.d).  Encephalography lab.  Retrieved September 22, 2016, from https://web.csulb.edu/~cwallis/482/eeg/eeg.html

Salzman, B. (2010). Gait and Balance Disorders in Older Adults. Am Fam Physician. 82(1):61-68 Retrieved September 22, 2016, from http://www.aafp.org/afp/2010/0701/p61.html

Never Forget

Today was a day of remembrance. Everyone on Facebook posted about the World Trade Center tragedy that occurred on September 11, 2001. Everyone that I spoke to seemed to still remember with clarity, even though it happened 15 years ago! They could still remember the exact location, place and time that they were in as they witnessed this traumatic life event. Over the years, we continue to see the phrases "Never forget 9.11.2001", "9/11 never forget", "We will never forget September 11, 2001", that remind us of our feelings, emotions, fears, and worries associated with our own experience. At the same time, we ask ourselves (or I ask myself) can these memories live forever?

According to (Yehuda, 2005) they probably can.

In this scientific study, 187 women who were pregnant at the time, and who had personally experienced the events associated with September 11, 2001 were recruited for their study.  One of the reasons for this study was to identify brain activity in the child after birth that could be associated with the trauma or psychological stress that their mothers experienced. They wanted to see in what ways could the children of these women have been affected. Saliva tests and questionnaires associated with post-traumatic stress (PTSD) and depression, were collected from participants. Their saliva would not only indicate if the stress hormone cortisol was present, but also in what amounts. One of the results of the study was that lower levels of cortisol correlated with PTSD, meaning that pregnant women who had developed PTSD had lower amounts of the hormone cortisol in their saliva. Interestingly, their children also showed to have low levels of the hormone cortisol.

The results in this study have been supported by other research studies and scientific literature that has shown that brain stimuli associated with certain fears can be passed on to other generations. (Dias 2014) demonstrated that pregnant mice who were exposed to a fear stimulus in relation to a certain smell, was also found in their future generations. They noticed that future generations who were exposed to this same scent, would demonstrate fear, and would try to avoid the scent.

As research continues to unfold and new discoveries are found about the exact mechanisms involved in this phenomena, we can continue to ask our selves, are these experiences related only to brain activity, or can we actually remember the memories of our ancestors?

Citations:

Yehuda R, et al.,  (2005). Psychological Trauma Associated with The World Trade Center Attacks and Its Effect on Pregnancy Outcome. Pediatric and Prenatal Epidemiology, 19:334-341.

Dias B.G, et al., (2014). Parental Olfactory Experience Influences Behavior and Neural Structure in Subsequent Generations. Nature Neuroscience, 17(1):89-96. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3923835/