Vassar Brothers Medical Center has established an integrated program of comprehensive care for conditions including Parkinson’s disease, chorea, dystonia, essential tremor, Huntington’s disease, Tourette syndrome and other rare movement disorders. Board-certified neurologist Michael Rezak, MD, PhD, directs the Movement Disorders Program, which offers state-of-the-art medical and surgical treatments, as well as support services. The program will also build on Dr. Rezak’s national reputation for clinical research and serve as an educational resource for patients and providers.
The need for specialty and subspecialty care for movement disorders is pressing. As baby boomers grow older, Dr. Rezak notes, they are quickly moving into the age when those conditions, especially Parkinson’s disease, are most prevalent.
“Parkinson’s disease is a chronically progressive neurodegenerative disease that affects 1 to 2 million people in the U.S. right now,” he says. “More and more patients are developing these symptoms. If we can identify and treat patients early, we can make a significant difference in their functionality and quality of life for decades to come. Additionally, other movement disorders, such as Huntington’s disease, Tourette syndrome and essential tremor, need to be recognized as early as possible, since many new treatments have been developed that can improve symptoms and allow patients to have a better life.”
Michael Rezak, MD, PhD, Director of the Movement Disorders Program at Health Quest, provides education to a patient on the brain anatomy related to his illness.
The interdisciplinary Movement Disorders Program opened Feb. 1 and encompasses all components of neurological care for movement disorders patients. Speech, occupational and rehabilitation therapists have joined the program, and other newcomers include another movement disorders specialist, as well as a neuropsychologist with extensive experience in caring for patients with movement disorders.
“We have incorporated a rehab program around special treatment options for physical, occupational and speech therapy,” Dr. Rezak says. “We offer treatments that are documented to help improve the lives of patients with movement disorders.”
Medical Options to Enhance Quality of Life
Often, movement disorders can be managed with medical intervention. But it takes a trained, experienced physician to recognize what patients need and to recommend the most effective medication options or to determine whether medication, surgery or a combination of the two will have the greatest impact. Dr. Rezak and his team perform a comprehensive assessment to individualize and optimize therapies for each patient’s condition.
Dr. Rezak tests for limb stiffness, otherwise known as “cogwheel rigidity.”
Because a lack of dopamine in the brain causes many Parkinson’s disease symptoms, medications that replicate dopamine’s function — l-dopa, dopamine agonists and others — have been found to be effective in symptom management. However, over time patients with Parkinson’s disease may have trouble absorbing medications — they may lack motility anywhere along their digestive tract, preventing timely absorption of medications. This results in motor fluctuations with “on and off times” common to patients with advancing Parkinson’s disease, those times during the day when there are erratic responses to the medications, including when patients experience excessive involuntary movements called “dyskinesias.”
Other medical regimens, such as botulinum toxin (Botox, Myobloc, Xeomin) for the treatment of focal or segmental dystonia, are available in the Movement Disorders Program as well. Dystonia is a condition that results in involuntary muscle contractions, which can sometimes be painful. Dystonia can be seen as a component of other illnesses — in Parkinson’s disease, for example — or may be an illness unto itself. Botulinum toxin may be injected with electromyography or ultrasound guidance to ensure it impacts the precise muscle that is causing the dystonic muscle contractions.
With each medication, there’s a balance to maintain. For instance, the therapeutic window during which a particular drug is effective without side effects for Parkinson’s disease can close early, so prompt diagnosis and treatment are key. An experienced neurologist can guide each patient, as well as his or her primary care physician, toward the most effective choices among supportive therapies, medications and surgery, being mindful that this mix may change over time.
“We employ all medication options available to us, but judiciously,” Dr. Rezak says. “We don’t prescribe too much too soon, nor do we prescribe too little. Quality of life is enhanced considerably with proper medication management. As diseases progress, we adjust medications accordingly over time. We stay in close contact with patients and their family physicians so we can optimize the care we provide to support the best quality of life. Communication is a critical component in the successful management of our patients.”
“The choice of whether to perform surgery for a movement disorder is a process; such decisions are not made overnight. We hold a series of meetings and discussions; then together we decide what course of action is most beneficial. Even in the case of oral medication, our philosophy is that we want to make patients better today, but we have to think about five to 15 years from now, too. We want to keep people functional for decades into the future.”
— Michael Rezak, MD, PhD, Director, Movement Disorders Program
Advanced Treatment Options
Deep Brain Stimulation (DBS). The Movement Disorders Program offers advanced treatment options such as deep brain stimulation surgery (DBS), which is often recommended for people with advanced Parkinson’s disease and for patients with medication-resistant tremor. Demonstrated by years of research to be effective in managing symptoms of Parkinson’s disease and other movement disorders, DBS involves implanting electrodes into a portion of the brain that conveys disordered signals responsible for the symptoms. In the case of Parkinson’s, DBS electrodes are typically implanted into the subthalamic nucleus or the internal portion of the globus pallidus; in essential tremor, the target is commonly a specific portion of the thalamus. A pulse generator (the battery) is connected to the leads containing the electrodes and is implanted under the skin against the chest wall. Electrical pulses are released to modulate the abnormal brain activity in the target area.
Dr. Rezak performs the “pull test” to assess the patient’s balance.
The surgery is performed by a specially trained functional neurosurgeon, supported by a neurophysiologist, who monitors the microelectrode recording to ensure accurate placement, and Dr. Rezak, who conducts intraoperative testing with the patient.
“During the procedure, the surgeon places the electrodes into the proper site based on the electrophysiological mapping,” Dr. Rezak says. “The neurophysiologist listens to the cells firing and identifies the optimal target for implantation. Every part of the brain has its own electrical signal, which helps us know where we are. We map the area to assure we have found the ‘sweet spot’ before the final decision to place the electrodes. Then we turn on the stimulator and test for benefit in the operating room.”
While being kept comfortable and secure, the patient is awake for about an hour of the surgery to note benefits and any side effects while testing. However, sedation is used for any parts of the procedure that might be painful or frightening to the patient, Dr. Rezak says.
“We need the brain to be active while we’re mapping,” he says. “When you keep the patient asleep for the entire procedure, you miss the quality control of making sure you’re in the right place. Some centers promote asleep DBS implantation, but, having been involved in more than 1,000 DBS implants, I have found that when patients are awake and not in pain, we can test and ensure there are no issues with the implantation.”
After testing, the patient is sedated again until he or she awakens in the recovery room. The DBS procedure typically requires only an overnight hospital stay, with the patient returning home the next day. An experienced DBS nurse cares for the patient during the visit.
Teamwork and rigorous coordination are essential to the procedure’s success — another reason Dr. Rezak has built out a strong cadre of neurological staff at Vassar Brothers Medical Center.
“We all work together,” he says. “We rely on each other and know what we need to do to maximize outcomes.”
About a month after the patient goes home, the stimulator is turned on. The procedure effectively alleviates stiffness, slowness and tremor, and patients may be able reduce their medications by as much as 40 percent.
“We learn something with every DBS procedure,” Dr. Rezak says. “We learn to appreciate the nuances; we don’t take anything for granted. What we do in the OR guides us when it comes time for programming the stimulator for maximal symptom control. Our goal is to make patients feel better by reducing symptoms using DBS, with the secondary benefit of reductions in medication and associated side effects.”
Dr. Rezak asks a patient to perform rapid alternating movements, which reflect fluidity of movement and slowness.
Duopa™. Dr. Rezak sometimes recommends another procedure, the use of another delivery system for the most effective medication for Parkinson’s disease, levodopa. A concentrated form of levodopa in a gel, Duopa™, is delivered continuously into the small intestine via a small tube and an externally worn, programmable pump. In this way, Duopa™ smooths out medication absorption to reduce erratic motor functioning. Duopa™ treatment is reserved for hard-to-manage patients with more advanced Parkinson’s, Dr. Rezak specifies. Implantation of a Duopa™ pump is fairly straightforward. It is an outpatient procedure, is reversible and can produce excellent outcomes for the correct patient.
“The gastroenterologist inserts the PEG-J tube through the stomach and threads it into the small bowel,” Dr. Rezak explains. “That allows for delivery of the Duopa™ gel exactly to where levodopa is absorbed. We deliver it in very small amounts, titrated for each patient’s symptoms, continuously for up to 16 hours of a patient’s waking day. For the right patient, Duopa™ can help manage advanced symptoms in a miraculous way.”
Whether a patient is a candidate for DBS or Duopa™ is determined by clinical symptoms, patient preferences and neuropsychological evaluation.
More than prescribing and performing treatments, Dr. Rezak and the other specialists and subspecialists in the Movement Disorders Program collaborate with skilled, knowledgeable nurses, psychologists, social workers and rehabilitation therapists to create a comprehensive resource for patients with movement disorders and their families. Dr. Rezak says this comprehensive model extends to ongoing relationships with primary care and all other physicians involved in the care of the patient. Ideally, at the first sign of Parkinson’s disease, he recommends referral, explaining that early treatment yields a markedly improved quality of life immediately and in the long run. Coordination of care is paramount, Dr. Rezak adds.
“We work with the primary care physician to devise plans that are compatible with the patient’s entire medical situation,” Dr. Rezak says. “Everything we do here is straightforward, transparent and in the patient’s best interest. For instance, one of the challenges with more advanced treatments is there may be anxiety about referring people for surgery. But these are treatment options that science has brought to medicine, and they can make the patient’s life better for years to come. Part of my goal is educating colleagues and letting them know who needs to be referred as well as the optimal time frame for referral. As one example, it is well-documented that patients do better when they start much earlier on medication programs. And sometimes just speech, occupational or physical therapy can make life significantly better. You want experts in the particular disease involved in care.”
Teaching and Learning
To further his goal of raising awareness in the region, Dr. Rezak intends to provide a hub of information for people at all levels who are affected by movement disorders — patients and family members, caregivers, and community physicians and therapists. These discussions will feature question-and-answer sessions about Parkinson’s and other movement disorders — a sort of “Parkinson’s 101,” he explains. For deeper discussions, support groups will be available as well.
Dr. Rezak and a nurse discuss a recent patient visit.
To advance scientific knowledge about movement disorders, treatments and quality-of-life issues, Dr. Rezak is continuing his longtime participation in clinical studies, including local investigator-initiated research.
“I anticipate taking part in clinical trials, which typically are sponsored by device and pharmaceutical manufacturers,” he says. “Additionally, we will perform our own research focused on early detection of Parkinson’s disease and disease-modifying treatments. If we can slow or stop the disorder’s progression, that’s a big step.”
“In the Movement Disorders Program, we want people to know that we are available for patients across the country to visit us for a consultation or second opinion.”
— Michael Rezak, MD, PhD, Director, Movement Disorders Program
A Unique Program for the Region
Dr. Rezak’s goal is for the Movement Disorders Program to grow into a nationally recognized, patient-centered hub for research, outreach and care. He and his team prioritize restoring maximum function to all patients so they can do the things they love, whether participating in a range of hobbies or maintaining employment. Following this philosophy, the Movement Disorders Program also assesses caregiver burden, looking at the patient and family as an interworking unit.
“We pay attention to what goes on with each patient, not just medically, but psychosocially,” Dr. Rezak says. “We are mindful of how movement disorders impact relationships, and we treat the whole person.”
Dr. Rezak documents findings in the patient’s chart.
Due to the comprehensive set of medical services it offers, the Movement Disorders Program is an exceptional gift to the region, as such programs are largely unavailable outside urban areas. Noting the high incidence of Parkinson’s — the second most common neurodegenerative disease following Alzheimer’s — Dr. Rezak takes satisfaction in seeing the unique combination of specialties at Vassar Brothers Medical Center that benefits patients who would not otherwise have local access to such advanced care.
“It’s unfortunate that some patients have to travel long distances for expert care,” he says. “Movement disorders neurologists have the special experience and training to treat Parkinson’s disease, tremors and related conditions. I’m thrilled by the opportunity to build a comprehensive program at Vassar Brothers Medical Center to support patients in the most robust way possible.”
To learn more, visit healthquest.org.