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Melanie Cole (Host): If you’ve ever known anyone with Parkinson’s or any other movement disorder; you know how really it can affect the quality of that person’s life whether they are drinking a glass of water or eating soup or just getting up and walking around. Here to tell us about movement disorders today, is Dr. Zain Guduru. He’s a Neurologist with UK Health. Dr. Guduru, tell us a little bit about movement disorders. How prevalent are they and really what do they encompass?

Zain Guduru, MD (Guest): Sure. Thank you, Melanie, first of all, thanks for the invite and I’m excited to share about the specialty which I practice and how we help our patients. I’m a Neurologist at UK Healthcare and specialize in movement disorders. Before we answer the question, I want to introduce this term movement disorder. It’s a neurological disorder where we see some abnormal excess movement or there’s some decreased movements which is bothering the patient significantly as you just heard.

Three of the movement disorders commonly which we see in our practice are Parkinson’s Disease, essential tremor, Huntington’s Disease. You might have heard about Huntington’s chorea and rare disorders like dystonia and we will be talking about some surgical options today, too.

Host: So, they’re classified in a certain way, yes? And you mentioned Parkinson’s and dystonia and Huntington’s. So, are these classified movement disorders based on the disease or are they in and of themselves a classification?

Dr. Guduru: There’s no standard way of classification but just to make it easy, we classify this into anyone who is having excess movements, for example, tremor. Someone is having shaking. Or for example myoclonus, someone is having jerking type of movements. That’s excess movement. And the second is decreased movement, low movement. Someone has dystonia, what it means is there’s some abnormal contraction causing abnormal postures, they are not moving much. It’s kind of a fixed deformity so that way we can classify into two groups. But in general, when we are talking, when we are diagnosing; it’s more based on a disease. We diagnose someone with Parkinson’s Disease, someone with essential tremor.

Host: These must be so frustrating Doctor, I mean like I said in the intro, they can really affect so many parts of a person’s life. How do you diagnose what is causing them or the root cause of why they are having these tremors?

Dr. Guduru: This is a tough question. First of all, as you have asked about tremor; tremor has different causes. They are different diagnoses in which tremor is the presentation. For example, if someone has fever; fever can be caused by thousands of diseases. Fever is just a presentation of that particular disease. In a similar way, tremor is also like that.

In Parkinson’s Disease, for example, there is tremor or shaking especially in the hands which significantly affects their daily living activities. They are not able to do their daily living activities. They are not able to write properly. They write smaller and smaller. In Parkinson’s Disease, they also have some stiffness and slowness which affects their again, their daily living activities. Most of these syndromes which we diagnose, most of the diseases which we diagnose are clinical diagnoses. It’s hardly that we order any specific blood tests or brain scans and even if we order, it is to rule out some other diseases. But in and all, this is more a clinical specialty, it’s a clinical diagnosis.

Host: Let’s talk about treatments then Doctor. What are some treatment options? And we’ve been hearing a little bit about Botox to help with some of these. Tell us some of the treatments and start with Botox for us.

Dr. Guduru: Sure. So, Botox is a brand name, I prefer the term botulinum toxin. This is the toxin which we inject in patients with dystonia. As I just described dystonia, there is some abnormal pulling of some certain group of muscles for example, if it happens in the neck, the neck is in abnormal posture or abnormal position and sometimes there can be associated pain. In order to relax these muscles, we inject this botulinum toxin in those groups of muscles. And the reason we prefer – this is very good treatment as these are local injections that means the chances of having any systemic side effects, the whole body getting affected with some side effects; is very unlikely. Even if there are side effects, they can happen only in that specific region but just out of experience, the tendency to have these side effects are very minimal. And we are trained in dystonia botulinum toxin injections.

We also use EMG, that’s electromyography machine to localize which muscles are affected to localize which areas in those specific muscles are affected. That way we can get the accuracy, we can get the right dose in that specific region which will benefit the patient with the least side effects.

Host: Isn’t that amazing? And how this field is changing for movement disorders. There’s also a new procedure, relatively new, not completely new I suppose; deep brain stimulation and we’ll talk about medications as well. But tell us a little bit about surgical interventions. Who is it most effective for? Tell us about it.

Dr. Guduru: So, this is a very broad topic. Deep brain stimulation is a neurosurgical technique. I always whenever I introduce this surgical option for our patients, I tell them that this is kind of minor surgical procedure because when a patient gets this surgery today, the patient is in their home by the next day itself. So, that we don’t cut open the brain. It’s a very small hole which is drilled in the skull and there is a lead which is put in the brain. There is a small amount of pulsatile electricity which we send in certain regions of the brain that will eventually help with the symptoms. Now the question is in whom do we do this kind of surgery.

First of all, in Parkinson’s Disease, this is a surgical option. Again, please note that there are medication options. Surgery is also one of the treatment options which is going to help with the symptoms in Parkinson’s Disease. This particular procedure has very less complication or side effect rate of only one to three percent. That too, I can tell you that University of Kentucky Healthcare is one of the leading centers in this kind of surgery with the surgeon having tremendous experience.

One very important thing to understand about this surgical technique is the timing of doing the surgery is the key here. Do not wait until you run out of all other options or until you run out of medication options. That is not the time. We usually, three to five years into the disease process in Parkinson’s Disease, that’s the time when we start thinking about deep brain stimulation. My recommendation here would be any person with Parkinson’s Disease, it’s better to get at least one evaluation at the University Healthcare where you can talk to your doctor about possibility of deep brain stimulation or other research options here.

The second disease where we use the same surgery is essential tremor where we target different area of the brain. Essential tremor is a shaking which runs almost runs in every generation in a family and medications helps very good with this tremor. There are only a few people who don’t respond to medications or who have side effects to the medications. They are the ones who eventually end up having surgery and these people have completely different lives as soon as the surgery is done, right from the next day after surgery. They are able to eat. They are able to drink. They are able to write themselves. We can see the tears flowing as soon as the surgery is done and when they start doing all these activities.

Host: Wow, that’s so cool Doctor. And it is amazing that people are able to see results that quickly. Very briefly, just touch on some of the medications that you might use for movement disorders, tremor, essential tremor and just really what are they intended to do?

Dr. Guduru: Sure. I’ll start off with the common disease which we see in our clinic, that’s Parkinson’s Disease. Before we go onto the medications, I want to let you know that this particular disease is the second most common neurodegenerative disorder in the United States. By the time they present to the hospital or the doctor, they have almost lost 70% of neurons in one specific area of the brain called substantia nigra and there is a tremendous burden globally, because of Parkinson’s Disease. Almost six million individuals have Parkinson’s Disease globally.

The medications which we are going to talk about in Parkinson’s are the ones which are going to help the symptoms. There are no medications at this time, which are FDA approved which slow down or stop the progression of the disease. But there is a significant amount of research going on right now where they are concentrating on discovering some medications which are going to slow or stop the progression of the disease. This is the future of Parkinson’s.

At this time, the gold standard treatment for Parkinson’s Disease is a medication called levodopa. It’s combined with carbidopa. It’s called carbidopa-levodopa and the trade name is Sinemet and this has been the gold standard for more than 50 years. There are other medications which we try in Parkinson’s Disease are selegiline or rasagiline, pramipexole, ropinirole. There are different, there are almost 12-13 types of medications available. All of these are going to help with your symptoms.

Moving to the next disorder which we see commonly is essential tremor. Not every person with this kind of tremor needs treatment. The key here is we start treatment in only those people where the shaking affects their daily living activities. And in them, the FDA approved medication is called propranolol and there’s another medication called primidone which also has similar efficacy and most of the patients do respond to these two drugs. If they do not respond to these two drugs; then we have other alternatives but that is the time we also start thinking about is this person a candidate for deep brain stimulation surgery, too.

And the last one which we also see here, is Huntington’s Disease. Whenever someone has abnormal movements with this particular disorder; there are medications like tetrabenazine, deutetrabenazine and valbenazine which is going to help with the abnormal movements, and these are called Huntington’s chorea. In addition to that, these people also have significant psychiatric symptoms like depression and anxiety which are treated with selective serotonin reuptake inhibitors like sertraline.

Host: Wow. What a great educator you are. That was an excellent lesson in the medications available. As we wrap up Dr. Guduru, what are some ongoing movement disorders research going on at UK and tell us about Lexington Area Parkinson’s Support Group.

Dr. Guduru: Sure. In terms of Parkinson’s Disease as I just mentioned, there is a significant burden globally and also if you think about economic burden of Parkinson’s Disease; it’s almost 14 billion dollars and the indirect cost is also added up to this which is six billion dollars which reduces the payment. The treatment of Parkinson’s Disease revolves around a comprehensive and multidisciplinary treatment pattern. So, you need a neurologist. You need a psychiatrist. You need a psychologist. Physical therapist, occupational therapist, speech therapist. University of Kentucky offers all this comprehensive team approach to treat our patients.

In addition to that, fortunately, in this city, Lexington, we also have the support group where patients and their caregivers go there, participate in a lot of activities which includes yoga, rock steady boxing, which is going to help with many symptoms. Physical therapy. They are also going to do some lecture series where sometimes physicians go there and teach and the patients and caregivers in a simple language so that they can understand how to recognize, what are the things that they have to talk to the doctor, what is new going on in the research field. All these are educated, and everything is almost free which is served by Lexington Area Parkinson’s Support Group.

In addition to this, I would like to point out a few other things in terms of research. The two big things in the research field as of now in Parkinson’s Disease is first, they are trying to see if we can diagnose Parkinson’s Disease early enough. As I just mentioned, that by the time a person develops their first symptom in Parkinson’s, they have already lost 70% of neurons in substantia nigra. The goal here is see if we can diagnose early enough so that we can start thinking or start developing some medications to prevent this neuron loss, neuron damage. That’s first.

Second important research field is discovering the treatments. It can be medical treatment or a surgical treatment which slows down or stops the progression of the disease. In the same context, University of Kentucky is the only center where we are doing research for more than six years where we implant some peripheral nerve cells into substantia nigra in the brain, at the time of deep brain stimulation and this is – the thought here is it’s going to slow down the progression of the disease. So far, the results we have seen that it is a safe procedure and we are seeing this might help slow down the progression of the disease.

Host: Wow. That’s a lot of information. Doctor, thank you so much for being with us today and sharing your incredible expertise on movement disorders and Parkinson’s and all of the conditions that can cause tremor and various movement disorders. Thank you for really educating us today. It was very informative. This is UK HealthCast with the University of Kentucky Healthcare. For more information, you can go to www.ukhealthcare.uky.edu, that’s www.ukhealthcare.uky.edu. I’m Melanie Cole. Thanks for tuning in.