Dr. Binit Shah, Division Head at University of Virginia, discusses the potential benefits of using focused ultrasound treatment for Parkinson's Disease.
Dr. Binit Shah, Division Head at University of Virginia, discusses the potential benefits of using focused ultrasound treatment for Parkinson's Disease.
(uplifting music)- Hi. I'm Margaret Preston, president of Power Over Parkinson's, and today in conjunction with our Pop Profile series we have Dr. Binit Shah, associate professor at the University of Virginia, the division head of the Parkinson's and Movement Disorders Division and the neurology clerkship director also at the University of Virginia. Dr. Shah, thank you so much for being with us today.- Thanks for having me Margaret.- Yeah. Yeah, we're excited. I know you've got a lot of great content you wanna share that our listeners will really value. So, let's get right to it.- Sounds good.- Dr. Binit, Dr. Shah, tell me a little bit about and our listeners, spend a few minutes, walk us through how you got into a career of neurology, neurosurgery?- Yeah. You know, I think everyone's journey is similar, though there are many, many different particular sort of inspirations and other things like that. You know, for me, you know, my decision to go into medicine overall was sort of with this thought that I would be somebody who'd build relationships with people, get to know patients, have them get to know me. And, really sort of forge a partnership for, you know, years potentially. And so, as I went through medical school, you know, I sort of was between internal medicine and neurology and neurology really kind of is a medicine specialty. So, I ultimately did a neurology rotation and found that that patient interaction especially in the clinic setting, but even to some degree in the inpatient setting is kind of what I saw myself being as a physician even before my medical career started. And, it's really been a journey where that's been sort of corroborated and supported where I've gotten to know really meaningful people.- And, I would presume if I can elaborate on that a little bit, with the type of disease that you're working with, you have a long relationship with a lot of your patients where that relationship approach is just so important to their navigating their diagnosis and ultimately their care?- Yeah. I mean, and I think that that goes along with going into movement disorders neurology.- Mm-hmm (affirmative). Yeah.- Where those relationships are really long lasting and sort of the deeper, the better.- Yeah, definitely. Well, I'd like to ask you a question I ask many of our interviewees around how you stay optimistic and enthusiastic while you work in this space that a lot of the disease have an inevitable decline associated with them. So, how do you remain optimistic and positive about the outlook within neurology?- You know, it can be a challenge at times, but I think the key is sort of focusing on positives.- Mm-hmm (affirmative).- And I think you know Pop, other sort of entities do that really well which is focusing on abilities as opposed to disabilities.- Mm-hmm (affirmative).- You know, in sort of the rehab community, there's different ways of defining what disability is versus changes that can happen with life. You know, I tell a lot of patients, you know,"Michael Jordan probably can't dunk anymore." And so, we focus on the things that we enjoy doing, the things that we can do safely. And, to the extent that those are not limiting sort of function in a meaningful way is really an opportunity more than anything else for people to get out do new things, explore new things that they haven't before, or really get to the things that they haven't enjoyed that they may not have paid as much attention to in the recent past.- Yeah. I think sometimes that change in perspective and whether it's a diagnosis that is the genesis of this is sometimes a good thing.- Yeah.- Yeah. Definitely. I'd like to jump into a series of questions regarding focused ultrasound. So, at a high level, can you share with our listeners what is entailed in the procedure?- Yeah. And, you know, I think a little of the background on it is that focused ultrasound as it applies to treating Parkinson's and essential tremor currently is in the category of sort of lesioning procedures. So, those have been around for decades, but what focused ultrasound really provides is a means of delivering lesions, or targeting lesions in a way that doesn't involve making any incisions or drilling through the skull. So, the way that that's done is that the head is unfortunately, has to be shaved to avoid any sort of heat getting trapped, you know, beneath the hair. So, for people like me, that's not that big of a deal, but for other people, rest assured, it grows back. And then, after that, there's sort of a frame with a bladder filled with water placed over the skull. And, that water is sort of a means for the ultrasound energy to sort of go from the transducers to the skull and through the skull and so on. Sound waves don't tend to travel in air as well as they do through a more dense material like water, for example. And so, attached to that bladder are these transducers, 1024 ultrasonic transducers. And, it's sort of like a sort a hemicircumferential helmet where the transducers are oriented all around up to the top. And, using those, our neurosurgical colleagues can sort of use certain coordinate targeting both via an individual's imaging prior to the procedure as well as based on sort of where a certain target should be anatomically, and start the energy focusing in an MRI scan during the procedure.- Okay. So, as a follow up to that question, share with our listeners who might be eligible for the focused ultrasound procedure.- Yeah, and I think that's important. And, I will make a note there Margaret, because I think a lot of people with Parkinson's will ask, "Oh, am I eligible for this particular treatment or procedure?" And, I like to sort of reframe how that question is sort of asked, because it's really more of a question of does this procedure have much to offer me? And, if it doesn't, then it's not necessarily a worth while thing.- Right.- And so, we try to align what our expectations and goals are with the treatments we have, whether that's medication, whether that's a procedure, whether that's, you know, other things like physical therapy, et cetera. So, you know, a lot of what ultrasound can offer is related to the targets that we use. The first target was a thalamic target or in the thalamus of the brain, something called the VIM, which really is used to suppress tremors. And so, it was developed initially in people who had essential tremor, and it was applied to Parkinson's based on a study that we did a few years ago now. And, it's really just treating tremor. And so, for people who have tremor that's really severe can be interfering with their function or quality of life and my not respond well to medication, then or that medication may cause side effects, then that's certainly an option that we can use. What it doesn't do, or what that previous target doesn't do is treat any other features of Parkinson's, slowness, stiffness that can manifest as decreased dexterity. So, just recently in the last few weeks, we've had a second target that's been FDA approved in the globus pallidus or a pallidotomy with focused ultrasound. And that, really is a target that has good evidence for lesioning procedures, again, going back decades with deep brain stimulation to not only help suppress tremor but also to reduce stiffness and slowness of movement, and for people who take PD meds who have excessive movements as a consequence. Dyskinesia, it can really suppress those dyskinesias on the side of the body that's being treated.- Okay, well share with our listeners the risks associated with the procedure.- You know, I think that's really important because we're talking about neurosurgical procedures. And, I think that having something that doesn't involve an incision doesn't mean that it's not invasive. If we're talking about making a lesion in the brain, I think that has to be done with a lot of thought and a lot of discussion. You know, when we first started sort of doing trials with this technology, we saw some degree of imbalance happen in many people. That imbalance usually lasted for a few hours, maybe a few days and resolved in the vast majority of people. Now, those were people with essential tremor who didn't necessarily have issues with balance prior. And, with Parkinson's it's a different disease. So, we had to be very cognizant of that and careful as we sort of applied this treatment in Parkinson's. And, what we found is as the technology's gotten better, people have really done well in terms of adverse affects. In the procedure, when their sonication is being delivered, and this is to say take a little bit of a step back. You know, it's not a one time procedure of you go in, you have the procedure done, and then you come out. It's a little bit of a scaling effect. So, the energy is dialed up in those transducers until we see an effect that might last only for a few seconds or a few minutes, and we can use that transient effect to identify, hey are we in the right spot? Do we need to move things a few millimeters in one direction or another, both to maximize benefit, but also minimize side effects.- Mm-hmm (affirmative).- And so, within the procedure as that energy is scaled up, there can be some degree of scalp pain or headache. And, that's usually pretty temporary during the sonications, and can be mitigated by things like IV Tylenol or other treatments during the procedure. After the procedure, some patients have noticed some abnormal sensation around the side of the mouth or the hand. Again, that's usually pretty transient, again lasting for hours, days, maybe weeks at a time, but usually resolves. The imbalance that we had seen in a little bit more frequency earlier is less prominent now. But, we do have to be careful about people who might be on the edge in terms of their balance of needing something to help them walk versus being wheelchair bound and saying,"We might want to be careful about considering this type of treatment."- That makes sense. Thank you for sharing that. Well, walk us through a typical Parkinson's progression with a tremor, and how it might look, or how it might differ for someone who has underwent or undergone rather the focused ultrasound and how those two run parallel and the differences once someone undergoes the procedure.- Yeah. And, it is important to note some people with PD don't have much tremor, whereas some people have what we call a tremor dominant form, and that's kind of the dominant feature. And, I think where the procedure, you know, and not just the focused ultrasound, but deep brain stimulation as well, where those procedures can sort of change a trajectory of management of disease is in what the main priority is and where, for example, medications have been used to try to control symptoms. So, we've had a lot of patients who have been on a large dose of medications to help control a tremor that can be quite severe, and in doing so can develop dyskinesia, can develop fluctuation and have tremor control that may only be sufficient for 50 to 60% of the day. And, in the meanwhile, they may have dyskinesia, or they may just feel sedated or have other adverse effects from medication. So, the procedure can really sort of dial back the clock a little bit when it comes to medication treatment. That doesn't mean people can get off medication for their Parkinson's necessarily, but it can sort of reduce the burden. And, if we talk about using tools, you know using tools in different amounts at different levels to target different things is always better than trying to just use one single thing and just keep escalating that.- You kind of jumped into my next question was going to be related to what's the relationship between the procedure and medication? So, let's say, I'm sure there's a lot of patients who are coming in or listening to this thinking, oh, I can get off my levodopa, or whatever I'm taking to manage my Parkinson's symptoms. So, talk to me about the relationship, and what you typically see if there's a typical which we know it's a little bit of the snowflake effect but what you see in terms of the relationship between the procedure and medication usage.- Yeah, and I think the key there, Margaret is these aren't mutually exclusive things.- Of course.- It's not to say, well let's choose one or the other.- Right.- But, you know, like we've said, some people don't tolerate medication as well or can have adverse effects. And, really, trying to scale that back is helpful, but even people who tolerate medications. You know, one thing that is inspiring to me in taking care of so many people who have Parkinson's is, you know, they can take medications three, four times a day and, you know, I have trouble remembering to take something once a day if I have to. So, that's a remarkable thing, but it's also burdensome.- Yes.- And, to the extent that, you know, people have to sort of set a lot of alarms and do a number of different things to sort of keep on a medication schedule, that's tough to being with, but if the consequence of getting of the schedule is really being disabled, then the role of any surgical procedure is to really try to create a floor effect that if the medication wears off, for example, I'm not gonna be as disabled as I would be otherwise.- Yeah. Mm-hmm (affirmative).- And so, I'm not as locked to that sort of schedule.- Yeah.- And, I can live my life. And then, the second is, you know, for people where we're aligning the goals in what the surgical treatments can do and the ultrasound can do to what the priorities are, you know, it really can allow for medications to be scaled back significantly. Maybe not permanently, but at least for a window of time that like I said is almost akin to kind of setting the clock back a little bit.- Mm-hmm (affirmative). I love how you described that. And, it's such a wonderful take away I think of your last answer regarding it's such a combination of things that go into ultimately the success of the procedure and treatment and creating that floor, elevating that floor rather that your baseline is a little bit higher so you're not so burdened by times and medication alerts on your phone. So, it frees up the individual a lot which I think is fantastic how you articulated that. To kind of tie a bow on focused ultrasound, if our listeners are interested in learning more about the procedure, where would you direct them to go?- You know, I think there's sort of two resources. One is what's called the Focused Ultrasound Foundation which is the not for profit entity that really promotes the technology, not just for neurologic applications, but for other applications in healthcare. And, that's just FUSFoundation.org. The other is sort of centers that sort of provide the treatment. So, at UVA, we have a very comprehensive website that goes through the University of Virginia's Focused Ultrasound Center, and kind of what the patient experience is, a couple of videos of the patient's journey, which can always be helpful.- Yeah. And, we can, for those listening, we can certainly provide all of those websites at the end of this presentation as well. So, thank you for that. You know, I would be remiss to, I've run many of these Pop profiles starting under COVID, and I don't think I've never said COVID, or had an interview that we've never mentioned COVID-19, so I'd be remiss not to say it. So, Dr. Shah, tell me what target advice you would give to people with Parkinson's under this climate who are still a little bit apprehensive, hesitant to get out there, start restart their lives and exercise routine, et cetera?- Yeah, and this is always a tough thing, because, you know, everyone who is watching and you as well Margaret, as well as me, we have different family members or other people we know who have different levels of comfort. I think the key is safety and trying to be as safe as possible, but also understanding that we have to balance that with what's healthy. And so, we can say,"Well, if our goal is to not get infected by a virus that can be really bad," that's great. But, staying in the house for the rest of our lives is not really a viable option for our overall health and wellbeing. So, what safety entails is talking with people's doctors, making sure they understand the role of vaccination, getting vaccinated if they feel comfortable, and having a chance to talk to their doctors about it, getting boosted as is the latest CDC sort of guidelines. But then, also just being cognizant of surroundings and saying, "Okay, well if I'm gonna be seeing family and maybe a child or grandchild who might be in daycare or some other setting where they might be at high risk making sure to either distance or wear a mask. But, in terms of, for example, you know, gyms, exercise programs, I think staff and facilities have made such great accommodations, and have responded well to the pandemic that I can clearly see the difference in the people that I follow who are back to doing those things versus not. And, the ones who are just, you know, getting back to having some semblance of normality and improved quality of life.- Mm-hmm (affirmative). And, I would suspect that just a simple getting outdoors and walking is generally with low risk associated with it and gets people out and moving as well.- Definitely. Especially now that it's not like 100 degrees every day.- You're right. You're right. And, so far it's been mild here in Virginia, so. Well, Dr. Shah as we summarize, where can our listeners go to find out more about you and the research you're conducting?- Yeah, I think, you know, the University of Virginia, we have sort of a clinical trials website, and I think that's a good place to know kind of what our group is up to in terms of our clinical research profile. And, I think that applies to centers everywhere. So, you know a lot of people with Parkinson's might think well I kind of live in the middle of nowhere. There's not really a university or a large hospital system near me, but there are resources that might be closer than they think. And, I think looking at even local community hospitals, there might be relationships with research entities. Of course, the Michael J. Fox Foundation, Pop, and, the ClinicalTrials.gov entity is really a comprehensive place to look at research trials and to find out what's going on.- Okay. Well, we will certainly, as I said before, we will put those at the conclusion of this presentation as well for folks to access. Well, that does it for me Dr. Shah. Thank you so much for being a part of the Pop Profile series.- Thanks for having me, Margaret.- Yeah. Thanks.(uplifting music)