Special outpatient clinic for Parkinson's disease and other movement disorders

Senior physicians / functional senior physicians

Prof. Dr. med. Dirk Dressler (focus: dystonia, spasticity and other central movement disorders)

PD Dr. med. Martin Klietz

Prof. Dr. med. Florian Wegner (focus: complex treatment of Parkinson's disease)

PD Dr. med. Christoph Schrader (focus: invasive Parkinson's therapies, chorea)

PD Dr. med. Franziska Hopfner (focus: tremor, Parkinson's disease, genetics of movement disorders)

Dr. med. Matthias Höllerhage (focus: Parkinson's disease)

Medical specialists

Lejla Paracka, PhD

Assistant physicians

Dr. med. Annika Schulte-Sutum

Johanne Heine

Dr. med. Lea Farina Magdalena Krey

Sophia Marie Rogozinski

Dr. med. Emil Valizada

General:

Movement disorders are disorders of movement and posture regulation caused by faulty control in the central nervous system. They manifest themselves through reduced movements, incorrect movements or excessive movements that are not subject to voluntary motor control and can therefore sometimes lead to considerable impairment of the patient. Hereditary factors, metabolic, traumatic and inflammatory damage to the central nervous system can lead to movement disorders. The diseases are often caused by a disorder of the basal ganglia. They are responsible for automatic movements and the precision of voluntary movements. Disorders of other areas of the brain such as the cerebellum or spinal cord also lead to movement disorders.

The following diseases are among the movement disorders:

• Idiopathic Parkinson's syndrome (Parkinson's disease)
• Atypical Parkinson's syndromes (e.g. multisystem atrophy, progressive supranuclear gaze palsy, corticobasal degeneration)
• Tremor syndromes (essential, dystonic, hereditary or Parkinson's tremor)
• Chorea (St. Vitus dance, e.g. in Huntington's disease)
• Dystonia (e.g. torticollis, writer's cramp, musician's dystonia, eyelid spasm)
• Spasticity (e.g. neurodegenerative or inflammatory brain disease, after a stroke or cerebral hemorrhage)

We diagnose and treat the entire spectrum of movement disorders.

Diagnostics:

The following methods can be used to diagnose movement disorders:

• Outpatient
  • Detailed medical history (anamnesis)
  • Standardized clinical examination
  • Electrophysiology/tremor analysis
  • Gait analysis
  • Genetic examinations (with the Department of Human Genetics)
  • Careful preliminary examinations are essential for the decision to undergo deep brain stimulation
  • Review of neurostimulation systems
  • Checking the pump systems
• Inpatient
  • The methods of outpatient diagnostics, as well as the following:
  • Standardized levodopa / apomorphine tests
  • Neuropsychological examinations
  • Autonomic function testing
  • Extended laboratory tests in blood, urine and cerebrospinal fluid (e.g. autoantibodies or metabolic tests) Imaging procedures
    • cMRT
    • FDG-PET
    • FP-CIT-SPECT (DaTScan®)
    • IBZM-SPECT
    • MIBG-SPECT

Therapy:

The treatment of movement disorders generally includes modern drug therapy, which focuses on the effectiveness and tolerability for the respective patient. This is supported by speech therapy, physiotherapy, occupational therapy and social counseling as required. In the inpatient area, a Parkinson's complex therapy is offered that is individually adapted to the respective needs.

The intensified treatment options include pump therapy with apomorphine or levodopa/carbidopa intestinal gel (for Parkinson's disease), and careful preliminary examination for deep brain stimulation and its aftercare (for Parkinson's disease, dystonia and tremor, in close cooperation with the Clinical Department of Neurosurgery).

Treatment methods for dystonia and spasticity include botulinum toxin injections and pump therapy with intrathecal baclofen.

Deep brain stimulation

Deep brain stimulation is one of several treatment options for patients with movement disorders. In deep brain stimulation, electrodes are implanted in certain regions of the brain by means of a neurosurgical procedure. The electrical impulses produced by these electrodes influence certain nerve cells and chemical processes in the brain. The stimulation is controlled by a brain pacemaker. It is connected to the electrodes implanted in the brain with a thin cable that is laid under the skin. As a result, the symptoms of the disease and quality of life are improved.

This procedure requires very close cooperation between neurologists, neurosurgeons and neuroradiologists.

Deep brain stimulation is admitted for the following diseases

- idiopathic Parkinson's syndrome (Parkinson's disease) with either a drug-resistant tremor or with motor effect fluctuations that cannot be treated satisfactorily with oral therapy.

- Essential tremor (predominantly symmetrical postural and intention tremor of the hands and arms) that cannot be treated satisfactorily with oral therapy. In individual cases, it can also be used successfully for tremors associated with other diseases (e.g. dystonia, multiple sclerosis or cerebellar diseases).

- Dystonia (e.g. generalized dystonia, cervical dystonia (torticollis), blepharospasm/meige syndrome) that cannot be treated satisfactorily with oral therapies or botulinum toxin injections.

During the consultation - preferably with the involvement of relatives - a detailed medical history and neurological examination, a review of the diagnosis and previous treatments and the definition of suitable treatment goals are carried out in order to determine the indication and exclude any contraindications. In interested patients or in unclear cases, a complete examination is carried out later during an inpatient stay to determine the indication.

The surgical procedure is performed as an inpatient at the Clinical Department of Neurosurgery.

The technical integrity of the stimulation system is checked at longer intervals on an outpatient basis. Smaller adjustments to the stimulation and medication can also be made during the outpatient consultation; in more complex cases, we recommend an inpatient stay.

Apomorphine pumps:

Apomorphine is the strongest dopamine agonist available for the treatment of motor symptoms of Parkinson's disease. It is a liquid that is injected under the skin and takes effect within 7-10 minutes. As a one-time administration via an injection aid, the so-called apomorphine pen, it is able to break through sudden off-phases faster than any other Parkinson's medication. The effect usually lasts for 50-70 minutes. Single injections with the apomorphine pen are usually used in situations where a quick effect is needed.

However, apomorphine can also be used as a continuous medication procedure in which apomorphine is infused via a small pump and a catheter inserted subcutaneously into the skin. Compared to tablets, the pump ensures a more even drug level and therefore a more even effect. The use of this pump makes sense for patients with strong fluctuations in effect, where there are fluctuations between good mobility (on-phases) and poor mobility (off-phases) several times a day.

The use of such a pump has some special features, and not every patient with Parkinson's disease with motor fluctuations is suitable for this procedure. During the consultation and, if necessary, during an inpatient stay, interested patients are individually assessed to determine whether this procedure can be used successfully. Patients with such a pump are then followed up on an outpatient basis.

Levodopa/carbidopa intestinal gel infusion therapy:

The use of this therapy makes sense in patients with strong fluctuations in effect, where there are fluctuations of good mobility (on-phases) and poor mobility (off-phases) several times a day.

Levodopa is the most effective, best tolerated and least side-effective medication for treating the motor symptoms of Parkinson's disease. Levodopa/Carbidopa Intestinal Gel (Duodopa®) is admitted for the treatment of motor fluctuations in advanced Parkinson's disease. The gel is pumped directly to the site of absorption of the active substance by a pump worn on the body via a double-barreled gastric tube placed through the abdominal wall, the inner tube of which is located in the upper small intestine (a so-called "J-PEG"). This effectively avoids delays in the onset of action due to a gastric emptying disorder. Furthermore, by permanently pumping the active ingredient into the small intestine, the pump is able to achieve significantly more even drug levels and therefore significantly fewer fluctuations in effect than is possible with tablets.

During the consultation and, if necessary, during an inpatient stay, interested patients are individually assessed to determine whether this procedure can be used successfully. Patients with such a pump are then followed up on an outpatient basis.

Baclofen pumps:

If severe, chronic spasticity cannot be adequately treated therapeutically with physiotherapy and oral antispastic agents, intrathecal baclofen treatment (ITB) may be indicated. Treatment goals may include functional gain, pain reduction and tone reduction to improve hygiene and Nursing.

During the consultation, it is checked whether such a procedure can be promising in principle. During a subsequent inpatient stay, a defined amount of Baclofen is then injected by means of a puncture of the cerebrospinal fluid space and the individual effect on tone, spasticity and strength is examined. If such a trial injection effectively alleviates the disturbing symptoms, the implantation of a drug pump would make sense in order to permanently alleviate the spasticity.

The capacity of a Baclofen pump is limited and the pump must be refilled at certain intervals. The refill intervals depend on the amount of medication required per day and generally range from 6 weeks to 12 months. Follow-up care for patients with such a pump is provided on an outpatient basis; minor dose adjustments and refills are carried out during consultation hours. Complete re-titration with the aim of finding the optimum dose for patients who have been newly implanted or who have had a pump implanted elsewhere is carried out on an inpatient basis.

Botulinum toxin:

Botulinum toxin acts on the neuromuscular endplate by reversibly blocking the release of acetylcholine from the terminal synapse. The temporary interruption of neuromuscular transmission results in a temporary weakening of the injected muscles. The effect of botulinum toxin usually occurs after 3-10 days and lasts for 10-12 weeks. A re-injection should take place after 8 weeks at the earliest in order to minimize the risk of the formation of neutralizing antibodies. The injections can be carried out using anatomical localization, ultrasound and electromyography (EMG).

People with various forms of dystonia and dyskinesia are treated in the special outpatient clinic for botulinum toxin. These include, for example

• Torticollis spasmodicus/cervical dystonia (torticollis)
• Blepharospasm/Meige syndrome
• segmental dystonia
• generalized dystonia
• Action-induced dystonia (e.g. writer's cramp)

Via the Neurological Polyclinic, ask for an appointment in the movement disorder outpatient clinic or botulinum toxin outpatient clinic The following conditions are also treated in the special outpatient clinic for botulinum toxin:

• Hemifacial spasm
• Focal spasticity (e.g. after a stroke or with multiple sclerosis)
• Chronic migraines (in close cooperation with the anesthesia pain outpatient clinic)
• Hypersalivation due to neurological diseases in adults, e.g. Parkinson's syndrome or amyotrophic lateral sclerosis (ALS).
• Hyperhidrosis

Cooperations:

There are close collaborations with the following Clinical Departments and Institutes:

• Clinical Department of Neurosurgery
• Clinical Department for Neuroradiology
• Clinical Department of Nuclear Medicine
• Institute of Human Genetics

Links:

German Society for Parkinson's and Movement Disorders e.V. , www.parkinson-gesellschaft.de

German PSP Society e.V., www.psp-gesellschaft.de

Botulinum toxin working group of the German Society of Neurology (DGN), www.ak-botulinumtoxin.de

German Dystonia Society e.V., www.dystonie.de

Studies:

Participation in studies is also possible via our special outpatient clinics.

We offer the opportunity to participate in

• Prospective observational studies to investigate the clinical course and development of new biomarkers of movement disorders (e.g. atypical Parkinson's syndromes, Huntington's disease and dystonia).
• Therapy studies with new drugs to test their safety, tolerability and efficacy.

Please contact us if you are interested in participating in clinical trials.

Appointments:
Mon to Fri 9am-12pm
Mon and Wed 2pm-3pm

Contact:
Phone 0511/532 3122

E-Mail:

Neurologie.Poliklinik@mh-hannover.de

If you are interested in participating in a study, please contact

Bewegungsstoerung.Neurologie@mh-hannover.de