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MARK HOUSTON: Well, let's then let's start very simple with this then, doctor, if you were explaining like you're going to do to me today, uh, you know, you were at a backyard barbecue here in South Dakota and someone said, what is deep brain stimulation? How would you put it?
DR. ROBERT ZIECHMANN: Um, so it's a surgery. It's a procedure that's done again for, uh, movement disorders for the most part that are, um, where medications just are not controlling the symptoms. And so I think of it as a, uh, quality of life surgery. It is an elective surgery. Um, there's, we're not doing this under emergency conditions. Um, and it's something that a lot of times people have suffered, as you said, from not being able to feed themselves, not being able to drink a cup of coffee, write their name, or even use their cell phone, um, or work at a computer, um, that, you know, they've been suffering for these things for essential tremor, the statistic is as much as ten years. Often when patients come kind of through the process, try medications or looking for answers before they come to surgery. Um, so, um, it's, it's a long time where people live with these things and then it gets more and more disabling to the point where they're thinking about doing a surgery. So surgery involves putting as, as we talked about, um, electrodes in the brain in the, in the deep areas of the brain. And the reason is that if you put them in these certain special nuclei, um, just a small amount of electrical stimulation can make a big difference in a patient's quality of life.
MARK HOUSTON: Who would be best suited for this? I mean, who is a good DBS patient in your mind?
DR. ROBERT ZIECHMANN: So, uh, there's kind of a couple categories. So let's talk about the, the most common is for Parkinson's. And this is what the therapy has been around for the longest.
MARK HOUSTON: Can you explain Parkinson's a little bit, though, to just what it is as a condition?
DR. ROBERT ZIECHMANN: Yeah. So Parkinson's is an increasingly common neurodegenerative disorder. Um, it is growing unfortunately. Um, and it is actually starting to outpace the growth of Alzheimer's disease is the most common form of dementia. However, people live with Parkinson's for a while and most people think of the movement disorders from Parkinson's, the tremor, um, shaking of the hands more than feet typically. Um, the, what we call bradykinesia, but slowness, the stiffness or rigidity. Um, and then there are some symptoms that are associated too with the medical treatment that that deep brain stimulation can actually help with.
MARK HOUSTON: Why do you, why do you think it's growing?
DR. ROBERT ZIECHMANN: So there is some data to suggest that, um, pretty convincing data that exposure to certain chemicals, such as certain pesticides, can actually cause Parkinson's. And so actually, just in the news lately, there have been a few states that have banned paraquat, which is has a very direct causal relationship. So that's good on the preventative side, but it doesn't really help if you have it already. And it's certainly not the only contributor to Parkinson's.
MARK HOUSTON: Right. But that had to be a pretty interesting study when it came out to find that to find something that could be preventative, wasn't it?
DR. ROBERT ZIECHMANN: Yes.
DR. ROBERT ZIECHMANN: And a lot of that work is coming out of a out of the University of Florida group with a movement disorders neurologist named Mike Okun. Um, and his, uh, he's online, so check that out.
MARK HOUSTON: Oh, absolutely. That's, that's really interesting because I don't think anybody, uh, probably for the first time just hearing this podcast and, you know, that's maybe dealt with Parkinson's would have ever heard that That's something that could happen. I'm sure they think it's just, you know, genetic. Is that does that play a big part in Parkinson's too?
DR. ROBERT ZIECHMANN: So there is a genetic component for some cases.
MARK HOUSTON: Okay.
DR. ROBERT ZIECHMANN: Um, and but it seems that as with many things, there is a combination of genetic predisposition, environmental factors, meaning, you know, what we're exposed to.
MARK HOUSTON: Yeah. Well, let's talk a little bit about, um, you know, the term brain surgery. I don't think anybody likes to hear that term at all. And when it comes to most surgeries and, and.
DR. ROBERT ZIECHMANN: And I agree, and I think deep brain stimulation, particularly the name might give people pause the most.
MARK HOUSTON: Um well what's the procedure actually like?
DR. ROBERT ZIECHMANN: Right. So, uh, I actually do this procedure. Historically it was done awake and, and the surgeon and the neurologist would be in the room and the patient would, uh, be in the head frame, which is meant to help, uh, hold the head still so that because this requires precision, it requires precision within one to one point five millimeters for the placement of the electrode. And it makes sense to have the patient still. Um, and so in the past they would do that and they would numb up the spots where the frame kept everybody still the patient still, and the, they would put the patient to sleep while they make incisions and, uh, make a small hole in the skull to pass the electrode down. Then they would wake the patient up and test them. So over the where I did fellowship. Um, and kind of the trend in the country is that is going toward doing this under anesthesia, because now we have better technology. Um, DBS deep brain stimulation was invented in the era of X-rays. And since has come CAT scan and MRI and advanced imaging. And now this can be done asleep. Now this can be done under anesthesia. Um you can, uh, it it is surgery. The process takes a while to set up and just to get perfect. Um, we like to have a perfect result. Uh, but, um, after five, it's a, it's kind of an all day thing. Yeah. Um, but it's kind of like going to the, we talk about it like going to the airport. There's a lot of setup. You got to get the plane in the right spot before taking off and getting to where you want to go. And, but at the end of it, you know, patient goes to sleep and they wake up, they have their device, um, and they go home the next day.
MARK HOUSTON: You know, because it's, it's interesting. Uh, you see a lot of viral videos that go around of people under brain surgery that are asked to play a guitar or recite a poem or play violin. Are there still this is a little off topic, but are there still surgeries that that's required for people to stay awake while they're having brain surgery?
DR. ROBERT ZIECHMANN: So there there are fewer and fewer. Okay. There are fewer and fewer. Um, and so for me, um, so another thing that I do is epilepsy surgery, which I can talk about at a different time, but for the most part, we only do awake surgery anymore, um, to map language because that's something that we can't test through any neurophysiology with electrodes on the, on the scalp and on the arms and legs. Um, and there's not really a, a way to test language otherwise. So.
MARK HOUSTON: Right. Okay. Um, well, what after a surgery like this happens then then what does, what does success look like for a patient? Is it, is it everything stopping or is it just the ability to button your shirt or play with your grandkids? I mean, does it vary success for patients?
DR. ROBERT ZIECHMANN: Right. So, um, kind of my approach is, is to take an individualized approach that, uh, because everyone is different and everyone's Parkinson's is different. So some people might have a lot more tremor. Uh, some people might have a lot more stiffness and slowness and people might have different goals. Um, whether it's just to get back to being able to go out and go to the grocery store and take a walk in the park, or I've had patients before who want to get back to cycling and doing fifty miles on a bike. Yeah.
MARK HOUSTON: And that happens. This must happen with this procedure though, right? You must be able to return people to that kind of level of activity.
DR. ROBERT ZIECHMANN: Right. And I think for the most part, especially to, with the with the essential tremor is that people also just, um, it's I've had a lot of patients tell me they, they don't want to go out anymore and eat at a restaurant because their spoon is shaking. Uh, they're spilling their glass. Um, or they just feel like people are looking at them. And even if they're not, you know, it just is the feeling and the confidence to go, to go back out. Um, so at least that's what patients have told me. And that's, that's what matters to them. And being able to go back and do those things, um, makes a big difference for them.
MARK HOUSTON: Now, once this device is in, is this, um, is this kind of a set it and forget it kind of device or do you have to fine tune this? Do people have to come back to dial it in more?
DR. ROBERT ZIECHMANN: So. So I guess I kind of stopped halfway with, with the description, but we placed the electrodes. We get a CAT scan and confirm because they're under anesthesia, we're not doing that awake testing. And they get this battery. The wires go underneath the skin to the battery in the chest, which is like a pacemaker, like you mentioned. Right. Uh, then there's a little bit of waiting. Um, we wait for, uh, the patient to heal up a little bit, and then we bring them back into clinic and, uh, the either the movement disorder neurologist, Doctor Krueger here at Monument or I will, will program the device. Um, and that's programming is a process. Um, and so we kind of, we go through, we adjust different settings and we ask patients how they feel. We can see their response in terms of their movement, their tremor, their slowness, their stiffness. We have them, uh, walk. Um, and, and it's a collaborative process with the patient that, you know, I want to get back to walking in the park. Okay. Let's go for a walk in clinic and, and see how you feel.
MARK HOUSTON: Uh, it must be battery operated. So is that what happens? So then what happens when eventually the battery wears out?
DR. ROBERT ZIECHMANN: So, uh, interestingly, there's just as with batteries, um, have, you know, they've developed in or in so many of our devices, um, there are options for batteries. So, um, the default kind of is this non-rechargeable battery that tends to last about five years, but it depends on how, how much energy you're using. Um, then there's the rechargeable option, which tends to be smaller. And typically patients have to charge it wearing a special kind of sling that holds the charger in place. It's a contact charger or induction charger. Um, kind of like when you place your phone on a coaster charger, and that typically takes about forty minutes. So we'll have patients do that once a week. You know, you can watch your TV show on, on a Sunday and maybe watch the news, right. And charge and just kind of make it a ritual every week. Sure. Um.
MARK HOUSTON: But something they have to come in for.
DR. ROBERT ZIECHMANN: Oh, no. At home.
MARK HOUSTON: They can do it at home. So the device is at home and I'll see.
DR. ROBERT ZIECHMANN: Yep. And every patient also gets regardless, there's three brands. Um there are three companies that have each their own unique advantage. Um, but the, all of them have their own patient controller and own patient charger. So they do it at home.
MARK HOUSTON: Okay. But once you have it set and you have it fine tuned, you don't mess with it, then it's, it is what it is. Unless they come back to see you for whatever reason.
DR. ROBERT ZIECHMANN: For the most part, yeah. For the most part, both Parkinson's and essential tremor do tend to progress over time. So we do we can make adjustments. So that's the nice thing about this therapy is that it's not just one and done set in stone and that's it. If something changes in the person's life, such as if their disease gets worse, then we can always adjust. And it. The. The nice thing is that even though we don't have a tool yet to slow the progression of Parkinson's, we can adjust the therapy throughout throughout the disease. So. And it will proportionately, we expect it to proportionately give the same benefit, even if the disease gets worse. If you're getting eighty percent relief, you should be getting eighty percent relief as it gets worse.
MARK HOUSTON: Right. Um, one thing I was kind of digging in a little bit on this, uh, on this device and the procedure and what it can help. I've seen research looking at DBS for things like Huntington's disease and chronic pain. Um, obesity was on this list too, right? Yeah. Um, what that's a really wide net for a lot of this stuff. Um, is What is it about this kind of technology that that that can it show up in so many different areas like this?
DR. ROBERT ZIECHMANN: Uh, it has to do with the connection that the brain has to the immune system, to the endocrine system. Uh, for example, there is another device that we have just brought to Monument that is a vagus nerve stimulator for rheumatoid arthritis. That electrical stimulation of that nerve is as effective as a biologic. Um, a drug that patient would have to take that would suppress the immune system, but without those immune suppression side effects.
MARK HOUSTON: Right.
DR. ROBERT ZIECHMANN: So there's, there is a lot that's still under development. So the obesity is off label research only. Um, there's a humanitarian device exemption for obsessive compulsive disorder. There is a randomized controlled trial going on for depression that should.
MARK HOUSTON: Depression would have been another one to that. You would think um, if I mean, if something like this works for depression, That's I mean, these are such game changing, um, you know, studies or realizations that you're coming to with this device and all is it all in the, in the same part of the brain?
DR. ROBERT ZIECHMANN: Those are all in different locations.
MARK HOUSTON: Just different locations.
DR. ROBERT ZIECHMANN: And so yeah, just to be clear, none of those outside of Parkinson's, essential tremor, dystonia and epilepsy. Those are the FDA indications currently. Those are what we what we do right now. Um, just for the listeners, right.
MARK HOUSTON: Well, okay. So, you know, like hypothetically, then on that list, which gets you most excited.
DR. ROBERT ZIECHMANN: Of what's coming.
MARK HOUSTON: Of yeah, of Huntington's or chronic pain or cluster headaches or depression, addiction, obesity. Do any of those, any of those, uh, you know, get you like, oh boy, if this works.
DR. ROBERT ZIECHMANN: You know, I think, uh, and I, during my fellowship, we did do, uh, a case for, for chronic dental, neuropathic dental pain. And, um, our patient had, you know, been taking a lot of opioid medication and was able to cut that down. Um, was able to improve mood, go out, go out more. Uh, so again, research only.
MARK HOUSTON: Right? Of course.
DR. ROBERT ZIECHMANN: But, um, I have seen that firsthand.
MARK HOUSTON: That is exciting. It is. Um, is there a, is there a myth or fear about deep brain stimulation that you wish you could clear up?
DR. ROBERT ZIECHMANN: I think so. I think it's that, um, uh, people worry about that. It will change who they are. Um, so. There, uh, there is a theoretical risk of some behavior and mood change in a mostly with associated with specific target that I don't particularly use. But regardless, there is a standard neuropsychological screening that all patients with Parkinson's are required to go through just to make sure that we do not have that. Um, and even though that's very rare, we're thorough and cautious to avoid that.
MARK HOUSTON: Right. But with any procedure, with any sort of medical procedure, there is always a risk. And I, and I'm sure you lay that out in plain English so everybody understands. Right.
DR. ROBERT ZIECHMANN: So the thing I talk about the most, and that most surgeons who do this talk about the most is nationally. And I think that's the same everywhere that data has borne out. There's about a three to five percent risk of an infection. So if you have a device and it gets infected, it has to come out. The good news is that even if it comes out, so let's say, um, out of seventy cases, two people had it. Um, I've seen people get reimplanted and not have an issue the second time, continue to get their therapy and have no long lasting side effects other than they had to go through surgery twice.
MARK HOUSTON: Right. Um, you earned you mentioned when we started that you have a degree in exercise science and German literature, right?
DR. ROBERT ZIECHMANN: That is true. Uh, so.
MARK HOUSTON: Well, what I want to know, um, how does that the German literature part specifically, does that kind of shape the way you think about this? Does it ever come into what you do in practice as a doctor?
DR. ROBERT ZIECHMANN: Um, I think that studying literature, studying stories, studying, uh, people's lived experiences, uh, the German word for which I forgot, but, um, just, uh, it was just another, a different way I think of, of thinking about people's experiences and being able to relate to people. And, um, I mean, that's super important. And just being a doctor in general and, and being able to, you know, as I said, this can be a very individualized therapy. And I think it's important to understand where people are coming from and what their goals are. To get them there.
MARK HOUSTON: Do you, uh, have you you've been to Germany? I'm assuming.
DR. ROBERT ZIECHMANN: I have.
MARK HOUSTON: Yes, yes. Favorite part?
DR. ROBERT ZIECHMANN: Uh, well, actually, um, in Austria, just next door, the my, uh, one of my favorite cities in the world was Vienna. Um, there was a, there was a lot of old and new side by side and, and, uh, good coffee and, and, and chocolate.
MARK HOUSTON: Chocolate. It's amazing. What do you have? Do you have a, do you have a favorite German writer? Do you have anybody that you've, you've enjoyed?
DR. ROBERT ZIECHMANN: Um. Uh, I mean, Kafka was kind of interesting. Uh, we read that, uh, I, we also read like in that department was, uh, old Norse and the old and the like Viking sagas, which was interesting because they, they just told it like it is.
MARK HOUSTON: Yes. Right. Well, anybody that's read something like Beowulf would know that that's I mean, that's. Yeah, yeah. They do. It's told. Yeah. Exactly. Like you said. Well I'm I'm bringing it up because I'm on day one thousand and nineteen of Duolingo in German and I can I can kind of read it. I can't hardly speak it, though. It's, it's a tough language to speak. Yeah. I think, um, I get the, you know, I can get the swear words. Okay, but the rest not so good. Um, well, for, for anyone doctor who's, who's listening or even watching this, um, with a, with a parent or a spouse who struggles with tremors. First off, great that this procedure is here right now. Uh, and that they don't have to travel to Denver or Minneapolis or a lot of these locations to have this done, which I'm assuming they used to have to do. Correct. Um, again, the more podcasts we've been doing recently has been good news like this for Monument that now these procedures are here. You don't have to leave Rapid City, which is super exciting, but if you've got a parent or a spouse. What is the first step you would like them to take that could lead to this device. Primary care doctor.
DR. ROBERT ZIECHMANN: Yeah. So, um, most of the time someone has been managing these, these medications, um, whether it's um and for essential tremor, if you look at the literature, uh, primary care doctors are taking care of a lot of it. Yeah. Because these are medications that primary care doctors do prescribe and, uh, or general neurologists many times. They're also referred to a movement disorder specialist, whether that's here or somewhere else. And then, um, but from anywhere where any of these points where they, the medication isn't controlling the symptoms, uh, I'm happy to see them. Um, and, and I do work with Doctor Krueger from neurology, from movement disorders and, you know, between, uh, so some of them can come straight to me or, or I may send them to Doctor Krueger. Um, but I'm happy to see them in, evaluate them. One of the important things that we do is to rule out kind of the mimics of Parkinson's. There are less common disorders that don't benefit from stimulation. That's part of the screening. And the same thing with essential tremor. We look for things that look like essential tremor but are not. And um, and do a thorough workup. Just want to make sure that the, the fit is right for the patient for the surgery.
MARK HOUSTON: Yeah. Well this is again, it's super exciting. And I encourage anybody to, uh, to look up and look more into detail into, uh, you know, what this device is, what it does. And again, Doctor Robert Ziechmann, thank you very much for coming in and talking about this. I would love to have you come in and talk about the epilepsy to anything that's brain related is just so interesting because what a baffling organ that is in our body. And if you can kind of understand even a small part of it, I think a lot of people enjoy, uh, hearing that. So again, doctor, thank you very much for coming in and doing this, I appreciate it.
DR. ROBERT ZIECHMANN: Thanks for having me.
MARK HOUSTON: You bet.