Andre Machado, MD, PhD

“We deliberately do not have a rigid algorithm on how to get a patient with a given symptom to have a given procedure—we like to tailor it. We tailor the decision-making for DBS, focused ultrasound, or medical treatment.”

For patients with movement disorders such as essential tremor, there are fortunately a number of options for treatment. They can range from medications to procedures such as focused ultrasound or deep brain stimulation (DBS).

Clinicians such as Andre Machado, MD, PhD, Institute Chair, Neurological Institute, Cleveland Clinic, know that the best approach to this process is a multidisciplinary one. As has been the trend across medicine, a group of physicians and providers come together to make informed decisions based on a number of factors—not just a rigid algorithm that reads out decision A based on symptom B, and so on.

, Machado provided his insight into this process at Cleveland Clinic, and spoke to how this multidisciplinary, all-encompassing approach can provide a more complex and more effective relationship with the patient and referring neurologist. This, in turn, adds an amount of value to the care that they provide.

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The Chairman of the Neurological Institute at Cleveland Clinic provided insight into the multidisciplinary decision-making process for patients with movement disorders at the center.

Andre Machado, MD, PhD: Multidisciplinary Treatment in Movement Disorders

“They complement each other, they don’t replace each other. They are both invasive&shy;...at the end of the day something is happening inside the brain.”

The interest in using non-drug interventions for movement disorders such as essential tremor or Parkinson disease has grown in recent years. Many clinicians have turned to 

focused ultrasound (FUS) and deep brain stimulation (DBS)

 to provide benefit to a wide variety of patients in varying ways.

Andre Machado, MD, PhD, Institute Chair, Neurological Institute, Cleveland Clinic, is all too familiar with these methods of treatment—as well as their differences. In a conversation with 

, he explained how those differences actually allow FUS and DBS to be used in a complementary fashion in some instances. He also shed light on the various situations and patient populations in which he finds them most useful.

Additionally, Machado spoke to the differences in invasiveness between the 2 procedures, noting that while DBS requires surgery, it can technically be considered less invasive due to the impermanence of its effects compared to FUS, which causes a permanent ablation.

The Chairman of the Neurological Institute at Cleveland Clinic spoke to the differences between deep brain stimulation and focused ultrasound, as well as how they can be utilized to complement one another.

Andre Machado, MD, PhD: Using DBS and FUS in Complementary Fashion

“The experience has been wonderful. Today, we are as comfortable seeing someone face to face… [as we are] seeing someone in video. My experience as the physician, and what the patients report to me as their experience, remains very good.”

Telemedicine has begun to alter the landscape of treatment for a number of conditions. In epilepsy, some experts, such as Imad Najm, MD, are expecting it to be a complete game-changer. He told 

 that “the physical confines of things are not going to be a limitation anymore. We're going to be able to reach out to the world, and the world will be able to reach out to us.”

Additionally, Andre Machado, MD, PhD, Institute Chair, Neurological Institute, Cleveland Clinic, has similar feelings regarding its use in movement disorders such as Parkinson disease or tremor. In a conversation with 

, Machado detailed his experience with telemedicine, and the impact it has had on his practice. He noted that it has offered a similar experience to in-person visits, allowing for the maintenance of human contact and good interactions despite the difference.

He also offered his insight into his beliefs on the future use of telemedicine, particularly how it may be able to supplement current care. In movement disorders, the window for patients to benefit from a treatment like deep brain stimulation (DBS) is sometimes missed due to a lack of referral. The ability to have a virtual visit with a movement disorder specialist ahead of a referral may offer a chance to hit that window.

The Chairman of the Neurological Institute at Cleveland Clinic shared his experience with telemedicine and how he foresees it supplementing the current care offered in movement disorders.

Andre Machado, MD, PhD: The Physician Experience With Telemedicine

“One of the sad things we deal with in our center is to evaluate a patient that was probably a good candidate for DBS a long time ago, but by the time the patient is referred, they’re no longer a viable candidate. We missed the window of opportunity.”

Deep brain stimulation (DBS) has become a valuable tool for clinicians in the movement disorder space, particularly for those with patients with Parkinson disease or essential tremor. Despite this, sometimes the window in which patients can receive the most benefit from the intervention are missed.

 sat down with Andre Machado, MD, PhD, Institute Chair, Neurological Institute, Cleveland Clinic. He offered some reasoning as to why clinicians may be hesitant to refer these patients or believe in the treatment. Ultimately, while he and colleagues in the center understand that their neurological care will be supplemental, he hopes that with a referral, they can become co-managers of these patients prior to and after DBS in order to boost their quality of life.

Additionally, he spoke to the educational tools and programs that Cleveland Clinic has put together for general neurologists and practitioners to develop a symbiotic relationship with their center in order to get patients DBS when it is still beneficial. Part of that includes their distance health program, which also offers telemedicine visits to patients who are interested in learning more about DBS.

The Chairman of the Neurological Institute at Cleveland Clinic discussed getting patient referrals for deep brain stimulation and how often patients miss the window during which the treatment could offer them benefit.

Andre Machado, MD, PhD: Referrals for Deep Brain Stimulation

“It is a very old idea, to treat the nervous system with electricity…but the modern use of neuromodulation with pacemaker-type devices was actually started here in Cleveland, some 50 years ago…the technology has evolved really well. Today, we do as much neuromodulation targeting the brain as we do targeting the spine and the nerves.”

Andre Machado, MD, PhD, Institute Chair, Neurological Institute, Cleveland Clinic, and colleagues are quite familiar with the use of neuromodulation techniques to treat movement disorders and other neurological illnesses. In fact, Machado told 

 that the process as we know it was originally enacted in Cleveland to treat chronic pain with spinal cord stimulation.

Now, neuromodulation procedures such as deep brain stimulation (DBS) have grown in popularity to become a more standard treatment for patients with Parkinson disease, among other conditions. Machado noted that increased use over time has paralleled the improvement, as the more it has been done, the safer it has become, and the more adept clinicians have become at utilizing it.

 to offer insight into the evolution of neuromodulation treatment. He discussed its history, where he foresees its use going forward, as well as how it is being utilized in practice at Cleveland Clinic.

The Chairman of the Neurological Institute at Cleveland Clinic spoke to the history of neuromodulation and how it has evolved in clinical practice today. 

Andre Machado, MD, PhD

Articles

Andre Machado, MD, PhD: Multidisciplinary Treatment in Movement Disorders

Andre Machado, MD, PhD: Using DBS and FUS in Complementary Fashion

Andre Machado, MD, PhD: The Physician Experience With Telemedicine

Andre Machado, MD, PhD: Referrals for Deep Brain Stimulation

Andre Machado, MD, PhD: The Evolution of Neuromodulation

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