Aug. 2, 2012 | Aug. 2, 2012 | In the neurology clinic at the Jackson T. Stephens Spine and Neurosciences Institute of the University of Arkansas for Medical Sciences (UAMS), W. Steven Metzer, M.D., performs the initial programming of Tommy Rickman’s deep brain stimulator.

“There are four little electrodes down in your brain,” explains Metzer, a neurologist and associate professor in the UAMS College of Medicine. “I’m trying to find the best one,” he says.

He plugs in data to a hand-held device that adjusts the frequency stimulus from a generator embedded beneath the skin, just below the collarbone, that’s connected by a thin, insulated wire to the electrodes in Rickman’s brain.

“I’ll turn the generator up a little bit. If you see any flashing lights, just let me know.”

“You mean in my eyes? I see those all the time!” exclaims Rickman, 61, of Cabot.

Metzer refines his question: “Do you see any new flashes?” he asks, laughing.

This is the kind of patient-doctor consultation that Metzer conducts four or five times a week for patients who have essential tremor, like Rickman, or other neurologic disorders such as Parkinson’s or dystonia.

Essential tremor is a benign, sometimes inherited condition that makes simple tasks like using a pen, holding a glass without spilling its contents or shaving difficult and, if symptoms worsen, impossible. Tremor can involve the hands, head, voice and legs.

“I’ve never been able to do this since I can’t say when,” Rickman says, his voice trailing off as though speaking only to himself, about touching index finger to thumb on his right hand.

While asking Rickman to go through a battery of exercises such as reciting nursery rhymes, drawing spirals on a sheet of paper and holding each hand straight out, Metzer looks for any signs of rhythmic shaking and checks in with Rickman:

“Any tingling?”

“How does that feel?”

“The left hand is better, but the right hand is quite cool,” says Rickman.

“Then let me see if I can change the circuit and give you a little more juice for your left hand,” Metzer says.

The consult is not without a little programmer humor.

“Now stick out your tongue, touch your ear.”

In this adjustment, post-surgery phase, Rickman’s brain will, as Metzer says, “get used to” the charge. Metzer says he enjoys “programming people because it really helps a lot.”

“You don’t have any side effects,” from the surgery, Metzer informs Rickman. “She’s really got good electrode placement here,” Metzer says, referring to Erika Petersen, M.D., Arkansas’ only fellowship-trained functional neurosurgeon.

When medications were no longer controlling his tremor, Rickman was referred to Petersen, an assistant professor of neurosurgery in the UAMS College of Medicine.

“Well, I’ve been hiding this problem for years because I could,” says Rickman, then he corrects himself. “People noticed me shaking; I just thought I was hiding it. The bobblehead issue geared me toward Dr. Petersen to begin with.”

To evaluate candidates for deep brain stimulation surgery, Petersen works with a collaborative, multidisciplinary team that includes Metzer as well as Sami I. Harik, M.D., professor in the Department of Neurology and Jennifer Kleiner-Fausett, Ph.D., a neuropsychologist and assistant professor in the Department of Psychiatry, both in the UAMS College of Medicine.

They hold monthly conferences to review the specifics of each case, including the position of electrodes, and whether the surgery would likely improve a patient’s quality of life.

“The message for patients to hear,” says Petersen, “is that there are surgical treatments for patients whose medications are not helping enough.” Deep brain stimulation is reversible and does not permanently disrupt the brain because it creates an electric force field of sorts in an area of the brain responsible for essential tremor. In the early 1980s, Petersen says, a big push to understand motor controls deep within the basal ganglia helped doctors understand motor disorders better.

With the help of precise planning and MRI scans, Petersen is able to target within a millimeter of accuracy exactly where she wants to place the electrodes in a patient’s brain. A patient is given numbing medication and is awake during the entire process so Petersen and her team can register any initial side effects, such as cramping or difficulty with speech, and document the decrease in shaking and other symptoms. A halo-style metal frame is used to secure the patient’s head during the procedure.

Part two of the deep brain procedure takes place about a week later when a small generator that serves as a battery pack is placed beneath the skin, just below the collarbone.

“Surgery is the easiest part,” says Rickman. “The surgery is not as bad as one might think it is. I would recommend it to people to go ahead and give it some more consideration than just a parting shot. I think that the surgery does work. I’m pretty amazed myself with what they did.”

Now, after instruction from Metzer, Rickman and his wife, Lena, know how to operate the device that turns off the deep brain stimulator when he goes to bed.

“Cool,” Lena said. “I can handle it.”