NEUROMODULATION
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CARING FOR
SOMEONE WITH
ESSENTIAL TREMOR

HOW TO HELP YOUR LOVED ONE BETTER MANAGE THEIR SYMPTOMS

SHARING THE DAILY CHALLENGES OF ESSENTIAL TREMOR

For millions of adults, essential tremor makes simple, everyday tasks a daily struggle. And what can be just as difficult is providing daily care and support the challenges and frustrations of someone losing physical control of their movements.

If you’re one of those caregivers, you’re not alone: Essential tremor is among the most common movement disorders. But relief and control are possible, even when standard treatments don’t work or cause too many side effects. Keep reading to see what you can expect as a caregiver for someone with essential tremor – and when a specialist suggests that deep brain stimulation (DBS) therapy may provide the control your loved one needs.

CARING FOR A LOVED ONE WITH ESSENTIAL TREMOR

Symptoms of this common movement disorder include rhythmic shaking in your loved one’s hands, arms, legs or midsection, a quiver in your loved one’s voice, or problems writing or holding tools. Living with essential tremor can take the simplest activity – getting dressed, drinking coffee – and turn it into a frustrating trial for your loved one.

As their caregiver, your loved one will look to you to help support them through the everyday challenge of struggling with control of their movements. Here are some important steps the two of you can take together to manage the emotional, physical, and financial challenges of caring for someone with essential tremor.

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PHYSICAL SUPPORT

When your loved one is diagnosed with tremor, you both need to prepare the impact it can have on simple daily tasks. One of the first steps in addressing your loved one’s changing physical needs is to ask them how you can best help them. It might be useful to prompt them about the different kinds of tasks they perform every day. Some common places to start are household duties, errands, driving, or other activities made more difficult by tremor symptoms.

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EMOTIONAL SUPPORT

Essential tremor can affect even the simplest daily task, from eating and drinking to writing and driving. These changes can be hard for both of you to adapt to, and it may be distressing to your loved one to lose control of movements they rely on for simple everyday activities. Your understanding, patience, and support will be very important in helping your loved one adjust to the emotional challenges that come with decreasing control of their movements.

  • Be patient and encouraging. The symptoms of essential tremor can be embarrassing for your loved one. The symptoms of their condition are easy to mistake for clumsiness, and can leave people with this condition feeling awkward, frustrated, or worried about going out in public. Let your loved one know you understand and support them – and that you’ll never be embarrassed by or for them.
  • Offer support—and ask for it, too. Being the primary caregiver for a person with a movement disorder can be exhausting and stressful. It is crucial that you take care of yourself, so you can provide the level of support they need. Learn more about caring for yourself >
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FINANCIAL PREPARATION

Essential tremor can be a significant financial challenge for both of you. It can limit your loved one’s ability to work, and can keep you away from the workplace to provide support and care.

That’s why one of the most important steps a caregiver can take is to prepare financially, to understand your insurance coverage, and to plan ahead for costs and expenses related to your loved one’s treatment and care.

  • Know your coverage. Insurance can be complicated. If you need help understanding your coverage, many healthcare providers can help connect you with patient navigators or financial counselors who specialize in medical expenses. 

TRACKING THEIR TREATMENT

Another important way you can help your loved one manage their essential tremor is by helping them manage their treatment.

People with essential tremor often try several different kinds of therapies as their symptoms change over time. And as their symptoms and treatments change, you can play an important role in helping your loved one adapt to the varying schedules and doses these therapies require. And when other treatments don’t work well enough, or cause side effects your loved one can’t tolerate, you can help them decide when they may need to try a surgical treatment like DBS therapy.

Learn more about how you can help your loved one stay on top of their changing treatment for essential tremor >

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TRACKING THEIR TREATMENT

The symptoms of essential tremor develop in different ways for each person affected by the condition. And as your loved one’s condition changes over time, so will their treatment needs. As a caregiver, it is important for you to help your loved track and stay consistent with their changing therapies. Your perspective will be valuable in deciding when it’s time to think about different treatment options.

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KNOW THEIR TREATMENT SCHEDULE

Treatments for essential tremor are often focused on managing the symptoms of the condition, which can sometimes be affected by your loved one’s mood, diet, and even sleep.

Whether it’s medications or something else, caregivers play an important role in making sure their loved one follows through with their treatment regimen. Doing so can help you both: Using each treatment exactly as prescribed can help ensure your loved one gets the most relief and control possible, and potentially make your caregiving role easier, too.

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KNOW THEIR TREATMENT HISTORY

Make sure to keep track of your loved one’s treatments, including the results and any side effects.

While there’s no known cure for essential tremor, there are a number of different treatment options that can help your loved one manage the symptoms. By understanding your loved one’s prior therapies – what has worked and what hasn’t, as well as what medications they rely on – you’ll get a sense of what’s working, what hasn’t, and when a more intensive treatment option may make sense.

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KNOW WHEN THEY NEED A DIFFERENT KIND OF TREATMENT

If other treatments don’t work, you and your loved one may want to consider DBS therapy. DBS therapy is a personalized, adjustable therapy involving an implanted device that blocks electrical signals from targeted areas in the brain that cause the symptoms of essential tremor.

Keep reading to learn what caregivers need to know when your loved one may need DBS therapy >

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CONSIDERING DBS THERAPY

For almost 20 years, DBS therapy has proven to be an effective treatment option for movement disorders like essential tremor.1-3 DBS is a targeted, personalized, and reversible therapy that works by stimulating areas of the brain associated with involuntary movements. With DBS, your loved one may experience reduced tremors, greater control over their movements – so you both can get back to the things that really matter.

WHAT IS DBS THERAPY?

For people with essential tremor, DBS works much like a pacemaker does. But instead of providing mild pulses of electrical current to the heart, it uses an implanted generator and a thin wire called a lead to send mild electrical pulses straight to areas of the brain that cause involuntary movements. These pulses interrupt the signals that cause essential tremor symptoms.

If a neurologist or movement disorder specialist has recommended DBS therapy, here are some important things to know as you both consider this effective surgical therapy.

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HOW TO PREPARE FOR THE PROCEDURE

DBS therapy starts with a very specific and specialized surgery to implant the DBS system. It should be an exciting step for both of you, with the potential to help you and your loved one share a fuller life with their essential tremor. But it will also be a time when your loved one will need your support and assistance through a period of recovery and adjustment.

Talking with your care team. Before the implant procedure, you’ll meet with the surgeon to go over everything you need to know and help answer any remaining questions. The surgeon will want to review a few key things with both of you – such as when to stop eating or drinking before to the procedure, what medications can be taken and whether there are any they have to stop taking before the surgery.

Making a plan for surgery day. It’s always smart to bring a list of the medications they are currently using, including prescription and nonprescription medicines, herbs, and supplements. Think about how you’re going to keep yourself comfortable and occupied that day, whether it’s a book, your tablet, or a hobby you can do while you wait. Also, make plans for someone to drive your loved one to and from the procedure – they won’t be allowed to drive themselves.

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WHAT TO EXPECT THE DAY OF THE PROCEDURE

The day of the surgery is a big step in your loved one’s future – and for you as caregiver. It is important to be organized and ready, so that both the procedure and the recovery process go as smoothly and with as little stress as possible. Learn more about what this specialized surgery involves >

Gather important information like the address, phone number, and parking instructions of the surgery location. Help them pack a bag that includes:

  • At least a week’s supply of all their medications in their original, labeled bottles and a list of medication names, dosages, and times taken
  • Personal effects like photos or reading materials to keep you occupied before and after surgery
  • Names and phone numbers of people to contact in case of an emergency

If your loved one is anxious about the surgery, you may offer suggestions to help them relax, such as quiet meditation, mindful breathing, or listening to music. Just remember: DBS therapy is a proven safe and effective treatment option that has helped over 120,000 people worldwide.1, 2

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ABOUT YOUR LOVED ONE’S RECOVERY

After being released from the hospital, they’ll take some time to heal. Your loved one may be able to eat regular meals, get up, and move around. Before you leave the hospital, your doctor will provide detailed instructions on activities to encourage that will aid recovery, as well as activities to avoid. Learn more about recovery after the DBS therapy procedure >

Within a few weeks, they’ll start to adjust to their new implanted therapy – and to have better control of their movements and their daily activities. As the DBS therapy begins to take effect and they get better control of their essential tremor, the two of you should be able to enjoy more and more freedom and confidence in your daily activities.

FINDING SUPPORT FOR YOUR NEXT STEPS FORWARD

Receiving deep brain stimulation (DBS) for essential tremor can help support a more fulfilling, independent life for both of you. As your loved one adjusts to the DBS system, they’ll gain more control over symptoms and feel more confident in daily activities.

As a caregiver, your needs will evolve along with your loved one’s symptoms. Always remember that your role will evolve as your journey together continues. Take advantage of the many resources available for caregivers for people with essential tremor – and let Abbott help you find the ones you need.

Learn more about how and when to look for family, community, and professional support for your loved one >

Learn more about understanding and finding the support you need for your own well-being >

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MORE MOVEMENT DISORDER RESOURCES

Caring for someone with Parkinson’s disease or essential tremor? Find more helpful information, guidance, and inspiration for you and your loved one.

 

References:
  1. “Premarket Approval (PMA).” U.S. Food and Drug Administration (FDA) P960009, 31 July 1997, https://www.accessdata.fda.gov/cdrh_docs/pdf/p960009.pdf.
  2. Fukaya, C., & Yamamoto, T. (2015). Deep brain stimulation for Parkinson’s disease: Recent trends and future direction. Neurologia Medico-Chirurgica (Tokyo), 55(5), 422-431. http://dx.doi.org/10.2176/nmc.ra.2014-0446
  3. Abbott. Essential Tremor Final Report C-04-02. 2014. n = 127.
IMPORTANT SAFETY INFORMATION

DEEP BRAIN STIMULATION

St. Jude Medical is now Abbott Medical

Prescription and Safety Information

Read this section to gather important prescription and safety information. For specific indications, contraindications, instructions, warnings, precautions, and adverse effects about system components available in your country or region, see the approved clinician's manual for those components.

Intended Use

This neurostimulation system is designed to deliver low-intensity electrical impulses to nerve structures. The system is intended to be used with leads and associated extensions that are compatible with the system.

Indications for Use

United States:

The neurostimulation system is indicated for the following conditions:

  • Bilateral stimulation of the subthalamic nucleus (STN) as an adjunctive therapy to reduce some of the symptoms of advanced levodopa-responsive Parkinson’s disease that are not adequately controlled by medications.
  • Unilateral or bilateral stimulation of the ventral intermediate nucleus (VIM) of the thalamus for the suppression of disabling upper extremity tremor in adult essential tremor patients whose tremor is not adequately controlled by medications and where the tremor constitutes a significant functional disability.

International:

The neurostimulation system is indicated for the following conditions:

  • Unilateral or bilateral stimulation of the thalamus, internal globus pallidus (GPi), or subthalamic nucleus (STN) in patients with levodopa-responsive Parkinson’s disease.
  • Unilateral or bilateral stimulation of the ventral intermediate nucleus (VIM) of the thalamus for the management of disabling tremor.
  • Unilateral or bilateral stimulation of the internal globus pallidus (GPi) or the subthalamic nucleus (STN) for the management of intractable, chronic dystonia, including primary and secondary dystonia, for patients who are at least 7 years old.

Contraindications

United States:

This system is contraindicated for patients who meet the following criteria:

  • Are unable to operate the system
  • Have unsuccessful test stimulation

The following procedures are contraindicated for patients with a deep brain stimulation system. Advise patients to inform their healthcare professional that they cannot undergo the following procedures:

  • Diathermy (short-wave diathermy, microwave diathermy, or therapeutic ultrasound diathermy)
  • Electroshock therapy and transcranial magnetic stimulation (TMS)

International:

Implantation of this neurostimulation system is contraindicated for the following:

  • Patients for whom test stimulation is unsuccessful.
  • Patients who are unable to properly operate the system.

The following procedures are contraindicated for patients that have been implanted with this device:

Diathermy therapy. Do not use short-wave diathermy, microwave diathermy, or therapeutic ultrasound diathermy (all now referred to as diathermy) on patients implanted with a neurostimulation system. Energy from diathermy can be transferred through the implanted system and can cause tissue damage at the location of the implanted electrodes, resulting in a severe injury or death. Diathermy is further prohibited because it may also damage the neurostimulation system components. This damage could result in loss of therapy, requiring additional surgery for system replacement. Injury or damage can occur during diathermy treatment whether the neurostimulation system is turned on or off. All patients are advised to inform their healthcare professional that they should not be exposed to diathermy treatment.

MRI Safety Information

Some models of this system are Magnetic Resonance (MR) Conditional, and patients with these devices may be scanned safely with magnetic resonance imaging (MRI) when the conditions for safe scanning are met. Scanning under different conditions may cause device malfunction, severe patient injury, or death. For more information about MR Conditional deep brain stimulation (DBS) components and systems, including equipment settings, scanning procedures, and a complete listing of conditionally approved components, refer to the MRI procedures clinician's manual for DBS systems (available online at manuals.sjm.com). For more information about MR Conditional products, visit the Abbott product information page at sjm.com/MRIReady.

Warnings

The following warnings apply to this neurostimulation system.

Pregnancy and nursing. Safety and effectiveness of neurostimulation for use during pregnancy and nursing have not been established. Patients should not use this neurostimulation system if they are pregnant or nursing.

Magnetic resonance imaging (MRI). Some patients may be implanted with the components that make up a Magnetic Resonance (MR) Conditional system, which allows them to receive an MRI scan if all the requirements for the implanted components and for scanning are met. A physician can help determine if a patient is eligible to receive an MRI scan by following the requirements provided by Abbott Medical. Physicians should also discuss any risks of MRI with patients.

If any component of the implanted neurostimulation system, such as an IPG, lead, or extension, does not meet the requirements for an MR Conditional system, do not perform an MRI scan. If a system does not meet the MR Conditional requirements, consider it MR Unsafe.

High stimulation outputs and charge density limits. Avoid excessive stimulation. A risk of brain tissue damage exists with parameter settings using high amplitudes and wide pulse widths. High amplitudes and wide pulse widths should only be programmed with due consideration of the warnings concerning charge densities. The system can be programmed to use parameter settings outside the range of those used in the clinical studies. If the programming of stimulation parameters exceeds the charge density limit of 30 μC/cm2, a screen will appear warning you that the charge density is too high. Charge density can be reduced by lowering the stimulation amplitude or pulse width. For more information, see the clinician programmer manual.

Higher amplitudes and wider pulse widths may indicate a system problem or a suboptimal lead placement. Stimulation at high outputs may cause unpleasant sensations or motor disturbances or may render the patient incapable of controlling the patient controller. If unpleasant sensations occur, the device should be turned off immediately using the patient magnet.

Risk of depression, suicidal ideations, and suicide. Depression, suicidal ideation, and suicide have been reported in patients receiving deep brain stimulation therapy for movement disorders, although no direct cause and effect relationship has been established. Preoperatively assess patients for suicide risk and carefully balance this risk with the potential clinical benefit. Postoperatively monitor patients for the presence of any of the following symptoms and manage these symptoms appropriately: depression, suicidal thoughts or behaviors, changes in mood, and impulse control. Emphasize the importance of sustained follow-up and support with all patients and their caregivers and family members.

Poor surgical risks. Neurostimulation should not be used on patients who are poor surgical risks or patients with multiple illnesses or active general infections.

Explosive or flammable gases. Do not use the clinician programmer or patient controller in an environment where explosive or flammable gas fumes or vapors are present. The operation of the clinician programmer or patient controller could cause them to ignite, causing severe burns, injury, or death.

Operation of machinery and equipment. Patients should not operate potentially dangerous machinery, power tools, or vehicles or engage in any activity that could be unsafe if their symptoms were to unexpectedly return.

Device components. The use of components not approved for use by Abbott Medical with this system may result in damage to the system and increased risk to the patient.

Electrosurgery. To avoid harming the patient or damaging the neurostimulation system, do not use monopolar electrosurgery devices on patients with implanted neurostimulation systems. Before using an electrosurgery device, place the device in Surgery Mode using the patient controller app or clinician programmer app. Confirm the neurostimulation system is functioning correctly after the procedure.

During implant procedures, if electrosurgery devices must be used, take the following actions:

  • Use bipolar electrosurgery only.
  • Complete any electrosurgery procedures before connecting the leads or extensions to the neurostimulator.
  • Keep the current paths from the electrosurgery device as far from the neurostimulation system as possible.
  • Set the electrosurgery device to the lowest possible energy setting.
  • Confirm that the neurostimulation system is functioning correctly during the implant procedure and before closing the neurostimulator pocket.

Radiofrequency or microwave ablation. Careful consideration should be used before using radiofrequency (RF) or microwave ablation in patients who have an implanted neurostimulation system since safety has not been established. Induced electrical currents may cause heating, especially at the lead electrode site, resulting in tissue damage.

Implanted cardiac systems. Physicians need to be aware of the risk and possible interaction between a neurostimulation system and an implanted cardiac system, such as a pacemaker or defibrillator. Electrical pulses from a neurostimulation system may interact with the sensing operation of an implanted cardiac system, causing the cardiac system to respond inappropriately. To minimize or prevent the implanted cardiac system from sensing the output of the neurostimulation system, (1) maximize the distance between the implanted systems; (2) verify that the neurostimulation system is not interfering with the functions of the implanted cardiac system; and (3) avoid programming either device in a unipolar mode (using the device’s can as an anode) or using neurostimulation system settings that interfere with the function of the implantable cardiac system.

Other active implanted devices. The neurostimulation system may interfere with the normal operation of another active implanted device, such as a pacemaker, defibrillator, or another type of neurostimulator. Conversely, the other active implanted device may interfere with the operation of the neurostimulation system.

Case damage. If the case of the implantable pulse generator (IPG) is pierced or ruptured, severe burns could result from exposure to battery chemicals.

Cremation. The IPG should be explanted before cremation because the IPG could explode. Return the explanted IPG to Abbott Medical.

Component disposal. Return all explanted components to Abbott Medical for safe disposal. IPGs contain batteries as well as other potentially hazardous materials. Do not crush, puncture, or burn the IPG because explosion or fire may result.

Coagulopathies. Physicians should use extreme care with lead implantation in patients with a heightened risk of intracranial hemorrhage. Physicians should also consider underlying factors, such as previous neurological injury or prescribed medications (anticoagulants), that may predispose a patient to the risk of bleeding.

Low frequencies. Stimulation frequencies at less than 30 Hz may cause tremor to be driven (meaning that tremor occurs at the same frequency as the programmed frequency). For this reason, programming at frequencies less than 30 Hz is not recommended.

IPG placement. The IPG should be placed into the pocket, at a depth not to exceed 4 cm (1.57 in), with the logo side facing toward the skin surface. Placing the IPG deeper than 4 cm (1.57 in) can impede or prohibit IPG communications with the clinician programmer or patient controller.

Return of symptoms and rebound effect. The abrupt cessation of stimulation for any reason will probably cause disease symptoms to return. In some cases, symptoms may return with a greater intensity than what a patient experienced before system implantation (rebound effect). In rare cases, this can create a medical emergency.

Precautions

The following precautions apply to this neurostimulation system.

General Precautions

Surgeon training. Implanting physicians should be experienced in stereotactic and functional neurosurgery.

Clinician training. Clinicians should be familiar with deep brain stimulation therapy and be experienced in the diagnosis and treatment of the indication for which the deep brain stimulation components are being used.

Patient selection. Select patients appropriately for deep brain stimulation. The patient should be able and willing to use the patient controller and correctly interpret the icons and messages that appear on the screen.

Especially consider the following additional factors when selecting patients:

  • Level of available support from a caregiver.
  • Expected effect from cessation of therapy, should disease symptoms return unexpectedly.
  • Patient's age, as very young or very old patients may have difficulty performing required monitoring of the device.
  • Patient's mental capacity, as patients with cognitive impairment or those prone to developing dementia would likely have difficulty performing device-related tasks without assistance.
  • Patient's physical ability, as patients with higher degrees of motor impairment might have difficulty with the physical requirements of monitoring the device.
  • Patient's visual ability to read the patient controller screen.

Infection. Follow proper infection control procedures. Infections may require that the device be explanted.

Electromagnetic interference (EMI). Some equipment in home, work, medical, and public environments can generate EMI that is strong enough to interfere with the operation of a neurostimulation system or damage system components. Patients should avoid getting too close to these types of EMI sources, which include the following examples: commercial electrical equipment (such as arc welders and induction furnaces), communication equipment (such as microwave transmitters and high-power amateur transmitters), high-voltage power lines, radiofrequency identification (RFID) devices, and some medical procedures (such as therapeutic radiation and electromagnetic lithotripsy).

Security, antitheft, and radiofrequency identification (RFID) devices. Some antitheft devices, such as those used at entrances or exits of department stores, libraries, and other public places, and airport security screening devices may affect stimulation. Additionally, RFID devices, which are often used to read identification badges, as well as some tag deactivation devices, such as those used at payment counters at stores and loan desks at libraries, may also affect stimulation. Patients should cautiously approach such devices and should request help to bypass them. If they must go through or near a gate or doorway containing this type of device, patients should move quickly and then check their IPG to determine if it is turned on or off.

Unauthorized changes to stimulation parameters. Caution patients to not make unauthorized changes to physician-established stimulation parameters.

Damage to shallow implants. Falling and other traumatic accidents can damage shallowly implanted components such as the leads and extensions.

Keep programmers and controllers dry. The clinician programmer and patient controller are not waterproof. Keep them dry to avoid damage. Advise patients to not use the patient controller when engaging in activities that might cause it to get wet, such as swimming or bathing.

Handle the programmers and controllers with care. The clinician programmer and patient controllers are sensitive electronic devices that can be damaged by rough handling, such as dropping them on the ground.

Battery care. Batteries can explode, leak, or melt if disassembled, shorted (when battery connections contact metal), or exposed to high temperature or fire.

Long-term safety and effectiveness. The long-term safety and effectiveness of this neurostimulation system has not been established beyond 5 years. Safety and effectiveness has not been established for patients with a neurological disease other than Parkinson’s disease or essential tremor, previous surgical ablation procedures, dementia, coagulopathies, or moderate to severe depression; patients under 22 years; implantation in targets other than the STN for Parkinson's disease and the VIM for essential tremor; patients with an active implantable device; patients requiring MRI.

Sterilization and Storage

Single-use, sterile device. The implanted components of this neurostimulation system are intended for a single use only. Sterile components in this kit have been sterilized using ethylene oxide (EtO) gas before shipment and are supplied in sterile packaging to permit direct introduction into the sterile field. Do not resterilize or reimplant an explanted system for any reason.

Storage environment. Store components and their packaging where they will not come in contact with liquids of any kind. Detailed information on storage environment is provided in the appendix of this manual.

Handling and Implantation

Expiration date. An expiration date (or “use-before” date) is printed on the packaging. Do not use the system if the use-before date has expired.

Care and handling of components. Use extreme care when handling system components. Excessive heat, excessive traction, excessive bending, excessive twisting, or the use of sharp instruments may damage and cause failure of the components.

Package or component damage. Do not implant a device if the sterile package or components show signs of damage, if the sterile seal is ruptured, or if contamination is suspected for any reason. Return any suspect components to Abbott Medical for evaluation.

Exposure to body fluids or saline. Prior to connection, exposure of the metal contacts, such as those on the connection end of a lead or extension, to body fluids or saline can lead to corrosion. If such exposure occurs, clean the affected parts with sterile, deionized water or sterile water for irrigation, and dry them completely prior to lead connection and implantation.

Skin erosion. To avoid the risk of skin erosion, implant components at the appropriate depth and inform patients to avoid touching their skin where components are implanted. The IPG should be placed into the pocket, at a depth not to exceed 4.0 cm (1.57 in), with the logo side facing toward the skin surface.

System testing. To ensure correct operation, always test the system during the implant procedure, before closing the neurostimulator pocket, and before the patient leaves the surgery suite.

Device modification. The equipment is not serviceable by the customer. To prevent injury or damage to the system, do not modify the equipment. If needed, return the equipment to Abbott Medical for service.

Multiple leads. When multiple leads are implanted, route the lead extensions so the area between them is minimized. If the lead extensions are routed in a loop, the loop will increase the potential for electromagnetic interference (EMI).

Abandoned leads and replacement leads. The long-term safety associated with multiple implants, leads left in place without use, replacement of leads, multiple implants into the target structure, and lead explant is unknown.

Placement of lead connection in neck. The lead-extension connector should not be placed in the soft tissues of the neck due to an increased incidence of lead fracture.

Hospital and Medical Environments

Electrical medical treatment. In the case that a medical treatment is administered where an electrical current is passed through the body from an external source, first deactivate the IPG by setting all electrodes to off, turning stimulation off, and setting amplitude to zero. Regardless if the device is deactivated, take care to monitor the device for proper function during and after treatment.

High-output ultrasonics and lithotripsy. The use of high-output devices, such as an electrohydraulic lithotriptor, may cause damage to the electronic circuitry of an implanted IPG. If lithotripsy must be used, do not focus the energy near the IPG.

Ultrasonic scanning equipment. The use of ultrasonic scanning equipment may cause mechanical damage to an implanted neurostimulation system if used directly over the implanted system.

External defibrillators. The safety of discharge of an external defibrillator on patients with implanted neurostimulation systems has not been established.

Therapeutic radiation. Therapeutic radiation may damage the electronic circuitry of an implanted neurostimulation system, although no testing has been done and no definite information on radiation effects is available. Sources of therapeutic radiation include therapeutic X rays, cobalt machines, and linear accelerators. If radiation therapy is required, the area over the implanted IPG should be shielded with lead. Damage to the system may not be immediately detectable.

Electrocardiograms. Ensure the neurostimulator is off before initiating an electrocardiogram (ECG). If the neurostimulator is on during an ECG, the ECG recording may be adversely affected, resulting in inaccurate ECG results. Inaccurate ECG results may lead to inappropriate treatment of the patient.

Home and Occupational Environments

Patient activities and environmental precautions. Patients should take reasonable care to avoid devices that generate strong EMI, which may cause the neurostimulation system to unintentionally turn on or off. Patients should also avoid any activities that would be potentially unsafe if their symptoms were to return unexpectedly. These activities include but are not limited to climbing ladders and operating potentially dangerous machinery, power tools, and vehicles. Sudden loss of stimulation may cause patients to fall or lose control of equipment or vehicles, injure others, or bring injury upon themselves.

Control of the patient controller. Advise patients to keep the patient controller away from children and pets in order to avoid potential damage or other hazards.

Activities requiring excessive twisting or stretching. Patients should avoid activities that may put undue stress on the implanted components of the neurostimulation system. Activities that include sudden, excessive or repetitive bending, twisting, or stretching can cause component fracture or dislodgement. Component fracture or dislodgement may result in loss of stimulation, intermittent stimulation, stimulation at the fracture site, and additional surgery to replace or reposition the component.

Component manipulation by patient. Advise your patient to avoid manipulating the implanted system components (e.g., the neurostimulator, the burr hole site). This can result in component damage, lead dislodgement, skin erosion, or stimulation at the implant site. Manipulation may cause device inversion, inhibiting the ability to use the magnet to start or stop stimulation.

Scuba diving or hyperbaric chambers. Patients should not dive below 30 m (100 ft) of water or enter hyperbaric chambers above 4.0 atmospheres absolute (ATA). Pressures below 30 m (100 ft) of water (or above 4.0 ATA) could damage the neurostimulation system. Before diving or using a hyperbaric chamber, patients should discuss the effects of high pressure with their physician.

Skydiving, skiing, or hiking in the mountains. High altitudes should not affect the neurostimulator; however, the patient should consider the movements involved in any planned activity and take precautions to avoid putting undue stress on the implanted system. Patients should be aware that during skydiving, the sudden jerking that occurs when the parachute opens may cause lead dislodgement or fractures, which may require surgery to repair or replace the lead.

Wireless use restrictions. In some environments, the use of wireless functions (e.g., Bluetooth® wireless technology) may be restricted. Such restrictions may apply aboard airplanes, near explosives, or in hazardous locations. If you are unsure of the policy that applies to the use of this device, please ask for authorization to use it before turning it on. (Bluetooth® is a registered trademark of Bluetooth SIG, Inc.)

Mobile phones. The effect of mobile phones on deep brain stimulation is unknown. Patients should be advised to avoid carrying mobile phones in their shirt pocket or otherwise placing them directly over the deep brain stimulation system components. If interference occurs, try holding the phone to the other ear or turning off the phone.

Household appliances. Household appliances that contain magnets (e.g., refrigerators, freezers, inductive cooktops, stereo speakers, mobile telephones, cordless telephones, standard wired telephones, AM/FM radios, and some power tools) may unintentionally cause the neurostimulation system to turn on or turn off.

Therapeutic magnets. Patients should be advised to not use therapeutic magnets. Therapeutic magnets (e.g., magnets used in pillows, mattress pads, back belts, knee braces, wrist bands, and insoles) may unintentionally cause the neurostimulation system to turn on or off.

Adverse Effects

Deep brain stimulation potentially has the following adverse effects:

Possible surgical complications. Surgical complications include, but are not limited to, the following: intracranial hemorrhage (which can lead to stroke, paralysis, or death); subcutaneous hemorrhage or seroma; hematoma; cerebrospinal fluid leakage or cerebrospinal fluid abnormality; brain contusion; infection or inflammation; antibiotic anaphylaxis; skin disorder; edema; persistent pain at surgery site or IPG site; erosion; brachial plexus injury (nerves to chest, shoulder and arm); postoperative pain, stress, or discomfort; neuropathy (nerve degeneration); hemiparesis (muscular weakness or partial paralysis on one side of body); ballism or hemiballism (uncontrollable movements on both or only one side of the body); confusion—transient, nocturnal or ongoing; cognitive impairment, including delirium, dementia, disorientation, psychosis and speech difficulties; aphasia; deep vein thrombosis; complications from anesthesia; phlebitis (vein inflammation); pulmonary embolism (sudden blood vessel obstruction); aborted procedures (air embolism, unable to find target, surgical complication, etc.); complications from unusual physiological variations in patients, including foreign body rejection phenomena; pneumonia, seizure or convulsions; paralysis (loss of motor function, inability to move); stroke and death.

Possible deep brain stimulation complications. Deep brain stimulation complications include, but are not limited to, the following:

  • Device-related complications

            -   Undesirable changes in stimulation related to cellular changes in tissue around the electrodes, changes in the                           electrode position, loose electrical connections, or lead fracture

            -   Loss of therapeutic benefit as a result of change in electrode positions, loose electrical connections, or lead or                           extension fracture

            -   Initial jolt or tingling during stimulation; jolting or shocking sensations

            -   Infection

            -   Paresthesia

            -   Lead fracture, migration, or dislodgement

            -   Misplaced lead

            -   Extension malfunction, fracture, or disconnect

            -   Deep brain stimulation system failure or battery failure within the device

            -   Deep brain stimulation system malfunction or dislodgement

            -   Spontaneous turning on or off of the IPG

            -   Allergic or rejection response to implanted materials

            -   Persistent pain, tightness, or redness at the incision sites or general pain

            -   General erosion or local skin erosion over the IPG

            -   Persistent pain, tightness, or discomfort around the implanted parts (e.g., along the extension path in the neck)

            -   Impaired wound healing (e.g., incision site drainage) or abscess formation

            -   Additional neurosurgical procedure to manage one of the above complications or to replace a malfunctioning                          component

  • Stimulation-related complications or other complications

            -   Worsening of motor impairment and Parkinson’s disease symptoms including dyskinesia, rigidity, akinesia or                           bradykinesia, myoclonus, motor fluctuations, abnormal gait or incoordination, ataxia, tremor, and dysphasia

            -   Paresis, asthenia, hemiplegia, or hemiparesis

            -   Dystonia

            -   Sensory disturbance or impairment including neuropathy, neuralgia, sensory deficit, headache, and hearing and                     visual disturbance

            -   Speech or language impairment including, aphasia, dysphagia, dysarthria, and hypophonia

            -   Cognitive impairment including attention deficit, confusion, disorientation, abnormal thinking, hallucinations,                        amnesia, delusions, dementia, inability to act or make decisions, psychic akinesia, long term memory impairment,                  psychiatric disturbances, depression, irritability or fatigue, mania or hypomania, psychosis, aggression, emotional                  lability, sleep disturbance, anxiety, apathy, drowsiness, alteration of mentation, postural instability and                                      disequilibrium

            -   Restless leg syndrome

            -   Supranuclear gaze palsy

            -   Hypersexuality or increased libido

            -   Decreased therapeutic response

            -   Urinary incontinence or retention

            -   Diarrhea or constipation

            -   Cardiac dysfunction (e.g., hypotension, heart rate changes, or syncope)

            -   Difficulty breathing

            -   Increased salivation

            -   Weight gain or loss

            -   Eye disorder including eye apraxia or blepharospasm

            -   Nausea or vomiting

            -   Sweating

            -   Fever

            -   Hiccups

            -   Cough

            -   Cramps

            -   Worsening existing medical conditions

SJM-NWEB-0818-0198a

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