Deep Brain Stimulation: How It Works for Parkinson’s and Essential Tremor
One of the questions I hear most often from patients living with Parkinson’s disease or essential tremor is some version of, “I’ve heard about a brain surgery that can calm the shaking. Am I a candidate?” It is a fair question, and the honest answer is that deep brain stimulation (DBS) can be very effective, but only when it is offered to the right patient at the right point in their care. So before we talk about how DBS works, it helps to talk about who it is actually for.
At New Jersey Brain and Spine, DBS is almost never the first conversation we have. It is a therapy we consider after medications have been carefully optimized, or when the medications themselves are causing problems that are becoming just as limiting as the disease. Understanding that sequence is the key to understanding DBS.
Who Is a Candidate for Deep Brain Stimulation
DBS tends to be most appropriate for patients who have a clear, well-established diagnosis and who have already worked through medical management. In our experience, the strongest candidates usually share a few features:
- A confirmed diagnosis: For Parkinson’s, this typically means a patient whose symptoms have responded to levodopa at some point, even if that response has become inconsistent. For essential tremor, it means a tremor that has been evaluated and is not explained by another cause.
- Symptoms that remain limiting despite optimized medication: This might be tremor that breaks through medication, or “off” periods in Parkinson’s where symptoms return before the next dose.
- Medication side effects that have become their own problem: In Parkinson’s, long-term levodopa use can cause dyskinesias (involuntary, dance-like movements). For some patients, the side effects are as disruptive as the disease.
- Good general health for a surgical procedure, and realistic, well-informed expectations about what DBS can and cannot do.
DBS is not a first step and it is not a substitute for good medical management. It is a tool we reach for once medications have been pushed as far as they reasonably can, or when their side effects start to define a patient’s day.
While candidacy can vary quite a bit from person to person, one point is worth stating plainly. DBS generally does not help symptoms that never responded to medication in the first place, and it is not a cure. It does not stop Parkinson’s from progressing. What it can do, for the right patient, is allow better management of symptoms, reducing off times, motor fluctuations, dyskinesias, and/or tremor.
The Anatomy: What DBS Actually Targets
To understand DBS, it helps to picture the brain as having deep control centers that help coordinate smooth, steady movement. In Parkinson’s and essential tremor, the signaling in these circuits becomes disordered, producing tremor, stiffness, and slowness. DBS works by placing thin electrodes into very specific deep targets and delivering carefully tuned electrical pulses that help regulate that faulty signaling.
There are three targets we most commonly discuss:
- Subthalamic nucleus (STN): A small structure deep in the brain that is a common target for Parkinson’s disease. Stimulating it can improve tremor, stiffness, and slowness, and often allows some patients to reduce their medication.
- Globus pallidus interna (GPi): Another deep target used for Parkinson’s. It is often chosen when troublesome dyskinesias from medication are a major issue.
- VIM of the thalamus (ventral intermediate nucleus): The go-to target for essential tremor. It is very effective at suppressing the tremor itself.
Choosing among these targets is not a one-size-fits-all decision. It depends on the diagnosis, which symptoms are most disabling, medication history, and the individual patient’s goals.
A “Pacemaker for the Brain”
The way I most often describe DBS to patients is that it is like a pacemaker for the brain. The system has three parts working together:
- The electrodes (leads): Thin wires placed precisely into the target deep in the brain.
- The pulse generator: A small battery-powered device, similar to a cardiac pacemaker, implanted under the skin near the collarbone.
- The connecting wire: A thin extension that runs under the skin and links the electrodes to the pulse generator.
Once everything is in place and healed, the device delivers steady electrical pulses to the target. Just as important, the settings are adjustable. In the weeks and months after surgery, we program and fine-tune the stimulation to get the best control of symptoms with the fewest side effects. That tuning process is a real strength of DBS, and it is why the relationship with your care team continues well beyond the operating room.
What DBS Does and Does Not Do
Setting expectations is one of the most important parts of the evaluation.
What DBS can do:
- Reduce tremor, often dramatically, especially in essential tremor.
- Improve Parkinson’s symptoms that respond to medication, and extend the good “on” time in the day.
- Reduce medication-related dyskinesias and, in some Parkinson’s patients, allow a lower medication dose.
What DBS generally does not do:
- It is not a cure and does not halt disease progression.
- It usually does not help symptoms that never responded to levodopa in Parkinson’s, such as certain balance and speech problems.
- It does not eliminate the need for ongoing care and adjustment.
Parkinson’s Disease vs. Essential Tremor: How DBS Compares
Because these two conditions are often mentioned together, it helps to lay them side by side.
| Feature | Parkinson’s Disease | Essential Tremor |
|---|---|---|
| Common DBS target | Subthalamic nucleus (STN) or globus pallidus interna (GPi) | VIM of the thalamus |
| What DBS tends to help | Tremor, stiffness, slowness, “off” periods, and medication-related dyskinesias | The tremor itself, particularly action tremor of the hands |
| Relationship to medication | Considered after levodopa is optimized or when side effects like dyskinesia become limiting | Considered when tremor is disabling despite medication or when medication is not tolerated |
| What it does not fix | Balance, speech, and other features that do not respond to medication | Does not address other neurologic conditions; targeted at tremor |
| Typical candidate | Clear Parkinson’s diagnosis with levodopa response, still limited despite optimized medication | Confirmed essential tremor that meaningfully interferes with daily tasks like eating or writing |
Clinical Decision-Making: Two Patient Scenarios
DBS for Parkinson’s With Medication Fluctuations
Consider a patient in their mid-60s with Parkinson’s diagnosed several years earlier. Levodopa worked well at first, but over time the good windows grew shorter. By late morning, before the next dose, tremor and stiffness would return, and shortly after each dose, involuntary dyskinesias would set in. The medication was, in a sense, working too well and not well enough at the same time. After a thorough evaluation and confirmation of a strong levodopa response, our multidisciplinary team discussed DBS targeting the subthalamic nucleus. The goal was not to replace medication but to smooth out the peaks and valleys and reduce the dyskinesias that were shrinking the usable part of the day.
DBS for Medication-Resistant Essential Tremor
Now consider a patient in their 70s with a long history of essential tremor. The tremor was not painful, but it had quietly taken over daily life. Handwriting had become illegible, and eating soup in public was out of the question. Two different medications had been tried; one was ineffective and the other caused too much fatigue. Because the diagnosis was clear and the tremor was genuinely limiting despite reasonable medication trials, the team discussed DBS targeting the VIM of the thalamus, focused specifically on quieting the action tremor in the dominant hand.
Note: These patient scenarios are representative, hypothetical examples used for illustrative purposes. Because every patient and medical history is unique, actual treatment recommendations and surgical settings depend entirely on your individual health circumstances and a thorough evaluation by your care team.
The NJBS Approach: Individualized, Multidisciplinary Evaluation
Deciding on DBS is never a decision made from a single scan or a single visit. At New Jersey Brain and Spine, candidacy is worked out through a comprehensive, coordinated evaluation process. Rather than working in silos, our movement disorder neurologists and functional neurosurgeons work hand in hand, reviewing cases together to map out the best path forward for each individual.
During this evaluation, our collaborative team looks closely at the whole patient in front of us. We assess how your symptoms actually affect daily life, like walking, writing, eating, and working, rather than just looking at a static image or a lab value in isolation.
This team-based setting is where a specialist or second-opinion evaluation carries real value. By combining deep neurological and surgical expertise in one unified review, we can refine diagnoses, set honest expectations, and be certain of our surgical recommendations. It is this rigorous, shared evaluation process that ensures DBS, when we do recommend it, lands with the right patient at the right time.
When Should You See a Specialist About Deep Brain Stimulation?
If Parkinson’s disease or essential tremor continues to significantly interfere with daily life despite appropriately managed medication, or medication side effects have become difficult to tolerate, it may be time for a DBS evaluation. Seeing a specialist does not mean committing to surgery. The purpose of the evaluation is to determine whether DBS is appropriate and whether other treatment options should be optimized first.
When to Seek Care: Red Flags With an Implanted Device
Once a DBS system is in place, most day-to-day life returns to routine. Still, because this involves an implanted device, there are warning signs worth knowing.
Contact your care team promptly if you notice:
- Signs of infection near any incision or over the device, such as increasing redness, warmth, swelling, drainage, or fever.
- Hardware concerns, such as skin breakdown over the device or wire, the device feeling loose or eroding, or a sudden loss of symptom control that may suggest a battery or connection issue.
- A sudden, unexplained worsening of tremor, stiffness, or other symptoms.
With any implanted device, do not wait on signs of infection or a sudden change in how the system is working. Early evaluation is almost always easier than waiting.
And to be clear about the most serious situations: if you experience severe symptoms such as sudden weakness, difficulty speaking, a severe headache, a change in consciousness, or any other sign of a medical emergency, call 911 or seek immediate medical attention.
FREQUENTLY ASKED QUESTIONS
No. DBS is not a cure and it does not stop Parkinson’s from progressing. For the right patient, it can help improve symptom management, including reducing off times, motor fluctuations, dyskinesias, and/or tremor.
Often, yes, though the picture differs by condition. Some Parkinson’s patients are able to reduce their medication after DBS, while others continue at a lower dose. In essential tremor, DBS is typically aimed at controlling the tremor itself. Any medication changes are made gradually and with your care team.
Most patients spend one night in the hospital following the first stage of the DBS procedure. You can expect some mild discomfort at the incision sites, but the physical recovery is generally very manageable. It is important to know that the device is not turned on immediately; you will typically return to the office a few weeks later, after the brain has had time to heal, for your initial programming session.
The device is adjustable, and that is one of its strengths. Over the weeks and months after surgery, we program and fine-tune the pulses to balance the best symptom control against the fewest side effects. This is an ongoing relationship, not a single setting locked in forever.
Contact your care team promptly for signs of infection, skin problems over the hardware, or a sudden loss of symptom control. If you experience severe symptoms or believe you are having a medical emergency, call 911 or seek immediate medical attention.
SCHEDULE A CONSULTATION
NJBS serves patients across northern New Jersey and the greater tri-state area, with offices in Paramus, Hackensack, Montclair, Montvale, Annandale, and Englewood. No referral is required to schedule a consultation.
