Our ProgramThe USC Parkinson’s Disease and Movement Disorder Center at Keck Medicine of USC in Los Angeles is the most comprehensive center in Southern California for Parkinson’s disease and other movement disorders. Our team is a unique collaboration of health-care professionals who deliver the highest quality care to ensure the most successful outcomes in our patients. We also are a National Parkinson Foundation Center of Excellence and home to the largest clinical trials program in Southern California for Parkinson’s disease and dystonia.
Our commitment to providing compassionate, comprehensive and customized care is reflected in the care we provide to our patients. Following are conditions we commonly see at our center:
- Parkinson’s disease and other parkinsonian syndromes
- Essential tremor
- Tourette’s syndrome and other tic disorders
- Huntington’s disease
- Myoclonus and other disorders of movement
The USC Parkinson’s Disease and Movement Disorder Center at Keck Medicine of USC in Los Angeles takes a multidisciplinary approach to treatment. Patients receive a wide range of medical care from our neurologists, neurosurgeons and nurse practitioners, but also can receive subspecialized services from clinical psychologists, social workers, speech therapists, occupational and physical therapists. As part of a major university-affiliated medical center, patients can also participate in clinical trials that lead to new developments in treatments. We also offer deep brain stimulation (DBS), in collaboration with the USC Deep Brain Stimulation Center, for those patients whose symptoms are not responding to otherwise useful medications.
As a Parkinson’s Foundation Center of Excellence – a designation bestowed on only 39 medical centers nationwide – we are recognized by peer institutions for our leadership in research, comprehensive care delivery, professional education and patient outreach services. The USC Parkinson’s Disease and Movement Disorder Center at Keck Medicine of USC is the only Center of Excellence in Southern California.
The Parkinson’s Disease and Movement Disorder Center at Keck Medical Center of USC in Los Angeles diagnoses and treats diseases that cause abnormal movement and impairment of movement, such as Parkinson’s disease, essential tremor, dystonia, tics and chorea.
Chorea is a type of abnormal movement. It is present in a variety of neurological illnesses. Most of the movements are rapid, jerky and small. The movements can seem to flow from one part of the body to another, but generally seem unpredictable. The movements usually worsen when walking, causing a jerky, dance-like gait. It is common for someone with chorea to be mistaken for being drunk. One type of Chorea is Huntington’s disease.
Dystonia is an abnormal muscle contraction that occurs in various diseases. The term specifically refers to frequent abnormal muscle contractions with a twisting quality. These movements can be fast enough to resemble a tremor. Disorders with dystonic movements are classified in several different ways. Classifications include: the cause of the dystonia (primary vs. secondary); the body part(s) affected by the movements (focal vs. segmental vs. multifocal vs. hemibody vs. generalized); and the age of onset (childhood vs. adulthood).
An essential tremor is a regular, rhythmic shaking movement. It is also known by other names, including: benign tremor, familial tremor, benign essential tremor, benign familial tremor and other combinations of these terms. It is the most common form of tremor, affecting five percent of the population. Essential tremor tends to worsen gradually, but this process can be so slow that many patients do not notice any progression, even over many years. Some patients with essential tremor have handwriting that is a shaky and sometimes illegible. Patients often have trouble using eating utensils or drinking liquids because everything spills. These problems are worsened by stress.
Huntington’s disease is a neurological disorder that causes degeneration of parts of the brain. It is hereditary, and a child has a 50 percent chance of getting the disease from a parent who carries the gene for the disease. The disease leads to chorea, deterioration of higher thinking and changes in behavior (psychiatric and psychological problems). The main movement problem is chorea, but in the late stages of the disease, the abnormal movements calm down, and the patient develops parkinsonism (see section on Parkinson’s disease). Patients with mild or moderate Huntington’s disease have abnormal, involuntary, extra movements, whereas patients with advanced disease have stiffness, slowness and loss of movement.
Other symptoms of Huntington’s disease include cognitive deterioration (dementia) and changes in behavior. The behavior changes can vary widely, but some of the common problems are: depression, alcoholism, hypersexuality and disinhibition (performing socially inappropriate acts). The symptoms of Huntington’s disease gradually worsen over time. Unfortunately, Huntington’s disease has no cure, and there are few treatments.
Parkinson’s disease is a neurologic disorder that causes degeneration of parts of the brain, which result in movement abnormalities. It affects about one percent of all people over 55 years of age. The main movement problems are slowness of movement (bradykinesia); involuntary shaking parts of the body, usually a limb, (rest tremor); muscle stiffness (rigidity); and abnormalities of walking and balance. Other symptoms separate from the movement problems can arise as well, such as constipation, sleep difficulties, loss of sense of smell/taste, depression and lightheadedness. The symptoms of Parkinson’s disease gradually worsen over time. The cause of Parkinson’s disease is not known, but is widely believed to involve a combination of both genetic factors and exposure to a triggering toxin or other event. Parkinson’s disease has no cure, but there are many treatments that are effective.
Tourette’s syndrome (TS) is a neurological disorder characterized by repetitive, stereotyped, involuntary movements and vocalizations called tics. The early symptoms of TS are typically noticed first in childhood, with the average onset between the ages of 3 and 9 years. Simple motor tics are sudden, brief, repetitive movements. More common simple tics include eye blinking and other eye movements, facial grimacing, shoulder shrugging, and head or shoulder jerking. Simple vocalizations might include repetitive throat-clearing, sniffing or grunting sounds. Complex tics are distinct, coordinated patterns of movements involving several muscle groups. Complex motor tics might include facial grimacing combined with a head twist and a shoulder shrug. Other complex motor tics may actually appear purposeful, including sniffing or touching objects, hopping, jumping, bending, or twisting. Simple vocal tics may include throat-clearing, sniffing/snorting, grunting or barking.
The causes of tics and Tourette’s are largely unknown. If the movements are not harmful to the patient or others, often no treatment is necessary. No single medication is helpful to all patients with these disorders.
Treatments and Services
The Parkinson’s Disease and Movement Disorder Center at Keck Medical Center of USC in Los Angeles is a National Parkinson Foundation Center of Excellence. Our neurologists, neurosurgeons, psychiatrists, nurse practitioners, clinical psychologists, neuropsychologists and social workers work together to diagnose and treat patients with Parkinson’s disease, essential tremor, dystonia, Tourette’s syndrome and other tic disorders, myoclonus, Huntington’s disease, ataxia and other movement disorders.
Parkinson’s disease can be treated with medications, physical and occupational therapy, exercise and brain surgery. Treatments for Parkinson’s do not cure the disease, but manage the symptoms. The treatment strategy is individualized for each patient.
Nearly every patient with Parkinson’s disease is treated with levodopa at some point in his or her therapy. Levodopa (Sinemet®) is the biochemical precursor for dopamine. Sinemet® replenishes dopamine.
Some studies suggest that rasagiline might slow the progression of Parkinson’s disease. Rasagiline prevents the breakdown of dopamine by the enzyme MAO, and prevents the formation of free radicals that are normally made during this chemical reaction.
Entacapone (Comtan®), or Tolcapone (Tasmar®) prevents the breakdown of dopamine by the enzyme COMT. These drugs enhance the effects of levodopa, but have no affect without levodopa.
Early in the course of the disease, each dose of levodopa works for many hours, sometimes seeming to have a good effect lasting the whole day. As the disease progresses, the duration of benefit from each dose shortens, so that the effect starts to wane after several hours. This phenomenon is known as “wearing off.” Some patients need to take their doses at shorter and shorter intervals in order to continue to remain mobile and functional. Some drugs can help extend the effects of levodopa. When wearing off becomes severe and can no longer be controlled with medications, treatment with deep brain stimulation can be considered.
Dopamine agonists, alternatively, are a different class of drugs than levodopa. Dopamine agonists, which include brands such as Apokyn®, Mirapex®, Requip® and Neupro®, may be used as initial treatments for certain Parkinson’s disease patients. They stimulate the receptors in nerves in the brain that would normally be stimulated by dopamine.
Amantadine is sometimes used to treat patients who are in the early stages of Parkinson’s disease. Amantadine may be used alongside levodopa in later stages of Parkinson’s disease to reduce dyskinesia, the impairment of voluntary movement. This medication is used to treat the symptoms of Parkinson’s disease.
Artane® (Trihexyphenidyl Hcl) is used to treat the stiffness, tremors, spasms and poor muscle control of Parkinson’s disease. It may also assist patients with improved walking ability.
When medical treatment can no longer control the symptoms of Parkinson’s disease, or when side effects of medications are intolerable, treatment with a surgical procedure is an option.
In deep brain stimulation (DBS), an electrode is permanently implanted in the brain and a low-intensity current is continually pulsed. DBS is a reversible and adjustable surgical treatment. For more information about the Deep Brain Stimulation Center, click here.
Essential Tremor Treatments
Essential tremor can be treated with medications, physical and occupational therapy, and brain surgery. None of these treatments are a cure. If medications do not control the tremor and the severity is bothersome enough, implantation of a deep-brain stimulator if often the next step.
Primidone (Mysoline®) is an anti-seizure drug that has been found useful for essential tremor. It can be sedating and sometimes causes dizziness.
Propranolol and other beta-blocker drugs are usually used to treat high blood pressure and can cause blood pressure to decrease, causing lightheadedness. They are often avoided in elderly patients due to cardiac effects.
Gabapentin (Neurontin®) is an anti-seizure drug that has been found useful for essential tremor. It is usually less effective than primidone or propranolol. It also can be sedating and sometimes causes dizziness.
Topirimate (Topamax®) is an anti-seizure drug that has been found useful for essential tremor. It can be sedating and sometimes causes dizziness. It also can cause weight loss and kidney stones.
Botulinum toxin (Botox®, Myobloc®, Dysport®, Xeomin®) weakens the muscles injected. It can lessen tremors, but usually does not eliminate them.
When medical treatment can no longer control the essential tremor or when side effects of medications are intolerable, treatment with a surgical procedure is an option.
Deep brain stimulation (DBS) is a surgical procedure in which an electrode is permanently implanted in the part of the brain that is overactive and causing the essential tremor. A low-intensity current is continually pulsed to deactivate it without causing permanent damage. DBS is a reversible and adjustable surgical treatment.
Learn more about Deep Brain Stimulation surgery at Keck Medical Center of USC in Los Angeles by clicking here.
At the Parkinson’s Disease and Movement Disorder Center at Keck Medical Center of USC in Los Angeles, you’ll be working with a wide range of experts from a number of disciplines. Patient will receive medical (and possibly surgical) care from leading physicians, but also a number of services from other specialists, including psychologists, social workers, speech therapists, occupational therapists and physical therapists.
Patients receiving medical care and/or Botox® will typically get their treatment on an outpatient basis, along with evaluations by the center’s specialists.
All DBS candidates at Keck Medical Center of USC undergo a complete pre-operative evaluation, including neurological examinations, psychological and cognitive assessments, and a brain MRI. You will be scheduled to meet your neurosurgeon and a movement disorder neurologist. If you are receiving DBS for OCD, you will meet with an OCD specialist. We will work closely with your referring neurologist or primary care provider, to ensure a cooperative and comprehensive evaluation.
DBS surgery is performed while the patient is awake and mild-moderately sedated. Patients need to be awake during parts of the surgery to confirm which location of the electrode is most beneficial to their symptoms. Immediately before the surgery, a rigid stereotactic frame is attached to the head and a CT scan is performed with the frame in place, to aid in planning the trajectory of the lead. Patients are then brought into the operating room, and under heavier sedation, holes are drilled into the skull, and the electrodes are inserted. The surgeon may then examine the patient briefly to assess for immediate clinical benefit of symptoms such as tremor or rigidity. The surgery itself lasts two to four hours, and the patient recovers overnight in the hospital. About one to two weeks following implantation of the brain electrodes, patients return for a same-day surgical placement of the battery in the chest. Ultimately, there are three small incisions (2 inches or less) on each side of the body following DBS surgery.
Following DBS surgery, patients stay overnight in the hospital and are discharged the next day. In Parkinson’s disease and essential tremor, you may feel an immediate improvement in your symptoms, termed the “lesion effect.” This beneficial effect may wane in the next one to two weeks before the battery is placed in the chest, and the device is turned “on”. After the battery is placed, you will be scheduled for wound checks, removal of stitches, and a series of programming sessions by our nurse practitioner. These programming sessions are at intervals of every two to three weeks, with complete optimization of DBS settings taking two to three months. During this time, your medications may be reduced and your symptoms should continue to improve.
After recovery from the surgery and optimization of your settings, you may return to your pre-operative activity level without major restrictions. You will be given a hand-held Access Patient Controller, which will enable you to check the device periodically and turn it ON and OFF as needed. The USC DBS team will see you once or twice a year at minimum, to check on your battery status, with routine follow-up with your neurologist or psychiatrist.
Incisions should be kept clean and dry for one week following surgery. Once the incisions are healed (two to three weeks), you may resume all normal activities, including exercise and swimming. Rarely, strenuous activity or accidental trauma (such as a car accident or fall) can cause lead breakages, which may need to be repaired surgically. Security devices at the airport or in stores can also accidentally turn off the device, but this is not dangerous.
Learn more about the Deep Brain Stimulation techniques at Keck Medical Center of USC in Los Angeles here.
The Movement Disorder Society
National Parkinson Foundation (NPF)
Parkinson’s Disease Foundation (PDF)
American Parkinson Disease Association (APDA)
Parkinson Study Group (PSG)
The Bachmann-Strauss Dystonia & Parkinson Foundation
International Essential Tremor Foundation
Tremor Action Network
Dystonia Medical Research Foundation (DMRF)
National Spasmodic Torticollis Assoiciation (NSTA)
National Spasmodic Dysphonia Association (NSDA)
Benign Essential Blepharospasm Research Foundation
The Bachmann-Strauss Dystonia & Parkinson Foundation
The center is home to the largest clinical trials program in Southern California for Parkinson’s disease and dystonia. The center participates in many clinical trials to expand our understanding of important issues for patients undergoing Deep Brain Stimulation therapy. We are currently working with our DBS patients to explore their expectations before and after Deep Brain Stimulation Therapy. We are also examining outcomes based on a comparison of our patient’s self-reporting of symptoms and clinician’s evaluation after DBS placement.
Our physicians also conduct research in other projects exploring areas such as behavioral side effects of DBS and medication for Parkinson’s disease, the effect of exercise in Parkinson’s disease, treatment of dyskinesias in Parkinson’s disease, and outcomes of DBS in patients with Parkinson’s disease, essential tremor, dystonia and OCD.
There is a great deal of promising research in the field of Parkinson’s disease. At any time, there are a number of clinical trials being conducted to examine new treatments. These can include new medications, gene therapy, stem cells, exercise regimens and other therapies. If you would like to learn more about clinical trials, please click here.
Practicing LocationsKeck Hospital of USC
USC Healthcare Center 2
USC Norris Comprehensive Cancer Center and Hospital
Practicing LocationsKeck Hospital of USC
USC Healthcare Center 2
USC Norris Comprehensive Cancer Center and Hospital
Additional Team Members
Nasrin Esnaashari MSN, CCRN, CNS CNP