Latest / Incredible Mind / Meet a Neurologist: Johnathan Reiner
Transcript
- speaker-1: You were made for creativity, learning, problem solving, and of course, action. On the Incredible Mind podcast, you'll hear from neuroscientists, psychologists, doctors, artists, and others whose work expands our understanding of how the brain works, where things can go wrong, and what simple everyday steps you can take to make the most of the unique intelligence you were born with. The Incredible Mind I'm Talking About. Is yours. Today's episode covers brain health, science, and creativity with a unique guest. Dr. Jonathan Reiner is a neurologist who is also an artist. Jonathan specializes in Parkinson's disease, so you can expect an excellent overview of Parkinson's and current treatment options. However, he also explains neurology as a medical discipline. Dopamine's role in the body, deep brain anatomy, and the importance of movement and creativity in maintaining brain health. This conversation is a reminder that our lives are dynamic and that many practitioners in modern medicine care deeply about their patients. Let's get started. Hello and welcome back to Incredible Mind. I'm your host, Michelle Cross-Smith. Today we are speaking with Dr. Jonathan Reiner, a movement disorder neurologist at Rabin Medical Center. Dr. Reiner focuses his research on Parkinson's disease, deep brain stimulation, that's a treatment for Parkinson's, and neurogenetics. Jonathan, welcome to Incredible Mind. speaker-0: Hi there, thank you so much for having me. speaker-1: So Jonathan, you are the first neurologist we have on the podcast. And I know for most people, unless you have had to go, or someone in your family or friends have had to go to a neurologist, you might not really understand what a neurologist does and how it compares to, say, a psychologist or a neuroscientist. So can you kind of explain neurologists and neurology in general? speaker-0: Absolutely. So first of all, neurology is a medical discipline. So it's a specialty within medicine. So a neurologist would be an MD, a doctor, who specializes in health and disease regarding the nervous system, be it the central nervous system, which is the brain and the spinal cord, or the peripheral nervous system, which is everything kind of beyond the spinal cord, the peripheral nerves, etc. And it spans a a wide variety of disorders. So you have within neurology disciplines that Focus on headaches, for instance, or on epilepsy, or on neuroinflammatory conditions such as multiple sclerosis, on neurodegenerative disorders such as Alzheimer's disease or Parkinson's disease, and cognitive disorders. But in general, a person would meet or come up to a neurologist when they have symptoms that they don't completely understand and that may be related to to the brain. And then they'll meet someone hopefully, you know, nice and that would ask them questions and help them diagnose the problem that they may be facing and provide also a medical plan to try and help them alleviate their symptoms. speaker-1: Thank you. That really helps. I had a loved one in my life have a stroke eight years ago. And that was my first introduction to a neurologist and what neurology does. So actually no one realized he had had a stroke. This neurologist walked in and in a minute said he had a stroke. And he was right. The MRI quickly backed him up. Neurology is some one of those professions kind of like oncology where you hope you don't have to work with one. speaker-0: Absolutely, absolutely. The first thing I always say to people when they say, ⁓ I've never met a neurologist is thank God for that, you know, that you've not met a neurologist before. That's good news. And the other thing just to tie into what you said is that what's interesting about neurology is that it's very much detective work. Because, you know, symptoms manifest in the body, in feelings, in emotions, in memory, our job as neurologists is to try and locate where that problem stems from. And it's always a matter of looking where in the brain, where in the central nervous system or or any other part of the spinal cord, does this problem arise? And it's interesting to see in different areas in the brain and how they manifest outside the brain in different symptoms such as visual disturbances, sensory disturbances, difficulty in power and or or strength in in the limbs. We're all just have this ability to look at patients and see what's hidden behind and inside. speaker-1: Feels like a wiring problem often when it comes to neurology, right? It's it's in the back wiring. Something went wrong. Yeah. So one of the topics that I really wanted to talk to you about since your specialty is in Parkinson's is Parkinson's disease. I feel that this is a disease that we are seeing more frequently out there in the world. Just off the top of my head, I know three people. Who are living with Parkinson's disease right now. But not everybody is familiar with Parkinson's. So can you give us a sort of an overview of what is Parkinson's disease and how would you start to wonder if you have it? speaker-0: Okay. So Parkinson's disease is a neurodegenerative disorder, which means that it's a progressive chronic disease, which is basically defined by motor symptoms. The cardinal symptoms that are part of the diagnostic criteria for Parkinson's disease are rigidity, slowness of movement, and tremor. And you don't necessarily have to have all these symptoms together. The must-have symptom for diagnosis is slowness of movement. Some patients manifest with things like change in their walking pattern, feeling a bit more clumsy, not as quick as they were before. And then they would approach a neurologist. But going back to your question and approaching it more systematically, so Parkinson's disease, as I said, is a chronic progressive disorder. It's caused basically by selective loss of dopamine producing cells within the brain. Brain basically has the use of many neurotransmitters which are signaling hormones that are distributed throughout the brain and give all kinds of instructions from the brain to the body in terms of just how we manifest in behavior and our abilities and functions. And so when we have this loss of dopamine within the brain, the loss occurs in specific areas in the brain which are involved in motor planning and execution. And so when you have this loss of dopamine, it's manifested as I mentioned With motor symptoms such as slowness of movement, rigidity, tremor, etc. But dopamine in itself is also, you know, a neurotransmitter which is widespread within the brain and has many other functions and many many other roles. And so Parkinson's disease, even though the hallmark of the disease is motor disability, it also affects many other aspects of individuals who suffer from Parkinson's disease. So dopamine is involved also in memory and involved also in motivation and in mood and And in autonomic kind of functions, so things like symptoms that aren't necessarily motor would be constipation, urgency of passing urine, sleep disturbances, pain, apathy, depression, loss of sense of smell, difficulties in your sleep patterns in terms of what's called REM sleep behavior disorder, which means that you manifest your dreams in while you sleep. So it has many, many, many symptoms, and it affects many aspects of these patients' lives. Going back to what you mentioned about you feeling that You see it more commonly these days. So the demographics basically state that above the age of 60, 1% of the population is affected by Parkinson's disease. And the largest risk factor to Develop Parkinson's disease is age. So the more we age, the more we're at risk of developing Parkinson's disease. And that number goes exponentially higher when you approach the 70s and 80s, where you see it even more commonly. Saying that, we know nowadays that we can see more and more younger people being affected by Parkinson's disease. And it's yet to be concluded whether it's environmental or what's going on in that respect. But the notion is that we're seeing younger people with Parkinson's disease. There are all kinds of risk factors. factors that are taken into account that may cause you to develop Parkinson's disease. speaker-1: Jonathan, I have two and maybe they're dumb questions, but I'm just going to ask. The first one is dopamine. I think most of us are familiar with it for things like dopamine hit, that kind of thing, and and why we get addicted to scrolling or something like that. When you first said a reduction of dopamine, I thought, ⁓ is everyone who has Parkinson's, are they all depressed? I didn't understand that this neurochemical, this neurotransmitter, also was involved in the motor system. speaker-0: So it it's actually a really good question because I think you would expect this notion that loss of dopamine would lead to just general depression in in every patient who's diagnosed with Parkinson's disease. It's obviously always much more complex than we think. What we know about dopamine is that within the brain it's quite widespread, as I mentioned, because it has so many roles, but also it has specific receptors for different roles. So dopamine is the same neurotransmitter, but it can affect different networks within brain to cause different effects. And classically, when you speak of dopamine, we think about it as a jack of all trades. It's associated with schizophrenia, for instance, which you have an overdrive of dopamine, which leads to all the positive symptoms within schizophrenia, meaning hallucinations, delusions, etc. But also this ideas being very fluent and ongoing and very fragmented. And then it's also associated with ADHD, being able to retain your concentration and your ability To focus on a specific task. And it's also related to addiction, where you have exactly that issue with the dopamine hit, with positive reward and positive feedback, which reinforces sometimes pathological circuits that you don't want to reinforce, but you you are reinforcing. So dopamine doesn't really fall into one specific category. And so even within Parkinson's disease, the loss of dopamine is specific to certain areas within the brain which are associated with specific networks, but eventually. Eventually the loss becomes kind of bigger and it spreads to other areas within the brain. And then you have this variety. You have patients which become suddenly very creative and very full of motivation to do things. And you have other patients which you see that are more apathetic and more depressed. It's not the one size fits all. It changes between different patients. And that's actually what's amazing about Parkinson's disease in general is that we we understand now that it's an umbrella term for many, many different phenotypes of the condition. So no single patient is similar to the one sitting to his or her left or right side. There are a lot of variables and each patient is a is a unique universe in itself. speaker-1: That is really interesting. Thank you. I think everyone needs a neurologist in their pocket to explain this stuff to them. The other question that maybe is a dumb question, maybe not, or maybe I'm stereotyping or not, but I know four people with Parkinson's and they're all men. So is this a disease more common to men? speaker-0: It is. The statistics of prevalence of the disease is leaning towards men and the ratio is one point seven to one, so one point seven male to female. speaker-1: So if you were a woman getting those symptoms, you might disregard them for Parkinson's because you have this preconceived notion that it's a male disease. Yeah. Yeah. But really not predominant, but there's still a lot of exceptions. But what about treatments? Yeah. I know that you are involved with the deep brain stimulation. I know someone who is getting this treatment. So tell me how it works and where in the brain exactly is it being stimulated? speaker-0: Of course, of course. Okay, so as I mentioned, the underlying pathology within Parkinson's disease is loss of dopamine within the brain. And so at this point in time, unfortunately, we have no treatment which stops the disease or even slows the progression of disease. All the treatments that we have are all medications which are symptomatic. And the the idea is basically that we're trying to help the individual that suffers from whichever symptom to kind of regain their confidence and their ability to benefit. And achieve their goals and go on their daily life as good and feeling as good as possible. And most of the medications that we have nowadays basically try to provide dopamine and raise the dopamine levels in the brain to normal levels, either indirectly or directly. So many of the medications that the patients take contain dopamine. And so when you take the dopamine, you're hoping that you take the pill, it goes into your digestive system, to your blood system. From there, it needs to deliver itself to the central nervous system and hopefully target the Places where we have low dopamine levels and help whichever symptoms the patient is experiencing. And these medications are very effective. And since they've been discovered in the 1960s, we're kind of in the same place. So even though medicine is progressing in terms of the medications we have nowadays for Parkinson's disease, most of it is dopamine-based. And the problem with that is that because we're speaking of a condition which progresses, and with time, basically, patients require usually to increase. The dose of medication and to take more medications throughout their day, then we face another stage in the disease where we need to manage both the symptoms and the side effects that are caused by the medications. And that causes things such as motor fluctuations. So the patient will report that they're either good and they're able to walk and do their daily activities, but then suddenly, after a few hours after taking the medications, they feel very rigid or their tremor returns, or they feel very unstable, or just feel very low and take. Tired and fatigued, etc. And so as we increase the dose, we're hoping to improve the symptoms, but we face other challenges, which is how do we manage the side effects of medications? And that's where DBS comes into play. Because in terms of the therapies that we have to offer these patients, once we've been able to provide them their pharmacological therapies, we need to think about advanced therapies that can also help with their symptoms. And the only treatment we have nowadays that is advanced treatment that doesn't rely On dopamine directly is deep brain stimulation. Deep brain stimulation has been around since 1997 was the first FDA approved treatment. So it's been around for 30 years now, and that's a good amount of time to say that we know that it's a good treatment. We're able to follow these patients now over decades and see that it's been helpful for these patients for quite a long time. The story is basically that before DBS was introduced, one of the surgical options we used to offer patients is a resection of a certain area in the brain that may be involved in producing tremor. And before the neurosurgeons would resect that speaker-1: Just a second. Is resection remove? speaker-0: Yes. Yes. Okay. So resection is removing. And the way the neurosurgeons used to work in order to define the area that they're trying to remove is prior to removing that area, they would give a small electrical stimulation to that that area to see whether they produce the wanted effect, which means that if a patient is tremulous, then if you stimulate that area, you're able to stop the tremor and then remove that area and And that's it, you're able to stop the tremor. One of the surgeons that used to do it, the founding father of DBS, a guy by the name of Ben Abid, said why not, instead of resecting an area, why not just provide a treatment that provides ongoing electrical current and stimulation to that area? Fast forward thirty years, we understand much more now about the brain and how it works. And the treatment for Parkinson's disease, DBS for Parkinson's disease has been around for a while now. We basically offer it to patients who have a well-established diagnosis, have been on medications, have reached the stage where they're starting to experience side effects from the medications, and we're there to offer them a different strategy that we can harness to try and help and alleviate their symptoms. And the process is a bit intimidating for these patients because we're talking about surgery and brain surgery. speaker-1: Brain surgery, the one of the scariest. Yeah. speaker-0: Exactly. So what we do is basically the patient goes through a procedure where we drill very small holes within the skull and we're trying to implant two electrodes usually to specific targets within the brain. And there are a few targets that we use for Parkinson's disease. One of which is the subtalamic nucleus, which is an area within the brain close to the region that is involved in dopamine loss or that suffers from dopamine loss. speaker-1: Is it deep in the brain? speaker-0: It is. The S T N, the subthalamic nucleus, is a very deep nuclei nucleus within the brain. It's ⁓ close to the brainstem. speaker-1: Why would that be a place where movement was impacted? Is it 'cause it's near the cerebellum or is it because 'cause I would think it would be closer to the sensory motor network or s something like that. speaker-0: That's a very good question. When we talk about Parkinson's disease, it's part of the conditions that we categorize under a network which is called the extra pyramidal system. So it's a group of nuclei deep within the brain that are mostly involved in planning and initiating and commanding movement to higher cortical areas which are involved in the actual execution of movement. So we've got a relationship between the motor cortex, which is quite superficial, where we have a very specific Somatotopic, what's called representation of different areas within our body, that from there you can send commands to move your arm, move your leg. But the whole idea of planning movement, which is much more complex because as we walk about and we sit and we encounter people that are facing us or walking towards us, or a stray cat or a dog barking, or a child running, or a car heading at us, we need to constantly adapt and reshape the way we move about. And that requires much more complex integration. of many sensory inputs, both coordination and visual and sensory from peripheral nerves, etc. in the body, and balance and all kinds of issues. speaker-1: Yeah. Your sense of space, physiospatial even, yeah. speaker-0: Exactly. And all that all that is basically integrated into a group of nuclei which relay that information through the thalamus onto the motor cortex to execute movements. So speaker-1: And the the Thalamus is is our grand central station, right? It's where all the signals speaker-0: Yeah. Yeah, that's exactly that's a grandson station. And often it's a target, by the way, for implanting electrodes. So the thalamus used to be a target most commonly used for essential tremor, which is another condition, not a neurodegenerative disorder, but a neurological condition which causes tremor. In Parkinson's disease, the subtalamic nucleus has become the hallmark of localization in terms of just where we implant the electrodes. Either the subthalamic nucleus or what's called the globus pallidus interna, another nuclei within the basal ganglia. Which is also in relation to the thalamus. And what we do is basically we implant these electrodes to these areas and provide high frequency stimulation. The idea behind that is that we understand now that what's called the electrophysiological manifestation of loss of dopamine, so the way loss of dopamine is translated into electrical activity within the brain, is altered when we go through a pathological process. So these cells which are Suffering, or cells in proximity to where we're implanting, which are suffering, they start to fire their electrical activity in a synchronized manner, which often causes disruptive relay of information from areas to areas within the brain. So I always think about it in this way that our brain is full of electrical activity. Each neuron knows its role and walks about and does about their role in the brain, and fires and wires, and fires and wires to Wherever they need to. When we sleep, for instance, our whole brain synchronizes into kind of a specific pattern, a theta or delta, wave pattern, etc. When we have an epileptic seizure, different regions and our brains suddenly synchronized in kind of these electrical spikes. So usually when we have a synchronization of cells within the brain, that means that their ability to relay the information, go about their business in a normal manner is disrupted. And The notion is that DBS provides high frequency stimulation which breaks that pathological pattern and hopefully normalizes the electrical activity within the brain. That's basically what we understand nowadays from DBS. And we also understand that this effect is not only localized to the area where we provide the stimulation, but it has a downstream effect that causes what's called neuromodulation. So it actually changes and affects the wiring of different. Different areas within the brain to hopefully provide better symptomatic relief. DBS at the end of the day is also a symptomatic treatment. It doesn't stop the disease, but it is another strategy that we use that we can harness and also interact with medication to give better treatment and more precise treatment for our patients. That's in a nutshell. speaker-1: No, that's fantastic. So what changes in a patient once they've had this? And the electrodes, I'm assuming they're battery operated. They're not like Yeah. speaker-0: ⁓ okay. So what we tell these patients is basically you're going to be admitted into hospital. Usually they're admitted the night before. The day of the operation, you know, they're connected to what's called the stereotactic system, which allows us to navigate with a precise GPS the target that we are we're heading for with these electrodes. After we implant the electrodes, the whole wiring is tunneled beneath the skin into a pulse generator which sits on the chest, just like a pacemaker for the heart. So it's a pacemaker for For the brain. The actual machine sits on the chest usually and is tunneled behind the ear onto these two burrholes within the skull and into the electrodes deep in the brain. The patients usually come to my clinic after they've gone through the operation for initial starting the stimulator and then optimizing the parameters that we can and monitoring the symptoms as we go along and hopefully changing and facing each challenge that these patients face as years go by. But what we try and tell the patients to match expectations is that the treatment is there to help with the motor symptoms at the end of the day. So with tremor, rigidity, slowness of movement. Patients do report other benefits, and it's not the same for each patient, but we do see benefit in quality of life, in just general sleep patterns, in mood. Often they also express suddenly a big change in their ability to interact with the world, with society, to become more social, because something about their ability to kind of ⁓ to go about their daily activities is easier for them and and and they gain more motivation and more interest in in life. But I have to say and this is going back to the fact that we're dealing with neurodegenerative disorder, the disease is is is dynamic and progresses. And not every patient is the same as the other and we're constantly trying to help these patients as we go along. speaker-1: It's a treatment, but it's not a panacea, right? The disease is still progressing. Of course. I have someone close to me who has been recently diagnosed with Parkinson's. So Chris, I hope you're listening. One of the questions that I I started thinking about is what do you recommend for maintaining your health if you have Parkinson's? And even for family members who are close, what they can do to support someone going through this. speaker-0: So I think ⁓ it's important to note that every individual that faces a chronic condition that you live with, it doesn't remain within the patient. So it's always a diagnosis that affects everyone who's close to that patient and becomes very much ⁓ something that needs to be addressed to improve and to to help everyone that's surrounding this patient to go through this process in a good way. What we talk about with patients is generally that the notion is we need to continue with our lives, yeah? Because no matter at what age you're diagnosed, life continues. Life expectancy doesn't necessarily change for these patients with good treatment and with the ability to maintain and be part of this process. And it's also because a stroke affects someone immediately and then you need to deal with the consequences. Here we're talking about a progressive and and quite slowly progressive disorder that becomes a bit of a marathon to manage. Obviously, with time you go through different phases of acknowledging and understanding where you're at in terms of your relations to the condition. So it takes a while for patients to initially really. Understand what it is they're experiencing, what symptoms do they actually attribute to Parkinson's disease or to other conditions. There's a lot of fear about how my life is going to look like in the future. How am I going to approach this? But then again, we also have a bit of breathing space and a bit of time to really deal with his questions and also interact with the condition. And so the motto that I try to convey is that the importance is to live alongside the medication and not let the medication manage you, but rather you managing the symptoms and the condition. What we know is that. Apart from pharmacology and apart from advanced therapies, it's very important to manage your daily life in terms of both physical activity, social activity, and cognitive activities. And that's really kind of important. And you can talk about nutrition as well and about many other ways we can try and manage symptoms. But the one thing that I stress and is backed and is evidence-based is that we know that even though the medications don't help us necessarily slow the progression of the disease or stop the disease. What we do know that may change the prognosis and the ability for the patient to go about their daily lives and manage their condition is movement. Nowadays it's very important as a prescription, as a medical prescription, to really, really, really hammer this message. Physical activity is vital. And I'm not necessarily talking about going to the gym and doing workouts, etc. It's everything, the whole spectrum is there, from dancing to yoga to Pilates to Tai Chi. To table tennis, to doing anything that provides not only the physical activity, but also the ongoing engagement between the brain and the body. So usually we recommend not to do repetitive activities such as walking, running, cycling in the gym, but rather be in a natural environment that provides constant stimuli for your brain to continue this relationship and sending these commands to the body to maintain as much of that ability as possible. So that's very important, very high. And high on the list. And it's very hard sometimes to recruit these patients to become motivated and do but it really does make a difference. The other thing is about not ⁓ minimizing your life and not giving up on things that are important to you or provide some kind of benefit to your well-being. And that's often about social interactions and maintaining a social environment that you know provides some support and gives you a sense of relevance and importance in the world. And the other thing is maintaining your cognitive abilities through exposure to cognitive of anything from lectures to interests to new hobbies and things in order once again to kind extend the boundaries of of where you're at because this disease has a tendency to continue reminding you that it's there and it could be quite daunting and quite heavy to carry on a daily basis. So speaker-1: Well, that's great advice, not just for Parkinson's patients, but for everyone. So we we could all benefit from that. Thank you so much. speaker-0: Yeah. I would say this that we're talking about from the perspective of Parkinson's disease, there are some interesting things that are also dopamine based in essence, because it's all about, you know, motivation and positive feedback, etc. But some of these patients basically develop a creative urge that they've not had before with the diagnosis and with treatment with dopaminergic medications. The interesting thing about creativity in that respect is that these people who suddenly express creative behaviors and urges, they would report symptomatic relief when they are engaging in that creative activity. So they would sometimes even skip meals or skip interactions because once they're sculpting, painting, writing poetry, thinking, dancing, etc., they're feeling good in their bodies and in themselves. For me, it's an interesting perspective to learn more about creativity in general and how we can finally hopefully provide some empirical evidence that creativity is essential for brain health and for our well being. But it also teaches us a lot about how we can hopefully use creativity also to alleviate and help with these neurological conditions and provide s another strategy to provide symptomatic relief for these patients that is non-pharmaceutical and that could be really, really interesting and engaging for these patients. speaker-1: Are you a creative person? It sounds like you must be. speaker-0: So yes, I grew up in a creative household. My mother is ⁓ an artist, a painter, and I've always been very much engaged and interacting with arts. For me growing up, it also became very much a tool for understanding who I am, what I am, processing emotions, ⁓ memories, integrating knowledge. I used to doodle on my notebooks, my teachers used to hate that, but that was a way of me really implementing the information that ⁓ I used to take in. And so Always been there as a tool for me to explore everything about myself, my mood, my thoughts, my emotions, you know, where I'm at, help solve conflicts, inner conflicts, to bring about ideas, to generate new ideas. And so alongside this interest I have in medicine and neurology and Parkinson's disease, I've always had this pull towards creativity and creative engagement. And so, yes, I'm an artist, I I sculpt, I paint, I do screen printing, and then over the past few Years suddenly I've had this amazing opportunity to combine both worlds and engage more in the neuroscience of creativity. So alongside my clinical practice with neurology and also learning about these Parkinson's patients that develop creative urges, I've started exploring and researching more about the neuroscience of creativity and understanding the inner processes and what causes them, where they're represented within the brain. I find that the more I learn about it, the more, the more questions I have about it. I still find it's quite magical that creativity is ⁓ is is quite amazing and now my real goal is to is to really go deep and hopefully create that connection between ⁓ therapy and creativity through a neurological perspective whatever speaker-1: We'll have to have you back on as things progress, 'cause that sounds super interesting. ⁓ Jonathan, thank you so much for speaking with me today. I learned a lot, so I'm sure our audience will too. speaker-0: Thank you, Michelle, thank you so much. speaker-1: This episode is dedicated to Chris, who was recently diagnosed with Parkinson's disease. You were on my mind throughout my conversation with Dr. Reiner. Incredible Mind Podcast is written, produced, and edited by me, Michelle Cross Smith. Peter Aronson is consulting producer. Angela Ferrero designed the cover art, and the music was created by Alex Grohl. If you're enjoying this content, please like and subscribe to Incredible Mind Podcast wherever you're listening. Extra credit if you share an episode with friends and family. For more information, including a look at our course Your Electric Brain, visit incredible-mind.org.