The Neurologist Is In, Episode 7: Current Practices for Treating Movement Disorders With Dr Harini Sarva

In this episode, Rachel Marie E. Salas, MD, MEd, interviews Harini Sarva, MD, on current practices for the treatment of movement disorders. Drs Salas and Sarva discuss best practices for neurologists to refer patients to movement neurology specialists.  

Listen to Part 2: Frontiers in Treating Movement Disorders With Dr Harini Sarva here!

Can't get enough of The Neurologist Is In? Make sure you're caught up on all the episodes--find the full catalogue here.

Rachel Marie E. Salas, MD, Med, FAAN, FANA, is a professor in the Department of Neurology at Johns Hopkins Medicine with a joint appointment in the School of Nursing. She is board certified in Sleep Medicine and Neurology. Dr Salas is the Director of Ambulatory Sleep Services at the Johns Hopkins Center for Sleep and Wellness. Dr Salas has been the Director of the Neurology Clerkship for over a decade. She is the Chair of the Undergraduate Education Subcommittee for the American Academy of Neurology and is an appointed member of the Alliance for Clinical Education. She is the director of the Interprofessional Education and Collaborative Practice for the School of Medicine and a Co-Director for Interprofessional Teaming for the High Value Practice Academic Alliance. Dr Salas is also the founder and Co-Director of the Johns Hopkins Osler Apprenticeship Program (in Neurology), a medical education research program for senior medical students and the Johns Hopkins PreDoc Program, a pipeline premedical college program. Dr Salas is a certified strengths coach and uses a strength-based approach and coaching to connect to, support, and develop those involved with her educational mission and clinical practice. Dr Salas is a 2019-21 Josiah Macy Scholar,  a 2019-20 AMA Health Systems Science Scholar and a 2021 AΩA Leadership Fellow.

Harini Sarva, MD completed a combined undergraduate-medical school eight year program at CUNY Brooklyn College and SUNY Downstate Medical Center.  She completed her undergraduate degree in economics with a magna cum laude from Brooklyn College, during which team she made the Dean’s List every semester and won an award in excellence in economics.  After completing her MD, she was recruited to complete her neurology residency from SUNY Downstate, where she was also a Chief Resident during her final year of training.  She won the SUNY Downstate Alumni Association Outstanding Resident in the Department of Neurology and the Department of Neurology Excellence in Teaching awards.  She subsequently completed her fellowship in Movement Disorders under the mentorship of Dr Susan Bressman and Dr Rachel Saunders-Pullman at Mount Sinai Beth Israel.  During her second year of fellowship, she was awarded the Clinical Teaching Fellowship grant from the Dystonia Medical Research Foundation and a travel grant from the International Society of Parkinson’s disease and Movement Disorders to attend their annual conference in Stockholm. After completing all of her training, she was an attending in neurology at Maimonides Medical Center in Brooklyn, NY, where she was co-director of medical student and resident rotations and developed a movement disorders elective for psychiatry residents.  She also arranged a CME conference entitled “Movement Disorders Review.” Dr Sarva subspecializes in Parkinson’s disease, Essential Tremor, Dystonia, Tics, Chorea, Myoclonus, Ataxia, and Gait Disorders.  She is experienced in botulinum toxin injection therapy for craniofacial and limb dystonia, hemifacial spasm, and spasticity. In addition, she is trained to evaluate patients for deep brain stimulation and is an experienced programmer. Dr Sarva is board certified by the American Board of Psychiatry and Neurology. She is an author of numerous publications and has presented her work at national and international conferences.

Read the Transcript:

Dr Rachel Salas:  Welcome back everyone, the Neurologist Is In podcast. I'm Dr Rachel Salas. I am a sleep neurologist at Johns Hopkins Medicine.

Here with me today is a movement neurologist. We have Dr Harini Sarva, and I'm excited to just pick her brain and learn a little bit more about the work she's doing. She deals a lot with students, has a clinical practice, and is involved in some clinical trial research.

Dr Sarva, can you tell the audience a little bit about yourself?

Dr Harini Sarva:  Thank you, Dr Salas, for this wonderful invitation. I am born and raised New Yorker, did my undergrad and med school in New York, med school and residency at SUNY Downstate, trained at Mount Sinai Beth Israel for movement disorders, worked for a couple of years at Maimonides Medical Center in Brooklyn, and then moved on to Cornell. I've been here for close to about six years now.

Live in New Jersey and I’m married. Pretty busy with a movement practice.

Dr Salas:  Great. Happy to have you. I don't think we've had a movement neurologist on the podcast as of yet. Why don't we start first with the clinical practice?

Obviously, we're still in this relentless pandemic, things are still crazy. Are you doing teleneuro? Are you seeing patients in clinic? What does your practice look like at the moment?

Dr Sarva:  It was definitely very tele‑heavy in the beginning, especially before the vaccines came out, but I think a lot of our patients really liked coming back into the office. We created very much a safe space. Occasionally, there is a mix of tele, but for the most part, I'm in the office five days a week.

Dr Salas:  How much clinic do you usually do? Do you do clinic a few times a week or a couple days or once a week? What does that look like for you?

Dr Sarva:  I started off with about three‑and‑a‑half days of clinic to build my practice and also it takes time to build the research side of things. I would say over the last few months, it's 50/50, so two‑and‑a‑half days of clinic and then two‑and‑a‑half days of research.

Dr Salas:  Are you also doing procedure work?

Dr Sarva:  I do. I do a full day of botulinum toxin injections for various movement disorders and I also do deep brain stimulation programming.

Dr Salas:  Cool. Can you tell us a little bit about your movement center like some of the things that maybe your center is known for, some of the procedures or evaluations that patients can come to? I'm just thinking about our audience, which tends to be a lot of general neurologists as well. If they wanted to refer a patient, what is your center all about?

Dr Sarva:  We're pretty much a comprehensive center. We see all types of movement disorders, Parkinson, dystonias, central tremor, ticks, ataxia. We have a great support staff with a nurse practitioner, RN, and a wonderful social worker.

There's three full‑time movement disorder doctors here at the main campus. We have another wonderful movement disorder doctor at our lower Manhattan campus. We have three others in our Brooklyn campus.

New York‑Presbyterian is quite spread out. We have a long history of doing neuromodulation surgery by Dr Michael Kaplitt, who is one of the leaders in DBS surgery and neurosurgery. We are also equipped to do the high‑frequency focused ultrasound for movement disorders.

We're branching out into other innovative therapies that are currently under clinical trial, such as gene therapies and stem cell therapies as well.

Dr Salas:  That's really awesome. Tell me, if I wanted to refer a patient to a movement neurologist or if I wanted to send a patient to you, what are some things that you would like to see on referrals? What kind of information should we be providing to our movement neurology colleagues?

Dr Sarva:  Oftentimes the referrals are assessed for Parkinson or gait disorder or tremor. Sometimes they're a little bit vague. Oftentimes they're quite good. I guess just a little bit of a summary. Where's the tremor? Why you think it's Parkinson?

What does the gait disorder look like? Just so that we're better equipped to help the patient. If you suspect normal pressure hydrocephalus or if you suspect any types of gait, a little bit more of a description will definitely help us to streamline not only their evaluation but further testing.

Sometimes they come in for gait abnormality is more likely to be a sensory neuropathy. It's unfortunate for the patient to come to us and then have to get referred to someone else, but that happens very rarely.

Dr Salas:  We work closely with our colleagues' movement neurology at the Center for Sleep and Wellness at Hopkins. Anytime I make a diagnosis, for example, of REM behavioral sleep disorder, it's part of our practice to automatically refer our patients to our colleagues in movement neurology.

We still do a neurological exam and document. Sometimes patients don't have any signs or even symptoms of Parkinson disease, for example. Sometimes they do. Sometimes they clearly have not been diagnosed with Parkinson then they have it. We always send them. It's part of our protocol.

I feel like ever since we started doing that several years ago, it's provided a more comprehensive approach to the patient. Then, our movement colleagues still continue to see the patient at least once a year if they have no signs or symptoms. It's been helpful.

I'm a neurologist and sure a lot of times I'll have these discussions that, "At this point, you don't meet the criteria for Parkinson's." They still go and get on Google and find out what RBD is associated with.

I'm able to say, "I don't see anything. I don't think you have Parkinson, but I'm going to send you to so and so, my movement neurology colleague. They're going to do their full evaluation. They're going to not only tell you whether you meet that criteria or not, but also things to look for and things to be helpful."

Do you guys do something like that or any recommendations from the RBD standpoint?

Dr Sarva:  We do work very closely with our sleep colleagues. Our lead sleep neurologist, Dr Dan Barone has collaborated with us on an RBD study. Everyone he's been diagnosing, he's been sending over to us.

They've been getting yearly evaluations for a period about three years, cognitive testing, new PDRS evaluations, other evaluations, to see if they are developing anything. Anytime we suspect something sleep‑related, it's crosstalk between us and them for sure. We work very closely with them.

Dr Sarva:  I'm glad to hear that. A lot of the academic centers have this process. I don't think it's widely available. For the audience, if you have a patient that is acting out their dreams, and maybe they're an older adult and their dreams are pretty vivid, they've gotten hurt or hurt someone else that sleeps in the room or in the bed with them, that referral to thesleep neurologist or the movement neurologist to get that ball rolling.

At academic centers, it's important for you all to know that we do work as a partnership to better evaluate and treat our patients. Just like Cornell, a lot of research is happening in the RBD World.

Do you want to talk a little bit about RBD? In the terms of how it's a precursor for Parkinson.

Dr Sarva:  It has the highest prognostic value of seeing if someone is going to develop…whether that's Parkinson disease, multiple system atrophy, or dementia with Lewy bodies.

Depending on the studies you look at, can pretty much be a higher rate of either DLB or MSA. Obviously, there's growing interest in using it as a predictive factor for PD. There are also other things to consider.

If they have anosmia or hypoxemia plus RBD plus a positive DaTscan, that increases the probabilities. Even if they don't have the clinical motor signs that they're going to develop something, probably, require a closer eye.

If they have a genetic abnormality such as GBA mutation, some of these precursor factors. Then, the likelihood is much higher. We still haven't gotten to the point where we can say we can help it as soon as we do find these factors.

There's a lot of interest and exciting work that's being done looking at disease‑modifying therapy. Hopefully, something will pan out compared to prior disease‑modifying strategies in the past.

Dr Salas:  I know it can be pretty scary for patients when they come to our clinic first and they get diagnosed with this because if you get on the internet there is lot of information out there and some of it is not correct. It's important to educate the patients up from the get‑go. That's great.

I'm happy that neurologists are from different sub‑specialties are working together to treat our patients. Anytime I can insert a little sleep medicine, I do.

We talked about RBD and I can't leave without talking about the other crossover that we have is restless leg syndrome. The other thing that ties us is sometimes people have movements during their sleep that aren't restless leg syndrome. It's not epilepsy.

It's something else. That's the other reason that your movement and sleep will also crosstalk as well. One of the things I like about restless leg syndrome and working with movement neurologists, sometimes people come and they don't meet the diagnostic criteria for RLS, but they clearly have something going on.

Could be a variant of RLS so working with our movement colleagues so that way, they can think about other things that could be the diagnosis. Any input on restless leg syndrome and how you're working with those patients and how you work with the sleep center at Cornell?

Dr Sarva:  For the RLS patient, sometimes they get divided amongst us and the sleep center, but we do see our fair share of RLS. I usually like to start with some of the more milder agents, gabapentin or pregabalin.

I do use dopamine agonist. I don't use levodopa for RLS therapy. My goal is to prevent augmentation as much as possible. That means putting them on a little bit of a cocktail of two or three agents. I'd rather do that or even switch them over to a 24‑hour dopamine agonist.

My favorite combo is the rotigotine patch and pregabalin combination of good with a 24‑hour dopamine agonist and the higher doses of pregabalin. We tend to get much better coverage and better symptoms side‑effect profile and the augmentative properties of the short‑acting agonist as well.

Although gabapentin, as old as it is, it works like a charm often. That's what I do. I also make sure I get iron studies, have the patients take iron supplementation, talk to them about exercise, diet, especially if they have known triggers like sweets or alcohol, and using compressive devices, when possible, can also help.

Dr Salas:  You're speaking my language, everything you just said is exactly what we do. I agree, levodopa is a big no, no for RLS. It is a magic hat for some patients, but you can't take it more than once or twice a week.

If you're at that level, that patient really should be seeing a specialist in it. This summer, we're about to bring on a new movement neurologist, but because of this cross with RBD and restless leg syndrome and movements during sleep, we're bringing her on as a movement neurologist, but in our sleep centers.

We're going to have the opportunity to have patients see her for a sleep disorder, but it's going to be one that she was trained in. This is the first time that we're doing it. I'm really excited about expanding our portfolio to have a movement neurologist. I still foresee us referring patients because there's just so many.

Our clinic is very neuro‑centric. We have sleep pulmonologists, sleep anesthesiologists. We have sleep neuro‑psychologists. We even have like a sleep ENT person. Having this movement neurologist who's actually a movement neurologist and not also sleep trained there, it expands our portfolio.

I'm just curious, do you have any thoughts on that? Have you ever thought about working, partnering with the sleep center, and saying, "Couple of days a month or once a month, I'm going to go to the sleep center clinic," and see patients that fall in these domains?

Dr Sarva:  I think that's really a great approach and a great multidisciplinary approach. We see over and over again for a lot of our movement disorders, whether it's Parkinson's or atypical Parkinson's. That having that spoke and that hub and spoke approach is much, much better than one doctor taking on everything because it's just impossible.

It's impossible to keep up with every aspect of the condition. It also helps because it'll be great to form pathways for treating these patients as well. When to order a DaTscan, when to order specific testing, MRIs, etc. When to get genetic testing also, for some of these patients, because RBD can be seen with GBA mutations. What about this person that we need to investigate further?

I think that's a great approach. I haven't had the opportunity to work that closely with our sleep group. I think that would be a great idea.

Part of it is also, geographically, we're a little bit spread apart in Manhattan. I think that multi‑disciplinary model. I would probably even bring in neurogenetics into that as well. It's a great approach.

Dr Salas:  I'll keep you posted on what how things go. I'm really excited for our center to do that. The pandemic as much of the craziness that it's caused, it's also caused a lot of opportunities for innovation. Just mentioning that, for example, with telemedicine, now we can see patients.

Patients we're always coming to our center and I'm sure it's the same for you. They come from all over. They've got to pay for travel and hotel, and they're looking for their second or third or even fourth opinion. They're coming at big academic institutions.

At telehealth or teleneuro, telesleep even, it's allowed us to meet the patient where they are and they could be in another state. We're also working towards getting licenses in different states, and I'm hoping at some point that there could be a national license, so we don't need to keep doing all these different state licenses.

I think that having these new movement neurologists in our center is going to hopefully lead to other pathways. This brought up the comment that you just said, geographically. I wondered too, should we be also thinking about telemovement for some of these patients?

For instance, RLS would be a good one. Even RBD too because a lot of it's really history. Although the RBD patients, they definitely have to examine them for Parkinson.

Dr Sarva:  For preliminary evaluations, for sure. RLS, RBD. I would even say for tic disorders, too. Oftentimes you can see it on video and then bring them in. It definitely lends itself for especially established Parkinson patients going back to PTS because that's such a big part of the movement disorder world.

We definitely still need to do the hands‑on exam to check for breaking vision rigidity because oftentimes you don't see the subtleties as well, and especially for chorea patients, if the chorea is very subtle in their face, just to see their walking, it can definitely go hand in hand, and there is a lot of room for it in the world.

Dr Salas:  Before we transition to some of the other aspects of what you do, anything you can share with the audience about what's new in movement? Is there something that just came out or something cool that maybe not everybody would know about?

Dr Sarva:  Yes, there's a lot going on in movement, and it's really exciting. The focused ultrasound initially was FDA‑approved about six years ago in 2016 for unilateral thalamotomies for ET. It got the Parkinson pallidotomy approval in the last three months.

There's a new study looking at the pallidothalamic tract where we can treat both sides for patients with motor fluctuations and/or dyskinesia. That's a great approach for patients who don't want deep‑brain stimulation having levodopa complications. Either medically, don't want DBS because of the implantable hardware, or live too far away from the programming center. That adds to our armamentarium.

There's an exciting gene therapy trial for the GBA mutation where we've dosed a couple of patients. We have a couple more all ready to get dosed. Stem cells are coming back, especially dopamine replacement stem cells. It's not a cure, but it can be a great potential alternative for DBS for patients.

There's also a lot of good disease‑modifying trials that are underway. I'm not just looking at vitamin supplementation and repurposing, hypertensive agents, less we had in the past, but looking at tyrosine kinase inhibitors as a disease‑modifying option alert to inhibitors and anti‑inflammatory molecules.

A lot of good innovation is happening. Will it all succeed? Time will tell, but definitely, the approaches are much more exciting than I would say even two or three years ago.