Latest / 20-Minute Health Talk / A better treatment for essential tremor

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A better treatment for essential tremor · 20-Minute Health Talk

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if this is as good as it gets. Did a great job. this is 300% improvement.
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Oh. That's great to hear. Yeah. There you go.
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That was Murray Bocian talking to his doctor minutes after a procedure that eased the uncontrollable shaking in his hands that had plagued him for 30 years To our
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My daily living was really bad. I mean, I shook, I dropped things. I couldn't do things myself. My wife had to help.
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Murray has essential tremor, a nervous system disorder that causes shaky extremities, most often in the hands. And as Mary pointed out, it makes everyday tasks like tying shoes or holding a glass very difficult. Some even have to stop working
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From the kitchen to the family room, it was how much I could spell by way of I.
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Otherwise, I really Mary, people living with this type of tremor
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have done so for years, if not decades.
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Most patients don't require treatment
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or can manage the condition with lifestyle changes and medication.
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But when those don't help, there are few other options,
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including the one that has Mary feeling like his old self again.
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Hello and welcome to 20 Minutes.
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How talk. I'm sandra Lindsay.
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today on the show we explore what everyone needs to know
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about essential tremor and the latest treatments.
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While surgery has been available
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since the 1950s, a new incision.
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This procedure called high intensity
2:00
focused ultrasound or high fu,
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is improving quality of life for people like Mary.
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Without the need for surgery.
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and the effects are immediate.
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Recently my colleague
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Rob Hoyle sat down with Murray's surgeon, Dr.
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Albert Finney, director of functional neurosurgery
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and the deep brain stimulation and Program at Northshore University Hospital.
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To learn more.
2:36
Thanks, Sandra.
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In the United States, there are approximately
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10 million Americans living with essential tremor, which Dr.
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Noy said makes it the most common movement disorder.
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it's a degenerative disease, It's progressive.
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We usually call it benign essential tremor,
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because it's not a reality that will lead to your death.
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It's something that just happened once you have it, it's progressive over time.
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And because it's progressive, it's really about quality of life.
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the biggest factor for patients with a sense
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tremor is their progressive loss of their quality of life.
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So, yeah, simple facts of eating, drinking, cutting their meat,
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putting on makeup, very big topic, you know, drinking
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water, coffee and people who are a handyman and a craftsman
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and they want to use a hand tools. Sure.
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That's a
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you know, it
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gets it interferes with their ability just to do fine things with their hands.
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So there's no other symptom that's really debilitating them.
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And you know, it comes to an issue about how long can a patient handle
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having their tremor interfere with their life. Right.
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Because you said it's progressive,
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which means it's going to get worse over time.
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It's not going to get better. That's for stay the same.
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That's why we call it essential.
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Because we don't know exactly.
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There's nothing that we use in medicine.
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We call things essential because there's no cause, there's no tumor, there's no
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abnormality structurally in the brain that is causing the tremor.
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While the cause is unknown, Dr.
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Finau says the biggest risk factor is genetics.
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But 80% of essential tremor is familial, meaning that there's a large hereditary
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component of it as opposed to being sporadic,
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whereas that's the kind of the opposite for Parkinson's disease.
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This is a common point of confusion.
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Many people think of essential tremor as being related to Parkinson's,
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but there is an easy way to tell the difference.
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essential tremor is really a tremor that at intention, not at rest.
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So they may notice as they're trying to use their hands
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to do some type of manipulation, say, holding a cup or trying to eat
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or write with a pen or using a utensil, that's when it becomes manifest.
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Unlike Parkinson's disease, where tremor is simply at rest.
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that really classifies the type of disease.
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There's also a test for Parkinson's disease that can help.
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one of the things that provider could do is automate that scan.
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That's a dopamine transporter, PET scan, positron emission tomography scan.
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Basically it's radio nucleotide.
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Looking at the mean dopamine transporter.
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Dopamine is important in Parkinson's disease, but not in essential tremor.
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So if there's an abnormal level of that transporter in
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the scan, then that would signify more Parkinson's disease than essential tremor.
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But it's not 100% either.
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Typically, patients with
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essential tremor have turn, it gets worse when they're stressed or anxious.
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Typically when they if you ask them do you drink alcohol
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and make patients who drink alcohol socially may notice that okay,
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after a glass of wine or beer at night, their tremor actually gets better.
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And that's because there's just respond to a depressing nervous system. do.
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We would obviously want to get an imaging of the brain at this
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the first time we're seeing this to make sure
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there is no structural abnormality that's there.
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if a patient has a stroke or a so you had some type of hemorrhage
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that could cause a different type of trauma that would be related to that.
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And if it's there isn't, as we would expect, then we would make that diagnosis.
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Unfortunately, many people don't seek medical care for a central tremor
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due to a lack of awareness, embarrassment or stigma.
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Essential tremor is one of those really undiagnosed situations, because it usually
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afflicts patients when they're older So a patient may develop a tremor
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very subtly over time, and that becomes more manifest as they age,
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but they may think nothing of it.
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So it's, hey, it's this is old age, or maybe it's due to nerves or anxiety.
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And so they're not going to seek medical attention.
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They're not going to have a proper diagnosis.
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Unfortunately, patients with tremor that is progressive,
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they seek less of social situations and try to be more reclusive
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so that they can not be seen with their tremor.
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That's a source of an embarrassment.
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That's one type of lifestyle change.
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Another one which is a little bit more progressive, would be weighted objects.
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So say if they're using a fork, a weighted fork or spoon, or specifically patients
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complain of, you know, having a spoon with cereal or a spoon with their peas.
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Uh, very difficult to control.
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But the weight, it obvious that patients have a little bit better use of.
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There are also some bracelets that are actually supplied
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by a prescribed by a neurologist that have ability to dampen that tremor
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pretty decently in the initial stages.
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Dr. Van Noy says it's important to see a doctor because, as he mentioned
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before, the condition worsens over time and can cause severe problems for some.
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And for patients who aren't sure where to start.
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who your family practitioner
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should be able to diagnose you with this, your general practitioner,
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but a neurologist obviously be better equipped to do so.
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Go see in or out.
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Just now, once you get see a neurologist,
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they would differentiate in tension tremor versus a resting tremor.
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They would probably start you on some medication.
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Typical medications would be Hannelore, which is a beta blocker.
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It's actually a heart rate
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reducing medication used for people who have blood pressure.
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That's a typical one that's been very common to use.
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Another one is called Printed down.
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It's an anti-seizure medicine.
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One or both of those would be used initially.
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They have a tendency
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they're not directly targeted at essential tremor, but
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because of the way they suppress activity in your nervous system,
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they have the ability
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to attenuate the amplitude, which means the degree of movement of your tremor
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you can suppress.
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It can be highly effective in a patient with a very small tremor.
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That is typically an initial thing that patients can get by for years.
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But he points out that medication is not for everybody.
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these medications are they suppress activity, but they can make you drowsy.
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They can make you nauseous.
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Patients don't like it or it's not working.
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So once that occurs, we look for treatments that are targeted
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actually at the problem that we have already identifying,
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which is this pathway that's apparently working.
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Surgery offers that more targeted approach that Dr.
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Finley just mentioned.
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While the medications used to treat essential tremor were initially designed
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for other conditions, procedures like deep brain stimulation and lesion therapy
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have been around for decades and are designed to stop or control
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the area of the brain, causing the tremors.
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deep brain stimulation,
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a very common procedure that's FDA approved in the last 30 years,
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where we put an electrode into this location,
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and through high frequency
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stimulation, we can then train the cells to fire at a normalized firing pattern.
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This can immediately take away the tremor As your measure of disease
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progresses, you have the ability to continue to control your tremor.
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like deep brain
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stimulation, lesion therapy targets brain tissue that is causing tremors
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while lesion on the brain is typically caused by injury or disease.
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Surgeons have been able
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to turn it into a treatment for conditions like essential tremor.
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In this approach, they create a lesion in the affected area of the brain
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to disrupt the electrical signals
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between the brain and the body that caused the tremors.
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This previously had been a surgical situation where we make
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an incision, cut a hole and put a probe into this target and cause a lesion
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And the node that is is involved in this pathway is in the thalamus,
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The thalamus, located in the middle of the brain,
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relays nerve singles between the body and the brain.
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So to intercept that information flow, we will create a lesion
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or create stimulation to stop that, and that automatically changes the tremor.
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It causes tremor improvement.
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the approach to lesion therapy has evolved.
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And the same effect can be achieved without surgery.
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There are two approaches.
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One uses radiation to slowly create the same lesion in the same spot
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of the brain, and the benefits develop over several months.
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This is called gamma knife therapy.
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Then there's high fu.
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I intensely focused ultrasound or high food has been FDA approved since 2016.
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this is a new way of creating a reason that making that
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roadblock of information transfer that improves tremor.
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What's interesting about this is that a patient can be outpatient
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and on one day can have an hour and a half procedure and go home without tremor.
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High fu occurs completely in an MRI scanner and uses sound waves to target
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the tremor causing tissue in the brain without harming the surrounding tissue.
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No anesthesia necessary.
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The process starts with a quick head CT to determine
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if a patient is a good candidate for the innovative procedure.
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essentially, we want to focus ultrasound beams
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through your skull without creating an incision.
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But we need to look at the actually the skull density ratio, the
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the difference between the inner and outer tables of your skull
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so that we can focus those ultrasound beams well enough to create that lesion.
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If that skull density is too low,
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then actually we can't focus those ultrasound beams well enough
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and we are not going to be able to create that lesion,
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which is kind of a disappointing.
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But we need to know that ahead of time. Right?
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So more than 95% of patients are candidates.
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But this is one of our this is the only screening test that we have.
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Our team followed Murray on the day of his high fu procedure,
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the second modestly, many years ago, I would have a seat in our lovely little
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chair here. The chair Right
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Put your hands up for me.
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It's a little bit worse on the right and put your hands up like this.
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All right.
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We just want to make sure obviously we're Peterson,
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So we're going to be treating the opposite side of your brain for the right side.
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So that's what we need to do, that you're going to sign this and then I'll sign it.
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And we should have a have to shave their head.
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While not an issue for Murray.
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It can be a barrier for some.
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As you might expect, this has been very much more common in females than males.
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And so, yes, so males have no problem with shaving their head.
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Women, we have this is our this is a constant struggle that we do see.
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But some women are getting around it.
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And the immediate benefit of high fu is what's helping women get around it.
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Those who get the procedure say the process is a minor inconvenience
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on their way to feeling freedom
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finally from the uncontrollable shaking in their hands.
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So why is shaving your head necessary for this procedure?
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that's going to affect how we can focus as well for something.
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So we want to make it very uniform.
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Once we see the patient's head right down to using a razor,
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we then put a stereotactic frame on a patient.
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And this is so that we can visualize your brain in three dimensional space
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with the MRI and pick a coordinate out to place that target.
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That frame is only on for the procedure.
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This frame looks like a vise and acts
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as a foundation for a visor like head covering.
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and brain area, pulling it down as low as it goes, Right over.
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So on top of top of the frame.
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So like a Once that frame is on,
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you know,
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we then put a membrane over the scalp which we will circulate water around
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to cool the scalp.
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As we're performing this procedure, we will then walk you over to the patient,
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over to the MRI scanner, which will then lay them down, connect the frame,
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and they will get some short sequences to visualize the chart,
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which we kind of need to do just at that moment.
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that process involves multiple tests during the actual procedure, which Dr.
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for Noy explained midway we want to play this lesion.
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We want to make sure that we're actually creating focusing those ultrasound
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beams directly into the area that we target.
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So we check it
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three different ways at least make sure of the three
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different orientations that we're actually getting it into this area correctly.
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If we have to make changes in how we're actually function, those beams we do.
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And then once we have that, then we can actually perform
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a test sonication So we can kind of kind of treat the area
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but not create a permanent lesion just to treat, to see if we're actually
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providing efficacy without a side effect.
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And so we do that, we're going to test it, we can test it multiple times.
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And what if that's all good set?
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We don't have to make any further adjustments.
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Then we'll create the actual permanent feature you.
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risks involved in complex brain surgery
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as well as radiation from the gamma knife approach mentioned earlier.
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This is FDA approved for only unilateral treatment, meaning that we can only create
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a an effect on one side of the brain to affect one side, one arm.
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Only nine months after the first side, we can do the second side.
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so we can see that we're trying.
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We are increase in temperature within the brain?
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this is going to if we get this temperature
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to rise above 50 or so, that we will start seeing an improvement.
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And he says he has an improvement already, but we're not quite
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where we want it to go.
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So we need to get there
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the reason why we're doing this in the MRI scanner
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so we can see real time
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that we're actually affecting the area that we want to target.
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In 2023, Dr.
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Van Noy and Team began using Hai Fu the first and only to do so
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on Long Island, and Murray was their second patient Murray is a great
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guy, had really bad essential tremor suffering for years
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both hands constant very difficult to eat drink right
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spilling on himself all the time wonderful support family
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so he had to with this back in maybe early May
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and you know, had a great outcome.
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and that family support includes his wife, Beth, who first learned about Hai Fu
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and encouraged her husband to seek treatment prior to Hai Fu,
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Murray was unable to complete
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a simple test that required him to draw a spiral and a straight line.
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Following the high fu session, he was able to easily draw both.
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right, all right.
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Both between the lines stuff.
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One 200% success.
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Better than I did it before.
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Close look.
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More smooth, that's for sure.
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nine months to obtain the same benefit on his left side.
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The difference on his right.
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He said, is night and day.
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he can, you know, hold hands with his wife, can eat without spilling on himself.
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And he says that his laundry bills have gone down.
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It's just like really, really a huge improvement in quality of life.
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I got it. And I already got it.
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Very well.
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It's good. It's pretty good. Nice.
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All right.
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Your head is not spinning. this year.
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Murray and his wife are looking forward to a lot more hand-holding
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and both consider Hai Fu a miracle.
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I would say in terms of efficacy,
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I would say greater than 90% improvement of his tremor on one side.
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And that's typical for most patients.
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We would have an initial improvement of over 90%
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improvement of their tremor, and that is sustained for a years now.
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Um, there has not been an amazing amount of studies,
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but we do know that the efficacy is sustained over time.
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the amount of tremor improvement will go well, we're reduced over time.
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That's a function of many things.
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Function of, you how great of a lesion the patient had
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and how that the progression of their disease.
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at three years post lesion in post
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treatment there is about at least a 75% efficacy efficacy rate.
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So still 75% better than as they were started,
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not as great as 90% still perfect.
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So after three years you could go back and get another procedure.
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Definitely could go back and get another procedure.
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Patients undergoing Hai Fu may experience some balance issues, but Dr.
17:05
Finau says it's only temporary.
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we're creating a lesion.
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There's some swelling
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that occurs around this lesion for a couple of days, two weeks,
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and that can affect a little bit of an imbalance.
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So actually we
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provide patients with a walk or actually Typically it's gone in the next few weeks.
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in addition to his role at Northshore University Hospital, Dr.
17:22
for Noy also conducts research in Essential Tremor through North Wales.
17:25
Feinstein Institutes for Medical Research.
17:28
And so actually I have an NIH grants and a principal investigator on a
17:32
an R one, which is a special type of grants from the
17:34
NIH investigating tremor and how different
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areas in the brain communicate with each other post-treatment.
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So when we do these procedures on these types of patients,
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we want to see what is actually happening in the brain
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because maybe we can make these treatments better.
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do you think you're gonna get to a point
17:52
where it's going to open up doorways for treating other abnormalities?
17:56
Absolutely.
17:56
So the only way we're going to progress in science is to in medicine is to buy,
18:01
is to investigate what we have
18:03
and see how we can use the same we're using here for other diseases.
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So say, for example, deep brain stimulation,
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which has been around much longer than focus ultrasound,
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where we are intervening just like leaves or lesion sales,
18:15
either one surgery, we're creating lesions in different pathways.
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These white matter tracts are abnormal.
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Well, initially they were used
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just for essential tremor or Parkinson's, these very common disorders.
18:25
But we have branched out and now we're tackling psychiatric disorders
18:29
such as treatment resistant depression or obsessive compulsive disorder.
18:33
We're looking at Alzheimer's disease.
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And these are we are treating these through surgery, not in a down the road.
18:40
We possibly can be helping these patients through focused
18:43
ultrasound, creating a lesion without doing surgery.
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But it's only through really studying
18:48
these patients and the pathways and how things are changing.
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Will we ever really get to know. Wow,
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on behalf of Rob, I want to thank Dr.
19:02
Albert for for joining us on this episode all about essential tremor
19:07
and this new innovative procedure that is changing lives for patients like Murray.
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Until next time. I'm Sandra Lindsay.
19:17
And this has been another episode of 20 minute
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