A Treatment for Essential Tremor!

It's really the stuff of sci-fi, our ability to map the brain so very precisely, and allow for the most targeted of interventions in this sacrosanct space.  Now comes an uplifting study in NEJM Rick and I discuss on PodMed this week, using these amazing high tech gizmos to benefit people with the most common movement disorder, essential tremor.  Yay! I say. Having known people with disabling tremor, and borne witness to their struggle to accomplish basic, ordinary movements, this is good news indeed.

The study was a pilot of 'focused ultrasound thalatomy' in 15 patients who ranged in age from 53 to 79, with severe essential tremor refractory to medication.  Most of the patients were male, right-handed, and had a family history of essential tremor. By necessity, of course, the trial was open label, and all of the participants had failed at least two trials of a full dose therapeutic medication as well as satisfying other entry criteria on degree of tremor and disability.

Treatment consisted of affixing a stereotactic head frame to the patient's shaved head, attaching an elastic diaphragm to the scalp and connecting it to the ultrasound transducer, and filling the diaphragm with chilled water.  The patient was then transferred to an MRI-guided focused ultrasound system, where the area to be treated was mapped and variable numbers of ultrasound pulses employed to ablate specific areas of the thalamus.  While treatment progressed patients communicated with investigators, were asked to draw a series of spirals and tremor suppression was monitored.  Treatment ceased when tremor suppression was observed, then subjects were observed in the neurological intensive care unit overnight. They were discharged the next day.

In the first year after treatment, the mean score for disability dropped by a mean of 85%. Participants also improved in self-rated quality of life and in their score for a simulated eating task.  Four of the study subjects who were unable to complete the task at all prior to the intervention were subsequently able to do so within normal time limits.  Pretty impressive, methinks.

Adverse effects of treatment included transient paresthesias of the face or fingers, and unsteadiness. Four patients were categorized as ataxic at week one but this resolved by week four. One persistent loss of sensation in the dominant index finger was seen. In comparison to other methods for ablating parts of the thalamus, including radiofrequency thalatomy, stereotactic radiosurgery and deep brain stimulation, these have all been associated with a range of adverse events, sometimes occurring quite some time after the intervention, including intracranial hemorrhage and neurological impairment.  This study did not assess possible cognitive impairment but the other adverse consequences of treatment were not seen.  The authors suggest that additional larger, blinded studies are appropriate including an assessment of cognitive function, but these early results are quite encouraging, and Rick and I agree.  What a great utilization of technology with few apparent downsides!

Other topics this week include early heart valve replacement for mitral valve prolapse in JAMA, who benefits from cardiac resynchronization therapy in the same issue, and finasteride for prostate cancer prevention in NEJM.  Until next week, y'all live well.

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A Treatment for Essential Tremor! | jhublogs
August 19, 2013 at 12:15 pm

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David R Foote September 10, 2016 at 10:08 pm

My tremor does not seem to be hereditary as I know of no one else in my family who has or had the affliction. I have failed every known form of medication and tried several other types of treatments. I can no longer write with either hand, have a very hard time eating, cooking or drinking from anything that doesn't have a cover. Tests have shown that I do not have Parkinson's, Thank God. I have been criticized by a neurologists for feeling sorry for myself, because as she says I should be thankful for the things I can do. I am thankful for the things I can do, but the frustration levels and embarrassment caused by the "essential" tremor I have is sometimes too much. I am just about willing to try anything. Where is this therapy available, when and how can I get a appointment? Thank You.

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Elizabeth Tracey November 4, 2016 at 7:10 am

David, thank you for your comments. We cannot advise on specifics of where to look for treatment. You could perhaps contact the authors of the paper and ask for their assistance. All the best.

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