Experts Review Surgical Treatments for Essential Tremor

We are fortunate that ET experts recently reviewed surgical treatments for ET to write this paper entitled Surgical Treatments for Essential Tremor. They include DBS (deep brain stimulation), FUS (focused ultrasound surgery/ablation), SRS (stereotactic radiosurgery), and radiofrequency ablation treatment. The authors detail when surgical treatment is an option (when tremor symptoms are severe) plus they cover complications and outcomes, including limited effectiveness and possible need for repeat or additional surgery. Details are also included for those with voice and head tremor. Patients may have tremors bilaterally, that is on both sides of their body, however certain surgeries are found to have better outcomes if the procedure is done unilaterally, meaning the outcome affects only one side and is therefore a partial solution.

For a better understanding of what is happening in the brain of someone with ET, read the paper’s introduction. It explains how the tremor signals travel along a communication loop in the brain known as the corticobulbocerebellothalamocortical loop. It also tells how the surgeries for ET target the ventralis intermedius (Vim) or the posterior subthalamic area (PSA) right below the Vim, and surgical stimulation in these spots disrupts the signals in the loop, lessening tremor.  If we can locate a visual image of this loop we will post it! The authors’ key issues, conclusions and expert commentary are worth reading especially for those interested in surgical options with supporting data. Overall, the authors, Elble, Shih and Cozzens comment on the rapid improvements being made in surgical treatments.

This paper was supported in part by a grant from the Illinois-Eastern Iowa District Kiwanis Neuroscience Foundation.

Surgical treatments for essential tremor

Act Now and Give Your Public Comment on Focused Ultrasound Procedure

If you suffer from Essential Tremor and are interested in receiving the non-invasive procedure Magnetic Resonance guided Focused Ultrasound (MRgFUS)……

YOU NEED TO ACT NOW!!!

National Government Services (NGS Medicare), the Local Medicare Contractor that oversees benefit administration for Medicare beneficiaries residing in the following states: Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, and Wisconsin recently published a “DRAFT” Local Coverage Determination (LCD) on the topic of MRgFUS for essential tremor. While NGS feels the technology is “promising”, they came to the conclusion that they will NOT consider this procedure to be a covered benefit. This is very disheartening as MANY people who suffer from tremor could benefit from this procedure.

NGS Medicare is allowing public comments on the subject through November 30, 2017. Without significant written comments by the public, the draft policy will likely be finalized in its current unfavorable decision.

If you would like to submit comments, encouraging NGS Medicare to provide coverage for its Medicare beneficiaries, you can do so by sending them electronically. Please reference the following in your subject line: Re: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor: DL37421 

The email address for submitting comments is: PARTBLCDCOMMENTS@anthem.com

Act Now and Give Your Public Comment on Focused Ultrasound Procedure

If you suffer from Essential Tremor and are interested in receiving the non-invasive procedure Magnetic Resonance guided Focused Ultrasound (MRgFUS)……

YOU NEED TO ACT NOW!!!

National Government Services (NGS Medicare), the Local Medicare Contractor that oversees benefit administration for Medicare beneficiaries residing in the following states: Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, and Wisconsin recently published a “DRAFT” Local Coverage Determination (LCD) on the topic of MRgFUS for essential tremor. While NGS feels the technology is “promising”, they came to the conclusion that they will NOT consider this procedure to be a covered benefit. This is very disheartening as MANY people who suffer from tremor could benefit from this procedure.

NGS Medicare is allowing public comments on the subject through November 30, 2017. Without significant written comments by the public, the draft policy will likely be finalized in its current unfavorable decision.

If you would like to submit comments, encouraging NGS Medicare to provide coverage for its Medicare beneficiaries, you can do so by sending them electronically. Please reference the following in your subject line: Re: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor: DL37421 

The email address for submitting comments is: PARTBLCDCOMMENTS@anthem.com

Highlights from Oct 6th ET Support Group Meeting – Columbia, MD

Peter opened the meeting by telling us about a new digital technology firm called NEW TOUCH, who has created an introduction powerpoint for the HopeNet community that will soon be on the website blog at thehopenet.org.

Peter said things are happening now, things are moving along. We [HopeNet] received a $10,000 check to be used for funding research here [Columbia]. We will be the test subjects for a study.

Peter told us about a conversation he had with Dr. Haubenberger who told him about a new study about how alcohol can help with Essential Tremors. Harvey mentioned that he had participated in an alcohol study for E.T. at NIH, and that the University of Maryland has a balance study.

Comments and questions throughout meeting:

Kinetic jerk as opposed to a tremor.

How does caffeine affect it?

There is a connection between cerebellum and fight or flight.

ET is heritary.

Can there be ET in the eyes? a movement disorder in the eyes. The visual cortex is involved in the loop that causes ET.

What is the biggest problem we come up against? Doctors – yes doctors.

Cranial tremor is more prevalent in women then men.

There will not be a meeting in November. We will meet again on the first Friday in December which is the 1st. The discussion will be about New Touch technology by the people from New Touch. Also, we are not funding the New Touch team.

There is no date set yet for the physical therapy study that Dr. Janice Sallit will present regarding balance and gait is. Dr. Sallit has to complete her “proof of concept” in order to get the funding for the study. Peter is working with a lawyer to put together the process & procedures for setting up the grant.

Someone asked Peter how he is coming along after being assaulted earlier in the summer. Peter said he is scheduled for 2 more surgeries on his right eye. One is to remove fluid, and the second one is cataract surgery, still no arrest.

Then we went around the room so each person can tell of any problems they are experiencing.

Mary Jane – has now developed a tremor in her left hand, still has trouble eating and uses a spoon, still has trouble writing, so she now prints when she can. She does not have any problems using the computer. She said she is open to having the focused ultrasound procedure done.

Ellie – This is Ellie’s first visit to our meeting. She said she has problems typing [double typing]. Dave suggested she change her keyboard setting to either sensitive or non-sensitive.

Harvey – spoke about the sensations he felt when he had the FUS done. He said he felt like he was elevated, with the head lower than his feet. Harvey had a newspaper article regarding a Canadian study having to do with ET.

Les – Les said that the tremors in his hands are getting worse, and so is his gait. Peter said if you walk on uneven surfaces [i.e. grass, sand, etc.] it becomes an issue for the feet to send messages to the brain, therefore causing you to have problems with your gait.

Jonathan – Jonathan re-interiated to us about the time back in the summer when he went on a trip and fell ill. The intravenous antibiotics they gave him in the hospital caused his tremors to diminish over a period of time. He was able to stand straight, lock his knees, and hold his head up. Something he had not been able to do in a very long time. Unfortunately, the effect is wearing off and now the problems he had with his gait before falling ill is coming back. Whatever the antibiotic was that the doctors had given him, may just be a lifeline for people suffering from E.T.

Doris – Doris told us that the tremors are getting worse. The medication prescribed by the doctor just exacerbated her condition. She now had a bottle of Primidone that she cannot use.

Judy – This is the first time Judy has attended our E.T. meeting, so a big shout-out welcome to Judy. Yeah!!

Judy told us that she has tremors in her throat, head and neck. She has had them for 35 years and no doctor can help her. It was diagnosed as spasmodic dystonia and Essential Tremors. Kathy went to Google while typing up these minutes, and typed in vocal tremors, one of the listings that came up was voicedoctor.net. In addition, Judy said the tremors are now starting in her hands.

Peter said she got bad advice and knew immediately when she came in and spoke that she had essential tremors in her voice. Also, he told us about a study in Syracuse of octanol and voice tremors. Kathy asked Peter what octanol was and he said it is the 1-Octanol. Google search -Octanols are alcohols with the formula C8H170H. A simple and important member is 1-Octanol, with an unbranched chain of carbons.

Dave – Dave brought in a special pen that he got from a website titled Pen-Again. The pen is made to stabilize your writing when using a pen. Another Google search and located it. Also, it is available as a pencil. You can find it on SmileAmazon and make a donation to TheHopeNet.com at the same time.

Kathy – Kathy brought in a magazine from University of Maryland Baltimore Washington Medical Center and gave it to Peter, with an article about Essential Tremors, listing the names of doctors some of you are already familiar with. She then mentioned another article she saw in the Howard magazine regarding boxing and Parkinson Disease. Unfortunately she did not bring it in. And then she had a question about pets and essential tremors. It seems her 11 year old poodle mix has developed a tremor in her hind leg. Can pets get essential tremors?

Peter said he did not see why not, and suggested she contact University of PA. They have a pet medicine department.

Then, Peter asked Ellie and Judy if they found the information helpful. Both were impressed with the information that was discussed and the helpful suggestions that were given.

Remember no meeting in November, next meeting December 1, 2017.

Respectfully submitted,

Kathy McElroy

 

Proposed Payment Rates for ET Treatment Too Low?

MRI-guided focused ultrasound (MRgFUS) for essential tremor became a method of treatment in July of 2016 when the FDA approved the procedure whereby thermal imaging is used to target and lesion brain tissue while keeping the skull intact. Since then it has progressed to the insurance coverage determination process where coverage rates are established for providers of the procedure and its technologies. Until payment rates are completely established, people who want it will pay out-of-pocket to the tune of about $25K to have the procedure.

There was an opportunity recently for public comment on the proposed coverage rule for 2018, and Peter Muller of HopeNET, who himself underwent the procedure when FDA approved it last year, submitted the following letter to CMS expressing his concern that if payment rates to hospital providers are too low the hospitals may choose not to offer to this care option, and those with ET who would benefit may have limited access to treatment.

CMS letter FUS 2018

 

 

Proposed Payment Rates for ET Treatment Too Low?

MRI-guided focused ultrasound (MRgFUS) for essential tremor became a method of treatment in July of 2016 when the FDA approved the procedure whereby thermal imaging is used to target and lesion brain tissue while keeping the skull intact. Since then it has progressed to the insurance coverage determination process where coverage rates are established for providers of the procedure and its technologies. Until payment rates are completely established, people who want it will pay out-of-pocket to the tune of about $25K to have the procedure.

There was an opportunity recently for public comment on the proposed coverage rule for 2018, and Peter Muller of HopeNET, who himself underwent the procedure when FDA approved it last year, submitted the following letter to CMS expressing his concern that if payment rates to hospital providers are too low the hospitals may choose not to offer to this care option, and those with ET who would benefit may have limited access to treatment.

CMS letter FUS 2018

 

 

Maryland Essential Tremor Support Group Welcomed Dr. Paul Fishman to Meeting

 The Columbia, Maryland ET support group was pleased to welcome Dr. Paul Fishman on 2/3/17 as a guest speaker for the monthly meeting at The Wellness Center. Dr. Fishman performs both Deep Brain Stimulation (DBS) surgery and the newer MR-guided Focused Ultrasound Surgery (FUS) on ET patients.

We were fortunate to have him visit and share his informative presentation with us.

Click here for presentation notes.

Present-Day Essential Tremor Medical Research Outlined:

Experts Reach Consensus on Research Priorities

In the quest to advance Essential Tremor (ET) research that could lead to better understanding and development of successful treatments, medical professionals in the movement disorder field collaborated on a white paper published in December, 2016 entitled “Knowledge Gaps and Research Recommendations for Essential Tremor.”

ET_poster (1)The paper developed out of a workshop these professionals attended in May 2015 and their subsequent brainstorming discussions. The non-profit ET patient advocacy organization HopeNET, which has for several years sought to connect the ET patient community to the medical research community, proudly played a role in the occurrence of the workshop, which was hosted by the National Institutes of Neurological Disease and Stroke (NINDS) in Bethesda, Maryland, USA, and included over 60 participants.

The resulting paper is a valuable guideline for the future. It is certain to be of interest to the ET community who will be glad to learn that medical professionals are indeed working to further knowledge of this movement disorder! The summary below serves as a layperson’s general overview of the detailed paper to convey information in terms that are more understandable to a general audience. Science-curious readers can pursue the paper in full through ScienceDirect here [1].

The causes of ET are poorly understood. Despite widespread occurrence, no medications have been created specifically to treat it. The goals of making ET less elusive and coordinating research efforts were driving forces behind the workshop discussions. One big challenge is limited knowledge about both the genetics and the neural pathway mechanisms involved in ET. Another has to do with inconsistencies in making an ET diagnosis. The fact that ET has multiple causes makes any simple definition of it inadequate.

Clinical research methods and approaches have been inconsistent. And without standardized procedures in place, analyses and findings disagree. The authors do an excellent job of taking an in-depth look at what they do and do not know about ET. Perhaps most importantly they take it a step further: they come to a consensus on recommendations for research in these areas: phenomenology and phenotypes, therapies/ clinical trials, physiology, pathology and genetics.

The authors recall the classic ET definition given roughly 20 years ago, as set forth by the International Parkinson and Movement Disorder Society (MDS). They mention that since that time there has been speculation about other characteristics that may need to be added to the definition such as, modest changes or abnormalities in these areas: cerebellar [2], cognitive [3] and hearing function [4, 5], plus dystonia [6].

The authors discuss how it is common for ET patients to present with new symptoms that do not fit in to the existing ET definition, changes that call into question the validity of the diagnosis. ET also appears to share overlapping features with other conditions [7]. New symptoms and overlapping features have encumbered clinicians, but they still believe a revised, workable definition is necessary clinically for the purpose of making inroads and facilitating important collaborative research.

They agree on new criteria and propose that ET going forward be considered as an isolated tremor “syndrome” rather than a single disease or condition since it has been established that ET has multiple causes.

The following are the authors’ recommended diagnostic criteria for defining ET as an “isolated tremor syndrome” in an individual:

  • Bi-brachial action tremor (postural or kinetic)
  • Duration of 3 years or more
  • With or without head tremor or tremor in other locations
  • No other diagnostic neurologic signs (e.g. overt dystonia or parkinsonism)
  • No identifiable endogenous (e.g., autoimmune disease) or exogenous (e.g., toxins) disturbances that could cause tremor
  • Difficulty with tandem walking is permissible, but no abnormality of gait [8]

Bi-brachial pertains to the 2 arms. Postural refers to holding a limb against gravity as in for example, holding arms out in front of the body, and kinetic refers to tremor that occurs when in action. The authors acknowledge that there are isolated tremors that do not meet the proposed ET criteria. They make clear this clinical ET definition is not meant as a detriment to continued research on other isolated tremors.

Given the absence of an identified ET gene or an identified biomarker to help with a diagnosis, emphasis is placed by the authors on gathering and classifying symptoms as fully as possible, with quality data collection and standardization efforts in place, including use of common data elements (CDEs). How is tremor measured in a clinical setting? Various tremor rating scales are used and the authors are calling for their evaluation. The rating scales include clinical assessment scales, patient-reported ratings/scales, and motion transducers, which are those devices that measure tremor amplitude or severity. Recommendations are made for development of a tremor monitor, among other technological devices. It is however pointed out that gaining insight from measuring the tremor is not as conclusive as it would seem since tremor amplitude or the severity of the oscillation can fluctuate at various times and the significance of those fluctuations is not known.

Regarding therapies or treatments for ET, the common drugs presently used were created to treat other conditions like epilepsy, high blood pressure and anxiety and were repurposed for ET when found to reduce tremor in some people. The paper explains briefly how these agents are thought to work at the cellular level. Besides the commonly used beta-blockers, anti-epilepsy drugs and benzodiazepines, clinical research has established ethanol, aka alcohol, as effective in its ability to reduce tremor amplitude for many people. Its effectiveness has led to studies in past years that isolate ethanol-related molecules such as sodium oxybate, 1-Octanol and octanoic acid, and these may turn into possible future treatments. They also seek to better understand how certain surgical interventions have met some success in reducing tremor: deep brain stimulation (DBS) and magnetic resonance focused ultrasound, both of which target and lesion the ventral intermediate nucleus (VIM) portion of the thalamus in the brain.

At the physiological level, researchers have identified a particular central nervous system circuit they think may be responsible for tremor oscillation in ET called the corticobulbocerebellothalamocortical circuit, and they are calling for investigation of it.

Genetics research findings make clear to the authors that the path to increased ET knowledge may be found in focusing on large patient cohort studies worldwide in order to make certain associations. Background is given on some important studies that have been done such as the Icelandic genome-wide association study (GWAS) that suggests the gene LINGO1 has possible associations to ET [9]. Common data elements, collection and storage of DNA bio-samples and coordinated multinational efforts are strongly encouraged.

The paper builds an awareness of scientific research being done in the ET field. The workshop provided an opportunity for experts to discuss present-day ET challenges. The authors discovered shared goals that ultimately revolve around deepening knowledge and making new treatments available, improving data, standardizing approaches, and evaluating therapies. It is a guideline for future research projects that, if adopted by researchers, could see momentum build in the direction of better outcomes for ET.

Lisa Gannon

 

 

 

References:

[1] F. Hopfner, D. Haubenberger, W.R. Galpern, K. Gwinn, A. Van’t Veer, S. White, …, G. Deuschl. Knowledge gaps and research recommendations for essential tremor. Parkinsonism and Related Disorders 33 (2016) 27-35. Retrieved from http://www.sciencedirect.com/science/article/pii/S1353802016303893

[2] J. Benito-Leon, A. Labiano-Fontcuberta, Linking essential tremor to the cerebellum: clinical evidence, Cerebellum 15(3)(2016) 253-262.

[3] E.D. Louis, J. Benito-Leon, S. Vega-Quiroga, F. Bermejo-Pareja, Neurological Disorders in Central Spain Study, Faster rate of cognitive decline in essential tremor cases than controls: a prospective study, Eur. J. Neurol. 17(10)(2010) 1291-1297]

[4, 5] W. G. Ondo, L. Sutton, K. Dat Vuong, D. Lai, J. Jankovic, Hearing impairment in essential tremor, Neurology 61 (8)(2003) 1093-1097.

Benito-Leon, E.D. Louis, F. Bermejo-Parmejo-Pareja, Neurological Disorders in Central Spain Study, Reported hearing impairment in essential tremor: a population based case-control study, Neuroepidemiology 29(3—4)(2007) 213-217.

[6] J. Jankovic. Essential tremor: a heterogenous disorder, Mov. Disord. 17(4)(2002) 638-644.

[7] R.J. Elble, What is essential tremor? Curr. Neurol. Neurosci. Rep. 13(6)(2013) 353.

[8] F. Hopfner, et al. Knowledge gaps and research recommendations for essential tremor. Parkinsonism and Related Disorders 33 (2016) 27-35, http://dx.doi.org/10.1016/j.parkreldis.2016.10.002

[9] H. Stefansson, S. Steinberg, H. Petursson, O. Gustafsson, I.H. Gudjonsdottir, G.A. Jonsdottir, …, K. Stefansson. Variant in the sequence of the LINGO1 gene confers risk of essential tremor. Nat. Genet. 41 (3)(2009) 277–279.