For the Love of Health

Revolutionizing Tremor Treatment Using MR-Guided Focused Ultrasound with Dr. Justin Martello

• ChristianaCare • Season 2 • Episode 6

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Tremor is a neurological condition that affects approximately 1% of the population overall, and 5% of adults age 60 and over. It is expected to increasingly impact Delawareans as the state's population ages.

A new treatment for people suffering from essential tremor and Parkinson's Disease is a game-changer for ChristianaCare patients. Dr. Justin Martello, Director of the Parkinson's and Movement Disorders Program at ChristianaCare, shares inspiring insights into MR-guided focused ultrasound, including how it works, exciting success stories, and potential uses for this technology for treating other conditions.

Justin Martello, M.D., is a board certified neurologist specializing in movement disorders and Parkinson's Disease at ChristianaCare. As Director of the Parkinson's and Movement Disorders Program at ChristianaCare, he has developed Delaware's first and only comprehensive Parkinson's disease program.

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Speaker 1:

It can heat up those cells in order to kill them, to make them stop causing the tremors.

Speaker 2:

You're listening to For the Love of Health, a podcast about delivering care and creating health, brought to you by Christiana Care. And now here are your hosts.

Speaker 3:

Hello everyone, I'm Megan McGerman.

Speaker 2:

And I'm Jason Tokarski. Welcome to For the Love of Health brought to you by ChristianaCare.

Speaker 3:

Tremor is a neurological condition that affects approximately 1% of the population overall and 5% of adults age 60 and over. It is expected to increasingly impact Delawareans as the state's population ages.

Speaker 2:

A new treatment for people suffering from essential tremor and Parkinson's disease is a game changer for ChristianaCare patients. Here to tell us more is Dr Justin Martello, Director of the Parkinson's and Movement Disorders Program and the Focused Ultrasound Program at ChristianaCare.

Speaker 3:

Justin, thank you so much for your time today.

Speaker 1:

Thanks for having me.

Speaker 3:

Let's start with definitions. What is tremor, and how does it differ from Parkinson's disease?

Speaker 1:

And a lot of people make that mistake. Everyone thinks tremors or the shaking of your hands usually involves your hands, happens either in old people or in Parkinson's disease, as you mentioned. But actually the most common reason for people having tremor, or the most common movement disorder, is actually called essential tremor. Don't ask me how they got the name, because people will tell me there's nothing essential about it. It is something that usually happens later in life, although younger people can get it too. It usually involves the hands, as I mentioned, and really when you're using your hands, so picking up a cup, usually it's a very gradually progressive issue, usually involving both hands the same, whereas in Parkinson's disease, patients usually get a tremor when they're at rest, so they're resting their hands in their laps and then start shaking on its own. That's not always the case. In about a third of Parkinson's patients don't have tremors, but that's usually the form of tremor that they have Now, with essential tremor again over many years.

Speaker 1:

So patients usually in the beginning just notice a little bit of shaking Maybe they're holding the glass or doing their makeup or brushing their teeth and then eventually it starts getting worse and worse, to the point where writing becomes, you know, impossible. So signing your name, which we still have to do on like checks and other important financial paperwork, so signing things again, holding a glass without needing two hands or needing a straw to. You know it's a lot of little things throughout the day and these things start to build up. I just had a patient actually today who was lamenting that trying to put his golf ball on the tee just couldn't do it, and you know people are there waiting for him and he just could not get it. So it affects, you know, it starts building up and quality of life starts becoming more of a problem.

Speaker 2:

What is the historical treatment for these tremors?

Speaker 1:

Usually we typically start with medications. Now there aren't that many medications, so there's really two first line options. One is called primidone, the other one's called propranolol. They're very old medicines, actually first created for other uses and then repurposed in the tremor world, but now we really just use them for tremor control. And then after that there's a second line agent called topiramate, and then after that there are several, you know, third and fourth line agents.

Speaker 1:

But once you get past the first few the likelihood that they're going to be really helpful for your tremor just goes, you know, drops off pretty significantly. That they're going to be really helpful for your tremor just goes, you know, drops off pretty significantly. And so most people get to a point where either the medications don't work anymore or they can't use them because of other, you know medical diseases that they have or other medications that contraindicated you know to use them both, or they have side effects. And so most of the time they get to a point where medications are no longer an option and they need to look for what we call more of the procedural options or advanced treatment options.

Speaker 3:

So an advanced treatment option that you're now doing here at Christiana Care is the MR-guided focused ultrasound Correct. Explain to us how that works.

Speaker 1:

So we actually know this procedure works because back in the 60s and 70s well before that we knew that there's an area in your brain that causes the tremors. You actually have one on either side of your brain contributing to tremors on the opposite side of your body. Now, in the 60s and 70s, there was this procedure where we would open up your skull, stick a probe down, burn that area to kill the cells that are causing the tremors and it would stop the tremors. So now we're able to do it without all the cutting or operating on your head, using ultrasound waves. So ultrasounds normally are harmless, but if we take 1,000 ultrasound waves and they all intersect at one area of your brain, it can heat up those cells in order to kill them, to make them stop causing the tremors. And we do it in such a fine way and we use the MRI machine to really not only locate that area of your brain that we're targeting, but also to measure how much heat we're delivering. Because that actually is what's happening.

Speaker 1:

When all the ultrasound waves are intersecting at one point it starts to heat up those cells and so we can actually measure the temperature that we're heating it up in order to permanently kill the cells and actually that's how we're able to avoid a lot of the side effects is we can deliver low levels of energy in the beginning to kind of like stun the cells.

Speaker 1:

And then we're constantly going in and out of the MRI machine saying like, how do you feel we treated with a low level of energy? And if their tremors start to slow down and they say I had no side effects, we know we're in the right spot. If the tremors are the same and they're like well, maybe I have numbness or tingling, okay, we're not in the right area. We move, no permanent damage is done. So we kind of use low levels and then we crank up the heat in order to permanently kill those cells when we know we're in the right area and it's an outpatient procedure, so you go home the same day and there's no rehab or medications you need afterwards. So it's a very appealing option for people who don't want a more invasive brain surgery.

Speaker 3:

It's not an invasive brain surgery, but killing brain cells still, I'm sure gives people pause. So are these brain cells that you really don't need? How does that work?

Speaker 1:

Yeah. So again, it's kind of the tremor center of everyone's brain. Everyone has it. That's why, you see, whenever people are nervous or excited or fearful, they kind of shake. It's interesting.

Speaker 1:

There's some arguments as far as why we have this area of our brain, but we do know that that's really all it contributes to as far as function. It does not really play a role in any other kind of physical or motor function or personality or memories or anything, and in fact it's actually far away from those things. Like you know, your thinking and memory and personality. And, like I said, we were able to do this procedure in a much more invasive way and we knew it was even safe doing it more invasively and really contributed to just little to no tremors without causing any other kind of problems. Having said that, there are areas around this tremor center that we want to avoid treating, because we do know that you can have some side effects right from the procedure.

Speaker 1:

Everything can have side effects, and so some of them include numbness and tingling, as I mentioned, usually of your hands, sometimes of the mouth, balance issues walking in balance. So that's the one thing that we can't really test for while you're on the MRI machine. You're just kind of on the table and so we're not getting you up and walking you around, and so that is one of the things that we worry about the most. Usually it's not significant balance issues afterwards, but there is about a 14% chance that that could be a permanent kind of mild worsening of your balance and walking, and so that's the thing that we worry about the most. The other things are usually temporary and go away weeks to months after the procedure.

Speaker 2:

And, as seems to be the case with a lot of brain surgeries, you made it sound like that the patient is awake through this procedure. Are you having them do some kinds of tests, aside from just how do you feel right now in the process?

Speaker 1:

Yeah, and a lot of people will say, oh, I'm claustrophobic, I need something to calm me down, right, but we actually don't give you any medicines. You're fully awake. No sedating medicines, because that will dampen the tremor. We want you fully awake, telling us not only how you feel while we're delivering the ultrasound energy, which, by the way, only takes several seconds, maybe 15 seconds to 20 seconds at a time, so it's very quick. We want the tremors at their worst.

Speaker 1:

So we even have you come off your tremor medicines before the procedure, so you're at your worst, and then we can see in real time, as we're delivering the energy, the tremor kind of go away, which is kind of amazing when you think about it. We have them draw spirals throughout the procedure to kind of test their tremors. We have them do other activities, sometimes like pretending to drink from a bottle and really bring out the tremor, Because some people will say my tremors really come out with this sort of action or this sort of activity. So we try and mimic how bad their tremor is at their worst so we can see in real time how they improve. And so we're constantly going in and out of the MRI machines, doing the spirals, doing handwriting samples to really see that effect.

Speaker 2:

Christiana Care is the first health center in Delaware to provide this procedure. There are others in the nation who are doing it, but what really is setting Christiana Care's offering of this procedure apart from others?

Speaker 1:

So we are the only center in the whole country where the procedure is run by the neurologist or by the movement disorder specialist or myself.

Speaker 1:

Usually it's done by a neurosurgeon, specifically a functional neurosurgeon, but there are centers that use neuroradiologists.

Speaker 1:

There's actually two others who use neuroradiologists, but neurologists have been involved in the procedure in other centers, but at Christiana Care I'm the one running the whole show without the role of a functional neurosurgeon being involved, and so that is unique, not only in the setting of not having a functional neurosurgeon involved, but also with neurosurgeons.

Speaker 1:

They don't follow patients over time, right, yeah, they'll have some pre-op appointments and post-op appointments, but I'm the one following the patient for their whole life as they're struggling with this disease, and so I am the best suited or my position is the best suited to really interact with these patients, not only before and after the procedure, but during the procedure too. I know them the best, I know what they're struggling with. You know, we examine patients all the time, and so learning to do this procedure which I did have in my fellowships, kind of where I got my background with this has been something that I can offer from both levels, that I'm not just a random doctor coming in and out for a procedure, that I'm holding their hand before and after, really taking care of them throughout the whole experience. And so it's something that I think is more comforting to patients knowing that they have this doctor not just for a single point in their lives, but for their whole life, kind of their whole journey with tremors.

Speaker 3:

Single point in their lives, but for their whole life, kind of their whole journey with tremors and as you continue your relationship with these patients, what success stories are you seeing? Are your patients coming back weeks later saying this really changed my life?

Speaker 1:

Our first patient is a great example. So he found it very difficult to impossible to drink coffee, right Obviously no one wants to do it with a straw and he just could not pick it up, even with two hands, to drink it. Immediately after the procedure, our project manager came over with a 20-ounce cup filled to the brim of steaming hot coffee. And I was joking. I was like, can we not start with water first? That would probably be better, right? And the patient just grabbed it and with one hand the hand we treated just started drinking the coffee, and it was the first time he couldn't even remember, maybe more than a decade since, he's had coffee.

Speaker 1:

So it's little things like that that really make you emotional and really happy to see for these patients who you know it's life-changing. I've had another patient who we just did come out of the procedure and can't wait to do their second side. So you know, one of the things with the procedure is we only can treat one side of your body at that procedure date and then we can treat the other side of your body nine months later. And so he was already coming out and he was like, sign me up for nine months, I'm coming back doing the other side right. So it's just really exciting to see you know patients. A lot of it is. You know their ability to drink right and you can imagine going out to a restaurant, right. This is patients will tell you they're like I can't even have, you know, a glass of champagne or wine without shaking all over and people are looking at me and it's really embarrassing and for many patients that's the issue.

Speaker 2:

Are there any other potential uses for this technology beyond what you've discovered it works for so far?

Speaker 1:

Yeah. So right now there's about 150 clinical trials going on with this technology throughout the country for about 40 or 50 indications that have yet to be approved by the FDA. Right now the FDA has approved to treat essential tremor and tremors with Parkinson's disease. In the hopefully soon-to-be future there's going to be a lot more applications, not just in the neurology space but in other kind of medical specialties, but even in the neurology space to treat seizures or epilepsy, to treat Alzheimer's, dementia, addiction which is totally crazy to think about treat bipolar disorder, treat certain types of cancers you know we can heat up those tumors to shrink them or kill them and that different cancers throughout the body, and so just so many different indications, some you know. Again, you would think how could that even be helpful, like even treating depression, things like that.

Speaker 1:

But we've been able to find that it can be helpful in certain ways that you deliver the ultrasound energy. So there's actually we're using high intensity ultrasound. There's actually a low intensity ultrasound that can be used on the brain, larger areas of the brain, to break open the blood brain barrier. This is kind of a barrier in your brain that prevents a lot of toxins and medicines from reaching the brain. Well, some of the medicines we want to get to the brain, like medicines for Alzheimer's, dementia, for chemotherapy, and we're just not able to deliver them effectively because of this natural barrier. Well, we can use low levels of low-intensity ultrasound to break up that barrier, just temporarily deliver the medicine so it actually can work on the brain, which is kind of an amazing thing to think about.

Speaker 3:

And Justin, you're doing a number of other things on top of this focused ultrasound. Tell us about the ChristianaCare Movement Disorders Clinic.

Speaker 1:

Yeah, so we actually have a pretty robust team part of our Movement Disorders Clinic. It's myself as the director, followed by my partner, dr Patrick Kearns, who joined us a couple years ago. We also have a nurse practitioner, sarah Hinkle, and a physician's assistant, katie Pisachensky, focus ultrasound coordinator, melissa Pacheco all great members of the team. We have a nurse, karen Reed, we have a social worker, we have a neuropsychologist. So we offer a very involved process, a very thorough process of taking care of our patients. We offer a lot of different services to them. We do deep brain simulation programming, we do botulinum toxin injections and we see patients, obviously for any type of movement disorder.

Speaker 1:

The more common ones we would talk about essential tremor, parkinson's, typically are the two most common ones that we see, but we also see dystonia, huntington's disease, ataxia, so a lot of different types of diseases, and we also offer clinical trials too. So we have one actively going on in the Parkinson's space. We hold annual symposiums for Parkinson's disease. They're usually every April, and so we also engage in community events. We do talks to support groups, usually in the Parkinson's space. We have quarterly newsletters that we send out. We actually just created a website for Parkinson's disease. It's pddeorg or parkinsonsofdelawareorg.

Speaker 1:

We're just really invested in the community and the Delaware region. We know we want to be here for a long time and really take care of this aging population where it just seems that every day there's more and more patients with either Parkinson's or central tremor, because we know that those diseases are mostly caused by environmental factors. And, growing up in the industrial age, you're more and more exposed to those things, which is why we see things like up in the industrial age, you're more and more exposed to those things, which is why we see things like Parkinson's is 50% higher of an incidence compared to 20 years ago. Same thing with essential tremor. Obviously, then, people are living longer, right, so they have more time to develop these conditions as well.

Speaker 2:

Justin, thanks so much for talking to us today.

Speaker 1:

It was great. Thank you for having me.

Speaker 3:

We'll have more information on the MR-guided focused ultrasound and movement disorders, including patient videos in the show notes for this me. We'll have more information on the MR-guided focused ultrasound and movement disorders, including patient videos in the show notes for this episode.

Speaker 2:

And don't forget to subscribe to For the Love of Health on Apple Podcasts or Spotify. And you can watch the video version of For the Love of Health on Christiana Care's YouTube channel.

Speaker 3:

We'll be back in two weeks with another great conversation.

Speaker 2:

Until then, thanks again for joining us for the love of health.

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