Essential Tremor is a movement disorder, most commonly affecting the hands, that makes daily tasks like eating, writing or shaving incredibly challenging for an estimated 10-million Americans.
Now, a new, non-invasive treatment called high-intensity focused ultrasound, or HiFu, is delivering life-changing results.
Dr. Justin Sporrer, director of functional neurosurgery at Miami Neuroscience Institute, joins Dr. Jonathan Fialkow to explain why HiFu is a game changer in the treatment of patients with essential tremor.
(See dramatic before and after video of a patient who received HiFu treatment at Miami Neuroscience Institute.)
Essential Tremor is a movement disorder, most commonly affecting the hands, that makes daily tasks like eating, writing or shaving incredibly challenging for an estimated 10-million Americans.
Now, a new, non-invasive treatment called high-intensity focused ultrasound, or HiFu, is delivering life-changing results.
Dr. Justin Sporrer, director of functional neurosurgery at Miami Neuroscience Institute, joins Dr. Jonathan Fialkow to explain why HiFu is a game changer in the treatment of patients with essential tremor.
(See dramatic before and after video of a patient who received HiFu treatment at Miami Neuroscience Institute.)
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At Baptist Health, South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist HealthTalk Podcast, where our respected experts bring you timely, practical health and wellness information to improve your family's quality of life.
Dr. Jonathan Fialkow:
Welcome back Baptist HealthTalk podcast listeners. Hope you're all masking up and staying safe. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at the Miami Cardiac and Vascular Institute and chief population health officer at Baptist Health, South Florida. Essential tremor's a neurological condition that causes a rhythmic trembling of parts to the body, such as your head and legs and other areas, though it mostly occurs most often in your hands. It can make simple things like tying your shoes or writing or even shaving an endeavor. Though it can be confused with Parkinson's disease, which it is not, essential tremor is much more common. It affects about 10 million Americans.
Dr. Jonathan Fialkow:
Movement disorders make daily life incredibly challenging for those who are affected by them, and while surgery and medical medications can be helpful, there is now a new non-invasive treatment available at Baptist Health that's being held as a game changer for people with this condition. Here today, to tell us about essential tremor and this new procedure, is neurosurgeon, Dr. Justin Sporrer. Justin is the associate medical director of neuroscience and the director of functional neurosurgery at the Miami Neuroscience Institute. Welcome to the podcast, Justin.
Dr. Justin Sporrer:
Thanks for having me, Jon. It's great to be here.
Dr. Jonathan Fialkow:
So let's start by talking about essential tremor in general, then clearly we want to get deep into this new, exciting procedure that we're performing at the Neuroscience Institute. What is essential tremor? What do patients with this condition experience?
Dr. Justin Sporrer:
It's pretty self-explanatory in the description of the disease. It's a tremor where on the hands or the arms can shake. It can often affect the head and neck as well, and sometimes even the feet, but usually the most debilitating aspect is when someone has a tremor of the hand. It tends to occur when someone goes to do an activity and not at rest, which sets it apart. The opposite of what you would find in Parkinson's disease.
Dr. Jonathan Fialkow:
Let's unpack that a little bit, because obviously when people have this tremor and I certainly see it in my practice, the biggest concerns is it's Parkinson. Why is it not Parkinson's and arguably, why is Parkinson's worse?
Dr. Justin Sporrer:
Parkinson's disease, one of the hallmarks is a resting tremor. So if someone's sitting there in their chair, you can see what we call the classic pill-rolling tremor, which is harkened back to when pharmacists would used to count pills, so their hand is rolling over and over. But when they go to do something, their actions might appear even a little bit smoother. That's only one symptom of Parkinson's disease. The others being rigidity, akinesia or slowness of movement and postural instability or imbalance. In essential tremor, it's the opposite. When they're sitting there, you might have no idea that they have a tremor, but when they go to do something like pick up a glass of water or something simple like that, they're spilling all over, they can't write their name, et cetera. The other thing is, people with essential tremor don't tend to have any other symptoms. It's just the tremor.
Dr. Jonathan Fialkow:
So arguably, essential tremor is less progressive and debilitating than Parkinson's. But let's talk a little bit about how essential tremor can be debilitating. When people have this tremor, is there a spectrum from people who, it's mild and doesn't bother them to... What could it look like in its extreme?
Dr. Justin Sporrer:
Yeah, absolutely. It is a progressive disease. It often manifests even in very young people. I'll have patients who are 60 years old, but when they come to me, I say, "When did you notice this?" They say, "Oh, when I was in college, I started to notice when I was taking notes that I would have a little bit of a tremor. And so slowly but surely, it progressed and became a more debilitating thing." That is very typical of essential tremor. Many year history. The other things that I look out for are a family history, because it does tend to run in families.
Dr. Justin Sporrer:
I recently had a patient who said, "I'm seeking medical care, and actually, my son has a much worse tremor than I do, and he was the one that encouraged me to come in." So it can be super debilitating. Although somewhat less popular in the news than Parkinson's disease, it can be every bit as disabling in the sense that you mentioned at the beginning of the podcast, they can't shave their face. They can't eat, they can't drink a glass of water. So those things are super important for quality of life.
Dr. Jonathan Fialkow:
If someone thinks they have essential tremor, and we'll get into a little bit of a workup and treatment, are there any things that what we can do from a lifestyle or medication? What can we do for essential tremor historically leading up to what its limitations may be getting into the new therapy? What are the general things that we have historically told people to do to improve such a tremor?
Dr. Justin Sporrer:
If we get nothing else out of this conversation, I would say that tremor is not just a normal part of aging. Now, there are lots of different types of tremor, physiologic tremor. I'm a neurosurgeon, so if you look at my hand under a microscope, there is a small shake that you have to account for when you're doing surgery. Every single human being has that. There's tremors that are associated with strokes. Obviously, we just mentioned Parkinson's disease, essential tremor. What I would say is to not ignore it and to go to your primary care physician, and oftentimes they'll refer you to a neurologist for a more detailed history and then start the first-line treatments, which you had started to mention. The first-line treatments or medications.
Dr. Jonathan Fialkow:
Beta blockers, things like that. Are there more advanced medications? Or are those still the standards of...
Dr. Justin Sporrer:
Those are the standards. Primidone is probably the most popular. Essentially, what it does is it just calms everything down. Now, people with a essential tremor, there is a problem with the circuits in their brain. But like any type of tremor and like any human being, that is made worse with stress or caffeine or other factors. It's something to definitely work up with a professional, somebody that's familiar with movement disorders.
Dr. Jonathan Fialkow:
So keeping our lists just in suspense as we lead into talking about the high frequency ultrasound, can you describe for the listeners what's going on in the brain that leads to this tremor? Something's happening in the brain, but the hands and the feet and the head are shaking as a response. What's that connection?
Dr. Justin Sporrer:
Our understanding of neural anatomy and the function of the different parts of the brain has evolved over the past century. It was a major breakthrough to even understand the concept that this part of the brain controls the arm, for example, and this part of the brain controls emotions. But it's really not a one-to-one ratio. It's more apt to describe all the activity in the brain as circuits, which is a communication of four or five, six, seven, dozens of different parts of the brain in continuity over and over again that are constantly modifying your movements, your feelings, your emotions, all of these activities so that the output is smooth and not having a tremor.
Dr. Justin Sporrer:
We know people who, for example, have "tremors" of their emotions. Up and down and up and down, instead of a more smooth activity. That is the result of an abnormal circuit. In this case, it is a communication between the cerebellum, which is the back part of the brain that controls coordination, the thalamus, which is a relay center for all brain activity and the cortex, which is the more traditional understanding of this part controls that part of the body. So if there's an abnormality of that circuit, then it's not going to be smooth electrical circuit, and you're not going to have smooth movements.
Dr. Jonathan Fialkow:
You may be happy, because whenever I can get to the thalamus into one of our podcasts, it's a win for me. It's very important information. Now, let's get into the high frequency ultrasound. I guess we call it HiFu. Tell me a little bit about Miami Neuroscience Institute, what this technology is, and then we'll get into what the patient experience can be in undergoing this treatment. What is HiFu?
Dr. Justin Sporrer:
HiFu stands for high frequency ultrasound. That's the shorthand. The technical term is MR Guided High-Frequency ultrasound. Essentially, what it is is that we are able to cause an ablation, which is really, a fancy term for burning a little piece of tissue, deep within the brain in one of those locations that we know is involved with tremor. By disrupting those cells, we disrupt this abnormal circuit. If you think of two negatives, we're stopping an abnormal circuit and we're getting a positive result. The way that we do that with this new technology is by aiming up to a thousand small little ultrasound transducers that are set up like a hairdryer in a salon that goes over the patient's head.
Dr. Justin Sporrer:
Those are all aiming at one specific point deep within the brain, as you mentioned, the thalamus. It's a long setup, a couple hours in total, but the treatment itself is 20 to 30 seconds. What we're able to do is introduce those ultrasonic waves, increase the energy, increase the temperature at those little spot in the brain, test the patient five minutes later, see if their tremor has gone. If it's not gone, we turn the energy up a little bit and try it again. But within 30 seconds, they can go from somebody who can not possibly drink a glass of water to somebody that you would be hard pressed to know that they had a tremor.
Dr. Jonathan Fialkow:
That's got to be remarkable for the patient and for the family to see such an immediate result. Is that pretty much the case?
Dr. Justin Sporrer:
Yeah. The patients are often in a situation where they're laughing or crying tears of joy and then believe it or not, the more satisfying reaction is that when we wheel them back to their husband or wife that's in the waiting room, and it's immediately apparent the patient was awake the whole time. They come out and they hand him a glass of water. Our last patient, it was around noon when we stopped. He had lunch with his wife and he sat there and ate a whole bowl of soup with his "bad hand" which he was not able to do for years before.
Dr. Jonathan Fialkow:
Remarkable, and no side effects or any follow-up concerns afterwards?
Dr. Justin Sporrer:
I think the risk profile is very low. Part of the reason that even though it's a "30 second procedure" but it takes hours is because a lot of that time is setting up, checking the accuracy, rechecking, calibrating, to make sure that we're focusing these beams where we think we are. The beauty of this procedure that was not available in previous technologies is what I like to call a test drive. What we can do is actually heat up that certain bundle of cells to a point where they're stunned, but not permanently damaged. That's when we test the patient out. We bring them out of the machine and we test finger to nose. We have them draw a spiral, drink from a glass of water. If they have a good result from stunning those cells, then we know we're exactly where we want to be.
Dr. Justin Sporrer:
And then we put them back in the machine for another 30 seconds, turn up the energy and make that change permanent. Whereas if we bring them out, their tremor is still there and maybe they're saying, "I have a little bit of tingling in my face," which is not to be unexpected, then that's fine. No permanent change has been made yet. We actually just alter the target, modify the target, two millimeters in front of the last one and do it over again. So we're able to test drive it before we make any permanent changes.
Dr. Jonathan Fialkow:
Great process, and obviously it should reassure the listeners of reminding again, its safety and accuracy. You're not cutting anything, like you said. You're applying ultrasound for the skull, which is reassuring. I love the concept of you're blocking the blocker. You're burning a piece of my brain, right. But we're burning a piece of the brain that's sending bad activity out there, so that's how we get the positive effect, which again, is really important as well. So as we've developed this technology and we're providing it again from Miami Neuroscience Institute, are there particular patients that are better candidates? Are there people with essential tremor that we may say, "Hey, this really isn't for you?" Or is it anyone with this medical condition is a candidate for it?
Dr. Justin Sporrer:
I would say three things about that quickly. One is that we do want to confirm that we think it's essential tremor and not some other type of tremor. We've had some Parkinson's patients come through and if their only complaint or 90% of their symptoms is tremor, then perhaps they would be a candidate. But in general, it's really reserved for those essential tremor patients. Number two, is that anybody who we've now deemed is a candidate needs to get a CT scan that looks actually at the density of their skull. It doesn't mean that you're a dense person or anything like that, but we have to make sure that those ultrasound waves can actually enter through the skull.
Dr. Justin Sporrer:
Some people unfortunately, just do not have the ratio needed in order to get those ultrasound waves in, so that's the final bit. Then the last piece that I would say though, is that certain people, even with a diagnosis of essential tremor are better than others. Those would be the ones who have a tremor in the hand or arm were not as effective at treating people with head or neck tremor. There's lots of reasons for that, but luckily, the vast majority of people with essential tremor are those with upper extremity tremors.
Dr. Jonathan Fialkow:
Perhaps as our experience and the technology improves, we might be able to offer this for people with those other presentations as well.
Dr. Justin Sporrer:
Exactly.
Dr. Jonathan Fialkow:
Going back to some of the clinical scenario, so if someone has essential tremor or a family member has essential tremor and they say, "It's gotten to the point where it bothers me, I want something done." You said the first step, primary care doctor, they may refer to a neurologist, is that correct? Do your referrals for the procedure come from the neurologist or are people able to inquire directly to see if they're a candidate?
Dr. Justin Sporrer:
Both is the short answer. For people with Parkinson's disease, I tend to want them to see a neurologist first because it's a much more complex diagnosis. The treatment leading up to it is very complex. In this case with essential tremor, the diagnosis is fairly easy. Even a lowly neurosurgeon can figure it out without a team of neurologists working with the patient for years.
Dr. Jonathan Fialkow:
Hey, this lowly cardiologist has picked it up in a couple of cases all the time as well.
Dr. Justin Sporrer:
It is very simple, I ask three questions. Does it happen when you go to do something or is it at rest? Do you have any family history? The last question I ask is, does it get better with a glass of wine? Because that is a hallmark of essential tremor that is not present with a lot of the other types of tremor. "Doctor," they say, "I have a glass or two of wine at night and my tremor is much better." That immediately, they almost get a rubber stamp at that point, because then I am very confident that that's what the diagnosis is.
Dr. Jonathan Fialkow:
Again, this is great stuff, both the information on essential tremor, its differentiation from Parkinson's, how those that are concerned should get evaluated, and of course, the technology of this HiFu with more importantly, the incredible results. Again, as you express the gratification that you, as a neurosurgeon, can provide with this instantaneous benefit. Any final comments, anything you want to add before we wrap up or that we missed, or anything you want to emphasize?
Dr. Justin Sporrer:
No, I just think it's an exciting treatment that is worth looking at if you think you might have it. I have had patients who've said, "I just figured I was getting older," and that's a pretty common thing, but you don't have to live with things that are debilitating. So get it checked out. Maybe there's something that we can help you with. Maybe it's easy.
Dr. Jonathan Fialkow:
For our listeners, we will have a link in the podcast notes that shows a short video of a before and after of a patient who's agreed to have his results provided. It's very provocative and a source of emotional, so please take a look at that. Otherwise, thanks for listening as usual. If any of you have any thoughts or recommendations for our podcast topics in the future, please email us at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. Mascotte, Florida, thanks for listening.
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