What is it like to live with shaky hands?
Drinking from a glass or inserting a key into a lock, texting, making a phone call, getting dressed, brushing teeth, signing a document… These daily activities become difficult or even impossible for patients with essential tremor because their hands, feet or head shake.
Tremor is the involuntary shaking of one or more parts of the body. There are a number of diseases that cause this movement disorder, such as Parkinson’s disease.
Essential tremor is another condition that is accompanied by tremor. It most commonly involves shaking of the hands, less commonly the legs, head or voice. Essential tremor is a common condition, occurring in between 0.3% and 22% of people, depending on the area and its inhabitants. In about 25% of cases, tremor leads to job change, early retirement or disability.
How can we help people with essential tremor?
These people with shaking hands, Parkinson’s disease or essential tremor can be helped.
Patients with essential tremor often experience severe psychological stress. In severe forms of the disease, the simplest everyday activities are often no longer possible, and essential tremor significantly worsens the quality of life. Sadly, society labeling a sick person with shaking hands makes life even more difficult for a tremor patient. The exact causes of this condition are still unclear. Research suggests the trigger may be abnormalities in certain nerve cells in brain areas such as the thalamus. Now, my childhood dream has come true when it has become possible to help people with shaky hands without incisions by targeting the culprit areas of the thalamus.The neurosurgeon Rezida Galimova, MD, PhD
Treatment methods for patients with essential tremor,
movement disorders and dystonia
Until the last decade, doctors used various medications, deep brain stimulation (DBS) surgery, gamma knife treatment and radiofrequency thalamotomy as treatments for essential tremor.
Conservative treatment (medications) of movement disorders in essential tremor, Parkinson’s disease or dystonia
We often can not adequately control tremor with medication therapy. Drugs quite often may not help. Sometimes, side effects such as dizziness can occur.
Deep Brain Stimulation (DBS) treatment of Parkinson’s disease
Deep brain stimulation is a neurosurgical procedure in which electrodes are implanted into the nuclei or conductive pathways of deep brain structures and stimulated using an alternating electric current. This results in a significant reduction in tremor. The advantage of the method is that it can treat two sides of the body at once, but like any invasive surgery, deep brain stimulation comes with risks such as infections or brain haemorrhage. Patient needs to replace the stimulator every few years.
Gamma knife thalamotomy treatment of tremor
Gamma knife thalamotomy allows to aim beams of ionising radiation at the area suspected of having tremor and irradiate it. The main disadvantage of the method is that the doctor determine a target area by anatomical landmarks. Deviation of the position of the target nuclei from the typical anatomy occurs in up to 40% of cases.If the irradiation target is an innocent area, the exposure effect becomes unpredictable. Complications can build up over several months due to gradual brain cell death in the irradiated area. Even deaths after such treatment have been described in the literature.
Radiofrequency ablation thalamotomy treatment of tremor
Radiofrequency ablation is a neurosurgical operation in which the surgeon inserts electrodes into the brain under anaesthesia. Then, he wakes up the patient and carries out tests to find the area responsible for the tremor. Then, the surgeon cauterises the target with radiofrequency exposure, such as in a microwave oven. The disadvantage of the surgery is primarily brain damage from the electrodes.
MRI-guided focused ultrasound treatment of essential tremor, Parkinson’s disease or dystonia
MRI-guided focused ultrasound treatment for tremor, Parkinson’s disease, and dystonias is a relatively young treatment method. The first treatment of people with neurological diseases with this method was published in 2009. The method is like a microscopic scalpel that appears inside the brain in the exact area where the effect will be effective and safe.
It sounds incredible! So how can it be achieved?
Doctors place a special helmet with 1,024 ultrasound transmitters on the patient’s head without incisions. Under MRI control, the device focuses ultrasound beams at a pre-calculated point less than 1 mm with an accuracy of 0.1 mm, allowing 2 minutes to put this brain area to sleep. At this point, the patient is conscious, and the doctor makes sure that the brain is functioning correctly and there are no unexpected effects, that the impact on this point eliminates symptoms and does not cause complications. If the sonication does not achieve the expected result, the doctor, according to a special map, changes the location of the target point. After finding the correct target, the doctor changes the mode of action and makes this effect permanent.
The advantage of the method is high accuracy, absence of such possible complications of neurosurgery as bleeding, infection, fractures and electrode dislocation, the patient does not require anaesthesia, the age limit is relative. Due to the fact that the procedure is non-invasive, there is no age restrictions for MRI-guided focused ultrasound treatment (MRgFUS). There are contraindications to the method, but they are mostly relative and needed to be discussed with specialist.
MRgFUS. What is this fantastic method of treating tremor?
Now, we can treat patients with essential tremor effectively and gently using MRI-guided focused ultrasound. Insightec developed this new treatment method for essential tremor and Parkinsonian syndrome with predominant tremor. This method has a CE mark, i.e., approved in Europe and has FDA approval in the USA. Medical centres around the world have already cured more than 5000 patients.
Firstly, the safety and effectiveness of MRI-guided focused ultrasound treatment of tremor is due to the fact that there is no need to open the skull and penetrate the brain with instruments.
Secondly, one of the incredible advantages of this method is that it allows you to probe areas of the brain suspected of causing hand tremor with an accuracy of 0.1 mm using ultrasound. Ultrasound has a remarkable property, it can “stun” brain cells for 2-3 minutes. So the doctor can simulate and check what will happen if you turn off this particular part of the brain in a given person. This avoids impairment of brain function, such as numbness, speech impairment in the treatment of tremor. The doctor can determine whether or not affecting that particular area will help with hand tremor.
How the process of treating tremor with MRI-guided focused ultrasound (MRGFUS) works
The medical team places a helmet with a thousand ultrasound emitters on the patient’s head. MRgFUS device can control these ultrasound sources individually and, like an optical magnifying glass, focus the ultrasound waves into a millimetre-sized brain area. The energy imparted by the ultrasound heats the tissue at the targeted target point. This heating temporarily stuns brain cells at low intensities and ensures accurate targeting. Ultrasound permanently shuts down the nerve cells responsible for tremor at high energies.
During treatment, the patient is awake and does not require anaesthesia. The doctors communicate with the patient and assess the patient’s sensations and neurological condition. In most cases, tremor improves immediately after treatment, but on one side VS Buzaev International Medical Centre is one of the most innovative medical centres in the world.
The attending physician, if he/she is up-to-date and well-read enough, should inform patients with essential tremor about the possibilities of MRGFUS treatment and may refer them to our centre. We also support the presence of him as a treating physician and the patient’s relatives at the procedure.
After a patient applies from anywhere, we consult online. We find out whether the treatment with focused ultrasound is suitable or whether our patient has contraindications.
You can make an appointment for an online consultation at this link.
Are there any disadvantages to the MRGFUS method of treating tremor?
With any treatment, patients should be informed about the efficacy and possible risks. Our YouTube channel has videos of before and after treatment examples.
Firstly, there is a small possibility that the tremor may return months or even years after treatment or may not improve at all. According to the literature, such patients are less than 5% among essential tremor patients.
Second, there is a small risk of temporary or permanent muscle weakness, unsteadiness, loss of sensation, numbness or tingling in fingers or other parts of the body.
Third, while the treatment may reduce tremor, it is important to understand that this procedure, like any other surgical technique, does not treat the underlying condition, nor does it prevent worsening or progression of the condition.
During the procedure, short periods of 10-20 seconds are spent turning on the ultrasound for short periods of time. At this point, patients usually do not feel anything, but some may experience nausea, pain or other sensations. These sensations disappear when the ultrasound is switched off.
MRI-guided focused ultrasound treatment is the latest non-traumatic treatment for patients with extrapyramidal motor disorders in Parkinson’s disease, patients with essential tremor, cervical dystonia is now available to our nearest foreign countries.
Table. Pros and cons of different treatments for essential tremor
|Drug treatment||DBS (deep brain stimulation)||RFA (radiofrequency ablation)||Gamma Knife||MRgFUS|
|Effectiveness||< 90%||> 90%||> 90%||< 90%||> 90%|
|Incisions and openings in the skull||NO||YES||YES||NO||NO|
|Damage to areas innocent of tremor||YES||YES||YES||NO|
|Introducing tools through the structures of the brain||NO||YES||YES||NO||NO|
|Foreign bodies implanted in the brain||NO||YES||NO||NO||NO|
|Need for repeat surgery to replace a discharged stimulator||NO||YES||NO||NO||NO|
|Possibility to test the target before treatment||NO||after inserting |
into the brain
|after inserting |
into the brain
|The risk of haemorrhage||NO||YES||YES||EXTREMELY LOW||EXTREMELY |
|Risk of infection and suppuration||NO||YES||YES||NO||theoretically it is possible |
at the point of helmet-skin contact, but no cases have been
described in the literature
|General Anaesthesia||NO||Awakening from anaesthesia |
for functional tests
|Awakening from anaesthesia |
for functional tests
|Average time spent in hospital||7 days||7 days||less than |
|less than |
|Need the Intensive Care Unit after procedure||Sometimes||Sometimes||LOW probability||LOW probability|
|Possibility of bilateral treatment||YES||Avoided due to |
possible loss of speech
|NO||Staged, can be simultaneous.|