Deep brain stimulation easing symptoms for essential tremor patients

MANSFIELD — Essential tremor can make completing daily tasks feel impossible.

Tying shoes, fastening a button, using a fork, all tasks done without thinking for most of us, can become issues without a resolution for those suffering from essential tremors.

According to Dr. Yagna Pathak, an Abbott Neuromodulation medical science manager, essential tremor is the most common type of movement disorder — with an estimated 7 to 10 million people affected in the United States, about 10 times more than Parkinson’s disease — including a number of people throughout north central Ohio.

“It (ET) can affect men and women at any time of their life, but it most often manifests in middle age,” Pathak said.

“People with essential tremor may experience uncontrollable rhythmic shaking usually affecting the hands, but can also involve head, voice and other body parts.”

Pathak said ET diagnosis is based on a patient’s medical history, clinical observation and a skilled physical examination.

No laboratory test can confirm an ET diagnosis, Pathak said, so neurologists often rely on a combination of criteria, including type of tremor, duration of symptoms and supporting tests.

The most effective treatment for tremor is a procedure known as deep brain stimulation, according to the International Essential Tremor Foundation.

During the procedure, a pulse generator or battery is implanted under the skin of the patient’s chest, Pathak said.

“This battery is then connected to thin wires, called leads, which are placed in a precise area of the brain,” she said.

“Once everything is in place, connected and turned on, the battery produces painless electrical impulses that are delivered to the brain to correct abnormal brain activity caused by movement disorders, such as essential tremor or Parkinson’s disease.”

DBS procedure, seeking diagnosis

Deep brain stimulation is typically done over the course of two visits, Pathak said.

Leads are implanted during the patient’s first visit — after which most people stay in the hospital, at least overnight, she said. The battery is implanted during the second visit and most patients are able to return home the same day.

“Ultimately, each person is different, so the road to recovery will look a bit different for every patient,” Pathak said. “Their doctor will be in the best position to guide them on what to expect from the recovery process.”

If someone believes they are suffering from essential tremor, she said they should speak to a neurologist who specializes in movement disorders — suggesting patients can maintain a journal to summarize symptoms and how they impact quality of life.

“A movement disorders specialist will conduct a physical examination to eliminate other movement disorders and confirm an ET diagnosis based on observations and medical history,” Pathak said.

“Additionally, the specialist can recommend next steps for the best course of therapy.”

Rehring’s injury inspired healthcare career

Former Ohio State football player Steve Rehring, who started on the 2006 and 2007 Buckeye offensive lines that each reached the national championship game, is now an Abbott Neuromodulation territory manager.

He provides technical support to surgeons and medical around the use of Abbott DBS products.

As the territory manager for Abbott’s brain therapies in the State of Ohio, Rehring’s job is to educate patients about DBS therapy as a treatment option for Parkinson’s disease or essential tremor.

The opportunity to see patients regain their ability to control areas affected by essential tremor never ceases to amaze Rehring.

“Having the opportunity to see patients and their families post-procedure makes my job so enjoyable and motivates me daily,” he said. “Quite frankly, it is the best part of my day.”

Looking back, the former Buckeye originally dreamed of having a chance to play in the National Football League — an idea in the back of Rehring’s mind each game he played.

“I ended up having a serious medical incident during my career that required extensive physician and medical staff intervention to even get out of a hospital bed,” he said.

“Fortunately, with their help I was able to get back to playing. From that point on, I was fascinated with working in healthcare.

“Playing football as a Buckeye, along with my coaches, staff and teammates, showed me what it was like to be surrounded by the best team of people working together towards a goal.

“All of the people who supported me early on inspired me to surround myself with a similar group of people in my career.”

Area hospitals share local ET insights

Richland Source spoke with doctors from area hospital networks, including Avita Health System, OhioHealth Mansfield and University Hospitals, about essential tremor and treatment options in Richland and Ashland counties.

Knox Community Hospital was unable to provide comments due to a current lack of neurologists.

Dr. Omar Ahmad, board certified in neurology and neurophysiology, sees patients at Avita Health System locations in Ontario and Galion. He treats all neurologic disorders, with a special interest in treating movement disorders.

Ahmad said referrals are made to Avita’s clinic when ET symptoms do not respond to initial therapy, or if a patient’s provider is doubtful of the diagnosis and would like a second opinion.

“As a result, I see many patients with essential tremor at our Ontario and Galion locations,” he said. “I also work closely with a nurse practitioner who sees ET patients in Ontario and Bucyrus.”

Medical therapy is considered when the tremor interferes with everyday activities — such as eating, drinking or signing one’s name — or causes embarrassment, Ahmad said.

He said approximately 75 to 80 percent of ET patients experience some benefit with medication.

A minority of patients seek surgical treatment because the tremor “is disabling and they are resistant to medical therapy.”

“There are two primary surgical treatments available — Deep Brain Stimulation and Focused Ultrasound Thalamotomy,” Ahmad said. “While these do not offer a cure, they can be quite effective therapies.”

Avita Health Systems doesn’t offer either procedure, but refers to The Ohio State University Medical Center and the Cleveland Clinic, based on patient preference.

Once a patient undergoes their procedure and initial treatment at a tertiary center, they can be followed locally at Avita locations if they wish, said Ahmad — who offers follow-up DBS programming for patients after surgery.

University Hospitals offers virtual programming

Dr. Aasef Shaikh, Penni and Stephen Weinberg chair in brain health and vice-chair for research at University Hospitals Neurological Institute, said increased awareness of essential tremor is beneficial for the community.

If patients don’t respond to a variety of medications, he said UH offers a robust deep brain stimulation program — including neurologists dedicated to practicing treatment of movement disorders.

Shaikh comes to Ashland’s UH Samaritan Medical Center once a month to see patients.

Once he considers them as a potential candidate for DBS, patients typically travel to UH Cleveland Medical Center for possibly two to three visits; which include meeting with a neurosurgeon and the surgical procedure itself.

“Many other things we can do virtually,” he said. “I can do the initial programming in Ashland, in-person, but then the remaining programming we can actually do virtually.”

Shaikh still likes to see patients one to two times a year in person after surgery.

“We can minimize the travel for the surgical procedure … but after that they don’t have to go anywhere so much,” he said. “So maybe two or three trips to Cleveland total, for the whole thing, and 95 percent of the things we can do in Ashland.”

OhioHealth continues to expand neurology program

Dr. Gubert Tan, neurologist and stroke medical director at OhioHealth Mansfield, said about 8 to 10 patients afflicted with ET are seen per month at the Mansfield hospital.

Tan said treatment usually begins with medication as an attempt to reduce the tremor, as well as non-medical practices, such as using weighted utensils when eating.

While DBS isn’t available at its Mansfield hospital, OhioHealth does offer the procedure — as well as high intensity focused ultrasounds — at its Riverside Methodist Hospital in Columbus.

Hesitancy to DBS among patients isn’t uncommon, Tan said.

“But even during the (patient’s) first visit, I would offer them ‘These are the available options, these are the medications we will use and these are the possibilities,'” he said.

Along with Mansfield patients, Tan said the Mansfield hospital has also treated patients from surrounding communities, including Ashland, Mount Vernon, Mount Gilead and the Knox County area.

He said OhioHealth Mansfield is continuing to expand its neurology program, which currently includes three neurologists, a nurse practitioner and two neurosurgeons.