Stanford Medicine Newsletter Updates For the Local Community

 

Controlling tremors

Device relieves symptoms of movement disorders

A minimally invasive procedure has helped to control Brad Ackerman's essential tremor and has given him the freedom to do regular activities.

   

Brad Ackerman has lived most of his life with essential tremor, a common movement disorder that most often affects the muscles in the head, tongue, jaw, voice and legs. The involuntary shaking or trembling caused by essential tremor can make the activities of daily life quite difficult. In Ackerman’s case, it disrupted the movement of his hands, limiting some of his daily activities, his career choices and his social life.

“No one wants to think about being disabled because of something like this,” Ackerman said. “It’s just not something you let yourself think about.”

Essential tremor, whose origin is not completely understood, is one of the most common movement disorders: An estimated 7 million Americans have been diagnosed with the condition, according to a 2014 study published in the journal Tremor. That is 2.2 percent of the U.S. population, far greater than the .15 to .3 percent of the population with Parkinson’s disease.

Family connection

In many cases, essential tremor is genetic and appears in families from generation to generation. Studies show that children have a 50 percent chance of inheriting the disorder from a parent. In Ackerman’s family, two uncles and several cousins had essential tremor. Because the condition was so visible in his family, he thought the difficulties he began to experience in childhood were normal. He learned how to compensate early on, figuring out how to hold his knife, fork and spoon in a way that allowed him to get food into his mouth without spilling. With a heavier object, he managed to grab it with one hand and then transfer it to the other before the tremor in that first hand would loosen it from his grasp.

But the tremor began to affect the direction of his life. In high school, he loved drawing and painting, but his tremor meant he could not easily hold or control a pencil, pen or paintbrush. He was in denial, telling himself that he just didn’t have the talent for art. But he did reimagine how to apply his creative drive: He became an industrial designer, where he could express and execute his visual ideas with the help of a computer.

The tremor, however, affected his social life. “I had to really think about what I would eat when I went out,” he said. “What could I get into my mouth?” Adjusting his movements to maintain his typical life became more and more stressful — and stress can worsen essential tremor symptoms. His wife, Carol, knew about the tremor years before their marriage and remembers the stress she felt (and knew he must have felt) as he struggled to light candles at their wedding ceremony in front of their 500 guests. She had also watched his condition deteriorate with time. “I would notice that when he would sign his name, it was illegible,” she said. “It was getting worse and worse.”

Another option

It is known that the underpinning for essential tremor is irregular electrical activity in deep circuits of the brain. But for many years, medication was the only option available to quiet that activity. However, medication doesn’t work for many people. For others, medication works but produces side effects that interfere with daily life. Ackerman did not like how he felt while medicated. “It just made me want to sit and do nothing,” he said. “It got harder and harder to do a drawing at work. After a while, I couldn’t do it.”

With his livelihood threatened, Ackerman turned to a newer treatment: surgery.

Stanford Medicine neurologists and neurosurgeons have a great deal of experience with devices implanted in the brain to help control its electrical activity. The treatment, called deep brain stimulation, is currently being used at Stanford to treat Parkinson’s disease and other movement disorders.

Targeted implant

Ackerman had a procedure in February 2014 that involves MRI-guided placement of a small, insulated wire into one of the targeted brain structures. At the tip of that wire are four small electrodes that can release electrical impulses to block tremor. The wires are connected to a 2-by-3-inch battery pack that sits under the skin in the chest, just as cardiac pacemakers do. Like most people undergoing the procedure, Ackerman was awake during the process, providing feedback to his neurosurgeon, Casey Halpern, MD, so the surgeon could adjust the pacemaker to meet Ackerman’s particular needs.

“To transform my patients’ lives with a millimeter-sized electrode placed in the brain without destroying any tissue or requiring any large incisions is what inspires me every day,” said Halpern, assistant professor of neurosurgery. “These kinds of procedures have that power of transformation — and, until recently, this type of therapy wasn’t available.”

Studies have shown that after five years, patients experience a 75 percent improvement in the degree of their tremor during regular activities.

Ackerman noticed an immediate change as soon as clinicians turned on and adjusted the device. “It was much better,” he said, “and I can do my job better. I had such anxiety as a result of the tremor, from all the things I had to think about to do what most people consider simple tasks. My whole life has changed. And the surgery has been so successful.”

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