Pioneering surgery that could end misery of shaky hands

A MILLION Britons suffer from uncontrollable shaking. Selwyn Lucas, 53, a painter and decorator from St Austell, Cornwall, talks to SOPHIE GOODCHILD about undergoing a pioneering treatment. The tremor in my right hand started about 20 years ago — it was steady when I wasn’t using it, but sometimes would shake when I picked something up. This happened just occasionally until ten years ago. Then, every time I went to pick up a paintbrush, my hand would shake uncontrollably.

It was so bad I’d have to stop painting until it stopped, usually after a few minutes. I’d also spill drinks because my hand made the glass shake so much.

My wife Marianna urged me to see the GP, but I just switched to using my left hand instead of my right one for painting. Washing and putting my clothes on were still OK so I tried to ignore the problem. It was embarrassing, though, if we went out socially.

In 2012, Marianna booked a doctor’s appointment for me because she knew I never would.

The GP said it could be linked to a car crash at the age of 18 when I shattered the top of my neck, but he wasn’t sure, so he referred me to The Royal Cornwall hospital in Truro for a brain scan.

Nothing showed up and they ruled out the accident as the cause. Instead, they prescribed me tablets. For the next two years the tremors didn’t get any worse, but they certainly didn’t get any better.

In 2014 I went to see tremor expert Dr Peter Bain, a consultant neurologist at Imperial College London. he explained I had a type of tremor caused by faulty circuits in the area of my brain controlling movement.

Given that the drugs hadn’t made much difference, another option was deep brain stimulation, where they drill through your skull and implant an electrode. But there’s a risk of stroke and having a hole in my skull sounded drastic. I wasn’t keen.

In 2016, Dr Bain contacted me about another treatment he was trialling, using ultrasound to destroy the faulty tissue that’s causing the problem. It’s called MRI-guided focused ultrasound: they put you in a scanning machine with a helmet on your head that sends the soundwaves into your brain.

You only need a local anaesthetic and there are no incisions.

I was a bit sceptical about all this, as it was new and I would be one of the first people in this country to have it. But I didn’t want brain surgery and decided to give it a go.

For the procedure last November, they shaved my head to stop the heat generated by the machine burning my scalp — apparently your hair traps heat.

THE PATIENT

A LOCAL anaesthetic was injected into my scalp and, using four tiny bolts, a metal frame was attached to my head to keep it totally still.

Before putting me into the MRI scanner, they placed a plastic helmet filled with ice- cold water on my head — as well as stopping the ultrasound burning my scalp, it would help the waves pass through my skull more effectively.

My head was in the MRI scanner for four-and-a-half hours. all that time they were zapping my brain.

It was making this bang, bang, bang sound like a drill and the noise gave me a bit of headache, but it didn’t make me anxious.

every hour they asked me to raise my right hand to check if it was still trembling, and also took me out of the scanner to check my speech wasn’t slurred, a warning sign that the right area wasn’t being targeted. They also asked me to mimic holding a glass of water and draw a spiral shape on paper.

afterwards, they removed the helmet and metal frame and put plasters over the 4mm holes in my head left by the bolts. Then they checked my tremor by asking me to raise my hand. It was completely still, which was incredible.

I went home the next morning and, apart from a headache, I felt fine. The tremor is 90 per cent better. I get the occasional shake but I can write my name for the first time in years, and pick things up. I’m glad I had the treatment.

THE SPECIALIST

PETER BAIN is a consultant neurologist at Imperial College Healthcare NHS Trust, London. TREMORS are involuntary and uncontrollable shaking of the body such as in the hands, head or legs — they can even affect the voice box, causing a shaky voice.

They occur when muscles repeatedly contract and relax. It’s thought they are caused by abnormal electrical circuits deep inside the brain in an area called the thalamus, affecting messages sent via nerves to the muscles.

There are many types of tremor. The most common is essential tremor (ET), affecting a million people in the UK — the tremor is the only symptom.

ET often runs in families and commonly occurs after the age of 40. around 100,000 people have other tremors caused by movement disorders such as Parkinson’s disease — sometimes ET is misdiagnosed as Parkinson’s.

Mild ET is a nuisance. But for 250,000 people it causes severe disability and they can’t perform daily tasks.

It can be socially isolating and many people are reluctant to go out because others assume they are drunk.

Treatments include medication such as beta-blockers (it’s not clear why these can help) and epilepsy drugs ( which reduce nerve impulses). But these aren’t always effective and can cause drowsiness and nausea.

some patients are offered deep brain stimulation, where an electrode is implanted into the thalamus to send continuous electrical pulses that block the abnormal signals. This involves drilling through the skull and the procedure carries a risk of brain haemorrhage of up to 3 per cent and a one in 10,000 chance of death from stroke.

The recovery time can be several months. at Imperial, we’ve been trialling a noninvasive approach — magnetic resonance- guided focused ultrasound ( MRgFUs) — for six months, though we have been using this technology for 16 years for other conditions.

The treatment uses MRI imaging to guide more than 1,000 high- powered, focused ultrasound beams to a very small point, in the same way that a magnifying glass can be used to focus the sun’s rays on a single point and burn a hole.

Once these beams hit the correct part of the brain, intense heat is created by the rapid vibration of molecules within the brain tissue. This heat ‘cooks’ to nearly 60c and destroys the abnormal tissue cells.

The scanner sends real-time images of the brain to a computer screen.

You can work out the right area to treat within a few millimetres, but it’s not exact, so we begin the treatment using ‘test’ pulses that don’t cause a permanent alteration. We then ask the patient to mimic drinking from a glass — if the tremor has improved, we know we’re at the right spot. If not, we reposition the pulses until we are.

We then switch the machine to deliver high-powered pulses.

The treatment works immediately and the results are expected to be long-lasting. Because it does not involve surgery, this approach is less risky than deep brain stimulation.

Patients can return home the same or the next day. It’s also cheaper — £12,000 to £20,000, compared with £35,000.

The machine is at st Mary’s hospital (part of Imperial) and we are the first UK site to take part in an international safety and efficacy trial into MRgFUs to treat ET.

Trials in the U.s. and Japan have shown it reduces the severity of tremor by at least 80 per cent. The hope is it could be used to treat tremors caused by multiple sclerosis.

Other countries have used MRgFUs in Parkinson’s tremor.

We hope to publish our trial results next year and then it could be offered more widely.

WHAT ARE THE RISKS?

BURNs on the scalp. headaches, temporary tingling in the fingers or unsteadiness when moving after the procedure.

‘There is an urgent need to improve the range of therapeutic options available to help people manage this debilitating symptom,’ says Professor Ray Chaudhuri, a consultant neurologist at King’s College hospital and King’s College London, and an adviser to Parkinson’s UK.

‘This new technique offers a new and promising tool for treating tremor.

‘It is particularly attractive because it could provide similar benefits to deep brain stimulation, but without the need for invasive surgery.’

THE procedure is only available as part of the trial, which is now full. But patients with a tremor can ask their GP or neurologist to refer them to Dr Bain.