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Friday, September 23, 2016
BY FRAN KRITZ
As many as 10 million people have essential tremor, a neurologic condition that causes involuntary and rhythmic shaking, mostly in the hands, but shaking can also occur in the head, arms, voice, and torso, according to the International Essential Tremor Foundation. The condition is sometimes mistaken for Parkinson's disease because tremor is a symptom of Parkinson's. But unlike with essential tremor, tremor in Parkinson's disease is one of many symptoms including a shuffling gait and movement difficulties, says Todd Herrington, MD, PhD, a neurologist at Harvard Medical School and Massachusetts General Hospital.
Essential tremor is incurable but it can be treated with beta blockers and anticonvulsant medication as well as deep brain stimulation (DBS), which involves a neurostimulator, a battery-operated medical device similar to a pacemaker that is surgically implanted into the chest. The neurotransmitter delivers electrical stimulation to targeted areas of the brain that control movement, blocking the abnormal nerve signals that cause tremor. Studies show that it improves arm tremor by 50 to 90 percent, says Dr. Herrington.
Ultrasound Burns Brain Cells
Now, a new treatment has been approved by the US Food and Drug Administration (FDA) that might help patients who haven't responded to other therapies. Called focused ultrasound thalamotomy, the device directs intersecting and concentrated beams of ultrasound energy that heat then burn away a portion of the thalamus, a part of the brain thought to generate some involuntary movement. During the procedure, the patient wears a helmet-like device and lies in a magnetic resonance imaging (MRI) machine. Images on a monitor help surgeons guide the ultrasound beams, and the amount of energy is increased incrementally until surgeons see a lessening of the tremor. No anesthesia or incision is required.
"Individual ultrasound beams pass through the scalp, skull, and brain tissue. Once at the target, the multiple beams converge to a precise focal point. This is a permanent treatment in which some brain cells causing the tremor are burned away," explains Vibhor Krishna, MD, a neurosurgeon at Ohio State Wexner Medical Center, one of six medical centers in the US that performed clinical trials on the procedure. "We hope to increase the effectiveness of this treatment by improving visualization of the brain region involved through advanced neuroimaging," adds Dr. Krishna.
FDA Approval Based on Small Clinical Trial
The double-blind, placebo-controlled trial, which was published in the New England Journal of Medicine in August, involved 76 patients with essential tremor who had previously not responded to medication. Fifty-six patients were randomly selected for focused ultrasound and 20 for a fake treatment but those patients were able to switch to the actual treatment three months later.
Patients treated with ultrasound showed nearly a 50 percent improvement in their tremors and motor function three months after treatment compared to their baseline score, while patients in the control group had no improvement. Some even experienced a slight worsening before they switched to the treatment group. A year after the procedure, improvement had dropped to 40 percent. Researchers and clinicians are following up with patients to see if the decrease stabilizes or if it's an indication that improvement wanes over time, says Dr. Krishna.
Procedure Has Side Effects
Patients in the clinical trials reported numbness or tingling in the fingers, headache, imbalance and unsteadiness, loss of control of body movements, and gait problems. The energy beams can cause tissue damage beyond the treatment site, as well as hemorrhaging, skin burns, and blood clots.
Not everyone is a candidate for the procedure, according to the FDA, including anyone who has an implantable medical device such as a pacemaker, people who are allergic to contrast dyes used for MRIs, pregnant women, and people with unstable blood pressure.
Pros and Cons
"We don't yet know how long the effects will last," says Dr. Herrington, who was not involved in the clinical trials. The procedure is also irreversible and even though it's termed noninvasive, that's not entirely accurate, he says. "Surgeons create a permanent hole in the brain." Advantages include no risk of infection at the incision site and no need to replace a neurostimulator battery periodically as is the case with DBS. And in rare cases, says Dr. Herrington, the neurotransmitter used for DBS can fail, and another surgery is needed to remove it.
Focused ultrasound thalamotomy for essential tremor is approved for use on one side of the brain only and surgeons are most likely to choose the side that is causing tremor in the dominant hand, says Dr. Herrington. "As the device has wider use, we'll have a chance to see how long the effects last and whether we can push it to treat symptoms on both sides," says Dr. Herrington. "I think it's an exciting tool but will take more time to understand how exactly it fits." Dr. Herrington says another upside is that the location where the energy is directed is similar to targets used for DBS so surgeons are already familiar with the anatomy involved.
Covering the Cost
Insightec, an Israeli company that manufactures ExAblate Neuro, the focused ultrasound device, is in talks with Medicare and private insurers about coverage and expects to have answers by next year, says Rick Schallhorn, vice president of neurosurgery at Insightec.
Meanwhile, the medical centers that conducted the clinical trials have the device so patients should discuss the option with their physician. The procedure, which is not yet covered by Medicare or insurance, currently costs more than $30,000, which includes the device and the surgery.
For more information about focused ultrasound thalamotomy for essential tremor, visit the FDA at bit.ly/FDA-Tremor or Insightec, the company that created the device, at bit.ly/ExAblateNeuro. Also, talk to your doctor to see if the procedure is something for you to consider. For more about essential tremor, visit our archives at bit.ly/NN-Essential Tremor.
Wednesday, September 21, 2016
Credit: Cleveland FES Center (http://fescenter.org)
BY SARAH OWENS
For patients whose stroke affected their ability to use their hand, a new electrical stimulation device may help. The device allows patients to control their impaired hand using their unaffected hand, and to control the timing and intensity of electrical stimulation. In a study published online on September 8 in Stroke, the new method led to improvements in hand dexterity.
Patient-Controlled Electrical Stimulation
Electrical stimulation is already widely available and used in stroke rehabilitation to help patients recover the use of their limbs. Traditional electrical stimulation, known as cyclic neuromuscular electric stimulation (cNMES), is controlled by a therapist and requires no active participation from the patient. By contrast, the new method, called contralaterally controlled functional electrical stimulation or CCFES, allows patients to exercise an impaired hand by controlling electrical stimulation to the impaired hand using their strong hand (or contralateral hand) and performing tasks.
The researchers hypothesized that because CCFES allows patients to use both hands, is done in real time, and involves tasks, it may result in better, faster rehabilitation compared to cNMES.
Researchers at MetroHealth Medical Center in Cleveland, Ohio enrolled 80 patients who had had a stroke and were partially paralyzed in one of their upper limbs for at least six weeks. Half the patients received 10 sessions per week of the new stimulation method, and half received 10 sessions of the traditional stimulation, for six months.
After the six months, the researchers administered the Box and Block Test (BBT) to gauge improvements in hand dexterity. The test counts how many times a person can pick up a block, move it over a partition, and release it in a target area within 60 seconds.
Patients who received CCFES had greater improvement in dexterity as measured by the Box and Block Test than patients who underwent cNMES. Patients who'd had a stroke less than two years prior to the study and had moderate, not severe, hand impairment at the start of the study had the biggest improvements.
A New Option for Stroke Rehabilitation
For recent stroke patients with moderate hand impairment, CCFES is a better option than cNMES, the study authors say, possibly because CCFES happens in real time, requires patients to open both hands at once, and/or allows patients to practice tasks with the impaired hand. They added that with CCFES—unlike with cNMES—patients can control the timing and intensity of tasks.
Watch a video showing the new stimulation device in action here: bit.ly/StimTherapy.
Monday, September 19, 2016
BY SARAH OWENS
People who are physically active in midlife may be less impaired cognitively in late life. Conversely, people who are more sedentary may have an increased risk of cognitive decline, according to a new study published in the Journal of Alzheimer's Disease.
The results are from the Finnish Twin Cohort, a long-running study (1974 through 1999) of identical twins, looking at genetic and environmental risk factors for chronic disorders. The participants' average age was 49 at the start of the study and 74 at the end.
Assessing Physical Activity
The researchers assessed the participants' levels of physical activity in 1975 and again in 1981, based on answers in a broad health questionnaire, including amount and intensity of activity.
Vigorous was defined as anything faster than walking (alternately walking and jogging, jogging, or running). Amount was based on participants' answers about average intensity, duration, and monthly frequency of physical activity. Based on their answers, participants were sorted into three groups: persistent vigorous activity, persistent inactivity, and changed status (those who had persistent activity in one year but not the other).
At the end of the 25-year study period, the researchers conducted a telephone assessment of cognitive status by asking questions on basic knowledge, word recall, subtraction, orientation, and attention. They also asked the participants to repeat sentences and provide the opposites of words.
People who were vigorous exercisers on at least one assessment had significantly better cognition compared to inactive participants. Because the study subjects were all twins, the researchers were also able to compare outcomes between twins who had different activity levels. The results were consistent with those in the study cohort as a whole: twins who vigorously exercised had a reduced chance of developing cognitive impairment compared to their inactive twins.
Finally, the researchers analyzed levels of physical activity within groups. Among inactive participants, those who exercised the very least had the greatest risk of cognitive impairment. However, among participants in the changed activity or persistent vigorous activity groups, more exercise was linked to a small, and non-significant, reduction in the risk of cognitive decline. The results suggests that only a moderate amount of physical activity is necessary, the researchers concluded, which confirms the findings of several other studies.
Train Your Brain
To protect your brain as you age, get regular exercise, but don't overexert yourself. Start walking, and try working up to a mix of walking and jogging. Researchers say this mix qualifies as vigorous exercise–and their research shows it can protect against cognitive decline.
Wednesday, August 31, 2016
Photo credit: Argonne National Laboratory via Foter.com / CC BY-NC-SA
BY SARAH OWENS
People who develop asthma after age 18 may have an increased risk of cardiovascular disease, including stroke, according to a new study published online on August 24 in the Journal of the American Heart Association.
Asthma is an inflammatory disorder that can develop in childhood or late in life. When it develops in adulthood, asthma is often more severe and more likely to be resistant to standard treatment, according to the study authors. Previous studies have linked asthma to cardiovascular disease risk, but most have not investigated the risk of a distinct subtype of asthma, the authors added.
Investigating the Asthma-Stroke Link
For their study, researchers at the University of Wisconsin enrolled 1,267 adults who were participants in the Wisconsin Sleep Cohort, an ongoing trial designed to investigate sleep, respiratory, and cardiovascular health in adults. Among the participants, 111 had a physician's diagnosis of late-onset asthma, 55 had early-onset asthma, and 1,103 did not have asthma. At the beginning of the study, the participants had not experienced a cardiovascular event, such as a heart attack or a stroke.
At the start, the researchers checked for cardiovascular risk factors, such as high blood pressure, smoking, diabetes, or a high body mass index (BMI). They also performed a polysomnogram, a test that records brain waves, heart-rate, breathing, and blood-oxygen levels during sleep, to determine if the participants had any other respiratory problems, such as obstructive sleep apnea.
Testing for Cardiovascular Events
Participants completed health history questionnaires during follow-up visits and sent in health surveys reporting any cardiovascular events, including heart attacks, angina (chest pain), stroke, coronary revascularization, or heart failure, during the study period. Using medical records, the researchers assessed the number of cardiovascular-related deaths at the end of the trial.
A total of 223 cardiovascular events occurred in the study group: 179 in the non-asthma group (8.9 percent), seven in the early-onset asthma group (3.8 percent), and 22 in the late-onset asthma group (12.7 percent). After adjusting for age, sex, and cardiovascular risk factors, the researchers found that late-onset asthma was associated with a "significantly higher" risk of cardiovascular events, including stroke and heart attack. Overall, participants with late-onset asthma had a 1.6-fold higher risk of a cardiovascular event compared to non-asthmatic participants.
The researchers found no significant link between obstructive sleep apnea or other sleep-related breathing problems and an increased risk of cardiovascular disease.
The Role of Risk Factors
The study authors noted that early- and late-onset asthma have very different disease processes and risk factors. For example, the risk factors for early-onset asthma include family history of atopic disease, viral and bacterial infections, and tobacco exposure; the risk factors for late-onset asthma include environmental irritants, obesity, stressful life events, and aspirin use.
More research is needed to determine the exact reasons for the asthma-cardiovascular disease link and to identify treatments, the study authors wrote. Still, they noted a few different risk factors linked to late-onset asthma that may be controllable such as obesity, tobacco use, and environmental irritants. By maintaining a healthy weight and restricting tobacco use, people may be able to lower their risk of developing late-onset asthma, which, in turn, may lower their risk of cardiovascular disease.
Tuesday, August 30, 2016
BY FRAN KRITZ
Many people with neurologic disabilities are eligible for public assistance for income, health care, food, and housing. To qualify for these benefits—either Medicaid for health insurance or supplemental security income (SSI) for monthly stipends—individuals cannot have more than $2,000 in cash savings, retirement funds, or other items of significant value. That eligibility requirement leaves a lot of people without government support for basic necessities like wheelchair-accessible housing and transportation, assistive technology, personal assistance services, and any supplemental health care not covered by Medicaid.
That could change for many people with the introduction of new tax-advantaged savings accounts for people with disabilities. Called Achieving a Better Life Experience (ABLE) accounts, these programs allow people with disabilities and their families to set up a special savings account for disability-related expenses such as a wheelchair ramp for the house or an adapted minivan. Participants can choose to invest their savings in an array of investment funds, and a beneficiary can change funds twice a year as well as withdraw money tax-free if used for eligible expenses. Anytime an ABLE account exceeds $100,000, SSI benefits would be suspended until the account goes below $100,000 again. Medicaid benefits are not suspended, regardless of how much is in the ABLE account.
Who Is Eligible?
The Stephen J. Beck ABLE Act, passed into law in December 2014, limits eligibility to individuals with significant disabilities that began before age 26 and who already are receiving government benefits, says Stuart Spielman, senior policy advisor and counsel for Autism Speaks in Washington, DC. People who are not currently receiving government benefits must meet the criteria of limitations in daily living as set by the Social Security Administration and have a letter of certification from a licensed doctor.
So far, four states—Ohio, Tennessee, Nebraska, and Florida—have launched ABLE programs, and other states are expected to roll them out over the next couple of years. Eligible individuals can open an account in any state that currently offers the program, though fees may be higher in non-resident states.
More Financial Flexibility
The total amount that can be contributed to an ABLE account in a single year is $14,000. (The amount may be adjusted periodically by an act of Congress to account for inflation.) If the amount in an ABLE account exceeds $100,000, the beneficiary's SSI cash benefit would be suspended until the account drops below $100,000 again. Medicaid benefits would remain unaffected. Once a beneficiary dies, the state can take some or all remaining funds in an ABLE account to cover costs spent on Medicaid for the individual who had held the account.
Legislation has been introduced in Congress that would raise the eligible age at which the disability began from before age 26 to 46. It would also allow individuals with a disability who are employed to contribute to their own ABLE account. In addition to the $14,000 that can be contributed by parents or guardians, the beneficiary would be able to contribute funds up to the federal poverty level, currently $11,880 per year. And those individuals would still qualify for the Savers Tax Credit, a provision under the tax code which allows people with low-to-moderate income to save for retirement.
Easing the Burden
"I think these accounts are fabulous," says Ann Neumeyer, MD, medical director of the Lurie Center for Autism at Massachusetts General Hospital in Boston. As part of the Center's clinical program, a team of specialists talks to patients and families about the financial implications of autism spectrum disorders and what services the funds might be spent on, including behavior therapies or vocational training programs, she says. "These accounts are important because having any chronic neurologic condition has huge financial implications for a family including reduced income because one parent may not be able to work full time," says Dr. Neumeyer.
For More Information
The National Disability Resource Center maintains a website called the ABLE Resource Center (ablenrc.org) which is updated regularly. Several patients' organizations that help individuals and families dealing with neurologic conditions including United Cerebral Palsy (ucp.org), Autism Speaks (autismspeaks.org), and the National Down Syndrome Society (ndss.org) also update their sites when news about ABLE accounts is announced.