---

NORTH ATTLEBORO - Jim Wishart thought his career was over. The 52-year-old nurse anesthetist had suffered from hand tremors since he was a young boy, but medication had managed to keep his condition in check. In the spring of 2007, however, things worsened. Wishart's doctors put him on anti-seizure medication, which made him "feel like crap" and, ultimately, could not stop his hands from shaking.

"I was headed toward disability," he recalled.

That's when Wishart with his wife, Maureen, attended an information seminar at Caritas St. Elizabeth's Medical Center in Boston on a procedure that would change his life - deep brain stimulation, or DBS.

It involved placing electrodes, fine wires, deep into the brain. The electrodes are connected to a stimulation device similar to a pacemaker that is surgically implanted in the chest. Electrical currents are sent from the neurostimulator to the electrodes with the intent of interrupting communication between "tremor cells" in the brain, thereby bringing the shaking under control.

Wishart did not opt for DBS immediately. His neurologist, Michael Hayes, first tried a new medication. "I took one dose and hated it." That's when Hayes told him surgery was his only option. "It scared me at first," said his wife, "but I knew Jim was in a desperate situation at work."

Wishart underwent the two-part surgery on July 10 and 11 of this year and, after a month of downtime, returned to work.

"He saved my career," Wishart said of his neurosurgeon, Craig van Horne, who along with Hayes works at Caritas St. Elizabeth's.

There are more than 20 kinds of tremors, but "essential tremor" or ET, the kind that afflicted Wishart, is the most common.

According to the International Essential Tremor Foundation (IETF), the condition is caused by abnormal communication between certain areas of the brain, including the cerebellum, thalamus and brain stem. The cause of the disorder is unknown.

People with ET get frustrated and even embarrassed by the condition and some wind up disabled. Experts estimate up to 10 million Americans have it, and it afflicts anyone from childhood to the elderly. Even infants have been diagnosed with the ET, although the average age of onset is 45, according to the foundation.

ET can run in families, said van Horne. It is a progressive disorder, beginning as a mild, benign tremor and getting worse over time, particularly under stressful conditions. Van Horne said the age of onset is "pretty variable."

"With Jim, it got to be so bad, he couldn't do his job," said van Horne. "About 5 percent of all essential tremor patients might be surgical candidates."

Wishart first began experiencing hand tremors at age 5 but wasn't formally diagnosed with essential tremor until the age of 25. Doctors put him on 10 milligrams a day of Inderal, a beta blocker that relaxes the autonomic nervous system.

Over time, the dosage increased steadily. By the spring of 2007, it was up to 280 milligrams a day. The added Inderal helped for awhile, as it always did. But the tremor broke through once again. "That fall, I started shaking badly," Wishart said. He sought help from a neurologist, who added 250 milligrams of primidone, an anti-seizure medication, to his regimen.

"That helped for a little while," Wishart said. "But I felt tired all the time."

"I have a very hands-on job, intubating (the placement of a breathing tube down the throat during surgery), starting IV's (intravenous therapy)," he said. "It was a struggle."

"People would see me shaking and would think I was nervous. It was horrible."

When Wishart and his wife attended the information seminar at St. Elizabeth's, he was surprised to see about 100 people in attendance. He never realized how many people live with severe tremors.

The doctors at St. Elizabeth's "didn't rush me to surgery," he said. They wanted to exhaust all medical options first. However, when told that only surgery could control his tremor, Wishart decided to go through with it. It was late winter 2008, but surgery was still about four or more months away.

"I couldn't wait," he said. "I was anxious to get it done."

A scar about two inches long and the width of cooked spaghetti appears on the right side of Jim Wishart's chest. That is where van Horne implanted the neurostimulator, about the size of a stop watch, during the first phase of the procedure on July 10.

"They tunneled a wire up my neck to the top of my head," he said. "Once in a while I can feel it, a tightness, but it's not disturbing," Wishart said. "A friend," he called it.

Sitting in his North Attleboro kitchen, Wishart pointed to a barely noticeable bump about the size of a dime on his skull. He is bald with a rim of neatly coiffed gray hair. The raised area is where the surgeon drilled a hole through Wishart's skull and into which he threaded 1.2-millimeter electrodes.

The first phase took about one and one-half hours, said Wishart. "Nothing to it. You're asleep. It's a breeze." The second phase took place the next day, July 11. Wishart was awake for the four-hour procedure.

Van Horne is the only surgeon in the country who does the DBS procedure in "reverse staging," meaning the leads are inserted into the brain after, rather than before, the neurostimulator and wires are implanted. He said he developed this method to enhance patient comfort and to obtain more effective electrode placement. At St. Elizabeth's, they are now performing every DBS procedure in this order and will soon be publishing a paper on their research and experience.

"He was great. He flew the surgery," van Horne said of Wishart.

Wishart said the procedure didn't hurt at all. He was awake the entire time and could hear the surgical team discussing where to place the electrodes.

"My hand was shaking," he said. "Then it just stopped. My hand went steady. I said, 'Oh my God, what did you do?'"

"In the operating room, we got control of the tremor," said van Horne. "We were going to give him a cup of water to see how much his hand shook, but instead Jim said, 'Give me the tool for intubation.'"

"Ahhh, that's it, that's great," van Horne recalled Wishart saying.

The surgical team had succeeded in placing an electrode into the "right" area of Wishart's brain.

After four weeks of recovery, Wishart was back at his job. He still takes 20 milligrams of Inderal to control the tremor in his right hand because the neurostimulator only controls the tremor in his left hand. Wishart so far has not experienced any side effects, though every surgery carries a risk for complication and DBS is no exception. According to the Web site of Medtronics, the device manufacturer, "Implanting the neurostimulator system carries the same risks associated with any other brain surgery."

The prognosis for Wishart is "quite good," said van Horne. "One of the benefits is that we can adjust the amount of stimulation."

Wishart has a hand-held controller that allows him to turn his neurostimulator on and off. The controller can be programmed by medical personnel to set the appropriate stimulation level.

The prodedure that Wishart underwent cost about $100,000, which he said included magnetic resonance imaging and CT scanning, neuropsychological testing, device hardware, surgery, and 3 1/2 days in the hospital.

Insurance covered the full cost, he said, and the benefit has gone beyond a rescued career. Recently, Maureen Wishart noticed her husband fixing something in the back yard.

"Jim, that's the first time I've ever seen you hold a drill steady," she said to her husband of 22 years.

"Everything turned out better than expected," she said, recalling that when her husband was on all the medication, he had "no energy at all."

"Since the surgery, I have my husband back," she said.

"I'm sure there are a lot of people who have this condition, suffering, and they should know there are options to treat them," said Wishart.

Resources:

International Essential Tremor Foundation

Overland Park, Kansas

www.essentialtremor.org

Tremor Action Network

Pleasanton, California

www.tremoraction.org

WE MOVE (Worldwide Education and Awareness for Movement Disorders)

New York, NY

www.wemove.org

ALEX SPEREDELOZZI is an intern at The Sun Chronicle and is pursuing a master's degree at the Harvard Extension School. He can be contacted at asperedelozzi@hotmail.com.