Essential Tremors
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Everyone has at least a small degree of tremor, but the movements usually cannot be seen or felt because the tremor is so small. When tremors are noticeable, the condition is classified as essential tremor.
Essential tremor (ET) is the most common movement disorder encountered in expert clinics. Family history is often positive. It is often confused with Parkinson’s disease. Essential tremor like Parkinson’s disease is now considered a neurodegenerative disease, however the speed of progression is extremely slow and the disease course can sometimes run for many decades. In the later stages of disease, tremors are noted to become more severe, there is a wider distribution and there may be changes in the gait and cognition of the affected individuals.
The cause of essential tremor is unknown. However, one theory suggests that your cerebellum and other parts of your brain are not communicating properly. The cerebellum controls muscle coordination.
In most people, the condition seems to be passed down from a parent to a child. If your parent has ET, there is a 50% chance you or your children will inherit the gene responsible for the condition. Sometimes, ancillary testing such as brain imaging or genetic testing may help with the diagnosis.
The typical age of onset is either in early 20s and 30s or in the late 60s and 70s. Men and women are affected equally. Essential tremor increases in frequency with age, and is present in more than 1% of individuals 70 years of age or older.
In most people, the condition seems to be passed down from a parent to a child. If your parent has ET, there is a 50% chance you or your children will inherit the gene responsible for the condition. Sometimes, ancillary testing such as brain imaging or genetic testing may help with the diagnosis.
The typical age of onset is either in early 20s and 30s or in the late 60s and 70s. Men and women are affected equally. Essential tremor increases in frequency with age, and is present in more than 1% of individuals 70 years of age or older.
If you have essential tremor, you will have shaking and trembling at different times and in different situations.
You might typically experience:
• Tremors occur when you move like trying holding an object either spoon or glass
• Tremors get worse when you are emotionally or physically stressed
• caffeine make your tremors worse
• Tremors may improve with ingestion of a small amount of alcohol. Alcohol is found to alleviate the tremors in some. Although response to alcohol is important for clinical diagnosis, it is not recommended as a treatment.
• Tremors get worse as you age.
• Tremors don’t affect both sides of your body in the same way, starts one side of body in the beginning and progresses to other regions, notably the head, face, voice, trunk, and legs, are seen either separately, or in combination. There is also a general rule, if prominent tremors are seen in the legs, Parkinson’s disease should be ruled out.
Here are some signs of essential tremor:
• Tremors occur mainly in the hands and are 4 to 12 Hz in frequency,
• You might experience difficulty doing tasks with your hands, such as buttoning, combing, writing or holding spoon
• Trembling sound in your voice
• Head shaking
You might typically experience:
• Tremors occur when you move like trying holding an object either spoon or glass
• Tremors get worse when you are emotionally or physically stressed
• caffeine make your tremors worse
• Tremors may improve with ingestion of a small amount of alcohol. Alcohol is found to alleviate the tremors in some. Although response to alcohol is important for clinical diagnosis, it is not recommended as a treatment.
• Tremors get worse as you age.
• Tremors don’t affect both sides of your body in the same way, starts one side of body in the beginning and progresses to other regions, notably the head, face, voice, trunk, and legs, are seen either separately, or in combination. There is also a general rule, if prominent tremors are seen in the legs, Parkinson’s disease should be ruled out.
Here are some signs of essential tremor:
• Tremors occur mainly in the hands and are 4 to 12 Hz in frequency,
• You might experience difficulty doing tasks with your hands, such as buttoning, combing, writing or holding spoon
• Trembling sound in your voice
• Head shaking
In a clinical setting a comprehensive interdisciplinary examination by an experienced movement disorders specialist can result in diagnosis of essential tremor.
Specific criteria observed during the clinical exam include
• The presence of tremors in both hands and forearms engaged in routine daily tasks and absence of any additional neurologic symptoms or signs.
• Emergence of tremors on simple physical exam during postural elevation of the arms, on dynamic tasks like painting, drawing an Archimedes spiral, writing, holding glass of water and on action manoeuvre such as finger-to nose testing.
To find out for certain, your health care provider may have you try to:
• Abstain from heavy alcohol use — trembling is a common symptom among people with alcohol use disorder.
• Avoid caffeine.
• Avoid or reduce certain medicines.
Specific criteria observed during the clinical exam include
• The presence of tremors in both hands and forearms engaged in routine daily tasks and absence of any additional neurologic symptoms or signs.
• Emergence of tremors on simple physical exam during postural elevation of the arms, on dynamic tasks like painting, drawing an Archimedes spiral, writing, holding glass of water and on action manoeuvre such as finger-to nose testing.
To find out for certain, your health care provider may have you try to:
• Abstain from heavy alcohol use — trembling is a common symptom among people with alcohol use disorder.
• Avoid caffeine.
• Avoid or reduce certain medicines.
Although at present there are no validated serologic, radiologic, or pathological markers for diagnosis, major initiatives are actively being explored. Recently an imaging technique known as DaTscan™ (125I-iofluane SPECT), which measures the integrity of the dopamine system in the brain was approved by the FDA, to help distinguish ET from PD. At KIMS Hospitals Dr. Manas, Dr. Dhanunjaya rao and colleagues are frequently conducting special sequences in MRI and contrast enhanced other imaging modalities to identify the nerve tracts in brain which are responsible for essential tremor. These techniques follow well established imaging methods. The functional MRI has an ability to look at the brain activity based on changes in regional blood flow, whereas DTI is used to examine changes in brain connectivity by measuring water diffusion along nerve fiber tracts in the brain. Parkinsons group also offers a quantitative computerized analysis using sensors attached to various parts of body that can helps distinguish essential tremor from other types of tremor. This technique is simple, noninvasive, and can be reconstructed into 3 D model in a dedicated laboratory and identify the difference between the various types of tremors.
At present there is no cure for essential tremor, but tremors can be alleviated with multiple therapies.
various non-pharmacological techniques are used to decrease the intensity of tremors but the benefits are not long lasting.
These techniques include
• The use of weighted utensils or application of weights to the wrists during daily functional tasks to reduce the amplitude of tremors.
• cooling the arms; a technique also used for the control of tremors.
various non-pharmacological techniques are used to decrease the intensity of tremors but the benefits are not long lasting.
These techniques include
• The use of weighted utensils or application of weights to the wrists during daily functional tasks to reduce the amplitude of tremors.
• cooling the arms; a technique also used for the control of tremors.
Propanolol and Primidone are two of the medicines often prescribed to treat essential tremor.
Propanolol blocks the stimulating action of neurotransmitters to calm your trembling. This beta blocker is effective in 40% to 50% of patients and is less useful in reducing head and voice tremor. Propanolol may reduce exercise tolerance, lower blood pressure or heart rate, exacerbate depression and cause impotence. Other adrenergic blockers with fewer side effects include atenolol, nadolol, metoprolol and timolol.
Primidone controls the actions of neurotransmitters. Some patients starting primidone may experience a “first dose phenomenon” during which they have transient feelings of unsteadiness, dizziness and nausea during the beginning stages of treatment. This is usually short-lived.
If primidone or propranolol are not effective by themselves, a combination of both may provide relief for some patients.
The potential benefit of these therapies should be weighed against the possible side effects. Side effects of the medications should always be explained before initiation of therapy. Propranolol is known to result in slowing of the heart rate, fatigue, worsening of diabetes, worsening of mood and exacerbation of asthma. It is usually avoided in patients with asthma, emphysema, congestive heart failure or heart block, and should be used with caution by people with diabetes who are on insulin
Primidone on the other hand is found to cause worsening of gait, balance, sleepiness and behavioural issues in some individuals. If tremors continue to remain inadequately controlled, a trial of a second-line medication, such as benzodiazepines, gabapentin, topiramate, or botulinum toxin, can also be tried.
Gabapentin and topiramate are two other anti-seizure medicines that are sometimes prescribed for essential tremor. In some cases, benzodiazepines such as alprazolam or clonazepam might be suggested.
For essential tremor in your hands, botulinum toxin (Botox) injections have shown some promise in easing the trembling. They work by slightly relaxing the overactive muscles. The injections are targeted to the specific muscles that are involved in the abnormal movement, while avoiding uninvolved muscles. Botox injections are typically recommended for patients with severe head tremor, and several studies have shown that the injections may significantly help head and voice tremors.
Propanolol blocks the stimulating action of neurotransmitters to calm your trembling. This beta blocker is effective in 40% to 50% of patients and is less useful in reducing head and voice tremor. Propanolol may reduce exercise tolerance, lower blood pressure or heart rate, exacerbate depression and cause impotence. Other adrenergic blockers with fewer side effects include atenolol, nadolol, metoprolol and timolol.
Primidone controls the actions of neurotransmitters. Some patients starting primidone may experience a “first dose phenomenon” during which they have transient feelings of unsteadiness, dizziness and nausea during the beginning stages of treatment. This is usually short-lived.
If primidone or propranolol are not effective by themselves, a combination of both may provide relief for some patients.
The potential benefit of these therapies should be weighed against the possible side effects. Side effects of the medications should always be explained before initiation of therapy. Propranolol is known to result in slowing of the heart rate, fatigue, worsening of diabetes, worsening of mood and exacerbation of asthma. It is usually avoided in patients with asthma, emphysema, congestive heart failure or heart block, and should be used with caution by people with diabetes who are on insulin
Primidone on the other hand is found to cause worsening of gait, balance, sleepiness and behavioural issues in some individuals. If tremors continue to remain inadequately controlled, a trial of a second-line medication, such as benzodiazepines, gabapentin, topiramate, or botulinum toxin, can also be tried.
Gabapentin and topiramate are two other anti-seizure medicines that are sometimes prescribed for essential tremor. In some cases, benzodiazepines such as alprazolam or clonazepam might be suggested.
For essential tremor in your hands, botulinum toxin (Botox) injections have shown some promise in easing the trembling. They work by slightly relaxing the overactive muscles. The injections are targeted to the specific muscles that are involved in the abnormal movement, while avoiding uninvolved muscles. Botox injections are typically recommended for patients with severe head tremor, and several studies have shown that the injections may significantly help head and voice tremors.
Yes, for select cases where tremors not responding to medication and in severe disabling tremors, Deep Brain Stimulation (DBS) of the thalamus is the new standard of care.
DBS surgery is now well established and FDA approved. More than 100,000 surgeries have been performed worldwide and several studies have proven its effectiveness in control of essential tremors. DBS will not stop progression of the tremor and in some cases there may be speech and walking related side effects. The Parkinson’s group offers each of these therapies through its integrated multidisciplinary program.
In conclusion, essential tremor is a slow progressive disease, has clear well-established guidelines for diagnosis and can be treated by non pharmacological, pharmacological and surgical approaches.
DBS surgery is now well established and FDA approved. More than 100,000 surgeries have been performed worldwide and several studies have proven its effectiveness in control of essential tremors. DBS will not stop progression of the tremor and in some cases there may be speech and walking related side effects. The Parkinson’s group offers each of these therapies through its integrated multidisciplinary program.
In conclusion, essential tremor is a slow progressive disease, has clear well-established guidelines for diagnosis and can be treated by non pharmacological, pharmacological and surgical approaches.
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