Essential tremor treatment

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Essential tremor is a neurological movement disorder characterised primarily by handshaking and may accompany cognitive and personality disorders. Critical in the treatment are medications, although many new options have appeared in recent years: Deep Brain Stimulation, MRI-guided focused ultrasound and thalamotomy.

Essential tremor is a nervous system disorder associated with rhythmic shaking of a part of the body, most commonly the hands. It can also affect the head, voice, arms, and legs.

A tremor is a movement disorder. At least one in every hundred people suffers from shaking without any recognizable underlying neurological disease. The attacks increase when the muscles tense, such as when trying to write, drink, or eat. In the case of Parkinson's patients, it's precisely the opposite: here, the tremor decreases when you carry out activities. Tremors can occur in different situations:

  • Resting tremor starts when the muscles are completely relaxed, for example, when the hand is lying on a table. It usually increases when the sufferer needs to concentrate on an upcoming task. A resting tremor is typical of Parkinson's disease.
  • Action tremor is divided into subtypes:
  • The postural tremor always occurs when the affected person needs strength to keep their finger, arm or leg in position. Typical of this is the trembling when holding a glass of water. Postural tremor is a hallmark of essential tremor but also may occur in people with Parkinson's disease.
  • The movement tremor shows up with specific movements. For example, it hinders writing or playing the piano. A movement tremor is also typical of an essential tremor.
  • In intention, tremor shaking increases when the goal of a specific movement is reached or "close enough to be done". It happens, for example, when a finger is moved to a certain point.

However, depending on the form, a tremor can manifest itself differently. Examples are:

  • An orthostatic tremor is a high-frequency shaking of the leg muscles, which is not always visible. The status of those affected becomes uncertain. They occasionally have an unsteady gait with a corresponding tendency to fall.
  • A tremor in Parkinson's disease is mainly a resting tremor (which occurs, for example, when the hand is resting in the lap and partially improves with movement).
  • Holmes Tremor is a slow, unrhythmic shaking.
  • Soft palate tremor manifests itself in rhythmic movements of the soft palate.
  • Psychogenic tremor occurs here only temporarily and in different degrees. It also wears off if you distract the sufferer.

The condition affects approximately 1% of the population worldwide. The incidence increases with age, with most studies showing no difference in prevalence between males and females.

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The cause of the tremor

Essential tremor results from impaired communication between specific brain areas, including the cerebellum, thalamus, and brainstem. The cause of the condition is not very well studied. There is evidence that some sufferers have a genetic cause. However, the disease can also develop without a prior history in the family.

On the other hand, tremor can be the symptom of a severe illness, traumatic experience, poisoning or withdrawal symptoms from drug or alcohol dependence. The possibilities are manifold. The tremor can originate in the brain, the nerve tracts or the muscles' metabolism.

Manifestation of essential tremor

Symptoms usually start gradually. People with mild signs can often get by for years, although essential tremors can be frustrating and disabling. Unfortunately, symptoms worsen over time in many patients and can become more serious.

  • An essential tremor is characterised by a rhythmic shaking that occurs with voluntary movement and holding the position against the force of gravity. It usually starts with a slight tremor in the dominant hand, and later both hands are affected.
  • The writing is becoming increasingly illegible, and eating and drinking are becoming more challenging.
  • There are often communication problems if the head, voice or facial muscles are affected.
  • Stress can also make symptoms worse. Many of those affected then withdraw more and more from their social environment.
  • Cognitive disorders and personality changes can also occur, especially in the late stages.
  • When the tremor affects the legs, people feel very unsteady when standing. In the beginning, they try to compensate for the insecurity by frequently changing to the other leg or looking for support. In the further course, free-standing becomes impossible and falls become more frequent.

The course varies from person to person. Some suffer from a mild tremor early on, which then lasts for life. For others, the manifestation starts late and quickly increases in severity.

Modern tests for essential tremor diagnosis

The disease is usually primarily suspected by GP and neurologist. A neurologist provides detailed anamnesis, a nervous system check, and cognitive abilities to select proper solutions. If necessary, various examinations follow the anamnesis interview to identify specific diseases as the cause of the tremor. These include:

  • Neurological examinations. Here the doctor checks the patient's eye movements, reflexes, sensitivity and coordination, among other things. It is routine to clarify various neurological diseases - from Parkinson's to stroke and essential tremors.
  • Blood tests. Blood values ​​allow, among other things, a statement about liver, kidney and thyroid function. Blood tests also provide information about certain infections and poisoning.
  • Electromyography (EMG). EMG tests the natural electrical activity of a muscle. It provides information about muscle and brain function. With the help of the EMG, the tremor can be precisely documented.
  • Magnetic resonance imaging (MRI) and Computed tomography (CT). With the help of these examinations, it can be determined whether the patient is suffering from brain damage (for example, after a stroke or tumour).
  • Liquor examination. The doctor takes a sample of the cerebrospinal fluid from the spinal cord canal (lumbar puncture) and examines it in the laboratory for differential diagnosis.
  • L-Dopa Test. The doctor administers a dose of the drug L-Dopa to the patient. If the tremor then improves, you may have Parkinson's disease. Otherwise, it is necessary to look for another cause.
  • Gene tests - is the best option for determining certain damages or mutations in DNA that can be one of the causes of essential tremor.
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Treatment options for essential tremor

A neurologist can significantly reduce the main symptoms with correct diagnosis and treatment tactics. Various medications are available. Some are used for long-term therapy, and others can be used as needed before tremor-triggering situations. Drug therapy depends entirely on individual needs and the level of suffering patients experience at work and in their free time.

  • Beta-blockers for essential and physiological tremors. Beta-blockers (Inderal, Hemangeol) in particular have proven effective in therapy. In the brain, they influence the control of the essential tremor, while at the nerve endings of the muscles, they reduce the deflection of physiological tremor. The success rate is about 50%. However, the drug has some side effects that doctors should consider.
  • Anticonvulsants for severe tremor. The antispasmodic primidone (Mizolin), approved for people with epilepsy, is particularly effective for tremors with an intense rash. In addition, it is suitable for patients who cannot tolerate beta blockers. Primidone is often effective from the first dose but is not accepted by around a quarter of patients. In some cases, the side effects of taking it are nausea, vomiting and dizziness.
  • ​​​​​​​Botox. Patients with certain types of tremors may experience relief from botulinum toxin injections. Botulinum toxin is injected into the muscles (contractions of which cause tremors) and temporarily weakens them. These injections should be repeated twice to four times yearly and are most effective for patients with head or voice tremors.

Although medical treatment can help some people and should be the first treatment, patients with severe tremors may need surgery. A neurologist can advise the most effective treatment methods according to your condition. There are the following types of operations:

  • Thalamotomy is a procedure when a specific part of the brain (thalamus) is cut. Radiosurgeons perform such an operation using the GammaKnife system, a non-invasive, minimally traumatic and safe method.
  • Deep brain stimulation (DBS) is surgery on the thalamus in which a thin wire (electrode) is placed into this structure and connected to a pacemaker-like device.
  • MRI-guided focused ultrasound ablation is a remote effect of ultrasound directed under MRI control to a target area in the brain. Within a few seconds, the tissue in the ultrasound's focus is heated to the temperature necessary for its necrosis (ablation). At the same time, the surrounding tissues are not damaged.

Rehabilitation (physiotherapy, speech and occupational therapy) also have a positive effect:

  • Physical exercises aim to restore muscle control and establish correct breathing when the diaphragm is trembling.
  • Hand tremors can be partially neutralised by finger exercises and working with small objects. The primary condition for the effect of such classes is their regularity.
  • Contrast showers, other water treatments, and balneotherapy in sanatorium-resort institutions help with essential tremors. In addition, the patient may be prescribed a special diet, relaxing and acupuncture massage.
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What is the prognosis?

The disease outlook is moderately favourable. As a rule, drug therapy and surgical interventions significantly reduce the symptoms, but it is difficult to rid the patient of this disease completely. Essential tremor is a chronic condition that, in most cases, persists for life.

The tremor can interfere with everyday activities and increase over time or spread to other parts of the body. As a result, up to 25% of patients change their job because of the disease or give it up. On the other hand, patients with a mild course may not need any specific therapy.

However, the prognosis for each patient is different depending on age, daily activity and treatment scheme. About a third of patients report worsening symptoms every six months. Another 30% of patients manage to control their tremors without deterioration for up to a year. In addition, there are severe cases when the disorder progresses faster and spreads to other body parts.

FAQ

Can an essential tremor go away?

There is currently no effective cure for essential tremors, but there are ways to treat it. The main treatment options are medications, adjuvants, botulinum toxin, deep brain stimulation, and focused ultrasound. Unfortunately, these still cannot permanently overcome the problem, but adequately selected therapy significantly reduces symptoms, facilitating the quality of patients' lives.

What is the new treatment for essential tremors?

There is only one FDA-approved medication for essential tremors, and that's propranolol (the brand name is Inderal). The other treatment options are medications (primarily beta-blockers and anticonvulsants), assistive devices, botulinum toxin, thalamotomy, deep brain stimulation and focused ultrasound. 

Can you live everyday life with essential tremor?

Tremor can affect how you do a wide range of daily activities, from working and driving to simply eating and brushing your teeth. But by changing your lifestyle, you can maintain independence and continue many routine activities.

How fast does essential tremor progress?

Essential tremor does not shorten life expectancy. Tremors can get worse over time, but their progression is slow, usually over many years. In the end, some patients can get some disability, which will be expressed in writing, eating, or even social contact difficulties.

What surgery is done for tremors?

The new treatment - transcranial MRI-guided focused ultrasound involves thermal tissue ablation, targeted at the areas of the brain causing the tremors. Deep brain stimulation (DBS) is another minimally invasive surgical procedure to treat neurological symptoms of essential tremor. Good results are also shown by radiosurgery (using the GammaKnife) to remove part of the brain - the thalamus (thalamotomy).

Where can I get Essential tremor treatment?

Germany, Poland, Turkey, Spain, Czech Republic are among the best for Essential tremor treatment.

6 countries and 18 cities for Essential tremor