WHILE almost everyone has some degree of tremor — an involuntary, rhythmic shaking, especially of the hands which, for most of us, are so small they can’t be seen or felt — many individuals develop a visible tremor (essential tremor) which is a common movement disorder that can trigger fears of Parkinson’s disease, says the July 2012 issue of the Johns Hopkins’ HealthAfter 50.

Essential tremor is a common movement disorder — the exact cause of which is unknown but has a clear hereditary component — initially manifested by an up-and-down rapid shaking of the hands, it can also affect the head, the voice, the arms or, more rarely, the legs.

More than half of all cases occur in individuals who have a close relative with a tremor.

Often, it first appears in midlife, gradually worsening with age — most patients are over 65.

Although, for most individuals, essential tremor is distressing but not debilitating, for those with severe symptoms, the tremor can hinder their ability to perform certain tasks, such as writing, dressing or drinking which can be a source of embarrassment, resulting in social withdrawal.

Frequently misdiagnosed, essential tremor is often confused with Parkinson’s disease.

Other diseases where tremor can be one of the multiple medical signs and symptoms of the underlying condition include thyroid disorders, rarely, brain tumors and, sometimes, the side effect of certain medications, like thyroid or asthma drugs.

Thus, your primary care provider must perform a medical evaluation and sometimes order blood tests and selective brain imaging and carefully review your prescription and over-the-counter drugs and nutritional supplements, before making a diagnosis of essential tremor and recommending appropriate therapy.

Known as an “action tremor” which means that it usually occurs while the affected body part is in motion, essential tremor is easily differentiated from the tremor of Parkinson’s disease which typically occurs at rest, and it’s usually accompanied by additional symptoms.

The hallmarks of essential tremor include:

• Rapid or moderate shaking of the hands and fingers and, less frequently, the head, tongue, voice or other parts of the body

• Worsening of the tremor when under emotional or physical stress; when voluntarily moving the hands, head and certain muscles; when trying to hold the head or hands still

• Cessation of the tremor when at rest

• Shaky handwriting

• Quavering voice

Self-care approaches that can help control essential tremor before trying medication include:

1) Cut back on coffee, tea and other caffeinated beverages, such as colas

2) If you smoke, quit — nicotine aggravates tremors

3) Avoid stress, anxiety and fatigue which may also intensify tremors

4) Relaxation techniques and support groups may help control tremors

5) Use adaptive devices — including wrist weights to promote hand stability, weighted utensils and plate guards to keep food from being pushed off the plate — can be useful for accomplishing daily tasks

6) Alcohol in small quantities can temporarily improve essential tremor in some individuals but should be used judiciously since its adverse effects can be greater than its benefits to reduce tremor.

For instance, a rebound effect can cause the tremor to worsen when the alcohol effect wears off; it can lead to alcohol abuse — heavy alcohol use has been shown to lead to essential tremor.

The American Academy of Neurology (AAN) updated its guidelines last fall for treating essential tremor, after analyzing the results of 252 studies that investigated the treatment of the condition and recommended the following interventions, if non-medical approaches fail to bring improvement:

• Drug therapy — Two drugs recommended by the AAN to be equally effective at reducing tremors so that either one could be used when tremor is severe enough to consider drug therapy, include:

1) Propranolol (Inderal, InnoPran XL) — A beta-blocker commonly prescribed for high blood pressure, it is effective against limb tremors and may also reduce head tremors.

One dose lasts about four to six hours (enough to help you through a social engagement) but daily use may be more effective, says the health letter.

Its side effects include light-headedness, fatigue, depression, bradycardia (a slow heartbeat) and sexual dysfunction.

It is contraindicated in individuals with asthma and certain heart conditions; those with diabetes can take it with caution since it can mask the symptoms of hypoglycemia;

2) Primidone (Mysoline) — An anticonvulsant typically used to treat seizures, it is effective in reducing limb tremor and is associated with side effects such as nausea, vomiting, fatigue, confusion, poor coordination and unsteadiness which frequently disappear within a few days. Unlike propranolol, primidone must be taken daily.

Propranolol and Primidone, the only drugs that the Food and Drug Administration (FDA) has approved for essential tremor, are sometimes combined, but for older adults who take multiple medications, the benefits are likely smaller than the adverse experiences associated with the combination, explains the letter.

Thirty to 50 percent of patients don’t see any improvement or can’t tolerate either drug — doctors may prescribe other beta-blockers or anticonvulsants.

While the anti-anxiety drug alprazolam (Xanax, Niravan) is considered as a second-line option by some doctors, and the FDA lists it as “probably effective” in treating essential tremor, the potential adverse effects of confusion, falls and addiction are significant reasons to avoid this medicine.

Botox injections in the hand can provide modest improvement for some individuals, but the injection can cause significant hand weakness and don’t provide clear functional benefits, adds the letter.

• Surgery — For severe tremors that don’t respond to other treatments, the AAN recommends two procedures that can provide long-term and, sometimes, permanent, improvement for most patients — unfortunately, they both require brain surgery:

1) Deep brain stimulation — A stimulation device (similar to a pacemaker) is implanted in the brain by a neurosurgeon.

The device is programmed to disrupt communication between nerve cells that produce tremors — the device can be reprogrammed for optimal benefit as needed;

2) Unilateral thalamotomy — Neurosurgeons drill a hole in the skull to create a lesion in the area of the brain that controls movement to destroy the tremor-causing brain cells, thereby suppressing tremors.

Both surgical procedures can cause side effects, such as difficulty speaking, visual disturbances and loss of balance and coordination, but deep brain stimulation is considered to be safer and has fewer complications, concludes the health letter.

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