Essential tremor (ET) is when you have uncontrolled shaking movements in parts of your body - most commonly the arms and hands. It tends to occur in families. It is mild in some people but can become severe, debilitating, and demoralizing. First and foremost, Essential Tremor can begin at any age from ages 1 to 100. ET doesn’t discriminate with age, race, sex, or national origin.
What is Essential Tremor? ET is a progressive neurological condition that causes a rhythmic trembling of the hands, head, voice, legs, or trunk. Over 10 million Americans, including children, have Essential Tremor. That’s about 5% of all people in the United States. Most people though haven’t heard about Essential Tremor and we have to educate schools, first responders, and even medical personal.
Essential tremor usually starts in one hand or one of your arms. Within 1-2 years, the other hand/arm is likely to be affected and it may spread to involve the legs, head, and voice. It can sometimes become quite severe so that everyday activities such as holding a cup can become difficult. ET isn’t only a social problem it can interfere with all aspects of your life like walking and speech can become difficult when your voice quivers so you have trouble talking. Loss of your abilities is hard to have a purpose in life. The tremor is usually not there at rest but becomes noticeable when the affected body part is held in a position, or with movement. The tremor can be present at all times and may be worse with stress, tiredness, hunger or certain emotions such as anger. Extremes in temperature may also make the tremor more severe.
What causes essential tremor?
Essential tremor is known to run in families. At least 5-7 out of 10 people with essential tremor have other members of the family with the same condition.
Up to 7 in 10 people with essential tremor find that the tremor reduces after drinking some alcohol.
How is essential tremor diagnosed? There is no test to diagnose essential tremor. Your doctor can usually diagnose essential tremor based on your explanation of the tremor and an examination. It is important for the doctor to make sure that there are no other conditions present that are causing tremor. In some cases, this may mean that you need to have some tests to rule out other conditions. For example, blood tests or a brain scan. You may also be referred to a neurologist (a doctor with a special interest and expertise in the brain and nerves).
While the diagnosis of ET remains a visual one, certain brain scans Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT) may be helpful in eliminating any other conditions which also produce tremor as a symptom. For example growths such as tumors or damage to the brain can be seen on certain brain scans. Blood samples may also be taken to rule out thyroid or copper metabolism problems, both of which can cause tremor. DATScan a diagnostic test can distinguish between ET and tremors of Parkinson's disease.
Other conditions that can cause tremor and need to be ruled out include a side effect from some prescribed medicines, anxiety, caffeine, some poisons, kidney, liver disease, thyroid disease, Parkinson's disease and other movement disorders.
What is the treatment for essential tremor? Essential tremor cannot be cured. Treatment may reduce the severity of the tremor. There are various treatments that are used.
Medication There are two medicines used initially for essential tremor - propranolol and primidone. These medicines have been shown to ease the tremor in up to 8 in 10 affected people.
Propranolol - this is a medicine that is usually used in heart disease. It is in a class of medicines called beta-blockers. It has also been shown to be effective in essential tremor. This medicine should be used with care if you have a heart conduction problem or a lung disease such as asthma. The most common side effects with propranolol are dizziness, tiredness, and nausea (feeling sick).
Primidone (Mysoline), - this is a medicine that is primarily used for epilepsy, but it also works very well in essential tremor. The most common side-effects are sleepiness, dizziness and nausea. These may improve if you continue to take this medicine.
OnabotulinumtoxinA (Botox) injections. Botox injections might be useful in treating some types of tremors, especially head and voice tremors. Botox injections can improve tremors for up to three months at a time.
However, if Botox is used to treat hand tremors, it can cause weakness in your fingers. If it's used to treat voice tremors, it can cause a hoarse voice and difficulty swallowing.
When the diagnosis of essential tremor is made, you may be offered one of these medicines. A low dose is usually started at first, and gradually increased until your tremor is eased. If you reach the maximum dose without a satisfactory improvement, then the other medicine can be tried. If that also doesn't work, you can try them together. Other medicines can be tried if these two are not effective. A wide range of medicines have been shown to have some effect on reducing the severity of the tremor.
Surgery If medicine treatment is not effective, and the tremor is severe, then a surgical procedure may be an option. There are two main surgical procedures that may be considered - thalamotomy and thalamic deep brain stimulation. They both involve the thalamus. This is a deep part of the brain that organizes messages travelling between the body and brain. High intensity focused ultrasound waves precisely target a focal point in the Vim nucleus of the thalamus can also be used.
What is Exablate Neuro?
High intensity focused ultrasound waves precisely target a focal point in the Vim nucleus of the thalamus, the tiny part of the brain that is thought to be responsible for causing tremors. The Exablate Neuro ultrasound transducer consists of 1024 beams that generate enough heat to ablate the targeted tissue during treatment. The result is an immediate and significant reduction of tremor for patients.
During planning and treatment for essential tremor, the patient is fully conscious and lying on the treatment bed in an MRI scanner. MRI provides high resolution visualization, patient-specific treatment planning and continuous monitoring of the procedure. Real-time thermal feedback allows the physician to control and adjust the treatment, ensuring that the targeted tissue is completely ablated without impacting adjacent healthy tissue.
This revolutionary, non-invasive treatment offers a life changing treatment to patients with essential tremor.
Difference in focused ultrasound:
MINIMAL HOSPITALIZATION and short recovery time
SHARP, ACCURATE Lesions as small as 2mm, no penetrating trajectories, no implanted hardware, no ionizing radiation, less risk of infection.
REAL TIME MRI guidance for targeting and thermal feedback, with immediate results
Thalamotomy -in this procedure, the thalamus on one side of the brain is destroyed. It has been shown to be very effective. It stops or greatly reduces the tremor in up to 9 out of 10 people with essential tremor. There are risks involved such as a bleed into the brain. Potential side-effects include muscle weakness, speech problems and memory loss. If the thalamus on both sides of the brain is destroyed, there is a higher chance of side effects. This is not usually recommended.
Thalamic deep brain stimulation- this procedure involves placing an electrode (fine wire) into the thalamus on one or both sides of the brain. The electrode is connected to a device called a stimulator. The electrode and stimulator stay in the body. (The stimulator is placed under the skin at the top of the chest.) The simulator sends electrical impulses down the electrode to the thalamus. It is not known exactly why this device works. It seems to interrupt or block the nerve signals coming through the thalamus that cause the tremor. If you have this procedure, you will need to have regular reviews to make sure that the stimulator setting is correct. This aims to minimize side-effects and maximize benefit. It may produce a good response in up to 9 out of 10 affected people. Again, there is a small risk that the procedure may cause a bleed into the brain. Side effects include loss of sensation, speech problems, and weakness. These usually resolve when the stimulator settings are adjusted.
Botulinum toxin injections. There is some evidence that Botox injections are helpful in reducing certain tremors. Unfortunately, a Botox injection into the arm also produces weakness of the arm. This is usually not tolerated. It is mainly useful when essential tremor affects the head and neck.
Alcohol - Many people find that alcohol is helpful in reducing their tremor. It needs to be used with caution to avoid developing an alcohol problem. It is not advisable to drink more than the normal recommended amount of alcohol. That is: men should drink no more than 21 units of alcohol per week, no more than four units in any one day, and have at least two alcohol-free days a week. Women should drink no more than 14 units of alcohol per week, no more than three units in any one day, and have at least two alcohol-free days a week. Pregnant women, and women trying to become pregnant, should not drink alcohol at all. One unit is in about half a pint of normal strength beer, or two thirds of a small glass of wine, or one small pub measure of spirits.
Avoid caffeine. Caffeine and other stimulants can increase tremors
Stress and anxiety Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors.
What is the outlook? Essential tremor is a progressive disease. This means that it tends to gets worse over time. There needs to be more research on the cause to find more medicines that work for ET and to find a cure.
What is it like to live with Essential Tremor?
Essential tremor: Aiken resident lives with, raises awareness of disease
Stephanie Turner Email stephaniedturnerAS
Oct 11 2015 3:47 pm
Staff Photo by Stephanie Turner
Diann Shaddox was diagnosed with essential tremor in her early 20s. Today, she is the founder of the Diann Shaddox Foundation, which raises money and awareness of essential tremor, and is an author, with her first book “A Faded Cottage” also featuring the main character with the disease.
You’re out enjoying a meal with your friends, when you hear a clattering behind you.
Curious, you look over your shoulder to see another patron trying to grasp his fork with a trembling hand.
“Essential tremor (ET) is a neurological condition that causes a rhythmic trembling of the hands, head, voice, legs or trunk."
It is said to affect at least seven million Americans, according to a 2014 “Tremor and Other Hyperkinetic Movements” journal article.
“Everyone has some ... tremor. But these movements usually can’t be seen or felt. It’s Hopkins Medicine.
Diann Shaddox, an Aiken resident in her late 50s, discovered she had ET in her early 20s.
Her hands would start to shake while she was just doing normal tasks, she said in her biography.
“In the beginning, doctors told me to go home, (that) I was nervous,” she said.
Shaddox knew that wasn’t true, so she bypassed the doctors and went straight to a neurologist, who immediately knew she had ET.
Last year, Shaddox began the Diann Shaddox Foundation with Randy Miles as the executive director; Quaid Witherspoon, the protagonist of her 2013, debut book, “A Faded Cottage: A South Carolina Love Story,” also has ET.
“Essential tremor (ET) is the most common movement disorder. It is a progressive, often inherited disorder that usually begins in later adulthood,” according to John Hopkins. “Essential tremor is thought to be caused by electrical fluctuations in the brain that send abnormal signals out to the muscles.”
The gene that causes ET has not been identified, and how it’s inherited, if the person does inherit it, differs among patients, according the National Library of Medicine’s Genetics Home Reference.
In some causes, “they almost know it’s coming, because generation after generation have a pretty pronounced tremor,” said Dr. Michelle Lyon, Carolina Musculoskeletal Institute’s neurologist.
Staff Photo by Stephanie Turner Dr. Michelle Lyon is the neurologist at Carolina Musculoskeletal Institute
Since Shaddox’s father passed away before she was born and her mother died when Shaddox was a toddler, she isn’t completely sure how she got her ET, though she suspects it’s from a great aunt whose hands would shake.
“In most affected families, essential tremor appears to be inherited in an autosomal dominant pattern, which means one copy of an altered gene in each cell is sufficient to cause the disorder, although no genes that cause essential tremor have been identified,” according to the National Library. “Essential tremor may also appear in people with no history of the disorder in their family.”
There is no genetic test to detect whether or not you will get ET, Lyon said.
“Your health care provider will ask you questions about your health history and family history. He or she will also look at your trembling symptoms. Your provider will probably need to rule out other conditions that could cause the shaking or trembling,” according to John Hopkins.
ET is often confused with Parkinson’s disease, which affects less people and is more detailed in its symptoms than ET, according to Lyon.
Parkinson’s, for example, “generally involves slow movements (bradykinesia), rigidity (stiffness) and problems with walking or balance,” whereas those symptoms are abnormal in people with ET, according to the International Essential Tremor Foundation.
Living with ET
“This (condition) affects all nationalities, all sexes, all ages – all everybody,” Shaddox said.
In addition to running the Diann Shaddox Foundation and publishing “A Faded Cottage,” Shaddox has written time-traveling romance “Whispering Fog” and the historical “Miranda: Her Life’s Story,” with proceeds from her books benefiting her foundation.
The condition first affected her right hand before progressing to her left.
Shaddox can no longer write for extended periods; when she does write, the words are often scribbled.
“If you are right handed, don’t use your right hand; (then) write your name when you are tired, and just keep writing your name, until your hand gets tired. That’s kind of like ET,” she said. “Really simple acts can be horrifying.”
Trouble with writing and eating are often when people come in to get examined, according to Lyon.
“They are embarrassed to go out to eat at a restaurant because they are unable to hold the fork and cut the food,” she said. “I think a lot of people ignore it, until they get to that social situation.”
Shaddox often has to use her opposite hand to steady the one cutting food or putting on make-up and can no longer cross-stitch or play the piano.
Though her hands trembling are the more noticeable symptom, Shaddox’s head shakes back and forth, and she can feel her voice starting to tremor.
“I’ll take two (words) and make up a whole new word while I’m talking,” she said, adding that she also mixes up and forgets words.
The tremors tire her hands but do settle when the limbs are resting, and Shaddox can drive.
“My case is mild,” she said.
Stress, hunger, fatigue and anger can aggravate the tremors, according to the National Institute.
“My hands look like a bird’s wings flapping, when I get stressed,” Shaddox said. “It’s so embarrassing when you are sitting there, and people are staring at you when you are trying to write. You want to scream, walk out, because it’s embarrassing.”
ET has no cure but can be treated, according to Lyon.
Medicines prescribed can include tranquilizers, ones that “affect how brain nerves work” or are anti-seizure, according to John Hopkins.
When the condition is so severe and medicine doesn’t help, there are surgical options, Lyon added. Two are deep brain stimulation and thalamotomy, with the main difference is thalamotomy, which, according to the American Academy of Neurology, actor Micheal J. Fox underwent for his Parkinson’s, involves destroying a piece of the brain while deep brain stimulation does not, according to the International Essential Tremor Foundation.
MCT Graphic/”Minneapolis Star Tribune,” 2009 This graphic explains how deep brain stimulation, using a device similar to a heart pacemaker, can improve the quality of life for people suffering from Parkinson’s disease. The procedure is also used in more severe cases of essential tremor.
Shaddox no longer takes medication but does lift weights and tries to stay healthy.
When she does her public appearances, she might have some wine nearby, as the drink temporarily calms her, she said.
Shaddox has 16 more books she wants to publish and would like to see her foundation match the The Michael J. Fox Foundation for Parkinson’s Research’s scale.
Shaddox said the foundation’s An Evening in the 1800s with Kim Peevy that was scheduled for Saturday has been postponed but she will have a book signing in April.
“The foundation’s mission is to bring awareness, to educate,” Miles said.
If you are experiencing abnormal tremors, consult with a physician.
For more information on ET, visit www.diannshaddoxfoundation.org, www.aan.com, andwww.essential tremor.org.
Stephanie Turner graduated from Valdosta State University in 2012. She then signed on with the Aiken Standard, where she is now the arts and entertainment reporter.
What is essential tremor?
Also known as, familial tremor, benign essential tremor or hereditary tremor, essential tremor (ET) is a progressive neurological condition that causes a rhythmic trembling of the hands, head, voice, legs, or trunk.
About 10 million Americans have Essential Tremor. That's about 5% of all people in the United States. For comparison sake, 7.8% of the population have some type of diabetes. Most people though haven’t heard about Essential Tremor and we are adamant to bring attention to the world
An estimated 10 million Americans have ET. People with ET are often stereotyped as being nervous, withdrawn, anxious, and elderly.
ET is not confined to the elderly. Children and middle-aged people can also have ET. In fact, newborns have been diagnosed with the
There is evidence that ET is genetic. Each child of a parent who has ET has a 50% chance of inheriting a gene
that causes the condition. However, sometimes people with no family history of tremor develop ET.
Can I Be Cured Of Benign Essential Tremor?
There is currently no cure or any specific laboratory test for Essential Tremor but the severity of the shaking, in many cases, can be reduced with the use of prescribed drugs. The treatment of Essential Tremor depends on the severity of the tremors and the impact they have on the quality of life of the patient.
Prescribed drugs to reduce the shaking include Beta Blockers, tranquilizers, or anticonvulsant drugs used to control epilepsy but these do not work for all patients.
The medications most commonly prescribed to control Essential Tremor are Primidone, an anti convulsant and Propranolol, a beta blocker more commonly associated with heart conditions and high blood pressure. Propranolol has been extremely effective in my case and so far has had no adverse side effects, however, it is known that patients with certain illnesses such as asthma, diabetes or heart problems may not be able to take drugs prescribed for tremor. Reducing caffeine intake and reducing stress levels, avoiding extreme temperatures and even using wrist weights to strengthen muscles is said to help.
Botulism toxin injections (Botox) are sometimes administered into the affected muscles in more severe cases. In a patient with a hand tremor the botulism would be injected into the forearm while botox would be injected into the muscles of the neck for a head tremor.
Fatigue and Parkinson's
Parkinsons New Zealand
Published on Oct 6, 2013
From the World Parkinson Congress 2013. Professor of Neurology, Joseph Friedman talks about fatigue and Parkinson's, and the difference between fatigue and sleepiness.
Can I Be Cured Of Benign Essential Tremor?
There is currently no cure or any specific laboratory test for Essential Tremor but the severity of the shaking, in many cases, can be reduced with the use of prescribed drugs. The treatment of Essential Tremor depends on the severity of the tremors and the impact they have on the quality of life of the patient.
Migraines with aura in middle age linked to Parkinson's disease
By Trisha Henry, CNN
updated 5:06 PM EDT, Wed September 17, 2014
Researchers don't yet understand why migraines might be linked to Parkinson's disease.
(CNN) -- People who suffer from migraines with aura during middle age have double the risk of developing Parkinson's disease or other movement disorders later in life than those who do not, according to a study published Wednesday in the journal Neurology.
Migraines are the most common brain disorder in both men and women, according to the World Health Organization, and one of thetop 10 most debilitating conditions.
Aura is the term used to describe the feelings and symptoms that happen shortly before and during a migraine.
"Roughly one-third of affected individuals can predict the onset of a migraine because it is preceded by an 'aura,' visual disturbances that appear as flashing lights, zig-zag lines or a temporary loss of vision," according to the National Institutes of Health.
Researchers followed more than 5,000 people between the ages of 33 and 65 for 25 years, who were originally enrolled in a clinical trial designed to study heart disease in Iceland. The participants were interviewed about migraine symptoms in middle age and then, about 25 years later, asked about Parkinson's disease symptoms. They were also asked about symptoms for a related disorder called Restless Legs Syndrome.
The results were based on the study participants' self-reported diagnoses, though in the majority of the cases researchers confirmed the diagnoses by looking at medical records and the participants' medication use.
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"The patients in this study were not carefully examined and definitely diagnosed with Parkinson's disease," said Dr. Michael S. Okun, national medical director of the National Parkinson Foundation, which is why he believes more research is needed before drawing any conclusion that the two are related.
"Head trauma and other neurological issues can manifest with symptoms similar to Parkinson's disease and future studies will need to better control for these factors."
Compared to those without headaches, people in the study who suffered from migraines with aura in middle age were about twice as likely to have been diagnosed with Parkinson's disease when the researchers checked back. They were also more likely to report at least four symptoms commonly associated with Parkinson's disease later in life.
Parkinson's-like symptoms were also more common in those with migraine without aura, though the link was not as strong, lead study author Ann Scher told CNN in an email.
Scher, a professor of epidemiology at Uniformed Services University in Maryland, wants to make sure people understand the actual risk of Parkinson's disease in people with migraine is still very low.
Researchers don't yet understand why migraines might be linked to Parkinson's disease or other movement disorders, Scher says. They don't believe that the link is due to medications taken to treat migraines, some of which block dopamine. Nor do they think that the link is due to related brain diseases, "since we controlled for these factors."
Possible explanations for the connection, she agrees, might be a previous head injury or a shared genetic risk factor that increases the risk for both migraine and Parkinson's disease.
One common link may be abnormalities in dopamine production and dopamine receptors in the brain, said Okun. Some groups suggest the same dopamine treatment that helps Parkinson's patients may also help with migraines.
"Another theory is that in migraine sufferers there seems to be a higher deposition of metals, such as iron, in the brain and specifically in areas important to movement," said Okun. "Some experts believe that this metal deposition may place patients at risk for diseases like Parkinson's."
What is the difference between Essential tremor and Parkinson Disease tremor? Essential Tremor Information What is Essential Tremor, how is it evaluated and how is it treated?
Aparna Wagle Shukla, M.D., Physician and Research Scientist at the University of Florida Center for Movement Disorders
What is the difference between Essential tremor and Parkinson Disease tremor?
What is Essential Tremor? Essential tremor (ET) is the most common movement disorder encountered in expert clinics. Family history is often positive and thus ET is frequently referred to as a benign tremor or familial tremor, though it is not benign. 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. Tremors in many cases are mild but can cause significant functional limitation of the activities of daily living, such as writing, eating, drinking or dressing. Essential tremor increases in frequency with age, and is present in more than 1% of individuals 70 years of age or older. Tremors typically worsen with emotional and physical stress. Alcohol is found to alleviate the tremors in some, but not all cases; and the underlying mechanism is not clear. Although response to alcohol is important for clinical diagnosis, it is not recommended as a treatment. 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.
What is the difference between Essential tremor and Parkinson Disease tremor?
Published on Jul 19, 2012
Dr. Michael Okun explains the differences between Essential tremor & Parkinson disease tremor.
Visit http://mdc.mbi.ufl.edu/ for more information.
How is Essential Tremor evaluated?
What is the difference between Essential Tremor and Parkinson Disease tremor? How is Essential Tremor evaluated? Essential tremor most commonly affects the arms, tremors are typically asymmetric in the beginning and with advancement, tremors of 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.
Diagnosis of essential tremor is based on specific criteria observed during the clinical exam. These criteria include the presence of tremors in both hands and forearms engaged in routine daily tasks and absence of any additional neurologic symptoms or signs. A bedside physical exam involves observation of tremors during postural elevation of the arms, on kinetic tasks like drawing an Archimedes spiral (See Figure), line drawing, writing, pouring water into glass and on intentional maneuver such as finger-to nose testing. Tremors occur mainly in the distal hands and are 4 to 12 Hz in frequency, but this can be widely variable. Tests such as those shown below are ways in which a physician can evaluate and monitor tremor.
Bedside assessment of essential tremor using the Archimedes spiral and the line drawing test
Sometimes during the passive movement of the forearm, a cogwheeling type of resistance is felt by the physicians resulting in a mistaken diagnosis of Parkinson’s Disease. This type of resistance is felt particularly in older individuals. However, in Parkinson’s Disease tremors in the hands are present mainly at rest, tremors are classically but not always pill rolling in character, tremors are unilateral or asymmetric in presentation, tremors in legs are prominent, and there are other pertinent accompanying symptoms such as slowness, lack of dexterity in the hands, stiff muscles, softening of speech, lack of expression on the face, shuffling gait and postural instability. It is possible however to have a resting tremor in essential tremor.
Another important differential diagnosis for essential tremor is enhanced physiologic tremor that is sustained as a result of either an identifiable cause, such as medication or hyperthyroidism; or a cause that is not readily identifiable. Caffeine, cigarettes, and medications such as lithium, prednisone, levothyroxine, beta-adrenergic bronchodilators, valproate, and selective serotonin-reuptake inhibitors commonly result in these enhanced physiologic tremors. Adult-onset idiopathic dystonia, and Wilson’s disease are other conditions on the list that are particularly applicable to younger individuals. Physicians should ask the necessary questions to distinguish these pertinent differential diagnoses.
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 University of Florida, Dr. Vaillancourt and colleagues are conducting a major NIH sponsored study to investigate the role of functional MRI (fMRI) and diffusion tensor imaging (DTI) in the diagnosis of 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. University of Florida also offers a quantitative computerized analysis of tremor that can helps distinguish essential tremor from other types of tremor. This technique is simple, noninvasive, and can be scheduled in the physiology laboratory on an as needed basis.
How is Essential Tremor treated and managed? At present there is no cure for essential tremor, but tremors can be alleviated with multiple therapies. Mild tremors may not require pharmacological treatments and can be addressed with various non-pharmacological techniques. 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. These weights are available at stores such as Walmart and Target, or can be ordered online. Another non-pharmacological approach is use of cooling the arms; a technique also used for the control of tremors. All of these techniques can successfully control some of the tremors in although the benefits are short-lasting for some patients. At University of Florida, clinicians routinely schedule essential tremor patients with an occupational therapist for evaluation and demonstration of these techniques.
Propranolol and primidone are the mainstays of medical treatment. Multiple studies have documented the efficacy of propranolol and primidone in the treatment of hand tremors, although these medications have less efficacy for control of tremors located in the head, voice, leg, and trunk. In the early stages these medications are effective in reducing the amplitude of tremors roughly in the range of 40-50% but over time they may lose efficacy. Sometimes a combination of these two drugs can be tried to facilitate greater synergistic benefits. 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. Primidone on the other hand is found to cause worsening of gait, balance, sleepiness and behavioral 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. Finally, for select cases of medication refractory 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 University of Florida 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 nonpharmacological, pharmacological and surgical approaches.
Do You Have Early Warning Signs of Parkinson’s Disease?
By Everyday Health Guest Columnist
Published Jun 2, 2014
By Michael S. Okun, MD, Special to Everyday Health
This year, more than 50,000 people worldwide will hear four simple words: “You have Parkinson’s disease.”
Once the shock subsides, four new words will dominate their thoughts: “Is there a cure?” Today, the answer is no; however, with advancements in early detection and expert care, treatments are helping many people live long and happy lives with Parkinson’s. Research has shown that seeing a neurologist improves outcomes, and seeing a movement disorders specialist can speed improvement in symptoms.
What Is – and Isn’t – Parkinson’s Disease?I am often asked if Parkinson’s Disease (PD) is
a form of Alzheimer’s. Parkinson’s is not Alzheimer’s, ALS or a brain tumor, and the prognosis for Parkinson’s, though not a perfect scenario, leaves room to live a productive life.
PD is a progressive and chronic neurological disease that often begins with mild symptoms that advance gradually over time. Symptoms can be so subtle in the early stages that they go unnoticed, leaving the disease undiagnosed for years. For patients with Parkinson’s, there is a reduction in the body chemical dopamine, which controls movement and mood – so simple activities like walking, talking and writing can be impacted.
Due to the complexity of PD, diagnosis is based on a variety of factors. The best diagnosis is made by an expert doing a careful history and exam followed by tracking responses to therapy. There is no blood or laboratory test to diagnose Parkinson’s disease.
While Parkinson’s reaches all demographics, the majority of people with PD are age 60 or older. Men and people with a family history of the disease have an increased risk.
12 Early Warning Signs of Parkinson’sThere is no one defining symptom or sign of Parkinson’s, but rather a combination of warning signs and symptoms. Not all of the signs and symptoms are present in every patient with PD, and this sometimes leads to confusion in diagnosis. Talk to your doctor if you or someone you know experiences more than one of the symptoms outlined below. Family and friends may be the first to spot the signs.Tremor or shaking: An incessant or intermittent shaking in your finger, thumb, hand, chin, body, leg, lips or tongue could indicate Parkinson’s. The tremor usually happens at rest, and when you move the extremity it may disappear. One in five patients with PD may not have a tremor, which is an important reason the diagnosis may be missed.
Changes in handwriting: You may notice the way you write words on a page has changed, and particularly that your letter sizes are smaller and the words may be crowded together.
Loss of smell: Some research suggests that loss of smell is one of the earliest warning signs of Parkinson’s and other cognitive disorders, appearing years before the onset of the motor and cognitive symptoms.
Trouble sleeping: Sudden and extreme movements during sleep – kicking and punching – or falling out of bed can be indicate PD. Patients with Parkinson’s often report vivid dreaming or acting out their dreams; in many cases these symptoms may predate the diagnosis.
Muscle tension: Some people with Parkinson’s may notice tightness in a wrist, elbow, hip or knee (rigidity). This uncontrolled tightness may cause mild to severe aches or pains and make it difficult to move around.
Changes in walking: Parkinson’s affects the area of your brain that controls movement. If you walk with short, shuffling steps, don’t swing your arms or have trouble starting, stopping and turning, talk to your doctor about PD.
Constipation: Constipation is a sign that may predate the other motor symptoms like tremor and rigidity in people with Parkinson’s.
A quiet voice: If friends and family are always asking you to speak up even though you feel like you are talking in a normal voice, you may be experiencing the Parkinson’s disease symptom of a muffled or soft voice – called hypophonia. PD patients are often unaware they are speaking softly.
Masked face: Masking is a term we use to describe facial expressions that appear muted and flat even though the person may be content. Many patients don’t realize masking is happeninguntil someone points it out. If people say you often look unhappy, have a blank stare, or do not blink your eyes, talk to your doctor.
Dizziness or fainting: Feeling dizzy or fainting on a regular basis can be signs of low blood pressure linked to Parkinson’s or to PD medications.
Stooping or hunching over: Stooping, leaning or slouching when you stand can all be symptoms of Parskinson’s.
Depression or anxiety: Depression is the biggest unmet Parkinson’s disease need. With PD,depressive symptoms can be mild and missed easily.
What If You Have Parkinson’s?After Parkinson’s is diagnosed, your doctor will help you develop an individualized plan to address the symptoms that have the biggest impact on your everyday life and help slow down the progression of the disease. The first step is getting a referral to a neurologist for expert care – especially one who is trained in movement disorders.
Why Is Expert Care Important?Early expert care can help reduce PD complications. Findings show that 60 percent of people with Parkinson’s fall short of getting the expert care they need. The National Parkinson Foundation has estimated that about 6,400 people with Parkinson’s die unnecessarily each year due to poor care.
Trained neurologists will help you recognize, treat and manage the disease. Common approaches include medication, surgical treatment, lifestyle modifications (such as rest and exercise), physical therapy, support groups, occupational therapy and speech therapy. The best approach is interdisciplinary care, where you are seen by multiple specialists on a regular basis and all of the specialists talk and arrange the best possible coordinated care. This is what is referred to as a patient-centric approach to Parkinson’s care.
The National Parkinson Foundation has easy-to-access communications options, including a toll-free helpline 1-800-4PD-INFO (1-800-473-4636) and a free “Ask the Doctor” online forumon Parkinson.org.
Arming yourself with knowledge and expert care are the best methods of facing Parkinson’s disease.
Michael S. Okun, MD, is the National Medical Director of the National Parkinson Foundationand co-director of the Center for Movement Disorders and Neurorestoration, part of the McKnight Brain Institute and the University of Florida College of Medicine. He is the author of Amazon’s No. 1 Parkinson’s Best Seller 10 Secrets to a Happier Life. As NPF’s medical director, he has worked with NPF Centers to help foster the best possible environments for care, research and outreach in Parkinson’s disease. Dr. Okun has published more than 300 articles and is considered a world’s expert on Parkinson’s disease, movement disorders and deep brain stimulation.
Up to 70% of Parkinson's disease (PD) patients experience sleep problems that negatively impact their quality of life. Some patients have disturbed sleep/wake patterns such as difficulty falling asleep or staying asleep, while other patients may be subject to sudden and involuntary daytime sleep "attacks." In the extreme, PD patients may exhibit REM-sleep behavior disorder (RBD), characterized by vivid, violent dreams or dream re-enactment, even before motor symptoms appear. A review in the Journal of Parkinson's Disease discusses the underlying causes of sleep problems in PD,
as well as medications, disease pathology, and comorbidities, and describes the most appropriate diagnostic tools and treatment options.
Sleep problems in PD patients can have wide-ranging adverse effects and can worsen in later stages of the disease. Sleepiness socially isolates patients and excessive sleepiness can put patients at risk of falls or injury, and can mean patients must give up driving. Sleepiness can impair cognition and concentration, exacerbatedepression, and interfere with employment. Wakefulness at night impairs daytime wakefulness and may also cause mood instabilities and can exhaust caregivers.
"Diagnosis and effective treatment and management of these problems are essential for improving the quality of life and reducing institutionalization of these patients," says lead author Wiebke Schrempf, MD, Technische Universität Dresden, Faculty of Medicine Carl Gustav Carus, Department of Neurology, Division of Neurodegenerative Diseases, Dresden, Germany.
Dr. Schrempf and colleagues describe some of the complexities associated with treating sleep problems in PD patients, such as the worsening of sleep problems by dopaminergic medications used to treat motor symptoms. Lower doses of levodopa or dopamine agonists are able to improve sleep quality partly by reducing motor symptoms such as nighttime hypokinesia (decreased body movement), dyskinesia (abnormal voluntary movements), or tremor (involuntary shaking), which interfere with normal sleep. However, the same medications may also cause excessive daytime sleepiness. The report describes how changing medication, dose, duration of treatment, or timing of administration can improve outcomes.
The presence of other conditions common in PD patients such as depression, dementia, hallucinations, andpsychosis may interfere with sleep. Unfortunately, some antidepressants can also impair sleep.
Sleep problems may also be harbingers of future neurodegenerative disease. Patients with RBD exhibit intermittent loss of normal muscle relaxation during REM sleep and engage in dream enactment behavior during which they may shout, laugh, or exhibit movements like kicking and boxing. "RBD seems to be a good clinical predictor of emerging neurodegenerative diseases with a high specificity and low sensitivity, whereas other early clinical features of PD, such as olfactory dysfunction and constipation, are less specific," says Dr. Schrempf. "These early clues may help identify PD patients before motor symptoms appear, when disease-modifying therapies may be most beneficial."
PD is the second most common neurodegenerative disorder in the United States, affecting approximately one million Americans and five million people worldwide. Its prevalence is projected to double by 2030. The most characteristic symptoms are movement-related, such as involuntary shaking and muscle stiffness. Non-motor symptoms, such as worsening depression, cognition, and anxiety, olfactory dysfunction, and sleep disturbances, can appear prior to the onset of motor symptoms.
The gait disorder of advanced essential tremor
Gait disturbances of patients with essential tremor (ET) have been described anecdotally, but have never been investigated quantitatively. Recent studies provided evidence for a cerebellar-like hand tremor in some patients with ET. Therefore, we designed a study to assess cerebellar-like abnormalities of leg function. Twenty-five patients with ET, eight patients with cerebellar diseases (CD) and 21 age-matched healthy subjects were studied for their normal and tandem gait using a three-dimensional gait analysis system. During normal walking, CD and ET patients showed only slight abnormalities. However, ET patients exhibited abnormalities in tandem gait with an increased number of mis-steps and a broad-based, ataxic and dysmetric gait which was indistinguishable from the findings in CD. When ET patients were separated into groups of those with or without intention tremor of the hands, the gait disorder was found to be much more pronounced in the intention tremor group. Patients with this gait disorder were more severely disturbed in their activities of daily living, and suffer from an advanced stage of ET. The present results quantitatively describe a gait disturbance in advanced ET which affects tandem gait, but leaves normal gait almost unaffected. This is strong evidence for a cerebellar-like disturbance in ET.
Diann Shaddox Foundation for Essential Tremor Blog
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