What is Essential Tremors or ET Have you ever observed someone's hands, head or body trembling when they are holding a glass, trying to write or just sitting still and wondered what was wrong with them.
Essential Tremors is a neurological disease in which there is a problem with movement control: either there is excessive movement, or a paucity of voluntary and automatic movements, that is unrelated to muscle weakness or paralysis.
Many people who have Essential Tremors become disabled at worst and feel frustrated or embarrassed at best.
Quality of life is a big issue for people with ET. Daily activities such as feeding, drinking, grooming and writing become difficult if not impossible. Many people with ET are too embarrassed to go into public and so remain isolated in their homes. Stereotypes shape the way we think about people and situations.
With awareness, people with Essential Tremors can come out of hiding; live normal lives as anyone with a disability.
Other names for Essential Tremor
- Familial tremor
- Benign essential tremor
- Hereditary essential tremor
Essential Tremors is caused by overactive cells in the area of the brain called the thalamus. The thalamus is about the size of a walnut and within the brain there are two of them. If there are overactive cells in the right thalamus, the person will have signs of tremor on the left side and vice versa. Some patients suffer from tremor on both sides.
Essential tremors (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 Tremors? 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. 42 million people in the world suffer from Essential Tremor. 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 tremors?
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 tremors 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 three surgical procedures that may be considered - thalamic deep brain stimulation (DBS)plus there are alternative less invasive treatment options for Essential Tremor such as the Gamma Knife thalamotomy and the other is Neuravive.
They involve the thalamus. This is a deep part of the brain that organizes messages travelling between the body and brain.
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.
The Gamma Knife procedure Is a non-surgical treatment using highly focused radiation to kill the cells causing the tremor. Overactive cells in this area can cause hand tremors in patients, and the ionizing radiation used during the procedure destroys the affected area without harming the surrounding, healthy tissue. Patients who opt for Gamma Knife generally see results within three to six months after the procedure, and they also experience lower complication rates in comparison to conventional surgery options. Because Gamma Knife destroys the affected cells, the results are not reversible or adjustable.
The result is an immediate and significant reduction of tremor for patients.
Similar to Gamma Knife’s approach, Neuravive aims to target and destroy the brain cells that are causing the patient to experience a tremor. However, Neuravive uses MR-guided focused ultrasound to treat the cells instead of ionized radiation. This technique has already seen success in treatment for uterine fibroids, prostate cancer, and other conditions. Patients often do not have to wait for results and generally enjoy a decreased tremor immediately following the procedure. Neuravive’s results are also not reversible or adjustable due to brain lesioning.
While patients have experienced positive results from Gamma Knife and Neuravive, results may vary from case to case.
This treatment approach requires no surgery or general anesthesia and results in minimal downtime. The procedure is performed as outpatient and does not require a hospital stay.
Difference in non-invasive procedures
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.
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.
Scientists at the National Institute of Neurological Disorders and Stroke are evaluating the effectiveness of 1-octanol, a substance similar to alcohol but less intoxicating, for treating essential tremor. Results of two previous NIH studies have shown this agent to be promising as a potential new treatment.
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.
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