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How to tame essential tremor
Albert Fenoy, MD, explains what treatments, surgical and non-surgical, can limit the uncontrollable shaking caused by the condition that impacts 10 million Americans.
Learn what treatments, surgical and non-surgical, can limit the uncontrollable shaking caused by the condition that impacts 10 million Americans
It's a condition that's well-known, yet rarely heard of. Often seen as more of a nuisance than a disability, it causes uncontrollable shaking of the body, usually in the hands. This makes everyday tasks like tying shoes or holding a glass very difficult.
Essential tremor (ET) is the most common form of movement disorder and impacts nearly 10 million Americans. It has posed debilitating conditions on public figures such as former actress Katharine Hepburn and playwright Eugene O’Neill.
Many confuse the tremor with Parkinson’s disease though the nature of the tremor is different. Also, unlike Parkinson’s disease, essential tremor is not considered a progressive neurodegenerative disease.
While most endure symptoms and forego treatment, there are treatment options. These include medications, as well as surgical interventions such as deep brain stimulation and a new FDA-approved treatment that utilizes focused ultrasound and MR imaging to target and treat the brain called high-intensity focused ultrasound, or HIFU for short.
Diagnosing essential tremor
A good history of present illness and clinical exam can help diagnose benign essential tremor. Patients typically have a strong family history of tremor with parents, siblings, or children with the disease. Stress and anxiety, as well as caffeine, typically make the tremor worse. Typically, tremor starts insidiously without any cause or precipitating factor. Essential tremor is usually diagnosed by an action such as a patient struggling to use utensils to eat, drink from a glass or cup, write with a pen or pencil, or put on make-up, all of which are frustrating and lead to a decreased quality of life.
DaT scan
A DaT scan is the lone FDA-approved imaging test to differentiate essential tremor from Parkinson’s, disease, though it cannot actually diagnose essential tremor. A radioactive drug that binds areas of the brain utilizing a neurotransmitter called dopamine is injected, which is then imaged with a single-photon emission computed tomography (SPECT) camera.
An abnormal DaT scan would be consistent with Parkinsonian disorders, whereas in essential tremor the scan is expected to be normal.
North Shore University Hospital is the only facility on Long Island offering high-intensity focused ultrasound.
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Lifestyle changes for essential tremor
The majority of essential tremor cases either don’t require treatment or are treated without surgery. The difference between these tremors and many other diseases is that the kinetic (action) tremor is visible during activities such as holding a cup or spoon, or with writing or drawing.
The first issue to consider for treatment is if the tremor is a problem or disabling. Many people just want to be reassured that it isn’t Parkinson’s disease.
In many patients, one of the features of essential tremor is its responsiveness to alcohol. Unfortunately, this can lead to people self-medicating, which can lead to serious dependency problems (though a small amount of alcohol with dinner may be helpful, especially in public situations).
As for nonpharmacological treatments, you can try using heavier spoons, metal cups or even wrist weights in order to dampen the tremor. A 1/8 or 1/4-lb band may suffice, which can help with eating or holding a cup because the weight dampens the tremor, making some activities more manageable.
Several assistive devices — such as spoons with stabilizing gyroscopes and responsive orthotics — have been developed to help reduce the impact of the tremor, though they tend to be expensive and are not formally approved by the FDA.
Traveling to a doctor’s office can present a physical challenge for those living with movement disorders. Telehealth is filling that void.
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Medications that can help
There are a number of medications people can use for the treatment of essential tremor. The two main medications that have proven to be effective are:
- Propranolol: A beta blocker (blood pressure medicine), which does have side effects such as lowering the heart rate, depression and exacerbation of asthma. Propranolol has also been used by actors with stage freight. Other beta blockers may have some benefit as well.
- Primidone: Also used to control seizures, primidone can be useful, though it often needs to be taken three times a day. Side effects are limited by sleepiness, mental slowing and imbalance.
If none of the medications prove sufficient, surgery may be necessary.
Medical treatments for essential tremor
Two-thirds of people with essential tremor won’t need treatment, let alone surgical treatment. In fact, essential tremor is often managed by a primary care physician or internist.
If necessary, there are two varieties of surgical treatment: deep brain stimulation (DBS), which is considered the gold standard, and lesion therapy.
Deep brain stimulation
This method has a long track record and works by stimulating the brain via an implanted electrode that connects to a pacemaker-like device implanted beneath the collarbone. This device continuously overrides the abnormal oscillations of the specific circuit in the brain that causes the symptoms, and is beneficial in both essential tremor and Parkinson’s disease. A major advantage of DBS is that it is reversible and adjustable over time, so that symptoms can be continuously controlled.
Lesion therapy
This involves creating a surgical lesion within the ventral intermediate nucleus of the thalamus. It has shown to be highly beneficial and does not require inserting permanent devices or hardware. However, attempts to control tremors on both sides of the body have an increased risk of cognitive difficulty and potential speech issues.
Lesions can also be performed without surgery. Incisionless treatments include thalamotomy via HiFu or stereotactic radiosurgery (gamma knife).
Gamma knife: Instead of using ultrasound to make the lesion, gamma knife employs radiation to slowly create the same lesion in the same spot of the brain. Gamma knife’s effects develop over several months, whereas focused ultrasound is immediate.
High-intensity focused ultrasound (HIFU): This procedure occurs completely in an MRI scanner in a single two-hour, outpatient session. Using sound waves HiFu targets a very small node within a circuit in the brain that causes tremors to create a lesion, without harming surrounding tissue.
The effects are immediate, and sustainable for years. HiFu is currently FDA-approved for single-side treatment in essential tremor and for Parkinson’s disease tremor, as it targets the same location in the brain; the second can be treated nine months after the first.
Martin Niethammer, MD, PhD, is a neurologist and movement disorders specialist at North Shore University Hospital and an assistant professor of neurology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.
Albert Fenoy, MD is director of functional neurosurgery and the deep brain stimulation program at North Shore University Hospital and an associate professor at the Feinstein Institutes for Medical Research.
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