For about 11 million Americans, involuntary tremors are a constant problem that can interfere with just about everything—getting dressed, drinking a cup of coffee or using a cell phone. The rhythmic shaking can be caused by Parkinson’s disease, but more often it’s caused by essential tremor, a benign, often inherited condition.

Although there is no cure for these forms of tremor, treatment options are available to help manage symptoms.

During a recent BCH health lecture, neurologist Alan Zacharias, MD, and neurosurgeon Kara Beasley, DO, described to a crowd of nearly 200 people the newest approaches for controlling essential or Parkinson’s tremors.

Essential Tremor
“Essential tremor is the most common neurological movement disorder, affecting about 4 percent of adults over 40 years old. Although essential tremor is non-life threatening, it can be severe in some people, impacting quality of life,” said Dr. Zacharias, who started off the lecture. “The cause of essential tremor remains poorly understood. However, a family history is very common.”

Symptoms
Tremors associated with essential tremor can cause rapid, uncontrollable:

  • Shakiness of the hands and arms—the most common symptom—which occurs mostly during action or movement such as when writing, eating or holding a posture.
  • Small up-and-down or side-to-side head shakes.
  • Shaky voice.
  • Leg and feet shakes that can affect balance or the way you walk.

Dr. Zacharias said, “Essential tremors are usually bilateral, meaning they appear on both sides of the body. They can occur for brief periods of time or constantly, and their severity typically worsens with age. In some cases, affected individuals may also develop a variety of non-motor symptoms such cognitive decline, depression, anxiety and hearing or smelling deficits.”

Treatment
Dr. Zacharias explained that some people with essential tremor don't require treatment if their symptoms are mild. But if the tremor makes it difficult to work or perform daily activities, there are treatment options.

“About 50 percent of patients have a meaningful response to medications. Medications that can help control essential tremor include the beta blocker propranolol, which is normally used to treat high blood pressure, or epilepsy drugs such as primidone,” Dr. Zacharias said. “Other medications that might be prescribed include sotalol, atenolol, alprazolam and topiramate.”

He added that Botox injections might be useful in treating some types of tremors, especially head and voice tremors. Surgery might be an option if your tremors are severely disabling and you don't respond to other treatments.

Parkinson’s Disease
Parkinson’s disease is the second most common movement disorder, affecting more than 1 million Americans. The disease can’t be cured, and it isn’t fatal. However, complications arising from the disease are serious and make it the 14th top cause of death in the U.S. Those who seek expert care, especially in early stages of the disease, are at a lower risk of complications, have a better quality of life and even live longer.

Dr. Zacharias said, “This tremor is mostly seen at rest, when the body part is not being used, and is often referred to as resting tremor. While most cases are sporadic, meaning they occur without an inherited genetic disposition, in 10 to 20 percent of cases there is a family history.”

According to Dr. Zacharias, 70 years of age is the average diagnosis, and the disease occurs more often in men than women.

Symptoms
Parkinson’s disease is progressive, with symptoms that develop gradually and worsen over time. The tremor usually starts on one side of the body and tends to develop on the other side as the disease progresses. Symptoms include:

  • Slow muscle movement.
  • Tremor that usually begins in hands or fingers.
  • Rigidity and muscle stiffness, limiting range of motion.
  • Posture instability, which can cause balance problems.
  • Walking problems characterized by small shuffling steps or hesitation before stepping forward.
  • A sensation of internal tremor (a feeling of tremor inside the chest, abdomen, arms or legs that cannot be seen).

Treatment
Dr. Zacharias explained that people with Parkinson's disease have low brain dopamine concentrations. Consequently, the standard treatment is to prescribe medications that can increase or replace dopamine.

“Dopamine-replacement medications can often dramatically control symptoms,” said Dr. Zacharias. “The most effective is Levodopa, a natural chemical that passes into your brain and is converted to dopamine. Levodopa is combined with carbidopa, which helps prevent the levodopa from converting to dopamine outside of your brain.”

In addition, physical therapy and exercise can greatly improve symptoms and delay progression of the disease. However, in some later cases, surgery may be advised.

DBS: A Pacemaker for the Brain
Dr. Beasley then followed Dr. Zacharias with a presentation on Deep Brain Stimulation, or DBS.

“DBS is a brain surgery that can help treat the debilitating symptoms of essential tremor or Parkinson’s disease when medication fails to provide consistent and adequate symptom control,” Dr. Beasley said.

The procedure involves implanting a device often described as a “pacemaker for the brain.”

“There are two stages to DBS. In the first stage, the surgeon implants electrodes on specific areas of either one side or both sides of the brain,” Dr. Beasley explained. “In the second stage, the neurosurgeon implants a pacemaker-like neurostimulator under the skin, near the collarbone, and connects it to the electrodes with long lead wires passed under the skin and along the neck. The stimulator sends constant high-frequency electrical impulses to the electrodes, which block the abnormal nerve signals causing the tremors.”

What are the Results of DBS?
For the treatment of essential tremor, DBS typically targets hand tremors. Clinical studies show that it can reduce hand tremor in 60 to 90 percent of essential tremor patients, improving their ability to do everyday activities.

Dr. Beasley stated that although it won’t slow the progression of Parkinson’s disease, DBS can significantly reduce the symptoms of tremor, rigidity, stiffness, slowed movement and some types of walking problems. Results show that more than 70 percent of patients with Parkinson’s disease experience significant improvements to their motor function.

“Yet to obtain maximum benefit from DBS, patients must receive treatment during a window of opportunity when it can be the most effective,” Dr. Beasley warned.

To schedule an appointment with Alan Zacharias, MD, call Associated Neurologists at (303) 415-8800. Schedule an appointment with Kara Beasley, DO, by calling Boulder Neurosurgical & Spine Associates at (303) 938-5700.

View PowerPoint slides from the lecture on “Controlling Involuntary Tremors.”

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