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Essential!Tremor:!The! Other& ET !

!

Sharon!Harrison !

!

2003 !

©!!2003!Sharon!Harrison

Abstract

This thesis provides a comprehensive understanding of the most common and perhaps

least known movement disorder called essential tremor. Written primarily for the general

population, it presents a compilation of the most recent medical studies by premiere

researchers and movement disorder specialists in the field of neurology. The focus is

educational, in order to raise awareness and sensitivity to the challenges posed by this

disorder. This paper provides general information on tremor manifestation, assessment

criteria and the challenges to differentiate this disorder from others involving tremor.

Personal stories are provided to bring special attention to the physical and social

disabilities and their great impact on quality of life. The paper concludes with a call for

further research from physicians and patients alike, with the hopes for a greater

knowledge of essential tremor, new treatment options and perhaps, eventually, prevention

strategies.

Table of Contents

Introduction

6

Movement Disorders/Essential Tremor

9

Classification of Tremor Types

10

Assessment/Diagnosis

12

Causes

Brain

14

Genetics

15

Environmental

16

Disabilities

16

Physical

17

Cognitive

17

Psycho/social

18

Treatment

Pharmaceutical

18

Neurosurgical

20

Holistic/Stress Reduction

21

Personal Stories

24

The Future of Essential Tremor

31

Conclusion

32

Appendix A

34

Appendix B

35

Appendix C

36

Table of Contents

Addendum: Additional Stories

37

Annotated Bibliography

53

Bibliography

61

Figure Captions

Figure 1.

Spiral drawing: 78 year old woman with essential tremor

Figure 2.

Handwriting comparison of a patient with essential tremor and with Parkinson’s disease.

Figure 3.

Suspected brain involvement in essential tremor

Introduction

I am an average sophomore in an equally average high school. I am waiting in a

long line for my preferred mid-morning snack of hot chocolate and a crunch bar. Not

content with the sweetness in these items separately, upon reaching a table in the

beckoning quad, I will ceremoniously dip the candy bar into the hot beverage until it just

begins to melt. “Life is good,” I think to myself. This is our ritual, my best friend and I,

and we have done this since winter began. And yet today, something is different. As I

take my leave from the snack window and head to the nearest table, the hot chocolate

sloshes over the side of the cup and onto my hand and wrist. As my girlfriend chuckles,

not unkindly, the hot beverage burns my skin. My embarrassment burns hotter still. I am

15 years old.

A year later, I am about to have my ears pierced for my sixteenth birthday. Before

the clinician takes the punching appliance to my ears, she must mark the point with a red

felt-tipped pen. She tells me I have to keep my head still, and I tell her I cannot. She asks

why, and I cannot tell her that either. I laugh and say, “Just do your best.” She looks

skeptical, but I assure her that if the holes are crooked, it will be my fault - not hers.

I am applying for my first ‘real’ job as a cashier in a loan office. The manager

smiles at me and asks me to calculate a long list of numbers on an adding machine. There

are two problems here. I have never used an adding machine, and in fact, my college

preparatory classes left me woefully under-qualified for this clerical position. However,

the bigger problem is that my hands are shaking so badly that I take a very long time and

make numerous mistakes. After many starts and stops, I am red-faced but I finish the

task. I leave the interview elated – I got the job! Much later, as the manager and I become

good friends, he tells me a secret. “Your hands were shaking so badly, I thought you were

an amphetamine addict!” “Why did you hire me?” I shot back. “Because I thought you

were cute,” he tells me. I am 18 years old.

It is my thirtieth birthday and I am sitting in a neurologist’s office. It is my

present to myself to again seek answers to my questions. I am fed up with the intermittent

shaking in my hands and head and even more so by the way my previous doctors have

dismissed my symptoms with a wave of their steady hands. “It’s just stress,” they say,

“You’ve got to calm down.” As I begin to relate my story as I have done many times

before, I now note an increased shakiness to my voice. I am prepared to hear nothing

new. I am mistaken. “You have a movement disorder. It is exacerbated by stress but not

caused by it. It’s called ET.” Happy birthday to me!

It is quite likely that for most of the general population the term ET conjures up

visions of an adorable alien in a Steven Spielberg movie who moved us to laughter and

occasionally, tears. And yet, for a surprisingly large part of the population ET takes on a

very different meaning. This ET also elicits a wide range of emotions, but they are more

often out of frustration or embarrassment rather than the result of lighthearted

entertainment.

Essential tremor, known as ET to physicians and patients alike, is the most

common movement disorder and yet few outside of those personally affected have ever

heard of it. A disorder that is manifested most often by tremors of the head, hands and

voice, it is often mistaken for Parkinson’s disease. In fact, ET is 20 times more common

than Parkinson’s and, in varying degrees, may affect as much as “6% of the general

population” (Louis, 2002b, p.5) and among those over age 65, “the prevalence may be as

high as 23%” (Louis, 2002a, ¶ 1). Despite these large numbers, researchers note that as

few as 10% actually seek treatment. The reasons for this are unknown, but it is theorized

that the tremors may not yet have progressed to the point of causing noticeable disability

and/or the patient has sufficiently adapted their movements by using “two hands or

performing tasks more slowly” (Louis, Wendt, Albert, Pullman, et al., 1999, Comments

section, ¶ 1). Quite likely, especially in the elderly, tremor may simply be seen as “an

accepted and inevitable consequence of normal human aging” (Louis, 1999, ¶ 2).

Although one of the earliest accounts of the disorder has been traced back to the

late eighteenth century, the exact cause of essential tremor is yet unknown (Louis,

2001c). Ongoing research has pinpointed four areas of the brain that are likely suspect.

Two studies also note a possible degeneration of important brain chemicals. This most

recent data suggests that essential tremor may be much more similar to Parkinson’s

disease than originally believed (Louis, 2002b).

Aside from the functional disability caused by the tremors, which may affect

everyday activities such as eating, writing and shaving, new research has also found a

correlation to deficits of memory and cognition. Although it is not considered to be life-

threatening, essential tremor is highly exacerbated by “emotion, exercise and fatigue”

(Victor & Ropper, 2001, p. 101). As a result, ET’s affects on the social life are profound,

and it is not uncommon for those with this disorder to withdraw from all but their closest

family and friends.

In the pages to follow, I will provide background information as to the

classification of tremor types which will highlight the diagnostic challenge to

differentiate this disorder from other movement disorders, especially Parkinson’s disease.

A discussion of the specific tools used in the clinical assessment will follow. I will

compile the latest research into the suspected causes of this disorder, the role of genetics

and brain chemicals as well as possible environmental concerns. As to the disabilities

caused by essential tremor, I will note the physical, cognitive, as well as the social.

Various medical treatment options will be detailed, including oral medications, botulinum

injections and two types of neurosurgery. I will end the discussion of treatment

modalities by noting the effectiveness of more holistic treatments such as acupuncture

and biofeedback. The importance of stress management will also be highlighted as well

as hopes for future research. Although this paper is predominately research based, I also

hope to bring a personal voice, albeit a tremulous one, to describe the challenges of living

with essential tremor. As I have shared my own story to introduce this topic, I will also

share the stories of people whom I have come to love and admire. It is my hope that

raising awareness in the general population will result in a renewed interest in research,

more satisfactory treatment methods and, ultimately, in an increased quality of life for

those with essential tremor; indeed, the other ET.

Movement Disorders/Essential Tremor

Movement disorders are broadly defined as neurological disturbances of the

motor system that are characterized by either an increase or a decrease in motor

functioning and mobility (Baylor College of Medicine, n.d.). According to Dr. John

Caviness (2000), Associate Professor of Neurology at the Mayo Clinic, most of the

research surrounding movement disorders generally focuses on those disorders that

restrict movement, such as Parkinson’s, rather than those that exacerbate it. However,

such hyperkinetic disorders are much more common and they often cause severe

disabilities. These disorders are also difficult to diagnose as there are often overlapping

areas of the brain which facilitate such erroneous movement (Caviness, 2000).

Essential tremor is the most common of the movement disorders causing tremors,

or involuntary shaking, to various body parts. It is considered to be slowly and variably

progressive, although studies note that the symptoms may progress more rapidly in

patients whose first symptoms begin after age 60 (Louis, 2000). The use of the term

essential implies that the tremor is the only significant finding of the disorder (Summit

Medical Center, n.d.), however, new studies alluding to cell death (Louis, 2002b) may

eventually discount this notion. Since ET is not considered to be life-threatening, it is also

frequently referred to as a benign tremor (Evidente, 2000). This is an unfortunate

misnomer and will be addressed more fully in the sections relating to disabilities and

personal stories.

Classification of Tremor-Types

Because tremor is a common neurologic symptom in many disorders, the

difficulty lies in distinguishing between the tremor types. For this reason, tremors are

classified in various ways: the two most important according to conditions that activate

the tremor and body part affected (Evidente, 2000). A third way to classify tremors is

through measuring the speed (frequency) of the tremors. This is usually denoted in Hertz

(Hz.).

Perhaps the most obvious classification is between a tremor that occurs when the

limb is at rest (resting tremor) or during activity (action tremor). Parkinson’s patients

most often display a resting tremor, as shaking can be noted when the hand is completely

supported in the lap. These tremors typically calm considerably when the hand is used.

Conversely, the essential tremor is generally inactive in the resting state and only

begins when the hand attempts a voluntary activity such as writing, eating or buttoning

clothing. An action tremor noted during these types of movement is more specifically

referred to as a kinetic tremor. And when the height of the tremor increases “during the

pursuit of a target” (Zesiewicz & Hauser, 2001), [as in touching a finger to the nose], it

may be termed an intention tremor. Although the kinetic tremor is often more severe in

ET (Brennan, Jurewicz, Ford, Pullman & Louis, 2002), there is also a postural

component. This type of action tremor becomes visible when the arms are held against

gravity, as in a fixed position, outstretched from the body (Zesiewicz & Hauser, 2001).

Another way to classify tremor is according to the part of the body that is

affected. In this respect, essential tremor may involve tremors of the hands, which are

generally more severe in men. Head tremors, which are typically more common in

women (Burke, 2001), may be “horizontal (no-no) or vertical (yes-yes)” (Evidente,

2000). There also may be tremors of the voice, and even of the facial muscles including

the jaw and lip area (Burke, 2001). There are occasionally tremors of the legs, as well

(Bradley, 2001). To add to the complexity, there is also a type of action tremor associated

with a condition called dystonia that is caused by an abnormal twisting and tightening of

the muscles of the neck (Zesiewicz & Hauser, 2001). Tremors caused by dystonia may

also initially be mistaken for essential tremor (Louis, 2001a). While some researchers feel

that it is not uncommon for a patient to present with both conditions simultaneously (Lou

& Jankovic as cited in Baylor College of Medicine, 2001, p. 3) and the personal stories of

ET patients seem to support this, other notables in the field are doubtful that two distinct

neurological disorders would occur in the same patient. This only underscores the

importance, as well as the difficulty, of distinguishing between the many types of tremors

and the specific disorders that cause them.

Once tremors have been classified in the ways previously mentioned, the noting

of tremor speed may help to confirm the diagnosis of ET. Although there is some

crossover between various tremors, ET tremors generally measure 4-8 Hz, which is faster

than the tremors of Parkinson’s, (3-5 Hz) and slower than tremors brought on by extreme

anxiety or fright (8-13 Hz) (Victor & Ropper, 2001).

Assessment/Diagnosis

While there are no definitive body scans or blood tests for diagnosing essential

tremor and the similarity of tremor types may add confusion, Dr. Elan Louis, Assistant

Professor of Neurology at Columbia University, and his associates have developed a

teaching videotape to aid in the diagnostic process. They note six tests in which tremor

severity can be calculated, both when holding a limb against gravity and during voluntary

movement. The tests include “arm extension, pouring, drinking, using a spoon, [touching]

finger-to-nose, and drawing spirals” (Louis, Barnes, Wendt, Ford, Sangiorgio, Tabbal,

Lewis, Kaufmann, Moskowitz, Comella, Goetz & Land, 2001). A handwriting sample

may also facilitate the correct diagnosis, revealing the ‘action’ nature of the essential

tremor which may in time become “large…and illegible” (Evidente, 2000, ¶ 12).

Conversely, in the Parkinson’s sample, there is no visible tremor and most notably, the

handwriting typically becomes very small. Note the spiral drawings, called the

Archimedes Spiral and the handwriting samples (Baylor College of Medicine, 2001) in

figures 1 and 2 in Appendix A.

Because there are no specific tests for essential tremor the “diagnosis is based

almost exclusively on clinical observations” (Baylor College of Medicine, 2001, p. 2). As

a result, the patient’s own anecdotal history of the disorder is vitally important. One

question involves the age of onset. Although the tremor is extremely common in the

elderly it can begin at any time, with 1 in 20 cases occurring in childhood (Louis, Dure &

Pullman, 2001). Interestingly, the symptoms most often occur in the second and sixth

decades of life (Evidente, 2000). Specific questions regarding the characteristics of

tremor in the early stages also help to rule out Parkinson’s disease, although, as noted, the

biggest difference between the two is that an ET tremor begins when movement is

attempted, rather than during rest, as in Parkinson’s. The tremors of ET are also fairly

symmetrical, and even if they initially affect only one arm, they will generally affect the

other as well (Burke & Hauser, 2001). They also usually begin, quite surreptitiously, in a

finger. Parkinson’s tremors generally begin on only one side of the body, typically the

thumb, and are much more noticeable at onset (Lieberman, n.d.). An early history of

intermittent tremor occurring only during times of exacerbated stress also points to ET,

but tremors of both essential tremor and Parkinson’s disease completely disappear during

sleep (Burke & Hauser, 2001).

Aside from the characteristics of the tremor itself, perhaps the two most important

findings derived from the patient’s personal history are the presence of a family member

with ET and the calming effects of a small amount of alcohol. The genetic component

will be addressed more fully in the following section; however, the role of alcohol as a

diagnostic tool cannot be minimized. Simply put, a preponderance of patients with

essential tremor will note a diminishment of tremor with minimal alcohol intake.

Conversely, alcohol has little or no effect on a Parkinson’s resting tremor (Victor &

Roper, 2001). Table 1 in Appendix B shows the distinguishing characteristics between

Essential tremor and Parkinson’s disease.

Brain

Causes

Although Dr. Rodger Elble of the Southern Illinois University School of Medicine

has noted that researchers “struggle with the elusive origins of tremor,” it is hoped that

new brain technology will eventually be helpful (2000, ¶ 8). However, as the specific

area of the brain responsible for ET remains yet unknown, most studies have focused on

the oldest parts of the brain, noting increased activity pertaining to the areas of the

inferior olive, the red nucleus, the thalamus and the cerebellum (Evidente, 2000). Other

research noted definite sensorimotor cortex involvement but remained inconclusive about

more specific involvement (Hellwig, Haubler, Schelter, Lauk, Guschlbauer, Timmer &

Lucking, 2001). In an attempt to clarify the specific areas of the brain that are believed to

be involved in ET, Dr. Elan Louis noted the following: “These are nerve fiber pathways

that start in the inferior olive, [the] brainstem. They then travel to the cerebellum, and

then end up in the thalamus. This pathway is thought to be abnormal in ET” (personal

communication, August 14, 2002). Figure 3 in Appendix C indicates the suspected areas

of brain involvement and a general description of their function.

Comparative brain research has also found differences in the ET brain, involving

either an increase or decrease of certain chemicals. These involve the neurotransmitters

noradrenaline, GABA and possibly N-acetylaspartate. Noradrenaline, a stimulatory

chemical largely responsible for the activation of ‘fight or flight,’ has been found in

increased amounts in four areas of the ET brain (IETF, 2001). GABA, an inhibitory

chemical necessary to movement, has been found to be deficient in the cerebellum. Two

very recent imaging studies also found that cells containing a chemical called

N-acetylaspartate die at an accelerated rate in that same area of the brain (Louis, 2002c).

This amino acid is also decreased in Alzheimer’s patients, where it appears to be

associated with cognition (Jessen, Block, Keller, Flacke, Lamerich, Schild & Heun,

2001). However, in the ET patient, it may be more specific to the tremor itself (Louis,

personal communication, February 7, 2003). Although these studies are on-going,

doctors note that the “chemical basis for ET is very poorly understood” (Louis, 2002c, p.

4).

Genetics

Although the exact brain mechanism responsible for ET is unknown, studies

report that as many as half of all cases may have a genetic component. Heredity is by

means of an autosomal (non-sex-linked) dominant trait, allowing that “[each child] of an

affected individual will have a 50% chance of also developing the disorder” (NCBI, n.d.).

There are conflicting studies, however. A small control-based study of ET patients, their

children and other relatives found that “relatives of ET patients [were] five times more

likely to develop the disease than are members of the population and ten times more

likely if the [ET patient’s] tremor began at an early age (Louis, Ford, Brucht, Barnes, X-

Tang & Ottman, 2001). Such disparities are explained by one researcher who noted that

“despite the high prevalence of the disease, families that are informative for genetic

linkage studies have been difficult to locate” (Louis, 2001b).

Although a specific ET gene has not yet been identified, genetic researchers have

discovered two areas of chromosomal susceptibility (Louis, personal communication,

February 12, 2003). One pertains to Icelandic families and another in four generations of

Americans (Burke & Hauser, 2001). Linkage has also been established in a third family

whose symptoms appear similar to both Parkinson’s and ET (Louis, personal

communication, February 12, 2003). Due to this highly genetic nature of the disorder, ET

is also often also referred to as a familial tremor.

Environmental

Completing the review of the possible causes of ET is a look at the “sporadic” or

non-genetic forms of the disorder. Researchers note that in this “sizable proportion of ET

cases” environmental concerns may be the cause of tremor (Louis, 2001b). Although

researchers are only just beginning to study pesticides, lead, mercury and naturally

occurring chemicals found in food as well as work-related chemical exposure, they

acknowledge the tremor-producing qualities of these substances and note a possible

connection to non-genetic cases of ET (Louis, 2001b).

Disabilities

Although researchers are not yet certain of the definitive cause of ET, the

disabilities from this disorder are readily apparent. The fact that ET does not appreciably

shorten the lifespan of those affected and, in fact, may even be associated with increased

longevity (Baylor College of Medicine, 2001), has prompted some in the medical field to

refer to this disorder as ‘benign.’ Gratefully, more recent studies note that this is entirely

misleading and, in fact, suggest that those with ET “endorse greater social,

communication, emotional, and physical difficulties than controls, in addition to

disruption of work, home and recreational activities” (Busenbark, 1991, as cited in

Lacritz, Dewey, Giller & Cullum, 2002). More specifically, in a study of both physical

and social disabilities caused by inherited essential tremor, it was revealed that “60% of

individuals did not seek employment, 65% did not dine out, 30% did not use public

transportation, attend parties, shop alone or partake of a favorite hobby and 20% stopped

driving” (Burke, 2001, ¶ 6).

Physical

The physical disabilities from ET are derived from the tremor itself and

specifically correlate to tremor severity. A mild tremor may cause little or no physical

challenge; however, a severe tremor can greatly impede the type of fine motor dexterity

necessary for writing, eating and drinking, dressing, (Louis, 1999) inserting a key in a

lock, signing one’s name, threading a needle, etc ( Louis, et al., 2001). More extreme

difficulties are noted for those in professions requiring steadiness, such as “surgeons,

artists, musicians and drafters” (Evidente, 2000, ¶ 11) and of these, many are forced to

change jobs or retire early (Burke, 2001).

Cognitive

Aside from the variable physical limitations imposed by ET, new research is also

pointing to possible cognitive deficits. Mild impairment was found in the areas of

“cognitive flexibility, figural fluency, selective attention, nonverbal memory, letter

fluency and aspects of problem solving.” These findings were similar to the cognitive

deficits caused by Parkinson’s disease (Lacritz, et al. 2002, p. 126).

Psycho/Social

Although the physical disabilities caused by ET can be quite limiting depending

upon tremor severity, and the cognitive effects mildly so, the social aspects of the

disorder can be devastating. In a study on social phobias secondary to ET, it was noted

that even for those whose tremors do not cause undue physical challenges, the

embarrassment from tremors when eating or writing in public often exact a high toll

(Schneier, Barnes, Albert & Louis, 2001). Researchers found that social phobia is present

in a “substantial minority of essential tremor patients, …is influenced by tremor severity

and is problematic in situations in which the tremor becomes evident to others”

(Schneier, et al., 2001, p.371-372). Researchers sympathetic to the social implications of

this disorder note the importance to “diagnose and effectively treat ET in order to reduce

the misperception by others that ‘tremor’ is an indicator of anxiety disorder or substance

abuse” (Baylor College of Medicine, 2001, p. 1).

Pharmaceutical

Treatment

There are a variety of ways to treat essential tremor including the use of

medications and surgery. There is no medication specific to ET; however, many were

found to be helpful ‘serendipitously’ when treating for another illness and noting a

lessening of the symptoms of ET (Louis, 2000). For example, the beta-blocker

propranolol (Inderal), which was predominately used to treat high blood pressure, is now

a first-line treatment for ET (Louis, 2001a). For those whose tremors do not respond to

propranolol or for whom it is contraindicated (for elderly patients or those with low blood

pressure), an anticonvulsant known as primidone (Mysoline) has been shown to be

variably effective. Although there have been numerous studies of a variety of

medications, these two are still considered the mainstays of pharmaceutically-treated ET

(NCBI, n.d.). They are not without potentially serious side effects, however, including

low blood pressure and depression with propranolol use, and dizziness, nausea and

vomiting with primidone (Burke, 2001). For this reason, these and all medications for ET

require medical monitoring.

Two other anti-convulsants occasionally used to treat ET are gabapentin

(Neurontin) and topiramate (Topamax). Although they have not shown the general

efficacy of either propranolol or primidone, they are sometimes used as second-line

agents or in conjunction with other medications (Baylor College of Medicine, 2001).

Anti-anxiety medications such as those in the benzodiazepine family

(Alprazolam) are used primarily to treat the anxiety of social situations rather than the

tremor itself. As these medicines are potentially addictive, they are not recommended for

long-term use (Baylor College of Medicine, 2001). And although the effectiveness of

small amounts of alcohol has been noted as a diagnostic tool, there is often a ‘rebound’

effect after about two hours, in which the tremors may actually increase (Baylor College

of Medicine, 2001). However, doctors note that “the benefit of a glass of wine or a beer

prior to any engagement that might aggravate tremor should not be overlooked as a

possible adjunct in the management of ET” (Zesiewicz, et al. 2001, ¶13).

Other medications have been used to treat ET including those for glaucoma and/or

depression (Baylor College of Medicine, 2001). Despite this variety of medications, even

those medications generally considered to be most effective for treating ET are less than

ideal. As one researcher noted, “even the front-line agents [propranolol and primidone]

are ineffective for a large proportion of the people who take them, and there is almost no

way to predict who will or won’t benefit from a particular medication” (Louis, 2002b, p.

1).

Injections of Botulinum toxin (Botox) have recently been added to the ET

treatment arsenal with “modest to good improvement in tremor” (Baylor College of

Medicine, 2001). Because of resultant muscle weakness when used for upper extremities

(Burke, 2001), they may prove to be more effective for head and voice tremors. Although

the use of Botox may provide optional treatment to those who cannot tolerate

medications, disadvantages include the high cost of the drug and the need for repeated

treatments at numerous muscle sites (Baylor College of Medicine, 2001).

Neurosurgical

For patients with extremely debilitating tremors that do not respond to other

treatment modalities, two types of surgery have been used, both targeting the thalamus.

The older technique, called thalamotomy, involves destroying the overactive cells of the

thalamus that cause the tremors, (Tatter, n.d.). Although the advantages to this type of

neurosurgery include a long history of use and little postoperative maintenance, this

procedure is permanent and the adverse effects may include brain hemorrhage, muscle

weakness, speech disturbance and memory loss (Burke, 2001). A newer form of the

surgery called deep brain stimulation (DBS) may have fewer and less severe side effects.

Instead of permanently “destroying the overactive cells…it temporarily disables them

[with] rapid pulses of electricity” (Tatter, n.d.). This technique costs more and also

involves an additional surgery to implant a pacemaker device under the collarbone

(Tatter, n.d.). However, because the implant is temporary, “even if the stimulator is not

correctly placed, serious permanent neurological deficits can be avoided” (Baylor

College of Medicine, 2001). The pacemaker is typically turned off at night (via a

magnet) when tremors naturally cease and reactivated in the morning. The batteries that

power the pacemaker will eventually “need to be replaced, calling for a subsequent,

although minor, surgery” (Tatter, n.d.). Side effects from deep brain stimulation include

numbness and tingling, difficult speech, gate disorders (Baylor College of Medicine,

2001) and a foreign body implant that may be subject to infection (Tatter, n.d.). Although

DBS appears to result in fewer side effects than thalamotomy, one research study noted

the high rate of “device failures” and suggested that long-term evaluations be undertaken

in order to truly “assess…the relative benefits and complications of these procedures”

(Burke & Hauser, 2001, ¶ 35). Although the surgeries can drastically reduce tremors for

as many as three years (IETF, Fall 2002, p. 4) it is important to note that surgery on one

side of the brain will only help the tremors on the opposite side of the body. Bilateral

surgeries are occasionally performed, however, only at the increased risk of side effects

(Baylor College of Medicine, 2001).

Holistic/Stress Reduction

The role of medications and surgery in tremor control are extremely important.

For patients who cannot tolerate the inherent side effects and for others who do not wish

to expose themselves to added risk, alternative treatments may also be quite beneficial.

These include acupuncture, biofeedback and autogenic training.

The research literature on acupuncture specific to tremors is limited; however, one

study did note the successful treatment of a patient with head tremor in three sessions,

“following Dr. Maurice Mussat’s ‘Energy of Living Systems’[using]…triangular

equilibration” (de la Torre, 1989). However, the age of the study, the lack of subsequent

studies and the resolution of tremor in three visits remain troublesome, prompting one

licensed acupuncturist to admit to skepticism (A. Harrison, personal communication,

August 15, 2002).

Despite the fact that acupuncture treatment specifically for tremors has not been

validated by this research, acupuncture and other holistic methods geared toward stress

reduction can be quite beneficial. These measures target the release of noradrenaline,

(already increased in the ET brain), which results in the sympathetic nervous arousal

known as ‘fight or flight.’ Their effectiveness is not in diminishing tremor per se, but by

keeping the tremor from exacerbating under stress. In auricular acupuncture, in which ear

points correspond to bodily organs and functions, two such points may result in stress

reduction: Shenmen or “spirit gate,” which produces a generalized calming effect and the

Sympathetic Point, which balances sympathetic nervous arousal (A. Hasper, L.A.c.,

personal communication, March 2000). Julie Shpiesel, a licensed acupuncturist in private

practice recommends a more thorough treatment, using the points mentioned above as

well as points that would “nourish the blood and yin of the liver on an ongoing basis.”

She also stresses dietary changes and the use of meditation to keep the “nerves settled

and calm.” And although Shpiesel realizes the chronic nature of this disorder and views

treatment by acupuncture as a “long-term project,” she anticipates it may “prevent the

condition from worsening…[and possibly begin] to reverse the condition” (J. Shpiesel,

L.Ac., personal communication, October 23, 2002).

Biofeedback, in which electronic machinery ‘feeds back’ information about the

body’s processes, is another holistic treatment that may be of benefit. Electromyographic

(EMG) or muscle biofeedback can bring muscular tension to the patient’s awareness,

even after the patient perceives complete relaxation. The use of neurofeedback, a more

specific type of biofeedback targeting brain waves, may aid the tremor patient by training

them to increase brainwaves more conducive to relaxation (Robbins, 2000).

Although each of these methods may be viable forms of treatment, they require

clinical guidance and may be quite expensive. Conversely, autogenic training, which also

targets the sympathetic nervous system is easy to learn, can be practiced in minutes a day

and does not require clinical assistance or machinery. Developed in the early 1900s by

Johannes Schultz and adapted for English-speaking patients by Wolfgang Luthe,

autogenic training incorporates the use of mental exercises and diaphragmatic breathing

to induce relaxation and “facilitate the natural self-healing mechanisms that already

exist” (Luthe, as cited in Peper & Gibney, 2000, p. 80).

Although there is little research into the specific treatment of essential tremor

using more holistic measures, it is likely that numerous other treatment modalities geared

toward relaxation will offer some benefit. Dr. Andrew Weil, physician, author and

founder of the Center for Integrative Medicine in Tucson, Arizona, highly recommends

adopting a practice of relaxation and suggests such methods as meditation, tai chi,

therapeutic touch, hypnosis or massage (Weil, 2001).

As an adjunct to any treatment for essential tremor, behavioral and lifestyle

changes may also be of benefit. Eliminating stimulating foods such as those containing

caffeine is often warranted. Using covered glassware, straws and weighted utensils can

aid in feeding. Functional tools such as word processors and special computer ‘mouse’

devices may also be of benefit. Membership in an ET support group is paramount.

Personal Stories

While acknowledging the far-reaching importance of the scientific medical

research on essential tremor, various coping strategies and the impact on the quality-of-

life of those affected, hard facts and percentages too often remain nothing more than

statistics on a page. For this reason, I turn to the intimate stories of those individuals who

have been living with the challenges posed by essential tremor. The stories have been

selected to show the variability of this tremor disorder, the frustrations and, hopefully, the

sense of humor that sustains those living with it.

“Janet” (personal communication, October 18, 2001) is a 46 year old nurse and

mother of two children who has had tremor for 17 years. She has been diagnosed with

both essential tremor and dystonia, which often causes severe shaking of her head, neck

and sometimes her shoulders. Although she once described herself as “very social” she

notes that this is no longer the case “since this condition took over my life.”

Janet shared that her mother had essential tremor but that it was never explained

to her or her brother. Because talking about her mother’s shaking head was considered to

be “taboo” in the family, Janet was both embarrassed and worried for her mother. “Most

of the time she just looked nervous and out of control. Other times I thought she might

die from her shaking.” Janet had never known her mother’s official diagnosis until she

herself was diagnosed at age 29. Janet notes that her brother also has the disorder, but

adds that he does not let it “have a negative impact on his life.” Aside from worrying that

her own two children may manifest signs of this disorder, Janet also worries about the

affect of her tremor on the children and hopes to spare her children any embarrassment:

“When they were young the tremor was not too bad and I could control it by tightening

my neck muscles…and eventually developed …dystonia.” Until six years ago, Janet

stated she could “still hide her tremor.” Now, she states, “I hide myself.”

Like many with essential tremor, Janet tried numerous medications only to find

that they “either didn’t work or the many side effects outweighed the benefits.” Also like

many with this disorder, social functions are particularly difficult.

When [I] do accept an invitation to dinner or anything social I have to drink at

least two glasses of wine and continue the ‘flow’ of alcohol in order to minimize the

tremor. Because I know my tremors will be worse afterward [due to the rebound effect of

the alcohol], I generally only accept those social invitations that are worth the trouble.

Janet is a registered nurse and would like to go back to work but is hesitant to do

so. She explains her reticence by noting that her embarrassment from the tremors even

impact everyday activities. “I see how other people sometimes stare at me as I fumble to

write a check and my head shakes away. I fear that they will think I am an alcoholic… or

that I will collapse at their feet in a seizure.” Although pain is not usually associated with

essential tremor, with the addition of dystonia as in Janet’s case, she notes that her “neck

muscles are in constant spasm because I try so hard to control the tremor.”

Janet also commented on the ability of high profile people to educate the public,

as actor Michael J. Fox did for Parkinson’s disease. Katherine Hepburn, who is often

erroneously believed to have Parkinson’s disease actually has essential tremor (Wang-

Cheng, 1998). And although the actress has chosen not to discuss her illness publicly,

Janet hopes for increased awareness of this disorder, as well. “It would help me feel more

accepted and more comfortable out in society,” she states.

As Janet explained more about how the disorder impacts her quality of life, she

noted with a laugh that even getting ready for the day is a challenge. “I put on my eye

makeup by holding my chin to steady it so that I won’t poke my eye out with the mascara

brush!” As the smile leaves her face, Janet’s head shakes again. But this time, it is out of

resignation.

Although “Robin” (personal communication, November 2, 2002) was not

diagnosed with essential tremor until ten years ago, she noted that her symptoms actually

began when she was in her teens. Now, at age 78 and recovering from major surgery for

the compression of her spinal cord, Robin looks back on a childhood that was shaped by

this disorder:

As a teenager, I felt an occasional ‘tic’ [in my neck] undetected by others. As I

became more aware of it, I attempted to hide it, and it began influencing my

social development. Although my head tremor was relatively mild, I became

increasingly tense at school and in other social situations. I avoided speaking in

front of a class or group or drawing attention to myself. As I grew older

it

became more obvious, but still I never spoke of it, even to best friends. Nor was it

ever mentioned to me. I became more tense, more angry with myself and others

and more determined to hide the thing over which I had no control.

Like Janet, Robin also noted a correlation between an attempt to control her head tremor

and the eventual diagnosis of torticollis, a form of dystonia.

I began turning my head to the right, avoiding looking at people straight on and [it

became increasingly] uncomfortable to look to the left. As I developed this over-

compensation, the large muscle on the left side of my neck became very strong

and distended, pulling my head to the left, causing my head to be off-set on my

neck. Eventually, the tremor began to be evidenced in my right hand, making it

difficult to write, use a fork, or carry a cup or plate. These additional problems

were embarrassing and added to my stress and tension.

Robin’s family history also includes a parent with tremor. Although her father

was diagnosed with Parkinson’s disease, Robin notes that because his “hand tremor did

not show when his hands were at rest, he too, may have had ET.”

Although Robin has tried many medications and has had Botox injections on three

different occasions, she notes that only Klonopin has been “somewhat effective in

lessoning the tremor without unpleasant side effects.” Consequently, a prominent

university movement disorder specialist advised Robin to undergo DBS surgery, which

she refused. “That was two years ago. Since that time I decided to ‘come out of the

closet’ with my … problems, talk about them to friends, and to get on with my life.”

However, complications arose three months ago resulting in emergency cervical spine

surgery to combat the threat of paralysis. Robin notes a connection with this latest

development and essential tremor. “I believe the ET compensation led to the torticollis

with the off-set head and the spinal curvature which finally compressed on my spinal

cord. I think the ET wearing on the cervical discs caused them to disintegrate.”

The impact of ET in Robin’s life has been quite profound and, like Janet, Robin

hopes that increased awareness will bring more effective treatment options for herself and

others:

Ten years of psychotherapy in my middle years helped me to accept the tremor to

some extent but never relieved me of the tension, stress and social pain associated

with feeling “different.” ET is an extremely destructive disease and deserves just

as much research and attention as Parkinson’s disease. [In its severity], ET causes

physical and emotional pain, an inability to reach one’s potential and ultimately

…to care for one’s self.

“John” (personal communication, November 7, 2001) also noted the onset of

tremor in childhood. Now a 49 year old businessman with a wife and two children of his

own, he noted the impact of his tremor on fine motor movements:

I was only eight years old when I knew something was different about how I

would play games with my schoolmates. When my friends gathered to play pick-

up-sticks, I only resigned myself to being defeated again. Each time, when my

turn required me to move a particular stick away from the pile, I would instead

upset the pile and make it easy for my mates to move in and win. I also had

difficulty with the paint-by-numbers kits that my sisters used. I could never keep

the paint in their own little sections.

Although John noted that he naturally excelled in sports, he realized only in

hindsight that they did not require the fine motor movements that were so difficult for

him.

I did notice that my hands would shake in gross terms after intense physical

activities. Otherwise, the right hand would shake primarily at the fingertips. Only

when I was at family events or sports banquets was I reminded that the shakiness

in my hands was still present. I would catch the concerned looks of those around

me and would only say that I was a little nervous-- even though nothing could be

further from the truth.

As John grew older, so did his concern for the shakiness in his hands. He was

drafted into Viet Nam and “when I took my pilot physical the Air Force physician

commented on my shaking hands but did not note it in my file. It was not mentioned

again.” When John entered into a sales career which required an increasing amount of

time spent in front of clients, his concerns were finally answered by a diagnosis of

essential tremor. “I remember the doctor even told me that millions have it, but so few

want to admit it.” To John, that fact made it seem much more crucial. “Just the sound of

it sounded major, but at least …someone knew what it was.”

John is taking propranolol, with good results “To this day, when public speaking

or presentations arise, I take my little blue pill and I am set.” John recently attended his

first ET support group and was not surprised to find that most in attendance were over 75

years old. “I know there are many [men] like me in age and action, but until we let them

know it is ok to have [ET] and discuss it, I am afraid it will remain the closeted shakes!”

Although the physical and social challenges of essential tremor may be quite

severe and may necessitate adaptations, retraining or even early retirement, at least one

woman credits her career in stress management to her tremor disorder. Citing the

“Wounded Healer [who] finds wholeness as healing flows through him or her to others”

(p. 7), Ann Bennett Sturgis, PhD, (2001) notes that she studied a multitude of healing

therapies in an attempt to help herself deal with the challenges of tremor. As a result, she

now uses those techniques to help others. Although her symptoms began early in

childhood and initially “seemed an impediment in her life,” she explains that she is now

able to view them as a “gift” (Sturgis, 2001, p. 7).

I

am well convinced that this ‘tremor’ that I have had so many years has led me to

a deeper spirituality, reverence for life in my cells, and an awareness of the

blessing of connection to people and creatures of the earth. This is a long, long

way I have come from being at war with the tremor, thereby increasing it and

feeling angry and unhappy with it. It is such a fine signal telling me when I need

to manage my thoughts, words, images, and choices with the creative intelligence

with which we are all so bountifully supplied. (Sturgis, 2001, p. 9)

Clearly, acceptance is key to living well with tremor. This point is reiterated by

artist Jim Fuess, who-- despite essential tremor-- maintains both his career and his sense

of humor. Jim’s particular brand of artwork is created with squeeze bottles rather than a

brush and he boasts of once completing a painting in three minutes; the catch was that it

took him 24 years to learn how to do it! In an interview for the New York Times, Fuess

had this to say about living with tremor:

It’s obvious when I’m in public. People ask, I tell them; I don’t volunteer. It just

doesn’t come up. I’ve had the tremor since I was born. [It primarily affects]

mostly my hands. It can affect your voice, arms, legs, head, individually or

collectively. There are medications, and I’m afraid of what they would do to me

personally and artistically. They all have side effects [and] not everything works.

Lethargy is one of those things that scares the hell out of me. (Fuess, as cited in

Kuehl, 2000, Question 5)

When asked about his specific day-to-day activities, Fuess responded with humor:

I don’t go to soup-eating contests in biker bars. If I order peas, I order mashed

potatoes [to stabilize the peas on the fork]. Other than that, you know, I don’t let it

affect me. I don’t mix nitroglycerine in the backyard” (Fuess, as cited in Kuehl,

2000, Question 7).

The Future of Essential Tremor

Although the ability of both Sturgis and Fuess to rise above the challenges of

essential tremor may be more the exception than the rule, researchers and patients alike

are indeed looking to the future with optimism. Dr. Elan Louis, whose research is

invaluable to both doctors and patients, recently received a bequest to fund further brain

research. Although he notes that essential tremor “is among the least studied and most

poorly understood neurological disorders,” he hopes to change this fact by implementing

a new study which will research the “pathological…[and] the neuro-chemical basis for

ET” (2002b, p. 5). Louis (2002b) is also in the process of developing an ET brain bank,

where post-mortem brains can be compared to patients without ET. These studies will

“emphasize the cerebellum and brainstem because they may be starting points for ET” (p.

5). Should these studies confirm that there are neurodegenerative changes involved in this

disorder, Dr. Louis then hopes to address the possibility of prevention strategies (2002b).

The development of new scanning technology may also be on the ET horizon.

Specifically, a new imaging technique called DaTSCAN has recently been approved for

use in Europe. This technique “allows identification of structures inside the body” and

may aid the diagnostic process by more easily differentiating between essential tremor

and Parkinson’s disease (IETF, Fall 2000, p. 1).

There may be one other area of hope for the future of ET: stem cell research.

Political and religious concerns aside, these cells typically can be used to mimic any cell

that is needed in the body. Although research on stem cells have not specifically

addressed essential tremor and it would likely be many years in the future, if at all, Dr.

Louis noted the following:

I think stem cells would make sense, although this is now closer to science fiction

than science. If, indeed, cells have died in the [ET] brain, then replacing those

cells would probably be of value. However, these cells would need to form the

appropriate connections in the brain. (personal communication, November 8,

2002)

Conclusion

Despite the fact that essential tremor has affected the lives of Samuel Adams and

Katherine Hepburn as well as millions of people in between, it remains a mystery to the

general public. With the compilation of this extensive research, it is hoped that this will

no longer be the case. Although the exact cause of essential tremor has not been

determined, researchers are fairly confident that the areas of the brainstem, thalamus and

the cerebellum are mostly likely suspect. And for the first time, recent research suggests

that a neurodegenerative process may also be involved. Genetic studies, although limited,

have discovered at least two chromosomal linkages for ET and further research into the

possible environmental causes are on-going.

However, despite the value of Botox injections and surgery for a small population

of tremor patients, pharmaceutical interventions for the largest population of essential

tremor patients remain only minimally effective. As such, the physical and cognitive

disabilities inherent in this tremor disorder test the knowledge of researchers as well as

the resilience of patients. The impact on quality-of-life issues, however, may be the

biggest challenge of all-- not necessarily in having the disorder, but in living with the

social implications of it (Glynn, personal communication, November 25, 2002).

Although the purpose of this thesis paper is solely to educate the general

population about the disorder known as essential tremor, it is hoped that the ramifications

of this education are much more far-reaching. With continued interest in research, the

exact cause of this disorder may eventually be realized. At that point, more effective

treatment modalities likely will be developed. And then, perhaps prevention strategies

will not be far behind. And for those who have witnessed their own trembling head or

hands and have not yet sought medical attention, may the research examined here provide

the impetus to invest in one’s own healthcare. And, at the very least, if this newfound

knowledge opens an empathic dialogue between neighbors and strangers alike, then the

challenges of living with this disorder may become easier to bear. Will people with

essential tremor choose to mix nitroglycerin in their backyard? Absolutely not. However,

when tremors are met with sensitivity and acceptance, with healthy curiosity but not

judgment, then quite possibly that soup-eating contest may someday become a reality.

Appendix A

Spiral Drawing and Handwriting Sample

Appendix A Spiral Drawing and Handwriting Sample Figure 1 . Spiral drawings are often used in

Figure 1. Spiral drawings are often used in neurological assessments for essential tremor.

(see p. 12). This one was drawn by a 78 year old woman with ET. (Jean, personal

communication, November 16, 2001).

with ET. (Jean, personal communication, November 16, 2001). Figure 2 . The first handwriting sample, tremulous
with ET. (Jean, personal communication, November 16, 2001). Figure 2 . The first handwriting sample, tremulous

Figure 2. The first handwriting sample, tremulous but normal in size, was written by the

essential tremor patient above. The second sample is an example of micrographia, the

small handwriting typical of Parkinson’s disease. (see p. 12). (BBSF, 1998, p. 15).

Table 1

Appendix B

Distinguishing Characteristics of Essential Tremor and Parkinson’s Disease

Characteristic

Essential Tremor

Parkinson’s Disease

Tremor location

Hands, head, neck, jaw, tongue,

Hands, chin, jaw, tongue, legs

voice

Tremor type

Postural, kinetic, rarely resting

Resting > postural, kinetic

Tremor frequency

4-8 Hz

3-5 H

(speed)

Bradykinesia

Absent

Present

(Slowed movements)

Rigidity

Absent

Present

Family history

Positive 60%

Usually negative

Response to alcohol

Marked transient reduction in

Little or no effect in resting

about 70% of cases

tremor, < postural

(Baylor College of Medicine, 2001, p. 5; Victor & Ropper, 2001, p. 100)

Appendix C

Appendix C ( DeArmond , S., Fusco, M., & Dewey, M., 1989, p. 9) Figure 3.

(DeArmond, S., Fusco, M., & Dewey, M., 1989, p. 9)

Figure 3. Suspected areas of brain involvement in Essential tremor. (see p. 14)

Researchers note that the loop (in yellow) involving the structures of the

brainstem, the cerebellum and the thalamus are abnormal. Their functions are as follows:

Brainstem: The portion of the brain closest to the spinal cord. It contains the

medulla, pons, and the midbrain and controls many of the involuntary functions that keep

us alive.

Cerebellum: Major region of the brain concerned with coordinating movements.

Thalamus: A collection of nerve cells in the brain. Although it performs many

functions, the primary role of the thalamus is to relay sensory information from other

parts of the brain to the cerebral cortex. (HOPES, 2002)

Addendum

The inclusion of additional personal stories is not necessarily intended to reflect

the research compiled in this thesis, but to give additional voice to the great variability of

symptoms and the challenges posed by essential tremor. It has been noted throughout this

paper that the diagnostic process is a difficult one. Although there is some disagreement

in the likelihood of a patient having two distinct neurological disorders (such as dystonia

and ET), the following stories suggest that many patients have been diagnosed as such. I

have every confidence that ongoing research by a dedicated few will resolve such

discrepancies. In the meantime, however, these stories reflect a deeper truth; one born out

of personal experience.

To those amazing women and men who have contributed their stories, I thank you

from the bottom of my heart.

Jeremy

I am a 76 year old member of an ET support group. I first noticed my hands

shaking at about age 40. I had a pretty good idea that it was hereditary because my

mother and her brother had the problem. It was thought to be due to some sort of brain

deficiency. So, I lived with it as it got worse. Around 1992 I began drug treatments. After

trying them all, I gave up and had the DBS operation in September of 1998 on my left

side - so that my right hand was helped. I have been incredibly better since then with the

exception of the last year. When my left hand began to get worse, I asked the experts

about performing surgery on that side also. They were reluctant to do so because some

who underwent bilateral surgeries have experienced unforeseen difficulties with speech

and balance. I don’t need any more difficulties than I now have, so that’s it for me. Now,

I am still incredibly better, but less so as the tremor’s strength increases. I guess I am a

work in progress.

Leon

I am too shaky to write much. Started age 10, now 69 (worse last 10 years).

Despite tremors and severe hearing loss, managed two PhD’s and psychologist license.

Still in practice. Went through most of my life working around impairments. Still manage,

though harder.

I wrote back to Leon and wished him well. I told him that he was an inspiration.

This was his reply:

I never aspire to be an inspiration. I am just a lousy patient and have recovered

or adjusted to numerous bodily assaults because bed is boring. I also enjoy exercise,

which helps. I learned to love learning, and with handicaps, it’s the only place I could

excel.

Mimi

I am a married 47 year old female with two children, ages 20 and 12. I have a

positive family history of tremor for two aunts; one deceased and one with Parkinson’s

disease. Two years ago I noticed that when I was using an eating utensil my hand was

shaking slightly as I raised it to my mouth. I thought I had just overdone some weight

workouts. A couple of months later I was raising my cup to my mouth and, much to my

surprise, my cup started to violently shake. Off to the doctors I went and was told I had

essential tremor.

My tremors progressed from just my right hand and arm to my neck. This affected

my vocal chords and, of course, caused my head to shake. My abdominals became

involved and then the legs, although they didn’t affect my walking. The tremors were

always of a very low-key variety. The neck tremor was the most annoying and tiring. And,

I tried to talk my way through the tremors in my throat, or, more accurately, force my

way through them.

My doctor wrote me a prescription for a beta-blocker. I did not want to go to the

drug route and I started to explore alternative therapies.

I have seen an Ayurvedic practitioner twice and they have been heaven-sent!

Their diagnosis is that one of my doshas [metabolic principles] is out of balance – in this

case VATA [governed by ‘wind’ and responsible for movement]. Vata is light, dry, cold,

fast, and airy – therefore, to counteract the tremors I must do the opposite. I eat heartier

meals with soup and bread, creamy foods, warm foods. I move a lot slower, calmer and

keep myself in a more relaxed state. I cover my head with a hat in the wind and cold to

keep myself from getting ‘scattered’ and to keep my heat in. I dress much warmer than I

used to. I sleep at least 8 hours a night. I minimize stressful situations in my life by being

more assertive as to what upsets me rather than letting people push me past my comfort

zone. I have had a couple of Ayurvedic whole body messages with sesame oil. The result

is that I am almost tremor-free for quite awhile afterwards!

I have a great deal of respect for this approach since the tremors make themselves

more noticeable when I am cold, tired, stressed and underfed. For a year now, I have

also been practicing gentle Hatha yoga.

Today my tremors are so gentle that you would not be able to notice them. I

recently just returned from a two week yoga retreat where I also saw an Ayurvedic

practitioner. In fact, I am hardly aware of even the tremor in my right hand, which is

where it originated and has been the most pronounced.

I have modified my lifestyle quite a bit. I soothe and pamper myself by healthy

lifestyle choices. In fact, my husband pointed out that through modifying my lifestyle I

have duplicated what the beta blockers attempt to do: slow one down by decreasing one’s

heart rate.

I choose not to closely identify with my condition. I do not want to internalize that

I have a ‘disease’ only a set of conditions that I am attempting to ameliorate through

positive thinking and affirmations and a very healthy lifestyle. I have told very few people

about my condition and initially only because it was somewhat obvious. I also did not

want to use it as a crutch or an excuse for making decisions in my life. It has made me

aware that I cannot take my good health for granted and to enjoy the miracle of everyday

life.

Catherine

The tremors began in 1996 when I was 48 years old. I noticed them in my left

hand while taking a class in Swedish massage. Although I did not feel nervous about

taking the class, I dismissed the tremors thinking that perhaps I was feeling more nervous

than I thought. Then in July 1998, I had an industrial injury that affected my back. This

overly zealous move created a herniated disk in my lumbar and sacral spine area. This

development resulted in a physical impairment that created increased physical pain,

stress and depression. Ultimately, the tremors took over and were bilateral. Within a

three-month period after my back injury, my mother passed away. Soon after, a diagnosis

of another neurological problem arose; glaucoma was added to the stressors of my

everyday living.

In May of 1999 I saw two prominent movement disorder specialists. After a

barrage of tests that included blood tests, urine, MRI of my brain, neurological tests

which showed balance impairment, and a videotaping of my tremors in action, I was

diagnosed with essential tremor.

I had no idea what essential tremor was, nor did I have any idea as to how bad it

could become. With my new diagnosis and a prescription for an anti-convulsant to

control my tremors, I went home. (The medication, primidone, was discontinued due to

unacceptable side effects.) Still, I was mystified by my diagnosis and began my own

search on the Internet. After an extensive search I found the home page of the

International Tremor Foundation. I learned so much from what IETF had put on their

WebPages and decided that I had much to be thankful for since my disorder was not

Parkinson’s disease.

Eventually, after learning increasingly more about essential tremor, I felt my ET

had some discrepancies when I compared my tremors to those of our support group

members. Yes, I had some tremor when using my hands to pour liquid into a cup or when

carrying a cup and saucer to the table. However, I found that I also had a resting tremor

in my left hand and my left leg developed a tremor. I also noticed a presumed weakness

in my left side and that my gait had become shorter. The difficulty I experienced raising

myself out of a chair had become quite noticeable and I had also fallen a couple of times.

I felt very unstable. Then my husband noticed I was not swinging my left arm when I

walked. It was clear that there was more to my diagnosis than essential tremor. Over

time I realized my tremor was also predominately one-sided. I began to think that the

tremors I initially experienced where probably physiological tremors brought on by

anxiety and the stress of my industrial injury, my mother’s passing and diagnosis of

glaucoma. I went to a neurosurgeon to find out.

The doctor confirmed my dual diagnosis. I not only have ET, but I also have

Parkinson’s disease. The definitive diagnosis came after he prescribed Sinemet for my

tremors. Within three days I called the doctor and exclaimed that I had no idea the

medication would work so quickly to alleviate my tremors and the painful stiffness in my

shoulder and neck muscles. (In fact, I felt the results of the medication within the first

day.) His comment after my revelation? “Congratulations, you have Parkinson’s

disease!”

I guess that was the ultimate test. If one responds to the medication it is usually a

given that your diagnosis is PD.

It has been a long time since my Swedish massage class. A lot has happened

since then. I feel so very grateful and blessed for all I have learned since that fateful day

in 1996.

Jennifer

I am a 51 year old female who has had ET from birth. My mother had it very

badly. I feel that doctors cannot comprehend the different symptoms of ET in each

individual. All the symptoms are similar, yet are quite varied. The doctors seem to sink

into the strict rule of the medical books, but with ET everything is different everyday.

When it comes to the brain and how it all works, no one, and I do mean no one, can

understand the intricate electrical or emotional circuits of the grey matter that collects

all of our memories and emotions and helps us to forget or remember.

As a child I was always shy. I did not know my mother until I was 21 years old.

My father was an alcoholic. Life was difficult. At school when the teacher would ask for

me to come before the class and write on the board, I would become petrified. My hands

would shake and the thought of my classmates seeing this and then making fun of me was

not pleasant. I was chosen for an outstanding book report in the second grade and was

asked to go before a group of teachers to share it. I sat in sheer terror of going in front

of anyone as I did not want to be the center of attention. Standing in front of the teachers

often brought on a nosebleed. I wanted to die. As they tried to clean me up I just bled

more and shook more. I flunked second grade due to my handwriting and, I'm sure, due

to my worry that performing well would set me apart and require me to be the focus of

attention. This only brought on shame.

My father took me to the doctors to find out why I shook so much. All I remember

is that the doctor said that I would never be fat in my life. At the age of eight this was of

no importance to me. However, he was correct, as I have been thin all my life. I also

never smoked cigarettes in high school like my friends. I just wouldn't look cool with a

shaky cigarette in hand. I did find that marijuana or other mild downers helped calm me

down. It felt so good to not have my insides shake to death. To be normal like everyone

else! To be able to think straight! Sometimes I just couldn't think. I couldn't talk.

I had surgery on my spine 1 1/2 years ago. A disk was removed and I have never

been the same since. While in the hospital in recovery I began to go into shaking

seizures. The doctors did not know why and the small amounts of tranquilizers they gave

me did not help. They were more concerned that I would become addicted to the drugs

than stopping my tremors. This misplaced concern did not make sense to me.

I have found out that being under anesthesia also irritates ET. My voice is very

affected now. I have about 60% of my voice most of the time. I stay home because I

never know when my shaking seizures will start and my voice will disintegrate. I had to

go in front of the social security officer and judge to be declared unable to work. This

was very frustrating as most people do not know of ET or how disabling it is.

I feel that stress does bring on more symptoms and the doctors need to be more

open to the emotional side of the life of someone with ET. We may not need a wheelchair

to show our disability, but everyday is a great challenge.

Annie

My ET began with a head tremor when I was 45. My family doctor had no idea

what was causing it and he sent me to a neurologist. I related that my elderly father’s

head shook, as did his mother’s, but I thought their shaking was just old age. The doctor

determined in a very few minutes that what I had was “familial palsy.” This was in

1973, years before I heard the term essential tremor. However, from the description of it,

I was certain he was right. The doctor told me that I must learn to live with it, as there

was no medicine for it except tranquilizers. I was told that these were addictive and

eventually would not work.

I took the doctor at his word and tried to live with it until 1996 when I read about

a support group and joined it. Every member except me was on medication. I went to

another neurologist who diagnosed it as torticollis. I didn’t think I had torticollis because

my grandmother did, and in her pictures her head was always bent to one side. A third

doctor agreed with the first and said I had ET. I was prescribed propranolol and have

continued that dosage to the present time.

In 1980 I began having trouble with my voice. I went to a speech therapist and

when I was comfortable in his presence my speech did get better, but only with him. He

released me from his care because he could not do anything for me. Still, answering the

phone in a one-person office was terrifying for me.

I have found that when I get to know

a person well and feel comfortable with them that I am able to speak almost naturally.

The voice tremor has been more embarrassing to me than the head tremors or the hand

tremors which developed nearly 10 years ago. I do have trouble signing my name at the

bank or when someone is watching me write.

I have worked part-time until I was 70. I am now 75. However, I have cried over

jobs I didn’t get and I always felt that it was because I told the truth about my ET. Some

people think my voice is due to a stroke. If I had one, I never knew it. Several of the

doctors I have seen over the years told me that my vocal cords are partially paralyzed.

I have discovered that I will not speak up in a group because of my voice tremor. I

belonged to a book club in my former hometown and I faithfully read the books, but I

very seldom spoke up at the meetings because my voice would shake. I gave a few

reviews over the years, but always had to use my notes. Even then, my voice quivered. I

finally gave up. I will not take Botox injections because they don’t seem to help everyone.

I had to give up my hobby of making ornaments for a few years, but I was able to

make some again last year. It gave me so much pleasure. I have not seen a neurologist in

about five years, but because both my head and hands are shaking again, I will do so. I

am sure I can get the name of a good doctor from my new support group or from our

dedicated leader.

Dennis

I am 71 years young and belong to a support group. I was the youngest of eleven

children raised on a farm. My mother said that I had always been jumpy. Since she had a

difficult childbirth with me, she blamed herself and went to her grave believing she was

the cause of my shaking. ET manifested itself in me with full blown tremors at age

thirteen. Over the years I have seen numerous doctors but was not diagnosed until I was

54 years old. When I received the diagnosis, I went home and cried. I finally could put a

name to the cause of my tremors. Just to identify them was a relief.

ET caused a great deal of mental anguish over the years. I was made fun of and

ridiculed by children during my school years. I could not understand why I had these

shaking arms and hands. No other part of my body has been affected. I determined very

early in life that this was not going to totally control me. I also suffered the wrath of

some school teachers about my hand writing. I did participate in sports and was quite

successful at it, but in the back of my mind I always wondered what I could

have accomplished had I not had tremors. The same applied later in life as far as my

occupation was concerned. I did remain employed until I was sixty-five and decided to

retire because the tremors were becoming progressively worse. Had it not been for ET, I

probably would have continued to work for some time.

I had one brother who had shaky arms and hands. My father had minor tremors. I

have one sister who has tremors in her voice and head.

I

did serve in the U.S. Air Force during the Korean War. I lied to get in. I told

them the tremors were present because I was nervous about my physical. I served four

years in spite of the tremors, but again, there was much ridicule from some of the

personnel about my "nervousness." In fact, I have been asked about my “nervousness”

throughout my entire life. The public and much of the medical profession do not fully

understand ET. When I tell some of my physicians I have ET, they say, "Oh yeah, I know

what that is." They may know what it is, but I don’t think they understand how it affects

us.

I choose to live my life in spite of what people think. I still refuse to hibernate

because of ET. I participate where I wish. If people think it is funny, then they have a

bigger problem than I. One of the positives I have gained from ET is that it has made me

a more sensitive and compassionate individual. I do find that most people understand

when I take the time to explain ET. Many are quite helpful, especially servers in

restaurants, cashiers, etc.

I am currently taking both propranolol and primidone. This helps control my ET,

but not completely. I would not be able to function without the medication because I

would need assistance in dressing and eating and many other daily tasks.

Laura

I was 45 years old when my oldest child went off to an out-of-state college town

where my daughter also lived. For eight years my husband and I made that long drive,

but at one point I began to have difficulty keeping my eyelids from shutting as I looked

out the window into the outdoor brightness. On our last trips, I was wearing two or three

pairs of sunglasses simultaneously, and my eyes still would not behave. This is my first

memory of blepharospasm [involuntary muscle contractions and spasms of the eyelid].

In my 50’s, I began doing a lot of hiking. When I returned to my car, I would try

to write down the name of a bird we saw or a restaurant someone told me about. I found

that I couldn’t write. I could not take control of my hand movements. The only marks I

could make on the paper were jagged lines. At an annual physical exam, I asked my

doctor about my hand-shaking and asked if it was just a part of the aging process. She

looked at my hands and smiled. “Yes,” she answered.

When my mother died, the blepharospasm became so severe that I was driving

around with one hand holding one eye open, while the other eye remained tightly shut. I

learned that if I pushed into the area above and to the side of my eyeball, the squeezing in

of that eyelid would be less severe. But I was a very handicapped driver and I began to

opt out of activities which required me to drive. As anyone in the U.S. knows, this is

severely limiting! I also could not sit in a restaurant facing a window if I wanted to look

at my companion’s face. Facing bright light, tiredness and physical or emotional stress

were common triggers for my blepharospasm.

Over the course of two years, I had exams by three different reputable

ophthalmologists. The first one tried treating me for allergies; the second one for ‘dry

eye.’ When I asked the third doctor to be a detective (because ordinary exams were

yielding nothing), he treated me for blepharitis [inflammation of the lash follicles or

glands of the eyelids]. I finally returned to the first and most trusted doctor who watched

the muscle action around my eyes and confirmed the diagnosis of blepharospasm.

Ironically, I had come to the same conclusion by doing my own research in the library!

The doctor observed, helpfully, that this disorder was affecting the muscles around my

eyes -- and not my eyes themselves, and he referred me to a well-known university

medical center. Instead, I once again referred to my home medical book for laypersons.

In a reference under Essential Tremor, it stated that the eyelids could also be affected.

I made an appointment with a neurologist who actually walked me outdoors in

order to see the tremors that began when I faced the sunlight. Although she

acknowledged the tremors, she told me that there was nothing she could do for me. In

other words, in her opinion, I did not have a neurological disorder. (I was making this

up???)

I continued my own research and made an appointment with a specialist in

movement disorders. She took my history and watched the blepharospasm when I opened

the blinds on the window. Her diagnosis was focal dystonia for my eyes, and either focal

dystonia or ET for my hand tremor.

The specialist recommended treatment with Botox, but I decided against it. I tried

Cogentin for the blepharospasm, which is working fairly well. I also take propranolol for

the hand tremor, which dramatically stops it. Because propranolol apparently does not

affect focal dystonia, the specialist felt that the hand tremor is most likely ET. Although

my hand tremors affect my handwriting, I have never had difficulty holding a glass of

liquid. And unlike many with ET, alcohol does not affect my tremor in any way. I do have

a warning about Cogentin. Early on, I was taking this medication twice a day. On two

occasions I forgot to take it with dinner and took it before bedtime instead. On those

occasions, I had terrifying hallucinations in the middle of the night. There was never a

third time!

Presently, at age 62, I have limited my driving to our local area only. On our

vacation last summer, I attempted to drive again and it was a mistake. There was no

accident, thank goodness. Afterward, I asked my husband how he felt while I was driving.

He hesitated for a minute and, ever the diplomat, replied, “Very alert!” So, we no longer

depend on my driving assistance, except to get myself to the grocery store, to my local

friends and to the BART station. I also do not drive between 2-4 pm, when my body gets

that afternoon tiredness.

I have had to increase my medications from the time I first began taking them and

I suspect the years ahead will see changes in this condition and in the treatment of it. But

for right now, I have a life I can live with happiness.

This contribution was originally written to the parents of a two year old boy who

had been diagnosed with ET. I received permission to include it here and do so with an

enthusiastic nod to his ‘rules for living with ET.’

Keith

I have had ET since very early childhood. I am now in my early 60’s. My mother

had it, as did her father. My brother has it also. Now one of my daughters, age 34, is

beginning to experience a tremor in her right hand. As we come from a rather proud

Irish Catholic family, I have always figured ET was given to me so that I would manage

to keep my ego under control and understand that it is important to be somewhat humble.

Well, that probably did not work but I am trying!

My tremor exhibits with a left-to-right jerk of my head and, about five years ago, I

began to notice a tremor in my right hand and arm when I worked out in the yard or

otherwise did strenuous activity. That hand tremor is now progressive but I can still drink

a hot cup of coffee without spilling. My head tremor is becoming more amplified and time

will only increase my “shaking.” However, I feel I have been prepared for whatever

physical motion I assume because my mother had the good sense and compassion to

accept my condition as part of this wonderful life we are all given.

Mom never talked about my tremors but if someone else would bring up the

subject, she would just smile and say, “That is Keith’s way of getting a little more

attention.” My family simply accepted me and my tremor as that which identified who I

was. If they could have seen me without any tremor they would probably have wondered,

“What’s wrong with him?!”

My tremors have always bordered on the slight-to-moderate side and I can

imagine that an increase in severity would result in a more self-conscious attitude. But in

the end, here are my rules:

1) My tremors are part of me and I will always try to be the best person I can be

no matter what! (And believe me, I have made a lot of mistakes trying to get to this

acceptance level.)

2) When my children begin to “shake” (and, as one has, more undoubtedly will), I

will share my feelings honestly but not overtly. In other words, when all is said and done,

it should be treated as “no big deal.” Because that is what it is - or what it really should

be!

3) Keep in touch with others who have this condition. Having common ground is

always more comfortable and new medical advances are interesting to share and discuss

with such a group.

4) Love is what this life is really about. If you love your child with ET, they will

pass on that love to others. And ET, in the middle of such love, will be only a slight

inconvenience.

Annotated Bibliography

Brennan, K., Jurewicz, E., Ford, B., Pullman, S., Louis, E. (2002). Is essential tremor

predominately a kinetic or a postural tremor? A clinical and electrophysiological

study. Movement Disorders, 17(2), 313-6. Retrieved July 23, 2002, from Medline.

The authors note that although essential tremor manifests itself with both kinetic

and postural tremors, it is generally considered to be more postural [noted when a

limb is held against gravity] in nature, rather than kinetic [noted during

movement]. However, in their study of 50 ET cases compared with 55 community

cases, it was noted that the kinetic tremor was rated twice as severe as the postural

tremor. As a result of their findings, the authors suggest that kinetic tremor be

more consistently included in the diagnostic criteria for ET.

Burke, D. & Hauser, R. (2001). Essential Tremor. eMedicine Journal, 2(11), pp. 1-20.

Retrieved July 9, 2002, from http://www.emedicine.com/neuro/topic129.htm

In this 20-page article the authors detail the most current research into essential

tremor, providing background history, frequency of occurrence, specifics of age,

sex and quality of life issues and genetic preponderances. Differential diagnoses

are presented to note the association between ET and other disorders such as

Parkinson’s and dystonia. The specific mechanisms of several commonly used

pharmaceuticals are presented, as well as information on the specific role of

alcohol in the treatment of ET. The authors end with a discussion of the various

surgeries used in the treatment of ET as well as suggestions for ongoing

outpatient follow-up. A detailed bibliography is included.

Deuschl, G., Bergman, H. (2002). Pathophysiology of nonparkinsonian tremors.

Movement Disorders, 17(Suppl. 3), S41-S48.

This article discusses the pathophysiology of tremor disorders other than

Parkinson Disease and notes that although these disorders make up the second

largest group to be treated with neurosurgery, much is yet unknown. The authors

note the four basic principles from which tremors, or oscillations originate and

state that although they often interact with one another to produce a specific

disorder, one principle is generally dominate. Included in this very technical

discussion are essential tremor, dystonic tremor, cerebellar tremor, Holmes tremor

and neuropathic Tremor.

Evidente, V. (2000). Understanding essential tremor: differential diagnosis and options

for treatment. Postgraduate Medicine 108 (5), 138-49.

The author provides a general understanding of essential tremor for non-medical

personnel. He discusses different types of tremor and the similarities between

essential tremor and other disorders involving tremor, including Parkinson’s

disease. He notes the exacerbation of tremor with stress or fear, and the role of

alcohol in tremor alleviation. In his discussion of the disability caused by ET, he

notes that those in occupations requiring fine motor skills are often forced to quit

their profession. The author provides a table for the various medications used to

treat this disorder and ends with a discussion of the two most common surgeries,

thalamotomy and deep brain stimulation. It is his contention that although both

surgeries are equally effective, the deep brain stimulation has fewer side effects.

Kuehl, C. (2000, October 22). Despite a disorder, a creator with many hats. New York

Times p.14.

The author interviewed artist and part-time curator Jim Fuess who has had

Essential tremor from childhood. Weaved between facts relating to essential

tremor is a story of a man with mild tremor who has not let it become a disability.

The article showcases not only Mr. Fuess’ handling of the disorder with humor,

but his artistic talent and his big heart. He hopes to have his artwork reproduced

onto greeting cards, donating the proceeds to the International Tremor Disorder in

Kansas. Although the artist admits to tremor of his hands, he is still able to create

paintings by using liquid paint in squeeze bottles, rather than a brush.

Lacritz, L., Dewey, R. Jr., Giller, C., Cullum, C.(2002). Cognitive functioning in

individuals with “benign” essential tremor. Journal of the International

Neuropsychological Society, 8, pp. 125-129.

After summarizing the prevailing research on essential tremor, the authors note

the unfortunate and misleading use of the term ‘benign tremor.’ They embarked

on a study of the neurocognitive functioning of patients with severe ET, and used

patients with Parkinson’s disease as controls. The results showed that the ET

group performed below the mean in cognition flexibility, figural fluency and

selective attention. Non-verbal memory, letter fluency and certain aspects of

problem solving were also diminished in this group. The authors concluded that

there is a definite correlation between severe ET and mild cognitive deficits. The

study also suggested that various areas of the brain, those correlated with specific

mental functioning, be included as suspect in the pathology of ET.

Lieberman, A. (n.d.). The National Parkinson Foundation, Inc. How is Parkinson disease

different from essential tremor? Miami, FL: NPF. Retrieved July 28, 2002, from

http://www.parkinson.org/pdvset.htm

This layperson’s article clearly notes the major differences between Parkinson’s

disease and essential tremor. Discussion includes information on the general

characteristics of both tremor disorders, as well accepted diagnostic criteria

including the minimizing effects of alcohol to tremor and the genetic correlation.

A very brief discussion of front line drugs is included as well as links to other,

more comprehensive sites.

Louis, E. (2001a). Essential tremor. NewEngland Journal of Medicine,345(12), 887-

891.

This article details the clinical workup of a 66-year-old woman with essential

tremor who presented with severe restrictions to her activities of daily living as

well as in her employment as a writer. The author describes the process for

tremor classification, diagnostic and assessment tools including a family history

of the disorder, age of onset and rate of progression. Various treatment modalities

are discussed, including pharmaceutical intervention and brain surgery. The

author makes the point that although a reduction in the size of the tremor is

important, the best judge of whether treatment is effective is to the extent that it

enables a resumption of the activities of daily living.

Louis, E. (2001b). Etiology of essential tremor: should we be searching for

environmental causes? Movement Disorders, 16(5), 822-829.

The author notes that although ET can be traced back thousands of years, much is

yet unknown about the pathology of the disorder. Although it is generally agreed

that this disorder has a genetic component, the author states that ET is not

completely genetic. This study discusses the similarity between tremors caused by

certain environmental or occupational contaminants and questions the possible

role of these substances in ET: Pesticides in a work environment or its

contamination of food sources; lead, mercury, naturally occurring chemicals

found in both meat and vegetable-based foods; and manganese. It is the author’s

contention that environmental or occupational factors likely contribute to the

cause of essential tremor and, as such, more research is needed.

Louis, E. (2001c). Samuel Adams’ Tremor. Neurology, 56(9), pp. 1201-5.

The author studied historical accounts and handwritten documents to determine

that Samuel Adams, American Revolutionist, brewer and signer of the

Declaration of Independence may have had one of the earliest known cases of

essential tremor. The author cites numerous references that Adams was bothered

by a hand tremor as early as his 40’s, which progressed to the point that he had

others write his correspondences for him. The early age of onset, its manifestation

upon initiating movement, as well as the fact that Adams’ daughter and her

children reportedly also had tremor, ruled out Parkinson’s and subsequently

brought the author to the conclusion that Adams’ tremor was likely due to

essential tremor.

Louis, E. (2002a). 1H magnetic resonance spectroscopic imaging to identify metabolic

abnormalities as potential biological markers in essential tremor. Retrieved

August 12, 2002, from http://www.dana.org/grants/health/imaging.cfm

The author notes that biological markers for essential tremor have not yet been

discovered and postulates as to whether ET is a neurodegenerative disease similar

to Parkinson’s and Alzheimer’s. He cites preliminary data from a recent study

suggesting that a neuronal marker called N-acetylaspartate has been found to be

decreased in the brains of essential tremor patients, suggesting neuronal damage

or death. The author hopes that an upcoming study of 26 ET cases will more

clearly identify such biological markers, enabling the design of long-term studies

to track whether the preliminary abnormalities progress with time, signifying

neurodegeneration.

Louis, E. (2002b). What’s shakin’ with shaking? Tremor talk, XV (2), 1, 4.

The author challenges both doctors and patients with essential tremor to become

advocates, raise awareness and support ongoing research for this disorder that

affects such a large part of the population. Noting that many of the frontline

medicines unsatisfactorily manage the disorder, the author calls for new research

to prevent the disorder as well as explore other therapeutic treatments. The author

also notes very recent research suggesting a possible neurodegenerative aspect to

ET, noting that essential tremor may be more like Parkinson’s than originally

believed. He concludes his article by explaining the need for more post-mortem

examinations and notes that a brain bank is being established to better understand

the neurochemical defects in this disorder.

Schneier, F., Barnes, L., Albert, S. and Louis, E. (2001). Characteristics of social phobia

among persons with essential tremor. Journal of Clinical Psychiatry, 62(5), 367-

372.

The authors note that although social phobias as a result of a medical disorder are

excluded from the DSM-IV social phobia criteria, they can be nonetheless

disabling. In this study, essential tremor subjects with clinically diagnosed

primary social phobias (social phobias diagnosed prior to onset of ET) were

compared with essential tremor patients with secondary social phobias (occurring

after diagnosis of ET). In the primary social phobia group, over 80% noted that

their social phobia was not related to ET. Conversely, 62% of those with

secondary social phobia attributed their phobia symptoms entirely to ET. Fears

and avoidance specific to the tasks of eating, drinking and writing in public were

also much greater in the secondary phobia group. The authors conclude that social

phobias do not necessarily accompany ET. However, they do occur in a

substantial minority of patients, more commonly among those patients with early

onset of symptoms and are associated with greater functional impairment,

regardless of the severity of tremor. The authors suggest that further studies be

made to note the viability of treating the social phobia as well as tremor.

South Shore Neurologic Associates. (n.d.) Essential tremor. NY: SSNA. Retrieved

August 20, 2002, from http://www.southshoreneurologic.com/move-dis/

tremor/tremor-2.html

This general article written for the layperson distinguishes essential tremor from

Parkinson’s disease, details the progression, various treatment modalities and

their potential side effects. Other treatment options are discussed including Botox

injections as well as nondrug therapy options such as the use of light weights

strapped to the wrists to dampen the tremor. The article concludes by assuring

patients that essential tremor is not attributable to a diminished mental state, nor is

it a natural part of the aging process.

Zesiewicz, T. and Hauser, R. (2001). Phenomenology and treatment of tremor disorders.

MD Consult. Retrieved July 17, 2001, from

http://www.home.mdconsult.com/das/arti

1.html

7301&sid=115829192/N/245496/

In this 28-page document, the authors discuss various types of tremor, their

causes, clinical manifestations and their treatments. After a general explanation of

tremor, the authors classify the tremors by various means: the body part affected,

speed and height of tremor, specific posture that elicits tremor and the

performance of specific tasks, such as “finger-to-nose.” They discuss the specific

tremors of essential tremor including those of head, hands, voice, legs and chin.

They follow with diagnostic, clinical and treatment (pharmaceutical and surgery)

specifics for each type. Tremors from other sources are detailed as well.

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