Essential Tremor

• What is essential tremor?

Essential tremor is a neurological condition that causes you to have involuntary and rhythmic shaking (tremor). It can affect almost any part of the body, even the voice box. The hands are most often affected, especially when performing simple tasks such as drinking water from a cup or when using a spoon.

• What are the symptoms of essential tremor?

The tremor starts gradually, usually in the hands first (either one or both hands).

You may find it difficult to perform tasks with your hands, such as writing or using tools. Some may experience uncontrollable head-nodding or shaking, or have a quivering voice. The tremor may worsen if you are stressed, fatigued, cold or have taken caffeine.

Symptoms may fluctuate depending on the task that you are doing, your state of mind, emotions and other factors.

• Does essential tremor result in balance problems?

Essential tremor is unlikely to cause balance issues even though it may affect the lower parts of your body in rare cases.

• What is the relationship between essential tremor and conditions such as Parkinson's disease? How are they similar or different?

Both conditions are a result of the brain aging (neurodegenerative disorder), but differ in many ways:

1. In essential tremor, your hands will start to shake when performing tasks, while tremors seen in patients with Parkinson's disease are most prominent when your hands are at rest. 
2. Essential tremor rarely causes other health problems, but people with Parkinson's disease often have a stooped posture, slow movement, shuffle when they walk, are prone to falling and have difficultly performing tasks which require thinking and planning.

• What is often confused with essential tremor?

Tremors can be caused by a variety of conditions or lifestyle factors including

1. Medications such as corticosteroids (such as prednisone), lithium, cyclosporine, valproate etc.
2. Alcohol
3. Caffeine
4. Parkinson’s disease
5. Multiple sclerosis
6. Low blood sugar
7. Drug withdrawal
8. Thyroid problems
9. Anxiety

• Can essential tremor be prevented?

Unfortunately, essential tremor cannot be prevented as our genes play an important role in the development of essential tremor.

• If diagnosed, what are triggers to avoid?

There are triggers to avoid to reduce the occurrence of tremors, such as products with caffeine e.g. coffee, tea, certain carbonated drinks and stressful situations as much as possible.

• What causes essential tremor?

The cause of essential tremor is unknown. However, some researchers believe that the condition is due to the lack of communication between the part of the brain that controls muscle coordination (cerebellum), and other parts of the brain.

About half of essential tremor cases are related to a genetic mutation. If one of your parents has a genetic mutation, the chances of you developing the disorder is 50% higher.

• What worsens essential tremor?

Certain medicines such as corticosteroids, lithium, cyclosporine, valproate etc., caffeine, alcohol or stress can worsen your tremors.

• Given that genetic mutation is a risk factor for essential tremors, should I go for genetic testing? Is it available?

Although the majority of essential tremor cases are hereditary, researchers have yet to identify any gene mutation that accounts for the development of the condition. Hence, genetic testing is not available currently.

• How is essential tremor diagnosed?

A comprehensive neurological examination is needed to confirm the diagnosis. Blood tests and brain imaging could also be ordered to rule out other conditions that may look similar to essential tremor.

• How is essential tremor treated? Can essential tremors be cured?

Currently, there are no cures for essential tremors. However, it can be controlled by medication and surgery (deep brain stimulation) (More below). Medications such as propanolol, primidone, gabapentin, topiramate and clonazepam are used to manage essential tremor. The choice of medicine depends on the patient’s medical history and preference.

Although some may experience relief of symptoms for about an hour after a glass of wine, it is not recommended to manage symptoms with alcohol. One may end up drinking too much alcohol, leading to other conditions such as obesity, stroke and fatty liver disease.

• What are types of exercises useful to manage essential tremor?

There are no specific exercises that can help manage essential tremor. It is important that you stay physically active to maintain physical well-being.

• What is the life expectancy of someone with essential tremor?

People diagnosed with essential tremors do not have a shorter life expectancy.

• Who will be a suitable candidate for surgery?

Candidates for deep brain stimulation (DBS) include those who:

• Have symptoms which are not well controlled despite appropriate medications
• Experience medication side effects which cannot be tolerated
• Quality of life is significantly impaired

• What to take note of before surgery?

You will be asked to undergo investigations to determine if you are fit for surgery.

• What happens during the surgery?

A small hole will be made in the skull for small leads to be inserted into the brain. A week later, a device will be implanted under the skin around the upper chest area, below your collarbone. Two to four weeks after the implant surgery, the device is turned on and adjusted to a setting that will best help manage the symptoms.

• What are activities to avoid after surgery?
• Avoid light activities such as house work two weeks after the surgery
• Activities such as jogging, swimming, or other physically-intensive activities should be avoided for four to six weeks after surgery.
• No heavy lighting (more than 2.5kg) for at least two weeks
• Avoid raising your arms above your shoulders or over bending/stretching your neck

• What are the follow-ups and therapies needed? Are lifestyle modifications needed?

Regular reviews with be arranged with the care team to monitor the condition 

• What side effects and complications are associated with this procedure?

Some may suffer from a bleed in the brain, brain infection, or the leads could be inserted in a different location than intended. The leads could move or the device could malfunction, with some experiencing pain in the area where the device was implanted, infection or the device breaking through the skin.

Over or under stimulation from the device could result in unintended movements, freezing, worsening of balance and gait, speech disturbance, involuntary muscle contractions, numbness and tingling, and double vision.