Tremor (cont.)
How is tremor diagnosed?
During a physical exam a doctor can determine whether the tremor occurs
primarily during action or at rest. The doctor will also check for tremor
symmetry, any sensory loss, weakness or muscle atrophy, or decreased reflexes. A
detailed family history may indicate if the tremor is inherited. Blood or urine
tests can detect thyroid malfunction, other metabolic causes, and abnormal
levels of certain chemicals that can cause tremor. These tests may also help to
identify contributing causes, such as drug interaction, chronic alcoholism, or
another condition or disease. Diagnostic imaging using
computerized tomography
or magnetic resonance imaging may help determine if the tremor is the result of
a structural defect or degeneration of the brain.
The doctor will perform a neurological exam to assess nerve function and
motor and sensory skills. The tests are designed to determine any functional
limitations, such as difficulty with handwriting or the ability to hold a
utensil or cup. The patient may be asked to place a finger on the tip of her or
his nose, draw a spiral, or perform other tasks or exercises.
The doctor may order an electromyogram to diagnose muscle or nerve problems.
This test measures involuntary muscle activity and muscle response to nerve
stimulation.
Are there any treatments?
There is no cure for most tremors. The appropriate treatment depends on
accurate diagnosis of the cause.
Some tremors respond to treatment of the underlying condition. For example,
in some cases of psychogenic tremor, treating the patient's underlying
psychological problem may cause the tremor to disappear.
Symptomatic drug therapy is available for several forms of tremor. Drug
treatment for parkinsonian tremor involves levodopa and/or dopamine-like drugs
such as pergolide mesylate,
bromocriptine mesylate, and
ropinirole. Other drugs
used to lessen parkinsonian tremor include amantadine hydrochloride and
anticholinergic drugs.
Essential tremor may be treated with propranolol or other beta blockers (such
as nadolol) and
primidone, an anticonvulsant drug.
Cerebellar tremor typically does not respond to medical treatment. Patients
with rubral tremor may receive some relief using
levodopa or anticholinergic
drugs.
Dystonic tremor may respond to clonazepam, anticholinergic drugs, and
intramuscular injections of botulinum toxin.
Botulinum toxin is also prescribed
to treat voice and head tremors and several movement disorders.
Clonazepam and
primidone may be prescribed for primary orthostatic tremor.
Enhanced physiologic tremor is usually reversible once the cause is
corrected. If symptomatic treatment is needed, beta blockers can be used.
Eliminating tremor "triggers" such as caffeine and other stimulants from the
diet is often recommended.
Physical therapy may help to reduce tremor and improve coordination and
muscle control for some patients. A physical therapist will evaluate the patient
for tremor positioning, muscle control, muscle strength, and functional skills.
Teaching the patient to brace the affected limb during the tremor or to hold an
affected arm close to the body is sometimes useful in gaining motion control.
Coordination and balancing exercises may help some patients. Some therapists
recommend the use of weights, splints, other adaptive equipment, and special
plates and utensils for eating.
Surgical intervention such as thalamotomy and deep brain stimulation may ease
certain tremors. These surgeries are usually performed only when the tremor is
severe and does not respond to drugs.
Thalamotomy, involving the creation of lesions in the brain region called the
thalamus, is quite effective in treating patients with essential, cerebellar, or
parkinsonian tremor. This in-hospital procedure is performed under local
anesthesia, with the patient awake. After the patient's head is secured in a
metal frame, the surgeon maps the patient's brain to locate the thalamus. A
small hole is drilled through the skull and a temperature-controlled electrode
is inserted into the thalamus. A low-frequency current is passed through the
electrode to activate the tremor and to confirm proper placement. Once the site
has been confirmed, the electrode is heated to create a temporary lesion.
Testing is done to examine speech, language, coordination, and tremor
activation, if any. If no problems occur, the probe is again heated to create a
3-mm permanent lesion. The probe, when cooled to body temperature, is withdrawn
and the skull hole is covered. The lesion causes the tremor to permanently
disappear without disrupting sensory or motor control.
Deep brain stimulation (DBS) uses implantable electrodes to send
high-frequency electrical signals to the thalamus. The electrodes are implanted
as described above. The patient uses a hand-held magnet to turn on and turn off
a pulse generator that is surgically implanted under the skin. The electrical
stimulation temporarily disables the tremor and can be "reversed," if necessary,
by turning off the implanted electrode. Batteries in the generator last about 5
years and can be replaced surgically. DBS is currently used to treat
parkinsonian tremor and essential tremor.
The most common side effects of tremor surgery include dysarthria (problems
with motor control of speech), temporary or permanent cognitive impairment
(including visual and learning difficulties), and problems with balance.
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