Guidelines for management of essential tremor

Abstract

Essential tremor (ET) is a common movement disorder, and approximately 50% of the cases are inherited as an autosomal dominant trait.[1] The incidence of ET increases with age, may manifest at any age (childhood to adulthood), and those with a positive family history have an earlier age of onset.[2] The tremor involves mainly the upper limbs distally and is postural or kinetic type. The less common parts involved with tremor are the head, lower limbs, voice, tongue, face, and the trunk. The tremor amplitude increases with time, and patients experience difficulty in writing, eating, holding objects and doing fine motor tasks, dressing, and speaking.[3] Although ET usually does not reduce life expectancy or cause other symptoms, many patients have severe psychosocial disability.[3] Tremor often increases with anxiety, stress, and in situations involving interaction with others. Patients with head and voice tremor often suffer severe embarrassments, and may develop depression. ET should be differentiated from the other types of tremors, especially tremor of Parkinson's disease, tremor associated with hyperthyroidism, and dystonic tremor of head in patients with isolated head tremor. Once a diagnosis is made, the severity of functional and psychosocial disabilities should be assessed by objective scales, which will help to determine the need for pharmacotherapy. The management of a patient with ET includes (a) behavioral techniques and physical therapy, (b) medical therapy, and (c) surgical treatment. The patient should be explained about the disease, the long-term outcome, and what the therapies can achieve. All therapies are essentially symptomatic and will not cure or change the course of the disease. If there is minimal functional disability, the patient need not take treatment. Even if the tremor is controlled by medical therapy, stress and anxiety can increase the symptoms. An outline of the management of ET is given in Figure 1. Figure 1 A flow chart showing the steps in the management of essential tremor