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What is Essential Tremor? Diagnosis and Treatments

Medically reviewed by Sandeep Dhanyamraju

Tremor is one of the most common symptoms that occur alone or in combination with other symptoms various lesions of the nervous system, as well as often accompanying endocrine, somatic diseases, and various intoxications. An international research group defines tremors as rhythmic mechanical oscillations in at least one functional body area.

There are two main types of tremors, physiological and pathological.

  • Physiological tremor exists in every healthy person. Its amplitude is so small that it is invisible to the naked eye; the frequency is from 8 to 12 Hz. An increased physiological tremor has an amplitude greater than usual but retains the same frequency. It can often be seen with the naked eye. Increased physiological tremor occurs in various conditions leading to the excitation of peripheral b-adrenergic receptors (exposure to increased doses of endogenous adrenaline with fear, excitement, and when taking drugs agonists of these receptors).
  • Pathological tremor A tremor that occurs in various diseases is visible and has several clinical and electrophysiological characteristics that differ from physiological tremor. The defining differential diagnostic sign of tremor among another hyperkinesis (chorea, athetosis, dystonia, ballism, orthostatic myoclonus, tics, Parkinson’s disease) is its recurrent oscillatory nature.

If you or your family members have a tremor, you need to make an appointment with your doctor. Contact our doctors at Lone Star Neurology will conduct a thorough diagnosis using modern equipment and prescribe treatment.

Tremor is Distinguished by the Nature of the Manifestations

There are two types of tremor, rest and action. This indicates the state in which the manifestation of tremor begins.

  • Rest tremor is a tremor that occurs when the muscles do not make active movements and are subject only to gravity. A decrease in resting tremor is observed with active voluntary movements, especially with precise targeted movements, to the complete disappearance of tremors. This type of tremor is most typical for Parkinson’s disease and other parkinson-like syndromes, accompanied by damage to the substantia nigra and basal ganglia.
  • Action tremor is a pathological tremor that occurs during voluntary muscle contraction. It includes:
  1. Postural tremor occurs with active muscle tension directed against the forces of gravity;
  2. Isometric tremor, with muscle contraction, experiencing stationary resistance when interacting with a stationary object;
  3. Kinetic tremor during any voluntary movement.

Orthostatic or essential tremor

The Main Types of Pathological Tremors

There are several main types of tremors that can have different causes.

Essential tremor Essential tremor is a syndrome characterized by an isolated bilateral tremor of the upper extremities, lasting at least three years, which can be combined with tremors in the head, larynx (tremor of the voice), or lower extremities. It is also called the orthostatic tremor. This pathology affects approximately 1% of the world’s population. Incidence increases with age, with most studies finding no difference in prevalence between men and women. Initial manifestations can occur in early childhood or the 2nd to 6th decade of life. The essential tremor history is characterized by a slow progression of intensity with age.
Parkinsonian tremor Parkinsonian tremor (tremor in Parkinson’s disease). Patients with Parkinson’s disease may have a different tremor, but there is often a classic resting tremor in 40-60% of patients. The frequency of this type of tremor is 4–6 Hz. In some patients with Parkinson’s disease, resting tremor is combined with a kinetic tremor of the same frequency. In some cases of Parkinson’s disease, the frequency of postural tremor is higher than resting tremor (up to 9 Hz); sometimes, postural tremor prevails over resting tremor. This type is observed only in 15% of patients. In some of them, postural tremor exists long before the onset of resting tremor, causing difficulties in differential diagnosis with essential tremor.
Dystonic tremor Dystonic tremor hyperkinesis is associated with some form of dystonia. It has a frequency of 4-10 Hz, is predominantly postural and/or kinetic, and is usually localized in the part of the body affected by dystonic hyperkinesis (limbs, neck, etc.). Sometimes this type of tremor occurs without manifestations of dystonia; it is usually observed in family members who suffer from torsion dystonia.
Cerebellar tremor Cerebellar tremor. This term is often used as a synonym for intentional tremor. However, various clinical forms of tremor can be observed in the pathology of the cerebellum, for example, rhythmic oscillations of the head and trunk (titubation). An extremely low frequency characterizes cerebellar tremor, usually less than 4–5 Hz, which distinguishes this tremor from most other types of tremor hyperkinesis.
Orthostatic tremor Orthostatic tremor is a rare syndrome in the form of pronounced instability when standing up from a prone or sitting position (transition to an upright position), accompanied by the tremor. Tremor is characterized by an unusually high frequency (13-18 Hz), recorded in all muscles but palpable only in the thighs and legs muscles. This type of tremor has a central origin; it is observed in middle-aged and older adults (usually without other neurological symptoms), often with certain abnormalities in the psyche.
Holmes tremor Holmes tremor. A combination of resting tremor, postural and intentional tremor is characteristic. Hyperkinesis increases sharply while maintaining a fixed position of the limb on weight, leading to rough, large-sweeping arms, legs, and trunk oscillations. Low frequency is characteristic (<4-5 Hz). With Holmes’ tremor, the cerebellothalamic (upper leg of the cerebellum), nigrostriatal pathways, and other central nervous system structures are often involved in the pathological process.
Primary writing tremor Primary writing tremor or tremor with other purposeful complexly coordinated movements. The typical frequency is 4-10 Hz. Such a tremor can sometimes appear during specific actions and when performing similar (imitating) movements affecting the same muscle group.
Drug-induced and toxic tremor Drug-induced and toxic tremor. A variety of medications can cause different types of pathological tremors. Typical examples are parkinson-like tremor that occurs after treatment with neuroleptics or other antidopaminergic drugs in Parkinson’s disease, intentional tremor after the use of lithium salts, tremor after acute alcohol intoxication, etc.
Psychogenic tremor Psychogenic tremor. This type of tremor has a variable frequency (from 4 to 10.5 Hz) and is characterized by the following features:

  • sudden onset of tremor, the presence of remission;
  • variations in the frequency and amplitude of tremor during the distraction of attention or voluntary movements of the contralateral hand;
  • signs of coactivation – increased tremor during passive movements;
  • the presence of additional mental symptoms;
  • resistance to antitremor drugs and a good effect of psychotherapy, hypnosis

Orthostatic or Essential Tremor

Different types of tremors have been described above. But in this article, we will discuss one of the types, it is orthostatic or essential tremor. Let’s start with its peculiarities:

  • Essential tremors are often familial with a typical autosomal dominant pattern. Genomic association studies have shown that several single nucleotide polymorphisms are associated with essential tremors. For example, a gene encodes a LINGO protein that appears to inhibit cell differentiation during development and axonal regeneration, and synaptic plasticity.
  • The question of certain pathophysiological features of essential tremor or primary orthostatic is controversial. However, several pieces of evidence point to cerebellar dysfunction. Magnetic resonance spectroscopy showed decreased levels of N-acetylaspartate in the cerebellum, indicating neuronal dysfunction. Some histological studies have shown a loss of Purkinje cells in the cerebellum; dysfunction of γ-aminobutyric acid has also been noted in the cerebellum of people with essential tremors.
  • The pathophysiology of essential tremor includes rhythmic activity in the cortical-ponto-cerebello-thalamocortical loop, although the origin of the oscillations is unknown. Resting cerebellar metabolism is high, increases with extension of the arms, and decreases with ethanol (suppresses essential tremor).

Essential tremor diagnosis

Essential Tremor Diagnosis

To diagnose orthostatic tremor or essential tremor, many tests need to be done so that the doctor can be sure of the correct diagnosis. Diagnostics should include the following analyzes.

  • Routine laboratory tests, including measuring thyroid-stimulating hormone and electrolyte levels in the blood, as well as examining liver and kidney function, are integral components in the diagnosis of essential tremor.
  • History taking should include:
  1. information about the age of onset of symptoms;
  2. family history and any exposure potentially causing tremors;
  3. medicines (eg, sodium valproate, selective serotonin reuptake inhibitors, sympathomimetics, or lithium);
  4. toxins (such as mercury, lead, or manganese).
  • Neurologic examination should assess the topical distribution of the tremor and the state of activation (resting or intentional tremor), include an assessment of the tremor frequency range (low [<4 Hz], moderate [4-8 Hz], or high [> 8 Hz]), and assess any signs suggesting a systemic disease or other neurological diseases.
  • Additional electrophysiologic studies, including superficial electroneuromyography and accelerometry to assess muscle activation, rhythm, and frequency characteristics, can help distinguish primary orthostatic tremor from cortical, functional, and increased physiological tremor.

Parkinson’s disease with a predominant tremor of action and little or no tremor at rest or bradykinesia can be distinguished from essential tremor by single-photon emission computed tomography using 123I-ioflupane, which assesses the distribution of dopamine transporters.

treatment of essential tremor

Treatment of Essential Tremor 

Deep brain stimulation (unilateral and bilateral) and thalamotomy (unilateral only) are aimed at the thalamic nucleus ventralis intermedius that are used to treat an orthostatic tremor refractory to medication. Although conventional stereotactic thalamotomy was the first available interventional treatment for tremors, its use is limited to unilateral interventions due to the high risk of irreversible dysarthria or ataxia after bilateral thalamotomy.

In a randomized trial of patients with tremors, deep brain stimulation produced more significant functional improvements than thalamotomy. It resulted in fewer side effects such as dysarthria, sensory disturbances, and gait disturbances. However, after five years of follow-up, half of the patients with essential tremors who were prescribed deep brain stimulation had a decrease in the effect, which was explained by the progression of the disease or the development of tolerance to stimulation. Adverse events are more common with bilateral than unilateral deep brain stimulation.

Undesirable effects of deep brain stimulation may include:

  • reversible stimulus induced by stimulation,
  • dysarthria,
  • paresthesia,
  • tonic muscle contractions.

The Food and Drug Administration has approved a focused ultrasound device to treat primary orthostatic tremors that do not respond to drug therapy. It was developed based on the results of a randomized controlled trial in 76 patients with essential tremor in which unilateral thalamic thermoablation using focused ultrasound, guided magnetic resonance imaging contributed to a significantly greater reduction in hand tremor and improved quality of life at 12 months. The most common adverse events of focused ultrasound thalamotomy were postoperative paresthesia or numbness (38% of participants) and gait disturbance (36%). Twelve months after the intervention, the frequency of paresthesia or numbness was 14%, and the degree of gait disturbance was 9%.

Medication for Orthostatic Tremor

Medication for Orthostatic Tremor

Propranolol and primidone are the two compounds with the highest evidence for the treatment of essential tremors by reducing the severity of upper limb symptoms.

In randomized controlled trials, the non-selective beta-adrenergic blocker propranolol is effective at doses ranging from 120 to 240 mg/day:

  • in randomized controlled trials, the amplitude of tremor, measured by accelerometry, was reduced by an average of 55%;
  • side effects include bradycardia and bronchospasm;
  • in one small study, long-acting propranolol was as effective as short-acting drugs in reducing the amplitude of essential tremor.

Primidone, which is metabolized to phenylethylmalonamide and phenobarbital, was effective at doses ranging from 250 to 750 mg/day:

  • the amplitude of the tremor decreases by 60%, which is similar to the effect observed with propranolol monotherapy;
  • early side effects, including dizziness, fatigue, and malaise, were noted in 23–32% of patients at the start of primidone treatment (versus 8% in the propranolol group), but usually resolved after 1–4 days, and the majority of patients who had such effects continued therapy.

A randomized controlled trial of combination therapy with propranolol and primidone compared with placebo demonstrated a 70% reduction in tremor. However, despite this, in a survey of people who received propranolol or primidone, about half said they eventually stopped taking the drugs. The most likely reasons for stopping treatment are limited effectiveness and unacceptable side effects.

There are limited data from randomized controlled trials to support other drugs for essential tremor, including topiramate, alprazolam, gabapentin, and other beta-adrenergic blockers such as atenolol, nadolol, and sotalol.

Controlled studies have not shown significant benefits with other medicines. 

Therapy of Orthostatic Tremor

The choice of first-line therapy should be made after consideration of contraindications (eg, symptomatic bradycardia or hypotension), and patient preference may also be considered after lightening the side effects of these drugs, such as dizziness, hypotension, and sedation.

For second-line orthostatic tremor therapy, it is recommended to switch to another first-line drug, unless contraindicated; if none of these have been effective on their own, combination therapy may be considered.

For patients with disabilities and lack of adequate response to pharmacotherapy, which also includes treatment with drugs with a lower level of evidence of efficacy, the option of deep brain stimulation or focused ultrasound thalamotomy should be considered after assessing the possible risks of surgery and the potential benefits.  

FAQs

  • What is Parkinson’s disease?

Parkinson’s disease is a chronic, steadily progressive disease of the brain, which is accompanied by autonomic and mental disorders. Experts distinguish three groups of the disease, idiopathic, symptomatic (toxic, vascular, infectious, etc.), and degenerative.

  • What are the symptoms of essential tremors?

Essential tremor is often characterized by only one symptom of tremor, which differs from resting tremor in Parkinson’s disease. It appears with muscle tension and movement of the limbs, more often the arms.

  • What is the main manifestation of Essential tremor?

Essential tremor is the most common extrapyramidal and one of the most common neurological diseases; the main manifestation is progressive bilateral action (kinetic-postural) hand tremors.

  • Why is tremor dangerous?

Tremors can be caused by various injuries to the brain stem, extrapyramidal system, or cerebellum. Dysfunction or damage to neurons causing tremors can result from trauma, ischemia, or metabolic damage, as well as from various neurodegenerative diseases.

  • Why does the whole body tremble?

Tremor is a process of trembling of certain parts or the whole body, which is involuntary. The main cause of this disease is structural damage to those parts of the nervous system that are associated with muscle tone.

  • What disease is causing the fine tremor and slow deterioration that extends to both hands?

These are symptoms of essential tremor, or it is also called orthostatic. If you or your relatives have similar symptoms, then immediately consult a doctor who can diagnose and prescribe treatment.

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Edward Medina
Edward Medina
15:34 30 Jun 22
Just such an amazing staff that makes you feel like part of their family. I’ve been going there for over 5 years now... and each visit I get the very best care and treatments that I have ever received in the 20+ years that I’ve been dealing with severe debilitating migraines. Since i started seeing them the number of my migraines has dropped from 15-20 a month to 2-3 every 3 month. I highly recommend them …they will change your life!read more
Daneisha Johnson
Daneisha Johnson
22:20 19 May 22
Dr. Askari was very kind and explained everything so I could understand. The other staff were nice as well. I would... have gave 5 stars but I was a little taken aback when I checked in and had to pay 600.00 upfront. I think that should have been discussed in a appointment confirmation call or email just so I could have been prepared.read more
Jean Cooper
Jean Cooper
16:54 29 Apr 22
I love the office staff they are friendly and very helpful. Dr. JODIE is very caring and understanding to your needs... and wants to help you. I will go back. would recommend Dr. Dr. Jodie to other Patients in a heart beat. The team works well together.read more
Linda M
Linda M
19:40 02 Apr 22
I was obviously stressed, needing to see a neurologist. The staff was so patient and Dr. Ansari was so kind. At one... point he told me to relax, we have time, when I was relaying my history of my condition. That helped ease my stress. I have seen 3 other neurologists and he was the only one who performed any assessment tests on my cognitive and physical skills. At one point I couldn't complete two assessments and got upset and cried. I was told, it's OK. That's why you're here. I was truly impressed, and super pleased with the whole experience!read more
Leslie Durham
Leslie Durham
15:05 01 Apr 22
I've been coming here for about 5 years. The staff are ALWAYS friendly and knowledgeable. The Doctors are the absolute... best!! Jodie Moore is always in such a great mood which is a plus when you are already stressed. Highly recommendedread more
Monica Del Bosque
Monica Del Bosque
14:13 25 Mar 22
Since my first post my thoughts have changed here. It's unfortunate. My doctor and PA were great, but the office staff... is horrible. They never call you back when they say they will, they misinform you, they cause you too much stress wondering what's going on, they don't keep you posted. They never answer the phone. At this point I've left four messages in the last week, and I have sent three messages. Twice from their portal and one direct email. No response. My appointment is on Monday morning at 8:30am, no confirmation on my insurance and what's going on. What the heck is going on, this is ridiculous!I've given up... the stress her office staff has put me through is just not worth it. You can do so much better, please clean house, either change out your office staff, or find a way for them to be more efficient please. You have to do something. This is not how you want to run your practice. It leaves a very bad impression on your business.read more
Ron Buckholz
Ron Buckholz
23:32 23 Mar 22
I was actually pleasantly surprised with this visit! It took me a long time to get the appointment scheduled because no... one answers your phones EVER! After a month, I finally got in, and your staff was warm, friendly, and I was totally impressed! I feel like you will take care of my needs!read more
Steve Nabavi
Steve Nabavi
16:28 16 Mar 22
It was a nice visit. Happy staff doing all they can do to comfort the patients in a very calming environment. You ask... me they are earned a big gold star on the fridge. My only complaint they didn't give me any cookies.read more
Katie Lewis
Katie Lewis
16:10 10 Feb 22
Had very positive appointments with Jodie and Dr. Sheth for my migraine care. Jodie was so fast with the injections and... has so much valuable info. I started to feel light headed during checkout and the staff was SO helpful—giving me a chair, water, and taking me into a private room until I felt better. Highly recommend this practice for migraine patients, they know what they’re doing!!read more
Joshua Martinez
Joshua Martinez
16:02 10 Dec 21
I was scheduled to be checked and just want to say that the staff was fantastic. They were kind and helpful. I was... asked many questions related to what was going on and not once did I feel as though I was being brushed off. The front desk staff was especially great in assisting me. I'm scheduled to go back for a mri and am glad that I'll be going there.read more
Isabel Ivy
Isabel Ivy
21:42 03 Nov 21
I had such a good experience with Lone Star Neurology, Brent my MRI Tech was so awesome and made sure I was very... comfortable during the appointment. He gave me ear plugs, a pillow, leg support and blanket, easiest MRI ever lol 🤣 My 72 hour EEG nurse Amanda was also so awesome. She made sure I was take care of over the 3 days and took her time with the electrodes to make sure it was comfortable for me! Paige was also a huge help in answering all my questions when it came to my test results, and letting me know her honest opinions about how I should go forth with my treatment.read more
Leslie Luce
Leslie Luce
17:37 20 Oct 21
The professionalism and want to help attitude of this office was present from the moment I contacted them. The follow... up and follow through as well as their willingness to find a way to schedule my dad was above and beyond. We visited two offices in the same day with the same experience. I am appreciative of this—we spend a lot of time with doctors and this was top notch start to finish.read more
robert Parker
robert Parker
16:38 16 Apr 21
I love going to this office. The staff is friendly and helpful. The doctor is great. I am getting the best... neurological tests and treatment I have ever had. The only reason I did not give them a 5 star rating is because it is impossible to reach a live person at the office to reschedule appointments. Every time I have tried to get through to the office it says all people are busy and I am sent to a voicemail. If they could get their phone answering fixed, I would give them a strong 5 stars.read more
MaryAnn Hornbaker
MaryAnn Hornbaker
00:26 25 Feb 21
Dr. Harney is an excellent Dr. I found him friendly , personable and thorough. I evidently am an unusual case. ... Therefore he spent a Hugh amount of time educating me. He even gave me literature to further explain my condition and how to follow up. This is something you rarely get from your doctors. So I am more than please with my doctor and his staff.read more
Roger Arguello
Roger Arguello
03:05 29 Jan 21
Always courteous, professional. The staff is very friendly and always work with you to find the best appointment time.... The care team has been great. Always taking the time to listen to your concerns and to find the best treatment.read more
Margaret Rowland
Margaret Rowland
01:12 27 Jan 21
I have been a patient at Lone Star Neurology for several years. Now both my adult daughters also are patients there. I... love Jodie. She is always so prompt whether it is a teleamed call are a visit in the office. She takes the time to explain everything to me and answers all my questions. I am so blessed to have Jodie as my doctor.read more
Susan Miller
Susan Miller
03:01 13 Jan 21
My husband had an accident 5 years ago and Lone Star Neurology has been such a blessing to us with my husbands care.... Jodie Moore is his provider and she is amazing! Jodie is very knowledgeable, caring, and thorough. She takes her time with you, making sure your needs are met and she is happy to answer any questions you may have. Lone Star Neurology’s patients are very lucky to have Jodie providing their care. Thank you Lone Star Neurology and especially Jodie for everything you have done for us. Jodie, you are the best!read more
Windalyn C
Windalyn C
01:32 09 Jan 21
Jodie is wonderful. She is very caring and knowledgeable. I have been to over a dozen neurologists, and none were able... to help me as much as they have here. Thanks!read more
Katie Kordel
Katie Kordel
00:40 09 Jan 21
Jodi Moore, nurse practitioner, is amazing. I have suffered from frequent, debilitating headaches for almost 20 years.... She has provided the best proactive and responsive care I have ever received. My quality of life has been greatly improved by her caring approach and tenacity in finding solutions.read more
Ellie Natsis
Ellie Natsis
15:41 07 Jan 21
I have had the best experience at this neurologist's office! For over a year I have been receiving iv treatments here... each month and my nurse, Bobbie is beyond wonderful!! She's so attentive, knowledgeable, caring, and detail oriented. She makes an otherwise uncomfortable experience much more pleasant and definitely puts me at ease! She also helps me with my insurance,ordering this specialty medication and dealing with the ordering process which is no easy feat.Needless to say, she goes above a beyond in every way and I'm so grateful to this office and to Bobbie for all they do for me!read more
Matt Morris
Matt Morris
15:39 07 Jan 21
Let me start by saying that I have been coming here for years. Due to my autoimmune disease, I am in this office... once every three weeks for multiple hours at a time. The office is very clean and the staff very friendly. My only complaint would be there communication via phone. They aren't the best at responding if you leave a voicemail and expect a call back. I understand that this is prob just due to the sheer number of alls they receive daily. What I can say I like the best about the office are the people. Bobby who handles my infusions is great. I never have any issues with her setting up my infusions. She is very quick to reply to messages sent via text and if she were to leave then my whole opinion of the office may change. I also enjoy people like Matt, Lauren, and Jodi. I appreciate all that they do for me and without this team I'm not sure I would be as happy as I am to visit the office as frequently as I have to. Please ensure that these folks are recognized as they are what makes my visit to this office so tolerable :).read more
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