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hi everyone this lesson is on essential

tremors so essential tremors are going

to be a movement disorder involving a

Tremor of a part of the body we'll

discuss what parts of the body are more

likely to be affected by a cenal Tremor

later on in this

lesson now a Tremor is going to be

defined as an involuntary rhythmic

oscillatory movement of a body part this

definition comes from the international

Parkinson and movement disorder Society

now there are many different types of

Tremors there are physiologic Tremors

which are going to occur in healthy

individuals so these are going to be

normal Tremors that can occur from

either too much caffeine or stress we

can also see Tremors occurring in

intention Tremors and we can also see

Tremors in Parkinson's disease NOW

essential tremor is going to have

particular characteristics which will

set it apart from other types of Tremor

and we'll discuss those characteristics

later on in this lesson NOW essential

tremor is going to be the most common

movement disorder it's going to be the

most common cause of Tremor and it is a

relatively common Condition it's ES to

affect up to 1 to 5% of the general

population so some estimates will put it

at closer to 1% some estimates will be

closer to 5% most of the time we're

going to see estimates around 1% of the

general population

worldwide and prevalence of essential

tremor increases with increasing age so

as individuals get older they're more

likely to have a essential tremor so a

lot of these higher numbers in some of

the estimates are likely related to

older aged populations or older

individuals and again as patients get

older especially after the age of 60 and

older than that their chances of getting

essential tremor increases so the

prevalence again increases especially

after the age of

60 now the underlying iology or the

cause of this condition is not

known it is known though that there is a

familial connection so there's likely

genetic involvement and some genes have

been proposed to be likely affected in

this condition and genetics are likely a

very strong aspect of this condition

because if we look at a patient who has

a essential tremor they have a family

history of essential tremor somewhere in

their family usually a first degree

relative and the family history is

present in 50% of cases and if there is

a strong family history we can sometimes

refer to this as a familial Tremor and

the heritability of this condition is

likely autosomal dominant meaning that

we only need one affected alal to

Manifest this condition so if we have

one affected parent 50% of the children

will be affected with essential tremor

so again it's proposed that only one

affected alal is required now the reason

that essential tremors occur is not

entirely understood it is likely that

there is some issue in the brain stem

especially in the locus cerus it also

has been hypothesized that there is some

issue or abnormal functioning of the

central oscillator which is also located

in the brain stem and involves the

inferior olivary nucleus or there has

also been some hypothesis as to whether

or not there's some issue with

cerebellar functioning or some

connection between the brain stem and

the cerebellum perhaps there's some

issue with connection between those two

structures so those are all potential

hypotheses for why this condition may

occur now let's discuss the signs and

symptoms of entral tremor we Define this

condition as monosymptomatic meaning

that there's only going to be a Tremor

it's an isolated

Tremor the Tremor is considered to be

slowly Progressive meaning that it can

start off very mildly and over time can

slowly and progressively become worse

and worse we'll talk about this in more

detail in the next slide an essential

trimmer is considered an action and

postural Tremor so an action tremor is

going to be a Tremor that occurs when

moving so if you're moving your hands or

your arms the Tremor is going to occur

during action and a postal Tremor is

going to occur when you're lifting your

arms or your hands Against Gravity so if

you're lifting them up you can have a

Tremor occur at that time as well and

we're not going to generally see a

resting Tremor although it can occur in

some cases as overflow so in some cases

if there's an action or postural Tremor

and then you were to put your hands down

at rest there can still be a trimor in

some of those cases this trimor is also

considered a high frequency trimor that

occurs at 6 to 12 Hertz the amplitude

however does vary because it's an action

trimmer movement will often worsen the

Tremor so as you're moving around moving

your arms or moving your hands the

Tremor can get worse it's going to be

bilateral there's going to be bilateral

involvement of upper extremities so both

upper extremities or both arms are going

to be affected and it's going to be

either symmetric or asymmetric meaning

that if it's symmetric the severity of

tremor on both sides will be essentially

equal or if it's asymmetric it'll be a

little less of a Tremor on one side than

the other generally speaking it's going

to be mostly symmetric or very very

minimally

asymmetric and other areas of the body

can also be affected with a Tremor so

not only the arms and the hands but also

the head the jaw The Voice the Torso and

the legs but the legs will occur very

very rarely so some head trimmers can be

a yes yes Tremor or no no Tremor and if

there is a head trimmer it's more likely

to have a voice Tremor as well so it's

important to discuss a few important

aspects of this particular Tremor

compared to other types of Tremors so

for an essential tremor there's often

going to be no rusting Tremor and the

Tremor is going to occur with action or

in a postural manner when if you're

holding your arms Up Against Gravity you

can have a trimmer in those cases and

because it's an action trimmer the

trimmer can get worse with movement

that's going to differ compared to

Parkinson's disease where there is a

resting Tremor in Parkinson's disease

and the Tremor improves with action so

that's a very important point to make

note of there we can also see no issues

with reflexes in a central Tremor and we

can also see no rigidity with essential

tremor that's also going to be different

compared to Parkinson's where we do see

rigidity and some other important points

to make note of here as well is that in

some cases there can be some voluntary

control of the Tremor this will be more

likely to occur in more mild cases and

in those particular cases the Tremor can

be suppressed by skilled manual tasks so

if there are certain manual tasks that

are performed with the hands or the arms

in some cases the Tremor can be

suppressed in those cases and we can

also note that the Tremor can resolve

during sleep so that's also another

point to make note of here as well and

again we're going to mostly see this

trimor occurring in the arms and hands

but in about 30% of cases we can see it

occurring in other parts of the body

like the head and the jaw now we

mentioned that a central Tremor is going

to be a slowly Progressive Tremor

meaning that the symptoms are going to

progress and worsen over time so

symptoms are progressive so what can

often happen is when there's an onset of

this condition the Tremor can begin in

only one of the upper limbs so it can

occur in one hand or one arm and over

time time it can spread to the other arm

so it can affect both arms or both hands

together so again starts usually in one

side one hand one arm and it can

eventually start to affect the other

initially the trimmer can be

intermittent meaning that it can only

occur or only will occur during certain

periods of time especially if it's

exacerbated by stress or some other

exacerbating Factor but over time the

Tremor can become more and more

persistent and constant and what we can

also see is that initially when there's

an onset of this condition the amplitude

of the Tremor the severity of the Tremor

is going to be mild and over time the

severity is going to worsen so there can

be a worsening amplitude or severity

over time So eventually we can have a

very severe and debilitating condition

for many patients so this can start to

affect their life in many different ways

including issues with job functioning

issues with getting themselves dressed

issues with getting themselves fed all

of those essential life skills can be

affected as this condition gets worse

over time and another important point to

make note of as well is that there is

again only a Tremor if there are other

signs and symptoms like changes in

mental status changes in personality

changes in memory these symptoms May

indicate another condition unless the

patient is themselves getting older they

may have a concurrent diagnosis of

entral Tremor and dementia for instance

if they're very very old but if they're

younger and they have more than a Tremor

this is something to think about perhaps

it's another condition now we alluded to

this earlier that there are some

exacerbating factors that can worsen

Tremors in patients these include

anxiety and stress hunger is also

another exacerbating Factor fatigue so

when patients are very very tired they

can have worsened severity of Tremors

caffeine use is also another

exacerbating factor that can worsen

Tremors and another one is extremes and

temperature so very very hot very very

cold these can also worsen the essential

tremor as well now there is some new

research showing a connection between an

essential tremor and an increased risk

for dementia so in patients who have had

a diagnosis of entral Tor when they were

younger those patients appear to have a

roughly three times higher risk of

dementia than patients who do not have

essential trors so this was found in a

logitudinal study showing that upwards

of 20% of essential patients that were

followed during the study develop

dementia so that's also very important

to point out here so although we don't

know the underlying iology we don't know

the exact brain structures that are

affected there does seem to be a strong

relationship at least with this new

evidence that patients with essential

tror are more likely to develop dementia

as they get older than patients who do

not have essential trors so that's a

very important point to make not of as

well let's talk about how clinicians

diagnose essential tremor essential

tremor diagnosis is going to be a

clinical diagnosis which means that

we're going to look at a history and

physical examination especially if

patients have a family history this will

make the diagnosis easier the diagnosis

is going to require the following an

isolated Tremor especially bilateral

mostly symmetrical and postural that

affects the upper extremities with or

without other areas affected and that

the Tremor has occurred for at least 3

years if the Tremor has occurred for

Less Than 3 years it's considered

indeterminant Tremor so if these other

characteristics are present but the

Tremor has only occurred for Less Than 3

years we consider this an indeterminant

Tremor and we wait to see if it

continues if it's at least 3 years then

it would be diagnosed as an essential

tremor some other considerations include

blood work so if there's some question

as perhaps there are other Associated

signs and symptoms with the Tremor

perhaps it's not only a Tremor then it's

something else to think about some other

diagnosis to think about or if there's

no family history this may also make the

clinician think perhaps there's another

diagnosis sometimes blood work can be

used in those cases so in those cases we

may look at TSH or thyroid simulating

hormone to see if there is hyper

thyroidism hyperthyroidism can cause

tremors lfts can be looked at so liver

function tests to see if patients have

liver disease serum ceruloplasmin can be

looked at if it's low that indicates

that a patient has Wilson's disease this

can also cause a Tremor and we can also

look at creatinine to check for kidney

functioning Imaging can also be

considered in some cases Imaging is

especially going to be important if

there's an acute onset so all of a

sudden there is very severe TR that look

like entral trimmers but it seems like

it's come on too quickly and too

severely all at once or if there's a

stepwise progression meaning that it's

come on very slowly but there's a

stepbystep increase in severity usually

again we talked about the fact that the

Tremor is going to slowly get worse over

time but if we see acute onset of a

severe Tremor or stepwise progression

this can indicate perhaps there are

other conditions that may be causing the

Tremor so MRI of the head or CD scan of

the head can be helpful in those cases

once technician has made the diagnosis

how do they treat it so before we talk

about treatment it's important to point

out that patients will often

self-medicate with alcohol and the

reason that they do this is because

alcohol can temporarily and

significantly reduce Tremor amplitude

often the numbers that are quoted are a

50 to 70% reduction in Tremor amplitude

with alcohol again it's going to be

temporary it's not going to be a

treatment that clinicians are going to

want their patients to be using but

patients will often use alcohol to at

least temporarily suppress their Tremors

now the staple of treatment for this

condition is pharmacological treatments

which we'll discuss in a moment but

there are other conservative

non-pharmacological treatments that can

be used in some cases if patients have

mild essential tremor some patients can

use wrist weights so they can have a

band around their wrist that has weight

and that can help suppress the Tremor as

well so some patients can use that to

help control their Tremor other

conservative managements include

avoiding those exacerbated factors that

we talked about before making sure that

there's less stress in your life having

more sleep all these can be very helpful

for reducing the Tremor severity but if

patients do require more Aid

pharmacological treatments can be

utilized these include anti-convulsants

like primidone so primidone is actually

going to be the Hallmark treatment for

this condition other anti-convulsants

include tapate tapate can also be used

to help reduce Tremors non-selective

beta blockers can also be used including

propanol so propenol and primidone are

going to be the two medications that

you'll see with regards to treating this

condition but propenol is mostly going

to be used for intermittent cases or

cases that are more mild so if the

patient has perhaps a speech or some

other function that they require a

suppression of the Tremor propanolol can

be used in those cases it's often going

to be taken one to one and a half hours

before they need the effect and again

it's only going to be for very temporary

intermittent cases if it's going to be a

more severe case PR is more likely to be

helpful other medications that can help

with tremors include benzidines

including Kazam and elazim these can

help the Tremor and also help with

anxiety if anxiety is a very significant

trigger for these patients and in other

cases if medicine hasn't helped if their

tremors are refractory to Medical

therapy then surgery may be employed in

those cases these types of surgeries

include thalamic vental intermedius

nucleus deep brain stimulation or DBS or

another one would be focused ultrasound

thalamotomy so there's going to be some

potential surgeries that can be used

again in patients who have not had

success with conservative management or

pharmacological management especially in

very severe cases so as patients get

older their severity can worsen and in

some cases surgery may be utilized in

those cases to help with very severe

especially arm and hand symptoms please

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watching and hope see you next time