Holding Steady: Adaptive Techniqes Make Daily Activities For Those With Essential Tremor Easier

Essential tremor is less well known than Parkinson’s disease, but it is eight times more common, according to the International Essential Tremor Foundation. An estimated 10 million Americans are affected by the condition, which does share symptoms with PD. The big difference between the two conditions is that people with essential tremor have noticeable shaking that intensifies as they move, while patients with PD have prominent resting tremors that become less obvious with activity.

"There are no PT interventions that can reverse or stop an essential tremor, but we can teach patients compensatory strategies to cope with the condition," Tara Tobias, PT, Florida Hospital in Orlando, said. 

While essential tremor is not life-threatening, it can cause severe disability. The nervous system disorder begins gradually and worsens over time, most adversely affecting people in middle age and older. The condition can affect almost any part of the body, but usually involves the hands and also may include a "yes-yes" or "no-no" motion of the head. The involuntary tremors can be aggravated by stress, fatigue, caffeine or even extreme temperatures, according to IETF.

There is no standard of care or practice guidelines for physical therapists to follow when treating essential tremor. However, therapy is the first line of defense for reducing shakiness and improving coordination and muscle control. In more severe cases, certain medications such as beta blockers, epilepsy drugs and Botox injections can help minimize tremors. 

"Essential tremor is ... very challenging to treat," Stewart Factor, MD, director of Movement Disorders Program at Emory University in Atlanta, said. "The medicines that we have provide some dampening of the tremors in a percentage of patients so therapy is very important to help patients with their tremors before they end up considering surgery."

For people who do not respond to medications and are severely disabled, deep brain stimulation is the main surgical option. The U.S. Food and Drug Administration approved the use of deep brain stimulation for essential tremor in 1997. "More patients are opting to have the surgery because it’s been around for a while and showing good results, but most patients still need therapy afterward," Factor said.

Daily dilemmas
The biggest challenges for most patients occur in their upper extremities. Routine tasks like drinking, eating, handwriting, dressing and grooming can become challenging activities for this patient population. Fine motor skills that require a steady hand — like writing a signature, buttoning a blouse and applying makeup, among others — are sometimes the hardest tasks for people to perform.

Occupational therapists work closely with patients to better manage these tasks, but PTs teach compensatory strategies to manage daily activities. "There’s a lot of crossover and shared care through a multidisciplinary approach between occupational and physical therapists," said Kristen Smigelski, PT, Northwestern Memorial Hospital in Chicago. 

At Florida Hospital, most patients with tremors receive occupational, physical and speech therapy at the medical center. "In the past, there was a lot more simultaneous co-treating with therapists, but current reimbursement models do not allow for that anymore," Tobias said. "So we work together on a treatment plan and coordinate care to incorporate various activities."

Tobias said many patients complain about having difficultly holding dining utensils or drinks without spilling them when they walk. To help, she leads these patients through balancing activities. That may start with sand in a cup or something that’s heavier and doesn’t move around as much as a drink, then eventually progress to liquid.

Balancing act
Difficulties with gait also are common with essential tremor. These include gait asymmetry, and decreased cadence and velocity. Some tremors can become so significant that balance is noticeably affected. Therefore, gait and balance training are a big focus in treatment plans. Teaching patients to use a cane or assisted device and safely getting their hand on a support surface to steady themselves are important strategies, according to Tobias.

In addition, therapy may include patients carrying plates with weights on them and walking quickly down a hall, or walking slowly and changing directions, or walking while turning their heads side to side. "We encourage them do to things to challenge their balance while they’re holding something," Tobias said.

When tremors affect the lower extremities, patients may have trouble getting up from bed or standing up from a chair. "Many patients fear falling and feel like they are losing control of their limbs," Tobias said. 

The shoulder area also can be affected. Patients with tremors may experience overuse musculoskeletal pain, similar to rotator cuff tendonitis. Overuse-related shoulder pain may eventually lead to loss of function, Jennifer Millar, PT, Johns Hopkins Medicine, Baltimore, said.

Millar develops home exercise programs for patients, including shoulder ROM and scapular muscle re-education, to prevent shoulder pain and disability. Treatment may include instruction on mobility strategies, core strengthening, as well as aerobic exercise. 

Relaxation techniques and exercise programs also are important to lower anxiety and stress levels in patients. Stretching and diaphragmatic breathing exercises are routinely taught at Johns Hopkins. Millar said she often asks her patients what exercises or hobbies they like to do for motivation. In younger patients, swimming, biking and yoga seem to be common. Walking is a good exercise at any age, Millar said.

"We often recommend a light walking program of 20 to 30 minutes at moderate intensity," Millar said. "This helps to improve balance and flexibility, and builds confidence among patients with essential tremors."

(Source: todayinpt.com)