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Holding steady
Monday August 6, 2012


More common than Parkinsonís disease, but less well known, is the neurological condition essential tremor. An estimated 10 million Americans are affected by the disorder that resembles the symptoms of PD. The big difference between the two conditions is that people with ET have noticeable shaking that gets worse as they move, while PD patients have resting tremors that are prominent without movement, but less obvious with activity.

"There is no cure for essential tremor. We canít make the tremors go away, but [occupational therapists] can help improve patientsí quality of life by assisting them with adaptive techniques," said Julie MacLean, OTR/L, senior therapist at Massachusetts General Hospital in Boston.

While the disease is not life-threatening, it can cause severe disability. ET begins gradually and worsens over time, mostly affecting middle-age and older people. The nervous system disorder can strike almost any part of the body, but largely affects the hands and 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.

Occupational therapy is the first line of defense for reducing tremors and improving coordination and muscle control in the earlier stages. There is no standard of care or practice guidelines for OTs to follow when treating ET. PD, multiple sclerosis and epilepsy command most of the attention and research dollars. As a result, there is insufficient evidence-based research for treating ET and many therapists look to studies of other neurological conditions for best practices, according to MacLean.

In more severe cases, certain medications such as beta blockers, epilepsy drugs and Botox injections can help minimize tremors. For people who do not respond to medications, but are severely disabled, deep brain stimulation is the main surgical option, according to information from the International Essential Tremor Foundation.

Daily dilemma

The biggest challenges for most patients are daily activities such as drinking, eating, handwriting, dressing and grooming. Fine motor skills that require a steady hand including writing a signature, buttoning a blouse and applying makeup are sometimes the hardest tasks for people to maintain.

To help improve fine motor skills, therapists often focus on strengthening exercises of the core muscles. "We assess a patientís strength, and if they are weak we give them an exercise program to get stronger core and proximal muscles to help with the control of the finer movements," MacLean said.

Therapists at New York University also use strength training. "Depending on the severity of the tremors, we would use the appropriate weight — usually half a pound up to 10 pounds — for an individualized program to build strength," said Nandita Singh, OTR/L, MPH, program manager at Rusk Institute of Rehabilitation Medicine at New York University.

When the tremors affect the lower extremities, many patients have trouble getting up from bed or sitting up from a chair, Singh said. "Itís a big safety concern because some patients fear falling since it feels like they are losing control of their limbs."

At Cedars-Sinai Medical Center, therapists develop an occupational therapy profile of the patient during the initial evaluation. "We think itís really important as clinicians to find out exactly what is happening in the patientís day-to-day [activities], what their lifestyle is like and what they want to get back to doing," said Aimee Bender, OTR/L, therapy supervisor at the Los Angeles-based hospital. "Through this we can find out what might be aggravating their tremors, such as fatigue or stress, so we can develop the right treatment plan."

To gather this information, Cedars-Sinaiís therapists ask their patients to keep a daily log of their activities. These logs often show patterns for the tremors — whether itís related to work, lack of sleep or other circumstances. For patients who have difficulty handwriting, therapists will offer writing aids, such as weighted pens, or voice recorders.

Adaptive techniques

OTs often rely on several adaptive techniques to reduce the effect of tremors on daily activities. These may include heavier plates, weighted utensils and pens, wrist weights, even magnetic clasps for jewelry. There is no definitive research that shows weighted pens and utensils actually improve tremors. "Some patients feel like it helps them, but others find it cumbersome," MacLean said. "The role of weighted items is misunderstood and highly overstated."

Dycem Ltd. products are widely recommended by therapists to assist in improving grip. To assist in eating, patients can place a piece of Dycem nonslip material on the table and put an adaptive plate on top, Bender said. She also suggests using plate guards that clip onto the plate to allow patients to scoop food more easily.

Bender said special plates can help people with hand tremors. One option, called Freedom Dinnerware by Therapro Inc., offers extended rims, built-in-dividers, special scoop angles and nonskid, no-spill suction pads that keep plates in place.

Then there are many simple tips patients can adopt to make life easier. Such tips include placing a napkin between a cup and saucer to avoid rattling, and avoiding certain foods that are hard to control, such as spaghetti. "Patients get frustrated with their day-to-day abilities, so teaching them ways to improve functional activities goes a long way," Singh said. •

Paul Wynn is a freelance writer.

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Monday August 6, 2012
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