What are the treatment options for hand tremors?

Treatment Options for Hand Tremors

Start with propranolol 80-240 mg/day as first-line pharmacotherapy for essential tremor, which is effective in up to 70% of patients, or primidone as an equally effective alternative; if medications fail or are contraindicated, proceed to surgical interventions including deep brain stimulation or MR-guided focused ultrasound thalamotomy. 1, 2

Initial Assessment and Etiology

Before initiating treatment, determine the tremor type:

• Essential tremor (ET) presents as bilateral upper limb action tremor and is the most common movement disorder apart from restless leg syndrome, affecting 0.3-5.55% of the US population 1, 3
• Enhanced physiologic tremor is triggered by anxiety, stress, caffeine consumption, or strenuous exercise 2
• Parkinsonian tremor occurs at rest and requires different management 3
• Functional tremor requires occupational therapy-based interventions rather than pharmacotherapy 1

First-Line Pharmacological Treatment

Propranolol

• Dosage: 80-240 mg/day, used successfully for over 40 years 2
• Efficacy: Effective in up to 70% of ET patients 1
• Contraindications: Avoid in chronic obstructive pulmonary disease, bradycardia, congestive heart failure; use caution in elderly patients due to risk of excessive heart rate reduction 1, 2
• Dual benefit: Particularly useful in patients with both tremor and hypertension 2

Primidone

• Equally effective as propranolol for first-line treatment 1
• Warning: Abrupt withdrawal may precipitate status epilepticus; therapeutic efficacy takes several weeks to assess 4
• Black box warning: Increases risk of suicidal thoughts or behavior (relative risk 1.8 compared to placebo) 4

Alternative Beta-Blockers

Other beta-blockers with evidence for tremor control include nadolol, metoprolol, atenolol, and timolol 2

Second-Line Pharmacological Options

When first-line therapies fail:

• Gabapentin and carbamazepine are less effective than propranolol and primidone 1
• Chondroitin sulfate may provide symptomatic benefit with low toxicity, though effect sizes are small 1
• Pharmacologic therapy limitations include lack of efficacy, dose-limiting side effects, and contraindications due to medical comorbidities 1

Non-Pharmacological Interventions

For Functional Tremor (Occupational Therapy Approach)

• Rhythm modification: Superimpose alternative voluntary rhythms on the existing tremor, gradually slowing movement to complete rest 1
• Unilateral tremor: Use the unaffected limb to dictate a new rhythm (tapping/opening and closing hand); music can be introduced to dictate rhythm 1
• Muscle relaxation: Assist the person to relax limb muscles to prevent cocontraction 1
• Discourage cocontraction or tensing of muscles as a tremor suppression method, as this is not a helpful long-term strategy 1
• Use gross rather than fine movements (e.g., marker on whiteboard with large lettering rather than normal handwriting) 1

For Enhanced Physiologic Tremor

• Lifestyle modifications: Avoid strenuous exercise before precision tasks, reduce caffeine consumption, implement stress reduction techniques 2
• Rhythm modification techniques including music-guided rhythms 2

For Hand Osteoarthritis-Related Tremor

• Education and training in ergonomic principles, pacing of activity, and assistive devices (Level 1b evidence, Grade A recommendation) 1
• Exercises to improve function and muscle strength while reducing pain (Level 1a evidence, Grade A recommendation) 1
• Orthoses for symptom relief in thumb base OA with long-term use advocated (Level 1b evidence, Grade A recommendation) 1
• Heat application (paraffin wax, hot pack) especially before exercise 1

Surgical Interventions

When to Consider Surgery

Surgical therapies should be considered when:

• Medications fail due to lack of efficacy, dose-limiting side effects, or contraindications 1
• Tremor causes marked pain and/or disability despite conservative treatment 1

MR-Guided Focused Ultrasound (MRgFUS) Thalamotomy

• Efficacy: Hand tremor improvement of 56% sustained at 4 years, with 63% improvement in disability scores 1
• Safety profile: Serious adverse events rare (1.6%); most adverse events (98.4%) are mild or moderate with >50% resolved by 1 year 1
• Early adverse effects: Gait disturbance (36%) and paresthesias (38%) initially, reduced to 9% and 14% respectively by 1 year 1
• Advantages: Incisionless thermal ablation avoiding open brain surgery, no hemorrhage or infection risk 1

Deep Brain Stimulation (DBS)

• FDA approved since 1997 for essential tremor 5
• Target: Ventral intermediate nucleus of thalamus (VIM) 1
• Advantage: Alleviates tremor without creating permanent lesion 6
• Consider when: Severe cases with medication failure 2

Other Surgical Options

• Radiofrequency thalamotomy and radiosurgical thalamotomy are alternatives, though MRgFUS offers advantages of being incisionless 1
• For hand OA: Trapeziectomy for thumb base OA; arthrodesis or arthroplasty for interphalangeal OA when conservative treatments fail 1

Emerging and Adjunctive Therapies

Botulinum Toxin Injections

• Potential effectiveness for head and voice tremors; methods being refined for upper limb tremors 5
• Caution: Risk of dysphagia, breathing difficulties, and spread of toxin effect; deaths reported as complication of severe dysphagia 7
• Contraindication: Known hypersensitivity to botulinum neurotoxin could lead to life-threatening allergic reaction 7

Noninvasive Transcutaneous Afferent Patterned Stimulation

• FDA-approved devices available for median and radial nerve stimulation 5
• Status: Needs further study but shows potential as future treatment option 5

Critical Pitfalls to Avoid

• Do not abruptly discontinue primidone due to risk of status epilepticus 4
• Monitor for suicidal ideation in patients on antiepileptic drugs including primidone 4
• Avoid aids and equipment in acute phase of functional tremor as they interrupt normal automatic movement patterns and cause maladaptive functioning 1
• Do not use beta-blockers in patients with COPD, bradycardia, or congestive heart failure 1, 2
• Recognize that therapeutic efficacy takes several weeks to assess; do not prematurely discontinue effective therapy 4