Question 1

What is essential tremor?

Accepted Answer

Essential tremor is the most common movement disorder — characterised by rhythmic, involuntary shaking (most commonly of the hands and arms) occurring during voluntary movement or posture maintenance. ET is often called "benign" essential tremor, but many patients experience significant functional disability and social embarrassment — difficulty with writing, eating, drinking from a cup, threading a needle, using tools. ET is not Parkinson's disease and does not cause Parkinson's — they are distinct conditions.

Question 2

How does ET differ from Parkinson's tremor?

Accepted Answer

The critical distinction: ET causes action tremor (worst during movement — writing, holding objects) while Parkinson's causes resting tremor (worst at rest, improves with voluntary movement). Additional differences: ET typically affects hands bilaterally (often asymmetric but not one-sided); Parkinson's tremor is often unilateral initially. ET does not cause the bradykinesia (slowness), rigidity, postural instability and gait changes that are hallmarks of Parkinson's. ET does not progress to Parkinson's — though both are more common with ageing and can coexist.

Question 3

What causes essential tremor?

Accepted Answer

The exact cause of ET is unknown. Strong genetic component: approximately 50% of cases have a family history (autosomal dominant inheritance in many families). Multiple genes implicated — LINGO1, FUS, and others — but no single gene accounts for most ET cases. Neuroimaging studies suggest abnormal activity in the cerebello-thalamo-cortical circuit. Some studies suggest abnormal Purkinje cell function in the cerebellum. No known environmental cause, though caffeine, fatigue, anxiety and stimulants temporarily worsen tremor.

Question 4

What are the treatment options?

Accepted Answer

First-line medications: propranolol (non-selective beta-blocker — approximately 50% tremor reduction in responders) and primidone (anticonvulsant). Both are on the WHO Essential Medicines List and are inexpensive. Other medications with evidence: topiramate, gabapentin, alprazolam (reserved for alcohol-responsive tremor). For medication-refractory severe ET: deep brain stimulation (DBS — adjustable, bilateral possible, approximately 80-90% improvement); MR-guided focused ultrasound (MRgFUS — non-invasive, immediate, unilateral only, FDA 2016, approximately 70-80% improvement); thalamotomy (lesion — permanent, unilateral, historical standard).

Question 5

What is MR-guided focused ultrasound?

Accepted Answer

MRgFUS (brand name Exablate Neuro, InSightec) uses 1,000+ ultrasound transducers arranged on a helmet to focus acoustic energy through the intact skull — heating a precise 3-4mm spot in the VIM thalamic nucleus to approximately 55-60°C, creating a precise thermal lesion that disrupts the tremor circuit. Done under continuous MRI guidance; the patient is awake during the procedure to allow tremor testing. FDA approved for ET 2016, Parkinson's tremor 2018. Advantages: no surgery/incision, no radiation, immediate tremor reduction, day-procedure. Limitations: unilateral only (bilateral carries dysarthria/ataxia risk); permanent lesion (not adjustable like DBS); effective skull density ratio (SDR) needed.

Question 6

How does ET affect quality of life?

Accepted Answer

ET has a profound impact on quality of life that is often underestimated by clinicians: functional disability (difficulty with handwriting, eating, drinking hot drinks, buttoning clothes, using tools — work impairment); social impact (embarrassment, social withdrawal, avoiding public eating/drinking, restaurant avoidance); psychological (depression and anxiety in approximately 50% of patients with moderate-severe ET); and underdiagnosis (many patients suffer for decades without a diagnosis, told it is "just nerves" or age-related). Tremor severity does not correlate with distress — even mild-moderate tremor causes significant QoL impairment in some patients.

Question 7

How does GMJ News cover essential tremor?

Accepted Answer

GMJ News covers WHO ET burden data, propranolol and primidone evidence, MRgFUS FDA approval and access, DBS for severe ET, the ET-Parkinson's distinction, and the underdiagnosis problem. Essential tremor is the most common movement disorder in Georgia — relevant to PHIG's neurological health priorities and the Georgian Medical Journal.

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