Stable Ground
Monday July 19, 2010
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Often associated with Parkinson’s disease, tremor is a common movement disorder with a number of causes. Those causes include multiple sclerosis, stroke, traumatic brain injury, neurodegenerative diseases, drug use, alcohol abuse or withdrawal, and mercury poisoning, according to the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health. Tremor also occurs in otherwise healthy people and may have no known cause. It appears equally in men and women, most commonly in middle age and after. Tremor can be occasional, temporary or intermittent.
“Tremors are a very non-specific symptom and sign, and can arise from a wide variety of etiologies,” says Neal Hermanowicz, MD, professor of neurology, director of the Movement Disorders Program at University of California, Irvine and the Philip and Carol Traub Center for Movement Disorders at Eisenhower Medical Center in Rancho Mirage, Calif. “The two most common are essential tremor, which runs in families, and Parkinsonian.”
Therapy Helps Tremor
Hermanowicz often refers tremor patients to physical therapy based on the underlying diagnosis. “The referral is not ‘treat this tremor,’ but ‘treat this disorder,’ of which tremor is one of the symptoms,” he says. Tremor can make daily function difficult, and physical therapy helps those patients with strategies to work around the tremor or minimize its effect. Therapy can increase function and quality of life, enabling patients to, for example, write, cut food and manage daily hygiene.
Effective treatment depends on identifying the source of tremor, says Kathy Kumagai, PT, DPT, MS, NCS, OCS, CSCS, assistant professor at Azusa Pacific University and clinical faculty of the Movement Science Fellowship at Kaiser Permanente in California. Therapists play a critical role in helping identify the type of tremor, if a patient does not have a definite diagnosis, and designing therapy to improve the patient’s quality of life. “We spend a lot of time looking at functional activity, changing positioning, changing alignment, teaching new positions and working on weight bearing to reduce tremor,” Kumagai says. Exercises to improve coordination and balance also help.
Using braces to support affected limbs can make daily activities easier, but braces can increase spasticity, according to the NINDS, and must be used with caution. Some therapists teach patients to brace affected limbs on their own to help gain motion control.
“If patients press down gently with a hand on the thigh when seated at a table, for example, that active movement and slight activation of the arm muscle dampens tremor,” says Mary Hudson-McKinney, PT, MS, DPT, NCS, assistant professor, department of physical therapy education, Western University of Health Sciences in Pomona, Calif.
Weights on the ankles or wrists can help, as can adaptive equipment such as special plates and utensils for eating. Weights can cause fatigue, however, so their use must be carefully monitored.
Mobilization and Strengthening
Tremor caused by Parkinson’s can be complicated by rigidity. “The disease may create discomfort for patients, so they don’t move their arms as much and can end up with reduction in range of motion,” Hudson-McKinney says. “I take a careful look at the individual, their range, posture and alignment, and attempt to restore more optimum body positioning and range of motion. The key is not just the arms but the trunk itself, a whole body influence. I look at whether they tend toward a flexed posture, if there is tightness in the pectorals, and so forth.”
Hudson-McKinney finds some individuals tolerate a rolled beach towel better than a half foam roll. “If they can tolerate the foam roll, that gives more intensive stretch, but I always make sure they are tolerating it well. I do soft tissue mobilization, and look at gentle thoracic mobilizations as well, often over a stiff ball. The goal is to mobilize them into more thoracic extension. Once we get soft tissue mobilization and posture improved, then we can work on strengthening posture muscles.
With non-Parkinsonian tremor, such as cerebellar, loss of movement or gradations of movement can occur. In those cases, Hudson-McKinney says, weighting the extremity sometimes helps. Use of weights is not typical with Parkinsonian tremor, she adds. Teaching patients to change the way they perform basic tasks in order to bear weight on their limbs can help. For example, she might teach a patient to use a bed lever by putting a hand in a weight-bearing position and moving over that weight-bearing arm rather than reaching straight out.
Computerized neural motor retraining programs also can be quite helpful with tremor. “It’s a fun activity that gives them feedback as they manipulate their arms and gives them a new approach,” Hudson-McKinney says. “These are kind of like a Wii [video] game, but specifically designed for individuals with weak or limited motor control, or those who need to learn how to grade the intensity of the contraction and movement.”
Skill Set Analysis
One of the most important things PTs bring to the table for tremor patients, Hudson-McKinney adds, is skill set analysis. “We can watch an individual move and determine the components of their function,” she says. “I start by asking patients to show me the movements they’re having difficulty with and looking at the elements affecting their ability to move effectively. Then I go after those elements. It depends on the individual, but I can see definite changes in ability to complete activities of daily living and functional movement.” She re-analyzes movement at the start of every session, and may reassess during a session. Generally, patients have exercises to do between sessions.
PTs also can help tremor patients by knowing what medications are out there, Kumagai says. “If a patient comes in and isn’t hooked up with a neurologist, we can help get them to one in order to manage their tremor optimally. Physical therapy and medication go together; generally one without the other is not optimal.
“There are things available such as botulinum toxin and deep brain stimulation that people don’t know about. We can make sure they understand what types of medications are available for their particular type of tremor. Neurologists who don’t specialize in movement disorders don’t always know what’s out there, so sometimes, physical therapists have to make connections and get patients to providers who can offer them something.”
Therapists need to remain on watch for any changes in tremor intensity. Regardless of its source, tremor increases with stress or acute illness, Hermanowicz says. “If someone is fairly stable and then the appearance or intensity of the tremor increases, that indicates the patient is under stress. The source could be acute illness or infection, or a medication that doesn’t agree with them. Any change is worth an inquiry.”
Hudson-McKinney employs guided imagery, relaxation and deep breathing to help patients modulate a stressful situation and give them specific strategies to help reduce stress. •
Melissa Gaskill is a freelance writer.
“Tremors are a very non-specific symptom and sign, and can arise from a wide variety of etiologies,” says Neal Hermanowicz, MD, professor of neurology, director of the Movement Disorders Program at University of California, Irvine and the Philip and Carol Traub Center for Movement Disorders at Eisenhower Medical Center in Rancho Mirage, Calif. “The two most common are essential tremor, which runs in families, and Parkinsonian.”
Therapy Helps Tremor
Hermanowicz often refers tremor patients to physical therapy based on the underlying diagnosis. “The referral is not ‘treat this tremor,’ but ‘treat this disorder,’ of which tremor is one of the symptoms,” he says. Tremor can make daily function difficult, and physical therapy helps those patients with strategies to work around the tremor or minimize its effect. Therapy can increase function and quality of life, enabling patients to, for example, write, cut food and manage daily hygiene.
Effective treatment depends on identifying the source of tremor, says Kathy Kumagai, PT, DPT, MS, NCS, OCS, CSCS, assistant professor at Azusa Pacific University and clinical faculty of the Movement Science Fellowship at Kaiser Permanente in California. Therapists play a critical role in helping identify the type of tremor, if a patient does not have a definite diagnosis, and designing therapy to improve the patient’s quality of life. “We spend a lot of time looking at functional activity, changing positioning, changing alignment, teaching new positions and working on weight bearing to reduce tremor,” Kumagai says. Exercises to improve coordination and balance also help.
Using braces to support affected limbs can make daily activities easier, but braces can increase spasticity, according to the NINDS, and must be used with caution. Some therapists teach patients to brace affected limbs on their own to help gain motion control.
“If patients press down gently with a hand on the thigh when seated at a table, for example, that active movement and slight activation of the arm muscle dampens tremor,” says Mary Hudson-McKinney, PT, MS, DPT, NCS, assistant professor, department of physical therapy education, Western University of Health Sciences in Pomona, Calif.
Weights on the ankles or wrists can help, as can adaptive equipment such as special plates and utensils for eating. Weights can cause fatigue, however, so their use must be carefully monitored.
Mobilization and Strengthening
Tremor caused by Parkinson’s can be complicated by rigidity. “The disease may create discomfort for patients, so they don’t move their arms as much and can end up with reduction in range of motion,” Hudson-McKinney says. “I take a careful look at the individual, their range, posture and alignment, and attempt to restore more optimum body positioning and range of motion. The key is not just the arms but the trunk itself, a whole body influence. I look at whether they tend toward a flexed posture, if there is tightness in the pectorals, and so forth.”
Hudson-McKinney finds some individuals tolerate a rolled beach towel better than a half foam roll. “If they can tolerate the foam roll, that gives more intensive stretch, but I always make sure they are tolerating it well. I do soft tissue mobilization, and look at gentle thoracic mobilizations as well, often over a stiff ball. The goal is to mobilize them into more thoracic extension. Once we get soft tissue mobilization and posture improved, then we can work on strengthening posture muscles.
With non-Parkinsonian tremor, such as cerebellar, loss of movement or gradations of movement can occur. In those cases, Hudson-McKinney says, weighting the extremity sometimes helps. Use of weights is not typical with Parkinsonian tremor, she adds. Teaching patients to change the way they perform basic tasks in order to bear weight on their limbs can help. For example, she might teach a patient to use a bed lever by putting a hand in a weight-bearing position and moving over that weight-bearing arm rather than reaching straight out.
Computerized neural motor retraining programs also can be quite helpful with tremor. “It’s a fun activity that gives them feedback as they manipulate their arms and gives them a new approach,” Hudson-McKinney says. “These are kind of like a Wii [video] game, but specifically designed for individuals with weak or limited motor control, or those who need to learn how to grade the intensity of the contraction and movement.”
Skill Set Analysis
One of the most important things PTs bring to the table for tremor patients, Hudson-McKinney adds, is skill set analysis. “We can watch an individual move and determine the components of their function,” she says. “I start by asking patients to show me the movements they’re having difficulty with and looking at the elements affecting their ability to move effectively. Then I go after those elements. It depends on the individual, but I can see definite changes in ability to complete activities of daily living and functional movement.” She re-analyzes movement at the start of every session, and may reassess during a session. Generally, patients have exercises to do between sessions.
PTs also can help tremor patients by knowing what medications are out there, Kumagai says. “If a patient comes in and isn’t hooked up with a neurologist, we can help get them to one in order to manage their tremor optimally. Physical therapy and medication go together; generally one without the other is not optimal.
“There are things available such as botulinum toxin and deep brain stimulation that people don’t know about. We can make sure they understand what types of medications are available for their particular type of tremor. Neurologists who don’t specialize in movement disorders don’t always know what’s out there, so sometimes, physical therapists have to make connections and get patients to providers who can offer them something.”
Therapists need to remain on watch for any changes in tremor intensity. Regardless of its source, tremor increases with stress or acute illness, Hermanowicz says. “If someone is fairly stable and then the appearance or intensity of the tremor increases, that indicates the patient is under stress. The source could be acute illness or infection, or a medication that doesn’t agree with them. Any change is worth an inquiry.”
Hudson-McKinney employs guided imagery, relaxation and deep breathing to help patients modulate a stressful situation and give them specific strategies to help reduce stress. •
Melissa Gaskill is a freelance writer.
Monday July 19, 2010