Editing Tremor (section)

==Treatment==
There is no cure for most tremors. The appropriate treatment depends on accurate diagnosis of the cause. Some tremors respond to treatment of the underlying condition. For example, in some cases of psychogenic tremor, treating the patient's underlying psychological problem may cause the tremor to disappear. A few medications can help relieve symptoms temporarily.{{citation needed|date=August 2021}}

===Medications===
Medications remain the basis of therapy in many cases. Symptomatic drug therapy is available for several forms of tremor:{{citation needed|date=June 2022}}<ref>{{Cite journal |date=July 2011 |title=Guidelines for management of essential tremor |pmc=3152172 |last1=Pal |first1=P. K. |journal=Annals of Indian Academy of Neurology |volume=14 |issue=Suppl1 |pages=S25–S28 |doi=10.4103/0972-2327.83097 |pmid=21847325 |doi-access=free }}</ref>
* '''Parkinsonian tremor''' drug treatment involves [[L-DOPA]] or dopamine-like drugs such as [[pergolide]], [[bromocriptine]] and [[ropinirole]]; They can be dangerous, however, as they may cause symptoms such as [[tardive dyskinesia]], [[akathisia]], [[clonus]], and in rare instances tardive (late developing) psychosis. Other drugs used to lessen parkinsonian tremor include [[amantadine]] and [[anticholinergic]] drugs like [[benztropine]]
* '''Essential tremor''' may be treated with [[beta blocker]]s (such as [[propranolol]] and [[nadolol]]) or  [[primidone]], an [[anticonvulsant]]
* '''Cerebellar tremor''' symptoms may decrease with the application of alcohol (ethanol) or benzodiazepine medications, both of which carry some risk of dependence or addiction
* '''Rubral tremor''' patients may receive some relief using [[L-DOPA]] or [[anticholinergic]] drugs. Surgery may be helpful
* '''Dystonic tremor''' may respond to [[diazepam]], anticholinergic drugs, and intramuscular injections of [[botulinum toxin]]. Botulinum toxin is also prescribed to treat voice and head tremors and several movement disorders
* '''Primary orthostatic tremor''' sometimes is treated with a combination of [[diazepam]] and [[primidone]]. Gabapentin provides relief in some cases
* '''Enhanced physiological tremor''' is usually reversible once the cause is corrected. If symptomatic treatment is needed, [[beta blocker]]s can be used

===Lifestyle===
Eliminating tremor "triggers," including stimulants such as [[caffeine]], from the diet is often recommended.<ref>{{Cite web |title=Essential Tremor - Neurology - Highland Hospital - University of Rochester Medical Center |url=https://www.urmc.rochester.edu/highland/departments-centers/neurology/conditions-we-treat/essential-tremor.aspx |access-date=2023-12-22 |website=www.urmc.rochester.edu}}</ref>
Essential tremor may benefit from slight doses of [[ethanol]], but the potential negative consequences of regular ethanol intake need to be taken into account. Due to the risks, alternatives such as "GABAergic drugs like sodium oxybate and NASs, LVA Ca2+ channel blockers like zonisamide, glutamate receptor antagonists like perampanel, and long-chain alcohols like 1-octanol" are preferred.<ref>{{Cite journal |last1=Wu |first1=Jingying |last2=Tang |first2=Huidong |last3=Chen |first3=Shengdi |last4=Cao |first4=Li |date=2020-08-25 |title=Mechanisms and Pharmacotherapy for Ethanol-Responsive Movement Disorders |journal=Frontiers in Neurology |volume=11 |pages=892 |doi=10.3389/fneur.2020.00892 |issn=1664-2295 |pmc=7477383 |pmid=32982923 |doi-access=free }}</ref><ref>{{Cite journal |last1=Ray |first1=Anaiska |last2=Biswas |first2=Dalia A |title=Association of Diet With Essential Tremor: A Narrative Review |journal=Cureus |date=2022 |volume=14 |issue=9 |pages=e29168 |doi=10.7759/cureus.29168 |doi-access=free |issn=2168-8184 |pmc=9567235 |pmid=36258958}}</ref> [[Beta blocker]]s have been used as an alternative to alcohol in sports such as competitive [[Darts|dart]] playing and carry less potential for addiction.<ref>{{Cite web |title=Surgical Treatments for Essential Tremor: Essential Facts for Patients |url=https://www.movementdisorders.org/MDS/Resources/Patient-Education/Surgical-Treatments-for-Essential-Tremor.htm |access-date=2023-12-22 |website=www.movementdisorders.org}}</ref>

[[Physical therapy]] and [[occupational therapy]] may help to reduce tremor and improve coordination and muscle control for some patients. A physical therapist or occupational therapist will evaluate the patient for tremor positioning, muscle control, muscle strength, and functional skills. Teaching the patient to brace the affected limb during the tremor or to hold an affected arm close to the body is sometimes useful in gaining motion control. Coordination and balancing exercises may help some patients. Some occupational therapists recommend the use of weights, splints, other adaptive equipment, and special plates and utensils for eating.<ref>{{Cite web |title=Essential tremor - Diagnosis and treatment - Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/essential-tremor/diagnosis-treatment/drc-20350539#:~:text=Physical%20therapists%20can%20teach%20you,Heavier%20glasses%20and%20utensils. |access-date=2023-12-22 |website=www.mayoclinic.org |language=en}}</ref>

===Surgery===
Surgical intervention such as thalamotomy and deep brain stimulation may ease certain tremors. These surgeries are usually performed only when the tremor is severe and does not respond to drugs, and further evidence is required to determine the best course of treatment for any individual patient.<ref>{{Cite journal |last1=Kremer |first1=Naomi I. |last2=Pauwels |first2=Rik W. J. |last3=Pozzi |first3=Nicolò G. |last4=Lange |first4=Florian |last5=Roothans |first5=Jonas |last6=Volkmann |first6=Jens |last7=Reich |first7=Martin M. |date=2021-08-05 |title=Deep Brain Stimulation for Tremor: Update on Long-Term Outcomes, Target Considerations and Future Directions |journal=Journal of Clinical Medicine |volume=10 |issue=16 |pages=3468 |doi=10.3390/jcm10163468 |issn=2077-0383 |pmc=8397098 |pmid=34441763 |doi-access=free }}</ref><ref>{{Cite web |title=Essential tremor - Diagnosis and treatment - Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/essential-tremor/diagnosis-treatment/drc-20350539 |access-date=2023-12-22 |website=www.mayoclinic.org |language=en}}</ref><ref>{{Cite journal |last1=Hallett |first1=Mark |last2=Litvan |first2=Irene |last3=the Task Force on Surgery for Parkinson’s Disease |date=1999 |title=Evaluation of surgery for Parkinson's disease: A Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology |url=https://www.neurology.org/doi/10.1212/WNL.53.9.1910 |journal=Neurology |language=en |volume=53 |issue=9 |pages=1910–1921 |doi=10.1212/WNL.53.9.1910 |pmid=10599758 |s2cid=28442991 |issn=0028-3878|url-access=subscription }}</ref> Response to surgeries can be excellent, reducing some symptoms such as "tremors, stiffness, slowness, and dyskinesias" for patients with Parkinson's Disease.<ref>{{Cite web |date=2021-08-08 |title=Deep Brain Stimulation |url=https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/deep-brain-stimulation |access-date=2023-12-22 |website=www.hopkinsmedicine.org |language=en}}</ref> 

[[Thalamotomy]], involving the creation of lesions in the brain region called the thalamus, is quite effective in treating patients with essential, cerebellar, or Parkinsonian tremor. This in-hospital procedure is performed under local anesthesia, with the patient awake. After the patient's head is secured in a metal frame, the surgeon maps the patient's brain to locate the thalamus. A small hole is drilled through the skull and a temperature-controlled electrode is inserted into the thalamus. A low-frequency current is passed through the electrode to activate the tremor and to confirm proper placement. Once the site has been confirmed, the electrode is heated to create a temporary lesion. Testing is done to examine speech, language, coordination, and tremor activation, if any. If no problems occur, the probe is again heated to create a 3-mm permanent lesion. The probe, when cooled to body temperature, is withdrawn and the skull hole is covered. The lesion causes the tremor to permanently disappear without disrupting sensory or motor control.

[[Deep brain stimulation]] (DBS) uses implantable electrodes to send high-frequency electrical signals to the thalamus. The electrodes are implanted as described above. The patient uses a hand-held magnet to turn on and turn off a pulse generator that is surgically implanted under the skin. The electrical stimulation temporarily disables the tremor and can be "reversed", if necessary, by turning off the implanted electrode. Batteries in the generator last about 5 years and can be replaced surgically. DBS is currently used to treat parkinsonian tremor and essential tremor. It is also applied successfully for other rare causes of tremor.

The most common side effects of tremor surgery include [[dysarthria]] (problems with motor control of speech), temporary or permanent cognitive impairment (including visual and learning difficulties), and problems with balance.<ref>{{Cite web |title=Surgical Treatments for Essential Tremor: Essential Facts for Patients |url=https://www.movementdisorders.org/MDS/Resources/Patient-Education/Surgical-Treatments-for-Essential-Tremor.htm |access-date=2023-12-22 |website=www.movementdisorders.org}}</ref>

===Biomechanical loading===
As well as medication, rehabilitation programmes and surgical interventions, the application of biomechanical loading on tremor movement has been shown to be a technique that is able to suppress the effects of tremor on the human body. It has been established in the literature<ref>{{Cite journal |last1=Castrillo-Fraile |first1=Victoria |last2=Peña |first2=Elena Casas |last3=Galán |first3=José María Trejo Gabriel y |last4=Delgado-López |first4=Pedro David |last5=Collazo |first5=Carla |last6=Cubo |first6=Esther |date=2019-12-05 |title=Tremor Control Devices for Essential Tremor: A Systematic Literature Review |journal=[[Tremor and Other Hyperkinetic Movements]] |language=en |volume=9 |doi=10.5334/tohm.511 |pmid=31867136 |pmc=6898897 |issn=2160-8288 |doi-access=free }}</ref>  that most of the different types of tremor respond to biomechanical loading. In particular, it has been clinically tested that the increase of damping or inertia in the upper limb leads to a reduction of the tremorous motion. Biomechanical loading relies on an external device that either passively or actively acts mechanically in parallel to the upper limb to counteract tremor movement. This phenomenon gives rise to the possibility of an orthotic management of tremor.{{citation needed|date=June 2022}}

Starting from this principle, the development of upper-limb non-invasive ambulatory robotic exoskeletons is presented as a promising solution for patients who cannot benefit from medication to suppress the tremor. In this area robotic exoskeletons have emerged, in the form of [[orthotics|orthoses]], to provide motor assistance and functional compensation to disabled people. An orthosis is a wearable device that acts in parallel to the affected limb. In the case of tremor management, the orthosis must apply a damping or inertial load to a selected set of limb articulations.{{citation needed|date=June 2022}}

Recently, some studies demonstrated that exoskeletons could achieve a consistent 40% of tremor power reduction for all users, being able to attain a reduction ratio in the order of 80% tremor power in specific joints of users with severe tremor.<ref name="TNRSE2007">{{cite journal |vauthors=Rocon E, Belda-Lois JM, Ruiz AF, Manto M, Moreno JC, Pons JL | year = 2007 | title = Design and Validation of a Rehabilitation Robotic Exoskeleton for Tremor Assessment and Suppression | url = https://digital.csic.es/bitstream/10261/24774/1/getPDF.pdf| journal = IEEE Transactions on Neural Systems and Rehabilitation Engineering | volume = 15 | issue = 3| pages = 367–378 | doi=10.1109/tnsre.2007.903917| pmid = 17894269 | hdl = 10261/24774 | s2cid = 575199 | hdl-access = free }}</ref> In addition, the users reported that the exoskeleton did not affect their voluntary motion. These results indicate the feasibility of tremor suppression through biomechanical loading.

The main drawbacks of this mechanical management of tremor are (1) the resulting bulky solutions, (2) the inefficiency in transmitting loads from the exoskeleton to the human musculo-skeletal system and (3) technological limitations in terms of actuator technologies. In this regard, current trends in this field are focused on the evaluation of the concept of biomechanical loading of tremor through selective Functional Electrical Stimulation (FES) based on a (Brain-to-Computer Interaction) BCI-driven detection of involuntary (tremor) motor activity.<ref>{{Cite web|url=http://www.iai.csic.es/tremor/|archive-url=https://web.archive.org/web/20120213122301/http://www.iai.csic.es/tremor/|url-status=dead|title=Tremor project&nbsp;– ICT-2007-224051|archive-date=February 13, 2012|access-date=Jun 4, 2020}}</ref>