What Causes Shaky Hands?

Tremor is an unintentional, rhythmic muscle movement, most often affecting the hands.  In some cases, tremor can be a sign of a neurological disease but the most common type of tremor occurs in otherwise healthy people.  Today's Health Tip will focus on this common type of tremor, known as "essential tremor".

Causes for tremor – There are a variety of causes for tremor, some serious, but most relatively benign or temporary. Neurological diseases including multiple sclerosis, Parkinson's disease, and stroke are some of the most serious causes. A number of drugs including amphetamines, corticosteroids, anti-depressants, thyroid replacement, and asthma medication can produce tremors.  While the exact cause for essential tremor is still being studied, there is some suggestion that it is related to mild degeneration of an area of the brain (cerebellum).
 
What does tremor look like?  Essential tremor is most likely to be noticed affecting the hands, but the head, voice, and arms may also be involved. The shaking involves small, to-and-fro movements which may not be noticed when the hands are at rest. A quivering sound to the voice may be present if the tremor affects the voice box.  Essential tremor is considered to be an "intention" or action-related tremor because it becomes worse with purposeful movements such as eating with a fork or reaching for a cup of coffee.  Some tremors, such as the one associated with Parkinson's disease, are more noticeable when muscles are relaxed.  In Parkinson's the tremor almost exclusively affects the hands or fingers and is known as a "resting tremor".
 
Is there a test for essential tremor? There is no specific test for diagnosing essential tremor.  For the most part the diagnosis is made by noting the characteristic movements and ruling out other potential causes.  Essential tremor occurs most commonly in middle-aged and older individuals. As a hereditary condition, there is a 50% chance that someone will develop essential tremor if one of their parents had the condition.  The possibility that the tremor could be due to a medication, excessive caffeine intake, nicotine stimulation or alcohol abuse should be considered.  Specific testing may be required if a medical condition such as an overactive thyroid, Parkinson's disease or multiple sclerosis is suspected. This could include blood tests and imaging studies of the brain, such as MRI scan.  With essential tremor, however, all of these tests would be normal.

How is essential tremor treated?  There is no cure for essential tremor.  So long as the tremor does not cause embarrassment or interfere with daily activity, no treatment is required.  For the most part, the condition can be managed with self-care measures such as:

• Avoiding caffeine or other stimulants
   
• Using Velcro fasteners for clothing instead of buttons
   
• Using large handled utensils when eating
   
• Using straws for drinking
   
• Wearing slip-on shoes instead of lace-ups

Should the symptoms worsen to the point that treatment is required, there are medications as well as surgical procedures that may help.  The beta blocker, propranolol and an anti-seizure medication, primidone, have shown some benefit in essential tremor. Surgery is reserved for severe cases of tremor that cannot be controlled with drugs or other measures.  Surgical procedures include deep brain stimulation (DBS) and thalamotomy.   DBS involves the use of implantable electrodes to send high-frequency electrical signals to the thalamus, the region of the brain where the tremor originates. During thalamotomy, the site of origin in the thalamus is destroyed with a heated electrode.  Other causes of tremor respond to treatment of the underlying condition. For example, if an overactive thyroid is responsible for the tremor, treatment to reduce the level of thyroid hormone in the bloodstream will help.  When medications are responsible, stopping or substituting the medication is effective.

Anyone with the recent or sudden development of shakiness should discuss this with their doctor.  In all likelihood it will turn out to be relatively benign, such as essential tremor or simply too much caffeine.  Since a tremor could represent something more serious, such as Parkinson's disease, it important to confirm the exact diagnosis as early as possible.

Dodging Restaurant "Calorie-Bombs"

A restaurant dining survey performed by the market research group, Living Social, found that the average American eats out on 4.8 occasions each week.  Nearly half of these respondents described themselves as "meat lovers," 22 percent said that they had a "sweet tooth," and 19 percent were self-described "fast food junkies". With the common tendency that many of us have to overdo it or splurge when it comes to eating, we need to be especially careful when eating in restaurants.  While restaurants happily cater to our “guilty pleasures”, they seem to be less concerned about our waistlines and general health.  The following are several “traps” that we can allow ourselves to become ensnared in when eating out.  

1. Beware the starters.  Eating bread or tortilla chips while waiting for your food to arrive can add hundreds of calories to your meal.  Sensible options are to ask the server to bring these items after your meal arrives, or take a piece of bread or a handful of chips and ask the waiter to remove them from the table. Don’t forget also that each tablespoon of butter (3 pats) spread on bread adds up to 100 calories.
    
2. Calorie-dense side dishes.  French fries or onion rings are often an automatic choice when the server asks for a choice of side dishes. As compared to a baked potato, however, two-ounces of French fries pack a hefty 174 calories while the same amount of baked potato has around 52. A baked potato can be a sensible alternative, but adding sour cream, cheese, or butter can turn this very reasonable side dish into a calorie bomb!   Instead of French fries, onion rings, or potatoes smothered in butter or gravy, consider lower fat sides like tossed salad, vegetables, or broth-based soup.
    
3. “Hidden calories” in beverages.  Can you imagine eating 8 to 9 teaspoons of sugar?  That’s the amount contained in 12 ounces of most soft drinks. When sugar is dissolved in soft drinks, however, it becomes much more palatable, as well as being dangerous to our waistlines. Alcoholic beverages are high in calories, too. The caloric content of most beer is in the 100 to 160 range for 12 ounces. By drinking water, unsweetened tea, or diet beverages these hidden calories can be avoided.
    
4. All salads are not created equal.  Salads can be a healthy choice, but those with high fat dressings, fried chicken tenders on top, or cheese and bacon bits can be just as calorie dense as the main course.  When eating out always order the dressing on the side. While olive oil/vinegar based dressings do contain fat and calories, they are generally healthier than creamy dressings.
    
5. Portion size out of control.  Over the years, the restaurant industry has increased the size of portions to coincide with the increasing American appetite. Just look at the options to “supersize” meals at many fast-food restaurants for just pennies more. One restaurant chain offers a twenty-four ounce steak which is the amount that most dieticians would recommended for six people!  Ask the server beforehand about portion size. If possible share an entrée or plan to take some of the meal home for a second meal.  And at all costs, avoid all-you-can-eat restaurants that simply encourage gluttony.
    
6.  “Meal-killer” desserts.  A sensible meal can be turned into a calorie-fest based on what and how much we choose to eat for dessert. Most large desserts contain between 500 and 1,000 calories. Amazingly, the Ultimate Red Velvet Cake Cheesecake from the Cheesecake Factory is reported to contain 1,540 calories and 59 grams of saturated fat!  Usually a post-meal sweet-tooth can be satisfied with a bite or two of a dessert shared among several people. Or, choose a lower calorie option like fresh fruit or a scoop of sorbet.

Everyone splurges from time to time, and an occasional indulgence is nothing to be ashamed of.  But with more and more people eating out, along with the calorie-packed dishes that are typical on restaurant menus, it makes sense to be careful about what you order. Calories and weight gain are only part of the concern.  The same foods that contribute to waistline expansion often contain higher amounts of sodium and saturated fat, both of which can contribute to heart disease and stroke.

Everyone Worries, but When Does Worry Constitute a Disease?

Everyone worries or feels anxious from time to time.  Financial issues, conflicts faced at work, problems with relationships--- these are just a few of the events that can bring about anxiety.  In prehistoric humans worry, or its more exaggerated counterpart, fear, may have even provided some benefits. Triggering the “fight or flight” response activated mental and physical responses developed to address threats to survival.
   
Most people experience what could be called “normal worry”.  This type of worry is relatively brief and doesn’t interfere with work, relationships, or other activities of life.  One study found that people may experience this type of worry for up to 55 minutes a day. This is in contrast to someone who has an anxiety disorder in which worry can be present for several hours a day.  Anxiety disorders are characterized by excessive or irrational worry, usually present for several months or years.  Millions of people in the United States are estimated to be affected by an anxiety disorder.

One of the most common anxiety disorders is called Generalized Anxiety Disorder (GAD).  People with GAD obsess over their concerns, even though they may recognize that these concerns are out of proportion to reality.  GAD may also be associated with physical symptoms such as rapid heart rate, sweating, dizziness, headaches, shaking, shortness of breath, lightheadedness, and difficulty swallowing.

The exact cause of GAD is not fully known, but has been linked to a number of factors including brain chemistry, heredity, and precipitating stressful events.  Additionally, using or withdrawing from addictive substances such as alcohol, nicotine or opiates can contribute to the development of GAD.

There is no specific test to diagnose GAD.  Health providers make the diagnosis based on symptoms and physical manifestations.  Often, a physical exam or laboratory tests are required to rule out other conditions that can cause anxiety-like symptoms. Excessive thyroid hormone (hyperthyroidism), asthma, and the heart condition supraventricular tachycardia are three medical conditions that can produce similar symptoms as those seen in GAD.
 
Treatment for GAD most often includes a combination of medication and cognitive-behavioral therapy, also known as “talk” therapy.  The most common drugs used to treat GAD are in the anti-depressant or anti-anxiety classes of medications.  Anti-anxiety medications (e.g. Xanax, Valium, Ativan, others) are typically only used short-term because of their potential for causing sedation, adverse side effects when mixed with other drugs, and addiction.

Cognitive-behavioral therapy (CBT) is delivered by a mental health professional over several sessions. Major goals of CBT are to help someone with GAD to understand the relationship between thoughts, behaviors, and symptoms as well as to gain control of distorted views of stress-provoking events.  Many people with GAD also benefit from joining a self-help or support group in which problems and successes are shared with others.

Factors that should steer someone toward receiving professional help are when excessive anxiety or worry:

• Interferes with work, relationships or social activities
  
• Lasts for several months,  seems overwhelming or uncontrollable
  
• Causes physical symptoms such as dizziness, rapid breathing or racing heartbeat
  
• Produces psychological symptoms such as sleep disturbance, irritability, or problems concentrating.
  
• Begins without an obvious cause  

“Do not anticipate trouble, or worry about what may never happen. Keep in the sunlight.” ― Benjamin Franklin

Feeling “Under the Weather”? How atmospheric conditions affect our health.

Bioclimatology is the study of climate in relation to living organisms, in particular the way in which weather conditions can affect human health.  While this would seem to be a relatively new science stemming from concern regarding environmental deterioration, the relationship between atmospheric conditions and health was touched on over 2,000 years ago by Hippocrates in his treatise on “Air, Water, and Places”.   Since then, weather has been shown to influence the course of a number of medical conditions including arthritis, the initiation of childbirth, and even heart attack.
 
Arthritis---Most people have heard of the association between changes in the weather, particularly the advancing of a low pressure system, and worsening of arthritis. An example is when someone with arthritis predicts that rain is coming because their knees are aching. The theory (although never proven) is that arthritic joints swell as the barometric pressure drops. This swelling irritates the nerves around the joints causing pain and stiffness.  This phenomenon, however, does not appear to affect every person with arthritis, nor is there evidence that this weather-related worsening brings about permanent joint damage. While moving to a warmer or more stable climate has been proposed as a remedy for this problem, it has not consistently been shown to provide a long-term benefit.   If weather predictably worsens arthritis, affected individuals may need to adjust their medications when a low-pressure system is approaching.  Light exercise to warm up joints and wearing appropriate clothing prior to going outside are other ways of addressing adverse weather factors.

Migraine Headache---Some of the atmospheric triggers for the development of migraines include bright sunlight, extremes in heart or cold, dry air, and barometric changes.  Drops in barometric pressure caused by traveling to a higher altitude, the onset of a low pressure weather system, and air travel seem to be particularly common triggers.  Many migraine sufferers are able to identify the specific weather trigger by keeping a careful headache diary, making note of each migraine and what could have caused it.  If traveling to a higher altitude, gradual acclimatization may help to prevent the headache.  If the trigger cannot be avoided, a medication used to prevent or abort attacks should be used at the first sign of a migraine.

Respiratory Disease---Respiratory conditions, such as asthma and chronic obstructive lung disease (COPD), can be affected by weather changes also.  COPD, formerly known as emphysema, is a progressive, life-long condition in which the flow of air from the lungs is partially blocked.  While the primary cause and irritant in COPD is cigarette smoking, certain weather factors including excessive heat or cold, high humidity, and air pollution can exacerbate symptoms.  Asthma is also a long-term lung disease that results from inflammation and narrowing of the airways. Cold air, allergens, and air pollutants commonly make asthma worse.  Thunderstorms can be a real problem in someone with allergen-sensitive asthma since the wind in these storms has been noted to stir up pollen grains at ground level and into the airways.  One specific atmospheric condition that can affect both COPD and asthma is called a “temperature inversion”. This occurs when the air near the surface of the earth is cooler than the air above.  This cooler air is heavier and does not move up to mix with the warmer air above.  Pollutants, such as ozone, dust, and smoke released near the surface will get trapped and build up in the cooler layer of air near the surface.  When the Air Quality Index reaches the “Red” (unhealthy) level, people with COPD or asthma are better off staying indoors in conditioned air and avoiding outdoor exertion. Keeping the air as pure as possible with use of a HEPA air filter and changing furnace filters regularly can help also. In cold weather the use of a scarf over the mouth can help to warm inhaled air when going outside.

Heart Disease---Heart attacks occur when blood flow through narrowed coronary arteries becomes blocked, cutting off the supply of oxygen to the heart.  Physical exertion as well as cold environmental temperatures increases the demand for oxygen by the heart.  The combination of the two, as when someone with coronary heart disease is shoveling snow in the winter, can be a formula for the development of a heart attack. In addition to causing exertional heat stroke, the stress imposed by hot weather can be dangerous in someone with a heart condition.  This is particularly true in athletes with underlying structural heart abnormalities and in the elderly. Coronary heart disease patients on medications such as beta blockers and diuretics need to be especially careful in hot weather since these medicines can affect the body’s ability to cool itself.
     
Mark Twain has been attributed with the quote, "Everybody talks about the weather, but nobody does anything about it".  While it is true that we have very little control over the weather, those with the medical conditions discussed would be wise to pay attention to the effect that weather has on their disease and learn to adjust their medications or lifestyle accordingly.    

Lyme Disease Awareness Month

In recognition of Lyme Disease Awareness month this May, the Centers for Disease Control and Prevention (CDC) encourages Americans to learn about this common tick-borne disease and take steps to protect themselves if they live in or visit areas with Lyme disease activity.  Statistics from the CDC indicate that there has been a progressive rise in the number of cases of Lyme disease diagnosed. In fact, it is now the most commonly reported vector-borne illness (disease transmitted to humans by ticks, mosquitoes or fleas) in the United States, with around 30,000 new cases each year. In 2010, 94% of Lyme disease cases were reported from 12 states, mostly in the northeastern U.S., near the town where the disease gets its name—Lyme Connecticut.

What causes Lyme disease? Lyme disease is an infection caused by a type of bacteria known as Borrelia burdorferi.  The infection is most often acquired from the bite of an infected deer tick, also known as a black-legged tick.  Ticks that spread the infection are in the nymph stage of their life cycle and are quite small when compared to the adult ticks. The infection is spread when a young tick feeds on an infected animal, taking Borrelia bacteria into its body. If the tick then feeds on a human, the bacteria can be passed along to its new host.  There is no evidence that Lyme disease can be passed on from person-to-person.

What is the first sign that someone may have Lyme disease? Lyme disease produces different manifestations at different times during the course of the illness.  The first sign of an infection is usually a rash called erythema migrans (EM).   This is a circular rash that develops at the site of the tick bite. This rash occurs in approximately 70-80% of those infected, appearing anywhere from a few days to a month after the tick bite.  EM gradually expands over a period of several days and can reach up to 12 inches in diameter. Sometimes the center of rash clears, resulting in a “bull’s eye” appearance.

What symptoms are associated with Lyme disease?  Along with the rash, most people with early Lyme disease develop symptoms such as fatigue, chills, fever, headache, muscle and joint aches. If treatment is not begun, other symptoms develop within days to weeks.  These include facial paralysis, headaches, neck stiffness, heart palpitations and “migratory” joint pain which moves from joint to joint.  Late manifestations of the disease includes  arthritis, particularly affecting large joints, such as the knees, and neurological complaints including mental status changes, altered sensation, malaise, headache, and sleep disturbance.

Is there a test available to diagnose Lyme disease?  The tests used in diagnosing Lyme disease are most accurate a few weeks after an infection develops. This is when the body has begun producing antibodies to fight the infection. The CDC currently recommends a two-step process when testing blood for evidence of antibodies against the Lyme disease bacteria. The first step involves procedure called “EIA” (enzyme immunoassay).  If this first step is negative, no further testing of the specimen is recommended.  If the first step is positive, a second step called an immunoblot test, or “Western blot”, is performed.  The laboratory diagnosis of Lyme disease is confirmed only when both the EIA and immunoblot are positive.

How is Lyme disease treated?  Most cases of Lyme disease can be cured with antibiotics, especially if treatment is begun early in the course of illness. Antibiotics that are effective for Lyme disease include doxycycline, amoxicillin, and cefuroxime axetil (Ceftin).

Can Lyme disease be prevented?  To prevent Lyme disease and other tick-borne diseases, the CDC recommends that people:

• Avoid areas with high grass or leaf litter and walk in the center of trails when hiking.
   
• Use repellent that contains 20%-30% DEET on exposed skin for protection that lasts several hours. Parents should apply repellent to children; the American Academy of Pediatrics recommends products with up to 30 percent DEET for kids. Always follow product instructions!
   
• Use products that contain permethrin to treat clothing and gear, such as boots, pants, socks and tents or look for clothing pre-treated with permethrin.
   
• Bathe or shower as soon as possible after coming indoors to wash off and more easily find crawling ticks before they bite you.
   
• Conduct a full-body tick check using a hand-held or full-length mirror to view all parts of your body upon returning from tick-infested areas. Parents should help children check thoroughly for ticks. Remove any ticks right away.
   
• Seek health care promptly if symptoms of Lyme disease develop, including fever, rash, and muscle or joint pain.