Medical
Acupuncture

A Journal For Physicians
By Physicians

Fall
/ Winter 1989
- Volume 1 / Number 1

"Aurum
Nostrum Non Est Aurum Vulgi"

BENIGN
ESSENTIAL TREMOR RESOLVED WITH ACUPUNCTURE

Cristina
S. de la Torre, M.D.

ABSTRACT--
This article reviews the complete resolution of a case of benign
essential tremor, in a patient treated with acupuncture, who previously
had limited response to drug therapy. Three treatments were given
over a three-week period. The patient's tremor of the head and
upper extremities resolved 100%, and she has remained asymptomatic
to date (5 months after the last treatment).

In
April, 1989, a 38-year-old white female, presented with the chief
complaint of intolerable shaking of her head for over one year.
From 1987 until then, she was treated for a variety of routine
conditions at the practice. She had been diagnosed as having benign
essential tremor for many years. Her mother, also a patient of
the practice, reported that the patient suffered tremor of the
upper extremities since approximately age 2~3, being nicknamed
"shaky bones" by her peers. The main medications were propanolol
and diazepam, which only provided modest reduction in the intensity
of the tremor.

Her condition had been extensively studied
at several medical centers, where she was repeatedly told that
"she had to learn to live with the tremor, hopefully obtaining
some relief by taking prescribed medications".

The patient's family history was significant
for alcoholism in both parents, a disease which had also afflicted
her. She became a heavy drinker between the ages of 21 and 25,
and then again between 35 and 37. Other significant medical history
included asthma in childhood, excision of an ovarian cyst in 1970,
and a twin pregnancy delivery in 1982. The patient is married
and owns a successful business.

Marked tremor of the upper extremities
(1,2,3), both postural and during voluntary activity, was observed
since her first visit in 1987. Around February, 1988, the patient
began to notice tremor of her head, which had not been present
previously. In May, 1988, she was hospitalized for alcohol detoxification.
Soon after discharge, she complained of worsening of her head
tremor. She continued sober but increasingly tremulous u ntil
April, 1989, when she returned, requesting acupuncture to help
her with her head tremor, which by then had become intolerable.

The patient's constitution was determined
to be JUE YIN- Wood, on the East position, according to Dr. Yves
Requena's classification (4). Treatment was then organized following
Dr. Maurice Mussat's "Energy of Living Systems" theory (5,6),
specifically the use of triangular equilibration.

Her first treatment, on April 14, 1989,
consisted of a JUE YIN triangular equilibration in evolution,
using points along the JUE YIN (Lived Master of the Heart), ABSOLUTE
YIN (Conception Vessel), and YANG MING (Large Intestine/Stomach).

On her follow-up visit, one week later,
she reported great improvement of her head tremor, and mentioned
the onset of an unusual craving for sweets. She was then treated
with a TAE YIN simple triangular equilibration, with points on
TAE YIN (Spleen/ Lung), YANG MING and ABSOLUTE YANG (Governor
Vessel).

On her third visit, on April 27, she
reported further improvement of her head tremor, and an unexpected
complete resolution of her upper extremities tremor. It was then
decided to conclude her treatment series with a SHAO YANG simple
triangular equilibration (Triple Heater/Gall Bladder), SHAO YIN
(Kidney/Hear[), and ABSOLUTE YANG. She was instructed to return
3 weeks later for reassessment.

She did not return until 2 months later,
on June 27, when she reported complete resolution of both her
upper extremities and head tremor. She was still taking di-azepam,
5 mg twice a day, but had stopped taking propanelei. She was advised
to taper off the diazepam, and return for another series of acupuncture
treatments, should symptoms recur.

She did not return until 3 months later,
on September 28, when she brought in her mother for treatment.
At the time, the patient reported no recurrence of her symptoms,
being free of tremor for 5 months to date, and without taking
any medications. A physical examination, including neurological
evaluation, was normal.

DISCUSSION

Tremors may be physiologic or a
symptom of neurologic disease, such as tumors, trauma, infections,
demyelinating disease, Parkinson's disease, peripheral neuropathy,
and essential tremor (7). Benign essential tremor (called familial
or hereditary tremor when there is a positive family history)
is thought to be inherited as a Mendelian autosomal dominant trait.
No neuropathological lesion has been recognized in post mortem
examinations, its neurochemistry is unknown, and its pathophysiology
is obscure (8). It may appear at almost any time, often in early
adult life, but it may begin in childhood (9}. It is characterized
by coarse, rhythmic and symmetric tremor, persisting throughout
the range of motion of voluntary activity, increasing in amplitude
as the limb approaches an object (finger-to-nose test), or in
handling or bringing food or liquid to the mouth.

The frequency of the tremor varies between
6 and 12 Hz, most commonly recording 6-8 Hz (10). The tremor amplitude
diminishes with rest and the use of alcohol, and is exacerbated
by emotional and physical stress. Tremor increases m amplitude
with age, and may eventually interfere with fine movements.

Propanolol (in doses of 40-240 mg/day)
and other beta-antagonists which pass the blood-brain barrier
and therefore have central and peripheral actions, have been used
with varying responses, but no definitive cure (11,12). More recently,
primidone has been reported to be as effective as propanolol in
treating this condition (13). Alcohol, although the most effective
agent, is not recommended. Chronic alcoholism in patients with
essential tremor is often a consequence of their attempts to control
the symptoms by drinking (14).

The treatment of tremors with acupuncture
has 1cng been documented in the classical Chinese medical texts,
and continued to be reported in the European and American literature
(15), as "problems related to Wind of External and Internal origin".

For wider clinical applications, the
therapeutic response of benign essential tremor to acupuncture
needs to be studied in a significant sample of patients with this
same condition. However, the complexity of medical acupuncture
is such that treatment protocols may be inadequate to incorporate
the necessary data into a useful diagnostic and therapeutic formulation
(16). The patient's own diagram of constitutional characteristics,
past history, family history, and associated symptoms, eventually
determine the most appropriate therapeutic intervention in each
case.

With this individualized approach, other
functional movement disorders may also be considered as potentially
responsive to Medical Acupuncture. Concomitantly, further observations
of the effect of acupuncture on tremors may lead to unexpected
insights into intrinsic aspects of the motor system.

REFERENCES

1. Critchley E. Clinical manifestations of essential tremor. J.
Neurology and Neurosurgery- Psychiatry. 1972; 35: 365-75.

2.
Critchley M. Observations on essential (heredo-familial) tremor.
Brain. 1949; 72: 113-39.

3.
Marshall J. Observations on essential tremor. J. Neurology and
Neurosurgery-Psychiatry. 1962; 25: 122-25.

4.
Requena Y. Terrains and pathology in acupuncture. Vol I- Correlation
with diathetic medicine. Paradigm Publications, Brookline, MA.
1986.

5.
Mussat M. Energetique des Systemes Vivants. Medecine et Sciences
Internationales, Paris. 1982. Transl. by J.M. Helms, 1983.

6.
Mussat M. Cours d'Energetique des Systemes Vivants Appliquee a
la Acupuncture. 1ere, 2eme, et 3eme Annee. Ecole Superieure d'Acupuncture
Francaise. 1983.

7.
Koller W., Lang A. et al. Psychogenic tremors. Neurology 1989;
39: 1094-99.

8.
Adams R.D., & Victor, M. Principles of neurology- 4th edition.
McGraw-Hill Information Services Co., New York. 1989, chapter
5.

9.
Young R.R. In: Diseases of the nervous system- clinical neurobiology.
Edited by Ashbury A.K. et al. W.B. Saunders Co. 1986, Vol 1, chapter
32.

10.
Weiner W.J. & Goetz C.G. Neurology for the non-neurologist. 2nd
edition. J.B.Lippincott Co., Philadelphia. 1989.

11.
Dupont E., Hansen H.J. et al. Treatment of benign essential tremor
with propanolol. Acta NeuroL Scand. 1973; 49: 75-84.

12.
Winkler G.F., & Young R.R. Efficacy of chronic propanolol therapy
in action tremors of the familial, senile or essential varieties.
New Eng. J. Med. 1974; 290: 984-88.

13.
Findley L.I., Cieeves L. et al. Primidone in essential tremor
of the hands and head: A double blind controlled clinical study.
J. Neurology and Neurosurgery- Psychiatry. 1985; 48: 911-15.

14.
Growdon J.H., Shahani B.T. et al. The effect of alcohol on essential
tremor. Neurology. 1975; 25: 259-62.

15.
Kaptchuk T.J. The webb that has no weaver- understanding Chinese
medicine. Congdon & Weed, New York. 1983.

16.
UCLA Extension. Medical Acupuncture for Physicians. Santa Monica,
California. J.M. Helms, course chairman.

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