An Occupational Therapy Perspective

by Jessica Floyd, MS, OTR/L

Tremor noticeably impacts an individual’s everyday life. Those with essential tremor know all aspects of their life can be affected; from getting up in the morning and brushing their teeth, to going out to a restaurant, or cooking a meal for friends, tremor has an impact. When everyday activities become difficult, individuals may feel depressed or anxious. They may feel embarrassed or even become socially isolated. It is crucial for Occupational Therapists to understand how ET impacts each individual, in order to help them participate fully in
daily activities.

Occupational therapy (OT) is a profession that helps people who have a disability, illness, or injury participate in “occupations” of everyday life. Occupations are all of the functional (useful and purposeful) activities someone participates in. Bathing, dressing, eating, reading, gardening, driving, and cooking are all occupations. In this article, strategies and adaptive equipment will be discussed in hopes of providing knowledge you can apply in your everyday lives. It is important to consider that an occupational therapist may be helpful, and a doctor can recommend an evaluation for individuals in need of services.

Useful Techniques
Occupational therapists teach principles that may help make functioning for individuals with tremor easier. Some ideas, which can be applied to many different activities, are listed here
and can be applied in any situation.

Use proper body mechanics. Body mechanics are the way in which you use and position your body to be most effective at completing a task. Simply sitting with your knees and hips in line, and placing both feet on the floor, will help to set your body up for success. This will decrease the stress on your arms and hands.

Maintain core stability for hand control.  Make sure your core is stable and in a good position by sitting in a chair with back and arm support; this will increase your ability to have controlled hand movements. Decreasing the demand on your hands and fingers will allow you to do tasks more efficiently, and use less effort.

Tuck your elbows in toward your body or support them on a surface. Tucking your elbows in toward your body or placing them on a supportive surface provides support. Sometimes, one-hand can be used to support the elbow of the opposite arm during an activity to further increase steadiness.

Use weighted utensils. The use of weighted utensils is something commonly suggested for those with tremor; however, these tools may not work for everyone.  Users may find these tools cumbersome or even annoying. However, it is worth considering use of these tools, which have helped many people.  Theories suggest the same amount of weight may not work for everyone, so try a variety of options to see what will work best for you.

Change or modify the task. Consider making small changes in the way you do things. For safety, use a dull fork or consider switching to a spoon while eating. To avoid spilling drinks, use straws, avoid overfilling, or use cups with covers such as travel mugs. If you are nervous about writing in public, consider writing bank-slips prior to going to the bank, or using pre-printed stickers with your name and address. Complete more difficult tasks when you have the most energy; for most, this will be influenced by the time of day or the order in which you complete tasks.  Incorporating simple changes into your routine can go a long way.

Adaptive Devices
Using tools or equipment that decrease the difficulty of the task being done, or allow the task to be done in a different way, can make functioning with tremor easier. There are endless products available for use during everyday functional activities. It can be overwhelming to find what may work well for you, and it is important to consider what is most applicable to your individual needs. Certain devices do not work for everyone, and it is essential you know what is available, consider various options, and are creative in the use of devices in order to gain the most benefit. Some tools may be targeted toward individuals with different problems, but can be applied to those with essential tremor as well. Other tools may be targeted specifically for tremor, but come in many different brands, sizes, models, or types. Consider exploring some of the equipment listed here to assist with basic activities. Ask an OT for assistance and recommendations about what products may work best for you.

Grooming. Here are some tips for adaptive devices to help with grooming. Use electric devices such as an electric toothbrush or razor; less work for your hand equals a lesser impact of your tremor. In addition, these devices are usually heavier and have larger handles for ease. An electric razor increases safety by decreasing the risk of cuts. Use a long-handled comb so your elbow can be tucked in at your side for support; doing this helps you to avoid reaching all the way up overhead. Use devices that can be secured on a supportive surface such as a suction cup toothbrush for dentures or a tabletop nail clipper.

Dressing and Bathing. To make dressing and bathing easier, use magnetic clasps or fasteners, Velcro™ closures, or elastic shoelaces. These changes do not make clothing look different, but decrease the need for fine motor control of the hands and fingers. For example, elastic shoelaces replace standard shoelaces in your sneakers or dress shoes. The laces remain tied and stretch to allow you to slip your shoes on and off; this decreases the need for tying and untying which can be very difficult for those with ET. Use a buttonhook or wash mitt. Buttonhooks come in both weighted and non-weighted and allow the user to pull buttons through the hole while holding a handle. A wash mitt allows use of larger body movements for washing with no need to worry about dropping your cloth.

Eating. For eating, many devices exist. Use weighted utensils or a weighted plate. Weighted utensils can even be purchased to look just like typical silverware, and come in a wide variety of styles to try. Use suction pads or non-skid materials such as a Dycem® placemat to ensure plates and bowls stay in place. Use a two-handled cup for increased control, or a plate guard or divided plates to assist with scooping food onto utensils. Bendable utensils or built-up utensils can be made to fit individual needs, and again they decrease the effort required by the hands. A rocker knife decreases the need for two utensils and two-hands working together. Simply rock the knife over any food with one hand to cut it into bite sized pieces.  Covered spoons are available to decrease spillage. Specialized self-stabilizing tremor utensils such as Liftware™ exist, but are more complex and expensive. Ask an OT or medical professional for more information.

Cooking. In the kitchen, consider paring boards with spikes to keep food being cut from moving around or slipping. Cutting boards are also available with supportive sidewalls or attached pivot knives to stabilize food and increase ease of cutting. Consider electric devices. One-touch can openers, electric choppers, and food processors are all available options. Consider use of mounted can openers or drink caddies designed to decrease spillage.

Computer and Phone Use. For computer and phone use consider adaptations that decrease the need for typing and increase the area for clicking. Adapted computer mouse software such as a free download at SteadyMouse.com is available. Speech activated software, hands free speakerphone features, and autodial options also exist. Large-button phones and keyboards can be purchased, and screens for most electronics can be set to a larger view.

Writing. For writing, various devices have been marketed for use with tremor. Weighted pens and pencils are commonly recommended. If weight works for you, consider wrist weights, weighted gloves, or universal weights that can be used on various utensils and are more cost efficient. These options also typically make it easier to change the amount of weight being used. The Steady Write Pen® (shown left) is designed to allow your hand to hold a plastic base, as opposed to the pen itself. This theoretically allows the hand to guide the pen more smoothly.  Another option is the Pen Again®. This pen changes how you grip and hold your fingers, and in theory allows the weight of your hand to stabilize as you write.

Other Useful Devices. Many more devices for around the house exist. Consider use of a hands free magnifying glass, electric pill organizer/dispenser, key turner, spill-proof urinal, cardholder, eye-drop aid, large button universal remote, or lamp switch enlargers. Also, consider options for creating your own devices. Use washers or bolts to add weight to utensils and adjust as needed. Use a paperclip as a zipper pull. Use shelf liners, Coban™, or elastic bands to provide non-skid surfaces. Create a cardholder by cutting slits in an egg carton. Hang recipes in the kitchen using a pants hanger or add no-rust nails to a paring board.

Now, the biggest question of all … Where can you find all of these devices? Unfortunately, there is no simple answer or one-stop-shop. The easiest way is to shop online. For a lot of individuals online shopping is not easy. Ask a caregiver, family member or medical professional for assistance if possible. Also, consider shopping at medical supply stores, using medical supply catalogs, or checking at local pharmacies or discount department stores.

Some websites to try include:  
www.caregiverproducts.com
www.activeforever.com
www.rehabmart.com
www.amazon.com
www.elderstore.com
In summary, consider compensatory techniques, adaptive equipment, and modifying or changing the task or demands. Remember, everyone is different and what works for one person may not work for another. Share your ideas and insight, and most of all be creative!

Jessica Floyd is a licensed and registered Occupational Therapist at Healthsouth Rehabilitation Hospital’s Neurological Rehab department, located in Concord, NH.