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Dr. Keith Roach
To Your Good Health
Dear Dr. Roach: I'm a 64-year-old man in good medical health. Recently, a bump the size of a pea appeared on the large knuckle of my index finger. My general physician glanced at it and said that it was an arthritic node. I asked him who could remove it, and he told me not to worry about it until it grew or started to cause pain.
I want a second opinion. Which kind of doctor am I looking for to get this node evaluated? -- R.R.
Answer: Heberden's and Bouchard's nodes are bony enlargements on the hand joints. (Heberden's nodes appear on the joint closest to the fingertip, while Bouchard's nodes occur on the middle joint.) They are associated with osteoarthritis of the hand. Over half of 64-year-old adults have osteoarthritis of the hands, so these are common. I suspect your physician was quite correct.
A rheumatologist is the expert on joint diseases, and a hand surgeon is another expert on hand diseases. Surgery is not recommended for these nodes as they are part of the disease process and are likely to grow back.
Although regular exercise can help maintain good hand function and reduce pain and stiffness, we don't have treatments that can stop the progression of osteoarthritis in the hand or other joints.
Dear Dr. Roach: What is your opinion on using deep-brain stimulation as a solution for essential tremors? -- D.R.H.
Answer: An essential tremor is a common tremor (often familial) that most often affects the hands. It is called an "action" tremor, meaning that it occurs with any voluntary action, such as pointing. It is present in 5% of adults over 60 and tends to worsen with time.
In addition to the hands, it may affect the head (both nodding and shaking tremors are seen) and voice. The tremor can be quite severe, making it difficult to write or eat.
The first-line treatment for essential tremors is usually medication such as primidone or propranolol. There are second-line medication therapies and some adaptive devices that have helped a few of my patients.
I don't recommend surgical treatments lightly. Deep-brain stimulation is a surgical treatment since electrical leads need to be placed in the thalamus -- a deep brain structure that is necessary for coordination of movement.
I have never referred a patient for this treatment (I defer to the neurologist), but the published data show a 60% to 90% reduction in tremors. After 10 years, the benefit is about 50%.