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Laurie Trlak

Why I Will Use Inderal

January 24, 2009 at 2:57 AM

I know, I know: its use is viewed with jaundiced eye by many professional musicians. Some consider that no musician worth his violin strings would even think of using it. After all, a professional musician should learn to deal with performance anxiety, right? Drugs like Inderal dull the edge of a performance and just show the weakness of the individual, don't they?

But I'm not talking about using Inderal to control performance anxiety. During the last year, tremors in my hands and fingers, especially my right hand, caused by multiple sclerosis, have gotten progressively worse, making playing all but impossible. At first it was just my right thumb. That posed a challenge for me in maintaining control of my bow, but it wasn't anything I couldn't handle. But over the course of the spring and summer, the tremors spread to the rest of my fingers. I asked my neurologist what I could do about it; she prescribed Gabapentin, a drug typically prescribed to control seizures. And she said if that didn't help I could try Lorazepam, a drug related to Valium. Neither of the drugs worked. The tremors continued to worsen; by the beginning of this year I couldn't play without my bow skipping horribly. In mid January I was asked to audition to play a wedding this coming summer. I almost cancelled. Feeling despondent as I faced the probability that I would no longer be able to play for weddings or for church, or at the nursing home, I prayed I would be able to perform well for the young couple who wanted me for their wedding.

The audition was, I thought, disastrous. My bow skipped horribly, and because I was concentrating so hard on just controlling my bow-arm, intonation and interpretation suffered terribly.

Inexplicably, the couple hired me.

On Monday of this week I saw my neurologist  and told her the drugs she'd presecribed four months ago were not helping. I had heard about a surgical procedure in which an electrode is placed deep into the hypothalamus in the brain to control tremors, and I was thinking of asking her about the procedure, even though it carries risks. But she told me that the Gabapentin was a newer drug, and that I should try the older "tried and true" drug, Inderal. She said to give it about three weeks to reach therapeutic levels in my blood, but tonight I had the best practice session I've had in months; my hand and fingers behaved, and Bach's Air and Handel's Sonata No. 4 in D Major rolled sweetly and smoothly from my fingers and my bow. For the first time in months I am encouraged rather than exhausted by a practice session and I don't feel that playing is a hopeless pipe-dream, and I am excited to be able to play well.

Now, after the setbacks of the past year I am a little leery of the possiblility that the tremors will worsen again, and I worry that I may develop a tolerance for Inderal that will require an increasing dosage. But the fact that I could play this evening and control my bow was a very encouraging sign.

Inderal: who'd a thunk it?


From Laurie Niles
Posted on January 24, 2009 at 3:59 AM

Laurie, I'm so happy for you, that this is helping!


From Stephen Brivati
Posted on January 24, 2009 at 4:37 AM

Greetings,

what some people don`t always seem to realize is that if you are violinist you -have to- play.  Whatever the challenges,  whatever the pain one doe s what is necessary to do what one was  put on this planet to do.

May you go from strength to strength,

Buri


From Pauline Lerner
Posted on January 24, 2009 at 7:14 AM

I didn't know that Inderal was used for controlling seizures.  I'm so glad you found something that worked for you. It must make a world of difference in your morale.  I'm glad you wrote about this, too.  I hope it will inspire others with bodily ailments to persist.


From sharelle taylor
Posted on January 24, 2009 at 9:08 AM

Its great to hear that something is working for you Laurie.  My sister with MS doesn't suffer from the tremors so much, but a lot of other things.  She recently had surgery on her parathyroids due to a tumour which was preventing calcium uptake.  The neuro didn't expect much change except for a drop in blood calcium levels and better bone density.  But - whoo-hoo, she can JUMP for the first time in about 10 years.  (I did have to ask, what was it that made her, at 58, think of jumping along the hallway.  She said she'd suddenly felt this urge to get up and try it!).  Many of her digestive symptoms have resolved also.  It has been a good lesson for the neuro, as he is now talking to his colleagues about the interaction.  You just never know what is waiting around the corner, and its good for us all to reflect on how such a little thing can have such a dramatic impact on the enjoyment we get.


From Anne-Marie Proulx
Posted on January 24, 2009 at 1:08 PM

Go ahead, it is not at all the same situation of those who are just nervous and take this!  You have a special condition and since violin is so important for you, try everything you can to play the longest possible!

Good luck!

Anne-Marie


From Jodi Bernard
Posted on January 24, 2009 at 2:08 PM

I have such a fear of the dentist that I they prescribed Lorazepam. You are right it doesn't stop the shaking.  I am glad you found something that works for you.

Best wishes.. Jodi


From Lisa Perry
Posted on January 24, 2009 at 2:18 PM

Pauline,

The way I read it was that the newer drug, Gabapentin, was anti-seizure, not the Inderal.

Good luck, Laurie.  I'm glad it's working for you.


From Royce Faina
Posted on January 24, 2009 at 2:13 PM

Lauri- Thank you for this blog, for it gives me encouragement as it will others. I have lived with morbid fear/anxiety (fight or flight responces) since my birth. You will be impressed at just how well your body and mind will adjust and adapt! I wish you the best,

Royce


From Kris Sargent
Posted on January 24, 2009 at 9:04 PM

Congratulations on finding something that's working for you!

Just to clarify for folks, gabapentin (trade name: Neurontin) is an anti-seizure medication that's also often helpful for neruopathic pain, and possibly for other nerve-related tremors.  It's occasionally also prescribed for migraine.

Propanalol (trade name: Inderal) is a beta-blocker that lowers blood pressure and can help reduce heart rate as well.  Many people use it for all kinds of performance anxiety.  It's not really a nerve-related medication, it just blocks the effects of that Fight-or-Flight response we all get when we're nervous (adrenalin stimulates your beta receptors, beta blockers block them).  Obviously it's not a great choice for people with low (and possibly even for folks with normal) blood pressure, as you can certainly pass through calm to "woozy" if your pressure drops too far.

They're both prescription meds, but there's quite a bit of precedent for using beta blockers for performance anxiety/stage fright.  Never heard of Neurontin used that way, but most people looking to help with stage fright don't, of course, also have MS.

Once again, congratulations on finding something successful!


From Karen Allendoerfer
Posted on January 25, 2009 at 12:12 AM

If it's helping you, I think by all means you should go ahead and use it.  I'd say that even if you were "just" dealing with performance anxiety. Congratulations on having that audition go better than you thought!


From al ku
Posted on January 25, 2009 at 1:06 AM

good going laurie!  not sure from your account if the tremor is related to performance anxiety or ms or a mixture of the 2 or others.  but, IF it is determined that the tremor is ms related and that it responds to inderal this well, having failed couple others,  your physician may be interested to inquire further.   as dr sargent pointed out, inderal is not a per se nerve drug and its adrenergic action is usually thought to be on the cardiovascular system.  however, since ms is a systemic demyelinating nerve disorder with various local or regional presentations, there is really no telling how it affects people... individually. 

often, if similar cases are encountered, a case report of some sort can be presented or even published, allowing other physicians to be more alert to this interesting presentation and outcome, and possibly helping with the management of other ms patients with similar conditions. 

 good luck and great playing!  great to see someone who helps the doctor to help self.


From Deborah McCann
Posted on January 25, 2009 at 7:17 AM

I am so happy for you.  Keep going!  I have a form of muscular dystrophy that affects my hands and feet, and know how bad I feel on days where there is no control over my own body especially in my playing.  Then on the days where it is not so bad, I take full advantage.  I believe Jacquline du Pres also had a formof MS and she did quite well for many years. 

Deborah


From Vartkes Ehramdjian
Posted on January 25, 2009 at 10:49 AM

Hello, I am in the (I was maybe), honestly I am confused, I had the same problems as yours exactly.
Tremors in the right hand (bow jumping), and difficulty in performing and teaching.
I saw a neurologist, he put me on Inderal. First dosage was 2 x 30mgs every four hours, and one valium one hour before performing.
It did not help. He then increased to 4 x 30 mgs of Inderal a day, and 2x2 valium.
Did not help either. He then added to Inderal and Valium ........ 4x50 mgs Topamax. (Plus the lithium and Cipralex that I was on) led to catastrophy.
That was a disaster. I ended up at the emmergency room,of the Royal Voc. I had  scans etc.
I then was lucky to see an excellent doctor at  the Montreal Neurological Institute, he told me to stop the Topamax,  the valium too ????, reduced lithium and guess what?
I played for my sweetheart Lisa's wedding  on Dec. the 21st, at the Sheraton, I played with my se violinist partner a "Duet" .Shostakovich, J.S.Bach Babadjanian and Sun rise Sun set to introduce them to the dance floor.
I consider what happened to me a "miracle"
I now have control of my bow, and thank GOD the tremors are gone.
I also have a technique for the bow (David Oistrakh).......if you want.
Here is my email, tram_violin@yahoo.ca
Vartkes


From Laurie Trlak
Posted on January 25, 2009 at 8:37 PM

Thanks to everyone for your responses. I am glad to have such encouragement. My professor in college encouraged the use of Inderal for performance anxiety; he had used it himself (and he is a world-class violinist) until he had to stop because of asthma. 

Just to be clear, the tremors in my hand (it also affects my left hand, to a lesser degree) are definitely caused by MS; that was one of the symptoms that led to my diagnosis (in addition to double vision, extreme dizziness and fatigue) although they weren't nearly as bad at that point as they are now (sometimes now my fingers will start "misbehaving" in my sleep, if as part of a dream I start to use them). My neurologist explained that Inderal used to be prescribed for intention tremors before Gabapentin came on the market. Since Gabapentin didn't help, she put me on the Inderal. It's helping so far. I may have to have the dosage increased (presently at 60 mg once a day), but the results I'm getting so far are very encouraging. The tremors are probably aggravated by performance anxiety, but not directly caused by it; before the tremors developed I didn't have any difficulty with that aspect of playing, even in front of an audience.

My performance at the nursing home today wasn't great, but I was able to play the Haydn Serenade and the Bach Air quite well. I found out afterwards that there was another violinist in the audience. She said she enjoyed the performance! Yay!

Laurie


From Leigh Latchum
Posted on January 26, 2009 at 1:19 AM

Hi Laurie,  I was fascinated in reading your article because I, too, have recently started noticing a tremor in my right wrist/hand.  It especially was acting up when I was playing very slowly in the lower half of the bow.  I absolutely freaked out when it was first coming on, say back in Sept of '08...so I started researching on line.  Within a week i also started noticing my right hand would  'dance' (tremor or kick)above the computer keys when resting...but nothing in my left hand.  I was actually thinking it was MS for me too, but all research pointed to familial tremors AKA essential tremors, a genetic/family trait.  Unfortunate for me, my Aunt had the shakes, my father has the shakes, and now at 52, I may have been given the trait.  A chiropractor told me my nerve endings were just overstimulated from too much performing violin and several massages/treatments would take care of the problem, but this did not help.  Then I went to my family doctor and he put me on a Beta Blocker.  This seemed to help, but my blood pressure dropped too low.  Now he has me on Primodone (anti seizure...I take 1/2 of a 5 mg tab/ day)which seems to really be helping.  I hope these comments help someone else out there as I personally was considering the deep implant surgery at one time.  My heart goes out to you because I knew exactly how you felt as I read your article. 

Sincerely,

Leigh


From Leigh Latchum
Posted on January 26, 2009 at 1:19 AM

Hi Laurie,  I was fascinated in reading your article because I, too, have recently started noticing a tremor in my right wrist/hand.  It especially was acting up when I was playing very slowly in the lower half of the bow.  I absolutely freaked out when it was first coming on, say back in Sept of '08...so I started researching on line.  Within a week i also started noticing my right hand would  'dance' (tremor or kick)above the computer keys when resting...but nothing in my left hand.  I was actually thinking it was MS for me too, but all research pointed to familial tremors AKA essential tremors, a genetic/family trait.  Unfortunate for me, my Aunt had the shakes, my father has the shakes, and now at 52, I may have been given the trait.  A chiropractor told me my nerve endings were just overstimulated from too much performing violin and several massages/treatments would take care of the problem, but this did not help.  Then I went to my family doctor and he put me on a Beta Blocker.  This seemed to help, but my blood pressure dropped too low.  Now he has me on Primodone (anti seizure...I take 1/2 of a 5 mg tab/ day)which seems to really be helping.  I hope these comments help someone else out there as I personally was considering the deep implant surgery at one time.  My heart goes out to you because I knew exactly how you felt as I read your article. 

Sincerely,

Leigh


From Michael Godfrey
Posted on January 26, 2009 at 1:38 AM

It seems to be a point of pride not to take drugs like beta-blockers.  But these are not performance-enhancing drugs like steroids.  For me, they greatly eliminate the excess adrenalin and the consequent uncontrollable shaking of hands, arms, and legs.  They also help me to retain my mental clarity when playing from memory.  I am very grateful to have this relief from performance anxiety that allows me to perform up to my ability.  Better power of mind or spirit over matter would be great, but these techniques go only so far for me.


From Pauline Lerner
Posted on January 26, 2009 at 10:42 AM

Laurie, thanks for the clarification about Inderal and Neurontin (generic name, gabapentin).  Gabapentin was originally developed as an antiseizure drug, but it is now used for many purposes.  As with many drugs, the psychiatrists learned about it from the neurologists and adopted it as their own.  It is commonly prescribed for depression and anxiety, and also for nonpsychiatric conditions such as prevention of migraines, treatment of chronic pain, and a host of other ailments.  Remarkably, it has some success for treating almost everything and it has very low toxicity.  Are you really taking only 60 mg once a day?  That is a very low dose.  I'm very glad that it is working for you.  I'm also glad that you wrote about it because other people with neurological problems are coming out of the closet and talking about their experiences.  I wish you all well.


From Mark Hartman
Posted on January 27, 2009 at 2:20 AM

What a wonderful thing, to find a drug that has few side effects and really helps alleviate a loss of the ability to perform. I'm very happy to hear of how this is helping Laurie. An earlier post commented "Go ahead, it is not at all the same situation of those who are just nervous and take this!" It is wonderful to see the outpouring of support for Laurie, but be careful that you don't fall into the trap of looking down on those whose use is based on performance anxiety instead of an identifiable physical condition. Performance anxiety is not "just being nervous." It can be a debilitating response to performance conditions and is not trivial to the musician who has spent their life developing the skills to have a professional career. I would like to say thank you to Laurie sharing her success. I'm happy that you've found something that helps!

Mark

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