Patients frequently come to see me for evaluation of their tremor. Invariably the history is that the tremor was first brought to their attention by a close friend or a family member. The patient is worried that he/she has Parkinson’s disease and hence seek a neurologist’ s attention. Rarely are they bothered by the tremor per-se. By that I mean the tremor is usually not disabling and does not impair their quality of life at least initially. So do all tremors represent Parkinson’s disease? Are there any benign tremors? Which tremors warrant medical attention? These are some of the issues I plan to dwell on in this blog post. I hope some of my readers shall find the information useful.
So what exactly is a tremor. Well neurologically a tremor is characterized by rhythmic oscillatory and involuntary movement across a joint. I used the work involuntary because tremors at times can be voluntary. Voluntary tremor is usually psychogenic (meaning it has a psychological basis to it). We shall not discuss psychogenic/voluntary tremors in this post though. Suffice to say that a doctor shall be able to identify psychogenic tremor based on the history and examination findings alone.
So what do I look for when a patient with tremor comes to me seeking an explanation. Well the age of the patient is the first clue to the etiology of the tremor. Idiopathic Parkinson’s disease usually starts off in the sixth to seventh decade of life. Familial Parkinson’s disease can start at a younger age but usually the tremor is not so prominent nor is it the initial manifestation. There can be many causes of tremor in the “young”. Various medical conditions some more common such as hyperthyroidism, hepatic and renal diseases and some more exotic such as Wilson’s disease (due to a problem with copper metabolism in the body)come to mind. At times the answer is more innocuous and the tremor is either due to stress or excessive intake of coffee and other caffeine containing drinks. In that case all that is needed is reassurance. One other disease that needs to be kept in mind is multiple sclerosis though usually more findings are documented in exam (meaning that the tremor is not see in isolation). One should never forget to ask patients about the use of prescription, over the counter and illicit drugs. Many drugs such as sodium valproate (commonly used to treat seizures and at times bipolar disorder), bronchodilators (drugs used to treat asthma, reactive airway disease and chronic obstructive airway disease) cause a coarse postural and kinetic tremor as a side-effect. Once the drug is stopped the tremor abates.
Another common entity frequently confused with Parkinson’s disease is what is called essential tremor or also sometimes referred to as benign essential tremor. Patients who have essential tremor are usually in the same age group as patients with idiopathic Parkinson’s disease and hence the confusion and concern arises. Essential tremor has the following characteristics: it is usually a postural tremor (meaning that the tremor is most prominent when the hands are kept out and maintained at a posture such as having them stretched out in front of you. Remember the classical tremor of Parkinson’s disease is a resting tremor. Meaning the tremor is most prominent when the hands are at rest like for example resting on the patient’s lap and the patient’s attention is diverted). Essential tremor is a faster and finer tremor as compared to the tremor of Parkinson’s disease which is a slower (2-5 Hz) and of higher amplitude. A point to note here is that tremors are frequently classified based on their frequency, amplitude and position (rest Vs postural Vs kinetic). Patients who have essential tremor frequently in addition to the hand tremor also may have a head tremor (the head shakes either from side to side [no-no tremor] or up and down [yes-yes tremor]). They may also have a tremor in their speech (voice tremor). On further questioning some of them may admit to having the tremor run in their family (meaning their father and grandfather also had a similar tremor). They may have also noted that when they drink alcohol the tremor becomes less prominent. Infact some patients start drinking excessively for this very reason! Essential tremor usually progresses very very slowly (if at all) and may never become problematic and disabling in the patient’s lifetime. Hence it does not need to be treated unless it is socially disabling (“Doctor Sethi I cannot drink a glass of wine without spilling it over my dress!” “Dr Sethi I am so embrassed when my hands shake in a business meeting!”). Essential tremor is not accompanied by the other signs and symptoms which accompany Parkinson’s disease such as gait problems, freezing, stiffness, rigidity and mask like facies.
So not all tremors represent Parkinson’s disease. A quick visit to your “local” neurologist shall give you an answer to what kind of tremor you have.
Braindisease's Weblog 
Dear Dr. Sethi,
I’m having a difficult constellation of symptoms, and while some clinicians aren’t giving me much feedback besides ‘the importance of a stepwise approach’, I’ve gotten a sinking feeling from some that the problem may be really serious.
I’ve had sinus disease for some time; had unilateral repeat left ethmoidectomy, etc. in Feb, started feeling ‘sick’ again w/in a month; added dizziness, ear pain, left eye pain, right eye ptosis, diplopia (vertical and torsional), right eye vertical skew deviation, nausea, vomiting, vertigo. Was told the sinus disease wasn’t causing other symptoms, referred for vestibular testing by neuro-opthlamologist (who mentioned to his fellow, not me, that I had some over-shoot/nystagmus/?). Advised that I had ~35% loss in vestibular function on left side after audiology testing. Not conclusive whether central or peripheral, but consensus is on central.
Have had many orthopedic procedures for left foot, and didn’t notice that I was becoming more unsteady, but began walking into things, and misjudging distances. Had a cervical kyphosis that I spent six months in PT for, thinking that it was a result of protective behavior resulting from a torn supraspinatus and another shoulder tear. Began having minor twitching, which one day turned into HUGE myoclonic movements, but very low amplitude (2-3Hz). Went to ER, had potassium, etc checked. All normal. Referred to Neurologist; copper serum, lyme titers, etc. were all normal, as was a 30min EEG. Then referred to a Movement Disorders specialist, who did intake, then suggested watchful waiting.
Myclonus became more insidious and persistent. One day, had light-headedness while seated at dinner, went to recline on a couch. Rose about 10 minutes later, and completely passed out (was caught on way down by two friends). Couldn’t move for about 15 minutes, was told I wasn’t making any sense/speaking clearly before I was finally able to get up. Felt terrible, went immediately to bed. Had follow up with Movement Disorders guy (incidentally he said he initially thought I had dystonia), who at seeing increased myoclonus, prescribed Klonopin, ordered paraneoplastic panel, results for Hu, Ma, Ri were all negative. Myasthenia Gravis labs came back within range.
Had Echocardiogram (normal); Holter monitor for 24hrs, “symptomatic sinus tachycardia”, (which I’ve had for a few years) and today, Tilt Table testing (passed with flying colors).
Should mention that two brain MRIs, and one of the orbits came back with no evidence of plaques, demyelination, atrophy, etc. Orbits one showed slight enopthlamosis (have hypoplastic right maxillary sinus), and suggested that as possible cause of dipolopia. At my insistense, because the myoclonus seems to be worse depending on what position my head is in (also have head-tilt in general), my doctor ordered a cervical spine MRI. Came back normal, noting a congenitally large spinal column.
Mentioned this to my new cardiologist, who said perhaps I wasn’t maintaining proper CSF pressure, which could be implicated.
No one has done a lumbar puncture yet, and I’ve been on leave from work for two months. My functioning has dropped through the floor–can’t pull dishes out of the dishwasher, have breathing trouble in shower, feeling of faintness, hands are losing motor control at times–feel like I’m washing my hair with lobster claws.
Do you have any guidance? Where should I go–what questions should I ask–what tests do I make them run?
Please, please, please, please, please…
-waiting for the other shoe to drop.
Dear Luanne,
I shall write a post on neurosarcoidosis–a fascinating disease.
Nitin Sethi, MD
Thank you for writing in Luanne.
Nitin Sethi, MD
Dear Sir,
I have tremors under two situations-
1. when Iam emotionally excited (all situations of emotionally excited like sudden angry or sudden happiness or anxious situations). In this situation my whole body starts shaking.It happens even when Iam extremely happy and laughing out loudly for say 5 minutes or more.
2. Another situation is when I do some physical work. Here the body part which i used start shaking. Like if I carry 2-3 Kg weight by same hand for 10 minutes then after putting off the weight my particular hand starts shaking and get normalize after 15-20 minutes. similarly if I remain standing on my legs in some uncomfortable postures (situation in a crowded bus or train)for say 20-30 minutes then my legs starts shaking.
My doctor said that it is because of anxiety but then why this happens when Iam not anxious but happy or when Iam not anxious but did some physical activity.
My mostly clinical tests are normal except:
1. GLOBULIN (lever func. test)–3.59, normal range–2.3-3.5 gm/dL
2. CREATININE (kidney func.)–1.22, normal range–0.6-1.2 mg/dL
3. HDL cholestrol–35, normal range–>60 mg/dL
Please advise what to do??
Dr. Sethi,
Have you ever seen a postural or kinetic tremor as a symptom of repetitive strain injury, such as a computer programmer might get by using a computer mouse excessively for years?
Thanks.
Shaun