Tremor: its essentials and management

In this post I shall talk a little bit about tremors. What exactly is a tremor you may ask. The way we define tremor in neurology is a rhythmic oscillatory movement across a joint. One may have a hand tremor (your hands shake), leg tremors, head tremor and even speech and tongue tremors. One way to classify tremors is to divide them into physiological and non-physiological tremor.

Physiological tremor is present in each and every one of us. If you hold your hands straight out and balance a sheet of paper on it, you can see the paper shaking a little. This is due to the physiological tremor in our hands. We all have it and the thinking behind it is that it is due to cardioballistic motion. Now suppose you go and have a large (I think they call it venti size) Starbucks coffee and repeat the above test again. You shall find that your tremor is now more prominent, this enhancement of the physiological tremor by coffee and some drugs like aminophylline is what is called enhanced physiological tremor. Physiological and enhanced physiological tremors do not need to be treated as they do not disturb the patient in any way. You may ask the patient to cut down on his coffee though.

Non-physiological tremor: as the name suggests these tremors are pathological. One way to classify pathological tremors is on the basis of how they present. So one may have a tremor which is most prominent when the hands are completely at rest and is not present once the hands come into motion (or start doing some activity). This is called a resting tremor (tremor at rest) and is classically seen in patients with Parkinson’s disease. Other tremors are prominent only when the hand is engaged in some action and hence those tremors are called action tremor.

When a patient comes to us for the evaluation of a tremor what we look for is whether the tremor is isolated (meaning there are no other manifestations apart from the tremor) or whether the tremor is a part of a larger neurological syndrome. We want to rule out neurodegenerative conditions like Parkinson’s disease which may present with tremor. Secondly we want to know whether the tremor shall remain static or whether it is going to worsen as time goes by. Then we try to classify the type of tremor and try to identify its etiology. Is it drug induced? What are its exacerrbating factors and what factors make the tremor become less prominent? Does the tremor become less prominent after consuming alcohol? Does the tremor run in the family (meaning is there a family history of tremors)? What does the tremor involve: just the limbs or also the head and speech?

In my next post I shall talk about the management of tremors.

Dr. Sethi