Not all tremors represent Parkinson’s disease

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.

The tremor of Parkinson’s disease

                                                     The tremor of Parkinson’s disease

Nitin. K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian

Weill Cornell Medical Center

New York, NY 10065

Since many of the readers of my blog and website (http://braindiseases.info) have written in asking about tremor, I thought in this post I shall describe the tremor seen in Parkinson’s disease in detail. The classical tremor described in Parkinson’s disease is a resting tremor which has a frequency of about 2-5 Hz. Let me explain in more simple terms what I mean by that.

The tremor in Parkinson’s disease is present at rest and not when the hands/ limbs are in motion (when the patient’s hands are placed on a table and are completely at rest, the tremor comes out. Now if you ask the patient to hold the hands in front of themselves or to perform some action like picking up a glass of water and bring it to their lips, the tremor becomes less prominent and may not be noticable. Hence it is called a RESTING TREMOR). Another way to observe the resting tremor is to see the patient walk. When we walk, our arms are held by the side of the body and are completely at rest, if a person has a resting tremor it is clearly visible.

The tremor in Parkinson’s disease has a frequency of about 2-5Hz ( meaning that the tremor is not very fast). It also has a large amplitude (meaning that it is not fine rather it is a gross tremor and can be well appreciated by the naked eye from a distance).

The tremor of Parkinson’s disease disappears/ stops when the patient falls asleep (most of the tremors abate on sleeping and hence this quality does not aid in differentiating the tremor of Parkinson’s disease from other tremors).

The classical tremor of Parkinson’s disease is a pill-rolling tremor (meaning the tremor consists of flexion and extension of the fingers in connection with adduction and abduction of the thumb. Imagine yourself rolling a pill, that is how the tremor looks like!!!)

Most importantly the tremor in Parkinson’s disease is accompanied by other signs of Parkinson’s disease such as rigidity (the tone of the muscles of the limbs is increased), bradykinesia (slowness in the execution of movement) and a disturbance of gait and posture (the gait is slow, stooped forward-we call this a festinating gait and their posture is off so patients are more prone to falls). That said and done signs of Parkinson’s disease may appear at different times and not all at once. At times the first/ earliest manifestation of Parkinson’s disease is the presence of an asymmetrical resting tremor (meaning the tremor usually appears asymmetrically/ only in one hand).

 

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