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

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31 thoughts on “Tremor: its essentials and management

  1. Hi-for the last six months to a year, whenever I awake, I have a resting tremor. It seems to disappear within a minute of becoming aware of it. It affects my legs, arms, abdomen. Sometimes it feels as though my whole body is shaking. It doesn’t happen during the day, only in that waking time or occasionally as I’m drifting off to sleep. Do you have any suggestions? Gail

  2. Hmmm tough to say what it is Gail unless I see you and examine you clinically. My advise to you would be to see a neurologist or a movement disorder specialist. Just to let you know nearly all tremors disappear during sleep.
    Personal Regards,
    Nitin Sethi, MD

  3. Hi Dr. Sethi,

    I have always had a central tremor going as far back as my early childhood.
    I’m now 43 years old. In the last six months I’ve developed a more pronounced resting tremor in my right handed thumb. It’s not exactly what I would call pill rolling, as in really only effects my thumb. But it’s persistent. Could be described as a persistent/recurring twitch. Often happens when I am standing with my hands at my waist… but I can pick my hand up and observe the twitching. Can happen any time during the day, and it does seem more pronounced when under stress.

    I have an annoying computer that has a “touch pad” – and I’m wondering if I might have some sort of a repetitive motion thing, as opposed to some sort of neurological issue.

    I’d welcome your thoughts.

  4. Dear Chris,
    thank you for writing in. I am not certain what you have but one of the possibility that comes to mind is what is called a dystonic tremor. A dystonic tremor is seen in some people like musicians, writers etc and has being preferred to by various names like task specific focal dystonia or primary writing tremor.
    The thinking is that the act of holding the hand in a sustained posture as when you are playing an instrument or some people hold their pen real tight while writing rewires the neuronal circuits. When the pressure is removed (as when they stop playing or writing) a coarse tremor along with some abnormal posturing of the hands is observed hence the name task specific focal dystonia.
    While I am not implying this is what you have, I would recommend you to read about the same and if the tremor is bothering you, consult a neurologist whose interests include movement disorders ( a movement disorder specialist).
    In the interim period it may be worth your while, to alter the way you are using this computer, the way you touch the touch-pad and see if your symptoms start to get better.
    Hope this helps you.
    Personal Regards,
    Nitin Sethi, MD

  5. Dear Dr,

    From the time i married my husband 4 yrs back, i have observed that he has mild tremors ( hand and leg) but only during his sleep. Is there any cause of concern? It hasn’t increased or decreased over the yrs, but is more prominent when he has a stressful day.

    Awaiting ur reply

    S

  6. Dear Susan,
    thank you for writing in. Actually nearly all tremors and this includes essential tremor and the tremor of Parkinson disease disappear during sleep (meaning they subside or become less prominent).
    Your husband may be having something more like restless leg syndrome or another sleep related movement disorder. I would advise your husband at some point in time to see a neurologist. A good history and examination should get to the root of the problem. That the “tremor” has not worsened in the past several years is good news indeed.
    Personal Regards,
    Nitin Sethi, MD

  7. I have problem with my right hand thumb. It shakes when I don’t use it, and it shakes and starts to curl when I try to hold a pen to write, or hold something (especially small things). It has been more than 10 years and it gets worse over the years. Right now, I can’t use my right hand to write, push cellphone keypad, can barely hold chopsticks, or other activities involving my right hand thumb. Do you know what condition is this and what doctor should I go to?

    Thank You,

  8. Dear Dhyta,
    thank you for writing in. From what you describe, it seems you have what we call a task specific focal dystonia. Please read my reply to Chris above. It would be advisable to consult a neurologist who has expertize in dystonias/ movement disorders. There are medicines out there which can surely help you out.
    Personal Regards,
    Nitin Sethi, MD

  9. Thanks for your quick reply. I have searched more information on dystonia based on your suggestion and I thought it described my condition well. I will see a neurologist as soon as possible.

    Best,
    D

  10. I’ve been having tremors over the past 4 months in my hands, feet and legs, and lips. They are more prominent (especially in my hands) after exercise. My physician did blood work and it indicated I was “mildly” hyperthyroid (slightly low TSH, normal T3/T4). He blames the tremors on this condition. He has prescribed propranolol 20mg BID for the tremors, but wants to wait and see if the thyroid might correct itself before putting me on Methimazole (due to its side effects). My symptoms seem rather profound for a “mild” case of hyperthyroidism. Do you have any further suggestions or input?

  11. I’ve been having tremors for almost a week now. It started of as more of a postural tremor in my hands when I had to hold them in a fixed position at work. It gradually worsened so it felt like muscle fatigue in my entire body…as if I’d just finsihed a really heavy workout! I now have continous tremors throughout my body…including a nodding head (Yes….I’m just like one of those dogs you see in the rear window of a car) I’ve had blood tests done yesterday and will get the results tomorrow….but to be honest I’m getting a little concerned at the speed of onset. I need steady hands for my job…so have had to take time off work. Is it possible that hyperthyroidism can so severely affect one with tremors…I thought it affected mainly the hands!! Have you any further advice?

    Thanks,
    R

  12. Dear Roisin
    thank you for writing in. Usually tremors if they are neurological in etiology have a slow steady progression. I am not certain what is plaguing you. I would rule any toxic/metabolic causes such as hyperthyroidism. Your doctor should be able to run some basic blood tests and help to pinpoint the problem.

    Personal Regards,
    Nitin Sethi, MD

  13. Thanks for your reply. I’m now having extreme difficutly typing this. I’ve been seen by 3 Neurologists today….they think I’m having Rubral tremors. Getting truncal tremors 3-4 x per second. Aren’t I the lucky one??? Not quite sure what lies ahead until I have the MRI to find out what the cause is. What a week its been!!!

    Any idea as to what I can expect??? I’ve had a quick look at the online literature….but couldn’t find anything conclusive.

    Kind regards,

  14. Dear Roisin,
    rubral tremor is the name given to a high amplitude truncal tremor (involves the trunk) which arises classically from the midbrain. Tremors can also come from the cerebellum.
    If your neurologists feel that you have a rubral tremor, you need to have a MRI scan to find out if there is anything in the midbrain. Further work-up shall be determined by what is seen on the MRI scan. What does not quite add up, it the rapid progression of this tremor.
    As I stated earlier there can be numerous causes of tremor. I would keep an open mind. Get the MRI scan done and follow up with your doctor as advised. Keep in touch.

    Personal Regards,
    Nitin Sethi, MD

  15. Hi,
    I have recently begun to have tremors, mainly in my hands, but sometimes (especially when just waking up) it feels like i have tremors in the muscles in my upper forearm. After being awake for a while, the tremor exists solely in my hands. Also, on days after I drink alchohol, I notice a shake in my legs and my hand tremors are just worse in general. My hand tremors are both kinetic and postural, when pulling my fingers back as if to put up a hand and say “stop” my hand shakes during the movement and will continue to tremor while holding this position. I have no tremor whatsoever when at rest. Also, any type of wrist turning motion with my fingers spread appears quite shaky but then will lessen when my final turned position is achieved. It is also important to note that my tremors are almost non-existant when drinking, but can sometimes be detected. I am not an alcoholic but drink several days a week in the summertime, I have gone up to 5 straight days without drinking since onset but the hand tremor persists mildly. This degree of drinking has been going on for 6 weeks, a couple weeks longer than the tremors have existed. I am not convinced that this is the cause as the tremors did not subside after 5 days of sobriety. I am waiting for my health insurance application to be approved before I get blood work but I have just been terrified since this started. My grandfather died due to MS and I know that an intention tremor potentially exists with this condition. Is there any detail you may have noticed which can help to put my mind at ease? I think the stress due to shaking actually makes my shakes worse. I remember years and years ago having mild shakes when eating soup and stuff after tough exercise but this came out of nowhere, I was trying to read a magazine on morning and could barely hold it still enough. I would be so greatful for any type of advise. Thanks for your time!

    1. Dear Travis,
      thank you for writing in. I am not certain what plagues you. There can be numerous causes of postural and kinetic tremors. The fact that your tremor lessens in amplitude when you drink points more towards benign essential tremor as a possible etiology. Other differential which remains is that the tremors are related to your alcohol consumption
      My advise to you would be simple. Stop drinking for a few weeks and when I say stop I mean abstain completely (not just cut your drinking down). 5 days is no litmus test. Also lessen your intake of caffeinated breverages (coffee, pepsi, coke etc). See what happens to your tremor after these simple interventions. Once you have health insurance you can be seen by a specialist who may order some basic blood tests to check your thyroid hormone status among others.
      I am sure your doctor shall be able to determine the etiology of your tremor.
      Personal Regards,
      Nitin Sethi, MD

  16. hi dr sethi,

    i have a tremor in my right cheek which is induced by smiling. this tremor also occurs when i wrinkle my nose. these tremors do not occur at rest.

    the tremor began spontaneously in march of 08. i have had two mris and lots of blood work. everything is so far normal, however i did notice i had a low TSH reading, and wondered if that might be the reason.

    any ideas what this could be?

    thanks

    1. Dear KBD,
      I do not know what plagues you since I have not examined you, a couple of things come to mind. Do you actually have a tremor or an abnormal movement due to irritation of the facial nerve (the facial nerve supplies the muscles of the face) and at times when something irritates the facial nerve ome may have abnormal movements eg hemifacial spasm and facial myokymia.
      My advise would be to see a neurologist/ movement disorder specialist. His/ her opinion might be worthwhile.

      Personal Regards,
      Nitin Sethi, MD

      1. hi dr sethi,

        i am not sure if it is an irritation of the 7th nerve. i did have a fiesta sequenced mri and it did not show any compressions on the 7th nerve.

        i was told it is not hemifacial spasm because it does not occur on its own at rest.

        my neurologist told me it is benign and usually happens to people who have anxiety. i do not have anxiety so i am not sure what he means by that.

        thank you,

        kbd

      2. Dear KBD,
        thank you for writing in again. Sometimes the compression of the facial nerve may not be visualized on the MRI scan. By the way did you just have a MRI scan or was a MRA scan also carried out ? MRA stands for magnetic resonance angiography. Did you have an EMG/NCV (electromyogram/ nerve conduction velocity) study of the facial musculature done? Facial tics are common and are usually exacerbated by stress and anxiety.

        Personal Regards,
        Nitin Sethi, MD

  17. I have what has been mainly self-diagnosed but discussed with my physician as right-hand focal dystonia. It presents itself in only one manner as far as I can tell – only when writing. My penmanship has always been poor but has degenerated to illegible during the past 5 years. I need for my wife to write checks, and frequently cannot sign my own name. Trying to draw a straight line with my right hand results in a jagged line. The condition affects my right hand only. I can draw a straight line with my left hand. I can extend my hands and there is no apparent tremor, nor is there tramor in any other part of my body. The condition came about gradually, beginning about 10 years ago. I do not consume alcohol during the week but will have a few drinks late at night on weekends, and I have noticed an improvement in the tremor after a couple of drinks. Sometimes the tremor completely goes away after alcohol consumption.

    Should I be concerned except for penmanship? My physician does not seem to be concerned and commented that he has ruled out Parkinson’s and other grave illness, and that an exact diagnosis may be difficult – requiring neurological specialist – and the likely result would be only to satisfy my curiosity.

    1. Dear Beck,
      thank you for writing in. It seems you have what we neurologists refer to as task specific focal dystonia. As the name suggests the dystonia (the hand assumes an unusual posture) comes on only when doing a specific task. This neurological condition has been referred to under various names such as primary writing tremor. It is commonly seen in professional musicians (as they tend to hold their hand in a sustained unnatural posture for many hours while playing) and may lead to a premature end to their promising career.
      There are treatments for this condition. One simple thing would to use a different hand grip (meaning the way you hold your pen) or use a pen with a thicker body. My advise to you would be to see a neurologist. He/ she shall be the best person to confirm your diagnosis and guide future treatment.

      Personal Regards,
      Nitin Sethi, MD

  18. hi i have had tremors im about 14 and they say i have a an anxiety disorder. the tremors are weird. my Dr said that they will go away, but they are sort of like ET but i can hold in the tremors. if i do a weird feeling builds up to a point it get to annoying that i have to let out the tremor. my Dr gave me Lorz..,ativan when they are bad. but now for some reason they are geting sort of hard to let out, do you what it mean?

    1. Dear BB,
      thank you for writing in. I am not sure what plagues you. Almost all tremors are excerbated/ made worse (either the frequency or the amplitude of the tremor increases) by stress and anxiety. Psychogenic tremor is a well documented clinical condition. In psychogenic tremor, no organic cause for the tremor is found. By organic I mean, the tremor is not due to any disease. Many patients with psychogenic tremor are able to voluntary suppress their tremor at least for a short time.
      Your doctor shall be the best person to guide your work-up further. I wish you my very best BB.

      Personal Regards,
      Nitin Sethi, MD

  19. Hello. I had cervical laminectomy surgery ( with fusion) in Sept. 2009. He did this surgery in hopes it would relieve my right leg weakness. I had a bone spur on my C-6. Prior to this surgery I was what I would call , losing the use of my right leg. I had 2 emg’s done that both came back abnormal. Althought the neurologist said that my left leg came back showing it was worse than the right leg, but I was losing the use of my RIGHT leg. ( ? ) So now I am having massive tremors in my right leg and it moves to my left leg and sometimes up into my right arm. I recently went to the e.r. for one of these attacks. It scared me to death. Does anyone know what could be going on with me?????

  20. hi, i have been diagnosed with a dystonic tremor. my neuro and doc have warned me this will get worse, but to be honest, from what i have read on the internet, i’m too scared to ask either of them, what this really means for me? i have had a tremor since the age of 3, my mum first noticed the shaking when i was trying to hold a bottle up, although she never took me to see a gp. over the last few years (i’m now 27) it has been getting really bad, some days are good, some are bad so i asked for help from my gp, as it started interfering in daily life, i dread to think of this getting worse, how much worse will i get? i’m on 80mg of propanolol that my gp gave me when he thought it was a familial essential tremor (sorry, i do have a family history of tremor in my cousin and dad, not sure if anyone else has it the family) the neuro did offer me other meds, but for some reason unbeknown to me, i refused?!? think it might have been shock, lol. i have another appointment with the neuro in 5 months and i will take her up on the different meds, as although the propanolol has calmed the tremor alot, i still have bad days but i have heard no one medicine will work for long and may result in surgery. im scaring myself as i don’t know exactly what dystonic tremor means, the tremor is in my arms, hands, head/neck, body and more recently my legs, i hope you can help me to understand what it is i have been diagnosed with. thankyou in advance. lou.

  21. Hello. A year and a half ago i had nose surgery and came away from the surgery with a tremor and a very weak right leg.
    The day after my operation was when the tremor began, it started with my head tremoring and it gradually moved down throughout my body, also my speech was slow and my right eye drooped meaning it does not close all the way shut. I could not walk properly for the first six months after surgery as my tremor was so severe. It has since calmed down but i still have the tremor and also have a weak leg which gives way at the knee. The tremor stops completely when i lie flat. It is now a year ahail half since this started and there is no sign of it stopping. I have had a brain and spine scan which came back as normal and no doctors can tell me what is wrong. I would be grateful for your views and any information you could give me. Thank you in advance.

  22. Hi, i have a tingling effect in my right hand thumb often in the day time, during the rest condition. And more over, in the nights when i sleep i can feel the heart beat in my fingers and feet. This bothers me a lot. Can you please comment on my symptoms.

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