Tremors, or shaking, are oscillations of the limb, part of the limb or combination of limbs that move about a joint. They have various frequencies and characteristics. When one thinks of shaking we often think of Parkinson’s disease and indeed this is a common condition that has tremor as one of its features. There are other types of tremor however and these include essential tremor, familial tremor, exaggerated physiologic tremor, chorea and athetosis.
The tremor of Parkinson’s disease is called a pill-rolling tremor because it usually involves making a motion that is like rolling a small object between the thumb and fingers and occurs while at rest. It can be temporarily suppressed by concentrating on the tremor but this is true of most tremors. Typically it is not there when one goes to use the hand, but eventually it does get to where it can interfere with activities such as eating or writing.
The other common type of shaking is called an essential tremor or ET. In this sense it is the opposite of a Parkinson’s tremor in that it is not present or very prominent while at rest but comes out with actions. Activities such as eating, drinking from a cup or holding objects will bring it out. Depending on when it is most noticeable, it can be more specifically called a postural tremor (e.g. when holding one’s hands out in front of you) or a kinetic tremor (showing itself while the hands are in actions such as using a spoon or fork) this tremor can be hereditary and it is then called a familial tremor but it’s really the same as an essential tremor. Most tremors are aggravated when one gets anxious or stressed. One of the things that can aggravate or even cause tremor is certain medications. The quality of this type of tremor is similar to ET and it is usually more of a nuisance than anything serious. Medications such as inhalers or pills used for asthma, valproic acid, lithium and caffeine can cause this. As the medications are often needed, it is usually better to put up with the tremor and to take the medication. If it is very severe, medications can be used. Hyperthyroidism can show itself as a tremor of this type.
Another type of shaking is called dyskinesia. There are various types and two of the more common are chorea which is a quick flicking movement of the hand and fingers, and athetosis which is more of a writhing or wiggling type movement of the arm. These can be caused by many conditions but nowadays it is more commonly seen in Parkinson’s disease patients who are on high doses of medications. It can be, but usually is not, debilitating and is often more annoying to people watching it than the patient themselves. This is because patients with Parkinson’s disease are usually more mobile and coordinated when they are “on” from the medications as opposed to when they are “off” and on lower doses or no medications and at that time are more stiff and immobile. Other conditions can cause dyskinesias such as Huntington’s disease, certain medications, stroke or so-called senile chorea. Some of these are benign and have minimal or no impact on function or longevity but some do have serious consequences, such as Huntington’s disease which is associated with progressive dementia. This latter condition is hereditary where one has a 50 percent chance of getting the disease if one parent has it.
Treatment varies depending on the type of tremor. Parkinson’s disease, essential tremor and familial tremor can be treated with medications which often, but not always are helpful. When effective at low doses they can have very few side effects and be quite beneficial. They don’t always work and at times high doses are required. The decision then has to be made as to whether to live with that amount of shaking, put up with the side effects of medications, or go to the next stage of treatment which is brain surgery. This is called deep brain stimulation (DBS) and involves putting a wire directly into the brain. This wire is attached to a control/battery pack that stays permanently under the skin in the upper chest area, not unlike a pacemaker. While this is often very effective, it does not cure either condition, medications are usually still needed, and is of course not risk free.
The last point to keep in mind is whether the tremor should be treated at all. This is certainly true with ET where the medication does not alter the condition per se and is used to treat the symptoms only. Therefore if the shaking is not so bothersome vis-à-vis taking a pill there is nothing wrong with not treating it at all. This is mostly true for Parkinson’s disease as well with the small proviso that there may be one or two medications that are used to treat Parkinson’s disease that may, although certainly not unequivocally proven, slow the progression of disease.
As with all medical conditions, talking over the options with one’s physician is always the best medicine.
Questions and or comments regarding this week’s health column please contact, Stuart Kieran, MD at Bitterroot Neurology 1019 West Main Street, Hamilton, MT 59840. Working together to build a healthier community!