Tremor Tutorial

“No matter how dark the moment, love and hope are always possible.”  George Chakiris

Start of the Story: Dr. James Parkinson was the first to describe (published in 1817) the condition that now bears his name.  He described Parkinson’s like this: “Involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported; with a propensity to bend the trunk forward, and to pass from a walking to a running pace: the senses and intellects being uninjured.” In other words, the original 6 patients he described had a resting tremor, flexed posture, and shuffling gait. Furthermore, Dr. Parkinson described the different types of tremors known at that time, and he said the tremor in “An Essay on the Shaking Palsy” occurred with the limb at rest, not during voluntary action.

Tremor Tutorial: I was asked to describe tremor in this blog, happy to do so.  If you need further information, here are some of the resources I used to research this topic:
http://emedicine.medscape.com/article/1150290-overview
http://www.tremor.org.uk/types-of-tremor.html
http://www.medscape.com/viewarticle/739106_4
http://www.ninds.nih.gov/disorders/tremor/tremor_FS.pdf
http://www.uptodate.com/contents/overview-of-tremor
http://www.webmd.com/parkinsons-disease/tc/tremor-topic-overview
http://www.medicinenet.com/tremor/article.htm
http://www.ninds.nih.gov/disorders/tremor/detail_tremor.htm
http://perspectivesinmedicine.cshlp.org/content/1/1/a008862.full
http://www.ohsu.edu/nod/documents/2007/05-07/Fahn%202003.pdf.

Tremor Defined:Tremor is an unintentional, rhythmic muscle movement involving to-and-fro movements (oscillations) of one or more parts of the body. It is the most common of all involuntary movements and can affect the hands, arms, head, face, voice, trunk, and legs. Most tremors occur in the hands. In some people, tremor is a symptom of a neurological disorder or appears as a side effect of certain drugs. The most common form of tremor, however, occurs in otherwise largely healthy people. Although tremor is not life-threatening, it can be embarrassing to some people and make it harder to perform daily tasks.”  http://www.ninds.nih.gov/disorders/tremor/detail_tremor.htm

Tremor Causes: Tremor may be caused by many different things, including: Parkinson’s; other central nervous system/movement disorders; brain tumor; normal aging; muscle tiredness; multiple sclerosis; certain medications; overactive thyroid; too much coffee or caffeinated drinks; and stress/anxiety/fatigue.

Tremor Types: When someone develops a tremor, your physician will likely classify it by its appearance and/or the origin/cause of the resulting movement. Tremor can be broadly classified usually as one of the following types: Parkinsonian tremor, Essential tremor, Dystonic tremor, Cerebellar tremor, Physiologic tremor, Psychogenic tremor, and Orthostatic tremor.

Parkinsonian tremor usually occurs as a ‘resting tremor’, and is often the first symptom of Parkinson’s (although >25 % of Parkinson’s patients have an ‘action tremor’).  A resting tremor occurs when a body part is at complete rest against gravity. Interestingly, tremor amplitude decreases with voluntary activity (i.e., with use it can decrease). The tremor, usually affects the hands, but also the chin, lips, legs, and trunk, can be markedly increased by stress or emotions.  Sadly, over time, this tremor usually starts on one side of the body and may progress to the other side. Video examples: https://www.youtube.com/watch?v=-Y3kex_8UoY and https://www.youtube.com/watch?v=WF5BDyNglwI

Essential tremor is the most common of abnormal tremors.  This is a type of ‘action’ (or kinetic) tremor, which occurs during voluntary movement  (i.e., at rest you are totally okay, but movement to do something initiates the tremor).  The hands are most often affected but the head, voice, tongue, legs, and trunk may also be involved.  Heightened emotion, stress, fever, physical exhaustion, or low blood sugar may trigger tremors.  Video example: https://www.youtube.com/watch?v=gICUe2708W4

It is important to distinguish Parkinsonian tremor from Essential tremor, as compared here: http://essentialtremor.org/wp-content/uploads/2013/07/ETvsPD092012.pdf

Dystonic tremor occurs in individuals of all ages who have dystonia, which is a movement disorder where sustained involuntary muscle contractions cause twisting and repetitive motions. Examples of dystonic tremor are twisting of the neck or writer’s cramp.  Video example: https://www.youtube.com/watch?v=a_qDXmuhRe0

Cerebellar tremor is a slow tremor of the extremities that occurs at the end of a purposeful movement.  Example of a cerebellar tremor is touching a finger to the tip of one’s nose.  Cerebellar tremor is caused by lesions in or damage to the cerebellum resulting from stroke, tumor, or multiple sclerosis. Video example: https://www.youtube.com/watch?v=raDdlDHh1Zo

Physiologic tremor occurs in every normal individual.  It may be heightened by strong emotion, physical exhaustion, hypoglycemia, hyperthyroidism, heavy metal poisoning, stimulants, alcohol withdrawal, caffeine, or fever.  It can occur in all voluntary muscle groups. Getting a grip on tremor: https://www.youtube.com/watch?v=pnRFbriztuQ

Psychogenic tremor can appear as any form of tremor movement.  The characteristics of this kind of tremor may vary but generally include sudden onset and remission, and greatly decreased tremor activity when the individual is distracted.

Orthostatic tremor is characterized by rhythmic muscle contractions that occur in the legs and trunk immediately after standing.

Tremor Treatment: There is no cure for most tremors. Some tremors respond to treatment of the underlying condition. Drug treatment for parkinsonian tremor involves levodopa and/or dopamine agonists.  Other drugs used for treating parkinsonian tremor are amantadine hydrochloride and anticholinergic drugs. Essential tremor is treated with beta blockers and primidone (an anticonvulsant).  Eliminating tremor “triggers” like caffeine (and other stimulants) is often recommended.  Physical therapy may reduce the tremor and improve coordination. Please refer to citations above for therapy of the other tremor types.

My Tremor: My symptoms include right hand-arm stiffness with an action tremor. At rest, my hand is stable.  By contrast, my hand can shake slightly while holding a coffee cup or when eating cereal with a spoon.  My tremor is not the typical type of tremor found in Parkinson’s.  My tremor is made worse by cold weather, lack of sleep and stress/nervousness.  However, all things considered, I’m not terribly concerned by my tremor, and so far, it’s not gotten any worse.

Google ‘Smart’ Spoon (Liftware http://www.google.com/liftware/ ): The Liftware spoon will help someone with Parkinson’s or with essential tremor.  This smart spoon senses how a hand is shaking. It then uses “active cancellation” to move the spoon opposite to the tremor to help keep the spoon steady.  The preliminary study has been published by Dr. Pathak and others (2014) “A noninvasive handheld assistive device to accommodate essential tremor: A pilot study”: http://onlinelibrary.wiley.com/doi/10.1002/mds.25796/abstract  Also see:  https://www.youtube.com/watch?v=99t5c6j8BR0 and http://www.theguardian.com/technology/2014/nov/25/google-launches-smart-spoon-shaking-hands-liftware

“Another way to be prepared is to think negatively. Yes, I’m a great optimist. but, when trying to make a decision, I often think of the worst case scenario. I call it ‘the eaten by wolves factor.’ If I do something, what’s the most terrible thing that could happen? Would I be eaten by wolves? One thing that makes it possible to be an optimist, is if you have a contingency plan for when all hell breaks loose. There are a lot of things I don’t worry about, because I have a plan in place if they do.” Randy Pausch

*Cover photo credit: http://grandcanyonsecrets.com/wp-content/uploads/2015/02/a7okka82dr3h7uaxycjr.jpg

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