Ancillary Tests For Tremor Differential Diagnoses
The overlap among tremor disorders is wide and complex. ET patients may present postural tremor coexisting with resting tremor, while postural tremor may coexist with resting tremor in PD and tremor in dystonia is often mixed including a rest tremor component. For the most complicated tremor patients, Dopamine transporter imaging can provide objective evidence to demonstrate presynaptic nigrostriatal dopaminergic deficit in PD, whereas, it is normal in essential, dystonic and psychogenic tremor.
Table 2 Potential neurophysiological tests for tremor differential diagnosis
How Is Tremor Treated
Although there is no cure for most forms of tremor, treatment options are available to help manage symptoms. In some cases, a persons symptoms may be mild enough that they do not require treatment.
Finding an appropriate treatment depends on an accurate diagnosis of the cause. Tremor caused by underlying health problems can sometimes be improved or eliminated entirely with treatment. For example, tremor due to thyroid hyperactivity will improve or even resolve with treatment of thyroid malfunction. Also, if tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.
If there is no underlying cause for tremor that can be modified, available treatment options include:
A new treatment for essential tremor uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brains thalamus thought to be responsible for causing the tremors. The treatment is approved only for those individuals with essential tremor who do not respond well to anticonvulsant or beta-blocking drugs.
When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation or very rarely, thalamotomy. While DBS is usually well tolerated, the most common side effects of tremor surgery include dysarthria and balance problems.
Clinical Examinations And Diagnostic Tests
Physicians evaluate tremors with clinical examination and diagnostic tests. Some of these tests are as follows:
Some tests, such as surface electromyograms and mechanical recording devices, help to define the rhythmicity, amplitude, and frequency of the tremors as well as the relationship between tremors and movements. These are not highly used in medical practice.
Other tests are useful to diagnose diseases that might be associated with the tremors.
In many instances a clinical examination might be more than enough to establish the diagnosis, and other tests are not indicated.
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S Of The Body Affected
The tremor in PD usually starts on one side of the body and may develop on the other side as the disease progresses. In ET, the tremor usually affects both sides from the beginning of the condition.2
The hands are more often affected with tremor than the legs in people with PD, and the voice and head are almost never involved. In ET, the hands are also predominantly affected, but the tremor can also be present in the head and voice.2,3
Clinical Conditions Associated With Enhanced Physiologic Psychogenic And Drug
Enhanced Physiologic Tremor
This is an action tremor similar to the essential tremor, best seen when the hands are outstretched and fingers spread apart. It is seen in association with intense anxiety and in situations of stress. It can also be associated with certain disease states such as hyperthyroidism and hypoglycemia in withdrawal syndromes and associated with drugs .
Psychogenic tremors are very complex and do not fit very well with any of the prior categorizations. Individuals with Psychogenic Tremor might show characteristics of action as well as resting tremors, with clinical features that change in short periods of time and with a degree of disability that is not proportional to the tremor. The onset of the tremor might be very acute and not related to any other diagnosed medical condition. In some cases, the tremor might be induced by suggestion. Some patients have a prior history of somatization . In some cases, there is some secondary gain associated or attention-seeking behavior associated with the tremors.
This is a very challenging diagnosis. If an underlying emotional condition is diagnosed the patient should be referred to a psychologist or a psychiatrist.
The following is a list of drugs and toxins that can induce tremors in otherwise healthy individuals:
- Advanced liver disease with encephalopathy
The treatment of these tremors is related to the primary condition.
Task- and Position Specific Tremor
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Softer Voice Or Masked Face
Doctors say that a softer voice or masked, expressionless face is a common sign of the disease. Some patients with Parkinsons disease symptoms may also talk softer without noticing or have excessively fast speech or rapid stammering. Parkinsons causes disruption of movement, including facial muscles.
Classification Of Tremor And Update On Treatment
P. DAVID CHARLES, M.D., GREGORY J. ESPER, B.S., THOMAS L. DAVIS, M.D., ROBERT J. MACIUNAS, M.D., and DAVID ROBERTSON, M.D., Vanderbilt University School of Medicine, Nashville, Tennessee
Am Fam Physician. 1999 Mar 15 59:1565-1572.
Tremor is a symptom of many disorders, including Parkinson’s disease, essential tremor, orthostatic tremor, cerebellar disease, peripheral neuropathy and alcohol withdrawal. Tremors may be classified as postural, rest or action tremors. Symptomatic treatment is tailored to the tremor type. Combination therapy with carbidopa and levodopa remains the first-line approach for parkinsonian tremor. Essential tremor may be amenable to propranolol or primidone. Propranolol may be useful in treating alcohol withdrawal tremor, and isoniazid may control the cerebellar tremor associated with multiple sclerosis. Clonazepam may relieve orthostatic tremor. Other agents are also available for the treatment of tremor. When medical therapy fails to control the tremor, surgical options such as thalamotomy, pallidotomy and thalamic stimulation should be considered in severe cases. Thalamic stimulation, the most recent of these surgical approaches, offers the advantage over ablative procedures of alleviating tremor without the creation of a permanent lesion.
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Is Shaky Hands A Symptom Of Thyroid
An overactive thyroid can produce several characteristic symptoms , such as hand tremors , racing heartbeat, a high blood pressure, increased appetite, decreased sleep, or weight loss. All these symptoms may not be present at the same time, but any of them should alert the person to the need for evaluation.
Who Is Affected By Tremor
About 70% of people with Parkinsons experience a tremor at some point in the disease. Tremor appears to be slightly less common in younger people with PD, though it is still one of the most troublesome symptoms. People with resting tremor usually have a more slowly progressing course of illness than people without tremor.
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Conditions That Can Cause Tremors Besides Parkinsons:
The tremor of Parkinsons disease occurs even at rest. Hence it is called a rest tremor. Very few other conditions produce rest tremor.
But, many other diseases produce a tremor which is seen only when moving, for example when writing. This is called an Action tremor or posturokinetic tremor. Even these diseases are sometimes misdiagnosed as Parkinsons disease.
|Causes of Rest Tremor|
2. Excessive stress, coffee or smoking
3. Medications such as bronchodilators, valproate and lamotrigine
4. Chromosomal problems such as Fragile-X syndrome
5. Parkinsons disease itself!
And many others
Dementia With Lewy Bodies
- Dementia with Lewy bodies is a progressive, neurodegenerative disorder in which abnormal deposits of a protein called alpha-synuclein build up in multiple areas of the brain.
- DLB first causes progressive problems with memory and fluctuations in thinking, as well as hallucinations. These symptoms are joined later in the course of the disease by parkinsonism with slowness, stiffness and other symptoms similar to PD.
- While the same abnormal protein is found in the brains of those with PD, when individuals with PD develop memory and thinking problems it tends to occur later in the course of their disease.
- There are no specific treatments for DLB. Treatment focuses on symptoms.
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Main Catagories Of Tremors
Two main categories can be recognized:
The normal or physiological tremor is a fine, almost imperceptible, tremor that is difficult to see by the naked eye and does not interfere with activities. It can be seen in the fingers when the arms are outstretched. The frequency of the contractions is in the area of 8 to 13 cycles per minute. The cause of this tremor is not known, but it is not considered to be associated with any disease process.
The abnormal or pathological tremor it is more obvious and more visible to the naked eye. As such, it does interfere with everyday activities. The frequency of the contractions is in the area of 4 to 7 cycles per minute. In many instances this tremor is associated with defined medical conditions.
Most often the abnormal tremor is observed in the distal parts of the limbs however, every part of the body can be affected by the tremor.
The clinical distribution of the tremor might be different depending upon the medical condition associated with it and some individual factors. However, in a particular individual the quality and distribution of the tremor is very constant.
These abnormal tremors can be subclassified into the following categories:
Surgery For Hand Tremors
In some cases of tremors, especially essential tremors, surgery may be necessary. A minimally invasive process of inserting a neurostimulator into the brain called deep brain stimulation is available. Similar to a pacemaker, the neurostimulator device sends an electrical pulse that can prevent tremors from occurring.
A thalamotomy is another surgery for individuals with essential tremors. This particular surgery interferes with the thalamus on one side of the brain. This surgery is often performed on the side of the brain opposite side of your dominant hand. The results of the operation will then impact and relieve symptoms of the dominant hand. Side effects of the surgery are often temporary but can include speech difficulties, confusion, and balance issues.
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When Should Someone See A Doctor For Shaky Hands
If you have hand tremors, seeking professional help sooner than later could prevent the worsening of a severe medical condition. Medications that slow the onset and progression of neurological disorders could be an essential step to managing your wellness. On the other hand, your healthcare professional may inform you that you just need to reduce stress in your life or switch to decaf. Either way, finding out why you have hand tremors should be a priority.
What Causes Tremors Besides Parkinsons Disease
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Hand Tremors: How To Stop Shaky Hands
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Tremors are involuntary muscle spasms that can occur in many areas of the body. While twitching muscles can affect the eyes, legs, face, vocal cords, and other body parts, tremors are often associated with the hands. Living with hand tremors can be frustrating and make daily activities such as eating or dressing oneself difficult. Approximately 10 million people in the United States experience some form of hand tremors.
There are numerous types of tremors and reasons why they happen. Some are temporary and go away on their own, and others are linked to more severe health problems. Learn more about what causes hand tremors, how to stop shaky hands, and when to seek medical advice from a healthcare professional about hand tremors.
Movement Disorders Similar To Parkinsons
Conditions causing excess movement or decreased movement that are sometimes associated with Parkinson’s disease-like symptoms include:
What Movement Disorder Could I Have?
When making a Parkinson’s diagnosis, your doctor will review your medical history and symptoms, perform a careful neurological exam, and, if necessary, carry out further tests to rule out other movement disorders.
Your symptoms may be caused by a movement disorder other than Parkinson’s disease if:
- You display Parkinson’s disease symptoms and features that are characteristic of an additional movement disorder.
- The results of a brain imaging study or laboratory test, such as a blood test, confirm the presence of another movement disorder.
- Your symptoms do not respond to Parkinson’s disease medication.
Because movement disorders are not all treated the same way, it is important to get a proper diagnosis as early as possible so you can formulate the right treatment plan with your doctor.
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What Vitamin Is Good For Shaky Hands
However, tremors and other movement disorders are associated with vitamin deficiency , most vitamins B1, B6 and especially B12 . B12 is very important for keeping your nervous system in good working order. Severe lack of Vitamin B12 is rare, but shakiness and tremors can occur even in mild deficiency.
How Is Tremor Diagnosed
Tremor is diagnosed based on a physical and neurological examination and an individuals medical history. During the physical evaluation, a doctor will assess the tremor based on:
- whether the tremor occurs when the muscles are at rest or in action
- the location of the tremor on the body
- the appearance of the tremor .
The doctor will also check other neurological findings such as impaired balance, speech abnormalities, or increased muscle stiffness. Blood or urine tests can rule out metabolic causes such as thyroid malfunction and certain medications that can cause tremor. These tests may also help to identify contributing causes such as drug interactions, chronic alcoholism, or other conditions or diseases. Diagnostic imaging may help determine if the tremor is the result of damage in the brain.
Additional tests may be administered to determine functional limitations such as difficulty with handwriting or the ability to hold a fork or cup. Individuals may be asked to perform a series of tasks or exercises such as placing a finger on the tip of their nose or drawing a spiral.
The doctor may order an electromyogram to diagnose muscle or nerve problems. This test measures involuntary muscle activity and muscle response to nerve stimulation.
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Medications That Cause Tremors
Hand tremors are the potential side effect of numerous medications. Prescription drugs used to treat depression, asthma, cancer, and acid reflux are among many that can cause shaky hands. Some antibiotics, weight loss medications, and antivirals are also on the list of drugs that can result in temporary hand tremors.
Treatment Of Essential Tremor
Treatment may not be necessary for essential tremor unless the disorder is hindering normal activities. Relaxation techniques may be effective in patients whose tremors are aggravated by stress. Medication may be used to treat symptoms and may include:
- Beta blockers
- Calcium-channel blockers
- Mild tranquilizers
Botox injections in the affected area can help to temporarily weaken the muscles and decrease tremors. In extreme cases, cranial surgery, or surgery of the head, may be performed to treat essential tremor. Surgical options include:
- Stereotactic radiosurgery
- Deep brain stimulation
Numerous types of assistive devices are also available to make dressing, eating, writing and other daily activities easier and more comfortable for patients with essential tremor.
What Are The Symptoms Of Essential Tremor
If you have essential tremor, you will have shaking and trembling at different times and in different situations, but some characteristics are common to all. Here is what you might typically experience:
- Tremors occur when you move and are less noticeable when you rest.
- Certain medicines, caffeine or stress can make your tremors worse.
- Tremors may improve with ingestion of a small amount of alcohol .
- Tremors get worse as you age.
- Tremors dont affect both sides of your body in the same way.
Here are signs of essential tremor:
- Tremors that are most obvious in your hands
- Difficulty doing tasks with your hands, such as writing or using tools
- Shaking or quivering sound in your voice
- Uncontrollable head-nodding
- In rare instances, tremors in your legs or feet
Surgical Treatment Of Essential Tremors
When medications are not effective, one additional option is surgery to destroy the abnormal brain cells that are responsible for the tremors. These cells are located deep in the brain in the thalamus in a bilateral structure called the basal ganglia. There are several nuclei in the thalamus, but the one that is related to tremors is called the ventral intermediate nucleus . The operation, thalamotomy, can be done by conventional stereotatic surgery or by the use of a Gamma knife . Since there is one thalamus in each side of the brain, the thalamotomy could be unilateral or bilateral. An additional option is by deep brain stimulation with implanted electrodes.
These techniques have proved to be very effective in some patients but are not free of side effects. At the present time the following are accepted recommendations: