When Is a Tremor a Sign of Parkinson’s Disease?: By Dr. De Leon

Are you often asked by others, if you are nervous or cold?

Do you frequently hide your hands in your pockets when you walk to avoid stares from onlookers ? When you are out in public  do feel all eyes are on you and makes you shake more? So you stick your hand(s) in your pocket as fast as you can? Sometimes do you feel the urge to just sit on top of your hands until they go numb just to stop them from shaking for a minute or two?

If you do any of these things- it maybe your brain telling you something is not quite right! The problem can be something as simple as drinking too much caffeine (but usually will also feel tired and  have a fast heart rate) to as difficult as having a neurological disease affecting the cerebellum caused by alcoholism or poor nutrition.

The first step in finding out the problem is getting to a neurologist preferably a movement disorder specialist.  He or she can tell if the tremor is metabolic due to thyroid problems or neurological in origin. May sometimes require a few blood test and even an MRI of the Brain when other symptoms are present to confirm there are no other underlying causes.

The key in diagnosis is in the characteristic of the tremor at hand. Typically neurodegenerative  diseases like stroke, MS, PD tend to start on one side and remain unilateral for a time. While tremors due to metabolic issues and benign essential tremors (ET) are usually bilateral (present on both sides). Although, in ET these can have a more severe dominant side.

However, when at the tremors are at rest, this could be a sign or one of the initial symptoms of Parkinson’s disease (PD), a chronic progressive neurologic disorder caused by the deficiency of a chemical called dopamine. PD tremors present typically in the hands. Usually it manifests itself while at rest in the thumbs; but any of the fingers can shake resembling a rapid tap as if sending a Morse code message. This tremor is often more noticeable to others when sitting or walking.  It can sometimes less frequently present in the feet with an involuntary rhythmic toe movement, most frequently noticed at night while trying to fall asleep. Unlike the more common tremor known as essential tremor (ET) which occur primarily with action; by definition, a rest tremor disappears as soon as a deliberate movement or motion is made such as reaching for a cup. The rest tremor is also usually accompanied by decrease in arm swing in the  opposite arm- opposite arm usually stiffer/ tighter. sometimes only way some patients have noticed a decrease in arm swing is by  decrease ability to keep time in a Rolex watch – since they are self winding with gait and arm movement.

Another important characteristic to look at is penmanship. Handwriting is significantly affected with both types of tremors which can be equally frustrating for different reasons and can lead to illegible handwriting in individuals suffering from both types of tremor. As you know, the characteristic features of those with PD are small, tight and progressively diminutive hand writing (micrographia) rather than shaky. Both types of tremors can worsen with stress, lack of sleep, and caffeine intake. According to Dr. Okun, National Medical director for the National Parkinson’s  Foundation, evaluating a sample handwriting helped identify early PD in over 97% of the cases. 

Along with tremors patients with PD are stiff, thus have trouble performing normal activities (i.e. bathing and dressing) due to lack of mobility. They often complain of shoulder pain caused by stiffness in the joint. Another important finding is an inherent slowness when performing any type of movement (e.g. walking, eating, and opening doors and jars). Further, Parkinson’s patients have difficulty with gait and balance leading to frequent falls. Other symptoms accompanying tremors include loss of smell, visual deficits, fatigue, pain, sleep and mood disorders along with bowel and bladder difficulties. Sometimes the latter findings may precede the tremor itself by up to 10 years.

People with ET typically have problems with shaving, putting on make up, drinking out of a cup etc. These individuals usually present in their later years unless there is a family history which tends to be anticipatory in nature. Some of them may be heavy drinkers due to self medication confounding etiology of tremor. (Alcohol alleviates these types of tremors; however I do not recommended as the treatment of choice). This means that if grandma had ET at 80, children will have at least 10 years earlier and so on. Eventually gene will die out with each generation. Interestingly persons with essential tremors especially those who are older at presentation tend to have increased hearing loss. On the upside of things these individuals have great longevity. They too may experience tremors of voice, and trunk as well as legs making them unsteady to walk and in cases where tremors start young there is an increased risk of developing PD in later years.

If you or a loved one have any of these characteristic features especially if there is a family history of tremors or Parkinson’s disease, then you maybe one of the nearly 10 or  1.5 million people living with essential tremors or  PD respectably in the USA. Although at present there is no known cure for either disease and we arte not certain of the cause, there are many efficacious therapies for both including medications such as levodopa- the Gold standard of treatment for PD. Also surgeries like deep brain stimulation (DBS) can be of great benefit to either disease and thus far is the only treatment available able to stop tremors 100%.

So, if you or a loved one got some tremors after a well shaken chocolate martini (preferably), seek immediate care from a movement disorder specialist. Early treatment is associated with an increased quality of life and decreased disability particularly for PD.

Go ahead & shake it like there is no tomorrow!

For more information-

Www.pdf.org  PDF Helpline -1800-457-6676 Www.essentialtremor.org





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