Carl Rosenkilde, - Westchester Health
 
 
 
Picasso, The Accordionist, 1911
 
 
Tremor
 
Tremor is the repetitive, involuntary shaking of a body part, most commonly the hands or head. It can be a disorder in its own right, or it can be a sign of another health problem.
 
There are several different types of tremor, all of which fall into one of three main categories:
 
Resting tremors — Resting tremors happen while you are sitting or lying down and relaxed. People who have a resting tremor can usually stop the tremor by deliberately moving the affected body part.
 
Postural tremors — Postural or positional tremors happen when you try to hold a body part still, against the force of gravity. If you have a postural tremor, your arms might shake if you hold them out in front of you.
 
Action tremors — Action tremors happen when you move deliberately.
 
Learning whether you have a resting, postural, or action tremor is the first step in discovering the cause of your tremor and its potential treatment. The different categories of tremor usually have very different causes.
 
 
Most Common Cause of Resting Tremor: Parkinson Disease
 
If that is the cause of your tremor, Drs. Rosenkilde and Caparoso will probably focus on treating the Parkinson disease in the hopes that doing so will also alleviate the tremor.
 
In a few instances, people with Parkinson disease who have a resting tremor also have  action tremor.
 
 
Most Common Causes of Action and Postural Tremors
 
 
Physiologic tremor
 
Everyone, even perfectly healthy people, has a little bit of shaking of the hands, especially when performing precise tasks, like threading a needle or focusing a camera.
 
This type of shaking, known as physiologic tremor, is not usually noticeable because it is so mild that it is not visible under normal circumstances.
 
Under some circumstances, physiologic tremor becomes exaggerated and therefore visible.
 
Causes of this exaggeration include:
 
  • Certain medications, such as those used to treat asthma or other breathing problems
  • Stimulants, such as caffeine and nicotine
  • Emotions: Anxiety, excitement, fear, etc...
  • Muscle fatigue, after a challenging workout
  • Alcohol or drug withdrawal
  • Overactive thyroid (hyperthyroidism)
  • Fever, infections, sepsis
 
Physiologic tremors caused by problems such as those listed above usually go away when the underlying cause is addressed.
 
If the physiologic tremor is caused by a medication, it may not be possible to eliminate the medication, but it may be possible to switch the medication or to lower the dose.
 
Essential tremor
Essential tremor (ET): is the most common type of tremor and is a common movement disorder.
 
Essential tremor is the term physicians use to describe tremors that do not seem to be physiologic or linked to another health problem.
 
It can be socially embarrassing and may cause difficulty in performing fine motor tasks such as writing, eating, and drinking. The tremor is usually absent or minimal with rest and disappears during sleep.
 
ET is a clinical diagnosis; there is no definitive test. Evaluation of ET includes a thorough history and physical examination.
 
  • ET is primarily genetic. In most, ET is inherited from one parent (autosomal dominant).
  • ET is due to abnormal communication between certain areas of the brain, including the cerebellum, the thalamus and the brain stem.
  • Each child of a parent with ET has a 50% chance of inheriting it. 
  • So far, researchers have identified 2 genes associated with ET.
  • Essential tremor can start at any time in life, sometimes as early as childhood, but typically after age 40.
  • Most essential tremor gradually and slowly become more noticeable.
  • The tremor tends to affect the hands and arms and can affect one side (left or right) more than the other.
 
When Do You Experience the Shaking?
 
People who have essential tremor usually shake when they try to hold the arms outstretched and still. They also tend to shake when they are doing a goal-directed movement, such as writing, drinking from a glass of water or touching the nose with a finger.
 
In fact, the shaking tends to get worse as the person is about to reach his or her goal.
 
Essential tremor sometimes affects the head, resulting in a repeated "yes-yes" nodding or a repeated "no-no" headshake. Usually, people who have these symptoms also have shaking in the hands or a tremor in the voice, although the head can be affected on its own. Less frequently, the legs and upper body are affected.
 
Essential tremor is often called a "benign" tremor because it does not usually affect the ability to perform daily tasks. However, it can be severe enough in some people that it can limit one's lifestyle.
 
 
 
 
 
Essential tremor test
 
One test used to evaluate essential tremor involves having you draw a spiral. The spiral on the left was drawn by a hand prominently affected by essential tremor. The spiral on the right is nearly normal.
 
 
Essential tremor vs. Parkinson's disease?
 
Many people associate tremors with Parkinson's disease, but the two conditions differ in key ways:
 
  • When tremors occur. Essential tremor of the hands typically occurs when during use of the hands. Tremors from Parkinson's are most prominent when the hands are at the sides or resting in your lap.
 
  • Associated conditions. Essential tremor doesn't cause other health problems, whereas Parkinson's is associated with a stooped posture, slow movement, stiffness, a shuffling gait, and perhaps other complaints. However, people with essential tremor may also sometimes develop other neurological signs and symptoms — such as an unsteady gait (ataxia).
 
  • Parts of body affected. Essential tremor can involve the hands, head, voice and legs. Tremors from Parkinson's typically affect the hands but not initially head or voice.
 
 
 
Coping Tips: General Suggestions

• Learn to use your tremor-free hand for as many activities as possible, including writing.

• Hold your chin toward your chest, or turn your head to the side to control head tremor.

• Use your tremor-free hand to steady your tremoring hand, and whenever possible use two hands.

• Use travel mugs with lids. When on the go, use lids for purchased beverages whenever possible.

• Carry straws with you. You can find sturdy, thick plastic straws in many houseware sections of stores if thin plastic straws are too flimsy.
 
• Avoid caffeine, mahuang, ephedra and other over-the-counter medications and herbs containing ingredients that increase your heart rate and can increase tremor temporarily.
 
• Keep your elbows close to your body when performing tasks to help control hand tremor.

• Carry small tape recorder with you to record notes.

• Carry large-handled, weighted pens & eating utensils.

• Use a signature stamp when possible for signing your name.

• Carry a strip of self-adhesive address labels to give to people who ask for your name and address.

• Fill out deposit and withdrawal slips at home before going to the bank.

• Consider using on-line banking to pay your monthly bills.

• If you write checks, do them all on a “good” tremor day.

• Consider using credit or debit cards instead of writing checks.
 
Dental visits

• Ask for adrenaline-free anethesia shots.

• Notify your dentist of all the medications you are taking. (Head tremor only)

• Request that your dentist stop periodically so you can massage and rest your jaw and your head.

• Ask your dentist whether a bite block will help steady your jaw during dental procedures.

• Talk with your dentist about having a person in addition to the dental assistant help with your procedure. The third person can gently hold your head to help control tremor.
 
 
Eating in restaurants

• Request that your meat be cut in the kitchen before being served.

• Consider ordering finger foods to eliminate the need for utensils.

• Ask that your soup be served in a mug.

• Request that drinking glass or mug be filled only half full.

• Ask for a straw.

• Avoid buffets or have someone assist you when going through the line.  
 
 
Eating, drinking, food preparation

• Use heavier glasses and mugs instead of light-weight cups. Soup mugs are also a good choice for drinking.

• When holding a mug or small glass, place your thumb along the rim and place your fingers across the bottom.

• Fill cups, mugs and glasses half-full.

• Consider using dishes that have vertical sides or buy rubber bumper guards from a medical supply store to place around the edges of your plates so you can more easily scoop your food.
 
 
Personal Care

• Use an electric razor when shaving.

• Have a manicurist care for your nails.

• Have a cosmetologist wax or pluck your eyebrows.

• Try using disposable floss holders when flossing your teeth.

• Hire a seamstress to do your mending, or find a volunteer to sew on buttons, thread needles and pin fabrics.

• Use an electric toothbrush or a child’s toothbrush for better control when brushing your teeth.
 
 
Applying makeup and putting on jewelry

• Apply mascara by resting your elbows on the countertop. Put the wand in one hand and use the other hand to keep the wand steady.

• Apply eyebrow pencil, mascara, eyeliner or lipstick by resting your finger or the palm of your hand on your face to steady your hand.

• Put on earrings by resting your elbows on a table. If you have head tremor, place your chin on an upended facial tissue box to steady your head. 
 
 
Writing

• Print rather than using cursive.

• Write in small letters — it’s easier than writing in large letters. Rest your forearm on a table while writing.

• Hold the pen between your index and middle finger.

• Place writing paper on a soft surface such as a newspaper to help control shaking hand movements.
 
Technology

Use a telephone with large buttons. Avoid phones with speed dial and redial buttons too close to the number buttons.

• Use a speakerphone, a headset or Bluetooth® device when using phones.

• Keep a small tape recorder next to the phone so you can record information when talking on the phone.

• Ask your security alarm representative to give you a remote to turn your system on and off.

• Use voice-activated dialing if available on your cell phone.

• Set your computer to omit double strikes on the key board and doubleclicks on the mouse.  Go to your computer’s Control Panel and click on Accessibility Options to set these options.
 
• Go to a store selling a number of different types of computer mouses, try them out, and choose the one that works best for you.

• Check into speech-recognition software.
 
• When choosing a digital camera, pick one with image stabilization technology.
 
Airport security

Getting through airport security can be especially difficult for people with ET. It can be a frustrating, intimidating experience.
 
• Give yourself plenty of time to arrive well before a flight so that you do not have to rush through security.

• When dressing for air travel, wear slip-on shoes that are easily removed to put into checkpoint trays and easily put back on afterwards. Bring shoehorm in hand luggage. Take your belt and watch off before going through security or don’t wear.

• Place everything you usually carry in your pockets, such as coins, keys and cell phone, into a plastic bag in advance so it is easier to place in the security tray.

• Have your ID and other travel documents together and in your hand before entering security.
 
[edited from several sites including mayoclinic.com, dukehealth.org, nih.minds.org]
 
 
 
 
P.S. Krøyer, Summer Evening on Skagen's Southern Beach, 1893
 
 
 
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