Tremor: why do hands shake and is it always Parkinson’s - examination in Tashkent

What is tremor and what are its signs?

Rhythmic oscillations arise from misalignment between the flexor and extensor muscles, which is controlled by a complex network of brain structures, including the cerebellum and its associated pathways. Different diseases disrupt different parts of this network, and this is reflected in the nature of the trembling. That is why the doctor asks and observes in detail: in what situation the trembling occurs, what increases and decreases, what part of the body is involved, on one side or both.

• Rest tremor - the hand trembles when lying on the knee or hanging freely, and decreases or disappears when the movement begins; typical for Parkinson's disease
• Postural tremor - appears when holding a posture, such as arms extended forward; characteristic of essential and physiological tremor
• Kinetic tremor - occurs when moving, for example when carrying a glass
• Intention tremor - intensifies as you approach the goal: the hand begins to move faster just at the moment when you need to get the key into the keyhole; indicates cerebellar damage
• Symmetry matters: essential tremor usually occurs on both sides, parkinsonian tremor begins on one side
• Involvement of the head and voice is typical of essential tremor; In Parkinson's disease, the head usually does not tremble, but the chin may tremble

There is a simple observation that a person can do himself before the appointment and bring it to the doctor as valuable information. Place your hands on your knees, palms down, and relax completely - are they shaking? Then stretch your hands in front of you and hold them - what happens? Then slowly bring your index finger to the tip of your nose - does the shaking get worse towards the end of the movement? The answers to these three questions already greatly narrow the search. It is also useful to record a short video, since tremor due to anxiety often looks different in the office than at home.

Physiological tremor: when healthy hands tremble

Every person has a barely noticeable tremor - this is a normal property of a working muscle, usually invisible to the naked eye. But in certain circumstances it intensifies so much that it becomes visible and interferes. This condition is called increased physiological tremor, and it is not a disease of the nervous system: the cause is eliminated and the trembling goes away.

• Caffeine: coffee, strong tea, energy drinks; the effect accumulates with several cups per day
• Lack of sleep and overwork, physical exhaustion after exercise
• Severe excitement, anxiety, public speaking, exam
• Hunger and low blood glucose
• Nicotine and withdrawal period
• Medicines: asthma medications in inhalers, some antidepressants, overdose of thyroid hormones, lithium, corticosteroids, antiemetics and antipsychotics
• Alcohol withdrawal after prolonged use - characteristic morning tremors
• Increased thyroid function, low glucose levels, magnesium deficiency

The practical approach here is simple and very effective: before looking for a neurological disease, you need to review your first aid kit and daily routine with your doctor. A huge proportion of complaints about shaky hands are attributed to three cups of coffee, an asthma inhaler, starting an antidepressant, or a sleepless week. If the trigger is removed, the tremor disappears within days or weeks and no further testing is required. Separately, it is worth checking the dose of thyroid hormone drugs in those who take them: an excessive dose gives the classic picture of small frequent trembling of outstretched arms.

Essential tremor: the most common and most underestimated

Essential tremor is the most common independent disease manifested by trembling, and it is much more common than Parkinson's disease. The word “essential” means that tremor is the main and essentially the only manifestation, and not a symptom of another disease. About half of the patients have a family history: the hands of their parents and grandparents trembled, and this feature is passed on from generation to generation.

• Occurs during action and while holding a pose: the hand with a cup, spoon, pen trembles, when shaving and applying makeup
• At complete rest, when the hand lies calmly, there is usually no shaking - this is a key difference from Parkinson's disease
• Typically bilateral, although may be slightly asymmetrical
• The head is often involved - characteristic nodding or nodding movements, as well as a voice that becomes shaky
• Slowly grows over years and decades; There is no sharp deterioration over the months
• It can begin at any age, including young people, but more often becomes noticeable after 40 years
• There is no slowness of movement, stiffness or change in gait - the gait remains normal

There is a characteristic symptom that patients usually report themselves if asked: a small dose of alcohol temporarily noticeably reduces essential tremor, sometimes almost completely, for one to two hours. This is so typical that doctors take this response into account when making a diagnosis. But here it must be said directly and without beating around the bush: alcohol is not a treatment and should not become one. The effect is short-lived, after its end the shaking often gets worse, and regular use of alcohol as a way to cope with the symptom leads to addiction - and this is a common and sad pitfall with this diagnosis. There are medications that are used specifically for this purpose and are prescribed by a doctor.

Tremor in Parkinson's disease: what is the difference?

Parkinson's disease is indeed accompanied by tremors, but its tremor is structured differently, and, just as important, it is never the only manifestation. It is the presence or absence of accompanying signs that makes it possible to distinguish between these states no less reliably than the nature of the trembling itself.

• Trembling occurs at rest: the hand lies on the knee and trembles, and when picking up an object, the trembling decreases or disappears
• The characteristic finger movement is reminiscent of counting coins or rolling a pill.
• It almost always begins on one side and remains noticeably asymmetrical for years.
• Other signs must be present: slowness of movements, decrease in their amplitude, muscle stiffness
• Small handwriting, shuffling gait with small steps, decreased arm span when walking, poor facial expressions, quiet monotonous speech
• Early non-motor signs, often preceding tremors by years: decreased sense of smell, constipation, restless sleep with active movements and screams in sleep
• Head trembling is not typical for Parkinson's disease, although the chin or lips may tremble

The comparison of the two states can conveniently be reduced to a few questions. Does your hand tremble when it lies quietly and you are not thinking about anything - or only when you are doing something? Is it shaking on one side or both? Is there, in addition to trembling, a feeling that the body has become slower, the movements are smaller, the gait has changed? Is your head shaking? If the tremor appears during action, symmetrically, involving the head and voice, while the gait and speed of movements have not changed - this is much more like an essential tremor. However, the final distinction is made by a neurologist: there are mixed and atypical pictures, and if in doubt, additional examination methods are used.

Other reasons worth knowing

In addition to the three main options, there are a number of conditions in which shaking is an important signal. Some of them are completely reversible with timely treatment, so a basic examination is done for everyone.

• Cerebellar tremor - slow, large-scale, intensifying towards the end of the movement, often together with impaired balance and slurred speech; occurs in multiple sclerosis, after a stroke, with lesions of the cerebellum
• Dystonic tremor - combined with an unnatural position of a part of the body, for example with turning or tilting the head; decreases with certain touch to the face or chin
• Drug tremor - from antipsychotics, antiemetics, lithium, some antiepileptic and immunosuppressive drugs; reversible with correction of therapy
• Alcohol tremor is a characteristic tremor in the morning and during withdrawal; severe withdrawal symptoms with high fever and confusion require emergency care
• Copper metabolism disorder is a rare, but fundamentally important cause in young people, since without treatment it leads to serious consequences, and if detected in a timely manner, it is well controlled
• Functional tremor - changes in frequency and character, decreases with distraction, often begins suddenly; this is a real condition that requires a special approach, and not a pretense
• Tremor with renal and liver failure, with severe anemia, with vitamin B12 deficiency

Examination and what can be done

1. Осмотр невролога с оценкой типа тремора: в покое, при удержании позы, при движении, при приближении к цели; проверка тонуса мышц, скорости движений, походки и мимики.
2. Подробная ревизия всех принимаемых препаратов и добавок, включая ингаляторы, гормоны щитовидной железы и антидепрессанты.
3. Оценка потребления кофеина, никотина и алкоголя, режима сна.
4. Анализ крови на тиреотропный гормон и, при необходимости, свободные гормоны щитовидной железы.
5. Общий анализ крови, глюкоза, показатели работы печени и почек, уровень витамина В12.
6. У пациентов моложе 40 лет при подозрении — обследование обмена меди.
7. МРТ головного мозга — при асимметричном треморе, при нарушении координации и походки, при внезапном начале и других настораживающих признаках.
8. Видеозапись тремора в домашних условиях — простая и очень полезная помощь врачу.

What you can do on your own now, regardless of the reason: reduce caffeine, improve sleep, don’t skip meals, reduce your alcohol intake. With severe tremor, everyday life is made much easier by simple devices - weighted cutlery and handles, mugs with a lid and straw, not filling a cup to the top, using both hands to hold an object, resting your elbows on the table while eating and writing. These little things sound banal, but they are the ones that return a person to the opportunity to calmly drink tea at a party.