Selected Podcast
Tremors: When Should You Be Concerned?
Dr. Fredy J. Revilla discusses when to be concerned about tremors when to see a doctor and exercises that may help.
Featuring:
Fredy J. Revilla, MD
Dr. Revilla is board certified neurologist with Prisma Health Neuroscience Associates in Greenville, S.C. Transcription:
Maggie McKay (Host): If you've ever experienced an involuntary quivering movement in your muscles, maybe you thought it was just from fatigue or a reaction to medicine. But perhaps they were tremors, which can be severe or hardly recognizable. But how do you know if they're tremors or something else? Today we'll talk about what tremors are, what the causes can be and how to treat them, among other things. Welcome to Flourish, a podcast brought to you by PRISMA Health. Thank you for joining us. I'm Maggie McKay. With us today is Dr. Fredy J Revilla, a Board Certified Neurologist with PRISMA Health Neuroscience Associates in Greenville, South Carolina, as well as a professor at University of South Carolina School of Medicine, also in Greenville, South Carolina. Welcome and thank you for helping us better understand and identify tremors Dr. Revilla.
Fredy J. Revilla, MD (Guest): Thank you for inviting me. Happy to be here today.
Host: Just to start, what are tremors? And when should we be concerned?
Dr. Revilla: A tremor is an oscillating movement around the joint, it's commonly known as shaking. Tremors can be relatively benign if they occur, for example, after drinking coffee or after having done a lot of exercise or maybe lack of sleep, however, if you develop a tremor that persists during most of the day or during most activities, then the recommendation I have is to see a physician for a diagnosis and ideally a neurologist, because tremors can be a sign of a neurological disorder.
Host: So don't ignore them.
Dr. Revilla: Definitely don't ignore a tremor.
Host: And if my hands tremble, does that mean I have a movement disorder? What could be the cause?
Dr. Revilla: Yes by definition, any abnormality of movement falls into the category of movement disorders. There are many causes for tremors. Some of the most common causes are a condition called essential tremor and another one called Parkinson's disease. Those are the two that may explain tremors in most patients.
Are also tremors caused by some medications. So it's always important to provide a complete list of medications to your physician to see if that could be the cause of the tremor. But tremors can be a sign of a neurological disease that needs to be diagnosed very carefully and treated adequately.
Host: And how do you know, you mentioned Parkinson's. How do you know if it's caused by that Parkinson's disease or some other movement disorder?
Dr. Revilla: That is an excellent question. There are some features that allows the neurologist to differentiate tremors caused by Parkinson's disease versus essential tremor, for example. In the case of Parkinson's disease, the tremors are usually at rest, meaning the person may be sitting down talking to somebody else or watching TV and sometimes without being aware of it, one of the hands is shaking.
So somebody else might have pointed to them. That is called the resting tremor. So an asymmetric onset of a resting tremor would be very typical of Parkinson's disease. Again, usually affecting one hand, for example, at rest. Whenever we see tremors that occur in both hands, and the tremors mostly occur with posture or action, meaning while holding something in your hand or pouring water from a cup, for example, then we think of essential tremor, essential tremor, usually causes tremors that have been present for many years, sometimes decades and occur in both hands, sometimes can affect the head for example, and other parts of the body.
But those are the two main differences. Tremor in one side of the body, mostly one hand at rest, points towards Parkinson's disease versus tremor affecting both hands in a symmetric fashion with posture and action and not at rest, points toward essential tremor.
Host: Do tremors only affect your hands? It sounds like they can also affect other parts of the body as you were saying.
Dr. Revilla: Tremors can affect other parts of the body other than the hands. Some patients develop tremors in the head, the neck, the legs, sometimes their whole body shakes. However the part of the body that most patients with tremor notice, is the hands. Mostly because we use our hands for many things. But to answer your question, yes, tremors can affect any part of your body.
Host: Who is most at risk for tremors?
Dr. Revilla: Patients who have risk factors for Parkinson's disease are at risk of developing tremors. Realizing that Parkinson's disease is not only tremor and sometimes patients with Parkinson's disease don't have tremor or have late in the disease. In other words, there can be slowness of movement called bradykinesia in the medical literature. There can be rigidity. There can be walking and balance abnormalities along with a tremor that point to a diagnosis of Parkinson's disease. Some of the risk factors for Parkinson's disease include exposure to toxic substances in the environment such as pesticides, welding fumes, and things like that.
And there are also some patients, a small proportion of patients who may have a genetic form of Parkinson's disease. Usually less than 5% of the patients with Parkinson's disease have a genetic cause for the illness and typically, they start at a younger age, usually before age 40. For essential tremor, which is a completely different disease that can also cause tremors. The risk factors are having a family history. And it's usually because essential tremor is usually a genetic disease and it runs in families. And so if somebody has many family members with tremors, there is an increased risk that the person will have similar symptoms during their lifetime.
Host: Is that rare?
Dr. Revilla: Essential tremor is relatively common. It's not rare. Parkinson's disease is not as frequent as essential tremor. So it is more rare to see, but we have enough people in the aging population who are at risk of developing Parkinson's disease. And as a consequence, we don't consider this as a rare condition either.
Host: So when you feel that you have tremors, when should you see a doctor?
Dr. Revilla: That's another excellent question. I recommend that anybody who has tremors should see a physician, starting with your primary care physician who should be able to provide a differential diagnosis for the cause of the tremor and be able to refer to a neurologist if needed. So I would recommend not to wait too long before seeing a physician, given that it could be a sign of a condition such as Parkinson's disease. On the other hand, could be something more benign, such as essential tremor. And as we said earlier, there are other possible causes of the tremor. Let's remember that tremor is a symptom of another disease. Tremor by itself is not usually a diagnosis or a disease. Tremor is a symptom reflective of something else going on.
And to be complete, there can be some metabolic illnesses or abnormalities of electrolytes, for example, or glucose abnormalities, et cetera, even thyroid function that can cause tremors. And those may not necessarily be neurological illness, but more of a medical illness manifesting in the forms of tremors.
So very important to realize that tremors are a symptom, not necessarily a disease.
Host: Interesting. How are tremors treated and can they be stopped?
Dr. Revilla: Tremors can be treated depending on their cause. In the case of patients with essential tremor, which is the majority of patients that get to us as a specialist in movement disorders, we can use medications. There's a group of medications called beta blockers. The medication, most representative of this category is propranolol.
There is another medication called primidone that can be used and these medications can help partially with the tremors. When the tremors are extremely severe and don't respond to medications, we have performed surgeries in some of these patients with excellent results. There is a procedure called deep brain stimulation surgery that can be performed and we do it here in our institution.
And for Parkinson's disease there are many treatments for Parkinson's disease. The main being a medication called levodopa, which turns into dopamine. Dopamine is a neurotransmitter that is low in the brain of patients with Parkinson's disease. So by replacing the dopamine with this medication called levadopa, tremors and other symptoms of Parkinson's disease, can improve substantially.
In the case of patients who have tremors induced by medications, the solution may be more obvious. You have to decrease the dose or stop the medication that is causing the tremors. And the tremor may go away. Sometimes that is difficult to do because it may be a medication that is very important for the treatment of a different condition. And it's hard to decrease the dose or eliminate that medication. But as long as the doctor and the patients are aware that can be managed adequately.
Host: Is it safe to drive if you have a tremor in your hand or leg?
Dr. Revilla: It depends on the level of impairment caused by the tremors. In the case of resting tremors, like seen in Parkinson's disease, the tremors tend to go away with action. So typically do not impair driving, especially in early Parkinson's disease. However, if we're talking about advanced Parkinson's disease, it may be other symptoms, not only the tremors, but the slowness of movement, gait and balance abnormalities, decreased reflex time, poor coordination that may impair their driving ability. In patients with essential tremor, it becomes a judgment call because if the tremors are mild, the ability to drive is still there. If the tremors are extremely severe, it may be difficult. So the recommendation has to be very carefully individualized for each patient.
Host: Do you have any tips Dr. Revilla on how to best cope with tremors?
Fredy J. Revilla, MD (Guest): Yes. The most important thing in regards to tremors is to be aware of the cause of the tremors, find the triggers. If there is a diagnosis made as the cause of the tremors, then medications have to be taken for the tremors. And as I said earlier, most of the time medications help. There are some surgeries, as we said, for severe forms of tremors, but everything goes back to having a early conversation with your physician, starting with a primary care physician and later with a neurologist, if necessary, to find the cause of the tremor and address it.
Host: it comes to exercises. Are there any that can help?
Dr. Revilla: In general exercise is extremely beneficial for all neurological conditions. In Parkinson's, for example, we know that exercise is recommended. It may be one of the few strategies to delay the disease and improve the symptoms. And this is valid for every neurological disease. However tremors may not specifically improve at the time of exercise. Sometimes tremors may exacerbate after exercise because of the fatigue that the patient may be going through. But over the long run exercise is absolutely recommended. At the time of the exercise, the tremors may be present or get worse, but over the long run, they may improve.
Host: Dr. Revilla, thank you so much for this information. It's been so useful and educational, and we appreciate you giving us the facts and helping us understand what tremors are.
Dr. Revilla: You are welcome. It was my pleasure.
Host: To find out more, go to Prismahealth.org/flourish. That's Dr. Fredy Revilla, a Board Certified Neurologist with PRISMA Health Neuroscience Associates in Greenville, South Carolina and Professor at University of South Carolina School of Medicine, also in Greenville, South Carolina.
And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. Thank you for listening to Flourish, a podcast brought to you by PRISMA Health. I'm Maggie McKay. Be well.
Maggie McKay (Host): If you've ever experienced an involuntary quivering movement in your muscles, maybe you thought it was just from fatigue or a reaction to medicine. But perhaps they were tremors, which can be severe or hardly recognizable. But how do you know if they're tremors or something else? Today we'll talk about what tremors are, what the causes can be and how to treat them, among other things. Welcome to Flourish, a podcast brought to you by PRISMA Health. Thank you for joining us. I'm Maggie McKay. With us today is Dr. Fredy J Revilla, a Board Certified Neurologist with PRISMA Health Neuroscience Associates in Greenville, South Carolina, as well as a professor at University of South Carolina School of Medicine, also in Greenville, South Carolina. Welcome and thank you for helping us better understand and identify tremors Dr. Revilla.
Fredy J. Revilla, MD (Guest): Thank you for inviting me. Happy to be here today.
Host: Just to start, what are tremors? And when should we be concerned?
Dr. Revilla: A tremor is an oscillating movement around the joint, it's commonly known as shaking. Tremors can be relatively benign if they occur, for example, after drinking coffee or after having done a lot of exercise or maybe lack of sleep, however, if you develop a tremor that persists during most of the day or during most activities, then the recommendation I have is to see a physician for a diagnosis and ideally a neurologist, because tremors can be a sign of a neurological disorder.
Host: So don't ignore them.
Dr. Revilla: Definitely don't ignore a tremor.
Host: And if my hands tremble, does that mean I have a movement disorder? What could be the cause?
Dr. Revilla: Yes by definition, any abnormality of movement falls into the category of movement disorders. There are many causes for tremors. Some of the most common causes are a condition called essential tremor and another one called Parkinson's disease. Those are the two that may explain tremors in most patients.
Are also tremors caused by some medications. So it's always important to provide a complete list of medications to your physician to see if that could be the cause of the tremor. But tremors can be a sign of a neurological disease that needs to be diagnosed very carefully and treated adequately.
Host: And how do you know, you mentioned Parkinson's. How do you know if it's caused by that Parkinson's disease or some other movement disorder?
Dr. Revilla: That is an excellent question. There are some features that allows the neurologist to differentiate tremors caused by Parkinson's disease versus essential tremor, for example. In the case of Parkinson's disease, the tremors are usually at rest, meaning the person may be sitting down talking to somebody else or watching TV and sometimes without being aware of it, one of the hands is shaking.
So somebody else might have pointed to them. That is called the resting tremor. So an asymmetric onset of a resting tremor would be very typical of Parkinson's disease. Again, usually affecting one hand, for example, at rest. Whenever we see tremors that occur in both hands, and the tremors mostly occur with posture or action, meaning while holding something in your hand or pouring water from a cup, for example, then we think of essential tremor, essential tremor, usually causes tremors that have been present for many years, sometimes decades and occur in both hands, sometimes can affect the head for example, and other parts of the body.
But those are the two main differences. Tremor in one side of the body, mostly one hand at rest, points towards Parkinson's disease versus tremor affecting both hands in a symmetric fashion with posture and action and not at rest, points toward essential tremor.
Host: Do tremors only affect your hands? It sounds like they can also affect other parts of the body as you were saying.
Dr. Revilla: Tremors can affect other parts of the body other than the hands. Some patients develop tremors in the head, the neck, the legs, sometimes their whole body shakes. However the part of the body that most patients with tremor notice, is the hands. Mostly because we use our hands for many things. But to answer your question, yes, tremors can affect any part of your body.
Host: Who is most at risk for tremors?
Dr. Revilla: Patients who have risk factors for Parkinson's disease are at risk of developing tremors. Realizing that Parkinson's disease is not only tremor and sometimes patients with Parkinson's disease don't have tremor or have late in the disease. In other words, there can be slowness of movement called bradykinesia in the medical literature. There can be rigidity. There can be walking and balance abnormalities along with a tremor that point to a diagnosis of Parkinson's disease. Some of the risk factors for Parkinson's disease include exposure to toxic substances in the environment such as pesticides, welding fumes, and things like that.
And there are also some patients, a small proportion of patients who may have a genetic form of Parkinson's disease. Usually less than 5% of the patients with Parkinson's disease have a genetic cause for the illness and typically, they start at a younger age, usually before age 40. For essential tremor, which is a completely different disease that can also cause tremors. The risk factors are having a family history. And it's usually because essential tremor is usually a genetic disease and it runs in families. And so if somebody has many family members with tremors, there is an increased risk that the person will have similar symptoms during their lifetime.
Host: Is that rare?
Dr. Revilla: Essential tremor is relatively common. It's not rare. Parkinson's disease is not as frequent as essential tremor. So it is more rare to see, but we have enough people in the aging population who are at risk of developing Parkinson's disease. And as a consequence, we don't consider this as a rare condition either.
Host: So when you feel that you have tremors, when should you see a doctor?
Dr. Revilla: That's another excellent question. I recommend that anybody who has tremors should see a physician, starting with your primary care physician who should be able to provide a differential diagnosis for the cause of the tremor and be able to refer to a neurologist if needed. So I would recommend not to wait too long before seeing a physician, given that it could be a sign of a condition such as Parkinson's disease. On the other hand, could be something more benign, such as essential tremor. And as we said earlier, there are other possible causes of the tremor. Let's remember that tremor is a symptom of another disease. Tremor by itself is not usually a diagnosis or a disease. Tremor is a symptom reflective of something else going on.
And to be complete, there can be some metabolic illnesses or abnormalities of electrolytes, for example, or glucose abnormalities, et cetera, even thyroid function that can cause tremors. And those may not necessarily be neurological illness, but more of a medical illness manifesting in the forms of tremors.
So very important to realize that tremors are a symptom, not necessarily a disease.
Host: Interesting. How are tremors treated and can they be stopped?
Dr. Revilla: Tremors can be treated depending on their cause. In the case of patients with essential tremor, which is the majority of patients that get to us as a specialist in movement disorders, we can use medications. There's a group of medications called beta blockers. The medication, most representative of this category is propranolol.
There is another medication called primidone that can be used and these medications can help partially with the tremors. When the tremors are extremely severe and don't respond to medications, we have performed surgeries in some of these patients with excellent results. There is a procedure called deep brain stimulation surgery that can be performed and we do it here in our institution.
And for Parkinson's disease there are many treatments for Parkinson's disease. The main being a medication called levodopa, which turns into dopamine. Dopamine is a neurotransmitter that is low in the brain of patients with Parkinson's disease. So by replacing the dopamine with this medication called levadopa, tremors and other symptoms of Parkinson's disease, can improve substantially.
In the case of patients who have tremors induced by medications, the solution may be more obvious. You have to decrease the dose or stop the medication that is causing the tremors. And the tremor may go away. Sometimes that is difficult to do because it may be a medication that is very important for the treatment of a different condition. And it's hard to decrease the dose or eliminate that medication. But as long as the doctor and the patients are aware that can be managed adequately.
Host: Is it safe to drive if you have a tremor in your hand or leg?
Dr. Revilla: It depends on the level of impairment caused by the tremors. In the case of resting tremors, like seen in Parkinson's disease, the tremors tend to go away with action. So typically do not impair driving, especially in early Parkinson's disease. However, if we're talking about advanced Parkinson's disease, it may be other symptoms, not only the tremors, but the slowness of movement, gait and balance abnormalities, decreased reflex time, poor coordination that may impair their driving ability. In patients with essential tremor, it becomes a judgment call because if the tremors are mild, the ability to drive is still there. If the tremors are extremely severe, it may be difficult. So the recommendation has to be very carefully individualized for each patient.
Host: Do you have any tips Dr. Revilla on how to best cope with tremors?
Fredy J. Revilla, MD (Guest): Yes. The most important thing in regards to tremors is to be aware of the cause of the tremors, find the triggers. If there is a diagnosis made as the cause of the tremors, then medications have to be taken for the tremors. And as I said earlier, most of the time medications help. There are some surgeries, as we said, for severe forms of tremors, but everything goes back to having a early conversation with your physician, starting with a primary care physician and later with a neurologist, if necessary, to find the cause of the tremor and address it.
Host: it comes to exercises. Are there any that can help?
Dr. Revilla: In general exercise is extremely beneficial for all neurological conditions. In Parkinson's, for example, we know that exercise is recommended. It may be one of the few strategies to delay the disease and improve the symptoms. And this is valid for every neurological disease. However tremors may not specifically improve at the time of exercise. Sometimes tremors may exacerbate after exercise because of the fatigue that the patient may be going through. But over the long run exercise is absolutely recommended. At the time of the exercise, the tremors may be present or get worse, but over the long run, they may improve.
Host: Dr. Revilla, thank you so much for this information. It's been so useful and educational, and we appreciate you giving us the facts and helping us understand what tremors are.
Dr. Revilla: You are welcome. It was my pleasure.
Host: To find out more, go to Prismahealth.org/flourish. That's Dr. Fredy Revilla, a Board Certified Neurologist with PRISMA Health Neuroscience Associates in Greenville, South Carolina and Professor at University of South Carolina School of Medicine, also in Greenville, South Carolina.
And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. Thank you for listening to Flourish, a podcast brought to you by PRISMA Health. I'm Maggie McKay. Be well.