Tremors are involuntary shaking of the body or limbs, as from disease, fear, weakness, or excitement.
Tremors can be caused by a variety of conditions.
Learn more about what causes tremors and the available treatment options from Dr. Matthew Barrett, a UVA specialist in movement disorders.
Treatment Options for Tremors
Featured Speaker:
Matthew Barrett, MD
Dr. Matthew Barrett is a board-certified neurologist whose specialties include movement disorders. Transcription:
Treatment Options for Tremors
Melanie Cole (Host): Tremors can be caused by a variety of conditions. My guest today is Dr. Matthew Barrett. He’s a board certified neurologist whose specialties includes movement disorders at UVA Neurosciences Center. Welcome to the show, Dr. Barrett. Tremors, people first see their hands shaking, they don’t know what the problem is, they right away go to the worst possible outcome: it’s Parkinson’s, it’s something terrible. Tell us what constitute a tremor, and what are the most likely causes?
Dr. Matthew Barrett (Guest): Sure. A tremor is any involuntary rhythmic movement of a body part. I want to underscore that it’s rhythmic. There are certainly other movement disorders that may not be tremors, and I think that’s where a movement disorder specialist can be helpful. The tremor can involve either the jaw, voice, head, arms, or legs. I think most often people think about arms and hands being involved by a tremor, and I would say that probably is the most common thing I see. One main distinction in classifying the tremors is whether they occur when a body part is at rest or if it’s involved with an action. And that really is one of the primary things we use to help distinguish between a Parkinson’s disease tremor and maybe a tremor from another cause. Tremors associated with Parkinson’s disease do present with other symptoms typically, and then other findings that we would see on an exam. And an essential tremor, which is another common cause of tremor, the tremor usually occurs without other neurological symptoms, hence the name essential tremor, that it really stands alone. And then I think I’d also mention that there are some drug-induced tremors, and then there are a number of other rare conditions that could be associated with a tremor.
Melanie: Can it be also associated with age, if someone is 90 years old and just their hand shakes when they go to grab a glass? Can this be an age-associated thing as well?
Dr. Barrett: Yes, definitely. I think more historically a term called senile tremor, there is some tendency to do develop a tremor as someone ages. And I would say both with Parkinson’s disease and essential tremors, both of these things become more common if someone gets older. I guess the distinction would be really about how severe a tremor is and whether it’s interfering with daily activities, whether it should be treated or not.
Melanie: If somebody gets really nervous, they’ve got this -- and as we said, they go to the worst outcome, but they come to see you. How do you even diagnose this?
Dr. Barrett: Yes. I think you bring up a very good point about bringing up stress, anxiety. I would say that everybody under a certain degree of stress will probably have some tremor. Someone who drinks too much caffeine, doesn’t get enough sleep, a tremor is possible, or works out too hard. I think all of us have experienced that at some point. And I would term that a physiological tremor. And under these certain circumstances that cause stress, that’s an enhanced physiological tremor. One of the distinctions in our evaluation really is whether that’s what we’re dealing with, or is this an essential tremor that is present without some identifiable underlying cause?
Melanie: Okay. People have these things. You look at what they’re doing. Do you run them through a series of tests? Do you get them to recreate whatever it was they were doing to find out if that tremor only happens, as you say, during activity or at rest?
Dr. Barrett: That’s exactly right. I think the distinction between a rest tremor and action tremor is a very important one. And I think the rest tremor can frequently either just be seen during the interview portion of an exam or brought out with certain activating maneuvers during the exam. It’s not uncommon that a Parkinson’s rest tremor will come out when someone is walking. It’s a part of my exam is having them walk up and down the length of a hallway. An essential tremor, like you said, may only come out with actions. And if that’s what I’m suspecting, I may have people write, pour liquids, and even moving a full glass of water back and forth, just because sometimes it’s only under those circumstances that the tremor becomes apparent.
Melanie: Okay. What about medication? What do you do for them? Is there anything? Does physical therapy or stretching, exercises, anything, can that help with the tremors or relieve them a little bit?
Dr. Barrett: Sure. I think, really, regardless of what the cause of tremors, unless we can identify some medication that may be inducing it, there are some medications, oral medications that can help. And with Parkinson’s disease, that opens up a whole area of medicine. Usually, we start with medications that somehow replaced the dopamine deficit in Parkinson’s, and with essential tremor there are other medications, different medications that we would use to start that sort of treatment. For treating a tremor, there is this issue of diagnosis, but whether to treat it or not really comes down to how much it interferes with the person’s life. For example, if someone is still working and they have a tremor, that may be something they socially and for their work life would like to eliminate. A person who is not working, a tremor may not interfere with their activities, so they don’t necessarily want to treat it. Of course, if it’s get to the point that it’s interfering with eating or drinking or performing other daily activities, then it is something we would treat, and we usually start again with the oral medication.
Melanie: Do isometric exercise 00 if the tremor is in the arm, in the legs or the hands, if you stop that tremor, can you grab the muscle? Can you grab the limb, whatever it is, and push against it? Does anything along those lines help to relieve the tremor at all?
Dr. Barrett: With a rest tremor in Parkinson’s Disease, I think individuals often find that if they activate the limb—usually the hand, but sometimes the leg that’s affected—that the tremor will go away. I could see how even just sort of -- even not necessarily moving the limb but just tensing those muscles or focusing on that tremor does allow someone to usually be able to stop it. That’s in the case of a Parkinson’s tremor. With an action tremor, they become a little less easy to control. There isn’t that aspect that there’s some control over the tremor. There are some techniques people have developed. I think there’s a specific utensil that can be used. Sometimes using a heavier object is actually better for the tremor. And there are utensils that have been developed that can entrain to the tremors so that it doesn’t cause food to fall off a spoon or fork, as it would otherwise.
Melanie: Is there any surgical interventions that you go to at some point, brain stimulation? Is there anything that you do to relieve a tremor if it’s really so bad that is affects the person’s quality of life?
Dr. Barrett: Definitely. I think it’s when we have tried the oral medication and they have failed, or there are side effects that make them not able to be tolerated that we move on to at least discussing the possibility of a neurosurgical procedure. And at this point, the deep brain stimulation is the standard surgery that is used. Some of the primary indications are essential tremor and the Parkinson’s disease tremor that the sites that are targeted with deep brain stimulation may be different. It depends on the patient whether that’s something they want to pursue, but certainly, like you say, if the disability is great and we haven’t made any headway with medications, then I think surgery is a very appropriate thing to consider for some patients.
Melanie: You mentioned stress, and I would just like to discuss that for just another minute here. Where does stress play a bigger role whether someone has Parkinson’s? Because obviously then they’re going to have that anxiety. But can stress cause tremors and things that just if we managed our stress will help to relieve those?
Dr. Barrett: That brings up a great point. A common thing I will say is that stress worsens any movement disorder, regardless of the cause. And I think tremor is a perfect example of that. Managing stress, identifying the underlying cause, treating it however it needs to be treated certainly can improve tremor. I think exercise is something I recommend. Anyways, they are certainly for patients with Parkinson’s disease. There’s some evidence that it may slow the progression of the disease. Probably by relieving stress also will improve the tremor that someone might be experiencing and that would, again, be worsened by stress.
Melanie: In just the last minute, please give your best advice, Dr. Barrett, for people that are suffering or people who have loved ones that are suffering from tremors and why they should come to UVA Neurosciences Center for their care.
Dr. Barrett: Yes. First I should say that correct diagnosis is really important because the treatments are going to vary depending on what the underlying cause is and that no one should suffer from the effects of a tremor without seeking a specialist’s opinion. Including myself, there are four movement disorder specialists at UVA who are trained to diagnose tremors, and it’s even possible that what’s being called a tremor may be another movement disorder. For treatment of tremors that don’t respond to oral medications, we talked about the use of deep brain stimulation. UVA has an established DBS program. It’s been in place for a long time with a dedicated medical team. That therapy is available if it wants to be pursued. And then the other thing is that UVA is a pioneering center for the application of focused ultrasound, which is a new experimental technique being used to treat tremors in a mechanism similar to deep brain stimulation but without incision. It’s very possible that in the next few years, this new surgical technique, focused ultrasound, will be available at UVA as another treatment option.
Melanie: That’s great information. Thank you so much. You’re listening to UVA Health Systems Radio. For more information, you can go uvahealth.com. That’s uvahealth.com. This is Melanie Cole. Thanks so much for listening.
Treatment Options for Tremors
Melanie Cole (Host): Tremors can be caused by a variety of conditions. My guest today is Dr. Matthew Barrett. He’s a board certified neurologist whose specialties includes movement disorders at UVA Neurosciences Center. Welcome to the show, Dr. Barrett. Tremors, people first see their hands shaking, they don’t know what the problem is, they right away go to the worst possible outcome: it’s Parkinson’s, it’s something terrible. Tell us what constitute a tremor, and what are the most likely causes?
Dr. Matthew Barrett (Guest): Sure. A tremor is any involuntary rhythmic movement of a body part. I want to underscore that it’s rhythmic. There are certainly other movement disorders that may not be tremors, and I think that’s where a movement disorder specialist can be helpful. The tremor can involve either the jaw, voice, head, arms, or legs. I think most often people think about arms and hands being involved by a tremor, and I would say that probably is the most common thing I see. One main distinction in classifying the tremors is whether they occur when a body part is at rest or if it’s involved with an action. And that really is one of the primary things we use to help distinguish between a Parkinson’s disease tremor and maybe a tremor from another cause. Tremors associated with Parkinson’s disease do present with other symptoms typically, and then other findings that we would see on an exam. And an essential tremor, which is another common cause of tremor, the tremor usually occurs without other neurological symptoms, hence the name essential tremor, that it really stands alone. And then I think I’d also mention that there are some drug-induced tremors, and then there are a number of other rare conditions that could be associated with a tremor.
Melanie: Can it be also associated with age, if someone is 90 years old and just their hand shakes when they go to grab a glass? Can this be an age-associated thing as well?
Dr. Barrett: Yes, definitely. I think more historically a term called senile tremor, there is some tendency to do develop a tremor as someone ages. And I would say both with Parkinson’s disease and essential tremors, both of these things become more common if someone gets older. I guess the distinction would be really about how severe a tremor is and whether it’s interfering with daily activities, whether it should be treated or not.
Melanie: If somebody gets really nervous, they’ve got this -- and as we said, they go to the worst outcome, but they come to see you. How do you even diagnose this?
Dr. Barrett: Yes. I think you bring up a very good point about bringing up stress, anxiety. I would say that everybody under a certain degree of stress will probably have some tremor. Someone who drinks too much caffeine, doesn’t get enough sleep, a tremor is possible, or works out too hard. I think all of us have experienced that at some point. And I would term that a physiological tremor. And under these certain circumstances that cause stress, that’s an enhanced physiological tremor. One of the distinctions in our evaluation really is whether that’s what we’re dealing with, or is this an essential tremor that is present without some identifiable underlying cause?
Melanie: Okay. People have these things. You look at what they’re doing. Do you run them through a series of tests? Do you get them to recreate whatever it was they were doing to find out if that tremor only happens, as you say, during activity or at rest?
Dr. Barrett: That’s exactly right. I think the distinction between a rest tremor and action tremor is a very important one. And I think the rest tremor can frequently either just be seen during the interview portion of an exam or brought out with certain activating maneuvers during the exam. It’s not uncommon that a Parkinson’s rest tremor will come out when someone is walking. It’s a part of my exam is having them walk up and down the length of a hallway. An essential tremor, like you said, may only come out with actions. And if that’s what I’m suspecting, I may have people write, pour liquids, and even moving a full glass of water back and forth, just because sometimes it’s only under those circumstances that the tremor becomes apparent.
Melanie: Okay. What about medication? What do you do for them? Is there anything? Does physical therapy or stretching, exercises, anything, can that help with the tremors or relieve them a little bit?
Dr. Barrett: Sure. I think, really, regardless of what the cause of tremors, unless we can identify some medication that may be inducing it, there are some medications, oral medications that can help. And with Parkinson’s disease, that opens up a whole area of medicine. Usually, we start with medications that somehow replaced the dopamine deficit in Parkinson’s, and with essential tremor there are other medications, different medications that we would use to start that sort of treatment. For treating a tremor, there is this issue of diagnosis, but whether to treat it or not really comes down to how much it interferes with the person’s life. For example, if someone is still working and they have a tremor, that may be something they socially and for their work life would like to eliminate. A person who is not working, a tremor may not interfere with their activities, so they don’t necessarily want to treat it. Of course, if it’s get to the point that it’s interfering with eating or drinking or performing other daily activities, then it is something we would treat, and we usually start again with the oral medication.
Melanie: Do isometric exercise 00 if the tremor is in the arm, in the legs or the hands, if you stop that tremor, can you grab the muscle? Can you grab the limb, whatever it is, and push against it? Does anything along those lines help to relieve the tremor at all?
Dr. Barrett: With a rest tremor in Parkinson’s Disease, I think individuals often find that if they activate the limb—usually the hand, but sometimes the leg that’s affected—that the tremor will go away. I could see how even just sort of -- even not necessarily moving the limb but just tensing those muscles or focusing on that tremor does allow someone to usually be able to stop it. That’s in the case of a Parkinson’s tremor. With an action tremor, they become a little less easy to control. There isn’t that aspect that there’s some control over the tremor. There are some techniques people have developed. I think there’s a specific utensil that can be used. Sometimes using a heavier object is actually better for the tremor. And there are utensils that have been developed that can entrain to the tremors so that it doesn’t cause food to fall off a spoon or fork, as it would otherwise.
Melanie: Is there any surgical interventions that you go to at some point, brain stimulation? Is there anything that you do to relieve a tremor if it’s really so bad that is affects the person’s quality of life?
Dr. Barrett: Definitely. I think it’s when we have tried the oral medication and they have failed, or there are side effects that make them not able to be tolerated that we move on to at least discussing the possibility of a neurosurgical procedure. And at this point, the deep brain stimulation is the standard surgery that is used. Some of the primary indications are essential tremor and the Parkinson’s disease tremor that the sites that are targeted with deep brain stimulation may be different. It depends on the patient whether that’s something they want to pursue, but certainly, like you say, if the disability is great and we haven’t made any headway with medications, then I think surgery is a very appropriate thing to consider for some patients.
Melanie: You mentioned stress, and I would just like to discuss that for just another minute here. Where does stress play a bigger role whether someone has Parkinson’s? Because obviously then they’re going to have that anxiety. But can stress cause tremors and things that just if we managed our stress will help to relieve those?
Dr. Barrett: That brings up a great point. A common thing I will say is that stress worsens any movement disorder, regardless of the cause. And I think tremor is a perfect example of that. Managing stress, identifying the underlying cause, treating it however it needs to be treated certainly can improve tremor. I think exercise is something I recommend. Anyways, they are certainly for patients with Parkinson’s disease. There’s some evidence that it may slow the progression of the disease. Probably by relieving stress also will improve the tremor that someone might be experiencing and that would, again, be worsened by stress.
Melanie: In just the last minute, please give your best advice, Dr. Barrett, for people that are suffering or people who have loved ones that are suffering from tremors and why they should come to UVA Neurosciences Center for their care.
Dr. Barrett: Yes. First I should say that correct diagnosis is really important because the treatments are going to vary depending on what the underlying cause is and that no one should suffer from the effects of a tremor without seeking a specialist’s opinion. Including myself, there are four movement disorder specialists at UVA who are trained to diagnose tremors, and it’s even possible that what’s being called a tremor may be another movement disorder. For treatment of tremors that don’t respond to oral medications, we talked about the use of deep brain stimulation. UVA has an established DBS program. It’s been in place for a long time with a dedicated medical team. That therapy is available if it wants to be pursued. And then the other thing is that UVA is a pioneering center for the application of focused ultrasound, which is a new experimental technique being used to treat tremors in a mechanism similar to deep brain stimulation but without incision. It’s very possible that in the next few years, this new surgical technique, focused ultrasound, will be available at UVA as another treatment option.
Melanie: That’s great information. Thank you so much. You’re listening to UVA Health Systems Radio. For more information, you can go uvahealth.com. That’s uvahealth.com. This is Melanie Cole. Thanks so much for listening.