Tremor (When the muscles refuse to obey)

At 40 plus, just at the peak of a successful career, the sudden onset of tremor can be devastating. Careers nosedive as the young executive, although with intelligence undiminished, is unable to speak lucidly. The handwriting has little spidery spikes and is illegible. The head constantly moves in a side-to-side motion, a  yes-yes no-no  see saw oscillation that sends confused signals to the bemused bystander. Eventually, the involuntary to and fro motion affects other muscle groups in the arms, legs and trunk. Gait is affected and becomes unsteady and lurching. Speech becomes tremulous with an up and down intonation as the vocal cords get affected. Even daily tasks like dressing and eating become difficult to perform. Worse still, typing and computer keyboard coordination become impossible. And once rapid button-pressing skills are compromised, life in the 21st century becomes impracticable.

Parkinsons disease  is the diagnosis that leaps to the mind. However, all tremors are not Parkinsons. Parkinsonism occurs later, around the age of 60 years. The tremor is typical and is described as  pill rolling . The face is mask-like and expressionless.

A young person is more likely to have hereditary essential tremor. This is inherited as an autosomal dominant condition (if one parent has tremor the offspring has a 50 per cent chance of inheriting it). It affects around 0.4-3 per cent of the population (both male and female) around the age of 40 years.

Any malfunction of the areas of the brain that control movement can cause tremor. This can be caused by infectious diseases like meningitis or encephalitis, stroke, traumatic brain injury, tumours and neurodegenerative diseases. Tremor can also be brought on by low blood sugar and a hyper functioning thyroid gland.

However, not all tremors are sinister. Standing for a long time in a particular position may cause the legs to shake. This tremor is normal and disappears if the person sits down.

Sometimes a person may complain of tremor and yet nothing may be grossly visible. This fine physiological or normal tremor can be proved by asking the person to hold a small, lighted torch and focus it on a wall. The light shakes from side to side. This kind of tremor is increased by anxiety and fear but disappears at rest and when the person is calm.

Alcohol can provoke or normalise tremor, depending on whether it is due to excessive consumption or withdrawal.

Tremors caused by an underlying medical condition spontaneously disappear once the condition is removed. Appropriate treatment depends on accurate diagnosis of the cause.

Symptomatic drug therapy is available for several forms of tremor. Parkinsonian tremor can be treated with a combination of levodopa, other dopamine-like drugs and anticholinergic medication. Unfortunately, the response decreases over time so the dosage has to be increased or more drugs added.

Essential tremor may be treated with beta blockers and primidone, an anticonvulsant drug. The response is variable.

Caffeine in coffee, tea and cola drinks, nicotine in cigarettes, and alcohol behave as tremor  triggers . Eliminating them from the diet controls all kinds of tremor.

Sometimes, the tremor can become so uncontrolled that the person expends all his or her energy. Food intake cannot keep pace and the person becomes cachexic and moribund. If the response to medication is also inadequate, surgical intervention may help. These procedures are usually performed only when the tremor is severe and does not respond to drugs.

The thalamus is the part of the brain that is responsible for most tremors. Implantable electrodes can be used to send high-frequency electrical signals to this region. A hand-held magnet can be used to turn on and turn off a pulse generator that is surgically implanted under the skin. This temporarily disables the tremor. The batteries in the generator last about five years and have to be replaced surgically. This procedure can be performed for both Parkinsonian and essential tremors.

If this is not practical, in severe cases the thalamus can be electrically ablated with brain surgery. This permanently cures the tremor without disrupting sensations or voluntary control of the muscles.

Tremor is debilitating and depressing for the patient. The caregiver also has a difficult time trying to cope with the uncoordinated and uncontrolled motor activity of a person whose muscles simply refuse to obey commands. Physical therapy helps to reduce the tremor. A qualified physiotherapist can work with the patient to improve coordination, muscle strength, control and functional skills. Control in a tremulous limb can be regained to some extent by bracing the limb and regularly exercising using weights and splints. Some traditional forms of exercise like yoga and Taichi are also beneficial. They may help to retard the progress of the disease if started in the early stages in conjunction with medication.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.

Written by:Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at

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