tremor

definition

The term "tremor" is derived from the Latin word "tremere", which means to tremble in German.
Tremor is a movement disorder that describes excessive mobility of the affected part of the body. It is caused by repetitive contractions of muscle groups that have an opposite effect, creating rapid movement first in one direction and then in the other.
A tremor is classified according to different aspects: According to the amplitude of the deflection (coarse or fine-pitched), according to the frequency (high or low frequency), according to the time of occurrence (at rest, when moving, when holding up the hands) and according to the Regularity (regular or irregular).

causes

Basically, a slight tremor is absolutely normal: The structure of the nervous system is based on various control loops, the activity of the nerve cells is subject to regular fluctuations. These fluctuations lead to a slight tremor e.g. of the hands while holding up the arms.
This physiological tremor is caused by fine, involuntary, rhythmic muscle movements in the submillimeter to millimeter range and is intensified by stress, excitement or caffeine. A tremor when you are under great tension is therefore (in most cases) completely harmless and only represents the amplification of the tremor that is always present.

A tremor only becomes pathological if it is very coarse, i.e. the tremor has large rashes, or if the trembling back and forth happens very quickly.
Various diseases can cause tremors. In Parkinson's disease, the cells that are responsible for suppressing involuntary movements perish. The result is a tremor at rest and possibly also during action, which is more pronounced on one side than on the other.
If the cerebellum is damaged, the coordination of all movements is disturbed. The result is an irregular tremor that becomes stronger as you approach the goal (goal or intention tremor). Large amounts of alcohol temporarily incapacitate the cerebellum, resulting in an intention tremor, uncoordinated gait and unsafe movements. Chronic alcohol abuse destroys cells in the cerebellum and thus leads to permanent cerebellar damage.

A stronger than usual tremor can be caused by essential tremor, which almost always affects the hands and arms symmetrically and can occur both at rest and in action. It is inherited in 60% of cases and otherwise occurs spontaneously due to unexplained causes. About 1% of the population is affected. A rare form of tremor is orthostatic tremor, which mainly affects women over the age of 60. After standing for a long time, the leg muscles tremble, an unsteady stance and falls are the result.
Psychogenic tremor affects the hands or the head and is the physical symptom of mental overload. It is interesting that the psychogenic tremor completely disappears when distracted.

Other causes of tremor are chronic mercury poisoning, Wilson's disease (copper storage disease), overactive thyroid or fibromyalgia syndrome.
Various medications can also trigger a tremor: theophylline (for COPD), cyclosporine A (immunosuppressant), cortisone (immunosuppressant), amiodarone (for cardiac arrhythmias), calcium antagonists (e.g. for high blood pressure), valproate (for epilepsy) and neuroleptics.

Parkinson's disease

In addition to a sedentary lifestyle, postural instability and increased stiffness of the muscles, tremor is one of the four main symptoms of Parkinson's disease.
In Parkinson's disease, cells in the substantia nigra (black substance) in the midbrain die. This brain region controls, together with other brain regions, the execution of voluntary motor skills and the suppression of unwanted movements. The cell death in the substantia nigra confuses the mechanisms of movement control, which is why, for example, unintentional tremors, or tremors, can occur.
Parkinson's tremor is a resting and holding tremor that gets worse when you are nervous. In most cases it affects the hands, typically one side is more affected than the other. The frequency of the Parkinson's tremor is about 4-7 per second, the amplitude is of medium amplitude.
The so-called pill-rolling phenomenon is a specific form of resting tremor in the hands: Parkinson's patients repeatedly rub their thumbs and forefingers together, as when turning pills or counting coins. In rare cases, Parkinson's tremor also affects the head, legs, or chin. If the chin is affected in Parkinson's disease, this is referred to by doctors as the "rabbit" phenomenon.

Read more on this topic: Parkinson's disease

What drugs cause tremor?

There are some drugs that are mainly used can cause a tremor if taken for many years or if taken incorrectly (e.g. if the dose is too high).
These include, for example, so-called cholinesterase inhibitors, which ensure that the neurotransmitter acetylcholine (a substance that mediates the transmission of information via nerves) can work longer. This group of drugs comes e.g. used in the treatment of Alzheimer's disease.
Other possible drugs that can cause tremor are neuroleptics and antidepressants, which are used to treat psychosis, depression, and anxiety disorders. Adrenaline, amphetamines or caffeine can also cause tremors due to their activating effects.
Conversely, withdrawal from tremor-relieving drugs can also be a possible cause. These include primarily beta blockers, which are used to treat what is known as essential tremor, but also primidone or gabapentin.

Overactive thyroid tremor

Thyroid disease can also cause tremors.
If the thyroid gland is overactive (hyperthyroidism), the thyroid gland produces too many hormones (especially the so-called T3 and T4). This leads to an increased activity of many organs in the body, such as the heart and muscles. This can make those affected fidgety and restless. Often there is twitching of the hands and fingers.

Is Tremor Hereditary?

Many forms of tremor have as yet unexplained causes. However, there are studies that show that the form of essential tremor in particular is related to heredity.
It has been shown that around 60% of people suffering from tremor have this disease in their families and are therefore likely to be inherited. It is still unclear whether heredity is the sole cause.

Concomitant symptoms

Since a tremor can be a disease of its own (as in the case of essential tremor that often occurs in families), but it can also be a symptom of another disease, the accompanying symptoms are also different.
If a tremor occurs as part of Parkinson's disease, sedentary lifestyle, stiffness and postural instability are common accompanying symptoms.
In most cases of essential tremor there are no accompanying symptoms, but in severe cases the patients also suffer from unsteadiness of gait, dysmetria (incorrect "measuring" of movements) and intention tremor (tremor increases the closer the patient gets to the object he is want to grab).
In the case of cerebellar damage, accompanying symptoms are nystagmus (eye tremors), impaired coordination of movements with unsafe movement sequences (ataxia) and a speech disorder. Accompanying symptoms of orthostatic tremor are unsteadiness and falls, with psychogenic tremor there is often a high level of basic tension and psychological overload.
Tremor in Wilson's disease is accompanied by liver damage and various other neurological symptoms. A tremor in the context of an overactive thyroid is supplemented by the classic symptoms: sweating, unwanted weight loss despite appetite, racing heart, sleep disorders and restlessness are just examples.

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treatment

The treatment of a tremor is adapted to the underlying cause.

Parkinson's tremor is improved by treating Parkinson's disease with L-dopa or with dopamine agonists. A tremor that cannot be controlled with Parkinson's medication can be treated with deep brain stimulation, a neurosurgical procedure. Electrodes are inserted directly into the brain in order to suppress the activity of the tremor in the nucleus intermedius ventralis, a core area of ​​the thalamus, by means of controlled electrical surges.
An overactive thyroid tremor can go away with proper treatment of the thyroid gland. Other forms of tremor caused by fatigue, anxiety disorders, alcohol withdrawal, or metabolic disorders can be treated with beta blockers such as propanolol.
Forms of tremor caused by drugs (e.g. by theophylline, cyclosporine, cortisone, amiodarone, nifedipine, valproic acid and neuroleptics) can disappear when the triggering drug is discontinued. If discontinuation of the drug is not possible due to other illnesses, this type of tremor can also be improved by a beta blocker.
The very common essential tremor, the cause of which is unknown but which occurs in families, is primarily treated with a beta blocker or primidone, an anticonvulsant drug. If the improvement is insufficient, benzodiazepines or clozapine are used.
A hypoglycemic tremor will go away once the hypoglycemia is resolved with sugary foods or drinks or glucose infusions.

Anticonvulsants (from the group of drugs against epilepsy) such as primidone are also used. If these drugs do not work well enough, other drugs such as gabapentin and topiramate can be given. In the case of drug resistance (i.e. if the treatment of the essential tremor with drugs is not effective), so-called deep brain stimulation can be considered, in which certain parts of the brain are stimulated directly via neurosurgery.

Orthostatic tremor is treated purely symptomatically, which means that the treatment options available do not cure the disease, but can only alleviate the symptoms. The focus here is on drugs such as gabapentin.

Beta blockers

For some types of tremors, beta blockers may be an option.
The exact mechanism by which beta-blockers improve tremor symptoms is not yet fully understood.What is certain is that beta-blockers indirectly reduce the tension in the muscles and promote blood flow to the muscles. The essential tremor, for example, can be treated well in many patients with beta blockers, either as monotherapy (i.e. as the sole drug) or as a combination therapy with primidone.

Can Vitamin B12 Help?

In the body, vitamin B12, together with other substances, fulfills the task of maintaining the functioning of the nerves.
It is important to mention that vitamin B12 is one of the essential vitamins, which means that it must be obtained mainly through food. With sufficient intake, the symptoms of tremors and rapid muscle movements in tremor can be improved, as the nerves are supported in their function. However, care should be taken to ensure that there is not too much vitamin B12. A balanced diet is therefore very useful.

What types of tremors are there?

In terms of tremor types, a general distinction is made between resting tremor, i.e. a tremor that occurs without physical or mental exertion, and an action tremor. The action tremor, in turn, can be divided into a holding tremor and a target tremor. Holding tremor is a tremor that occurs when objects are held against gravity. The target tremor is a tremor in which the rapid muscle movements occur when the affected person tries to approach a target with his hand.

One of the most common forms of tremor is essential tremor, which is usually a holding tremor and in 50% of cases also a target tremor. The symptoms increase under stress, briefly decrease under alcohol consumption and are treated with propanolol, for example.
In orthostatic tremor, the muscle twitching occurs mainly after standing for a long time, which makes the affected person feel insecure in their stance. Further forms are e.g. the tremor that occurs in Parkinson's disease or a psychogenic tremor that can be caused by mental health problems.

Essential tremor

Essential tremor is one of the most common forms of tremor.
This leads to a so-called symmetrical postural tremor, which means that the rapid movements of the muscles mainly occur in situations in which, for example, a weight is held with the arms. In about half of those affected, there is also a target tremor. This is a so-called intention tremor, which means that the rapid muscle movements occur when the person concerned tries to approach a target with his hand. This is tested by the doctor using the finger-nose experiment, in which the person concerned is asked to bring the finger to the nose and the closer he gets to his nose, the stronger the hand twitches.

Essential tremor is characterized by worsening of symptoms due to stress and a brief improvement in symptoms after consuming alcohol. The essential tremor can usually be diagnosed by a clinical examination with various neurological tests, such as the finger-nose test. The therapy focuses on drugs, especially from the group of beta blockers, such as Propanolol.

More on this topic at: Essential tremor

Tremor on the hand

The hand is often affected by tremor, regardless of the underlying cause of the tremor. A hand tremor can be fine or coarse (small or large movements), fast or slow.
The tremor of the hand is a big problem for the affected patients because simple everyday things become difficult: Pouring water into a glass or signing can become an impossible task, depending on the extent of the tremor. The hand tremor can manifest itself as a resting tremor, holding tremor (when holding the arms against gravity), action tremor (during voluntary movements) or target tremor (increasing as you approach a target). An action-specific tremor, e.g. only occurs when writing is conceivable in the hand.

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Head tremor

Head tremors are less common than hand tremors and are also less restrictive in everyday life than this. It manifests itself in an involuntary shaking of the head in a horizontal or vertical direction.
The so-called Musset's sign must be differentiated from the head tremor by differential diagnosis. The Musset sign describes the patient's head nodding in sync with the pulse in severe aortic valve insufficiency, which is associated with very large blood pressure amplitudes. This nod of the head is usually not noticed by the patients themselves; rather, these patients notice a roar of the head due to the high blood pressure amplitude.

Tremor and alcohol

The effect of alcohol must be assessed according to whether there has been a one-off high alcohol consumption or chronic alcohol abuse.
The function of the cerebellum is temporarily disturbed in the event of a single high consumption of alcohol. In addition to trembling, the result is a broad and unsteady gait and difficulties in performing movements precisely. The tremor in the drunk is the result of the disturbed coordination of movements by the cerebellum.
Long-term alcohol abuse permanently destroys cells in the cerebellum, probably in combination with the frequent malnutrition and deficiency in vitamins. Since the body adjusts to the constant consumption of alcohol, chronic alcohol addicts suffer from milder symptoms for a long time than a one-time drunk. Only later do the severe consequences of the cerebellar damage become apparent. A tremor can occur in alcohol addicts as part of alcohol withdrawal.

Read more on this topic: Consequences of alcohol

Duration

The duration of a tremor depends on the type of tremor.
An essential tremor is characterized, for example, by the fact that there are around 5-10 movements in one second, most of which occur in the hands. In some types of tremors, symptoms only occur with certain movements. In orthostatic tremor, for example, the twitching occurs mainly when standing for a long time. Accordingly, the duration of the tremor depends on the time of standing. Depending on the effectiveness of the therapy, the duration of a tremor can sometimes be significantly reduced.

forecast

The prognosis for tremor usually implies that the tremor will accompany the affected person throughout life.
The tremor can vary in severity. The prognosis in all cases depends on the type of tremor. Some forms of tremor are very pronounced right from the start and their severity can only be influenced by various forms of therapy. The essential tremor, in turn, is slowly progressive, which means that the twitches are only occasional for a few minutes at first and become more frequent as the disease progresses.

Here you can find out whether the essential tremor curable is