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You can get trembling or shivering of your hands and legs. Have you noticed this in someone you know or others in your family? Have you experienced the shivering of your voice?
Yes it can happen when you are frightened or due to stage fright. But if it occurs otherwise, please do not ignore it. It may be a sign of various serious diseases. If you have tremor ie, trembling or shivering which affects your day to day activities, you should consult a neurologist.
1) What is tremor ?
Tremor is rhythmic oscillation of a body part, occurring due to abnormality in the nervous system. It can affect any part of the body, head , hand and legs. Tremor can occur during speech also. It occurs due to the abnormalities in some nervous system  structures like basal ganglia and cerebellum.Cerebellum is the part in the brain which  controls the balance and posture.
2)  Which are the types of Tremor
A) Resting Tremor
Tremor which is experienced during resting state. It may be starting in one hand and gradually both the hands may be affected. This type of tremor increases as age advances. This is usually seen in Parkinson's disease.  Resting brain in Parkinson's Disease is also called Pill Rolling Tremor. Patients will show movements like they are rotating a pill with fingers. They may be showing movements to mask the tremor they are having. For example, holding hands with tremor with the other hand, crossing legs to mask leg tremor and so on.
B) Essential Tremor
50% of those who are having this type of tremor will have a hereditary background in their family. Tremor is mostly experienced in hands/legs. It is felt mostly in hands more than legs. They will experience tremor when they hold things in their hands also. Those with essential tremor will have increased shivering when they have mental stress, anxiety , tension and also in the exam hall or when they are in stage. Essential tremor can affect speech also.
C) Intention Tremor
This type of tremor happens when you attempt to take something. For example,  if you want to take a glass, your hand will drift away from the glass due to tremor, then you will miss the object. Patients with such tremor will have the difficulty to button the shirt, difficulty to put thread in the needle and so on. The cause for this tremor is abnormality in the cerebellum. This can happen due to different causes like stroke, genetic causes like Spinocerebellar ataxia (SCA).
D)    Alcohol Withdrawal Tremor
Those who are addicted to alcohol, if they do not consume alcohol for one or two days, they will get tremors in their hands. For those patients, medicines and de addiction treatment can be given.

E)    Other Tremors

Orthostatic tremor- Tremor occuring when he is standing

Writing tremor - Tremor occuring while writing
Neuropathic tremor- Such tremors occur when nerves are affected.
3) What are the causes of tremor
Overuse of some medicines, low sugar level, inhalers used in asthma can cause tremor. Drugs which commonly cause tremor are drugs given for seizure like Valproate, Lithium used for mood disorders, Thyroxine tablets etc. During this situation, the patient needs to consult a doctor and need to adjust these medicine.

4)    When you identify a tremor, which doctor do you need to visit?
Tremor is associated with problems in the nervous system. When you identify such symptoms you need to see a neurologist. If you are a perfectly normal person when you get tremor only on one side, it can be a sign of a stroke associated with tremor and has to be immediately brought to the hospital. It happens due to damage to the cerebellar area. If you have tremors like alcohol withdrawal essential tremor which can affect day to day activities, you need to visit a doctor. Those patients who are taking medicines, need to follow up with a neurologist for dose modification.

5)    How is tremor related to Parkison's disease ?
Tremor is a major symptom of Parkinson's Disease and other symptoms are bradykinesia which is slowness in movement, loss of balance and postural instability. They may be walking with stooped posture, absent  facial expressions, reduced salivation, reduced eye blinking etc. With these signs and symptoms, we can differentiate tremor as Parkinson's Disease or not.

6)    In what age group do Parkinsons appear first?
Usually it is seen in those above 65 years of age. It is also seen in the age group between 30 and 45 years. Genetic causes are also described. There are several causes explained for Parkinson’s disease. One reason for that is head trauma. For example, the famous boxer Mohammed Ali had this problem. The cause may be due to multiple contusions due to attack on his head during boxing. Other causes explained are carbon monoxide, carbon disulphide, organophosphorus poisons, continuous exposure to these agents causes Parkinson's Disease. If you use drugs described above for prolonged period of time or if there is reduced blood supply to basal banglia, causing basal ganglia stroke are other contributing factors to Parkinson’s disease.

7)    Types of Parkinson's Diseases

A) Idiopathic Parkinson's - For 10 -20 years the patient's condition may not worsen
B) Atypical- within five years patients will worsen and maybe confined to wheelchair. Types of atypical Parkinson’s disease are progressive supranuclear palsy, Multiple system atrophy ,Corticobasal syndrome

8) Can tremor occur as prerunner of any severe disease?

First you need to identify which type of tremor it is.
Postural/Intention Tremor occurs in cerebellar problems. For example cerebellar diseases, genetic, spinocerebellar, stroke, multiple sclerosis etc.
Neuropathic tremor occurs in peripheral neuropathy.
Rubral tremor occurs if there is abnormality in the midbrain. 
Toxins like mercury, lead etc can cause tremor.

9) Can we treat this disease completely
Mostly we can. For that, first we need to identify the exact cause of tremor.  Need to take a proper history to identify pattern of tremor, how long it lasts, whether is it present during sleep, any precipitating or relieving factors, associated with loss of balance, stiffness, any medication or family history. Then it needs  proper evaluation like testing the blood for thyroid, sugar, liver function tests and so on. Scan may be done to rule out structural causes.

10) Treatment
If neuropathic causes are there, treatment for neuropathy should be given. If it is caused due to increased copper accumulation in the body due to Wilson's disease, treatment for that is given. For essential tremor beta blocker is given. For complete cure of tremor, in selected cases surgery may be offered, electrical stimulation to specific areas may be given. If you identify the correct cause and if proper treatment  is given, it can be cured  by medicines.
Dr Krishnasree K S
Associate Consultant
Department of Neurology

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