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Dr. Miller: You have a tremor in your hand. What's that all about? This is Dr. Tom Miller here today to tell you about that on Scope Radio.

Hi, I'm here with Dr. Lauren Schrock. She's an assistant professor of neurology and specializes in movement disorders. Today, she's going to help us try to figure out what tremors are about. Lauren, my patients talk to me about tremors pretty frequently, and there are different kinds, right? Could you clue us in and tell us a little bit about the different kinds of tremors that people might experience.

Dr. Schrock: There are several types of tremors, but there are two most common ones that people will see in friends or family. Those include Parkinson's disease tremor and . . .

Dr. Miller: That's the one you don't want to have, right? That's what people, I think, might be worried about.

Dr. Schrock: That's what people worry about most commonly when they come in, actually, but they happen to have something called essential tremor.

Dr. Miller: That's more common.

Dr. Schrock: That's more common than Parkinson's disease. There are clear differences between the two. With essential tremor it's mostly tremor, and that's your main symptom. What's unique about it is it doesn't occur when you're resting. If you're resting and not doing anything, your hands are very still, whereas when you try to do something with your hands, such as writing or even holding a coffee cup, your hands will be tremoring. That's something unique.

Dr. Miller: This is interesting, because I remember my grandfather when he reached out to pick up his peas with a fork he would have a lot of trouble with that. Then, of course, when he was resting he didn't have that tremor. He would always tell me that he thought this was Parkinson's, and I guess that's not true.

Dr. Schrock: That's a common misconception, and people really worry about it. That's what they come in frequently to my office worrying about. The reason why they worry is they think of Parkinson's disease, correctly, as more of a progressive disorder.

Dr. Miller: They worry that that might be the start of a long, progressive problem. Essential tremor, it can start mild and stay mild, or does it progress also? Does the essential tremor get worse?

Dr. Schrock: Essential tremor definitely can get worse. Really, when it comes down to it, probably two decades from now we're going to find out there are many different types of essential tremors. There are a lot of varieties of the different severity of tremor, what part of the body it includes. Most commonly . . .

Dr. Miller: So it's not just the hands?

Dr. Schrock: It's not just the hands. Head tremor can be involved, head and voice tremor.

Dr. Miller: I've heard some people that sound like their voice is almost trembling when they talk, and you wonder if they're anxious. Actually, it's the essential tremor, that type of tremor at least, right?

Dr. Schrock: It definitely can be. There's one other thing that can be mixed up or misdiagnosed as essential tremor, and that's something that's much more rare, so most people haven't heard of it. It's something called dystonic tremor, something when someone has dystonia, meaning abnormal spasm of a muscle that causes either pulling or abnormal postures.

Dr. Miller: Is essential tremor mostly in both hands, or is it usually in one?

Dr. Schrock: In most people, essential tremor will come on in both hands. Most patients who come in will complain of it more in their dominant hand, of course, but when you actually examine them they'll have the tremor in both hands. Whereas with Parkinson's disease, by definition it starts with one hand and at rest, so the Parkinson's tremor will be where someone is just sitting down. You see their hand moving on its own, tremoring rhythmically. Often, people describe it as a pill rolling tremor. You'll see the movement of the thumb and the finger kind of together.

Dr. Miller: But the essential tremor is a little finer tremor, it's worse as you move towards something or try to do something. It's a finer base tremor. I guess sometimes it can actually be a pretty marked tremor, depending on who has it.

Dr. Schrock: Yeah, it can become severe. Most people don't come into a doctor for essential tremor. There's a lot more essential tremor out there than we see in our clinics.

When people have done studies just knocking on doors and seeing if someone has tremor, the rates are much higher than would be estimated just by how many people come to clinic. Because the majority of people, really it's probably relatively mild, so they don't see a physician about it. In general, when you look at essential tremor you can have some people who have a very fine tremor, almost even a jerky sort of tremor, and then you can have other people who will have a tremor that is much more severe. For example, when they hold up their hand in front of them their finger may move up to three inches.

Dr. Miller: Wow, that would be very difficult to live with, I would think. Do essential tremors travel in families? Are they associated with a family history? Because many of my patients will say, "Yeah, I really haven't worried about it because I knew my dad had it and his mother had it."

Dr. Schrock: Yes. It's very common to see essential tremor strongly travel in families. In medical school, we're taught that it's what they call autosomal dominant disorder, so that each child has a 50 percent chance of getting the gene.

Dr. Miller: Is that still true? Does that hold?

Dr. Schrock: I would say there's definitely a sub-group where you definitely see that, but as I mentioned before, essential tremor probably includes many different tremors, some of them where you see clear family inheritance and others where you actually don't.

Dr. Miller: What about the age difference when these tremors might develop? Does the Parkinson's tremor occur a little bit later, that pill rolling tremor you described? Is that a little bit later on in life, or essential tremor earlier in life?

Dr. Schrock: On average, when you look at the large groups, you will see that essential tremor comes on a little bit earlier than Parkinson's disease. However, even within a single family who has multiple family members with this essential tremor, you may have one family member who has the onset at age 20 and another family member at age 75. There really is not a clear indicator of what your diagnosis is based on the age of onset.

In Parkinson's disease, the large majority of patients have their onset in their 60s, 70s. However, there is a small subset of patients who can have early onset Parkinson's disease. A great example of that would be Michael J. Fox who had his onset around age 30.

Dr. Miller: Also, tremors are related to certain drugs, I think. A lot of us think about people who maybe are withdrawing from alcohol having a tremor. Is that actually a tremor? Is that something that is separate from what we've been talking about?

Dr. Schrock: The answer is yes and no. You can get that with certain drugs. Most commonly, I'm thinking of drugs that block dopamine. That would be in a class of medicines called anti-psychotic medications or medications that can be used for mood stabilization. An old one is called Haldol. Those can cause a Parkinsonian tremor. That's a very true tremor. The tremor will go away when the medication is taken away, but it may take up to six to 12 months for the tremor to actually go away.

Dr. Miller: A long time. I didn't know that.

Dr. Schrock: Then, there is another. You're talking about withdrawal of alcohol, for example, or someone who is under stress. This is something I often describe to my patients who have tremors, because tremors always worsen with stress, whether it be stress of having the flu or stress of having your mother in law coming to dinner.

Every single human being has the potential to have tremor. What we call that is physiologic tremor. Whenever someone is extremely hungry, didn't get enough sleep, they will get some very fine tremor in their hand. There are sayings called to shake with rage. Well, there's a reason for that. Because humans . . .

Dr. Miller: I've had that. It seems like that's about three times a week.

Dr. Schrock: . . . have a natural inherent tendency to have some tremor during times of stress.

Dr. Miller: What would you say to the person that develops a tremor? Should they see a physician about the type of tremor they have if they're concerned? Could they by looking on the web to figure out if it was an essential tremor and maybe diagnose themselves?

Dr. Schrock: In self-diagnosis, I've definitely had patients who've correctly done that, but I would beware. I think that anyone who has a tremor and has a concern about it should bring it up to his or her primary physician. If you're worrying and it's bothering you, then you definitely should see a physician about it.

Dr. Miller: Finally, there's treatment for both types, correct?

Dr. Schrock: Yes. There are treatments for both types. They are very different, the approaches to treatment.

Dr. Miller: That would require a physician to make the diagnosis and provide the treatment. Thanks very much, Dr. Schrock.

Dr. Miller: Advanced Parkinson's disease and movement disorders. We're going to talk about what to do next on The Scope radio. This is Tom Miller.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here today with Dr. Lauren Schrock. She's an assistant professor in neurology and in charge of the movement disorders program. Lauren, we're going to talk about sort of advanced Parkinson's. I think it's pretty well known that after a period of time, a lot of folks who responded to medications and treatment of their Parkinson's start not doing as well on the medications. I think the thing that we would like to talk with you about today is that there are new therapies and those involve deep brain stimulation. When should a patient maybe start thinking about this option of treatment and whom they should be working with if they're thinking about this option for treatment?

Dr. Schrock: When medications start causing complications is often the term we use in Parkinson's specialists. Basically, over time, medicines don't last as long and they wear off in between doses and people can develop dyskinesias.

Dr. Miller: Yeah, what is a dyskinesia for our listeners?

Dr. Schrock: Dyskinesia is an extra involuntary movement. It almost looks like a wiggling and a squirming. The most known person who most people have seen have this issue publicly would be Michael J. Fox. That wiggling back and forth. That is something that can be caused by a combination of both having the Parkinson's disease and also having taken Parkinson's disease medication.

Dr. Miller: Did Mohammed Ali have a deep brain stimulation device implanted? Do you know?

Dr. Schrock: No. Mohammed Ali did not, as far as I know. His Parkinson's is likely thought to be a secondary Parkinson's disease related to the multiple hits to the head. In that type of Parkinson's disease, that's caused by something else, it's not expected to respond to deep brain stimulation.

Dr. Miller: Okay. Good to know.

Dr. Schrock: Very important point about when a person is considering, "Should I have deep brain stimulation?" because there are many things that go into predicting whether someone will respond well to deep brain stimulation and how they will do afterwards.

Dr. Miller: So tell us about how someone makes the decision about inquiring on this new type of treatment.

Dr. Schrock: I'm going to actually start with one and explain what it is a little bit more. If you imagine almost like a brain pacemaker, in the same way that people have pacemakers to help their heart keep beating, in Parkinson's disease there is something called deep brain stimulation where a wire is placed deep down within the brain. When it's in place it's often not very visible. Some neurosurgeons are going to pay a lot of attention to the aesthetics of it and others put it in the way it was designed, so to speak.

With deep brain stimulation, the first thing you want to do when you're considering asking the question of whether it would be appropriate is you'd want to see a specialist in Parkinson's disease. That would be a type of neurologist who specifically has done specialized training in things like Parkinson's disease and tremors.

Dr. Miller: Both medications and in the deep brain stimulation.

Dr. Schrock: Absolutely. Yes, in medications. Because many of my colleagues, who are involved heavily in D.B.S., like myself, really will say the most important visit is the visit with the Parkinson's specialist or we call movement disorder specialist. It's not uncommon for me to be able to work with a patient and actually say, "Oh, why don't you try this medication change," and then they call and say, "Oh, cancel that neurosurgery idea," which is deep brain stimulation.

Dr. Miller: So that must mean you also have close ties to the surgeons who implant the deep brain stimulation devices. Is that correct?

Dr. Schrock: Absolutely.

Dr. Miller: So you're working with them pretty much hand in glove to design a therapy and treatment for the patient.

Dr. Schrock: Absolutely, because our goal is to have good outcomes in all patients we select. So we have special selection procedures to be able to ensure that, voiding any complications with the surgery as can happen with any type of surgery, that patients are going to do well and have improvement in the symptoms that they want to have improvement in.

Dr. Miller: Now what percentage of patients that you see will benefit from a deep brain stimulation device?

Dr. Schrock: Usually, when we think about a patient who's going to be ready for deep brain stimulation, is someone who despite optimizing their medicines is having lots of ups and downs where their medicines are wearing off and they've developed dyskinesias. They also have not developed significant problems with memory and thinking. Early on in D.B.S. most centers would say maybe 10% of their patients who were referred for deep brain stimulation would actually be candidates.

Dr. Miller: So one out of 10.

Dr. Schrock: Yeah.

Dr. Miller: One out of 10. Okay.

Dr. Schrock: However, I would say that our regional neurologists are very well educated around here and I would say that 70% of the patients who are referred to me specifically for the question of deep brain stimulation end up going on into deep brain stimulation within two years of that referral. So I really feel fortunate here. We have great neurologists in the area who really know what the indications are for the therapy.

Dr. Miller: Once this is put in you're able, just like with a pacemaker for the heart, to make adjustments in the way that you'd provide the treatment.

Dr. Schrock: Yeah, absolutely. So this is not a straight forward, like a medication sometimes can be. What you have is, with deep brain stimulation, you place this wire but it's going into a target in the brain that's about 3 by 6 by 6 millimeters. That target in the brain has several different sub areas that we have to get into. So we have to get into the little motor sub territory so any error more than 2 millimeters in our targeting is the difference between a success and a failure of surgery. So I'm dependent so much on the skills, excellent skills, of the surgeon for my ability to have great outcomes.

Dr. Miller: You say great outcomes. Tell me about that because you've got this person now that's sort of resistant to the medications. They've got the dyskinesias as you've mentioned. What do they see happening if it works?

Dr. Schrock: This only helps with what they call the motor symptoms of Parkinson's disease. So deep brain stimulation helps with tremor, slowness of movement, stiffness in the muscles as well as dyskinesias. So if you imagine a person with Parkinson's disease who's been taking medications for several years, when the medications now are only lasting every two to three hours, some people only one hour before they wear off, they can't count on any certain time. They can't go to a play and expect to be able to . . . they don't know if they're going to be able to get up and go home.

So what deep brain stimulation can do is by helping control these symptoms it can really give the person confidence in their day. That they're not going to go somewhere and get stuck. They're not going to go somewhere and start to have these wild dyskinesias that are going to be embarrassing for them. So really it's more of a smoothing out of the symptoms during the day.

Dr. Miller: How long can one expect to see that benefit from the deep brain stimulator?

Dr. Schrock: There's been growing research looking at the length of time and what symptoms are helped as time goes on. The early studies were one to three years out and showed there was very good persistence of benefits. Then we have now five-year and some 10-year studies. What they show for the symptoms that we expect it to benefit such as tremor, the dyskinesias, those continue to be well controlled even at 10 years.

Immediately after deep brain stimulation we often reduce medications anywhere from 30 to 80% but we have to gradually increase those medicines over time. What does gradually get worse is the slowness of movement. We aren't able to keep up with that as much as we are with tremor. The symptoms that D.B.S. doesn't help in the first place and those include balance, speech, freezing of gait where they get stuck and they can't keep moving, and memory and thinking issues. So all these things that D.B.S. didn't help in the beginning, at 10 years out those are the major issues.

Dr. Miller: But still, this is a great therapy to help people live a better life.

Dr. Schrock: Absolutely. As far as quality of life, all the studies that have looked at comparing optimization of medications or best medication management versus deep brain stimulation in patients with Parkinson's disease have shown much better quality of life in those with D.B.S. as compared to medicines alone. Many patients will explain to me they feel like their disease has been taken back five or 10 years.

Dr. Miller: It sounds like if you're a patient with Parkinson's or a physician's taking care of a patient with Parkinson's and they're staring to develop dyskinesias and they've been on the medications and they've been increasing the doses of the medications and things just aren't getting better, it probably is time to consider referring them to a movement disorder specialist in neurology.

Dr. Schrock: Earlier referrals are always better because we're never going to recommend surgery before it's needed and we can always provide education so you know when the time might be right.

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updated: April 16, 2019
originally published: May 13, 2014