Movement Disorders
Assessment of tremor, slowness and stiffness, including Parkinson’s disease
Your consultant
Dr. Oliver Bernath
MD, AASM, ESRS, DGSM
Assessment of tremor, slowness and stiffness, including Parkinson’s disease
Movement disorders affect the control of movement rather than strength. The two seen most often are essential tremor and Parkinson’s disease, and telling them apart is the single most useful thing an assessment does, because they look superficially similar to a worried patient and are managed entirely differently.
The distinction is largely in when the tremor appears. Essential tremor is an action tremor: the hands are steady at rest and shake when doing something, so the difficulty is with a cup, a spoon, handwriting or holding a newspaper. It is often symmetrical, frequently affects the head or voice, commonly runs in families, and characteristically improves for a short time after a small amount of alcohol. The tremor of Parkinson’s disease is the opposite: it is present at rest, in a hand lying in the lap, and settles when the hand is used. It usually starts on one side and stays asymmetrical, and it comes with slowness of movement, stiffness, smaller handwriting, reduced arm swing and a quieter voice.
Not every tremor is either. An overactive thyroid, a number of common medications, excess caffeine and alcohol withdrawal all produce tremor, and those are worth identifying because removing the cause removes the tremor.
Assessment establishes which is which, treats what is treatable, reviews existing medication where a diagnosis is already made, and arranges onward referral where ongoing specialist team care is needed.
What it looks and feels like
- Shaking of the hands when reaching, writing, eating or holding something
- Shaking of a hand at rest, in the lap or by the side, that stops on movement
- Tremor of the head, or a quavering voice
- Slowness getting going with movements, and difficulty with fine tasks such as buttons
- Stiffness or rigidity in a limb, sometimes mistaken for arthritis or a frozen shoulder
- Handwriting becoming smaller and more cramped
- Reduced arm swing on one side, shuffling steps, or a stooped posture
- Reduced facial expression, or a quieter, more monotonous voice
- Loss of sense of smell, constipation, or acting out dreams, which can precede other symptoms by years
Why it happens
- Essential tremor, the most common movement disorder, frequently inherited
- Parkinson’s disease, caused by progressive loss of dopamine-producing brain cells
- Medication-induced tremor or Parkinsonism, notably some antipsychotics and anti-sickness drugs
- An overactive thyroid
- Excess caffeine, nicotine, or alcohol withdrawal
- Anxiety, which exaggerates a physiological tremor everyone has
- Dystonic tremor, and tremor associated with other neurological conditions
- Vascular disease affecting the movement pathways of the brain
Seek advice if a tremor is new, is worsening, affects one side more than the other, or is interfering with eating, writing, dressing or work. Seek advice if you have noticed slowness, stiffness, a change in walking or smaller handwriting, particularly if someone else has commented on it. It is also worth an assessment if you have a tremor and have started a new medication, or if you have been told you have Parkinson’s disease and want the diagnosis or the treatment reviewed.
Frequently asked questions
Does a tremor mean I have Parkinson’s disease?
Usually not. Essential tremor is considerably more common than Parkinson’s disease, and the pattern differs: essential tremor appears when the hands are being used and is often symmetrical, while Parkinsonian tremor appears at rest, typically starts on one side and comes with slowness and stiffness. Tremor alone, without slowness of movement, is not Parkinson’s disease. That distinction is a large part of what the appointment is for.
How is Parkinson’s disease diagnosed?
Clinically, from the history and a neurological examination, by an experienced clinician. There is no single blood test for it. The core requirement is bradykinesia, slowness and reduction of movement, together with rigidity or rest tremor. Imaging such as a DaTscan is used in a minority of cases where the picture is genuinely uncertain, not routinely. Guidance is that suspected Parkinson’s should be assessed by a specialist before any anti-Parkinsonian medication is started.
Can medication cause tremor or Parkinsonism?
Yes, and it is more common than most people expect. Certain antipsychotics, some anti-sickness medications, lithium, valproate, salbutamol and thyroid replacement in excess can all produce tremor, and some can cause a drug-induced Parkinsonism that closely resembles the disease. This is why a full medication review is part of the assessment: where a drug is responsible, the problem often resolves once it is changed.
Is it true alcohol helps essential tremor?
A characteristic feature of essential tremor is that it improves temporarily after a small amount of alcohol, and this can be a useful diagnostic clue in the history. It is not a treatment. The effect is short-lived, the tremor typically rebounds afterwards, and using alcohol to manage it leads somewhere unhelpful. Effective medical treatments exist and are the right route.
My handwriting has got smaller. Does that matter?
It can be significant. Micrographia, handwriting that becomes progressively smaller and more cramped across a line or a page, is a recognised early feature of Parkinson’s disease and often appears before anyone has thought about tremor. Reduced arm swing on one side, a quieter voice, loss of sense of smell and acting out dreams during sleep are other early features that commonly precede the classic signs by years.
What is the link with sleep?
A close one. REM sleep behaviour disorder, in which someone physically acts out their dreams because the normal paralysis of REM sleep is absent, is strongly associated with later development of Parkinson’s disease and related conditions, often preceding it by many years. Sleep problems are also very common once Parkinson’s is established. Assessment here covers both, which is unusual and useful.
What happens after a diagnosis?
The diagnosis is explained properly, along with what it does and does not mean, and treatment is discussed. Where a diagnosis is already established, existing medication can be reviewed. Long-term Parkinson’s care involves a specialist multidisciplinary team including a Parkinson’s nurse, physiotherapy and speech therapy, so onward referral is arranged for that ongoing care rather than it being provided from a visiting clinic.
Concerned about movement disorders?
Book a consultation with our specialist team. We will assess the cause and recommend the right combination of treatments for you.
Book a consultation