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Monday, August 18, 2025

Shaking


Introduction

“Shaking” is a general term often used by patients to describe involuntary, rhythmic, oscillatory movements of one or more body parts. In medical terminology, this is most often referred to as a tremor. Shaking can be a benign, physiological phenomenon (such as shivering from cold or nervousness) or a manifestation of significant neurological, metabolic, or systemic disease.

The most common causes include essential tremor, Parkinson’s disease, medication-induced tremor, hyperthyroidism, anxiety, alcohol withdrawal, and systemic disorders. Distinguishing between these requires careful evaluation, as management varies from reassurance to targeted pharmacological or surgical intervention.

Types of Tremors

  • Physiological Tremor: Normal, low-amplitude tremor seen in everyone; exaggerated by stress, caffeine, or fatigue.

  • Essential Tremor: The most common pathological tremor, typically postural or kinetic, often affecting both hands.

  • Parkinsonian Tremor: Resting tremor, “pill-rolling,” asymmetrical, decreases with movement.

  • Cerebellar Tremor: Intention tremor, worsens as the hand approaches a target; due to cerebellar lesions.

  • Holmes Tremor: Combination of rest, action, and postural tremors, usually from brainstem/midbrain lesions.

  • Drug- or Toxin-Induced Tremor: From stimulants, lithium, valproate, corticosteroids, alcohol withdrawal.

  • Psychogenic Tremor: Variable, inconsistent, often distractible.

Etiology of Shaking

1. Neurological Causes

  • Parkinson’s disease.

  • Essential tremor.

  • Cerebellar disorders (stroke, tumor, multiple sclerosis).

  • Peripheral neuropathy.

  • Dystonia.

2. Systemic and Metabolic Causes

  • Hyperthyroidism (thyrotoxic tremor).

  • Hypoglycemia.

  • Electrolyte disturbances (low calcium, magnesium, potassium).

  • Hepatic encephalopathy (asterixis or “flapping tremor”).

  • Uremic encephalopathy.

3. Medication- or Substance-Related

  • Drugs: lithium, valproate, SSRIs, beta-adrenergic agonists (salbutamol), corticosteroids, caffeine.

  • Alcohol withdrawal (tremulousness).

  • Stimulants (amphetamines, cocaine).

4. Psychiatric Causes

  • Anxiety disorders.

  • Panic attacks.

  • Psychogenic tremor.

5. Physiological Causes

  • Fatigue.

  • Emotional stress.

  • Cold exposure (shivering).

Clinical Presentation

  • Location: Hands, arms, head, voice, legs, trunk.

  • Timing: Resting (Parkinson’s) vs postural/action (essential tremor) vs intention (cerebellar).

  • Amplitude/frequency: Fine vs coarse.

  • Associated symptoms:

    • Rigidity, bradykinesia (Parkinson’s).

    • Gait instability (cerebellar).

    • Sweating, palpitations, anxiety (thyrotoxicosis, hypoglycemia).

    • Confusion, asterixis (hepatic/uremic encephalopathy).

Diagnostic Evaluation

1. History

  • Onset, progression, triggers, relieving factors.

  • Family history (essential tremor often inherited).

  • Alcohol response (improvement suggests essential tremor).

  • Medication and substance use.

2. Physical Examination

  • Tremor type: rest, postural, action, intention.

  • Neurological exam: rigidity, reflexes, coordination.

  • Thyroid exam: goiter, tachycardia.

  • Signs of systemic illness: jaundice, edema, confusion.

3. Laboratory Tests

  • Thyroid function tests (TSH, free T4).

  • Blood glucose (hypoglycemia).

  • Electrolytes, liver function, renal function.

  • Toxicology/drug screen if needed.

4. Imaging

  • Brain MRI: cerebellar lesions, stroke, tumors.

  • DaTscan (dopamine transporter imaging) in atypical Parkinson’s cases.

Management

Treatment is cause-specific, supplemented by general symptomatic therapy.

1. Essential Tremor

  • First-line pharmacological agents:

    • Propranolol 40–120 mg/day orally in divided doses (can increase to 320 mg/day if tolerated).

    • Primidone 25–50 mg orally at bedtime, gradually titrated to 250 mg twice daily.

  • Second-line therapies:

    • Topiramate 25–100 mg/day orally.

    • Gabapentin 300–1200 mg/day orally in divided doses.

  • Procedural therapies (refractory cases):

    • Botulinum toxin injections (for head/voice tremors).

    • Deep brain stimulation (DBS) of ventral intermediate nucleus of thalamus.

2. Parkinson’s Disease Tremor

  • Levodopa/carbidopa: Start 100/25 mg orally three times daily; titrate as needed.

  • Dopamine agonists:

    • Pramipexole 0.125–1.5 mg orally three times daily.

    • Ropinirole 0.25–8 mg orally three times daily.

  • Anticholinergics (younger patients only):

    • Trihexyphenidyl 1–2 mg orally two to three times daily (max 15 mg/day).

  • Amantadine: 100 mg orally twice daily.

3. Cerebellar Tremor

  • Often resistant to medications.

  • Supportive therapy: physiotherapy, occupational therapy.

  • Trial of Clonazepam 0.5–2 mg orally twice daily may reduce amplitude.

  • Surgical options (DBS, thalamotomy) in refractory cases.

4. Metabolic and Systemic Tremors

  • Thyrotoxicosis:

    • Propranolol 20–40 mg orally three to four times daily.

    • Methimazole 10–30 mg/day orally in divided doses.

  • Hypoglycemia-induced shaking:

    • Immediate oral glucose (15–20 g).

    • IV Dextrose 25–50 mL of 50% solution if unconscious.

    • Glucagon 1 mg intramuscular if IV access unavailable.

  • Hepatic encephalopathy (asterixis):

    • Lactulose 15–30 mL orally two to four times daily, titrated to 2–3 soft stools per day.

    • Rifaximin 550 mg orally twice daily.

  • Uremic encephalopathy:

    • Dialysis is definitive treatment.

5. Medication/Substance-Induced Tremor

  • Review and discontinue offending drugs if possible.

  • Benzodiazepines may be used short-term in withdrawal states:

    • Diazepam 5–10 mg orally every 8–12 hours as needed.

  • Alcohol withdrawal:

    • Chlordiazepoxide 25–50 mg orally every 6 hours, tapered over 5–7 days.

6. Psychogenic Tremor

  • Psychological support, reassurance, and cognitive behavioral therapy (CBT).

  • Short-term anxiolytics if severe anxiety: Lorazepam 0.5–2 mg orally as needed.

  • SSRIs (e.g., Sertraline 50–200 mg orally once daily) for long-term management.

Precautions and Patient Counseling

  • Emphasize lifestyle modifications: avoid caffeine, nicotine, stimulants.

  • Encourage alcohol moderation; rebound worsening occurs after withdrawal.

  • Stress adherence to prescribed medication regimens.

  • Educate on safety: using assistive devices if tremors impair daily activities.

  • Advise patients with Parkinson’s or severe essential tremor about surgical options if drug therapy fails.

Drug Interactions

  • Propranolol: Interacts with calcium channel blockers (risk of bradycardia, hypotension). May reduce hypoglycemic awareness in diabetics.

  • Primidone: Interacts with warfarin, oral contraceptives (induces CYP enzymes).

  • Topiramate: Reduces efficacy of oral contraceptives; additive sedation with alcohol, CNS depressants.

  • Levodopa/carbidopa: Reduced absorption with high-protein diet; interacts with MAO inhibitors (hypertensive crisis).

  • Trihexyphenidyl: Additive anticholinergic effects with antihistamines, tricyclic antidepressants.

  • Methimazole: May enhance anticoagulant effect of warfarin.

  • Lactulose: May alter absorption of other oral drugs due to GI motility changes.

  • Rifaximin: Interacts with cyclosporine (increases levels).

  • Benzodiazepines: Additive CNS depression with opioids, alcohol, sedatives.

  • SSRIs: Risk of serotonin syndrome with other serotonergic drugs (triptans, MAOIs).

Prognosis

  • Essential tremor: Chronic but benign; can be controlled with medications or surgery.

  • Parkinson’s disease tremor: Progressive; requires long-term dopaminergic therapy.

  • Cerebellar tremor: Often resistant to treatment but supportive therapy helps function.

  • Metabolic tremors: Reversible if underlying cause treated (thyrotoxicosis, hypoglycemia, hepatic encephalopathy).

  • Psychogenic tremors: Good prognosis with psychological intervention.




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