Peter Hibberd, M.D., is a doctor whose advice is based on more than 28 years of hospital outpatient and inpatient experience. He is an experienced emergency medicine physician, surgeon, and consultant. Dr. Hibberd is certified by the American Board of Emergency Medicine. He is also a fellow and active member of the American Academy of Family Physicians, an active member of the American College of Emergency Physicians, and a member and fellow of the American Academy of Emergency Medicine. Dr. Hibberd has earned numerous national and international professional certifications, memberships, and awards.

What Can I Do About Tremors?

Monday, 02 August 2010 09:39 AM

Question: I have tremors which seem to be coming from a bad back. I have seen five or six neurologists, which was a waste of time, and I am on about 10 different drugs, including some for Parkinson's disease. What should I do next?

Dr. Hibberd's Answer:

Tremor is a general term for movement disorder. The correct treatment will hinge on a correct diagnosis. Tremor rarely produces pain. However, if you only notice your tremor when you have back pain, it may be more prudent to address the cause of the back pain first, as many common tremor states become more pronounced when we are uncomfortable, in pain, or even when we are more nervous than usual.

The back is rarely the primary cause of tremor. In my experience, correcting underlying medical, neurological, and orthopedic conditions has the potential to clear up tremors that are difficult to manage. Your failure to improve on Parkinson's disease (PD) medication is unfortunate, but not unusual. Remember, the diagnosis is often a guide to possible treatment.

Clearly, you and your doctors are not communicating well. I suggest that you:
• Start again. Perhaps ask your neurologist for permission to stop or at least minimize all your medication for a short time. If this is not Parkinson's, other medication combinations may be better.
• Establish the cause for your tremor/movement disorder, then seek remedies.
• Set up a treatment plan with your doctor, including contingencies.
• If therapy is advised, allow for a trial period, but maintain close follow-up.

Some tremor is related to medication. Many Parkinson's medications have a very slim tolerance curve and are apt to cause their own movement disorders, especially in combination with other medications. A skilled clinician who is knowledgeable about the side effects of combining medications is often very important.

Tremor should be fully investigated, and if persistent, you should seek the advice of a subspecialist.

In summary: Parkinsonism tremor improves with appropriate dosing of PD medication, while essential or familial tremor may respond to anticonvulsant or beta blocker medication.

Hyperthyroidism produces its own tremor that can be improved by beta blocker (usually used for managing heart and blood pressure). Vitamin B-12 deficiency may cause spinal cord degeneration and a lack of coordination. It may be masked by the use of folic acid, but it is treated by B-12 supplementation, etc.

I am emphasizing to you to re-address this systematically. It is possible that your tremor and pain are interrelated. This should be relatively straightforward for any skilled clinician to sort out. See your primary care physician for re-evaluation, and follow their referral suggestions. As an alternative, you may travel to a major hospital for multispecialty consultation and re-review.

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