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Are Resting Tremors In Hands Suggestive Of Parkinson's Disease?
Question: My dad has been diagnosed with Parkinsons based on
resting tremor in one hand. He has had 4 doses of Levadopa
and he still has the tremor. Is this a sign that he does not
have Parkinsons? Maybe something like essential tremor
instead? Please answer this is a very important question
as we are very concerned about the diagnosis.
resting tremor in one hand. He has had 4 doses of Levadopa
and he still has the tremor. Is this a sign that he does not
have Parkinsons? Maybe something like essential tremor
instead? Please answer this is a very important question
as we are very concerned about the diagnosis.
Brief Answer:
Typically resting tremor= Parkinsonian tremor
Detailed Answer:
Good afternoon. You are correct to wonder about the validity of the diagnosis of PD if levodopa appears not to confer any relief of symptoms at all. However, a single clinical sign of a resting tremor neither allows us to confirm or deny the diagnosis of PD. There are many more features of a patient which you have not said anything about such as the presence of slowness, rigidity, gait disturbance, changes in voice, swallowing capability, stooped posture, freezing gait, etc. etc. which are all features of (yet not even diagnostic of PD).
Also, we must remember that typically the clinically therapeutic response of levodopa is taken to be approximately 25/100 dosed at least 2 if not 3x/day. If he's only received 4 total doses and you still see a tremor I would not say that he has taken anywhere close to the dose he needs to take nor for the time he needs to take the medicine in order for us to make any hard and fast decisions as to whether the initial diagnosis is wrong or not.
There are those Parkinsonologists even who believe that MAKING a diagnosis on a patient of PD in a time frame of anything less than 3-5 years after getting to know them (even if medication seems to be awesomely successful is a potential road to disaster since it takes just about that time for things that may start out looking like Parkinson's to go down a different track. That means, potentially a patient who thinks they've had PD for years because the doctor diagnosed them based upon their response to medication or because they have the correct type of tremor or facial expression may end up having to change their diagnosis to something unexpected such as Multiple System Atrophy or Corticobasal Ganglionic Degeneration, or some other diagnosis that is NOT PD.
So you see, the one single feature of tremor at rest and the very short duration of taking the medication combine to make it pretty impossible to say with any security that your father does or doesn't have PD. We need much more clinical as well as historical information as well as more time and more doses of levodopa to see if the tremor stops.
Essential tremors tend to be tremor that get WORSE upon engaging the hands and they tend to be BOTH SIDES as opposed to one hand. Also, they extinguish very well with the ingestion of alcohol and get decidedly worse when taking in coffee or anything with caffeine and there are certain other things we could point to about essential tremor that she may not have. ET typically respond very well to propranolol while Parkinsonian tremors do not respond well to anything initially except carbidopa (when taken in the correct dose and for a minimum time frame.)
I hope these answers satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
The query has required a total of 18 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Typically resting tremor= Parkinsonian tremor
Detailed Answer:
Good afternoon. You are correct to wonder about the validity of the diagnosis of PD if levodopa appears not to confer any relief of symptoms at all. However, a single clinical sign of a resting tremor neither allows us to confirm or deny the diagnosis of PD. There are many more features of a patient which you have not said anything about such as the presence of slowness, rigidity, gait disturbance, changes in voice, swallowing capability, stooped posture, freezing gait, etc. etc. which are all features of (yet not even diagnostic of PD).
Also, we must remember that typically the clinically therapeutic response of levodopa is taken to be approximately 25/100 dosed at least 2 if not 3x/day. If he's only received 4 total doses and you still see a tremor I would not say that he has taken anywhere close to the dose he needs to take nor for the time he needs to take the medicine in order for us to make any hard and fast decisions as to whether the initial diagnosis is wrong or not.
There are those Parkinsonologists even who believe that MAKING a diagnosis on a patient of PD in a time frame of anything less than 3-5 years after getting to know them (even if medication seems to be awesomely successful is a potential road to disaster since it takes just about that time for things that may start out looking like Parkinson's to go down a different track. That means, potentially a patient who thinks they've had PD for years because the doctor diagnosed them based upon their response to medication or because they have the correct type of tremor or facial expression may end up having to change their diagnosis to something unexpected such as Multiple System Atrophy or Corticobasal Ganglionic Degeneration, or some other diagnosis that is NOT PD.
So you see, the one single feature of tremor at rest and the very short duration of taking the medication combine to make it pretty impossible to say with any security that your father does or doesn't have PD. We need much more clinical as well as historical information as well as more time and more doses of levodopa to see if the tremor stops.
Essential tremors tend to be tremor that get WORSE upon engaging the hands and they tend to be BOTH SIDES as opposed to one hand. Also, they extinguish very well with the ingestion of alcohol and get decidedly worse when taking in coffee or anything with caffeine and there are certain other things we could point to about essential tremor that she may not have. ET typically respond very well to propranolol while Parkinsonian tremors do not respond well to anything initially except carbidopa (when taken in the correct dose and for a minimum time frame.)
I hope these answers satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
The query has required a total of 18 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
He doesn't have any other of the
symptoms of Parkinsons. He is a
farmer and is very physically active,
although lately he says he is extremely
tired. He says he seems a little of balance
but he has a history of that symptom with
allergies and sinus problems. Otherwise the
diagnosis was made strickly on the resting
tremor without much of a physical exam,
although they did do scans and bloodwork
to rule out other causes. He has now taken
the meds twice a day for 5 days and the tremor
is no better at all. He is very upset over the
diagnosis, the neurologist told him conclusively
that "you have Parkinsons". He also told him the
Levadopa has few side effect, which I KNOW is not
true. I just think if the fact that the meds are
not working reduces the odds that it is Parkinsons
it might at least relieve a bit of anxiety. I have read
that they sometimes give that medication just to rule
out Parkinsons if it does not work, so I was hoping
it was good news that the tremor is no better. Thanks!
symptoms of Parkinsons. He is a
farmer and is very physically active,
although lately he says he is extremely
tired. He says he seems a little of balance
but he has a history of that symptom with
allergies and sinus problems. Otherwise the
diagnosis was made strickly on the resting
tremor without much of a physical exam,
although they did do scans and bloodwork
to rule out other causes. He has now taken
the meds twice a day for 5 days and the tremor
is no better at all. He is very upset over the
diagnosis, the neurologist told him conclusively
that "you have Parkinsons". He also told him the
Levadopa has few side effect, which I KNOW is not
true. I just think if the fact that the meds are
not working reduces the odds that it is Parkinsons
it might at least relieve a bit of anxiety. I have read
that they sometimes give that medication just to rule
out Parkinsons if it does not work, so I was hoping
it was good news that the tremor is no better. Thanks!
Brief Answer:
I would not have made that diagnosis in the way you described, HOWEVER--
Detailed Answer:
Thanks for the updates and increased detail. You should know that Levodopa can also be used to treat Essential Tremor and I have done that successfully in some patients.
I simply wouldn't've made a diagnosis of PD based strictly on a resting tremor and nothing else. The fact that the medicine doesn't seem to be having an effect is beside the point....rest tremor by itself is not diagnostic, HOWEVER, if you did not ask the neurologist about whether or not they tested your father for other clinical signs such as cogwheel rigidity, slowness of movement, or asymmetric arm swing on walking then, perhaps he did note other things that could bolster the diagnosis of PD but just didn't reveal that information to you.
Perhaps, the neurologist feels that your dad is right at the very front end of the picture and that within several weeks to several months more symptoms will manifest?
I don't know and I can't really answer for him/her or what the thinking process was to decide on PD definitely. Again, I would respectfully disagree with the approach and conclusion based upon what you've presented but to be completely fair I would also need to give the other neurologist the benefit of the doubt compared to myself since he has had the benefit of being able to physically examine your dad.
I typically also don't START with medication on patients when tremor is the sole presenting symptom since we know that there are physical rehabilitation methods of treating these patients at the earliest stages of disease which could help them stave off medication for some time, make them more functional, and potentially avoid having to record a movement disorder diagnosis which of course, most people would expect would be PD because of the tremors.
I always remember what one of the most well known Parkinsinologists here in XXXXXXX said to me during my training, "Not everything that shakes is Parkinson's....and not everything that DOESN'T SHAKE ISN'T Parkinson's." You have to think about that for a moment but what he's saying essentially is that there is such a spectrum of presentation for PD in the general population that it is often an error of judgment to make any such diagnosis on a first visit no matter how classical symptoms may seem to be......I've practiced with that rule in my back pocket at all times and I think it has helped me avoid making incorrect diagnoses and unwittingly or unnecessarily scaring or worrying people who then, I would've had to come back to a few years later and change their diagnosis to something else.
Good luck.
I hope these answers satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
The query has required a total of 32 minutes of physician specific time to read, research, and compile a return envoy to the patient.
I would not have made that diagnosis in the way you described, HOWEVER--
Detailed Answer:
Thanks for the updates and increased detail. You should know that Levodopa can also be used to treat Essential Tremor and I have done that successfully in some patients.
I simply wouldn't've made a diagnosis of PD based strictly on a resting tremor and nothing else. The fact that the medicine doesn't seem to be having an effect is beside the point....rest tremor by itself is not diagnostic, HOWEVER, if you did not ask the neurologist about whether or not they tested your father for other clinical signs such as cogwheel rigidity, slowness of movement, or asymmetric arm swing on walking then, perhaps he did note other things that could bolster the diagnosis of PD but just didn't reveal that information to you.
Perhaps, the neurologist feels that your dad is right at the very front end of the picture and that within several weeks to several months more symptoms will manifest?
I don't know and I can't really answer for him/her or what the thinking process was to decide on PD definitely. Again, I would respectfully disagree with the approach and conclusion based upon what you've presented but to be completely fair I would also need to give the other neurologist the benefit of the doubt compared to myself since he has had the benefit of being able to physically examine your dad.
I typically also don't START with medication on patients when tremor is the sole presenting symptom since we know that there are physical rehabilitation methods of treating these patients at the earliest stages of disease which could help them stave off medication for some time, make them more functional, and potentially avoid having to record a movement disorder diagnosis which of course, most people would expect would be PD because of the tremors.
I always remember what one of the most well known Parkinsinologists here in XXXXXXX said to me during my training, "Not everything that shakes is Parkinson's....and not everything that DOESN'T SHAKE ISN'T Parkinson's." You have to think about that for a moment but what he's saying essentially is that there is such a spectrum of presentation for PD in the general population that it is often an error of judgment to make any such diagnosis on a first visit no matter how classical symptoms may seem to be......I've practiced with that rule in my back pocket at all times and I think it has helped me avoid making incorrect diagnoses and unwittingly or unnecessarily scaring or worrying people who then, I would've had to come back to a few years later and change their diagnosis to something else.
Good luck.
I hope these answers satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
The query has required a total of 32 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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