What causes tremors in hands?

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Posted on Tue, 23 Dec 2014 in Brain and Spine
Question: Dear Dr Bishnoi,

I would like to ask for your help with the diagnosis of my symptoms.

I’m a European, 22 year old male. I believe that some of my problems started in the fall of 2011, after a prolonged tonsillitis treated with ATB. I started ATB about a week after the onset. I didn't get any blood tests so the diagnosis is presumed (it's unknown what it was). The ATB didn't work, the illness lasted about 4 weeks until it subsided on its own. After I got better I started feeling mild fatigue persistent until now. The mild fatigue started getting progressively worse in 2012 and 2013 and I started sleeping 9-10 hours a day (I did 7-8 before). I had to drink green tea to keep me going but soon even that wasn't very helpful. But it was still manageable fatigue and I could work and study, albeit with some small limitations.

In January 2014 I suffered another respiratory tract infection, possibly bronchitis. I was very stressed at that time, having to organise a conference and write my dissertation, so I paid no attention to my body. The main symptom was persistent dry cough with no phlegm. After about 6 weeks of this I finally decided to see my GP, but again, my GP did not do any blood tests, only prescribed a 3-day course of ATB. I'm not sure whether the ATB were effective but after some time the bronchitis ended, however, all my current problems described below started.

The fatigue got worse after the infection subsided. It is worst after sleeping, in the morning and afternoon, and best in the evening. On most days it's medium level fatigue and on a few days a week it's severe. I have a good appetite, no weight changes.

The second symptom, also very annoying, is that since the infection this year I've started to have problems with reading. In particular - when reading, my eyes jump over words causing me to misread words for something else or just omit words. The sentence then does't make sense. Essentially, I feel that I have a problem with moving my eyes smoothly along the line, they just jump forward a bit more than needed or jump slightly downward or upward. I have read that this might indicate a problem with the saccadic movements of the eyes.

Thirdly, I have had some sort of strange feeling in my whole body, especially in my hands. I have mild to moderate tremor when doing some intentional activity, such as eating, or buttoning my shirts. It's most prominent when I rotate my wrists. What's most annoying, however, is that I'm experiencing some sort of strange clumsiness. For example, I used to be a good piano player but now I find it hard to hit the right keys. When I press buttons on the microwave, I often miss. Or when opening the door I miss the handle and grasp air. In severity I think it's mild to moderate. I don't have tremor when resting my hands. I have the same kind of tremor in my legs and feet, less so in the trunk. Further, I feel that I am a little unstable when walking. This doesn't happen when I walk fast. When I walk slowly though, I feel slightly wobbly. I generally feel a sense of unsteadiness in my body.

The problems have rather severe so I had to take stop studying and working. I can take care of myself in terms of common daily activities but studying or working tires me down too much.

I have had 2 MRI scans of the brain, an MRI of the spine, a week-long EEG monitoring. I had all possible blood tests done, including full blood count, thyroid function test, liver function test, kidney function test, serum electrolytes, thyroid function test, basic immunological work-up (anti-dsDNA, anti-ENA, ASLO, CRP, ESR, C4/C3, folate, vitamin B12, ACE), gluten intolerance, glucose, urine microscopy and microbiology;; I also had a sleep study, ultrasonography of the stomach organs; and everything is OK.

On one neurological examination I had a positive Babinski sign and a positive finger-to-finger test, but negative finger-to-nose test and everything else. However, on another neurological examination with a different doctor, I had a negative plantar reflex. The finger-to-finger test wasn't repeated.

I have spoken to a psychiatrist who believes that my problems could be a manifestation of a somatisation/conversion class of disorders, or possibly chronic fatigue syndrome.

I have read about some possible conditions on the internet and what I'm experiencing regarding my problems with reading and the tremors and hand coordination, it sounds a little bit like some form of mild ataxia, accompanied by problem with eye saccades. But I'm no doctor to diagnose myself. My question is, whether I should pursue any more diagnosis in the form of EMG or evoked potentials (which is quite painful I've heard) or whether you could satisfactorily explain my reading problems, the tremor and the hand coordination problems, on a psychological basis, which would imply that I should begin psychotherapy and medication.

Thank you very much in advance.
doctor
Answered by Dr. Seikhoo Bishnoi 59 minutes later
Brief Answer:
Somatic symptoms

Detailed Answer:
Hello thanks for asking from Health Care Magic

I have read your clinical history and I will try to explain the situation. Before going into details I would like to summarise your clinical history. You are a young otherwise healthy male with no significant past medical history. You had tonsillar infection in 2011 and you were given antibiotics for that infection. As per you, no blood tests were done at that time. You improved at about 4 weeks but started having persistent fatigue and increased sleepiness. The symptoms worsened but you were able to do your work properly. Again in 2014 you developed one more respiratory infection and you didn't visit doctor for about 6 weeks because of burden of work and paucity of time. Later the infection subsided after taking a course of antibiotics for 3 days. The symptoms of fatigue worsened. Later symptoms like difficulty in reading (which caused difficulty in work), tremors like sensation in body especially in fingers, you started missing targets, problems of balance developed. All investigations came normal including scans, immunological workup, blood workup, urine tests, thyroid functions, liver and kidney functions etc. EEG and sleep studies are also normal. Neurological examination was insignificant but positive planter and finger to finger once.

Now coming to discussion-

Your symptoms like chronic fatigue, difficulty in balance, intentional tremors, balance problems, gait problems etc points towards some cerebellum disorder. But you are young and mere presentation of these symptoms are not sufficient to make diagnosis of cerebellar disorder. All investigations and work up came normal. No significant positive finding on CNS examination. Positive Babinski once and finger finger co-ordination test can't help to make diagnosis. All other tests of cerebellar functions came normal so as per my opinion the possibility of some organic neurological lesion is rare.

Then why these symptoms are occurring..?

You have chronic fatigue which was preceded by chronic respiratory infection. Some respiratory infection especially viral infections results in malaise and chronic fatigue even after remission. In most cases symptoms resolve in about 4 weeks but in some the symptoms progress and may complicate in chronic fatigue and symptoms of mild depression. The fatigue lasted and then you developed second infection after which symptoms got complicated and fatigue worsened. The symptoms gets worse in morning and as day progress symptoms start improving.

Other symptom like difficulty in reading is because of poor concentration. Lack of focus and concentration is one of common symptom of mild depression. The poor concentration is causing thinking about eye movement again and again. The saccadic movements or nystagmus can't be diagnosed by self examination, and secondly they result in a lot of other symptoms also. The symptoms like weird feeling in body, tremors, difficulty in touching targets, mild tremors in fingers, when nothing significant came on examination and investigations can be explained by somatic symptoms. Somatic symptoms are generalised body symptoms which remain persistent even no organic basis found on workup.

So as per my opinion there is no need to fear from any significant neurological lesion. Most likely your symptoms are due to mild to moderate depression with somatic symptoms. Depression doesn't mean that one should have low mood or lack of interest. A lot of individuals present with chronic fatigue, difficulty in working, poor work performance, generalised somatic symptoms etc symptoms.

As most preliminary investigations came normal so there is no need to go for EMG or evoked potential because these investigations will also come normal. Psychotherapy at this point will not help much but medicines should be started.

Medicines like Duloxetine, Milnacipran etc are used in somatic symptoms. Consult a psychiatrist for proper evaluation and treatment.

One thing I would like to know in follow up that if you are having problems of incoordination during routine work?

Thanks, hope this helps you. Ask again for more doubts.

Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Seikhoo Bishnoi 2 hours later
Dear Dr Bishnoi

thank you very much for such an extensive answer. You got my medical history spot on.

1) As for a cerebellar disorder, I agree it seems unlikely, for these reasons: I don't have any family history of such disease, so that rules out autosomal dominant ataxias; sporadic ataxias with multiple atrophy are extremely rare if not impossible in my age so I wouldn't consider that either... which only leaves autosomal recessive ataxias, some of which do begin precisely in young adulthood. But they are as rare as 10-30 people in a million. There is clearly no lesion in my cerebellum or the spine, as both MRIs came out clean. However, from what I've read, MRIs of brain are often unremarkable in the early stages of the disease, if it's atrophy. Further, what I failed to mention is that the tremor had been slight and developing for a few years before markedly worsening after the infection. Also, one of the neurologists told me I have somewhat abnormal gait. So I'm not totally convinced that ataxia is 100% out of the question.

2) Despite that, I completely agree that I should start a therapy of antidepressants. If they don't help with the coordination problems then am I right in saying that perhaps some sort of ataxia should be considered? And further testing done? If they do help, however, then I'll finally get a diagnosis.

3) the coordination problems (both eyes and hans) are constant. They haven't got better or worse since the infection (almost a year now), they've remained the same. It doesn't matter what I do, I'm constantly being reminded that something's wrong. The tremors get significantly better after ingesting alcohol - not the discoordination though.

4) You mentioned concentration. One thing that leads me away from ataxia, for a change, is that maybe we could explain the reading problems with concentration. But I'm afraid I don't understand very well the way you explained it. (((The poor concentration is causing thinking about eye movement again and again??))) Something along the lines that I lose concentration every second word and my eyes just jump? I'm not very sure about that as the reading problem happens even when I concentrate very hard. But of course, if there's a concentration issue then as hard as I try I can't break it.

5) what test could I take to diagnose the saccadic eye problem? it would be nice to have an objective proof to show to doctors because sometimes I feel they think I'm making this up. The same holds for the discoordination of hands. I'll happily do the examinations, at least for the peace of mind - to know that it's really somatic.

Understandably, clearing all doubts that my condition is truly without doubt psychological would be immensely beneficial to actually start feeling better and perhaps that would on its own help me recover.

Thanks again for your answers.

All the best
doctor
Answered by Dr. Seikhoo Bishnoi 48 minutes later
Brief Answer:
Ataxia

Detailed Answer:
Hello again, and thanks for asking a follow up

I would come to your doubts one by one-

1) First of all your main symptoms are slight incoordination, tremors and little imbalance. There are no other cerebellar disease symptoms and signs. Your CNS examination came almost normal. Tone was not decreased and in cerebellar lesions hypotonia is common finding. Other cerebellar signs were also not there. You have ruled out most ataxias by yourself. Common recessive ataxias usually start showing clinical symptoms at earlier age like around 5 years of age. They don't present with isolated mild symptoms and are progressive.

MRI can detect common cerebellar lesions and there is no doubt for that. Even atrophy causing symptoms can be detected. So any morphological lesion can be ruled out.

Slightly abnormal gait may need evaluation but in absence of other signs of cerebellum, I am sure that you are not having ataxia. Ataxia cause significant imbalance and not mild. (Don't rely of internet :))

2) Visit a psychiatrist and you will be examined again. Only after ruling out everything you will be started with anti-depressants which will help to control somatic symptoms. As per my opinion trial should work. Out of anxiety and availability of excessive information you have developed fear of some cerebellar disease which might be the reason of insecurity. There is no need to worry, all investigations came normal so you are absolutely normal.

3) The coordination problems are not progressive. You are remaining always in belief that something is wrong. This is also a part of anxiety. Tremors are improving with alcohol. Alcohol is a brain depressant and it tend to relieve anxiety. This also supports us. Ataxia should get worsened by alcohol.

4) Due to lack of focus and concentration you are skipping or omitting words. Persistent poor focus has made you conscious about that something is wrong in eyes. You have to check (better term "think") about eye movements. You feel that something is wrong in eyes but that is not true. CNS examination easily detect abnormal eye movements and nystagmus if any. The concentration will improve with improvement of your symptoms.

5) Most of detailed neurological examinations can detect Saccadic eye movements easily. Still a test that is commonly used for evaluation is King Devick Test. The test is usually performed by a psychologist or ophthalmologist. Most people prefer CNS examination than this test. Similarly for poor coordination of hands you can self examine yourself by finger nose test, finger-finger test, picking an object from table etc. All tests should come normal.

Now why the condition is having psychological basis-

- The chronicity of symptoms. Most of neurological lesions progress rapidly. The chronicity without any organic objective evidence points us to some psychiatric phenomenon.

- All investigations and clinical CNS examinations came normal.

- You are looking for neurological or cerebellar illness because of fear despite normal findings.

- Fatigue get worsened in morning and improve with day, which points us to some depressive illness.

- There is no significant history in family, no past medical history, no chronic alcohol abuse (I guess), no trauma. These things may increase risk of neuro lesion.


Thanks, hope I cleared some of your doubts, please ask again if you have more questions or you want to clear something from my question.


Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Seikhoo Bishnoi 27 hours later
Dear Dr Bishnoi

I posted an answer but it seems to have got lost somewhere in the system. So again...

1) You've managed to convince me that for 99% everything I'm experiencing is psychological. To be 100% sure I'm going to ask my ophthalmologist to do the test that you suggested. I've done the finger-to-finger test and the finger-to-nose test with my parents. In the finger-to-nose test my hand doesn't tremble. In the finger-to-finger test, my hand trembles visibly for other people when I'm approaching the other person's finger but when I concentrate then I never miss the finger. So it seems that dysmetria is not the problem, rather it's intention tremor, which is common in anxiety disorder, right? Further, I've read that clumsiness is also a feature of anxiety disorder and it sort of looks like some symptoms of ataxia but it's not ataxia... It's just caused by a lack of concentration and tremor, which are caused by anxiety. So basically it may look like some bits of ataxia but in fact we can explain it very well based on a concentration problem and tremor, right?

(I do admit that some form of health anxiety is present at me, especially after what you've written)

2) what other things should the psychiatrist rule out? do you mean some other psychiatric disorders?

I think that will be all. After this I will close the discussion and give you the best rating. All your answers well excellent and it is very clear now why you are the very top psychologist on this portal. I don't wanna sound flattering but you're exceptionally good. So thanks again. Wish you the best of luck.

doctor
Answered by Dr. Seikhoo Bishnoi 4 hours later
Brief Answer:
Anxiety most likely

Detailed Answer:
Hello thanks for asking again, I hope you are doing well

Coming to your questions-

-Yes, if still some doubt left then you can visit an ophthalmologist to rule out the eye movements abnormalities if any. But make a pact with yourself that if everything come normal then you will not bother about these things again. In states of anxiety slight tremors can be seen. Typical cerebellar intentional tremors are evident by other persons also. These tremors will be observed while doing routine work also. As you haven't mentioned such thing so I assume you never had intentional tremors during routine work. So we can easily rule out cerebellar tremors. Then anxiety can be kept as possibility for mild tremors and slight clumsiness.

-Psychiatric disorders are diagnosis made after ruling out other organic neurological diagnosis. Anxiety is the first possibility I want to keep. Anxiety along with some features of health anxiety (hypochondical ideas) should also be there. I am not saying that these symptoms are occurring due to health anxiety but these symptoms have become more evident and significant only due to anxiety about some cerebellar illness.

One thing I would like to suggest you that, don't visit different doctors again and again, because for some time they can reassure you but after some time you will again develop fear and anxiety. To improve from such symptoms you have to help yourself. Try to control the symptoms by relaxation exercises and diverting your attention by doing any constructive thing. Don't think about the symptoms again and again because this will make insignificant symptom, significant only. You have visited doctors and they didn't make any serious diagnosis this itself prove that there is nothing serious. Even if we assume by mistake one doctor missed diagnosis but different doctors will not make same mistake again.

Hope this helps you. Don't be quick in closing the discussion, If you still have some doubts left you can ask again.

Wish you a good health.

Thanks Dr. Seikhoo Bishnoi, Consultant Psychiatrist.
Above answer was peer-reviewed by : Dr. Shanthi.E
doctor
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Follow up: Dr. Seikhoo Bishnoi 12 hours later
Hello again,

I won't be so quick then.

I don't know what you mean by routine work, because I usually work with the computer. If you include cooking and eating though then I do have a tremor while doing these activities. The tremor is independent of the activity that I'm doing, it's persistent, symmetrical and bilateral. It happens no matter what activity I do but mainly in certain types of movements, for example when I'm rotating or moving my hand in the wrist or when I'm moving my fingers. There's no tremor from the wrists upward the hand. The same thing holds for the tremor in my feet. It also happens when I move my feet in the ankle. I used to do yoga before the infection this year and now when I try it it's much more difficult to keep balance and I get tremor in certain postures which require muscle strength, in addition to having tremor when changing yoga postures.

If the eyes can be measured objectively by a test, and this way rule out human factor both on my side and the side of the doctor, is there an objective test that can be used which can measure the tremor? Such as EMG or evoked potentials? I'll happily take it (I know it's painful) just to objectively prove or disprove the tremor. If I'm a hypochondriac then I'm a hypochondriac who doesn't believe doctors but believes machines. When my problems started I thought I might be having multiple sclerosis but when 2 MRIs showed no lesions I finally stopped pursuing it. I DO read too much but I've read that it's impossible to have 2 MRIs separated by 5 months with no lesions and still have multiple sclerosis. It just doesn't happen, full stop. I wouldn't believe a doctor if they said so (and I have perfectly good reasons for that given the atrocious sate of healthcare in my country) but I DO believe the machine and I do believe statistical data found in academic articles. So, if you will, I'm a doctor-hypochondriac who can be quite easily convinced by a machine-based proof but I just don't believe two sloppy neurologists who just came, looked at me, checked my reflexes quickly, said hmm and that was it (because I saw on youtube what a proper cerebellar examination should look like it mine was far from it)... You may counter that radiologists interpreting the MRIs are also the same doctors I don't trust but I had the pictures double-checked by doctors like you whom I trust.

At the same time, there's literally NOTHING else that could be causing my problems except somatisation OR ataxia, I've taken care to rule out everything; so when I've disproved ataxia then I'll be able to rest my head and stop bothering doctors.

Since it's my health, obviously, not the doctors', I have every right to be cautious and make sure that nothing serious is going on there. I'm sure that if a doctor were having such relatively strange symptoms as I am then they would get themselves tested very quickly for anything serious and only in the last instance diagnose themselves as somatic depressed hypochondriacs...

But enough of this rant on my side, I've decided to provide at least some objective data for you so you can tell me for yourself. Below are links to three videos with me doing the finger-to-finger test and using a spoon to eat... I'm not sure that it's all valid - you tell me. I can also ask my parents to do this test with real fingers and then post it.

But if based on this you can confidently rule out intention tremor and dysmetria, I'll be tremendously grateful and very happy. Thank you again.

http://youtu.be/Uh3fNXFAG_A
http://youtu.be/7UAjvVpizrQ
http://youtu.be/bWg1fMbu14c

All the best.






doctor
Answered by Dr. Seikhoo Bishnoi 53 minutes later
Brief Answer:
Be assured you are normal.

Detailed Answer:
Hello again and thanks for asking again

By routine work I meant about normal day to day chores like working on computer, cooking etc. You have mentioned that you have problem in routine work also.

First of all, I have seen all there videos (two videos of finger to pen test and one of spoon coordination) and after seeing videos I can surely tell you that these are not intentional tremors. What I observe in my clinic are gross tremors which are very much evident to anyone. Though I don't have any recent video but I am posting a link in which there is demonstration of intentional tremor of cerebellar origin. Please have a look at it to get idea-

https://www.youtube.com/watch?v=5eBwn22Bnio

Objective test to measure saccadic eye movements is King Devick Test, I have mentioned earlier also.

To rule out any evidence of tremor you can go for Surface EMG, which is a non invasive test and can detect abnormal electric potential in muscles. Invasive EMG is also an option but the investigation doesn't have more benefit than usual surface EMG. But I don't think there is need to go for such investigation, still you want objective test to rule out so you can go for it.

The videos on youtube for CNS examination are demonstration videos and they are usually posted for students to learn CNS examination. These videos include each and every details of CNS examination. Detailed examination in practice is done only if a doctor finds something positive in screening. You never had any positive signs, so repeated examinations were not done.

I can assure you that this is not ataxia, each and every investigation came normal, every examination came normal so there should be no fear of ataxia.

This is not an issue about your health or doctor's health. Most of doctors are ethically bound to examine their patients carefully and most of the times they never miss a diagnosis deliberately. You have been to two doctors and both doctors didn't find anything, so please don't think that they are missing your symptoms. They can diagnose illness only if they will find any objective evidence, but if they are not getting any objective evidence on screening examinations then there is no benefit in getting tests done.

Be assured you are absolutely normal. You are not having any signs that suggest ataxia.

Thanks, hope this helps you. You can contact me again if you have any doubts.

Wish you a good health.






Above answer was peer-reviewed by : Dr. Ashwin Bhandari
doctor
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Follow up: Dr. Seikhoo Bishnoi 1 hour later
Dear Dr Bishnoi,

thank you for watching the videos. You were the second doctor to actually do this test so now 2 doctors feels better than one. I feel kind of bad about this situation now. You've done your best to reassure me and I thank you for it. I don't want to sound that I'm making fun of it, but I'm becoming rather sarcastic of the whole situation and myself included.

As a hypochondriac, I will consider the two tests - King Devick Test.. and maybe a surface EMG... They're both quite cheap to get. But given what you said they're clearly superfluous both... Yet the hypochondria rules... Thanks for the suggestions! When these are done and there are no other possible medical examinations left for me, my hypochondriac mind will have to come to terms with that. Hopefully, it will stop bothering me and other doctors. (or I'll think I have a new syndrome which is not discovered yet - I'm joking, that's statistically impossible).

Also as a hypochondriac, my very last question is, whether you actually saw any tremor in the videos and if yes then what tremor is it given that it's not intentional. (any other type of tremor is not cerebellar so I won't worry about ataxia if you say yes. I promise). If you saw no tremor then perhaps I should really get my eyes checked.

That will be all I needed. Thanks again. I hope I won't end up on your list of case-studies for your students.

Best wishes and a lot of patience. I will close the question after your answer.









doctor
Answered by Dr. Seikhoo Bishnoi 32 minutes later
Brief Answer:
No there were no tremors in videos

Detailed Answer:
Hello thanks for asking again

I have watched the videos again and I don't think there was any evidence of tremors of cerebellar origin or any other origin. Just watch the videos by yourself and even you will not find any evidence of tremors.


Yes you can go for these tests but keep one thing in mind that on testing negative you will not bother yourself about these symptoms. Tests will reassure you for some time but only you have to reassure yourself.

Don't think yourself as hypochondriac, health anxiety is common in people these days because of wide spread access to health related information on internet and the reliability of these informations can't be proved.

Yes I will not mention your case in case studies :), and I will also advise you to delete the videos from youtube.

I hope all this solve your doubts, wish you a good health and GOOD LUCK

Thanks, just remember one thing you don't have any tremors that can have any organic basis. You are absolutely normal. Enjoy your life and try to ignore anxiety.

Regards,
Above answer was peer-reviewed by : Dr. Raju A.T
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Dr. Seikhoo Bishnoi

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