Tom wrote:
>Several folk have mentioned experiencing the dreaded internal
tremor,...My neuro,...seems puzzled about it.I would be deeply grateful
for any info at all about this blight on sleep.
UNUSUAL SYMPTOMS IN PARKINSON’S DISEASE
(posted to PIEN, August 1994)
By Lisa M. Shulman, MD, Clinical Research Fellow,
and William J. Weiner, MD, Director,
Movement Disorders Center, University of Miami School of Medicine.
Do you ever feel a tremor inside your body that cannot be seen by
others?
Forty-four (44) percent of patients with Parkinson's disease said "yes"
in a recent study conducted at the U. of Miami School of Medicine,
Department of Neurology, Movement Disorders Center. This "internal
tremor" is experienced in either the extremities, chest or abdomen.
Commonly, it is reported on the same side as the other
parkinsonian symptoms, such as the typical observable tremor. Internal
tremor generally occurs in brief episodes lasting less than half an hour
and with a frequency of several times per week. Eighty (80) percent of
patients describe this as unpleasant, uncomfortable or painful.
The sensation of internal tremor is the most recent example of a number
of sensory symptoms that have gained increasing recognition in
Parkinson's disease. A variety of sensory phenomena such as aching,
burning, tingling and numbness have been previously studied.
Approximately 40% of patients report these sensations. Similar to
our findings in internal tremor, these other sensory symptoms occur
intermittently and often correspond in location to the side of the body
more affected by Parkinson's disease.
Internal tremor and other sensory symptoms of Parkinson's disease are
not simply a curiosity; they are a significant source of difficulty and
disability for many patients.
Sensory symptoms may appear early in the course of illness, perhaps
prior to the motor symptoms. Both patients and physicians are less
familiar with the sensory manifestations of Parkinson's disease,
impeding accurate and early diagnosis. Sensory symptoms are often not
mentioned in descriptions of parkinsonism. This may be a source of
bewilderment and concern to both patients and family members.
Additionally, both internal tremor and other Parkinson's related
sensations may be uncomfortable and of sufficient intensity to merit
specific treatment.
While sensory symptoms may be of special, or even predominant concern
to the patient, they pose a unique dilemma to the physician. The doctor
must rely totally on the historical accuracy and insights of the
patient. Unlike the assessment of motor symptoms, such as the
observable resting tremor, rigidity, slowing of movement or difficulty
walking, sensory symptoms cannot be observed or objectively evaluated by
the physician. Identification and management will be optimized by
precise reporting of the timing, frequency, location and severity of
symptoms. Information regarding factors associated with both the
exacerbation and relief of unusual sensation can also be helpful.
Interestingly, when patients with and without internal tremor are
compared, there is no difference in the duration or severity of their
Parkinson's disease symptoms. There also is no observable tremor
alone. The patients with internal tremor are far more likely
to experience other sensory symptoms (aching, tingling, burning,
numbness) than their counterparts without internal tremor.
What is the cause of internal tremor?
The answer to this question remains unclear, but we can speculate that
it may represent a very mild tremor that is too subtle to be detected by
observation. If this is true, it is indeed surprising that there was no
discrepancy in the presence or severity of
resting tremor. More than 80 percent of patients with Parkinson's
disease have an observable resting tremor.
Alternatively, the sensation of internal tremor may have more in common
with the other Parkinson's related sensory symptoms. The parts of the
brain that are affected by the changes of Parkinson's disease may play a
role in the interpretation of sensory information. Misinformation in
the form of unusual sensory phenomena may be the
result. In certain patients readjustment of the medications used in the
treatment of their motor symptoms can relieve the sensory symptoms as
well.
Although it is important for both patients and physicians to be aware
of the existence of Parkinson's related sensory symptoms, one must be
wary of developing an overly casual attitude to reports of unusual
sensations. When symptoms suggest other possible causes, appropriate
evaluation should be pursued to exclude these alternatives.
The potential causes of recurring sensory symptoms are numerous, and
need to be approached on an individual basis.
While our knowledge of these symptoms remains incomplete, awareness of
the widespread nature of this problem can be reassuring. Further
studies of the sensation of internal tremor are currently planned at the
U. of Miami to aid in both better understanding and treatment of this
previously undescribed symptom in Parkinson's
disease.
--
Judith Richards, London, Ontario, Canada
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