Introduction

Dr. Bob: And welcome to The Dr. Bob Show. Thank you so much for taking your time to gather around your television set learning a little bit about how to make our lives healthier and happier. I hope you have been exercising 20 to 30 minutes, seven days a week and wake up after eight hours of refreshing sleep! How wonderful that is! And start the day off with a good breakfast, a breakfast of fruit and fiber. And most of all, we want to have laughter in your life.

I am Dr. Robert Overholt and I will be your host for the next 30 minutes on The Dr. Bob Show. Have you ever had a little bit of a tremor? You pick up a cup and it's sort of shaking a little bit and you wonder if maybe you're too stressed, or you wonder if maybe its medicines you're taking, or too much coffee or something else, or is there something going on in the central nervous system? We'll be talking about tremors and special kinds of tremors and we've got a lot to learn on that. I've got an outstanding guest. My guest is Dr. Bill Paulsen from Neurology Associates of Knoxville, TN. Dr. Paulsen is a long-time friend of mine, a great teacher and we've got a lot to learn on tremors. Later on in the show we will be talking about blood pressure. Which value is the most important? And yawning-why do we yawn? Do we know why? And what happens if you don't yet enough iron in your diet? Another topic, if we have time-does lifting weights help your heart or hurt? So, we've got a lot of information. You stay tuned. It's going to be a great show.

We're talking with Dr. Bill Paulsen, Board-Certified Neurologist, and we're going to be talking about tremors. I've had Dr. Paulsen on my show before and he's talked about strokes and he's talked about headaches. He's a wonderful teacher and I'm looking forward to learning about tremors. Bill, welcome to The Dr. Bob Show.

Dr. Paulsen: Thank you Bob. It's good to be here.

Dr. Bob: Bill, you're a neurologist. What is a neurologist?

Dr. Paulsen: A neurologist is a physician who deals with disorders of the nervous system but does not do any type of surgery.

Dr. Bob: I see. So you're sort of a medical nervous system doctor.

Dr. Paulsen: That's correct.

Dr. Bob: You did your training where?

Dr. Paulsen: University of Wisconsin.

Dr. Bob: And your chief was?

Dr. Paulsen: Dr. Frank Forrester.

Dr. Bob: And he was the one that started your society.

Dr. Paulsen: He was one of the founders of The American Academy of Neurology. And as a matter of fact, he's the only living founder of the Academy.

Dr. Bob: Oh, that's great. What is a tremor and what causes tremors?

Dr. Paulsen: Well, a tremor is an involuntary movement that involves reciprocating muscles alternating because there is some lack of control.

Dr. Bob: O.K. Now, can that be any place in the body. I take it that reciprocating muscles…that means they're out of whack and you're not controlling what you're doing.

Dr. Paulsen: That's correct. It can involve the hands. It can involve the chin. It can involve the head, the legs, the eyes.

Dr. Bob: Now, when I think of tremors, I think predominantly of the hands. Your hands are shaking when you get nervous…tell me about tremors of the hand. What causes tremors?

Dr. Paulsen: Well, it's kind of hard to say specifically what causes tremor because there are many tremors where we don't recognize a specific cause. The, one of the most common tremors is "essential tremor" and it's named essential tremor because we don't know what the cause is. Like essential hypertension. So that the tremor may not have any recognizable cause or it might be part of a disease such as Parkinson's disease. It could be related to some physiologic changes that are taking place in the body.

Dr. Bob: Now, physiologic changes…Bill, you mean what by that?

Dr. Paulsen: By that I mean mental changes such as stress, anger, fear, anxiety-metabolic changes such as fever, hyperthyroidism. One of my basic rules about evaluating patients in the hospital that have this type of tremor is that I indicate to them that we're going to see how they are after they're over their sickness because their sickness is making it worse.

Dr. Bob: Now, let's talk about what does a thyroid tremor look like?

Dr. Paulsen: Thyroid tremor is a fine, low amplitude tremor that is almost, it's actually the same as essential tremor. Interestingly enough, one of the treatments for essential tremor was derived from the use of Inderal in the treatment of thyrotoxicosis.

Dr. Bob: Overactive thyroid.

Dr. Paulsen: That's correct. And the hope was to slow the heart down so they didn't go into heart failure when they were being treated for their hyperthyroidism. And patients would come back and they would say their fine tremor had been reduced so that's how we came to use Inderal for the treatment of essential tremor.

Dr. Bob: How about tremor caused by too much caffeine, too much…

Dr. Paulsen: Certain food substances such as stimulants? Black coffee can do it. Certain drugs can do it. One of the drugs that I use a lot, Depokote, for the treatment of seizures and headaches-if it gets too high in their system, can do it. But what you have to remember is that different people have different thresholds at which they will have their physiologic tremors. So, that if a person has an underlying mild essential tremor or a tendency towards developing physiologic tremor, then you put them on a drug that ordinarily wouldn't cause tremor but in that individual might cause tremor at a lower dose. Lithium, a drug used in psychiatry, can cause tremor. Theophyllin, a drug that's commonly used for the treatment of a respiratory problem, can cause a tremor.

Dr. Bob: Now, when I've seen a patient with asthma, if I teach them how to use a puffer called Albuterol, I can't write very good for a period of about 90 minutes because I get a fine tremor. Is it stimulating the nervous system? What's it doing?

Dr. Paulsen: It's hard to say what is actually happening. Something in the nervous system is being disturbed a little bit. But exactly what that is, we just can't say.

Dr. Bob: Let's talk about essential tremor, benign, familial. Apparently it occurs in families. Tell me about that.

Dr. Paulsen: It is a very very common tremor and it can occur at most ages. I don't believe I've ever seen it in children but I've seen it in teenagers. I've certainly seen it in young adults. It becomes more common as we get older and for that reason it's sometimes referred to as senile tremor. But the essential tremor of an older person is the same essential tremor of a younger person. Now, if you really dig hard, it's usual that you're going to find a family history of tremor but some family, some patients, they just can't remember or think of anybody. So then you wouldn't want to use the term familial. But it's very commonly inherited.

Dr. Bob: Now, what does it look like? Both hands? Or is it the head or the chin? What is that familial essential tremor?

Dr. Paulsen: Well, it can begin in the hands and I would say it's more common there and it can also begin in the head. There are some patients who have it exclusively in their voice, you would not know that they have it until they start to talk.

Dr. Bob: Like what?

Dr. Paulsen: Katherine Hepburn is a good example of somebody that had essential tremor in her voice and in her head.

Dr. Bob: Well now, is that different from stuttering, or is there lip quivering, or what happens if it's in their voice?

Dr. Paulsen: It's coming from down in their larynx. It's not in their lips. It's not stuttering. It's a tremulousness and everybody has had the experience of seeing somebody with that type of tremor because we know people who get nervous when they speak and there's a tendency to talk like that when you're nervous and that's your essential tremor of the voice.

Dr. Bob: And if somebody is talking, or getting ready to talk, and they're holding a piece of paper and the paper is just shaking. That's just…

Dr. Paulsen: That's physiologic tremor. But physiologic tremor is sort of like a lower amount of essential tremor. I like to explain to patients that essential tremor is like turning the volume up on physiologic tremor. Everybody, or most people, have had the experience of when they're tired or they've worked out real hard and then they hold their hands out and there is a fine tremor or if they were nervous, so it's a common thing. And that's physiologic. You turn up the volume a little bit, then you have essential tremor.

Dr. Bob: In the familial essential tremor, what's the treatment?

Dr. Paulsen: There are two drugs that we use commonly. Beta blockers, particularly Inderal, and a drug called Mysoline or Primidone. Those are the two most commonly used drugs. There are some other drugs that are used. Any agent that has a sedating effect will have some beneficial effect. We try to stay away from them a little bit.

Dr. Bob: If somebody has Parkinson's disease, is it a specific type tremor?

Dr. Paulsen: Yes it is.

Dr. Bob: And that's what we're going to be talking about. We're going to come back talking about Parkinson's and if you get a tremor, how do you know if you've got Parkinson's disease? But first, I want to show you a beautiful young lady who has familial benign essential tremor.

A Patient's Experience with Tremors

Dr. Bob: Pam, when did you first know that you began having a tremor? How long ago was that?

Pam: I was actually diagnosed by a neurologist about three years ago.

Dr. Bob: Now, why did you see the neurologist?

Pam: I had noticed that my hands seemed to be shaking more than normal. My husband had been noticing much longer and continued to bring it to my attention that he really felt like I needed to go and have it checked out further.

Dr. Bob: Did you think you were just nervous at first?

Pam: I've always been kind of a high-strung, high-energy type person. I drink a lot of caffeine, eat a lot of things with caffeine in it and I just really thought that it was probably diet related.

Dr. Bob: Now, where were you having the tremor?

Pam: In my hands.

Dr. Bob: Both hands?

Pam: Both hands.

Dr. Bob: Which was the worse?

Pam: The right.

Dr. Bob: Now, when I look at your hand right here, it's not shaking. What do you have to do to make your hand not shake?

Pam: Anytime I apply pressure, either put them against my body, against a chair, if I'm speaking, against a podium,

Dr. Bob: It goes away.

Pam: It totally goes away.

Dr. Bob: What if you hold your fingers out there….

Pam: Well…

Dr. Bob: and I say hold them still….

Pam: I can't, it's impossible.

Dr. Bob: Does it embarrass you sometimes?

Pam: Very much. Very much. In social settings, if we're out, if I'm trying to hold coffee, or a drink of some type, it's really difficult to do that. So, I find myself taking a sip and immediately sitting it down or my husband will hold it for me.

Dr. Bob: That's a wonderful story. If you have a tremor, it could be you just haven't had enough sleep. Maybe it may be a little bit too much stress. Maybe it's your medicines that you're taking or maybe it's hereditary. Work that out with your doctor and find the cause of your tremor.

And now we're going to be talking about Parkinson's disease and Bill, I have more questions. People call in wanting to know if they could be getting early Parkinson's. First of all, what is Parkinson's and what happens in the brain?

Dr. Paulsen: Parkinson's disease is a degenerative disease of the brain which has characteristic clinical features and a very classic straight-forward pathology for which we don't know the cause. The characteristics of Parkinson's disease are tremor.

Dr. Bob: And what's the tremor like? Or do you want to go through all………

Dr. Paulsen: No, I can do that. The tremor is basically very different than essential tremor. Essential tremor is an action tremor. In the, the tremor of Parkinson's disease is a tremor at rest. And the patients will oftentimes be able to distinguish that and will tell you that. For example, if a person with essential tremor writes, they've got shaky writing. Whereas if a person with Parkinson's disease writes, they have small writing but it doesn't shake and they can draw a circle very well because they don't have an action tremor. They have a tremor at rest. It's a coarser tremor. One thing we didn't talk about when we talked about essential tremor that makes it differentiate between Parkinson's tremor is that you never get a tremor of the head in Parkinson's disease. A famous French neurologist by the name of Charcot designed an elaborate hat with little feathers that came down from the edges of the hat to detect the head tremor because it was so important for him to differentiate essential tremor from Parkinson's tremor. So, it's a different kind of tremor. It's coarser, slower, doesn't involve the head, very, very often asymmetrical. That's true of an essential tremor also. So, about 80% of patients with Parkinson's disease will have tremor. A lot of people think that, well, a lot of people have the idea that if you don't have tremor, you don't have Parkinson's disease but that's not true. 20% of patient's with Parkinson's disease never have tremor.

Dr. Bob: So, what are some of the other signs of Parkinson's disease?

Dr. Paulsen: The other cardinal features are what we call akinesia.

Dr. Bob: Now, what's akinesia?

Dr. Paulsen: Decreased mobility.

Dr. Bob: Now, where does that show up? Decreased mobility. That means you can't move and get around good?

Dr. Paulsen: That's right. So that if you get out of a chair, you get out slowly. If you walk, you walk slowly and when you turn, your whole body turns in one motion rather than associated motions.

Dr. Bob: Is there a rigid motion, are they sort of stiff?

Dr. Paulsen: Well, the third cardinal feature… the third cardinal feature of Parkinson's disease is rigidity. Rigidity is something that you don't see as much as feel. When you, when I bend a person's head, I can feel the rigidity. When I bend their arms, I can feel the rigidity. Oftentimes, the patients will have a hard time telling you, "I have decreased mobility, I have rigidity." They say, "I'm weak." And that's why when you take a history from someone with Parkinson's disease, it isn't as important as taking a history from patients who have other types of conditions and the examination is so much more important because there are so many things that you see that the person has a hard time explaining to you.

Dr. Bob: How about facial characteristics of Parkinson's?

Dr. Paulsen: That's part of the akinesia. The patient does not have all of the associated movements of their face that you and I have that we use to express our emotions, our feelings, the patient's will have decreased facial mobility and for that reason sometimes they are thought to be depressed. But they really aren't, they just don't have all those facial appearances.

Dr. Bob: Do they think well? Do these people have good thinking process?

Dr. Paulsen: The Parkinson's disease, per se, does not involve the thinking process but as the disease progresses and in the older individual with Parkinson's disease, a fair number of patients, maybe 20-25%, will develop progressive problems with their mind and, as a matter of fact, may become very demented. But that's not a clear characteristic of Parkinson's disease. It's sort of an associated symptom in some patients.

Dr. Bob: Let's talk about the treatment because I understand the treatment is getting better and better for Parkinson's. If somebody comes in to you and they've got early Parkinson's disease, do you tell them it's a progressive illness, we've got good medicines? What do you tell them?

Dr. Paulsen: If I am quite certain that they've got Parkinson's disease, I tell them this is a progressive illness, that the treatment is strictly symptomatic. There is no cure for Parkinson's disease so we have to keep in mind that we don't want to put them on a drug that will make them more symptomatic than what they are from the Parkinson's disease. So, example, if they just have tremor, we're probably going to avoid for, at least for a time, the really primary drugs for later Parkinson's disease which are Sinemet, which is a combination of L-Dopa - Carbidopa and then dopamine agonists which are, you could look at them as, artificial stimulants of the dopamine system.

Dr. Bob: So, dopamine is the deficit in Parkinson's disease and you have to create more, give it more, stimulate it more.

Dr. Paulsen: Right. It's like a diabetic who needs Insulin. The Parkinson patient needs more dopamine or needs to have a medicine that will stimulate the receptor sensor system of the dopamine system.

Dr. Bob: Do the medicines work well?

Dr. Paulsen: Medicines work very well. The biggest problem that we have with Sinemet and with the Dopamine Agonist is after a period of time they can cause involuntary movements or they can cause some confusion and they can cause some problems like dillusions and hallucinations. So, that you have to use that when you're determining when to put them on the medicine. For example, if you have a person with Parkinson's disease starting at age 50, you're going to stay away from the Sinemet at least in the beginning and go with the Dopamine agonists when you have to use that kind of drug because the Dopamine agonists are less likely to cause involuntary movements but are more likely to cause the confusional types of symptoms. In an older individual who is more prone to the confusional type of symptoms, you're going to want to go with the Sinemet because you are less concerned about the involuntary movements. So, you have to fine tune these drugs and many patients in the development of the disease and in the progression of the disease will need to be on many drugs, Dopamine agonists, Sinemet, other adjunctive drugs. And then finally, there are some patients that will benefit from certain kinds of special surgery that is done. And again the surgery is symptomatic. It is not curative.

Dr. Bob: Bill, we're out of time but I want to ask you one other question. Do you see any cure in the future?

Dr. Paulsen: There is a tremendous amount of research that's being done on Parkinson's disease. It's one of the areas in neurology where there's just an enormous amount of research going on. But as far as cure is concerned, I don't think, I personally can see that out in the near future. The surgery for implanting cells which you think might be a curative procedure is still at a very embryonic experimental stage and there are great developments happening. Whether there'll be a cure in the next 25 years, I would be very, very speculative.

Dr. Bob: Bill Paulsen, I want to thank you. As usual, you've got just huge amounts of information and it's great to learn about Parkinson's and about tremors and thank you so much for taking your time to teach.

Dr. Paulsen: You welcome.

Dr. Bob: And we're going to be coming back later on talking about other things that will be helpful to you. Blood pressure problems, yawning-why do we do it? How about that iron in your diet? And pumping iron, does that help you? So, we'll be back with a lot of information.

Announcer: Coming up next on the Dr. Bob Show reporter Hallerin Hilton Hill gives us some tips for living a healthy life. And later Dr. Bob answers his mail.

Hallerin Hill: Parkinson's Disease is a nervous system disorder that effects the middle aged and the elderly. There are some very popular Americans you might recognize that deal with Parkinson's Disease. Michael J. Fox, former US Attorney Janet Reno, Pope John Paul the II, Mohammad Ali. For the million or so people that struggle with Parkinson's Disease, every day activities like walking or standing can be very painful. It causes many to turn to medication to relieve the tremors or the slow movement or the muscle stiffness but some are now turning to surgery as an answer, a way to regain control of their lives. Several surgical treatments are available to Parkinson's patients. One of these surgical treatments is called Pallidotomy. This process creates lesions on a portion of the brain which interrupts some of the neuro pathways. The result is the improvement of the symptoms of tremors and rigidity. Pallidotomy and other surgical procedures are becoming more and more popular because of a couple of things. First of all with medications, some people have severe side effects or they've built up incredible resistance to the drugs. If you would like to know more about treating Parkinson's, the Internet is a great place to start.

For The Dr. Bob Show, I am Hallerin Hilton Hill.

Conclusion of Interviews
Dr. Bob: I want to thank Dr. Bill Paulsen for a wonderful discussion on tremors and on Parkinson's disease. If you have a tremor, shuffling gait, rigidity, see your doctor and work out that problem.

And now some information I think you, the viewer, will want to know from some questions we've had:

Letters

Now, we're going to be talking about questions from you, the viewer. One question is...

Letter #1: . "Dr. Bob, which number in the blood pressure is most important?"

Response #1:
Great question. A lot of times the doctors expect people to know what a normal blood pressure is. Do you know? Most people don't. 120 over 80 is classically a normal blood pressure. The upper number, if it's over 135 or 140, that's getting into the high level. Or if the lower number is above 85, some people say over 90, it is considered higher than "normal." Know what your blood pressure is. How often have you had your blood pressure taken and which is the most important? Well, there're lots and lots of studies. The lower number, the diastolic, we used to think was the most important and we really treated it aggressively, the diastolic blood pressure. But we now know that the systolic, the upper number, is also just as important in preventing heart failure, heart attacks and stroke. Be sure you know your blood pressure and if it's elevated, don't make any excuses-get it under control.

Letter #2: "Dr. Bob, does weightlifting help or hurt the heart?"

Response #2: Well, weightlifting is a form of exercise, we call it resistance training and what lifting weights does is, it builds up muscle mass. That's very interesting that that muscle mass, when it builds up, does several things to help us. Number one, the more muscle, the more metabolism. We burn off calories more so it might be a pretty good way to help lose some of that weight that we want to lose. I'm a firm believer that if we do enough stomach exercises, then we start thinking about how trim our stomach is and that makes that sagging stomach with too much food a little bit more of a problem and easier to control. One of the most important things with resistance exercising, or pumping iron, as we get older it's easier to stumble and break our bones. All studies have shown that if you do exercise to increase the muscles around joints, you'll have less falling, less broken bones and a happier life. So, let muscle building, weightlifting be part of your exercise program but we've got to do that aerobic exercising at least five, six, seven days a week.

Letter #3: "Dr. Bob, what happens if I don' get enough iron in my diet?"

Response #3: Popeye ate a lot of spinach. Spinach has a lot of iron and spinach also has some folate which will help cut down on mass that causes hardening of the arteries if you don't get enough iron in your diet. We need iron for the red blood vessels to form and you can become anemic where your blood count gets too low. So, you should always have your blood count checked and to be sure your serum iron is also normal.

Closing

Dr. Bob: And, that's all the time we have. As we end this show, be sure that you're exercising. Start that day off with eight hours of sleep. Eat a good breakfast with fruit and fiber and have laughter in your life.

If you have a question for Dr. Bob, write to The Dr. Bob Show - 6700 Baum Drive, Suite 1, Knoxville, TN 37919 or send your e-mail to letters at letters@drbobshow.com