Parkinsonian tremor
Reviewed by A parkinsonian tremor is a type of tremor often associated with Parkinson’s disease. While it doesn’t affect everyone with the condition, it is often one of the first motor symptoms of Parkinson’s people notice.
The term “parkinsonian” refers to parkinsonism — a group of conditions, including Parkinson’s disease, that have different causes but similar features and symptoms. Therefore, not everyone with a parkinsonian tremor will have Parkinson’s, though the disease is the most common form of parkinsonism.
Understanding the features of a parkinsonian tremor, how it differs from other types of tremor, and which treatments can help manage it is an important first step for people with this symptom.
What is a Parkinsonian tremor?
A tremor is an involuntary, rhythmic muscle contraction that can look like shaking or trembling. About 70% of people with Parkinson’s disease experience this symptom at some point. There are two types of tremors: resting tremors and action tremors.
One key characteristic of a parkinsonian tremor is that it typically occurs while a person is at rest. Action tremors are less common in Parkinson’s, but are still estimated to affect more than a quarter of people with the condition.
Another distinctive feature of a parkinsonian tremor is its asymmetric presentation. Rather than appearing in both hands at once, it characteristically begins on one side of the body, such as in one hand or even a single finger, before spreading in that limb and adjacent body parts, such as the leg on the same side.
Because it often begins in one hand, the low-frequency, rhythmic movement is often described as a “pill-rolling” motion, resulting from the rubbing together of the thumb and forefinger.
This one-sided onset is an important clinical clue. It helps doctors distinguish Parkinson’s disease from movement disorders that tend to affect both sides symmetrically from the start. Even as the condition advances, the side where the tremor first appeared usually remains more affected.
Some people with Parkinson’s disease also describe a shaking sensation on the inside of their body that isn’t visible to an observer, commonly called “internal tremor.” It may feel like a vibration or buzzing in the chest, abdomen, or limbs, with or without a visible tremor.
Onset varies from person to person, and while tremors are less common in younger patients, they can affect those with both early- and late-onset Parkinson’s. For some people with the disease, a subtle shake in one hand is the first sign that prompts a visit to a neurologist.
Contact a medical professional if you think ‌you might have‌ parkinsonian tremors.
Types of tremors seen in Parkinson’s disease
Parkinsonian tremors may be classified as resting or action. The table below outlines the key differences.
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| Feature | Resting tremor | Action tremor |
|---|---|---|
| Occurs when | Muscles are relaxed, e.g., hands resting in the lap or lying in bed | Alongside a voluntary movement |
| Prevalence in Parkinson’s | Most common form of tremor associated with Parkinson’s disease | Less common; still predicted to affect more than 25% of people with Parkinson’s |
| Also known as/classified by | Sometimes called a “pill-rolling tremor,” resembling the motion of rolling a pill between the thumb and index finger | Further classified based on the specific movement it accompanies |
Resting tremor
Resting tremor is the most common form of tremor associated with Parkinson’s disease. It occurs when the muscles are relaxed, such as when the individual is lying in bed or resting their hands in their lap.
In Parkinson’s disease, resting tremor is sometimes called “pill-rolling tremor.” This is because the tremor causes a hand motion that resembles rolling a small pill between the thumb and index finger. It typically oscillates at a low, steady frequency and diminishes once the affected limb moves voluntarily, such as reaching for an object. Resting tremors ‌often disappear during sleep.
Action tremor
Action tremors, which occur alongside a voluntary movement, are less common in Parkinson’s. However, some studies suggest that more than one-third of patients experience them.
Medical professionals further classify action tremors based on the type of movement they accompany. Postural tremors appear when a limb is held up against gravity, such as arms stretched out in front of the body. Kinetic tremors occur during voluntary movement, including simple tasks like reaching for a cup. Intention tremors are a specific type of kinetic tremor that worsen as the limb nears its target, making precise tasks like buttoning a shirt especially difficult.
Scientists aim to distinguish the different tremor types for diagnostic purposes. This is because people with Parkinson’s disease may have only resting tremors, only action tremors, both, or neither.
Parkinsonian tremor vs. nonParkinsonian tremor
Tremors can vary in terms of how, when, and where they manifest in the body. Not all tremors are associated with Parkinson’s disease. For instance, essential tremor and dystonic tremor may be associated with other conditions and genetic mutations.
Differentiating parkinsonian action tremor from essential tremor is one of the most common diagnostic challenges neurologists face. This is because both can cause visible hand shaking, and essential tremors primarily appear when the hands or arms are in use.
However, essential tremors usually affect both hands roughly symmetrically from the outset. They often involve the head or voice, especially as they worsen, and they tend to run in families.
Meanwhile, dystonic tremors may be linked to abnormal, sustained muscle contractions that pull a body part into an unusual posture, such as a twisted neck or an inward-turning foot. These tremors are often jerky. They may temporarily ease with a light touch or “sensory trick,” such as gently touching the chin, a response not typically seen with parkinsonian tremors.
A dystonic tremor can occur alone or alongside other neurological movement disorders. Medical experts generally consider dystonic tremors to be a distinct condition from Parkinson’s disease, though the two types of tremor can occasionally coexist.
Because several tremor types can look similar at a glance, the pattern of a resting tremor is diagnostically important. When a tremor comes with rigidity, slowness of movement, or a stooped posture, this strongly points toward Parkinson’s disease.
Progression and impact on daily life
A person with a parkinsonian tremor may find that their symptoms worsen and spread to other parts of the body over time. Generally, the tremor starts in one hand and can progress to the arm and foot on the same side of the body, and eventually to the other side of the body. This normally takes several years. In severe cases, tremors can also affect the jaw or lips.
The long-term outlook for tremor varies considerably. Some people with Parkinson’s disease fall into what clinicians describe as a tremor-dominant subtype of Parkinson’s. This occurs when the tremor remains the most prominent feature for many years, while symptoms like balance and gait issues progress relatively slowly.
Others follow a pattern in which nontremor symptoms become more prominent, sometimes called a postural instability and gait difficulty subtype. Tremor-dominant presentations are generally associated with a somewhat slower overall progression, though every individual’s course differs. It cannot be predicted with certainty at diagnosis.
Beyond the visible shaking, tremor can meaningfully affect everyday life. Fine motor tasks that rely on steady hands can become slow, causing frustration. Such tasks include writing, buttoning a shirt, using cutlery, applying makeup, and typing. Carrying a full cup or signing one’s name legibly can become difficult.
Tremor is often the most visible sign of the disease. Many people with Parkinson’s disease report feeling self-conscious in social or professional settings because of it. This mix of practical and emotional impact is part of why managing tremor can be a high priority for people with this condition, as well as for their care teams.
Treatment and management options
Parkinsonian tremors cannot be cured. However, there are several options to manage them, ranging from medication to surgical and lifestyle-based approaches.
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| Approach | Examples | How it helps |
|---|---|---|
| Dopaminergic/oral medication | Levodopa; dopamine agonists | Typical Parkinson’s drug treatments associated with a reduction in tremors |
| Surgical/procedural | Deep brain stimulation | Offered to control tremors that are otherwise unmanageable |
| Physical therapy and lifestyle strategies | Physical therapy; reducing caffeine intake; reducing stress; complementary therapies such as yoga or aromatherapy | Can help some people control tremors better and limit symptom-triggering factors like caffeine and stress |
Dopaminergic and oral medications
Many of the typical Parkinson’s drug treatments are associated with a reduction in tremors, particularly levodopa. Levodopa remains the most effective medication for many Parkinson’s motor symptoms, including rigidity and slowness of movement. However, some people with Parkinson’s may experience dyskinesia (involuntary movements) or motor fluctuations, including irregular on-off periods, when taking levodopa, so ongoing monitoring is crucial.
Dopamine agonists, such as pramipexole and ropinirole, may also be used to treat parkinsonian tremors. While they generally aren’t as effective as levodopa for controlling motor symptoms, they are less likely to cause or contribute to dyskinesia. Possible side effects include excessive daytime sleepiness, impulse control disorders, and hallucinations or confusion.
Doctors may also consider other medications prescribed for Parkinson’s motor symptoms, including anticholinergics such as benztropine or trihexyphenidyl. These therapies can help reduce resting tremor but are generally reserved for younger people, as they can cause cognitive impairment, hallucinations, and confusion, particularly in older adults.
Deep brain stimulation and other procedures
A surgical procedure called deep brain stimulation (DBS) may be considered when tremors aren’t adequately controlled with medication alone. It works by implanting thin electrodes into specific brain areas, most often the subthalamic nucleus or globus pallidus. The electrodes are connected to a small pulse generator placed under the skin, near the collarbone.
The device delivers targeted electrical impulses that can help restore a more typical nerve firing pattern, easing Parkinson’s motor symptoms. Its settings can be adjusted over time as needs change.
Another technique is magnetic resonance-guided focused ultrasound. This option uses precisely targeted sound waves to create a lesion in specific tremor-generating parts of the brain. Unlike DBS, focused ultrasound does not require an incision or implanted hardware. However, it permanently destroys the targeted tissue and cannot be fine-tuned over time, as DBS can.
Wearables, physical therapy, and lifestyle strategies
Physical therapy can help some people better control their tremors. Reducing the intake of substances such as caffeine, which can induce tremors, can also help. Many people with Parkinson’s disease experience an increase in the severity of their tremors when they are stressed. Some people may benefit from trying to reduce sources of anxiety and engaging in complementary therapies, such as yoga or aromatherapy.
A growing category of wearable devices is also being explored to help manage tremors. Some wearable sensors track tremor frequency and severity throughout the day, giving individuals with Parkinson’s disease and doctors data to help fine-tune medication timing. These tools aren’t a substitute for medical treatment. However, these and other devices can complement medication, surgery, and physical therapy.
Occupational therapy can also help by teaching people ways of adapting their daily routines and home environments to reduce the impact of tremors. Therapeutic tools range from adaptive clothing fasteners to steadier handwriting techniques. Combined with regular exercise, consistent sleep, and stress reduction, these strategies are often used alongside medical treatment to manage parkinsonian tremors long-term.
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