Treatment for Shaky Legs and Arms
For tremors affecting the arms and legs, begin with propranolol (a beta-blocker) as first-line therapy, which is effective for most tremor types including essential tremor and enhanced physiologic tremor, though dosing varies widely depending on tremor severity. 1
Initial Assessment and Classification
Before starting treatment, determine the tremor type by observing when it occurs:
- Resting tremor (occurs at rest): Suggests Parkinsonian tremor - treat with carbidopa-levodopa combination therapy 2, 3
- Postural tremor (occurs with maintained posture): Most commonly essential tremor - treat with propranolol or primidone 2, 1
- Kinetic tremor (occurs with movement): Also suggests essential tremor - propranolol remains first-line 2
- Action tremor (occurs during voluntary movement): Propranolol is effective for most action tremors 1
First-Line Pharmacologic Treatment Algorithm
For Essential Tremor (Most Common Type)
Start with propranolol as the beta-blocker of choice, which effectively treats both enhanced physiologic tremor and essential tremor. 4, 1 Note that propranolol can fail to control tremor even in essential tremor cases, so monitor response closely. 1
Alternative first-line option: Primidone, which is equally effective for essential tremor and can be used if propranolol is contraindicated or ineffective. 3
Second-line option: Benzodiazepines (such as clonazepam) can be added if first-line agents provide inadequate control. 3
For Parkinsonian Tremor (Resting Tremor)
Carbidopa-levodopa combination remains the first-line approach for parkinsonian tremor, as it addresses the underlying dopamine depletion in the corpus striatum. 5, 2, 3 The carbidopa component reduces peripheral side effects and allows more levodopa to reach the brain. 5
Alternative: Anticholinergics can also be effective for Parkinson's disease-related tremor. 3
For Specific Tremor Types
- Orthostatic tremor: Clonazepam is the preferred agent 2
- Cerebellar tremor (especially with multiple sclerosis): Isoniazid may provide control 2
- Alcohol withdrawal tremor: Propranolol is useful 2
Non-Pharmacologic Interventions
Implement physical therapy techniques that promote normal movement patterns to prevent learned non-use and improve functional recovery. 6, 7
Key rehabilitation strategies include:
- Engage in tasks promoting normal movement, proper alignment, and even weight-bearing such as transfers, sit-to-stand exercises, and bilateral upper extremity activities 6, 7
- Use gross movements initially rather than fine movements, as these require less concentration and are easier to control 6
- Employ anxiety management and distraction techniques during tasks, as anxiety can exacerbate tremor symptoms 8, 6, 7
- Grade activities progressively to increase the time affected limbs are used within functional activities 7
- Consider video recording interventions (with consent) to demonstrate improvement and identify changes in tremor amplitude 8, 6
Important Cautions
Avoid prolonged splinting, as this may prevent restoration of normal movement and can lead to increased symptom focus, accessory muscle use, compensatory movement strategies, muscle deconditioning, learned non-use, and increased pain. 8, 6
For patients on carbidopa-levodopa: Be aware that high protein diets may impair levodopa absorption, as levodopa competes with certain amino acids for gut transport. 5 The plasma half-life of levodopa increases from 50 minutes to approximately 1.5 hours when combined with carbidopa. 5
When Medical Therapy Fails
Consider surgical options including thalamotomy, pallidotomy, or thalamic stimulation for severe, medically refractory tremor. 2 Thalamic stimulation offers the advantage of alleviating tremor without creating a permanent lesion. 2
Monitoring and Follow-up
Reassess function every 2-3 weeks to evaluate treatment effectiveness and adjust therapy progression accordingly. 7 Regular clinical evaluation should include assessment of tremor severity, functional status, and overall quality of life. 7