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Tremor

Last updated: February 10, 2021

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Tremors are the most common movement disorder and are defined as rhythmic, involuntary movements of one or more parts of the body. Tremors are classified as resting or action tremor (i.e., postural and intention tremors). Resting tremors typically occur in patients with Parkinson disease and usually present as asymmetrical tremors that occur during rest. Postural tremors are usually essential or physiologic. Essential tremors are the most common type of tremor and usually involve the hands and head. They characteristically improve with alcohol consumption. Physiologic tremors occur when holding a position against gravity and are enhanced by increased sympathetic stimulation (e.g., caffeine, anxiety). Intention tremors suggest cerebellar lesions, which typically occur with strokes, trauma, or tumors. Patients present with a coarse hand tremor that is aggravated by goal-directed movements. A combination of tremor types is also possible. The diagnosis of tremors is typically clinical. Further laboratory tests and imaging may be required to determine the underlying condition. Treatment depends on the type of tremor.

Common types of tremors [1]
Resting tremor Action tremor
Postural tremor Intention tremor
Essential Physiologic
Description
  • Fine
  • Fine
  • Coarse
Etiology
  • Hereditary
  • Physiological
Onset
  • At rest
  • With certain sustained postures
  • Worse with voluntary movement or anxious state
  • With certain postures
  • Enhanced with sympathetic stimulation (e.g., stress)
Associated features
Improved by
  • Action
  • Alcohol
  • Rest

Rest in the park”: One of the main causes of resting tremor is Parkinson disease.

References:[1]

Essential tremor

Consider an essential tremor in a patient presenting with chronic bilateral hand tremors without further neurological deficits and positive family history.

Physiologic tremor [1]

Orthostatic tremor [3]

  • Epidemiology
    • Rare
    • Sex: >
    • Age of onset: 60 years (usually)
  • Etiology: unknown
  • Clinical features: associated with long periods of standing
    • Trembling feeling in the legs
    • Subjective feeling of unstable balance, and falling over
  • Diagnostics
    • Clinical diagnosis: Synchronized shaking of the legs may be seen or felt by the examiner.
    • Electromyography of the legs while the patient is standing; detection of 13–18 Hz tremor
  • Treatment

References:[1]

Flapping tremor (asterixis) [1][4]

Psychogenic tremor [6]

  • Etiology
  • Clinical features
    • Mostly postural tremor with a sudden onset
    • Worsens under direct observation and diminishes with distraction
  • Diagnostics
    • Ask about somatization in past history.
    • Diagnosis of exclusion
  • Treatment: cognitive-behavioral therapy

Other types of tremor

  1. Smaga S. Tremor. Am Fam Physician. 2003; 68 (8): p.1545-1552.
  2. Agarwal R, Baid R. Asterixis. J Postgrad Med. 2016; 62 (2): p.115-117. doi: 10.4103/0022-3859.180572 . | Open in Read by QxMD
  3. Hallett M. Electrophysiologic Evaluation of Movement Disorders. Elsevier ; 2012 : p. 437-453
  4. Tremor Fact Sheet. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Tremor-Fact-Sheet. Updated: July 1, 2012. Accessed: March 31, 2017.
  5. Raina GB, Cersosimo MG, Folgar SS, et al. Holmes tremor: Clinical description, lesion localization, and treatment in a series of 29 cases.. Neurology. 2016; 86 (10): p.931-8. doi: 10.1212/WNL.0000000000002440 . | Open in Read by QxMD
  6. Zesiewicz TA, Elble RJ, Louis ED, et al. Evidence-based guideline update: Treatment of essential tremor. Neurology. 2011; 77 (19): p.1752–1755. doi: 10.1212/WNL.0b013e318236f0fd . | Open in Read by QxMD
  7. Puschmann A, Wszolek ZK. Diagnosis and Treatment of Common Forms of Tremor. Semin Neurol. 2011; 31 (1): p.65-77. doi: 10.1055/s-0031-1271312 . | Open in Read by QxMD