Neurology Book

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Tremor

Aka: Tremor
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  1. See Also
    1. Pediatric Tremor
  2. Definition
    1. Body part involuntarily oscillates around point in space
  3. Differential Diagnosis
    1. Choreoathetosis
    2. Dystonia
    3. Clonus
  4. Characteristics
    1. Frequency
      1. Slow Tremor: 3-5 Hz (e.g. Rest Tremor)
      2. Intermediate: 5-8 Hz (e.g. Isometric Tremor)
      3. Rapid Tremor: 9-12 Hz (e.g. Postural Tremor)
    2. Amplitude
      1. Fine Tremor: Barely noticeable (e.g. Postural Tremor)
      2. Medium
      3. Coarse Tremor: Large displacement (e.g. Rest Tremor)
  5. Classification
    1. Rest Tremor
      1. Most cases are due to Parkinsonism (although severe Essential Tremor can mimic this)
      2. Patient attempts to maintain body position at rest
      3. Provoked by stress or distraction (e.g. counting backwards) or moving another body part (e.g. walking)
    2. Action Tremor
      1. Isometric Tremor
      2. Task-specific tremor
      3. Postural Tremor
        1. Patient attempts to maintain Posture against gravity (stretch hands out in front of them)
        2. Includes Essential Tremor, Physiologic Tremor, Drug-Induced Tremor, Physiologic Tremor
      4. Kinetic Tremor
        1. Occurs with any form of voluntary movement
      5. Intention Tremor
        1. Tremor amplifies as target is reached
        2. Exercise high index of suspicion for cerbellar lesion
  6. Examination
    1. Characterize Tremor
      1. Record part of body with Tremor
      2. Provocative and palliative factors
      3. Tremor frequency (fast or slow Tremor)
      4. Tremor amplitude (coarse or fine Tremor)
    2. Observe with hands resting in lap (Rest Tremor)
    3. Observe writing or drinking (Action Tremor)
    4. Perform finger-nose-finger test (Intention Tremor)
    5. Draw a spiral (Archimedes Spiral in Essential Tremor)
    6. Focus exam based on Tremor type
      1. Action Tremor
      2. Postural Tremor
      3. Rest Tremor
  7. Labs
    1. Individualize work-up per Tremor type
    2. Basic metabolic panel
    3. Liver Function Tests
    4. Complete Blood Count (CBC)
    5. Thyroid Function Tests
  8. Evaluation
    1. Step 1: Enhanced Physiologic Tremor
      1. Consider TSH, Glucose, LFTs
      2. Manage by avoiding provocative factors
    2. Step 2: Drug-Induced Tremor
      1. Eliminate or reduce dose of offending agent
    3. Step 3: Psychogenic Tremor (e.g. relieved with distraction)
      1. See Psychogenic Tremor for management
    4. Step 4a: Patient under age 40
      1. Wilson's Disease
        1. Low serum ceruloplasmin and high 24 hour urinary copper
      2. Associated Neurologic findings
        1. Evaluate with MRI Brain and labs above
      3. Essential Tremor
        1. Diagnosis of exclusion if other causes excluded
        2. Trial on Beta Blocker
    5. Step 4b: Patient over age 40
      1. Rest Tremor
        1. Parkinsonism likely
        2. If rigidity, Bradykinesia or postural instability then trial on Parkinsonism treatment
      2. Action Tremor
        1. Consider Alcohol Tremor
        2. Postural Tremor
          1. Essential Tremor
        3. Intention Tremor
          1. Cerebellar Tremor: Obtain MRI Brain for MS, CVA, tumor
  9. Causes (See specific Tremor types)
    1. Physiologic Tremor
    2. Drug-Induced Tremor
    3. Pathologic Tremor
      1. Essential Tremor
      2. Parkinson's Disease
      3. Multiple Sclerosis
      4. Brain Tumor
      5. Brain abscess
      6. Peripheral Neuropathy
      7. Pheochromocytoma
      8. Psychogenic Tremor
      9. Thyrotoxicosis
      10. Alcohol Abuse or Drug-Induced Tremor
      11. Hypoglycemia (Tremor 3 hours after eating)
      12. Panic Disorder
      13. Dystonic Tremor
      14. Wilson Disease (wing-beating Tremor)
  10. Resources
    1. International Tremor Foundation
      1. Overland Park, Kansas
      2. Phone: (913) 341-3880
    2. See Parkinson's Disease Resources
  11. Reference
    1. Crawford (2011) Am Fam Physician 83(6): 697-702
    2. Charles (1999) Am Fam Physician 59(6):1565-72
    3. Habib-ur-Rehman (2000) Arch Intern Med 160(16):2438-44
    4. Smaga (2003) Am Fam Physician 68:1545-52
    5. Velickovic (2002) Geriatrics 57(7):32-6

Tremor (C0040822)

Definition (ICF) Functions of alternating contraction and relaxation of a group of muscles around a joint, resulting in shakiness.
Definition (ICF-CY) Functions of alternating contraction and relaxation of a group of muscles around a joint, resulting in shakiness.
Definition (NCI) A disorder characterized by the uncontrolled shaking movement of the whole body or individual parts.
Definition (MEDLINEPLUS)

Tremors are unintentional trembling or shaking movements in one or more parts of your body. Most tremors occur in the hands. You can also have arm, head, face, vocal cord, trunk and leg tremors. Tremors are most common in middle-aged and older people, but anyone can have them.

Tremors commonly occur in otherwise healthy people. Sometimes, however, nerve diseases such as Parkinson's disease or dystonia, an overactive thyroid, or certain medicines can cause them. Heavy drinking, because it kills certain nerve cells, can cause tremors, too. Some forms are inherited and run in families. Others have no known cause.

There is no cure for most tremors. Treatment to relieve them depends on their cause. In many cases, medicines and sometimes surgical procedures can reduce or stop tremors and improve muscle control. Tremors are not life threatening. However, they can be embarrassing and make it hard to perform daily tasks.

NIH: National Institute of Neurological Disorders and Stroke
Definition (MSH) Cyclical movement of a body part that can represent either a physiologic process or a manifestation of disease. Intention or action tremor, a common manifestation of CEREBELLAR DISEASES, is aggravated by movement. In contrast, resting tremor is maximal when there is no attempt at voluntary movement, and occurs as a relatively frequent manifestation of PARKINSON DISEASE.
Definition (CSP) involuntary trembling or quivering.
Definition (NCI) The shaking movement of the whole body or just a certain part of it, often caused by problems of the neurons responsible for muscle action.
Concepts Sign or Symptom (T184)
MSH D014202
ICD10 R25.1
SnomedCT 274239004, 206806000, 162229006, 158188003, 139505005, 26079004
English Tremor, SHAKING, TREMOR, TREMORS, Trembled, Tremor, NOS, [D]Tremor (context-dependent category), [D]Tremor NOS (context-dependent category), Tremor NOS, Tremor, unspecified, [D]Tremor NOS, Tremors, Tremor [D], tremor (physical finding), involuntary shaking or trembling movements, tremors as symptom, involuntary shaking or trembling movements (tremor), A46-A47 TREMORS, involuntary shaking or trembling movements (symptom), tremor, (Has a tremor) or (tremor symptom) or (shaking) (finding), Tremor [D] (situation), [D]Tremor NOS (situation), [D]Tremor (situation), [D]Tremor, TREMORS/SHAKING, SHAKING/TREMORS, Tremor [Disease/Finding], quivering, shakeing, d tremors, quiver, shaked, tremors, quivers, shakings, the shakes, shake, shakes, tremoring, Shakes, Shaking, Has a tremor, The shakes, Shaking all over, Tremor (finding), Tremor [D] (finding), Tremor symptom, (Has a tremor) or (tremor symptom) or (shaking), shaking
French TREMBLEMENT, Tremblant, TREMBLEMENTS, Tremblement
Portuguese TREMOR, Tremente, ESTREMECIMENTO, Tremor
Spanish TEMBLOR, Temblorina, [D]temblor, SAI (categoría dependiente del contexto), [D]temblor (categoría dependiente del contexto), (Has a tremor) or (tremor symptom) or (shaking), Shaking, Has a tremor, Tremor symptom, Tremor [D], SACUDIDAS, [D]temblor, SAI, [D]temblor, SAI (situación), [D]temblor, [D]temblor (situación), sacudida, temblor (hallazgo), temblor, Temblor
German TREMOR, bebend, SCHUETTELN, Tremor, nicht naeher bezeichnet, Tremor, Zittern
Dutch schudden, Tremor, niet gespecificeerd, tremor, Tremor
Italian Brividi scuoteni, Tremore
Japanese からだのゆれ, ｼﾝｾﾝ, ｶﾗﾀﾞﾉﾕﾚ, 振戦, 振顫, 振せん, ふるえ(振戦)
Swedish Darrning
Czech tremor, Tremor, Třes
Finnish Vapina
Russian TREMOR, DROZHANIE, ДРОЖАНИЕ, ТРЕМОР
Korean 상세불명의 떨림
Croatian TREMOR
Polish Drżenie
Hungarian Tremor, Remegő
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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