Tremor

Aka: Tremor

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II. Definitions

  1. Tremor
    1. Body part involuntarily oscillates around point in space

III. Epidemiology

  1. Tremor Prevalence increases with age

IV. Differential Diagnosis

  1. Choreoathetosis
  2. Dystonia
  3. Clonus

V. 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)

VI. Classification

  1. Background
    1. Tremor causes cross-over categories (rest, postural, action)
    2. Many Postural Tremors also have Rest Tremor and Action Tremor features
  2. 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 (despite support against gravity)
    3. Provoked by stress or distraction (e.g. counting backwards) or moving another body part (e.g. walking)
    4. Rest Tremor decreases with voluntary movement
  3. Postural Tremor
    1. Patient attempts to maintain Posture against gravity (stretch hands out in front of them)
    2. Essential Tremor
    3. Physiologic Tremor or Enhanced Physiologic Tremor
    4. Drug-Induced Tremor
    5. Other causes
      1. Dystonia
      2. Psychogenic Tremor
      3. Metabolic Causes of Tremor (esp. Thyrotoxicosis)
  4. Action Tremor
    1. Isometric Tremor
      1. Muscle Contraction against rigid item (e.g. grasping with fist)
    2. Kinetic Tremor
      1. Occurs with any form of voluntary movement
    3. Intention Tremor (subtype of Kinetic Tremor)
      1. Tremor amplifies as target is reached
      2. Exercise high index of suspicion for cerbellar lesion (see Cerebellar Tremor)
    4. Task-specific tremor (subtype of Kinetic Tremor)
      1. Tremor on performing highly skilled activity (e.g. writing, speaking, playing music)

VII. 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

VIII. 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

IX. Evaluation

  1. Step 1: Enhanced Physiologic Tremor
    1. Consider Thyroid Stimulating Hormone, Serum Glucose, Liver Function Tests
    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 or Cerebellar Tremor
        1. Obtain MRI Brain
        2. Evaluate for Multiple Sclerosis, Cerebrovascular Accident, Brain Tumor

X. 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)

XI. Resources

  1. International Tremor Foundation
    1. Overland Park, Kansas
    2. Phone: (913) 341-3880
  2. See Parkinson's Disease Resources

XII. Reference

  1. Crawford (2011) Am Fam Physician 97(3): 180-6 [PubMed]
  2. Crawford (2018) Am Fam Physician 83(6): 697-702 [PubMed]
  3. Charles (1999) Am Fam Physician 59(6):1565-72 [PubMed]
  4. Habib-ur-Rehman (2000) Arch Intern Med 160(16):2438-44 [PubMed]
  5. Smaga (2003) Am Fam Physician 68:1545-52 [PubMed]
  6. Velickovic (2002) Geriatrics 57(7):32-6 [PubMed]

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