Tremor

Aka: Tremor

advertisement

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]

Images: Related links to external sites (from Bing)

These images are a random sampling from a Bing search on the term "Tremor." Click on the image (or right click) to open the source website in a new browser window. Search Bing for all related images

Related Studies

Ontology: 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 (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.

The cause of tremors is a problem in the parts of the brain that control muscles in the body or in specific parts of the body, such as the hands. They commonly occur in otherwise healthy people. They may also be caused by problems such as

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 (MSHCZE) Tremor – lat. třes. Mimovolní rytmický pohyb různých částí těla, nejnápadněji rukou. Hodnotí se jeho frekvence, amplituda, symetričnost, může být patrný v klidu či naopak souviset s pohybem, který může být třesem znesnadněn. Je způsoben různými chorobami, zejm. neurologickými, ale i interními aj. Esenciální familiární t. může mít autozomálně dominantní dědičnost, nemá jasnou příčinu a obv. je benigní, i když může některé činnosti znesnadňovat. Intenční t. vzniká u poruch mozečku. Nebývá v klidu, objevuje se až při pohybu, zejm. k jeho konci (chce-li se postižený dotknout určitého předmětu, zesílí třes těsně před ním). Parkinsonský t. je nápadným příznakem Parkinsonovy nemoci. Je pomalý (4–6 Hz) a je přítomný vklidu, zatímco při pohybu mizí. Nejnápadnější je na končetinách a zejm. zpočátku bývá obv. asymetrický. Zvyšuje jej únava, stres. Třes Holmesův vzniká při lézi ncl. ruber, je jednostranný, má hrubý charakter a je staticko-intenční. Z interních chorob je t. přítomen při tyreotoxikóze, při jaterní encefalopatii je typický t. označovaný flapping tremor. K t. vede rovněž alkoholismus. T. může být i neurotického původu či znakem rozrušení. Třes v oblasti hlavy je patrný např. při aortální insuficienci (Mussetův příznak), kdy je synchronní s pulsem. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
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.
Definition (NCI_CTCAE) A disorder characterized by the uncontrolled shaking movement of the whole body or individual parts.
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.
Concepts Sign or Symptom (T184)
MSH D014202
ICD10 R25.1
SnomedCT 274239004, 206806000, 162229006, 139505005, 158188003, 26079004
LNC LA17301-5
English Tremor, SHAKING, TREMOR, [D]Tremor (context-dependent category), [D]Tremor NOS (context-dependent category), 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), involuntary shaking or trembling movements (symptom), tremor, Tremor [Disease/Finding], quivering, d tremors, quiver, tremors, quivers, the shakes, shake, shakes, tremor (diagnosis), (Has a tremor) or (tremor symptom) or (shaking) (finding), [D]Tremor, [D]Tremor NOS (situation), Tremor [D] (situation), Tremor symptom, (Has a tremor) or (tremor symptom) or (shaking), [D]Tremor (situation), Involuntary shaking, SHAKING/TREMORS, TREMORS/SHAKING, Shakes, Shaking, Has a tremor, The shakes, Shaking all over, Tremor (finding), Tremor, NOS, Tremor [D] (finding), Tremor NOS, 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), SACUDIDAS, [D]temblor, SAI (situación), [D]temblor (situación), [D]temblor, [D]temblor, SAI, sacudida, temblor (hallazgo), temblor, Temblor
German TREMOR, bebend, SCHUETTELN, Tremor, nicht naeher bezeichnet, Tremor, Zittern
Dutch schudden, Tremor, niet gespecificeerd, tremor, Tremor
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, třes
Finnish Vapina
Russian TREMOR, ТРЕМОР
Korean 상세불명의 떨림
Croatian TREMOR
Polish Drżenie
Hungarian Tremor, Remegő
Norwegian Tremor
Italian Brividi scuotenti, Tremore
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Tremor

advertisement

2025 Family Practice Notebook, LLC. Terms | Privacy | About | Site Map | Newsletter | Blog

Footer Site Logo