3. Tremor
• The most common involuntary movement disorders seen
in clinical practice
• A rhythmic, involuntary, oscillating movement of a body
part occurring in isolation or as part of a clinical
syndrome.
4. Types of tremor Descriptions
Resting tremor
occurs when the affected extremity is at complete rest
and diminishes with movement
Postural tremor
occurs when the affected limb is held in sustention
against gravity.
Action or kinetic
tremor
occurs during voluntary movement.
Intention tremor
marked increase in tremor amplitude during the
terminal portion of a targeted movement
Task-specific tremor.
emerges during a specific activity.
e.g primary writing tremor
5.
6. PATHOPHYSIOLOGY
• not fully understood
• combinations of these
mechanisms produce
tremor in different
disease states
7. PATHOPHYSIOLOGY
• Mechanical oscillations of the limb can occur at a particular joint; this
mechanism applies in cases of physiologic tremor.
• Reflex oscillation is elicited by afferent muscle spindle pathways and is
responsible for stronger tremors by synchronization. This mechanism is a
possible cause of tremor in hyperthyroidism or other toxic states.
• Central oscillators are groups of cells in the central nervous system in the
thalamus, basal ganglia, and inferior olives. These cells have the capacity to
fire repetitively and produce tremor. Parkinsonian tremors may originate in
the basal ganglia, and essential tremors may originate within the inferior
olives and thalamus.
• Abnormal functioning of the cerebellum can produce tremor. PET studies
have shown cerebellar activation in almost all forms of tremor.
10. Physiologic Tremor
• Very-low-amplitude, fine tremor (6–12 Hz) that is
barely visible to the eye.
• Present in every normal person while a posture
or movement is being maintained.
• Does not interfere with ADL.
11. Enhanced Physiologic Tremor
• A high-frequency, low-amplitude, visible when a
specific posture is maintained.
• Induced by :
– drugs and toxins
– hyperthyroidism, liver disease,anxiety, and
hypoglycemia.
12.
13. Enhanced physiologic tremor
• Tx:
– Metabolic etiology (eg, thyroid, glucose)--> treated
accordingly.
– Anxious patient--> treatment of the anxiety
– Drug-induced--> decrease the dose or stop the drug
14. Essential Tremor
• The most common
• Prevalence: 0.4% to 6.7% in persons over 40 years
• Postural and action tremors
• Frequency: 4 and 8 Hz.
• Symmetriccal onset (most patients)
• Most commonly :
– hands (95%) head (34%) and voice (12%)
• Less common:
– legs (20%) trunk and face (5%)
• with increasing time, frequency decreases and the
amplitude may increase
15. Essential Tremor
• In familial ET(AD) with incomplete penetrance.
– A positive family history (50% to 70%)
• Worsens during eating, drinking, and writing.
• Long-standing ET Mild resting tremor
• A ‘‘no-no’’ or ‘‘yes-yes’’ head tremor is characteristic of
ET
16. *Elble RJ. Diagnostic criteria for essential tremor and differential diagnosis.
Neurology 2000;54:S2–6.
17. Essential Tremor
• Improves with relaxation and alcohol (50%)
• Associated symptoms: gait difficulty (manifested as
tandem walking), decreased hearing.
• Variants of essential tremor:
– Task-specific tremor (eg, primary writing tremor)
– Isolated voice tremor
– Isolated chin tremor
18. Essential Tremor
• Tx not recommended for mild cases
• Decision to treat is based on:
– age, coexistent conditions, prior exposure to drug therapy,
concurrent drug therapies, contraindications, physician and
patient bias, benefits and potential adverse effects
• Different body parts a may also have different
pharmacological responsiveness
19. Essential tremor
• First-line treatments: Propranolol and primidone
– better response for hand tremors than for voice and head tremors
20. Essential tremor
Other therapies:
1. Botulinum toxin injections - limb, head, vocal, palatal,
and other tremors.
2. Anxiolytics (Tremors associated with anxiety)
3. Refractory thalamic lesioning or DBS
21. Parkinson’s Disease
• Tremor:
– a low-frequency resting tremor :70% (pill-rolling tremor)
– asymmetric
– 4 to 6 Hz, (distal --> proximal --> contralat)
– Some patients: postural and action tremors.
– Re-emergent tremor (occurs a few seconds after the hands have
been held in sustention and action).
• Most commonly affected: hands, legs, chin, and jaw.
• a/w, bradykinesia, rigidity, micrographia
27. Cerebellar Tremor
• slow-frequency tremor (3 and 5 Hz)
• Occurs during the execution of a goal-directed
(intentional) movement
• can be associated with a postural component.
• S&Sx of cerebellar dysfunction may be present (ataxia,
dysmetria, dysdiadochokinesia, and dysarthria)
• best elicited during the finger-nosefinger or heel-shin-
heel tests
28. Cerebellar Tremor
• Titubation tremor:
– described as a slow-frequency “bobbing”
motion of the head or trunk.
– usually seen in MS, hereditary ataxia
syndromes, cerebellar infarction, and
traumatic brain injury.
29. Cerebellar tremor
• No medication has been consistently
successful
• Medications that can be tried:
– clonazepam, propranolol, trihexyphenidyl,
levodopa, physostigmine, and topiramate.
• Thalamic stimulation for disabling tremor
may be an option
30. Psychogenic Tremors
• onset a/w a stressful life event
• irregular frequency & amplitude
• sudden onsets and remissions.
• increase of their tremor amplitudes during loading
• selective disability
• Most often: right hand (84%), followed by legs (28%),
generalized (20%), left arm (8%) and head (8%)
• Uncommon: voice, face, tongue, and fingers
31. *Manyam BV. Uncommon forms of tremor. In: Watts RL, Koller WC, eds. Movement disorders: neurologic principles and
practice. 2nd ed. New York: McGraw-Hill, 2004:459–80.
32. Psychogenic tremor
1. Suggestibility
– Suggestion and placebo can to exacerbate or relieve tremor
2. Distractibility
3. Entrainability
– tremor automatically changes to the frequency that is being
enforced on the uninvolved hand or foot
4. Coactivation sign
– presence of voluntary coactivation of agonist and antagonist
muscles of the respective joint
– fluctuation of the tone with reduction or increase in the tremor
– produce bizarre positioning of the hands when they are
outstretched.
34. Holmes Tremor
• a combination of rest, postural, and action tremors due
to midbrain lesions in the vicinity of the red nucleus.
• Irregular and of low frequency tremor(2–4 Hz)
• predominantly proximal limbs
• Signs of ataxia and weakness may be present.
• Common causes : CVA, MS with a possible delay of 2
weeks to 2 years in onset and sx.
• The tremor is disabling and resistant to treatment.
35. Dystonic Tremor
• tremor that occurs in a body region affected by
dystonia.
• Postural/action tremor with irregular amplitudes
and frequencies.
• E.g: no-no or yes-yes head tremor associated
with spasmodic torticollis.
• Irregular or arrhythmic tremor and may improve
with a “sensory trick” (geste antagoniste)
36. Dystonic tremor.
• botulinum toxin injections.
• Other medications:
– anticholinergic agents, levodopa, propranolol,
and clonazepam
37. Neuropathic tremor
• Neuropathic tremors are mostly postural or
action tremors that occur in the setting of a
peripheral neuropathy.
• 3 and 6 Hz in the hand and arm muscles.
• They are more commonly a/w demyelinating
neuropathies of the dysgammaglobulinemic
type.
• The exact etiology of this tremor is unknown.
38. Neuropathic tremors.
• No successful pharmacologic treatment
has been reported.
• Pharmacotheraphy:
– clonazepam, primidone, and propranolol
(inconsistent benefit).
• Disabling neuropathic tremor thalamic
DBS
39. Palatal Tremor
• brief, rhythmic, involuntary, low-frequency movements of the soft
palate.
• Classified in two forms:
1. Symptomatic palatal tremor
– arise from a lesion of the brainstem or cerebellum (within the Guillain-
Mollaret triangle), resulting in a rhythmic contraction of the levator veli
palatini.
– Movement of the edge of the palate is appreciated.
1. Essential palatal tremor(often a/w an ear click)
– not associated with CNS lesions
– a result of the rhythmic contractions of the tensor veli palatini
– Movement of the roof of the palate is also seen.
40. Palatal tremors
• usually not disabling.
• Patients who are bothered by the ear click
may benefit from trihexyphenidyl,
valproate, or flunarizine.
• Injection of botulinum toxin in the tensor
veli
41. Drug-Induced Tremors
• Types of tremors include enhanced physiologic tremor,
rest tremor, and action tremor.
• The signs and symptoms depend on the drug used and
on a patient’s predisposition to its side effects.
• Some drugs cause extrapyramidal side effects
manifesting as bradykinesia, rigidity, and tremor.
• Tx: discontinuation/reduction of the dose of the offending
agent
43. Orthostatic Tremor
• Middle aged/elderly people
• characterised by unsteadiness on standing
– tremors remit on walking, but disappear when sitting or lying
down
• Confirmation : EMG showing a 16 Hz pattern
• The treatment of choice :
– low-dose clonazepam.
– Other options: Phenobarbital, primidone, propranolol, levodopa,
pramipexole, and gabapentin
44. Tremor in Wilson’s disease
• All tremor types can be seen.
– Most common: resting and postural tremors.
– “wing-beating tremor” late stage,refractory to medication
• Other neurological manifestations: Ataxia, parkinsonism, dysarthria,
dystonia, and risus sardonicus.
• Often accompanied by liver disease and psychiatric manifestations
(eg, depression, anxiety, psychosis).
• This diagnosis should be considered for any patient with a
movement disorder presenting before the age of 50 years.
46. Wilson’s disease.
• Low copper diet.
• Copper chelation agent:
– penicillamine (1–2 g/d) with pyridoxine (50 mg/d),
– trientine (500 mg 2 times daily)
– tetrathiomolybdate (80–120 mg daily in 3 to 4 divided doses)
– zinc (50 mg/d without food).
• Thalamotomy.
47. EVALUATION OF THE PATIENT WITH TREMOR
• History
– history of the neuropathy, drug use, and toxic
exposure and the family history
• Examination
• Workout
– not necessary for most patients
53. *Deuschl G, Bain P, Brin M; Ad Hoc Scientific
Committee. Consensus statement of the Movement
Disorder Society on Tremor. Mov Disord.
1998;13(suppl 3):2-23.
54.
55. Summary
• Make sure it is Tremor
• Predominenat tremor
• Evidence of functional tremor
• Additional sign
– Parkisonism
– Cerebellar
– Dystonia
– Peripheral neuropathy
– Hyperthyrodism
56. References
1. A Practical Approach to Movement Disorders, 2nd Edition,
Diagnosis and Management-Hubert Fernandez, Andre Machado,
Mayur Pandya Demos Medical (2014)
2. R Bhidayasiri, Differential diagnosis of common tremor syndromes,
Postgrad Med J 2005;81:756–762.
3. PAUL CRAWFORD, MD ETHAN E. ZIMMERMAN, MD,
Differentiation and Diagnosis of Tremor, American Family Physician
4. Elble RJ. Diagnostic criteria for essential tremor and differential
diagnosis.Neurology 2000;54:S2–6.
5. Deuschl G, Bain P, Brin M; Ad Hoc Scientific Committee.
Consensus statement of the Movement Disorder Society on Tremor.
Mov Disord. 1998;13(suppl 3):2-23.
