Tremor

Tremors are abnormal, rhythmic, involuntary movements. They are classified as resting and intention or action tremors, the former occurring at rest (resting tremor) or in a static position (postural tremor), such as when holding the arms outstretched, and the latter occurring or increasing with purposeful activity, such as reaching for an object. A very common type of resting tremor is the physiologic tremor, which is not usually visible, but can be enhanced by anxiety, medications (e.g., caffeine), and other circumstances.

Differential Diagnosis

Resting tremors

• Parkinson's disease
  –“Pill-rolling” appearance
  –Associated cog-wheel rigidity, shuffling gait, akinesis, and/or depression

• Benign familial or essential tremor
  –Especially common with head tremor (e.g., actress Katherine Hepburn)
  –Positive family history
  –No other neurologic findings

Workup and Diagnosis

• Evaluation of tremors includes a complete history and physical examination with attention to the onset and other characteristics of the tremor; medication history; a limited general physical examination and a comprehensive neurologic examination
• CT or MRI of head to rule out mass lesions, CVA, and normal pressure hydrocephalus
• Initial labs may include TSH, T₄, CBC, vitamin B₁₂ and folate, RPR, and a comprehensive metabolic panel (electrolytes, calcium, glucose, BUN/creatinine, liver function tests, and albumin)
• Essential or familial tremor is diagnosed by excluding other etiologies and by a positive response to propranolol
• Parkinson's disease is diagnosed by the characteristic constellation of symptoms and response to treatment (Parkinson's is often diagnosed and treated before tremor develops)
• Toxicology screen to rule out drug ingestion
• The following types of movement may be confused with tremor, but are actually separate entities
  –Tics are usually unifocal and slower and are not tremors
  –Chorea causes jerky irregular movements
  –Myoclonus is rapid and irregular
  –Athetosis and dystonia are slow movements
  –Asterixis results from inhibition of muscle contractions due to hepatic encephalopathy

Treatment

• Parkinson's disease
  –Anticholinergic medications (e.g., benztropine)
  –Amantidine
  –Levodopa-carbidopa
  –Dopamine agonists (e.g., bromocriptine)
  –Selegiline treats symptoms, but may also have a neuroprotective effect that slows disease progression
  –Surgical intervention had been the used in the past
  –Transplantation of fetal nigral cells into the putamen is under investigation
• Essential or familial tremor responds well to propranolol (10–80 mg BID), primidone, mysoline, or low-dose valium; however, treatment is only symptomatic
• Thyrotoxicosis is treated by surgery or nuclear ablation, propranolol, and/or antithyroid medications (tapazole or propylthiouracil)
• Drug and alcohol withdrawal is treated with detoxification
• Wilson's disease is treated with chelation

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

Other Book Chapters Related to Movement symptoms

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Movement symptoms

• Back to symptom: Movement symptoms: Introduction (review 2705 causes)
• Next Book Extract About Movement symptoms: Ataxia (In A Page: Pediatric Signs and Symptoms)
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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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• Ataxia (In A Page: Pediatric Signs and Symptoms)
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• Ataxia (Handbook of Signs & Symptoms (Third Edition))
• Asterixis [Liver flap, flapping tremor] (Handbook of Signs & Symptoms (Third Edition))

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