Tremors
The most common type of involuntary muscle movement, tremors are regular rhythmic oscillations that result from alternating contraction of opposing muscle groups. They’re typical signs of extrapyramidal or cerebellar disorders and can also result from certain drugs.
Tremors can be characterized by their location, amplitude, and frequency. They’re classified as resting, intention, or postural. Resting tremors occur when an extremity is at rest and subside with movement. They include the classic pill-rolling tremor of Parkinson’s disease. Conversely, intention tremors occur only with movement and subside with rest. Postural (or action) tremors appear when an extremity or the trunk is actively held in a particular posture or position. A common type of postural tremor is called an essential tremor.
Stress or emotional upset tends to aggravate a tremor. Alcohol commonly diminishes postural tremors.
History
Begin the patient history by asking the patient about the tremor’s onset. Was onset sudden or gradual? Also, ask about the tremor’s duration, progression, and any aggravating or alleviating factors. Does the tremor interfere with the patient’s normal activities? Does he have other symptoms? Has he noticed any behavioral changes or memory loss? (The patient’s family or friends may provide more accurate information on this.)
Explore the patient’s personal and family medical history for a neurologic (especially seizures), endocrine, or metabolic disorder. Obtain a complete drug history, noting especially the use of phenothiazines. Also, ask about alcohol use.
Physical assessment
Assess the patient’s overall appearance and demeanor, noting mental status. Test range of motion and strength in all major muscle groups while observing for chorea, athetosis, dystonia, and other involuntary movements. Check deep tendon reflexes and, if possible, observe the patient’s gait.
Medical causes
Alcohol withdrawal syndrome
Acute alcohol withdrawal after long-term dependence may first be manifested by resting and intention tremors that appear as soon as 7 hours after the last drink and progressively worsen. Other early signs and symptoms include diaphoresis, tachycardia, elevated blood pressure, anxiety, restlessness, irritability, insomnia, headache, nausea, and vomiting. Severe withdrawal may produce profound tremors, agitation, confusion, hallucinations and, possibly, seizures.
Alkalosis
Severe alkalosis may produce a severe intention tremor along with twitching, carpopedal spasms, agitation, diaphoresis, and hyperventilation. The patient may complain of dizziness, tinnitus, palpitations, and peripheral and circumoral paresthesia.
Cerebellar tumor
An intention tremor is a cardinal sign of a cerebellar tumor; related findings may include ataxia, nystagmus, incoordination, muscle weakness and atrophy, and hypoactive or absent deep tendon reflexes.
Graves’ disease
Fine tremors of the hand, nervousness, weight loss, fatigue, palpitations, dyspnea, and increased heat intolerance are some of the typical signs of Graves’disease. It’s also characterized by an enlarged thyroid gland (goiter) and exophthalmos.
Hypercapnia
Hypercapnia (elevated partial pressure of carbon dioxide) may result in a rapid, fine intention tremor. Other common findings include headache, fatigue, blurred vision, weakness, lethargy, and decreased level of consciousness (LOC).
Hypoglycemia
Acute hypoglycemia may produce a rapid, fine intention tremor accompanied by confusion, weakness, tachycardia, diaphoresis, and cold, clammy skin. Early patient complaints typically include mild generalized headache, profound hunger, nervousness, and blurred or double vision. The tremor may disappear as hypoglycemia worsens and hypotonia and decreased LOC become evident.
Kwashiorkor
Coarse intention and resting tremors may occur in the advanced stages of kwashiorkor. Examination reveals myoclonus, rigidity of all extremities, hyperreflexia, hepatomegaly, and pitting edema in the hands, feet, and sacral area. Other signs include a flat affect, pronounced hair loss, and dry, peeling skin.
Multiple sclerosis
An intention tremor that waxes and wanes may be an early sign of multiple sclerosis. Commonly, visual and sensory impairments are the earliest findings. Associated effects vary greatly and may include nystagmus, muscle weakness, paralysis, spasticity, hyperreflexia, ataxic gait, dysphagia, and dysarthria. Constipation, urinary frequency and urgency, incontinence, impotence, and emotional lability may also occur.
Parkinson’s disease
Tremors, a classic early sign of Parkinson’s disease, usually begin in the fingers and may eventually affect the foot, eyelids, jaw, lips, and tongue. The slow, regular, rhythmic resting tremor takes the form of flexion-extension or abduction-adduction of the fingers or hand, or pronation-supination of the hand. Flexion-extension of the fingers combined with abduction-adduction of the thumb yields the characteristic pill-rolling tremor.
Leg involvement produces flexion-extension foot movement. Lightly closing the eyelids causes them to flutter. The jaw may move up and down, and the lips may purse. The tongue, when protruded, may move in and out of the mouth in tempo with tremors elsewhere in the body. The rate of the tremor holds constant over time, but its amplitude varies.
Other characteristic findings include cogwheel or lead-pipe rigidity, bradykinesia, propulsive gait with forward-leaning posture, monotone voice, masklike facies, drooling, dysphagia, dysarthria, and occasionally oculogyric crisis (eyes fix upward, with involuntary tonic movements) or blepharospasm (eyelids close completely).
Porphyria
Involvement of the basal ganglia in porphyria can produce a resting tremor with rigidity, accompanied by chorea and athetosis. As the disease progresses, generalized seizures may appear along with aphasia and hemiplegia.
Thalamic syndrome
Central midbrain syndromes are heralded by contralateral ataxic tremors and other abnormal movements, along with Weber’s syndrome (oculomotor palsy with contralateral hemiplegia), paralysis of vertical gaze, and stupor or coma.
Anteromedial-inferior thalamic syndrome produces varying combinations of tremor, deep sensory loss, and hemiataxia. However, the main effect of this syndrome may be an extrapyramidal dysfunction, such as hemiballismus or hemichoreoathetosis.
Thyrotoxicosis
Neuromuscular effects of thyrotoxicosis include a rapid, fine intention tremor of the hands and tongue, along with clonus, hyperreflexia, and Babinski’s reflex. Other common signs and symptoms include tachycardia, cardiac arrhythmias, palpitations, anxiety, dyspnea, diaphoresis, heat intolerance, weight loss despite increased appetite, diarrhea, an enlarged thyroid and, possibly, exophthalmos.
Wernicke’s disease
An intention tremor is an early sign of Wernicke’s disease. Other features of Wernicke’s disease include ocular abnormalities (such as gaze paralysis and nystagmus), ataxia, apathy, and confusion. Orthostatic hypotension and tachycardia may also develop.
West Nile encephalitis
In West Nile encephalitis, mild infections are common and include fever, headache, and body aches, commonly accompanied by rash and swollen lymph glands. More severe infections are marked by headache, high fever, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.
Other causes
Drugs
Phenothiazines (particularly piperazine derivatives such as fluphenazine) and other antipsychotics may cause resting and pill-rolling tremors. Infrequently, metoclopramide and metyrosine also cause these tremors. Lithium toxicity, sympathomimetics (such as terbutaline and pseudoephedrine), amphetamines, and phenytoin can all cause tremors that disappear with dose reduction.
Manganese toxicity
Early signs of manganese poisoning include resting tremor, chorea, propulsive gait, cogwheel rigidity, personality changes, amnesia, and masklike facies.
Mercury poisoning
Mercury is a chronic form of poisoning that’s characterized by irritability, copious amounts of saliva, loose teeth, gum disease, slurred speech and tremors.
Special considerations
Severe intention tremors may interfere with the patient’s ability to perform activities of daily living. Assist the patient with these activities as necessary, and take precautions against possible injury during such activities as walking or eating.
Pediatric pointers
A normal neonate may display coarse tremors with stiffening — an exaggerated hypocalcemic startle reflex — in response to noises and chills. Pediatric-specific causes of pathologic tremors include cerebral palsy, fetal alcohol syndrome, and maternal drug addiction.
Patient counseling
Encourage the patient to express his feelings about changes in his body image to reduce anxiety and depression. Because reinforcing independence may help maintain self-esteem, encourage the patient to do as much of his own personal care as possible. Provide assistive devices, if necessary, to help with activities of daily living.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Shakiness
Read excerpts from these other book chapters related to Shakiness:
Medical Books Excerpts
- TREMOR
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- "In a Page: Signs and Symptoms" (2004)
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- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- "A Pocket Manual of Differential Diagnosis" (1999)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "Nursing: Interpreting Signs and Symptoms" (2007)
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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Shakiness
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