Tremor/InvoluntaryMovements

Tremor/InvoluntaryMovements: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

Tremor

❑ Anxiety

❑ Physiologic tremor

❑ Essential tremor

❑ Parkinson disease

❑ Cerebellar disease

❑ Hyperthyroidism

❑ Opiate withdrawal

❑ Myoclonus

❑ Multiple sclerosis

❑ Amyotrophic lateral sclerosis

Involuntary Movements

❑ Tics

❑ Drugs

❑ Systemic lupus erythematosus

❑ Rheumatic fever

❑ Huntington disease

❑ Tourette syndrome

❑ Wilson disease

Diagnostic Approach

A postural tremor is characterized by fine regular movement of the fingers or hands with the arms outstretched. It is not present at complete rest. Anxiety, benign essential tremor, hyperthyroidism, or medications (alcohol, caffeine, lithium, beta agonists, or phenytoin) may cause it. Proximal postural tremors involving the shoulder, pelvis, and neck are due to cerebellar lesions.

An intention or action tremor, characterized by irregular jerking brought out by movement, can be caused by cerebellar disorders such as multiple sclerosis and alcoholic or paraneoplastic cerebellar degeneration (lung or ovarian cancer). Hereditary ataxias also follow this pattern.

A rest tremor is evident with the affected part supported and at rest and dampened during voluntary activity, fluctuating in amplitude. It is activated during walking, and interferes with use of eating utensils and with writing. It occurs with Parkinson disease, phenothiazines, severe essential tremor, Wilson disease, mercury poisoning, general paresis, and with midbrain lesions (stroke or demyelinating disease).

Choreiform movements are brief, irregular, jerky, nonrhythmic muscle contractions. Ballismus is a large amplitude jerk that produces flinging of the limb. It is commonly unilateral (hemiballismus). Athetosis is a continuous, sinuous, writhing movement of the digits, limbs, trunk, face, or tongue. Dystonia is a slow, involuntary twisting spasm. Tics are patterned coordinated movements that appear suddenly and intermittently.

Writing or drawing may demonstrate the large, tremulous, angulated loops of essential tremor or the micrographia of Parkinsonism. Horizontal or vertical head tremor is associated with essential tremor, cervical dystonia, or midline cerebellar syndromes, while face, lip, and jaw tremors are seen in Parkinsonism.

Clinical Findings

Anxiety  A psychological stimulus is evident. It is accompanied by sweating, tachycardia, and diarrhea.

Physiologic tremor  This occurs as a fine tremor with a frequency of 8 to 12 Hz and is most noticeable while the patient is holding a fixed position. It may be increased by anxiety, muscle fatigue, hypoglycemia, caffeine, lithium, or tricyclic antidepressants.

Essential tremor  Absent at rest and clearly present in the outstretched arms, it is accentuated by tasks requiring precision (e.g., writing) and alleviated by alcohol. Handwriting is therefore large and irregular, and the patient may have difficulty drinking from a cup. Essential tremor is of greater amplitude and slower frequency than physiologic tremor, and is bilaterally symmetrical. A head tremor and quavering voice may develop. A family history and gradual progression are usually present.

Parkinson disease  It is marked by a rest tremor in a relaxed supported limb, which diminishes with use. The “pill-rolling” tremor of thumb and index finger occurs at a frequency of 3 to 8 Hz. It is inhibited during movement and sleep, and aggravated by emotional distress. The tremor does not occur in isolation but is accompanied by cogwheel rigidity, bradykinesia, masked facies, stooped posture, micrographia, retropulsion with standing, and decreased voice volume.

Cerebellar disease  As the limb approaches the target, the tremor progressively increases in amplitude. It is multiplanar, large, slow (2 to 4 Hz), and worsened by alcohol. Titubation of the head and neck (“to-and-fro”) may be observed. It may be found in multiple sclerosis, cerebellar infarction, degenerative disorders of the spinocerebellar pathways, and polyneuropathy.

Hyperthyroidism  A fine tremor of the outstretched fingers is associated with other signs of hyperthyroidism (lid lag, tachycardia, silky skin).

Opiate withdrawal  Tremor will be present in the hands, lips, and tongue. There will be a history of opiate use and often confusion or delirium.

Myoclonus  It appears as brief, lightning-like muscular jerks. Asterixis is a form of this tremor, characterized by a rhythmic flapping of the hands at full extension. This is characteristic of metabolic disorders such as hepatic or uremic encephalopathy.

Multiple sclerosis  The Charcot triad of intention tremor, nystagmus, and scanning speech is a classic presentation. Optic neuritis or atrophy and internuclear ophthalmoplegia are clues.

Amyotrophic lateral sclerosis  Early in the disease there is a subacute onset of asymmetric weakness, with visible atrophy and fasciculations. The tongue will appear twitching, scalloped, and atrophic. Corticospinal tract involvement will produce an upgoing plantar reflex (Babinski sign).

Tics  These are usually benign although it is often difficult to distinguish pathologic causes. Eye blinking and facial grimaces are common manifestations.

Drugs  Phenothiazines and levodopa may produce dystonia or chorea, such as an acute dystonic reaction with neck torsion. Long-term use may also produce tardive dyskinesia, with lip smacking and tongue protrusion.

Systemic lupus erythematosus  Chorea occurs with cerebral arteritis. Malar rash, serositis, arthritis, and fever are clues to the underlying diagnosis.

Rheumatic fever  Sydenham chorea occurs in children and young adults in the context of rheumatic fever, recognized by the syndrome of fever, arthritis, carditis, pharyngitis, and erythema marginatum. Movements of the face, tongue, and extremities are absent at rest and exaggerated by movement. Fluctuation of grip strength is characteristic. Hypotonia is present. Speech and swallowing may be distorted.

Huntington disease  A slowly progressive chorea of dominant inheritance, it appears after age 40. An associated manifestation is mental deterioration with delusions.

Tourette syndrome  Motor and vocal tics, including coprolalia (swearing), are essential and distinctive features.

Wilson disease  The tremor will be flapping or wing-beating, with coarse to-and-fro movements, flexing and extending the wrist. It may appear like Parkinson disease, but it usually occurs in young adults and is accompanied by cirrhosis and a golden iridic (Kayser-Fleischer) ring.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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