Tremor
Peter G. Teichman
Tremor, a rhythmic, involuntary oscillatory movement of a body part, is the most common movement disorder.
Approach.
It is important to classify the tremor based on clinical findings, identify possible reversible causes, and assess the impact that tremor has on the patient’s activities. Multiple causative, physiologic, and treatment response classifications have been proposed, although not validated in clinical research. Clinical observation and historical data remain the basis for grouping specific clinical features into tremor syndromes (1).
A. Physiologic tremor is a nonprogressing tremor that occurs in any body part and remits spontaneously with removal of a triggering agent.
B. Essential tremor, the most common type of tremor, is a largely hereditary, mainly postural tremor of the hands and sometimes the head (1). Primary writing tremor (tremor predominantly or only during writing but not during other tasks in the active hand) and isolated voice tremor (tremulous vocalization without involvement of other body parts) are types of essential tremor syndromes (1).
C. Parkinsonian tremor is a tremor at rest that occurs in the setting of other features of Parkinson’s disease (PD) such as bradykinesia and rigidity.
D. Secondary tremor syndromes. Many conditions can cause tremor, including drug-induced, toxic, and drug withdrawal tremors; tremor in peripheral neuropathy or dystonia (a syndrome dominated by sustained muscle contractions that cause twisting repetitive movements and abnormal postures) (1); psychogenic tremor; and tremor secondary to specific central nervous system lesions such as stroke or tumor (cerebellar tremor, Holme’s tremor, and palatal tremor).
History
A. Tremor characteristics. Does the tremor occur at rest, with goal-directed movement, or with maintenance of a specific posture? Parkinsonian tremor is a classic resting tremor, whereas essential tremor occurs or increases with maintenance of a posture. Drug-induced, drug withdrawal, and psychogenic tremors can occur at rest, with postural maintenance, or with movement.
B. What worsens the tremor? Parkinsonian tremor increases during mental stress or with movement of other body parts. Observation, stress, anxiety, fatigue, and certain drugs exacerbate essential tremor. Exposure to cold, fear, pain, caffeine, emotional loss, and stressful situations can initiate and promote physiologic tremors. A complete alcohol and medication history will further elicit possible secondary causes of tremor. Some known tremor-precipitating agents include antidepressants, lithium, neuroleptics, dopamine blocking agents, sympathomimetics, pseudoephedrine, theophylline, caffeine, methylphenidate, and withdrawal of alcohol (1,2).
C. What inhibits the tremor? Sleep stops all tremors. Whereas essential tremors increase with movement, Parkinsonian tremors diminish with goal-directed actions of the affected body part. Alcohol ingestion decreases tremor in 75% of patients with essential tremor (3). Physiologic and secondary tremors usually remit with removal of the precipitator or correction of the underlying disorder.
D. How has the tremor changed over time? Essential tremor slowly progresses. It can advance to cause social embarrassment, loss of function, and disability. Parkinsonian tremor and secondary tremors parallel the course and treatment of the underlying disease.
E. Family history. Only a slight familial relationship is seen with Parkinson’s disease, whereas at least 60% of essential tremor patients have a relative with tremor (3).
F. Onset and progression. When did the tremor begin? How has the tremor affected your life, your job, and your relationships? Parkinsonian and essential tremors usually occur after the fifth decade. Both can progress to cause decreased function, social embarrassment and isolation, disability, and loss of livelihood. Physiologic and psychogenic tremors rapidly occur and regress.
Physical examination.
A general search for signs of central nervous system involvement, drug use or withdrawal, and peripheral neuropathy may uncover secondary tremor causes. A focused examination of affected body parts, including provocative tests, may distinguish among the tremor types. Essential tremor is usually bilateral, symmetric, and increases with observed provocative testing such as maintaining a posture against gravity, pouring water, or drawing. It most commonly involves the hands and arms. It can also involve the head and voice. In advanced stages, leg and feet involvement can occur.
Parkinsonian tremor, the classic “pill rolling” resting tremor, remits with movement. It can herald the onset of Parkinson’s disease, or develop concurrently with rigidity, bradykinesia, and postural instability. Psychogenic tremors appear and remit suddenly, can exhibit unusual combinations of rest and intention tremors, occur in the presence of other unrelated neurologic signs, and diminish with distraction.
Testing.
The diagnosis and classification of tremor is usually made without laboratory testing or imaging studies, although drug- and disease-specific testing may identify secondary causes. In some cases, electromyographic studies can help distinguish among tremor types; indirectly measure functional disability; and, by repeated testing, assess the progression of the tremor. Clinical functional disability scales may also assess tremor progression. Pharmacotherapeutic challenges (dopaminergic agents in suspected PD and beta-blockers or primidone in suspected essential tremor) may provide further diagnostic insight.
Diagnostic assessment.
In most cases, the diagnosis of tremor is based on specific historical and physical examination findings. Proper treatment depends on classification of the tremor type and the identification of secondary causes. When the cause or classification of tremor is unclear, observation of tremor progression over time may uncover its cause, and guide patient and provider expectations of severity and dysfunction.
References
1. Deuschl G, Bain P, Brin M, et al. Consensus statement of the Movement Disorder Society on Tremor. Mov Disord 1998;13(Suppl 3):2–23.
2. Charles PD, Esper GJ, Davis TL, Maciunas RJ, Robertson D. Classification of tremor and update on treatment. Am Fam Physician 1999;59:1565–1572.
3. Koller WC, Busenbark K, Miner K, et al. The relationship of essential tremor to other movement disorders: report on 678 patients. Ann Neurol 1994;35:717–722.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Shivering
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