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 the use of 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.
Tremorlike movements may also be elicited—for example, asterixis, the characteristic flapping tremor seen in hepatic failure. (See “Asterixis,” page 76.)
Stress or emotional upset tends to aggravate tremors. Alcohol commonly diminishes postural tremors.
History and physical examination
Begin the patient history by asking the patient about the tremor’s onset (sudden or gradual) and about its 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.
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 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.
Benign familial essential tremor
This disorder of early adulthood produces a bilateral essential tremor that typically begins in the fingers and hands and may spread to the head, jaw, lips, and tongue. Laryngeal involvement may result in a quavering voice.
Cerebellar tumor
An intention tremor is a cardinal sign of this disorder; related findings may include ataxia, nystagmus, incoordination, muscle weakness and atrophy, and hypoactive or absent deep tendon reflexes.
General paresis
This effect of neurosyphilis may cause an intention tremor accompanied by clonus, a positive Babinski’s sign, ataxia, Argyll Robertson pupils, and a diffuse, dull headache.
Graves’ disease
Fine tremors of the hand, nervousness, weight loss, fatigue, palpitations, dyspnea, and increased heat intolerance are typical signs and symptoms of this disorder. An enlarged thyroid gland (goiter) and exophthalmos are also characteristic.
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 decreasing 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 a 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 this disease. 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 (MS)
An intention tremor that waxes and wanes may be an early sign of MS, but visual and sensory impairments are usually 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 this degenerative 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 is known as 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 remains 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 this disorder 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 encephalopathy
An intention tremor is an early sign of this thiamine deficiency. Other features include ocular abnormalities (such as gaze paralysis and nystagmus), ataxia, apathy, and confusion. Orthostatic hypotension and tachycardia may also develop.
West Nile encephalitis
This brain infection is caused by West Nile virus, a mosquito-borne flavivirus endemic in Africa, the Middle East, western Asia, and the United States. 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, and paralysis. Death rarely occurs.
Wilson’s disease
This disorder of abnormal copper metabolism produces slow “wing-flapping” tremors in the arms and pill-rolling tremors in the hands; these tremors appear early in the disease and progressively worsen. The most characteristic sign, however, is Kayser-Fleischer rings—rusty brown rings around the corneas. Other signs and symptoms include incoordination, dysarthrial chorea, ataxia, muscle spasms and rigidity, abdominal distress, fatigue, personality changes, hypotension, syncope, and seizures. Liver and spleen enlargement, ascites, jaundice, and hyperpigmentation may also occur.
Other causes
Drugs
Phenothiazines (particularly piperazine derivatives such as fluphenazine) and other antipsychotics may cause resting and pill-rolling tremors. Metoclopramide and metyrosine also cause these tremors occasionally. Lithium toxicity, sympathomimetics (such as terbutaline and pseudoephedrine), amphetamines, and phenytoin can all cause tremors that disappear when the dosage is decreased.
Herb Alert
i>Herbal products, such as ephedra (ma huang), have been known to cause serious adverse reactions, which may include tremors. (Note: The FDA has banned the sale of dietary supplements containing ephedra because they pose an unreasonable risk of injury or illness.)
Manganese toxicity
Early signs of manganese poisoning include resting tremor, chorea, propulsive gait, cogwheel rigidity, personality changes, amnesia, and masklike facies.
Mercury poisoning
The chronic form of mercury poisoning is 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 and 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.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Tremor
Read excerpts from these other book chapters related to Tremor:
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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- Tremor
- "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: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Tremor
» Next page: Asterixis [Liver flap, flapping tremor] (Professional Guide to Signs & Symptoms (Fifth Edition))
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