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Tremor-Assessment

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Tremor-Assessment

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Tremor is an involuntary , rhythmic , oscillatory movement of a body part. Tremor results from contractions of agonist and antagonist muscles 
entrained by a signal pattern originating from an oscillator in the CNS 
( International Parkinson and Movement Disorder Society )

Background- Most common movement disorder Generally affects the upper extremities but can also affect the head , chin , voice or legs It can manifest as an isolated symptom or as a sign of another neurological pathology Diverse etiology e.g
◘ essential tremor – 50 % have + ve FH but no single gene identified
◘ part of genetic disorder e.g Wilson’s dis
◘ degenerative disorders as Parkinson’s disease
◘ metabolic disturbance as thyroid , para-thyroid , liver dis , hypoglycemia
◘ peripheral neuropathies e.g Charcot-Marie-Tooth 
◘ drug induced
◘ toxins
◘ psychogenic / functional disorders It is possible to see patients with more than 1 type of tremor 
( e.g mixed rest and action tremor components ) Most common tremors seen in primary care are
◘ enhanced physiological tremor
◘ essential tremor ( most common pathological tremor )
◘ parkinsonian tremor Most patients have mild symptoms and can be reassured

Management of tremor will depend on the underlying cause. 
Identification of tremor type is valuable for diagnosis , prognosis and 
treatment
 Modality / activity in which tremor happens e.g rest / action Anatomic distribution Frequency ( e.g 3-5 Hz , 8-10 Hz ) Amplitude Exacerbating or alleviating factors Associated symptoms

Rest tremor – Tremoring body part is completely supported against gravity without voluntary muscle contraction. Low to medium frequency ( 3-6 Hz ) High amplitude – reduced with target directed movements Happens when limb is supported against gravity with muscles not activated Seen with
◘ parkinson’s disease
◘ drugs
◘ vascular midbrain lesions
◘ severe essential tremor Idiopathic PD is the most common 
cause of a resting tremor

Action tremor A tremor that emerges during voluntary muscle contraction Postural tremor -happens when a posture is maintained against gravity e.g physiological tremor
essential tremor , drug induced tremor ,dystonic , cerebellar
 Kinetic tremor -occurs during voluntary movement includes
◘ task-specific tremor
◘ intention tremor- tremor that is specific to goal directed movements
Action tremors often both postural and kinetic
 Isometric ( uncommon ) occurs as a result of muscle contraction against a rigid stationary object


Questions – Onset ( sudden or gradual ) age of onset ( if < 40 think of Wilson’s disease ) progression over time intermittent or constant when does it happen relieving and exacerbating factors how long present which part of the body affected functional impairment – how does it affect daily life e.g writing , cup holding , using the phone does the tremor happen only with one specific task ? family history ( imp if essential tremor is suspected ) occupation social history ? alcohol – withdrawal
drug abuse e.g amphetamine abuse caffeine intake medication- check complete list incl OTC medications associated symptoms – particularly to look for parkinsonian symptoms like speech disturbance , gait , facial expression

Drugs which can cause tremor –Amiodarone , Alcohol , Amphetamines Salbutamol, salmeterol sodium valporate Tamoxifen Theophylline Thyroxine Nifedipine Neuroleptics Prochlorperazine Metoclopramide Neuroleptics and dopamine depleters Valporic acid Lamotrigine Lithium Tricyclic antdepressants MAO inhibitors Caffeine

Differential –Parkinsons disease Lewy body dementia Enhanced physiological tremor Hypoglycemia Thyrotoxicosis Drug withdrawal e.g alcohol , benzodiazepines Drug induced tremor Essential tremor Psychogenic tremor

Observe – which body part symmetry activation condition- when is it actually present and gets worse frequency ( fast / slow ) regularity ( regular / jerky ) amplitude ( fine / coarse ) any leg tremors voice tremor

Examine – arms resting on lap extending in front of body- straight outstretched , extended at elbows and fingers spread apart wing-beating position ( see image ) finger- nose test heel to shin toe-to-finger holding a cup with water or pour from one cup to another get up and put both hands on leg drawing a spiral / writing . Full neurological exam Cranial N exam Test cerebellar function- test eye movements Sensory exam Gait / Balance / Muscle tone Tongue movements -fasciculations / slowness Reflexes Speech Inspect the head for any tremor / abnormal position/ lateral shift etc for torticollis
If tremor present look for dystonic posturing Systemic signs ? excessive sweating / wt loss/ palpitations ( thyroid )

Investigations – FBC , U/Es ,LFT, bone profile ,
TFT , Bl glucose , B12 , 

Ceruloplasmin / 24 hr urinary copper 
( if Wilson’s dis suspected ) Toxicology screen Drug levels EMG- electromyography Coherence analysis ( EMG-EEFG ) Somatosensory evoked potential measurements PET or SPECT Acute levadopa challenge test Trascranial sonography MRI Genetic testing ( Fragile X tremor ataxia syndrome )

Red flags- Tremor in children- can be potentially serious & poorly understood- refer promptly Sudden onset and progressive tremor Early onset e.g
< 40 consider testing for Wilson’s disease
< 50 with no family h/o ETr Early hallucinations , cognitive decline ( dementia with Lewy bodies ) Early autonomic symptoms e.g
orthostatic hypotension , erectile dysfunction , bladder disturbance , odd nocturnal breathing pattern ? Multiple System Atrophy Alcohol withdrawal Hypoglycemia Thyrotoxicosis Phaechromocytoma Cerebellar tremor or stepwise tremor ( r/o stroke )

Diagnosis not clear You suspect and treat ET with beta blockers – no response or
symptoms disabling Parkinsons disease is suspected Other asymmetric tremor or Tremor associated with stiffness , slowness , balance problems or gait disorders Focal neurology Troublesome tremor of the head Any red flag

Wilson’ s disease – rare 
tremor with wing beating 
pattern ( arms abducted at shoulders , 
elbows bent ) which presents under
 40 yrs of age. Ceruloplasmin levels < 50 mg/l is a strong indicator, abnormal
 LFTs and Kayser- Fleischer rings 
in eyes are important 
associations

Enhance physiological tremor- Low amplitude , slight , usually b/l postural or kinetic action tremor – particularly in hands and fingers is normal can be seen by holding a piece of paper on an outstretched hand ↑↑ by anxiety , stress , work , exercise , caffeine does not interfere with daily life normal neurological exam and absence of a neurological disease when seen possible associations as thyrotoxicosis , Cushing’s syndrome , hypoglycemia , alcohol withdrawal and drugs – should be excluded beta blockers can be used in trouble some cases

Orthostatic tremor –Unusual and unique – sufferers feel unsteadiness during standing rather than tremor per se ie tremor of lower limbs Lifting the standing patient off the ground abolishes the tremor High frequency Absent during rest

Dystonic tremor-Postural and kinetic tremor in an extremity or body part affected by dystonia Often jerky , irregular and variable depending upon posture and activity- can be quite disabling if upper limbs are involved e.g tremulous spasmodic torticollis

Holmes tremor –Due to lesions in the brainstem , cerebellum or thalamus Postural or action in nature- worsen during movement and markedly increase during goal directed movements Can be confused with Parkinsonian tremor

Psychogenic tremor-Abrupt onset , spontaneous remission , relief with distraction and changing tremor pattern Does not involve fingers Multiple somatization and clinical inconsistencies

References- Process Tremor : Clinical Phenomenology and Assessment Techniques Christopher W. Hess et al Tremor and Other Hyperkinetic Movements https://www.tremorjournal.org The Center for Digital Research and Scholarship Columbia University Libraries/ Information Services BMJ Best Practice Assessment of tremor Diagnosis and Treatment of Common Forms of Tremor Andreas Puschmann MD et al Semin Neurol , Mayo Clinic , Jacksonville , Florida 10-Minute Consultation Tremor BMJ 2013;347:f7200 My hands shake Classification and treatment of tremor Dharshana Srisena Differential diagnosis of common tremor syndromes R Bhidayasiri Postgraduate Medical Journal 2005; 81:756-762 NICE Suspected neurological conditions : recognition and referral May 2019 A Clinical approach to tremor Dilip Kumar Jha , Anupam Kumar Singh Chapter 19 How to tackle tremor – systematic review of the literature and diagnostic work-up A.W.G Buijink et al Review Article Frontiers in Neurology October 2012 Diagnosis and Management of Tremor Habib-ur-Rahman MRCP American Medical Association 2000 Tremor : Sorting Through the Differential Diagnosis Paul Crawford M.D et al American Family Physician 2018

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