Tremor resident survival guide
Synonyms and keywords: Approach to tremors, Approach to movement disorders, Approach to Resting Tremors, Approach to Essential Tremors.
|Tremor resident survival guide Microchapters|
Tremor can be defined as involuntary, rhythmic, and oscillatory movement of the concerned body parts which can be caused by alternating or synchronous contractions of antagonistic muscles. Tremors have a broad etiology and can have overlapping characteristics. Classification and diagnosis of tremors is usually based on history, tremor frequency, severity, associated neurological signs, or sometimes a family history. Diagnosing the type and etiology of the tremor is important as prompt treatment can improve the quality of life in patients. Treatment is most of the time based on the etiologies but sometimes isolated tremors can be treated by certain medications.
The causes of tremor are vast and overlapping in nature.According to the International Parkinson and Movement Disorder Society tremors can be classified on the base of etiological agents as follows.
|Postural Tremors||Resting Tremors||Intention Tremors||Complex Tremors|
|Postural tremors can occur when the patient maintains a specific posture such as holding the arms outstretched or while standing.
|Rest tremor presents as the affected body part fully supported against gravity. It occurs at rest and can be abolished during voluntary activity.
||Intention tremors can be characterized by a crescendo increase in tremor as the affected body part approaches its target.
|Essential Tremors: Essential tremor is usually progressively persistent coarse or fine, slow (4–8 Hz) tremor. It is usually symmetric and affecting both upper extremities and sometimes the head and voice. A family history of ET is usually present.
Physiological Tremor: Physiological tremor is a fine, rapid (8–13 Hz) tremor that occurs in otherwise healthy people.
FIRE: Focused Initial Rapid Evaluation
- A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention.
Boxes in red signify that an urgent management is needed.
|Paitent presenting with new-onset tremors|
|Is the tremor physiological in nature?|
|Rule out anxiety, Excessive Caffeine intake,blood glucose level,thyroid function tests||Medication Associated Tremor?|
|Trial off medication||Relieved by distraction?|
|Psychiatric Evaluation||Rule out Organic Cause|
|Patiet with history of tremor|
•Ask about age of onset
Focused Neurological Examination should be conducted and following features should be assessed.
• Are the movements recurrent and oscillatory?
Assessment of the following features should be done
• Does the tremor worsen when approaching a target?
•Laboratory evaluation should include
|Age less than 40 years|
|Serum Ceruloplasmin level and 24 hour urinary copper secretion||Rest or action tremor ?|
|YES||NO||Rest tremor + Signs of Parkinsonism ( Rigidity,bradycardia,postural instability?)||Action tremor ?|
|Wilson's Disease||Neurogical Signs/Symptoms?||Parkinsonism||Alcohol Use Disorder?|
|If present, evaluate for metabolic,genetic or anatomic abnormalities with brain imaging.||IF No, it is likely Essential tremor.||Withdrawal or Alcohol tremor||Postural/Intentional tremor?|
|Postural Essential Tremor||Intentional Cerebellar tremor|
Shown below is an algorithm summarizing the treatment of Tremors according to the American Academy of Neurology guidelines.
|Type of Tremor|
|Rest Tremor||Enhanced Physiological Tremor||Essential Tremor||Orthostatic Tremor||Cerebellar Tremor||Rubural Tremor||Dystonic Tremor|
||Enhanced Physiological Tremor
||Rubural Tremor Rubral tremors can sometimes be treated with levodopa therapy. ||Dystonic Tremor Dystonic tremors can be treated with botulinum toxin injections into affected muscles. |
- Treatment of underlying disorder should be the primary approach.
- Some medications or drugs can exacerbate tremors. Patients should avoid those drugs and should not use them unless prescribed by the physician.
- Most tremors sometimes don't have a cure developed yet. Patients should be counseled about the disease, treatment, and prognosis of the disease.
- Sleep can affect some tremors. Getting enough sleep hours can reduce the frequency and severity of some tremors.
- Stress and anxiety can also worsen tremors. Deep breathing exercises and meditation can help reduce stress and anxiety levels.
- Caffeine, ma huang, ephedra, and drugs that can increase heart rate should be avoided as they can cause a temporary increase in tremor.
- Patients should be advised to write in small letters than large letters.
- Patients should be advised to use light-weight cups.
- Dental visits should be conducted with adrenaline-free anesthesia shots.
- Bhatia, Kailash P.; Bain, Peter; Bajaj, Nin; Elble, Rodger J.; Hallett, Mark; Louis, Elan D.; Raethjen, Jan; Stamelou, Maria; Testa, Claudia M.; Deuschl, Guenther (2017-11-30). "Consensus Statement on the classification of tremors. from the task force on tremor of the International Parkinson and Movement Disorder Society". Movement disorders : official journal of the Movement Disorder Society. Wiley. 33 (1): 75–87. doi:10.1002/mds.27121. ISSN 0885-3185. PMC 65305521029322 Check
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- "Tremor Fact Sheet". National Institute of Neurological Disorders and Stroke. 2020-03-17. Retrieved 2020-09-30.
- Louis, Elan D. (2019). "Tremor". Continuum (Minneapolis, Minn.). Ovid Technologies (Wolters Kluwer Health). 25 (4): 959–975. doi:10.1212/con.0000000000000748. ISSN 1080-2371. PMID 31356289.
- Pal, PramodKumar; Kamble, Nitish (2018). "Tremor syndromes: A review". Neurology India. Medknow. 66 (7): 36. doi:10.4103/0028-3886.226440. ISSN 0028-3886.
- Miskin, Chandrabhaga; Carvalho, Karen S. (2018). "Tremors: Essential Tremor and Beyond". Seminars in pediatric neurology. Elsevier BV. 25: 34–41. doi:10.1016/j.spen.2018.02.002. ISSN 1071-9091. PMID 29735115.
- McAuley, J. H. (2000-08-01). "Physiological and pathological tremors and rhythmic central motor control". Brain. Oxford University Press (OUP). 123 (8): 1545–1567. doi:10.1093/brain/123.8.1545. ISSN 1460-2156.
- Crawford, Paul F. (2018-02-01). "Tremor: Sorting Through the Differential Diagnosis". American Family Physician. 97 (3): 180–186. ISSN 0002-838X. Retrieved 2020-09-30.
- Armstrong, Melissa J.; Okun, Michael S. (2020-02-11). "Diagnosis and Treatment of Parkinson Disease". JAMA. American Medical Association (AMA). 323 (6): 548. doi:10.1001/jama.2019.22360. ISSN 0098-7484. PMID 32044947 Check
- Beudel, M.; Brown, P. (2016). "Adaptive deep brain stimulation in Parkinson's disease". Parkinsonism & related disorders. Elsevier BV. 22: S123–S126. doi:10.1016/j.parkreldis.2015.09.028. ISSN 1353-8020. PMC 4671979. PMID 26411502.
- "Tremor". Therapeutische Umschau. Revue therapeutique (in Deutsch). Hogrefe Publishing Group. 64 (1): 35–40. 2007-01-01. doi:10.1024/0040-5918.104.22.168. ISSN 0040-5930. PMID 17221823.
- Sharma, Soumya; Pandey, Sanjay (2019-10-01). "Treatment of essential tremor: current status". Postgraduate medical journal. BMJ. 96 (1132): 84–93. doi:10.1136/postgradmedj-2019-136647. ISSN 0032-5473. PMID 31575730. Check date values in:
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- Ure, Robert J; Dhanju, Sanveer; Lang, Anthony E; Fasano, Alfonso (2016-03-16). "Unusual tremor syndromes: know in order to recognise". Journal of neurology, neurosurgery, and psychiatry. BMJ. 87 (11): 1191–1203. doi:10.1136/jnnp-2015-311693. ISSN 0022-3050. PMID 26985048.
- Sveinbjornsdottir, Sigurlaug (2016-07-11). "The clinical symptoms of Parkinson's disease". Journal of neurochemistry. Wiley. 139: 318–324. doi:10.1111/jnc.13691. ISSN 0022-3042. PMID 27401947.
- Deuschl, G (2003). "Dystonic tremor". Revue neurologique. 159 (10 Pt 1): 900–5. ISSN 0035-3787. PMID 14615679.
- "Coping Tips for Everyday Living". Essential Tremor. 2020-08-06. Retrieved 2020-09-30.