Tremor resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usman Ali Akbar, M.B.B.S.[2]

Synonyms and Keywords: Approach to tremors, Approach to movement disorders, Approach to Resting Tremors, Approach to Essential Tremors.

Tremor resident survival guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

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.

Causes

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.[1]

Causes of Tremors
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.[2]

Causes :


Rest tremor presents as the affected body part fully supported against gravity. It occurs at rest and can be abolished during voluntary activity.[3]


Causes :

Intention tremors can be characterized by a crescendo increase in tremor as the affected body part approaches its target.[4]


Causes :

  • Drug-induced
  • Cerebellar lesions:
Neuropathic tremor:

Chronic relapsing polyneuropathy

Guillain-Barré syndrome

Diabetes

•IgM neuropathy

Holmes' tremor (midbrain, red nucleus, rubral, or thalamic tremor)

Other

Psychogenic tremor

Wilson's disease

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.[5]

Physiological Tremor: Physiological tremor is a fine, rapid (8–13 Hz) tremor that occurs in otherwise healthy people.[6]



FIRE: Focused Initial Rapid Evaluation

  • A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention.[3]

Boxes in red signify that an urgent management is needed.

 
 
 
Paitent presenting with new-onset tremors
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the tremor physiological in nature?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out anxiety, Excessive Caffeine intake,blood glucose level,thyroid function tests
 
 
 
Medication Associated Tremor?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Trial off medication
 
 
 
Relieved by distraction?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Psychiatric Evaluation
 
 
 
Rule out Organic Cause

Diagnosis

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the American Academy of Neurology guidelines.[3] [7]

 
 
 
Patiet with history of tremor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History

•Ask about age of onset
•The involved body regions
•Any precipitating or supressing factor?
•Is the patient aware of thetremor?
•Any pain associated with tremors?
•Any neurological deficits?
•Are any medications being taken for tremor?
•Use of any caffeinated products
•History of diarrhea , weight loss or heat intolerance

•Is there any family history of tremor?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neurological Examination
Focused Neurological Examination should be conducted and following features should be assessed.

• Are the movements recurrent and oscillatory?
• Which joints are involved in the movements?
• Does the tremor in each arm occur in phases?
• IS the tremor has an emergent quality?
• Does the tremor occurs in flexed posturing or dystonic posturing?
• Is the tremor increases or decreases while performing a task?

Assessment of the following features should be done

• Does the tremor worsen when approaching a target?
• What is the severity and frequency of the tremor?
Postural & Kinetic tremor are best exhibited with arms held outstretched.
• Abnormal posturing of the tremor in fingers, hand, or upper limb is required to rule out dystonic tremor.
Functional tremor vary in frequency and amplitude.

Parkinsonian tremor is exhibited by repetitive movements of the contralateral hand during walking.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Laboratory Investigations

•Laboratory evaluation should include
• Thyroid Function Test
• Serum copper and ceruloplasmin levels to exclude Wilson disease
• Screening for heavy metal poisoning
Blood Glucose level to rule out hypoglycemia
• Blood tests to rule out pheochromocytoma
Essential tremor and Parkinsonian tremor can be differentiated with the help of striatal dopamine transporter imaging (DaTscan)
• MRI to exclude rubral or Holmes tremor

• Quantitative computerized analysis of tremor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Age less than 40 years
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 

Treatment

Shown below is an algorithm summarizing the treatment of Tremors according to the American Academy of Neurology guidelines.[3]

 
 
 
 
 
 
 
 
Type of Tremor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rest Tremor
 
Enhanced Physiological Tremor
 
Essential Tremor
 
Orthostatic Tremor
 
Cerebellar Tremor
 
Rubural Tremor
 
Dystonic Tremor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rest Tremor
 
Enhanced Physiological Tremor
  • Removal of the offending agent
  • Treatment of underlying endocrine disorders such as hyperthyroidism
  • Propranolol should be taken in situations that can exacerbate these tremors.[10]
  •  
    Essential Tremor
  • Essential tremor can be treated with propranolol and primidone.[11]
  • Refractory conditions can be treated with agents such as topiramate and gabapentin.
  • Medically Refractory ET can be treated with Deep brain stimulation.
  •  
    Orthostatic Tremor
  • Orthostatic Tremor can be treated with benzodiazepines e.g, clonazepam.[12]
  • Deep brain stimulation has shown modest improvement in some studies
    .[9]
  •  
    Cerebellar Tremor
  • Deep brain stimulation of the ventral intermediate nucleus of the thalamus can be helpful in some cases.
  •  
    Rubural Tremor Rubral tremors can sometimes be treated with levodopa therapy. [13]
     
    Dystonic Tremor Dystonic tremors can be treated with botulinum toxin injections into affected muscles. [14]

    Do's

    • 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 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.[15]
    • Stress and anxiety can also worsen tremors. Deep breathing exercises and meditation can help reduce stress and anxiety levels.

    Don'ts

    • Caffeine, ma huang, ephedra, and drugs that can increase heart rate should be avoided as they can cause a temporary increase in tremor.[15]
    • Patients should be advised to write in small letters than large letters.[15]
    • Patients should be advised to use light-weight cups.
    • Dental visits should be conducted with adrenaline-free anesthesia shots.

    References

    1. 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 |pmc= value (help). PMID 29193359. Check date values in: |year= / |date= mismatch (help)
    2. "Tremor Fact Sheet". National Institute of Neurological Disorders and Stroke. 2020-03-17. Retrieved 2020-09-30.
    3. 3.0 3.1 3.2 3.3 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.
    4. Pal, PramodKumar; Kamble, Nitish (2018). "Tremor syndromes: A review". Neurology India. Medknow. 66 (7): 36. doi:10.4103/0028-3886.226440. ISSN 0028-3886.
    5. 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.
    6. 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.
    7. 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.
    8. 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 |pmid= value (help).
    9. 9.0 9.1 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.
    10. "Tremor". Therapeutische Umschau. Revue therapeutique (in Deutsch). Hogrefe Publishing Group. 64 (1): 35–40. 2007-01-01. doi:10.1024/0040-5930.64.1.35. ISSN 0040-5930. PMID 17221823.
    11. 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: |year= / |date= mismatch (help)
    12. 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.
    13. 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.
    14. Deuschl, G (2003). "Dystonic tremor". Revue neurologique. 159 (10 Pt 1): 900–5. ISSN 0035-3787. PMID 14615679.
    15. 15.0 15.1 15.2 "Coping Tips for Everyday Living". Essential Tremor. 2020-08-06. Retrieved 2020-09-30.

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