Tremor resident survival guide: Difference between revisions

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!Complex Tremors
!Complex Tremors
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|Postural tremor occurs when the patient maintains a specific posture such as holding the arms outstretched or while standing.
|Postural tremors can occur when the patient maintains a specific posture such as holding the arms outstretched or while standing.
'''Causes :'''  
'''Causes :'''  


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Wilson's disease
Wilson's disease
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|'''Essential Tremors''': Essential tremor Progressively persistent coarse or fine, slow (4–8 Hz) tremor, usually symmetric and affecting both upper extremities and sometimes the head and voice, particularly in patients with a family history of tremor
|'''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''':Fine, rapid (8–13 Hz) tremor that occurs in otherwise healthy people and may be enhanced by certain drugs or conditions
'''Physiological Tremor''': Physiological tremor is a fine, rapid (8–13 Hz) tremor that occurs in otherwise healthy people.


Usually, suppression of tremor with low doses of alcohol and other sedatives
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Revision as of 12:49, 29 September 2020


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:

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

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

The causes of tremor are vast and overlapping in nature.

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.

Causes :

  • Alcohol & drug withdrawal
  • Metabolic causes
  • Parkinson disease
  • Parkinsonian syndromes
  • Midbrain (rubral) tremor
  • Wilson disease
  • Severe essential tremor


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


Causes :

  • Progressive supranuclear palsy
  • Drug-induced parkinsonism
  • Parkinson's disease
characterized by a crescendo increase in tremor as the affected body part approaches its target


Causes :

  • Drug-induced
  • Cerebellar lesions:
  • Friedreich's ataxia
  • Hemorrhage
  • Multiple sclerosis
  • Spinocerebellar degeneration
  • Stroke
  • Tumor
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.

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?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out anxiety, Excessive Caffine 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.

 
 
 
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 the tremor?
•Any pain associated with tremors?
•Any neurological deficits?
•Are any medications being taken for tremors?
•Use of any caffeinated products
•History of diarrhea , weight loss or heat intolerance

•Is there any family history of tremors?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 tremors 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 tremors are best exhibited with arms held outstretched.
• Abnormal posturing of the tremors 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 Tests
• 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 Disease
 
Neurogical Signs/Symptoms?
 
 
Parkinsonism
 
Alcohol Use Disorder?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If present, evaluatte for metabolic,genetic or anatomic abnormalities with brain imaging.
 
IF No, it is likely Essential tremor.
 
 
Withdrawl or Alcohol tremor
 
Postural/Intentional Tremor?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Postural Essential Tremor
 
Intentional Cerebellar Tremor
 
 

Treatment

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

 
 
 
 
 
 
 
 
Type of Tremor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rest Tremor
 
Enhanced Physiological Tremor
 
Essential Tremor
 
Orthostatic Tremor
 
Cerebellar Tremor
 
Rubural Tremor
 
Dystonic Tremor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rest Tremor
  • Resting Tremors is associated with Parkinson's disease and other movement disorders.
  • Management Depends upon treating the underlying disorders.
  • Drugs used for Parkinson's such as amantadine, dopamine agonists, levodopa are used.
  • Tremors refractory to these interventions can be treated with deep brain stimulation
 
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.
  •  
    Essential Tremor
  • Essential tremor can be treated with propranolol and primidone.
  • 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.
  • Deep brain stimulation has shown modest improvement in some studies.
  •  
    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
     
    Dystonic Tremor Dystonic tremors can be treated with botulinum toxin injections into affected muscles.

    Do's

    • The content in this section is in bullet points.

    Don'ts

    • The content in this section is in bullet points.

    References

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