Tremor differential diagnosis: Difference between revisions

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[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Tremor]]
{{Tremor}}
Template:Tremor


{{CMG}}; {{AE}} {{ZMalik}}
{{CMG}}; {{AE}} {{ZMalik}}
==Overview==
==Overview==
Tremor must be differentiated from other diseases that cause [[myoclonus]], [[clonus]], [[asterixis]], and [[epilepsia partialis continua]].
Tremor must be differentiated from [[diseases]] that cause involuntary movement: [[myoclonus]], [[clonus]], [[asterixis]], and [[epilepsia partialis continua]]. The cause of tremor must also be differentiated from other conditions that cause tremor: [[essential tremor]], [[physiological tremor]], [[Parkinson's disease]], [[cerebellar]] tremor, [[orthostatic]] tremor.


OR
==Differentiating Tremor from other Diseases==
*Tremor must be differentiated from diseases that cause involuntary movement: <ref name="pmid16344298">{{cite journal| author=Bhidayasiri R| title=Differential diagnosis of common tremor syndromes. | journal=Postgrad Med J | year= 2005 | volume= 81 | issue= 962 | pages= 756-62 | pmid=16344298 | doi=10.1136/pgmj.2005.032979 | pmc=1743400 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16344298  }} </ref>
**[[Myoclonus]]: Brief [[muscle]] twitches, limited to single [[limb]] or to adjacent parts.[[EEG]] shows association with spike-wave complexes.
**[[Clonus]]: Rhythmic movement aggravated by [[muscle]] stretching.
**[[Asterixis]]: On [[electromyographic]], flapping/abduction of the [[upper extremities]] is indicated as prolong absence of [[EMG]] activity.
**[[Epilepsia partialis continua]]: Regular jerks of the arm/hand. 
*Differentiating the cause of tremor from other [[diseases]] on the basis of the type of tremor, associated [[signs]], and [[symptoms]].<ref name="pmid19750493">{{cite journal| author=Deuschl G, Elble R| title=Essential tremor--neurodegenerative or nondegenerative disease towards a working definition of ET. | journal=Mov Disord | year= 2009 | volume= 24 | issue= 14 | pages= 2033-41 | pmid=19750493 | doi=10.1002/mds.22755 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19750493  }} </ref><ref name="pmid14596441">{{cite journal| author=Smaga S| title=Tremor. | journal=Am Fam Physician | year= 2003 | volume= 68 | issue= 8 | pages= 1545-52 | pmid=14596441 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14596441  }} </ref><ref name="pmid21404980">{{cite journal| author=Crawford P, Zimmerman EE| title=Differentiation and diagnosis of tremor. | journal=Am Fam Physician | year= 2011 | volume= 83 | issue= 6 | pages= 697-702 | pmid=21404980 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21404980  }} </ref>


[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
{| class="wikitable"
 
!align="center" style="background: #4479BA; color: #FFFFFF | '''Common Cause of Tremor'''
==Differentiating [Disease name] from other Diseases==
! align="center" style="background: #4479BA; color: #FFFFFF|  '''Differentiating Feature of Tremor'''  
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
! align="center" style="background: #4479BA; color: #FFFFFF| '''Main Feature of Disease'''
 
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OR
| [[Essential tremor]] || Postural Tremor - [[Frequency]] 4–12 Hz, Bilateral onset || [[gait]] [[ataxia]], [[vestibulo-cerebellar]] involvement, reduced by [[alcohol]], [[family history]], [[stress]]/[[fatigue]] can increase tremor [[amplitude]], increases with voluntary movements
 
|-
[Disease name] must be differentiated from [differential dx1], [differential dx2], and [differential dx3].
| [[Parkinson’s disease]] || [[Resting Tremor]] - Unilateral onset || [[Bradykinesia]], [[micrographia]], [[stooped posture]], [[ataxia]], [[rigidity]], [[imbalance]], [[depression]], [[apathy]], decreases with voluntary movements
 
|-
OR
| [[Physiologic Tremor]] || Postural tremor - High [[frequency]] 8–10 Hz, low [[amplitude]], irregular oscillations || Tremor occurs while maintaining a posture and mostly disappears if [[eyes]] are closed or a load is placed on the [[muscles]]. Subtle [[innate]] tremor normally present in the general [[population]].
 
|-
As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].
| Enhanced [[Physiologic]] Tremor ||Increased [[amplitude]]  ||[[Physiologic]] tremor enhanced due to [[fatigue]], [[sleep deprivation]], [[drugs]], [[endocrine disorders]], [[caffeine]], [[stress]].
 
|-
===Differentiating [disease name] from other diseases on the basis of [symptom 1], [symptom 2], and [symptom 3]===
| [[Cerebellar]] Tremor || [[Intention tremor]] - Low [[frequency]] <4 Hz || Occurs in [[multiple sclerosis]], [[stroke]], [[brainstem]] [[tumor]], or [[cerebellar]] [[trauma]]. May feature [[ataxia]], [[dysmetria]], [[dysdiadochokinesia]], and [[dysarthria]].
 
|-
On the basis [symptom 1], [symptom 2], and [symptom 3], [disease name] must be differentiated from [disease 1], [disease 2], [disease 3], [disease 4], [disease 5], and [disease 6].
| [[Drug]] Induced Tremor || Can enhance rest, action, postural tremors || [[Amiodarone]], [[bronchodilators]], [[lithium]], [[metoclopramide]], [[neuroleptics]], [[theophylline]], [[valproate]]
{|
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|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
| [[Orthostatic]] Tremor || [[Essential tremor]] variant, high [[frequency]] 14 Hz-18 Hz|| Occurs in the [[legs]] on standing and is relieved by sitting down
! rowspan="4"  style="background: #4479BA; color: #FFFFFF; text-align: center;|Diseases
|-
| colspan="6" rowspan="1"  style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Clinical manifestations'''
|Holmes tremor || Combination of rest, action, and postural tremors, [[Frequency]] 2Hz-5Hz || Mostly due to [[vascular]] [[lesion]] in [[mesencephalic]], [[thalamic]] or both regions.
! colspan="7" rowspan="2"  style="background: #4479BA; color: #FFFFFF; text-align: center;|Para-clinical findings
| colspan="1" rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Gold standard'''
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;|Additional findings
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| colspan="3" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;|'''Symptoms'''
! colspan="3" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical examination
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! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab Findings
! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;|Histopathology
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! style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 1
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 2
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Symptom 3
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 1
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 2
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Physical exam 3
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 1
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 2
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Lab 3
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 1
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 2
! style="background: #4479BA; color: #FFFFFF; text-align: center;|Imaging 3
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 1
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 2
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 3
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|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Diseases
!Symptom 1
! colspan="1" rowspan="1" |Symptom 2
!Symptom 3
!Physical exam 1
! colspan="1" rowspan="1" |Physical exam 2
!Physical exam 3
!Lab 1
!Lab 2
!Lab 3
!Imaging 1
!Imaging 2
!Imaging 3
!Histopathology
|'''Gold standard'''
!Additional findings
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 4
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 5
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 6
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{{WH}}
[[Category:Neurology]]
{{WS}}
[[Category:Primary care]]
[[Category: (name of the system)]]
[[Category:Signs and symptoms]]
[[Category:Medicine]]

Latest revision as of 20:38, 18 February 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]

Overview

Tremor must be differentiated from diseases that cause involuntary movement: myoclonus, clonus, asterixis, and epilepsia partialis continua. The cause of tremor must also be differentiated from other conditions that cause tremor: essential tremor, physiological tremor, Parkinson's disease, cerebellar tremor, orthostatic tremor.

Differentiating Tremor from other Diseases

Common Cause of Tremor Differentiating Feature of Tremor Main Feature of Disease
Essential tremor Postural Tremor - Frequency 4–12 Hz, Bilateral onset gait ataxia, vestibulo-cerebellar involvement, reduced by alcohol, family history, stress/fatigue can increase tremor amplitude, increases with voluntary movements
Parkinson’s disease Resting Tremor - Unilateral onset Bradykinesia, micrographia, stooped posture, ataxia, rigidity, imbalance, depression, apathy, decreases with voluntary movements
Physiologic Tremor Postural tremor - High frequency 8–10 Hz, low amplitude, irregular oscillations Tremor occurs while maintaining a posture and mostly disappears if eyes are closed or a load is placed on the muscles. Subtle innate tremor normally present in the general population.
Enhanced Physiologic Tremor Increased amplitude Physiologic tremor enhanced due to fatigue, sleep deprivation, drugs, endocrine disorders, caffeine, stress.
Cerebellar Tremor Intention tremor - Low frequency <4 Hz Occurs in multiple sclerosis, stroke, brainstem tumor, or cerebellar trauma. May feature ataxia, dysmetria, dysdiadochokinesia, and dysarthria.
Drug Induced Tremor Can enhance rest, action, postural tremors Amiodarone, bronchodilators, lithium, metoclopramide, neuroleptics, theophylline, valproate
Orthostatic Tremor Essential tremor variant, high frequency 14 Hz-18 Hz Occurs in the legs on standing and is relieved by sitting down
Holmes tremor Combination of rest, action, and postural tremors, Frequency 2Hz-5Hz Mostly due to vascular lesion in mesencephalic, thalamic or both regions.

References

  1. Bhidayasiri R (2005). "Differential diagnosis of common tremor syndromes". Postgrad Med J. 81 (962): 756–62. doi:10.1136/pgmj.2005.032979. PMC 1743400. PMID 16344298.
  2. Deuschl G, Elble R (2009). "Essential tremor--neurodegenerative or nondegenerative disease towards a working definition of ET". Mov Disord. 24 (14): 2033–41. doi:10.1002/mds.22755. PMID 19750493.
  3. Smaga S (2003). "Tremor". Am Fam Physician. 68 (8): 1545–52. PMID 14596441.
  4. Crawford P, Zimmerman EE (2011). "Differentiation and diagnosis of tremor". Am Fam Physician. 83 (6): 697–702. PMID 21404980.