Tremor
February 15th, 2021
Overview
Look For
- Rhythmic, involuntary vibration of one or more body parts. Note whether the tremor is worse with movement and whether it increases with target-directed movement (increases on approaching a target).
Resting Tremor
Look For
- Tremor while at rest, that decreases with target-directed movement.
The tremor of Parkinsonism is classically pill-rolling, meaning that the thumb and forefinger and rubbed together, at a rate of 3-6hz.
Significance
- Resting tremor is associated with Parkinsonism, either in the setting of Parkinson's disease or secondary causes.
Causes of Parkinsonism
- Parkinson's disease - Parkinsonism, anosmia, REM sleep behavioural disturbance, frontal executive dysfunction, depression
- Parkinson's plus syndromes - progressive supranuclear palsy (PSP), multiple systems atrophy (MSA), dementia with Lewy bodies (DLB), corticobasal degeneration (CBD)
- Drugs - antipsychotics, metoclopramide, lithium
- Normal pressure hydrocephalus
- Hypoxic brain injury
- Wilson's disease
Postural Tremor
Look For
- Tremor that increases with voluntary muscle contraction, but does not increase with target-directed movement.
Causes of Postural Tremor
- Physiologic tremor
- Essential tremor
- Metabolic disturbances
- Drug induced - alcohol, amphetamine, caffeine, beta agonists, lithium, steroids, thyroxine, TCAs, valproate
- Withdrawal - alcohol, benzodiazepines, opioids
Intention Tremor
Look For
- Tremor that increases with target-directed movement.
This is best demonstrated with the finger-nose test, where the patient is asked to use their index finger to touch their nose and then your finger. Their finger will tremor increasingly as it approaches its target.
Significance
- Cerebellar disease in the form of stroke, tumour or multiple sclerosis.
Psychogenic Tremor
Look For
- Variable tremor that disappears when not under direct observation.
Ask the patient to tap a beat with the unaffected limb. A tremor that decreases or aligns with the frequency of the tapping is likely to be psychogenic.
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