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Upper Limb Neuro
 
 

Tremor

 
 
 
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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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