Tremor

Tremor classification

Type	Causes
Static (resting, supported, alleviated by movement, pill rolling tremor of the hands, can also affect the head, trunk, jaw and lips)	Parkinsonism eg drugs Parkinson's disease Extrapyramidal MS	Orthostatic tremor: legs > trunk or arms, occurs when standing, improves with sitting or walking, very fast, 16-18 Hz.
Postural (in a maintained position - may also be present during movement)	Physiological Exaggerated physiological Fever Thyrotoxicosis Anxiety Drugs Caffeine Alcohol Sympathomimetics: Phenylpropanolamine, Pseudoephedrine Antidepressants: fluoxetine Sodium valproate Lithium Haloperidol, metoclopramide Theophylline Heavy metal poisoning	Structural Cerebellar lesions - Slow, action-induced tremor which may be associated with scanning speech, dysarthria, nystagmus Wilson's disease Neurosyphillis Peripheral neuropathy Benign essential tremor
Kinetic / action (active voluntary movement)	Brainstem/cerebellar MS Vascular
Psychogenic

Benign essential tremor

Kinetic tremor greater than resting tremor. May affect: hands, head, voice, legs.

Management

Alcohol: increasing amounts may be needed
Primidone: more effective than propranolol.
Propranolol or other beta blockers
Gabapentin
Benzodiazepines: limited efficacy - clonazepam, topiramate
Botulinum toxin: helps voice and head tremor
Surgical: thalamotomy, thalamic stimulation

Parkinson's disease and parkinsonism

Initial presentation

70% tremor, 20% stiffness or slowness of movement
13% loss of dexterity or handwriting disturbance (e.g. micrographia)
12% gait disturbance
8% muscle pain/cramps/aching
1-5% other (depression, nervousness, psychiatric disturbance, speech disturbances, drooling, dysphagia.
20% have no tremor but need to consider other diagnoses, especially supranuclear palsy.

Brad Cheek: last updated Dec 2006
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