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Tremor SHARON SMAGA, M.D., Southern Illinois University School of Medicine, Carbondale, Illinois

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Tremor SHARON SMAGA, M.D., Southern Illinois University School of Medicine, Carbondale, Illinois PROBLEM-ORIENTED DIAGNOSIS Tremor SHARON SMAGA, M.D., Southern Illinois University School of Medicine, Carbondale, Illinois Tremor, a rhythmic, involuntary, oscillatory movement of body parts, is the most com- mon movement disorder. Tremors are classified as rest or action tremors. Rest tremor O A patient informa- occurs when the affected body part is completely supported against gravity. Action tion handout about essential tremor, writ- tremors are produced by voluntary muscle contraction and are further divided into ten by the author of postural, isometric, or kinetic tremors. This article describes clinical signs and symp- this article, is provided toms of six tremor syndromes, including physiologic tremor, essential tremor, Parkin- on page 1553. son’s disease, toxic and drug-induced tremor, cerebellar tremor, and psychogenic tremor, and presents a detailed diagnostic approach to tremor. Although new tech- nologies such as positron emission tomography and single photon emission computed tomography are under investigation for possible use in diagnosing specific tremor syn- dromes, they have no widespread applicability or use at this time. The history and physical examination remain the most important diagnostic tools available to clini- cians in identifying and classifying tremor syndromes. (Am Fam Physician 2003;68: 1545-52,1553. Copyright© 2003 American Academy of Family Physicians.) Members of various remor—a rhythmic, involun- into postural, isometric, or kinetic tremors. family practice depart- tary, oscillatory movement of Postural tremor occurs when the affected ments develop articles body parts1—is the most com- body part maintains position against gravity for “Problem-Oriented 2 Diagnosis.” This article mon movement disorder. The (e.g., extending arms in front of body). Iso- is one in a series coor- diagnosis is based on a careful metric tremor results from muscle contrac- dinated by the Depart- Tassessment of the history and physical exami- tion against stationary objects (e.g., squeezing ment of Family Medi- nation, although some tests, including the examiner’s fingers). Kinetic tremor, which cine at the Southern positron emission tomography (PET) and occurs with voluntary movement, is either Illinois University School of Medicine, single photon emission computed tomogra- simple kinetic tremor or intention tremor. Springfield, Illinois. phy (SPECT), are being investigated as diag- Simple kinetic tremor is associated with Guest editor of the nostic aids.2-5 This article reviews the classifi- movement of extremities (e.g., pronation- series is John G. cation and causes of tremor and provides supination or flexion-extension wrist move- Bradley, M.D. evaluation guidelines. ments). Intention tremor occurs during visu- ally guided movement toward a target (e.g., Classification finger-to-nose or finger-to-finger testing), Tremors are classified as rest or action with significant amplitude fluctuation on tremors. Rest tremor occurs when the affected approaching the target2 (Table 1).1,6 body part is completely supported against grav- Although this classification helps in deter- ity (e.g., hands resting in the lap). Amplitude mining cause, the presentation of tremor syn- increases during mental stress (e.g., counting dromes varies. Other aspects of the history backwards) or with general movement (e.g., and physical examination should be consid- walking) and diminishes with target-directed ered when evaluating patients with tremor. movement (e.g., finger-to-nose test).1,2,6 Action tremors are produced by voluntary Tremor Syndromes muscle contraction. They are further divided PHYSIOLOGIC TREMOR All normal persons exhibit physiologic tremor, a benign, high-frequency, low-ampli- All normal persons exhibit physiologic tremor, a benign, tude postural tremor. Usually invisible to the naked eye, it can be amplified by holding a high-frequency, low-amplitude postural tremor. piece of paper on the outstretched hand or pointing a laser at a distant screen.1,2 Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2003 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. kinetic component.1 It is the most common Essential tremor is the most common movement disorder in movement disorder worldwide; prevalence the world, ranging from 4.1 to 39.2 cases per 1,000 persons ranges from 4.1 to 39.2 cases per 1,000 per- sons, to as high as 50.5 per 1,000 in persons younger than 60 years. older than 60 years.8 These figures may underestimate the true prevalence, however, because up to 50 percent of persons with mild Enhanced physiologic tremor is a visible, essential tremor are unaware of it.9 Reports of high-frequency postural tremor that occurs in family history vary widely, with 21.7 percent the absence of neurologic disease and is of patients in one study9 and 62 percent in caused by medical conditions such as thyro- another study10 reporting a family history of toxicosis, hypoglycemia, the use of certain tremor. drugs, or withdrawal from alcohol or benzo- Essential tremor develops insidiously and diazepines. It is usually reversible once the progresses slowly, presenting as a postural, cause is corrected1,2 (Table 2).6,7 distal arm tremor in 95 percent of patients. Onset peaks bimodally in the teens and 50s. ESSENTIAL TREMOR The tremor may start in a single limb, but it Essential tremor is a visible postural tremor becomes bilateral over time, most often as a of hands and forearms that may include a flexion-extension movement of the wrist with TABLE 1 Classification and Characteristics of Tremor Type of tremor Frequency Amplitude Occurrence Examples Rest tremor Low to medium High; decreases with Limb supported against Parkinson’s disease; drug-induced (3 to 6 Hz) target-directed gravity; muscles are not parkinsonism (neuroleptics; movement activated metoclopramide [Reglan]) Action tremor — — Any voluntary muscle contraction Postural tremor Medium to high Low; increases with Limb maintains position Physiologic tremor; essential (4 to 12 Hz) voluntary movement against gravity tremor; metabolic disturbance; drug or alcohol withdrawal Kinetic tremor Simple kinetic Variable (3 to Does not change with Simple movements of — 10 Hz) target-directed the limb movement Intention Low (< 5 Hz) Increases with target- Target-directed movement Cerebellar lesion (stroke, multiple directed movement sclerosis, tumor); drug-induced (lithium, alcohol) Isometric tremor Medium Variable Muscle contraction against Holding a heavy object in stationary objects one hand Task-specific Variable (4 to Variable Occurs with specific action Handwriting tremor; musician’s tremor 10 Hz) tremor Information from references 1 and 6. 1546 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 68, NUMBER 8 / OCTOBER 15, 2003 Tremor TABLE 2 Potential Effects of Drugs on Physiologic Tremor May exacerbate physiologic tremor May reduce physiologic tremor Amphetamines Lithium Alcohol Beta-adrenergic agonists Methylphenidate (Ritalin) Benzodiazepines (albuterol [Proventil]) Pseudoephedrine Beta-adrenergic antagonists Caffeine Terbutaline sulfate (Brethine) (propranolol [Inderal]) Carbamazepine (Tegretol) Theophylline Primidone (Mysoline) Epinephrine Thyroid hormones Fluoxetine (Prozac) Tricyclic antidepressants Haloperidol (Haldol) Valproic acid (Depakene) Hypoglycemic agents Information from references 6 and 7. a frequency of 4 to 12 Hz. It may involve the tural reflexes are examined by the pull test: the head, appearing as a yes-yes or no-no head patient stands with arms hanging loosely at movement. Amplitude increases with stress, the sides; from behind, the examiner holds the fatigue, and certain medications such as cen- patient’s upper arms just under the shoulders tral nervous system stimulants, and may and gently pulls backward; if the patient increase with certain voluntary activities such begins to fall, postural instability is indicated12 as holding a fork or cup. Rest, beta blockers, (Table 3).16 primidone (Mysoline), and alcohol ingestion decrease the tremor.2,10,11 CEREBELLAR TREMOR Cerebellar tremor presents as a unilateral or PARKINSON’S DISEASE bilateral, low-frequency (less then 5 Hz) inten- Parkinson’s disease (PD) is 20 times less tion tremor caused by stroke, brainstem tumor, common than essential tremor.8 Nevertheless, or multiple sclerosis.2,17 It may include postural approximately 1 million Americans have PD.12 tremor.1 Classically, cerebellar lesions produce Because specific treatment options are avail- able, accurate diagnosis is essential.2,6,12,13 Symptoms develop insidiously, often after TABLE 3 age 50, although early-onset disease may Comparison of Essential Tremor and Parkinson’s Disease appear in the 20s.13 Initial symptoms include resting tremor beginning distally in one arm Clinical features Parkinson’s disease Essential tremor at a 4- to 6-Hz frequency. Typically, the tremor Age at onset > 50 years Bimodal: teens and 50s is a flexion-extension elbow movement, a Gender Men more than women Men and women equal pronation-supination of the forearm, or a pill-rolling finger movement. It worsens with Family history > 25 percent > 90 percent stress and diminishes with voluntary move- Asymmetry Affects ipsilateral limbs Often symmetric ment. It may have postural or kinetic compo- at first nents.2,12 However, 10 to 20 percent of patients Character At rest Postural, kinetic have no tremor during the course of PD.2,14 Frequency 4 to 6 Hz 4 to
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