Tremor

Introduction

A tremor is an involuntary repetitive movement of part of the body – most commonly the hands. Tremor is a common presenting complaint to general practice. Defining the features of the tremor can help to narrow down the diagnosis. In particular knowing if the tremor is worse at rest or during action, and if there are any other neurological features can help to make the diagnosis. The most common type of tremor is essential tremor (ET).

There are may possible cases of tremor including:

• Essential tremor
• Parkinson’s disease
• Cerebellar
• Physiological
  • Alcohol withdrawal is a type of enhanced physiological tremor
• Hyperthyroidism
• Drug induced

Differentiating type of tremor

	Parkinsons	Essential	Cerebellar	Physiological
Tremor	Worse at rest Reduced with intentional movements “Pill rolling” Initially unilateral, later becomes bilateral	Worse on intentional movements Often reduced or absent at rest Bilateral (may initially be unilateral May involve head and vocal tremor Never involves legs Absent during sleep	Worse on intentional movements “Past pointing” Unilateral or bilateral Tremor often irregular and jerky	Worse on intentional movements
Other features	“Mask-like” facial appearance Low, quiet speech Slowed gait – often has to ‘work-up’ to get moving	FHx of essential tremor Commonly improves after drinking alcohol

Examination

• Tone, power, reflexes and co-ordination in all 4l imbs
• Cerebellar signs – nystagmus, ataxia, dysdiadochokinesia (inability to perform rapidly alternating movements)
• Assessment of cognitive function – e.g. with MMSE or MoCA
• Gait and posture
• Lying and standing BP

Investigations

• FBC
• U+E
• TFTs
• LFTs

Essential Tremor

Epidemiology and aetiology

• Essential tremor is the common cause of tremor and one of the most common neurological disorders
• Affects 50 per 1000 people over 60
• Incidence increases with age
• Associated with family history
  • >50% of cases have a family history
  • Can be inherited in an autosomal dominant pattern
  • Age of onset is often much younger (40 ± 22 yrs) in those with family history compared to those without (57 ± 18 yrs)
  • Relative risk is approx 5x higher if first degree relative and 10x higher if first degree relative has early onset
• M:F

Clinical features

• Affects upper limbs, face / neck and voice
  • Lower limbs are not usually affected by tremor – if LL symptoms – consider an alternate diagnosis
  • HOWEVER – essential tremor is associated with gait and balance changes
• Can progress over time
  • The tremor itself often begins as transient but then becomes more persistent over time
  • The amplitude of the tremor often increases
• Worse with intentional movements
  • As opposed to Parkinson’s disease where the tremor often improves with intentional movements
• Does not occur during sleep
• Tremore often improves with alcohol
• The typical tremor has a frequency of 4-12Hz
• Neurological examination will usually be normal
• Exclude another cause before starting treatment
  • Important to exclude Parkinson’s disease and hyperthyroidism

Management

• Reassure patients that it is not likely to be serious
• Avoid: caffeine, stress, tiredness
• Practical tips:
  • Use heavier utensils (yes really!)
  • Type instead of writing
  • Use wrist weights
  • Yoga or relaxation exercises
• Propranolol 10mg PO BD. Dose can be increased slowly to a maximum of 160mg OD in 2-3 divided doses
• Primidone 62.5mg PO nocte. Dose can be increased slowly up to a maximum of 250mg daily
  • Is just as effective as propranolol but more prone to side effects such as confusion and fatigue
• Some patients may require a combination of both drugs
• If it is unresponsive to therapy – consider a specialist referral – deep brain stimulation and botox injections may be considered

Enhanced Physiological Tremor

• May be normal
• Exacerbated by certain postures
• Ask about anxiety, fatigue
• Check for endocrine causes – hyperthyroidism, Cushing disease, pheochromocytoma, hypoglycaemia
• Drugs – salbutamol, caffeine, dopamine agonists, sodium valproate, tricyclic anti-depressants
• Alcohol withdrawal

References

• My hands shake – RACGP
• Tremor – patient.info
• Arkadir D, Louis ED. The balance and gait disorder of essential tremor: what does this mean for patients? Ther Adv Neurol Disord. 2013 Jul;6(4):229-36. doi: 10.1177/1756285612471415. PMID: 23858326; PMCID: PMC3707350.
• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
• Essential Tremor – eTG
• Tremor – Health Pathways

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