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TREMOR

Nadya Zaragita (= = ) ~| 130110110184 | Tutor B1 NBSS

Definition: a more or less involuntary and rhythmic oscillatory movement produced by


alternating or irregularly synchronous contractions of reciprocally innervated muscles.

General categories:

Normal (or physiologic)


o Present in all contracting muscle groups and persists throughout the
waking state and even in certain phases of sleep
o Very fine movement, can barely be seen by naked eye
o Frequency: 8-13 Hz (usually 10 Hz in adulthood)
o Cause: mechanical activity of cardiac origin, spindle input, unfused grouped
firing rates of motor neurons, natural resonating frequencies and inertia of
the muscles and other structures (hypothesis)

Abnormal (or pathologic)


o Affects certain muscle groupsthe distal parts of the limbs (especially the
fingers and hands); less often, the proximal parts; the head, tongue, jaw, or
vocal cords; and rarely the trunkand is present only in the waking state.
o Frequency: 4 to 7 Hz
o Subdivided according to:

Rate

Relationship to posture of the limbs and volitional movement

Pattern of EMG activity (synchronous or alternating) in opposing


muscle groups

Response to certain drugs


o In clinical analysis, they are usually distinguishable on the basis of (1)
rhythmicity, (2) amplitude, (3) frequency, and (4) relation to movement,
postural set, and relaxation.
POSTURAL AND ACTION TREMORS

Present when the limbs and trunk are actively maintained in certain positions (such as
holding the arms outstretched) and that may persist throughout active movement.

The tremor is absent when the limbs are relaxed but becomes evident when the
muscles are activated.

Most cases of action tremor are characterized by relatively rhythmic bursts of grouped
motor neuron discharges that occur not quite synchronously and simultaneously in
opposing muscle groups.

Types of action tremors:


o Enhanced Physiologic Tremor

An exaggeration of normal or physiologic tremor

Frequency: 10 Hz, but a greater amplitude

Best elicited by holding the arms outstretched with fingers spread apart

Characteristic of intense fright and anxiety, certain metabolic


disturbances (hyperthyroidism, hypercortisolism, hypoglycemia),
pheochromocytoma, intense physical exertion, withdrawal from alcohol
and other sedative drugs, and the toxic effects of several drugs
lithium, nicotinic acid, xanthines (coffee, tea, aminophylline, colas), and
corticosteroids.
o Alcohol Withdrawal Tremor

Frequency: >8 Hz and continuous activity in antagonistic muscles, thus


resembling physiologic tremor but of greater amplitude and responsive
to propranolol (Koller et al).

The second tremor, of less


than 8 Hz, is characterized by discrete bursts of EMG activity occurring
synchronously in antagonistic muscles, like that observed
in one type of familial tremor (see below). Either of these may
occur after a relatively short period of intoxication (morning
shakes). A number of alcoholics, on recovery from the withdrawal
state, exhibit a persistent tremor of essential-familial type, described
below. The mechanisms involved in alcohol withdrawal
symptoms are discussed in Chap. 42.

Essential (Familial) Tremor This, the commonest type of


tremor, is of lower frequency (4 to 8 Hz) than physiologic tremor
and is unassociated with other neurologic changes; it is therefore
called essential. Tremor of this relatively slow type very often
occurs as the only neurologic abnormality in several members of
a family, in which case it is called familial or hereditary tremor.
Inheritance is as an autosomal dominant trait with virtually complete
penetrance. The idiopathic and familal tremors cannot be distinguished
on the basis of their physiologic and pharmacologic
properties and probably should not, therefore, be considered as separate
entitities. This condition, sometimes also referred to as benign
tremor, is hardly so in many patients, in whom it worsens
with age and greatly interferes with normal activities. Quite ambiguous
is the term action tremor when applied to essential tremor,
as noted earlier; strictly speaking, it denotes a worsening of tremulousness
with activity of the limb, but, as discussed further on, it
is the maintenance of a posture that truly exaggerates these tremors.
Clinically, one type of faster essential tremor is of the same frequency
(6 to 8 Hz) as enhanced physiologic tremor, which has led
several clinicians to declare their identity. However, there are certain
clinical and physiologic differences, as indicated below.
Familial or essential tremor most often makes its appearance
late in the second decade, but it may begin in childhood and then
persist. A second peak of increased incidence occurs in adults over
35 years of age. Both sexes are affected. It is a relatively common
disorder, with an estimated prevalence of 415 per 100,000 persons
over the age of 40 years (Haerer et al). The tremor frequency, as
remarked earlier, is 4 to 8 Hz, usually at the lower end of this range;
it is of variable amplitude. The frequency diminishes slightly with
age while its amplitude increases, as described by Elble. Aside from
its frequency, the identifying feature is its appearance or marked
enhancement with attempts to maintain a static limb posture. Like
most tremors, essential tremor is worsened by emotion, exercise,
and fatigue.
The tremor practically always begins in the arms and is usually
symmetrical; in approximately 15 percent of patients, however,
it may appear first in the dominant hand. A severe isolated arm or
leg tremor should suggest another disease (Parkinson disease or
focal dystonia, as described further on). The tremor may be limited
to the upper limbs, or a side-to-side or nodding movement of the
head may be added or may occur independently. Infrequently, the
tremor of the head precedes that of the hands. The head tremor is
also postural in nature and disappears when the head is supported.
It has also been noted that the limb and head tremors tend to be
muted when the patient walks. In some of our patients whose
tremor remained isolated to the head for a decade or more, there
has been little if any progression to the arms and almost no wors
REFERENCE:

Brunton, LL. Lazo, JS. Parker, KL. Goodman and Gilmans: The Pharmacological Basis of
Therapeutics. 11th ed. Mc-Graw Hill; 2006.
http://www.macalester.edu/psychology/whathap/UBNRP/spinalcord05/drugtreatment1.html

Katzung, BG. Basic & Clinical Pharmacology. 11th edition. San Fransisco: McGraw-Hill; 2009.