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Tremor, the most common form kinsonism, comprising approximately 1) and narrowed down based on clues
of abnormal involuntary movement three quarters of all cases seen in move- obtained from the clinical history and
(AIM), is a rhythmic oscillation of a ment disorders centers.3 neurological examination. Historical
body region produced by alternating Action tremor is present during the elements that are important to elicit
contractions of reciprocally innervated voluntary contraction of muscles, and include: 1) age at onset of the tremor,
muscles.I,llt occurs across a wide spec- can be subdivided into four types: pos- 2) mode of onset (sudden vs. gradual),
trum of neurological disorders and is tural, kinetic, isometric, and task-spe- 3) anatomical site(s) affected by the
easily distinguished from other AIMs cific. Postural tremor is seen during the tremor, 4) rate of progression to other
such as chorea, tics, and myoclonus by maintenance of an anti-gravity posture, sites, 5) exacerbating and remitting fac-
its rhythmic, repetitive and stereotypi- such as when a patient holds a newspa- tors (such as alcohol responsiveness),
cal appearance. Tremor causes not only per up to read, whereas kinetic tremor 6) histoty of alcohol abuse, and 7) fam-
discomfort and social embarrassment happens during voluntary movement. ily history of tremor. Furthermore,
for patients, but also disability. Since Often brought out using the finger- many pharmacologic agents can cause
successful treatment depends on the nose-finger test, a kinetic tremor can tremor (Table 2), so a thorough review
correct diagnosis, it is important for the occur at the beginning of the move- of the patient's medications is essen-
clinician to recognize the various pre- ment, during the course of the move- tial. Associated examination findings
sentations of tremor and associated ment, or when approaching a target. In that may shed light on the underlying
symptoms. This article describes the the latter condition, it is also known as etiology of the tremor include bradyki-
general clinical approach to the patient an intention tremor, commonly seen nesia or rigidity (PO); nystagmus, scan-
who presents with tremor and reviews with cerebellar lesions. Isometric trem- ning speech, ataxia (cerebellar lesion);
the most common tremor syndromes ors are present during voluntary muscle and a wide variation in tremor fre-
and their management. contractions not accompanied by move- quency (psychogenic).
ment, for example, when standing or If the diagnosis can be established
CLASSIFICATION OF when making a fist. Task-specific trem- on clinical criteria and the patient re-
TREMOR ors, as the name implies, occur only sponds to treatment, ancillaty studies are
When evaluating a patient who during specific activities, such as writ- usually unnecessary. However, in young
presents with tremor, first categorize ing, singing, or playing an instrument. patients «50 years of age) with tremor,
the tremor based on its positional prop- The postural and kinetic tremor sub- Wilson's disease (WD) should always
erties. Tremor can be divided into two types are seen far more frequently than be excluded, because it is devastating
main types: rest and action. Rest the isometric and task-specific subtypes. and potentially life-threatening if left
tremor occurs in a body part that is Just as each tremor type has mul- untreated. WD is a rare, autosomal re-
relaxed or supported against gravity tiple etiologies, more than one tremor cessive disorder believed to be caused
and not involved in purposeful activi- type can occur in the same condition. by mutations in a gene encoding a cop-
ties, for example, a hand tremor evi- For example, PO patients often have an per transporting ATP-ase, resulting in
dent when the upper limb rests on the action component in addition to their abnormal deposition of copper in brain,
arm of a chair. When intermittent or classic rest tremor, while the postural liver and other organs of the body.
minimal, a rest tremor can be brought tremor seen in essential tremor (ET) can Although classically described as
out or enhanced on examination by sometimes persist when the hands rest "wing-beating", the tremor in WO can
having the patient concentrate on other in the patient's lap. Though this overlap occur in any pattern and is the most
tasks, such as performing arithmetic or can sometimes cause difficulty for the common neurological manifestation of
opening and closing the contralateral diagnosing clinician, a tremor that di- the disease.4 Most cases can be ruled
hand. The presence of a rest tremor is minishes with voluntaty movement is out with a normal serum ceruloplas-
virtually synonymous with parkin- likely to be a rest tremor, while a tremor min and 24-hour urinary copper ex-
sonism, a condition with multiple eti- that is present at rest but worsens with cretion. Other groups of patients in
ologies, including drug-induced (due movement is probably an action tremor. whom investigational studies may be
mainly to neuroleptics) and other helpful include those with asymmetri-
neurodegenerative disorders such as CLUES TO THE DIAGNOSIS cal, cerebellar, or postural tremors.
multiple system atrophy (MSA) or OF TREMOR Asymmetrical or cerebellar tremors
progressive supranuclear palsy (PSP). Once the predominant type of may result from focal lesions such as
Parkinson's disease (PD), however" is tremor is identified, a short differen- neoplasm, stroke, hemorrhage or de-
by far the most common cause of par- tial diagnosis can be generated (Table myelinating disease and may be de-
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VOL. 87 No.5 MAY 2004
tected with a magnetic resonance im- hol, but these features are not present single daily dose at bedtime, beginning
aging stUdy of the brain. Patients who in every patient. Although ET can with 25 mg, and increased by 25 mg
present with postural tremor may have occur at any age, its prevalence gener- weekly until the desired tremorlytic
hyperthyroidism as an underlying eti- ally increases with age. effect is obtained or side effects occur.
ology and should have their thyroid ET tends to start distally in the Drowsiness is the most common side
function checked. arms with a typical flexion-extension effect, but patients may also experience
motion at the wrists or abduction-ad- nausea, vertigo and unsteadiness. Pro-
COMMON TREMOR duction movement of the fingers. Al- pranolol, a beta-blocker, is usually ef-
SYNDROMES AND THEIR though it may be unilateral in onset, fective between 240 and 320 mg daily.9
MANAGEMENT both sides will eventually be involved. Patients are frequently referred to
The most common tremor syn- The most common anatomical sites of movement disorders centers and la-
dromes encountered in clinical prac- involvement after the hands are (in beled as having "failed" propranolol
tice are ET and PD. Although decreasing order) the head, voice, legs, treatment, when in fact, an adequate
cerebellar and psychogenic tremors are and chin.6 The tremor tends to in- dose was never administered. As with
less frequently seen, they are important crease with stress, anxiety, excitement, primidone, propranolol should be
for the general clinician to be aware of emotional upset, fatigue or cold tem- started at low doses and increased over
and will be briefly reviewed. Iatrogenic perature. Although ET is sometimes weeks, while monitoring blood pres-
causes of tremor are common, and may preceded by the term "benign", many sure and pulse. Contraindications for
even mimic ET or PD. If a patient is patients dispute the adjective. ET the use of propranolol include cardiac
taking a medication known to induce causes both physical and social disabil- conduction block, heart failure, asthma
tremor (Table 2), that medication ity. Simple tasks such as signing a and diabetes; side effects include
should be discontinued before initiat- check, eating, drinking from a cup, lightheadedness, fatigue, nausea and
ing other therapy. shaving, brushing teeth, and dressing depression.
can become frustrating ordeals, and Other medications for ET are gen-
ESSENTIAL TREMOR (ET) embarrassed patients often avoid social erally not proven to be as effective as
ET is the most common move- sitUations. primidone or propranolol, though
ment disorder.2 The diagnosiscan be Primidone (Mysoline) and propra- topiramate was recently shown to re-
made when a persistent, bilateral, nolol (Inderal) continue to be the duce tremor in a double-blind, pla-
mainly symmetrical, postural and/or mainstays of treatment for ET. cebo-con trolled trial. 10
kinetic tremor of the hands or arms is Primidone, an anticonvulsant, may be Benzodiazepines such as alprazolam or
present, without other neurological the more effective agent, with approxi- clonazepam may also help if the patient
signs or exposure to drugs that may mately 70% of patients experiencing has concurrent anxiety.
cause tremor.5 A head tremor can also benefit, compared to 50% of patients When the medications fail to con-
be part of the syndrome, either in ad- on propranoloU Though dosages be- trol the tremor, surgery should be con-
dition to the hand tremor or in isola- tween 50 and 250 mg of primidone sidered. Stereotactic ablation of the
tion, as long as there is no dystonic daily are usually needed to reduce ventral intermediate nucleus (Vim) of
postUring. Clinical or historical fea- tremor,8 this medication should be the thalamus used to be the preferred
tures consistent with a diagnosis ofET started at a low dose and titrated slowly surgical procedure for control of ET
include a positive family history and up in order to minimize adverse effects. tremor, but has become obsolete with
improvement of the tremor with alco- Primidone is usually prescribed in one the advent of deep brain stimulation
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