A tremor is an involuntary

,[1] somewhat rhythmic, muscle contraction and relaxation involving oscillations or twitching
movements of one or more body parts. It is the most common of all involuntary movements and
can affect the hands, arms, eyes, face, head, vocal folds, trunk, and legs. Most tremors occur in
the hands. In some people, a tremor is a symptom of another neurological disorder.

Types
Tremor is most commonly classified by clinical features and cause or origin. Some of the better-
known forms of tremor, with their symptoms, include the following:

Cerebellar tremor (also known as intention tremor) is a slow, broad tremor of the extremities that
occurs at the end of a purposeful movement, such as trying to press a button or touching a finger
to the tip of one's nose. Cerebellar tremor is caused by lesions in or damage to the cerebellum
resulting from stroke, tumor, or disease such as multiple sclerosis or some inherited degenerative
disorder. It can also result from chronic alcoholism or overuse of some medicines. In classic
cerebellar tremor, a lesion on one side of the brain produces a tremor in that same side of the
body that worsens with directed movement. Cerebellar damage can also produce a "wing-
beating" type of tremor called rubral or Holmes' tremor — a combination of rest, action, and
postural tremors. The tremor is often most prominent when the affected person is active or is
maintaining a particular posture. Cerebellar tremor may be accompanied by other manifestations
of ataxia, including dysarthria (speech problems), nystagmus (rapid, involuntary rolling of the
eyes), gait problems and postural tremor of the trunk and neck. Titubation is tremor of the head,
hands, and torso and is of cerebellar origin.[2]
Dystonic tremor occurs in individuals of all ages who are affected by dystonia, a movement
disorder in which sustained involuntary muscle contractions cause twisting and repetitive
motions or painful and abnormal postures or positions. Dystonic tremor may affect any muscle in
the body and is seen most often when the patient is in a certain position or moves a certain way.
The pattern of dystonic tremor may differ from essential tremor. Dystonic tremors occur
irregularly and can often be relieved by complete rest. Touching the affected body part or muscle
may reduce tremor severity (a geste antagoniste). The tremor may be the initial sign of dystonia
localized to a particular part of the body. The dystonic tremor has usually a frequency of about 7
Hz.[3]
Essential tremor (sometimes inaccurately called benign essential tremor) is the most common of
the more than 20 types of tremor. Although the tremor may be mild and nonprogressive in some
people, in others, the tremor is slowly progressive, starting on one side of the body but affecting
both sides within 3 years. The hands are most often affected but the head, voice, tongue, legs,
and trunk may also be involved. Head tremor may be seen as a vertical or horizontal motion.
Essential tremor may be accompanied by mild gait disturbance. Tremor frequency may decrease
as the person ages, but the severity may increase, affecting the person's ability to perform certain
tasks or activities of daily living. Heightened emotion, stress, fever, physical exhaustion, or low
blood sugar may trigger tremors or increase their severity. Onset is most common after age 40,
although symptoms can appear at any age. It may occur in more than one family member.
Children of a parent who has essential tremor have a 50 percent chance of inheriting the
condition. Essential tremor is not associated with any known pathology. Its frequency is between
4 and 8 Hz.[3]
Orthostatic tremor is characterized by fast (>12 Hz) rhythmic muscle contractions that occur in
the legs and trunk immediately after standing up. Cramps are felt in the thighs and legs and the
patient may shake uncontrollably when asked to stand in one spot. No other clinical signs or
symptoms are present and the shaking ceases when the patient sits or is lifted off the ground. The
high frequency of the tremor often makes the tremor look like rippling of leg muscles while
standing. Orthostatic tremor may also occur in patients who have essential tremor, and there
might be an overlap between these categories of tremor.
Parkinsonian tremor is caused by damage to structures within the brain that control movement.
This resting tremor, which can occur as an isolated symptom or be seen in other disorders, is
often a precursor to Parkinson's disease (more than 25 percent of patients with Parkinson's
disease have an associated action tremor). The tremor, which is classically seen as a "pill-rolling"
action of the hands that may also affect the chin, lips, legs, and trunk, can be markedly increased
by stress or emotion. Onset is generally after age 60. Movement starts in one limb or on one side
of the body and usually progresses to include the other side. The tremor's frequency is between 4
and 6 Hz.[3]
Physiological tremor occurs in every normal individual and has no clinical significance. It is
rarely visible and may be heightened by strong emotion (such as anxiety[4] or fear), physical
exhaustion, hypoglycemia, hyperthyroidism, heavy metal poisoning, stimulants, alcohol
withdrawal or fever. It can be seen in all voluntary muscle groups and can be detected by
extending the arms and placing a piece of paper on top of the hands. Enhanced physiological
tremor is a strengthening of physiological tremor to more visible levels. It is generally not caused
by a neurological disease but by reaction to certain drugs, alcohol withdrawal, or medical
conditions including an overactive thyroid and hypoglycemia. It is usually reversible once the
cause is corrected. This tremor classically has a frequency of about 10 Hz.[5]
Psychogenic tremor (also called hysterical tremor and functional tremor) can occur at rest or
during postural or kinetic movement. The characteristics of this kind of tremor may vary but
generally include sudden onset and remission, increased incidence with stress, change in tremor
direction or body part affected, and greatly decreased or disappearing tremor activity when the
patient is distracted. Many patients with psychogenic tremor have a conversion disorder (see
Posttraumatic stress disorder) or another psychiatric disease.
Rubral tremor is characterized by coarse slow tremor which is present at rest, at posture and with
intention. This tremor is associated with conditions which affect the red nucleus in the midbrain,
classically unusual strokes.
Neuropathic tremor may occur in patients with peripheral neuropathies, when the nerves that
supply the body's muscles are traumatized by injury, disease, abnormality in the central nervous
system, or as the result of systemic illnesses. It is most commonly observed in patients with an
immunoglobulin M paraproteinaemic neuropathy (IgMNP), but also in patients with chronic
inflammatory demyelinating polyneuropathy (CIDP). The tremor is predominantely exhibited as
an action or postural tremor with a frequency of 3 to 10 Hz.[6] Peripheral neuropathy can affect
the whole body or certain areas, such as the hands, and may be progressive. Resulting sensory
loss may be seen as a tremor or ataxia (inability to coordinate voluntary muscle movement) of
the affected limbs and problems with gait and balance. Clinical characteristics may be similar to
those seen in patients with essential tremor.
Tremor can result from other conditions as well

Alcoholism, excessive alcohol consumption, or alcohol withdrawal can kill certain nerve cells,
resulting in a tremor known as asterixis. Conversely, small amounts of alcohol may help to
decrease familial and essential tremor, but the mechanism behind it is unknown. Alcohol
potentiates GABAergic transmission and might act at the level of the inferior olive.
Tobacco withdrawal symptoms include tremor.
Most of the symptoms can also occur randomly when panicked.
Causes
Tremor can be a symptom associated with disorders in those parts of the brain that control
muscles throughout the body or in particular areas, such as the hands. Neurological disorders or
conditions that can produce tremor include multiple sclerosis, stroke, traumatic brain injury,
chronic kidney disease and a number of neurodegenerative diseases that damage or destroy parts
of the brainstem or the cerebellum, Parkinson's disease being the one most often associated with
tremor. Lesions of the Guillain-Mollaret triangle (also called myoclonic triangle or dentato-
rubro-olivary pathway) impair the predictions performed by the cerebellum, causing repetitive
muscle discharges by triggering oscillatory activity in the central nervous system.[7] Other
causes include the use of drugs (such as amphetamines, cocaine, caffeine, corticosteroids, SSRIs)
or alcohol, mercury poisoning, or the withdrawal of drugs such as alcohol or benzodiazepine.
Tremors can also be seen in infants with phenylketonuria (PKU), overactive thyroid or liver
failure. Tremors can be an indication of hypoglycemia, along with palpitations, sweating and
anxiety. Tremor can also be caused by lack of sleep, lack of vitamins, or increased stress.[8][9]
Deficiencies of magnesium and thiamine[10] have also been known to cause tremor or shaking,
which resolves when the deficiency is corrected.[11] Tremors in animals can also be caused by
some spider bites, e.g. the redback spider of Australia.[12]

Diagnosis
During a physical exam, a doctor can determine whether the tremor occurs primarily during
action or at rest. The doctor will also check for tremor symmetry, any sensory loss, weakness or
muscle atrophy, or decreased reflexes. A detailed family history may indicate if the tremor is
inherited. Blood or urine tests can detect thyroid malfunction, other metabolic causes, and
abnormal levels of certain chemicals that can cause tremor. These tests may also help to identify
contributing causes, such as drug interaction, chronic alcoholism, or another condition or disease.
Diagnostic imaging using CT or MRI imaging may help determine if the tremor is the result of a
structural defect or degeneration of the brain.[13]

The doctor will perform a neurological examination to assess nerve function and motor and
sensory skills. The tests are designed to determine any functional limitations, such as difficulty
with handwriting or the ability to hold a utensil or cup. The patient may be asked to place a
finger on the tip of her or his nose, draw a spiral, or perform other tasks or exercises.[citation
needed]

The doctor may order an electromyogram to diagnose muscle or nerve problems. This test
measures involuntary muscle activity and muscle response to nerve stimulation. The selection of
the sensors used is important. In addition to studies of muscle activity, tremor can be assessed
with accuracy using accelerometers .[14]

Categories
The degree of tremor should be assessed in four positions. The tremor can then be classified by
which position most accentuates the tremor:[15]

Position Name Description

At rest Resting tremors Tremors that are worse at rest include Parkinsonian syndromes and
essential tremor if severe. This includes drug-induced tremors from blockers of dopamine
receptors such as haloperidol and other antipsychotic drugs.
During contraction (e.g. a tight fist while the arm is resting and supported) Contraction tremors
Tremors that are worse during supported contraction include essential tremor and also
cerebellar and exaggerated physiological tremors such as a hyperadrenergic state or
hyperthyroidism.[15] Drugs such as adrenergics, anticholinergics, and xanthines (such as
caffeine) can exaggerate physiological tremor.
During posture (e.g. with the arms elevated against gravity such as in a 'bird-wing' position)
Posture tremors Tremors that are worse with posture against gravity include
essential tremor and exaggerated physiological tremors.[15]
During intention (e.g. finger to nose test) Intention tremors Intention tremors are tremors
that are worse during intention, e.g. as the patient's finger approaches a target, including
cerebellar disorders. The terminology of "intention" is currently less used, to the profit of
"kinetic".
Treatment
There is no cure for most tremors. The appropriate treatment depends on accurate diagnosis of
the cause. Some tremors respond to treatment of the underlying condition. For example, in some
cases of psychogenic tremor, treating the patient's underlying psychological problem may cause
the tremor to disappear. A few medications can help relieve symptoms temporarily.[citation
needed]

Medications
Medications remain the basis of therapy in many cases. Symptomatic drug therapy is available
for several forms of tremor:[citation needed]

Parkinsonian tremor drug treatment involves L-DOPA or dopamine-like drugs such as pergolide,
bromocriptine and ropinirole; They can be dangerous, however, as they may cause symptoms
such as tardive dyskinesia, akathisia, clonus, and in rare instances tardive (late developing)
psychosis. Other drugs used to lessen parkinsonian tremor include amantadine and
anticholinergic drugs like benztropine
Essential tremor may be treated with beta blockers (such as propranolol and nadolol) or
primidone, an anticonvulsant
Cerebellar tremor symptoms may decrease with the application of alcohol (ethanol) or
benzodiazepine medications, both of which carry some risk of dependence or addiction
Rubral tremor patients may receive some relief using L-DOPA or anticholinergic drugs. Surgery
may be helpful
Dystonic tremor may respond to diazepam, anticholinergic drugs, and intramuscular injections of
botulinum toxin. Botulinum toxin is also prescribed to treat voice and head tremors and several
movement disorders
Primary orthostatic tremor sometimes is treated with a combination of diazepam and primidone.
Gabapentin provides relief in some cases
Enhanced physiological tremor is usually reversible once the cause is corrected. If symptomatic
treatment is needed, beta blockers can be used
Lifestyle
Eliminating tremor "triggers" such as caffeine and other stimulants from the diet is often
recommended. Essential tremor may benefit from slight doses of ethanol, but the potential
negative consequences of regular ethanol intake need to be taken into account. Beta blockers
have been used as an alternative to alcohol in sports such as competitive dart playing and carry
less potential for addiction.[citation needed]

Physical therapy and occupational therapy may help to reduce tremor and improve coordination
and muscle control for some patients. A physical therapist or occupational therapist will evaluate
the patient for tremor positioning, muscle control, muscle strength, and functional skills.
Teaching the patient to brace the affected limb during the tremor or to hold an affected arm close
to the body is sometimes useful in gaining motion control. Coordination and balancing exercises
may help some patients. Some occupational therapists recommend the use of weights, splints,
other adaptive equipment, and special plates and utensils for eating.[citation needed]