Essential tremor

Question 1

Presentation of an essential tremor aka benign essential tremor?

Answer 1

• Affects both upper limbs - bilateral and symmetrical
• Postural tremor: worse when arms are extended
• Difficulty in writing, eating, holding objects i.e. tea cup and doing fine motor tasks, dressing, and speaking
• Improved by alcohol and rest
• Tremor increases with anxiety, stress, and in when interacting w/ people
• Head tremor may also be present
• low mood/depression due to effect on life.
• fine tremor of voluntary muscles

Question 2

Investigations of essential tremor?

Answer 2

Usually clinical Dx

If feel is necessary:
- CT/MRI of head - helps figure out the type of tremor
- Serum ceruloplasmin - done if pt is <40yrs, and has features of Parkinsonism, dysarthria, rule out other types of tremor.
- 24-hr urine copper - high levels, slit lamp examination for Kayser-Fleischer rings = Wilson’s disease
- TFTs - low TSH = hyperthyroidism could be causing tremor
- SPECT scan of head = for Parkinson’s.

Question 3

Management of essential tremor?

Answer 3

Management is symptomatic

1. Behavioural techniques and physical therapy
2. Pharmacological:
   - propranolol is first-line
   - primidone is sometimes used
3. Surgical:
   - e.g. deep brain stimulation
   - e.g. focused ultrasound thalamotomy

Question 4

Risk factors for essential tremor?

Answer 4

Increasing age
FHx - auotosomal dominant inheritance
Caucasian
Environmental toxins/ask about occupation

Question 5

Differential Dx for essential tremor?

Answer 5

Parkinsons/Parkinsonism
Dystonia
Drug-induced tremor
Psychogenic tremor
Hyperthyroidism
Wilson’s disease
Orthostatic tremor - tremor that occurs on standing/disappears when sitting or walking

Question 6

What does low ceruloplasmin indicate?

Answer 6

Wilson’s disease

Question 7

exampes of drugs causing a tremor?

Answer 7

Alcohol
lithium (fine) - lithium toxicity = coarse
steroids
ciclosporin
sodium valporate

Question 8

What is a tremor ? what is a normal physiological tremor?

Answer 8

Def: rhythmical involuntary oscillatory movement of a body part

normal physiological tremor 5-12 Hz due to increased anxiety, caffeine, ++ T4

Question 9

Differenicate between essential tremor and tremor in Parkinsons Disease

Answer 9

Essential tremor (ET) is 10 x more prevalent than PD

ET: postural + action tremor e.g holding cup of tea against gravity and drinking. If severe present at rest BUT NEVER PILL ROLLING

ET: may have vocal tremor and head tremor

PD: may be a jaw tremor, leg rest tremor