Tremor

Question 1

Holmes Tremor

Answer 1

Holmes tremor is caused by a lesion in the red nucleus. This is most commonly due to a previous stroke of this area. It is classically an irregular low frequency tremor which is a combination of resting, postural and action tremor. It may also arise from any underlying structural disorders including multiple sclerosis, tumors, haemorrhage, trauma, neuroleptic agents, radiation. Treatments include medical therapy such as levodopa however thalamotomy or chronic thalamic stimulation have also shown to play a role in managing this condition.

Example Question:

A 73 year old female presents with a low frequency irregular tremor of the left hand and ataxia. The tremor is present at rest and when she holds her arms outstretched. The frequency of the tremor ranges from 3-4 Hz and is enhanced with posture and aggravated with movement. On neurological examination patient was found to have an ataxic gait with mild left arm weakness (power 4/5). She had a past medical history of type 2 diabetes mellitus, hypertension and previous stroke. What is the most likely diagnosis for her tremor?

	Essential tremor
	> Holmes tremor
	Parkinsonian tremor
	Cerebellar tremor
	Physiological tremor

Question 2

Essential Tremor

Answer 2

Essential tremor

Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs

Features
postural tremor: worse if arms outstretched
improved by alcohol and rest
most common cause of titubation (head tremor)

Management
propranolol is first-line
primidone is sometimes used

Example Question:
You are the medical registrar on call. While reviewing another patient, you notice an 82-year-old female inpatient on the same ward, currently treated for community-acquired pneumonia sitting in a chair. You notice a persistent movement of her head, in a nodding motion, associated with a tremor of both hands, worse in the left than the right. Reading through her notes, she has previously been treated for epilepsy and was started on oral phenytoin by her GP 4 months ago. On examination, the hand tremor appears to worsen when her arms are outstretched. She performs finger-nose dysmetria testing without difficulty with no speech. She demonstrates no cogwheeling. The patient appears unconcerned by the symptoms ‘I have learned to live with it for years doctors!’ she tells you. What is the most likely diagnosis?

	Tremor-predominant Parkinson's disease
	Phenytoin induced cerebellar tremor
	> Essential tremor
	Physiological tremor
	Orthostatic tremor

The patient’s examination is one of isolated tremor with no other cerebellar or neurological features. The clinical features of worsening on posture, head nodding and lack of cerebellar symptoms suggest a diagnosis of essential tremor. She demonstrates no signs of Parkinson’s disease, a tremor that does not alleviate with movement and the history describes onset beyond the start of phenytoin. Orthostatic tremor onsets in the trunk and legs when the patient stands. The described features are perhaps too severe for a physiological tremor, which is typically low in amplitude and barely visible. It is unlikely the patient would have received a beta agonist for a community-acquired pneumonia in the absence of obstructive airways disease, hence a drug-induced tremor is also unlikely.