Tremor Flashcards
What are the clinical features of a resting tremor and its causes?
- Evident with the affected body part supported or completely at rest, and disappears during voluntary actions
- Idiopathic Parkinson disease and parkinsonian syndromes
What are the clinical features of a postural / action tremor and its causes?
• Refers to tremors elicited when arms suspended against gravity in a fixed posture, and during course of goal-directed activity
• Small amplitude, affects distal (not proximal like intention) muscles
• Essential / familial tremor
• Physiological tremor
- Enhanced by beta-agonists, anxiety, thyrotoxicosis, fever, often improves with ETOH
What are the clinical features of an intention tremor and its causes?
- Tremor typically increases in severity as the hand moves closer to its target (in contrast to postural or action tremors which either remain constant throughout the range of motion or abruptly increase at terminal fixation)
- Tremor is frequently very large in amplitude due to involvement of proximal muscles
- Cerebellar disease
What are the features of a rubral tremor and its causes?
• Abduction/adduction movements of the upper limbs with flexion-extension of the wrists
• Tremor that has both resting and postural/action and intention characteristics
- cerebellar outflow tract tremor
What is an orthostatic tremor? What are the features?
Orthostatic tremor or ““shaky leg”” syndrome is a disorder of middle-aged or elderly people and is characterized by feelings of unsteadiness in the legs and a fear of falling when standing. Tremor is limited to the legs and trunk and occurs exclusively while standing.
Other associated symptoms include difficulty in initiating walking and leg discomfort when standing. The symptoms are attenuated by walking, abolished by sitting, and due to a high frequency tremor in the weight-bearing muscles.
Both high and low frequency orthostatic tremors have been described; their relationship to ET is uncertain.
Orthostatic tremor is uniquely, but not always, responsive to treatment with clonazepam.
What are the features of a primary writing tremor?
Many action tremors are particularly severe during the act of writing. Tremor that occurs exclusively while writing, and not during other voluntary motor activities, is referred to as primary writing tremor. This tremor is limited to the hand and causes relatively large amplitude supination-pronation movements at a frequency of 5 to 6 Hz. The low frequency and large amplitude of the tremor, its frequent occurrence in writer’s “cramp” or writer’s dystonia, its relative resistance to propranolol, and its occasional response to anticholinergic drugs suggest a closer relationship to dystonia than to ET.
What are the features of a functional tremor?
Functional tremor, also known as psychogenic tremor, is typically characterized by complex resting, postural, and action tremor with abrupt onset, a static course, changeable features, functional disability out of proportion to tremor magnitude, and resistance to treatment. Any body part may be involved, but, remarkably, the fingers are often spared with much of the tremor of the arm occurring at the wrist. Other features of psychogenic movement disorders are also often present, such as inconsistent display of symptoms and clinical features that are incongruous with known tremors. Examination usually shows variable tremor frequency or tremor entrainment (ie, shift of tremor frequency to the speed of contralateral finger tapping), especially with distraction maneuvers such as repetitive tapping tasks with an uninvolved opposite hand or foot.
Management of essential tremor?
Primidone and propranolol are the two treatment options for essential tremor.
This patient has essential tremor and would be best initially treated with primidone. Propranolol would be relatively contraindicated in a patient with diabetes. (propranolol should be used with caution in patients with DM as can cause hypoglycaemia. Not to be used in asthma (bronchospasm), and caution with HF
