Tremor

Question 1

Tremor:

Approach to tremor?

Answer 1

1) History
- Family history
- onset
- progression
- exacerbating and relieving factors
- frequency
2) Examine
- character (slow, moderate, fast, jerky)
- at rest
- arms extended
- finger nose test
- holding and object (cup)
- draw a spiral
- Neurolgical (cranial nerves, cerebellar, upper and lower limbs)
- bradykinesia

Question 2

Tremor:

How to filter the diagnosis?

Answer 2

Resting vs Action tremor

Question 3

Tremor:

How to diagnose a resting tremor?

Answer 3

Resting
(increases at rest when supported or with stress, reduces with targeted moving)
a) parkinsonian features -> levodopa trial (if successful = parkinsons, if unsuccessful = parkinsons plus/brain lesions)
b) On dopamine blocker medications -> withdrawal trial (if successful = drug induced)

Question 4

Tremor:

How to diagnose an Action tremor?

Answer 4

Action

1) Isometric (with opposing force) -> Dystonic tremor (jerky) OR Multiple causes
2) Postural (when moving against gravity) -> Multiple causes
3) Kinetic
a) task specific (musician, writing etc) -> Dystonic tremor (jerky)
b) Intention (on targeted movments) -> Alcohol/Lithium induced OR Cerebellar (MS, CVA)
c) Simple (on all movements) -> Multiple causes

Multiple causes = Essential, Physiological, thyrotoxicosis, hypoglycaemia, cushings, diet/medications*)

*Alcohol, Amiodarone, Amphetamines, Beta adrenergic agonists, Caffeine, Cyclosporin, Dopamine, Corticosteroids, Sodium valproate, Theopylline, Thyroid hormones, Tricyclic antidepressants)