Tremor

Question 1

Approach

Answer 1

• Exclude infection (rigors/chills)
  -Exclude neurological injury (midbrain injury/tumour, cerebellar disease.
  -Exclude physiological tremors (thyrotoxicosis, hypoglycaemia, anxiety, drug withdrawal)
  Consider Parkinson’s vs. essential tremors

Question 2

History

Answer 2

1) Tremor – onset, duration
Location of tremors: head, vocal cords, arms, legs
Type of tremor: resting tremor, postural tremor, action tremor, intention tremor,
Worsening/relieving factors (drugs, caffeine, alcohol, exercise, stress, fatigue), drug overuse/withdrawal
Consequences: functional limitations

2) Screen DDX Infectious symptoms, focal neurological deficits/ataxia, visual changes, hyperthyroidism, hypoglycaemia,

General medical history: PMHX (anxiety, panic attacks, thyroid), FHX (ET, Parkinson’s, thyroid),
Essential tremor: positive FHX, improves with alcohol
3) General medical history, GP screening

Question 3

Examination

Answer 3

Examination
1) Tremor - Location of tremor
Type of tremor: resting (arms resting on lap), postural (arms in front of body), intention (finger-nose test), dystonic (tremor when supinating hands until thumbs point to ceiling),
- Functional limitations: holding a cup/eating utensils, drawing a spiral/sentence
Describe tremor:
- body part involved
- activation condition (when it is present)
- frequency (slow <6Hz, fast >6Hz),
- regularity (regular or jerky)
- distractible (count backwards)
2) Screen DDX
- Full neurological exam + gait exam: Parkinsonism, cerebellar disease, midbrain (focal neurological deficits), dystonia (irregular, jerky resting/postural tremor)
Thyrotoxicosis (thyroid exam),

Question 4

Investigations

Answer 4

Investigations
Resting tremor: clinical diagnosis
Postural-action tremor: BSL , TFT
Intention tremor: consider stroke workup, Wilson’s disease (FBC, LFT, serum ceruloplasmin, serum copper levels)
- orthostatic tremor (EMG)

Question 5

Management

Answer 5

2. Management
   Resting tremor
   - Parkinson disease: levodopa, referral to neurologist, dopamine agonists, anticholinergics,

Essential tremor:
Mild ET + non-disabling - no treatment
Mild ET + intermittent disability
[1] Intermittent therapy for exacerbating situations with propranolol,
[2] Continuous therapy with propanolol (if good response to propranolol)
ET + persistent disability
[1] Continuous therapy with propranolol OR primidone OR both
[2] Other AED including gabapentin OR topirimate OR nimodipine OR combinations,
[3] Surgery with DBS or thalamotomy OR Botox

Dystonia: botulinum toxin injection
Cerebellar disease: workup for underlying pathology (stroke, MS) or drug toxicity (valproate, phenytoin, amiodarone)