Tremors

Question 1

What is a rest tremor?

Answer 1

Tremor present when affected body part is relaxed, non-contracting and supported against gravity

Can be enhanced by counting backwards and walking

Triggered by stress/anxiety

Typically affects upper limbs, legs, jaws and lips

Question 2

What is are the 3 types of action tremor?

Answer 2

Postural
-occurs when limb held against gravity i.e. stretching arm out

Kinetic
-occurs with goal directed voluntary movments i.e. picking up pen

Isometric
-sustained muscle contraction against fixed object i.e. pressing hands against table

Question 3

How can tremor frequency be classified and which conditions might be associated with the different freqeuncies?

Answer 3

Low frequency

• <4 Hz
• Cerebellar tremor

Medium frequency

• 4-7 Hz
• PD tremor

High frequency

• > 8Hz
• Physiological tremor

Question 4

What are the key feaures of essential tremor?
When is the tremor present?
What are the exacerbating and relieving factors?

Answer 4

Presents mid-late life
50-70% have FH

Present with bilateral symmetrical postural hand tremor but can effect jaw, voice, head and legs

Present when:

• holding objects
• writing i.e. messy handwriting
• pouring drinks

Exacerbating:

• stress + anxiety
• faituge
• extremes of temperature

Relieved:

• alcohol
• disappears during sleep

Question 5

What is the treatment for essential tremor?

Answer 5

Only require treatment if tremor is becoming invasive in life and affecting abilities to carry out ADL

Betablockers i.e. propranolol used
Primidone is used if betablockers not tolerated
Benzo (alprazolam)= should be avoided due to problems with dependence and tolerance

Question 6

What are the features of Parkinon’s rest tremor?

Answer 6

Unilateral
Pill polling
Re-emergent tremor i.e. delay of >2 seconds for tremor to re-emerge after moving to different posisiton
Can involve jaw or lip tremor

Question 7

What are the differential diagnosis for an essential tremor?

Answer 7

Parkinson’s disease 
MS
Huntingtons chorea
Hyperthyroidism 
Fever 
Medication i.e. antipsychotics or salbutamol

Question 8

What is an orthostatic tremor?
When does it present?
What relieves the tremor?
How is it treated?

Answer 8

NOTE= RARE
High frequency tremor (13-18 Hz) in the legs which is most frequently seen in males in their 60s, can be felt by palpitating the legs i.e. quads + gastroc

On standing

Sitting/walking/leaning

Clonazepem

Question 9

What is a dystonic tremor?
When does it present?
How is it treated?

Answer 9

Irregualr jerky rhythm and amplitude which can be rest, posture or kinetic
Can be task or position specific

Clonazepem
Botulinum toxin injections to neck muscles

Question 10

What is a cerebellar tremor?

What are the possible causes?

Answer 10

Irregular high amplitude postural and action tremor
I.e. can present as past-pointing and over-shooting
Low frequenct i.e. <5Hz

Posterior circulation stroke 
Neurodegenerative diseases
Wilson’s disease 
MS
Drugs i.e. antiepileptic or alcohol 
Tumours 
Infections