Resting tremor

resting tremor 1

1.  Rest tremor

Quick info:

Scope:

  • this page provides information on the different causes of rest tremor Definition:
  • rest tremor is present in a body part that is not voluntarily activated and is completely supported against gravity
  • often caused by Parkinson's disease and other causes of parkinsonism
  • however other causes of rest tremor should be considered Features of Parkinson's disease:
  • typical unilateral onset of tremor in hand and occasionally a leg
  • "pill rolling tremor" rare but a characteristic of Parkinson's disease
  • rest tremor present in 70% of Parkinson's disease patients (practical tip - to induce rest tremor ask patient to count down from 10 out loud)
  • Look for
    • facial or vocal impassivity
    • reduced arm swing on walking and shoulder shrug test (look for arm swing whilst shaking patient's shoulders)
    • cogwheel rigidity
    • bradykinesia
    • micrographia
    • postural instability
  • refer to a person with expertise in Parkinson's disease prior to instigating medication Main causes:
  • Parkinson's disease (see pathway)
  • other causes of parkinsonism
  • drug-induced tremor
  • dystonic tremor syndromes
  • severe essential tremor
  • Holmes tremor (also termed rubral)
  • psychogenic tremor
  • Wilson's disease
  • vascular parkinsonism - multiple system atrophy, progressive supranuclear palsy
  • drug induced parkinsonism - phenothiazines, metoclopramide, hydrocephalus, encephalitis, toxicity (eg. manganese) Investigations:
  • routine biochemistry, including thyroid function, liver function tests, calcium & phosphate
  • Other possible investigations:
    • to rule out Wilson's diseasecopper studies if <50 years old at onset, but still consider if >50 years
    • dopamine transporter scan
    • consider genetic tests in appropriate cases
    • in young people (less than age 30 years) consider diagnostic studies to rule out Wilson's disease

2.   Parkinson's disease suspected

Quick info:

Features of Parkinson's disease

  • typical unilateral onset of tremor in a hand and occasionally a leg
  • "pill rolling tremor" rare but characteristic of Parkinson's disease
  • rest tremor present in 70% of Parkinson's disease patients (practical tip - to induce rest tremor ask patient to count down from 10 out loud)
  • Look for:
    • facial or vocal impassivity
    • reduced arm swing on walking and shoulder shrug test
    • cogwheel rigidity
    • bradykinesia (slow movements with decrement)
    • micrographia
    • postural instability
  • refer to a person with expertise in Parkinson's disease prior to instigating medication 

3.  Psychogenic tremor

Quick info:

The following are clues to a psychogenic aetiology:

  • history:
    • sudden onset, remissions or both
    • unusual combinations of rest, postural or intention tremors
    • somatization in past medical history
  • consider medical causes for tremor with psychiatric illness (eg. Wilson's disease)
  • Examination:
    • decreased tremor amplitude during distraction
    • variations in tremor frequency with distractions or voluntary movements of the other hand (entrainment)
    • co-activation sign of psychogenic tremor (tremor only present when arm is voluntarily stiffened)
    • appearance of additional and unrelated neurological signs
    • finger tremor is unusual in psychogenic tremor
    • simple reflex time studies
  • consider other causes of tremor
  • focus of treatment should be predominantly psychological

4.   Drug-induced tremor

Quick info:

  • can be caused by numerous drugs or drug withdrawal
  • usually presents as postural tremor, but rest and/or intention tremors may occur
  • Commonly associated with:
    • alcohol
    • sympathomimetics
      • bronchodilators - รข2 agonists
      • theophylline
      • caffeine
      • dopamine
      • epinephrine and norepinephrine
    • lithium
    • sodium valproate
    • antipsychotic medication
    • anti-emetics (metoclopramide, prochlorperazine)
    • tricyclic antidepressants
    • corticosteroids
  1. any drug with a primary effect on the central nervous system can produce tremor as a side-effect 

5.   Holmes (rubral) tremor

Quick info:

  • Typically three tremor components are present: rest, postural tremorand intention tremor
  • often severe. The action tremor severity is usually greater than that of the rest component
  • slow (frequency <4.5Hz) irregular tremor
  • tends to involve proximal (action tremor) and distal (rest tremor) muscles
  • Holmes tremor has numerous causes including stroke, vascular malformations, tumours, head injury, toxoplasmosis, major tranquilizers, radiation)
  • typically 2 weeks to 2 years delay from causal lesion to tremor onset
  • lesions typically sited in midbrain or thalamus
  • structural imaging (MRI scan) recommended
  • dopamine transporter scan often abnormal
  • multiple sclerosis is a rare cause of Holmes tremor 

6.   Tremor with other neurological disease present

Quick info:

  • multiple sclerosis (predominantly postural and intention tremor)
  • peripheral neuropathy (predominantly postural and intention tremor)
  • Wilson's disease
  • hereditary ataxia

Download PDF: resting tremor

 

References

Prodigy. Parkinson's disease. Newcastle upon Tyne: PRODIGY; 2005.