Image

References

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

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 - â2 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
  • Upcoming event

    Fun run
    26th Sep 2020 12:00am

    If you loved The Journey, this weekend of 26 September is the NTF Fun Run. Take the family for an autumn walk, go for a cycle around the park, take the dog for a jog, or complete the challenge however you like! This is also an opportunity to raise awareness of tremor whilst getting active and having fun. 

    Take part in the challenge, share your experience and pictures with the hashtag on Twitter #ntfchallenges.

    More info

The latest news from NTF