Tremor resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usman Ali Akbar, M.B.B.S.[2]

Synonyms and keywords: Approach to tremors, Approach to movement disorders, Approach to Resting Tremors, Approach to Essential Tremors.

Tremor resident survival guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Tremor can be defined as involuntary, rhythmic, and oscillatory movement of the concerned body parts which can be caused by alternating or synchronous contractions of antagonistic muscles. Tremors have a broad etiology and can have overlapping characteristics. Classification and diagnosis of tremors is usually based on history, tremor frequency, severity, associated neurological signs, or sometimes a family history. Diagnosing the type and etiology of the tremor is important as prompt treatment can improve the quality of life in patients. Treatment is most of the time based on the etiologies but sometimes isolated tremors can be treated by certain medications.

Causes

The causes of tremor are vast and overlapping in nature.According to the International Parkinson and Movement Disorder Society tremors can be classified on the base of etiological agents as follows.

Causes of Tremors

Postural Tremors	Resting Tremors	Intention Tremors	Complex Tremors
Postural tremors can occur when the patient maintains a specific posture such as holding the arms outstretched or while standing. Causes : Alcohol & drug withdrawal Metabolic causes Parkinson's disease Parkinsonian syndromes Midbrain (rubral) tremor Wilson's disease Severe essential tremor	Rest tremor presents as the affected body part fully supported against gravity. It occurs at rest and can be abolished during voluntary activity. Causes : Progressive supranuclear palsy Drug-induced parkinsonism Parkinson's disease	Intention tremors can be characterized by a crescendo increase in tremor as the affected body part approaches its target. Causes : Drug-induced Cerebellar lesions: Friedreich's ataxia Hemorrhage Multiple sclerosis Spinocerebellar degeneration Stroke Tumor	Neuropathic tremor: •Chronic relapsing polyneuropathy •Guillain-Barré syndrome •Diabetes •IgM neuropathy Holmes' tremor (midbrain, red nucleus, rubral, or thalamic tremor) Other Psychogenic tremor Wilson's disease
Essential Tremors: Essential tremor is usually progressively persistent coarse or fine, slow (4–8 Hz) tremor. It is usually symmetric and affecting both upper extremities and sometimes the head and voice. A family history of ET is usually present. Physiological Tremor: Physiological tremor is a fine, rapid (8–13 Hz) tremor that occurs in otherwise healthy people.

FIRE: Focused Initial Rapid Evaluation

• A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

Paitent presenting with new-onset tremors

Is the tremor physiological in nature?

Yes

No

Rule out anxiety, Excessive Caffeine intake,blood glucose level,thyroid function tests

Medication Associated Tremor?

Yes

No

Trial off medication

Relieved by distraction?

Yes

No

Psychiatric Evaluation

Rule out Organic Cause

Diagnosis

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the American Academy of Neurology guidelines.

Patiet with history of tremor

History •Ask about age of onset •The involved body regions •Any precipitating or supressing factor? •Is the patient aware of thetremor? •Any pain associated with tremors? •Any neurological deficits? •Are any medications being taken for tremor? •Use of any caffeinated products •History of diarrhea , weight loss or heat intolerance •Is there any family history of tremor?

Neurological Examination Focused Neurological Examination should be conducted and following features should be assessed. • Are the movements recurrent and oscillatory? • Which joints are involved in the movements? • Does the tremor in each arm occur in phases? • IS the tremor has an emergent quality? • Does the tremor occurs in flexed posturing or dystonic posturing? • Is the tremor increases or decreases while performing a task? Assessment of the following features should be done • Does the tremor worsen when approaching a target? • What is the severity and frequency of the tremor? • Postural & Kinetic tremor are best exhibited with arms held outstretched. • Abnormal posturing of the tremor in fingers, hand, or upper limb is required to rule out dystonic tremor. • Functional tremor vary in frequency and amplitude. • Parkinsonian tremor is exhibited by repetitive movements of the contralateral hand during walking.

Laboratory Investigations •Laboratory evaluation should include • Thyroid Function Test • Serum copper and ceruloplasmin levels to exclude Wilson disease • Screening for heavy metal poisoning •Blood Glucose level to rule out hypoglycemia • Blood tests to rule out pheochromocytoma • Essential tremor and Parkinsonian tremor can be differentiated with the help of striatal dopamine transporter imaging (DaTscan) • MRI to exclude rubral or Holmes tremor • Quantitative computerized analysis of tremor

Age less than 40 years

Yes

No

Serum Ceruloplasmin level and 24 hour urinary copper secretion

Rest or action tremor ?

YES

NO

Rest tremor + Signs of Parkinsonism ( Rigidity,bradycardia,postural instability?)

Action tremor ?

Wilson's Disease

Neurogical Signs/Symptoms?

Parkinsonism

Alcohol Use Disorder?

If present, evaluate for metabolic,genetic or anatomic abnormalities with brain imaging.

IF No, it is likely Essential tremor.

Withdrawal or Alcohol tremor

Postural/Intentional tremor?

Postural Essential Tremor

Intentional Cerebellar tremor

Treatment

Shown below is an algorithm summarizing the treatment of Tremors according to the American Academy of Neurology guidelines.

Type of Tremor

Rest Tremor

Enhanced Physiological Tremor

Essential Tremor

Orthostatic Tremor

Cerebellar Tremor

Rubural Tremor

Dystonic Tremor

Rest Tremor Resting Tremors is associated with Parkinson's disease and other movement disorders. Management Depends upon treating the underlying disorders. Drugs used for Parkinson's such as amantadine, dopamine agonists, levodopa are used. Tremors refractory to these interventions can be treated with deep brain stimulation.

Enhanced Physiological Tremor Removal of the offending agent Treatment of underlying endocrine disorders such as hyperthyroidism Propranolol should be taken in situations that can exacerbate these tremors.

Essential Tremor Essential tremor can be treated with propranolol and primidone. Refractory conditions can be treated with agents such as topiramate and gabapentin. Medically Refractory ET can be treated with Deep brain stimulation.

Orthostatic Tremor Orthostatic Tremor can be treated with benzodiazepines e.g, clonazepam. Deep brain stimulation has shown modest improvement in some studies .

Cerebellar Tremor Deep brain stimulation of the ventral intermediate nucleus of the thalamus can be helpful in some cases.

Rubural Tremor Rubral tremors can sometimes be treated with levodopa therapy.

Dystonic Tremor Dystonic tremors can be treated with botulinum toxin injections into affected muscles.

Do's

• Treatment of underlying disorder should be the primary approach.
• Some medications or drugs can exacerbate tremors. Patients should avoid those drugs and should not use them unless prescribed by the physician.
• Most tremors sometimes don't have a cure developed yet. Patients should be counseled about the disease, treatment, and prognosis of the disease.
• Sleep can affect some tremors. Getting enough sleep hours can reduce the frequency and severity of some tremors.
• Stress and anxiety can also worsen tremors. Deep breathing exercises and meditation can help reduce stress and anxiety levels.

Don'ts

• Caffeine, ma huang, ephedra, and drugs that can increase heart rate should be avoided as they can cause a temporary increase in tremor.
• Patients should be advised to write in small letters than large letters.
• Patients should be advised to use light-weight cups.
• Dental visits should be conducted with adrenaline-free anesthesia shots.