Tremor classification: Difference between revisions

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Latest revision as of 19:30, 25 February 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S [2]

Overview

Tremor may be classified into resting or action tremor. Action tremor includes postural, kinetic (simple or intentional), isometric and task-specific tremor.

Classification

Tremor may be classified into two main groups: ^[1]^[2]

Resting tremor: Occurs when the body is not moving and is at rest, the muscle is relaxed and supported against gravity. It could occur in hands, legs, or arms. Resting tremor decreases in intensity with targeted movement. Parkinson's disease and drug-induced parkinsonism exhibit resting tremors. Other causes of resting tremor are Wilson's disease, dystonia, rubral tremor (brainstem lesion), and progressive supranuclear palsy.
Action Tremor: Could occur with any voluntary movement. It is further classified into:
- Postural Tremor: Increases with voluntary movement. Physiologic tremor, essential tremor, drug or alcohol withdrawal and metabolic changes in thyroid, kidney, liver may result in postural tremor.
- Kinetic Tremor:
  - Simple kinetic: Not affected by targeted movement. Occurs with normal limb movement.
  - Intentional tremor: Increases in intensity by targeted movement. Observed in cerebellar lesion caused by stroke, multiple sclerosis or tumor, spinocerebellar ataxia, vitamin E deficiency and lithium or alcohol toxicity.
- Isometric tremor: Voluntary contraction of muscle against a heavy/rigid/stationary object. For instance, making a fist, using one hand to hold a heavy object, or pushing against a wall.
- Task-induced tremor: Occurs when performing a highly skilled task, handwriting tremor, or musicians tremor.

References

↑ Deuschl G, Bain P, Brin M (1998). "Consensus statement of the Movement Disorder Society on Tremor. Ad Hoc Scientific Committee". Mov Disord. 13 Suppl 3: 2–23. doi:10.1002/mds.870131303. PMID 9827589.
↑ Charles PD, Esper GJ, Davis TL, Maciunas RJ, Robertson D (1999). "Classification of tremor and update on treatment". Am Fam Physician. 59 (6): 1565–72. PMID 10193597.

[pmid9827589-1] Deuschl G, Bain P, Brin M (1998). "Consensus statement of the Movement Disorder Society on Tremor. Ad Hoc Scientific Committee". Mov Disord. 13 Suppl 3: 2–23. doi:10.1002/mds.870131303. PMID 9827589.

[pmid10193597-2] Charles PD, Esper GJ, Davis TL, Maciunas RJ, Robertson D (1999). "Classification of tremor and update on treatment". Am Fam Physician. 59 (6): 1565–72. PMID 10193597.

[1]

[2]

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 __NOTOC__
 {{Tremor}}
-Please help WikiDoc by adding content here.  It's easy!  Click  [[Help:How_to_Edit_a_Page|here]]  to learn about editing.
-{{CMG}}
+{{CMG}}; {{AE}} {{ZMalik}}
 ==Overview==
+Tremor may be [[classified]] into resting or action tremor. Action tremor includes [[postural]], [[kinetic]] (simple or intentional), [[isometric]] and task-specific tremor.
 ==Classification==
-Tremor is most commonly classified by clinical features and cause or origin. Some of the better known forms of tremor, with their symptoms, include the following:
+Tremor may be classified into two main groups: <ref name="pmid9827589">{{cite journal| author=Deuschl G, Bain P, Brin M| title=Consensus statement of the Movement Disorder Society on Tremor. Ad Hoc Scientific Committee. | journal=Mov Disord | year= 1998 | volume= 13 Suppl 3 | issue=  | pages= 2-23 | pmid=9827589 | doi=10.1002/mds.870131303 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9827589  }} </ref><ref name="pmid10193597">{{cite journal| author=Charles PD, Esper GJ, Davis TL, Maciunas RJ, Robertson D| title=Classification of tremor and update on treatment. | journal=Am Fam Physician | year= 1999 | volume= 59 | issue= 6 | pages= 1565-72 | pmid=10193597 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10193597  }} </ref>
+*'''Resting tremor''': Occurs when the [[body]] is not moving and is at rest, the [[muscle]] is relaxed and supported against [[gravity]]. It could occur in [[hands]], [[legs]], or [[arms]]. Resting tremor decreases in intensity with targeted movement. [[Parkinson's disease]] and [[drug]]-induced [[parkinsonism]] exhibit [[resting tremors]]. Other [[causes]] of resting tremor are [[Wilson's disease]], [[dystonia]], [[rubral]] tremor ([[brainstem]] [[lesion]]), and [[progressive supranuclear palsy]].
-* '''[[Essential tremor]]''' (sometimes called benign essential tremor) is the most common of the more than 20 types of tremor.  Although the tremor may be mild and nonprogressive in some people, in others, the tremor is slowly progressive, starting on one side of the body but affecting both sides within 3 years. The hands are most often affected but the head, voice, tongue, legs, and trunk may also be involved.  Head tremor may be seen as a “yes-yes” or “no-no” motion. Essential tremor may be accompanied by mild gait disturbance. Tremor frequency may decrease as the person ages, but the severity may increase, affecting the person’s ability to perform certain tasks or activities of daily living.  Heightened emotion, stress, fever, physical exhaustion, or low [[blood sugar]] may trigger tremors and/or increase their severity.  Onset is most common after age 40, although symptoms can appear at any age.  It may occur in more than one family member. Children of a parent who has essential tremor have a 50 percent chance of inheriting the condition. Essential tremor is not associated with any known pathology.
+*'''Action Tremor''': Could occur with any [[voluntary]] [[movement]]. It is further classified into:
+**[[Postural]] Tremor: Increases with voluntary movement. [[Physiologic tremor]], [[essential tremor]], [[drug]] or [[alcohol]] [[withdrawal]] and [[metabolic]] changes in [[thyroid]], [[kidney]], [[liver]] may result in [[postural]] tremor.
-* '''[[Parkinsonian]] tremor''' is caused by damage to structures within the brain that control movement.  This resting tremor, which can occur as an isolated symptom or be seen in other disorders, is often a precursor to [[Parkinson's disease]] (more than 25 percent of patients with Parkinson’s disease have an associated action tremor). The tremor, which is classically seen as a “pill-rolling” action of the hands that may also affect the chin, lips, legs, and trunk, can be markedly increased by stress or emotions.  Onset of parkinsonian tremor is generally after age 60. Movement starts in one limb or on one side of the body and usually progresses to include the other side.
+**Kinetic Tremor:
+***Simple [[kinetic]]: Not affected by targeted movement. Occurs with normal [[limb]] movement.
-* '''[[Dystonic]] tremor''' occurs in individuals of all ages who are affected by [[dystonia]], a movement disorder in which sustained involuntary muscle contractions cause twisting and repetitive motions and/or painful and abnormal postures or positions.  Dystonic tremor may affect any muscle in the body and is seen most often when the patient is in a certain position or moves a certain way.  The pattern of dystonic tremor may differ from essential tremor. Dystonic tremors occur irregularly and often can be relieved by complete rest. Touching the affected body part or muscle may reduce tremor severity (a [[geste antagoniste]]).  The tremor may be the initial sign of dystonia localized to a particular part of the body.
+***[[Intentional tremor]]: Increases in intensity by targeted movement. Observed in [[cerebellar]] lesion caused by [[stroke]], [[multiple sclerosis]] or [[tumor]], [[spinocerebellar ataxia]], [[vitamin E deficiency]] and [[lithium]] or [[alcohol]] [[toxicity]].
+**Isometric tremor: Voluntary contraction of [[muscle]] against a heavy/rigid/stationary object. For instance, making a fist, using one hand to hold a heavy object, or pushing against a wall.
-* '''[[Cerebellar]] tremor''' (also known as "intention tremor") is a slow, broad tremor of the extremities that occurs at the end of a purposeful movement, such as trying to press a button or touching a finger to the tip of one’s nose. Cerebellar tremor is caused by lesions in or damage to the cerebellum resulting from stroke, tumor, or disease such as multiple sclerosis or some inherited degenerative disorder.  It can also result from chronic alcoholism or overuse of some medicines. In classic cerebellar tremor, a lesion on one side of the brain produces a tremor in that same side of the body that worsens with directed movement. Cerebellar damage can also produce a “wing-beating” type of tremor called rubral or Holmes’ tremor — a combination of rest, action, and postural tremors. The tremor is often most prominent when the affected person is active or is maintaining a particular posture. Cerebellar tremor may be accompanied by other manifestations of [[ataxia]], including [[dysarthria]] (speech problems), [[nystagmus]] (rapid, involuntary rolling of the eyes), gait problems and postural tremor of the trunk and neck.
+**Task-induced tremor: Occurs when performing a highly skilled task, handwriting tremor, or musicians tremor.
-* '''[[Psychogenic]] tremor''' (also called hysterical tremor) can occur at rest or during postural or kinetic movement. The characteristics of this kind of tremor may vary but generally include sudden onset and remission, increased incidence with stress, change in tremor direction and/or body part affected, and greatly decreased or disappearing tremor activity when the patient is distracted. Many patients with psychogenic tremor have a [[conversion disorder]] or another psychiatric disease.
-* '''[[Orthostatic]] tremor''' is characterized by fast (>12Hz) rhythmic muscle contractions that occur in the legs and trunk immediately after standing. Cramps are felt in the thighs and legs and the patient may shake uncontrollably when asked to stand in one spot.  No other clinical signs or symptoms are present and the shaking ceases when the patient sits or is lifted off the ground. The high frequency of the tremor often makes the tremor look like rippling of leg muscles while standing. Orthostatic tremor may also occur in patients who have essential tremor.
-* '''[[Rubral]] tremor''' is characterized by coarse slow tremor which is present at rest, at posture and with intention. This tremor is associated with conditions which affect the red nucleus in the midbrain, classically unusual strokes.
-* '''[[Physiologic]] tremor''' occurs in every normal individual and has no clinical significance. It is rarely visible to the eye and may be heightened by strong emotion (such as anxiety or fear), physical exhaustion, [[hypoglycemia]], [[hyperthyroidism]], heavy metal poisoning, stimulants, alcohol withdrawal or [[fever]]. It can be seen in all voluntary muscle groups and can be detected by extending the arms and placing a piece of paper on top of the hands. Enhanced physiologic tremor is a strengthening of physiologic tremor to more visible levels. It is generally not caused by a neurological disease but by reaction to certain drugs, alcohol withdrawal, or medical conditions including an overactive thyroid and hypoglycemia. It is usually reversible once the cause is corrected.
-===Categories===
-The degree of tremor should be assessed in four positions. The tremor can then be classified by which position most accentuates the tremor: <ref name="pmid7001967">Jankovic J, Fahn S. Physiologic and pathologic tremors. Diagnosis, mechanism, and management. Ann Intern Med. 1980;93:460-5. PMID 7001967</ref>
-{| class="wikitable"
-| '''Position''' || '''Name''' || '''Description'''
- |-
- | At rest || Resting tremors || Tremors that are worse at rest include Parkinsonian syndromes and essential tremor if severe. This includes drug-induced tremors from blockers of [[dopamine receptors]] such as [[haloperidol]] and other [[antipsychotic]] drugs.
- |-
- | During contraction (eg a tight fist while the arm is resting and supported) || Contraction tremors || Tremors that are worse during supported contraction include essential tremor and also cerebellar and exaggerated physiologic tremors such as a hyperadrenergic state or hyperthyroidism<ref name="pmid7001967">.</ref>. Drugs such as [[adrenergic]]s, [[anti-cholinergic]]s, and [[xanthine]]s can exaggerate physiologic tremor.
- |-
- | During posture (eg with the arms elevated against gravity such as in a 'bird-wing' position) || Posture tremors || Tremors that are worse with posture against gravity include [[essential tremor]] and exaggerated physiologic tremors<ref name="pmid7001967">.</ref>.
- |-
- | During intention (eg finger to nose test) || Intention tremors|| [[Intention tremor]]s are tremors that are worse during intention, e.g. as the patient's finger approaches a target, including cerebellar disorders.
-|}
 ==References==
 {{Reflist|2}}
-[[Category:Needs content]]
+[[Category: Neurology]]
+[[Category:Primary care]]
+[[Category:Up-to-date]]
+[[Category:Signs and symptoms]]
+[[Category:Medicine]]

Tremor classification: Difference between revisions

Latest revision as of 19:30, 25 February 2021

Overview

Classification

References

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