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:

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

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

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

FIRE: Focused Initial Rapid Evaluation

Paitent presenting with new-onset tremors

Is the tremor physiological in nature?

Yes

No

Rule out anxiety, Excessive Caffine 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 [...] 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 the tremor? •Any pain associated with tremors? •Any neurological deficits? •Are any medications being taken for tremors? •Use of any caffeinated products •History of diarrhea , weight loss or heat intolerance •Is there any family history of tremors?

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 tremors 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 tremors are best exhibited with arms held outstretched. • Abnormal posturing of the tremors 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 Tests • 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 Disease

Neurogical Signs/Symptoms?

Parkinsonism

Alcohol Use Disorder?

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

IF No, it is likely Essential tremor.

Withdrawl or Alcohol tremor

Postural/Intentional Tremor?

Postural Essential Tremor

Intentional Cerebellar Tremor

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] 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

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Don'ts

• The content in this section is in bullet points.