Diagnosis and Treatment of Common Forms of Tremor

Andreas Puschmann, M.D.; Zbigniew K. Wszolek, M.D.

Disclosures

Semin Neurol. 2011;31(1):65-77. 

In This Article

Abstract and Introduction

Abstract

Tremor is the most common movement disorder presenting to an outpatient neurology practice and is defined as a rhythmical, involuntary oscillatory movement of a body part. The authors review the clinical examination, classification, and diagnosis of tremor. The pathophysiology of the more common forms of tremor is outlined, and treatment options are discussed. Essential tremor is characterized primarily by postural and action tremors, may be a neurodegenerative disorder with pathologic changes in the cerebellum, and can be treated with a wide range of pharmacologic and nonpharmacologic methods. Tremor at rest is typical for Parkinson's disease, but may arise independently of a dopaminergic deficit. Enhanced physiologic tremor, intention tremor, and dystonic tremor are discussed. Further differential diagnoses described in this review include drug- or toxin-induced tremor, neuropathic tremor, psychogenic tremor, orthostatic tremor, palatal tremor, tremor in Wilson's disease, and tremor secondary to cerebral lesions, such as Holmes' tremor (midbrain tremor). An individualized approach to treatment of tremor patients is important, taking into account the degree of disability, including social embarrassment, which the tremor causes in the patient's life.

Introduction

Tremor is defined as a rhythmical, involuntary oscillatory movement of a body part that is produced by alternating contractions of reciprocally innervated muscles.[1,2] It is the most commonly encountered movement disorder symptom, and is frequently evaluated and treated in family medicine, internal medicine, emergency medicine, and of course in neurology practices.[3,4] When assessing a patient with tremor, the phenomenology of the tremor, the presence or absence of other neurologic signs or symptoms, and the possible modifying influence of medications or alcohol are important factors to be determined. The patient's history and a targeted neurologic examination will usually suffice to diagnose the cause of the tremor.

A wide array of treatment modalities are available for tremor, and most depend on the type or the underlying cause of the tremor. Treatment is tailored individually, taking into account the objectively measurable tremor severity, the degree of disability or impairment experienced by the patient, including embarrassment in social situations, as well as the patient's preference among the various treatment options.[5] The majority of patients with tremor have relatively mild symptoms and some may benefit from reassurance alone. The overall effectiveness of pharmacologic treatments of tremor unfortunately remains mediocre, and patients frequently decide to discontinue such treatments. A fraction of patients with tremor has such severe symptoms that surgical procedures, such as deep brain stimulation (DBS), may be necessary. In this article, we provide the clinician with a review of the assessment, pathophysiology, and treatment of the more common forms of tremor.

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