This document provides an overview of approaches to diagnosing and classifying tremors. It discusses the definition of tremor, common classifications based on phenomenology, frequency, amplitude and anatomical distribution. Common tremor syndromes like essential tremor and Parkinson's tremor are described. The document outlines the examination process for different tremor types and the typical diagnostic workup. It emphasizes that the history, body parts affected, tremor characteristics and family history are important for diagnosis.

1. APPROACH TO TREMOR
Dr Sandhya Manorenj ,Associate Professor, Department t of Neurology,
Deccan College of Medical Sciences,Hyderabad,Telangana
28/1/18

2. CONTENTS OF PRESENTATION
• Introduction
• Definition
• Classifications
• Common tremor syndromes
• Other diseases with tremor
• Examination in a case of tremor
• Diagnostic work up in a case of tremor
• Conclusion
• Assessment/Questions
Sandhya Manorenj

3. INTRODUCTION
• Tremors are commonly encountered in clinical practice and are the most common
movement disorders seen.
• Tremor is a hyperkinetic movement disorder.
• Its prevalence is more ,but a large number of patients do not seek medical advice
and treatment, as usually it is mild and is not disabling.
• Prevalence: Seen in 5% of the population over age of 40 years.
Deuschl G, Bain P, Brin M. Consensus statement of the movement disorder society on tremor. Ad Hoc Scientific
Committee. Mov Disord. 1998;13(Suppl 3):2–23. Sandhya Manorenj

4. DEFINITION
• It is defined as a rhythmic, involuntary oscillatory movement of a body part around
one or more joints. [RIO].
• Tremor has a relatively constant frequency and variable amplitude.
• It is produced when there are alternating and synchronous contractions of
reciprocally innervated agonistic and antagonistic muscles that cause a symmetrical
displacement about the midpoint of the movement in both the directions.
Daschle G, Bain P, Brin M. Consensus statement of the movement disorder society on tremor. Ad Hoc Scientific Committee. Mov Disord. 1998;13(Suppl 3):2–23.

5. CLASSIFICATIONS ACCORDING TO
PHENOMENOLOGY
Tremor
Resting tremor Action tremor
Postural tremor Isometric
tremor
Kinetic tremor
Sandhya Manorenj

6. CLASSIFICATIONS

7. CLASSIFICATIONS ACCORDING TO
FREQUENCY AND AMPLITUDE
Frequency
• Very Low frequency: (2-4Hz) Holmes and
cerebellar tremor.
• Low freq ( 3-6Hz): PD rest tremor
• Medium to High freq (8-12 Hz):ET,EPT
• Very high freq (14-16Hz) : Orthostatic tremor
• Variable frequency: Psychogenic tremor
Amplitude
• Low amplitude : EPT
• Medium amplitude : PD,ET
• Large amplitude: Cerebellar
Sandhya Manorenj

8. CLASSIFICATIONS BASED ON
ANATOMICAL DISTRIBUTION
• Head and neck tremors: ET, Dystonic, cerebellar, rarely PD
• Palatal tremor : Primary or secondary
• Jaw tremor: PD,ET, hereditary geniospasm, Orthostatic tremor.
• Voice tremor : ET,dystonic voice tremor
• Hands: ET, PD, cerebellar, Enhanced physiological tremor.
• Toes and feet : PD
• Legs : Orthostatic tremor,PD
• Lip tremor: PD,ET
• Tongue tremor : ET
Sandhya Manorenj

9. GRADING OF TREMOR IN
PARKINSONS DISEASE

10. COMMON TREMOR SYNDROMES
• Essential Tremors. ( Second common)
• Tremor of Parkinsonism (third common)
• Dystonic tremors
• Psychogenic tremors
• Wing beating tremors
• Cerebellar tremors
• Enhanced physiological tremors: Most common tremor

12. DYSTONIC TREMOR SYNDROME
dystonic tremor: Tremor in dystonia involves most commonly the head or arm,
followed by the jaw, facial, or voice tremor and least the legs.
• In dystonic tremor, dystonia as well as tremor (postural/kinetic) is simultaneously present in
the same body part, for example, dystonic head tremor. This tremor is position specific.
Dystonic head tremor differs from essential head tremor by being jerky, more pronounced
when the head is turned to one side and by its persistence while lying down.
• tremor associated with dystonia (TAWD):characterized by the presence of tremor in one
body part and dystonia in another, for example, postural tremor in hands with cervical
dystonia
• dystonia-gene associated tremor: presence of tremor in a patient who has family history of
dystonia

13. DRUGS INDUCED TREMOR

14. OTHER DISEASES WITH TREMOR
• Fragile X tremor ataxia
• Palatal tremors
• Holmes tremor
• Thalamic tremor
• Neuropathic tremor syndromes.
• Spinocerebellar ataxia type 12
• Hereditary chin tremor or hereditary geniospasm

15. EXAMINATION IN A CASE OF
TREMOR
• For Rest tremor
• https://youtu.be/7uhT2ipQpKs

16. EXAMINATION FOR A POSTURAL
TREMOR
• Ask the patient to keep arms outstretched in front with palms up, palms down and
palms facing each other for 10 -15 sec
• Ask patients to keep arm outstretched ,bent in elbow with fingers near the nose but
not touching each other.
• Check for re-emergent tremor.
• Lateral wing beating posture is held for
20 sec

17. EXAMINATION FOR A KINETIC
TREMOR
• Several voluntary tasks
• Finger nose test
• Poring from a glass to another
• Drinking from a cup
• Holding a glass
• Writing, Dot approximation test for 10 sec
• Draw archimedis spiral [ lines of spiral should be 1.3 cm or 0.5 inch apart]
• Ask to hold a note aaaaa,eeeee for 5 sec
• Ask to do any other task which patient may have noted to bring on tremor
Sandhya Manorenj

18. ARCHIMEDIS SPIRAL

19. Cervical dystonia
Orthostatic tremor
Lateral wing beat
tremor posture
Parkinsonism

20. DIAGNOSTIC WORK UP IN A CASE
OF TREMOR
Routine blood tests including sugar level
Thyroid function tests
Calcium,Phosphorous
Review of intake of drugs
Exclude wilsons diseae
Toxic screen in selected cases
Non contrast CT scan brain
NCV study ,tremerogram,acclerometry,EMG computer tracking
Porphyria
MRI brain in selected cases

21. SEVERITY OF TREMOR
• TETRAS scale for ET
• Archiemdis spiral grading
• Clinical rating scale
• Effect on ADL -- Disability,handicap,QOL,Overall impact or burden

22. FLOW CHART :APPROACH TO
TREMOR
Tremor
No
yes Symmetrical
Asymmetrical
Enhanced tremor (EPT),drug
induced,toxin,alcohol
Cerebellar degenerative
Essential tremor
PD,Dystonic
tremor,Psychogenic tremor
Max amplitude,
body part
effected
Family history positive
ET,FXTAS,SCA 12,YOPD
Sandhya Manorenj

23. CONCLUSION
• Appropriate history, part of body affected, tremor phenomenology, associated
feature, past and family history can help easily in diagnosis.
• In PD ,tremor become less prominent when part of the body is in action.

24. QUESTIONS
• Prevalence of tremor? Definition
• Most common tremor?
• Re-emergent tremor? Grading of PD tremor
• Symmetrical tremor ?
• Positive family history?
• Archimedis spiral distance between 2 spirals
• Null Phenomenon seen in which tremor?
• Alcohol relief of symptoms?
Drugs inducing tremors?