This is the third presentation after approach to dystonia and approach to chorea . This one is based upon the concensus statement on tremor by MDS. The original article is a practical ready reckoner in clinical practice. Comments are welcome .

1. Clinical approach to tremor
Dr Srimant Pattnaik
DM PDT Neuromedicine
BIN , Kolkata

3. • Most common movement disorder
encountered in clinical practice
• Defined as : “Involuntary , rhythmic,
oscillatory movement of a body part.”
• Frequency and amplitude of oscillation is
relatively constant

4. Axis 1
Tremor syndrome
Axis 2
Clinical features
Etiology

5. et

7. Points in history
• Age at onset
• Temporal onset and evolution
• Past medical history
• Family history
• Alcohol and drug sensitivity

8. Tremor characteristic
• Body distribution / Topography
• Activation condition
• Tremor frequency

9. Body distribution
• focal : only one body region is affected, such as
voice, head, jaw, one limb, etc.
• segmental :when two or more contiguous body
parts in the upper or lower body are affected e.g.,
head and arm, or when tremor is bibrachial or
bicrural
• hemitremor :when one side of the body is
affected
• generalized :when tremor affects the upper and
lower body

18. ACTION OR REST TREMOR

22. Types of essential tremor

23. Isolated segmental action or postural
tremor
• Many patients from this category ultimately
fulfil the criteria for ET
• Some may develop dystonia later

24. Enhanced physiological tremor
• Defined as : Symptomatic upper extremity
action tremor that is potentially reversible if
the cause of the trem or is eliminated.
• It is caused by enhancement of the normal
mechanical reflex and 8- to 12-Hz central
neurogenic oscillations of physiological tremor
by a variety of reversible conditions.
• anxiety, fatigue, hyperthyroidism, drugs

26. • D/D of EPT
1. ET
2.cortical myoclonus

27. Isolated rest tremor syndromes
• Carefully look for associated symptoms
• DaT scan may be necessary to exclude a
parkinsonian condition
• Patients with isolated rest tremor with normal
DaT scan are sometimes considered to have
dystonia
• Striatal dopaminergic deficiency without nigral
degenration is a possibility

28. ISOLATED FOCAL TREMORS

29. ISOLATED VOICE TREMOR
• a visible and/or audible tremor of the vocal
apparatus.
• No signs of tremor/dystonia elsewhere

30. Isolated head tremor
• shaking of the head in yes-yes, no-no, or
variable directions

31. Rare focal tremors
• Hereditary geniospasm
• isolated jaw tremor
• isolated tongue tremor
• rabbit syndrome
• tremor during smiling(risus tremulous)

32. Palatal tremor (rhythmic movement
of the soft palate at 0.5 to 5 Hz)
ESSENTIAL PALATAL TREMOR
• Isolated tremor syndrome
• Tensor veli palatini
• Ear click
• Extremity , eye not involved
• Inferior olive normal
SYMPTOMATIC PALATAL TREMOR
• Combined tremor syndrome
• Levator veli palatini
• No ear click
• Extremity ,eye involved
• Pseudohypertrophy of
inferior olive

33. TASK AND POSITION SPECIFIC TREMOR

34. • Primary writing tremor
• Primary Bowing tremor
• Should be differentiated from similar
condition having dystonia

35. ORTHOSTATIC TREMOR

36. • Primary orthostatic tremor is a generalized
highfrequency (13-18 Hz) isolated tremor
syndrome that occurs when standing.
• Confirmation of the tremor frequency is
needed, typically with an electromyography
• Helicopter sign

39. TREMOR SYNDROMES WITH PROMINENT ADDITIONAL SIGNS

40. Dystonic tremor
• Dystonic tremor syndromes are tremor
syndromes combining tremor and dystonia as
the leading neurological signs.
• Dystonic tremor should be differentiated from
TAWD, though pathophysiologically they are
similar
• Dystonic tremor associated with Geste
Antagoniste, null point phenomenon,
overflow to adjoining areas etc.

41. Tremor associated with parkinsonism

43. Intention tremor
• Intention tremor syndromes consist of
intention tremor at <5 Hz, with or without
other localizing signs
• usually caused by a lesion in the
cerebellothalamic pathway

44. Holmes tremor
• Holmes tremor is a syndrome of rest, postural,
and intention tremor that usually emerges from
proximal and distal rhythmic muscle contraction
at low frequency (<5 Hz)
• Due to disruption of dentato rubro thalamic
circuit
• Stroke, trauma, tumor among most common
cause
• Delay as long as 2 years may be seen between
insult and clinical manifestation, due to neuronal
plasticity

45. Myorythmia
• Myorhythmia is a hyperkinetic involuntary
movement disorder characterized by slow (1-4
Hz) rhythmic movement, typically affecting
the cranial or limb muscles

46. Myorythmia: contd

47. OTHERS

48. Functional tremor syndrome
• Among all the psychogenic movement
disorder, tremor is the most common
• Characterized by rest, postural and kinetic
tremor , most often seen in unision
• Characteristaically starts in both arms ,
spreads to head and legs

49. Clues from history
• Abrupt onset
• Changing tremor characteristics
• Episodic with spontaneous remissions
• Spontaneous recovery in one limb only to occur
in another limb
• Comorbid psychiatric illness
• History of psychological stressors/stressful
precipitating event
• History of other functional disorders

50. Examination
• Distractibility - Change in tremor amplitude/direction or
complete cessation of tremor on distracting the patient
with another task, for example, counting the months
backward, serial sevens, or finger tapping with the other
limb
• Variability - A constant change in the amplitude, frequency,
or the direction of the tremor
• Presence of whole body tremor
• Absence of finger tremors

51. • Ballistic movement test/pointing test Tremor in
the “involved” limb stops while a sudden ballistic
movement is performed by the unaffected limb
• Entrainment - The tremor in the affected limb
“takes on” the rhythm of the movement of the
opposite, unaffected limb, i.e., it gets “entrained.”
• Coherence entrainment test - Demonstrating that
two limbs are tapping at the same frequency
helps identify psychogenic tremors as two hands
cannot tap at different frequencies
simultaneously

52. • Suggestibility - Variation in the tremor with
certain suggested stimuli, for example, tuning
fork application to the affected limb and
suggesting that patient will have tremors at the
frequency that the fork is vibrating
• Coactivation sign - Simultaneous activation of
extensors and flexors in a limb before the
alternating pattern of contraction of muscles
develops clinically manifesting as increased tone
• Tremor moves from one limb to another
especially when the “tremulous” limb is held

53. • When the examiner places his hands firmly on the
tremulous limb, it gets exaggerated
• Loading of the limb with weights enhances the
amplitude of the tremor unlike a decrease seen in
physiological and pathological tremor
• “Give way” weakness on examination
• Spiral drawing - Draws a spiral with several pauses,
with parts of the drawing showing differing amplitude
and directions
• Gait - Has an irregular frequency, direction, deliberate
pauses
• Pull test - Exaggerated, but no fall

54. Indeterminate tremor
• This term is reserved for tremor not fitting
into any established tremor syndromes
• Needs further observation to clarify the
tremor syndrome

55. Neuropathic tremor
• Tremor developing in association with
neuropathy is termed as neuropathic tremor
• Association :
– Charcot-Marie Tooth disease,
– inflammatory neuropathies such as
• IgM-monoclonal gammopathy of undetermined significance
(IgM-MGUS),
• chronic inflammatory demyelinating neuropathy (CIDP),
• multifocal motor neuropathy with conduction block
(MMNCB),
• recovering Guillian Barre syndrome

56. Neuropathic tremor : contd
• Acivation state : rest or action
• Frequency : 3-6 Hz
• Topography : upper limbs

57. Examination of a tremulous patient
• Observe at rest : limb supported against
gravity
• Maneuvers to elicit subtle rest tremor :
cognitive –motor co-activation
• Check for re-emergent tremor

58. • Check for postural tremor by bringing hands in
front approximating , for 15-20 seconds
• Supinate arms to look for dystonic component
• Wing beating posture

59. • Finger-nose-finger for kinetic tremors
• Water pouring/drinking
• Handwriting
• Spiral drawing

62. Other specific examination
• Tachycardia
• Thyroid swelling
• Eyes for
– Movements
– KF ring
• Rigidity
• Cerebellar signs

63. Quantitative assessment of tremor
• Clinical
• Biomechanical
– Surface EMG
– Acclerometer
– Gyroscope

64. Clinical Scales for tremor assessment
• Tremor Research Group Essential Tremor
Rating Assessment Scale (TETRAS)
• The Fahn-Tolosa-Marin Tremor Rating Scale
• Bain and Findley Clinical Tremor Rating Scale
and spirography scale
• Washington Heights-Inwood Genetic Study of
Essential Tremor Tremor Rating Scale (WHIGET
version 2)

65. Surface EMG
• Physiological tremors don’t show any rhythmic activity on
EMG
• Quantifies pathological tremors in terms of frequency
• Gives mean amplitude of oscillations and not the absolute
amplitude
• Burst duration can be useful in identifying the type of
pathological tremor
• Can identify if tremor contractions are synchronous or
alternating
• Useful in studying upper limb pathological tremors
• Can record entrainment, coherence, distractibility, ballistic
movement in psychogenic tremors

66. Acclerometer
• Most common method used to electronically
evaluate a tremor
• Measures tremor amplitude and frequency
• Can detect sub-clinical cases of essential tremor
(ET)
• Study the effect of treatment
• Helps differentiate from other movements
• Wide variations in frequency and amplitude in
psychogenic tremors can be measured

67. • The tremor frequency is the same when
recording is made from several body parts in
psychogenic tremor whereas it differs in the 2
arms in ET
• Arm loading increases amplitude in psychogenic
tremors which is recordable
• Co-activation sign: tonic contraction of wrist
extensor and flexor can be demonstrated before
the alternating reciprocal tremor bursts develop
• Used intra-operatively to decide the best position
for the placement of electrodes during DBS

68. Gyroscope
• Gyroscopic transducers are similar to
accelerometers, but they measure angular
acceleration compared to the linear
acceleration measured by latter.
• They are also useful in quantifying
pathological tremor in terms of amplitude and
frequency.

69. Tremor stability index
• Measures the stability of tremor frequency over
time
• In ET, the frequency of tremor remains stable
only over a narrow range of frequencies, whereas
in Parkinson’s disease tremor the frequency can
remain stable over a much broader range.
• The instantaneous frequency of tremor and its
temporal evolution is readily revealed by
accelerometry