Tremors Overview

Tremor Type	Description	Etiology	Onset
Resting tremor	🔹 Pill-rolling	🔹 Idiopathic Parkinson disease
🔹 Side effect of neuroleptic medication	🔹 At rest	🔹 Rigidity
🔹 Bradykinesia
🔹 Postural instability	🔹 Action
Essential tremor	🔹 Fine	🔹 Hereditary	🔹 With certain sustained postures
🔹 Worse with voluntary movement or anxious state
🔹 Head tremor
🔹 Normal neurological examination	🔹 Alcohol
Physiologic tremor	🔹 Fine	🔹 Physiological	🔹 With certain postures
🔹 Enhanced with sympathetic stimulation	🔹 Normal neurological examination	🔹 Managing cause of sympathetic stimulation
Intention tremor	🔹 Coarse	🔹 Cerebellar lesion	🔹 Slow zigzag movement towards a target
🔹 Dysmetria (overshooting/undershooting target)	🔹 Ataxia
🔹 Hypotonia
🔹 Gait instability
🔹 Dysdiadochokinesia
🔹 Dysarthria
🔹 Nystagmus	🔹 Rest

Resting Tremor

Normal low-amplitude high-frequency
Fine, symmetric action (may also occur at rest) tremor of the hands that increases with sympathetic activity.
Can become apparent in high adrenergic states
- Anxiety
- Medications
  - Selective serotonin reuptake inhibitors
  - Beta-adrenergic agonists
  - Lithium
  - Tricyclic antidepressants
  - Nicotine
  - Caffeine
  - Corticosteroids
- Medical conditions
  - Hypoglycemia
  - Alcohol and opioid withdrawal
  - Thyrotoxicosis
  - Liver disease
<aside> 🧠 Lithium-enhanced physiologic tremor must be distinguished from tremor due to lithium toxicity

▷ Toxicity Tremor
- Typically causes an irregular, asymmetric, coarse tremor (🆚 Physiologic tremor which is symmteric)
- Involving multiple parts of the body (not just the hands)
- Accompanied by gastrointestinal or additional neurologic symptoms
- UWT - Lithium toxicity </aside>

High- frequency action tremor with sustained posture most commonly of hands/forearms
Worsened with movement or when anxious
Improved by alcohol

Coarse Tremor when approaching an object!