Tremor is a common neurological sign, but it has little diagnostic value unless it is properly characterized with a thorough history and physical exam. Broadly speaking, tremor may be the only physical abnormality (isolated tremor), or it may be combined with other neurologic or systemic signs (combined tremor). Essential tremor is the most common example of an isolated tremor syndrome, and rest tremor with parkinsonism is the most common combined tremor syndrome. However, there are many other isolated and combined tremor syndromes that occur in the elderly. These tremor disorders include dystonic tremor, action tremor with ataxia, focal and task-specific tremors, isolated bi-brachial tremor, and orthostatic tremor. Four tremor syndromes may occur acutely or subacutely: (1) whole body tremulousness with myoclonus, (2) isolated bi-brachial action tremor, (3) rest tremor with parkinsonism, and (4) focal or unilateral tremor with associated focal signs. The differential diagnosis and treatment of these tremor syndromes are summarized in this chapter.
KeywordsTremor Dystonia Ataxia Myoclonus Parkinson disease Essential tremor Tremor definition and classification
This work was supported by the Spastic Paralysis Research Foundation of Kiwanis International, Illinois-Eastern Iowa District.
Disclosures Rodger Elble receives research grant support from the Spastic Paralysis Research Foundation of Kiwanis International, Illinois-Eastern Iowa District, and he received consulting fees from Sage Therapeutics. He was also paid by InSightec to rate videotaped exams of patients undergoing thalamotomy with high-intensity focused ultrasound.
- 18.Zesiewicz TA, Elble RJ, Louis ED, Gronseth GS, Ondo WG, Dewey RB Jr, et al. Evidence-based guideline update: treatment of essential tremor: report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2011;77:1752–5. doi: 10.1212/WNL.0b013e318236f0fd. WNL.0b013e318236f0fd [pii].CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Witjas T, Carron R, Krack P, Eusebio A, Vaugoyeau M, Hariz M, et al. A prospective single-blind study of Gamma Knife thalamotomy for tremor. Neurology. 2015; doi: 10.1212/WNL.0000000000002087.
- 26.Pogarell O, Gasser T, van Hilten JJ, Spieker S, Pollentier S, Meier D, et al. Pramipexole in patients with Parkinson’s disease and marked drug resistant tremor: a randomised, double blind, placebo controlled multicentre study. J Neurol Neurosurg Psychiatry. 2002;72(6):713–20.Google Scholar
- 41.Contarino MF, Bour LJ, Schuurman PR, Blok ER, Odekerken VJ, van den Munckhof P, et al. Thalamic deep brain stimulation for orthostatic tremor: clinical and neurophysiological correlates. Parkinsonism Relat Disord. 2015;21(8):1005–7. doi: 10.1016/j.parkreldis.2015.06.008. CrossRefPubMedGoogle Scholar
- 42.Erro R, Schneider SA, Stamelou M, Quinn NP, Bhatia KP. What do patients with scans without evidence of dopaminergic deficit (SWEDD) have? New evidence and continuing controversies. J Neurol Neurosurg Psychiatry. 2015; doi: 10.1136/jnnp-2014-310256.