Tremor
Diagnosis/Definition
Rhythmic oscillating movements by agonist and antagonist muscles around a fixed axis which are equal in frequency in both directions.
Initial Diagnosis and Management
- History with particular attention to medications, history of prior strokes, age of onset, suppression of tremor with alcohol consumption and family history of similar symptoms.
- Physical exam should define tremor as resting, coarse or fine, postural or intention tremor. Also, physical exam should look for evidence of cerebellar involvement, weakness or loss of proprioception.
- Laboratory studies should exclude hypoglycemia or thyrotoxicosis.
- With no other physical findings:
- Fine tremor with no other physical findings is likely physiologic and requires no treatment.
- Coarse postural tremor in patient on lithium or depakote is likely an effect of the medication, in which case, substitution with another medication, if possible, may resolve tremor.
- Coarse postural tremor with positive family history (familial essential tremor) in young patient suppressed by alcohol (essential tremor), or in elderly patient (senile tremor) can be given trial of medication if there are no contraindications. Usual agents are propranolol or primidone.
- Resting tremor with associated features (or without in early stages)-consider Parkinson’s Disease in the differential diagnosis.
Ongoing Management and Objectives
In patients with isolated tremor, the goal of therapeutic intervention is the reduction in the tremor to the point where it does not affect the functioning of the patient (i.e., their ability to write, eat or work) without the patient experiencing side-effects from the medications being used as treatment.
Indications for Specialty Care Referral
Diagnosis in doubt.
Asymmetric exam, weakness or coordination difficulties present.
Patient diagnosed with essential tremor, who has failed trials of appropriate medications.
Criteria for Return to Primary Care
Patient has responded to medical therapy or has failed trials of all appropriate therapeutic agents and has no other underlying etiology for their tremor.
