Activation | Kinetic (intentional component) > postural | Postural or kinetic |
(amplitude of kinetic > postural) | (amplitude of postural > kinetic) | |
Rest (in severe cases with action tremor) | Intentional component uncommon | |
Distribution | Hands (flexion/extension of wrist, bilateral) | Fingers > hands (+/− voice) |
Head, voice, jaw (with hands) | NOT head, jaw | |
Frequency | 4–10 Hz (decrease with age) | 8–12 Hz |
Changes with different tasks and different body parts | ||
Amplitude | Fine to large | Fine |
Aggravating /relieving factors | Alcohol responsiveness | Increase with stress, exercise, fatigue, caffeine |
Pathophysiology | Central oscillator in the cerebello-thalamo-cortical pathway | Sympathetic overactivity and increase sensitivity of peripheral components |
Weighting | Similar frequency | Decrease frequency |
Treatment | Beta-blocker, primidone, topiramate | Beta-blocker |
Surgery (DBS, MRI FUS thalamotomy) | Decrease aggravating factors | |
Assistive devices |
Symmetry | Asymmetry | Asymmetry | Symmetry (mostly) |
Activation | R > P > K | P ~ K > R | K > P >>> rest |
(Not intentional) | (Not intentional) | (Intentional) | |
**Suppression of rest tremor with movements** | Rest (can be early) | Rest (in severe cases with action tremor) | |
**Re-emergent tremor** | **position or task specific** | ||
Distribution | Hands (pill-rolling, rotation of wrist, forearm) > jaw, tongue > leg > head | Head > Hands > jaw Isolated head, voice, jaw | Hands >> head > voice > jaw (with hands in severe cases) |
Frequency | 4–7 Hz | 5–7 Hz | 4–10 Hz |
Amplitude | Large, waxing & waning | Large, irregular, jerky | Fine to large |
Association | Parkinsonism | Dystonic posture | Mild ataxia |
Non-motor symptoms: RBD, anosmia, constipation, depression | Null point (head), overflow/mirror dystonia, sensory trick | Non-motor symptoms: anxiety, depression, cognitive impairment | |
Family history | Usually absent in late onset | Sometimes present | Present in early onset |
Treatment | Dopaminergic agent (response 50%) | Anticholinergics | Beta-blocker, primidone, topiramate |
Anticholinergics | Botulinum toxin injection | Surgery (DBS, MRI FUS thalamotomy) | |
Surgery (DBS, FUS) | Assistive devices |
Movement | Oscillatory | Shock-like or jerky | Tonic/clonic |
Single or repetitive | Repetitive | ||
Rhythmicity | Regular but sometimes looks irregular in dystonic tremor syndromes or with some variability in amplitude of tremor | Irregular but can be rhythmic with repetitive myoclonus (8–18 Hz) | Regular and rhythmic (2–3 Hz) but can be irregular |
Condition | Rest, postural, kinetic | Rest, postural, kinetic | Rest |
Stimulus sensitivity | No reflex sensitivity | Can be triggered with sensory stimulation | No reflex sensitivity |
Distribution | Bilateral or unilateral | Bilateral, symmetrical | Unilateral |
Distal or proximal | Distal > proximal | Distal > proximal | |
Upper limb > lower limb | Upper limb ~ lower limb | Upper limb > lower limb |
- Semi-prone - Complete prone - Hanging down from the armrests with forearm supported - Hanging down on sides of a chair |
- Count backwards - Calculation (100-7) - Sequential fingers (1–4) tapping or alternating toes tapping on the contralateral side |
Parkinsonism Dystonic posture |
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- Hands supported by pillows - Legs supported on the bed - Head supported by pillows |
*Observe characteristics of tremor* *Unilateral vs bilateral* * |
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- Outstretched arms with hands pronated and fingers spread - Outstretched arms with hands supinated and fingers spread - Outstretched arms with palms or dorsum of hands facing each other - Wing position (elbows flexed, hands underneath the chin, not touching each other) - Outstretched leg with knee extended - Head unsupported while turning head to the extreme side |
Putting a slip of paper on top of hands (visualize fine tremor) |
Parkinsonism Dystonic posture Cerebellar sign Neuropathy |
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Putting the weight on the dorsum of hands | |||
*Observe *Observe *Observe null point, sensory trick* |
Systemic signs (hyperthyroidism) Kayser-Fleischer (KF) ring |
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*Listening to high frequency tremor with stethoscope* | |||
- Finger-to-nose test (hands) - Heel-to-knee test (legs) - Simple maneuvers (pouring water from a glass, drinking water, using utensils) - Writing (spiral, lines, sentences) - Specific tasks (from history) - Jaw: open a month - Tongue: protrude a tongue - Voice: Say “Ahh and Eee) |
*Observe simple kinetic vs intentional tremor *Observe |
Parkinsonism Dystonic posture Cerebellar sign Neuropathy |
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*Observe axis, size* *Observe occurrence of tremor at rest vs action* |
Systemic signs (hyperthyroidism) KF ring |
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Keep the position that elicits tremor | |||
- Cognitive test and motor test with the contralateral/less affected side - Tapping with different frequencies with the contralateral/less affected side - Ballistic movements of the contralateral/less affected side - Passively move tremulous limb before the onset of tremor |
* *Observe *Observe a pause of tremor* |
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*Observe co-activation sign* |