Evaluation of tremor

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Last reviewed: 23 Sep 2025

Last updated: 22 Oct 2025

Tremor is defined as an involuntary oscillatory and rhythmic movement of a body part.[1] It commonly affects the upper extremities but can also affect the head, chin, voice, or legs. Tremor, if severe, may impair activities of daily living or occupation, and may lead to embarrassment and social withdrawal.

The rhythmicity of tremor differentiates it from other involuntary movements such as myoclonus, clonus, chorea, dystonia, and tics, although patients with these other conditions may complain of "shaking" or "tremulousness". For appropriate diagnosis and treatment, it is critical to determine the positional properties that make the tremor most noticeable. Most tremors can be classified as "rest" or "action".

Rest tremors occur when the body region is relaxed (i.e., not actively moving, contracting, sustaining a position, or opposing gravity). Examples include tremor in a hand relaxed by the side when walking or resting in a lap when sitting.
Action tremors occur during voluntary muscle contraction. They are further divided into postural, kinetic, isometric, or task-specific subtypes.
- Postural tremors occur during maintenance of a posture, usually against gravity (e.g., holding up a newspaper).
- Kinetic tremors occur during active movement. A subtype of kinetic tremor, intention tremor, is seen with a goal-directed movement (e.g., finger-to-nose testing). Action tremors are often both postural and kinetic.
- Isometric and task-specific subtypes are uncommon. Isometric tremors occur during muscle contractions without movement (e.g., fist-clenching or standing). Task-specific tremors occur with a specific activity (e.g., writing or playing an instrument).

Differentials

Common

Parkinson disease (PD)
Dementia with Lewy bodies
Enhanced physiologic tremor
Hypoglycemia (enhanced physiologic tremor)
Thyrotoxicosis (enhanced physiologic tremor)
Alcohol withdrawal (enhanced physiologic tremor)
Essential tremor or essential tremor plus
Drug-induced tremor

Full details

Uncommon

Multiple system atrophy
Progressive supranuclear palsy (PSP)
Cortico basal syndrome
Toxin-induced tremor
Pheochromocytoma (enhanced physiologic tremor)
Cerebellar tremor (multiple sclerosis, trauma, or stroke)
Fragile X tremor ataxia syndrome
Orthostatic tremor
Primary writing tremor
Dystonic tremor
Wilson disease
Holmes tremor (rubral or midbrain tremor)
Functional tremor

Full details

Contributors

Authors

Camilla Kilbane, MD, FAAN

Associate Professor Neurology

Center Director Parkinson’s Disease and Movement disorder Center

Institution University Hospitals Cleveland Medical Center / Case Western Reserve University

Cleveland

Disclosures

CK has served as a consultant for Medtronic, including participation on the Data Safety Monitoring Board (DSMB) for the ADAPT-PD trial. CK has participated in the speakers bureau for Teva Pharmaceuticals and has served as an expert witness in one legal case.

Acknowledgements

Dr Camilla Kilbane would like to gratefully acknowledge Professor Kelvin L. Chou and Dr Praveen Dayalui, previous contributors to this topic.

Disclosures

KLC serves as a consultant for Abbott (DBS manufacturer). PD declares that he has no competing interests.

Peer reviewers

Aparna Wagle Shukla, null

Professor

Movement Disorders Division

Department of Neurology

University of Florida

Gainesville

Disclosures

WS has been reimbursed by Merz, ES therapeutics, Sage, Jazz, and Acadia.

Paul Greene, MD

Associate Professor of Clinical Neurology

Yale School of Medicine

New Haven

Disclosures

PG declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

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Key articles

Bhatia KP, Bain P, Bajaj N, et al. Consensus statement on the classification of tremors. from the task force on tremor of the International Parkinson and Movement Disorder Society. Mov Disord. 2018 Jan;33(1):75-87.Full text Abstract

Shanker V. Essential tremor: diagnosis and management. BMJ. 2019 Aug 5;366:l4485.Full text Abstract

American College of Radiology. ACR appropriateness criteria: movement disorders and neurodegenerative diseases. 2019 [internet publication].Full text

Reference articles

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Evaluation of tremor

Summary

Differentials

Common

Uncommon

Contributors

Authors

Camilla Kilbane, MD, FAAN

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Aparna Wagle Shukla, null

Disclosures

Paul Greene, MD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

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