Tremor is defined as an involuntary rhythmic oscillation of ≥1 body parts, mediated by alternating contractions of reciprocally acting muscles. 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.
Its rhythmicity 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 sub-types.
Postural tremors occur during maintenance of a posture, usually against gravity (e.g., holding up a newspaper).
Kinetic tremors occur during active movement. A sub-type 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 sub-types 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).
- Parkinson's disease (PD)
- Dementia with Lewy bodies
- Enhanced physiological tremor
- Hypoglycaemia (enhanced physiological tremor)
- Thyrotoxicosis (enhanced physiological tremor)
- Alcohol withdrawal (enhanced physiological tremor)
- Essential tremor or essential tremor plus
- Drug-induced tremor
- Multiple system atrophy
- Progressive supra-nuclear palsy
- Cortical basal degeneration
- Toxin-induced tremor
- Post-encephalitic parkinsonism
- Phaeochromocytoma (enhanced physiological tremor)
- Cerebellar tremor (multiple sclerosis, trauma, or stroke)
- Fragile X tremor ataxia syndrome
- Orthostatic tremor
- Primary writing tremor
- Dystonic tremor
- Wilson's disease
- Rubral tremor
- Functional (psychogenic) tremor
Kelvin L. Chou, MD
Professor of Neurology and Neurosurgery
University of Michigan
KLC serves on the medical advisory board (unpaid position) for the International Essential Tremor Foundation.
Praveen Dayalu, MD
Associate Professor of Neurology
University of Michigan
PD declares that he has no competing interests.
Aparna Wagle Shukla, null
Movement Disorders Division
Department of Neurology
University of Florida
WS has been reimbursed by Merz, ES therapeutics, Sage, Jazz, and Acadia.
Paul Greene, MD
Associate Professor of Clinical Neurology
Yale School of Medicine
PG declares that he has no competing interests.
- ACR Appropriateness Criteria: movement disorders and neurodegenerative diseases
- Evidence-based guideline update: treatment of essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology
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