What is the appropriate evaluation and management for a patient with an intention tremor of the hands?

Evaluation and Management of Intention Tremor of the Hands

For a patient presenting with intention tremor of the hands, the priority is to identify cerebellar pathology through targeted neuroimaging (MRI brain without contrast) and initiate physical/occupational therapy with adaptive strategies, as intention tremor is notoriously resistant to pharmacological treatment. 1, 2, 3

Initial Diagnostic Approach

Confirm the tremor is truly intentional by observing that it becomes progressively worse during goal-directed movements (finger-to-nose testing), often with a coarse, irregular "wing-beating" appearance. 1 This distinguishes it from:

• Essential tremor: Primarily postural/action tremor that occurs with sustained postures 1, 2
• Parkinsonian tremor: Resting tremor that improves with movement 2, 3
• Functional tremor: Demonstrates distractibility—stops completely when attention is redirected 2

Look for associated cerebellar signs that confirm the diagnosis:

• Dysarthria (slurred speech) 1
• Ataxic gait (wide-based, unsteady walking) 1
• Dysmetria (overshooting targets) 4

Critical Imaging Evaluation

Order MRI brain without contrast as the optimal imaging modality to identify structural cerebellar lesions, focal atrophy, vascular disease, or tumors. 2 The American College of Radiology recommends this due to superior soft-tissue characterization. 2

Common etiologies to consider:

• Spinocerebellar ataxias 5
• Cerebellar stroke 5
• Multiple sclerosis affecting cerebellar pathways 5
• Cerebellar tumors 5
• Paraneoplastic cerebellar degeneration 5

Management Strategy

Pharmacological Treatment (Limited Efficacy)

Intention tremor is more challenging to treat pharmacologically than essential tremor, but trial certain medications if functional impairment is severe. 1

• Consider propranolol 80-240 mg/day as first-line despite limited evidence for intention tremor specifically 2, 6
• Primidone may be trialed, though efficacy is uncertain for cerebellar tremor 6
• Do not expect dramatic improvement—pharmacologic agents are generally not helpful for intention tremor 3

Avoid beta-blockers in patients with:

• Chronic obstructive pulmonary disease 2, 6
• Bradycardia or heart block 6
• Decompensated congestive heart failure 2, 6

Non-Pharmacological Interventions (Primary Treatment)

Physical and occupational therapy with adaptive devices are the mainstay of treatment for intention tremor. 1

Specific therapeutic strategies include:

• Use gross rather than fine movements for functional tasks—for example, handwriting retraining using large markers on whiteboards with big lettering rather than attempting normal handwriting 7
• Assist the patient to relax muscles in the affected limb to prevent cocontraction 7
• Try to control tremor at rest first before progressing to activity-based tasks 7

Regarding adaptive equipment:

• Avoid aids in the acute phase as they interrupt normal automatic movement patterns and cause maladaptive functioning 7
• If aids are necessary for safety (e.g., safe hospital discharge), issue them as short-term solutions with a clear plan to progress toward independence 7
• Provide follow-up appointments to monitor equipment use and support progression 7

Surgical Options for Refractory Cases

For medication-refractory tremor causing significant disability, consider surgical interventions:

• Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy: Shows 56% sustained tremor improvement at 4 years with lower complication rate (4.4%) 2, 6

  • Contraindications: Cannot undergo MRI, skull density ratio <0.40, bilateral treatment needed, or previous contralateral thalamotomy 2, 6

• Deep brain stimulation (DBS) of VIM thalamus: Preferred for bilateral tremor involvement, provides adjustable and reversible control (complication rate 21.1%) 2, 6

• Radiofrequency thalamotomy: Available but carries higher complication risk (11.8%) 2, 6

Common Pitfalls to Avoid

Do not assume all tremors are essential tremor—the presence of intention tremor with dysarthria and ataxic gait mandates cerebellar evaluation. 1

Do not rely solely on medications—intention tremor is notoriously resistant to pharmacological treatment, making rehabilitation strategies essential. 1, 3

Do not provide adaptive equipment without a clear plan to wean—this reinforces maladaptive movement patterns and prevents recovery. 7

Do not overlook secondary causes—review all medications for tremor-inducing agents including lithium, sympathomimetics, antiparkinsonians, and antipsychotics. 2