From the Guidelines
The workup for tremors when reaching for objects should begin with a thorough neurological examination to assess tremor characteristics and associated symptoms, as recommended by the most recent guidelines 1. The initial evaluation should include a complete medical history focusing on onset, progression, exacerbating factors, and family history of movement disorders.
- Laboratory tests should include:
- Thyroid function tests
- Liver function tests
- Complete blood count
- Comprehensive metabolic panel
- Serum ceruloplasmin to rule out Wilson's disease
- Brain imaging with MRI is essential to identify structural lesions, particularly in the cerebellum or brainstem, as intention tremors typically indicate cerebellar dysfunction, as noted in the study 1. Additional tests may include electromyography to characterize the tremor and rule out peripheral neuropathy.
- If medication-induced tremor is suspected, a medication review should be conducted, considering the potential for drug-induced movement disorders 1. Common causes of intention tremors include multiple sclerosis, stroke, cerebellar tumors, and neurodegenerative diseases, such as Parkinson's disease, which has been associated with 22q11.2 deletion syndrome 1. Treatment depends on the underlying cause but may include medications such as propranolol, primidone, or topiramate.
- Physical and occupational therapy can help improve function and teach compensatory strategies. For severe, medication-resistant tremors, deep brain stimulation might be considered in appropriate candidates.
- A comprehensive clinical examination, including vital signs and basic neurological examination, can help inform the appropriate investigations or explore alternative diagnoses, as suggested by the study 1.
From the Research
Types of Tremors
- Essential tremor: characterized by symmetric bilateral postural and kinetic tremor, which may respond to low alcohol consumption 2
- Parkinson's disease (PD) tremor: typically an asymmetric rest tremor, which is treated with dopaminergic agents such as levodopa 3, 2
- Enhanced physiologic tremor: can be caused by anxiety, medication use, caffeine intake, or fatigue 4
- Psychogenic tremor: features include abrupt onset, spontaneous remission, changing tremor characteristics, and extinction with distraction 4
Diagnosis and Treatment
- Diagnosis of tremor is based on clinical information obtained from the history and physical examination 4
- Treatment options for essential tremor include beta blockers, anticonvulsants, benzodiazepines, and carbonic anhydrase inhibitors 3
- Treatment options for PD include levodopa, dopamine agonists, amantadine, anticholinergics, selegiline, and COMT inhibitors 3
- Alternative forms of therapy for medication refractory and functionally disabling tremor include botulinum toxin injections, deep brain stimulation, magnetic resonance-guided focused ultrasound, and thalamotomy 5
Evaluation and Management
- Evaluation should begin with a tremor history and a focused neurologic examination 6
- Examination should attend to the many subtleties of tremor phenomenology, including whether the main type of tremor is an action tremor or a resting tremor 6
- Clinician should formulate two sets of differential diagnoses: disorders in which action tremor is the predominant tremor versus those in which resting tremor is the main tremor 6