Tremors

Clinical Features

Tremor consists of alternating contractions of agonist and antagonist muscles in an oscillating, rhythmic manner. It can be most prominent at rest (rest tremor), on assuming a posture (postural tremor), or on actively reaching for a target (kinetic tremor). Tremor is also assessed based on distribution, frequency, and related neurologic dysfunction.
PD is characterized by a resting tremor, essential tremor (ET) by a postural tremor, and cerebellar disease by an intention or kinetic tremor. Normal individuals can have a physiologic tremor that typically manifests as a mild, high-frequency, postural or action tremor that is usually of no clinical consequence and often is only appreciated with an accelerometer. An enhanced physiologic tremor (EPT) can be seen in up to 10% of the population, often in association with anxiety, fatigue, underlying metabolic disturbance (e.g., hyperthyroidism, electrolyte abnormalities), drugs (e.g., valproate, lithium), or toxins (e.g., alcohol). Treatment is initially directed to the control of any underlying disorder and, if necessary, can often be improved with drugs.
ET is the commonest movement disorder.It can present in childhood, but dramatically increases in prevalence with advancing age. ET is characterized by a high-frequency tremor (up to 11 Hz) that predominantly affects the upper extremities. The tremor is most often manifest as a postural or kinetic tremor. It is typically bilateral and symmetric,but may begin on one side and remain asymmetric.Tremor can involve the head , voice , tongue, face/jaw , and lower limbs. The tremor is characteristically improved by alcohol and worsened by stress. Subtle impairment of coordination or tandem walking may be present. The major differential is a dystonic tremor. PD can usually be differentiated from ET based on the presence of bradykinesia, rigidity, micrographia, and other parkinsonian features. Etiology and Pathophysiology
The etiology and pathophysiology of ET are not known. Approximately 50% of cases have a positive family history with an autosomal dominant pattern of inheritance. Linkage studies have detected loci at chromosomes 3q13 (ETM-1), 2p22-25 (ETM-2), and 6p23 (ETM-3). Recent genomewide studies demonstrate an association with the LINGO1 gene, particularly in patients with young-onset ET, and it is likely that there are many other undiscovered loci

Treatment

Many cases are mild and require no treatment other than reassurance. Occasionally, tremor can be severe and interfere with eating, writing, and activities of daily living. This is more likely to occur as the patient ages and is often associated with a reduction in tremor frequency. Beta-Blockers or primidone are the standard drug therapies for ET and help in about 50% of cases. Propranolol (20–80 mg daily, given in divided doses) is usually effective at relatively low doses, but higher doses may be effective in some patients. The drug is contraindicated in patients with bradycardia or asthma. Hand tremor tends to be most improved, while head tremor is often refractory. Primidone can be helpful, but should be started at low doses (12.5 mg) and gradually increased (125–250 tid) to avoid sedation. Benefits have been reported with gabapentin and topiramate.. Surgical therapies targeting the VIM nucleus of the thalamus can be very effective for severe and drug-resistant cases.

ABSTRACT

Background: This evidence-based guideline is an update of the 2005 American Academy of Neurology practice parameter on the treatment of essential tremor (ET).>

 

Methods: A literature review using MEDLINE, EMBASE, Science Citation Index, and CINAHL was performed to identify clinical trials in patients with ET published between 2004 and April 2010.

 

Results and Recommendations: Conclusions and recommendations for the use of propranolol, primidone (Level A, established as effective); alprazolam, atenolol, gabapentin (monotherapy), sotalol, topiramate (Level B, probably effective); nadolol, nimodipine, clonazepam, botulinum toxin A, deep brain stimulation, thalamotomy (Level C, possibly effective); and gamma knife thalamotomy (Level U, insufficient evidence) are unchanged from the previous guideline. Changes to conclusions and recommendations from the previous guideline include the following: 1) levetiracetam and 3,4-diaminopyridine probably do not reduce limb tremor in ET and should not be considered (Level B); 2) flunarizine possibly has no effect in treating limb tremor in ET and may not be considered (Level C); and 3) there is insufficient evidence to support or refute the use of pregabalin, zonisamide, or clozapine as treatment for ET (Level U).