Category Archive Musculoskeletal System

Examination of musculoskeletal system it is important to keep the concept of function in mind. Note any gross abnormalities of mechanical function beginning with the initial introduction to the patient. Continue to observe for such problems throughout the interview and the examination.

On a screening examination of a patient who has no musculoskeletal complaints and in whom no gross abnormalities have been noted in the interview and general physical examination, it is adequate to inspect the extremities and trunk for observable abnormalities and to ask the patient to perform a complete active range of motion with each joint or set of joints.

If the patient presents complaints in the musculoskeletal system or if any abnormality has been observed, it is important to do a thorough musculoskeletal examination, not only to delineate the extent of gross abnormalities but also to look closely for subtle anomalies.

To perform an examination of the muscles, bones, and joints, use the classic techniques of inspection, palpation, and manipulation. Start by dividing the musculoskeletal system into functional parts. With practice the examiner will establish an order of approach, but for the beginner it is perhaps better to begin distally with the upper extremity, working proximally through the shoulder. Then, beginning with the temporomandibular joint, pass on to the cervical spine, the thoracic spine, the lumbar and sacral spine, and the sacroiliac joints. Finally, in the lower extremity, again begin distally with the foot and proceed proximally through the hip.

Use the opposite side for comparisons: it is easier to spot subtle differences as well as identify symmetrical problems. If there is any question, use your own anatomy as a control.

Glean the maximum information from observation. Concentrating on one area at a time, inspect the area for discoloration (e.g., ecchymoses, redness), soft tissue swelling, bony enlargement, wasting, and deformity (abnormal angulation, subluxation). While noting these changes, attempt to determine whether they are limited to the joint or whether they involve the surrounding structures (e.g., tendons, muscles, bursae).

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Intention tremor is a dyskinetic disorder characterized by a broad, coarse, and low frequency (below 5 Hz) tremor evident during deliberate and visually-guided movement (hence the name intention tremor). Intention tremor is usually perpendicular to the direction of movement. When experiencing an intention tremor, one often overshoots or undershoots one’s target, a condition known as dysmetria.^[rx][rx] Intention tremor is the result of dysfunction of the cerebellum, particularly on the same side as the tremor in the lateral zone, which controls visually guided movements. Depending on the location of cerebellar damage, these tremors can be either unilateral or bilateral.^[rx]

Intention tremor is produced with purposeful movement toward a target, such as lifting a finger to touch the nose.  Typically the tremor will become worse as an individual gets closer to their target.

Intention tremors are involuntary, rhythmic muscle contractions (oscillations) that occur during a purposeful, voluntary movement. The oscillations’ amplitude typically worsens as the movement proceeds, meaning that the tremor increases in intensity upon reaching a target.

Causes of Intention Tremor

Generally, tremor is caused by a problem in the deep parts of the brain that control movements.  Most types of tremors have no known cause, although there are some forms that appear to be inherited and run in families.

Tremor can occur on its own or be a symptom associated with a number of neurological disorders, including

• Multiple sclerosis
• Stroke
• Traumatic brain injury
• Neurodegenerative diseases that affect parts of the brain (e.g.,  Parkinson’s disease).
• Neurologic disorders, including multiple sclerosis, Parkinson’s disease, stroke, and traumatic brain injury
• Certain medicines, such as asthma medicines, amphetamines, caffeine, corticosteroids, and medicines used for certain psychiatric and neurological disorders
• Alcohol use disorder or alcohol withdrawal
• Mercury poisoning
• Hyperthyroidism (overactive thyroid)
• Liver or kidney failure
• Anxiety or panic

Some other known causes can include

• the use of certain medicines (particular asthma medication, amphetamines, caffeine, corticosteroids, and drugs used for certain psychiatric and neurological disorders)
• alcohol abuse or withdrawal
• mercury poisoning
• overactive thyroid
• liver or kidney failure
• anxiety or panic.

Symptoms of Intention Tremor

Symptoms of tremor may include

• A tremor is involuntary, rhythmic contractions of various muscles. Shaky legs syndrome causes feelings of “vibration”, unsteadiness or imbalance in the legs.
• A rhythmic shaking in the hands, arms, head, legs, or torso
• Balance and muscle coordination problem
• Spasticity and muscle spasm with wasting
• Shaky voice
• Difficulty writing or drawing
• Problems holding and controlling utensils, such as a spoon.
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement
• Usually occur in the hands first, affecting one hand or both hands
• Can include a “yes-yes” or “no-no” motion of the head
• It May be aggravated by emotional stress, fatigue, caffeine, or temperature extremes
• Tremors that get worse during emotional stress
• Tremors that get worse when you move on purpose
• Tremors that lessen with rest
• Balance problems (in rare cases)
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement

Essential tremor vs. Parkinson’s disease

Many people associate tremors with Parkinson’s disease, but the two conditions differ in key ways:

Timing of tremors. Essential tremor of the hands usually occurs when you use your hands. Tremors from Parkinson’s disease are most prominent when your hands are at your sides or resting in your lap.

Associated conditions. Essential tremor doesn’t cause other health problems, but Parkinson’s disease is associated with stooped posture, slow movement and shuffling gait. However, people with essential tremor sometimes develop other neurological signs and symptoms, such as an unsteady gait (ataxia).

Parts of body affected. Essential tremor mainly involves your hands, head and voice. Parkinson’s disease tremors usually start in your hands, and can affect your legs, chin and other parts of your body.

Signs

What we feel in both legs simultaneously is extreme straining, fatigue, unsteadiness, and a fear of falling. The muscles in our legs become hard, our ankles feel weak and our toes curl under as our legs fail to support us. We can stand for only a short period of time, in some cases only seconds. There is a feeling of panic to find a place to sit, or if possible, walk to gain some relief from our symptoms. Some tremors /shaky legs syndrome may be triggered by or become worse during times of stress or strong emotion, when an individual is physically exhausted, or when a person is in certain postures or makes certain movements.

Diagnosis of Intention Tremor

Medical history

During the physical evaluation, a doctor will assess the tremor based on:

• whether the tremor occurs when the muscles are at rest or inaction
• the location of the tremor on the body (and if it occurs on one or both sides of the body)
• the appearance of the tremor (tremor frequency and amplitude).

The doctor will also check other neurological findings such as impaired balance, speech abnormalities, or increased muscle stiffness.  Blood or urine tests can rule out metabolic causes such as thyroid malfunction and certain medications that can cause tremors/shaky legs syndrome.  These tests may also help to identify contributing causes such as drug interactions, chronic alcoholism, or other conditions or diseases.  Diagnostic imaging may help determine if the tremor is the result of damage to the brain.

Clinical observations

The diagnosis is based on a combination of a number of clinical observations and recognition of typical characteristics (phenomenology) that include, but are not necessarily limited to the following:

• Onset of the movements is abrupt/sudden.
• Movements are triggered by emotional or physical trauma, or by some conflict (marital, sexual, work-related).
• Movements are episodic or appear intermittent.
• There are spontaneous remissions of the movements.
• Movements disappear with distraction.
• Movements are suggestible, meaning they may disappear by making a suggestion. For example, suggesting that the application of a tuning fork to the body part affected may help relieve the movements.
• Underlying psychiatric disturbances (depression, anxiety) are present.
• There are multiple somatizations and undiagnosed conditions.
• There is a lack of emotional concern about the disorder (“la belle indifference”).
• There has been exposure to neurologic disorders during one’s occupation (e.g. nurse, physician) or while caring for someone with similar problems.
• Slurred speech, soft voice, gibberish, foreign accent
• Delayed and excessive startle (bizarre movements in response to sudden, unexpected noise or threatening movement)
• Presence of additional types of abnormal movements that are not known to be part of the primary or principal movement disorder pattern that the patient manifests
• Active resistance against passive movement
• Fixed posture

Treatment of Intention Tremor

Non-pharmacological

• Physical, language, and manual therapy – may help to control tremors and meet daily challenges caused by the tremor.  A physical therapist can help people improve their muscle control, functioning, and strength through coordination, balancing, and other exercises.  Some therapists recommend the use of weights, splints, other adaptive equipment, and special plates and utensils for eating.  Speech-language pathologists can evaluate and treat speech, language, communication, and swallowing disorders.  Occupational therapists can teach individuals new ways of performing activities of daily living that may be affected by tremors.
• Eliminating or reducing tremor-inducing substances such as caffeine and other medication – (such as stimulants) can help improve tremor. Though small amounts of alcohol can improve tremors for some people, tremors can become worse once the effects of the alcohol wear off.
• Interventional Therapy – For patients who fail pharmacologic treatment with the above drugs or are unable to tolerate the side effects, surgical options include deep brain stimulation (DBS), focused ultrasound, or radio-surgical gamma knife thalamotomy to treat persistently disabling limb tremor, and botulinum toxin injections to treat persistently disabling head or vocal cord tremor.
• Deep-brain stimulation – This is the most common surgical treatment for essential tremors. Most series report 70% to 90% hand tremor control. In deep-brain stimulation, electrical stimulation is delivered to the brain through an electrode implanted deep into the ventral intermediate nucleus (VIM) of the thalamus. This is typically done by implanting 4 electrodes in the VIM using stereotactic methods. Computerized programming of the pulse generator is most commonly done with a handheld device after the patient leaves the hospital to optimize the electrode montage, voltage, pulse frequency, and pulse width. Deep-brain stimulation can be done unilaterally or bilaterally depending on the patient’s symptoms. There is an increased risk of speech and balance difficulties with bilateral procedures. If the tremor significantly affects both hands, the dominant hand is targeted, bilateral procedures may be considered.
• Focused ultrasound – Approved by the FDA in 2016, magnetic resonance imaging-guided, high-intensity, focused ultrasound thalamotomy is an innovative method for the treatment of essential tremors. Although it is transcranial and does not require an incision, skull penetration, or an implanted device, it is an invasive therapy that produces a permanent thalamic lesion.
• Radio-surgical gamma knife thalamotomy – Gamma-knife thalamotomy fo­cuses high-energy gamma rays on the ventral intermediate resulting in the death of neurons. It is an unproven treatment that has not generally been adopted due to concerns about potential radiation side effects, including a theoretical, long-term risk of secondary tumor formation.
• Ultrasound Therapy – A new treatment for essential tremors uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brain’s thalamus thought to be responsible for causing the tremors.  The treatment is approved only for those individuals with essential tremors who do not respond well to anticonvulsant or beta-blocking drugs.
• Biofeedback – is a mind-body technique that involves using visual or auditory feedback to teach people to recognize the physical signs and symptoms of stress and anxiety, such as increased heart rate, body temperature, and muscle tension.
• Relaxation techniques – can reduce stress symptoms and help you enjoy a better quality of life, especially if you have an illness. Explore relaxation techniques you can do by yourself.
• Learn to relax – Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors. Although you can’t eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques, such as massage or meditation.
• Noninvasive techniques – Include gait rehabilitation, visually guided techniques, tendon vibration, weighting extremities, positioning techniques, and manual techniques, all of which can be useful for the recovery of functional activities.[rx]
• Invasive techniques – Thalamic deep brain stimulation can alleviate the tremor in MS, providing better functional performance.[rx] Stereotactic radiosurgery thalamotomy at the nucleus ventralis intermedius with a median maximum dose of 140 Gy also provides good functional outcomes in patients with MS.[rx][rx] Radiofrequency thalamotomy had been successfully used in the past but has been replaced with the newer techniques of radiosurgery and deep brain stimulation as they had fewer adverse effects.
• Physical therapy – can help some patients control their tremors better, as can reducing the intake of substances such as caffeine, which can induce tremors. Many patients experience an increase in the severity of their tremors when they are stressed. Therefore, trying to reduce sources of anxiety and engaging in complementary therapies (such as yoga or aromatherapy) may help some patients.
• Speech and occupational therapy – may be useful not only in improving physical and psychological functioning, such as activities of daily living, but also to alter the abnormally learned pattern of movement – “motor reprogramming.” Antidepressants and muscle relaxants may be also beneficial. Rarely, transcutaneous electrical stimulation applied to the area of spasm or involuntary movement may be helpful, analogous to the application of a tuning fork during clinic evaluation. Most importantly, however, the patient should try to understand which stress factors may be playing a role and seek the expertise of a psychologist experienced and skilled in stress management. The role of a psychiatrist is not to make the diagnosis but to provide insights into underlying psychological or psychiatric issues and to aid in the treatment of psychiatric issues such as depression or anxiety.
• Psychogenic movement Therapy –  It may be difficult to treat, especially if the patient is diagnosed late or is not accepting of the diagnosis. Indeed, patients with the best prognosis are those who initially accept the diagnosis and work with the movement disorder neurologist, psychologist, psychiatrist and physical, speech and occupational therapists in implementing a short-term and long-term therapeutic program. The diagnosis should be disclosed to patients in a manner that is empathetic and nonjudgmental.

For example, tremors due to thyroid hyperactivity will improve or even resolve (return to the normal state) with the treatment of thyroid malfunction.  Also, if the tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.

Medical Therapy

The therapeutic approach to essential tremors many times follows a trial and error approach, and patients should be challenged by several medications if the first choice is ineffective or associated with debilitating adverse effects. Medical therapy can be divided into first, second, and third-line therapies.

First-line therapy – It is either approved by the FDA or supported by double-blinded, placebo-controlled studies that meet the criteria for the class I evidence. This class of medications includes propranolol and primidone. If both primidone and propranolol are not effective alone, combinations of both may provide relief in selected patients.

Second-line therapy – Second-line therapy is supported by double-blinded, placebo-controlled trials that do not meet other requirements for the class I evidence studies. This includes gabapentin, pregabalin, topiramate, benzodiazepines (clonazepam, alprazolam), beta-blockers (atenolol and metoprolol) and zonisamide.

Third-line therapy – These therapies are based on open-label studies or case series. Drugs in this class include nimodipine and clozapine.

Medication

• Beta-blocking drugs such as propranolol are normally used to treat high blood pressure but they also help treat essential tremors.  Propranolol can also be used in some people with other types of action tremors.  Other beta-blockers that may be used include atenolol, metoprolol, nadolol, and sotalol.
• Anti-seizure medications such as primidone can be effective in people with essential tremors who do not respond to beta-blockers.  Other medications that may be prescribed include gabapentin and topiramate.  However, it is important to note that some anti-seizure medications can cause tremors.
• Intention tremors–  are known to be very difficult to treat with pharmacotherapy and drugs. Although there is no established pharmacological treatment for an intention tremor, several drugs have been found to have positive effects on intention tremors and are used as a treatment by many health professionals. Isoniazid, buspirone hydrochloride, glutethimide, carbamazepine, clonazepam, topiramate, Zofran, propranolol, and primidone have all seen moderate results in treating intention tremor and can be prescribed treatments. Isoniazid inhibits γ-aminobutyric acid-aminotransferase, which the first step in the enzymatic breakdown of GABA, thus increasing GABA, the major inhibitory neurotransmitter in the central nervous system. This causes a reduction in cerebellar ataxias. Another neurotransmitter targeted by drugs that have been found to alleviate intention tremors is serotonin. The agonist buspirone hydrochloride, which decreases serotonin’s function in the central nervous system, has been viewed as an effective treatment of intention tremors.^[rx]
• Tranquilizers (also known as benzodiazepines) such as alprazolam and clonazepam may temporarily help some people with tremors.  However, their use is limited due to unwanted side effects that include sleepiness, poor concentration, and poor coordination.  This can affect the ability of people to perform daily activities such as driving, school, and work.  Also, when taken regularly, tranquilizers can cause physical dependence and when stopped abruptly can cause several withdrawal symptoms.
• Parkinson’s disease medications (levodopa, carbidopa) are used to treat tremors associated with Parkinson’s disease.
• Botulinum toxin – injections can treat almost all types of tremors.  It is especially useful for head tremor, which generally does not respond to medications.  Botulinum toxin is widely used to control dystonic tremors.  Although botulinum toxin injections can improve tremors for roughly three months at a time, they can also cause muscle weakness.  While this treatment is effective and usually well tolerated for head tremors, botulinum toxin treatment in the hands can cause weakness in the fingers.  It can cause a hoarse voice and difficulty swallowing when used to treat voice tremors.

Additional drug therapies that have been used to treat individuals with primary orthostatic tremors include primidone (Mysoline), chlordiazepoxide (Librium), pregabalin (Lyrica), pramipexole (Mirapex), phenobarbital, and valproic acid (Depakote). Drugs commonly used to treat people with Parkinson’s disease (levodopa or pramipexole) may also be prescribed for individuals with primary orthostatic tremors.

Surgery

When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation (DBS) or very rarely, thalamotomy.  While DBS is usually well-tolerated, the most common side effects of tremor surgery include dysarthria (trouble speaking) and balance problems.

• Deep brain stimulation (DBS) – is the most common form of surgical treatment of tremors.  This method is preferred because it is effective, has low risk, and treats a broader range of symptoms than thalamotomy.  The treatment uses surgically implanted electrodes to send high-frequency electrical signals to the thalamus, the deep structure of the brain that coordinates and controls some involuntary movements.  A small pulse generating device placed under the skin in the upper chest (similar to a pacemaker) sends electrical stimuli to the brain and temporarily disables the tremor.  DBS is currently used to treat parkinsonian tremors, essential tremors, and dystonia.

• Thalamotomy – is a surgical procedure that involves the precise, permanent destruction of a tiny area in the thalamus.  Currently, surgery is replaced by radiofrequency ablation to treat severe tremors when deep brain surgery is contraindicated—meaning it is unwise as a treatment option or has undesirable side effects.  Radiofrequency ablation uses a radio wave to generate an electric current that heats up a nerve and disrupts its signaling ability for typically six or more months.  It is usually performed on only one side of the brain to improve tremors on the opposite side of the body.  Surgery on both sides is not recommended as it can cause problems with speech.
• Focused ultrasound thalamotomy – This non-invasive surgery involves using focused sound waves that travel through the skin and skull. The waves generate heat to destroy brain tissue in a specific area of the thalamus to stop a tremor. A surgeon uses magnetic resonance imaging to target the correct area of the brain and to be sure the sound waves are generating the exact amount of heat needed for the procedure. Focused ultrasound thalamotomy creates a lesion that can result in permanent changes to brain function. Some people have experienced the altered sensation, trouble with walking or difficulty with movement. However, most complications go away on their own or are mild enough that they don’t interfere with the quality of life.
•  Stereotactic surgical techniques – can be used to create a lesion in the ventral intermediate (VIM) nucleus of the thalamus.

Rehabilitation

Exercise is an important part of healthy living for everyone. For people with tremors, exercise is more than healthy it is a vital component to maintaining balance, mobility, and activities of daily living. Exercise and physical activity can improve many tremors symptoms. These benefits are supported by research.

The tremors show that people with tremors who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.

What Type of Exercise Should I Do?

To help manage the symptoms of tremors, be sure your exercise program includes a few key ingredients:

• Aerobic activity
• Strength training
• Balance, agility, and multitasking
• Flexibility

These elements are included in many types of exercise. Biking, running, Tai chi, yoga, Pilates, dance, weight training, non-contact boxing, qi gong, and more — all have positive effects on tremors symptoms.

There is no “exercise prescription” that is right for every person with tremors. The type of exercise you do depends on your symptoms and challenges. For sedentary people, just getting up and moving is beneficial. More active people can build up to the regular, vigorous activity. Many approaches work well to help maintain and improve mobility, flexibility, and balance to ease non-motor tremors symptoms such as depression or constipation.

Researchers in the study did not distinguish between what type of exercise participants did and determined that all types of exercise are beneficial. The most important thing is to do the exercise regularly. We suggest finding an exercise you enjoy and stick with it.

Challenges to Exercising

• People in the early stages of tremors tend to be just as strong and physically fit as healthy individuals of the same age.
• Disease progression can lead to the following physical change:
• Loss of joint flexibility, which can affect balance.
• Decreased muscle strength or deconditioning can affect walking and the ability to stand up from sitting.
• The decline in cardiovascular conditioning, which affects endurance.

Tips for Getting Started

• First, be safe. Before starting an exercise program, consult your neurologist and primary care doctor about concerns and recommendations.
• Ask your doctor or members in your support group to refer to a physical therapist (PT) who knows about tremors. Work together to identify your concerns and limitations. Target exercises to improve them. For most people, a structured exercise program will include aerobic exercise (such as brisk walking) and resistance training (using weights or bands).
• Purchase a pedometer (step-counter) and figure out how many steps you take on average each day, then build up from there. Many smartphones or smartwatches have a built-in pedometer feature or an application that can be downloaded.
• Exercise indoors and outdoors. Change your routine to stay interested and motivated.
• Again, most importantly pick an exercise you enjoy.

What research is being done?

The mission is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.  The NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world.

Researchers are working to better understand the underlying brain functions that cause tremors, identify the genetic factors that make individuals more susceptible to the disorder, and develop new and better treatment options.

• Brain functioning – It can be difficult to distinguish between movement disorders such as Parkinson’s disease and essential tremor. These debilitating movement disorders have different prognoses and can respond very differently to available therapies. NINDS researchers are working to identify structural and functional changes in the brain using non-invasive neuroimaging techniques to develop sensitive and specific markers for each of these diseases and then track how they change as each disease progresses. Other researchers are using functional magnetic resonance imaging technology to better understand normal and diseased brain circuit functions and associated motor behaviors.  Scientists hope to design therapies that can restore normal brain circuit function in diseases such as Parkinson’s disease and tremor.
• Genetics – Research has shown that essential tremors may have a strong genetic component affecting multiple generations of families.  NINDS researchers are building on previous genetics work to identify susceptibility genes for familial early-onset (before age 40) essential tremor.  Researchers are focusing on multigenerational, early-onset families to better detect linkages.

Additionally, NINDS scientists are researching the impact of genetic abnormalities on the development of essential tremors.  Previous research that has shown a link between essential tremor and possible genetic variants on chromosome 6 and 11; ongoing research is targeting the impact of other genetic variations in families.

Medications and other treatment methods

While drugs can be effective for some people, approximately 50 percent of individuals do not respond to medication.  In order to develop assistive and rehabilitative tremor-suppressing devices for people with essential tremors, researchers are exploring where and how to minimize or suppress tremors while still allowing for voluntary movements.

Many people with essential tremors respond to ethanol (alcohol); however, it is not clear why or how.  NINDS researchers are studying the impact of ethanol on tremors to determine the correct dosage amount and its physiological impact on the brain and whether other medications without the side effects of ethanol can be effective.

Other NIH researchers hope to identify the source of essential tremors, study the effects of currently available tremor-suppressant drugs on the brain, and develop more targeted and effective therapies.

FAQ

Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

Which of the following constellations of clinical findings is typical of tremor in patients with Parkinson’s disease?

1. bilateral postural tremor

2. unilateral rest tremor and diminished ipsilateral arm swing while walking

3. severe unilateral tremor while holding a cup or glass

4. tremor that only appears when the patient writes

5. postural tremor of both hands and ataxic gait

Question 2

A 25-year-old man has a mild postural tremor of both hands that improves when he drinks alcohol. His mother had the same condition. What can you advise him?

1. He should definitely be evaluated for possible early Parkinson’s disease.

2. He must get treatment now, as otherwise the condition could worsen.

3. If treatment is indicated, propranolol or primidone could be given.

4. Relaxation exercises and physiotherapy are effective treatment options.

5. Genetic testing is needed to confirm the diagnosis of essential tremor.

Question 3

A man who received the diagnosis of multiple sclerosis two years ago presents to you with the new onset of tremor. What constellation of clinical findings is typical of tremor due to multiple sclerosis?

1. rest tremor, only occasionally observable when the patient is excited

2. a tremor that appears sometimes on the left side, sometimes on the right

3. a tremor that is only present in the morning

4. a swaying, broad-based gait and an intention tremor

5. a postural tremor that is easily suppressed by voluntary effort

Question 4

A 55-year-old man with essential tremor says that he can no longer feed himself because of tremor, can dress himself only with great difficulty, and has not had legible handwriting for many years. Drug treatment as recommended in the relevant clinical guidelines brings only slight improvement. What can you advise the patient about the option of surgical treatment?

1. Deep brain stimulation (DBS) might help but is not available in Germany.

2. DBS is an experimental technique that is only performed in clinical trials.

3. DBS is indicated only to treat Parkinson’s disease and plays no role in the treatment of essential tremor.

4. DBS has a high chance of success in this situation; it is now established as a standard treatment for essential tremor.

5. DBS is no more effective than pharmacotherapy for this indication.

Question 5

What information is most important for the diagnostic classification of a tremor syndrome?

1. the clinical findings

2. brain magnetic resonance imaging (MRI) with fine cerebellar sections

3. nuclear-medical visualization of brain perfusion

4. ultrasonography of the basal ganglia

5. measurement of serum drug levels

Question 6

What findings indicate that tremor may be psychogenic?

1. no evidence of essential tremor or Parkinson’s disease on brain MRI

2. a longstanding marital conflict

3. a tremor of inconstant location that diminishes on distraction and is found to be irregular on tremor analysis

4. a clearly identifiable underlying psychological conflict

5. remission after psychotherapy

Question 7

When can tremor be treated surgically?

1. When the patient is unwilling to take drugs to treat tremor.

2. When the patient is under 50 years old.

3. When the tremor cannot be adequately suppressed by drugs and there is no contraindication to surgery.

4. When the patient is willing to see a neurosurgeon once a week so that brain stimulation can be performed.

5. When the patient is willing to assume the cost of weekly battery changes.

Question 8

What must be borne in mind with respect to drug treatment for various tremor syndromes?

1. That the treatment is based on the clinical findings and not on the underlying disease causing tremor.

2. That causally directed treatment is generally possible only for drug-induced tremors or tremors due to metabolic disturbance.

3. That parkinsonian tremor responds best to anticholinergic drugs and does not respond at all to the classic dopamine preparations.

4. That the cerebellar tremor of multiple sclerosis is treated in exactly the same way as essential tremor.

5. That essential tremor is usually medically intractable.

Question 9

What drugs can induce tremor?

1. lithium, valproic acid, cyclosporine A

2. carbamazepine, propranolol, Seroxat

3. aspirin, diclofenac, paracetamol

4. penicillin, erythromycin, cephalosporin

5. antilipid drugs, antidiabetic drugs

Question 10

What is the drug, or drug class, of first choice for the treatment of parkinsonian tremor?

1. dopaminergic drugs

2. propanolol

3. primidone

4. gabapentin

5. ondansetron

References

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Tremor – Causes, Symptoms, Diagnosis, Treatment Enhanced Physiological Tremor – Causes, Symptoms, Treatment Orthostatic Tremor – Causes, Symptoms, Diagnosis, Treatment Idiopathic Orthostatic Tremor – Causes, Symptoms, Treatment Primary Orthostatic Tremor – Causes, Symptoms, Treatment Functional Tremor – Causes, Symptoms, Treatment Psychogenic Tremor – Causes, Symptoms, Treatment Parkinsonian Tremor – Causes, Symptoms, Diagnosis, Treatment Postural Tremor – Causes, Symptoms, Treatment Dystonic Tremor – Causes, Symptoms, Treatment Kinetic Tremor – Causes, Symptoms, Treatment Essential Tremor – Causes, Symptoms, Treatment

Kinetic tremor is associated with any voluntary movement, such as moving the wrists up and down or closing and opening the eyes.  A kinetic tremor occurs when a body part is moving. Kinetic tremors occur for example, when the arm is moving toward the mouth to eat. Parkinson’s tremors classically occur at two characteristic times. One is at rest. The other is when the limb is moved and then held against gravity.

Causes of Kinetic Tremor

Generally, tremor is caused by a problem in the deep parts of the brain that control movements.  Most types of tremors have no known cause, although there are some forms that appear to be inherited and run in families.

Tremor can occur on its own or be a symptom associated with a number of neurological disorders, including

• Multiple sclerosis
• Stroke
• Traumatic brain injury
• Neurodegenerative diseases that affect parts of the brain (e.g.,  Parkinson’s disease).
• Neurologic disorders, including multiple sclerosis, Parkinson’s disease, stroke, and traumatic brain injury
• Certain medicines, such as asthma medicines, amphetamines, caffeine, corticosteroids, and medicines used for certain psychiatric and neurological disorders
• Alcohol use disorder or alcohol withdrawal
• Mercury poisoning
• Hyperthyroidism (overactive thyroid)
• Liver or kidney failure
• Anxiety or panic

Some other known causes can include

• the use of certain medicines (particular asthma medication, amphetamines, caffeine, corticosteroids, and drugs used for certain psychiatric and neurological disorders)
• alcohol abuse or withdrawal
• mercury poisoning
• overactive thyroid
• liver or kidney failure
• anxiety or panic.

Symptoms of Kinetic Tremor

Symptoms of tremor may include

• A tremor is involuntary, rhythmic contractions of various muscles. Shaky legs syndrome causes feelings of “vibration”, unsteadiness or imbalance in the legs.
• A rhythmic shaking in the hands, arms, head, legs, or torso
• Balance and muscle coordination problem
• Spasticity and muscle spasm with wasting
• Shaky voice
• Difficulty writing or drawing
• Problems holding and controlling utensils, such as a spoon.
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement
• Usually occur in the hands first, affecting one hand or both hands
• Can include a “yes-yes” or “no-no” motion of the head
• It May be aggravated by emotional stress, fatigue, caffeine, or temperature extremes
• Tremors that get worse during emotional stress
• Tremors that get worse when you move on purpose
• Tremors that lessen with rest
• Balance problems (in rare cases)
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement

Essential tremor vs. Parkinson’s disease

Many people associate tremors with Parkinson’s disease, but the two conditions differ in key ways:

Timing of tremors. Essential tremor of the hands usually occurs when you use your hands. Tremors from Parkinson’s disease are most prominent when your hands are at your sides or resting in your lap.

Associated conditions. Essential tremor doesn’t cause other health problems, but Parkinson’s disease is associated with stooped posture, slow movement and shuffling gait. However, people with essential tremor sometimes develop other neurological signs and symptoms, such as an unsteady gait (ataxia).

Parts of body affected. Essential tremor mainly involves your hands, head and voice. Parkinson’s disease tremors usually start in your hands, and can affect your legs, chin and other parts of your body.

Signs

What we feel in both legs simultaneously is extreme straining, fatigue, unsteadiness, and a fear of falling. The muscles in our legs become hard, our ankles feel weak and our toes curl under as our legs fail to support us. We can stand for only a short period of time, in some cases only seconds. There is a feeling of panic to find a place to sit, or if possible, walk to gain some relief from our symptoms. Some tremors /shaky legs syndrome may be triggered by or become worse during times of stress or strong emotion, when an individual is physically exhausted, or when a person is in certain postures or makes certain movements.

Diagnosis of Kinetic Tremor

Medical history

During the physical evaluation, a doctor will assess the tremor based on:

• whether the tremor occurs when the muscles are at rest or inaction
• the location of the tremor on the body (and if it occurs on one or both sides of the body)
• the appearance of the tremor (tremor frequency and amplitude).

The doctor will also check other neurological findings such as impaired balance, speech abnormalities, or increased muscle stiffness.  Blood or urine tests can rule out metabolic causes such as thyroid malfunction and certain medications that can cause tremors/shaky legs syndrome.  These tests may also help to identify contributing causes such as drug interactions, chronic alcoholism, or other conditions or diseases.  Diagnostic imaging may help determine if the tremor is the result of damage to the brain.

Clinical observations

The diagnosis is based on a combination of a number of clinical observations and recognition of typical characteristics (phenomenology) that include, but are not necessarily limited to the following:

• Onset of the movements is abrupt/sudden.
• Movements are triggered by emotional or physical trauma, or by some conflict (marital, sexual, work-related).
• Movements are episodic or appear intermittent.
• There are spontaneous remissions of the movements.
• Movements disappear with distraction.
• Movements are suggestible, meaning they may disappear by making a suggestion. For example, suggesting that the application of a tuning fork to the body part affected may help relieve the movements.
• Underlying psychiatric disturbances (depression, anxiety) are present.
• There are multiple somatizations and undiagnosed conditions.
• There is a lack of emotional concern about the disorder (“la belle indifference”).
• There has been exposure to neurologic disorders during one’s occupation (e.g. nurse, physician) or while caring for someone with similar problems.
• Slurred speech, soft voice, gibberish, foreign accent
• Delayed and excessive startle (bizarre movements in response to sudden, unexpected noise or threatening movement)
• Presence of additional types of abnormal movements that are not known to be part of the primary or principal movement disorder pattern that the patient manifests
• Active resistance against passive movement
• Fixed posture

Treatment of Kinetic Tremor

Non-pharmacological

• Physical, speech-language, and occupational therapy – may help to control tremors and meet daily challenges caused by the tremor.  A physical therapist can help people improve their muscle control, functioning, and strength through coordination, balancing, and other exercises.  Some therapists recommend the use of weights, splints, other adaptive equipment, and special plates and utensils for eating.  Speech-language pathologists can evaluate and treat speech, language, communication, and swallowing disorders.  Occupational therapists can teach individuals new ways of performing activities of daily living that may be affected by tremors.
• Eliminating or reducing tremor-inducing substances such as caffeine and other medication – (such as stimulants) can help improve tremor. Though small amounts of alcohol can improve tremors for some people, tremors can become worse once the effects of the alcohol wear off.
• Interventional Therapy – For patients who fail pharmacologic treatment with the above drugs or are unable to tolerate the side effects, surgical options include deep brain stimulation (DBS), focused ultrasound, or radio-surgical gamma knife thalamotomy to treat persistently disabling limb tremor, and botulinum toxin injections to treat persistently disabling head or vocal cord tremor.
• Deep-brain stimulation – This is the most common surgical treatment for essential tremors. Most series report 70% to 90% hand tremor control. In deep-brain stimulation, electrical stimulation is delivered to the brain through an electrode implanted deep into the ventral intermediate nucleus (VIM) of the thalamus. This is typically done by implanting 4 electrodes in the VIM using stereotactic methods. Computerized programming of the pulse generator is most commonly done with a handheld device after the patient leaves the hospital to optimize the electrode montage, voltage, pulse frequency, and pulse width. Deep-brain stimulation can be done unilaterally or bilaterally depending on the patient’s symptoms. There is an increased risk of speech and balance difficulties with bilateral procedures. If the tremor significantly affects both hands, the dominant hand is targeted, bilateral procedures may be considered.
• Focused ultrasound – Approved by the FDA in 2016, magnetic resonance imaging-guided, high-intensity, focused ultrasound thalamotomy is an innovative method for the treatment of essential tremors. Although it is transcranial and does not require an incision, skull penetration, or an implanted device, it is an invasive therapy that produces a permanent thalamic lesion.
• Radio-surgical gamma knife thalamotomy – Gamma-knife thalamotomy fo­cuses high-energy gamma rays on the ventral intermediate resulting in the death of neurons. It is an unproven treatment that has not generally been adopted due to concerns about potential radiation side effects, including a theoretical, long-term risk of secondary tumor formation.
• Ultrasound Therapy – A new treatment for essential tremors uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brain’s thalamus thought to be responsible for causing the tremors.  The treatment is approved only for those individuals with essential tremors who do not respond well to anticonvulsant or beta-blocking drugs.
• Biofeedback – is a mind-body technique that involves using visual or auditory feedback to teach people to recognize the physical signs and symptoms of stress and anxiety, such as increased heart rate, body temperature, and muscle tension.
• Relaxation techniques – can reduce stress symptoms and help you enjoy a better quality of life, especially if you have an illness. Explore relaxation techniques you can do by yourself.
• Learn to relax – Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors. Although you can’t eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques, such as massage or meditation.
• Noninvasive techniques – Include gait rehabilitation, visually guided techniques, tendon vibration, weighting extremities, positioning techniques, and manual techniques, all of which can be useful for the recovery of functional activities.[rx]
• Invasive techniques – Thalamic deep brain stimulation can alleviate the tremor in MS, providing better functional performance.[rx] Stereotactic radiosurgery thalamotomy at the nucleus ventralis intermedius with a median maximum dose of 140 Gy also provides good functional outcomes in patients with MS.[rx][rx] Radiofrequency thalamotomy had been successfully used in the past but has been replaced with the newer techniques of radiosurgery and deep brain stimulation as they had fewer adverse effects.
• Physical therapy – can help some patients control their tremors better, as can reducing the intake of substances such as caffeine, which can induce tremors. Many patients experience an increase in the severity of their tremors when they are stressed. Therefore, trying to reduce sources of anxiety and engaging in complementary therapies (such as yoga or aromatherapy) may help some patients.
• Speech and occupational therapy – may be useful not only in improving physical and psychological functioning, such as activities of daily living, but also to alter the abnormally learned pattern of movement – “motor reprograming.” Antidepressants and muscle relaxants may be also beneficial. Rarely, transcutaneous electrical stimulation applied to the area of spasm or involuntary movement may be helpful, analogous to the application of a tuning fork during clinic evaluation. Most importantly, however, the patient should try to understand which stress factors may be playing a role and seek the expertise of a psychologist experienced and skilled in stress management. The role of a psychiatrist is not to make the diagnosis but to provide insights into underlying psychological or psychiatric issues and to aid in the treatment of psychiatric issues such as depression or anxiety.
• Psychogenic movement Therapy –  It may be difficult to treat, especially if the patient is diagnosed late or is not accepting of the diagnosis. Indeed, patients with the best prognosis are those who initially accept the diagnosis and work with the movement disorder neurologist, psychologist, psychiatrist and physical, speech and occupational therapists in implementing a short-term and long-term therapeutic program. The diagnosis should be disclosed to patients in a manner that is empathetic and nonjudgmental.

For example, tremors due to thyroid hyperactivity will improve or even resolve (return to the normal state) with the treatment of thyroid malfunction.  Also, if the tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.

Medical Therapy

The therapeutic approach to essential tremors many times follows a trial and error approach, and patients should be challenged by several medications if the first choice is ineffective or associated with debilitating adverse effects. Medical therapy can be divided into first, second, and third-line therapies.

First-line therapy – It is either approved by the FDA or supported by double-blinded, placebo-controlled studies that meet the criteria for the class I evidence. This class of medications includes propranolol and primidone. If both primidone and propranolol are not effective alone, combinations of both may provide relief in selected patients.

Second-line therapy – Second-line therapy is supported by double-blinded, placebo-controlled trials that do not meet other requirements for the class I evidence studies. This includes gabapentin, pregabalin, topiramate, benzodiazepines (clonazepam, alprazolam), beta-blockers (atenolol and metoprolol) and zonisamide.

Third-line therapy – These therapies are based on open-label studies or case series. Drugs in this class include nimodipine and clozapine.

Medication

• Beta-blocking drugs such as propranolol are normally used to treat high blood pressure but they also help treat essential tremors.  Propranolol can also be used in some people with other types of action tremors.  Other beta-blockers that may be used include atenolol, metoprolol, nadolol, and sotalol.
• Anti-seizure medications such as primidone can be effective in people with essential tremors who do not respond to beta-blockers.  Other medications that may be prescribed include gabapentin and topiramate.  However, it is important to note that some anti-seizure medications can cause tremors.
• Tranquilizers (also known as benzodiazepines) such as alprazolam and clonazepam may temporarily help some people with tremors.  However, their use is limited due to unwanted side effects that include sleepiness, poor concentration, and poor coordination.  This can affect the ability of people to perform daily activities such as driving, school, and work.  Also, when taken regularly, tranquilizers can cause physical dependence and when stopped abruptly can cause several withdrawal symptoms.
• Parkinson’s disease medications (levodopa, carbidopa) are used to treat tremors associated with Parkinson’s disease.
• Botulinum toxin – injections can treat almost all types of tremors.  It is especially useful for head tremor, which generally does not respond to medications.  Botulinum toxin is widely used to control dystonic tremors.  Although botulinum toxin injections can improve tremors for roughly three months at a time, they can also cause muscle weakness.  While this treatment is effective and usually well tolerated for head tremors, botulinum toxin treatment in the hands can cause weakness in the fingers.  It can cause a hoarse voice and difficulty swallowing when used to treat voice tremors.

Additional drug therapies that have been used to treat individuals with primary orthostatic tremors include primidone (Mysoline), chlordiazepoxide (Librium), pregabalin (Lyrica), pramipexole (Mirapex), phenobarbital, and valproic acid (Depakote). Drugs commonly used to treat people with Parkinson’s disease (levodopa or pramipexole) may also be prescribed for individuals with primary orthostatic tremors.

Surgery

When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation (DBS) or very rarely, thalamotomy.  While DBS is usually well-tolerated, the most common side effects of tremor surgery include dysarthria (trouble speaking) and balance problems.

• Deep brain stimulation (DBS) – is the most common form of surgical treatment of tremors.  This method is preferred because it is effective, has low risk, and treats a broader range of symptoms than thalamotomy.  The treatment uses surgically implanted electrodes to send high-frequency electrical signals to the thalamus, the deep structure of the brain that coordinates and controls some involuntary movements.  A small pulse generating device placed under the skin in the upper chest (similar to a pacemaker) sends electrical stimuli to the brain and temporarily disables the tremor.  DBS is currently used to treat parkinsonian tremors, essential tremors, and dystonia.

• Thalamotomy – is a surgical procedure that involves the precise, permanent destruction of a tiny area in the thalamus.  Currently, surgery is replaced by radiofrequency ablation to treat severe tremors when deep brain surgery is contraindicated—meaning it is unwise as a treatment option or has undesirable side effects.  Radiofrequency ablation uses a radio wave to generate an electric current that heats up a nerve and disrupts its signaling ability for typically six or more months.  It is usually performed on only one side of the brain to improve tremors on the opposite side of the body.  Surgery on both sides is not recommended as it can cause problems with speech.
• Focused ultrasound thalamotomy – This non-invasive surgery involves using focused sound waves that travel through the skin and skull. The waves generate heat to destroy brain tissue in a specific area of the thalamus to stop a tremor. A surgeon uses magnetic resonance imaging to target the correct area of the brain and to be sure the sound waves are generating the exact amount of heat needed for the procedure. Focused ultrasound thalamotomy creates a lesion that can result in permanent changes to brain function. Some people have experienced the altered sensation, trouble with walking or difficulty with movement. However, most complications go away on their own or are mild enough that they don’t interfere with the quality of life.
•  Stereotactic surgical techniques – can be used to create a lesion in the ventral intermediate (VIM) nucleus of the thalamus.

Rehabilitation

Exercise is an important part of healthy living for everyone. For people with tremors, exercise is more than healthy it is a vital component to maintaining balance, mobility, and activities of daily living. Exercise and physical activity can improve many tremors symptoms. These benefits are supported by research.

The tremors show that people with tremors who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.

What Type of Exercise Should I Do?

To help manage the symptoms of tremors, be sure your exercise program includes a few key ingredients:

• Aerobic activity
• Strength training
• Balance, agility, and multitasking
• Flexibility

These elements are included in many types of exercise. Biking, running, Tai chi, yoga, Pilates, dance, weight training, non-contact boxing, qi gong, and more — all have positive effects on tremors symptoms.

There is no “exercise prescription” that is right for every person with tremors. The type of exercise you do depends on your symptoms and challenges. For sedentary people, just getting up and moving is beneficial. More active people can build up to the regular, vigorous activity. Many approaches work well to help maintain and improve mobility, flexibility, and balance to ease non-motor tremors symptoms such as depression or constipation.

Researchers in the study did not distinguish between what type of exercise participants did and determined that all types of exercise are beneficial. The most important thing is to do the exercise regularly. We suggest finding an exercise you enjoy and stick with it.

Challenges to Exercising

• People in the early stages of tremors tend to be just as strong and physically fit as healthy individuals of the same age.
• Disease progression can lead to the following physical change:
• Loss of joint flexibility, which can affect balance.
• Decreased muscle strength or deconditioning can affect walking and the ability to stand up from sitting.
• The decline in cardiovascular conditioning, which affects endurance.

Tips for Getting Started

• First, be safe. Before starting an exercise program, consult your neurologist and primary care doctor about concerns and recommendations.
• Ask your doctor or members in your support group to refer to a physical therapist (PT) who knows about tremors. Work together to identify your concerns and limitations. Target exercises to improve them. For most people, a structured exercise program will include aerobic exercise (such as brisk walking) and resistance training (using weights or bands).
• Purchase a pedometer (step-counter) and figure out how many steps you take on average each day, then build up from there. Many smartphones or smartwatches have a built-in pedometer feature or an application that can be downloaded.
• Exercise indoors and outdoors. Change your routine to stay interested and motivated.
• Again, most importantly pick an exercise you enjoy.

What research is being done?

The mission is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.  The NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world.

Researchers are working to better understand the underlying brain functions that cause tremors, identify the genetic factors that make individuals more susceptible to the disorder, and develop new and better treatment options.

• Brain functioning – It can be difficult to distinguish between movement disorders such as Parkinson’s disease and essential tremor. These debilitating movement disorders have different prognoses and can respond very differently to available therapies. NINDS researchers are working to identify structural and functional changes in the brain using non-invasive neuroimaging techniques to develop sensitive and specific markers for each of these diseases and then track how they change as each disease progresses. Other researchers are using functional magnetic resonance imaging technology to better understand normal and diseased brain circuit functions and associated motor behaviors.  Scientists hope to design therapies that can restore normal brain circuit function in diseases such as Parkinson’s disease and tremor.
• Genetics – Research has shown that essential tremors may have a strong genetic component affecting multiple generations of families.  NINDS researchers are building on previous genetics work to identify susceptibility genes for familial early-onset (before age 40) essential tremor.  Researchers are focusing on multigenerational, early-onset families to better detect linkages.

Additionally, NINDS scientists are researching the impact of genetic abnormalities on the development of essential tremors.  Previous research that has shown a link between essential tremor and possible genetic variants on chromosome 6 and 11; ongoing research is targeting the impact of other genetic variations in families.

Medications and other treatment methods

While drugs can be effective for some people, approximately 50 percent of individuals do not respond to medication.  In order to develop assistive and rehabilitative tremor-suppressing devices for people with essential tremors, researchers are exploring where and how to minimize or suppress tremors while still allowing for voluntary movements.

Many people with essential tremors respond to ethanol (alcohol); however, it is not clear why or how.  NINDS researchers are studying the impact of ethanol on tremors to determine the correct dosage amount and its physiological impact on the brain and whether other medications without the side effects of ethanol can be effective.

Other NIH researchers hope to identify the source of essential tremors, study the effects of currently available tremor-suppressant drugs on the brain, and develop more targeted and effective therapies.

FAQ

Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

Which of the following constellations of clinical findings is typical of tremor in patients with Parkinson’s disease?

1. bilateral postural tremor

2. unilateral rest tremor and diminished ipsilateral arm swing while walking

3. severe unilateral tremor while holding a cup or glass

4. tremor that only appears when the patient writes

5. postural tremor of both hands and ataxic gait

Question 2

A 25-year-old man has a mild postural tremor of both hands that improves when he drinks alcohol. His mother had the same condition. What can you advise him?

1. He should definitely be evaluated for possible early Parkinson’s disease.

2. He must get treatment now, as otherwise the condition could worsen.

3. If treatment is indicated, propranolol or primidone could be given.

4. Relaxation exercises and physiotherapy are effective treatment options.

5. Genetic testing is needed to confirm the diagnosis of essential tremor.

Question 3

A man who received the diagnosis of multiple sclerosis two years ago presents to you with the new onset of tremor. What constellation of clinical findings is typical of tremor due to multiple sclerosis?

1. rest tremor, only occasionally observable when the patient is excited

2. a tremor that appears sometimes on the left side, sometimes on the right

3. a tremor that is only present in the morning

4. a swaying, broad-based gait and an intention tremor

5. a postural tremor that is easily suppressed by voluntary effort

Question 4

A 55-year-old man with essential tremor says that he can no longer feed himself because of tremor, can dress himself only with great difficulty, and has not had legible handwriting for many years. Drug treatment as recommended in the relevant clinical guidelines brings only slight improvement. What can you advise the patient about the option of surgical treatment?

1. Deep brain stimulation (DBS) might help but is not available in Germany.

2. DBS is an experimental technique that is only performed in clinical trials.

3. DBS is indicated only to treat Parkinson’s disease and plays no role in the treatment of essential tremor.

4. DBS has a high chance of success in this situation; it is now established as a standard treatment for essential tremor.

5. DBS is no more effective than pharmacotherapy for this indication.

Question 5

What information is most important for the diagnostic classification of a tremor syndrome?

1. the clinical findings

2. brain magnetic resonance imaging (MRI) with fine cerebellar sections

3. nuclear-medical visualization of brain perfusion

4. ultrasonography of the basal ganglia

5. measurement of serum drug levels

Question 6

What findings indicate that tremor may be psychogenic?

1. no evidence of essential tremor or Parkinson’s disease on brain MRI

2. a longstanding marital conflict

3. a tremor of inconstant location that diminishes on distraction and is found to be irregular on tremor analysis

4. a clearly identifiable underlying psychological conflict

5. remission after psychotherapy

Question 7

When can tremor be treated surgically?

1. When the patient is unwilling to take drugs to treat tremor.

2. When the patient is under 50 years old.

3. When the tremor cannot be adequately suppressed by drugs and there is no contraindication to surgery.

4. When the patient is willing to see a neurosurgeon once a week so that brain stimulation can be performed.

5. When the patient is willing to assume the cost of weekly battery changes.

Question 8

What must be borne in mind with respect to drug treatment for various tremor syndromes?

1. That the treatment is based on the clinical findings and not on the underlying disease causing tremor.

2. That causally directed treatment is generally possible only for drug-induced tremors or tremors due to metabolic disturbance.

3. That parkinsonian tremor responds best to anticholinergic drugs and does not respond at all to the classic dopamine preparations.

4. That the cerebellar tremor of multiple sclerosis is treated in exactly the same way as essential tremor.

5. That essential tremor is usually medically intractable.

Question 9

What drugs can induce tremor?

1. lithium, valproic acid, cyclosporine A

2. carbamazepine, propranolol, Seroxat

3. aspirin, diclofenac, paracetamol

4. penicillin, erythromycin, cephalosporin

5. antilipid drugs, antidiabetic drugs

Question 10

What is the drug, or drug class, of first choice for the treatment of parkinsonian tremor?

1. dopaminergic drugs

2. propanolol

3. primidone

4. gabapentin

5. ondansetron

References

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Postural tremor occurs when holding a position against gravity, such as holding your arm or leg outstretched. Task-specific tremors occur during a specific activity, such as writing. Kinetic tremors occur during movement of a body part, such as moving your wrist up and down.

Causes of Postural Tremor

Generally, tremor is caused by a problem in the deep parts of the brain that control movements.  Most types of tremors have no known cause, although there are some forms that appear to be inherited and run in families.

Tremor can occur on its own or be a symptom associated with a number of neurological disorders, including

• Multiple sclerosis
• Stroke
• Traumatic brain injury
• Neurodegenerative diseases that affect parts of the brain (e.g.,  Parkinson’s disease).
• Neurologic disorders, including multiple sclerosis, Parkinson’s disease, stroke, and traumatic brain injury
• Certain medicines, such as asthma medicines, amphetamines, caffeine, corticosteroids, and medicines used for certain psychiatric and neurological disorders
• Alcohol use disorder or alcohol withdrawal
• Mercury poisoning
• Hyperthyroidism (overactive thyroid)
• Liver or kidney failure
• Anxiety or panic

Some other known causes can include

• the use of certain medicines (particular asthma medication, amphetamines, caffeine, corticosteroids, and drugs used for certain psychiatric and neurological disorders)
• alcohol abuse or withdrawal
• mercury poisoning
• overactive thyroid
• liver or kidney failure
• anxiety or panic.

Symptoms of Postural Tremor

Symptoms of tremor may include

• A tremor is involuntary, rhythmic contractions of various muscles. Shaky legs syndrome causes feelings of “vibration”, unsteadiness or imbalance in the legs.
• A rhythmic shaking in the hands, arms, head, legs, or torso
• Balance and muscle coordination problem
• Spasticity and muscle spasm with wasting
• Shaky voice
• Difficulty writing or drawing
• Problems holding and controlling utensils, such as a spoon.
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement
• Usually occur in the hands first, affecting one hand or both hands
• Can include a “yes-yes” or “no-no” motion of the head
• It May be aggravated by emotional stress, fatigue, caffeine, or temperature extremes
• Tremors that get worse during emotional stress
• Tremors that get worse when you move on purpose
• Tremors that lessen with rest
• Balance problems (in rare cases)
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement

Essential tremor vs. Parkinson’s disease

Many people associate tremors with Parkinson’s disease, but the two conditions differ in key ways:

Timing of tremors. Essential tremor of the hands usually occurs when you use your hands. Tremors from Parkinson’s disease are most prominent when your hands are at your sides or resting in your lap.

Associated conditions. Essential tremor doesn’t cause other health problems, but Parkinson’s disease is associated with stooped posture, slow movement and shuffling gait. However, people with essential tremor sometimes develop other neurological signs and symptoms, such as an unsteady gait (ataxia).

Parts of body affected. Essential tremor mainly involves your hands, head and voice. Parkinson’s disease tremors usually start in your hands, and can affect your legs, chin and other parts of your body.

Signs

What we feel in both legs simultaneously is extreme straining, fatigue, unsteadiness, and a fear of falling. The muscles in our legs become hard, our ankles feel weak and our toes curl under as our legs fail to support us. We can stand for only a short period of time, in some cases only seconds. There is a feeling of panic to find a place to sit, or if possible, walk to gain some relief from our symptoms. Some tremors /shaky legs syndrome may be triggered by or become worse during times of stress or strong emotion, when an individual is physically exhausted, or when a person is in certain postures or makes certain movements.

Diagnosis of Postural Tremor

Medical history

During the physical evaluation, a doctor will assess the tremor based on:

• whether the tremor occurs when the muscles are at rest or inaction
• the location of the tremor on the body (and if it occurs on one or both sides of the body)
• the appearance of the tremor (tremor frequency and amplitude).

The doctor will also check other neurological findings such as impaired balance, speech abnormalities, or increased muscle stiffness.  Blood or urine tests can rule out metabolic causes such as thyroid malfunction and certain medications that can cause tremors/shaky legs syndrome.  These tests may also help to identify contributing causes such as drug interactions, chronic alcoholism, or other conditions or diseases.  Diagnostic imaging may help determine if the tremor is the result of damage to the brain.

Clinical observations

The diagnosis is based on a combination of a number of clinical observations and recognition of typical characteristics (phenomenology) that include, but are not necessarily limited to the following:

• Onset of the movements is abrupt/sudden.
• Movements are triggered by emotional or physical trauma, or by some conflict (marital, sexual, work-related).
• Movements are episodic or appear intermittent.
• There are spontaneous remissions of the movements.
• Movements disappear with distraction.
• Movements are suggestible, meaning they may disappear by making a suggestion. For example, suggesting that the application of a tuning fork to the body part affected may help relieve the movements.
• Underlying psychiatric disturbances (depression, anxiety) are present.
• There are multiple somatizations and undiagnosed conditions.
• There is a lack of emotional concern about the disorder (“la belle indifference”).
• There has been exposure to neurologic disorders during one’s occupation (e.g. nurse, physician) or while caring for someone with similar problems.
• Slurred speech, soft voice, gibberish, foreign accent
• Delayed and excessive startle (bizarre movements in response to sudden, unexpected noise or threatening movement)
• Presence of additional types of abnormal movements that are not known to be part of the primary or principal movement disorder pattern that the patient manifests
• Active resistance against passive movement
• Fixed posture

Treatment of Postural Tremor

Non-pharmacological

• Physical, speech-language, and occupational therapy – may help to control tremors and meet daily challenges caused by the tremor.  A physical therapist can help people improve their muscle control, functioning, and strength through coordination, balancing, and other exercises.  Some therapists recommend the use of weights, splints, other adaptive equipment, and special plates and utensils for eating.  Speech-language pathologists can evaluate and treat speech, language, communication, and swallowing disorders.  Occupational therapists can teach individuals new ways of performing activities of daily living that may be affected by tremors.
• Eliminating or reducing tremor-inducing substances such as caffeine and other medication – (such as stimulants) can help improve tremor. Though small amounts of alcohol can improve tremors for some people, tremors can become worse once the effects of the alcohol wear off.
• Interventional Therapy – For patients who fail pharmacologic treatment with the above drugs or are unable to tolerate the side effects, surgical options include deep brain stimulation (DBS), focused ultrasound, or radio-surgical gamma knife thalamotomy to treat persistently disabling limb tremor, and botulinum toxin injections to treat persistently disabling head or vocal cord tremor.
• Deep-brain stimulation – This is the most common surgical treatment for essential tremors. Most series report 70% to 90% hand tremor control. In deep-brain stimulation, electrical stimulation is delivered to the brain through an electrode implanted deep into the ventral intermediate nucleus (VIM) of the thalamus. This is typically done by implanting 4 electrodes in the VIM using stereotactic methods. Computerized programming of the pulse generator is most commonly done with a handheld device after the patient leaves the hospital to optimize the electrode montage, voltage, pulse frequency, and pulse width. Deep-brain stimulation can be done unilaterally or bilaterally depending on the patient’s symptoms. There is an increased risk of speech and balance difficulties with bilateral procedures. If the tremor significantly affects both hands, the dominant hand is targeted, bilateral procedures may be considered.
• Focused ultrasound – Approved by the FDA in 2016, magnetic resonance imaging-guided, high-intensity, focused ultrasound thalamotomy is an innovative method for the treatment of essential tremors. Although it is transcranial and does not require an incision, skull penetration, or an implanted device, it is an invasive therapy that produces a permanent thalamic lesion.
• Radio-surgical gamma knife thalamotomy – Gamma-knife thalamotomy fo­cuses high-energy gamma rays on the ventral intermediate resulting in the death of neurons. It is an unproven treatment that has not generally been adopted due to concerns about potential radiation side effects, including a theoretical, long-term risk of secondary tumor formation.
• Ultrasound Therapy – A new treatment for essential tremors uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brain’s thalamus thought to be responsible for causing the tremors.  The treatment is approved only for those individuals with essential tremors who do not respond well to anticonvulsant or beta-blocking drugs.
• Biofeedback – is a mind-body technique that involves using visual or auditory feedback to teach people to recognize the physical signs and symptoms of stress and anxiety, such as increased heart rate, body temperature, and muscle tension.
• Relaxation techniques – can reduce stress symptoms and help you enjoy a better quality of life, especially if you have an illness. Explore relaxation techniques you can do by yourself.
• Learn to relax – Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors. Although you can’t eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques, such as massage or meditation.
• Noninvasive techniques – Include gait rehabilitation, visually guided techniques, tendon vibration, weighting extremities, positioning techniques, and manual techniques, all of which can be useful for the recovery of functional activities.[rx]
• Invasive techniques – Thalamic deep brain stimulation can alleviate the tremor in MS, providing better functional performance.[rx] Stereotactic radiosurgery thalamotomy at the nucleus ventralis intermedius with a median maximum dose of 140 Gy also provides good functional outcomes in patients with MS.[rx][rx] Radiofrequency thalamotomy had been successfully used in the past but has been replaced with the newer techniques of radiosurgery and deep brain stimulation as they had fewer adverse effects.
• Physical therapy – can help some patients control their tremors better, as can reducing the intake of substances such as caffeine, which can induce tremors. Many patients experience an increase in the severity of their tremors when they are stressed. Therefore, trying to reduce sources of anxiety and engaging in complementary therapies (such as yoga or aromatherapy) may help some patients.
• Speech and occupational therapy – may be useful not only in improving physical and psychological functioning, such as activities of daily living, but also to alter the abnormally learned pattern of movement – “motor reprograming.” Antidepressants and muscle relaxants may be also beneficial. Rarely, transcutaneous electrical stimulation applied to the area of spasm or involuntary movement may be helpful, analogous to the application of a tuning fork during clinic evaluation. Most importantly, however, the patient should try to understand which stress factors may be playing a role and seek the expertise of a psychologist experienced and skilled in stress management. The role of a psychiatrist is not to make the diagnosis but to provide insights into underlying psychological or psychiatric issues and to aid in the treatment of psychiatric issues such as depression or anxiety.
• Psychogenic movement Therapy –  It may be difficult to treat, especially if the patient is diagnosed late or is not accepting of the diagnosis. Indeed, patients with the best prognosis are those who initially accept the diagnosis and work with the movement disorder neurologist, psychologist, psychiatrist and physical, speech and occupational therapists in implementing a short-term and long-term therapeutic program. The diagnosis should be disclosed to patients in a manner that is empathetic and nonjudgmental.

For example, tremors due to thyroid hyperactivity will improve or even resolve (return to the normal state) with the treatment of thyroid malfunction.  Also, if the tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.

Medical Therapy

The therapeutic approach to essential tremors many times follows a trial and error approach, and patients should be challenged by several medications if the first choice is ineffective or associated with debilitating adverse effects. Medical therapy can be divided into first, second, and third-line therapies.

First-line therapy – It is either approved by the FDA or supported by double-blinded, placebo-controlled studies that meet the criteria for the class I evidence. This class of medications includes propranolol and primidone. If both primidone and propranolol are not effective alone, combinations of both may provide relief in selected patients.

Second-line therapy – Second-line therapy is supported by double-blinded, placebo-controlled trials that do not meet other requirements for the class I evidence studies. This includes gabapentin, pregabalin, topiramate, benzodiazepines (clonazepam, alprazolam), beta-blockers (atenolol and metoprolol) and zonisamide.

Third-line therapy – These therapies are based on open-label studies or case series. Drugs in this class include nimodipine and clozapine.

Medication

• Beta-blocking drugs such as propranolol are normally used to treat high blood pressure but they also help treat essential tremors.  Propranolol can also be used in some people with other types of action tremors.  Other beta-blockers that may be used include atenolol, metoprolol, nadolol, and sotalol.
• Anti-seizure medications such as primidone can be effective in people with essential tremors who do not respond to beta-blockers.  Other medications that may be prescribed include gabapentin and topiramate.  However, it is important to note that some anti-seizure medications can cause tremors.
• Tranquilizers (also known as benzodiazepines) such as alprazolam and clonazepam may temporarily help some people with tremors.  However, their use is limited due to unwanted side effects that include sleepiness, poor concentration, and poor coordination.  This can affect the ability of people to perform daily activities such as driving, school, and work.  Also, when taken regularly, tranquilizers can cause physical dependence and when stopped abruptly can cause several withdrawal symptoms.
• Parkinson’s disease medications (levodopa, carbidopa) are used to treat tremors associated with Parkinson’s disease.
• Botulinum toxin – injections can treat almost all types of tremors.  It is especially useful for head tremor, which generally does not respond to medications.  Botulinum toxin is widely used to control dystonic tremors.  Although botulinum toxin injections can improve tremors for roughly three months at a time, they can also cause muscle weakness.  While this treatment is effective and usually well tolerated for head tremors, botulinum toxin treatment in the hands can cause weakness in the fingers.  It can cause a hoarse voice and difficulty swallowing when used to treat voice tremors.

Additional drug therapies that have been used to treat individuals with primary orthostatic tremors include primidone (Mysoline), chlordiazepoxide (Librium), pregabalin (Lyrica), pramipexole (Mirapex), phenobarbital, and valproic acid (Depakote). Drugs commonly used to treat people with Parkinson’s disease (levodopa or pramipexole) may also be prescribed for individuals with primary orthostatic tremors.

Surgery

When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation (DBS) or very rarely, thalamotomy.  While DBS is usually well-tolerated, the most common side effects of tremor surgery include dysarthria (trouble speaking) and balance problems.

• Deep brain stimulation (DBS) – is the most common form of surgical treatment of tremors.  This method is preferred because it is effective, has low risk, and treats a broader range of symptoms than thalamotomy.  The treatment uses surgically implanted electrodes to send high-frequency electrical signals to the thalamus, the deep structure of the brain that coordinates and controls some involuntary movements.  A small pulse generating device placed under the skin in the upper chest (similar to a pacemaker) sends electrical stimuli to the brain and temporarily disables the tremor.  DBS is currently used to treat parkinsonian tremors, essential tremors, and dystonia.

• Thalamotomy – is a surgical procedure that involves the precise, permanent destruction of a tiny area in the thalamus.  Currently, surgery is replaced by radiofrequency ablation to treat severe tremors when deep brain surgery is contraindicated—meaning it is unwise as a treatment option or has undesirable side effects.  Radiofrequency ablation uses a radio wave to generate an electric current that heats up a nerve and disrupts its signaling ability for typically six or more months.  It is usually performed on only one side of the brain to improve tremors on the opposite side of the body.  Surgery on both sides is not recommended as it can cause problems with speech.
• Focused ultrasound thalamotomy – This non-invasive surgery involves using focused sound waves that travel through the skin and skull. The waves generate heat to destroy brain tissue in a specific area of the thalamus to stop a tremor. A surgeon uses magnetic resonance imaging to target the correct area of the brain and to be sure the sound waves are generating the exact amount of heat needed for the procedure. Focused ultrasound thalamotomy creates a lesion that can result in permanent changes to brain function. Some people have experienced the altered sensation, trouble with walking or difficulty with movement. However, most complications go away on their own or are mild enough that they don’t interfere with the quality of life.
•  Stereotactic surgical techniques – can be used to create a lesion in the ventral intermediate (VIM) nucleus of the thalamus.

Rehabilitation

Exercise is an important part of healthy living for everyone. For people with tremors, exercise is more than healthy it is a vital component to maintaining balance, mobility, and activities of daily living. Exercise and physical activity can improve many tremors symptoms. These benefits are supported by research.

The tremors show that people with tremors who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.

What Type of Exercise Should I Do?

To help manage the symptoms of tremors, be sure your exercise program includes a few key ingredients:

• Aerobic activity
• Strength training
• Balance, agility, and multitasking
• Flexibility

These elements are included in many types of exercise. Biking, running, Tai chi, yoga, Pilates, dance, weight training, non-contact boxing, qi gong, and more — all have positive effects on tremors symptoms.

There is no “exercise prescription” that is right for every person with tremors. The type of exercise you do depends on your symptoms and challenges. For sedentary people, just getting up and moving is beneficial. More active people can build up to the regular, vigorous activity. Many approaches work well to help maintain and improve mobility, flexibility, and balance to ease non-motor tremors symptoms such as depression or constipation.

Researchers in the study did not distinguish between what type of exercise participants did and determined that all types of exercise are beneficial. The most important thing is to do the exercise regularly. We suggest finding an exercise you enjoy and stick with it.

Challenges to Exercising

• People in the early stages of tremors tend to be just as strong and physically fit as healthy individuals of the same age.
• Disease progression can lead to the following physical change:
• Loss of joint flexibility, which can affect balance.
• Decreased muscle strength or deconditioning can affect walking and the ability to stand up from sitting.
• The decline in cardiovascular conditioning, which affects endurance.

Tips for Getting Started

• First, be safe. Before starting an exercise program, consult your neurologist and primary care doctor about concerns and recommendations.
• Ask your doctor or members in your support group to refer to a physical therapist (PT) who knows about tremors. Work together to identify your concerns and limitations. Target exercises to improve them. For most people, a structured exercise program will include aerobic exercise (such as brisk walking) and resistance training (using weights or bands).
• Purchase a pedometer (step-counter) and figure out how many steps you take on average each day, then build up from there. Many smartphones or smartwatches have a built-in pedometer feature or an application that can be downloaded.
• Exercise indoors and outdoors. Change your routine to stay interested and motivated.
• Again, most importantly pick an exercise you enjoy.

What research is being done?

The mission is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.  The NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world.

Researchers are working to better understand the underlying brain functions that cause tremors, identify the genetic factors that make individuals more susceptible to the disorder, and develop new and better treatment options.

• Brain functioning – It can be difficult to distinguish between movement disorders such as Parkinson’s disease and essential tremor. These debilitating movement disorders have different prognoses and can respond very differently to available therapies. NINDS researchers are working to identify structural and functional changes in the brain using non-invasive neuroimaging techniques to develop sensitive and specific markers for each of these diseases and then track how they change as each disease progresses. Other researchers are using functional magnetic resonance imaging technology to better understand normal and diseased brain circuit functions and associated motor behaviors.  Scientists hope to design therapies that can restore normal brain circuit function in diseases such as Parkinson’s disease and tremor.
• Genetics – Research has shown that essential tremors may have a strong genetic component affecting multiple generations of families.  NINDS researchers are building on previous genetics work to identify susceptibility genes for familial early-onset (before age 40) essential tremor.  Researchers are focusing on multigenerational, early-onset families to better detect linkages.

Additionally, NINDS scientists are researching the impact of genetic abnormalities on the development of essential tremors.  Previous research that has shown a link between essential tremor and possible genetic variants on chromosome 6 and 11; ongoing research is targeting the impact of other genetic variations in families.

Medications and other treatment methods

While drugs can be effective for some people, approximately 50 percent of individuals do not respond to medication.  In order to develop assistive and rehabilitative tremor-suppressing devices for people with essential tremors, researchers are exploring where and how to minimize or suppress tremors while still allowing for voluntary movements.

Many people with essential tremors respond to ethanol (alcohol); however, it is not clear why or how.  NINDS researchers are studying the impact of ethanol on tremors to determine the correct dosage amount and its physiological impact on the brain and whether other medications without the side effects of ethanol can be effective.

Other NIH researchers hope to identify the source of essential tremors, study the effects of currently available tremor-suppressant drugs on the brain, and develop more targeted and effective therapies.

FAQ

Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

Which of the following constellations of clinical findings is typical of tremor in patients with Parkinson’s disease?

1. bilateral postural tremor

2. unilateral rest tremor and diminished ipsilateral arm swing while walking

3. severe unilateral tremor while holding a cup or glass

4. tremor that only appears when the patient writes

5. postural tremor of both hands and ataxic gait

Question 2

A 25-year-old man has a mild postural tremor of both hands that improves when he drinks alcohol. His mother had the same condition. What can you advise him?

1. He should definitely be evaluated for possible early Parkinson’s disease.

2. He must get treatment now, as otherwise the condition could worsen.

3. If treatment is indicated, propranolol or primidone could be given.

4. Relaxation exercises and physiotherapy are effective treatment options.

5. Genetic testing is needed to confirm the diagnosis of essential tremor.

Question 3

A man who received the diagnosis of multiple sclerosis two years ago presents to you with the new onset of tremor. What constellation of clinical findings is typical of tremor due to multiple sclerosis?

1. rest tremor, only occasionally observable when the patient is excited

2. a tremor that appears sometimes on the left side, sometimes on the right

3. a tremor that is only present in the morning

4. a swaying, broad-based gait and an intention tremor

5. a postural tremor that is easily suppressed by voluntary effort

Question 4

A 55-year-old man with essential tremor says that he can no longer feed himself because of tremor, can dress himself only with great difficulty, and has not had legible handwriting for many years. Drug treatment as recommended in the relevant clinical guidelines brings only slight improvement. What can you advise the patient about the option of surgical treatment?

1. Deep brain stimulation (DBS) might help but is not available in Germany.

2. DBS is an experimental technique that is only performed in clinical trials.

3. DBS is indicated only to treat Parkinson’s disease and plays no role in the treatment of essential tremor.

4. DBS has a high chance of success in this situation; it is now established as a standard treatment for essential tremor.

5. DBS is no more effective than pharmacotherapy for this indication.

Question 5

What information is most important for the diagnostic classification of a tremor syndrome?

1. the clinical findings

2. brain magnetic resonance imaging (MRI) with fine cerebellar sections

3. nuclear-medical visualization of brain perfusion

4. ultrasonography of the basal ganglia

5. measurement of serum drug levels

Question 6

What findings indicate that tremor may be psychogenic?

1. no evidence of essential tremor or Parkinson’s disease on brain MRI

2. a longstanding marital conflict

3. a tremor of inconstant location that diminishes on distraction and is found to be irregular on tremor analysis

4. a clearly identifiable underlying psychological conflict

5. remission after psychotherapy

Question 7

When can tremor be treated surgically?

1. When the patient is unwilling to take drugs to treat tremor.

2. When the patient is under 50 years old.

3. When the tremor cannot be adequately suppressed by drugs and there is no contraindication to surgery.

4. When the patient is willing to see a neurosurgeon once a week so that brain stimulation can be performed.

5. When the patient is willing to assume the cost of weekly battery changes.

Question 8

What must be borne in mind with respect to drug treatment for various tremor syndromes?

1. That the treatment is based on the clinical findings and not on the underlying disease causing tremor.

2. That causally directed treatment is generally possible only for drug-induced tremors or tremors due to metabolic disturbance.

3. That parkinsonian tremor responds best to anticholinergic drugs and does not respond at all to the classic dopamine preparations.

4. That the cerebellar tremor of multiple sclerosis is treated in exactly the same way as essential tremor.

5. That essential tremor is usually medically intractable.

Question 9

What drugs can induce tremor?

1. lithium, valproic acid, cyclosporine A

2. carbamazepine, propranolol, Seroxat

3. aspirin, diclofenac, paracetamol

4. penicillin, erythromycin, cephalosporin

5. antilipid drugs, antidiabetic drugs

Question 10

What is the drug, or drug class, of first choice for the treatment of parkinsonian tremor?

1. dopaminergic drugs

2. propanolol

3. primidone

4. gabapentin

5. ondansetron

References

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Essential tremor (previously also called benign essential tremor or familial tremor, idiopathic tremor ) is one of the most common movement disorders.  The exact cause of essential tremors is unknown.  For some people, this tremor is mild and remains stable for many years.  The tremor usually appears on both sides of the body but is often noticed more in the dominant hand because it is an action tremor.

Essential Tremor (ET) is a relatively common condition that results in trembling in the hands or arms, which in some cases can subsequently spread to cause tremor of the head, legs, trunk or voice.

The key feature of essential tremor is a tremor in both hands and arms, which is present during the action and when standing still.  Additional symptoms may include head tremor (e.g., a “yes” or “no” motion) without abnormal posturing of the head and a shaking or quivering sound to the voice if the tremor affects the voice box.  The action tremor in both hands in essential tremor can lead to problems with writing, drawing, drinking from a cup, or using tools or a computer.

Tremor frequency (how “fast” the tremor shakes) may decrease as the person ages, but the severity may increase, affecting the person’s ability to perform certain tasks or activities of daily living.  Heightened emotion, stress, fever, physical exhaustion, or low blood sugar may trigger tremors and/or increase its severity.  Though the tremor can start at any age, it most often appears for the first time during adolescence or in middle age (between ages 40 and 50).  Small amounts of alcohol may help decrease essential tremors, but the mechanism behind this is unknown.

About 50 percent of the cases of essential tremors are thought to be caused by a genetic risk factor (referred to as familial tremors).  Children of a parent who has familial tremors have a greater risk of inheriting the condition.  Familial forms of essential tremors often appear early in life.

Causes of Essential Tremor

Generally, tremor is caused by a problem in the deep parts of the brain that control movements.  Most types of tremors have no known cause, although there are some forms that appear to be inherited and run in families.

Tremor can occur on its own or be a symptom associated with a number of neurological disorders, including

• Multiple sclerosis
• Stroke
• Traumatic brain injury
• Neurodegenerative diseases that affect parts of the brain (e.g.,  Parkinson’s disease).
• Neurologic disorders, including multiple sclerosis, Parkinson’s disease, stroke, and traumatic brain injury
• Certain medicines, such as asthma medicines, amphetamines, caffeine, corticosteroids, and medicines used for certain psychiatric and neurological disorders
• Alcohol use disorder or alcohol withdrawal
• Mercury poisoning
• Hyperthyroidism (overactive thyroid)
• Liver or kidney failure
• Anxiety or panic

Some other known causes can include

• the use of certain medicines (particular asthma medication, amphetamines, caffeine, corticosteroids, and drugs used for certain psychiatric and neurological disorders)
• alcohol abuse or withdrawal
• mercury poisoning
• overactive thyroid
• liver or kidney failure
• anxiety or panic.

Symptoms of Essential Tremor

Symptoms of tremor may include

• A tremor is involuntary, rhythmic contractions of various muscles. Shaky legs syndrome causes feelings of “vibration”, unsteadiness or imbalance in the legs.
• A rhythmic shaking in the hands, arms, head, legs, or torso
• Balance and muscle coordination problem
• Spasticity and muscle spasm with wasting
• Shaky voice
• Difficulty writing or drawing
• Problems holding and controlling utensils, such as a spoon.
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement
• Usually occur in the hands first, affecting one hand or both hands
• Can include a “yes-yes” or “no-no” motion of the head
• It May be aggravated by emotional stress, fatigue, caffeine, or temperature extremes
• Tremors that get worse during emotional stress
• Tremors that get worse when you move on purpose
• Tremors that lessen with rest
• Balance problems (in rare cases)
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement

Essential tremor vs. Parkinson’s disease

Many people associate tremors with Parkinson’s disease, but the two conditions differ in key ways:

Timing of tremors. Essential tremor of the hands usually occurs when you use your hands. Tremors from Parkinson’s disease are most prominent when your hands are at your sides or resting in your lap.

Associated conditions. Essential tremor doesn’t cause other health problems, but Parkinson’s disease is associated with stooped posture, slow movement and shuffling gait. However, people with essential tremor sometimes develop other neurological signs and symptoms, such as an unsteady gait (ataxia).

Parts of body affected. Essential tremor mainly involves your hands, head and voice. Parkinson’s disease tremors usually start in your hands, and can affect your legs, chin and other parts of your body.

Signs

What we feel in both legs simultaneously is extreme straining, fatigue, unsteadiness, and a fear of falling. The muscles in our legs become hard, our ankles feel weak and our toes curl under as our legs fail to support us. We can stand for only a short period of time, in some cases only seconds. There is a feeling of panic to find a place to sit, or if possible, walk to gain some relief from our symptoms. Some tremors /shaky legs syndrome may be triggered by or become worse during times of stress or strong emotion, when an individual is physically exhausted, or when a person is in certain postures or makes certain movements.

Diagnosis of Essential Tremor

Medical history

During the physical evaluation, a doctor will assess the tremor based on:

• whether the tremor occurs when the muscles are at rest or inaction
• the location of the tremor on the body (and if it occurs on one or both sides of the body)
• the appearance of the tremor (tremor frequency and amplitude).

The doctor will also check other neurological findings such as impaired balance, speech abnormalities, or increased muscle stiffness.  Blood or urine tests can rule out metabolic causes such as thyroid malfunction and certain medications that can cause tremors/shaky legs syndrome.  These tests may also help to identify contributing causes such as drug interactions, chronic alcoholism, or other conditions or diseases.  Diagnostic imaging may help determine if the tremor is the result of damage to the brain.

Clinical observations

The diagnosis is based on a combination of a number of clinical observations and recognition of typical characteristics (phenomenology) that include, but are not necessarily limited to the following:

• Onset of the movements is abrupt/sudden.
• Movements are triggered by emotional or physical trauma, or by some conflict (marital, sexual, work-related).
• Movements are episodic or appear intermittent.
• There are spontaneous remissions of the movements.
• Movements disappear with distraction.
• Movements are suggestible, meaning they may disappear by making a suggestion. For example, suggesting that the application of a tuning fork to the body part affected may help relieve the movements.
• Underlying psychiatric disturbances (depression, anxiety) are present.
• There are multiple somatizations and undiagnosed conditions.
• There is a lack of emotional concern about the disorder (“la belle indifference”).
• There has been exposure to neurologic disorders during one’s occupation (e.g. nurse, physician) or while caring for someone with similar problems.
• Slurred speech, soft voice, gibberish, foreign accent
• Delayed and excessive startle (bizarre movements in response to sudden, unexpected noise or threatening movement)
• Presence of additional types of abnormal movements that are not known to be part of the primary or principal movement disorder pattern that the patient manifests
• Active resistance against passive movement
• Fixed posture

Treatment of Essential Tremor

Non-pharmacological

• Physical, speech-language, and occupational therapy – may help to control tremors and meet daily challenges caused by the tremor.  A physical therapist can help people improve their muscle control, functioning, and strength through coordination, balancing, and other exercises.  Some therapists recommend the use of weights, splints, other adaptive equipment, and special plates and utensils for eating.  Speech-language pathologists can evaluate and treat speech, language, communication, and swallowing disorders.  Occupational therapists can teach individuals new ways of performing activities of daily living that may be affected by tremors.
• Eliminating or reducing tremor-inducing substances such as caffeine and other medication – (such as stimulants) can help improve tremor. Though small amounts of alcohol can improve tremors for some people, tremors can become worse once the effects of the alcohol wear off.
• Interventional Therapy – For patients who fail pharmacologic treatment with the above drugs or are unable to tolerate the side effects, surgical options include deep brain stimulation (DBS), focused ultrasound, or radio-surgical gamma knife thalamotomy to treat persistently disabling limb tremor, and botulinum toxin injections to treat persistently disabling head or vocal cord tremor.
• Deep-brain stimulation – This is the most common surgical treatment for essential tremors. Most series report 70% to 90% hand tremor control. In deep-brain stimulation, electrical stimulation is delivered to the brain through an electrode implanted deep into the ventral intermediate nucleus (VIM) of the thalamus. This is typically done by implanting 4 electrodes in the VIM using stereotactic methods. Computerized programming of the pulse generator is most commonly done with a handheld device after the patient leaves the hospital to optimize the electrode montage, voltage, pulse frequency, and pulse width. Deep-brain stimulation can be done unilaterally or bilaterally depending on the patient’s symptoms. There is an increased risk of speech and balance difficulties with bilateral procedures. If the tremor significantly affects both hands, the dominant hand is targeted, bilateral procedures may be considered.
• Focused ultrasound – Approved by the FDA in 2016, magnetic resonance imaging-guided, high-intensity, focused ultrasound thalamotomy is an innovative method for the treatment of essential tremors. Although it is transcranial and does not require an incision, skull penetration, or an implanted device, it is an invasive therapy that produces a permanent thalamic lesion.
• Radio-surgical gamma knife thalamotomy – Gamma-knife thalamotomy fo­cuses high-energy gamma rays on the ventral intermediate resulting in the death of neurons. It is an unproven treatment that has not generally been adopted due to concerns about potential radiation side effects, including a theoretical, long-term risk of secondary tumor formation.
• Ultrasound Therapy – A new treatment for essential tremors uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brain’s thalamus thought to be responsible for causing the tremors.  The treatment is approved only for those individuals with essential tremors who do not respond well to anticonvulsant or beta-blocking drugs.
• Biofeedback – is a mind-body technique that involves using visual or auditory feedback to teach people to recognize the physical signs and symptoms of stress and anxiety, such as increased heart rate, body temperature, and muscle tension.
• Relaxation techniques – can reduce stress symptoms and help you enjoy a better quality of life, especially if you have an illness. Explore relaxation techniques you can do by yourself.
• Learn to relax – Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors. Although you can’t eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques, such as massage or meditation.
• Noninvasive techniques – Include gait rehabilitation, visually guided techniques, tendon vibration, weighting extremities, positioning techniques, and manual techniques, all of which can be useful for the recovery of functional activities.[rx]
• Invasive techniques – Thalamic deep brain stimulation can alleviate the tremor in MS, providing better functional performance.[rx] Stereotactic radiosurgery thalamotomy at the nucleus ventralis intermedius with a median maximum dose of 140 Gy also provides good functional outcomes in patients with MS.[rx][rx] Radiofrequency thalamotomy had been successfully used in the past but has been replaced with the newer techniques of radiosurgery and deep brain stimulation as they had fewer adverse effects.
• Physical therapy – can help some patients control their tremors better, as can reducing the intake of substances such as caffeine, which can induce tremors. Many patients experience an increase in the severity of their tremors when they are stressed. Therefore, trying to reduce sources of anxiety and engaging in complementary therapies (such as yoga or aromatherapy) may help some patients.
• Speech and occupational therapy – may be useful not only in improving physical and psychological functioning, such as activities of daily living, but also to alter the abnormally learned pattern of movement – “motor reprograming.” Antidepressants and muscle relaxants may be also beneficial. Rarely, transcutaneous electrical stimulation applied to the area of spasm or involuntary movement may be helpful, analogous to the application of a tuning fork during clinic evaluation. Most importantly, however, the patient should try to understand which stress factors may be playing a role and seek the expertise of a psychologist experienced and skilled in stress management. The role of a psychiatrist is not to make the diagnosis but to provide insights into underlying psychological or psychiatric issues and to aid in the treatment of psychiatric issues such as depression or anxiety.
• Psychogenic movement Therapy –  It may be difficult to treat, especially if the patient is diagnosed late or is not accepting of the diagnosis. Indeed, patients with the best prognosis are those who initially accept the diagnosis and work with the movement disorder neurologist, psychologist, psychiatrist and physical, speech and occupational therapists in implementing a short-term and long-term therapeutic program. The diagnosis should be disclosed to patients in a manner that is empathetic and nonjudgmental.

For example, tremors due to thyroid hyperactivity will improve or even resolve (return to the normal state) with the treatment of thyroid malfunction.  Also, if the tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.

Medical Therapy

The therapeutic approach to essential tremors many times follows a trial and error approach, and patients should be challenged by several medications if the first choice is ineffective or associated with debilitating adverse effects. Medical therapy can be divided into first, second, and third-line therapies.

First-line therapy – It is either approved by the FDA or supported by double-blinded, placebo-controlled studies that meet the criteria for the class I evidence. This class of medications includes propranolol and primidone. If both primidone and propranolol are not effective alone, combinations of both may provide relief in selected patients.

Second-line therapy – Second-line therapy is supported by double-blinded, placebo-controlled trials that do not meet other requirements for the class I evidence studies. This includes gabapentin, pregabalin, topiramate, benzodiazepines (clonazepam, alprazolam), beta-blockers (atenolol and metoprolol) and zonisamide.

Third-line therapy – These therapies are based on open-label studies or case series. Drugs in this class include nimodipine and clozapine.

Medication

• Beta-blocking drugs such as propranolol are normally used to treat high blood pressure but they also help treat essential tremors.  Propranolol can also be used in some people with other types of action tremors.  Other beta-blockers that may be used include atenolol, metoprolol, nadolol, and sotalol.
• Anti-seizure medications such as primidone can be effective in people with essential tremors who do not respond to beta-blockers.  Other medications that may be prescribed include gabapentin and topiramate.  However, it is important to note that some anti-seizure medications can cause tremors.
• Tranquilizers (also known as benzodiazepines) such as alprazolam and clonazepam may temporarily help some people with tremors.  However, their use is limited due to unwanted side effects that include sleepiness, poor concentration, and poor coordination.  This can affect the ability of people to perform daily activities such as driving, school, and work.  Also, when taken regularly, tranquilizers can cause physical dependence and when stopped abruptly can cause several withdrawal symptoms.
• Parkinson’s disease medications (levodopa, carbidopa) are used to treat tremors associated with Parkinson’s disease.
• Botulinum toxin – injections can treat almost all types of tremors.  It is especially useful for head tremor, which generally does not respond to medications.  Botulinum toxin is widely used to control dystonic tremors.  Although botulinum toxin injections can improve tremors for roughly three months at a time, they can also cause muscle weakness.  While this treatment is effective and usually well tolerated for head tremors, botulinum toxin treatment in the hands can cause weakness in the fingers.  It can cause a hoarse voice and difficulty swallowing when used to treat voice tremors.

Additional drug therapies that have been used to treat individuals with primary orthostatic tremors include primidone (Mysoline), chlordiazepoxide (Librium), pregabalin (Lyrica), pramipexole (Mirapex), phenobarbital, and valproic acid (Depakote). Drugs commonly used to treat people with Parkinson’s disease (levodopa or pramipexole) may also be prescribed for individuals with primary orthostatic tremors.

Surgery

When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation (DBS) or very rarely, thalamotomy.  While DBS is usually well-tolerated, the most common side effects of tremor surgery include dysarthria (trouble speaking) and balance problems.

• Deep brain stimulation (DBS) – is the most common form of surgical treatment of tremors.  This method is preferred because it is effective, has low risk, and treats a broader range of symptoms than thalamotomy.  The treatment uses surgically implanted electrodes to send high-frequency electrical signals to the thalamus, the deep structure of the brain that coordinates and controls some involuntary movements.  A small pulse generating device placed under the skin in the upper chest (similar to a pacemaker) sends electrical stimuli to the brain and temporarily disables the tremor.  DBS is currently used to treat parkinsonian tremors, essential tremors, and dystonia.

• Thalamotomy – is a surgical procedure that involves the precise, permanent destruction of a tiny area in the thalamus.  Currently, surgery is replaced by radiofrequency ablation to treat severe tremors when deep brain surgery is contraindicated—meaning it is unwise as a treatment option or has undesirable side effects.  Radiofrequency ablation uses a radio wave to generate an electric current that heats up a nerve and disrupts its signaling ability for typically six or more months.  It is usually performed on only one side of the brain to improve tremors on the opposite side of the body.  Surgery on both sides is not recommended as it can cause problems with speech.
• Focused ultrasound thalamotomy – This non-invasive surgery involves using focused sound waves that travel through the skin and skull. The waves generate heat to destroy brain tissue in a specific area of the thalamus to stop a tremor. A surgeon uses magnetic resonance imaging to target the correct area of the brain and to be sure the sound waves are generating the exact amount of heat needed for the procedure. Focused ultrasound thalamotomy creates a lesion that can result in permanent changes to brain function. Some people have experienced the altered sensation, trouble with walking or difficulty with movement. However, most complications go away on their own or are mild enough that they don’t interfere with the quality of life.
•  Stereotactic surgical techniques – can be used to create a lesion in the ventral intermediate (VIM) nucleus of the thalamus.

Rehabilitation

Exercise is an important part of healthy living for everyone. For people with tremors, exercise is more than healthy it is a vital component to maintaining balance, mobility, and activities of daily living. Exercise and physical activity can improve many tremors symptoms. These benefits are supported by research.

The tremors show that people with tremors who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.

What Type of Exercise Should I Do?

To help manage the symptoms of tremors, be sure your exercise program includes a few key ingredients:

• Aerobic activity
• Strength training
• Balance, agility, and multitasking
• Flexibility

These elements are included in many types of exercise. Biking, running, Tai chi, yoga, Pilates, dance, weight training, non-contact boxing, qi gong, and more — all have positive effects on tremors symptoms.

There is no “exercise prescription” that is right for every person with tremors. The type of exercise you do depends on your symptoms and challenges. For sedentary people, just getting up and moving is beneficial. More active people can build up to the regular, vigorous activity. Many approaches work well to help maintain and improve mobility, flexibility, and balance to ease non-motor tremors symptoms such as depression or constipation.

Researchers in the study did not distinguish between what type of exercise participants did and determined that all types of exercise are beneficial. The most important thing is to do the exercise regularly. We suggest finding an exercise you enjoy and stick with it.

Challenges to Exercising

• People in the early stages of tremors tend to be just as strong and physically fit as healthy individuals of the same age.
• Disease progression can lead to the following physical change:
• Loss of joint flexibility, which can affect balance.
• Decreased muscle strength or deconditioning can affect walking and the ability to stand up from sitting.
• The decline in cardiovascular conditioning, which affects endurance.

Tips for Getting Started

• First, be safe. Before starting an exercise program, consult your neurologist and primary care doctor about concerns and recommendations.
• Ask your doctor or members in your support group to refer to a physical therapist (PT) who knows about tremors. Work together to identify your concerns and limitations. Target exercises to improve them. For most people, a structured exercise program will include aerobic exercise (such as brisk walking) and resistance training (using weights or bands).
• Purchase a pedometer (step-counter) and figure out how many steps you take on average each day, then build up from there. Many smartphones or smartwatches have a built-in pedometer feature or an application that can be downloaded.
• Exercise indoors and outdoors. Change your routine to stay interested and motivated.
• Again, most importantly pick an exercise you enjoy.

What research is being done?

The mission is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.  The NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world.

Researchers are working to better understand the underlying brain functions that cause tremors, identify the genetic factors that make individuals more susceptible to the disorder, and develop new and better treatment options.

• Brain functioning – It can be difficult to distinguish between movement disorders such as Parkinson’s disease and essential tremor. These debilitating movement disorders have different prognoses and can respond very differently to available therapies. NINDS researchers are working to identify structural and functional changes in the brain using non-invasive neuroimaging techniques to develop sensitive and specific markers for each of these diseases and then track how they change as each disease progresses. Other researchers are using functional magnetic resonance imaging technology to better understand normal and diseased brain circuit functions and associated motor behaviors.  Scientists hope to design therapies that can restore normal brain circuit function in diseases such as Parkinson’s disease and tremor.
• Genetics – Research has shown that essential tremors may have a strong genetic component affecting multiple generations of families.  NINDS researchers are building on previous genetics work to identify susceptibility genes for familial early-onset (before age 40) essential tremor.  Researchers are focusing on multigenerational, early-onset families to better detect linkages.

Additionally, NINDS scientists are researching the impact of genetic abnormalities on the development of essential tremors.  Previous research that has shown a link between essential tremor and possible genetic variants on chromosome 6 and 11; ongoing research is targeting the impact of other genetic variations in families.

Medications and other treatment methods

While drugs can be effective for some people, approximately 50 percent of individuals do not respond to medication.  In order to develop assistive and rehabilitative tremor-suppressing devices for people with essential tremors, researchers are exploring where and how to minimize or suppress tremors while still allowing for voluntary movements.

Many people with essential tremors respond to ethanol (alcohol); however, it is not clear why or how.  NINDS researchers are studying the impact of ethanol on tremors to determine the correct dosage amount and its physiological impact on the brain and whether other medications without the side effects of ethanol can be effective.

Other NIH researchers hope to identify the source of essential tremors, study the effects of currently available tremor-suppressant drugs on the brain, and develop more targeted and effective therapies.

FAQ

Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

Which of the following constellations of clinical findings is typical of tremor in patients with Parkinson’s disease?

1. bilateral postural tremor

2. unilateral rest tremor and diminished ipsilateral arm swing while walking

3. severe unilateral tremor while holding a cup or glass

4. tremor that only appears when the patient writes

5. postural tremor of both hands and ataxic gait

Question 2

A 25-year-old man has a mild postural tremor of both hands that improves when he drinks alcohol. His mother had the same condition. What can you advise him?

1. He should definitely be evaluated for possible early Parkinson’s disease.

2. He must get treatment now, as otherwise the condition could worsen.

3. If treatment is indicated, propranolol or primidone could be given.

4. Relaxation exercises and physiotherapy are effective treatment options.

5. Genetic testing is needed to confirm the diagnosis of essential tremor.

Question 3

A man who received the diagnosis of multiple sclerosis two years ago presents to you with the new onset of tremor. What constellation of clinical findings is typical of tremor due to multiple sclerosis?

1. rest tremor, only occasionally observable when the patient is excited

2. a tremor that appears sometimes on the left side, sometimes on the right

3. a tremor that is only present in the morning

4. a swaying, broad-based gait and an intention tremor

5. a postural tremor that is easily suppressed by voluntary effort

Question 4

A 55-year-old man with essential tremor says that he can no longer feed himself because of tremor, can dress himself only with great difficulty, and has not had legible handwriting for many years. Drug treatment as recommended in the relevant clinical guidelines brings only slight improvement. What can you advise the patient about the option of surgical treatment?

1. Deep brain stimulation (DBS) might help but is not available in Germany.

2. DBS is an experimental technique that is only performed in clinical trials.

3. DBS is indicated only to treat Parkinson’s disease and plays no role in the treatment of essential tremor.

4. DBS has a high chance of success in this situation; it is now established as a standard treatment for essential tremor.

5. DBS is no more effective than pharmacotherapy for this indication.

Question 5

What information is most important for the diagnostic classification of a tremor syndrome?

1. the clinical findings

2. brain magnetic resonance imaging (MRI) with fine cerebellar sections

3. nuclear-medical visualization of brain perfusion

4. ultrasonography of the basal ganglia

5. measurement of serum drug levels

Question 6

What findings indicate that tremor may be psychogenic?

1. no evidence of essential tremor or Parkinson’s disease on brain MRI

2. a longstanding marital conflict

3. a tremor of inconstant location that diminishes on distraction and is found to be irregular on tremor analysis

4. a clearly identifiable underlying psychological conflict

5. remission after psychotherapy

Question 7

When can tremor be treated surgically?

1. When the patient is unwilling to take drugs to treat tremor.

2. When the patient is under 50 years old.

3. When the tremor cannot be adequately suppressed by drugs and there is no contraindication to surgery.

4. When the patient is willing to see a neurosurgeon once a week so that brain stimulation can be performed.

5. When the patient is willing to assume the cost of weekly battery changes.

Question 8

What must be borne in mind with respect to drug treatment for various tremor syndromes?

1. That the treatment is based on the clinical findings and not on the underlying disease causing tremor.

2. That causally directed treatment is generally possible only for drug-induced tremors or tremors due to metabolic disturbance.

3. That parkinsonian tremor responds best to anticholinergic drugs and does not respond at all to the classic dopamine preparations.

4. That the cerebellar tremor of multiple sclerosis is treated in exactly the same way as essential tremor.

5. That essential tremor is usually medically intractable.

Question 9

What drugs can induce tremor?

1. lithium, valproic acid, cyclosporine A

2. carbamazepine, propranolol, Seroxat

3. aspirin, diclofenac, paracetamol

4. penicillin, erythromycin, cephalosporin

5. antilipid drugs, antidiabetic drugs

Question 10

What is the drug, or drug class, of first choice for the treatment of parkinsonian tremor?

1. dopaminergic drugs

2. propanolol

3. primidone

4. gabapentin

5. ondansetron

References

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Dystonic tremor occurs in people who are affected by dystonia—a movement disorder where incorrect messages from the brain cause muscles to be overactive, resulting in abnormal postures or sustained, unwanted movements.  Dystonic tremor usually appears in young or middle-aged adults and can affect any muscle in the body.  Symptoms may sometimes be relieved by complete relaxation.

Dystonic Head and Neck Tremor involuntary shaking of the head occurs when neck muscles intermittently con- tract resulting in jerking movements. If the contractions are rhythmic and balanced on the right and left sides, a tremor typical of ET may result.

Two forms of tremor in dystonia are currently recognized: 1) dystonic tremor, which is tremor produced by dystonic muscle contraction and 2) tremor associated with dystonia, which is tremor in a body part that is not dystonic, but there is dystonia elsewhere. Both forms of tremor in dystonia frequently resemble essential tremor or another pure tremor syndrome (e.g., isolated head and voice tremors and task-specific writing tremor), and relationships among these tremor disorders have long been debated.

Although some of the symptoms are similar, dystonic tremor differs from essential tremor in some ways.  The dystonic tremor:

• is associated with abnormal body postures due to forceful muscle spasms or cramps
• can affect the same parts of the body as essential tremor, but also—and more often than essential tremor—the head, without any other movement in the hands or arms
• can also mimic resting tremors, such as the ones seen in Parkinson’s disease.
• Also, the severity of dystonic tremors may be reduced by touching the affected body part or muscle, and tremor movements are “jerky” or irregular instead of rhythmic.

Causes of Dystonic Tremor

Generally, tremor is caused by a problem in the deep parts of the brain that control movements.  Most types of tremors have no known cause, although there are some forms that appear to be inherited and run in families.

Tremor can occur on its own or be a symptom associated with a number of neurological disorders, including

• Multiple sclerosis
• Stroke
• Traumatic brain injury
• Neurodegenerative diseases that affect parts of the brain (e.g.,  Parkinson’s disease).
• Neurologic disorders, including multiple sclerosis, Parkinson’s disease, stroke, and traumatic brain injury
• Certain medicines, such as asthma medicines, amphetamines, caffeine, corticosteroids, and medicines used for certain psychiatric and neurological disorders
• Alcohol use disorder or alcohol withdrawal
• Mercury poisoning
• Hyperthyroidism (overactive thyroid)
• Liver or kidney failure
• Anxiety or panic

Some other known causes can include

• the use of certain medicines (particular asthma medication, amphetamines, caffeine, corticosteroids, and drugs used for certain psychiatric and neurological disorders)
• alcohol abuse or withdrawal
• mercury poisoning
• overactive thyroid
• liver or kidney failure
• anxiety or panic.

Symptoms of Dystonic Tremor

Symptoms of tremor may include

• A tremor is involuntary, rhythmic contractions of various muscles. Shaky legs syndrome causes feelings of “vibration”, unsteadiness or imbalance in the legs.
• A rhythmic shaking in the hands, arms, head, legs, or torso
• Balance and muscle coordination problem
• Spasticity and muscle spasm with wasting
• Shaky voice
• Difficulty writing or drawing
• Problems holding and controlling utensils, such as a spoon.
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement
• Usually occur in the hands first, affecting one hand or both hands
• Can include a “yes-yes” or “no-no” motion of the head
• It May be aggravated by emotional stress, fatigue, caffeine, or temperature extremes
• Tremors that get worse during emotional stress
• Tremors that get worse when you move on purpose
• Tremors that lessen with rest
• Balance problems (in rare cases)

Signs

What we feel in both legs simultaneously is extreme straining, fatigue, unsteadiness, and a fear of falling. The muscles in our legs become hard, our ankles feel weak and our toes curl under as our legs fail to support us. We can stand for only a short period of time, in some cases only seconds. There is a feeling of panic to find a place to sit, or if possible, walk to gain some relief from our symptoms. Some tremors /shaky legs syndrome may be triggered by or become worse during times of stress or strong emotion, when an individual is physically exhausted, or when a person is in certain postures or makes certain movements.

Diagnosis of Dystonic Tremor

Medical history

During the physical evaluation, a doctor will assess the tremor based on:

• whether the tremor occurs when the muscles are at rest or inaction
• the location of the tremor on the body (and if it occurs on one or both sides of the body)
• the appearance of the tremor (tremor frequency and amplitude).

The doctor will also check other neurological findings such as impaired balance, speech abnormalities, or increased muscle stiffness.  Blood or urine tests can rule out metabolic causes such as thyroid malfunction and certain medications that can cause tremors/shaky legs syndrome.  These tests may also help to identify contributing causes such as drug interactions, chronic alcoholism, or other conditions or diseases.  Diagnostic imaging may help determine if the tremor is the result of damage to the brain.

Clinical observations

The diagnosis is based on a combination of a number of clinical observations and recognition of typical characteristics (phenomenology) that include, but are not necessarily limited to the following:

• Onset of the movements is abrupt/sudden.
• Movements are triggered by emotional or physical trauma, or by some conflict (marital, sexual, work-related).
• Movements are episodic or appear intermittent.
• There are spontaneous remissions of the movements.
• Movements disappear with distraction.
• Movements are suggestible, meaning they may disappear by making a suggestion. For example, suggesting that the application of a tuning fork to the body part affected may help relieve the movements.
• Underlying psychiatric disturbances (depression, anxiety) are present.
• There are multiple somatizations and undiagnosed conditions.
• There is a lack of emotional concern about the disorder (“la belle indifference”).
• There has been exposure to neurologic disorders during one’s occupation (e.g. nurse, physician) or while caring for someone with similar problems.
• Slurred speech, soft voice, gibberish, foreign accent
• Delayed and excessive startle (bizarre movements in response to sudden, unexpected noise or threatening movement)
• Presence of additional types of abnormal movements that are not known to be part of the primary or principal movement disorder pattern that the patient manifests
• Active resistance against passive movement
• Fixed posture

Treatment of Dystonic Tremor

Non-pharmacological

• Physical, speech-language, and occupational therapy – may help to control tremors and meet daily challenges caused by the tremor.  A physical therapist can help people improve their muscle control, functioning, and strength through coordination, balancing, and other exercises.  Some therapists recommend the use of weights, splints, other adaptive equipment, and special plates and utensils for eating.  Speech-language pathologists can evaluate and treat speech, language, communication, and swallowing disorders.  Occupational therapists can teach individuals new ways of performing activities of daily living that may be affected by tremors.
• Eliminating or reducing tremor-inducing substances such as caffeine and other medication – (such as stimulants) can help improve tremor. Though small amounts of alcohol can improve tremors for some people, tremors can become worse once the effects of the alcohol wear off.
• Interventional Therapy – For patients who fail pharmacologic treatment with the above drugs or are unable to tolerate the side effects, surgical options include deep brain stimulation (DBS), focused ultrasound, or radio-surgical gamma knife thalamotomy to treat persistently disabling limb tremor, and botulinum toxin injections to treat persistently disabling head or vocal cord tremor.
• Deep-brain stimulation – This is the most common surgical treatment for essential tremors. Most series report 70% to 90% hand tremor control. In deep-brain stimulation, electrical stimulation is delivered to the brain through an electrode implanted deep into the ventral intermediate nucleus (VIM) of the thalamus. This is typically done by implanting 4 electrodes in the VIM using stereotactic methods. Computerized programming of the pulse generator is most commonly done with a handheld device after the patient leaves the hospital to optimize the electrode montage, voltage, pulse frequency, and pulse width. Deep-brain stimulation can be done unilaterally or bilaterally depending on the patient’s symptoms. There is an increased risk of speech and balance difficulties with bilateral procedures. If the tremor significantly affects both hands, the dominant hand is targeted, bilateral procedures may be considered.
• Focused ultrasound – Approved by the FDA in 2016, magnetic resonance imaging-guided, high-intensity, focused ultrasound thalamotomy is an innovative method for the treatment of essential tremors. Although it is transcranial and does not require an incision, skull penetration, or an implanted device, it is an invasive therapy that produces a permanent thalamic lesion.
• Radio-surgical gamma knife thalamotomy – Gamma-knife thalamotomy fo­cuses high-energy gamma rays on the ventral intermediate resulting in the death of neurons. It is an unproven treatment that has not generally been adopted due to concerns about potential radiation side effects, including a theoretical, long-term risk of secondary tumor formation.
• Ultrasound Therapy – A new treatment for essential tremors uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brain’s thalamus thought to be responsible for causing the tremors.  The treatment is approved only for those individuals with essential tremors who do not respond well to anticonvulsant or beta-blocking drugs.
• Biofeedback – is a mind-body technique that involves using visual or auditory feedback to teach people to recognize the physical signs and symptoms of stress and anxiety, such as increased heart rate, body temperature, and muscle tension.
• Relaxation techniques – can reduce stress symptoms and help you enjoy a better quality of life, especially if you have an illness. Explore relaxation techniques you can do by yourself.
• Learn to relax – Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors. Although you can’t eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques, such as massage or meditation.
• Noninvasive techniques – Include gait rehabilitation, visually guided techniques, tendon vibration, weighting extremities, positioning techniques, and manual techniques, all of which can be useful for the recovery of functional activities.[rx]
• Invasive techniques – Thalamic deep brain stimulation can alleviate the tremor in MS, providing better functional performance.[rx] Stereotactic radiosurgery thalamotomy at the nucleus ventralis intermedius with a median maximum dose of 140 Gy also provides good functional outcomes in patients with MS.[rx][rx] Radiofrequency thalamotomy had been successfully used in the past but has been replaced with the newer techniques of radiosurgery and deep brain stimulation as they had fewer adverse effects.
• Physical therapy – can help some patients control their tremors better, as can reducing the intake of substances such as caffeine, which can induce tremors. Many patients experience an increase in the severity of their tremors when they are stressed. Therefore, trying to reduce sources of anxiety and engaging in complementary therapies (such as yoga or aromatherapy) may help some patients.
• Speech and occupational therapy – may be useful not only in improving physical and psychological functioning, such as activities of daily living, but also to alter the abnormally learned pattern of movement – “motor reprograming.” Antidepressants and muscle relaxants may be also beneficial. Rarely, transcutaneous electrical stimulation applied to the area of spasm or involuntary movement may be helpful, analogous to the application of a tuning fork during clinic evaluation. Most importantly, however, the patient should try to understand which stress factors may be playing a role and seek the expertise of a psychologist experienced and skilled in stress management. The role of a psychiatrist is not to make the diagnosis but to provide insights into underlying psychological or psychiatric issues and to aid in the treatment of psychiatric issues such as depression or anxiety.
• Psychogenic movement Therapy –  It may be difficult to treat, especially if the patient is diagnosed late or is not accepting of the diagnosis. Indeed, patients with the best prognosis are those who initially accept the diagnosis and work with the movement disorder neurologist, psychologist, psychiatrist and physical, speech and occupational therapists in implementing a short-term and long-term therapeutic program. The diagnosis should be disclosed to patients in a manner that is empathetic and nonjudgmental.

For example, tremors due to thyroid hyperactivity will improve or even resolve (return to the normal state) with the treatment of thyroid malfunction.  Also, if the tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.

Medical Therapy

The therapeutic approach to essential tremors many times follows a trial and error approach, and patients should be challenged by several medications if the first choice is ineffective or associated with debilitating adverse effects. Medical therapy can be divided into first, second, and third-line therapies.

First-line therapy – It is either approved by the FDA or supported by double-blinded, placebo-controlled studies that meet the criteria for the class I evidence. This class of medications includes propranolol and primidone. If both primidone and propranolol are not effective alone, combinations of both may provide relief in selected patients.

Second-line therapy – Second-line therapy is supported by double-blinded, placebo-controlled trials that do not meet other requirements for the class I evidence studies. This includes gabapentin, pregabalin, topiramate, benzodiazepines (clonazepam, alprazolam), beta-blockers (atenolol and metoprolol) and zonisamide.

Third-line therapy – These therapies are based on open-label studies or case series. Drugs in this class include nimodipine and clozapine.

Medication

• Beta-blocking drugs such as propranolol are normally used to treat high blood pressure but they also help treat essential tremors.  Propranolol can also be used in some people with other types of action tremors.  Other beta-blockers that may be used include atenolol, metoprolol, nadolol, and sotalol.
• Anti-seizure medications such as primidone can be effective in people with essential tremors who do not respond to beta-blockers.  Other medications that may be prescribed include gabapentin and topiramate.  However, it is important to note that some anti-seizure medications can cause tremors.
• Tranquilizers (also known as benzodiazepines) such as alprazolam and clonazepam may temporarily help some people with tremors.  However, their use is limited due to unwanted side effects that include sleepiness, poor concentration, and poor coordination.  This can affect the ability of people to perform daily activities such as driving, school, and work.  Also, when taken regularly, tranquilizers can cause physical dependence and when stopped abruptly can cause several withdrawal symptoms.
• Parkinson’s disease medications (levodopa, carbidopa) are used to treat tremors associated with Parkinson’s disease.
• Botulinum toxin – injections can treat almost all types of tremors.  It is especially useful for head tremor, which generally does not respond to medications.  Botulinum toxin is widely used to control dystonic tremors.  Although botulinum toxin injections can improve tremors for roughly three months at a time, they can also cause muscle weakness.  While this treatment is effective and usually well tolerated for head tremors, botulinum toxin treatment in the hands can cause weakness in the fingers.  It can cause a hoarse voice and difficulty swallowing when used to treat voice tremors.

Additional drug therapies that have been used to treat individuals with primary orthostatic tremors include primidone (Mysoline), chlordiazepoxide (Librium), pregabalin (Lyrica), pramipexole (Mirapex), phenobarbital, and valproic acid (Depakote). Drugs commonly used to treat people with Parkinson’s disease (levodopa or pramipexole) may also be prescribed for individuals with primary orthostatic tremors.

Surgery

When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation (DBS) or very rarely, thalamotomy.  While DBS is usually well-tolerated, the most common side effects of tremor surgery include dysarthria (trouble speaking) and balance problems.

• Deep brain stimulation (DBS) – is the most common form of surgical treatment of tremors.  This method is preferred because it is effective, has low risk, and treats a broader range of symptoms than thalamotomy.  The treatment uses surgically implanted electrodes to send high-frequency electrical signals to the thalamus, the deep structure of the brain that coordinates and controls some involuntary movements.  A small pulse generating device placed under the skin in the upper chest (similar to a pacemaker) sends electrical stimuli to the brain and temporarily disables the tremor.  DBS is currently used to treat parkinsonian tremors, essential tremors, and dystonia.

• Thalamotomy – is a surgical procedure that involves the precise, permanent destruction of a tiny area in the thalamus.  Currently, surgery is replaced by radiofrequency ablation to treat severe tremors when deep brain surgery is contraindicated—meaning it is unwise as a treatment option or has undesirable side effects.  Radiofrequency ablation uses a radio wave to generate an electric current that heats up a nerve and disrupts its signaling ability for typically six or more months.  It is usually performed on only one side of the brain to improve tremors on the opposite side of the body.  Surgery on both sides is not recommended as it can cause problems with speech.
•  Stereotactic surgical techniques – can be used to create a lesion in the ventral intermediate (VIM) nucleus of the thalamus.

Rehabilitation

Exercise is an important part of healthy living for everyone. For people with tremors, exercise is more than healthy it is a vital component to maintaining balance, mobility, and activities of daily living. Exercise and physical activity can improve many tremors symptoms. These benefits are supported by research.

The tremors show that people with tremors who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.

What Type of Exercise Should I Do?

To help manage the symptoms of tremors, be sure your exercise program includes a few key ingredients:

• Aerobic activity
• Strength training
• Balance, agility, and multitasking
• Flexibility

These elements are included in many types of exercise. Biking, running, Tai chi, yoga, Pilates, dance, weight training, non-contact boxing, qi gong, and more — all have positive effects on tremors symptoms.

There is no “exercise prescription” that is right for every person with tremors. The type of exercise you do depends on your symptoms and challenges. For sedentary people, just getting up and moving is beneficial. More active people can build up to the regular, vigorous activity. Many approaches work well to help maintain and improve mobility, flexibility, and balance to ease non-motor tremors symptoms such as depression or constipation.

Researchers in the study did not distinguish between what type of exercise participants did and determined that all types of exercise are beneficial. The most important thing is to do the exercise regularly. We suggest finding an exercise you enjoy and stick with it.

Challenges to Exercising

• People in the early stages of tremors tend to be just as strong and physically fit as healthy individuals of the same age.
• Disease progression can lead to the following physical change:
• Loss of joint flexibility, which can affect balance.
• Decreased muscle strength or deconditioning can affect walking and the ability to stand up from sitting.
• The decline in cardiovascular conditioning, which affects endurance.

Tips for Getting Started

• First, be safe. Before starting an exercise program, consult your neurologist and primary care doctor about concerns and recommendations.
• Ask your doctor or members in your support group to refer to a physical therapist (PT) who knows about tremors. Work together to identify your concerns and limitations. Target exercises to improve them. For most people, a structured exercise program will include aerobic exercise (such as brisk walking) and resistance training (using weights or bands).
• Purchase a pedometer (step-counter) and figure out how many steps you take on average each day, then build up from there. Many smartphones or smartwatches have a built-in pedometer feature or an application that can be downloaded.
• Exercise indoors and outdoors. Change your routine to stay interested and motivated.
• Again, most importantly pick an exercise you enjoy.

What research is being done?

The mission is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.  The NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world.

Researchers are working to better understand the underlying brain functions that cause tremors, identify the genetic factors that make individuals more susceptible to the disorder, and develop new and better treatment options.

• Brain functioning – It can be difficult to distinguish between movement disorders such as Parkinson’s disease and essential tremor. These debilitating movement disorders have different prognoses and can respond very differently to available therapies. NINDS researchers are working to identify structural and functional changes in the brain using non-invasive neuroimaging techniques to develop sensitive and specific markers for each of these diseases and then track how they change as each disease progresses. Other researchers are using functional magnetic resonance imaging technology to better understand normal and diseased brain circuit functions and associated motor behaviors.  Scientists hope to design therapies that can restore normal brain circuit function in diseases such as Parkinson’s disease and tremor.
• Genetics – Research has shown that essential tremors may have a strong genetic component affecting multiple generations of families.  NINDS researchers are building on previous genetics work to identify susceptibility genes for familial early-onset (before age 40) essential tremor.  Researchers are focusing on multigenerational, early-onset families to better detect linkages.

Additionally, NINDS scientists are researching the impact of genetic abnormalities on the development of essential tremors.  Previous research that has shown a link between essential tremor and possible genetic variants on chromosome 6 and 11; ongoing research is targeting the impact of other genetic variations in families.

Medications and other treatment methods

While drugs can be effective for some people, approximately 50 percent of individuals do not respond to medication.  In order to develop assistive and rehabilitative tremor-suppressing devices for people with essential tremors, researchers are exploring where and how to minimize or suppress tremors while still allowing for voluntary movements.

Many people with essential tremors respond to ethanol (alcohol); however, it is not clear why or how.  NINDS researchers are studying the impact of ethanol on tremors to determine the correct dosage amount and its physiological impact on the brain and whether other medications without the side effects of ethanol can be effective.

Other NIH researchers hope to identify the source of essential tremors, study the effects of currently available tremor-suppressant drugs on the brain, and develop more targeted and effective therapies.

FAQ

Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

Which of the following constellations of clinical findings is typical of tremor in patients with Parkinson’s disease?

1. bilateral postural tremor

2. unilateral rest tremor and diminished ipsilateral arm swing while walking

3. severe unilateral tremor while holding a cup or glass

4. tremor that only appears when the patient writes

5. postural tremor of both hands and ataxic gait

Question 2

A 25-year-old man has a mild postural tremor of both hands that improves when he drinks alcohol. His mother had the same condition. What can you advise him?

1. He should definitely be evaluated for possible early Parkinson’s disease.

2. He must get treatment now, as otherwise the condition could worsen.

3. If treatment is indicated, propranolol or primidone could be given.

4. Relaxation exercises and physiotherapy are effective treatment options.

5. Genetic testing is needed to confirm the diagnosis of essential tremor.

Question 3

A man who received the diagnosis of multiple sclerosis two years ago presents to you with the new onset of tremor. What constellation of clinical findings is typical of tremor due to multiple sclerosis?

1. rest tremor, only occasionally observable when the patient is excited

2. a tremor that appears sometimes on the left side, sometimes on the right

3. a tremor that is only present in the morning

4. a swaying, broad-based gait and an intention tremor

5. a postural tremor that is easily suppressed by voluntary effort

Question 4

A 55-year-old man with essential tremor says that he can no longer feed himself because of tremor, can dress himself only with great difficulty, and has not had legible handwriting for many years. Drug treatment as recommended in the relevant clinical guidelines brings only slight improvement. What can you advise the patient about the option of surgical treatment?

1. Deep brain stimulation (DBS) might help but is not available in Germany.

2. DBS is an experimental technique that is only performed in clinical trials.

3. DBS is indicated only to treat Parkinson’s disease and plays no role in the treatment of essential tremor.

4. DBS has a high chance of success in this situation; it is now established as a standard treatment for essential tremor.

5. DBS is no more effective than pharmacotherapy for this indication.

Question 5

What information is most important for the diagnostic classification of a tremor syndrome?

1. the clinical findings

2. brain magnetic resonance imaging (MRI) with fine cerebellar sections

3. nuclear-medical visualization of brain perfusion

4. ultrasonography of the basal ganglia

5. measurement of serum drug levels

Question 6

What findings indicate that tremor may be psychogenic?

1. no evidence of essential tremor or Parkinson’s disease on brain MRI

2. a longstanding marital conflict

3. a tremor of inconstant location that diminishes on distraction and is found to be irregular on tremor analysis

4. a clearly identifiable underlying psychological conflict

5. remission after psychotherapy

Question 7

When can tremor be treated surgically?

1. When the patient is unwilling to take drugs to treat tremor.

2. When the patient is under 50 years old.

3. When the tremor cannot be adequately suppressed by drugs and there is no contraindication to surgery.

4. When the patient is willing to see a neurosurgeon once a week so that brain stimulation can be performed.

5. When the patient is willing to assume the cost of weekly battery changes.

Question 8

What must be borne in mind with respect to drug treatment for various tremor syndromes?

1. That the treatment is based on the clinical findings and not on the underlying disease causing tremor.

2. That causally directed treatment is generally possible only for drug-induced tremors or tremors due to metabolic disturbance.

3. That parkinsonian tremor responds best to anticholinergic drugs and does not respond at all to the classic dopamine preparations.

4. That the cerebellar tremor of multiple sclerosis is treated in exactly the same way as essential tremor.

5. That essential tremor is usually medically intractable.

Question 9

What drugs can induce tremor?

1. lithium, valproic acid, cyclosporine A

2. carbamazepine, propranolol, Seroxat

3. aspirin, diclofenac, paracetamol

4. penicillin, erythromycin, cephalosporin

5. antilipid drugs, antidiabetic drugs

Question 10

What is the drug, or drug class, of first choice for the treatment of parkinsonian tremor?

1. dopaminergic drugs

2. propanolol

3. primidone

4. gabapentin

5. ondansetron

References

People Also Reading

Tremor – Causes, Symptoms, Diagnosis, Treatment Enhanced Physiological Tremor – Causes, Symptoms, Treatment Postural Tremor – Causes, Symptoms, Treatment Kinetic Tremor – Causes, Symptoms, Treatment Orthostatic Tremor – Causes, Symptoms, Diagnosis, Treatment Idiopathic Orthostatic Tremor – Causes, Symptoms, Treatment Primary Orthostatic Tremor – Causes, Symptoms, Treatment Parkinsonian Tremor – Causes, Symptoms, Diagnosis, Treatment Functional Tremor – Causes, Symptoms, Treatment Psychogenic Tremor – Causes, Symptoms, Treatment Essential Tremor – Causes, Symptoms, Treatment Intention Tremor – Causes, Symptoms, Treatment

Functional Tremor/Psychogenic tremor (also called functional tremor) can appear as any form of tremor.  It symptoms may vary but often start abruptly and may affect all body parts. The tremor increases in times of stress and decreases or disappears when distracted.  Many individuals with psychogenic tremors have an underlying psychiatric disorder such as depression or post-traumatic stress disorder (PTSD).

Psychogenic movement disorders are characterized by unwanted movements, such as spasms, shaking or jerks involving any part of the face, neck, trunk or limbs. In addition some patients may have bizarre gait or difficulties with their balance that are caused by underlying stress or some psychological condition. Speech and voice disorders are also relatively common in patients with psychogenic movement disorders, in which patients may experience stuttering, speech arrest, lower speech volume (hypophonia), or even a foreign accent.

Causes of Functional Tremor

Generally, tremor is caused by a problem in the deep parts of the brain that control movements.  Most types of tremors have no known cause, although there are some forms that appear to be inherited and run in families.

Tremor can occur on its own or be a symptom associated with a number of neurological disorders, including

• Multiple sclerosis
• Stroke
• Traumatic brain injury
• Neurodegenerative diseases that affect parts of the brain (e.g.,  Parkinson’s disease).
• Neurologic disorders, including multiple sclerosis, Parkinson’s disease, stroke, and traumatic brain injury
• Certain medicines, such as asthma medicines, amphetamines, caffeine, corticosteroids, and medicines used for certain psychiatric and neurological disorders
• Alcohol use disorder or alcohol withdrawal
• Mercury poisoning
• Hyperthyroidism (overactive thyroid)
• Liver or kidney failure
• Anxiety or panic

Some other known causes can include

• the use of certain medicines (particular asthma medication, amphetamines, caffeine, corticosteroids, and drugs used for certain psychiatric and neurological disorders)
• alcohol abuse or withdrawal
• mercury poisoning
• overactive thyroid
• liver or kidney failure
• anxiety or panic.

Symptoms of Functional Tremor

Symptoms of tremor may include

• A tremor is involuntary, rhythmic contractions of various muscles. Shaky legs syndrome causes feelings of “vibration”, unsteadiness or imbalance in the legs.
• A rhythmic shaking in the hands, arms, head, legs, or torso
• Balance and muscle coordination problem
• Spasticity and muscle spasm with wasting
• Shaky voice
• Difficulty writing or drawing
• Problems holding and controlling utensils, such as a spoon.
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement
• Usually occur in the hands first, affecting one hand or both hands
• Can include a “yes-yes” or “no-no” motion of the head
• It May be aggravated by emotional stress, fatigue, caffeine, or temperature extremes
• Tremors that get worse during emotional stress
• Tremors that get worse when you move on purpose
• Tremors that lessen with rest
• Balance problems (in rare cases)

What we feel in both legs simultaneously is extreme straining, fatigue, unsteadiness, and a fear of falling. The muscles in our legs become hard, our ankles feel weak and our toes curl under as our legs fail to support us. We can stand for only a short period of time, in some cases only seconds. There is a feeling of panic to find a place to sit, or if possible, walk to gain some relief from our symptoms. Some tremors /shaky legs syndrome may be triggered by or become worse during times of stress or strong emotion, when an individual is physically exhausted, or when a person is in certain postures or makes certain movements.

Diagnosis of Functional Tremor

Medical history

During the physical evaluation, a doctor will assess the tremor based on:

• whether the tremor occurs when the muscles are at rest or inaction
• the location of the tremor on the body (and if it occurs on one or both sides of the body)
• the appearance of the tremor (tremor frequency and amplitude).

The doctor will also check other neurological findings such as impaired balance, speech abnormalities, or increased muscle stiffness.  Blood or urine tests can rule out metabolic causes such as thyroid malfunction and certain medications that can cause tremors/shaky legs syndrome.  These tests may also help to identify contributing causes such as drug interactions, chronic alcoholism, or other conditions or diseases.  Diagnostic imaging may help determine if the tremor is the result of damage to the brain.

Clinical observations

The diagnosis is based on a combination of a number of clinical observations and recognition of typical characteristics (phenomenology) that include, but are not necessarily limited to the following:

• Onset of the movements is abrupt/sudden.
• Movements are triggered by emotional or physical trauma, or by some conflict (marital, sexual, work-related).
• Movements are episodic or appear intermittent.
• There are spontaneous remissions of the movements.
• Movements disappear with distraction.
• Movements are suggestible, meaning they may disappear by making a suggestion. For example, suggesting that the application of a tuning fork to the body part affected may help relieve the movements.
• Underlying psychiatric disturbances (depression, anxiety) are present.
• There are multiple somatizations and undiagnosed conditions.
• There is a lack of emotional concern about the disorder (“la belle indifference”).
• There has been exposure to neurologic disorders during one’s occupation (e.g. nurse, physician) or while caring for someone with similar problems.
• Slurred speech, soft voice, gibberish, foreign accent
• Delayed and excessive startle (bizarre movements in response to sudden, unexpected noise or threatening movement)
• Presence of additional types of abnormal movements that are not known to be part of the primary or principal movement disorder pattern that the patient manifests
• Active resistance against passive movement
• Fixed posture

Treatment of Functional Tremor

Non-pharmacological

• Physical, speech-language, and occupational therapy – may help to control tremors and meet daily challenges caused by the tremor.  A physical therapist can help people improve their muscle control, functioning, and strength through coordination, balancing, and other exercises.  Some therapists recommend the use of weights, splints, other adaptive equipment, and special plates and utensils for eating.  Speech-language pathologists can evaluate and treat speech, language, communication, and swallowing disorders.  Occupational therapists can teach individuals new ways of performing activities of daily living that may be affected by tremors.
• Eliminating or reducing tremor-inducing substances such as caffeine and other medication – (such as stimulants) can help improve tremor. Though small amounts of alcohol can improve tremors for some people, tremors can become worse once the effects of the alcohol wear off.
• Interventional Therapy – For patients who fail pharmacologic treatment with the above drugs or are unable to tolerate the side effects, surgical options include deep brain stimulation (DBS), focused ultrasound, or radio-surgical gamma knife thalamotomy to treat persistently disabling limb tremor, and botulinum toxin injections to treat persistently disabling head or vocal cord tremor.
• Deep-brain stimulation – This is the most common surgical treatment for essential tremors. Most series report 70% to 90% hand tremor control. In deep-brain stimulation, electrical stimulation is delivered to the brain through an electrode implanted deep into the ventral intermediate nucleus (VIM) of the thalamus. This is typically done by implanting 4 electrodes in the VIM using stereotactic methods. Computerized programming of the pulse generator is most commonly done with a handheld device after the patient leaves the hospital to optimize the electrode montage, voltage, pulse frequency, and pulse width. Deep-brain stimulation can be done unilaterally or bilaterally depending on the patient’s symptoms. There is an increased risk of speech and balance difficulties with bilateral procedures. If the tremor significantly affects both hands, the dominant hand is targeted, bilateral procedures may be considered.
• Focused ultrasound – Approved by the FDA in 2016, magnetic resonance imaging-guided, high-intensity, focused ultrasound thalamotomy is an innovative method for the treatment of essential tremors. Although it is transcranial and does not require an incision, skull penetration, or an implanted device, it is an invasive therapy that produces a permanent thalamic lesion.
• Radio-surgical gamma knife thalamotomy – Gamma-knife thalamotomy fo­cuses high-energy gamma rays on the ventral intermediate resulting in the death of neurons. It is an unproven treatment that has not generally been adopted due to concerns about potential radiation side effects, including a theoretical, long-term risk of secondary tumor formation.
• Ultrasound Therapy – A new treatment for essential tremors uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brain’s thalamus thought to be responsible for causing the tremors.  The treatment is approved only for those individuals with essential tremors who do not respond well to anticonvulsant or beta-blocking drugs.
• Biofeedback – is a mind-body technique that involves using visual or auditory feedback to teach people to recognize the physical signs and symptoms of stress and anxiety, such as increased heart rate, body temperature, and muscle tension.
• Relaxation techniques – can reduce stress symptoms and help you enjoy a better quality of life, especially if you have an illness. Explore relaxation techniques you can do by yourself.
• Learn to relax – Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors. Although you can’t eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques, such as massage or meditation.
• Noninvasive techniques – Include gait rehabilitation, visually guided techniques, tendon vibration, weighting extremities, positioning techniques, and manual techniques, all of which can be useful for the recovery of functional activities.[rx]
• Invasive techniques – Thalamic deep brain stimulation can alleviate the tremor in MS, providing better functional performance.[rx] Stereotactic radiosurgery thalamotomy at the nucleus ventralis intermedius with a median maximum dose of 140 Gy also provides good functional outcomes in patients with MS.[rx][rx] Radiofrequency thalamotomy had been successfully used in the past but has been replaced with the newer techniques of radiosurgery and deep brain stimulation as they had fewer adverse effects.
• Physical therapy – can help some patients control their tremors better, as can reducing the intake of substances such as caffeine, which can induce tremors. Many patients experience an increase in the severity of their tremors when they are stressed. Therefore, trying to reduce sources of anxiety and engaging in complementary therapies (such as yoga or aromatherapy) may help some patients.
• Speech and occupational therapy – may be useful not only in improving physical and psychological functioning, such as activities of daily living, but also to alter the abnormally learned pattern of movement – “motor reprograming.” Antidepressants and muscle relaxants may be also beneficial. Rarely, transcutaneous electrical stimulation applied to the area of spasm or involuntary movement may be helpful, analogous to the application of a tuning fork during clinic evaluation. Most importantly, however, the patient should try to understand which stress factors may be playing a role and seek the expertise of a psychologist experienced and skilled in stress management. The role of a psychiatrist is not to make the diagnosis but to provide insights into underlying psychological or psychiatric issues and to aid in the treatment of psychiatric issues such as depression or anxiety.
• Psychogenic movement Therapy –  It may be difficult to treat, especially if the patient is diagnosed late or is not accepting of the diagnosis. Indeed, patients with the best prognosis are those who initially accept the diagnosis and work with the movement disorder neurologist, psychologist, psychiatrist and physical, speech and occupational therapists in implementing a short-term and long-term therapeutic program. The diagnosis should be disclosed to patients in a manner that is empathetic and nonjudgmental.

For example, tremors due to thyroid hyperactivity will improve or even resolve (return to the normal state) with the treatment of thyroid malfunction.  Also, if the tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.

Medical Therapy

The therapeutic approach to essential tremors many times follows a trial and error approach, and patients should be challenged by several medications if the first choice is ineffective or associated with debilitating adverse effects. Medical therapy can be divided into first, second, and third-line therapies.

First-line therapy – It is either approved by the FDA or supported by double-blinded, placebo-controlled studies that meet the criteria for the class I evidence. This class of medications includes propranolol and primidone. If both primidone and propranolol are not effective alone, combinations of both may provide relief in selected patients.

Second-line therapy – Second-line therapy is supported by double-blinded, placebo-controlled trials that do not meet other requirements for the class I evidence studies. This includes gabapentin, pregabalin, topiramate, benzodiazepines (clonazepam, alprazolam), beta-blockers (atenolol and metoprolol) and zonisamide.

Third-line therapy – These therapies are based on open-label studies or case series. Drugs in this class include nimodipine and clozapine.

Medication

• Beta-blocking drugs such as propranolol are normally used to treat high blood pressure but they also help treat essential tremors.  Propranolol can also be used in some people with other types of action tremors.  Other beta-blockers that may be used include atenolol, metoprolol, nadolol, and sotalol.
• Anti-seizure medications such as primidone can be effective in people with essential tremors who do not respond to beta-blockers.  Other medications that may be prescribed include gabapentin and topiramate.  However, it is important to note that some anti-seizure medications can cause tremors.
• Tranquilizers (also known as benzodiazepines) such as alprazolam and clonazepam may temporarily help some people with tremors.  However, their use is limited due to unwanted side effects that include sleepiness, poor concentration, and poor coordination.  This can affect the ability of people to perform daily activities such as driving, school, and work.  Also, when taken regularly, tranquilizers can cause physical dependence and when stopped abruptly can cause several withdrawal symptoms.
• Parkinson’s disease medications (levodopa, carbidopa) are used to treat tremors associated with Parkinson’s disease.
• Botulinum toxin – injections can treat almost all types of tremors.  It is especially useful for head tremor, which generally does not respond to medications.  Botulinum toxin is widely used to control dystonic tremors.  Although botulinum toxin injections can improve tremors for roughly three months at a time, they can also cause muscle weakness.  While this treatment is effective and usually well tolerated for head tremors, botulinum toxin treatment in the hands can cause weakness in the fingers.  It can cause a hoarse voice and difficulty swallowing when used to treat voice tremors.

Additional drug therapies that have been used to treat individuals with primary orthostatic tremors include primidone (Mysoline), chlordiazepoxide (Librium), pregabalin (Lyrica), pramipexole (Mirapex), phenobarbital, and valproic acid (Depakote). Drugs commonly used to treat people with Parkinson’s disease (levodopa or pramipexole) may also be prescribed for individuals with primary orthostatic tremors.

Surgery

When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation (DBS) or very rarely, thalamotomy.  While DBS is usually well-tolerated, the most common side effects of tremor surgery include dysarthria (trouble speaking) and balance problems.

• Deep brain stimulation (DBS) – is the most common form of surgical treatment of tremors.  This method is preferred because it is effective, has low risk, and treats a broader range of symptoms than thalamotomy.  The treatment uses surgically implanted electrodes to send high-frequency electrical signals to the thalamus, the deep structure of the brain that coordinates and controls some involuntary movements.  A small pulse generating device placed under the skin in the upper chest (similar to a pacemaker) sends electrical stimuli to the brain and temporarily disables the tremor.  DBS is currently used to treat parkinsonian tremors, essential tremors, and dystonia.

• Thalamotomy – is a surgical procedure that involves the precise, permanent destruction of a tiny area in the thalamus.  Currently, surgery is replaced by radiofrequency ablation to treat severe tremors when deep brain surgery is contraindicated—meaning it is unwise as a treatment option or has undesirable side effects.  Radiofrequency ablation uses a radio wave to generate an electric current that heats up a nerve and disrupts its signaling ability for typically six or more months.  It is usually performed on only one side of the brain to improve tremors on the opposite side of the body.  Surgery on both sides is not recommended as it can cause problems with speech.
•  Stereotactic surgical techniques – can be used to create a lesion in the ventral intermediate (VIM) nucleus of the thalamus.

Rehabilitation

Exercise is an important part of healthy living for everyone. For people with tremors, exercise is more than healthy it is a vital component to maintaining balance, mobility, and activities of daily living. Exercise and physical activity can improve many tremors symptoms. These benefits are supported by research.

The tremors show that people with tremors who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.

What Type of Exercise Should I Do?

To help manage the symptoms of tremors, be sure your exercise program includes a few key ingredients:

• Aerobic activity
• Strength training
• Balance, agility, and multitasking
• Flexibility

These elements are included in many types of exercise. Biking, running, Tai chi, yoga, Pilates, dance, weight training, non-contact boxing, qi gong, and more — all have positive effects on tremors symptoms.

There is no “exercise prescription” that is right for every person with tremors. The type of exercise you do depends on your symptoms and challenges. For sedentary people, just getting up and moving is beneficial. More active people can build up to the regular, vigorous activity. Many approaches work well to help maintain and improve mobility, flexibility, and balance to ease non-motor tremors symptoms such as depression or constipation.

Researchers in the study did not distinguish between what type of exercise participants did and determined that all types of exercise are beneficial. The most important thing is to do the exercise regularly. We suggest finding an exercise you enjoy and stick with it.

Challenges to Exercising

• People in the early stages of tremors tend to be just as strong and physically fit as healthy individuals of the same age.
• Disease progression can lead to the following physical change:
• Loss of joint flexibility, which can affect balance.
• Decreased muscle strength or deconditioning can affect walking and the ability to stand up from sitting.
• The decline in cardiovascular conditioning, which affects endurance.

Tips for Getting Started

• First, be safe. Before starting an exercise program, consult your neurologist and primary care doctor about concerns and recommendations.
• Ask your doctor or members in your support group to refer to a physical therapist (PT) who knows about tremors. Work together to identify your concerns and limitations. Target exercises to improve them. For most people, a structured exercise program will include aerobic exercise (such as brisk walking) and resistance training (using weights or bands).
• Purchase a pedometer (step-counter) and figure out how many steps you take on average each day, then build up from there. Many smartphones or smartwatches have a built-in pedometer feature or an application that can be downloaded.
• Exercise indoors and outdoors. Change your routine to stay interested and motivated.
• Again, most importantly pick an exercise you enjoy.

What research is being done?

The mission is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.  The NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world.

Researchers are working to better understand the underlying brain functions that cause tremors, identify the genetic factors that make individuals more susceptible to the disorder, and develop new and better treatment options.

• Brain functioning – It can be difficult to distinguish between movement disorders such as Parkinson’s disease and essential tremor. These debilitating movement disorders have different prognoses and can respond very differently to available therapies. NINDS researchers are working to identify structural and functional changes in the brain using non-invasive neuroimaging techniques to develop sensitive and specific markers for each of these diseases and then track how they change as each disease progresses. Other researchers are using functional magnetic resonance imaging technology to better understand normal and diseased brain circuit functions and associated motor behaviors.  Scientists hope to design therapies that can restore normal brain circuit function in diseases such as Parkinson’s disease and tremor.
• Genetics – Research has shown that essential tremors may have a strong genetic component affecting multiple generations of families.  NINDS researchers are building on previous genetics work to identify susceptibility genes for familial early-onset (before age 40) essential tremor.  Researchers are focusing on multigenerational, early-onset families to better detect linkages.

Additionally, NINDS scientists are researching the impact of genetic abnormalities on the development of essential tremors.  Previous research that has shown a link between essential tremor and possible genetic variants on chromosome 6 and 11; ongoing research is targeting the impact of other genetic variations in families.

Medications and other treatment methods

While drugs can be effective for some people, approximately 50 percent of individuals do not respond to medication.  In order to develop assistive and rehabilitative tremor-suppressing devices for people with essential tremors, researchers are exploring where and how to minimize or suppress tremors while still allowing for voluntary movements.

Many people with essential tremors respond to ethanol (alcohol); however, it is not clear why or how.  NINDS researchers are studying the impact of ethanol on tremors to determine the correct dosage amount and its physiological impact on the brain and whether other medications without the side effects of ethanol can be effective.

Other NIH researchers hope to identify the source of essential tremors, study the effects of currently available tremor-suppressant drugs on the brain, and develop more targeted and effective therapies.

FAQ

Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

Which of the following constellations of clinical findings is typical of tremor in patients with Parkinson’s disease?

1. bilateral postural tremor

2. unilateral rest tremor and diminished ipsilateral arm swing while walking

3. severe unilateral tremor while holding a cup or glass

4. tremor that only appears when the patient writes

5. postural tremor of both hands and ataxic gait

Question 2

A 25-year-old man has a mild postural tremor of both hands that improves when he drinks alcohol. His mother had the same condition. What can you advise him?

1. He should definitely be evaluated for possible early Parkinson’s disease.

2. He must get treatment now, as otherwise the condition could worsen.

3. If treatment is indicated, propranolol or primidone could be given.

4. Relaxation exercises and physiotherapy are effective treatment options.

5. Genetic testing is needed to confirm the diagnosis of essential tremor.

Question 3

A man who received the diagnosis of multiple sclerosis two years ago presents to you with the new onset of tremor. What constellation of clinical findings is typical of tremor due to multiple sclerosis?

1. rest tremor, only occasionally observable when the patient is excited

2. a tremor that appears sometimes on the left side, sometimes on the right

3. a tremor that is only present in the morning

4. a swaying, broad-based gait and an intention tremor

5. a postural tremor that is easily suppressed by voluntary effort

Question 4

A 55-year-old man with essential tremor says that he can no longer feed himself because of tremor, can dress himself only with great difficulty, and has not had legible handwriting for many years. Drug treatment as recommended in the relevant clinical guidelines brings only slight improvement. What can you advise the patient about the option of surgical treatment?

1. Deep brain stimulation (DBS) might help but is not available in Germany.

2. DBS is an experimental technique that is only performed in clinical trials.

3. DBS is indicated only to treat Parkinson’s disease and plays no role in the treatment of essential tremor.

4. DBS has a high chance of success in this situation; it is now established as a standard treatment for essential tremor.

5. DBS is no more effective than pharmacotherapy for this indication.

Question 5

What information is most important for the diagnostic classification of a tremor syndrome?

1. the clinical findings

2. brain magnetic resonance imaging (MRI) with fine cerebellar sections

3. nuclear-medical visualization of brain perfusion

4. ultrasonography of the basal ganglia

5. measurement of serum drug levels

Question 6

What findings indicate that tremor may be psychogenic?

1. no evidence of essential tremor or Parkinson’s disease on brain MRI

2. a longstanding marital conflict

3. a tremor of inconstant location that diminishes on distraction and is found to be irregular on tremor analysis

4. a clearly identifiable underlying psychological conflict

5. remission after psychotherapy

Question 7

When can tremor be treated surgically?

1. When the patient is unwilling to take drugs to treat tremor.

2. When the patient is under 50 years old.

3. When the tremor cannot be adequately suppressed by drugs and there is no contraindication to surgery.

4. When the patient is willing to see a neurosurgeon once a week so that brain stimulation can be performed.

5. When the patient is willing to assume the cost of weekly battery changes.

Question 8

What must be borne in mind with respect to drug treatment for various tremor syndromes?

1. That the treatment is based on the clinical findings and not on the underlying disease causing tremor.

2. That causally directed treatment is generally possible only for drug-induced tremors or tremors due to metabolic disturbance.

3. That parkinsonian tremor responds best to anticholinergic drugs and does not respond at all to the classic dopamine preparations.

4. That the cerebellar tremor of multiple sclerosis is treated in exactly the same way as essential tremor.

5. That essential tremor is usually medically intractable.

Question 9

What drugs can induce tremor?

1. lithium, valproic acid, cyclosporine A

2. carbamazepine, propranolol, Seroxat

3. aspirin, diclofenac, paracetamol

4. penicillin, erythromycin, cephalosporin

5. antilipid drugs, antidiabetic drugs

Question 10

What is the drug, or drug class, of first choice for the treatment of parkinsonian tremor?

1. dopaminergic drugs

2. propanolol

3. primidone

4. gabapentin

5. ondansetron

References

People Also Reading

Tremor – Causes, Symptoms, Diagnosis, Treatment Enhanced Physiological Tremor – Causes, Symptoms, Treatment Parkinsonian Tremor – Causes, Symptoms, Diagnosis, Treatment Orthostatic Tremor – Causes, Symptoms, Diagnosis, Treatment Idiopathic Orthostatic Tremor – Causes, Symptoms, Treatment Primary Orthostatic Tremor – Causes, Symptoms, Treatment Psychogenic Tremor – Causes, Symptoms, Treatment Dystonic Tremor – Causes, Symptoms, Treatment Postural Tremor – Causes, Symptoms, Treatment Kinetic Tremor – Causes, Symptoms, Treatment Essential Tremor – Causes, Symptoms, Treatment Intention Tremor – Causes, Symptoms, Treatment

Psychogenic tremor (also called functional tremor) can appear as any form of tremor.  It symptoms may vary but often start abruptly and may affect all body parts. The tremor increases in times of stress and decreases or disappears when distracted.  Many individuals with psychogenic tremors have an underlying psychiatric disorder such as depression or post-traumatic stress disorder (PTSD).

Psychogenic movement disorders are characterized by unwanted movements, such as spasms, shaking or jerks involving any part of the face, neck, trunk or limbs. In addition some patients may have bizarre gait or difficulties with their balance that are caused by underlying stress or some psychological condition. Speech and voice disorders are also relatively common in patients with psychogenic movement disorders, in which patients may experience stuttering, speech arrest, lower speech volume (hypophonia), or even a foreign accent.

Causes of Physiologic Tremor

Generally, tremor is caused by a problem in the deep parts of the brain that control movements.  Most types of tremors have no known cause, although there are some forms that appear to be inherited and run in families.

Tremor can occur on its own or be a symptom associated with a number of neurological disorders, including

• Multiple sclerosis
• Stroke
• Traumatic brain injury
• Neurodegenerative diseases that affect parts of the brain (e.g.,  Parkinson’s disease).
• Neurologic disorders, including multiple sclerosis, Parkinson’s disease, stroke, and traumatic brain injury
• Certain medicines, such as asthma medicines, amphetamines, caffeine, corticosteroids, and medicines used for certain psychiatric and neurological disorders
• Alcohol use disorder or alcohol withdrawal
• Mercury poisoning
• Hyperthyroidism (overactive thyroid)
• Liver or kidney failure
• Anxiety or panic

Some other known causes can include

• the use of certain medicines (particular asthma medication, amphetamines, caffeine, corticosteroids, and drugs used for certain psychiatric and neurological disorders)
• alcohol abuse or withdrawal
• mercury poisoning
• overactive thyroid
• liver or kidney failure
• anxiety or panic.

Symptoms of Physiologic Tremor

Symptoms of tremor may include

• A tremor is involuntary, rhythmic contractions of various muscles. Shaky legs syndrome causes feelings of “vibration”, unsteadiness or imbalance in the legs.
• A rhythmic shaking in the hands, arms, head, legs, or torso
• Balance and muscle coordination problem
• Spasticity and muscle spasm with wasting
• Shaky voice
• Difficulty writing or drawing
• Problems holding and controlling utensils, such as a spoon.
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement
• Usually occur in the hands first, affecting one hand or both hands
• Can include a “yes-yes” or “no-no” motion of the head
• It May be aggravated by emotional stress, fatigue, caffeine, or temperature extremes
• Tremors that get worse during emotional stress
• Tremors that get worse when you move on purpose
• Tremors that lessen with rest
• Balance problems (in rare cases)

What we feel in both legs simultaneously is extreme straining, fatigue, unsteadiness, and a fear of falling. The muscles in our legs become hard, our ankles feel weak and our toes curl under as our legs fail to support us. We can stand for only a short period of time, in some cases only seconds. There is a feeling of panic to find a place to sit, or if possible, walk to gain some relief from our symptoms. Some tremors /shaky legs syndrome may be triggered by or become worse during times of stress or strong emotion, when an individual is physically exhausted, or when a person is in certain postures or makes certain movements.

Diagnosis of Physiologic Tremor

Medical history

During the physical evaluation, a doctor will assess the tremor based on:

• whether the tremor occurs when the muscles are at rest or inaction
• the location of the tremor on the body (and if it occurs on one or both sides of the body)
• the appearance of the tremor (tremor frequency and amplitude).

The doctor will also check other neurological findings such as impaired balance, speech abnormalities, or increased muscle stiffness.  Blood or urine tests can rule out metabolic causes such as thyroid malfunction and certain medications that can cause tremors/shaky legs syndrome.  These tests may also help to identify contributing causes such as drug interactions, chronic alcoholism, or other conditions or diseases.  Diagnostic imaging may help determine if the tremor is the result of damage to the brain.

Clinical observations

The diagnosis is based on a combination of a number of clinical observations and recognition of typical characteristics (phenomenology) that include, but are not necessarily limited to the following:

• Onset of the movements is abrupt/sudden.
• Movements are triggered by emotional or physical trauma, or by some conflict (marital, sexual, work-related).
• Movements are episodic or appear intermittent.
• There are spontaneous remissions of the movements.
• Movements disappear with distraction.
• Movements are suggestible, meaning they may disappear by making a suggestion. For example, suggesting that the application of a tuning fork to the body part affected may help relieve the movements.
• Underlying psychiatric disturbances (depression, anxiety) are present.
• There are multiple somatizations and undiagnosed conditions.
• There is a lack of emotional concern about the disorder (“la belle indifference”).
• There has been exposure to neurologic disorders during one’s occupation (e.g. nurse, physician) or while caring for someone with similar problems.
• Slurred speech, soft voice, gibberish, foreign accent
• Delayed and excessive startle (bizarre movements in response to sudden, unexpected noise or threatening movement)
• Presence of additional types of abnormal movements that are not known to be part of the primary or principal movement disorder pattern that the patient manifests
• Active resistance against passive movement
• Fixed posture

Treatment of Physiologic Tremor

Non-pharmacological

• Physical, speech-language, and occupational therapy – may help to control tremors and meet daily challenges caused by the tremor.  A physical therapist can help people improve their muscle control, functioning, and strength through coordination, balancing, and other exercises.  Some therapists recommend the use of weights, splints, other adaptive equipment, and special plates and utensils for eating.  Speech-language pathologists can evaluate and treat speech, language, communication, and swallowing disorders.  Occupational therapists can teach individuals new ways of performing activities of daily living that may be affected by tremors.
• Eliminating or reducing tremor-inducing substances such as caffeine and other medication – (such as stimulants) can help improve tremor. Though small amounts of alcohol can improve tremors for some people, tremors can become worse once the effects of the alcohol wear off.
• Interventional Therapy – For patients who fail pharmacologic treatment with the above drugs or are unable to tolerate the side effects, surgical options include deep brain stimulation (DBS), focused ultrasound, or radio-surgical gamma knife thalamotomy to treat persistently disabling limb tremor, and botulinum toxin injections to treat persistently disabling head or vocal cord tremor.
• Deep-brain stimulation – This is the most common surgical treatment for essential tremors. Most series report 70% to 90% hand tremor control. In deep-brain stimulation, electrical stimulation is delivered to the brain through an electrode implanted deep into the ventral intermediate nucleus (VIM) of the thalamus. This is typically done by implanting 4 electrodes in the VIM using stereotactic methods. Computerized programming of the pulse generator is most commonly done with a handheld device after the patient leaves the hospital to optimize the electrode montage, voltage, pulse frequency, and pulse width. Deep-brain stimulation can be done unilaterally or bilaterally depending on the patient’s symptoms. There is an increased risk of speech and balance difficulties with bilateral procedures. If the tremor significantly affects both hands, the dominant hand is targeted, bilateral procedures may be considered.
• Focused ultrasound – Approved by the FDA in 2016, magnetic resonance imaging-guided, high-intensity, focused ultrasound thalamotomy is an innovative method for the treatment of essential tremors. Although it is transcranial and does not require an incision, skull penetration, or an implanted device, it is an invasive therapy that produces a permanent thalamic lesion.
• Radio-surgical gamma knife thalamotomy – Gamma-knife thalamotomy fo­cuses high-energy gamma rays on the ventral intermediate resulting in the death of neurons. It is an unproven treatment that has not generally been adopted due to concerns about potential radiation side effects, including a theoretical, long-term risk of secondary tumor formation.
• Ultrasound Therapy – A new treatment for essential tremors uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brain’s thalamus thought to be responsible for causing the tremors.  The treatment is approved only for those individuals with essential tremors who do not respond well to anticonvulsant or beta-blocking drugs.
• Biofeedback – is a mind-body technique that involves using visual or auditory feedback to teach people to recognize the physical signs and symptoms of stress and anxiety, such as increased heart rate, body temperature, and muscle tension.
• Relaxation techniques – can reduce stress symptoms and help you enjoy a better quality of life, especially if you have an illness. Explore relaxation techniques you can do by yourself.
• Learn to relax – Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors. Although you can’t eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques, such as massage or meditation.
• Noninvasive techniques – Include gait rehabilitation, visually guided techniques, tendon vibration, weighting extremities, positioning techniques, and manual techniques, all of which can be useful for the recovery of functional activities.[rx]
• Invasive techniques – Thalamic deep brain stimulation can alleviate the tremor in MS, providing better functional performance.[rx] Stereotactic radiosurgery thalamotomy at the nucleus ventralis intermedius with a median maximum dose of 140 Gy also provides good functional outcomes in patients with MS.[rx][rx] Radiofrequency thalamotomy had been successfully used in the past but has been replaced with the newer techniques of radiosurgery and deep brain stimulation as they had fewer adverse effects.
• Physical therapy – can help some patients control their tremors better, as can reducing the intake of substances such as caffeine, which can induce tremors. Many patients experience an increase in the severity of their tremors when they are stressed. Therefore, trying to reduce sources of anxiety and engaging in complementary therapies (such as yoga or aromatherapy) may help some patients.
• Speech and occupational therapy – may be useful not only in improving physical and psychological functioning, such as activities of daily living, but also to alter the abnormally learned pattern of movement – “motor reprograming.” Antidepressants and muscle relaxants may be also beneficial. Rarely, transcutaneous electrical stimulation applied to the area of spasm or involuntary movement may be helpful, analogous to the application of a tuning fork during clinic evaluation. Most importantly, however, the patient should try to understand which stress factors may be playing a role and seek the expertise of a psychologist experienced and skilled in stress management. The role of a psychiatrist is not to make the diagnosis but to provide insights into underlying psychological or psychiatric issues and to aid in the treatment of psychiatric issues such as depression or anxiety.
• Psychogenic movement Therapy –  It may be difficult to treat, especially if the patient is diagnosed late or is not accepting of the diagnosis. Indeed, patients with the best prognosis are those who initially accept the diagnosis and work with the movement disorder neurologist, psychologist, psychiatrist and physical, speech and occupational therapists in implementing a short-term and long-term therapeutic program. The diagnosis should be disclosed to patients in a manner that is empathetic and nonjudgmental.

For example, tremors due to thyroid hyperactivity will improve or even resolve (return to the normal state) with the treatment of thyroid malfunction.  Also, if the tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.

Medical Therapy

The therapeutic approach to essential tremors many times follows a trial and error approach, and patients should be challenged by several medications if the first choice is ineffective or associated with debilitating adverse effects. Medical therapy can be divided into first, second, and third-line therapies.

First-line therapy – It is either approved by the FDA or supported by double-blinded, placebo-controlled studies that meet the criteria for the class I evidence. This class of medications includes propranolol and primidone. If both primidone and propranolol are not effective alone, combinations of both may provide relief in selected patients.

Second-line therapy – Second-line therapy is supported by double-blinded, placebo-controlled trials that do not meet other requirements for the class I evidence studies. This includes gabapentin, pregabalin, topiramate, benzodiazepines (clonazepam, alprazolam), beta-blockers (atenolol and metoprolol) and zonisamide.

Third-line therapy – These therapies are based on open-label studies or case series. Drugs in this class include nimodipine and clozapine.

Medication

• Beta-blocking drugs such as propranolol are normally used to treat high blood pressure but they also help treat essential tremors.  Propranolol can also be used in some people with other types of action tremors.  Other beta-blockers that may be used include atenolol, metoprolol, nadolol, and sotalol.
• Anti-seizure medications such as primidone can be effective in people with essential tremors who do not respond to beta-blockers.  Other medications that may be prescribed include gabapentin and topiramate.  However, it is important to note that some anti-seizure medications can cause tremors.
• Tranquilizers (also known as benzodiazepines) such as alprazolam and clonazepam may temporarily help some people with tremors.  However, their use is limited due to unwanted side effects that include sleepiness, poor concentration, and poor coordination.  This can affect the ability of people to perform daily activities such as driving, school, and work.  Also, when taken regularly, tranquilizers can cause physical dependence and when stopped abruptly can cause several withdrawal symptoms.
• Parkinson’s disease medications (levodopa, carbidopa) are used to treat tremors associated with Parkinson’s disease.
• Botulinum toxin – injections can treat almost all types of tremors.  It is especially useful for head tremor, which generally does not respond to medications.  Botulinum toxin is widely used to control dystonic tremors.  Although botulinum toxin injections can improve tremors for roughly three months at a time, they can also cause muscle weakness.  While this treatment is effective and usually well tolerated for head tremors, botulinum toxin treatment in the hands can cause weakness in the fingers.  It can cause a hoarse voice and difficulty swallowing when used to treat voice tremors.

Additional drug therapies that have been used to treat individuals with primary orthostatic tremors include primidone (Mysoline), chlordiazepoxide (Librium), pregabalin (Lyrica), pramipexole (Mirapex), phenobarbital, and valproic acid (Depakote). Drugs commonly used to treat people with Parkinson’s disease (levodopa or pramipexole) may also be prescribed for individuals with primary orthostatic tremors.

Surgery

When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation (DBS) or very rarely, thalamotomy.  While DBS is usually well-tolerated, the most common side effects of tremor surgery include dysarthria (trouble speaking) and balance problems.

• Deep brain stimulation (DBS) – is the most common form of surgical treatment of tremors.  This method is preferred because it is effective, has low risk, and treats a broader range of symptoms than thalamotomy.  The treatment uses surgically implanted electrodes to send high-frequency electrical signals to the thalamus, the deep structure of the brain that coordinates and controls some involuntary movements.  A small pulse generating device placed under the skin in the upper chest (similar to a pacemaker) sends electrical stimuli to the brain and temporarily disables the tremor.  DBS is currently used to treat parkinsonian tremors, essential tremors, and dystonia.

• Thalamotomy – is a surgical procedure that involves the precise, permanent destruction of a tiny area in the thalamus.  Currently, surgery is replaced by radiofrequency ablation to treat severe tremors when deep brain surgery is contraindicated—meaning it is unwise as a treatment option or has undesirable side effects.  Radiofrequency ablation uses a radio wave to generate an electric current that heats up a nerve and disrupts its signaling ability for typically six or more months.  It is usually performed on only one side of the brain to improve tremors on the opposite side of the body.  Surgery on both sides is not recommended as it can cause problems with speech.
•  Stereotactic surgical techniques – can be used to create a lesion in the ventral intermediate (VIM) nucleus of the thalamus.

Rehabilitation

Exercise is an important part of healthy living for everyone. For people with tremors, exercise is more than healthy it is a vital component to maintaining balance, mobility, and activities of daily living. Exercise and physical activity can improve many tremors symptoms. These benefits are supported by research.

The tremors show that people with tremors who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.

What Type of Exercise Should I Do?

To help manage the symptoms of tremors, be sure your exercise program includes a few key ingredients:

• Aerobic activity
• Strength training
• Balance, agility, and multitasking
• Flexibility

These elements are included in many types of exercise. Biking, running, Tai chi, yoga, Pilates, dance, weight training, non-contact boxing, qi gong, and more — all have positive effects on tremors symptoms.

There is no “exercise prescription” that is right for every person with tremors. The type of exercise you do depends on your symptoms and challenges. For sedentary people, just getting up and moving is beneficial. More active people can build up to the regular, vigorous activity. Many approaches work well to help maintain and improve mobility, flexibility, and balance to ease non-motor tremors symptoms such as depression or constipation.

Researchers in the study did not distinguish between what type of exercise participants did and determined that all types of exercise are beneficial. The most important thing is to do the exercise regularly. We suggest finding an exercise you enjoy and stick with it.

Challenges to Exercising

• People in the early stages of tremors tend to be just as strong and physically fit as healthy individuals of the same age.
• Disease progression can lead to the following physical change:
• Loss of joint flexibility, which can affect balance.
• Decreased muscle strength or deconditioning can affect walking and the ability to stand up from sitting.
• The decline in cardiovascular conditioning, which affects endurance.

Tips for Getting Started

• First, be safe. Before starting an exercise program, consult your neurologist and primary care doctor about concerns and recommendations.
• Ask your doctor or members in your support group to refer to a physical therapist (PT) who knows about tremors. Work together to identify your concerns and limitations. Target exercises to improve them. For most people, a structured exercise program will include aerobic exercise (such as brisk walking) and resistance training (using weights or bands).
• Purchase a pedometer (step-counter) and figure out how many steps you take on average each day, then build up from there. Many smartphones or smartwatches have a built-in pedometer feature or an application that can be downloaded.
• Exercise indoors and outdoors. Change your routine to stay interested and motivated.
• Again, most importantly pick an exercise you enjoy.

What research is being done?

The mission is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.  The NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world.

Researchers are working to better understand the underlying brain functions that cause tremors, identify the genetic factors that make individuals more susceptible to the disorder, and develop new and better treatment options.

• Brain functioning – It can be difficult to distinguish between movement disorders such as Parkinson’s disease and essential tremor. These debilitating movement disorders have different prognoses and can respond very differently to available therapies. NINDS researchers are working to identify structural and functional changes in the brain using non-invasive neuroimaging techniques to develop sensitive and specific markers for each of these diseases and then track how they change as each disease progresses. Other researchers are using functional magnetic resonance imaging technology to better understand normal and diseased brain circuit functions and associated motor behaviors.  Scientists hope to design therapies that can restore normal brain circuit function in diseases such as Parkinson’s disease and tremor.
• Genetics – Research has shown that essential tremors may have a strong genetic component affecting multiple generations of families.  NINDS researchers are building on previous genetics work to identify susceptibility genes for familial early-onset (before age 40) essential tremor.  Researchers are focusing on multigenerational, early-onset families to better detect linkages.

Additionally, NINDS scientists are researching the impact of genetic abnormalities on the development of essential tremors.  Previous research that has shown a link between essential tremor and possible genetic variants on chromosome 6 and 11; ongoing research is targeting the impact of other genetic variations in families.

Medications and other treatment methods

While drugs can be effective for some people, approximately 50 percent of individuals do not respond to medication.  In order to develop assistive and rehabilitative tremor-suppressing devices for people with essential tremors, researchers are exploring where and how to minimize or suppress tremors while still allowing for voluntary movements.

Many people with essential tremors respond to ethanol (alcohol); however, it is not clear why or how.  NINDS researchers are studying the impact of ethanol on tremors to determine the correct dosage amount and its physiological impact on the brain and whether other medications without the side effects of ethanol can be effective.

Other NIH researchers hope to identify the source of essential tremors, study the effects of currently available tremor-suppressant drugs on the brain, and develop more targeted and effective therapies.

FAQ

Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

Which of the following constellations of clinical findings is typical of tremor in patients with Parkinson’s disease?

1. bilateral postural tremor

2. unilateral rest tremor and diminished ipsilateral arm swing while walking

3. severe unilateral tremor while holding a cup or glass

4. tremor that only appears when the patient writes

5. postural tremor of both hands and ataxic gait

Question 2

A 25-year-old man has a mild postural tremor of both hands that improves when he drinks alcohol. His mother had the same condition. What can you advise him?

1. He should definitely be evaluated for possible early Parkinson’s disease.

2. He must get treatment now, as otherwise the condition could worsen.

3. If treatment is indicated, propranolol or primidone could be given.

4. Relaxation exercises and physiotherapy are effective treatment options.

5. Genetic testing is needed to confirm the diagnosis of essential tremor.

Question 3

A man who received the diagnosis of multiple sclerosis two years ago presents to you with the new onset of tremor. What constellation of clinical findings is typical of tremor due to multiple sclerosis?

1. rest tremor, only occasionally observable when the patient is excited

2. a tremor that appears sometimes on the left side, sometimes on the right

3. a tremor that is only present in the morning

4. a swaying, broad-based gait and an intention tremor

5. a postural tremor that is easily suppressed by voluntary effort

Question 4

A 55-year-old man with essential tremor says that he can no longer feed himself because of tremor, can dress himself only with great difficulty, and has not had legible handwriting for many years. Drug treatment as recommended in the relevant clinical guidelines brings only slight improvement. What can you advise the patient about the option of surgical treatment?

1. Deep brain stimulation (DBS) might help but is not available in Germany.

2. DBS is an experimental technique that is only performed in clinical trials.

3. DBS is indicated only to treat Parkinson’s disease and plays no role in the treatment of essential tremor.

4. DBS has a high chance of success in this situation; it is now established as a standard treatment for essential tremor.

5. DBS is no more effective than pharmacotherapy for this indication.

Question 5

What information is most important for the diagnostic classification of a tremor syndrome?

1. the clinical findings

2. brain magnetic resonance imaging (MRI) with fine cerebellar sections

3. nuclear-medical visualization of brain perfusion

4. ultrasonography of the basal ganglia

5. measurement of serum drug levels

Question 6

What findings indicate that tremor may be psychogenic?

1. no evidence of essential tremor or Parkinson’s disease on brain MRI

2. a longstanding marital conflict

3. a tremor of inconstant location that diminishes on distraction and is found to be irregular on tremor analysis

4. a clearly identifiable underlying psychological conflict

5. remission after psychotherapy

Question 7

When can tremor be treated surgically?

1. When the patient is unwilling to take drugs to treat tremor.

2. When the patient is under 50 years old.

3. When the tremor cannot be adequately suppressed by drugs and there is no contraindication to surgery.

4. When the patient is willing to see a neurosurgeon once a week so that brain stimulation can be performed.

5. When the patient is willing to assume the cost of weekly battery changes.

Question 8

What must be borne in mind with respect to drug treatment for various tremor syndromes?

1. That the treatment is based on the clinical findings and not on the underlying disease causing tremor.

2. That causally directed treatment is generally possible only for drug-induced tremors or tremors due to metabolic disturbance.

3. That parkinsonian tremor responds best to anticholinergic drugs and does not respond at all to the classic dopamine preparations.

4. That the cerebellar tremor of multiple sclerosis is treated in exactly the same way as essential tremor.

5. That essential tremor is usually medically intractable.

Question 9

What drugs can induce tremor?

1. lithium, valproic acid, cyclosporine A

2. carbamazepine, propranolol, Seroxat

3. aspirin, diclofenac, paracetamol

4. penicillin, erythromycin, cephalosporin

5. antilipid drugs, antidiabetic drugs

Question 10

What is the drug, or drug class, of first choice for the treatment of parkinsonian tremor?

1. dopaminergic drugs

2. propanolol

3. primidone

4. gabapentin

5. ondansetron

References

People Also Reading

Tremor – Causes, Symptoms, Diagnosis, Treatment Orthostatic Tremor – Causes, Symptoms, Diagnosis, Treatment Idiopathic Orthostatic Tremor – Causes, Symptoms, Treatment Primary Orthostatic Tremor – Causes, Symptoms, Treatment Enhanced Physiological Tremor – Causes, Symptoms, Treatment Parkinsonian Tremor – Causes, Symptoms, Diagnosis, Treatment Functional Tremor – Causes, Symptoms, Treatment Postural Tremor – Causes, Symptoms, Treatment Dystonic Tremor – Causes, Symptoms, Treatment Kinetic Tremor – Causes, Symptoms, Treatment Essential Tremor – Causes, Symptoms, Treatment Intention Tremor – Causes, Symptoms, Treatment

Enhanced physiological tremor is a more noticeable case of physiologic tremor that can be easily seen.  It is generally not caused by a neurological disease but by the reaction to certain drugs, alcohol withdrawal, or medical conditions including an overactive thyroid and hypoglycemia.  It is usually reversible once the cause is corrected

Causes of Enhanced Physiological Tremor

Generally, tremor is caused by a problem in the deep parts of the brain that control movements.  Most types of tremors have no known cause, although there are some forms that appear to be inherited and run in families.

Tremor can occur on its own or be a symptom associated with a number of neurological disorders, including

• Multiple sclerosis
• Stroke
• Traumatic brain injury
• Neurodegenerative diseases that affect parts of the brain (e.g.,  Parkinson’s disease).
• Neurologic disorders, including multiple sclerosis, Parkinson’s disease, stroke, and traumatic brain injury
• Certain medicines, such as asthma medicines, amphetamines, caffeine, corticosteroids, and medicines used for certain psychiatric and neurological disorders
• Alcohol use disorder or alcohol withdrawal
• Mercury poisoning
• Hyperthyroidism (overactive thyroid)
• Liver or kidney failure
• Anxiety or panic

Some other known causes can include

• the use of certain medicines (particular asthma medication, amphetamines, caffeine, corticosteroids, and drugs used for certain psychiatric and neurological disorders)
• alcohol abuse or withdrawal
• mercury poisoning
• overactive thyroid
• liver or kidney failure
• anxiety or panic.

Symptoms of Enhanced Physiological Tremor

Symptoms of tremor may include

• A tremor is involuntary, rhythmic contractions of various muscles. Shaky legs syndrome causes feelings of “vibration”, unsteadiness or imbalance in the legs.
• A rhythmic shaking in the hands, arms, head, legs, or torso
• Balance and muscle coordination problem
• Spasticity and muscle spasm with wasting
• Shaky voice
• Difficulty writing or drawing
• Problems holding and controlling utensils, such as a spoon.
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement
• Usually occur in the hands first, affecting one hand or both hands
• Can include a “yes-yes” or “no-no” motion of the head
• It May be aggravated by emotional stress, fatigue, caffeine, or temperature extremes
• Tremors that get worse during emotional stress
• Tremors that get worse when you move on purpose
• Tremors that lessen with rest
• Balance problems (in rare cases)

What we feel in both legs simultaneously is extreme straining, fatigue, unsteadiness, and a fear of falling. The muscles in our legs become hard, our ankles feel weak and our toes curl under as our legs fail to support us. We can stand for only a short period of time, in some cases only seconds. There is a feeling of panic to find a place to sit, or if possible, walk to gain some relief from our symptoms. Some tremors /shaky legs syndrome may be triggered by or become worse during times of stress or strong emotion, when an individual is physically exhausted, or when a person is in certain postures or makes certain movements.

Diagnosis of Enhanced Physiological Tremor

Medical history

During the physical evaluation, a doctor will assess the tremor based on:

• whether the tremor occurs when the muscles are at rest or inaction
• the location of the tremor on the body (and if it occurs on one or both sides of the body)
• the appearance of the tremor (tremor frequency and amplitude).

The doctor will also check other neurological findings such as impaired balance, speech abnormalities, or increased muscle stiffness.  Blood or urine tests can rule out metabolic causes such as thyroid malfunction and certain medications that can cause tremors/shaky legs syndrome.  These tests may also help to identify contributing causes such as drug interactions, chronic alcoholism, or other conditions or diseases.  Diagnostic imaging may help determine if the tremor is the result of damage to the brain.

Treatment of Enhanced Physiological Tremor

Non-pharmacological

• Physical, speech-language, and occupational therapy – may help to control tremors and meet daily challenges caused by the tremor.  A physical therapist can help people improve their muscle control, functioning, and strength through coordination, balancing, and other exercises.  Some therapists recommend the use of weights, splints, other adaptive equipment, and special plates and utensils for eating.  Speech-language pathologists can evaluate and treat speech, language, communication, and swallowing disorders.  Occupational therapists can teach individuals new ways of performing activities of daily living that may be affected by tremors.
• Eliminating or reducing tremor-inducing substances such as caffeine and other medication – (such as stimulants) can help improve tremor. Though small amounts of alcohol can improve tremors for some people, tremors can become worse once the effects of the alcohol wear off.
• Interventional Therapy – For patients who fail pharmacologic treatment with the above drugs or are unable to tolerate the side effects, surgical options include deep brain stimulation (DBS), focused ultrasound, or radio-surgical gamma knife thalamotomy to treat persistently disabling limb tremor, and botulinum toxin injections to treat persistently disabling head or vocal cord tremor.
• Deep-brain stimulation – This is the most common surgical treatment for essential tremors. Most series report 70% to 90% hand tremor control. In deep-brain stimulation, electrical stimulation is delivered to the brain through an electrode implanted deep into the ventral intermediate nucleus (VIM) of the thalamus. This is typically done by implanting 4 electrodes in the VIM using stereotactic methods. Computerized programming of the pulse generator is most commonly done with a handheld device after the patient leaves the hospital to optimize the electrode montage, voltage, pulse frequency, and pulse width. Deep-brain stimulation can be done unilaterally or bilaterally depending on the patient’s symptoms. There is an increased risk of speech and balance difficulties with bilateral procedures. If the tremor significantly affects both hands, the dominant hand is targeted, bilateral procedures may be considered.
• Focused ultrasound – Approved by the FDA in 2016, magnetic resonance imaging-guided, high-intensity, focused ultrasound thalamotomy is an innovative method for the treatment of essential tremors. Although it is transcranial and does not require an incision, skull penetration, or an implanted device, it is an invasive therapy that produces a permanent thalamic lesion.
• Radio-surgical gamma knife thalamotomy – Gamma-knife thalamotomy fo­cuses high-energy gamma rays on the ventral intermediate resulting in the death of neurons. It is an unproven treatment that has not generally been adopted due to concerns about potential radiation side effects, including a theoretical, long-term risk of secondary tumor formation.
• Ultrasound Therapy – A new treatment for essential tremors uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brain’s thalamus thought to be responsible for causing the tremors.  The treatment is approved only for those individuals with essential tremors who do not respond well to anticonvulsant or beta-blocking drugs.
• Biofeedback – is a mind-body technique that involves using visual or auditory feedback to teach people to recognize the physical signs and symptoms of stress and anxiety, such as increased heart rate, body temperature, and muscle tension.
• Relaxation techniques – can reduce stress symptoms and help you enjoy a better quality of life, especially if you have an illness. Explore relaxation techniques you can do by yourself.
• Learn to relax – Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors. Although you can’t eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques, such as massage or meditation.
• Noninvasive techniques – Include gait rehabilitation, visually guided techniques, tendon vibration, weighting extremities, positioning techniques, and manual techniques, all of which can be useful for the recovery of functional activities.[rx]
• Invasive techniques – Thalamic deep brain stimulation can alleviate the tremor in MS, providing better functional performance.[rx] Stereotactic radiosurgery thalamotomy at the nucleus ventralis intermedius with a median maximum dose of 140 Gy also provides good functional outcomes in patients with MS.[rx][rx] Radiofrequency thalamotomy had been successfully used in the past but has been replaced with the newer techniques of radiosurgery and deep brain stimulation as they had fewer adverse effects.
• Physical therapy – can help some patients control their tremors better, as can reducing the intake of substances such as caffeine, which can induce tremors. Many patients experience an increase in the severity of their tremors when they are stressed. Therefore, trying to reduce sources of anxiety and engaging in complementary therapies (such as yoga or aromatherapy) may help some patients.

For example, tremors due to thyroid hyperactivity will improve or even resolve (return to the normal state) with the treatment of thyroid malfunction.  Also, if the tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.

Medical Therapy

The therapeutic approach to essential tremors many times follows a trial and error approach, and patients should be challenged by several medications if the first choice is ineffective or associated with debilitating adverse effects. Medical therapy can be divided into first, second, and third-line therapies.

First-line therapy – It is either approved by the FDA or supported by double-blinded, placebo-controlled studies that meet the criteria for the class I evidence. This class of medications includes propranolol and primidone. If both primidone and propranolol are not effective alone, combinations of both may provide relief in selected patients.

Second-line therapy – Second-line therapy is supported by double-blinded, placebo-controlled trials that do not meet other requirements for the class I evidence studies. This includes gabapentin, pregabalin, topiramate, benzodiazepines (clonazepam, alprazolam), beta-blockers (atenolol and metoprolol) and zonisamide.

Third-line therapy – These therapies are based on open-label studies or case series. Drugs in this class include nimodipine and clozapine.

Medication

• Beta-blocking drugs such as propranolol are normally used to treat high blood pressure but they also help treat essential tremors.  Propranolol can also be used in some people with other types of action tremors.  Other beta-blockers that may be used include atenolol, metoprolol, nadolol, and sotalol.
• Anti-seizure medications such as primidone can be effective in people with essential tremors who do not respond to beta-blockers.  Other medications that may be prescribed include gabapentin and topiramate.  However, it is important to note that some anti-seizure medications can cause tremors.
• Tranquilizers (also known as benzodiazepines) such as alprazolam and clonazepam may temporarily help some people with tremors.  However, their use is limited due to unwanted side effects that include sleepiness, poor concentration, and poor coordination.  This can affect the ability of people to perform daily activities such as driving, school, and work.  Also, when taken regularly, tranquilizers can cause physical dependence and when stopped abruptly can cause several withdrawal symptoms.
• Parkinson’s disease medications (levodopa, carbidopa) are used to treat tremors associated with Parkinson’s disease.
• Botulinum toxin – injections can treat almost all types of tremors.  It is especially useful for head tremor, which generally does not respond to medications.  Botulinum toxin is widely used to control dystonic tremors.  Although botulinum toxin injections can improve tremors for roughly three months at a time, they can also cause muscle weakness.  While this treatment is effective and usually well tolerated for head tremors, botulinum toxin treatment in the hands can cause weakness in the fingers.  It can cause a hoarse voice and difficulty swallowing when used to treat voice tremors.

Additional drug therapies that have been used to treat individuals with primary orthostatic tremors include primidone (Mysoline), chlordiazepoxide (Librium), pregabalin (Lyrica), pramipexole (Mirapex), phenobarbital, and valproic acid (Depakote). Drugs commonly used to treat people with Parkinson’s disease (levodopa or pramipexole) may also be prescribed for individuals with primary orthostatic tremors.

Surgery

When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation (DBS) or very rarely, thalamotomy.  While DBS is usually well-tolerated, the most common side effects of tremor surgery include dysarthria (trouble speaking) and balance problems.

• Deep brain stimulation (DBS) – is the most common form of surgical treatment of tremors.  This method is preferred because it is effective, has low risk, and treats a broader range of symptoms than thalamotomy.  The treatment uses surgically implanted electrodes to send high-frequency electrical signals to the thalamus, the deep structure of the brain that coordinates and controls some involuntary movements.  A small pulse generating device placed under the skin in the upper chest (similar to a pacemaker) sends electrical stimuli to the brain and temporarily disables the tremor.  DBS is currently used to treat parkinsonian tremors, essential tremors, and dystonia.

• Thalamotomy – is a surgical procedure that involves the precise, permanent destruction of a tiny area in the thalamus.  Currently, surgery is replaced by radiofrequency ablation to treat severe tremors when deep brain surgery is contraindicated—meaning it is unwise as a treatment option or has undesirable side effects.  Radiofrequency ablation uses a radio wave to generate an electric current that heats up a nerve and disrupts its signaling ability for typically six or more months.  It is usually performed on only one side of the brain to improve tremors on the opposite side of the body.  Surgery on both sides is not recommended as it can cause problems with speech.
•  Stereotactic surgical techniques – can be used to create a lesion in the ventral intermediate (VIM) nucleus of the thalamus.

Rehabilitation

Exercise is an important part of healthy living for everyone. For people with tremors, exercise is more than healthy it is a vital component to maintaining balance, mobility, and activities of daily living. Exercise and physical activity can improve many tremors symptoms. These benefits are supported by research.

The tremors show that people with tremors who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.

What Type of Exercise Should I Do?

To help manage the symptoms of tremors, be sure your exercise program includes a few key ingredients:

• Aerobic activity
• Strength training
• Balance, agility, and multitasking
• Flexibility

These elements are included in many types of exercise. Biking, running, Tai chi, yoga, Pilates, dance, weight training, non-contact boxing, qi gong, and more — all have positive effects on tremors symptoms.

There is no “exercise prescription” that is right for every person with tremors. The type of exercise you do depends on your symptoms and challenges. For sedentary people, just getting up and moving is beneficial. More active people can build up to the regular, vigorous activity. Many approaches work well to help maintain and improve mobility, flexibility, and balance to ease non-motor tremors symptoms such as depression or constipation.

Researchers in the study did not distinguish between what type of exercise participants did and determined that all types of exercise are beneficial. The most important thing is to do the exercise regularly. We suggest finding an exercise you enjoy and stick with it.

Challenges to Exercising

• People in the early stages of tremors tend to be just as strong and physically fit as healthy individuals of the same age.
• Disease progression can lead to the following physical change:
• Loss of joint flexibility, which can affect balance.
• Decreased muscle strength or deconditioning can affect walking and the ability to stand up from sitting.
• The decline in cardiovascular conditioning, which affects endurance.

Tips for Getting Started

• First, be safe. Before starting an exercise program, consult your neurologist and primary care doctor about concerns and recommendations.
• Ask your doctor or members in your support group to refer to a physical therapist (PT) who knows about tremors. Work together to identify your concerns and limitations. Target exercises to improve them. For most people, a structured exercise program will include aerobic exercise (such as brisk walking) and resistance training (using weights or bands).
• Purchase a pedometer (step-counter) and figure out how many steps you take on average each day, then build up from there. Many smartphones or smartwatches have a built-in pedometer feature or an application that can be downloaded.
• Exercise indoors and outdoors. Change your routine to stay interested and motivated.
• Again, most importantly pick an exercise you enjoy.

What research is being done?

The mission is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.  The NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world.

Researchers are working to better understand the underlying brain functions that cause tremors, identify the genetic factors that make individuals more susceptible to the disorder, and develop new and better treatment options.

• Brain functioning – It can be difficult to distinguish between movement disorders such as Parkinson’s disease and essential tremor. These debilitating movement disorders have different prognoses and can respond very differently to available therapies. NINDS researchers are working to identify structural and functional changes in the brain using non-invasive neuroimaging techniques to develop sensitive and specific markers for each of these diseases and then track how they change as each disease progresses. Other researchers are using functional magnetic resonance imaging technology to better understand normal and diseased brain circuit functions and associated motor behaviors.  Scientists hope to design therapies that can restore normal brain circuit function in diseases such as Parkinson’s disease and tremor.
• Genetics – Research has shown that essential tremors may have a strong genetic component affecting multiple generations of families.  NINDS researchers are building on previous genetics work to identify susceptibility genes for familial early-onset (before age 40) essential tremor.  Researchers are focusing on multigenerational, early-onset families to better detect linkages.

Additionally, NINDS scientists are researching the impact of genetic abnormalities on the development of essential tremors.  Previous research that has shown a link between essential tremor and possible genetic variants on chromosome 6 and 11; ongoing research is targeting the impact of other genetic variations in families.

Medications and other treatment methods

While drugs can be effective for some people, approximately 50 percent of individuals do not respond to medication.  In order to develop assistive and rehabilitative tremor-suppressing devices for people with essential tremors, researchers are exploring where and how to minimize or suppress tremors while still allowing for voluntary movements.

Many people with essential tremors respond to ethanol (alcohol); however, it is not clear why or how.  NINDS researchers are studying the impact of ethanol on tremors to determine the correct dosage amount and its physiological impact on the brain and whether other medications without the side effects of ethanol can be effective.

Other NIH researchers hope to identify the source of essential tremors, study the effects of currently available tremor-suppressant drugs on the brain, and develop more targeted and effective therapies.

FAQ

Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

Which of the following constellations of clinical findings is typical of tremor in patients with Parkinson’s disease?

1. bilateral postural tremor

2. unilateral rest tremor and diminished ipsilateral arm swing while walking

3. severe unilateral tremor while holding a cup or glass

4. tremor that only appears when the patient writes

5. postural tremor of both hands and ataxic gait

Question 2

A 25-year-old man has a mild postural tremor of both hands that improves when he drinks alcohol. His mother had the same condition. What can you advise him?

1. He should definitely be evaluated for possible early Parkinson’s disease.

2. He must get treatment now, as otherwise the condition could worsen.

3. If treatment is indicated, propranolol or primidone could be given.

4. Relaxation exercises and physiotherapy are effective treatment options.

5. Genetic testing is needed to confirm the diagnosis of essential tremor.

Question 3

A man who received the diagnosis of multiple sclerosis two years ago presents to you with the new onset of tremor. What constellation of clinical findings is typical of tremor due to multiple sclerosis?

1. rest tremor, only occasionally observable when the patient is excited

2. a tremor that appears sometimes on the left side, sometimes on the right

3. a tremor that is only present in the morning

4. a swaying, broad-based gait and an intention tremor

5. a postural tremor that is easily suppressed by voluntary effort

Question 4

A 55-year-old man with essential tremor says that he can no longer feed himself because of tremor, can dress himself only with great difficulty, and has not had legible handwriting for many years. Drug treatment as recommended in the relevant clinical guidelines brings only slight improvement. What can you advise the patient about the option of surgical treatment?

1. Deep brain stimulation (DBS) might help but is not available in Germany.

2. DBS is an experimental technique that is only performed in clinical trials.

3. DBS is indicated only to treat Parkinson’s disease and plays no role in the treatment of essential tremor.

4. DBS has a high chance of success in this situation; it is now established as a standard treatment for essential tremor.

5. DBS is no more effective than pharmacotherapy for this indication.

Question 5

What information is most important for the diagnostic classification of a tremor syndrome?

1. the clinical findings

2. brain magnetic resonance imaging (MRI) with fine cerebellar sections

3. nuclear-medical visualization of brain perfusion

4. ultrasonography of the basal ganglia

5. measurement of serum drug levels

Question 6

What findings indicate that tremor may be psychogenic?

1. no evidence of essential tremor or Parkinson’s disease on brain MRI

2. a longstanding marital conflict

3. a tremor of inconstant location that diminishes on distraction and is found to be irregular on tremor analysis

4. a clearly identifiable underlying psychological conflict

5. remission after psychotherapy

Question 7

When can tremor be treated surgically?

1. When the patient is unwilling to take drugs to treat tremor.

2. When the patient is under 50 years old.

3. When the tremor cannot be adequately suppressed by drugs and there is no contraindication to surgery.

4. When the patient is willing to see a neurosurgeon once a week so that brain stimulation can be performed.

5. When the patient is willing to assume the cost of weekly battery changes.

Question 8

What must be borne in mind with respect to drug treatment for various tremor syndromes?

1. That the treatment is based on the clinical findings and not on the underlying disease causing tremor.

2. That causally directed treatment is generally possible only for drug-induced tremors or tremors due to metabolic disturbance.

3. That parkinsonian tremor responds best to anticholinergic drugs and does not respond at all to the classic dopamine preparations.

4. That the cerebellar tremor of multiple sclerosis is treated in exactly the same way as essential tremor.

5. That essential tremor is usually medically intractable.

Question 9

What drugs can induce tremor?

1. lithium, valproic acid, cyclosporine A

2. carbamazepine, propranolol, Seroxat

3. aspirin, diclofenac, paracetamol

4. penicillin, erythromycin, cephalosporin

5. antilipid drugs, antidiabetic drugs

Question 10

What is the drug, or drug class, of first choice for the treatment of parkinsonian tremor?

1. dopaminergic drugs

2. propanolol

3. primidone

4. gabapentin

5. ondansetron

References

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Parkinsonian tremor is a common symptom of Parkinson’s disease, although not all people with Parkinson’s disease have tremors.  Generally, symptoms include shaking in one or both hands at rest.  It may also affect the chin, lips, face, and legs.  The tremor may initially appear in only one limb or on just one side of the body.  As the disease progresses, it may spread to both sides of the body.  The tremor is often made worse by stress or strong emotions.  More than 25 percent of people with Parkinson’s disease also have an associated action tremor.

A tremor is an involuntary, uncontrollable muscle contraction, which manifests as shaking in body parts, most commonly the hands. About 70 percent of Parkinson’s disease patients experience tremors in the early stages of the disease. There are two types of tremors: Resting tremors and action tremors.

Causes of Parkinsonian Tremor

Generally, tremor is caused by a problem in the deep parts of the brain that control movements.  Most types of tremors have no known cause, although there are some forms that appear to be inherited and run in families.

Tremor can occur on its own or be a symptom associated with a number of neurological disorders, including

• Multiple sclerosis
• Stroke
• Traumatic brain injury
• Neurodegenerative diseases that affect parts of the brain (e.g.,  Parkinson’s disease).
• Neurologic disorders, including multiple sclerosis, Parkinson’s disease, stroke, and traumatic brain injury
• Certain medicines, such as asthma medicines, amphetamines, caffeine, corticosteroids, and medicines used for certain psychiatric and neurological disorders
• Alcohol use disorder or alcohol withdrawal
• Mercury poisoning
• Hyperthyroidism (overactive thyroid)
• Liver or kidney failure
• Anxiety or panic

Some other known causes can include

• the use of certain medicines (particular asthma medication, amphetamines, caffeine, corticosteroids, and drugs used for certain psychiatric and neurological disorders)
• alcohol abuse or withdrawal
• mercury poisoning
• overactive thyroid
• liver or kidney failure
• anxiety or panic.

Symptoms of Parkinsonian Tremor

Symptoms of tremor may include

• A tremor is involuntary, rhythmic contractions of various muscles. Shaky legs syndrome causes feelings of “vibration”, unsteadiness or imbalance in the legs.
• A rhythmic shaking in the hands, arms, head, legs, or torso
• Balance and muscle coordination problem
• Spasticity and muscle spasm with wasting
• Shaky voice
• Difficulty writing or drawing
• Problems holding and controlling utensils, such as a spoon.
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement
• Usually occur in the hands first, affecting one hand or both hands
• Can include a “yes-yes” or “no-no” motion of the head
• It May be aggravated by emotional stress, fatigue, caffeine, or temperature extremes
• Tremors that get worse during emotional stress
• Tremors that get worse when you move on purpose
• Tremors that lessen with rest
• Balance problems (in rare cases)

What we feel in both legs simultaneously is extreme straining, fatigue, unsteadiness, and a fear of falling. The muscles in our legs become hard, our ankles feel weak and our toes curl under as our legs fail to support us. We can stand for only a short period of time, in some cases only seconds. There is a feeling of panic to find a place to sit, or if possible, walk to gain some relief from our symptoms. Some tremors /shaky legs syndrome may be triggered by or become worse during times of stress or strong emotion, when an individual is physically exhausted, or when a person is in certain postures or makes certain movements.

Diagnosis of Parkinsonian Tremor

Medical history

During the physical evaluation, a doctor will assess the tremor based on:

• whether the tremor occurs when the muscles are at rest or inaction
• the location of the tremor on the body (and if it occurs on one or both sides of the body)
• the appearance of the tremor (tremor frequency and amplitude).

The doctor will also check other neurological findings such as impaired balance, speech abnormalities, or increased muscle stiffness.  Blood or urine tests can rule out metabolic causes such as thyroid malfunction and certain medications that can cause tremors/shaky legs syndrome.  These tests may also help to identify contributing causes such as drug interactions, chronic alcoholism, or other conditions or diseases.  Diagnostic imaging may help determine if the tremor is the result of damage to the brain.

Treatment of Parkinsonian Tremor

Non-pharmacological

• Physical, speech-language, and occupational therapy – may help to control tremors and meet daily challenges caused by the tremor.  A physical therapist can help people improve their muscle control, functioning, and strength through coordination, balancing, and other exercises.  Some therapists recommend the use of weights, splints, other adaptive equipment, and special plates and utensils for eating.  Speech-language pathologists can evaluate and treat speech, language, communication, and swallowing disorders.  Occupational therapists can teach individuals new ways of performing activities of daily living that may be affected by tremors.
• Eliminating or reducing tremor-inducing substances such as caffeine and other medication – (such as stimulants) can help improve tremor. Though small amounts of alcohol can improve tremors for some people, tremors can become worse once the effects of the alcohol wear off.
• Interventional Therapy – For patients who fail pharmacologic treatment with the above drugs or are unable to tolerate the side effects, surgical options include deep brain stimulation (DBS), focused ultrasound, or radio-surgical gamma knife thalamotomy to treat persistently disabling limb tremor, and botulinum toxin injections to treat persistently disabling head or vocal cord tremor.
• Deep-brain stimulation – This is the most common surgical treatment for essential tremors. Most series report 70% to 90% hand tremor control. In deep-brain stimulation, electrical stimulation is delivered to the brain through an electrode implanted deep into the ventral intermediate nucleus (VIM) of the thalamus. This is typically done by implanting 4 electrodes in the VIM using stereotactic methods. Computerized programming of the pulse generator is most commonly done with a handheld device after the patient leaves the hospital to optimize the electrode montage, voltage, pulse frequency, and pulse width. Deep-brain stimulation can be done unilaterally or bilaterally depending on the patient’s symptoms. There is an increased risk of speech and balance difficulties with bilateral procedures. If the tremor significantly affects both hands, the dominant hand is targeted, bilateral procedures may be considered.
• Focused ultrasound – Approved by the FDA in 2016, magnetic resonance imaging-guided, high-intensity, focused ultrasound thalamotomy is an innovative method for the treatment of essential tremors. Although it is transcranial and does not require an incision, skull penetration, or an implanted device, it is an invasive therapy that produces a permanent thalamic lesion.
• Radio-surgical gamma knife thalamotomy – Gamma-knife thalamotomy fo­cuses high-energy gamma rays on the ventral intermediate resulting in the death of neurons. It is an unproven treatment that has not generally been adopted due to concerns about potential radiation side effects, including a theoretical, long-term risk of secondary tumor formation.
• Ultrasound Therapy – A new treatment for essential tremors uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brain’s thalamus thought to be responsible for causing the tremors.  The treatment is approved only for those individuals with essential tremors who do not respond well to anticonvulsant or beta-blocking drugs.
• Biofeedback – is a mind-body technique that involves using visual or auditory feedback to teach people to recognize the physical signs and symptoms of stress and anxiety, such as increased heart rate, body temperature, and muscle tension.
• Relaxation techniques – can reduce stress symptoms and help you enjoy a better quality of life, especially if you have an illness. Explore relaxation techniques you can do by yourself.
• Learn to relax – Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors. Although you can’t eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques, such as massage or meditation.
• Noninvasive techniques – Include gait rehabilitation, visually guided techniques, tendon vibration, weighting extremities, positioning techniques, and manual techniques, all of which can be useful for the recovery of functional activities.[rx]
• Invasive techniques – Thalamic deep brain stimulation can alleviate the tremor in MS, providing better functional performance.[rx] Stereotactic radiosurgery thalamotomy at the nucleus ventralis intermedius with a median maximum dose of 140 Gy also provides good functional outcomes in patients with MS.[rx][rx] Radiofrequency thalamotomy had been successfully used in the past but has been replaced with the newer techniques of radiosurgery and deep brain stimulation as they had fewer adverse effects.
• Physical therapy – can help some patients control their tremors better, as can reducing the intake of substances such as caffeine, which can induce tremors. Many patients experience an increase in the severity of their tremors when they are stressed. Therefore, trying to reduce sources of anxiety and engaging in complementary therapies (such as yoga or aromatherapy) may help some patients.

For example, tremors due to thyroid hyperactivity will improve or even resolve (return to the normal state) with the treatment of thyroid malfunction.  Also, if the tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.

Medical Therapy

The therapeutic approach to essential tremors many times follows a trial and error approach, and patients should be challenged by several medications if the first choice is ineffective or associated with debilitating adverse effects. Medical therapy can be divided into first, second, and third-line therapies.

First-line therapy – It is either approved by the FDA or supported by double-blinded, placebo-controlled studies that meet the criteria for the class I evidence. This class of medications includes propranolol and primidone. If both primidone and propranolol are not effective alone, combinations of both may provide relief in selected patients.

Second-line therapy – Second-line therapy is supported by double-blinded, placebo-controlled trials that do not meet other requirements for the class I evidence studies. This includes gabapentin, pregabalin, topiramate, benzodiazepines (clonazepam, alprazolam), beta-blockers (atenolol and metoprolol) and zonisamide.

Third-line therapy – These therapies are based on open-label studies or case series. Drugs in this class include nimodipine and clozapine.

Medication

• Beta-blocking drugs such as propranolol are normally used to treat high blood pressure but they also help treat essential tremors.  Propranolol can also be used in some people with other types of action tremors.  Other beta-blockers that may be used include atenolol, metoprolol, nadolol, and sotalol.
• Anti-seizure medications such as primidone can be effective in people with essential tremors who do not respond to beta-blockers.  Other medications that may be prescribed include gabapentin and topiramate.  However, it is important to note that some anti-seizure medications can cause tremors.
• Tranquilizers (also known as benzodiazepines) such as alprazolam and clonazepam may temporarily help some people with tremors.  However, their use is limited due to unwanted side effects that include sleepiness, poor concentration, and poor coordination.  This can affect the ability of people to perform daily activities such as driving, school, and work.  Also, when taken regularly, tranquilizers can cause physical dependence and when stopped abruptly can cause several withdrawal symptoms.
• Parkinson’s disease medications (levodopa, carbidopa) are used to treat tremors associated with Parkinson’s disease.
• Botulinum toxin – injections can treat almost all types of tremors.  It is especially useful for head tremor, which generally does not respond to medications.  Botulinum toxin is widely used to control dystonic tremors.  Although botulinum toxin injections can improve tremors for roughly three months at a time, they can also cause muscle weakness.  While this treatment is effective and usually well tolerated for head tremors, botulinum toxin treatment in the hands can cause weakness in the fingers.  It can cause a hoarse voice and difficulty swallowing when used to treat voice tremors.

Additional drug therapies that have been used to treat individuals with primary orthostatic tremors include primidone (Mysoline), chlordiazepoxide (Librium), pregabalin (Lyrica), pramipexole (Mirapex), phenobarbital, and valproic acid (Depakote). Drugs commonly used to treat people with Parkinson’s disease (levodopa or pramipexole) may also be prescribed for individuals with primary orthostatic tremors.

Surgery

When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation (DBS) or very rarely, thalamotomy.  While DBS is usually well-tolerated, the most common side effects of tremor surgery include dysarthria (trouble speaking) and balance problems.

• Deep brain stimulation (DBS) – is the most common form of surgical treatment of tremors.  This method is preferred because it is effective, has low risk, and treats a broader range of symptoms than thalamotomy.  The treatment uses surgically implanted electrodes to send high-frequency electrical signals to the thalamus, the deep structure of the brain that coordinates and controls some involuntary movements.  A small pulse generating device placed under the skin in the upper chest (similar to a pacemaker) sends electrical stimuli to the brain and temporarily disables the tremor.  DBS is currently used to treat parkinsonian tremors, essential tremors, and dystonia.

• Thalamotomy – is a surgical procedure that involves the precise, permanent destruction of a tiny area in the thalamus.  Currently, surgery is replaced by radiofrequency ablation to treat severe tremors when deep brain surgery is contraindicated—meaning it is unwise as a treatment option or has undesirable side effects.  Radiofrequency ablation uses a radio wave to generate an electric current that heats up a nerve and disrupts its signaling ability for typically six or more months.  It is usually performed on only one side of the brain to improve tremors on the opposite side of the body.  Surgery on both sides is not recommended as it can cause problems with speech.
•  Stereotactic surgical techniques – can be used to create a lesion in the ventral intermediate (VIM) nucleus of the thalamus.

Rehabilitation

Exercise is an important part of healthy living for everyone. For people with tremors, exercise is more than healthy it is a vital component to maintaining balance, mobility, and activities of daily living. Exercise and physical activity can improve many tremors symptoms. These benefits are supported by research.

The tremors show that people with tremors who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.

What Type of Exercise Should I Do?

To help manage the symptoms of tremors, be sure your exercise program includes a few key ingredients:

• Aerobic activity
• Strength training
• Balance, agility, and multitasking
• Flexibility

These elements are included in many types of exercise. Biking, running, Tai chi, yoga, Pilates, dance, weight training, non-contact boxing, qi gong, and more — all have positive effects on tremors symptoms.

There is no “exercise prescription” that is right for every person with tremors. The type of exercise you do depends on your symptoms and challenges. For sedentary people, just getting up and moving is beneficial. More active people can build up to the regular, vigorous activity. Many approaches work well to help maintain and improve mobility, flexibility, and balance to ease non-motor tremors symptoms such as depression or constipation.

Researchers in the study did not distinguish between what type of exercise participants did and determined that all types of exercise are beneficial. The most important thing is to do the exercise regularly. We suggest finding an exercise you enjoy and stick with it.

Challenges to Exercising

• People in the early stages of tremors tend to be just as strong and physically fit as healthy individuals of the same age.
• Disease progression can lead to the following physical change:
• Loss of joint flexibility, which can affect balance.
• Decreased muscle strength or deconditioning can affect walking and the ability to stand up from sitting.
• The decline in cardiovascular conditioning, which affects endurance.

Tips for Getting Started

• First, be safe. Before starting an exercise program, consult your neurologist and primary care doctor about concerns and recommendations.
• Ask your doctor or members in your support group to refer to a physical therapist (PT) who knows about tremors. Work together to identify your concerns and limitations. Target exercises to improve them. For most people, a structured exercise program will include aerobic exercise (such as brisk walking) and resistance training (using weights or bands).
• Purchase a pedometer (step-counter) and figure out how many steps you take on average each day, then build up from there. Many smartphones or smartwatches have a built-in pedometer feature or an application that can be downloaded.
• Exercise indoors and outdoors. Change your routine to stay interested and motivated.
• Again, most importantly pick an exercise you enjoy.

What research is being done?

The mission is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.  The NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world.

Researchers are working to better understand the underlying brain functions that cause tremors, identify the genetic factors that make individuals more susceptible to the disorder, and develop new and better treatment options.

• Brain functioning – It can be difficult to distinguish between movement disorders such as Parkinson’s disease and essential tremor. These debilitating movement disorders have different prognoses and can respond very differently to available therapies. NINDS researchers are working to identify structural and functional changes in the brain using non-invasive neuroimaging techniques to develop sensitive and specific markers for each of these diseases and then track how they change as each disease progresses. Other researchers are using functional magnetic resonance imaging technology to better understand normal and diseased brain circuit functions and associated motor behaviors.  Scientists hope to design therapies that can restore normal brain circuit function in diseases such as Parkinson’s disease and tremor.
• Genetics – Research has shown that essential tremors may have a strong genetic component affecting multiple generations of families.  NINDS researchers are building on previous genetics work to identify susceptibility genes for familial early-onset (before age 40) essential tremor.  Researchers are focusing on multigenerational, early-onset families to better detect linkages.

Additionally, NINDS scientists are researching the impact of genetic abnormalities on the development of essential tremors.  Previous research that has shown a link between essential tremor and possible genetic variants on chromosome 6 and 11; ongoing research is targeting the impact of other genetic variations in families.

Medications and other treatment methods

While drugs can be effective for some people, approximately 50 percent of individuals do not respond to medication.  In order to develop assistive and rehabilitative tremor-suppressing devices for people with essential tremors, researchers are exploring where and how to minimize or suppress tremors while still allowing for voluntary movements.

Many people with essential tremors respond to ethanol (alcohol); however, it is not clear why or how.  NINDS researchers are studying the impact of ethanol on tremors to determine the correct dosage amount and its physiological impact on the brain and whether other medications without the side effects of ethanol can be effective.

Other NIH researchers hope to identify the source of essential tremors, study the effects of currently available tremor-suppressant drugs on the brain, and develop more targeted and effective therapies.

FAQ

Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

Which of the following constellations of clinical findings is typical of tremor in patients with Parkinson’s disease?

1. bilateral postural tremor

2. unilateral rest tremor and diminished ipsilateral arm swing while walking

3. severe unilateral tremor while holding a cup or glass

4. tremor that only appears when the patient writes

5. postural tremor of both hands and ataxic gait

Question 2

A 25-year-old man has a mild postural tremor of both hands that improves when he drinks alcohol. His mother had the same condition. What can you advise him?

1. He should definitely be evaluated for possible early Parkinson’s disease.

2. He must get treatment now, as otherwise the condition could worsen.

3. If treatment is indicated, propranolol or primidone could be given.

4. Relaxation exercises and physiotherapy are effective treatment options.

5. Genetic testing is needed to confirm the diagnosis of essential tremor.

Question 3

A man who received the diagnosis of multiple sclerosis two years ago presents to you with the new onset of tremor. What constellation of clinical findings is typical of tremor due to multiple sclerosis?

1. rest tremor, only occasionally observable when the patient is excited

2. a tremor that appears sometimes on the left side, sometimes on the right

3. a tremor that is only present in the morning

4. a swaying, broad-based gait and an intention tremor

5. a postural tremor that is easily suppressed by voluntary effort

Question 4

A 55-year-old man with essential tremor says that he can no longer feed himself because of tremor, can dress himself only with great difficulty, and has not had legible handwriting for many years. Drug treatment as recommended in the relevant clinical guidelines brings only slight improvement. What can you advise the patient about the option of surgical treatment?

1. Deep brain stimulation (DBS) might help but is not available in Germany.

2. DBS is an experimental technique that is only performed in clinical trials.

3. DBS is indicated only to treat Parkinson’s disease and plays no role in the treatment of essential tremor.

4. DBS has a high chance of success in this situation; it is now established as a standard treatment for essential tremor.

5. DBS is no more effective than pharmacotherapy for this indication.

Question 5

What information is most important for the diagnostic classification of a tremor syndrome?

1. the clinical findings

2. brain magnetic resonance imaging (MRI) with fine cerebellar sections

3. nuclear-medical visualization of brain perfusion

4. ultrasonography of the basal ganglia

5. measurement of serum drug levels

Question 6

What findings indicate that tremor may be psychogenic?

1. no evidence of essential tremor or Parkinson’s disease on brain MRI

2. a longstanding marital conflict

3. a tremor of inconstant location that diminishes on distraction and is found to be irregular on tremor analysis

4. a clearly identifiable underlying psychological conflict

5. remission after psychotherapy

Question 7

When can tremor be treated surgically?

1. When the patient is unwilling to take drugs to treat tremor.

2. When the patient is under 50 years old.

3. When the tremor cannot be adequately suppressed by drugs and there is no contraindication to surgery.

4. When the patient is willing to see a neurosurgeon once a week so that brain stimulation can be performed.

5. When the patient is willing to assume the cost of weekly battery changes.

Question 8

What must be borne in mind with respect to drug treatment for various tremor syndromes?

1. That the treatment is based on the clinical findings and not on the underlying disease causing tremor.

2. That causally directed treatment is generally possible only for drug-induced tremors or tremors due to metabolic disturbance.

3. That parkinsonian tremor responds best to anticholinergic drugs and does not respond at all to the classic dopamine preparations.

4. That the cerebellar tremor of multiple sclerosis is treated in exactly the same way as essential tremor.

5. That essential tremor is usually medically intractable.

Question 9

What drugs can induce tremor?

1. lithium, valproic acid, cyclosporine A

2. carbamazepine, propranolol, Seroxat

3. aspirin, diclofenac, paracetamol

4. penicillin, erythromycin, cephalosporin

5. antilipid drugs, antidiabetic drugs

Question 10

What is the drug, or drug class, of first choice for the treatment of parkinsonian tremor?

1. dopaminergic drugs

2. propanolol

3. primidone

4. gabapentin

5. ondansetron

References

People Also Reading

Tremor – Causes, Symptoms, Diagnosis, Treatment Orthostatic Tremor – Causes, Symptoms, Diagnosis, Treatment Resting Tremor – Causes, Symptoms, Diagnosis, Treatment Enhanced Physiological Tremor – Causes, Symptoms, Treatment Idiopathic Orthostatic Tremor – Causes, Symptoms, Treatment Primary Orthostatic Tremor – Causes, Symptoms, Treatment Functional Tremor – Causes, Symptoms, Treatment Psychogenic Tremor – Causes, Symptoms, Treatment Postural Tremor – Causes, Symptoms, Treatment Kinetic Tremor – Causes, Symptoms, Treatment Dystonic Tremor – Causes, Symptoms, Treatment Essential Tremor – Causes, Symptoms, Treatment

Idiopathic Orthostatic Tremor, also known as Orthostatic Tremor (OT), is a progressive neurological movement disorder, characterized by high-frequency tremors, predominantly in the legs when in a standing position, and an immediate sense of instability.

The term “orthostatic tremor” (OT), also known as “shaky legs syndrome”^[rx] was first coined in 1984 by Heilman,^[rx] although the earlier descriptions of this entity date back to 1970 when Pazzaglia et al.^[rx] reported on three patients with a peculiar disorder only occurring on standing.

Orthostatic tremor (OT) is a rare disorder characterized by tremor and a feeling of unsteadiness while standing that resolves upon walking or sitting. A pathognomonic 13-18 Hz tremor is seen on surface EMG while standing. Though its clinical features have been better defined over time, much of its pathophysiology remains unknown and treatment options are limited. We review here recent developments in both of these areas.

Another Name

• Shaky legs syndrome
• Idiopathic orthostatic tremor

Causes of Idiopathic Orthostatic Tremor

Generally, tremor is caused by a problem in the deep parts of the brain that control movements.  Most types of tremors have no known cause, although there are some forms that appear to be inherited and run in families.

Tremor can occur on its own or be a symptom associated with a number of neurological disorders, including:

• Multiple sclerosis
• Stroke
• Traumatic brain injury
• Neurodegenerative diseases that affect parts of the brain (e.g.,  Parkinson’s disease).
• Neurologic disorders, including multiple sclerosis, Parkinson’s disease, stroke, and traumatic brain injury
• Certain medicines, such as asthma medicines, amphetamines, caffeine, corticosteroids, and medicines used for certain psychiatric and neurological disorders
• Alcohol use disorder or alcohol withdrawal
• Mercury poisoning
• Hyperthyroidism (overactive thyroid)
• Liver or kidney failure
• Anxiety or panic

Some other known causes can include:

• the use of certain medicines (particular asthma medication, amphetamines, caffeine, corticosteroids, and drugs used for certain psychiatric and neurological disorders)
• alcohol abuse or withdrawal
• mercury poisoning
• overactive thyroid
• liver or kidney failure
• anxiety or panic.

Symptoms of Idiopathic Orthostatic Tremor

Symptoms of tremor may include

•  A tremor is involuntary, rhythmic contractions of various muscles. Orthostatic tremor causes feelings of “vibration”, unsteadiness or imbalance in the legs.
• A rhythmic shaking in the hands, arms, head, legs, or torso
• Balance and muscle coordination problem
• Spasticity and muscle spasm with wasting
• Shaky voice
• Difficulty writing or drawing
• Problems holding and controlling utensils, such as a spoon.
• Begin gradually, usually more prominently on one side of the body
• Worsen with movement
• Usually occur in the hands first, affecting one hand or both hands
• Can include a “yes-yes” or “no-no” motion of the head
• It May be aggravated by emotional stress, fatigue, caffeine, or temperature extremes
• Tremors that get worse during emotional stress
• Tremors that get worse when you move on purpose
• Tremors that lessen with rest
• Balance problems (in rare cases)

What we feel in both legs simultaneously is extreme straining, fatigue, unsteadiness, and a fear of falling. The muscles in our legs become hard, our ankles feel weak and our toes curl under as our legs fail to support us. We can stand for only a short period of time, in some cases only seconds. There is a feeling of panic to find a place to sit, or if possible, walk to gain some relief from our symptoms. Some tremors may be triggered by or become worse during times of stress or strong emotion, when an individual is physically exhausted, or when a person is in certain postures or makes certain movements.

Diagnosis of Idiopathic Orthostatic Tremor

Medical history

During the physical evaluation, a doctor will assess the tremor based on:

• whether the tremor occurs when the muscles are at rest or inaction
• the location of the tremor on the body (and if it occurs on one or both sides of the body)
• the appearance of the tremor (tremor frequency and amplitude).

The doctor will also check other neurological findings such as impaired balance, speech abnormalities, or increased muscle stiffness.  Blood or urine tests can rule out metabolic causes such as thyroid malfunction and certain medications that can cause tremors.  These tests may also help to identify contributing causes such as drug interactions, chronic alcoholism, or other conditions or diseases.  Diagnostic imaging may help determine if the tremor is the result of damage to the brain.

Treatment of Idiopathic Orthostatic Tremor

Non-pharmacological

• Physical, speech-language, and occupational therapy – may help to control tremors and meet daily challenges caused by the tremor.  A physical therapist can help people improve their muscle control, functioning, and strength through coordination, balancing, and other exercises.  Some therapists recommend the use of weights, splints, other adaptive equipment, and special plates and utensils for eating.  Speech-language pathologists can evaluate and treat speech, language, communication, and swallowing disorders.  Occupational therapists can teach individuals new ways of performing activities of daily living that may be affected by tremors.
• Eliminating or reducing tremor-inducing substances such as caffeine and other medication – (such as stimulants) can help improve tremor. Though small amounts of alcohol can improve tremors for some people, tremors can become worse once the effects of the alcohol wear off.
• Interventional Therapy – For patients who fail pharmacologic treatment with the above drugs or are unable to tolerate the side effects, surgical options include deep brain stimulation (DBS), focused ultrasound, or radio-surgical gamma knife thalamotomy to treat persistently disabling limb tremor, and botulinum toxin injections to treat persistently disabling head or vocal cord tremor.
• Deep-brain stimulation – This is the most common surgical treatment for essential tremors. Most series report 70% to 90% hand tremor control. In deep-brain stimulation, electrical stimulation is delivered to the brain through an electrode implanted deep into the ventral intermediate nucleus (VIM) of the thalamus. This is typically done by implanting 4 electrodes in the VIM using stereotactic methods. Computerized programming of the pulse generator is most commonly done with a handheld device after the patient leaves the hospital to optimize the electrode montage, voltage, pulse frequency, and pulse width. Deep-brain stimulation can be done unilaterally or bilaterally depending on the patient’s symptoms. There is an increased risk of speech and balance difficulties with bilateral procedures. If the tremor significantly affects both hands, the dominant hand is targeted, bilateral procedures may be considered.
• Focused ultrasound – Approved by the FDA in 2016, magnetic resonance imaging-guided, high-intensity, focused ultrasound thalamotomy is an innovative method for the treatment of essential tremors. Although it is transcranial and does not require an incision, skull penetration, or an implanted device, it is an invasive therapy that produces a permanent thalamic lesion.
• Radio-surgical gamma knife thalamotomy – Gamma-knife thalamotomy fo­cuses high-energy gamma rays on the ventral intermediate resulting in the death of neurons. It is an unproven treatment that has not generally been adopted due to concerns about potential radiation side effects, including a theoretical, long-term risk of secondary tumor formation.
• Ultrasound Therapy – A new treatment for essential tremors uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brain’s thalamus thought to be responsible for causing the tremors.  The treatment is approved only for those individuals with essential tremors who do not respond well to anticonvulsant or beta-blocking drugs.
• Biofeedback – is a mind-body technique that involves using visual or auditory feedback to teach people to recognize the physical signs and symptoms of stress and anxiety, such as increased heart rate, body temperature, and muscle tension.
• Relaxation techniques – can reduce stress symptoms and help you enjoy a better quality of life, especially if you have an illness. Explore relaxation techniques you can do by yourself.
• Learn to relax – Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors. Although you can’t eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques, such as massage or meditation.
• Noninvasive techniques – Include gait rehabilitation, visually guided techniques, tendon vibration, weighting extremities, positioning techniques, and manual techniques, all of which can be useful for the recovery of functional activities.[rx]
• Invasive techniques – Thalamic deep brain stimulation can alleviate the tremor in MS, providing better functional performance.[rx] Stereotactic radiosurgery thalamotomy at the nucleus ventralis intermedius with a median maximum dose of 140 Gy also provides good functional outcomes in patients with MS.[rx][rx] Radiofrequency thalamotomy had been successfully used in the past but has been replaced with the newer techniques of radiosurgery and deep brain stimulation as they had fewer adverse effects.
• Physical therapy – Physical therapy may help strengthen your muscles and improve your coordination. The use of wrist weights and adaptive devices, such as heavier utensils, may also help relieve tremors.

For example, tremors due to thyroid hyperactivity will improve or even resolve (return to the normal state) with the treatment of thyroid malfunction.  Also, if the tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.

Medical Therapy

The therapeutic approach to essential tremors many times follows a trial and error approach, and patients should be challenged by several medications if the first choice is ineffective or associated with debilitating adverse effects. Medical therapy can be divided into first, second, and third-line therapies.

First-line therapy – It is either approved by the FDA or supported by double-blinded, placebo-controlled studies that meet the criteria for the class I evidence. This class of medications includes propranolol and primidone. If both primidone and propranolol are not effective alone, combinations of both may provide relief in selected patients.

Second-line therapy – Second-line therapy is supported by double-blinded, placebo-controlled trials that do not meet other requirements for the class I evidence studies. This includes gabapentin, pregabalin, topiramate, benzodiazepines (clonazepam, alprazolam), beta-blockers (atenolol and metoprolol) and zonisamide.

Third-line therapy – These therapies are based on open-label studies or case series. Drugs in this class include nimodipine and clozapine.

Medication

• Beta-blocking drugs such as propranolol are normally used to treat high blood pressure but they also help treat essential tremors.  Propranolol can also be used in some people with other types of action tremors.  Other beta-blockers that may be used include atenolol, metoprolol, nadolol, and sotalol.
• Anti-seizure medications such as primidone can be effective in people with essential tremors who do not respond to beta-blockers.  Other medications that may be prescribed include gabapentin and topiramate.  However, it is important to note that some anti-seizure medications can cause tremors.
• Tranquilizers (also known as benzodiazepines) such as alprazolam and clonazepam may temporarily help some people with tremors.  However, their use is limited due to unwanted side effects that include sleepiness, poor concentration, and poor coordination.  This can affect the ability of people to perform daily activities such as driving, school, and work.  Also, when taken regularly, tranquilizers can cause physical dependence and when stopped abruptly can cause several withdrawal symptoms.
• Parkinson’s disease medications (levodopa, carbidopa) are used to treat tremors associated with Parkinson’s disease.
• Botulinum toxin – injections can treat almost all types of tremors.  It is especially useful for head tremor, which generally does not respond to medications.  Botulinum toxin is widely used to control dystonic tremors.  Although botulinum toxin injections can improve tremors for roughly three months at a time, they can also cause muscle weakness.  While this treatment is effective and usually well tolerated for head tremors, botulinum toxin treatment in the hands can cause weakness in the fingers.  It can cause a hoarse voice and difficulty swallowing when used to treat voice tremors.

Additional drug therapies that have been used to treat individuals with primary orthostatic tremors include primidone (Mysoline), chlordiazepoxide (Librium), pregabalin (Lyrica), pramipexole (Mirapex), phenobarbital, and valproic acid (Depakote). Drugs commonly used to treat people with Parkinson’s disease (levodopa or pramipexole) may also be prescribed for individuals with primary orthostatic tremors.

Surgery

When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation (DBS) or very rarely, thalamotomy.  While DBS is usually well-tolerated, the most common side effects of tremor surgery include dysarthria (trouble speaking) and balance problems.

• Deep brain stimulation (DBS) – is the most common form of surgical treatment of tremors.  This method is preferred because it is effective, has low risk, and treats a broader range of symptoms than thalamotomy.  The treatment uses surgically implanted electrodes to send high-frequency electrical signals to the thalamus, the deep structure of the brain that coordinates and controls some involuntary movements.  A small pulse generating device placed under the skin in the upper chest (similar to a pacemaker) sends electrical stimuli to the brain and temporarily disables the tremor.  DBS is currently used to treat parkinsonian tremors, essential tremors, and dystonia.

• Thalamotomy – is a surgical procedure that involves the precise, permanent destruction of a tiny area in the thalamus.  Currently, surgery is replaced by radiofrequency ablation to treat severe tremors when deep brain surgery is contraindicated—meaning it is unwise as a treatment option or has undesirable side effects.  Radiofrequency ablation uses a radio wave to generate an electric current that heats up a nerve and disrupts its signaling ability for typically six or more months.  It is usually performed on only one side of the brain to improve tremors on the opposite side of the body.  Surgery on both sides is not recommended as it can cause problems with speech.
•  Stereotactic surgical techniques – can be used to create a lesion in the ventral intermediate (VIM) nucleus of the thalamus.

Rehabilitation

Exercise is an important part of healthy living for everyone. For people with tremors, exercise is more than healthy it is a vital component to maintaining balance, mobility, and activities of daily living. Exercise and physical activity can improve many tremors symptoms. These benefits are supported by research.

The tremors show that people with tremors who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.

What Type of Exercise Should I Do?

To help manage the symptoms of tremors, be sure your exercise program includes a few key ingredients:

• Aerobic activity
• Strength training
• Balance, agility, and multitasking
• Flexibility

These elements are included in many types of exercise. Biking, running, Tai chi, yoga, Pilates, dance, weight training, non-contact boxing, qi gong, and more — all have positive effects on tremors symptoms.

There is no “exercise prescription” that is right for every person with tremors. The type of exercise you do depends on your symptoms and challenges. For sedentary people, just getting up and moving is beneficial. More active people can build up to the regular, vigorous activity. Many approaches work well to help maintain and improve mobility, flexibility, and balance to ease non-motor tremors symptoms such as depression or constipation.

Researchers in the study did not distinguish between what type of exercise participants did and determined that all types of exercise are beneficial. The most important thing is to do the exercise regularly. We suggest finding an exercise you enjoy and stick with it.

Challenges to Exercising

• People in the early stages of tremors tend to be just as strong and physically fit as healthy individuals of the same age.
• Disease progression can lead to the following physical change:
• Loss of joint flexibility, which can affect balance.
• Decreased muscle strength or deconditioning can affect walking and the ability to stand up from sitting.
• The decline in cardiovascular conditioning, which affects endurance.

Tips for Getting Started

• First, be safe. Before starting an exercise program, consult your neurologist and primary care doctor about concerns and recommendations.
• Ask your doctor or members in your support group to refer to a physical therapist (PT) who knows about tremors. Work together to identify your concerns and limitations. Target exercises to improve them. For most people, a structured exercise program will include aerobic exercise (such as brisk walking) and resistance training (using weights or bands).
• Purchase a pedometer (step-counter) and figure out how many steps you take on average each day, then build up from there. Many smartphones or smartwatches have a built-in pedometer feature or an application that can be downloaded.
• Exercise indoors and outdoors. Change your routine to stay interested and motivated.
• Again, most importantly pick an exercise you enjoy.

What research is being done?

The mission is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.  The NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world.

Researchers are working to better understand the underlying brain functions that cause tremors, identify the genetic factors that make individuals more susceptible to the disorder, and develop new and better treatment options.

• Brain functioning – It can be difficult to distinguish between movement disorders such as Parkinson’s disease and essential tremor. These debilitating movement disorders have different prognoses and can respond very differently to available therapies. NINDS researchers are working to identify structural and functional changes in the brain using non-invasive neuroimaging techniques to develop sensitive and specific markers for each of these diseases and then track how they change as each disease progresses. Other researchers are using functional magnetic resonance imaging technology to better understand normal and diseased brain circuit functions and associated motor behaviors.  Scientists hope to design therapies that can restore normal brain circuit function in diseases such as Parkinson’s disease and tremor.
• Genetics – Research has shown that essential tremors may have a strong genetic component affecting multiple generations of families.  NINDS researchers are building on previous genetics work to identify susceptibility genes for familial early-onset (before age 40) essential tremor.  Researchers are focusing on multigenerational, early-onset families to better detect linkages.

Additionally, NINDS scientists are researching the impact of genetic abnormalities on the development of essential tremors.  Previous research that has shown a link between essential tremor and possible genetic variants on chromosome 6 and 11; ongoing research is targeting the impact of other genetic variations in families.

Medications and other treatment methods

While drugs can be effective for some people, approximately 50 percent of individuals do not respond to medication.  In order to develop assistive and rehabilitative tremor-suppressing devices for people with essential tremors, researchers are exploring where and how to minimize or suppress tremors while still allowing for voluntary movements.

Many people with essential tremors respond to ethanol (alcohol); however, it is not clear why or how.  NINDS researchers are studying the impact of ethanol on tremors to determine the correct dosage amount and its physiological impact on the brain and whether other medications without the side effects of ethanol can be effective.

Other NIH researchers hope to identify the source of essential tremors, study the effects of currently available tremor-suppressant drugs on the brain, and develop more targeted and effective therapies.

FAQ

Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

Which of the following constellations of clinical findings is typical of tremor in patients with Parkinson’s disease?

1. bilateral postural tremor

2. unilateral rest tremor and diminished ipsilateral arm swing while walking

3. severe unilateral tremor while holding a cup or glass

4. tremor that only appears when the patient writes

5. postural tremor of both hands and ataxic gait