Tremor differential diagnosis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]
Overview
Tremor must be differentiated from diseases that cause involuntary movement: myoclonus, clonus, asterixis, and epilepsia partialis continua. The cause of tremor must also be differentiated from other conditions that cause tremor: essential tremor, physiological tremor, Parkinson’s disease, cerebellar tremor, orthostatic tremor.
Differentiating Tremor from other Diseases
- Tremor must be differentiated from diseases that cause involuntary movement: [1]
- Myoclonus: Brief muscle twitches, limited to single limb or to adjacent parts.EEG shows association with spike-wave complexes.
- Clonus: Rhythmic movement aggravated by muscle stretching.
- Asterixis: On electromyographic, flapping/abduction of the upper extremities is indicated as prolong absence of EMG activity.
- Epilepsia partialis continua: Regular jerks of the arm/hand.
- Differentiating the cause of tremor from other diseases on the basis of the type of tremor, associated signs, and symptoms.[2][3][4]
| Common Cause of Tremor | Differentiating Feature of Tremor | Main Feature of Disease |
|---|---|---|
| Essential tremor | Postural Tremor – Frequency 4–12 Hz, Bilateral onset | gait ataxia, vestibulo-cerebellar involvement, reduced by alcohol, family history, stress/fatigue can increase tremor amplitude, increases with voluntary movements |
| Parkinson’s disease | Resting Tremor – Unilateral onset | Bradykinesia, micrographia, stooped posture, ataxia, rigidity, imbalance, depression, apathy, decreases with voluntary movements |
| Physiologic Tremor | Postural tremor – High frequency 8–10 Hz, low amplitude, irregular oscillations | Tremor occurs while maintaining a posture and mostly disappears if eyes are closed or a load is placed on the muscles. Subtle innate tremor normally present in the general population. |
| Enhanced Physiologic Tremor | Increased amplitude | Physiologic tremor enhanced due to fatigue, sleep deprivation, drugs, endocrine disorders, caffeine, stress. |
| Cerebellar Tremor | Intention tremor – Low frequency <4 Hz | Occurs in multiple sclerosis, stroke, brainstem tumor, or cerebellar trauma. May feature ataxia, dysmetria, dysdiadochokinesia, and dysarthria. |
| Drug Induced Tremor | Can enhance rest, action, postural tremors | Amiodarone, bronchodilators, lithium, metoclopramide, neuroleptics, theophylline, valproate |
| Orthostatic Tremor | Essential tremor variant, high frequency 14 Hz-18 Hz | Occurs in the legs on standing and is relieved by sitting down |
| Holmes tremor | Combination of rest, action, and postural tremors, Frequency 2Hz-5Hz | Mostly due to vascular lesion in mesencephalic, thalamic or both regions. |
References
- ↑ Bhidayasiri R (2005). “Differential diagnosis of common tremor syndromes”. Postgrad Med J. 81 (962): 756–62. doi:10.1136/pgmj.2005.032979. PMC 1743400. PMID 16344298.
- ↑ Deuschl G, Elble R (2009). “Essential tremor–neurodegenerative or nondegenerative disease towards a working definition of ET”. Mov Disord. 24 (14): 2033–41. doi:10.1002/mds.22755. PMID 19750493.
- ↑ Smaga S (2003). “Tremor”. Am Fam Physician. 68 (8): 1545–52. PMID 14596441.
- ↑ Crawford P, Zimmerman EE (2011). “Differentiation and diagnosis of tremor”. Am Fam Physician. 83 (6): 697–702. PMID 21404980.
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