Look at this patient's hands. Demonstrate tremors.


Patient 1

· Coarse resting tremor which is slow (4-6 per second).

· Adduction-abduction of the thumb with flexion-extension of fingers (pill-rolling movement).

· The tremor is halted by purposive movements of the hands. The upper limb tremor often increases as the patient walks.

Proceed as follows:

Tell the examiner that you would like to do the following:

· Look for cog-wheel rigidity.

· Comment on mask-like facies.

· Check gait for festinant gait.

· Ask the patient's relatives whether sleep relieves the tremor and whether emotion makes it worse.


This patient with resting tremor and mask-like facies (lesion) has Parkinson's disease (aetiology) and is severely disabled by the

tremor (functional status).

Patient 2

There is a 10-second physiological tremor which is brought on when the arms are outstretched. It can be amplified by laying a sheet

of paper on the hands.

Proceed as follows:

Tell the examiner that you would like to do the following:

· Check for thyrotoxicosis.

· Take a history for alcoholism.

· Take a drug history (salbutamol, terbutaline, lithium).

· Occupational history to mercury ('hatter's shakes').

* Know whether tremor runs in the family and is relieved by alcohol (benign essential tremor).


This patient has fine tremor with an enlarged thyroid gland (lesion), which could be due to hyperthyroidism (aetiology).

Patient 3

The patient does not have a resting tremor or a tremor with outstretched hands.

Proceed as follows:

· Check for past-pointing - the intention tremor of cerebellar disease.

· Tell the examiner that you would like to check for other cerebellar signs (see p. 144).


This patient has an intention tremor (lesion) due to cerebellar syndrome (aetiology).

Patient 4

· Unsteadiness when standing still; by contrast patient has little or no difficulty while walking, which relieves the symptoms.

. Fine rippling of the muscles of the legs may be seen or felt when the patient attempts to stand still; after a short interval the

patient becomes increasingly unsteady and is forced to take a step to regain balance.


This patient has primary orthostatic tremor (lesion).

Read this review on tremors: Med Clin North Am 1972; 56: 1363-75.


What are the tremors?

Involuntary movements that result from alternating contraction and relaxation of groups of muscles, producing rhythmic oscillations

about a joint or a group of joints.

How would you classify tremors?

· Resting tremor, as in Parkinson's disease.

· Pastural tremor (brought on when the arms are outstretched) due to the following: -exaggerated physiological tremor, caused

by anxiety, thyrotoxicosis, alcohol.


-brain damage seen in Wilson's disease, syphilis.

· Intention tremor (aggravated by voluntary movements) in cerebellar disease.

· Tremor due to neuropathy (pastural tremor; arms more than legs).

Mention a few involuntary movements.

· Chorea.

· Athetosis.

· Hemiballismus.

· Fasciculation.

· Torticollis.

· Clonus.

What are the causes of drug-associated tremors?

· Drug-induced tremors: beta-2 agonists (e.g. salbutamol), caffeine, theophylline, lithium, tricyclic antidepressants, 5-HT reuptake

inhibitors, neuroleptics, sodium valproate, corticosteroids.

· Tremors associated with drug withdrawal: alcohol (delirium tremens), benzodiazepines, barbiturates, opiates.


What do you know about the investigation and management of primary orthostatic tremor?

In primary orthostatic tremor:

· EMG shows rhythmic activation of lower limb muscles at a frequency of 4-18 Hz.

· Positron emission tomography shows increased activity in the cerebellum.

· Treatment is supportive; the patient is often relieved to know the diagnosis, especially when a psychiatric cause has been

suspected previously.

What is the treatment for tremor?

· Tremor due to Parkinson's disease: Levodopa, anticholinergic agents, dopamine agonists, or budipine. When all other types of

medication are not effective,

clozapineis often beneficial. More than 50% of patients respond to this treatment (N Engl J Med 2000; 342: 505).

· Essential tremor: Beta-blockers, primidone or both; 40-70% of these patients have some improvement with this treatment.

· Cerebellar tremor: No standard treatment; clonazepam is sometimes effective, as is treatment with levodopa, anticholinergic

agents or clozapine.

· Drug-resistant tremor: Thalamic stimulation (continuous deep-brain stimulation) and thalamotomy are equally effective, but

thalamic stimulation has fewer adverse effects and results in a greater improvement of function (N Engl J Med 2000; 342:


Mercury poisoning was known as 'hatter's shakes' because workers involved in the manufacture of felt hats were exposed to