Overview of tremor
- Daniel Tarsy, MD
Daniel Tarsy, MD
- Professor of Neurology
- Harvard Medical School
Tremor is defined as a rhythmic and oscillatory movement of a body part with a relatively constant frequency and variable amplitude. It is caused by either alternating or synchronous contractions of antagonistic muscles. Tremor is the most common of all movement disorders, occurring from time to time in most normal individuals in the form of exaggerated physiologic tremor .
This topic will cover the classification, clinical features, diagnostic evaluation, and treatment of tremor. The treatment of essential tremor (ET) is discussed separately. (See "Pharmacologic treatment of essential tremor" and "Surgical treatment of essential tremor".)
Tremors may be broadly classified into static and action tremors (table 1). Static tremors may be further divided into those occurring at rest (resting tremor) and those occurring with the head and limbs held in a fixed posture (postural tremor) (table 2 and table 3). Action tremors remain unchanged during the course of a voluntary movement, while intention tremors increase during the course of goal-directed movement. The term kinetic tremor has been used to designate action and intention tremor.
Parkinson disease (PD) and other parkinsonian syndromes are the most common causes of resting tremor. This tremor is evident with the affected body part supported and completely at rest and temporarily dampens or disappears during voluntary activity. Resting tremors usually fluctuate in amplitude and may appear and disappear depending upon the degree of patient repose, whether the patient feels he or she is under observation, and other unknown factors.
Resting tremor is typically less disabling than postural, action, or intention tremors because of its absence during voluntary activity. However, the tremor may quickly reappear as soon as the body part assumes a new resting posture and may therefore interfere with the use of eating utensils, handwriting, typing, and other purposeful postures or movements. In such cases, resting tremor is more of a handicap or disability than pure resting tremor, which is of greater cosmetic concern.
- Jankovic J, Fahn S. Physiologic and pathologic tremors. Diagnosis, mechanism, and management. Ann Intern Med 1980; 93:460.
- Cohen O, Pullman S, Jurewicz E, et al. Rest tremor in patients with essential tremor: prevalence, clinical correlates, and electrophysiologic characteristics. Arch Neurol 2003; 60:405.
- Schneider SA, Edwards MJ, Mir P, et al. Patients with adult-onset dystonic tremor resembling parkinsonian tremor have scans without evidence of dopaminergic deficit (SWEDDs). Mov Disord 2007; 22:2210.
- Louis ED, Ottman R, Hauser WA. How common is the most common adult movement disorder? estimates of the prevalence of essential tremor throughout the world. Mov Disord 1998; 13:5.
- Dogu O, Sevim S, Camdeviren H, et al. Prevalence of essential tremor: door-to-door neurologic exams in Mersin Province, Turkey. Neurology 2003; 61:1804.
- Benito-León J, Bermejo-Pareja F, Morales JM, et al. Prevalence of essential tremor in three elderly populations of central Spain. Mov Disord 2003; 18:389.
- Busenbark KL, Nash J, Nash S, et al. Is essential tremor benign? Neurology 1991; 41:1982.
- Benito-León J, Louis ED, Bermejo-Pareja F, Neurological Disorders in Central Spain Study Group. Risk of incident Parkinson's disease and parkinsonism in essential tremor: a population based study. J Neurol Neurosurg Psychiatry 2009; 80:423.
- Jasinska-Myga B, Wider C. Genetics of essential tremor. Parkinsonism Relat Disord 2012; 18 Suppl 1:S138.
- Merner ND, Girard SL, Catoire H, et al. Exome sequencing identifies FUS mutations as a cause of essential tremor. Am J Hum Genet 2012; 91:313.
- Gulcher JR, Jónsson P, Kong A, et al. Mapping of a familial essential tremor gene, FET1, to chromosome 3q13. Nat Genet 1997; 17:84.
- Higgins JJ, Loveless JM, Jankovic J, Patel PI. Evidence that a gene for essential tremor maps to chromosome 2p in four families. Mov Disord 1998; 13:972.
- Higgins JJ, Pho LT, Nee LE. A gene (ETM) for essential tremor maps to chromosome 2p22-p25. Mov Disord 1997; 12:859.
- Shatunov A, Sambuughin N, Jankovic J, et al. Genomewide scans in North American families reveal genetic linkage of essential tremor to a region on chromosome 6p23. Brain 2006; 129:2318.
- Kovach MJ, Ruiz J, Kimonis K, et al. Genetic heterogeneity in autosomal dominant essential tremor. Genet Med 2001; 3:197.
- Louis ED, Ford B, Frucht S, et al. Risk of tremor and impairment from tremor in relatives of patients with essential tremor: a community-based family study. Ann Neurol 2001; 49:761.
- Tanner CM, Goldman SM, Lyons KE, et al. Essential tremor in twins: an assessment of genetic vs environmental determinants of etiology. Neurology 2001; 57:1389.
- Stefansson H, Steinberg S, Petursson H, et al. Variant in the sequence of the LINGO1 gene confers risk of essential tremor. Nat Genet 2009; 41:277.
- Thier S, Lorenz D, Nothnagel M, et al. LINGO1 polymorphisms are associated with essential tremor in Europeans. Mov Disord 2010; 25:717.
- Jiménez-Jiménez FJ, García-Martín E, Lorenzo-Betancor O, et al. LINGO1 and risk for essential tremor: results of a meta-analysis of rs9652490 and rs11856808. J Neurol Sci 2012; 317:52.
- Thier S, Lorenz D, Nothnagel M, et al. Polymorphisms in the glial glutamate transporter SLC1A2 are associated with essential tremor. Neurology 2012; 79:243.
- Louis ED. Essential tremor: evolving clinicopathological concepts in an era of intensive post-mortem enquiry. Lancet Neurol 2010; 9:613.
- Louis ED, Faust PL, Vonsattel JP, et al. Neuropathological changes in essential tremor: 33 cases compared with 21 controls. Brain 2007; 130:3297.
- Shill HA, Adler CH, Sabbagh MN, et al. Pathologic findings in prospectively ascertained essential tremor subjects. Neurology 2008; 70:1452.
- Nicoletti G, Manners D, Novellino F, et al. Diffusion tensor MRI changes in cerebellar structures of patients with familial essential tremor. Neurology 2010; 74:988.
- Rajput AH, Robinson CA, Rajput ML, Rajput A. Cerebellar Purkinje cell loss is not pathognomonic of essential tremor. Parkinsonism Relat Disord 2011; 17:16.
- Jankovic J. Essential tremor: a heterogenous disorder. Mov Disord 2002; 17:638.
- Louis ED. Essential tremors: a family of neurodegenerative disorders? Arch Neurol 2009; 66:1202.
- Findley LJ, Koller WC. Essential tremor: a review. Neurology 1987; 37:1194.
- Louis ED, Dogu O. Isolated head tremor: part of the clinical spectrum of essential tremor? Data from population-based and clinic-based case samples. Mov Disord 2009; 24:2281.
- Lombardi WJ, Woolston DJ, Roberts JW, Gross RE. Cognitive deficits in patients with essential tremor. Neurology 2001; 57:785.
- Gasparini M, Bonifati V, Fabrizio E, et al. Frontal lobe dysfunction in essential tremor: a preliminary study. J Neurol 2001; 248:399.
- Benito-León J, Louis ED, Bermejo-Pareja F, Neurological Disorders in Central Spain (NEDICES) Study Group. Population-based case-control study of cognitive function in essential tremor. Neurology 2006; 66:69.
- Benito-León J, Louis ED, Sánchez-Ferro Á, Bermejo-Pareja F. Rate of cognitive decline during the premotor phase of essential tremor: a prospective study. Neurology 2013; 81:60.
- Benito-León J, Louis ED, Bermejo-Pareja F, Neurological Disorders in Central Spain Study Group. Elderly-onset essential tremor is associated with dementia. Neurology 2006; 66:1500.
- Thawani SP, Schupf N, Louis ED. Essential tremor is associated with dementia: prospective population-based study in New York. Neurology 2009; 73:621.
- Pahwa R, Koller WC. Is there a relationship between Parkinson's disease and essential tremor? Clin Neuropharmacol 1993; 16:30.
- Stolze H, Petersen G, Raethjen J, et al. The gait disorder of advanced essential tremor. Brain 2001; 124:2278.
- Bain PG, Findley LJ, Britton TC, et al. Primary writing tremor. Brain 1995; 118 ( Pt 6):1461.
- Papa SM, Gershanik OS. Orthostatic tremor: an essential tremor variant? Mov Disord 1988; 3:97.
- Heilman KM. Orthostatic tremor. Arch Neurol 1984; 41:880.
- Gerschlager W, Münchau A, Katzenschlager R, et al. Natural history and syndromic associations of orthostatic tremor: a review of 41 patients. Mov Disord 2004; 19:788.
- Mestre TA, Lang AE, Ferreira JJ, et al. Associated movement disorders in orthostatic tremor. J Neurol Neurosurg Psychiatry 2012; 83:725.
- Koller W, Lang A, Vetere-Overfield B, et al. Psychogenic tremors. Neurology 1989; 39:1094.
- Deuschl G, Köster B, Lücking CH, Scheidt C. Diagnostic and pathophysiological aspects of psychogenic tremors. Mov Disord 1998; 13:294.
- Louis ED. Clinical practice. Essential tremor. N Engl J Med 2001; 345:887.
- RESTING TREMOR
- Idiopathic Parkinson disease
- Tremor-dominant Parkinson disease
- Rubral tremor
- POSTURAL AND ACTION TREMORS
- Physiologic tremor
- Essential tremor
- - Clinical features of ET
- - Differential diagnosis of ET
- Primary writing tremor
- Orthostatic tremor
- Cerebellar tremors
- NEUROPATHIC TREMOR
- INTENTION TREMOR
- PSYCHOGENIC TREMOR
- Laboratory studies
- Enhanced physiologic tremor
- Rest tremor
- Cerebellar tremor
- Orthostatic tremor
- Essential tremor
- INFORMATION FOR PATIENTS