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Patient education: Tremor (Beyond the Basics)

Patient education: Tremor (Beyond the Basics)
Literature review current through: Jan 2024.
This topic last updated: May 25, 2023.

TREMOR OVERVIEW — Tremor is the repetitive, involuntary shaking of a body part, most commonly the hands or head. It can be a disorder in its own right, or it can be a sign of another health problem.

There are several different types of tremor, all of which fall into one of the following categories.

Rest tremors — Rest tremors happen while you are sitting or lying down and relaxed. People who have a rest tremor can usually stop the tremor by deliberately moving the affected body part.

Action tremors — Action tremors occur with voluntary muscle contraction. This category is further divided as follows:

Kinetic tremor — This type of tremor happens when you are doing a goal-directed activity, such as writing or drinking from a cup. "Simple kinetic tremor" remains constant throughout the action. "Intention tremor" gets worse gradually as you get closer to your target (eg, whatever you are reaching for with your arm).

Postural tremor — Postural tremor happens when you try to hold a body part still, against the force of gravity. For example, your arms might shake if you hold them out in front of you.

Isometric tremor — This type of tremor happens when you contract a muscle against an unmoving object, for example, pushing against a wall or making a fist.

Functional tremor — Functional tremor can combine features of rest, postural, and action tremors. Unlike other kinds of tremor, functional tremor has no known medical cause and is thought to be a manifestation of recognized or sometimes unrecognized stress. This kind of tremor usually gets less severe if you are distracted while your doctor examines you, for example, if he or she asks you to do something else with another part of your body (such as tap the fingers of your opposite hand). Other types of tremor tend to get worse with distraction.

Doctors use the term "tremor syndromes" to describe specific combinations of signs and symptoms that often happen together. They also define tremor syndromes as isolated, meaning that tremor is the only neurologic symptom, or combined, in which other neurologic problems are also present. Learning what type of tremor you have is the first step in discovering the cause of your tremor and its potential treatment. The different categories of tremor usually have very different causes.

More detailed information about tremor is available by subscription. (See "Overview of tremor" and "Essential tremor: Treatment and prognosis" and "Surgical treatment of essential tremor".)

MOST COMMON CAUSES OF REST TREMOR

Parkinson disease — The most common cause of rest tremor is Parkinson disease. If that is the cause of your tremor, your healthcare provider will probably focus on treating the Parkinson disease in the hopes that doing so will also alleviate the tremor.

In a few instances, people with Parkinson disease who have a rest tremor also have an action tremor. A detailed discussion of the treatment options for Parkinson disease appears elsewhere. (See "Patient education: Parkinson disease treatment options — medications (Beyond the Basics)".)

Other causes — Other possible causes of rest tremor include:

Rubral tremor, caused by conditions that damage part of the brainstem

Dystonia, a neurologic disorder causing twisting movements and abnormal postures (see "Etiology, clinical features, and diagnostic evaluation of dystonia")

Wilson disease, a rare inherited disease that causes copper to build up in the body (see "Wilson disease: Clinical manifestations, diagnosis, and natural history")

MOST COMMON CAUSES OF ACTION TREMOR

Physiologic tremor — Everyone, even people who are healthy, has a little bit of shaking of the hands, especially when performing precise tasks, like threading a needle or focusing a camera. This type of shaking, known as physiologic tremor, is not usually noticeable because it is so mild that it is not visible under normal circumstances.

Under some circumstances, physiologic tremor becomes exaggerated and therefore visible. Common causes of this exaggeration include:

Certain medications, such as those used to treat asthma or other breathing problems, steroids (glucocorticoids), and some drugs used to treat neurologic or psychiatric disorders

Stimulants, such as caffeine and nicotine

Anxiety, excitement, fear, and other extreme emotions

Muscle fatigue, which can happen after a challenging workout

Alcohol or drug withdrawal

Overactive thyroid (hyperthyroidism)

Fever

Physiologic tremors caused by problems such as those listed above usually go away when the underlying cause is addressed. If the physiologic tremor is caused by a medication, it may not be possible to eliminate the medication, but it may be possible to switch the medication or to lower the dose. Always talk to your doctor first before changing the way you take a medication that has been prescribed for you.

Essential tremor — Essential tremor (ET) is a neurologic disorder that causes action tremor. ET may be hard to diagnose in people who have prominent physiologic tremor, because the differences between them can be small. Scientists do not understand what causes ET, but they do know that it can be passed on within families. Sometimes, ET is referred to as "familial" tremor.

ET can start at any time in life, sometimes as early as childhood. More commonly, ET becomes noticeable in the young adult or later years. The tremor tends to affect the hands and arms and can affect one side (left or right) more than the other.

People who have ET usually shake when they try to hold their arms outstretched and still. They also tend to shake when they are doing a goal-directed movement, such as writing, drinking from a glass of water, or touching their nose with their finger. In fact, the shaking tends to get worse as the person is about to reach his or her goal.

ET always affects the hands, but sometimes also affects the head, resulting in a repeated "yes-yes" nod or a repeated "no-no" headshake. Shaking in the head may start before or after the hand shaking starts. People with ET may also notice shaking in their voice, legs, or upper body.

In the past, ET was referred to as a "benign" tremor because it may not affect your ability to perform daily tasks. However, we now know ET can be severe enough in some people that it causes a serious limitation in lifestyle.

Other causes — Other possible causes of action tremors include:

Cerebellar tremor, caused by damage to a part of the brain called the cerebellum or the pathways that connect to it; patients with multiple sclerosis, brainstem trauma, and stroke may experience this tremor

Primary writing tremor, which occurs exclusively while writing and not during other voluntary movements

Orthostatic tremor, which is limited to the legs and occurs only while standing

Disorders affecting the nerves outside the brain that control muscle movement

People with anxiety and other psychologic problems may experience an enhanced physiologic tremor, which can be difficult to distinguish from ET

TREMOR DIAGNOSIS — To determine what type of tremor you have and what might be causing it, your healthcare provider will need to ask you a list of detailed questions about your tremor. Your provider will probably ask:

Does your tremor happen when you are resting, when you stand still, when you hold your arms outstretched, or when you are moving?

Are there activities or circumstances that make the tremor better or worse?

Which body parts are affected? Are the left and right side equally affected?

When did the tremor start? Did the start time coincide with any other symptoms, starting new medications, or any injuries or illnesses?

Does drinking alcohol affect the severity of your tremor? (Some types of tremor, particularly essential tremor [ET], improve temporarily with alcohol.)

Your description of the tremor and your healthcare provider's observations of the tremor hold the most important clues about your condition. Your healthcare provider may recommend a brain scan or blood tests to pursue the diagnosis, especially if the cause of the tremor is not due to Parkinson disease or ET.

Even though these tests can provide helpful clues, ultimately, your healthcare provider must rely on old-fashioned medical sleuthing and skilled observation. That's why it's so important that you share as many details of your story as possible, even if they seem unimportant to you.

During the examination, your healthcare provider may ask you to stand and hold your arms outstretched, or ask you to do other things that might elicit or worsen the tremor. For instance, he or she may ask you to touch your nose with one finger, or to show a sample of your handwriting. Seeing how the tremor changes under these circumstances can help determine what the cause of your tremor might be.

Lab tests — Because tremor is sometimes caused by another medical problem, your healthcare provider may recommend tests to check for one or more of those conditions. For example, he or she may order:

Blood tests to measure thyroid hormone levels or to check for copper or other metals in the blood

Brain scans to exclude tumors, strokes, or other types of brain damage

TREMOR TREATMENT — If a tremor is caused by another medical problem, treating that problem (whenever it can be treated) sometimes helps alleviate the tremor, too. For example, people whose tremor is caused by excess thyroid hormone often stop shaking when their hormone levels are restored to normal.

Likewise, people whose tremor is caused by Parkinson disease sometimes improve when they begin treatment for the disease. (See "Patient education: Parkinson disease treatment options — medications (Beyond the Basics)".)

Essential tremor — Essential tremor (ET) occurs on its own and cannot be explained by other underlying health problems. Even so, treatments for ET exist. In particular, the beta blocker propranolol (sample brand names: Inderal, InnoPran XL) and the barbiturate primidone (brand name: Mysoline) may be effective in reducing ET. (See "Essential tremor: Treatment and prognosis".)

If medications do not work well enough and the tremor is severe and disabling, a neurosurgical procedure called deep brain stimulation may be an option. This treatment requires surgery to place small electrical stimulators into the brain. Magnetic resonance guided focused ultrasound is a newer treatment for ET that, unlike deep brain stimulation, does not require brain surgery. (See "Surgical treatment of essential tremor".)

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Tremor (The Basics)
Patient education: Myoclonus (The Basics)
Patient education: Fragile X syndrome (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Parkinson disease treatment options — medications (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Etiology, clinical features, and diagnostic evaluation of dystonia
Clinical manifestations of Parkinson disease
Diagnosis and differential diagnosis of Parkinson disease
Overview of tremor
Essential tremor: Treatment and prognosis
Surgical treatment of essential tremor
Wilson disease: Clinical manifestations, diagnosis, and natural history

The following organizations also provide reliable health information.

US National Library of Medicine

     (www.medlineplus.gov/tremor.html)

The International Essential Tremor Foundation

     (www.essentialtremor.org)

National Institute of Neurological Disorders and Stroke

     (www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Tremor-Fact-Sheet)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Daniel Tarsy, MD, who contributed to earlier versions of this topic review.

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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