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Updated: Dec 19 2021

Essential Tremor

  • Snapshot
    • A 62-year-old man reports involuntary shaking of both his hands, arms, and head. The hand shaking appears to worsen with writing, eating, or drinking from a cup. During periods of stress, his shakes worsens. He has noticed that drinking wine improves his symptoms. Family history is significant for his father also having similar symptoms. On physical examination, there is a 4-10 Hz tremor elicited when both of his arms are outstretched forward. There is no tremor at rest.
  • Introduction
    • Definition
      • a type of rhythmic oscillatory movement that occurs with posturing and action
    • Associated conditions
      • worsens with stress
      • improve with alcohol intake
  • Epidemiology
    • Incidence
      • 0.3-5.6% in the general population
    • Demographics
      • affects males and females equally
      • mean age is 35-45 years of age and incidence increases with age
    • Location
      • bilateral hands and arm
      • head
      • larynx
    • Risk factors
      • family history
      • aging
  • Pathophysiology
    • Unknown
  • Presentation
    • Symptoms
      • worsening tremor with posturing and voluntary movement
        • worsens with stress and voluntary movement
        • improves with alcohol and rest
    • Physical exam
      • rhythmic and oscillatory movement that most commonly affects the hands and arms
        • can be asymmetric
        • may also affect the head and voice
  • Studies
    • Diagnostic criteria
      • clinical diagnosis
  • Differential
    • Parkinsonian tremor
      • these patients are expected to have a tremor at rest
    • Physiologic tremor 
      • low amplitude tremor that worsens with movement, associated with increased sympathetic tone (e.g., anxiety, caffeine, hyperthyroidism)
    • Physiologic tremor
    • Dystonic tremor
    • Cerebellar tremor
      • most often presents as an intention tremor
    • Drug-induced tremor
  • Treatment
    • Medical
      • propranolol
        • indication
          • considered first-line treatment for essential tremor
        • asthma is contraindication to propranolol use
      • primidone
        • indication
          • considered first-line treatment for essential tremor
    • Operative
      • deep brain stimulation
        • indication
          • in patients unresponsive to treatment
        • technique
          • electrodes placed within the ventral intermediate nucleus of the thalamus
  • Complications
    • Complications
      • can be a disabling disorder that may negatively affect quality of life
  • Prognosis
    • A progressive disorder
    • No spontaneous remissions
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Private Note

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