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Tremor

Defined as a more or less involuntary and rhythmic oscillatory movement produced by alternating or irregularly synchronous contractions of reciprocally innervated muscles.

It rhythmic quality distinguishes tremor from other involuntary movements, and the involvement of agonist and antagonistic muscles distinguishes it from clonus.

Involuntary

Defined as a more or less —— and rhythmic oscillatory movement produced by alternating or irregularly synchronous contractions of reciprocally innervated muscles.

Rhythmic quality, Agonist and Antagonistic muscles

It —— distinguishes tremor from other involuntary movements, and the involvement of — and — distinguishes it from clonus.

(1) rhythmicity,

(2) amplitude,

(3) frequency,

(4) relation to movement, postural set, and relaxation

What are the 4 ways to characterize a tremor? 

Normal Tremors

Normal phenomenon;

Present in all contracting muscle groups

Persists throughout the waking state and even in certain phases of sleep.

Movement is so fine, barely seen by the naked eye, and then only if the fingers are firmly outstretched

It ranges in frequency between 8 and 13 Hz (average=10 Hz) in adulthood and somewhat less in childhood and old age.

Enhanced Physiologic Tremor

Same fast frequency as physiologic tremor (about 10 Hz) but with a greater amplitude

Best elicited by holding the arms outstretched with fingers spread apart

Seen in:

• fright and anxiety,

▪ certain metabolic disturbances (hyperthyroidism,

hypercortisolism, hypoglycemia),

▪ Pheochromocytoma,

▪ Intense Physical exertion

Withdrawal from alcohol and other sedative drugs, and the toxic effects of several drugs—lithium, nicotinic acid, xanthines (coffee, tea, aminophylline, colas), and corticosteroids

Abnormal Tremor 

Preferentially affects certain muscle groups—the distal parts of the limbs (especially the fingers and hands); less often, the proximal parts; the head, tongue, jaw, or vocal cords; and rarely the trunk—and is present only in the waking state.

The rate in most forms is from 4 to 7 Hz, or about half that of physiologic tremor.

Distal parts of the limbs, Present only in the waking state

Preferentially affects certain muscle groups—the — (especially the fingers and hands); less often, the proximal parts; the head, tongue, jaw, or vocal cords; and rarely the trunk—and is ——-

Familial Hereditary Tremor

Essential Familial Tremor is AKA what?

Essental Familial Tremor

Peaks in childhood and at > 35 years old

This is the most common type of tremor

Lower frequency (4 to 8 Hz)

Worsens with age

Greatly interferes with normal activities

The identifying feature is its appearance or marked enhancement with attempts to maintain a static limb posture.

Worsened by emotion, exercise,and fatigue.

Maintain a static limb posture

The identifying feature is its appearance or marked enhancement with attempts to ——

Physiologic (enhanced)

Frequency: 8-13

Predominant Locations: Hands

Enhancing Agents: Epinephrine, Beta-adrenergics

Attenuating Agents: Alcohol, Beta-adrenergic antagonists

Parkinson (rest)

Frequency: 3-5

Predominant Locations: Hands, forearms, fingers, feet, lips, tongue

Enhancing Agents: Emotional stress

Attenuating Agents:  L-DOPA, anticholinergics

Cerebellar (intention, ataxic “rubral”)

Frequency: 2-4

Predominant Locations: Limbs, trunk, head

Enhancing Agents: Emotional stress

Attenuating Agents: Alcohol

Postural or action

Frequency: 5-8

Predominant Locations: Hands

Enhancing Agents: Anxiety, fright,  Alcohol withdrawal, Beta-adrenergic, xanthines, lithium, exercise, fatigue

Attenuating Agents: B-adrenergic antagonists in some cases

Essential (familial, senile)

Frequency: 4-8

Predominant Locations: Hands, head, vocal cords

Enhancing Agents: Anxiety, fright,  Alcohol withdrawal, Beta-adrenergic, xanthines, lithium, exercise, fatigue

Attenuating Agents: Alcohol, propanolol, primidone

Alternate beat

Frequency: 3.5-6

Predominant Locations: Hands, head

Enhancing Agents: Anxiety, fright,  Alcohol withdrawal, Beta-adrenergic, xanthines, lithium, exercise, fatigue

Attenuating Agents: Clonazepam, alcohol, B-adrenergic antagonists

Orthostatic

Frequency: 4-8, irregular

Predominant Locations: Legs

Enhancing Agents: Quiet Standing

Attenuating Agents: Repose, walking

Tremor of Neuropathy

Frequency: 4-7

Predominant Locations: Hands

Enhancing Agents: —-

Attenuating Agents: Clonazepam, valproate

“Palatal-myoclonus”

Frequency: 60-100/min

Predominant Locations: Palate, sometimes facial, pharyngeal, proximal limb muscles

Enhancing Agents: —-

Attenuating Agents: Clonazepam, valproate

Alcohol Withdrawal Tremor

The most prominent feature of the alcohol withdrawal syndrome is a special type of action tremor closely related to enhanced physiologic tremor.

Parkinsonian Rest Tremor

• Coarse, rhythmic tremor with a frequency of 3 to 5 Hz

• Characterized by bursts of activity that alternate between opposing muscle groups.

• Localized in one or both hands and forearms and less frequently in the feet, jaw, lips, or tongue

• Flexion-extension or abduction-adduction of the fingers or the hand (pill-rolling tremor) pronation-supination of the hand and forearm

Intention Tremor (Ataxic Tremor)

• Ambiguous term because tremor itself is not intentional and does not occur when the patient intends to make a movement

• Occurs only during the most demanding phases of active performance

• Action tremor (kinetic tremor)

• Always combined with cerebellar ataxia and adds to it

• Salient feature is that it requires for its full expression the performance of an exacting, precise, projected movement. (Finger-to-nose test)

Dystonic Tremor

• Also difficult to classify but not to be overlooked are tremors that are intermixed with dystonia.

• Tend to be focal in the neck, which is typically rotated slightly to one side, or they may be evident in one dystonic hand.

• The tremor is not entirely rhythmic, sometimes jerky, and often intermittent

PRIMARY ORTHOSTATIC TREMOR

This is a rare tremor isolated to the legs that is remarkable by its occurrence only during quiet standing and its cessation almost immediately on walking.

HYSTERICAL TREMOR

Tremor is a relatively rare but quite dramatic manifestation of hysteria

Geniospasm

• A strongly familial episodic tremor disorder of the chin and lower lip that begins in childhood and may worsen with age

• Psychic stress and concentration are known to precipitate the movements

DYSTONIA (TORSION SPASM)

• It is manifested as an attitude or posture in one or other of the extremes of athetoid movement, with a predilection for muscles of the trunk and limb girdles and a tendency to persist

• A manifestation of heredodegenerative diseases

• Affects facial, oromandibular, tongue, cervical and hand muscles

Chorea

Abrupt spasmodic, irregular movement of short duration involving the fingers, hands, arms, face, tongue or head

Sydenham’s Chorea & Huntington’s Chorea

Two types of Chorea?

Sydenham’s Chorea

a neurological manifestation of rheumatic fever in which anti-streptococcal antibodies cross react with neuronal tissue in the basal ganglia

Huntington’s Chorea

emotional depression, irritability, apathy, slow progressive dementia, with athetosis, rigidity, and bradykinesia

ATHETOSIS

• Irregular, slow, sinuous movements involving the hands and fingers

• Also seen in biochemical disorders of genetic origin e.g,. Aminoaciduria, PKU, lipidoses and leukodystrophies, Lesch Nyhan syndrome (purine metabolism), and Wilson disease (Copper metabolism)

Choreoathetosis

• A neurological condition characterized by a combination of involuntary, purposeless movements: rapid, jerky "chorea" and slow, writhing "athetosis".

• These movements can affect the fingers, toes, face, and limbs and are caused by various disorders affecting the basal ganglia, such as stroke, drug toxicity, or metabolic conditions.

Hereditary and Acquired

Two types of Choreoathetosis?

Hereditary Choreoathetosis

1. Huntington’s Disease

2. Familial Paroxysmal Choreoathetosis

3. Wilson's Disease (Hepatolenticular degeneration)

4. Lesch Nyhan Syndrome

5. Hallevorden-Spatz Syndrome

6. Familial Calcification of the Basal Ganglia

Acquired Choreoathetosis

1. Infarction of the caudate nucleus of the putamen

2. Drug induced – lithium, phenytoin, carbamazepine,

amphetamines

Clonus

Refers to a series of rhythmic, uniphasic (unidirectional contractions) and relaxations of a group of muscles, thus differing from tremors, which are diphasic (bidirectional) and involve both agonist and antagonist muscles

Myoclonus

• Specifies the arrhythmic, shock like contractions of muscle groups almost always asynchronous and asymmetric on the two sides of the body

• Very brief lasts for 50 to 100 ms

Asterixis

• Consists essentially of arrhythmic lapses of sustained posture.

• These sudden interruptions in sustained muscular contraction allow gravity or the inherent elasticity of muscles to produce a movement, which the patient then corrects, sometimes with overshoot.

BLEPHAROSPASM

Involuntary blinking or spams of the orbicularis oculi muscle

MYOKIMIA

• An involuntary eyelid muscle contraction, typically involving the lower eyelid, less often the upper eyelid.

• The condition occurs and disappears spontaneously, but can sometimes last up to three weeks.

• Excess caffeine, high levels of anxiety, fatigue, stress, overwork, and a lack of sleep, drugs and alcohol may also be involved.

Epilepsia partialis continua

a special type of clonus , series of rhythmic monophasic contractions without spreading

POLYMYOCLONUS

Widespread lightning-like arrhythmic contractions of muscles in many parts of the body