Tremor

Tremor may be defined as a rhythmic, mechanical oscillation of any functional body region. Although any movement is accompanied by a normal physiological tremor, we are usually concerned with pathological tremors (like the kinetic tremors) that affect the activities of daily living or produce an esthetic problem (like the rest tremor of Parkinson's disease).2,3

Resting tremor occurs in a body part that is not voluntarily activated and that is completely supported against gravity. Usually it occurs in a relaxed limb, and is one of the major symptoms observed in Parkinson's disease. Action tremor is any tremor occurring during a voluntary contraction of muscle. This includes postural, isometric and kinetic tremor. Kinetic tremor includes intention tremor. Postural tremor occurs while a subject voluntarily maintains a position against gravity. This type of tremor sometimes occurs also in Parkinson's disease, but has usually been described in essential or familial tremor and in upper midbrain or thalamic lesions. Variants of this type of tremor have been described and are usually position-specific or position-sensitive.

Tremor observed during target-oriented movements is called intentional tremor, and usually represents a disturbance of the cerebellum or its afferent or efferent pathways. Task-specific kinetic tremor may appear or become exacerbated during specific activities, e.g. writing tremor.

Tremor is usually increased in fatigue, weakness, anxiety, hypercapnia, drug and alcohol withdrawal, and some metabolic and endocrine syndrome (uremia, hypoglycemia, hepatic disease, thyro-toxicosis and heavy-metal intoxication). Some medications increase physiological tremor, e.g. amphetamines, valproic acid, theophyllines, lithium,

Table 33.1 Drug responsiveness of various basal ganglia diseases

Highly responsive

Poorly responsive

Parkinson's disease

Cerebellar tremor

Neuroleptic 'persistent' parkinsonism

Rubral tremor

DOPA-responsive dystonia

Writer's cramp

Paroxysmal hypnogenic dystonia

Palatal tremor (myoclonus)

Paroxysmal kinesigenic choreoathetosis/dystonia

Oromandibular dystonia

Neuroleptic-induced, acute dystonic reactions

Spasmodic dysphonia

Postanoxic action myoclonus

Blepharospasm

Restless leg syndrome

Striatonigral degeneration

Hereditary periodic ataxia

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