Tremor: Sorting Through the Differential Diagnosis

 

Am Fam Physician. 2018 Feb 1;97(3):180-186.

  Patient information: A handout on tremors, written by the authors of this article, is available.

Tremor is an involuntary, rhythmic, oscillatory movement of a body part. It is the most common movement disorder encountered in primary care. The diagnosis of tremor is based on clinical information obtained from the history and physical examination. The most common tremors in patients presenting to primary care physicians are enhanced physiologic tremor, essential tremor, and parkinsonian tremor. All persons have low-amplitude, high-frequency physiologic tremors at rest and during action that are not reported as symptomatic, but can be enhanced by anxiety, medication use, caffeine intake, or fatigue. Features consistent with psychogenic tremor are abrupt onset, spontaneous remission, changing tremor characteristics, and extinction with distraction. Other types of tremor include cerebellar, dystonic, and drug- or metabolic-induced. The first step in evaluating a patient with tremor is to categorize the tremor based on its activation condition, topographic distribution, and frequency. Resting tremors occur in a body part that is relaxed and completely supported against gravity. Action tremors occur with voluntary contraction of a muscle and can be further subdivided into postural, isometric, and kinetic tremors. The most common pathologic tremor is essential tremor, which affects 0.4% to 6% of the population. In one-half of cases, it is transmitted in an autosomal-dominant fashion. More than 70% of patients with Parkinson disease have tremor as the presenting feature. This tremor is typically unilateral, occurs at rest, and becomes less prominent with voluntary movement. If there is diagnostic uncertainty, single-photon emission computed tomography can be used to visualize the integrity of the dopaminergic pathways in the brain, and transcranial ultrasonography may be useful to diagnose Parkinson disease.

Tremor is an involuntary, rhythmic, oscillatory movement of a body part and is the most common movement disorder encountered in primary care practices.13 Aside from careful clinical examination and imaging when needed, there is no standard test to distinguish between common types of tremor, which can make the evaluation challenging. However, establishing the underlying cause is important because prognosis and specific treatment plans vary considerably. The most common tremors in patients presenting to primary care physicians are enhanced physiologic tremor, essential tremor, and parkinsonian tremor.1,36 All tremors are more common in older age.7

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A resting tremor is usually caused by parkinsonism.

C

1, 11

Patients with new-onset tremor should have a comprehensive review of medications (prescribed and over-the-counter), with specific attention to medications started before the onset of tremor.

C

8, 12, 13

The diagnosis of tremor is based on clinical information obtained from the history and physical examination.

C

2, 17

Tremor in children is potentially serious; patients should be promptly referred to a neurologist.

C

26, 27

In select cases when there is significant diagnostic uncertainty, single-photon emission computed tomography using ioflupane can be useful for distinguishing Parkinson disease from other tremor types.

C

29, 30, 32


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A resting tremor is usually caused by parkinsonism.

C

1, 11

Patients with new-onset tremor should have a comprehensive review of medications (prescribed and over-the-counter), with specific attention to medications started before the onset of tremor.

C

8, 12, 13

The diagnosis of tremor is based on clinical information obtained from the history and physical examination.

C

2, 17

Tremor in children is potentially serious; patients should be promptly referred to a neurologist.

C

26, 27

In select cases when there is significant diagnostic uncertainty, single-photon emission computed tomography using ioflupane can be useful for distinguishing Parkinson disease from other tremor types.

C

29, 30, 32


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

The Authors

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PAUL CRAWFORD, MD, is the program director of the Nellis Family Medicine Residency, Nellis Air Force Base, Nev., and a professor of family medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

ETHAN E. ZIMMERMAN, MD, is a faculty member at Nellis Family Medicine Residency and an assistant professor of family medicine at the Uniformed Services University of the Health Sciences.

Author disclosure: No relevant financial affiliations.

Address correspondence to Paul Crawford, MD, Mike O'Callaghan Military Medical Center, 4900 Las Vegas Blvd. N., Las Vegas, NV 89191 (e-mail: paul.f.crawford.mil@mail.mil). Reprints are not available from the authors.

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