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Tremor is steady rhythmic, involuntary, purposeless, oscillating movement resulting from the alternate contraction of opposing groups of muscles. A patient's tremor should be carefully described and defined prior to treatment.
Tremor is a symptom, not a diagnosis. Correct diagnosis of the many tremulous syndromes may be difficult, but is very important for the selection of appropriate therapies.
An attempt should also be made to measure, record and grade tremor severity.
The classification of tremor agreed by the International Tremor Foundation, Tremor Investigation Group (TRIG) should be followed (see below). Although tremor may be physiological, there are many different pathological causes and the clinical differential diagnosis will determine the subsequent investigations and treatment pathway.
TRIG classification of tremor
Assessment of tremor
Treatment of tremor is usually aimed at restoring or improving quality of life. It is therefore important to be aware of the consequences of the tremor for the patient (e.g. diagnostic anxiety, social embarrassment) and the effects on their everyday life. The overall assessment of tremor severity should reflect these effects.
There is often no immediate need to start medication. Decisions should be made after discussions between the patient, their spouses or carer and the clinician about the degree of disability and the risks and benefits of starting drug therapy. If referral to a specialist is considered appropriate, it is preferable to delay starting treatment until they have been seen by the specialist.
In general, start only one new class of medication at a time. Dose titration should always be gradual - medication intended to alter nervous system neurotransmission should never be started or stopped suddenly. It may take three months or more on a therapeutic dose before the full symptomatic benefits become apparent.
Tremor is often refractory to treatment.
The commonest example of a rest tremor is that seen in Parkinson's disease.
Parkinsonian tremor should be treated as Parkinson's disease (see Parkinsonian Tremor section of Parkinson's disease guidance).
Essential tremor is the commonest example of an action tremor. Essential tremor is not uncommonly misdiagnosed as Parkinson's disease, but should also be distinguished from dystonic tremor.
Essential tremor is usually a postural tremor of 4-10Hz. In contrast to Parkinson's disease, it is a monosymptomatic disorder.
Alcohol in essential tremor
Dystonic tremor should be treated as for dystonia. Antimuscarinics or dopamine agonists may be helpful. Specialist referral to a dystonia clinic may be required for treatment with either Botulinum toxin type A or Botulinum toxin type B by intramuscular injection.