Tremors are involuntary, rhythmic, oscillating movements of the reciprocal antagonistic muscle groups; typically these include hands, head, face, vocal cords, trunk or legs. The diagnosis is made clinically. Treatment depends avoidance of triggers of the origin and nature of tremor and can (physiological), propranolol or primidone (essential), physical Therapier (cerebellar), Levodopa (Parkinson’s disease) or deep brain stimulation contain (on disability leading and arzneimittelrefraktär).
Tremor may be
Tremors are involuntary, rhythmic, oscillating movements of the reciprocal antagonistic muscle groups; typically these include hands, head, face, vocal cords, trunk or legs. The diagnosis is made clinically. Treatment depends avoidance of triggers of the origin and nature of tremor and can (physiological), propranolol or primidone (essential), physical Therapier (cerebellar), Levodopa (Parkinson’s disease) or deep brain stimulation contain (on disability leading and arzneimittelrefraktär). Tremor may be normal (physiological) Pathological a physiological tremor, which is barely perceptible usually becomes apparent in many people with physical or mental stress. Tremors vary in appearance pattern (eg. B. intermittent, constant) severity of field (z. B. gradual, abrupt) not related to the severity of the underlying disease, the severity of tremor needs. An essential tremor z. B. i. Gen. viewed as benign and life expectancy should not shorten, but the symptoms can lead to disability. Pathophysiology Various lesions in the brain stem, cerebellum extrapyramidalem system or can cause tremors. Neuronal dysfunction or lesions that cause tremors may originate disease of injury, ischemia, metabolic disorders or neurodegenerative. Sometimes a tremor is familial (z. B. essential tremor). Classification The classification of tremors is primarily based on when it occurs: calm tremors can be seen at rest and occur when a body part is fully supported against gravity. Ruhenremores are minimal pronounced in activity or lacking. They occur with a frequency of 3-6 cycles / second (Hz). Action tremors are maximally pronounced when a body part is arbitrarily moved. Action tremors can, after a goal is reached, vary in severity or not; they can occur at very different frequencies, but always be <13 Hz. Among the action tremors include kinetic, intentional and postural tremors. Kinetic tremors appear in the final portion of a movement in the direction of a target; the amplitude is low. Intentional tremors occur during voluntary movement toward a goal, but throughout the entire movement, the amplitude is high and the frequency is low, with the tremor worsens when the target is reached (to watch the finger-to-nose test) ; the frequency is 3-10 Hz postural tremors are maximum pronounced when a limb is held in a fixed position against the force of gravity. (eg outstretched arms.); the frequency is 5-8 Hz. Sometimes they are modified by certain locations or activities that may indicate their origin, z. Example, a trigger dystonia tremor (dystonic tremor). Complex tremors may have components of more than one kind of tremor. A Tremor can also be classified according to whether he (stroke z. B.) occurs within the normal range (physiological tremor), as part of a primary disorder (essential tremor, MP) or as a result of a fault. Tremor will be described and the amplitude of the movement (fine or grobschlägig) is usually based on the oscillation frequency (fast or slow). Etiology Physiological tremor Physiological tremor occurs in otherwise healthy people. It is an action or postural tremor, which tends to affect both hands alike; the amplitude is feinschlägig generally. It is often only recognized when certain stressors are present. These stressors are anxiety fatigue lack of sleep withdrawal from alcohol or certain other substances that dampen the CNS (eg. As benzodiazepines, opioids) Certain diseases (eg. As Hperthyreose), unless they are symptomatic consumption of caffeine or recreational drugs such as cocaine, amphetamines or phencyclidine use of certain therapeutic drugs such as theophylline, ?-adrenergic agonists, corticosteroids and valproate Pathological (non-physiological) tremor There are many causes (see table: causes of tremors) that are commonly In action or postural tremor: essential tremor In resting tremor: MP In intentional tremor: dysfunction of the cerebellum (. eg by stroke, trauma or multiple sclerosis) causes of tremors Cause findings that indicate the fault diagnostic approach action tremor alcohol or drug / drug withdrawal (eg. B. benzodiazepines or opioids) agitation and fine tremor from 24-72 h after the final intake of alcohol or substance (eg. As a benzodiazepine) Sometimes, hypertension, tachycardia, fever, v. a. in hospitalized patients Clinical Evaluation substance induces substance use history of improvement of tremor after discontinuation of substance endocrine, metabolic and toxic abnormalities anoxic encephalopathy heavy metal poisoning Hepatic encephalopathy hyperparathyroidism hyperthyroidism hypoglycemia pheochromocytoma uremic encephalopathy tremor plus altered state of consciousness (indicates a encephalopathy out) and an obvious underlying disease (z. B. kidney or liver failure) Exophthalmos, hyperreflexia, tachycardia, heat intolerance (indicates a hyperthyroidism out) extreme, intractable hypertension (indicated on a pheochromocytoma out) TSH levels 24-hour urine collection for checking metanephrines and measuring the ammonia level, BUN (blood urea nitrogen) , glucose, calcium and PTH levels test for heavy metals essential tremor Step persistent coarse or feinschlägiger, slowly (4-8 Hz) tremor, usually symmetrical, relates both to both upper extremities and sometimes the head and the voice, especially in patients with tremor in the Familienanmnese Clinical evaluation of physiological tremor Feinschlägiger, faster (8-13 Hz) tremor that occurs in otherwise healthy people and can be improved by certain medications or circumstances (s. above) Typically, suppression of the tremor with low doses of alcohol and other depressants Clinical evaluation resting tremor substance-induced parkinsonism drug use history of improvement of tremor after discontinuation of the substance M. Parkinson Low-frequency (3-5 Hz) of alternating tremor, often of the thumb against the forefinger (pill turning ) but sometimes the chin or leg usually accompanying other symptoms like micrograph, bradykinesia (slow movement), cogwheel rigidity and shuffling gait often no family history of P Arkinson tremor and no removal of the alcohol by Tremors specific clinical criteria Good response to empirical test with dopaminergic drugs progressive supranuclear palsy tremor (sometimes grobschlägig or jerky) in middle-aged patients with supranuclear (v. a. vertical) View disorder, extrapyramidal symptoms and cognitive dysfunction specific clinical criteria intentional tremor cerebellar lesions abscess Friedreich's ataxia hemorrhage Multiple sclerosis Spinozerebellaäre degeneration stroke SHV tumor Low-frequency (<4 Hz) tremor, the side appears to be with ataxia, Dysmetria, Dysdiadochokinesie (inability usually rapid movement changes) and dysarthria in some patients with a family history of the disease (eg. as Friedreich's ataxia) MRI of the brain Substance induced history with drug / drug use, improvement of tremor after completion of the drug / drug use complexes tremors Holmes tremor (midbrain, nucleus-ruber-, Ruber- or thalamic tremor) irregular, low frequency (<4.5 Hz) tremor predominantly in the proximal extremities combination of a resting, postural tremor and intentional caused by means (e.g. brain lesions. As a result of stroke or multiple sclerosis) near the red nucleus Sometimes signs of ataxia and weakness MRI of the brain Neuropathic tremor Chronic recurrent polyneuropathy Guillain-Barre syndrome Diabetes IgM neuropathy type and frequency of the tremors variable, usually postural and intentional tremor Other symptoms in the affected limb peripheral neuropathy electromyography psychogenic tremor Sudden onset and / or spontaneous remission of complex mixed tremor with changing properties is determined by the attention ness of the patient amplified by distraction reduces Clinical Evaluation M. Wilson Variable tremor (usually in the proximal arm) in children or young adults, often with signs of liver failure, rigors, clumsy gait, dysarthria, inappropriate grin, increased salivation and neuropsychiatric signs 24- h urine to determine the copper mirror; Serum ceruloplasmin slit-lamp examination, to check for Kayser-Fleischer ring around the iris (caused by copper deposition) PTH = parathyroid hormone; SHV = traumatic brain injury; TSH = thyroid-stimulating hormone. Drug / drug (see Table: drug / drug-induced tremor causes, ordered by the type of tremor), various types of tremor cause or exacerbate. Low doses of some sedatives (. Eg alcohol), some tremors alleviate (eg essential and physiological tremor.); larger doses may cause tremors or trigger. Drug / drug-induced tremor causes, ordered by the type of tremor drug / drug Postural Tremor resting tremor (drug / arzneimtielinduzierter parkinsonism) intentional tremor amiodarone * ? ? amitriptyline * Amphotericin B ? ?-agonists (inhalation) * ? ? ? calcitonin caffeine * ? ? cimetidine Cocaine * ? ? ? * cyclosporine cytarabine ? ? ? adrenaline ethanol * ? ? ? haloperidol * ? ? ? ? ifosfamide interferon-alpha lithium ? ? ? ? * MDMA (Ecsta sy) ? ? ? medroxyprogesterone metoclopramide * ? ? mexiletine nicotine * ? Procainamide ? ? ? reserpine SSRI * ? ? ? ? tacrolimus tamoxifen Theophylline * ? ? ? * thioridazine thyroxine * ? ? ? * valproate Vidarabine ? * More frequent tremors cause. MDMA = methylenedioxymethamphetamine data from Morgan JC, Sethi KD: Drug-induced tremors. The Lancet Neurology 4: 866-876, 2005. Since the clarification of diagnosis tremor is largely made clinically, a careful history and physical examination are essential. History The history of the present illness should cover sharpness of the outbreak (z. B. gradually, abruptly) age at onset affected body parts e Provocative factors (eg. As exercise, rest, standing) Soothing or aggravating factors (eg., Alcohol, caffeine, stress, anxiety) abrupt onset, patients should be asked about potential triggering events (eg. as recent trauma or illness, use of a new drug). A review of organ systems should investigate symptoms of the causative diseases, including multiple episodic neurological problems: multiple sclerosis) Recently sudden onset of motor weakness, speech difficulties or dysarthria: Stroke confusion and fever: meningitis, encephalitis, or brain abscess or tumor muscle rigidity, gait and postural problems and slowness of movement: Parkinson's disease from other forms of parkinsonism weight loss, increased appetite, palpitations, diarrhea and heat intolerance: hyperthyroidism Sensory deficits: Peripheral neuropathy excitement and hallucinations: alcohol withdrawal or drug toxicity the medical history should cover the states with tremors associated resource (see table: causes of tremors). The family history should include questions about tremor in first-degree relatives. The medication profile should be checked for causative substances (see table: drug / drug-induced tremor causes, according to the type of tremor), and patients should specifically by caffeine and alcohol consumption and the use of recreational drugs (especially after the last interruption of revenue) asked werden.Körperliche examination A complete and comprehensive neurological examination is mandatory and should the evaluation of mental status, cranial nerves, motor and sensory function, gait, muscle stretch reflexes and cerebellar function (with observation of finger-nose, shin-heel and rapidly changing hand movements ) include. The examiner should test the muscles stiffness by moving the extremities of their range of motion. Vital signs should be checked for tachycardia, hypertension or fever. The general examination should each cachexia, psychomotor agitation and lack of facial expressions (which can display a bradykinesia) document. The thyroid should be keyed to nodules and enlargement, and all signs of exophthalmos or slowing of the eyelids should be noted. Focused investigation should note Frequency of tremor, while the affected body parts are at rest and fully supported (eg. As on the lap of the patient). The patient takes certain postures (for. Example the outstretched arms holding). The patient runs or performs tasks with the affected body part. The Untersuchuer should consider whether the tremors during mental distraction tasks (such as serial subtraction: 100 minus 7.) Changed. The quality of voice should be observed while the patient hält.Warnzeichen a long tone The following results are of particular importance: Abrupt onset start in people <50 years old and no family history of benign tremor Other neurological deficits (eg change in the mental. status, motor weakness, cranial nerve palsy, ataxic gait, dysarthria) tachycardia and restlessness interpretation of the findings Clinical findings contribute to the adoption of a cause (see table: causes of tremors). Art and the beginning of the Tremors are a useful guide: calm tremors usually show Parkinson's disease on, especially if they occur on one side or are limited to chin, voice or leg. Intentional tremors indicate a malfunction of the cerebellum, but they can also result from multiple sclerosis or M. Wilson. Postural tremor talks with gradual onset of a physiological or essential tremor; with sudden onset, he points to a toxic or metabolic disorder. Strong essential tremor is often confused with Parkinson's disease, but it can be distinguished as a rule based on specific characteristics (see Table: Characteristics for the differentiation of Parkinson's disease and essential tremor). Occasionally, the two syndromes overlap (mixture of essential tremor and Parkinson's disease). Features for the differentiation of Parkinson's disease and essential tremor characteristic of Parkinson's disease essential tremor kind of tremor resting tremor Postural and intentional tremor Age Advanced age (> 60 years) All ages family history Usually negative positive in> 60% of patients No alcohol benefits often advantageous onset of tremor on one side on both sides muscle stiffness Gear Normal facial expression Decreases normal gait Decreased arm swing Normal or slightly unequal weight latency of tremor longer (8-9 s) Less (1-2 s) The following findings may eventually help the cause to determine: A sudden onset is typical of psychogenic tremor. Stepwise progression suggests a ischemic vascular disease or multiple sclerosis include Develops tremor after the application of a new drug, this suggests that the drug is the cause. Sets of the tremor with restlessness, tachycardia and hypertension within 24-72 h after admission to a hospital one, which may indicate the withdrawal of alcohol, a sedative or an illegal substance. The transition is observed. Gait disturbance may indicate multiple sclerosis, stroke, Parkinson’s disease or a disorder of the cerebellum. The corridor is characteristically small steps and shuffling with Parkinson’s disease and spreading and ataxtisch at cerebellar disorders. The passage may have in patients with psychogenic tremor theatrical or inconsistent characteristics. In patients with essential tremor of transition is often normal, but the tandem transition (the heel of one foot touches the tip of the other) may be abnormal. A complex tremor, which decreases with mental distraction or the frequency of an arbitrary knock rhythm of a non-affected part of the body involving (the simultaneous maintenance of two different frequencies of voluntary movements in 2 different body parts is difficult) indicates a psychogenic Tremor.Tests In most patients are anamnesis and physical examination sufficient to identify the likely etiology. However, an MRI or CT scan of the brain should be performed when the start of the tremor is acute. The progression is very fast. indicate neurological signs of a stroke, a demyelinating disease or structural lesions. If the cause of the tremor is unclear (based on medical history and results of physical examination), the following is done: Thyroid-stimulating hormone (TSH) and thyroxine (T4) are measured to check whether hyperthyroidism is present. Ca and parathyroid hormone are measured in order to examine on hyperparathyroidism. Glucose is measured in order to avoid hypoglycaemia. In patients with toxic encephalopathy, the underlying disorder is usually readily apparent, but the determination of BUN (blood urea nitrogen) – and ammonia levels can help to confirm the diagnosis. The determination of free Metanephrine in plasma is indicated in patients with unexplained refractory hypertension; Serum-Coeruloplasmin und Kupferspiegel im Harn sollten gemessen werden bei Patienten < 40 Jahre und mit Tremor unklarer Genese (mit oder ohne Parkinsonismus) und ohne Familienanamnese mit benignem Tremor. Obwohl mit der Elektromyographie (EMG) ein echter Tremor von anderen Bewegungsstörungen (z. B. Myoklonus, Klonus, Epilepsia partialis continua) unterschieden werden kann, ist diese nur selten erforderlich. Allerdings kann ein EMG bei klinischem V. a. Neuropathie dazu beitragen, eine periphere Neuropathie als mögliche Ursache des Tremors zu identifizieren. Behandlung Physiologische Tremores Es ist keine Behandlung nötig, sofern die Symptome nicht stören. Das Vermeiden von Auslösern (wie Koffein, Müdigkeit, Schlafmangel, Drogen/Arzneimittel und, wenn möglich, Stress und Angst) kann helfen, die Symptome zu verhindern oder zu reduzieren. Ein durch Alkohol