Tremor

Original Editor - Muskan Rastogi Top Contributors - Muskan Rastogi and Lucinda hampton

Introduction

Tremor assessment and management represents an important area of physiotherapy practice, particularly in neurological rehabilitation. Understanding the different types of tremors and their clinical presentations is essential for effective patient care. It is a Hyperkinetic Movement Disorder.

Classification of Tremors

Tremors are classified primarily based on when they occur:

Action Tremors:

• Postural tremor: Occurs when maintaining a position against gravity
• Kinetic tremor: Appears during voluntary movement
• Intention tremor: Increases as the limb approaches a target

Resting Tremor:

• Occurs when the body part is at rest and supported against gravity

Common Tremor Types

Essential Tremor typically presents as bilateral postural tremor of the hands (6-12 Hz frequency), which may progress to include kinetic and resting components.

Physiologic Tremor represents normal motor oscillations that can become enhanced by situational factors including excitement, fatigue, and caffeine consumption.

Rubral Tremor results from structural or functional abnormalities in the midbrain and thalamus.

Psychogenic Tremor has acute onset and is nonprogressive, associated with underlying psychiatric conditions.

Orthostatic Tremor specifically occurs when standing still and requires evaluation in this position.

Clinical Assessment

The examination should systematically evaluate tremor in multiple body regions:

• Head and neck (seated and lying positions)
• Jaw (mouth open and closed)
• Facial muscles (forehead, cheek)
• Chin and tongue
• Voice (during sustained phonation and speech)

Begin assessment with open-ended questions such as "Can you tell me about your tremor?" or "When do you notice tremor?" to gather initial information about the patient's experience.

Physiotherapy Management

Physiotherapy intervention for tremor focuses on:

• Strengthening affected muscles
• Improving balance and functional ability
• Enhancing independence in activities of daily living
• Functional training to compensate for movement limitations

Treatment approaches complement medical management, which may include medications, deep brain stimulation, focused ultrasound, and assistive devices. The physiotherapy approach emphasizes maximizing functional capacity and quality of life despite the presence of tremor.

Pathophysiology

Tremor's pathophysiology is still a debatable topic. The researchers have been unable to identify a particular cause for tremors due to the complex nature of the condition. A hypothesis given in a 2014 article the pathogenesis of both classic tremor and essential tremor is hypothesized to be caused by cerebello–thalamo– cortical network. The distinction appears to be in how this network is activated to oscillate.

1. In classic tremor, the setting is the stability of a body part where an abnormal beta rhythm synchronizes the basal ganglia and in a mechanism still to be elucidated triggers the cerebellar network.
2. In essential tremor, the irregularity appears to be in the cerebellar network itself, and dysfunction of the motor controller for generating an action sets off the oscillation.

Neurological Examination

A detailed and focused neurologic examination should be performed.

First, the healthcare professional should ask the patient to raise arms against gravity, with the palms down in front and then in the wing-beat position with the hands facing one another in the midline.

If a postural tremor is present during sustained arm extension, the examiner should assess the following:

• Is the tremor is regularly recurrent and oscillatory
• What all joints are involved (e.g., elbow, wrist, metacarpophalangeal joints) and in what directions (e.g., for the wrist, flexion-extension, pronation-supination)
• Is the tremor in each arm is synchronous with that of the other arm (i.e., in phase or out of phase)
• Is the tremor is of a reemergent quality (i.e., initially absent and the time it takes to emerge)

Next, the examiner should attempt to elicit kinetic tremor. Thus, the examiner may ask the patient to perform

The finger-nose-finger maneuver

• Pour water between cups
• Draw spirals
• Write a sentence.

Also, the examiner should assess the following items:

• Does the tremor have an intentional component (ie, does the tremor worsen as the limb approaches a target [eg, during the finger-nose-finger maneuver])?
• Are dystonic movements or postures present (eg, do some of the fingers flex, extend, or twist during the finger-nose-finger maneuver)?
• What is the relative severity of the kinetic tremor that is being observed to that which was observed during sustained posture (above)?

Further, the examiner should assess whether there is any tremor at rest in the patient’s arms or legs. Tremor at rest in the arms can be assessed while the patient is seated, standing, walking, and lying down. Resting tremor in the legs can be assessed while the patient is seated or lying down. In addition, tremor while standing (i.e., orthostatic tremor) may be assessed while the patient is standing in a stationary position.

Finally, the examiner may assess for tremor in the head (i.e., neck) (while the patient is seated and lying down), jaw (with the patient’s mouth closed and then with the mouth held open), facial muscles (e.g., forehead, cheek), chin, tongue, and voice (during sustained phonation and during speech).

Diagnosis

The history and physical examination are first used to establish whether the main type of tremor is an action tremor (i.e., postural, kinetic, or intention tremor) or a tremor at rest.

Medical Management

• Drug
• Beta blockers
• Anticonvulsants
• Antipsychotics
• Chemo denervation
• Deep brain stimulation
• Focused ultrasound
• Devices