tremor

This article deals with tremor in terms of muscle tremors; for further meanings see under tremor (disambiguation) . Furthermore, “trembling” is used here, for further meanings see under trembling .

As tremor ( latin tremor "trembling") or ( colloquially ) tremor - more precisely (the) muscle tremors - the involuntary, repetitive rhythmically is contracting each other counteracting muscle groups, respectively. The so-called physiological tremor of healthy people is measurable, but hardly visible. Clearly visible tremor can appear as a symptom of various diseases.

Tremors differ according to the part of the body affected, frequency, strength, cause and occurrence. In some cases, the tremor can appear in isolation ( essential tremor ) without being considered a symptom of an illness.

Physiological tremor

The physiological tremor is involved in every muscle movement of a healthy person, in its nature high-frequency and with a low amplitude, which makes it imperceptible and invisible to the eye during short and demanding movements. However, this can be made visible, for example, by stretching out the index finger and paying attention to its tip. The physiological tremor becomes clear when it is cold or under stress, as its amplitude then increases.

The movements of the tremor generate heat necessary for survival in endothermic animals, including humans. Z. For example, if the human body temperature is below 33 ° C, there is a risk of hypothermia . In general, C body temperature starts at 35 °, the involuntary trembling to increase body heat ( shivering ); this tremor is inevitably associated with increasing energy consumption in the organism.

The exact mechanisms and causes of physiological tremors are still debated in the neurosciences.

The physiological tremor is relevant in sport shooting; so alcohol was designated as the target water and was consumed to increase accuracy. Whether alcohol actually increases the accuracy noticeably is questioned today and was already controversial at the beginning of the 20th century. Alcohol is listed as an illegal doping substance in archery.

Diagnosis of pathological tremor

Tremor analysis in Parkinson's disease: antagonist tremor, frequency 6.5 Hz (surface EMG)

If a tremor occurs, complex differential diagnostics are usually necessary in order to either find or rule out an underlying disease. First, the appearance, location and strength of the tremor can be determined in a direct examination. At the same time, the attending physician must examine the patient for further neurological abnormalities and investigate the medical history.

Thereafter, the tremor can be recorded more precisely in terms of medical equipment using an EMG lead; Since the muscle activity in the affected region can be made visible, the frequency of the tremor can be precisely determined. The frequency also allows conclusions to be drawn about a possible cause, since different diseases tend to produce certain frequencies. Thereafter, clinical pictures must be excluded or checked: Wilson's disease through a blood and urine test as well as an ophthalmological check for the presence of a Kayser-Fleischer corneal ring . Parkinson's disease can be checked with the administration of L-Dopa . Brain damage or tumors appear on an MRI , multiple sclerosis appears by examining the CSF after a lumbar puncture . Essential tremor can usually be tapped by the administration of alcohol and questions about genetic predisposition (previous family illnesses).

A tremor caused by brain damage (stroke, tumor, trauma) is called symptomatic tremor.

Tremor types; the manifestations of the tremor

There are different types of tremor that can accompany different illnesses. The various tremors differ, for example, in the frequencies and the conditions under which the tremor is activated - at rest, in action, when holding, with non-directed or targeted movements.

When classifying tremors, there are a wide variety of classification variants, some purely descriptive, others based on pathophysiological mechanisms. But none of the current classification schemes can be used to diagnose tremor. In addition, there are often similarities in the presentation of the tremor for different causes, which makes differential diagnosis difficult. The problem with the classification by etiology is that one sometimes does not know the cause (e.g. essential tremor). In addition, one clinical picture can cause several types of tremors. No single tremor type can be pathognomically assigned to a disease.

Action tremor

According to the definition, an action tremor occurs (only) with voluntary movements. A distinction is made between four different types of action tremor:

• Movement tremor (kinetic tremor): Movement tremor occurs when the patient moves the affected extremities , but without a targeted, precise intention, for example by moving the hands horizontally in front of him.
• Holding tremor (postural tremor): The holding tremor appears under pure gravity loading, i.e. when the patient stretches and holds his hands forward.
• Intention tremor ( goal movement tremor): An intention tremor occurs with a goal-oriented movement, for example the pointing of a finger to a certain point. As the goal gets closer, the intention tremor increases.
• Isometric tremor: Isometric tremor occurs with voluntary muscle contraction without any movement effect (such as when the fist is firmly closed or when you press against the wall).

Other types of tremors that are occasionally also listed as action tremors in the literature:

• Task-specific tremor: occurs e.g. B. when writing or other fine motor skills.
  • Writing tremor: tremor that occurs while writing and can be severely impairing even if it is not as severe.
  • Orthostatic tremor: occurs while standing upright; trembling of the legs. Trembling imperceptible if it is mild.
  • Voice tremor (vocal or laryngeal tremor): Oscillating voice tremor that can be heard when speaking.

Resting tremor

This form appears when the affected parts of the patient are at rest, e.g. B. Hands resting quietly on a surface. It is possible that the resting tremor occurs after taking the rest position and then disappears after a while, cf. Parkinson's Remor . Most often, the tremor occurs in the upper extremities. Depending on the clinical picture, the tremor only appears in certain situations. It is possible that a patient has only one or two of the possible characteristics.

Other types of tremors that occur at rest and that do not depend solely on voluntary movement to occur:

• Head tremor (titubation): Involuntary “shaking” of the head, horizontal or vertical direction.
• Wing flapping tremor: Low-frequency, high-amplitude rhythmic movement of both bent arms.
• Trunk tremor (axial tremor or titubation): Tremor of the trunk
• Hand tremor: Tremor that manifests itself dominantly on the hands.
• Pill-rolling tremor: Hand tremor that is pronounced in the fingers and is similar to the pill-rolling or the rhythmic opening and closing of the hand.
• Orolingual tremor: tremor of the chin, tongue, pharynx and (parts of) the face.
• Palatal tremor (soft palate tremor, soft palate myoclonus, soft palate nystagmus): Rhythmic, involuntary movement of the soft palate.
• Chin tremor: trembling of the chin (and lower lip).

Other tremor-like symptoms, the occurrence of which does not depend solely on voluntary movement, but which are often not classified as tremor in the literature:

• Flutter tremor ( Asterixis ): The flutter tremor is particularly noticeable in the hold attempt. There is a sudden loss of holding tone, followed by a reflex corrective movement.
• Clonus : Involuntary, rhythmic contractions of muscles or muscle groups; similar to the Asterixis.
• Nystagmus , ocular tremor and superior oblique myokymia : tremor affecting the eyes resp. Eye muscles.
• Chills : Serious, severe tremor. Causes: sunstroke, infection, sepsis.

Tremor frequency, amplitude and location

The tremor frequency depends on the respective muscle systems and possibly on the clinical pictures. One differentiates:

• low frequency tremor; 4 Hz or less (often gross tremor)
• medium frequency tremor; 4-7 Hz
• high frequency tremor; 7–15 Hz (often fine-pitched tremor)

The amplitude is classified as follows:

• fine-hit tremor
• moderate tremor
• gross tremor

Localization; A tremor can occur individually in each region of the body, e.g. on an extremity (focal), a certain part of the body such as the hand (isolated), on one half of the body (asymmetrical) or in a combination or on the whole body (generalized). In the case of combined tremors in several parts of the body, the severity of the severity can vary (e.g. stronger in the left hand than in the right hand).

Causes, clinical pictures

Increased physiological tremor

• Characteristics: fine to medium impact, high frequency (7–12 Hz), holding and action tremors
• Causes: Hyperthyroidism , hypoglycemia , medication (drug-induced tremor), caffeine, stress, exhaustion, cold, poisoning or drugs (toxic tremor), vitamin B ₁₂ deficiency, other metabolic disorders
• Therapy: Elimination of the cause, beta blockers ( propranolol ), anti-epileptics ( primidone , gabapentin , topiramate )
• Description: “The physiological tremor is present in everyone, hardly visible and consists of a high frequency and low amplitude. This can occur more intensely as a result of a stimulus (e.g. pain , caffeine , fear , cold, muscle overexertion, exhaustion) and is then clearly visible, usually when the muscle is held in place; this is then referred to as increased physiological tremor. Usually there is no pathological cause here either. This tremor is mostly reversible when the triggering stimulus is no longer present. There are also drugs that can cause an increased physiological tremor as a side effect.
  The increased physiological tremor is pathological only as a result of a metabolic disorder (e.g. hyperthyroidism). If the severity of the tremor is low, for example hyperthyroidism and hypoglycemia, it is usually only perceived on the hands and fingers. ”Causes of drug-induced tremor: serotonin syndrome , bromism , lithium , neuroleptic malignant syndrome .

Psychogenic tremor

• Characteristics: changing frequency and amplitude, reduction in distraction, sudden onset and spontaneous remission, simultaneous tensing of antagonistic muscles during rigorous testing / passive joint movement, significant reduction in tremor when a limb is loaded with weights
• Causes: mental disorder, traumatic experiences
• Description: This type of tremor involves sudden tremor attacks that go away as suddenly as they occurred. It could be observed in returnees from the First World War (see war tremors ), but also after accidents, physical attacks, fear , fright or emotional stress ( acute stress disorder ).
• In the context of the therapy of traumatic events (cf. Berceli 2007), the tremor is assigned a healing function based on its tension-relieving function. One of the internationally best known methods is TRE (short for Tension and Trauma Releasing Exercises ).

Essential tremor (familial tremor)

• Characteristics: medium beat, medium frequency (5–8 Hz), holding and movement tremor, progressive (slight intention tremor, head tremor and voice tremor when developed), response to alcohol
• Causes: Mostly: autosomal dominant gene defect (chromosome 16, gene: FUS / chromosome 3, gene: DRD3 or DNAJC13)
• Therapy: beta blockers (propranolol), anti-epileptic drugs ( primidone , gabapentin , topiramate ), botulinum toxin A or deep brain stimulation in the nucleus ventralis intermedius in the thalamus .
• Description: “The essential tremor (ET) is a typical postural tremor with a frequency of five to six Hertz. It occurs alone and is hereditary in around 60% of patients and can therefore be detected in other family members (autosomal dominant inheritance via chromosomes 2 , 3 and 6 is suspected), but can also occur spontaneously.
  Symptoms of ET can begin at any age, from childhood to old age. However, a start in childhood is less common. The frequency peaks are in the second and sixth decades of life. Men and women can be equally affected by ET. The symptoms and the possibility that e.g. B. the hands / arms and legs are affected, grow with age. As the disease progresses, the frequency of tremors may decrease; however, the tremor size (tremor amplitude) may increase. In addition, the tremor can occur more intensely in states of excitement, so that objects can no longer be held at times.
  In most people affected, ET is a slowly progressive disorder. However, there may be periods when symptoms remain unchanged and do not worsen. But there are also cases in which the ET is weakened and does not have a major impact on quality of life for a lifetime. "

Parkinson's Remor

• Characteristics: 4–7 Hz, rest, holding and movement tremors. Typical Parkinson's symptoms such as bradykinesia and rigidity. Pill roll tremor. Amplification of the tremor in case of nervousness. No response to alcohol. Uncommon: Orthostatic tremor (4–12 Hz)
• Causes: Parkinson's disease , parkinsonism
• Therapy: Resting tremor: anticholinergics, budipine and clozapine. Holding and movement tremors: propranolol, primidone. Deep brain stimulation in the subthalamic nucleus (STN) or in the intermediate ventral nucleus (VIM)
• Description: “Parkinson's tremor also occurs at rest. The cause is usually Parkinson's disease ; however, resting tremor does not occur in all forms of Parkinson's disease. "

Tremor in Wilson's disease

• Characteristics: rest, holding and movement tremors, asterixis, dystonia , wing beating tremor. For Wilson's disease typical symptoms such as Kayser-Fleischer ring . Progressive, strongly variable expression of the symptoms.
• Causes: Wilson's disease: copper accumulation in the organism due to an autosomal recessive genetic defect in the ATP7B gene.
• Therapy: copper uptake inhibitors, chelating agents, liver transplantation
• Description: “The symptoms of Wilson's disease are very variable and can even be asymptomatic; Symptoms such as the Kayser-Fleischer ring can only be observed when the disease is pronounced. With a strong progression, the disease can take on life-threatening features. "

Primary orthostatic tremor (shaky legs syndrome)

• Properties: 13-18 Hz, fine-grained and mostly invisible. Task-specific tremor: when the leg muscles are tensed while standing, unsteady standing up to shaky legs, familial accumulation.
• Causes: Unknown genetic defect, vitamin B ₁₂ deficiency
• Therapy: Clonazepam is most effective. Others: Benzodiazepines, anti-epileptics (valproate, gabapentin), beta blockers (propranolol), muscle relaxants
• Description: “The orthostatic tremor is related to the essential tremor, but can be clearly distinguished from it. It occurs while standing, rarely when walking. This can go so far that those affected fall. Mostly people over the age of 60 are affected. Once started, the orthostatic tremor escalates to such an extent that the tremor spreads throughout the body. Gabapentin is often helpful even in low doses . Primidon is the second choice for orthostatic tremor. Unlike essential tremor, propranolol is ineffective. A distinction must be made between primary orthostatic tremor of the second type, which can be caused by Parkinson's disease or cerebellar lesions, which has a much lower frequency of 4–12 Hz. "

Neuropathic tremor

• Properties: 4–8 Hz, coarse
• Causes: u. a. Peripheral neuropathies, hereditary neuropathies type CMT1, inflammatory neuropathies
• Therapy: If inflammatory neuropathy: reduce inflammation. Propranolol, primidone, pregabalin, deep brain stimulation in the Ncl. ventralis intermedius
• Description: “Neuropathic tremor is a tremor that is usually triggered by (demyelating poli- & peripheral) hereditary neuropathies, Guillan-Barré or multiple sclerosis. Characteristic is a subtle postural and kinetic tremor with a frequency of 3–6 Hz. Although the occurrence of tremor in (hereditary) neuropathies is rather rare, in multiple sclerosis an intention tremor often occurs in the context of the Charcot triad. "

Holmes tremor

• Synonyms: midbrain tremor, rubral tremor, rubral tremor, myorhythmia, tremor in Benedict syndrome, tied arm tremor, thalamic tremor
• Characteristics: 2–5 Hz, rest, holding and intention tremors, coarse. Common: hemidystonia ( unilateral dystonia)
• Causes: tumors, bleeding, ischemic strokes, inflammatory lesions (multiple sclerosis)
• Therapy: L-Dopa, anticholinergics, clonazepam, clozapine, deep brain stimulation in the Ncl. ventralis intermedius

Cerebellar tremor (cerebellar tremor)

• Characteristics: 2–5 Hz, rest, holding and intention tremors, coarse. Trunk or extremity tremor (axial tremor)
• Causes: Tumors, bleeding, ischemic strokes, inflammatory lesions (multiple sclerosis), cerebellar ataxia, spinocerebellar ataxia (SCA)
• Therapy: L-Dopa, anticholinergics, clonazepam, clozapine, deep brain stimulation in the Ncl. ventralis intermedius
• Description: “With SCA3, tremor does not necessarily occur; if this does occur, the clinical picture can be divided into two categories: a) medium-frequency (6–8 Hz) action tremor, orthostatic tremor and postural tremor, parkinsonism and b) low-frequency (3–4 Hz) rest, action and intention tremors together axial tremor. "

Other tremors

• Dystonic tremor: This tremor (3–7 Hz) is characterized by a malfunction in the control of movement. The affected person suffers from sudden incorrect movements and cramps in the muscles, which can be very painful.
• Isolated (essential) voice tremor: With an isolated voice tremor, only the pronunciation is affected by the tremor. The cause is focal dystonia of the vocal cords (focal laryngeal dystonia) or (as a variant) an essential tremor.
• Isolated chin tremor (hereditary geniospasm / chin spasm): Usually occurs in a stress-induced and therefore episodic manner; manifests itself as a high frequency tremor resp. Contractions of the mentalis muscle. The cause can be a genetic defect that is inherited as an autosomal dominant trait.
• Delirium tremens , neonatal abstinence syndrome : tremor caused by alcohol withdrawal.
• Primary (essential) and secondary (symptomatic) soft palate tremor - Primary: Unknown cause, audible click for patient. Secondary: damage u. a. of the dentatoolivar pathway, no audible click.
• Bobble-head doll syndrome : head tremor that occurs in young children, mostly due to hydrocephalus.
• Titubation due to a cerebellar cause: genetic causes and the like a .: Joubert syndrome , Pelizaeus-Merzbacher disease , leukodystrophy . Acquired titubation: mostly tumors or lesions of the cerebellum.
• Primary writing tremor: tremor that occurs only while writing. It can be divided into two categories; Type A only occurs when writing, while Type B occurs when writing is started.
• Other causes of tremor: Spastic paraplegia , subcortical dementia , Creutzfeldt-Jakob disease , Kuru , neurodegeneration with iron deposition in the brain , fragile X-associated tremor / ataxia syndrome , neosporosis , infectious serositis , supranuclear palsy, lithium (hands), Hypernatremia , hyponatremia , radiation sickness , heavy metal poisoning.

treatment

Surgically

The essential tremor and the Parkinson's tremor are ultimately caused by a synchronously “firing” region of cells in the brain, whose interference signal generates the tremor. The surgical approach therefore provides for the deactivation of this area. Since the affected cell region is very small and lies deep in the brain, this operation is performed in a minimally invasive manner using stereotaxic surgery . During the operation, the surgeon can then directly derive the nerve activity in the brain and use it to determine whether or not he has reached the corresponding region. If a disturbance current is then applied to the corresponding point, the tremor will be "switched off" if successful because the disturbance signal has been superimposed. Therefore, the operation is only performed under local anesthesia in order to see the success directly.

When the job is found, there are two options. The site can be heated to over 60 ° C for a short time using a probe, which destroys the nerve tissue there. However, this procedure is not reversible and carries the risk of accidentally destroying too much, which can have serious side effects (such as hemiplegia). From this the idea of ​​a brain pacemaker was developed, which instead sends a constant interference signal; in this case, a probe is left in place and a small, battery-operated device is planted in the chest of the patient who powers the probe. This can be switched on and off by means of a strong permanent magnet.

The operation is not successful in all patients.

Medicinal

Other treatments may be required depending on the cause of the tremor. If the tremor is caused by another disease, it must be treated; the tremor subsides, for example, with successful treatment of Wilson's disease. The essential tremor can only be dampened with beta blockers or anticonvulsants , so far there has been no possibility of targeted treatment. Botulinum toxin injections can help if the cause is dystonic; however, they always need to be refreshed.

Other treatment options

It is not possible to improve or eliminate a tremor with physical therapy.

Occupational therapy can help to maintain or regain the greatest possible independence (through compensation strategies, provision of aids, ADL training, etc.). However, symptoms can be reduced in the short term with relaxation exercises such as autogenic training, yoga or meditation. As another treatment option, weight cuffs on the affected extremities can reduce the tremor. Here, however, a habituation effect occurs quite quickly.

Tremor as a disability

The tremor itself can affect the patient's life to a greater or lesser extent, depending on its severity, appearance and affected regions. However, there are also very mild forms that those affected do not even notice as a disease. A pronounced intention tremor in particular can be very disabling, since in the end pretty much every movement in everyday life is goal-oriented and makes things like eating, drinking and writing difficult or even impossible. A slight resting tremor, on the other hand, that occurs on the head, for example, is less directly disabling, but it is noticeable.

Especially in stressful, for example social situations, the tremor usually intensifies and is also stigmatized as "nervous, insecure" or even "alcoholic". There is therefore a risk that those affected will withdraw from public life.

See also

• Extrapyramidal hyperkinesia
• Superior oblique myokymia

literature

• S1- Tremor guidelines of the German Society for Neurology (DGN). In: AWMF online (as of 2012)

Web links

Wiktionary: Tremor  - explanations of meanings, word origins, synonyms, translations

• International Essential Tremor Foundation
• Article . In: Scholarpedia . (English, including references)

Individual evidence

1. ↑ GEOlino: Why we tremble when we are cold. Retrieved April 22, 2016.
2. ↑ Dräger review No. 389, p. 36. Lübeck 2012. Retrieved on April 22, 2016.
3. ↑ Rob Herbert: Shaking when stirred: mechanisms of physiological tremor . In: The Journal of Physiology . tape 590 , no. 11 , June 1, 2012, ISSN  1469-7793 , p. 2549-2549 , doi : 10.1113 / jphysiol.2012.232876 .
4. ↑ International monthly for research into alcoholism and the fight against drinking habits , October / November 1916, issue 10/11, p. 266
5. ↑ Prohibited List of NADA 2015. (PDF)
6. ^ LJ Findley: Classification of tremors. In: J Clin Neurophysiol. 1996 Mar; 13 (2), pp. 122-132.
7. ^ CW Hess, SL Pullman: Tremor: Clinical Phenomenology and Assessment Techniques. In: Tremor Other Hyperkinet Mov. (NY). 2012 Jun 28; 2, p. 65.
8. ^ David Berceli, Maria Napoli: A Proposal for a Mindfulness-Based Trauma Prevention Program for Social Work Professionals. (PDF) accessed October 28, 2014.
9. ↑ Tremors . University of Freiburg.
10. ↑ Julián Benito-León, Jesús Porta-Etessam: Shaky-Leg Syndrome and Vitamin B12 Deficiency . In: New England Journal of Medicine . tape 342 , no. 13 , March 30, 2000, ISSN  0028-4793 , p. 981-981 , doi : 10.1056 / NEJM200003303421318 .
11. ^ Primary orthostatic tremor. In: orpha.net. Retrieved September 27, 2015 . 
12. ↑ Roongroj Bhidayasiri, Daniel Tarsy: Movement Disorders: A Video Atlas . Humana Press, 2012, ISBN 978-1-60327-425-8 , Neuropathic Tremor, pp. 72-73 .
13. ↑ Cecilia Bonnet, Emmanuelle Apartis, Mathieu Anheim, Andre P. Legrand, Jose F. Baizabal-Carvallo, Anne M. Bonnet, Alexandra Durr, Marie Vidailhet: Tremor-spectrum in spinocerebellar ataxia type 3 . In: Journal of Neurology . tape 259 , no. 11 , November 1, 2012, ISSN  1432-1459 , p. 2460-2470 , doi : 10.1007 / s00415-012-6531-5 , PMID 22592286 .
14. ↑ emedicine.medscape.com
15. ↑ Thomas L Carroll: Laryngeal Tremor: Background, Etiology, Epidemiology . ( medscape.com ).
16. ↑ Geniospasm, hereditary. In: orpha.net. Retrieved September 27, 2015 . 
17. ^ G. Deusch, C. Toro, J. Valls-Solé, T. Zeffiro, DS Zee, M. Hallett: Symptomatic and essential palatal tremor . In: Brain . tape 117 , no. 4 , August 1994, pp. 775-788 , doi : 10.1093 / brain / 117.4.775 .
18. ↑ PG Bain, LJ Findley, TC Britton, JC Rothwell, MA Gresty, PD Thompson, CD Marsden: Primary writing tremor . In: Brain : A Journal of Neurology . 118 (Pt 6), December 1995, p. 1461-1472 , PMID 8595477 .

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