• Rigidity
  • Impaired postural reflexes
  • Abnormality of speech
  • Nystagmus
  • Irritability
  • Jaundice
  • Bradykinesia

Tremor is the most common of the movement disorders, but with such a huge differential, the diagnosis is not always easy to establish. Identifying whether the tremor is resting, postural or kinetic is key to making an accurate diagnosis.

Thorough history taking and physical examination are crucial. It is important to consider how the tremor is affecting the patient's quality of life. What are the exacerbating and relieving factors? Explore the family and medication history. CNS stimulants, for example, may increase the amplitude of the tremor.

Type of tremor
Recognising the type of tremor and associated symptoms is essential. Red flag symptoms for Parkinson's disease include a resting tremor, characteristically a pill-rolling tremor, along with rigidity, impaired postural reflexes and bradykinesia.

NICE guidelines state that if Parkinson's is suspected, the patient should be referred quickly and without treatment.

Tremor may have a cerebellar cause, such as stroke. Other causes of cerebellar disease include multiple sclerosis, hypothyroidism, bronchogenic carcinoma and medication. Cerebellar tremor typically presents as a kinetic tremor ipsilateral to the pathology. Tremor along with nystagmus and abnormalities of gait or speech should alert you to a cerebellar cause.

Benign essential tremor is an action tremor which most commonly affects the arms and head. The voice may also be affected.

Tremor may occur as a side-effect of prescription drugs, such as lithium, or as a withdrawal symptom from alcohol. Look for other signs of alcoholism, such as depression, irritability or stigmata of chronic liver disease.

Rarer causes of tremor include orthostatic tremor, a high frequency tremor of the legs when standing up, or Wilson's disease, which is associated with abnormal copper metabolism, psychosis and deranged LFTs.

A patient with tremor and appearing to be anxious may have thyrotoxicosis so have a low threshold for TFTs.


NICE guidelines for Parkinson's disease

Possible causes

  • Parkinson's disease
  • Benign essential tremor
  • Thyrotoxicosis
  • Stroke
  • Cerebellar tumour
  • Alcohol withdrawal
  • Anxiety
  • Trauma
  • Wilson's disease
  • Primary orthostatic tremor

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