QuestionSBA
QuestionChoice
Whilst cerebellar dysfunction can cause a bilateral intention tremor (occurs at the end of a purposeful movement e.g. as a finger reaches almost to its target), you would expect other cerebellar signs on examination (remember neumonic DANISH: Disdiadochokinesis, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia). Again, the family history and jaw involvement make Essential tremor more likely.
61962
e
Cerebellar lesion
QuestionChoice
PD is characterised by a **resting** tremor, usually unilateral, and is often-described as 'pill-rolling' (small circular movements of thumb and forefinger) in nature. It would not usually affect the jaw and PD is usually idiopathic and so would not be expected to affect multiple other family members. There are no other features of parkinsonism in the question to support this.
61960
c
Parkinson's Disease
QuestionChoice
Essential tremor is a common condition characterised by an action/postural tremor which is classically bilateral and can also affect the neck/jaw/voice. There is often a family history and onset can be at any age. Symptoms can sometimes be transiently improved with alcohol or beta-blockade.
61958
a
Essential Tremor
QuestionChoice
Whilst withdrawal tremors do affect both hands, there is no indication that this patient drinks excess alcohol, nor any other symptoms of withdrawal such as sweating/anxiety/nausea. These clues and the family history make it a less likely answer than Essential tremor.
61959
b
Alcohol dependence syndrome
QuestionChoice
Salbutamol use can cause a transient fine (rather than coarse) tremor in both hands. Whilst the patient is noted to have asthma, this is a red-herring and less likely to be causing his tremor. It also would not be expected to affect multiple family members or the jaw.
61961
d
Salbutamol
Concept
Chapter
## Summary

Essential tremor (ET) is a common neurological movement disorder, often characterized by a rhythmic, postural or action tremor primarily affecting the upper extremities. Its prevalence increases with age and can have a significant impact on daily activities and quality of life. It is heritable in about 50% of cases, and while there are treatment options available, they only manage symptoms and don't cure the underlying disorder.

## Definition

Essential tremor (ET) is a chronic neurologic condition that typically manifests as an involuntary shaking or trembling usually on changing posture or performing an action, most commonly in the hands and arms, but can also affect other body parts such as the head, voice, lower limbs, tongue, face, and the trunk.

## Epidemiology

ET is one of the most prevalent movement disorders, with the incidence increasing with age. The condition may manifest at any age, from childhood to adulthood. The age of onset tends to be earlier in those with a positive family history.

## Aetiology 

The etiology of ET is complex and not completely understood, but it is believed to be multifactorial, involving both genetic and environmental factors. 

In approximately 50% of the cases, ET is inherited as an autosomal dominant trait, suggesting a significant genetic component.

## Signs and symptoms

The main clinical feature of ET is a postural or kinetic tremor, which predominantly affects the upper limbs distally. 

Additional symptoms may include:

- Involvement of the head, lower limbs, voice, tongue, face, and the trunk, although less common.
- Increased tremor amplitude over time, causing difficulty with tasks such as writing, eating, holding objects, dressing, and speaking.
- Exacerbation of tremor during situations of anxiety, stress, and social interaction.
- Potential development of severe psychosocial disability, including depression, particularly in patients with head and voice tremors.

Classically, ingestion of alcohol can temporarily improve the tremor.

## Differential diagnosis

ET should be distinguished from other types of tremors. Main differentials include:

- **Parkinson's disease**: Resting tremor, bradykinesia, rigidity, postural instability.
- **Hyperthyroidism-associated tremor**: Palpitations, heat intolerance, weight loss, anxiety.
- **Dystonic tremor**: Abnormal posturing, muscle contractions, worsened by voluntary movement. 

## Investigations

The diagnosis of ET is mainly clinical. 

Once suspected, a thorough evaluation of functional and psychosocial disabilities should be performed using objective scales to determine the need for pharmacotherapy. 

Further investigations, such as blood tests or neuroimaging, may be warranted to rule out other potential causes of tremor.

## Management

Management of ET is primarily symptomatic and may include:

- Pharmacological therapy, using agents such as **propranolol** (first line), primidone, topiramate, gabapentin, clonazepam.
- Surgical intervention for severe cases, including deep brain stimulation, focused ultrasound thalamotomy, and radiosurgical (Gamma Knife) thalamotomy.

## References

[More information on Essential Tremor](https://www.ncbi.nlm.nih.gov/books/NBK499986/)


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Essential tremor
Topic
34
Neurology
12453
A 70 year old man presents to the GP for a routine asthma check-up. He is incidentally noted to have a coarse tremor in his right hand whilst reaching for a pen. On examination, the tremor is present in both hands when outstretched, and also affects his jaw. Neurological examination is otherwise unremarkable. He mentions that several family members also have similar tremors.

Which condition is the most likely cause of his tremor?
a