Pathologies in which tremor predominates: Holmes's tremor, radiculopathy, Wilson's disease tremors

The article was written by MSc Vu Duy Dung - Doctor of Neurology, Department of General Internal Medicine - Vinmec Times City International Hospital.

Tremor is among the most common movement disorders. Diagnosing these disorders is challenging. Approaching a patient with tremor requires a careful history and neurologic examination focusing on clinical phenomenological nuances.

Run Holmes is also referring to midbrain tremor or red nucleus tremor. In most cases, tremors are unilateral and have three components: resting tremor, postural tremor, and voluntary/kinetic tremor, with relative severity more kinesthetic than postural and postural tremors. more tremor at rest. Run is slow (< 5 Hz).
In some cases, tremors are severe and disabling and can cause the limb to lose function. Patients often also have other neurological signs, including hemiparesis, cranial nerve abnormalities, ataxia, hypoesthesia, and dystonia in the same body part as tremor.
Tremor can occur in a variety of clinical settings (eg, stroke, head trauma, or many other conditions, including multiple sclerosis), and when it occurs after a cerebral infarction , tremor may appear after a latency period of 1 month to 2 years.
On brain imaging, there is often but not always a lesion in the pons midbrain, affecting cerebellar exit bundles and striatal striatal dopaminergic fibers, although lesions are often found at other sites (eg, thalamus) is one of the motivating factors for the naming of the tremor as Holmes tremor rather than erythropoiesis or midbrain tremor.
Because the dopaminergic system is affected in most cases, treatment with carbidopa/levodopa (25 mg/100 mg daily to 250 mg/1000 mg daily) has been reported to be beneficial, improving all three outcomes. part of the tremor (at rest, posture, and kinematics).
In addition, drugs used for the treatment of essential tremor may be effective in alleviating the postural or kinetic components of tremor. DBS surgery has also been shown to be beneficial in some cases, treating all three components of tremor.

Historically, tremors in patients with primary or functional tremor have often had an abrupt onset with maximal tremor at onset rather than an insidious onset followed by a typically slow progression. of various types of entity tremors. In addition, tremors can fluctuate and have periods of remission.
On examination, tremors have unusual and non-physiological features (eg, tremors may present with varied frequencies; tremors may change direction; or there is an unusual combination of tremor types when rest, postural tremor, and kinesthesia).
Positive signs suggestive of psychogenic tremor may include charisma, distraction, and suggestion. Furthermore, many patients exhibit excessive fatigue during examination.
Notably, in the quantitative computerized analysis of tremors, inertial loading can cause a paradoxical increase in tremor amplitude rather than a decrease in amplitude as expected to be observed in substantial tremors.
Treatment of essential tremor begins with a discussion of the diagnosis, recognition of the patient's symptoms, and referral to a psychiatrist to find out the underlying psychiatric problems. Some evidence suggests that cognitive-behavioral therapy is effective.

Patients with Wilson's disease can exhibit a wide variety of involuntary movements, the most common of which is tremor. Tremor is often accompanied by other neurological signs, although rare reports have reported tremor only and even rarer reports have reported tremor only with movement.
Although the typical tremor of Wilson's disease is flapping tremor (ie, proximal tremor, which manifests with abducted shoulders and arms flexed at the elbows), it is not the most common tremor in Wilson's disease.
In fact, the phenomenology of tremor is quite diverse. Various types of tremor are possible, including kinesthetic, resting, postural, and voluntary tremors; symmetrical or asymmetrical tremor; tremors of low or high amplitude; Tremor can be intermittent or continuous and progressive.
Most of the published large case series studies adequately describe the neurological signs, and new video-based features of tremors. According to one study, 32% of patients had tremors at the time of their initial visit to a tertiary care center; In another report, 60% of patients presented with tremor at the same time. Tremor is most common in the hand or hand, with one study reporting 72% of patients with tremors in such locations and another study reporting an incidence of 82%.
Most patients are stable before age 40, and laboratory testing may reveal low serum ceruloplasmin, abnormal brain MRI (intensity in T2 and FLAIR in the duckweed nucleus is characteristic, and basal ganglia structures are affected. effects are most common, followed by striatum and pallor), high 24-hour urine copper levels, abnormalities on slit-lamp ophthalmology (with Kayser-Fleischer rings), or elevated liver enzymes.
Treatment with D-penicillamine, zinc, or trientine is recommended; There is little literature on the specific treatment of tremor symptoms.
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Article references source: Louis ED. Tremor. Continuum (Minneap Minn) 2019;25(4, Movement Disorders): 959–975.