General Overview

  • Children with tremor is potentially serious (Wilson, fragile X, nutritional deficiency, heavy metal, essential) - refer to neuro

Types of Tremor

  • Resting (most commonly parkinsonism)
  • Action
    • Postural - against gravity (essential, physiologic, cerebellar, dystonic, drug-induced)
    • Isometric - contraction against stationary object
    • Kinetic - any form of voluntary movement (essential, cerebellar, dystonic, drug-induced)
    • Intention - amplified as target reached (cerebellum)

Enhanced Physiologic Tremor

  • Normal tremor enhanced by anxiety, stress, medication, caffeine, fatigue
  • Does not need further testing

Essential Tremor

  • Action tremor - postural, kinetic, may even be sporadic resting
  • Bilateral involving wrists/hands, head, lower extremities, voice
  • 50% of cases are autosomal-dominant


  • Resting, low-frequency, pill-rolling fingers, progression to forearm pronation/supination and elbow flexion/extension tremor
  • Typically unilateral, rest, and fades with voluntary movement
  • Can involve leg and jaw as well
  • Associated with classic parkinsonism syndrome (bradykinesia, rigidity, postural instability)

Drug-Induced Tremor

  • r/o medication use in new-onset tremor

Metabolic-Induced Tremor

  • Consider work-up for hepatic encephalopathy (ammonia), hypocalcemia, hypoglycemia, hyponatremia, hypomagnesemia, hyperthyroidism, hyperparathyroidism, B12 deficiency

Cerebellar Tremor

  • Disabling, low-frequency, slow-intention or postural tremor (r/o MS, stroke, brainstem tumor)
  • Most have signs of cerebellar dysfunction - dysmetria (overshoot on finger-to-nose), dyssynergia (abnormal heel-to-shin) and hypotonia)


  • Abrupt onset, spontaneous remission, changing tremor characteristics (location, frequency), and extinction with distraction