Tremor

As tremor (Latin tremere " tremble " ) the involuntary, rhythmically repetitive contraction is called each other counteracting muscle groups. The so-called physiological tremor of healthy individuals is measurable, but barely visible. Clearly visible tremor can be seen as a symptom of various diseases.

Tremors differ by Affected body area, frequency, intensity, cause and occurrence. In some cases, the tremor may also occur in isolation ( essential tremor ), without being considered as a symptom of disease.

• 4.1 Task -specific tremor
• 4.2 dystonic tremor
• 4.3 Essential Tremor
• 4.4 flutter tremor
• 4.5 An isolated voice tremor
• 4.6 Orthostatic tremor
• 4.7 Parkinson's tremor
• 4.8 Physiological tremor
• 4.9 Psychogenic tremor

• 6.1 Surgically
• 6.2 Drug-
• 6.3 Other treatment options

Affected parts of the body

The tremor may individually ( trunk, head, extremities ) or a combination occur in any body region. For combined tremors in several parts of the body, the expression can vary greatly (eg, more in the left hand than in the right hand).

Appearance of tremor

There are several types of tremor, which may be associated symptoms of different diseases. The various tremors for example, differ in the frequencies and the conditions under which the tremor is activated - at rest, in action, while keeping in un - or goal-directed movements.

In the classification of tremors, a varied classification variants. Purely descriptive, the other based on pathophysiological mechanisms But none of the current classification schemes can be used for the diagnosis of tremor. In addition, there are often similarities in various causes in the presentation of the tremor, which complicates the differential diagnosis. In the classification according to etiology, the problem is that sometimes you do not know the cause (eg, essential tremor ). In addition, a disease can cause several types of tremor. Not a single tremor type can be associated with a pathognomonic disease.

Action tremor

A distinction is made between four different subspecies of action tremor:

• Tremor movement: The movement tremor occurs when the patient moves the affected limb, but without targeted, precise intention, for example, by reciprocating the hands horizontally in front.
• Postural tremor: The postural tremor appears under pure gravity load, so if the patient his hands stretched forward and holds.
• Intention tremor: An intention tremor occurs with a purposeful movement, such as the lead of a finger to a certain point. With increasing approximation to the target is amplified the intention tremor.
• Isometric tremor: Isometric tremor occurs when the person lifts a heavy object and holds it.

Task -specific tremor

The task-specific tremor occurs when the persons concerned only with certain activities, such as playing a vibrato on an instrument or in singing.

Resting tremor

This form appears when the affected area of the patient at rest, eg hands, lying quietly on a surface. It is possible that the resting tremor occurs after assuming the position of rest and then disappears after a while, see Parkinson tremor.

Not every tremor is morbid. The physiological tremor for example, is involved in every muscle movement of a healthy person.

Most commonly, the tremor occurs in the upper extremities. Depending on the clinical picture of tremor appears only in certain situations. It is possible that a patient has only one or two of the possible variants.

Tremor frequency

The tremor frequency depends on the particular muscle systems and, where appropriate, the clinical pictures. We distinguish:

• Low, grobschlägigen tremor ( rare, but ausfahrender )
• Medium-frequency tremor and
• High frequency, often feinschlägigen tremor, a kind of fine tremor.

The frequencies are in the first case below 4 Hz, the medium frequency tremor at 4 to 7 Hz, in feinschlägigen tremor at up to 15 Hz

Causes, diseases

Task -specific tremor

Occurs not only in highly specialized motor loads, but also in very simple activities, such as writing ( writing tremor).

Dystonic tremor

The tremor is characterized by a malfunction in the control of movements. The person suffers from sudden failure movements and muscular cramps, which can be very painful.

Essential Tremor

Essential tremor (ET) is a typical postural tremor with a frequency of five to six hertz. It occurs standing alone and is hereditary and therefore with other family members detectable ( autosomal dominant inheritance of the chromosomes 2, 3 and 6 is suspected ), but can also occur spontaneously in about 60 % of patients.

The symptoms of ETs can begin at any age, from infancy to old age. However, beginning in childhood is rare. The peak incidence lie in the second and sixth decade of life. Men and women can be equally affected by ET. The symptoms and the possibility that, for example, the hands / arms, and the legs are affected, grow with age. As the disease progresses, the tremor frequency may decrease; the tremor extent, (the tremor amplitude) may increase. In addition, the tremor in arousal states may increasingly occur, so that at times no more objects can be maintained.

For most sufferers of ET runs as a slowly progressive ( progressive ) disorder. However, there may be periods in which the symptoms remain unchanged and not deteriorate. But there are also cases in which the ET is attenuated and yet does not lead to a lifetime large influence on the quality of life.

Flatter tremor

The flutter tremor falls on mainly in the holding experiment. In this case, there occurs a sudden loss of postural tone, followed by a reflex correction movement. This is also referred to as Asterixis. For Flatter tremor occurs eg in hepatic encephalopathy (grade II) and other liver diseases.

Isolated voice tremor

In an isolated voice tremor only the pronunciation of tremor is affected.

Orthostatic tremor

The orthostatic tremor is indeed related to essential tremor, can be clearly distinguished from the latter. It occurs in a standing position, rarely even while walking. This can go so far that those affected fall. It affects people mostly from the age of 60. Once started, the orthostatic tremor escalated such that the tremor passes on the entire body. Often a low dose gabapentin is helpful. Primidone is true when orthostatic tremor as second choice. Unlike the essential tremor propranolol is ineffective.

Parkinson's tremor

The Parkinson's tremor occurs even at rest. Cause is a Parkinson's disease.

Physiological tremor

This is the most common form of shakes and occurs in all healthy people. The physiological tremor obviously has a function in the control of the motion therefore can with it the so-called voluntary movement faster than without tremor to be implemented.

This tremor is easily visible, for example on the fingers, at the proximal joints but barely. At a high frequency and a low amplitude it is regarded as non-pathological.

The physiological tremor can be amplified occur as a result of a stimulus (eg, pain, caffeine, anxiety, cold, muscle strain ) and is then clearly visible, mostly in holding conditions of the muscle. Mostly, however, there is again no pathological cause. This tremor is usually reversible when the triggering stimulus is no longer present. There are also medicines that can trigger an enhanced physiological tremor as a side effect.

Psychogenic tremor

In this type of tremor is sudden tremor attacks, as suddenly as they appeared also disappear. It could be observed among returnees from the First World War, but also after accidents, assaults, fear, fright or emotional stress (acute stress disorder ).

As part of the therapy of traumatic events (see Berceli 2007) is assigned to the tremor based on its stress-relieving function a healing function.

Diagnosis

When a tremor occurrence usually a complex differential diagnosis is necessary to find an underlying medical condition either include or exclude. At first appearance, localization and intensity of the tremor can be detected in a direct examination. At the same time, the attending physician must examine the patient for further neurological abnormalities, and explore the clinical history.

After the tremor can be detected devices medically accurate means of EMG activity; since it limits the muscle activity of the affected region can be made visible, lowers the frequency of the tremor accurately determine. The frequency also allows to draw conclusions on a possible cause, as different diseases each tends to produce certain frequencies. After medical conditions must be ruled out or checked: Wilson's disease through a blood and urine test and an ophthalmological examination for the presence of a Kayser -Fleischer ring. Parkinson's disease can be checked by the administration of L -dopa. Brain damage or tumors appear in MRI, multiple sclerosis appears by examination of the cerebrospinal fluid by lumbar puncture. Essential tremor can usually be opened by the administration of alcohol and question of genetic predisposition (family medical history ).

Treatment

Surgical

Essential tremor and tremor in Parkinson's are ultimately caused by a synchronous " firing " region of cells in the brain, whose interference creates the tremor. The surgical approach therefore provides the deactivation of this area. Since the affected cell region is very small and lies deep in the brain, this operation is performed by minimally invasive stereotactic. During surgery, the surgeon can then make a direct derivation of the neural activity in the brain, recognized by the fact, whether it has reached the corresponding region or not. Are you then a noise current to the appropriate location, the tremor is "switched off" in case of success, since the interference signal was superimposed. Therefore, the operation is carried out under local anesthetic to see directly the success.

If the point has been found, there are two possibilities. Can be the location of a probe by means of heat for a short time to over 60 ° C, whereby the nerve tissue is destroyed there. However, this procedure is not reversible and involves the risk of accidentally too much to destroy what can have serious side effects (such as a hemiparesis ). Hence the idea of a brain pacemaker has been developed which instead sends a constant noise signal; In this case, a probe is left in place, and a small, battery-powered device is planted in the chest of the Patentien which supplies the probe. This can be turned on and off by means of a strong permanent magnet.

The operation is not successful for all patients.

Medicinal

Depending on the cause of the tremor other treatment methods are required. If the tremor caused by another disease, it must be treated; the tremor subsides example, in case of successful treatment of Wilson's disease. Essential tremor can only be attenuated with beta-blockers or anticonvulsants, so far there is no way for targeted treatment. In dystonic cause botulinum toxin injections can help; However, they need to be refreshed again and again.

Other treatment options

It is not possible to improve a tremor through physiotherapy or eliminate. With relaxation exercises such as autogenic training, yoga and meditation, symptoms can, however, reduce the short term. Another treatment option can reduce the tremor ankle weights on the affected extremities. Here, however, occurs very quickly a habituation effect.

Tremor as a disability

The tremor itself may affect more or less strongly the patient's life, depending on strength, appearance and affected regions. There are, however, very mild forms that do not even notice the person concerned as a disease. In particular, a marked intention tremor can be very disabling because ultimately pretty much every move is targeted for everyday life, it complicates things as eating, drinking, writing to impossible. A slight resting tremor, however, occurs for example in the head, although less directly incapacitating, but striking.

Especially in stressful, such as social situations, the tremor usually reinforced and is still stigmatized to as " nervous, insecure," or even " an alcoholic ." There is therefore a risk that retreat Move out of public life.