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Review Article |

Diagnosis and Management of Tremor FREE

Not Available Habib-ur-Rehman, MRCP
[+] Author Affiliations

From the Department of Medicine, Hull Royal Infirmary, Hull, England.


Arch Intern Med. 2000;160(16):2438-2444. doi:10.1001/archinte.160.16.2438.
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Published online

Tremor is the most common involuntary movement disorder. It is differentiated from other involuntary movement disorders, such as chorea, athetosis, ballismus, tics, and myoclonus, by its repetitive, stereotyped, movements of a regular amplitude and frequency. Tremor can be defined as an involuntary, rhythmic, periodic, mechanical oscillation of a body part. Since small-amplitude tremors may not be visible to the naked eye and may only be detectable by sensitive recording devices, amplitude of the tremor is therefore not critical to the definition. Accurate diagnosis of tremor is important because appropriate treatment depends on the accuracy of the clinical diagnosis. This article reviews the classification and management of tremor.

Tremor is the most common movement disorder. There are many varieties of tremors, each with characteristic features. It is important to recognize and diagnose them accurately and confidently for their successful management.

Tremors can be classified according to their specific clinical features or by etiology (Table 1). Because of the numerous and ever expanding etiologies of tremor, etiologic classification is not helpful, whereas classification based on clinical features is more useful to the clinician. Tremors can be divided into the following types.

Resting Tremor

Resting tremor occurs when there is no voluntary muscle activity and the limb is fully supported against gravity. Unlike essential tremor, resting tremor typically becomes less prominent with voluntary movement and therefore rarely results in motor disability. As with all forms of tremor, resting tremor becomes more evident with stress and is ameliorated by rest. The tremor amplitude increases with movements of another body part. Resting tremor is most commonly found in Parkinson disease but seldom in other conditions. It may initially involve the legs, a feature uncommon in essential tremor.

Action Tremor

This occurs with voluntary muscle contraction and includes postural, kinetic, and isometric tremor. Postural tremor is produced by voluntary maintenance of a particular posture held against gravity. Examples are physiologic tremor, essential tremor, certain drug-induced tremors, and postural tremor of Parkinson disease. Some postural tremors continue when the limb is supported, thus making it difficult to differentiate from resting tremor. However, tremor amplitude almost always diminishes during target-directed movements in resting tremor, while increasing or constant tremor amplitudes are found during voluntary movements in postural tremor.1

Kinetic tremor is evident during any voluntary movement. It can be intention tremor, task-specific tremor, or simple kinetic tremor. Kinetic tremor, which is exacerbated toward the end of a visually guided goal-directed movement, is called intention tremor. It is characteristically seen in cerebellar disorders.2 Intention tremor can sometimes be confused with action myoclonus. Task-specific tremor occurs during the performance of highly skilled activities such as writing, shaving, or playing a musical instrument. Primary writing tremor was first described by Rothwell et al in l979.3 The etiology of primary writing tremor is controversial. Some authors believe it is a variant of essential tremor4 while others believe it is a type of focal dystonia.5 However, unlike intention tremor, primary writing tremor is unilateral and tends to appear rather than suppress during skilled manual tasks.6 It may occur sporadically or be inherited as an autosomal dominant trait.3 It has 2 forms. Type A is characterized by tremor appearing during writing only, and type B occurs when the hand adopts a writing position.7 Simple pronation and supination movements test simple kinetic tremor.

Isometric tremor occurs when a voluntary muscle contraction is opposed by a rigid stationary object. It can be tested while making a fist or squeezing the examiner's fingers.

Physiologic Tremor

Physiologic tremor is an action tremor and is present in every healthy person. It becomes more pronounced during periods of muscular fatigue, anxiety, emotional stress, and fear or excitement. Other causes of enhanced physiologic tremor are thyrotoxicosis, pheochromocytoma, catecholamine infusion, methylxanthine administration, drug withdrawal states, and alcohol intoxication. These tremors are mostly reversible if the cause of the tremor is identified and corrected. The frequency of physiologic tremor in young adults is 8 to 12 Hz, gradually decreasing with age to around 6 to 7 Hz in persons older than 60 years.8 β-Receptor agonists enhance physiologic tremor whereas nonselective β-blockers and β-2 antagonists are effective in preventing such tremor.

Essential Tremor

Essential tremor is an action tremor, either postural or kinetic in character, mainly affecting the hands. It is bilateral and largely symmetrical. It affects 0.3% to 1.7% of the population9,10 and is the most common movement disorder. Half the cases are familial, with an autosomal dominant pattern of inheritance. The median age of onset is 15 years and both sexes are affected with equal frequency and severity.11 It commonly affects the head, neck, facial muscles, voice, jaw, tongue, and upper extremities,11 but except for upper extremities, does not affect the other parts of the body in isolation.12 The condition commonly progresses in severity with increasing age. The frequency of the tremor is 4 to 8 Hz. The diagnostic criteria include exclusion of other abnormal neurologic signs, especially dystonia.1 Positron emission tomography in patients with essential tremor reveals increased cerebellar activity even at rest.

Indeterminate Tremor Syndrome

Patients with indeterminate tremor syndrome have classic essential tremor in addition to other neurologic signs not sufficient to make a diagnosis of a recognizable neurologic disorder.1

Orthostatic Tremor

This is a rare entity first described by Heilman in 1984.13 It is a disorder of middle-aged or elderly people that is characterized by unsteadiness on standing secondary to a 16-Hz tremor of the lower limbs, which remits on walking or sitting. Patients stand on a wide base but walk normally. Only a fine ripple of muscle activity is visible. Lifting the standing patient off the ground abolishes the tremor,13 and when walking, tremor disappears from the non–weight-bearing limb. Tremor persists in the weight-bearing leg and in truncal muscles. Standing on "all fours" also induces a 16-Hz tremor in proximal upper limb muscles.14 It is most pronounced in leg and trunk muscles and usually does not involve the face, although a single case report of orthostatic jaw tremor has been described.15 Thirty percent of patients may also have essential tremor of the legs, which does not attenuate on walking. Recently it has been shown that orthostatic tremor is invariably present during stance or other weight-bearing positions; however, it is not always associated with orthostasis. Isometric contraction of the arm and leg muscles also induces 16-Hz tremor in some patients when supine or suspended upright with orthostatic tremor, implying that muscle contraction seems to be the critical factor in generating the 16-Hz tremor and that it is not a true orthostatic tremor.16 Symptomatic orthostatic tremor has been described in nontumoral aqueduct stenosis, relapsing polyradiculoneuropathy, pontine lesions, and following head trauma.1719 Only electromyographic recordings can confirm the diagnosis. The tremor frequency of 16 Hz has not been described in any other kind of tremor and is pathognomonic of orthostatic tremor. However, it has been suggested that auscultation with the diaphragm of a stethoscope over quadriceps and hamstrings during stance may reveal a repetitive thumping sound, thus obviating the need to recourse to electromyographic recordings.20

Isolated Chin Tremor

Isolated chin tremor, also called geniospasm, is an autosomal dominant hereditary syndrome characterized by episodic, usually stress-induced, high-frequency, contraction of the mentalis muscle.21 The onset is typically in infancy or childhood. Usually there is no evidence of any other nervous system abnormality, although abnormal electroencephalographic findings, sleep disorders, and involvement of other facial muscles have been described in rare cases.

Isolated Voice Tremor

Isolated voice tremor22 occurs in 2 variants. One is considered to be a form of focal dystonia of the vocal cords23; the other is considered to be a variant of essential tremor.24

Dystonic Tremor

Dystonic tremor is mainly a postural and kinetic tremor in an extremity or body part affected by dystonia. A typical example is tremulous spasmodic torticollis. Although essential tremor commonly accompanies dystonia, dystonic tremor is considered a separate entity. It is localized, asymmetric, and irregular in amplitude and periodicity.25 Some patients with dystonia have tremor of the body part not affected by dystonia. For example, patients with cervical dystonia often show an enhanced essential tremor of the upper limb.26,27 Isolated head tremor is also found in patients with first-degree relatives with spasmodic torticollis.

Monosymptomatic Resting Tremor

Monosymptomatic resting tremor is a resting and/or postural tremor in the absence of bradykinesia or rigidity significant enough to diagnose Parkinson disease.

Parkinson Disease

A pill-rolling resting tremor is characteristic of Parkinson disease, but postural tremor is also present in most cases.28 In many patients, 2 separate tremor peaks may be distinguished by spectral analysis and this pattern is considered pathognomonic of basal ganglia disease. Typically the parkinsonian tremor is asymmetrical, at least initially and affects the upper limb before involving the ipsilateral leg after a period of about 2 years. Tremor of the lips, jaw, or tongue may also occur, but head or voice tremor is rare.

Cerebellar Tremor

Intention tremor is the most common form of cerebellar tremor. There may be postural tremor, but resting tremor is not found in cerebellar diseases.

Holmes Tremor

This is a symptomatic tremor caused by lesions in the brainstem, cerebellum, or thalamus. It has been labeled in the past as rubral tremor,29 midbrain tremor,30 thalamic tremor,31 myorhythmia,32 and Benedikt syndrome, but the Ad Hoc Scientific Committee on Movement Disorders has applied the term "Holmes tremor" to all these forms of tremor.1 The tremors attributed to these different lesions are postural and/or action in nature and worsen during movement and markedly increase during goal-directed movements. These tremors affect predominantly proximal limbs and are of low frequency.33

Palatal Tremor

Palatal tremor can be either symptomatic due to brainstem and/or cerebellar lesions or essential without any demonstrable brain lesion. In symptomatic palatal tremor, olivary hypertrophy can be demonstrated on magnetic resonance imaging.34 In the essential palatal tremor, the patient usually has ear clicks, which do not occur in symptomatic variety. The symptomatic form is often associated with pendular vertical nystagmus. Rhythmic movements of tensor veli palatini and levator veli palatini muscles occur in essential and symptomatic palatal tremor, respectively.35

Symptomatic palatal tremor has been observed in patients with cerebrovascular disease, encephalitis, multiple sclerosis, trauma, and neurodegenerative diseases including olivopontocerebellar atrophy, Alexander disease, spinocerebellar degeneration, progressive supranuclear palsy, and other neurodegenerative diseases of uncertain origin. Approximately two thirds of patients with palatal tremor and neurodegenerative diseases have evidence of rhythmic tremors in other parts of the body, involving the eyes, larynx, neck, and diaphragm.36

Drug-Induced Tremor

The most common form of drug-induced tremor is enhanced physiologic tremor due to sympathomometic use, antidepressant use, or alcohol withdrawal. Neuroleptics or dopamine antagonists cause classic parkinsonian tremor. Long-term neuroleptic treatment can result in a postural tremor with a frequency of 3 to 5 Hz, but is also present at rest and during goal-directed movements. This is called tardive tremor. Lithium intoxication can cause a cerebellar tremor.37 Treatment is withdrawal or dose reduction of the offending agent if possible.

Neuropathic Tremor

Tremor has been described in many neuropathies including X-linked bulbospinomuscular atrophy,38 hereditary motor-sensory neuropathy,39 multifocal motor neuropathy,40 Charcot-Marie-Tooth syndrome,41 Guillain-Barré syndrome,42 and human T-lymphotropic virus 1–associated neuropathy,43 but demyelinating neuropathies and dysgammaglobulinemic neuropathies are the most common causes of such tremors.44,45 Characteristically, an action tremor resembling essential tremor is found in these patients.

Psychogenic Tremor

Psychogenic tremor is usually a combination of resting and postural or intention tremors. Onset and remission of the tremor is sudden and tremor amplitude decreases during distraction. The tremor does not involve the fingers.46 There may be a history of somatization, and additional unrelated neurologic signs might appear.

Table 2 lists treatment for various tremor types.

Medical Treatment

The first line of treatment for tremor is oral medication. β-Blockers, anticholinergic medication, and levodopa are useful modalities for resting tremor. Kinetic tremor may respond to β-blockers, primidone, anticholinergic medication, and alcohol.

Physiologic Tremor. Usually no treatment is required for physiologic tremor. However, it may interfere with activities requiring extreme precision. Treatment of exaggerated physiologic tremor requires identification and removal or treatment of the precipitating cause such as thyrotoxicosis, hypoglycemia, emotional stress, pheochromocytoma, and use of tricyclic antidepressants, neuroleptics, and lithium. In cases in which the precipitating cause cannot be removed or highly skilled fine motor function is desired, treatment with propranolol may be effective.47

Essential Tremor. Alcohol intake will temporarily cause dramatic tremor reduction lasting 45 to 60 minutes in the majority of patients with essential tremor.48 However, this temporary improvement is followed by a rebound phenomenon when the alcohol effect wears off. Moreover, tolerance develops to the effect of alcohol and with time larger amounts of alcohol may be needed to cause tremor reduction. The mechanism of action of alcohol is unknown. However, in a positron emission tomography study, alcohol has been shown to reduce the overactivity of cerebellar connections seen in essential tremor.49

Propranolol was discovered by chance to improve essential tremor.50 β-Adrenergic blocking drugs (mainly a nonselective blocker such as propranolol or a β2-selective blocker) have been the mainstays for the treatment of essential tremor. They are, however, less effective in the treatment of essential voice and head tremor. Propranolol reduces tremor amplitude but not tremor frequency. The clinical response to propranolol is variable and often incomplete.51 Nipradilol, a new β-blocker, has been shown to be effective in essential tremor in a study involving 20 patients.52

Gabapentin has been used in the treatment of essential tremor. In a comparative double-blind crossover placebo-controlled trial of patients with essential tremor, both propranolol and gabapentin demonstrated significant and comparable efficacy in reducing tremor.53 Theophylline has been shown to be a useful agent in the treatment of essential tremor. In a blind crossover trial, theophylline reduced tremor to the same extent as propranolol.54 Primidone has been shown to be effective in the treatment of essential tremor.55 It reduces tremor more than propranolol and its antitremor effect is maintained over the first year of therapy.56 Benzodiazepines have been used in the treatment of tremor. However, their efficacy is limited. Thompson et al57 found no effect of clonazepam on essential tremor. Clozapine can substantially improve essential tremor, but its use is limited as it can cause fatal agranulocytosis.58 Botulinum toxin has been used in the treatment of essential tremor of the hand, voice, and head. It has been found to improve tremor severity significantly without improving function. This may be due to the resultant focal weakness. In a randomized clinical trial of 25 patients with essential tremor of the hand, significant improvement in tremor severity rating scales was reported.59 It was concluded that botulinum toxin has modest tremorlytic effect. Botulinum toxin has been found to be useful in the treatment of essential tremors of the head and voice60,61 and since these tremors are difficult to treat pharmacologically, botulinum toxin treatment should be triedbefore recourse to other modalities. Use of botulinum toxin for essential head and voice tremors, however, can be complicated with dysphasia.

Parkinsonian Tremor. The response of parkinsonian tremor to treatment is variable. Several drugs have been tried. Both trihexiphenidyl hydrochloride and carbidopa-levodopa combination have been shown to significantly reduce the tremor of Parkinson disease. In a study comparing the effects of trihexiphenidyl, carbidopa-levodopa, and amantadine hydrochloride, tremor amplitude was reduced by 59% with trihexiphenidyl, 55% by carbidopa-levodopa, and 23% by amantadine.62 Dopaminergic and anticholinergic agents are equally effective in patients with parkinsonian tremor, but dopaminergic substances additionally improve other parkinsonian signs.63 However, other studies involving dopamine agonists have shown variable results.6467 Propranolol has been shown to reduce the amplitude of resting tremor by 70% and that of postural tremor by 50% and so can be used as adjunctive therapy in the treatment of parkinsonian tremor.68 Apomorphine hydrochloride has been shown to reduce the resting tremor of Parkinson disease In a study of 20 patients, Hughes et al69 demonstrated good responses to short-term, single challenges of subcutaneous apomorphine in 19 patients. Clozapine has also been shown to be effective in parkinsonian tremor.70 Friedman et al,71 in a double-blind crossover study, compared the effects of clozapine with benztropine mesylate in 19 patients. Both drugs were found to be equally effective in reducing tremor. An added advantage of clozapine is its effectiveness in the treatment of hallucinations in Parkinson disease. In a double-blind trial of parkinsonian patients with mixed levodopa-resistant tremors, 15 of the 17 patients reported moderate to marked reduction of tremor.72

Orthostatic Tremor. Orthostatic tremor rarely responds to β blocker therapy but can be ameliorated by clonazepam alone or in combination with primidone.73 In one small study,74 8 of 9 patients responded to clonazepam. The patient who did not respond to clonazepam, responded to chlordiazepoxide. In another study,75 10 of 18 patients showed improvement with clonazepam and the remaining 8 patients responded to valproic acid. Levodopa76 or gabapentin77,78 may also improve orthostatic tremor.

Dystonic Tremor. Pharmacologic treatment of dystonic tremor is usually disappointing; however, clonazepam or anticholinergics may be tried.79,80 Treatment of the underlying dystonia with botulinum toxin often results in significant improvement of tremor.81

Cerebellar Tremor. There is no effective treatment of cerebellar tremor. However, some success has been reported with clonazepam.82 It may also respond to levodopa and anticholinergic agents or clozapine when a clinically significant resting tremor is present. Odansetron, a 5-hydroxytryptophan-3 antagonist, has been shown to improve cerebellar tremor in a placebo-controlled double-blind crossover study involving 20 patients.83

Holmes Tremor. Treatment of Holmes tremor is usually unsuccessful. Some success with carbidopa-levodopa and clonazepam has been reported.84,85

Neuropathic Tremor. Treatment of neuropathy may or may not improve neuropathic tremor. The tremor of hereditary motor-sensory neuropathy often responds to treatment with propranolol and alcohol.86

The minimal criteria for a patient to be considered a candidate for neurosurgery are a lack of response to medical treatment, tremor resulting in severe disability, and the absence of contraindications to neurosurgery.

Thermocoagulation (thalamotomy) and deep brain stimulation target nucleus ventralis intermedius thalami. Thalamotomy and thalamic stimulation cause an improvement of the tremor in 80% to 90% of patients with Parkinson disease. Unilateral thalamotomy improves the contralateral tremor in 90% of patients.87 However, problems associated with bilateral thalamotomy, such as dysphagia and dysarthria, limit its use. Deep brain stimulation has similar benefits to thermocoagulation but fewer side effects, including lower perioperative mortality.88 Koller et al89 and Limousin et al90 have shown the benefits of deep brain stimulation in patients with Parkinson disease or essential tremor in controlled, prospective studies. Other targets for the treatment of parkinsonian tremor are internal pallidum (pallidotomy) and subthalamic nucleus. In a series of 259 patients who underwent pallidotomy for parkinsonian tremor, complete relief of all symptoms on the contralateral side occurred in 81.9% of patients. Nearly 77% of the remaining patients experienced substantial improvement.91 Pallidotomy also improves akinesia and decreases levodopa-induced dyskinesia.92 The side effects associated with pallidotomy are visual field defects, hemiparesis, dysarthria, and cognitive deficits.

Stimulation of subthalamic nucleus improves not only tremor but also akinesia by about 70%.93

Thalamotomy can achieve a permanent satisfying tremor relief in the contralateral extremities of 69% to 93% of patients with essential tremor.94 Thalamic stimulation has the advantage of less morbidity and the possibility of bilateral surgical treatment, as is needed in most patients with essential tremor.

Patients with tremor due to multiple sclerosis have also shown a favorable response to deep brain stimulation in smaller studies.95

Isolated reports of satisfying symptomatic and functional results of thalamotomy have been reported in patients with task-specific tremors.96

Tremor is the most common movement disorder. There are many varieties of tremors, each with characteristic features. It is important to recognize and diagnose them accurately and confidently for their successful management.

Accepted for publication April 18, 2000.

Reprints: Habib-ur-Rehman, MRCP, Specialist Registrar, Department of Medicine, Hull Royal Infirmary, Hull HU3 2JZ, England (e-mail: habib@rehman786.freeserve.co.uk).

Deuschl  GBain  PBrin  M Consensus statement of Movement Disorder Society on Tremor. Mov Disord. 1998;13(suppl 3)2- 23
Link to Article
Sanes  JNLeWitt  PAMauritz  KH Visual and mechanical control of postural and kinetic tremor in cerebellar system disorders. J Neurol Neurosurg Psychiatry. 1988;51934- 943
Link to Article
Rothwell  JCTraub  MMMarsden  CD Primary writing tremor. J Neurol Neurosurg Psychiatry. 1979;421106- 1114
Link to Article
Kachi  TRothwell  JCCowan  JMAMarsden  CD Writing tremor: its relationship to benign essential tremor. J Neurol Neurosurg Psychiatry. 1985;48545- 550
Link to Article
Ravits  JHallett  MBaker  MWilkins  D Primary writing tremor and myoclonic writer's cramp. Neurology. 1985;351387- 1391
Link to Article
Bain  PGFindley  LJBritton  TC  et al.  Primary writing tremor. Brain. 1995;1181461- 1472
Link to Article
Bain  PGFindley  LJBritton  TC  et al.  Primary writing tremor. Brain. 1995;1181461- 1472
Link to Article
Marshall  J The effect of aging upon physiological tremor. J Neurol Neurosurg Psychiatry. 1961;2414- 17
Link to Article
Rajput  AHOddord  KPBeard  CMKurland  LT Essential tremor in Rochester, Minnesota: a 45 year study. J Neurol Neurosurg Psychiatry. 1984;47466- 470
Link to Article
Larsson  TSjogren  T Essential tremor: a clinical and genetic population study. Acta Psychiatr Scand. 1960;361- 176
Bain  PGFindley  LJThompson  PD  et al.  A study of hereditary essential tremor. Brain. 1994;117 ((pt 4)) 805- 824
Link to Article
Bain  PGFindley  LJThompson  PD  et al.  A study of hereditary essential tremor. Brain. 1994;117805- 824
Link to Article
Heilman  KM Orthostatic tremor. Arch Neurol. 1984;41880- 881
Link to Article
Britton  TCThompson  PDvan der Kamp  W  et al.  Primary orthostatic tremor: further observations in six cases. J Neurol. 1992;239209- 217
Link to Article
Schrag  ABhatia  KBrown  PMarsden  CD An unusual jaw tremor with characteristics of primary orthostatic tremor. Mov Disord. 1999;14528- 530
Link to Article
Boroojerdi  BFerbert  AFoltys  HKosinski  CMNoth  JSchwarz  M Evidence for a non-orthostatic origin of orthostatic tremor. J Neurol Neurosurg Psychiatry. 1999;66284- 288
Link to Article
Gabellini  ASMartinelli  PGulli  MRAmbrosetto  GCiucci  GLugaresi  E Orthostatic tremor: essential and symptomatic cases. Acta Neurol Scand. 1989;79119- 122
Link to Article
Sanitate  SSMeerschaert  JR Orthostatic tremor: delayed onset following head trauma. Arch Phys Med Rehabil. 1993;74886- 889
Link to Article
Benito-León  JRodríguez  JOrtí-Pareja  MAyuso-Peralta  LJiménez-Jiménez  FJMolina  JA Symptomatic orthostatic tremor in pontine lesions. Neurology. 1997;491439- 1441
Link to Article
Brown  P New clinical sign for orthostatic tremor. Lancet. 1995;346306- 307
Link to Article
Danek  A Geniospasm: hereditary chin trembling. Mov Disord. 1993;8335- 338
Link to Article
Hachinski  VCThomsen  IVBuch  NH The nature of primary vocal tremor. Can J Neurol Sci. 1975;2195- 197
Aminoff  MJDedo  HHIzdebski  K Clinical aspects of spasmodic dysphonia. J Neurol Neurosurg Psychiatry. 1978;41361- 365
Link to Article
Massey  EWPaulson  GW Essential vocal tremor: clinical characteristics and response to therapy. South Med J. 1985;78316- 317
Link to Article
Wasielewski  PGBurns  JMKoller  WC Pharmacologic treatment of tremor. Mov Disord. 1998;13(suppl 3)90- 100
Link to Article
Van  ZM Cervical dystonia (spasmodic torticollis): some aspects of the natural history. Acta Neurol Belg. 1995;95210- 215
Deuschl  GHeinen  FGuschlbauer  B  et al.  Hand tremor in patients with spasmodic torticollis. Mov Disord. 1997;12547- 552
Link to Article
Findley  LJGresty  MAHalmagyi  GM Tremor, the cogwheel phenomenon and clonus in Parkinson's disease. J Neurol Neurosurg Psychiatry. 1981;44534- 546
Link to Article
Krack  PDeuschl  GKaps  M  et al.  Delayed onset of `rubral tremor' 23 years after brainstem trauma. Mov Disord. 1994;9240- 242
Link to Article
Defer  GLRemy  PMalapert  D  et al.  Rest tremor and extrapyramidal symptoms after midbrain haemorrhage: clinical and 18F-dopa PET evaluation. J Neurol Neurosurg Psychiatry. 1994;57987- 989
Link to Article
Rajshekhar  V Benign thalamic cyst presenting with contralateral postural tremor. J Neurol Neurosurg Psychiatry. 1994;571139- 1140
Link to Article
Masucci  EFKurtzke  JFSaini  N Myorhythmia: a widespread movement disorder: clinicopathological correlations. Brain. 1984;10753- 79
Link to Article
Vidailhet  MJedynak  CPPollak  PAgid  Y Pathology of symtomatic tremors. Mov Disord. 1998;13(suppl 3)49- 54
Link to Article
Deuschl  GMischke  GSchenk  E  et al.  Symptomatic and essential rhythmic palatal myoclonus. Brain. 1990;1131645- 1672
Link to Article
Hallett  M Overview of human tremor physiology. Mov Disord. 1998;13(suppl 3)43- 48
Link to Article
Kulkarni  PKMuthane  UBTaly  ABJayakumar  PNShetty  RSwamy  HS Palatal tremor, progressive multiple cranial nerve palsies, and cerebellar ataxia: a case report and review of literature of palatal tremors in neurodegenerative disease. Mov Disord. 1999;14689- 693
Link to Article
Stacy  MJankovic  J Tardive tremor. Mov Disord. 1992;753- 57
Link to Article
Albers  JWBromberg  MB X-linked bulbospinomuscular atrophy (Kennedy's disease) masquerading as lead neuropathy. Muscle Nerve. 1994;17419- 423
Link to Article
Cardoso  FEJankovic  J Hereditary motor-sensory neuropathy and movement disorders. Muscle Nerve. 1993;16904- 910
Link to Article
Chaudhry  VCorse  AMCornblath  DR  et al.  Multifocal motor neuropathy: response to human immune globulin. Ann Neurol. 1993;33237- 242
Link to Article
de Freitas  MNascimento  OJde Freitas  G Charcot-Marie-Tooth disease: clinical study in 45 patients. Arq Neuropsiquiatr. 1995;53545- 551
Link to Article
Grand' Maison  FFeasby  TEHahn  AF  et al.  Recurrent Guillain-Barré syndrome: clinical and laboratory features. Brain. 1992;1151093- 1106
Link to Article
Kanzaki  AYabuki  SShirabe  T HTLV-1 associated neuropathy. No To Shinkei. 1995;47497- 501
Bain  PGBritton  TCJenkins  IH  et al.  Tremor associated with benign IgM paraproteinaemic neuropathy. Brain. 1996;119789- 799
Link to Article
Dalakas  MCTeravainen  HEngel  WK Tremor as a feature of chronic relapsing and dysgammaglobulinemic polyneuropathies: incidence and management. Arch Neurol. 1984;41711- 714
Link to Article
Deuschl  GKöster  BCHLScheidt  C Diagnostic criteria and clinical course of psychogenic tremors. Mov Disord. 1998;13294- 302
Link to Article
Hallet  M Classification and treatment of tremor. JAMA. 1984;2661115- 1117
Link to Article
Koller  WCBiary  N Effect of alcohol on tremor: comparison to propranolol. Neurology. 1984;34221- 222
Link to Article
Boecker  HWills  AJCeballos-Baumann  A  et al.  The effect of ethanol on alcohol-responsive essential tremor: a positron emission tomography study. Ann Neurol. 1996;39650- 658
Link to Article
Barbeau  A Treatment du tremblement essential familial par le propranolol. Union Med Can. 1962;102899- 902
Larsen  TACalne  DB Essential tremor. Clin Neuropharmacol. 1983;6185- 206
Link to Article
Yoshii  FShinohara  YTakeoka  TKitagawa  YAkiyama  KYazaki  K Treatment of essential and parkinsonian tremor with nipradilol. Intern Med. 1996;35861- 865
Link to Article
Gironell  AKulisevsky  JBarbanoj  M  et al.  A randomized placebo-controlled comparative trial of gabapentin and propranolol in essential tremor. Arch Neurol. 1999;56475- 480
Link to Article
Mally  JStone  TW Efficacy of an adenosine antagonist, theophylline, in essential tremor: comparison with placebo and propranolol. J Neurol Sci. 1995;132129- 132
Link to Article
Koller  WCRoyse  V Efficacy of primidone in essential tremor. Neurology. 1986;36121- 124
Link to Article
Sasso  EPerucca  EFava  NCalzetti  S Primidone in the long-term treatment of essential tremor: a prospective study with computerized quantitative analysis. Clin Neuropharmacol. 1990;1367- 76
Link to Article
Thompson  CLang  AParkes  JDMarsden  CD A double-blind trial of clonazepam in benign essential tremor. Clin Neuropharmacol. 1984;783- 88
Link to Article
Ceravolo  RSalvetti  SPiccini  PLucetti  CGambaccini  GBonuccelli  U Acute and chronic effects of clozapine in essential tremor. Mov Disord. 1999;14468- 472
Link to Article
Jankovic  JSchwartz  KClemence  WAswad  AMordrunt  J A randomized double-blind, placebo-controlled study to evaluate botulinum toxin type A in essential hand tremor. Mov Disord. 1996;11250- 256
Link to Article
Pahwa  RBusenbark  KSwanson-Hyland  EF  et al.  Botulinum toxin treatment of essential head tremor. Neurology. 1995;45822- 824
Link to Article
Ludlow  CL Treatment of speech and voice disorders with botulinum toxin. JAMA. 1990;2642671- 2675
Link to Article
Koller  WC Pharmacologic treatment of parkinsonian tremor. Arch Neurol. 1986;43126- 127
Link to Article
Schrag  ASchelosky  LScholz  UPoewe  W Reduction of parkinsonian signs in patients with Parkinson's disease by dopaminergic versus anticholinergic single-dose challenges. Mov Disord. 1999;14252- 255
Link to Article
Kartzinel  RTeychenne  PGillespie  MM  et al.  Bromocriptine and levodopa (with or without carbidopa) in parkinsonism. Lancet. 1976;2272- 275
Link to Article
Lieberman  AZolfaghari  MBoal  D  et al.  The antiparkinsonian efficacy of bromocriptine. Neurology. 1976;26405- 409
Link to Article
Parkes  JDSchachter  MMarsden  CDSmith  BWilson  A Lisuride in parkinsonism. Ann Neurol. 1981;948- 52
Link to Article
Gopinathan  GTeravainen  HDambrosia  JM  et al.  Lisuride in parkinsonism. Neurology. 1981;31371- 376
Link to Article
Koller  WCHerbster  G Adjuvant therapy of parkinsonian tremor. Arch Neurol. 1987;44921- 923
Link to Article
Hughes  AJLees  AJStern  GM Apomorphine in the diagnosis and treatment of parkinsonian tremor. Clin Neuropharmacol. 1990;13312- 317
Link to Article
Pakkenberg  HPakkenberg  B Clozapine in the treatment of tremor. Acta Neurol Scand. 1986;73295- 297
Link to Article
Friedman  JHKoller  WCLannon  MC  et al.  Benztropine versus clozapine for the treatment of tremor in Parkinson's disease. Neurology. 1997;481077- 1081
Link to Article
Bonuccelli  UCeravolo  RSalvetti  S  et al.  Clozapine in Parkinson's disease: effects of acute and chronic administration. Neurology. 1997;491587- 1590
Link to Article
Poersch  M Orthostatic tremor: combined treatment with primidone and clonazepam. Mov Disord. 1994;9467
Link to Article
Gates  PC Orthostatic tremor (shaky legs syndrome). Clin Exp Neurol. 1993;3066- 71
McManis  PGSharbrough  FW Orthostatic tremor: clinical and electrophysiologic characteristics. Muscle Nerve. 1993;161254- 1260
Link to Article
Wills  AJBrusa  LWang  HCBrown  PMarsden  CD Levodopa may improve orthostatic tremor: case report and trial of treatment. J Neurol Neurosurg Psychiatry. 1999;66681- 684
Link to Article
Evidente  VGAdler  CHCaviness  JNGwinn  KA Effective treatment of orthostatic tremor with gabapentin. Mov Disord. 1998;13829- 831
Link to Article
Onofrj  MThomas  APaci  CD'Andreamatteo  G Gabapentin in orthostatic tremor: results of a double-blind crossover with placebo in four patients. Neurology. 1998;51880- 882
Link to Article
Rivest  JMarsden  CD Trunk and head tremor in isolated manifestations of dystonia. Mov Disord. 1990;560- 65
Link to Article
Davis  TLCharles  PDBurns  S Clonazepam-sensitive intermittent dystonic tremor. South Med J. 1995;881069- 1071
Link to Article
Manyam  BV Uncommon forms of tremor. Watts  RLKoller  WCedsMovement Disorders Neurologic Principles and Practice. New York, NY McGraw-Hill1997;387- 403
Trelles  LTrelles  JOCastro  CAltamirano  JBenaquen  M Successful treatment of two cases of intention tremor with clonazepam. Ann Neurol. 1984;16621
Link to Article
Rice  GPALesaux  JVandervoort  PMacewan  LEbers  GC Odansetron, a 5-HT3 antagonist, improves cerebellar tremor. J Neurol Neurosurg Psychiatry. 1997;62282- 284
Link to Article
Findley  LJGresty  MA Suppression of `rubral' tremor with levodopa. BMJ. 1980;281043
Link to Article
Biary  NCleeves  LFindley  LKoller  W Post-traumatic tremor. Neurology. 1989;39103- 106
Link to Article
Cardoso  FECJankovic  J Hereditary motor-sensory neuropathy and movement disorders. Muscle Nerve. 1993;16904- 910
Link to Article
Kelly  PJGillingham  FJ The longterm results of stereotaxic surgery and L-dopa therapy in patients with Parkinson's disease. J Neurosurg. 1980;53332- 337
Link to Article
Schuurman  PRBosch  DABossuyt  PMM  et al.  A comparison of continuous thalamic stimulation and thalamotomy for suppression of severe tremor. N Engl J Med. 2000;342461- 468
Link to Article
Koller  WPahwa  RBusenbark  K  et al.  High-frequency unilateral thalamic stimulation in the treatment of essential and parkinsonian tremor. Ann Neurol. 1997;42292- 299
Link to Article
Limousin  PSpeelman  JDGielen  FJanssens  M Multicentre European study of thalamic stimulation in parkinsonian and essential tremor. J Neurol Neurosurg Psychiatry. 1999;66289- 296
Link to Article
Laitinen  LV Pallidotomy for Parkinson's disease. Neurosurg Clin N Am. 1995;6105- 112
Laitinen  LVBergenheim  ATHariz  MI Leksell's posteroventral pallidotomy in the treatment of Parkinson's disease. J Neurosurg. 1992;7653- 61
Link to Article
Krack  PPollak  PLimousin  PBenazzouz  ABenabid  AL Stimulation of subthalamic nucleus alleviates tremor in Parkinson's disease. Lancet. 1997;3501675
Link to Article
Van Manen  J Stereotaxic operation in cases of hereditary and intention tremor. Acta Neurochir. 1974;2149- 55
Benabid  ALPollak  PGao  D  et al.  Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders. J Neurosurg. 1996;84203- 214
Link to Article
Ohye  CMiyazaki  MHirai  TShibazaki  TNakayima  HNagaseki  Y Primary writing tremor treated by stereotactic selective thalamotomy. J Neurol Neurosurg Psychiatry. 1982;45988- 997
Link to Article

Figures

References

Deuschl  GBain  PBrin  M Consensus statement of Movement Disorder Society on Tremor. Mov Disord. 1998;13(suppl 3)2- 23
Link to Article
Sanes  JNLeWitt  PAMauritz  KH Visual and mechanical control of postural and kinetic tremor in cerebellar system disorders. J Neurol Neurosurg Psychiatry. 1988;51934- 943
Link to Article
Rothwell  JCTraub  MMMarsden  CD Primary writing tremor. J Neurol Neurosurg Psychiatry. 1979;421106- 1114
Link to Article
Kachi  TRothwell  JCCowan  JMAMarsden  CD Writing tremor: its relationship to benign essential tremor. J Neurol Neurosurg Psychiatry. 1985;48545- 550
Link to Article
Ravits  JHallett  MBaker  MWilkins  D Primary writing tremor and myoclonic writer's cramp. Neurology. 1985;351387- 1391
Link to Article
Bain  PGFindley  LJBritton  TC  et al.  Primary writing tremor. Brain. 1995;1181461- 1472
Link to Article
Bain  PGFindley  LJBritton  TC  et al.  Primary writing tremor. Brain. 1995;1181461- 1472
Link to Article
Marshall  J The effect of aging upon physiological tremor. J Neurol Neurosurg Psychiatry. 1961;2414- 17
Link to Article
Rajput  AHOddord  KPBeard  CMKurland  LT Essential tremor in Rochester, Minnesota: a 45 year study. J Neurol Neurosurg Psychiatry. 1984;47466- 470
Link to Article
Larsson  TSjogren  T Essential tremor: a clinical and genetic population study. Acta Psychiatr Scand. 1960;361- 176
Bain  PGFindley  LJThompson  PD  et al.  A study of hereditary essential tremor. Brain. 1994;117 ((pt 4)) 805- 824
Link to Article
Bain  PGFindley  LJThompson  PD  et al.  A study of hereditary essential tremor. Brain. 1994;117805- 824
Link to Article
Heilman  KM Orthostatic tremor. Arch Neurol. 1984;41880- 881
Link to Article
Britton  TCThompson  PDvan der Kamp  W  et al.  Primary orthostatic tremor: further observations in six cases. J Neurol. 1992;239209- 217
Link to Article
Schrag  ABhatia  KBrown  PMarsden  CD An unusual jaw tremor with characteristics of primary orthostatic tremor. Mov Disord. 1999;14528- 530
Link to Article
Boroojerdi  BFerbert  AFoltys  HKosinski  CMNoth  JSchwarz  M Evidence for a non-orthostatic origin of orthostatic tremor. J Neurol Neurosurg Psychiatry. 1999;66284- 288
Link to Article
Gabellini  ASMartinelli  PGulli  MRAmbrosetto  GCiucci  GLugaresi  E Orthostatic tremor: essential and symptomatic cases. Acta Neurol Scand. 1989;79119- 122
Link to Article
Sanitate  SSMeerschaert  JR Orthostatic tremor: delayed onset following head trauma. Arch Phys Med Rehabil. 1993;74886- 889
Link to Article
Benito-León  JRodríguez  JOrtí-Pareja  MAyuso-Peralta  LJiménez-Jiménez  FJMolina  JA Symptomatic orthostatic tremor in pontine lesions. Neurology. 1997;491439- 1441
Link to Article
Brown  P New clinical sign for orthostatic tremor. Lancet. 1995;346306- 307
Link to Article
Danek  A Geniospasm: hereditary chin trembling. Mov Disord. 1993;8335- 338
Link to Article
Hachinski  VCThomsen  IVBuch  NH The nature of primary vocal tremor. Can J Neurol Sci. 1975;2195- 197
Aminoff  MJDedo  HHIzdebski  K Clinical aspects of spasmodic dysphonia. J Neurol Neurosurg Psychiatry. 1978;41361- 365
Link to Article
Massey  EWPaulson  GW Essential vocal tremor: clinical characteristics and response to therapy. South Med J. 1985;78316- 317
Link to Article
Wasielewski  PGBurns  JMKoller  WC Pharmacologic treatment of tremor. Mov Disord. 1998;13(suppl 3)90- 100
Link to Article
Van  ZM Cervical dystonia (spasmodic torticollis): some aspects of the natural history. Acta Neurol Belg. 1995;95210- 215
Deuschl  GHeinen  FGuschlbauer  B  et al.  Hand tremor in patients with spasmodic torticollis. Mov Disord. 1997;12547- 552
Link to Article
Findley  LJGresty  MAHalmagyi  GM Tremor, the cogwheel phenomenon and clonus in Parkinson's disease. J Neurol Neurosurg Psychiatry. 1981;44534- 546
Link to Article
Krack  PDeuschl  GKaps  M  et al.  Delayed onset of `rubral tremor' 23 years after brainstem trauma. Mov Disord. 1994;9240- 242
Link to Article
Defer  GLRemy  PMalapert  D  et al.  Rest tremor and extrapyramidal symptoms after midbrain haemorrhage: clinical and 18F-dopa PET evaluation. J Neurol Neurosurg Psychiatry. 1994;57987- 989
Link to Article
Rajshekhar  V Benign thalamic cyst presenting with contralateral postural tremor. J Neurol Neurosurg Psychiatry. 1994;571139- 1140
Link to Article
Masucci  EFKurtzke  JFSaini  N Myorhythmia: a widespread movement disorder: clinicopathological correlations. Brain. 1984;10753- 79
Link to Article
Vidailhet  MJedynak  CPPollak  PAgid  Y Pathology of symtomatic tremors. Mov Disord. 1998;13(suppl 3)49- 54
Link to Article
Deuschl  GMischke  GSchenk  E  et al.  Symptomatic and essential rhythmic palatal myoclonus. Brain. 1990;1131645- 1672
Link to Article
Hallett  M Overview of human tremor physiology. Mov Disord. 1998;13(suppl 3)43- 48
Link to Article
Kulkarni  PKMuthane  UBTaly  ABJayakumar  PNShetty  RSwamy  HS Palatal tremor, progressive multiple cranial nerve palsies, and cerebellar ataxia: a case report and review of literature of palatal tremors in neurodegenerative disease. Mov Disord. 1999;14689- 693
Link to Article
Stacy  MJankovic  J Tardive tremor. Mov Disord. 1992;753- 57
Link to Article
Albers  JWBromberg  MB X-linked bulbospinomuscular atrophy (Kennedy's disease) masquerading as lead neuropathy. Muscle Nerve. 1994;17419- 423
Link to Article
Cardoso  FEJankovic  J Hereditary motor-sensory neuropathy and movement disorders. Muscle Nerve. 1993;16904- 910
Link to Article
Chaudhry  VCorse  AMCornblath  DR  et al.  Multifocal motor neuropathy: response to human immune globulin. Ann Neurol. 1993;33237- 242
Link to Article
de Freitas  MNascimento  OJde Freitas  G Charcot-Marie-Tooth disease: clinical study in 45 patients. Arq Neuropsiquiatr. 1995;53545- 551
Link to Article
Grand' Maison  FFeasby  TEHahn  AF  et al.  Recurrent Guillain-Barré syndrome: clinical and laboratory features. Brain. 1992;1151093- 1106
Link to Article
Kanzaki  AYabuki  SShirabe  T HTLV-1 associated neuropathy. No To Shinkei. 1995;47497- 501
Bain  PGBritton  TCJenkins  IH  et al.  Tremor associated with benign IgM paraproteinaemic neuropathy. Brain. 1996;119789- 799
Link to Article
Dalakas  MCTeravainen  HEngel  WK Tremor as a feature of chronic relapsing and dysgammaglobulinemic polyneuropathies: incidence and management. Arch Neurol. 1984;41711- 714
Link to Article
Deuschl  GKöster  BCHLScheidt  C Diagnostic criteria and clinical course of psychogenic tremors. Mov Disord. 1998;13294- 302
Link to Article
Hallet  M Classification and treatment of tremor. JAMA. 1984;2661115- 1117
Link to Article
Koller  WCBiary  N Effect of alcohol on tremor: comparison to propranolol. Neurology. 1984;34221- 222
Link to Article
Boecker  HWills  AJCeballos-Baumann  A  et al.  The effect of ethanol on alcohol-responsive essential tremor: a positron emission tomography study. Ann Neurol. 1996;39650- 658
Link to Article
Barbeau  A Treatment du tremblement essential familial par le propranolol. Union Med Can. 1962;102899- 902
Larsen  TACalne  DB Essential tremor. Clin Neuropharmacol. 1983;6185- 206
Link to Article
Yoshii  FShinohara  YTakeoka  TKitagawa  YAkiyama  KYazaki  K Treatment of essential and parkinsonian tremor with nipradilol. Intern Med. 1996;35861- 865
Link to Article
Gironell  AKulisevsky  JBarbanoj  M  et al.  A randomized placebo-controlled comparative trial of gabapentin and propranolol in essential tremor. Arch Neurol. 1999;56475- 480
Link to Article
Mally  JStone  TW Efficacy of an adenosine antagonist, theophylline, in essential tremor: comparison with placebo and propranolol. J Neurol Sci. 1995;132129- 132
Link to Article
Koller  WCRoyse  V Efficacy of primidone in essential tremor. Neurology. 1986;36121- 124
Link to Article
Sasso  EPerucca  EFava  NCalzetti  S Primidone in the long-term treatment of essential tremor: a prospective study with computerized quantitative analysis. Clin Neuropharmacol. 1990;1367- 76
Link to Article
Thompson  CLang  AParkes  JDMarsden  CD A double-blind trial of clonazepam in benign essential tremor. Clin Neuropharmacol. 1984;783- 88
Link to Article
Ceravolo  RSalvetti  SPiccini  PLucetti  CGambaccini  GBonuccelli  U Acute and chronic effects of clozapine in essential tremor. Mov Disord. 1999;14468- 472
Link to Article
Jankovic  JSchwartz  KClemence  WAswad  AMordrunt  J A randomized double-blind, placebo-controlled study to evaluate botulinum toxin type A in essential hand tremor. Mov Disord. 1996;11250- 256
Link to Article
Pahwa  RBusenbark  KSwanson-Hyland  EF  et al.  Botulinum toxin treatment of essential head tremor. Neurology. 1995;45822- 824
Link to Article
Ludlow  CL Treatment of speech and voice disorders with botulinum toxin. JAMA. 1990;2642671- 2675
Link to Article
Koller  WC Pharmacologic treatment of parkinsonian tremor. Arch Neurol. 1986;43126- 127
Link to Article
Schrag  ASchelosky  LScholz  UPoewe  W Reduction of parkinsonian signs in patients with Parkinson's disease by dopaminergic versus anticholinergic single-dose challenges. Mov Disord. 1999;14252- 255
Link to Article
Kartzinel  RTeychenne  PGillespie  MM  et al.  Bromocriptine and levodopa (with or without carbidopa) in parkinsonism. Lancet. 1976;2272- 275
Link to Article
Lieberman  AZolfaghari  MBoal  D  et al.  The antiparkinsonian efficacy of bromocriptine. Neurology. 1976;26405- 409
Link to Article
Parkes  JDSchachter  MMarsden  CDSmith  BWilson  A Lisuride in parkinsonism. Ann Neurol. 1981;948- 52
Link to Article
Gopinathan  GTeravainen  HDambrosia  JM  et al.  Lisuride in parkinsonism. Neurology. 1981;31371- 376
Link to Article
Koller  WCHerbster  G Adjuvant therapy of parkinsonian tremor. Arch Neurol. 1987;44921- 923
Link to Article
Hughes  AJLees  AJStern  GM Apomorphine in the diagnosis and treatment of parkinsonian tremor. Clin Neuropharmacol. 1990;13312- 317
Link to Article
Pakkenberg  HPakkenberg  B Clozapine in the treatment of tremor. Acta Neurol Scand. 1986;73295- 297
Link to Article
Friedman  JHKoller  WCLannon  MC  et al.  Benztropine versus clozapine for the treatment of tremor in Parkinson's disease. Neurology. 1997;481077- 1081
Link to Article
Bonuccelli  UCeravolo  RSalvetti  S  et al.  Clozapine in Parkinson's disease: effects of acute and chronic administration. Neurology. 1997;491587- 1590
Link to Article
Poersch  M Orthostatic tremor: combined treatment with primidone and clonazepam. Mov Disord. 1994;9467
Link to Article
Gates  PC Orthostatic tremor (shaky legs syndrome). Clin Exp Neurol. 1993;3066- 71
McManis  PGSharbrough  FW Orthostatic tremor: clinical and electrophysiologic characteristics. Muscle Nerve. 1993;161254- 1260
Link to Article
Wills  AJBrusa  LWang  HCBrown  PMarsden  CD Levodopa may improve orthostatic tremor: case report and trial of treatment. J Neurol Neurosurg Psychiatry. 1999;66681- 684
Link to Article
Evidente  VGAdler  CHCaviness  JNGwinn  KA Effective treatment of orthostatic tremor with gabapentin. Mov Disord. 1998;13829- 831
Link to Article
Onofrj  MThomas  APaci  CD'Andreamatteo  G Gabapentin in orthostatic tremor: results of a double-blind crossover with placebo in four patients. Neurology. 1998;51880- 882
Link to Article
Rivest  JMarsden  CD Trunk and head tremor in isolated manifestations of dystonia. Mov Disord. 1990;560- 65
Link to Article
Davis  TLCharles  PDBurns  S Clonazepam-sensitive intermittent dystonic tremor. South Med J. 1995;881069- 1071
Link to Article
Manyam  BV Uncommon forms of tremor. Watts  RLKoller  WCedsMovement Disorders Neurologic Principles and Practice. New York, NY McGraw-Hill1997;387- 403
Trelles  LTrelles  JOCastro  CAltamirano  JBenaquen  M Successful treatment of two cases of intention tremor with clonazepam. Ann Neurol. 1984;16621
Link to Article
Rice  GPALesaux  JVandervoort  PMacewan  LEbers  GC Odansetron, a 5-HT3 antagonist, improves cerebellar tremor. J Neurol Neurosurg Psychiatry. 1997;62282- 284
Link to Article
Findley  LJGresty  MA Suppression of `rubral' tremor with levodopa. BMJ. 1980;281043
Link to Article
Biary  NCleeves  LFindley  LKoller  W Post-traumatic tremor. Neurology. 1989;39103- 106
Link to Article
Cardoso  FECJankovic  J Hereditary motor-sensory neuropathy and movement disorders. Muscle Nerve. 1993;16904- 910
Link to Article
Kelly  PJGillingham  FJ The longterm results of stereotaxic surgery and L-dopa therapy in patients with Parkinson's disease. J Neurosurg. 1980;53332- 337
Link to Article
Schuurman  PRBosch  DABossuyt  PMM  et al.  A comparison of continuous thalamic stimulation and thalamotomy for suppression of severe tremor. N Engl J Med. 2000;342461- 468
Link to Article
Koller  WPahwa  RBusenbark  K  et al.  High-frequency unilateral thalamic stimulation in the treatment of essential and parkinsonian tremor. Ann Neurol. 1997;42292- 299
Link to Article
Limousin  PSpeelman  JDGielen  FJanssens  M Multicentre European study of thalamic stimulation in parkinsonian and essential tremor. J Neurol Neurosurg Psychiatry. 1999;66289- 296
Link to Article
Laitinen  LV Pallidotomy for Parkinson's disease. Neurosurg Clin N Am. 1995;6105- 112
Laitinen  LVBergenheim  ATHariz  MI Leksell's posteroventral pallidotomy in the treatment of Parkinson's disease. J Neurosurg. 1992;7653- 61
Link to Article
Krack  PPollak  PLimousin  PBenazzouz  ABenabid  AL Stimulation of subthalamic nucleus alleviates tremor in Parkinson's disease. Lancet. 1997;3501675
Link to Article
Van Manen  J Stereotaxic operation in cases of hereditary and intention tremor. Acta Neurochir. 1974;2149- 55
Benabid  ALPollak  PGao  D  et al.  Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders. J Neurosurg. 1996;84203- 214
Link to Article
Ohye  CMiyazaki  MHirai  TShibazaki  TNakayima  HNagaseki  Y Primary writing tremor treated by stereotactic selective thalamotomy. J Neurol Neurosurg Psychiatry. 1982;45988- 997
Link to Article

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