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Intention tremor

intention tremor, intention tremor causes and treatment
Intention tremor, also known as cerebellar tremor, is a dyskinetic disorder characterized by a broad, coarse, and low frequency below 5 Hz tremor The amplitude of an intention tremor increases as an extremity approaches the endpoint of deliberate and visually guided movement hence the name intention tremor An intention tremor is usually perpendicular to the direction of movement When experiencing an intention tremor, one often overshoots or undershoots their target, a condition known as dysmetria12 Intention tremor is the result of dysfunction of the cerebellum, particularly on the same side as the tremor in the lateral zone, which controls visually guided movements Depending on the location of cerebellar damage, these tremors can be either unilateral or bilateral1

A variety of causes have been discovered to date, including damage or degradation of the cerebellum due to neurodegenerative diseases, trauma, tumor, stroke, or toxicity There is currently no established pharmacological treatment; however, some success has been seen using treatments designed for essential tremors13


  • 1 Causes
  • 2 Mechanism
  • 3 Diagnosis
  • 4 Management
  • 5 Research directions
  • 6 History
  • 7 External links
  • 8 References


Intention tremors are common among individuals with multiple sclerosis MS One common symptom of multiple sclerosis is ataxia, a lack of coordinated muscle movement caused by cerebellar lesions characteristic of multiple sclerosis The disease often destroys physical and cognitive function of individuals

Intention tremors can be a first sign of multiple sclerosis, since loss or deterioration of motor function and sensitivity are often one of the first symptoms of cerebellar lesions14

Intention tremors have a variety of other recorded causes as well These include a variety of neurological disorders, such as stroke, alcoholism, alcohol withdrawal, peripheral neuropathy, Wilson's disease, Creutzfeldt–Jakob disease, Guillain–Barré syndrome and fragile X syndrome, as well as brain tumors, low blood sugar, hyperthyroidism, hypoparathyroidism, insulinoma, normal aging, and traumatic brain injury1567 Holmes tremor, a rubral or midbrain tremor, is another form of tremor that includes intention tremors, among other symptoms This disease affects the proximal muscles of the head, shoulders, and neck Tremors of this disease occur at frequencies of 2–4 Hz or more8

Intention tremor is also known to be associated with infections, West Nile virus, rubella, H influenza, rabies, and varicella19 A variety of poisons have been shown to cause intention tremor, including mercury, methyl bromide, and phosphine11011 In addition, vitamin deficiencies have been linked to intention tremor, especially deficiency in vitamin E12 Pharmacological agents such as anti-arrhythmic drugs, anti-epileptic agents, benzodiazepine, cyclosporine, lithium, neuroleptics, and stimulants have been known to cause intention tremor3 Some ordinary activities including ingesting too much caffeine, cigarettes, and alcohol, along with stress, anxiety, fear, anger and fatigue have also been shown to cause intention tremor by negatively affecting the cerebellum, brainstem, or thalamus, as discussed in mechanisms5


The cerebellum is highlighted in purple

Intention tremors that are caused by normal, everyday activities, such as stress, anxiety, fear, anger, caffeine, and fatigue do not seem to result from damage to any part of the brain These tremors instead seem to be a temporary worsening of a small tremor that is present in every human being These tremors generally go away with time5

More persistent intention tremors are often caused by damage to certain regions of the brain The most common cause of intention tremors is damage and/or degeneration in the cerebellum The cerebellum is a part of the brain responsible for motor coordination, posture and balance It is responsible for fine motor movements When the cerebellum is damaged, a person may have difficulty executing a fine motor movement, such as attempting to touch one's nose with one's finger One common way for the cerebellum to become damaged is through the development of cerebellar lesions13 The most common site for cerebellar lesions that lead to intention tremors has been reported to be the superior cerebellar peduncle, through which all fibers carrying information to the midbrain pass, and the dentate nucleus, which is also responsible for linking the cerebellum to the rest of the brain3 Alcohol abuse is one typical cause of this damage to the cerebellum The alcohol abuse causes degeneration of the anterior vermis of the cerebellum This leads to an inability to process fine motor movements in the individual and the development of intention tremors In Multiple Sclerosis, damage occurs due to demyelination and neuron death, which again produces cerebellar lesions and an inability for those neurons to transmit signals13 Because of this tight association with damage to the cerebellum, intention tremors are often referred to as cerebellar tremors1

Intention tremors can also be caused as a result of damage to the brainstem or thalamus Both of these structures are involved in the transmission of information between the cerebellum and the cerebral cortex, as well as between the cerebellum and the spinal cord, and then on to the motor neurons When these become damaged, the relay system between the cerebellum and the muscle which it is trying to act upon is compromised, resulting in the development of a tremor13


A working diagnosis is made from a neurological examination and evaluation Parts of a complete examination include a physical examination, MRI, patient history, and electrophysiological and accelerometric studies A diagnosis of solely intention tremor can only be made if the tremor is of low frequency below 5 Hz and without the presence of any resting tremors1 Electrophysiological studies can be useful in determining frequency of the tremor, and accelerometric studies quantify tremor amplitude MRI is used to locate damage to and degradation of the cerebellum that may be causing the intention tremor Focal lesions such as neoplasms, tumors, hemorrhages, demyelination, or other damage may be causing dysfunction of the cerebellum and correspondingly the intention tremor14

Physical tests are an easy way to determine the severity of the intention tremor and impairment of physical activity Common tests that are used to assess intention tremor are the finger-to-nose and heel-to-shin tests In a finger-to-nose test, a physician has the individual touch their nose with their finger while monitoring for irregularity in timing and control of the movement An individual with intention tremors will have coarse side-to-side movements that increase in severity as the finger approaches the nose Similarly, the heel-to-shin test evaluates intention tremors of the lower extremities In such a test, the individual, in a supine position, places one heel on top of the opposite knee and is then instructed to slide the heel down the shin to the ankle while being monitored for coarse and irregular side-to-side movement as the heel approaches the ankle Important historical elements to the diagnosis of intention tremor are:

  1. age at onset
  2. mode of onset sudden or gradual
  3. anatomical affected sites
  4. rate of progression
  5. exacerbating and remitting factors
  6. alcohol abuse
  7. family history of tremor15
  8. current medications12

Secondary symptoms commonly observed are dysarthria a speech disorder characterized by poor articulation and slurred speech, nystagmus rapid involuntary eye movement, especially rolling of the eyes, gait problems abnormality in walking, and postural tremor or titubation to-and-fro movements of the neck and trunk A postural tremor may also accompany intention tremors112


A radiography during an intervention of deep brain stimulation

It is very difficult to treat an intention tremor16 The tremor may disappear for a while after a treatment has been administered and then return This situation is addressed with a different treatment First, individuals will be asked if they use any of the drugs known to cause tremors If so, they are asked to stop taking the medication and then evaluated after some time to determine if the medication was related to the onset of the tremor If the tremor persists, treatment that follows may include drug therapy, lifestyle changes, and more invasive forms of treatment, such as surgery and thalamic deep brain stimulation14

Intention tremors are known to be very difficult to treat with pharmacotherapy and drugs Although there is no established pharmacological treatment for an intention tremor, several drugs have been found to have positive effects on intention tremors and are used as treatment by many health professionals Isoniazid, buspirone hydrochloride, glutethimide, carbamazepine, clonazepam, topiramate, zofran, propranolol and primidone have all seen moderate results in treating intention tremor and can be prescribed treatments Isoniazid inhibits γ-aminobutyric acid-aminotransferase, which the first step in enzymatic breakdown of GABA, thus increasing GABA, the major inhibitory neurotransmitter in the central nervous system This causes a reduction in cerebellar ataxias Another neurotransmitter targeted by drugs that has been found to alleviate intention tremors is serotonin The agonist buspirone hydrochloride, which decreases serotonin's function in the central nervous system, has been viewed as an effective treatment of intention tremors1

Physical therapy has had great results in reducing tremors but usually does not cure them Relaxation techniques, such as meditation, yoga, hypnosis, and biofeedback, have seen some results with tremors Wearing wrist weights which weigh down one's hands as they make movements, masking much of the tremor, is a proven home remedy This is not a treatment, since wearing the weights does not have any lasting effects when they are not on However, they do help the individual cope with the tremor immediately12

A more radical treatment that is used in individuals who do not respond to drug therapy, physical therapy, or any other treatment listed above, with moderate to severe intention tremors, is surgical intervention Deep brain stimulation and surgical lesioning of the thalamic nuclei has been found to be an effective long-term treatment with intention tremors

Deep brain stimulation treats intention tremors but does not help related diseases or disorders such as dyssynergia and dysmetria17 Deep brain stimulation involves the implantation of a device called a neurostimulator, sometimes called a 'brain pacemaker' It sends electrical impulses to specific parts of the brain, changing brain activity in a controlled manner In the case of an intention tremor, the thalamic nuclei is the region targeted for treatment This form of treatment causes reversible changes and does not cause any permanent lesions Since it is reversible, deep brain stimulation is considered fairly safe: Reduction in tremor amplitude is almost guaranteed and sometimes resolved Some individuals with multiple sclerosis have seen sustained benefits in MS progress18

Thalamotomy is another surgical treatment where lesions of the thalamus nucleus are created to disrupt the tremor circuit Thalamotomy has been used to treat many forms of tremors, including those that arise from trauma, multiple sclerosis, stroke, and those whose cause it unknown This is a very invasive, high-risk treatment with many negative effects, such as multiple sclerosis worsening, cognitive dysfunction, worsening of dysarthria, and dysphagia Immediate positive effects are seen in individuals treated with a thalamotomy procedure However, the tremor often comes back; it is not a complete treatment Thalamotomy is in clinical trials to determine the validity of the treatment of intention tremors with all its high risks119

Research directionsedit

Research has focused on finding a pharmacological treatment that is specific for intention tremor Limited success has been seen in treating intention tremor with drugs effective at treating essential tremor12 Clinical trials of levetiracetam, typically used to treat epilepsy, and pramipexole, used to treat resting tremor, were completed in 2009-2010 to establish their effectiveness in treating kinetic tremor2021 A clinical trial for riluzole, typically used to treat amyotrophic lateral sclerosis, was completed at the Sapienza University of Rome to evaluate its effectiveness of treating cerebellar ataxia and kinetic tremor22


In 1868, French neurologist Jean-Martin Charcot first characterized the distinction between multiple sclerosis MS, with its resulting intention tremor, and the resting tremor characteristic of Parkinson's disease Intention tremor became known as part of Charcot's triad which, along with nystagmus and scanning speech, act as strong indications of MS23

External linksedit

  • Intention tremor video


  1. ^ a b c d e f g h i j k l 1 Seeberger, Lauren "Cerebellar Tremor-Definition and Treatment" The Colorado Neurological Institute Review Fall 2005
  2. ^ 2 National Institute of Neurological Disorders and Stroke “Tremor Fact Sheet” Jan 2011 National Institutes of Health
  3. ^ a b c Bhidayasiri, R 2005 "Differential diagnosis of common tremor syndromes" Postgraduate Medical Journal 81 962: 756–62 PMC 1743400  PMID 16344298 doi:101136/pgmj2005032979 
  4. ^ Deuschl, G; Wenzelburger, R; Löffler, K; Raethjen, J; Stolze, H 2000 "Essential tremor and cerebellar dysfunction Clinical and kinematic analysis of intention tremor" Brain 123: 1568–80 PMID 10908187 doi:101093/brain/12381568 
  5. ^ a b c 3 Hoch, Daniel MD “Tremor” Updated 6/15/2010 US National Library of Medicine
  6. ^ 4 Hagerman, Paul, Hagerman, Randi “Fragile X-Associated Tremor/Ataxia Syndrome-An Older Face of the Fragile X Gene” 2007 In Nature Clinical Practice Neurology Nature Publishing Group
  7. ^ 5 Eidelberg, David, Pourfar, Michael "Tremor" 2007 In The Merck Manuals Online Medical Library
  8. ^ 6 "Postischemic Holmes Tremor Investigated by FDG- and H2 O-PET" Jan Kassubek, G Bernhard Landwehrmeyer, Carl H Lücking, Freimut D Juengling The Journal of Radiology, June 2003
  9. ^ Debiasi, Roberta L; Tyler, Kenneth L 2006 "West Nile virus meningoencephalitis" Nature Clinical Practice Neurology 2 5: 264–75 PMID 16932563 doi:101038/ncpneuro0176 
  10. ^ 7 “Epidemiological Notes and Reports Elemental Mercury Poisoning in a Household – Ohio 1989” 1990 In Morbidity and Mortality Weekly Report Centers for Disease Control and Prevention
  11. ^ 8 “Medical Management Guidelines for Acute Chemical Exposures” 1992 US Department of Human Health Services
  12. ^ a b c d e Wyne, Kevin T 2005 "A comprehensive review of tremor" JAAPA 18 12: 43–50; quiz 57–8 PMID 16392266 
  13. ^ a b c 9 Purves, Dale et al Neuroscience Fourth Edition 2008 Sinauer Associates, Inc
  14. ^ a b Chou, Kelvin L 2004 "Diagnosis and management of the individual with tremor" PDF Medicine and health, Rhode Island 87 5: 135–8 PMID 15250610 
  15. ^ Walker, H Kenneth 1990 "The Cerebellum" In Walker HK, Hall WD, Hurst JW Clinical Methods: The History, Physical, and Laboratory Examinations Reed Publishing ISBN 0-409-95003-3 page needed
  16. ^ C Nava, Clark "Tremor in Multiple Sclerosis: Prevalence, Cause and Treatment" Rosenfeld Retrieved 27 June 2010 
  17. ^ Wishart, H A 2003 "Chronic deep brain stimulation for the treatment of tremor in multiple sclerosis: review and case reports" Journal of Neurology, Neurosurgery & Psychiatry 74: 1392–7 doi:101136/jnnp74101392 
  18. ^ Mandat T, Koziara H, Tutaj M, Rola R, Bonicki W, Nauman P "Thalamic deep brain stimulation for tremor among multiple sclerosis patients" Neurologia i neurochirurgia polska 44: 542–5 PMID 21225515 doi:101016/s0028-38431460150-x CS1 maint: Multiple names: authors list link
  19. ^ Benabid, AL; Pollak, P; Gervason, C; Hoffmann, D; Gao, DM; Hommel, M; Perret, JE; De Rougemont, J 1991 "Long-term suppression of tremor by chronic stimulation of the ventral intermediate thalamic nucleus" Lancet 337 8738: 403–6 PMID 1671433 doi:101016/0140-67369191175-T 
  20. ^ Clinical trial number NCT00430599 for "The Effect of Levetiracetam Keppra on the Treatment of Tremor in Multiple Sclerosis" at ClinicalTrialsgov
  21. ^ Clinical trial number NCT01100073 for "Kinetic Tremor in Parkinson's Disease: Its Course Under Pramipexole Mirapexin® Treatment and Impact on Quality of Life" at ClinicalTrialsgov
  22. ^ Clinical trial number NCT01104649 for "Efficacy of Riluzole in Hereditary Cerebellar Ataxia" at ClinicalTrialsgov
  23. ^ Orrell, Richard W 2005 "Multiple Sclerosis: The History of a Disease" Journal of the Royal Society of Medicine 98 6: 289 PMC 1142241  doi:101258/jrsm986289 

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