About This Page
This is a clinician-written, evidence-based guide aligned to the MCC Examination Objectives. It is structured by clinical presentation — the way the MCCQE tests and the way patients actually present. Management reflects current Canadian guidelines (CMA, CFPC, CPS). Always cross-reference with institutional protocols and clinical judgment.
Key points
- Classify tremor: rest, postural, kinetic/intention or task-specific.
- Parkinson disease requires bradykinesia plus rest tremor, rigidity or postural instability.
- Essential tremor is bilateral action tremor, often familial and improved by alcohol.
- Always review medicines: dopamine blockers, lithium, valproate, SSRIs, stimulants and thyroid replacement can cause tremor or parkinsonism.
- Red flags include acute onset, focal neurological signs, cerebellar signs and exposure to dopamine-blocking drugs with fever/rigidity.
Approach to the Presentation
Observe the patient at rest, posture, action, writing and gait. Examine tone, bradykinesia, rigidity, cerebellar signs, dystonia and cognition. Ask about alcohol response, family history, medication exposure, thyroid symptoms, functional impairment and falls.
Differential Diagnosis
| diagnosis | likelihood | key features | distinguishing test |
|---|---|---|---|
| Cerebellar tremor/ataxia | must-not-miss | Intention tremor with dysmetria, ataxia, nystagmus; stroke, tumour, MS or alcohol | MRI brain if acute/progressive |
| Parkinson disease | common | Asymmetric rest tremor, bradykinesia, rigidity, reduced arm swing, micrographia, REM sleep behaviour disorder, anosmia | Clinical diagnosis; levodopa responsiveness supports |
| Drug-induced parkinsonism | common | Symmetric parkinsonism after antipsychotics/metoclopramide/prochlorperazine; less rest tremor | Medication history and improvement after withdrawal |
| Essential tremor | common | Bilateral action/postural tremor, hands/head/voice, family history, improves with alcohol | Clinical; no bradykinesia/rigidity |
| Thyrotoxicosis/enhanced physiological tremor | common | Fine tremor, weight loss, heat intolerance, tachycardia, anxiety | TSH/free T4 |
| Dystonia | less common | Sustained twisting postures, task-specific cramp, cervical dystonia | Clinical; medication history |
| Tardive dyskinesia | less common | Orobuccolingual movements after chronic dopamine blocker exposure | Medication history; AIMS assessment |
| Functional movement disorder | less common | Distractible, entrainable or variable tremor; sudden onset | Positive bedside signs |
| Chorea/Huntington disease | rare | Irregular dance-like movements, psychiatric/cognitive changes, family history | Genetic testing with counselling |
Red Flags & Key History
Symptoms
Acute onset tremor/ataxia or focal neuro deficit
Fever, rigidity, autonomic instability after dopamine blocker
Rapid progression, falls or early cognitive/autonomic features
Medication exposure to dopamine blockers/lithium/valproate
Signs
Bradykinesia and rigidity
Cerebellar dysmetria or inability to walk
Symmetric parkinsonism soon after medication
Distractibility/entrainment
Approach to Investigation
First-line
Medication and toxin reviewOften diagnostic.
TSH, glucose, electrolytesMetabolic tremor contributors.
Focused movement examRest/postural/action tremor, bradykinesia, rigidity, cerebellar testing and gait.
Second-line
MRI brainAcute focal signs, cerebellar syndrome or atypical rapid progression.
DaTscanRarely needed; specialist use when essential tremor versus Parkinsonian syndrome remains unclear.
Specialist
Movement disorder neurologyAtypical parkinsonism, disabling tremor, dystonia, chorea or diagnostic uncertainty.
Management Principles
Canadian guideline for Parkinson disease1
Parkinson disease
- Start treatment when symptoms affect quality of life; levodopa is most effective for motor symptoms
- Exercise, physiotherapy, falls prevention and non-motor symptom management are central
2
Essential tremor
- Reduce caffeine/stimulants; propranolol or primidone if functionally impairing
- Consider occupational strategies and specialist therapies if refractory
3
Drug-induced
- Reduce/stop offending drug where possible; liaise with psychiatry when antipsychotic changes are needed
4
Emergency syndromes
- Treat neuroleptic malignant syndrome/serotonin syndrome or acute cerebellar stroke urgently when suggested
Complications & Pitfalls
- Diagnosing Parkinson disease from tremor alone: bradykinesia is required.
- Missing medication causes: antipsychotics and antiemetics are common.
- Ignoring gait: early falls suggest atypical parkinsonism or cerebellar disease.
- Over-imaging classic essential tremor: typical bilateral action tremor is clinical.
MCCQE1 Exam Tips
- 1Rest tremor + bradykinesia = Parkinsonian syndrome.
- 2Essential tremor is action/postural and bilateral.
- 3Drug-induced parkinsonism is often symmetric.
- 4Cerebellar tremor is intention tremor with ataxia.
- 5Thyroid disease causes fine tremor and systemic symptoms.
- 6Levodopa is the most effective symptomatic motor therapy for Parkinson disease.
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