Orthostatic Tremor

What is orthostatic tremor?

Orthostatic tremor is a rare movement disorder that causes rapid muscle contractions (tremor) in your legs when standing. The tremor improves or disappears when you walk, sit or lean, and can make you feel unsteady or unbalanced while standing.

Most people with orthostatic tremor develop it around 60 years of age. But studies show a wide range of onset, ranging from 13 to 85 years.

A researcher first described orthostatic tremor in 1984, so it’s a relatively new condition. Healthcare providers are still learning about it.

What are the symptoms of orthostatic tremor?

The main symptom people with orthostatic tremor report is a feeling of unsteadiness while standing but not while sitting or walking. Going from standing to sitting, walking, leaning against a wall or lying down usually stops or greatly reduces the tremors.

You may try to reduce the feeling of unsteadiness by having a widened stance and “grabbing” the floor with your toes.

You may not see or sense that your legs are having rapid muscle contractions (tremors) when you’re standing — it may just feel like unsteadiness or a loss of balance. But if you press your hands to your thighs or calves, you may be able to feel the muscle contractions as a rippling sensation. The tremors typically aren’t painful while they’re happening, but you may develop leg muscle pain over time.

Some people with primary orthostatic tremor also have tremor in their hands or trunk but no other neurological symptoms.

The severity of orthostatic tremor can vary. The tremors may start suddenly when you change positions to standing. Or it may take several minutes of standing before the tremors start. For many people, the tremors get more severe over time.

What causes orthostatic tremor?

Researchers are still studying orthostatic tremor and don’t know its cause. Some experts think it’s a variation of essential tremor, while others think orthostatic tremor is a distinct condition.

Most cases seem to affect people randomly. But a few cases have affected biological family members, including twins, siblings, and a parent and child. Researchers are looking into potential genetic factors, like genetic changes (mutations), that may cause orthostatic tremor.

Types of orthostatic tremor

Researchers and healthcare providers group orthostatic tremor into two types: primary and secondary.

Primary orthostatic tremor is idiopathic, meaning it has no known cause. People with primary orthostatic tremor have no other signs of neurological conditions.

Secondary orthostatic tremor happens due to another condition. Studies show cases of secondary orthostatic tremor developing from a range of conditions, including:

• Graves’ disease.
• Head trauma.
• Multiple sclerosis (MS).
• Parkinsonism.
• Restless legs syndrome.
• Pontine and midbrain lesions.
• Spinal cord lesion.
• Stiff person syndrome.
• Vitamin B12 deficiency.

How is orthostatic tremor diagnosed?

To diagnose orthostatic tremor, your healthcare provider will begin by asking about your symptoms and medical history. They’ll then do a physical exam and neurological exam to assess how and when the tremor happens.

Specialized centers sometimes perform surface EMG to confirm the diagnosis of orthostatic tremor, but it’s sometimes also clinically diagnosed by movement disorders specialists. An EMG evaluates the health and function of your skeletal muscles and the nerves that control them. Your provider might recommend other tests — like blood tests and imaging tests — to rule out other conditions that cause tremor.

Unfortunately, because orthostatic tremor is so rare, providers often misdiagnose it as something else, especially functional (psychogenic) tremor, a type of functional movement disorder.

What is the treatment for orthostatic tremor?

There’s no cure for orthostatic tremor, but certain medications may help improve your symptoms.

The go-to medication is typically clonazepam (a benzodiazepine). But not everyone responds well to this medication. Other options include:

• Gabapentin.
• Primidone.
• Propranolol.
• Pregabalin.
• Phenobarbital.

Treatments that help other types of tremor may help orthostatic tremor symptoms, too, but there’s not as much research on them. They include:

• Deep brain stimulation.
• Spinal cord stimulation.

As researchers are actively studying orthostatic tremor, you may qualify for a clinical trial. Ask your healthcare provider if this is an option.

Can I prevent orthostatic tremor?

Researchers don’t know the cause of orthostatic tremor, so you can’t do anything to prevent it.

What can I expect if I have orthostatic tremor?

Even though orthostatic tremor typically only causes issues with standing, it can affect your quality of life. You may eventually avoid situations in which you have to stand still for a long period, like taking a shower, waiting in line, cleaning or cooking a meal.

Certain modifications to your everyday activities may help, like using a shower seat or using a wheelchair when you have to wait in line for something. Occupational therapists can help you come up with strategies for everyday tasks.

Because it’s so rare, it may be difficult for others to understand orthostatic tremor — and for healthcare providers to correctly diagnose it. Be sure to lean on loved ones for support. Consider seeing a mental health professional, like a psychologist, if orthostatic tremor is causing depression, anxiety or social isolation.