A tremor is a rhythmic motion of the distal parts of the limbs or head. A physiologic tremor has an oscillation of 10 to 12 cycles per second and is more obvious after exercise. A pathologic tremor is slower. Parkinson's disease is the most frequently encountered extrapyramidal movement disorder. In this condition, the tremor is present at rest and is decreased with action. It has a frequency of three to six cycles per second and is worsened by anxiety. An intention, or ataxic, tremor is slow (two to four cycles per second) and worsens on attempted movement. Multiple sclerosis is one of the many causes of intention tremor. Metabolic problems from liver or kidney failure are frequently responsible. Withdrawal from alcohol or caffeine is often a precipitating factor. Any patient with the symptom of tremor should be asked these questions:

' 'Does the tremor worsen when you try to do something?''

' 'Is there a history of thyroid disease?''

''Have you ever been told about any problems with your liver or kidneys?'' ''What is your daily consumption of alcoholic beverages?'' How much coffee or tea do you drink?'' ''How much chocolate do you eat?''

Chorea is involuntary jerky motions of the face and limbs. A common cause is Huntington's disease, in which chorea is accompanied by personality changes and progressive mental deterioration terminating in dementia.

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