Orthostatic Tremor (OT) is a rare neurological movement disorder characterized by a high-frequency (13–18 Hz) tremor in the legs and trunk that occurs specifically during standing and is relieved by sitting, walking, or leaning.
Patients often describe it as a feeling of severe unsteadiness, vibration, or “shaking inside the legs” rather than a visible tremor.

OT is classified as:

• Primary OT – no identifiable underlying neurological disease

• Secondary OT – associated with conditions such as Parkinson’s disease, cerebellar disorders, peripheral neuropathy, or brainstem lesions

Orthostatic Tremor affects multiple interacting systems, not just one:

• Abnormal central oscillatory activity (likely brainstem–cerebellar–thalamic circuitry)

• Altered motor unit firing synchronicity

• Impaired postural control mechanisms

• Excessive involuntary muscle activation in:

  • Quadriceps

  • Hamstrings

  • Gastrocnemius/soleus

  • Hip stabilizers

• Fatigue

• Reduced postural endurance

• Proprioceptive system: impaired joint position sense under weight-bearing

• Vestibular system: reduced ability to use vestibular input for postural stability

• Visual system: increased visual dependency for balance

• Deconditioning due to activity avoidance

• Reduced tolerance to upright posture

• Anxiety related to fear of falling

• Depression from activity restrictions

• Social withdrawal

OT can be profoundly disabling despite being invisible on casual observation:

• ❌ Difficulty standing in:

  • Lines at stores

  • Social gatherings

  • Church events

  • Kitchens while cooking

• ❌ Inability to tolerate:

  • Showers without support

  • Static standing at work

• ❌ Dependence on:

  • Leaning on surfaces

  • Canes, walkers, or stools

• ❌ Increased fall risk

• ❌ Loss of independence

• ❌ Occupational limitations

• ❌ Social isolation

• ❌ Fear-based mobility avoidance

Many patients report:

“I can walk, but I can’t stand still.”

Since OT improves with movement, gait becomes a therapeutic tool.

✔ Continuous walking programs
✔ Treadmill training with:

• Body-weight support if needed

• Speed variations
  ✔ Turning and transition training (stand → walk quickly)
  ✔ Step initiation and stopping drills
  ✔ Backward walking for neural recalibration
  ✔ Rhythm-based gait training (metronome)

✔ Trunk endurance training including dual tasking options seen here..✔ Hip abductor/extensor strengthening
✔ Cardiovascular conditioning using:

• Recumbent bike

• Elliptical

• Pool therapy
  ✔ Upright tolerance building using graded intervals