Objective: To report a patient with billiards-related tremor, a form of task-specific tremor.

Background: Task-specific tremor is a tremor that occurs when performing specific tasks such as writing (i.e., primary writing tremor) or playing violin (i.e., primary bowing tremor). In billiard players, billiards-related dystonia has been reported. In these patients, movement arrests occurred when moving a cue, but there was no tremor.

Method: Case report

Results: A 55-year-old right-handed man came for evaluation of right arm tremor when holding a billiard cue. He owned a billiard club and played billiards every day. He noted tremor 10 years ago, which had been slowly worse, but stable in the past 4 years. Tremor markedly impaired his performance in aiming and shooting the balls. He denied locking or movement arrests when moving a cue. There was no tremor when holding a cue with the left hand, and when performing other activities including writing. He reported marked improvement of tremor after drinking 1.5 L of beer (5.0% alcohol by volume). There was no family history of tremor. On examination, as soon as he held a cue backward with extended right shoulder, there was prominent tremor of the arm in the internal-external rotation axis resulting in side-to-side tremor of the forearm. Once he advanced the cue forward when shooting, tremor disappeared. There was also very mild terminal kinetic and postural tremor of bilateral hands, slightly greater on the left, of which he was unaware. There were no features of dystonia. Surface polymyography on the supraspinatus and teres major muscles demonstrated 6-Hz tremor when he held a cue backward with extension of the right shoulder. He was unable to tolerate multiple trials of medications including propranolol, topiramate, gabapentin and zonisamide, but interested in botulinum toxin injections.

Conclusion: This patient demonstrates task-specific tremor when holding a billiard cue with the right hand. There is also position specificity: tremor occurs when holding a cue in the specific posture with extension of the right shoulder. Our report expands a spectrum of movement disorders in billiard players, and a spectrum of task-specific tremor. This case also provides an insight that task-specific tremor likely represents a form of essential tremor (ET), given other clinical features of ET including kinetic and postural tremor and apparent alcohol responsiveness.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/billiards-related-tremor-a-form-of-task-specific-tremor/