2 Observe the patient walking to see if gait triggers his or her tremor. Ask the patient to write in both script and print and to draw the Archimedes spiral with each hand while ensuring that the patient keeps his or her writing arm off the table and extends the spiral to the edge of the page ( Figure 1). Next, assess the patient’s ability to repeatedly bring the finger of an outstretched arm and hand to her or his own nose repeatedly and bilaterally, understanding that patients with action (kinetic) tremor will hurry through this maneuver in order to improve accuracy. Without holding of these 2 postures, any postural-reemergent tremor will be missed, as will the rare postural crescendo tremor of Wilson’s disease. Follow this with a request for the patient to hold his or her arms outstretched to the sides-in the wing-beating position-for at least 10 seconds as well. Ask patients to raise their arms forward in an outstretched position, holding it for at least 10 seconds. Ask the patient to reposition her or his hands with pinkies down and thumbs up, as both parkinsonian and Holmes tremors are often triggered by this posture. Remember that some forms of tremor take 30 seconds or more to emerge-patience is a virtue! Examine all patients in the true rest position, with hands pronated and resting on their lap. Tips for Examining a Patient With TremorĪ common mistake in examining patients with tremor is to rush the examination. Note the axis of maximal amplitude of tremor at 60°. Archimedes spiral performed by a patient with essential tremor. Although a point of controversy, it is probably best to include these patients in the tremor rubric, characterizing their tremor as irregular in frequency.įigure 1. While tremor is defined as a regular oscillatory movement, some patients present with movements that are tremulous in appearance but irregular. 2 Define and document the frequency and amplitude of tremor, especially if these vary during the examination. Triggers of tremor at rest, with posture, with action, and with specific tasks are important. Whether the tremor appears in isolation or not, accurate diagnosis depends on characterization of phenomenology. In these patients, look for sustained dystonic postures, task-specific dystonic movements, and improvement with sensory tricks (geste antagoniste maneuvers). Tremor may accompany dystonia and is usually irregular with a null point, a position in which dystonic movements and tremor may abate. Tremor also often accompanies cerebellar dysfunction, in which case patients may also have nystagmus, impaired ocular pursuits, dysmetria, overshoot, truncal ataxia, and a wide-based gait. Once these are ruled out, determine whether the tremor is isolated or accompanied by other neurologic abnormalities.īecause parkinsonism is the most common syndrome accompanying tremor, assess for the presence or absence of facial masking, decreased blink rate, appendicular bradykinesia and cogwheeling, shortening of stride length, stooped posture, and impairment in postural reflexes. Several hyperkinetic movement disorders can mimic tremor, including action myoclonus and dystonia of the upper limbs. Document any family history of tremor or other neurologic complaints in parents, siblings, and children. Obtain a detailed history of drug exposure, current medications, and interventions that improve tremor (eg, alcohol ingestion). Ask about the time course, acuity of onset, progression, and specific triggers of the tremor. What are the phenomenologic features of the tremor?Ī meticulous history and examination are indispensable in answering these questions. Is the tremor isolated, or are there accompanying neurologic abnormalities?ģ. Is the movement disorder actually tremor?Ģ. The history and examination of the patient with tremor should focus on 3 practical questions:ġ. Tremor is a regular, hyperkinetic movement in which a body part oscillates to and fro around an axis. Using a series of 3 questions focusing on history and phenomenology, we demonstrate a practical approach to patients with tremor in the outpatient setting. 1 Most internists and all neurologists will encounter patients with tremor in their practice. Tremor is the most common movement disorder in adults.
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