History
General
- Is the movement disorder actually tremor?
- Is the tremor isolated, or are there accompanying neurologic abnormalities?
- What are the phenomenologic features of the tremor?
Medical history
- Age of onset
- Infancy (birth to 2 years)
- Childhood (3-12 years)
- Adolescence (13-20 years)
- Early adulthood (21- 45 years)
- Middle adulthood (46-60 years)
- Late adulthood (>60 years).
- Family history
- Past medical history
- Temporal evolution
- Exposure to drugs and toxins
Tremor characteristics
- Body distribution
- Activation condition
- Frequency
Associated signs
- Associated or concomitant signs that may aid in clinical diagnosis.
- We propose two broad categories of tremor in Axis 1:
- Isolated tremor
- In which tremor is the only abnormal sign
- Combined tremor
- In which other abnormal signs are present.
- May occur with
- Other neurological signs
- (e.g., dystonic postures, rigidity, bradykinesia, or myoclonus)
- With relevant systemic signs
- (e.g., Kayser-Fleischer ring, hepatosplenomegaly, or exophthalmos).
Anatomical distribution of tremor
- Focal
- Only one body region is affected,
- Eg: voice, head, jaw, one limb, etc.
- Segmental
- >2 contiguous body parts in the upper or lower body are affected
- e.g., head and arm, or when tremor is bibrachial or bicrural
- Hemitremor
- One side of the body is affected
- Generalized
- Tremor affects the upper and lower body
Additional laboratory tests
- Electrophysiological tests
- Structural imaging
- Receptor imaging
- Serum and tissue biomarkers
Examination
- Some forms of tremor take >30s to emerge
- Examine all patients in the true rest position, with hands pronated and resting on their lap.
- 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.
- Posture (Without holding of these 2 postures, any postural-reemergent tremor will be missed, as will the rare postural crescendo tremor of Wilson’s disease)
- Ask patients to raise their arms forward in an outstretched position, holding it for at least 10 seconds.
- 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.
- 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.
- 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
- Observe the patient walking to see if gait triggers his or her tremor.
- In patients with specific tremor disorders, observing maneuvers that trigger tremor can be particularly useful.
- Essential tremor (ET) to
- Draw a straight line connecting 2 dots,
- Pour water between cups with each hand,
- Drink from a cup,
- Use soup spoon to drink liquid.
- Task-specific or position-specific tremors
- Writing,
- Playing a musical instrument
- Holding an object such as a racquet or golf club.
- Orthostatic tremor
- Standing,
- Tremor typically resolves when the patient touches a wall or walks.