<abstract xmlns="http://www.w3.org/1999/xhtml">

<p>The diagnostic approach for patients with tremor is challenging due to the complex and overlapping phenotypes among tremor syndromes. The first step in the evaluation of tremor is to identify the tremulous movement and exclude the tremor mimics. The second step is to classify the tremor syndrome based on the characteristics of tremor from historical clues and focused examination (Axis 1). Comprehensive tremor examinations involve the assessment of tremor in different conditions (rest, action or mixed, position or task-specific), distribution of tremor (upper limb, lower limb, head, jaw), positive signs for functional tremor (FT) if suspected (distractibility, entrainment, co-contraction), and associated neurological signs including parkinsonism, dystonic posture, cerebellar/brainstem signs, neuropathy, and cognitive impairment. A pivotal feature in this step is to determine any distinct feature of a specific isolated or combined tremor syndrome. In this review, we propose an algorithm to assess upper limb tremors. Ancillary testing should be performed if clinical evaluation is unclear. The choice of investigation depends on the types of tremors considered to narrow down the spectrum of etiology (Axis 2). Laboratory blood tests are considered for acute onset and acute worsening of tremors, while structural neuroimaging is indicated in unilateral tremors with acute onset, nonclassical presentations, and a combination of neurological symptoms. Neurophysiological study is an important tool that aids in distinguishing between tremor and myoclonus, etiology of tremor and document specific signs of FT. Treatment is mainly symptomatic based depending on the etiology of the tremor and the patient’s disabilities.</p>
</abstract>

The diagnostic approach for patients with tremor is challenging due to the complex and overlapping phenotypes among tremor syndromes. The first step in the evaluation of tremor is to identify the tremulous movement and exclude the tremor mimics. The second step is to classify the tremor syndrome based on the characteristics of tremor from historical clues and focused examination (Axis 1). Comprehensive tremor examinations involve the assessment of tremor in different conditions (rest, action or mixed, position or task-specific), distribution of tremor (upper limb, lower limb, head, jaw), positive signs for functional tremor (FT) if suspected (distractibility, entrainment, co-contraction), and associated neurological signs including parkinsonism, dystonic posture, cerebellar/brainstem signs, neuropathy, and cognitive impairment. A pivotal feature in this step is to determine any distinct feature of a specific isolated or combined tremor syndrome. In this review, we propose an algorithm to assess upper limb tremors. Ancillary testing should be performed if clinical evaluation is unclear. The choice of investigation depends on the types of tremors considered to narrow down the spectrum of etiology (Axis 2). Laboratory blood tests are considered for acute onset and acute worsening of tremors, while structural neuroimaging is indicated in unilateral tremors with acute onset, nonclassical presentations, and a combination of neurological symptoms. Neurophysiological study is an important tool that aids in distinguishing between tremor and myoclonus, etiology of tremor and document specific signs of FT. Treatment is mainly symptomatic based depending on the etiology of the tremor and the patient’s disabilities.

Bedside clinical assessment of patients with common upper limb tremor and algorithmic approach

Chulalongkorn Centre of Excellence for Parkinson’s Disease and Related Disorders, Department of Medicine, Faculty of Medicine

Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society

Division of Neurology, Department of Medicine, Faculty of Medicine

Asian Biomedicine

This work is licensed under the Creative Commons Attribution 4.0 International License.

The diagnostic approach for patients with tremor is challenging due to the complex and overlapping phenotypes among tremor syndromes. The first step in the...

Bedside clinical assessment of patients with common upper limb tremor and algorithmic approach

Article Category: Review

Published Online: Apr 30, 2024

Page range: 37 - 52

DOI: https://doi.org/10.2478/abm-2024-0008

Keywords
clinical assessment, investigations, neurophysiology, tremor, upper limb tremor

© 2024 Pattamon Panyakaew et al., published by Sciendo

This work is licensed under the Creative Commons Attribution 4.0 International License.

Bedside clinical assessment of patients with common upper limb tremor and algorithmic approach

Article Category: Review

Published Online: Apr 30, 2024

Page range: 37 - 52

DOI: https://doi.org/10.2478/abm-2024-0008

Keywordsclinical assessment, investigations, neurophysiology, tremor, upper limb tremor

© 2024 Pattamon Panyakaew et al., published by Sciendo

This work is licensed under the Creative Commons Attribution 4.0 International License.

Keywords
clinical assessment, investigations, neurophysiology, tremor, upper limb tremor