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
© 2024 Pattamon Panyakaew et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
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Clinical features of essential tremor and enhanced physiological tremor
| Activation | Kinetic (intentional component) > postural | Postural or kinetic |
| (amplitude of kinetic > postural) | (amplitude of postural > kinetic) | |
| Rest (in severe cases with action tremor) | Intentional component uncommon | |
| Distribution | Hands (flexion/extension of wrist, bilateral) | Fingers > hands (+/− voice) |
| Head, voice, jaw (with hands) | NOT head, jaw | |
| Frequency | 4–10 Hz (decrease with age) | 8–12 Hz |
| Changes with different tasks and different body parts | ||
| Amplitude | Fine to large | Fine |
| Aggravating /relieving factors | Alcohol responsiveness | Increase with stress, exercise, fatigue, caffeine |
| Pathophysiology | Central oscillator in the cerebello-thalamo-cortical pathway | Sympathetic overactivity and increase sensitivity of peripheral components |
| Weighting | Similar frequency | Decrease frequency |
| Treatment | Beta-blocker, primidone, topiramate | Beta-blocker |
| Surgery (DBS, MRI FUS thalamotomy) | Decrease aggravating factors | |
| Assistive devices |
Clinical characteristics of Parkinson’s disease, dystonic tremor, and essential tremor
| Symmetry | Asymmetry | Asymmetry | Symmetry (mostly) |
| Activation | R > P > K | P ~ K > R | K > P >>> rest |
| (Not intentional) | (Not intentional) | (Intentional) | |
| **Suppression of rest tremor with movements** | Rest (can be early) | Rest (in severe cases with action tremor) | |
| **Re-emergent tremor** | **position or task specific** | ||
| Distribution | Hands (pill-rolling, rotation of wrist, forearm) > jaw, tongue > leg > head | Head > Hands > jaw Isolated head, voice, jaw | Hands >> head > voice > jaw (with hands in severe cases) |
| Frequency | 4–7 Hz | 5–7 Hz | 4–10 Hz |
| Amplitude | Large, waxing & waning | Large, irregular, jerky | Fine to large |
| Association | Parkinsonism | Dystonic posture | Mild ataxia |
| Non-motor symptoms: RBD, anosmia, constipation, depression | Null point (head), overflow/mirror dystonia, sensory trick | Non-motor symptoms: anxiety, depression, cognitive impairment | |
| Family history | Usually absent in late onset | Sometimes present | Present in early onset |
| Treatment | Dopaminergic agent (response 50%) | Anticholinergics | Beta-blocker, primidone, topiramate |
| Anticholinergics | Botulinum toxin injection | Surgery (DBS, MRI FUS thalamotomy) | |
| Surgery (DBS, FUS) | Assistive devices |
Differentiation of tremor from tremor mimics
| Movement | Oscillatory | Shock-like or jerky | Tonic/clonic |
| Single or repetitive | Repetitive | ||
| Rhythmicity | Regular but sometimes looks irregular in dystonic tremor syndromes or with some variability in amplitude of tremor | Irregular but can be rhythmic with repetitive myoclonus (8–18 Hz) | Regular and rhythmic (2–3 Hz) but can be irregular |
| Condition | Rest, postural, kinetic | Rest, postural, kinetic | Rest |
| Stimulus sensitivity | No reflex sensitivity | Can be triggered with sensory stimulation | No reflex sensitivity |
| Distribution | Bilateral or unilateral | Bilateral, symmetrical | Unilateral |
| Distal or proximal | Distal > proximal | Distal > proximal | |
| Upper limb > lower limb | Upper limb ~ lower limb | Upper limb > lower limb |
Step-by-step description of tremor examination
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- Semi-prone - Complete prone - Hanging down from the armrests with forearm supported - Hanging down on sides of a chair |
- Count backwards - Calculation (100-7) - Sequential fingers (1–4) tapping or alternating toes tapping on the contralateral side |
Parkinsonism Dystonic posture |
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- Hands supported by pillows - Legs supported on the bed - Head supported by pillows |
*Observe characteristics of tremor* *Unilateral vs bilateral* * |
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- Outstretched arms with hands pronated and fingers spread - Outstretched arms with hands supinated and fingers spread - Outstretched arms with palms or dorsum of hands facing each other - Wing position (elbows flexed, hands underneath the chin, not touching each other) - Outstretched leg with knee extended - Head unsupported while turning head to the extreme side |
Putting a slip of paper on top of hands (visualize fine tremor) |
Parkinsonism Dystonic posture Cerebellar sign Neuropathy |
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| Putting the weight on the dorsum of hands | |||
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*Observe *Observe *Observe null point, sensory trick* |
Systemic signs (hyperthyroidism) Kayser-Fleischer (KF) ring |
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| *Listening to high frequency tremor with stethoscope* | |||
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- Finger-to-nose test (hands) - Heel-to-knee test (legs) - Simple maneuvers (pouring water from a glass, drinking water, using utensils) - Writing (spiral, lines, sentences) - Specific tasks (from history) - Jaw: open a month - Tongue: protrude a tongue - Voice: Say “Ahh and Eee) |
*Observe simple kinetic vs intentional tremor *Observe |
Parkinsonism Dystonic posture Cerebellar sign Neuropathy |
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*Observe axis, size* *Observe occurrence of tremor at rest vs action* |
Systemic signs (hyperthyroidism) KF ring |
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| Keep the position that elicits tremor | |||
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- Cognitive test and motor test with the contralateral/less affected side - Tapping with different frequencies with the contralateral/less affected side - Ballistic movements of the contralateral/less affected side - Passively move tremulous limb before the onset of tremor |
* *Observe *Observe a pause of tremor* |
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| *Observe co-activation sign* | |||