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

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

Asian Biomedicine
Volume 18 (2024): Issue 2 (April 2024)
By: Pattamon Panyakaew,  Warongporn Phuenpathom,  Roongroj Bhidayasiri and  Mark Hallett  
Open Access
|Apr 2024

Figures & Tables

Figure 1.

The example of a spiral/line drawing and sentence writing in patients with EPT (A), ET (B), and writer’s cramp with DT (C). EPT and ET show bilateral tremors with spiral drawing with unilateral axis, while DT exhibits tremor on the affected side with multidirectional axis. DT, dystonic tremor; EPT, enhanced physiologic tremor; ET, essential tremor.
The example of a spiral/line drawing and sentence writing in patients with EPT (A), ET (B), and writer’s cramp with DT (C). EPT and ET show bilateral tremors with spiral drawing with unilateral axis, while DT exhibits tremor on the affected side with multidirectional axis. DT, dystonic tremor; EPT, enhanced physiologic tremor; ET, essential tremor.

Figure 2.

Differential diagnosis of tremor syndromes in the category of action and rest tremor of the upper limb CB; cerebellar, BS; brainstem.
Differential diagnosis of tremor syndromes in the category of action and rest tremor of the upper limb CB; cerebellar, BS; brainstem.

Figure 3.

Practical step-by-step algorithms of approaching tremor.
Practical step-by-step algorithms of approaching tremor.

Clinical features of essential tremor and enhanced physiological tremor

Essential tremorEnhanced physiologic tremor
ActivationKinetic (intentional component) > posturalPostural or kinetic
(amplitude of kinetic > postural)(amplitude of postural > kinetic)
Rest (in severe cases with action tremor)Intentional component uncommon
DistributionHands (flexion/extension of wrist, bilateral)Fingers > hands (+/− voice)
Head, voice, jaw (with hands)NOT head, jaw
Frequency4–10 Hz (decrease with age)8–12 Hz
Changes with different tasks and different body parts
AmplitudeFine to largeFine
Aggravating /relieving factorsAlcohol responsivenessIncrease with stress, exercise, fatigue, caffeine
PathophysiologyCentral oscillator in the cerebello-thalamo-cortical pathwaySympathetic overactivity and increase sensitivity of peripheral components
WeightingSimilar frequencyDecrease frequency
TreatmentBeta-blocker, primidone, topiramateBeta-blocker
Surgery (DBS, MRI FUS thalamotomy)Decrease aggravating factors
Assistive devices

Clinical characteristics of Parkinson’s disease, dystonic tremor, and essential tremor

Parkinson’s diseaseDystonic tremorEssential tremor
SymmetryAsymmetryAsymmetrySymmetry (mostly)
ActivationR > P > KP ~ K > RK > 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**
DistributionHands (pill-rolling, rotation of wrist, forearm) > jaw, tongue > leg > headHead > Hands > jaw Isolated head, voice, jawHands >> head > voice > jaw (with hands in severe cases)
Frequency4–7 Hz5–7 Hz4–10 Hz
AmplitudeLarge, waxing & waningLarge, irregular, jerkyFine to large
AssociationParkinsonismDystonic postureMild ataxia
Non-motor symptoms: RBD, anosmia, constipation, depressionNull point (head), overflow/mirror dystonia, sensory trickNon-motor symptoms: anxiety, depression, cognitive impairment
Family historyUsually absent in late onsetSometimes presentPresent in early onset
TreatmentDopaminergic agent (response 50%)AnticholinergicsBeta-blocker, primidone, topiramate
AnticholinergicsBotulinum toxin injectionSurgery (DBS, MRI FUS thalamotomy)
Surgery (DBS, FUS) Assistive devices

Differentiation of tremor from tremor mimics

TremorCortical myoclonusEPC
MovementOscillatoryShock-like or jerkyTonic/clonic
Single or repetitiveRepetitive
RhythmicityRegular but sometimes looks irregular in dystonic tremor syndromes or with some variability in amplitude of tremorIrregular but can be rhythmic with repetitive myoclonus (8–18 Hz)Regular and rhythmic (2–3 Hz) but can be irregular
ConditionRest, postural, kineticRest, postural, kineticRest
Stimulus sensitivityNo reflex sensitivityCan be triggered with sensory stimulationNo reflex sensitivity
DistributionBilateral or unilateralBilateral, symmetricalUnilateral
Distal or proximalDistal > proximalDistal > proximal
Upper limb > lower limbUpper limb ~ lower limbUpper limb > lower limb

Step-by-step description of tremor examination

Activation of tremorPosition/taskProvocation test/Specific observationAssociated examination
Rest tremor

  • Sitting position (hands: hands completely relaxed on the lap; legs: foot placed on the floor, supported against gravity)

  • - Semi-prone

  • - Complete prone

  • - Hanging down from the armrests with forearm supported

  • - Hanging down on sides of a chair

  • Cognitive test

  • - Count backwards

  • - Calculation (100-7)

  • Motor test

  • - Sequential fingers (1–4) tapping or alternating toes tapping on the contralateral side

  • Parkinsonism

  • Dystonic posture

  • Supine position (hands, legs, head)

  • - Hands supported by pillows

  • - Legs supported on the bed

  • - Head supported by pillows

  • Walking (hands)

  • *Observe characteristics of tremor*

  • *Unilateral vs bilateral*

  • *Suppression of rest tremor at the onset of voluntary movements*

Postural tremor

  • Sitting position (hands, legs, head held against gravity)

  • - 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

  • Standing position (legs)

Putting a slip of paper on top of hands (visualize fine tremor)

  • Parkinsonism

  • Dystonic posture

  • Cerebellar sign

  • Neuropathy

Putting the weight on the dorsum of hands

  • *Observe re-emergence of tremor during postural holding*

  • *Observe position-specific tremor*

  • *Observe null point, sensory trick*

  • Systemic signs (hyperthyroidism)

  • Kayser-Fleischer (KF) ring

*Listening to high frequency tremor with stethoscope*
Kinetic tremor

  • Performing task

  • - 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)

  • Action of specific parts of body

  • - Jaw: open a month

  • - Tongue: protrude a tongue

  • - Voice: Say “Ahh and Eee)

  • *Observe simple kinetic vs intentional tremor

  • *Observe task-specific*

  • Parkinsonism

  • Dystonic posture

  • Cerebellar sign

  • Neuropathy

  • *Observe axis, size*

  • *Observe occurrence of tremor at rest vs action*

  • Systemic signs (hyperthyroidism)

  • KF ring

Specific signs for functional tremorKeep the position that elicits tremor

  • - 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 distractibility and tremor variability*

  • *Observe entrainment (change/adopt the tapping frequency)

  • *Observe a pause of tremor*

*Observe co-activation sign*
DOI: https://doi.org/10.2478/abm-2024-0008 | Journal eISSN: 1875-855X | Journal ISSN: 1905-7415
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Language: English
Page range: 37 - 52
Published on: Apr 30, 2024
Published by: Chulalongkorn University
In partnership with: Paradigm Publishing Services
Publication frequency: 6 issues per year
Keywords:
clinical assessment,
investigations,
neurophysiology,
tremor,
upper limb tremor
Related subjects:
Medicine,
Assistive professions, nursing,
Basic medical science,
Basic medical science, other,
Clinical medicine,
Clinical medicine, other

© 2024 Pattamon Panyakaew, Warongporn Phuenpathom, Roongroj Bhidayasiri, Mark Hallett, published by Chulalongkorn University
This work is licensed under the Creative Commons Attribution 4.0 License.

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