What are the examination and investigation findings in a patient (pt) with tremors?

From the Guidelines

The examination and investigation of a patient with tremors should prioritize the use of I-123 ioflupane SPECT/CT Brain to differentiate Parkinsonian syndromes from essential tremor and drug-induced tremor, as it demonstrates abnormality early in the disease course and can essentially exclude Parkinsonian syndromes if normal 1. When evaluating a patient with tremors, a thorough clinical assessment is crucial to characterize the tremor and identify its potential cause. This includes:

• A detailed history focusing on tremor onset, progression, exacerbating factors, family history, medication use, and associated neurological symptoms
• Physical examination to observe the tremor at rest, with posture maintenance, and during action, noting its frequency, amplitude, distribution, and symmetry
• A complete neurological examination including mental status, cranial nerves, motor strength, reflexes, sensation, coordination, and gait
• Specific tremor assessment techniques such as having the patient extend their arms, perform finger-to-nose testing, draw spirals, write sentences, and hold a cup of water Laboratory investigations should include:
• Complete blood count
• Metabolic panel
• Liver function tests
• Thyroid function tests
• Ceruloplasmin (for Wilson's disease)
• Toxicology screening Additional tests may include:
• Brain imaging (MRI or CT) to rule out structural lesions
• Electromyography to characterize the tremor's neurophysiological pattern
• DaTscan for Parkinson's disease, as I-123 ioflupane SPECT/CT is a valuable test to demonstrate the loss of presynaptic dopaminergic neurons in PD 1
• Genetic testing when hereditary tremor is suspected Medication review is essential as many drugs can cause or exacerbate tremors, including beta-agonists, antipsychotics, antidepressants, and stimulants. This systematic approach helps distinguish between common tremor types such as essential tremor, parkinsonian tremor, cerebellar tremor, and drug-induced tremor, guiding appropriate management strategies.

From the FDA Drug Label

Part III of the UPDRS contains 27 questions (for 14 items) and is scored as described for part II. It is designed to assess the severity of the cardinal motor findings in patients with Parkinson's disease (e.g., tremor, rigidity, bradykinesia, postural instability, etc.), scored for different body regions, and has a maximum (worst) score of 108 The patient with tremors should undergo an examination using the Unified Parkinson's Disease Rating Scale (UPDRS), specifically Part III, to assess the severity of motor findings such as tremor.

• The UPDRS Part III is designed to evaluate the severity of cardinal motor findings in patients with Parkinson's disease, including tremor.
• The scale has a maximum score of 108, with higher scores indicating greater severity of symptoms.
• The patient's tremor severity can be assessed and scored using this scale, providing a quantitative measure of the symptom's impact on the patient's daily life 2.

From the Research

Examination and Investigations in Patients with Tremors

• The diagnosis of tremor is based on clinical information obtained from the history and physical examination 3
• The most common tremors in patients presenting to primary care physicians are enhanced physiologic tremor, essential tremor, and parkinsonian tremor 3
• Features consistent with psychogenic tremor are abrupt onset, spontaneous remission, changing tremor characteristics, and extinction with distraction 3

Types of Tremors

• Resting tremors occur in a body part that is relaxed and completely supported against gravity 3
• Action tremors occur with voluntary contraction of a muscle and can be further subdivided into postural, isometric, and kinetic tremors 3, 4
• The most common pathologic tremor is essential tremor, which affects 0.4% to 6% of the population 3
• Parkinson disease is the most common form of resting tremor, along with drug-induced resting tremor 4

Diagnostic Approach

• The evaluation should begin with a tremor history and a focused neurologic examination 4
• The examination should attend to the many subtleties of tremor phenomenology 4
• Single-photon emission computed tomography can be used to visualize the integrity of the dopaminergic pathways in the brain, and transcranial ultrasonography may be useful to diagnose Parkinson disease 3

Treatment Options

• Levodopa is the first-line therapeutic option for all motor symptoms, including tremor 5
• The addition of dopamine agonists or anticholinergics can lead to further tremor reduction 5
• Botulinum toxin injection is an effective alternative for patients with pharmacological-resistant tremor who are not seeking advanced therapies 5, 6
• Deep brain stimulation is the most well-established advanced therapy owing to its long-term efficacy, reversibility, and effectiveness in other motor symptoms and fluctuations 5