From the Guidelines
A structured tremor exam should begin with observation of the patient at rest, followed by assessment during posture maintenance, and finally during action or movement. This approach is crucial for accurate diagnosis and treatment planning, as it allows for the classification of tremor type (resting, postural, intention, or task-specific) 1. Start by observing the patient's hands resting in their lap for resting tremor, then ask them to extend their arms forward to detect postural tremor. Next, evaluate action tremor by having the patient perform the finger-to-nose test and rapid alternating movements.
- Include specific tasks like drawing a spiral, writing a sentence, and pouring water between cups to assess functional impact.
- Quantify tremor characteristics including frequency (slow, medium, fast), amplitude (fine, moderate, coarse), and distribution (which body parts are affected).
- Note any exacerbating or alleviating factors such as stress or alcohol. The exam should also include assessment of associated neurological signs that might help determine etiology, such as bradykinesia or rigidity for Parkinson's disease, or cerebellar signs for intention tremor.
- The National Institutes of Health Stroke Scale (NIHSS) can be used as a reference for assessing neurological signs, although it is not specifically designed for tremor assessment 1. This systematic approach enables proper monitoring of progression or treatment response over time, and the exam findings should be documented with specific descriptions rather than vague terms.
- Intervention strategies for functional tremor, such as superimposing alternative rhythms and assisting the person to relax the muscles in the limb, can be useful in managing symptoms 1.
From the Research
Structured Tremor Exam
To create a structured tremor exam, the following components should be considered:
- Tremor history: A detailed history of the tremor, including its onset, duration, and progression 2
- Neurologic examination: A focused neurologic examination to assess the nuances of tremor phenomenology, including the type of tremor (action or resting) and its characteristics (postural, kinetic, or intention) 2
- Differential diagnoses: Formulation of two sets of differential diagnoses: disorders with action tremor as the predominant tremor and those with resting tremor as the main tremor 2
- Assessment of tremor severity: Evaluation of the severity of the tremor, including its impact on daily activities and quality of life 3, 4, 5
- Evaluation of treatment response: Assessment of the patient's response to previous treatments, including pharmacotherapy, botulinum toxin injections, and surgical interventions 3, 4, 6, 5
Components of the Exam
The structured tremor exam should include:
- Physical examination: A thorough physical examination to assess the presence and characteristics of the tremor, including its frequency, amplitude, and distribution 2
- Laboratory tests: Laboratory tests, such as blood work and imaging studies, to rule out secondary causes of tremor and to assess for any underlying conditions that may be contributing to the tremor 6, 2
- Tremor rating scales: Use of standardized tremor rating scales, such as the Fahn-Tolosa-Marin Tremor Rating Scale, to assess the severity of the tremor and to monitor treatment response 3, 5
Considerations for Special Cases
Special consideration should be given to certain cases, including:
- Essential tremor plus: Patients with essential tremor plus, who have associated subtle neurological "soft signs", such as dystonic posturing of limbs, may require a different treatment approach 5
- Medication-refractory tremor: Patients with medication-refractory tremor may require alternative forms of therapy, such as botulinum toxin injections or surgical interventions 3, 4, 5