From the Guidelines
When evaluating a patient with tremor, a primary care physician should begin with a thorough physical examination, including neurological screening tests, assessment of mobility, and/or muscle strength, as this approach is supported by high-quality clinical practice guidelines 1. The physical examination is crucial in characterizing the tremor and determining its underlying cause. The physician should assess the tremor's location, amplitude, frequency, and exacerbating factors, as well as perform coordination tests like finger-to-nose, rapid alternating movements, and handwriting samples. Some key points to consider during the physical examination include:
- Neurological assessment to identify any associated neurological symptoms or signs
- Assessment of mobility and muscle strength to rule out any underlying musculoskeletal conditions
- Evaluation of the tremor's characteristics, such as its occurrence at rest, with action/posture, or with specific tasks The physician should also take a thorough history, including a family history, as some tremors are hereditary, and note any medications that may be contributing to the tremor, such as beta-agonists, antidepressants, lithium, valproic acid, and stimulants. If red flags are present, such as asymmetry, rapid progression, or associated neurological symptoms, or if the diagnosis is unclear, referral to a neurologist is warranted, as indicated by the high-quality clinical practice guidelines 1.
From the FDA Drug Label
CLINICAL PHARMACOLOGY Mechanism of Action Parkinson’s disease is a progressive, neurodegenerative disorder of the extrapyramidal nervous system affecting the mobility and control of the skeletal muscular system. Its characteristic features include resting tremor, rigidity, and bradykinetic movements.
The FDA drug label does not answer the question.
From the Research
Evaluation of Tremor
To evaluate a complaint of tremor, a primary care physician (PCP) should follow a systematic approach:
- Categorize the tremor based on its activation condition, topographic distribution, and frequency 2, 3
- Determine if the tremor occurs at rest or with action, as this can help differentiate between types of tremor 2, 4, 3
- Assess the severity of the tremor and response to treatment using clinical rating scales and electrophysiological measurements 4
Types of Tremor
Common types of tremor include:
- Enhanced physiologic tremor, essential tremor, and parkinsonian tremor 2
- Psychogenic tremor, which can be diagnosed based on clinical signs such as abrupt onset, spontaneous remission, and extinction with distraction 2, 4, 3
- Cerebellar, dystonic, and drug- or metabolic-induced tremor 2, 3
Diagnostic Approach
The diagnosis of tremor is based on clinical information obtained from a thorough history and physical examination 2, 3
- Single-photon emission computed tomography can be used to visualize the integrity of the dopaminergic pathways in the brain and diagnose Parkinson disease 2, 3
- Transcranial ultrasonography may be useful to diagnose Parkinson disease 2
Treatment
Treatment of tremor is symptomatic, and medications are effective in half the cases of essential hand tremor 4