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

Abstract

The diagnostic approach for patients with tremor is challenging due to the complex and overlapping phenotypes among tremor syndromes. The first step in the evaluation of tremor is to identify the tremulous movement and exclude the tremor mimics. The second step is to classify the tremor syndrome based on the characteristics of tremor from historical clues and focused examination (Axis 1). Comprehensive tremor examinations involve the assessment of tremor in different conditions (rest, action or mixed, position or task-specific), distribution of tremor (upper limb, lower limb, head, jaw), positive signs for functional tremor (FT) if suspected (distractibility, entrainment, co-contraction), and associated neurological signs including parkinsonism, dystonic posture, cerebellar/brainstem signs, neuropathy, and cognitive impairment. A pivotal feature in this step is to determine any distinct feature of a specific isolated or combined tremor syndrome. In this review, we propose an algorithm to assess upper limb tremors. Ancillary testing should be performed if clinical evaluation is unclear. The choice of investigation depends on the types of tremors considered to narrow down the spectrum of etiology (Axis 2). Laboratory blood tests are considered for acute onset and acute worsening of tremors, while structural neuroimaging is indicated in unilateral tremors with acute onset, nonclassical presentations, and a combination of neurological symptoms. Neurophysiological study is an important tool that aids in distinguishing between tremor and myoclonus, etiology of tremor and document specific signs of FT. Treatment is mainly symptomatic based depending on the etiology of the tremor and the patient's disabilities.

Keywords: clinical assessment; investigations; neurophysiology; tremor; upper limb tremor.

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.

Figure 2.

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.