Tremor physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]

Overview

Physical examination of patients with tremor varies depending on the cause of tremor. The basis of physical examination is to determine the type of tremor, phenomenological features of tremor, associated neurological signs.

Physical Examination

Physical examination of patients with tremor varies depending on the cause of tremor.

• Important factors in physical examination are:
  • Type of tremor
  • Phenomenological features of tremor
  • Associated neurological signs

Appearance of the Patient

• Patients with tremor may present with variable appearance depending on the cause of tremor. It is important to observe for gait, apathy, resting tremor, tremor with voluntary movement, posture, facial masking, sweating when the patient walks in and during history taking.

Vital Signs

• Temperature is usually normal in common causes of tremor.
• Hyperthermia may be present in hyperthyroidism.
• Tachycardia with regular pulse may be found in hyperthyroidism, stress, anxiety
• Tachypnea may be found in stress, anxiety
• Blood pressure with usually normal.

Skin

• Skin examination of patients with tremors is usually normal.

HEENT

• HEENT examination of patients with tremor depends on the cause.
• Look for eye changes characteristic of hyperthyroidism.
• Eye movement should be assessed for cerebellar disorders and Parkinson's disease could have double vision due to convergence insufficiency.
• Action tremor in patients under forty should be examined for Wilson's disease eye changes, Kayser–Fleischer ring in the cornea.
• Assess for nystagmus if cause of tremor is sudden in onset, associated with new onset headache, vertigo, gait changes. possible cause could be a stroke.
• Decreased blinking in Parkinson's disease.

Neck

• Neck examination of patients with tremors is usually normal.
• Hyperthyroidism may have neck swelling, thyromegaly / thyroid nodules.

Lungs

• Pulmonary examination of patients with tremor is usually normal.

Heart

• Cardiovascular examination of patients with tremor is usually normal. Palpitation may occur in hyperthyroidism, stress, alcohol withdrawal.

Abdomen

• Abdominal examination of patients with tremor is usually normal.

Back

• Back examination of patients with tremor is usually normal.

Genitourinary

• Genitourinary examination of patients with tremor is usually normal.

Neuromuscular

Assessment of tremor.

Position	Category	Causes
At rest	Resting tremors	Tremors that are worse at rest include Parkinsonian syndromes and essential tremor if severe. This includes drug-induced tremors from blockers of dopamine receptors such as haloperidol and other antipsychotic drugs.
During contraction (eg a tight fist while the arm is resting and supported)	Contraction tremors	Tremors that are worse during supported contraction include essential tremor and also cerebellar and exaggerated physiologic tremors such as a hyperadrenergic state or hyperthyroidism. Drugs such as adrenergics, anti-cholinergics, and xanthines can exaggerate physiologic tremor.
During posture (eg with the arms elevated against gravity such as in a 'bird-wing' position)	Posture tremors	Tremors that are worse with posture against gravity include essential tremor and exaggerated physiologic tremors.
During intention (eg finger to nose test)	Intention tremors	Intention tremors are tremors that are worse at during intention and the patient's finger approaches a target include cerebellar disorders.

• Patients are usually oriented to persons, place, and time. Detailed neuromuscular examination of patients with tremor should include:
• Parkinson's disease
  • Muscle rigidity: Cogwheel rigidity
  • Bradykinesia: Slow movement, occurs in Parkinsons disease.
  • Abnormal gait: Romberg's test
  • Unilateral/bilateral tremor:Frequency, amplitude, pattern, distribution.
  • Dysdiadochokinesia (palm tapping test)
  • Postural reflexes impaired.
• Essential Tremor:
  • Bilateral action tremor
  • Effecting hands,forearms
  • Absence of other neurological signs
• Cerebellar Tremor:
  • Finger-to-nose test / Dysmetria
  • Truncal ataxia
  • Wide-based gait.
• Alcohol induced tremor:
  • Finger-to-nose test / Dysmetria

Extremities

• Hands should be pronated and resting on the lap to induce resting tremor, it is important to be patient as tremors may take up to thirty seconds to appear. Repositioning hand with little finger down and thumb up can induce Parkinsonian tremor and Holmes tremor.
• Parkinson's disease: Shortening of stride length, appendicular bradykinesia
• Essential Tremors: Bilateral action tremor affecting hands and forearms. Other neurological signs are absent. Following quick test should be done to evaluate tremor, drink from a glass, outstretch arms, and draw a spiral.