Tremor physical examination: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Tremor}} | {{Tremor}} | ||
{{CMG}} | {{CMG}}; {{AE}} {{ZMalik}} | ||
==Overview== | ==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== | ||
[[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]]. <ref name="pmid27994349">{{cite journal| author=Sharma S, Pandey S| title=Approach to a tremor patient. | journal=Ann Indian Acad Neurol | year= 2016 | volume= 19 | issue= 4 | pages= 433-443 | pmid=27994349 | doi=10.4103/0972-2327.194409 | pmc=5144461 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27994349 }} </ref> | |||
*[[Eye]] movement should be assessed for [[cerebellar]] [[disorders]] and [[Parkinson's disease]] could have double vision due to convergence insufficiency. <ref name="pmid14596441">{{cite journal| author=Smaga S| title=Tremor. | journal=Am Fam Physician | year= 2003 | volume= 68 | issue= 8 | pages= 1545-52 | pmid=14596441 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14596441 }} </ref> | |||
*[[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]]. <ref name="pmid14596441">{{cite journal| author=Smaga S| title=Tremor. | journal=Am Fam Physician | year= 2003 | volume= 68 | issue= 8 | pages= 1545-52 | pmid=14596441 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14596441 }} </ref> | |||
===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=== | |||
{| class="wikitable" | {| class="wikitable" | ||
| '''Position''' || ''' | |+ Assessment of tremor<ref name="pmid7001967">{{cite journal| author=Jankovic J, Fahn S| title=Physiologic and pathologic tremors. Diagnosis, mechanism, and management. | journal=Ann Intern Med | year= 1980 | volume= 93 | issue= 3 | pages= 460-5 | pmid=7001967 | doi=10.7326/0003-4819-93-3-460 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7001967 }} </ref>. | ||
|- | | '''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. | | 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<ref name="pmid7001967">.</ref>. Drugs such as [[adrenergic]]s, [[anti-cholinergic]]s, and [[xanthine]]s can exaggerate physiologic tremor. | | 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<ref name="pmid7001967">.</ref>. Drugs such as [[adrenergic]]s, [[anti-cholinergic]]s, and [[xanthine]]s 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<ref name="pmid7001967">.</ref>. | | 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<ref name="pmid7001967">.</ref>. | ||
|- | |- | ||
| During intention (eg finger to nose test) || Intention tremors|| [[Intention tremor]]s are tremors that are worse during intention | | During intention (eg finger to nose test) || Intention tremors|| [[Intention tremor]]s 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]] <ref name="pmid28638597">{{cite journal| author=Chen W, Hopfner F, Becktepe JS, Deuschl G| title=Rest tremor revisited: Parkinson's disease and other disorders. | journal=Transl Neurodegener | year= 2017 | volume= 6 | issue= | pages= 16 | pmid=28638597 | doi=10.1186/s40035-017-0086-4 | pmc=5472969 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28638597 }} </ref> | |||
**[[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]]. <ref name="pmid27833521">{{cite journal| author=Alqwaifly M| title=Treatment responsive Holmes tremor: case report and literature review. | journal=Int J Health Sci (Qassim) | year= 2016 | volume= 10 | issue= 4 | pages= 558-562 | pmid=27833521 | doi= | pmc=5085351 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27833521 }} </ref> | |||
*[[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. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category: | [[Category:Neurology]] | ||
[[Category:Primary care]] | |||
[[Category:Signs and symptoms]] | |||
[[Category:Medicine]] | |||
Latest revision as of 16:05, 26 May 2021
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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. [1]
- Eye movement should be assessed for cerebellar disorders and Parkinson's disease could have double vision due to convergence insufficiency. [2]
- 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. [2]
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
| 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[3]. 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[3]. |
| 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 [4]
- 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:
- 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. [5]
- 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.
References
- ↑ Sharma S, Pandey S (2016). "Approach to a tremor patient". Ann Indian Acad Neurol. 19 (4): 433–443. doi:10.4103/0972-2327.194409. PMC 5144461. PMID 27994349.
- ↑ 2.0 2.1 Smaga S (2003). "Tremor". Am Fam Physician. 68 (8): 1545–52. PMID 14596441.
- ↑ 3.0 3.1 3.2 Jankovic J, Fahn S (1980). "Physiologic and pathologic tremors. Diagnosis, mechanism, and management". Ann Intern Med. 93 (3): 460–5. doi:10.7326/0003-4819-93-3-460. PMID 7001967.
- ↑ Chen W, Hopfner F, Becktepe JS, Deuschl G (2017). "Rest tremor revisited: Parkinson's disease and other disorders". Transl Neurodegener. 6: 16. doi:10.1186/s40035-017-0086-4. PMC 5472969. PMID 28638597.
- ↑ Alqwaifly M (2016). "Treatment responsive Holmes tremor: case report and literature review". Int J Health Sci (Qassim). 10 (4): 558–562. PMC 5085351. PMID 27833521.