Revisiting the assessment of tremor: clinical review

INTRODUCTION

Tremor, an involuntary, rhythmic, and oscillatory movement of a body part, is a frequent presenting symptom to general practice and by far the most common movement disorder presentation, impacting up to 15% of such cases.¹ A common initial pattern is symmetric upper-limb involvement during posture and action. Although patients are often worried about Parkinson’s disease (PD), PD tremor usually has easily recognisable features.² This concern tends to lead to frequent referrals for specialist input despite an alternative diagnosis being more likely in a majority of cases. Essential tremor (ET) is the most common diagnosis given to patients with this presentation, which is estimated to affect 0.4–6.0% of the general population.³ This may be an overestimate as the rubric of ET and the relationship between clinical features and underlying pathophysiology is uncertain. These aspects also potentially contribute to variable diagnostic and treatment outcomes.⁴ A recent Movement Disorder Society consensus on phenotyping charts a course towards more precise classification.⁵ This will not only be useful for research but also help in clarifying common clinical syndromes seen in everyday practice. This article outlines an approach to upper-limb tremor presentations in adult patients, developing a previously proposed three cardinal question method for neck pain⁶ while highlighting salient aspects of the consensus statement that could potentially aid in clinical stratification of cases.