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Clinical Practice

Revisiting the assessment of tremor: clinical review

Nirosen Vijiaratnam, Thomas Wirth and Huw R Morris
British Journal of General Practice 2020; 70 (701): 611-614. DOI: https://doi.org/10.3399/bjgp20X713849
Nirosen Vijiaratnam
Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London; National Hospital for Neurology and Neurosurgery, London; Department of Neurology, Royal Free Hospital, London.
Roles: Clinical research fellow
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Thomas Wirth
Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London; National Hospital for Neurology and Neurosurgery, London.
Roles: Clinical research fellow
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Huw R Morris
Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London; National Hospital for Neurology and Neurosurgery, London; Department of Neurology, Royal Free Hospital, London; UCL Movement Disorders Centre, UCL Queen Square Institute of Neurology, London.
Roles: Professor of neurology and consultant neurologist
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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.

CLINICAL ASSESSMENT

History

Characterising the onset age, anatomical distribution (head, voice, hands, and symmetry), and temporal evolution of the tremor is important, forms the first step of the assessment, and aids in determining the underlying syndrome (outlined in subsequent sections). A key aspect to establish early is if the tremor results in functional impairment as this will determine if treatment is warranted (all current treatment options are symptomatic, that is, non-disease modifying).7,8 Useful questions to establish this …

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British Journal of General Practice: 70 (701)
British Journal of General Practice
Vol. 70, Issue 701
December 2020
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Revisiting the assessment of tremor: clinical review
Nirosen Vijiaratnam, Thomas Wirth, Huw R Morris
British Journal of General Practice 2020; 70 (701): 611-614. DOI: 10.3399/bjgp20X713849

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Revisiting the assessment of tremor: clinical review
Nirosen Vijiaratnam, Thomas Wirth, Huw R Morris
British Journal of General Practice 2020; 70 (701): 611-614. DOI: 10.3399/bjgp20X713849
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  • Article
    • INTRODUCTION
    • CLINICAL ASSESSMENT
    • SYNDROMES, AETIOLOGIES, AND RED FLAGS
    • THREE ‘CARDINAL’ QUESTIONS CLINICAL APPROACH TO TREMOR
    • CONCLUSION
    • Notes
    • REFERENCES
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