Neurology diagnoses and treats disorders of the nervous system, including the brain, spinal cord, and nerves, as well as thought and memory.
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The diagnosis of tremor is primarily phenomenological, relying on the “eyes and ears” of the neurologist. The exam involves observing the patient in three states: rest, posture, and action. The patient is asked to rest their hands on their lap, extend them forward (wing beating), and perform finger to nose testing.
Handwriting analysis and spiral drawing are standard bedside tests. In Essential Tremor, the spiral is often large and shaky along a specific axis, while the handwriting is large and tremulous. In Parkinson’s, the spiral may be small (micrographia) and tight, reflecting bradykinesia rather than just tremor. This simple paper test provides a permanent record of severity.
When the clinical presentation is ambiguous, neurophysiology can define the tremor characteristics. Surface Electromyography (EMG) measures the timing of muscle bursts. In Essential Tremor, agonist and antagonist muscles typically fire synchronously. In Parkinson’s tremor, they usually fire in an alternating pattern.
Accelerometry involves placing a sensor on the limb to measure the precise frequency. This is critical for diagnosing rare tremors like Primary Orthostatic Tremor, which has a distinct high frequency (16 Hz) that can be felt by the examiner (like a buzzing vibration) but is too fast to be seen clearly by the eye.
The most robust imaging tool for differentiating Essential Tremor from Parkinsonian Tremor is the DaTscan (Dopamine Transporter SPECT). This nuclear medicine scan visualizes the dopamine nerve terminals in the striatum. In Essential Tremor, the dopamine system is intact, so the scan appears normal (comma shaped).
In Parkinson’s disease or other degenerative parkinsonisms, there is a loss of dopamine terminals. The scan will show a reduction in uptake, typically appearing as a period or full loss of the tail of the comma. A normal DaTscan in a patient with resting tremor strongly argues against a diagnosis of Parkinson’s disease.
Structural MRI of the brain is performed to rule out secondary causes (“Symptomatic Tremor”). A stroke in the thalamus, a tumor in the cerebellum, or a plaque from Multiple Sclerosis in the brainstem can all cause focal tremors. Specifically, hypertrophic olivary degeneration can cause palatal tremor, visible as a specific signal change in the brainstem.
Metabolic screening is mandatory for new onset tremor. This includes Thyroid Stimulating Hormone (TSH) to rule out hyperthyroidism, electrolytes to check for hypocalcemia or hypomagnesemia, and liver function tests. In young patients (under 40), serum ceruloplasmin is checked to rule out Wilson’s Disease, a treatable copper storage disorder.
Diagnosing functional (psychogenic) tremor is a positive process, not just a diagnosis of exclusion. The “entrainment test” is a key diagnostic maneuver. The patient is asked to tap a rhythm with their non affected hand. In organic tremor, the tremor persists at its own frequency. In functional tremor, the tremor will often shift to match the tapping frequency or stop altogether due to the inability of the brain to maintain two different voluntary rhythms simultaneously.
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A DaTscan is a specialized brain imaging test that uses a radioactive tracer to see if the dopamine producing cells in the brain are healthy or dying, distinguishing Parkinson’s from other tremors.
Drawing a spiral forces your hand to move in a continuous, unsupported motion; the specific way the lines shake tells the doctor if the tremor is cerebellar, essential, or parkinsonian.
Blood tests cannot diagnose the tremor itself, but they are essential to rule out reversible causes like thyroid disease, vitamin deficiencies, or heavy metal poisoning.
It is rare, but it is a “can’t miss” diagnosis in young people with tremor because it is treatable; missing it can lead to severe, irreversible liver and brain damage.
Yes, doctors often ask you to avoid caffeine before a tremor exam because stimulants can temporarily worsen the shaking, making it harder to determine your baseline severity.
essential tremor About 10 million people in the United States deal with uncontrollable shaking, often in their hands. This is called essential tremor. It makes
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