Rest Tremor
Let hands rest on legs or forearms on armrest, flexed elbows, with palms facing upwards. Often enhanced by cognitive tasks. Rest tremor is brought out by walking, or when performing movements of another body part.
Action Tremor:
It is ideal for action tremor to be tested in multiple settings. When the arm moves from rest to posture, tremor may be seen to be ongoing and can be seen as the arm is lifted. Re-emergent tremor of PD should be regarded as an action tremor. Note that the suppression of tremor amplitude during movement onset is in favour of a dopaminergic deficiency syndrome like PD.
Kinetic Tremor
- Simple Kinetic Tremor: Non target directed movements e.g. finger tapping, pronation-supination of the forearm, or flexion-extension of the elbow.
- Kinetic Tremor, Goal directed
- Intention Tremor: At the endpoint of a movement during visually guided movement, e.g. finger to nose test. The examiner’s finger should be at a distance such that the patient must move the arm to a full extension to reach the target, allowing the physician to see whether there is an intention component to the tremor.
In addition to the finger-nose test and drawing spirals, other helpful tasks for determining the quality and severity of the kinetic tremor include: - Pouring water between two cups over a sink
- Drinking water from a cup with one hand
- Using a spoon to scoop water from a cup and then place it in the mouth
- Intention Tremor: At the endpoint of a movement during visually guided movement, e.g. finger to nose test. The examiner’s finger should be at a distance such that the patient must move the arm to a full extension to reach the target, allowing the physician to see whether there is an intention component to the tremor.
- Task specific Kinetic Tremor: During a specific skilled task, for example, writing.or speaking.
Postural Tremor: Keep arms and fingers in two positions:
- Stretched position: in addition to holding arms outstretched, useful to perform additional movements of flexing and extending the hands about the axis of the wrist (A below).
- Flexed position (patient is instructed to place the arms in a batwing position with the hands facing inward, but not touching each other) (B below).
Isometric Tremor: During isometric contraction e.g. making a fist, contraction against static object, such as examiner’s fingers.
