Assessment of tremor

unilateral or asymmetrical rest tremor, slowed movements, stiffness, micro-graphia, drooling, difficulty turning over in bed, difficulty with buttons and utensil use, shuffling gait, and decreased arm swing; history of hyposmia, history of rapid eye movement sleep behaviour disorder

masked facies (reduced facial animation), hypophonia, unilateral or asymmetrical rest tremor (may be pill rolling), slow or low-amplitude finger taps and hand grips, rigidity, difficulty standing from chair, shuffling gait, stooped posture, decreased arm swing, retropulsion on pull-back testing, stooped posture

fluctuating cognition, cognitive impairment, and parkinsonism occurring within 1 year of each other, visual hallucinations (not related to dopaminergic therapy) and delusions, sensitivity reactions to neuroleptics

muscle rigidity, stooped posture, cogwheel rigidity, shuffling gait, impairment on cognitive testing

tremor noticed in situations of stress, anxiety, or excessive caffeine use; absence of neurological disease

anxious appearance; fine high-frequency postural and kinetic tremor that occurs in arms, legs, and voice but not the head

history of diabetes or glucose intolerance, history of insulin use

sympathoadrenal or neuroglycopenic symptoms; action tremor

weight loss, diaphoresis (excessive sweating), heat intolerance, palpitations, anxiety

diaphoresis, tachycardia, enlarged thyroid gland; action tremor

history of alcohol misuse

tremulousness, seizures, delirium, hallucinations, spider angiomata, gynaecomastia, enlarged liver, signs of autonomic hyper-activity, no alcohol for 6 hours produces intention tremor; hypertension; tachycardia

tremor mainly affects hands, shaky handwriting or utensil use; positive family history; tremors may improve with alcohol use

postural and/or kinetic tremors of hands, tremors may also involve head and voice; essential tremor occurs in absence of other neurological signs; if subtle neurological signs such as impaired tandem gait, subtle body posturing suggestive of dystonia, or mild memory impairment are present, then essential tremor plus is the more appropriate classification

occurs following ingestion of certain drugs; rest tremors can be caused by dopamine receptor blockers such as antipsychotics and antiemetics (e.g., metoclopramide, prochlorperazine, promethazine), or dopamine depletors (e.g., tetrabenazine); action tremors are common following treatment with antidepressants (e.g., selective serotonin-reuptake inhibitors [SSRIs], tricyclic antidepressants, monoamine oxidase inhibitors [MAOIs]), mood stabilisers (e.g., lithium), anticonvulsants (e.g., valproic acid), cardiac drugs (e.g., amiodarone), immunosuppressants (e.g., ciclosporin, tacrolimus, corticosteroids), drugs for asthma (e.g., salbutamol, theophylline), and stimulants (e.g., amphetamines); tremor occurs in a reasonable time frame following drug ingestion

rest or action tremor

lightheadedness and syncope, erectile dysfunction, urinary dysfunction, dysarthria, gait difficulty, slow movements, rest tremor, lack of coordination, early postural instability

orthostatic hypotension, parkinsonism, ataxia, hyper-reflexia, shuffling or ataxic gait

frequent falls, visual problems, axial rigidity, dysarthria, dysphagia, personality and cognitive change, rest tremor

supra-nuclear gaze palsy, dysarthria, 'surprised' facial expression, axial rigidity, bradykinesia, frontal release signs, cognitive impairment, marked gait instability

asymmetrical rest tremor; disorder of skilled, learned, purposeful movement; dystonic limb posturing; alien limb phenomenon

parkinsonism (rest tremor, rigidity, bradykinesia, postural instability), limb apraxia, dystonia, spontaneous and reflex focal myoclonus, rigidity

history of toxic exposure to the neurotoxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) (heroin addicts), carbon monoxide, manganese (may be seen in welders or in patients receiving parenteral nutrition), methanol, or cyanide

parkinsonism (rest tremor, rigidity, bradykinesia, and postural instability)

headache, sweating, palpitations

hypertension, tachycardia, action tremor

complaints of incoordination, imbalance, family history of cerebellar ataxia, history of multiple sclerosis, head trauma, stroke, or cerebellar haemorrhage

coarse irregular kinetic tremor generated proximally, abnormal finger-to-nose testing and heel-to-shin testing, dysdiadochokinesis, wide-based ataxic gait, dysarthria (speech problems)

occurs in upper limbs, age >60 years, more common in men, gait ataxia, may be a family history of premature ovarian failure in females and/or intellectual disability (fragile X syndrome) in males

intention tremor, ataxic gait, often have acquired cognitive impairment especially executive dysfunction

tremor in legs that occurs on standing, accompanied unsteadiness, tremor disappears on sitting or walking

high-frequency tremor of legs when standing

tremor of hand only when writing

hand tremor when writing only

tremor in a body region (usually head or neck, but may be limb) often with a directional pulling or jerking quality

often irregular head and neck tremor with a jerky, directional quality; patient may use a sensory trick (geste antagoniste) to relieve or diminish tremor; tremor may be very sensitive to task-specific or positional factors e.g., may disappear at a specific position (‘null point’)

tremor, dysarthria, incoordination, dystonia, gait abnormalities, psychiatric changes, <40 years of age, hepatitis or cirrhosis

Kayser-Fleischer rings, tremor, dysarthria, dystonia, ataxia

history of stroke or central nervous system insult such as multiple sclerosis; uncontrollable coarse tremor

tremor of arm with equal rest, action, and intention components

sudden onset of tremor, history of anxiety or depression, history of sexual or child abuse

tremor that is distractible or can be entrained to a new frequency; may be associated with other non-organic signs such as give-way weakness; non-anatomical sensory examination; astasia-abasia (inability to either stand or walk in a normal manner)