Table 3

The tremor examination

Look for tremor at rest:
    Seated or supine with all muscle groups fully supported against gravity
    Distraction manoeuvres with eyes closed, eg:
        (a) counting backwards
        (b) stating the months of the year backwards
        (c) naming Presidents in reverse order
    Does tremor occur with walking? (seen in Parkinson’s disease)
Look for tremor with posture:
    Arms are outstretched, then in a position where both hands are brought toward the face with the fingers almost touching. Repeat several times (it is crucial to evaluate the patient with the hands near the face since many times the tremor will appear only in this position).
    Does the tremor occur immediately when the hands are placed in a posture or is there a delay? In essential tremor the tremor should be almost immediate (0–1 second). In Parkinson’s disease, there can be a re-emergence of the baseline resting tremor when the hands are placed in a posture up to 9 seconds later.24
Look for kinetic (intention) tremor:
    Voluntary movements are evaluated, eg:
        (a) finger to nose testing
        (b) pouring water from cup to cup
        (c) drinking water from a cup
        (d) using a spoon to drink water
    Essential tremor is often present during kinetic testing; however, during these target directed movements the tremor is typically not made much worse except in advanced disease. Essential tremor is not commonly present only with kinetic movement. A predominant intention tremor is more commonly described with cerebellar dysfunction or Wilson’s disease.
Evaluation of specific tasks:
    Handwriting. Have the patient write three sentences. In essential tremor it is usually normal to large sized and sloppy. Tremor can be observed in the handwriting itself. This is in contrast to the handwriting in patients with Parkinson’s disease who have micrographia.
    Spiral drawing. An Archimedes spiral should be performed with each hand. To observe the maximum amplitude of essential tremor, spiral drawing should be performed using an unsupported, freehand style.