PT  - JOURNAL ARTICLE
AU  - Jaron van de Wardt
AU  - A M Madelein van der Stouwe
AU  - Michiel Dirkx
AU  - Jan Willem J Elting
AU  - Bart Post
AU  - Marina AJ Tijssen
AU  - Rick C Helmich
TI  - Systematic clinical approach for diagnosing upper limb tremor
AID  - 10.1136/jnnp-2019-322676
DP  - 2020 Aug 01
TA  - Journal of Neurology, Neurosurgery & Psychiatry
PG  - 822--830
VI  - 91
IP  - 8
4099  - http://jnnp.bmj.com/content/91/8/822.short
4100  - http://jnnp.bmj.com/content/91/8/822.full
SO  - J Neurol Neurosurg Psychiatry2020 Aug 01; 91
AB  - Tremor is the most common movement disorder worldwide, but diagnosis is challenging. In 2018, the task force on tremor of the International Parkinson and Movement Disorder Society published a consensus statement that proposes a tremor classification along two independent axes: a clinical tremor syndrome and its underlying aetiology. In line with this statement, we here propose a stepwise diagnostic approach that leads to the correct clinical and aetiological classification of upper limb tremor. We also describe the typical clinical signs of each clinical tremor syndrome. A key feature of our algorithm is the distinction between isolated and combined tremor syndromes, in which tremor is accompanied by bradykinesia, cerebellar signs, dystonia, peripheral neuropathy or brainstem signs. This distinction subsequently informs the selection of appropriate diagnostic tests, such as neurophysiology, laboratory testing, structural and dopaminergic imaging and genetic testing. We highlight treatable metabolic causes of tremor, as well as drugs and toxins that can provoke tremor. The stepwise approach facilitates appropriate diagnostic testing and avoids unnecessary investigations. We expect that the approach offered in this article will reduce diagnostic uncertainty and increase the diagnostic yield in patients with tremor.