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Tremors Tests and Diagnosis

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The proper diagnosis of tremor relies on clinical information gleaned from the physical examination and the thorough history of the patient. Single photo emission computed tomography can be performed on more difficult cases to view the integrity of the neural pathways in the brain which may also be useful in diagnosing Parkinson’s disease.

In evaluating the patient with tremor, the initial step is to classify the tremor according to its activation condition, frequency and body part distribution. The activation condition can be described as isometric, postural, intention (or kinetic), or rest. The doctor may require the patient to sit with his hands in his lap to observe for rest tremor. For kinetic or postural tremors a sequential test that entails the patient stretching his hands and arms out, followed by a simple finger-to-nose test can be carried out. A person with rest tremor more often than not suffers from Parkinson’s disease. An intention tremor may mean the patient suffers from a cerebellar lesion. There are three frequencies associated with tremors. They include a frequency of less than 4 Hz, a medium frequency of 4 to 7 Hz, and high-frequency greater than 7 Hz. In terms of body part distribution, tremor can occur in the voice, head and limbs, among others. The doctor can combine these factors to come up with a diagnosis. A high frequency tremor for example, occurring in the head is more likely to be classified as an essential tremor than a parkinsonian tremor. Age can also be a factor in diagnosing tremors. Older patients are more prone to develop essential tremor and parkinsonian tremor. For patients who suddenly develop tremor they should be thoroughly assessed to see if their tremor is the result of a psychogenic cause, a brain tumor, toxins, or from medications. Patients suffering from a slow and progressive tremor should be assessed for signs of Parkinson’s disease.

Tremors usually affect both sides of the body; however, brain tumors can cause tremors on just one side of the body. Fatigue and caffeine often aggravate essential tremor and it is difficult to find anything (except a small amount of alcohol intake) that can mitigate this type of tremor. Physiologic tremor often comes with sleeping disorders since tired muscles usually exacerbate this type of tremor. A patient with a family history of tremor or neurologic disease implies a tremor that is genetically acquired which is often the case in an essential tremor. To rule out drug-induced tremor, the patient’s medicine history should be studied thoroughly. Moreover the patient may be tested for alcohol consumption or drugs since alcohol abuse and withdrawal can and likewise result in tremor. Conversely, moderate or small doses of alcohol can help relieve essential tremor and can be a useful tool for diagnosis.

Also useful for the diagnosis of tremor is an evaluation or examination of symptoms and signs that may be related to tremor syndromes. Postural abnormalities and bradykinesia strongly indicate parkinsonian tremor. Masked facies, limited arm swinging motion while walking, micrographia, and difficulty rising up from a seated position may all indicate bradykinesia. Abnormalities in posture can be observed through a positive pull test. This test entails the patient standing in a neutral position with the doctor causing him to fall by pulling the patient’s upper arms from behind. This test can also help diagnose stroke or multiple sclerosis and can help isolate cerebellar tremor as well. It can also diagnose for psychogenic tremor. The positive pull test could also allow the doctor to observe for sustained muscle contraction (dystonia); uncoordination and ataxia (cerebellar signs); evidence of systemic disease (thyrotoxicosis, for example); neuropathic signs and pyramidal signs. A normal gait with an unsteady stance can be evidence of orthostatic tremor which is a lower body condition, whereas a shuffling gait is an indication of parkinsonian tremor.
Tremor in Children

Medical science still has a hard time diagnosing tremor in children. There are a number of genetic diseases that are related to tremor in children. These diseases include homocystinuria, pyruvate carboxylase deficiency, prescription drugs, heavy metal poisoning vitamin B12 efficiency, hydrocephalus, brain tumors, fragile X syndrome, Huntington disease, mitochondrial diseases, and spinal muscular atrophy. Tremor in children is a potentially dangerous condition and children suffering from this condition should be immediately seen by a neurologist.

Imaging

A number of imaging techniques have been used to help identify the different causes of tremor. Presently diagnosing tremors remains basically clinical. However, SPECT or single-photo emission computed tomography has been used for complex cases. Single -photon emission computed tomography as mentioned a while ago can help the doctor visualize the health of the neural pathways in the brain which is often effective in diagnosing Parkinson disease. SPECT combined with presynaptic radiotracers has been successfully used to differentiate between parkinsonian tremor from essential tremor, and vascular parkinsonism from Parkinson disease.

Magnetic resonance and plain computed tomography imaging are effective options to help exclude secondary causes of tremor such as stroke or multiple sclerosis among others especially if the diagnosis of tremor is inconclusive from the patient’s physical examination and history.

 

Nelya de Brun is a licensed acupuncturist in Boynton Beach, FL., practicing acupuncture, Chinese herbal medicine and Western medical pathology. She is also the founder of Classical Oriental Medicine, LLC.

 

Written by Valerie

February 18th, 2014 at 4:04 am

Posted in Acupuncture

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