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Breaking Down an Essential Tremor Diagnosis with Neurologist, Paul Fishman, MD

By: Neil Adler
January 20, 2019

While essential tremor (ET) is the most common form of tremor in adults, each case can be very different. Yet even with this variability, a physician diagnosing ET focuses on identifying symptoms that are consistently seen across people who suffer from it.

Neurologists specializing in movement disorders have a tool kit they use to identify and assess the severity of ET. I sat down with Paul S. Fishman M.D., Ph.D., a Professor of Neurology, Adjunct Professor of Pharmacology and Neurobiology at the University of Maryland School of Medicine, and Chief of Neurology for the Maryland VA Health Care System, to learn more about how ET is diagnosed. Dr. Fishman also spoke about how practical it is to use telemedicine to perform an exam without having the patient travel to the hospital.

The first step in diagnosing a tremor, Dr. Fishman explained, is to have a conversation with a patient. During this initial conversation, it is important to find out what activities are limited by their tremor. For example, do patients have challenges eating, drinking, writing, and/or speaking?

The physician follows up by discussing the patient’s medical history looking at factors such as what medications they are currently taking to understand if this could be contributing to the tremor. The next step is a physical examination including observing the symptoms the patient is experiencing.

If the patient has described tremor symptoms while at rest, the physician may ask a patient to put their hands on their lap to see how much motion occurs while in this position. When a patient has symptoms that are present during an activity, the physician may ask the patient to hold a cup of water, or to draw spirals.

Why spirals, you ask? The Archimedes spiral drawing captures the frequency, amplitude and direction of a tremor. Because drawing a spiral demands one continuous movement, unlike the breaks when writing words, the spiral emphasizes the abnormal movements associated with a tremor.

These visual tests help the neurologist to understand and assess the severity of the tremor. Dr. Fishman highlighted the importance of understanding all possible impacts of the tremor and not just what the patient indicates is a problem. Additionally, there is discussion to understand if the patient has other symptoms such as stiffness, slowness, weakness and difficulties with balance.

Researchers have developed a tool for evaluating tremors called the Clinical Rating Scale for Tremor (CRST). This CRST has been validated by showing consistent results across physicians. The scale rates the effect of tremor on physical activity as well as other on aspects affecting quality of life (e.g., social withdrawal).

A physician diagnosing tremor may use imaging to rule out other conditions such as Parkinson’s disease.

Dr. Fishman suggests that, in comparison with some other conditions, the visual assessment of ET is fairly straightforward, making ET a prime candidate for remote observation using telemedicine. Physicians can perform most of the analysis without being in the same location as the patient; however, logistics of telemedicine delivery play a large role in the success of a telemedicine exam.

One of the main issues is whether there is a nurse, or physician’s assistant with the patient throughout the exam. A healthcare professional can help explain the physician’s requests to the patient, as well as confirm the observations noted by the physician. Logistics considerations also include making sure that the physician has a direct view of the patient’s activity and, of course, that a reliable high speed internet connection is available.

New technologies, such as wearables, are making a significant impact on ET diagnosis because neurologists are now able to monitor the activity of a patient outside the clinical environment.

Neurologists specializing in movement disorders can diagnose essential tremor by asking patients the right questions and making observations of specific tasks that provide insight on the severity of the tremor. The most common include touching a finger to the nose and drawing spirals. There is potential for technology, such as videoconferencing applications and wearables, to provide additional tools in the neurologists’ tool box for diagnosis and monitoring essential tremor patients.

* This post is intended only to educate readers and does not constitute medical advice. Always consult with your own medical providers for diagnosis and treatment of your conditions.

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