Objective: To report a novel and inexpensive method for evaluating tremor in the clinic and at the bedside.

Background: Tremor is the most common involuntary movement [1], defined by the Task Force on Tremor of the International Parkinson and Movement Disorder Society as ‘involuntary, rhythmic, oscillatory movement of a body part’ [2]. It is important to tell between different forms of tremor since the long-term outcome and management may differ. There are several observations about tremor quality like activation, postural component, frequency, and rhythmicity, etc. Rhythmicity is one of the most important features that may not be easily appreciable with the naked eye [3] especially if the tremor is small in amplitude requiring time-consuming and expensive testing [4].
The frequency of tremor can be important in determining the underlying cause, it’s variability indicating functionality and arrhythmicity indicating functionality or dystonic element. Indeed, PD and dystonic tremor are the types most frequently misdiagnosed as ET [5]. It can be difficult to appreciate rhythmicity of tremor on the bedside, unless the tremor is coarse or of large amplitude while dystonic tremor may appear rhythmic if it is of small amplitude and may require EMG. In the past, a stethoscope has been used for evaluating orthostatic tremors by placing it on the muscles of the legs when the patient is standing producing a ‘helicopter’ sound [6].

Method: Report a simple and inexpensive method of examining tremors at the bedside using a stethoscope. This will allow evaluating for frequency and rhythmicity, which can sometimes be difficult to appreciate visually.

Results: Using the bell of a stethoscope by gently placing it on the tremoring body part, so that the moving surface rubs against the diaphragm of the stethoscope, may make it easier to appreciate rhythmicity and frequency of tremor. The stethoscope may be held against the head, hand or even the foot. This can help differentiate dystonic and functional tremor from other kinds of tremor without resorting to time consuming and often expensive neurophysiologic investigations.

Conclusion: By auscultating the tremoring body part, the clinician can appreciate frequency and rhythmicity thus providing additional details in a cheap and reliable way in the clinic and bedside. This can help in differentiating between tremor diagnosis thus helping with appropriate counselling and management.

References: [1] Fahn S, Jankovic J, Hallett M (2011) Principles and practice of movement disorders E-book, Elsevier Health Sciences. [2] Bhatia KP, Bain P, Bajaj N, Elble RJ, Hallett M, Louis ED, Raethjen J, Stamelou M, Testa CM, Deuschl G (2018) Consensus Statement on the classification of tremors. from the task force on tremor of the International Parkinson and Movement Disorder Society. Mov Disord 33, 75-87. [3] Abdo WF, Van De Warrenburg BP, Burn DJ, Quinn NP, Bloem BR (2010) The clinical approach to movement disorders. Nature Reviews Neurology 6, 29. [4] Deuschl G, Krack P, Lauk M, Timmer J (1996) Clinical neurophysiology of tremor. J Clin Neurophysiol 13, 110-121. [5] Jain S, Lo SE, Louis ED (2006) Common misdiagnosis of a common neurological disorder: how are we misdiagnosing essential tremor? Arch Neurol 63, 1100-1104. [6] Brown P (1995) New clinical sign for orthostatic tremor. Lancet (London, England) 346.

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