Essential tremor. Essential tremor. (A) The Archimedes spiral drawing shows a unidirectional tremor axis in the 8–2 o’clock direction, suggesting essential.

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Essential tremor. Essential tremor. (A) The Archimedes spiral drawing shows a unidirectional tremor axis in the 8–2 o’clock direction, suggesting essential tremor, but it is not clear whether the amplitude and frequency are constant. Both straight lines show the frequency to be regular; the line drawn perpendicular to the tremor axis emphasises the amplitude and makes it easier to discern that it is also constant. (B) The handwriting is tremulous and potentially compatible with either essential tremor or dystonic tremor. The spirals show a unidirectional 8–2 o’clock axis in the right hand spirals and a 10–4 o’clock axis in the left hand, symmetrical in size and severity—all features that point towards essential tremor. However, the regularity of the amplitude and frequency is difficult to determine from the spirals as the severity of the tremor causes the turns to overlap. The straight line drawings demonstrate that the amplitude, frequency and axis are all constant. The left (dominant) handed vertical line has 18 oscillations drawn over 2 s, giving an estimated frequency of 9 Hz. (C) Spiral drawings from a patient with severe essential tremor showing large tremor oscillations with a unidirectional axis, fairly regular amplitude and frequency, and symmetry between the hands. An enlarged spiral is sometimes seen in severe essential tremor, perhaps reflecting ataxia that may occur as part of the disorder, or to compensate for the size of the penstroke undulations. Jane Alty et al. Pract Neurol 2017;17:456-463 ©2017 by BMJ Publishing Group Ltd