Non-parkinsonian Movement Disorders: Tremors

00:01 In this talk, let's review non-parkinsonian movement disorders.

00:08 So let's begin with tremor.

00:09 Tremor is a rhythmic, involuntary, oscillating movement of a body part occurring in isolation or as a part of a clinical syndrome.

00:19 So we can see isolated tremors or tremor that means something else is going on, some other syndrome is causing it.

00:26 Importantly, it is rhythmic.

00:27 So tremors should always be rhythmic.

00:29 And they should oscillate about a limb or a joint and that results in the movement of the body part.

00:37 When we think about tremor, there are several types of tremors that we can remember.

00:41 The first is a rest tremor.

00:43 This occurs when the limb is at rest.

00:45 We often see it in the hands or in the feet and sometimes in the head.

00:50 The limb should be supported against gravity when we're evaluating this and the muscles should not be activated.

00:56 And the classic syndrome diagnosis that we see rest tremor with is Parkinson's disease.

01:03 But we can also see it with drug-induced Parkinsonism and occasionally some of the other Parkinson's plus syndromes.

01:10 The second type of tremor is an action tremor.

01:13 This is tremor occurring with action and that means any voluntary muscle contraction.

01:19 And there are several different types of action tremor that we can see.

01:22 The first is a postural tremor.

01:24 And this is a tremor when the limbs are maintained in a position against gravity.

01:29 We often test this with having the patient move their arms in a rested position out in front of them.

01:35 Types of postural tremor include physiologic tremor and benign essential tremor.

01:40 We can see postural tremor in both of those conditions.

01:44 Kinetic tremor.

01:46 Kinetic tremor is tremor occurring with action.

01:48 And we typically see this tremor with simple targeted or target-directed movements.

01:54 And so we can evaluate this on exam by looking at spirals and we're looking for tremor that's occurring with the spiral.

02:00 We can ask the patient to drink a cup of water and looking for movement of the water spillage of the water.

02:06 And we can see kinetic tremors with various lesions including benign essential tremor which is the classic condition to see a kinetic tremor.

02:16 Isometric tremor is a rare action tremor that occurs with muscle contraction against a stationary object.

02:22 And we can see this in the setting of orthostatic tremor which is extremely rare and one to be aware of but probably not to devote significant time to.

02:31 And then there are also task-specific tremors that occur with a specific action.

02:35 We think of handwriting, some of us have had a tremor with a significant or prolonged handwriting and that's a dystonic tremor or a task specific tremor.

02:43 And then finally is intention tremor.

02:46 And intention tremor is intent is a tremor that worsens as we get closer to a target.

02:52 And that tremor is something that we see with cerebellar lesions such as multiple sclerosis, or occasionally with cerebellar strokes.

03:01 Let's talk about some common tremors and some syndromes that we see those in.

03:06 First physiologic tremor, we all have a tremor just a part of being human.

03:10 It's benign, it's high frequency, it's low amplitude.

03:13 So it's really quick and often can't be seen very well do the low amplitude nature, and it's usually not visible.

03:21 We can see it in certain settings.

03:23 And in those settings, we will see an enhanced physiologic tremor.

03:27 And this is a visible high frequency postural tremor that occurs in the absence of neurologic disease.

03:32 But there are some causes of this.

03:34 Stress is probably one of the most common.

03:37 Increased caffeine intake can enhance our underlying physiologic tremor.

03:41 Sleep deprivation, we've all had a little bit of sleep deprivation and this will enhance our physiologic tremor.

03:47 As well as thyrotoxicosis, hypoglycemia, certain drugs like amphetamines, and withdrawal from various agents including alcohol and benzodiazepines.

03:59 The enhanced physiologic tremor isn't a problem.

04:02 It doesn't require evaluation.

04:03 It typically doesn't require treatment unless it interferes with activities of living.

04:10 Let's talk a little bit about a common condition where we see a kinetic tremor or action tremor.

04:15 And that is benign essential tremor or benign familial tremor.

04:19 Here we see a visible postural tremor and the upper limbs that may include a kinetic component so we can see both kinetic and postural tremor.

04:28 This is one of the most common movement disorders that we see.

04:31 And it tends to run in families and we hear this is called in many families is a familial tremor, where my grandmother or grandfather and mother and father and I and children may have it, it's passed down into families.

04:43 Uniquely, this tremor gets better with alcohol and that can be a supportive historical detail that supports a diagnosis of benign familial or benign essential tremor.

04:53 The clinical manifestations that we see in this syndrome include postural tremor that's often in the distal arm in 95% of patients.

05:01 It's usually begins symmetrically in both arms.

05:04 It can be insidious in its development and very slow in its progression.

05:08 It can get worse over time as individuals age.

05:12 It can involve the head and we call that head titubation where the head tilts in a yes-yes, or even a no-no movement.

05:20 And that's not uncommon in patients with benign familial tremor.

05:23 And things like stress, fatigue medications can increase the amplitude, and alcohol can reduce the amplitude.

05:30 We don't encourage alcohol as a treatment, but it can be an important diagnostic tool when taking the history for these patients.

05:38 So let's compare essential tremor and Parkinsonian tremor in Parkinson's disease.

05:44 And let's look at some of the clinical features that differentiate these two tremors and conditions.

05:48 So with Parkinson's disease, we often see the onset around the age of 50s.

05:53 With a essential tremor there's a bimodal distribution.

05:55 We can see essential tremor early in teens or individuals over the age of 50.

06:01 Parkinson's disease is more common in men than women and essential tremor is equally reported in both men and women.

06:09 We can see a family history in Parkinson's disease and around 25 or up to 25% of patients.

06:15 Family history is extremely common in patients with essential tremor.

06:19 The vast majority will report a familial history of some type.

06:23 Parkinson's disease tremor the rest tremor and Parkinson's disease is typically asymmetric but often symmetric.

06:30 The tremor is symmetric in essential tremor.

06:34 The character of the tremor in Parkinson's disease is rest and the character nature of the tremor in essential tremor as postural and kinetic.

06:42 Parkinsonian rest tremor is lower frequency 4 to 6 Hz and we can see a higher frequency tremor in benign essential tremor that postural and kinetic tremor in essential tremor.

06:53 The distribution of the tremor in Parkinson's disease is hands and legs.

06:56 Whereas an essential tremor we can see hands as well as that head titubation.

07:01 Alcohol doesn't change Parkinsonian tremor, but can reduce the tremor in essential tremor.

07:06 And in Parkinson's disease, we should see associated findings of Bradykinesia, rigidity and postural instability.

07:11 So in patients presenting with a new complaint of tremor, we want to differentiate is this a rest tremor that's unaffected by alcohol that's predominant in the hands and asymmetric and associated with Parkinsonian features.

07:23 And that's a Parkinsonian tremor.

07:25 Or is this something that's symmetric running in the family.

07:27 It's a high frequency tremor, maybe involving the hands and head and maybe reduced by alcohol, and that's suggestive of a diagnosis of essential tremor.

07:37 How do we treat benign essential tremor? We can think about cardioselective agents like beta blockers and propranolol is a common agent that is used, or antiepileptics and primidone is the most common agent to use.

07:50 And the goal of these is to reduce the severity and functional impairment of the tremor.

07:56 Botulinum toxin can be used particularly if there's an associated voice tremor, and occasionally thalamic deep brain stimulation can be used in particularly severe cases.

08:06 The next type of tremor is Holmes Tremor or Rubral Tremor.

08:10 And this is rare.

08:11 It's a combination of three types of tremors, rest, action and postural tremor.

08:17 And it looks quite dramatic because we have tremors going on at all types of movement and rest.

08:22 This is caused by lesions typically affecting the brainstem or the cerebellar outflow in the superior cerebellar peduncle or thalamus.

08:32 In terms of clinical manifestations, we see other findings that result from brainstem dysfunction and prominent tremor both rest action and postural tremors.

08:42 Uniquely rubral tremor can result in a wing-beating tremor that's a proximal upper extremity tremor that seen with the arms outstretched and bent at the elbows and we see a wing-beating appearance which is highly suggestive of a rubral tremor.

08:57 In terms of treatment, pharmacologic treatment is usually initiated and is often ineffective in these patients.

09:04 Levodopa, anticholinergics and clonazopam can be attempted and thalamic deep brain stimulation has been performed in patients.