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.