Non-parkinsonian Movement Disorders: Tremors

by Roy Strowd, MD

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    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.

    About the Lecture

    The lecture Non-parkinsonian Movement Disorders: Tremors by Roy Strowd, MD is from the course Non-parkinsonian Movement Disorders.

    Included Quiz Questions

    1. A rhythmic, involuntary oscillating movement of a body part
    2. An irregular, voluntary oscillating movement of a single hand
    3. An irregular, involuntary oscillating movement involving symmetric limbs
    4. An oscillating movement of any body part associated specifically with a metabolic disturbance
    5. Seizure-like activity
    1. Rest tremor; Parkinson disease
    2. Essential tremor; Lewy body dementia
    3. Holmes tremor; Alzheimer disease
    4. Intention tremor; alcoholism
    1. Essential tremor
    2. Physiologic tremor
    3. Rest tremor
    4. Orthostatic tremor
    5. Isometric tremor
    1. Cerebellum
    2. Brainstem
    3. Prefrontal cortex
    4. Arcuate gyrus
    5. Area postrema
    1. Thyrotoxicosis
    2. Hyperglycemia
    3. Hypothyroidism
    4. Acute opioid intoxication
    5. Heart failure
    1. Parkinson disease displays a rest tremor, while essential tremor is usually kinetic/postural.
    2. The tremor of Parkinson disease often improves with alcohol use, while essential tremor does not.
    3. The tremor of Parkinson disease is usually associated with a positive family history, while essential tremor usually is not.
    4. Essential tremor is more often seen in older populations compared to the tremor of Parkinson disease.
    1. Propranolol
    2. Levodopa
    3. Venlafaxine
    4. Naltrexone
    5. Loratadine
    1. Holmes tremor
    2. Normal pressure hydrocephalus
    3. Seizure disorder
    4. Multiple sclerosis
    5. Essential tremor

    Author of lecture Non-parkinsonian Movement Disorders: Tremors

     Roy Strowd, MD

    Roy Strowd, MD

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