In this talk, let's review
non-parkinsonian movement disorders.
So let's begin with tremor.
Tremor is a rhythmic, involuntary,
oscillating movement of a body part
occurring in isolation or as
a part of a clinical syndrome.
So we can see isolated tremors
or tremor that means
something else is going on,
some other syndrome
is causing it.
Importantly, it is rhythmic.
So tremors should
always be rhythmic.
And they should oscillate
about a limb or a joint
and that results in the
movement of the body part.
When we think about tremor,
there are several types of
tremors that we can remember.
The first is a rest tremor.
This occurs when
the limb is at rest.
We often see it in the hands or in
the feet and sometimes in the head.
The limb should be supported against
gravity when we're evaluating this
and the muscles should
not be activated.
And the classic
that we see rest tremor
with is Parkinson's disease.
But we can also see it with
and occasionally some of the
other Parkinson's plus syndromes.
The second type of tremor
is an action tremor.
This is tremor
occurring with action
and that means any voluntary
And there are several different types
of action tremor that we can see.
The first is a postural tremor.
And this is a tremor when the limbs are
maintained in a position against gravity.
We often test this with having
the patient move their arms
in a rested position
out in front of them.
Types of postural tremor
include physiologic tremor
and benign essential tremor.
We can see postural tremor
in both of those conditions.
Kinetic tremor is tremor
occurring with action.
And we typically see this
tremor with simple targeted
or target-directed movements.
And so we can evaluate this
on exam by looking at spirals
and we're looking for tremor
that's occurring with the spiral.
We can ask the patient
to drink a cup of water
and looking for movement of the
water spillage of the water.
And we can see kinetic
tremors with various lesions
which is the classic condition
to see a kinetic tremor.
Isometric tremor is
a rare action tremor
that occurs with muscle contraction
against a stationary object.
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.
And then there are also task-specific
tremors that occur with a specific action.
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.
And then finally is
And intention tremor
is intent is a tremor
that worsens as we get
closer to a target.
And that tremor is something that
we see with cerebellar lesions
such as multiple sclerosis,
or occasionally with cerebellar strokes.
Let's talk about some common tremors
and some syndromes that we see those in.
First physiologic tremor, we all have
a tremor just a part of being human.
It's benign, it's high
frequency, it's low amplitude.
So it's really quick and often can't be
seen very well do the low amplitude nature,
and it's usually not visible.
We can see it in
And in those settings, we will see
an enhanced physiologic tremor.
And this is a visible high
frequency postural tremor
that occurs in the absence
of neurologic disease.
But there are some
causes of this.
Stress is probably one
of the most common.
Increased caffeine intake can enhance
our underlying physiologic tremor.
Sleep deprivation, we've all had
a little bit of sleep deprivation
and this will enhance
our physiologic tremor.
As well as thyrotoxicosis, hypoglycemia,
certain drugs like amphetamines,
and withdrawal from various agents
including alcohol and benzodiazepines.
The enhanced physiologic
tremor isn't a problem.
It doesn't require evaluation.
It typically doesn't
unless it interferes with
activities of living.
Let's talk a little bit
about a common condition
where we see a kinetic
tremor or action tremor.
And that is benign essential
tremor or benign familial tremor.
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.
This is one of the most common
movement disorders that we see.
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.
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.
The clinical manifestations
that we see in this syndrome
include postural tremor that's often
in the distal arm in 95% of patients.
It's usually begins
symmetrically in both arms.
It can be insidious in its development
and very slow in its progression.
It can get worse over
time as individuals age.
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.
And that's not uncommon in patients
with benign familial tremor.
And things like stress, fatigue
medications can increase the amplitude,
and alcohol can
reduce the amplitude.
We don't encourage
alcohol as a treatment,
but it can be an important diagnostic tool
when taking the history for these patients.
So let's compare
and Parkinsonian tremor
in Parkinson's disease.
And let's look at some
of the clinical features
that differentiate these
two tremors and conditions.
So with Parkinson's disease, we often
see the onset around the age of 50s.
With a essential tremor
there's a bimodal distribution.
We can see essential
tremor early in teens
over the age of 50.
Parkinson's disease is more
common in men than women
and essential tremor is equally
reported in both men and women.
We can see a family history
in Parkinson's disease
and around 25 or up
to 25% of patients.
Family history is extremely common
in patients with essential tremor.
The vast majority will report a
familial history of some type.
tremor the rest tremor
and Parkinson's disease is typically
asymmetric but often symmetric.
The tremor is symmetric
in essential tremor.
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.
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.
The distribution of the tremor in
Parkinson's disease is hands and legs.
Whereas an essential tremor we can see
hands as well as that head titubation.
Alcohol doesn't change
but can reduce the tremor
in essential tremor.
And in Parkinson's disease,
we should see associated findings
rigidity and postural instability.
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
And that's a
Or is this something that's
symmetric running in the family.
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.
How do we treat benign
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.
And the goal of these is
to reduce the severity
impairment of the tremor.
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.
The next type of tremor is
Holmes Tremor or Rubral Tremor.
And this is rare.
It's a combination of three types of
tremors, rest, action and postural tremor.
And it looks quite dramatic
because we have tremors
going on at all types
of movement and rest.
This is caused by lesions
typically affecting the brainstem
or the cerebellar outflow in the
superior cerebellar peduncle or thalamus.
In terms of clinical manifestations,
we see other findings
that result from brainstem
dysfunction and prominent tremor
both rest action and
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.
In terms of treatment, pharmacologic
treatment is usually initiated
and is often ineffective
in these patients.
Levodopa, anticholinergics and
clonazopam can be attempted
and thalamic deep brain stimulation
has been performed in patients.