Tremor -Overview of neurological earthquakes .pptx

It is a detailed presentation on Neurological Tremors . Helpful for MBBS,MD and even residents and fellows for a complete clear picture to tremor diagnosis and treatment .

1. Tremor : Overview Of The Neurological Earthquakes Dr. Purnashree Chowdhury MBBS,MD

2. Tremor vs Other Abnormal Movements: Tremor : Involuntary ,rhythmic ,oscillatory movement of one or more body parts Chorea: Unpredictable, dance-like movements, non-repetitive,. Athetosis: Slow, twisting or squirming-like motions, involving hands and feet. Ballism: Violent, flinging movements of the limbs, often caused by a stroke. Tics: Paroxysmal, stereotyped muscle contractions, temporarily suppressible, preceeded by urge Myoclonus: Shock-like, arrhythmic twitches, not suppressible.

3. Types of Tremor Tremor Rest tremor Action tremor Parkinson’s Disease Kinetic Postural Isometric Intention Essential tremor Orthostatic tremor Mixed (PD,ET etc ) Cerebellar Disease

4. Types of Tremor-Per pattern (Cont.)

5. HOW TO APPROACH A TREMOR CASE History - Detailed description of the tremor (onset, pattern, which body part affected, symmetrical/asymmetrical involvement, progression if any, time frame of progression, any time or position when tremor is worse) -Associated pathological condition specific history (Drug, sleep hx and dream enactment, bowel/bladder hx , h/o falls, unsteadiness, family hx , psychiatric hx , swallowing issues, memory and cognition) Examination

6. Rest Tremor When muscles in complete rest and body part is supported against gravity Non distractable Conditions: PD (Pill rolling) , advanced ET, drug induced, Examination : ‘perform with a numerical math’ ( for distraction) Hands: Sit straight ,rest arms on laps Legs: sitting upright with feet relaxed on floor /lying flat with leg support

7. Kinetic Tremor Occurs throughout the entire duration of voluntary movement of muscle/muscle group Writing, performing fine motor tasks like combing hair, buttoning shirt etc Conditions: ET (most common cause) , Metabolic conditions, drugs Examination: Hold arms outstretched > move hands as in supination-pronation Writing : Today is a sunny day Drawing: Spiral Voice: Ask a full sentence

8. Postural Tremor When a muscles are engaged against gravity in a specific position Conditions: ET, advanced physiological tremor Examination: hold a posture against gravity Hold arms outstretched>pronation of hand > spread fingers Move the hands in semi pronated position while limb extended Flex forearms at elbow by bringing them close to chest>stretch fingers Head/Jaw: hold head straight, Open jaw slightly and hold

9. Intention Tremor Worse while body part reaches towards target (end point tremor) Condition: cerebellar dysfunction Examination: Finger Nose test Heel Shin test

10. Isometric Tremor Occurs during voluntary muscle contraction without actual movement, specially when exerting force against a stationary object Examination: Stretch out arms and ask to hold a moderately heavy object (book/glass) Push against wall with both hands while standing with arms extended Lift one leg and stretch it out straight and holding it in position .

11. Orthostatic Tremor A type of isometric tremor Very fine, rapid tremor (13-18 Hz) Legs and torso, upon standing still Difficulty standing for prolonged period: Sensation of discomfort in the legs or unsteadiness/imbalance Symptoms improve with walking, sitting or supine position ‘Helicopter rumbling sound’ on calf with stethoscope First line drugs: Clonazepam, Gabapentin, Beta-blockers Severe-DBS

12. Enhanced Physiological Tremor Low –amplitude , high frequency tremor Present both at rest and in action Associated with increased stress, caffeine intake

13. Functional Tremor Clinical and neurological inconsistency ( Hx , exam, labs, imaging ) H/O major past or ongoing stressor, psychiatric diagnosis Tremor: Distractability Spontaneous remission, can sometimes ‘ask tremor to stop’ Change of directionality/planes

14. Essential Tremor Diagnosis of exclusion, no other neurological signs than isolated tremors No known cause ( idiopathic) Epidemiology : 4-5% in >65 years (males>female) Bimodal age distribution( 24 yrs or less, 46 years and above) Family history in 50% cases

15. Essential Tremor (Cont.) Tremor characteristics: 4-12 Hz Affects daily functioning- eating, grooming ,buttoning shirts Kinetic mostly with or without postural tremor Resting and intention tremors may be seen in advanced disease Usually bilateral, unilateral possible Worse with stress, lack of sleep, caffeine, anxiety, fatigue and old age Improves with alcohol

16. Essential Tremor (Cont.) Location and Progression: Arms (90%), Head (30%), Voice (15%), legs (<10%) Arm tremors appear first followed by others (vs. cervical dystonia, Parkinson’s)

17. Essential Tremor (Cont.) Examination: Limbs: Look for kinetic, postural tremors Head: Late finding ; ‘yes-yes’, ‘no-no’ Voice: ‘ Ahhh ’, ‘ eehhhh ’ Jaw: ET never present at rest and manifests when talking (vs Parkinson’s jaw tremor) Spiral drawing and writing-macrographic Isolated head, vocal, jaw tremors > suspect alternative dx

18. Essential Tremor (Cont.) Diagnosis: Usually clinical If other suspicious neurological signs present , to exclude other conditions: MRI, if normal then CT scan ( DaT Scan) Vit B12 assay Thyroid Function tests Other labs as per suspicion-LFTs, RFTs, S. copper

19. Essential Tremor : Treatment Depends on severity Always reassure patient, counsel for PT First Line Drugs: Propranolol Primidone ( favourable QT-prolongation profile) Others: Benzos (clonazepam, alprazolam), Gabapentin, Topiramate Drugs mostly help with limb tremors Similar efficacy of both 1 st line drugs

20. Contraindications of Propranolol Asthma Bradycardia Heart failure DM PVD

21. Contraindications of Primidone Allergy to barbiturate derivatives Porphyria Mood disorders, depression, suicidal thoughts Ataxia FDA cat D for pregnancy Resp depression Hepatic impairment Renal insufficiency Alcoholism Sleep apnea Drug dependency

22. Medically Refractory ET For medically refractory cases and to help mainly with head /voice tremors: - Botox inJ -Deep Brain Stimulation of VIM of Thalamus (Surgical Treatment of Choice) -Thalamotomy Newer : -MRI guided high intensity focused USG -Non-invasive neuromodulation

23. Deep Brain Stimulation Surgical treatment of choice for medically refractory disabling cases Pulsatile electric signals, stereotactic sx under local anesthesia Indications: Head tremors as well as other tremors in medically refractory ET Tremors and motor sx ( rigidity, bradykinesia) in PD >>choose candidate visa on-off test

24. DBS (Cont.) Targets: DBS in ET: VIM of thalamus >>(for dug resistant tremors , sp head) DBS in PD: Subthalamic Nucleus , GPi >>(for tremor, rigidity, dyskinesia,bradykinesia ) DBS cannot cure or stop disease progression, cannot help with gait improvement

25. DBS (Cont.) Advantages: Customizable stimulation-Chief advantage Effective when bilateral effects are desired Can be done in elderly who often have multiple comorbidities Less complications vs Thalamotomy Decrease pill burden and improve quality of life Limitations: Cannot help outside tremor and motor sx ( eg - Gait does not improve)

26. ET Vs Parkinsonian Vs Dystonic Tremors

27. Parkinson’s Disease Chronic neurodegenerative disorder manifesting primarily as slowing of motor and non-motor activities. Loss of dopaminergic neurons in the substantia nigra pars compacta Dx: Bradykinesia + Tremor/Rigidity or Both Begins with motor sx and progresses to cognitive deficits later stage (vs Lewy Body Dementia) Clinical dx and most important supportive dx: Dramatic response to Levodopa-carbidopa drug trial Imaging not necessary usually but done when other atypical Parkinsonism is suspected or in inconclusive diagnosis

28. Parkinson’s Disease (Cont.) Examination: Bradykinesia : UL: Outstretched hands>imagine holding door knob>open and close Flexion and extension of fingers Big fast taps LL: Taps on floor with foot

29. Parkinson’s Disease (Cont.) Examination: Rigidity >>Lead-pipe rigidity >>Cogwheel rigidity

30. Parkinson’s Disease Examination: Tremor: >>Rest tremor, action component in advanced disease

31. Parkinson’s Disease (Cont.) Examination: Gait: Small, shuffling steps Difficulty picking up feet Tendency to lean forward Reduced arm swinging Trouble initiating or continuing movement

32. Holme’s Tremor: Rubral /Midbrain tremor >>superior cerebellar peduncle, red nucleus Combines rest and action tremors( postural,intention ) Slow, irregular and coarse tremor (low frequency, high amplitude) Unilateral UL tremor predominantly Marked exacerbation during movement and certain postures(wing-beating) Often associated with other midbrain sx : bradykinesia, ataxia, ophthalmoplegia Dx: Clinical and MRI

33. Drug Induced Tremor Stimulants: Caffeine, Amphetamine,Metylphenidate Antidepressants: TCA, SSRI, Bupropion Antipsychotics: Haloperidol, Risperidone Mood stabilizers: Lithium Antiepileptics: Valproic acid Chemo drugs: Cyclosporine,Tacrolimus

34. Drug Induced Tremor (cont.) Both resting and action tremor (more action component) Bilateral and symmetric Rx: Reducing the dose or stopping the culprit drug

35. Courtesy: Dr. Miller Patterson –an amazing mentor!