The Approach to Tremor (with case examples) Praveen Dayalu MD Associate Professor Department of Neurology University of Michigan

Tremor Rhythmic involuntary oscillation of a body part Aside from hands, may affect head, chin, voice, palate, or lower extremities May be better or worse with certain actions or positions

Upper Limb Tremor Resting tremor (parkinsonian) Action tremor is postural and/or kinetic -- “Intention tremor” is a confusing term. Action tremor? Ataxia? -- Always think of thyroid, meds/drugs; and Wilson disease in young people

Action tremor: causes Essential tremor Enhanced physiologic tremor Drugs: stimulants, VPA, Li, tricyclics Withdrawal: alcohol, benzos Thyroid disease Other neurological disorders (like Wilson disease, MS), other medical disorders (pheochromocytoma, hypoglycemia)

Essential tremor: A Postural & Kinetic Tremor Most common cause of tremor Dominantly inherited More with increasing age Shaky hands, sometimes head and voice. Writing is shaky, spills drinks or soup Can be better after an alcoholic drink “Benign”: should not see significant other neurological signs or symptoms Does not increase mortality Rx if needed: propranolol, primidone

The basal ganglia

Basal ganglia Cerebellum

Parkinsonism: 4 cardinal motor features Bradykinesia (slow and small movements). Reduced blink, face expression, and gesturing. Soft voice. Difficulty getting out of chair, shuffling steps, reduced arm swing, freezing Tremor (usually resting) “pill rolling”, often involves thumb Rigidity (different from spasticity) Postural changes. Imbalance, falls; stooped flexed posture

Differential diagnosis of parkinsonism Parkinson disease (idiopathic or genetic) Drug-induced parkinsonism (anti-dopaminergics, especially antipsychotics and antiemetics) Parkinson-plus degenerative syndromes Rare but treatable in young people: Wilson disease and Dopa-responsive dystonia Other: hydrocephalus, “vascular” parkinsonism, brain lesions

Parkinson Disease (PD) Usually idiopathic Substantia nigra degeneration causes dopamine deficiency in striatum  motor symptoms Dopaminergic therapy relieves motor symptoms (levodopa, dopamine agonists) L-dopa is the diagnostic test

Parkinson disease: Common early complaints Resting tremor Writing smaller; harder to do buttons Slowness, “weakness”, limb not working well Stiff or achy limb Stoop, shuffle-walk, “dragging” leg(s) Trouble getting out of chairs or turning in bed Low or soft voice Non-motor: anosmia, dream enactment, constipation, anxiety/ depression, “passiveness” asymmetry

Case 1 69 man describes weakness x2 years. Has a hard time playing cards. Hard to get out of chairs and turn in bed; balance is poor. Meds: atenolol, atorvastatin, allopurinol, citalopram, insulin, metoclopramide

Case 2 63 year old woman Shake of both hands, occasionally head R > L; Spills soup, can’t sign checks Slowly progressive x 12 years “Accelerated” in last 2 years Grandmother with “parkinson’s” Meds: alprazolam, valproic acid, lisinopril Not better with alcohol; TSH? Etoh w/d?

Case 3 58 year old woman with low energy x 4 years, decreased motivation, harder to keep up with family on hikes Meds: cyclobenzaprine, HCTZ, psyllium, senna Achy R shoulder

Case 4 63 year old woman with whole body shakes x 6 years Father had whole body shakes in his 70’s Worse when nervous Depression and anxiety, drinks 4 beers/ day Med: albuterol inhaler for smoker’s cough

Case 5 59 year old man with head shakes Slowly progressive over 12 years Worse when nervous or after caffeine Not better with alcohol No family history of tremor Medications failed: Primidone (Mysoline) Propranolol (Inderal) Topiramate (Topamax) Citalopram (Celexa)

Case 6 13 year old boy with movements of left hand x 2 weeks

Case 7 62 year old man with shaking when he tries to read paper x 4 years Small handwriting, but not shaky Soft low pitched voice x 3 years Per wife, sometimes acts out dreams x 10 years