Richard Leckey Oct 2,2015

 Faculty: Dr. Richard Leckey  Relationships with commercial interests:  Biogen  Merck  Serono  Novartis  Allergen CFPC CoI Templates: Slide 1

CFPC CoI Templates: Slide 2

CFPC CoI Templates: Slide 3

 To review common movement disorders  Diagnosis  Investigations  Treatment

 Most common type of tremor  Family history in about 60%  Worsens with age  Can be very disabling  Not due to a degenerative brain disease

 Enhanced physiologic tremor – typically thyroid  Secondary causes MEDS – puffers, SSRI, lithium, neuroleptics, Epival,Cordarone  Dietary causes – too much JAVA, energy drinks  Anxiety states  Functional tremor –most commonly in this category

 Present with activity, particularly fine movements- screwdriver, teacup, soup etc  Relatively absent at rest  Worse with fatigue, stress, caffeine, not eating  Most common in hands but can involve head, legs, trunk and voice  Handwriting commonly poor- they print  Embarrassing and disabling

 TSH, CBC  Physical exam  No need to CT

 Remove aggravating factors  Counseling  B blocker  Mysoline  OT adaptations  Gabapentin  DBS

 Most common tremor seen in Parkinsons or parkinsons like diseases  They may also have a postural or essential type tremor component  Present at rest goes away with activity  Activating procedures; other activities, walking  Associated features, rigidity, akinesia, postural symptoms  Remember TRAP

 Rare before age 40  Unilateral onset, eventually bilateral, asymetrical  Parkinsonian syndromes more symmetrical and bilateral more rigid associated features  Most have lost sense of smell  If typical symptoms little investigation needed  Ensure no secondary causes

 Symmetrical  Early falls  Lack of tremor  Eye movement problems  Hx of strokes  Always remember meds  Strongly associated with dementia  Rapid downhill course

 Sometimes none at first  Levodopa most effective  Dopamine agonists – beware of S/E  Anticholinergics  EXERCISE  Periodic physio, home adaptations  DBS

 Has often poor coordination at rest  Amplitude increases as you approach target  Very disabling  If unilateral think structural – stroke, tumor trauma, MS  If symmetrical think degenerative or meds, toxic

 Most common in elderly for unilateral is stroke so they need a Ct  Young – MS and tumor are 1 and 2  Bilateral – can be familial, idiopathic but must rule out secondary so they need a CT too  Look for meds ie AED, Sedatives, Lithium And of course the king ETOH both acute and chronic  If you see a cerebellar tremor refer it

 These cases show some interesting features  Other history may support  Fluctuant  Variable amplitude  Variable frequency  No consistent pattern  There are usually other clues from the physical exam and history

 Postural – ET  Resting Parkinsons  Cerebellar – intention  Non organic – inconsistetnt

 These are numerous  So balance peaks at age 25 or so – sad for us  Young people cope better  Older people gait problems can come from many things  Obesity, OA (knees hips back)  Stroke  Degenerative diseases  neuropathy

 I will demonstrate  Laugh if you wish

 Best defined and remembered as a variation on habits  They are a suppressible (for a while) desire to move  They are usually rapid and jerky can involve extremities, trunk, eyes, head, voice  Most have tics

 Defined as multiple vocal and motor tics  Large spectrum  Can be mild or very disabling  It is my personal bias not to treat tics unless markedly disabling  Behavioral associations may be more devastating

 Behavioral I am not an expert  Explanation in key  Clonidine rarely helpful  Neuroleptics atypicals  Nitoman  Biofeedback  DBS

Treatment is suboptimal Often patients are very bright and treatment blunts them This makes it an as necessary phenomenon Note SSRI can worsen tics RISK of EPS with neuroleptics