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

2. 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

3. 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

4. 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)

5. 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

6. The basal ganglia

7. Basal ganglia
Cerebellum

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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?

14. 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

15. 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

16. 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)

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

18. 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