1. Leslie Cloud, MD Department of Neurology Division of Movement Disorders Emory University School of Medicine

2.  The videos shown in this lecture were filmed in the Movement Disorders Clinic at Emory University.  All patients provided written consent for the filming of their examination to be used for educational purposes.  All videos have been edited to protect patient privacy.

3.  Rest tremor: occurs in a body part that is not voluntarily activated and is completely supported against gravity  ↑ with activation  ↓ with voluntary action  Action tremors: any tremor occurring on voluntary contraction of muscle  postural  kinetic –simple vs. intention  task-specific  isometric

4.  Topography  Head  Chin  Jaw  Upper/lower extremity  Trunk  Activation condition  Rest  Posture  Specific tasks

5.  Frequency  low <4 HZ  medium 4-7 Hz  high >7 Hz  Amplitude

6.  Medical history should include details of tremor onset, family history, alcohol sensitivity, associated diseases, medications, and drug use/abuse.  The general neurological exam is very important and has a great impact on the differential diagnosis.  Clinical situation should guide additional workup (labs, imaging, etc…)

7.  Physiological tremor is present in every normal subject with posture and action.  Enhanced physiological tremor is a visible, predominantly postural, and high frequency tremor of short duration (<2 years). Evidence for neurological disease related to the tremor must be excluded.  Hyperthyroidism  Drugs (TCAs, Lithium, bronchodilators, cocaine, alcohol,...)

8.  Predominantly posture and action tremor that is usually slowly progressive over time. Rarely, resting tremors can also occur.  Mean onset between 35-45 years of age.  Prevalence rates vary from 0.4-5.6%.  AD in 60%  50-90% improve with alcohol ingestion.  Topography: hand>head>voice>leg>jaw>trunk/face

9.  First choice:  Propranolol LA (60-240 mg daily)  Primidone (150 mg qhs)  Second line  Clonazepam  Gabapentin  Topiramate  Medically-Refractory cases:  DBS  Thalamotomy

10. http://www.mdvu.org/library/ratingscales/et/

12.  Classic Parkinsonian tremor:  Rest tremor  Asymmetric  Temporarily suppressed with voluntary movement  Increased amplitude with mental stress, contralateral movements, and during gait  Treat with anti-Parkinsonian agents and DBS in medically-refractory cases of tremor- predominant PD

13.  AKA intention tremors  Pure intention tremor  Often unilateral  Slow (<5 Hz)  Postural tremor may be present but no rest tremor  Medical treatments typically ineffective

14.  Neuroleptics  Reglan  Antiepileptics (especially VPA)  Antidepressants  Steroids  Antiarrhythmics (especially amiodarone)  Cyclosporine  Cytostatics (e.g. vincristine)

15.  Postural and kinetic tremor not usually seen during complete rest that occurs in a body part affected by dystonia.  They are focal tremors with irregular amplitudes and variable frequencies.  Geste antagoniste  Botulinum toxin treatment of first choice  DBS for medically-refractory cases

16.  Most common PMD  Tend to be equal at rest, with posture holding and with action  Highly variable within the same individual  Fingers rarely involved  Co-activation sign (tremor amplitude ↑ when weight applied to the involved limb)  Entrainment  Distractible  May emerge during a period of emotional stress  May have other psychogenic features on exam

17.  25 year old woman with tremor for two years.  Bilateral hands and head affected.  Alcohol helps the tremor.  Anxiety makes it worse.  Father has hand tremor.  Told by 2 other neurologists that she has ET.  Propranolol not tolerated.  On primidone now without much benefit.