1. Richard Leckey Oct 2,2015

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

3. CFPC CoI Templates: Slide 2

4. CFPC CoI Templates: Slide 3

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

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

7.  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

8.  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

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

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

11.  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

12.  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

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

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

15.  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

16.  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

17.  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

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

19.  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

20.  I will demonstrate  Laugh if you wish

21.  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

22.  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

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

24. 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