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Evaluation & management of tremor

Evaluation & management of tremor . Leslie Cloud, MD Department of Neurology Division of Movement Disorders Emory University School of Medicine. The videos shown in this lecture were filmed in the Movement Disorders Clinic at Emory University.

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Evaluation & management of tremor

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  1. Evaluation & management of tremor 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. Phenomenology & terminology • 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. Clinical Assessment of Tremor • Topography • Head • Chin • Jaw • Upper/lower extremity • Trunk • Activation condition • Rest • Posture • Specific tasks

  5. Clinical Assessment of Tremor • Frequency • low <4 HZ • medium 4-7 Hz • high >7 Hz • Amplitude

  6. Clinical Assessment of Tremor • 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. Enhanced Physiological tremor (EPT) • 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. Classical essential tremor (ET) • 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. Treatment of Essential Tremor • 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/

  11. Parkinson’s Disease • 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

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

  13. Drug-induced Tremor • Neuroleptics • Reglan • Antiepileptics (especially VPA) • Antidepressants • Steroids • Antiarrhythmics (especially amiodarone) • Cyclosporine • Cytostatics (e.g. vincristine)

  14. Dystonic tremor • 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

  15. Psychogenic Tremor • 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

  16. Case 1. • 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.

  17. “If it walks like a duck, quacks like a duck, looks like a duck, it must be a duck”

  18. Slit Lamp Examination

  19. Penlight exam

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