062_Tremor Revised.ppt

7/27/2019 062_Tremor Revised.ppt

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Definition of TremorRhythmic, oscillatory movement.

Rhythmic: regularly recurrent.

Oscillatory: alternate movement

around a central plane.

Commonly encountered in clinical

practice.

Variety of different tremor types &

diseases.


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Basic Tremor Terminology Is classified:1. Action tremor: occurs during voluntary

contraction of skeletal muscles.

A. kinetic: during guided voluntarymovements: writing, touching finger tonose.

B. Postural: in a body part maintainedagainst gravity: sustained arm extension.

2. Rest tremor: when a limb is fully relaxed.

3. Intentional tremor: tremor is present, withvisually guided movement, and increases

in amplitude with approach of the target.


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Basic Tremor TerminologyCentral tremor : when thought to

arise from CNS. E.g: Essential

tremor, Cerebellar tremor.Peripheral tremor: they arise from

mechanisms outside the CNS.

E.g: Enhanced Physiologicaltremor, P.P tremor


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Essential Tremor Most common adult- onsetmovement disorder. 4- 12 Hz, kinetic arm tremor. In severe cases, may bepostural. ? Abnormal cerebellar thalamic outflow pathway.


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Essential Tremor What helps in Dx:1. Gradual, yet progressive, increase

in tremor amplitude over time.2. May involve the head (neck), andvoice.3. Acute reduction of tremor, withEthanol.4. Presence of other family memberswith tremor.


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Treatment of EssentialTremor Is it disabling or embarasing enoughto merit treatment? Most treatments are only partiallysuccessful, and accompanied byside- effects. Surgical treatments are moreeffective, but may have potentiallysignificant risks.


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Treatment of EssentialTremor The more severe the tremor, the lesslikely that oral medications alone, will besufficient to control the tremor. Treatment response for head & voicetremor, is generally less clear than armtremor. Biofeedback are medestly successful, forpts with mild tremor, who do not want oralmedications. Use of wrist weights, weighted utensils to

eat.


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Treatment of EssentialTremor Mainstay of treatment:1. adrenergic receptor blocking

agents: Propranolol.2. Anticonvulsant Primidone.Efficacy is roughly equivalent.Decision is taken mainly by side effectsprofile, and tolerability, in addition topossible need for certain one for HTN

or SZs.


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Treatment of EssentialTremor

Other more selective - blockers: Sotalol,Metoprolol , are used, but the non- selectivePropranolol is the most studied, and is moreeffective.

Action is peripheral, and may be central. Standard or long acting. Start 10- 20 mg qd, titrate q w, to as high as320 mg/ d. average 120 mg/ d. In elderly, lower dose: symptomatic

bradycardia, hypotension, esp orthostatic.


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Treatment of EssentialTremor 45- 75% of patients improve on Propranolol. Less satisfactory for voice, and headtremor. Side effects are generally mild to moderate,but occur in 50% of patients: fatigue,depression, orthostatic hypotension,impotence, exercise intolerence. Most side effects dont decrease with time,and need lowering the dose, or anothermedication. Asthma is a relative contra-indication (notabsolute), and not common.


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Treatment of EssentialTremor Primidone is partially metabolized intophenobarbital, and 2- ethyl- 2phenylmalonamide. The former has someefficacy as well. Efficacy is similar to Propranolol. Long- term tolerability is better than

Propranolol. However, > 20% develop acute reaction ofnausea, vomiting, or ataxia. Pretreat with PhB 30 mg bid for 3 days to

activate liver P450.


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Treatment of EssentialTremor Use combination, If both are not effective. Add- on, or alternative therapy is the nextstep. Medications that enhance - aminobutyricacid function: Gabapentin: start 300 mg/d to 1800- 2400mg/d in 3 divided doses. Alprazolam: 0.75- 2.75 mg/d. Topiramate: 25- 400 mg/d. modest tomoderate efficacy, but side effects in 32%of pts: paresthesiae, weight loss, fatigue,

memory difficulties.


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Treatment of EssentialTremorthanol: controversial. dependence and abuse.oderate situatianal use, can provide transienteduction of tremor.thanol analogs: 1- octanol.. Na Oxybate (Xyrem in US, Alcorem in Italy), used forarcolepsy, insomnia, depression, alcoholism, by somthletes for body building (inc GH), as solution to mixith water.evetiracetam: showed some promise.otulinum Toxin: binds to presynaptic Ach receptors.an be used for 1 or both the paired muscle groups, toeaken and dampen tremor.


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Treatment of EssentialTremor Botox is Suboptimal for Limb tremor, assufficient doses, can cause weakness. Limb tremor: Botox is injected into both the

extensor, & flexor carpi radialis (15- 100 units),with the stronger flexors receiving slightlyhigher dose.

Greatest advantage is for Head & voicetremor.

Head tremor: 40- 300 units into involvedsternocleidomastoid, splenii, and scalenemuscles. Need fine tuning over 3- 4 ms intervals,until optimal sites & doses are achieved.


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For head tremor, Pure horizontal or verticalmovements are easier to treat, thancomplex, directional movements.

Voice tremor: Botox, 0.6- 15 units

injections into the vocal cords.

Side effects: transient breathiness,dysphagia, rarely more severe

complications.


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Surgery is the best tool for severe cases. Thalamotomy: has been used for more than

half a century. Prolonged & significant improvement intremor of the contralateral limb. Side effects, esp Dysarthria can be severe,esp if bilateral thalamotomies. Has been largely replaced by stimulationtechniques.


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Treatment of EssentialTremor Deep brain stimulation: electrodes in theventralis intermedius nucleus of the thalamus. 90% improvement. Most effective in Limbtremors, but also in axial, head & voice. Severe side effects: perioperative ICH,Hemiparesis, and death, in less than 1% inexperienced centers. Later complications of hardwaremalfunctions, and infections, needingrevision in 25% of pts. Always more conservative medication, and

very appropriate patient selection.


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Enhanced Physiologicaltremor

Rapid (8- 12 Hz), low amplitude, posturalor kinetic tremor of the hands and voice. Mechanism: increased - adrenergicstimulation. Occurs intermittently in most normalindividuals, esp limb fatigue, stress, or

high emotion. After the consumption of stimulants:caffeine, tobacco. After treatment with some medications:

Lithium, Thyroxine, VPA, cyclosporine


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Enhanced Physiologicaltremor In a small proportion of people, theamplitude of it, is chronically elevated, andbothersome to the patient. Usually, young anxious adults. May be accompanied by mild cogwheelingwithout rigidity. Sometimes, hard to differentiate from ET,

and here quantitative computerized tremoranalysis is helpful. Addition of weight on the tremulousoutstretched arm, will reduce the tremorfrequency (unlike ET).


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D I d d A ti


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Drug- Induced Action

Tremor

A form of Enhanced physiological tremor. Temporal link between the initial use of themedication, and the onset of tremor. Dose escalation is associated with anincrease in the tremor. Complete resolution with removal of themedication. 8- 12 Hz, involves the arms, but spares thehead. Tx: removal of the causative agent. If not possible, reduction + low dose Inderal

D I d d A ti


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Drug- Induced Action

Tremor

Possible causative Medications: Amiodarone, Amitriptyline. Calcitonin, Cimetidine, Cyclosporine, Cytarabine. Ifosfamide, Interferon. Lithium, Medroxyprogesterone, mexiletine. Procainamide, Salbutamol, Salmeterol. SSRIs. Tacrolimus, tamoxifene. Thyroxine. Valproic Acid. Lead, mercury..etc.


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Dystonic Tremor Patients with Dystonic movements &postures, may have accompanying dystonic

tremor, particularly, when they attempt tomove in the direction opposite to the forceof the dystonia. Can happen: 1) in the neck (in Torticolis). 2) in the arms (Hand/ arm dystonia). 3) in the voice (spasmodic dysphonia).


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Dystonic Tremor Key diagnostic Features:1. Associated feeling of pulling or pain (espwhen the neck is involved).2. The tremor is directional (i.e, with

movements in one direction, rather thanoscillating around a central plane).Treatment: is not well- documented, and ismodest, and must be weighted against the

severity of side effects.Trihexiphenidyl: anticholinergic, start 1 mg/d, increase gradually to 15 mg/d, moreintolerable.Side effects: confusion, difficulty urinating.


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Dystonic Tremor 2. Baclofen: 10- 60 mg/ d. drowsiness 3. Benzodiazepines: clonazepam,Lorazepam, Diazepam, all have a dualantidystonic + tranquilizing effect. 4. I.M Botox: very effective in Torticolis, forlessening dystonic muscle contractions, &relieving tremor. Usually 200 units in the

sternocleidomastoid, splenius, or trapeziusmuscles, depending on the individualpatients situation. Side effects: mild, transient dysphagia, and

neck weakness.


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Cerebellar Tremor Well- known feature of cerebellar disease. In patients with lesions in the cerebellum,or cerebellar outflow pathways ( M.S,spinocerebellar ataxia, phenytoinintoxication, Alcohol). Intention tremor (with visually guidedmovement : e.g Finger to nose). Typically slow (3 5 Hz). Hypometria, and Hypermetria phenomena. Presence of other cerebellar features:dysarthria, nystagmus, scanning speech,ataxic gait).


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Treatment of CerebellarTremor Still difficult. Not much data. Carbamazepine 400- 600 mg/d decreasedamplitude of cerebellar tremor in 2 studies. Isoniazid 1000- 1200 mg/ d has beeneffective in some, but not other studies. Topiramate 50- 200 mg/d. Buspirone 60 mg/d. Thalamic DBS Thalamotomy.


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Orthostatic Tremor Feelings of unsteadiness while standing,

acompanied by a 13- 18 Hz tremor. Tremor markedly attenuates or resolves, when pteither lies down, sits, or begins to walk. Exam shows fine tremor, visible or palpable in the

calves. EMG: 13- 18 Hz tremor in the leg muscles. No generally accepted therapy. Most success with Clonazepam (1-4 mg/d),

Carbidopa/ Levodopa (300- 800 mg/d) Minimal efficacy: Propranolol, primidone,Gabapentin, Phenytoin, CBZ, Ethosuccimide,Baclofen, Acetazolamide.


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Action Tremor in WilsonsDisease Rare autosomal recessive Ds of coppermetabolism.. Variety of neurological manifestations:1. Cognitive/ Psychiatric disorders.2. Movement disorders (parkinsonism,dystonia, action tremor).3. Long- tract signs. Action tremor may be postural (severecases: wing- beat), or kinetic, as in ET.


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Peripheral Neuropathy- relatedtremor D.M, uremia, Etoh, compressions, Motor neuron Ds,familialetc. History: the onset of neuropathy, andtremor must be linked. Exam: weakness, sensory loss, DTRs. Tremor must be limited to affected limbs byneuropathy. Inertial loading, leads to decrease in tremorfrequency, indicating a tremor with a peripheralgenerator. Improvement of the neuropathy, reduces thetremor. Low- dose Inderal. DBS not recommended (peripheral).


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Holmes Tremor(Midbrain, Rubral)

Usually lesions, involving both thecerebellar outflow tracts + thedopaminergic nigrostriatal fibers in thepontine, and midbrain regions.

May be acute (e.g stroke). May be insidious (tumor, slowly expandingvascular lesion). Strikingly Unilateral, one limb, or hemibody. 3 components: Rest tremor (least severe),Postural, and kinetic/ intentional (most

severe).


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Holmes Tremor(Midbrain, Rubral)

Treatment: Diagnostic management of the underlying

cause: cyst, abscess, tumor. Postural + kinetic/ intentional tremor: -blockers, CBZ, Isoniazid. Rest tremor; Carbidopa/ L- dopa,dopaminergic agonists, Anticholinergics. Severe refractory cases: Thalamic DBS,usually responsive, especially its unilateral

nature.


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Psychogenic Tremor Can occur in many psychiatric disorders.Most common is Conversion disorder, andmalingering. Usually sudden onset, with maximal tremorat commencement, rather than being

insidious, slowly progressive.


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Psychogenic Tremor1. non- physiological or unusual features(variable frequency, direction, unusualcombination of rest + postural + kinetic).2. Presence of Entrainement (differentfrequency of tremor to match repetitivemovements in the other side.3. Distractibility.4. Suggestibility.


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Treatment of

Psychogenic Tremor

1. Establish the diagnosis.2. Establish the underlying psychiatricdiagnosis (with a psychiatrist).3. Validate his/ her symptoms. Dont tell: itsonly in your head, you have nothing.4. Make them feel that you understand thedual nature: psych + neuro.


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062_Tremor Revised.ppt

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