Richard Leckey Oct 2,2015. Faculty: Dr. Richard Leckey Relationships with commercial interests: ...
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Transcript of Richard Leckey Oct 2,2015. Faculty: Dr. Richard Leckey Relationships with commercial interests: ...
SHAKES, SHUFFLESTICS AND TREMORS
Richard Leckey Oct 2,2015
Faculty/Presenter Disclosure
Faculty: Dr. Richard Leckey
Relationships with commercial interests:
Biogen Merck Serono Novartis Allergen
CFPC CoI Templates: Slide 1
Disclosure of Commercial Support
CFPC CoI Templates: Slide 2
Mitigating Potential Bias
CFPC CoI Templates: Slide 3
Intro
To review common movement disorders Diagnosis Investigations Treatment
ET
Most common type of tremor Family history in about 60% Worsens with age Can be very disabling Not due to a degenerative brain disease
Things to rule out
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
Characteristics
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
Investigations
TSH, CBC Physical exam No need to CT
Treatment
Remove aggravating factors Counseling B blocker Mysoline OT adaptations Gabapentin DBS
Resting tremor
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
Parkinsons
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
Warning signs
Symmetrical Early falls Lack of tremor Eye movement problems Hx of strokes Always remember meds Strongly associated with dementia Rapid downhill course
Treatment
Sometimes none at first Levodopa most effective Dopamine agonists – beware of S/E Anticholinergics EXERCISE Periodic physio, home adaptations DBS
Cerebellar Tremor
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
Causes
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
Non- organic
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
Summary
Postural – ET Resting Parkinsons Cerebellar – intention Non organic – inconsistetnt
Gait disorders
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
Examples
I will demonstrate Laugh if you wish
Tics
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
Tourettes
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
Treatment
Behavioral I am not an expert Explanation in key Clonidine rarely helpful Neuroleptics atypicals Nitoman Biofeedback DBS
Treatment
Treatment is suboptimalOften patients are very bright and treatment blunts them This makes it an as necessary phenomenonNote SSRI can worsen ticsRISK of EPS with neuroleptics