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