Tremors - Orthostatic, Essential, Dystonic, Cortical, Functional, Enhanced physiological, Psychogenic Flashcards

1
Q

Tremor history key questions

A

Involuntary, rhythmic, oscillatory movement of a body part

Age of onset
Temporal evolution

Bodily distribution
Activation conditions - rest, action (kinetic, postural, isometric)
Tremor frequency - cortical (fastest)

Associated signs
-isolated tremor
-combined with dystonia/rigidity/bradykinesia/systemic disease signs

Anatomical distribution
-focal or generalised

FHx or sporadic

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2
Q

Tremor, investigations to consider

A

EMG - presence of tremor, frequency and rhythm

Structural imaging - MRI, CT for lesions, metabolic disorders (basal ganglia, cerebellum)
-decreased metabolic activity in FDGPET (PD vs ET)

Receptor imaging - dopamine deficiency (PD vs ET)

Serum, tissue markers - metabolic blood tests (Cu in Wilsons, hyperthyroidism

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3
Q

Activation conditions of a tremor?

A

Only at rest

Action

kinetic => simple/intention/task specific?
postural => position independent/dependent
isometric tremor

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4
Q

Orthostatic tremor

presentation
investigations

A

50+

Fast tremor in legs and trunks when standing still
-unsteadiness, calf pain
Relieved by walking, sitting, supine

EMG confirmation

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5
Q

Essential tremor

epidemiology, pathophysiology
presentation
management

A

40+, familial
-thought to be a problem between the cerebellum and other parts of the brain => poor muscle coordination

Isolated bilateral upper limb action tremor
No other neuro signs
:) alcohol and rest
:( stress, caffeine, some medications
-slow progression

Treatment not needed if mild
1st line - propanolol + avoid triggers
2nd line - primidone (AED) or BZ
Botox, DBS for medically refractory

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6
Q

Dystonic tremor syndrome
-presentation
-management

A

Tremor + dystonia
Adults - generally focal
Children - multiple body parts involved

Arises after specific movements/tasks, affecting same muscle groups => irregular amplitude
:) antagonistic gestures, rest
Head, arm tremor

Lifestyle
-avoid mv that trigger dystonia
-stress management, rest, relaxation
-antagonistic muscle use

Medical
-trihexylphenidyl
-DBS of GPI

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7
Q

Cortical tremor
-cause
-presentation
-investigations

A

Genetic - mitochondrial
Most common cause - drugs (fluoxetine, clozapine, gabapentin)

Short duration bursts => irregular, jerky movements

EMG

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8
Q

Functional tremor syndrome
-presentation

A

Distractibility
Frequency entrainment
Antagonistic muscle coactivation

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9
Q

Enhanced physiologic tremor

A

Normally, we all have a low amplitude fine tremor to help us maintain a posture or movement

Enhanced when a specific posture is maintained

Tremor improves after cause addressed

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10
Q

Psychogenic tremor

A

Can involve any body part, most commonly the extremities
Sudden onset

Combination of postural, action, resting tremor

Decreases with distraction, associated with psychosomatic

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