Tremors - Orthostatic, Essential, Dystonic, Cortical, Functional, Enhanced physiological, Psychogenic Flashcards
Tremor history key questions
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
Tremor, investigations to consider
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
Activation conditions of a tremor?
Only at rest
Action
kinetic => simple/intention/task specific?
postural => position independent/dependent
isometric tremor
Orthostatic tremor
presentation
investigations
50+
Fast tremor in legs and trunks when standing still
-unsteadiness, calf pain
Relieved by walking, sitting, supine
EMG confirmation
Essential tremor
epidemiology, pathophysiology
presentation
management
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
Dystonic tremor syndrome
-presentation
-management
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
Cortical tremor
-cause
-presentation
-investigations
Genetic - mitochondrial
Most common cause - drugs (fluoxetine, clozapine, gabapentin)
Short duration bursts => irregular, jerky movements
EMG
Functional tremor syndrome
-presentation
Distractibility
Frequency entrainment
Antagonistic muscle coactivation
Enhanced physiologic tremor
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
Psychogenic tremor
Can involve any body part, most commonly the extremities
Sudden onset
Combination of postural, action, resting tremor
Decreases with distraction, associated with psychosomatic