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Management of Tremor


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This presentation was made from Vinken and Bruyn's Handbook of Clinical Neurology, Marsden's Book of Movement Disorder, Movement Disorder Society

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Management of Tremor

  1. 1. TREMOR Compiled by Dr PS Deb MD, DM (Neurology) Director Neurology GNRC Hospitals Guwahati, Assam, India
  2. 2. TREMOR  Rhythmical, involuntary oscillatory movement of a body part, produced by either synchronous or alternating contractions of antagonist muscles (1- 3).  Type:  Rest  Action  Postural  Kinetic
  3. 3. TREMOR EVALUATION  History  Age of onset, progression  Family history  Systemic symptoms : diaphoresis, palpitations, and bowel irregularities  Association: other neurological disease, Drug use  Examination  Rate : Frequency  Amplitude  Location: Part of the body affected  Modification:  Rest (repose)  Actional  Postural (static)  Movement  Task specific  Other factors: Anxiety, exertion, sleep, drugs  Special tests:  Handwriting  Drawing Archimedes spirals  Ability to transfer water between 2 cups or drink from a cup  Investigation  EMG: Antagonist muscle shows, burst synchronous / asynchronous  Recording: Acceterometer, Goniometer, Computer
  4. 4. PATHOPHYSIOLOGY  Due to burst of α motor neuron, synchrony in antagonistic muscle, presumably inadequately in the strength and timing of contraction of opposite muscle group.  Rhythmic burst of discharge of unitary cellular activity in VIM of thalamus synchronous with tremor on contralateral side with stopping of tremor by voluntary or passive movement due to disappearance of burst  The neurons are arranged somatotopically and respond to kinesthetic impulse from the muscle and joint involved  In monkey VIM contains large sized neuron receive dense projection from the cerebellar nuclei and spinocerebellar tract  Tremor can be abolished by lesion of VIM  VIM is key nucleus which is sensory in character as well as interfering motor activity
  5. 5. PATHOPHYSIOLOGY  Synchronous burst also occur in sensory-motor cortex, important for tremor generations.  Passive stretching of muscle →  >1Hz Non Parkinsonian  < 1Hz Parkinsonian  Suggest tremor rhythm is strongly influenced by spinal reflex mechanism  Pathway not clear pyramidal / extrapyramidal  Probably tremor is produced in the reticular formation the brain stem or thalamus and is modified and regulated in its rhythm setting by spinal reflex mechanism most prominently by the kinesthetic sence.
  6. 6. PATHOPHYSIOLOGY Frequency Site System involved Human form 8-12Hz None Olivocerebellum Physiological 6-8 Hz Dentate N. Olivocerebellum Essential 3-6 Hz Midbrain tegmentum Thalamo-cortical Parkinsonism Lamore 1984 in monkey Hornalive (GABA antagonist) injection
  7. 7. Oscillation in Inf- Olive Activation of Purkenji Cells Reticulospinal, vestibulospinal, cerebellothalamic system Tremor Tremor abolished by inf. Olive lesion But, no such lesion found in human except palatal myoclonus
  8. 8. PATHOGENESIS OF TREMOR Red- nucleus OliveCerebellum Cortex Basal Ganglion Thalamus Ant. Horn Cells Muscle External Protuberance
  9. 9. REST TREMOR  Parkinsonian syndrome  Multiple Systems Atrophy,  Progressive Supranuclear Palsy (PSP),  Corticobasal Syndrome,  Parkinsonism-Dementia-ALS of Guam,  Progressive Pallidal Atrophy,  Diffuse Lewy Body disease  Heredodegenerative disorders  Huntington's disease,  Neuroacanthocytosis,  Neurodegeneration with Brain Iron Accumulation,  Gerstmann-Strausler-Scheinker disease,  Neuronal Ceroid Lipofuscinosis
  10. 10. CAUSES OF REST TREMOR  Secondary parkinsonism  Toxins  carbon monoxide,  MPTP,  manganese,  methanol,  cyanide poisoning)  Drugs  neuroleptics,  dopamine depleting drugs,  Antiemetics  Infections  Creutzfeldt-Jakob disease,  Subacute Sclerosing Panencephalitis,  fungal  post-encephalitic  Metabolic disorders  hypothyroidism,  chronic hepatic degeneration,  mitochondrial cytopathies  Other:  vascular events,  head trauma,  neoplastic or  paraneoplastic conditions  Severe essential tremor  Midbrain (rubral) tremor  Psychogenic tremor
  11. 11. PARKINSONIAN TREMOR  Incidence: 60-70% at the onset(8).  Rate : 3-7Hz variable  Amplitude: moderate  Location: One of both hand→ feet → jaw → tongue  Type:  Flexion extension of hand , adduction abduction of finger, pronation supination of forearm  Flexion extension of finger + adduction abduction of thumb – pin rolling tremor  Foot flexion extension  Lips and jaw opening and clossing  Tongue in and out  Eyes flutter when closed  Other type: 15-30%  Fast frequency postural or action tremor  Paralysis agitance: gentle distal tremor  Post encephalatic: proximal slow tremor  Elderly my have tremor for long time without other features of parkinsonism which may develop later  Progression:  Modification:  Increased  At the time of repose  Emotional stress  Walking  Reduced  when hand is supported  by willed movement  During deep sleep, relaxation  Rigidity  Functional interference  Does not interfere with voluntary movement  Association: other neurological disease  EMG: Antagonist muscle shows, burst synchronous / asynchronous  Recording: Acceterometer, Goniometer, Computer
  12. 12. PAHTOPHYSIOLOGY  Not due to nigrostriatal dopaminergic deficit  Animal lesion of SN, striatopallidal → no tremor  All patients with SN lesion do not have tremor  Central oscillator in thalamus, cerebellum, globus pallidus, or subthalamic nucleus,  Monkey: lesion between SN and RN in midbrain tegmentum → parkinsonian like tremor (Ward)  Severity may correlates with loss of subgroup of mesencephalic neurons  A midbrain lesion near the red nucleus can involve the nigrostriatal pathway in addition to cerebellar outflow tracts and cause a tremor at rest as well as an action tremor, known as a Holmes, or rubral, tremor. (5)
  13. 13. RX PD TREMOR  Dopamineric agent : 50% reduction with levodopa , Amantadine, clozapine, propranolol,and mirtazapine,  Botulinum toxin has been found to effective for some patients with PD hand tremor (19,20) and jaw tremor (21).  The subthalamic nucleus is the most common surgical target for medically refractory PD-related tremor (8)  but lesioning or deep brain stimulation of the thalamic nucleus ventralis intermedius can also be performed.  A lack of major benefit has been observed with gamma knife thalamotomy (22).
  14. 14. OTHER REST TREMORS  Cerebellar rest tremor: also due to striatonigral lesion  Hereditary chin tremor  Paroxysmal tremor  Dystonic disorder with tremor – spasmodic torticollis – 1-6.5 Hz  Shuttering attack of children  Whole body tremor + sympathetic changes  ± Essential tremor or FH of ET  Jittering of new born infent  With other signs of CNS hyperactivity  Hypermobility  Hypertonicity  Easy to startle  Due to pre or post natal insult
  15. 15. POSTURAL TREMOR  Physiologic  Essential
  16. 16. PHYSIOLOGICAL TREMOR  Asymptomatic oscillation of body  Present even during sleep  Cannot be seen by eyes  Frequency 8-13 Hz  Due to (Marsden)  Mechanical resonance frequency of related joints  Irregularity of muscle contraction in an un-fused tetanus of slow firing motor unit  Reflexion of balistocardiogram  Oscillation in the spinal monosynaptic reflex
  17. 17. ENHANCED PHYSIOLOGIC TREMOR  Frequency :8-13Hz (altered by mechanical loading, alpha/beta stimulation)  Due to increased operation of segmental stretch reflex consequent to mechanical changes produced in the muscles by its beta adgrenergic stimulation
  18. 18. PHYSIOLOGIC TREMOR  Physiologic tremor enhanced by  Emotion – anxiety stress  Exercise, fatigue  beta-agonists,  dopaminergic drugs,  stimulants,  valproic acid,  carbamazepine,  verapamil,  epinephrine,  psychiatric drugs,  methylxanthines (coffee, tea),  cyclosporine,  interferon, and flunarizine.(5- 7)  stress,  Endocrine: hypoglycemia, thyrotoxicosis, pheochromocytoma, adrenocorticosteroids  Toxin: mercury, lead, alcohol withdrawal
  19. 19. OTHER CAUSES OF POSTURAL TREMOR  Dystonia,  Parkinsonism,  Myoclonus,  Kennedy syndrome,  Roussy-Levy syndrome.  Parkinson syndromes may have a postural component, known as a re-emergent tremor,  Midbrain lesion or cerebellar dysfunction (titubation) (5).  Psychogenic.
  20. 20. ESSENTIAL TREMOR  Inherited, constitutional malady characterized by kinetic tremor in the absence of other neurological signs  Prevalence – 0.9% increases with age >95years >20%  Onset: childhood or late life  Progression : Unilateral to bilateral and from arm to head after several year, voice, tongue, leg and trunk can be involved rarely, slowly progressive with increased severity  It can be hereditary (30%) with variable penetrance or sporadic and has a bimodal age at onset.  Etiology : Unknown (Genetic, toxic)  Pattern: Kinetic tremor, postural and during action (writing, drinking,), >50% have intention component, rarely rest tremor also
  21. 21. ESSENTIAL TREMOR  Frequency : 4-12 Hz inversely related to amplitude  Amplitude more than physiological, increases gradually and large proportion are disabled  Type: Postural action tremor, sometime intentional, rarely rest (frequency 4-12Hz)  Site: Aadduction-abduction movement of the fingers (individual finger can be affected) and flexion-extension movement of the hands-> Head no-no (F>M)-> voice and jaw, lower limbs are rarely affected.  Modification: Forment’s sign: Tremor and cog-wheeling increased voluntary activity even in opposite limbs and reduced by relaxation  Increased by cold, exercise, emotion, sympathetic stimulation  Associated cerebellar features (mild ataxia of gait ), Mild cognitive difference
  22. 22. PATHOPHYSIOLOGY  Cerebellum (Purkinje cells) and inferior olive have been implicated by fMRI, PET, diffusion tensor imaging and Pathological studies
  23. 23. ASSOCIATED NEUROLOGIC DISEASE  Parkinson’s disease  Higher incidence of PD in ET 24times  In familial PD ET common  Spasmodic torticollis  Torsion dystonia  Essential myoclonus  Peripheral neuropathy  Fredrick's ataxia  Physiological tremor  Other condition  Essential hypertension  CVD  CHD  Alcoholism  Intelligent professional
  24. 24. ESSENTIAL TREMOR TYPE (MARSDEN)  Type I – Benign exaggerated essential tremor (8-12Hz)  Type II – Benign pathological essential tremor (5-7Hz)  Type III – Severe pathological essential tremor (4-6Hz) frequently spasmodic, not responsive to therapy  Type IV – Symptomatic essential tremor, associated with other neurological conditions
  25. 25. ESSENTIAL TREMOR - RX  Standard Rx: Propranolol, Primidone  Other Rx: Other beta blockers, Topiramate , Gabapentin , benzodiazepine  Deep brain stimulation: in resistance cases  Ventralis intermedius (Vim)  Thalamotomy not recommended
  26. 26. KINETIC TREMOR  Kinetic tremor refers to oscillation during a visually-guided voluntary movement (5).  Cerebellar outflow tract disorder  Stroke  Demyelination  Infection or post-infection  Viral, bacterial, fungal, parasitic, prion  Trauma  Neoplastic or paraneoplastic  Endocrinopathies  Hereditary disease  Spinocerebellar ataxias,  Wilson's disease  Medications  Phenytoin, valproate, amiodarone, lithi um  Heavy metals & toxins  Organic mercury, alcohol, toluene  Midbrain (rubral) tremor  Severe essential tremor  Psychogenic tremor
  27. 27. CEREBELLAR TREMOR MILD  Mild (simple) rapid 10Hz distal (unresponsive to INH)  Severe (Rubral – Gorden Holmes 1904) – not rubral but upper brain stem lesion involving dentato-thalaminc and dentato-olivary system  Proximal can be distal Arm > Leg, head and trunk can be involved  Irregular low frequency (3-5Hz)  High amplitude, increased amplitude with prolonged posture  Intention tremor, increased with goal directed movement of difficult pathway  Perpendicular to the direction of movement  Associated rest tremor due to involvement of different pathway.
  28. 28. CAUSES OF INTENTION TREMOR  Multiple sclerosis  Brainstem tumor  Benedict’s syndrome
  29. 29. PATHOPHYSIOLOGY  Dysfunction of cerebellar-based motor control  mechanical oscillation of joints and their muscles,  stretch reflex oscillations through afferent muscle spindle pathways to the brain, and centrally-located oscillatory neuronal groups (5).  Cerebellar tremor tends to occur ipsilateral to a lesion of the deep cerebellar nuclei or outflow tracts through the superior cerebellar peduncle (5).  It is likely injury to these outflow tracts through the midbrain that cause the kinetic component of a Holmes, or rubral, tremor.
  30. 30. TREATMENT OF KINETIC TREMOR  Difficult:  CBZ in small trial  Glutethimide in MS  Bnezodiazepine  Baclofen  Botox no use  Tetrahydrocanabinol  5 Hydroxytryptophan  INH 900-1200mg/d with Pyridoxin  Removal of cause  Behavioral modification: wrist weight while eating  Surgical  Thalamotomy or  Deep brain stimulation of the nucleus ventralis intermedius (Vim)
  31. 31. CEREBELLAR INTENTION TREMOR  Rhythmic oscillation on reaching the target perpendicular to the direction of movement  Once the target is reached tremor will cease after 1 sec (postural tremor will continue once the target is reached)  Frequency 3-5 Hz  Sometime associated with titubation of head and trunk  Interferes with voluntary act  Drugs ineffective  Stereotaxis improve tremor but not function  Adding wt to the limb  Vigorous friction of the joints
  32. 32. PERIPHERAL NEUROPATHY WITH TREMOR  Hereditary motor sensory neuropathy with ET  Chronic relapsing neuropathy after 2-3rd relapse 6-8Hz tremor improve with neuropathy  Paraprotenemia with neuropathy (IgM benign)  Muscles are not weak, motor conduction reduced, proprioception normal  Recovery phase of GBS  Rarely Diabetic neuropathy  Uremic neuropathy  Porphyria
  33. 33. PATHOGENESIS OF TREMOR IN PN  Enhanced physiologica tremor by weakness and impairment of stretch reflex (Shid et al)  Loss of large fiber sensory function -> imbalance in the sensory input to the motor neuron pool (Shahani and Yong)  Primary CNS disorder  Spinocerbellar pathway involved -> impaired central function
  34. 34. WILSON DISEASE  Postural and intension tremor  3-5Hz severe poximally  Can increase amplitude with time  Wing beating tremor at shoulder when abducted at 90 degree and elbow flexed
  35. 35. POST TRAUMATIC  Proximal postural and intentional  Following sever head trauma  Stereotactic VIM lesion  Propranolol
  36. 36. ALCOHOLIC TREMOR  Exaggerated physiological  Essential tremor – inherited as different tract  3Hz leg tremor - by standing and closing eyes – ant cerebellar lesion
  37. 37. TASK SPECIFIC TREMOR 1. Primary writing tremor  Related to essential tremor, writer’s cramp, dystonia  Alcohol, Propranolol, Anticholinergic improve in some 2. Vocal tremor 1. Related to ET, family history 1. Respond to alcohol, propranolol 2. Not related to ET, no family 1. Does not respond to beta blocker
  38. 38. ORTHOSTATIC TREMOR  On standing  Reduced by walking  Clonazepam 4-6mg effective
  39. 39. HYSTERICAL TREMOR  Commonly action tremor  May persist in repose  Irregular frequency  Unilateral  Disappear when attention diverted and restart tremor shift to other parts of body
  40. 40. ASTERIXIS  Arrhythmic lapses of sustained posture  Sudden interruption of muscular contraction allow gravity or inherent elasticity of muscle to produce a movement when the patient corrects with overshoot  Metabolic encephalopathy  Anticonvulsant  Anticonvulsant  Unilateral Asterixis  Ant. Cerebral occlusion  Thalamotomy  Mid brain lesion
  41. 41. THANK YOU