1/29/18 TREMOR. Tremor definition. Classification of tremors. International Congress of Parkinson's Disease and Movement Disorders

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1 TREMOR International Congress of Parkinson's Disease and Movement Disorders 5-9 Oct 2018 Hong Kong Prof Pille Taba University of Tartu, Estonia 3 February 2018, Bordeaux MDS-ES Winter School for Young Neurologists Membership Regular Junior Health Professional Student Waived dues Journals Movement Disorders Movement Disorders Clinical Practice Moving Along Library Tremor definition Rhythmical, involuntary, oscillatory movement of a body part Multiple etiologies; multiple clinical syndromes Oscillatory nature - to distinguish from other involuntary movements Amplitude - not critical Consensus Statement.. Deuschl G et al. Mv Disord 1998 Consensus Statement.. Bhatia K et al. Mov Disord 2018 Consensus Statement.. Deuschl G et al. Mv Disord 1998 Classification of s Common Essential Parkinsonian Physiological Dystonic Cerebellar Drug induced Uncommon Psychogenic Post-traumatic or poststroke Rare Neuropathic Primary orthostatic Holmes 1

2 Clinical features Body Distribution SITE Hands Leg Trunk Head Voice Jaw Lips Tongue (rare) COMMON CAUSES Essential, PD, dystonic, cerebellar, psychogenic, rubral, writing Essential, PD, orthostatic, psychogenic Cerebellar, psychogenic, orthostatic Dystonic, essential, cerebellar Dystonic, essential PD, dystonic, tardive Essential, tardive Drug induced, PD Activation conditions Parkinsonian Physiological Essential Dystonic Orthostatic Cerebellar Holmes Palatal Tremor frequency Hz Raethjen J, Deuschl G. Curr Opin Neurol Diagnostic clues History Age at onset Mode at onset and course Affected body region Spread during course Other signs Concomitant diseases Medications Family history Toxin exposure Examination Observe: rest, postural, kinetic Positional dependence Abnormal postures Mental or motor distractibility of Writing and spiral drawing Specific tasks 2

3 Associated clinical signs Additional tests Neurological Dystonia or dystonic posturing Parkinsonism Cerebellar Pyramidal Neuropathy Systemic Kaiser-Fleischer ring Hepatosplenomegaly Hyperthyroidism Psychiatric Regular Thyroid function tests Copper metabolism Brain structural imaging (if unilateral or persistent ) By indications EMG, nerve conduction studies DaTSCAN imaging Toxicology studies: if on relevant drugs) Metabolic blood tests (porphyria screen, etc) Tests for infections Genetic testing Etiology ESSENTIAL TREMOR (ET) Neurodegenerative diseases PD, MSA, PSP, Wilson, SCA, SMA, neuroferritinopathy,.. Mitochondrial genetic diseases Endocrine and metabolic diseases Neuropathies Infectious and other inflammatory diseases SM, SSPE, HIV, tuberculosis, syphilis, neuroborreliosis,.. Toxins Metals (Hg, Pb, Mn, As), cyanide, toluene,.. Drugs Anticonvulsants, antidepressants, neuroleptics, metoclopramide, anticancer,.. Others Brain tumors, trauma, vascular Anxiety and stress, fatigue,.. Clinical picture: Persistent, bilateral, largely symmetric Action or postural involving hands and forearms May spread to other body parts (head, voice, legs) Isolated of the head in the absence of abnormal posturing. No other neurological signs or disease At least 3 years history Fasano E et al. Mov Disord 33; 2018 Essential : diagnostic challenges Exclusion isolated focal s orthostatic task-specific sudden onset Differential diagnosis Dystonic; Neuropathic; Functional ET-plus: additional neurological signs impaired tandem gait, postural disorder mild memory impairment Essential Common movement disorder 1% of the general population; 5% over 65 years Positive family history Molecular mechanisms uncovered Treatment: effect in half cases but rarely completely Medications Primidone, propranolol Topiramate, gabapentin Alprazolam Atenolol Botulinum toxin Surgery VIM-DBS Thalamic lesions 3

4 1/29/18 PARKINSONIAN TREMOR Differentiating PD and essential Movement disorders Classic Parkinsonian rest is a pill rolling of 4-7 Hz Characteristics Tremor in PD Essential Hallmark of a parkinsonian syndrome Type Rest 4-7 Hz Kinetic and postural 8-12 Hz Body parts Hands, upper and lower limbs Hands, head, voice Bradykinesia Present Absent Age at onset Middle and older Any age Course Progressive Slowly progressive Family history Mostly negative 50% positive Alcohol Reduces Levodopa Effective β-blockers Effective In ~80% of PD patients Up to 10% of patients with atypical parkinsonism (MSA, PSP, CBD, VP) Predominantly in hands; can also occur in legs, jaw or tongue PD patients may also have postural or kinetic of faster frequency Figure 2 Improvement of dystonic (DT) or primary writing (PWT) according to the involved body site and the given treatment: the outcomes were highly variable, depending on the specific type of intervention and distribution. Numbers under the bars represent the respective number of studies and enrolled patients (note that the total of studies exceeds 43 because some of them adopted more than a single therapeutic approach). Botulinum neurotoxin (BoNT) and surgery are the most successful strategies, significantly more effective than drugs. With respect to distribution, BoNT was the most useful strategy in the management of axial (head/trunk or vocal cord), although no statistically significant difference emerged. As for hand as a whole group (PWT or in the context of upper limb dystonia), BoNT and surgery were equally effective, significantly more than other strategies (A). When splitting the hand group into PWT and DT involving upper limbs, drugs are less effective in PWT than other strategies, whereas no data are available for BoNT in DT (B). largest amount of data in the literature confirming its efficacy. With respect to appendicular, BoNT and surgery might be effective in PWT, whereas no data are available for DT of the Treatment of dystonic DYSTONIC TREMOR Tremor can be a element of dystonia Postural/ kinetic, occuring in the region affected by dystonia Worsens with voluntary movements against dystonia (eg torticollis) Geste antagoniste (sensory trick) TAD associated with dystonia in a different region Dystonic vs essential? upper limbs. Drugs are generally less efficacious but could be tried especially when involves different body regions, thus allowing the use of BoNT in a stepwise approach (in order Hand - subtle dystonic posturing of fingers or wrist Head - subtle dystonic posturing of neck Fasano et al, J Neurol Neurosurg Psychiatry 2014 Figure 3 A possible algorithm for the treatment of dystonic (DT) or primary writing (PWT) on the basis of the limited evidence available to date. Botulinum neurotoxin (BoNT) is the most useful strategy in the management of axial (head or vocal cord) s, whereas appendicular with the exception of PWT should be firstly treated with drugs, thus allowing the use of BoNT in a stepwise approach (in order to further improve the regions not adequately improved). By contrast, BoNT might be first-choice therapy in PWT, followed by drugs or surgery. Surgery (DBS) should be considered only when the disability derived by overcomes the risks of its invasiveness. Unilateral procedures can be tried in case of appendicular, whereas bilateral surgery is indicated for head. As for the target of DBS, Vim and Gpi are the most used ones, based on the predominance of (Vim) or dystonic postures (Gpi). The combined approach Vim+Gpi might be considered in case of failure of the single target procedure. Other targets (VLp, STN and surrounding areas, ie, PSA or czi) might be considered in very selected cases. czi, caudal zona incerta; DBS, deep brain stimulation; Gpi, globus pallidus internus; PSA, posterior subthalamic area; STN, subthalamus; Vim, ventralis intermedius nucleus of thalamus; VLp, posterior part of the ventrolateral thalamus. Fasano A, et al. J Neurol Neurosurg Psychiatry 2014;85: doi: /jnnp ORTHOSTATIC TREMOR 767 CEREBELLAR TREMOR Hassan A, van Gerpen JA. Orthostatic Hyperkinetic Disorders: A Review Isolated syndrome in legs when standing Hz Palpation if not visible Auscultation: helicopter sign EMG confirmation Treatments: Dominant intention component, but also can be postural Usually slow (<5 Hz) but can be faster Often disabling Etiology: stroke, multiple sclerosis, trauma Clonazepam, levetiracetam DBS Treatment of limited effect: isoniazid, carbamazepine, propranolol, gluthetimide Primary orthostatic plus: in combination of other neurological conditions Dementia, parkinsonism, ataxia Hassan A, van Gerpen JA. Tremor Hyperkin Mov 2016 Figure 1. Classical Orthostatic Tremor. (A) A 14 Hz, highly synchronized is present in the patient s legs as the patient stands. (B) As the patient leans onto a chair, the transfers to the left triceps. It remains in the legs, but its amplitude is reduced. ADM, Abductor Digiti Minimi; MG, Medial Gastrocnemius; Quad, Quadriceps; TA, Tibial Anterior; Tri, Triceps; WE, Wrist Extensors. clinical, electrophysiological, neuroimaging, pathophysiological, and treatment features of these disorders. Both orthostatic hyperkinesias can be definitively diagnosed and distinguished from each other by surface electromyography (SEMG).8 Other methods, such as leg muscle palpation and auscultation, are neither sufficiently sensitive nor specific to diagnose OT and OM reliably.11,12 OT is designated as primary OT when it occurs in isolation (with or without an associated postural arm ) and as OT-plus when associated with parkinsonism or other neurological disorders.13 However, OT appears to evolve independently, whether isolated or associated with additional neurological disorders.14 There is controversy whether OM occurs in isolation.8,15 Unlike other forms of and myoclonus, which may be present in a person s lower limbs while a patient is standing, the orthostatic hyperkinesias are isometric phenomena; i.e., they abate or significantly attenuate when a standing individual takes weight off their legs, such as by leaning onto an object.16,17 In this paper, the first joint review of these disorders, we draw from the literature and our collective experience, to discuss the demographic, Tremor and Other Hyperkinetic Movements Methods A systematic literature search of PubMed was performed in July 2016 using the search terms orthostatic (1,158 articles), orthostatic myoclonus (169 articles), shaky legs (16 articles), and shaky leg syndrome (72 articles). The MeSH entry term of primary orthostatic is a unique identifier for both orthostatic and shaky legs since 2010 and yielded 1,053 articles. There is no unique identifier in MeSH for orthostatic myoclonus. A manual review of all 1,485 abstracts was then performed to exclude duplicated articles, irrelevant articles (e.g., orthostatic hypotension) and those with non-english abstracts. In total, 246 reviews, case reports, case series, and clinical studies (from 1970 to 2016) were evaluated for this review. 2 The Center for Digital Research and Scholarship Columbia University Libraries/Information Services 4

5 HOLMES TREMOR MEDICATION INDUCED TREMOR Or: rubral, midbrain Syndrome of rest, postural and intension Slow: <5 Hz May worsen in certain position Other neurological signs Antiarrhythmic Antidepressant ß-adrenergic agents H2 antagonist Anticonvulsants Neuroleptics Antipsychotics ß-adrenergic inhibitors Antiobstructive agent Triazole antifungal agent Medication Medication induced Tremor character PSYCHOGENIC TREMOR Amiodarone Tricyclic, serotonin re-uptake inhibitor, monoamineoxidase inhibitor Terbutaline, metaproterenol, isoetharine, epinephrine, adrenaline Cimetidine Ciclosporine A Lamotrigine Valproate sodium Lithium Low- and high potent (i.e. Haloperidol, Clozapine) Pindolol Theophylline Clinically similar to essential, 6 10Hz action Generalized action, 6 11Hz Rest and action, low amplitude and high frequency Action 8 12Hz Generalized action, rarely cerebellar ; treatment with propranolol Postural and action Rest and postural Irregular, not rhythmic in arms/legs; treatment with primidone/ß-blocker Rest and postural 4 7Hz; tardive as postural 3 5Hz; asterixes Low amplitude, high frequency High frequency, low amplitude postural Any combination of rest, postural or kinetic Sudden onset and remissions Variability Antagonistic muscle coactivation Distractibility with mental or motor tasks Other signs of psychogenic illness Somatisation in history Other non-organic signs Itraconazole Heterogeneous, from 4 6Hz to rest Zeyner KE, Deuschl G. Curr Opin Neurol 2013 OTHER TREMOR SYNDROMES Isolated focal s Head Voice Tongue Face Jaw Palatal Task specific s Writing Musicians Conclusions Tremor is the most common movement disorder Multiple etiologies Multiple clinical syndromes Challenging diagnosis Challenging treatment 5