Presented by Joanna O Leary, MD Providence St. Vincent Medical Center Movement Disorder Department

Presented by Joanna O Leary, MD Providence St. Vincent Medical Center Movement Disorder Department

Hyperkinetic movement disorders Increase in muscle movements causing involuntary motion Tremor Dystonia Myoclonus Chorea Tic

Questions to ask Where is your involuntary movement? When does the movement occur? How long have you had the movement? Was the onset abrupt? Do your arms feel uncoordinated? Do you have difficulty walking? Do you act out your dreams at night? Are you on psych or antiemetic meds?

Exam Rest Finger to nose Wing beat Spiral Handwriting Water pour Bradykinesia, rigidity and gait eval Neck range of motion Eye abnormalities

Parkinsonian tremor Rest tremor > posture > kinetic Usually asymmetric Pronation-supination tremor Distal joints involved primarily Often posturing of the limb Re-emergent tremor with posture

Parkinsonian tremor

Essential tremor Kinetic tremor Mildly asymmetric Intentional 50% Bringing spoon to mouth is challenging!! Worse in wing-beat position Kinetic > postural > rest Rest in 20%, late feature, only in arms Gait ataxia typically mild

Essential tremor Usually starts in arms Can progress to neck, voice and jaw over time Jaw tremor occurs with action, not rest Neck tremor starts yes-yes or no-no but can become multidirectional with time Neck tremor should resolve when patient is lying flat Neck tremor with minimal arm tremor is likely dystonic

Essential tremor

Dystonic tremor Dystonia - muscle contractions that cause sustained or intermittent torsion of a body part or repetitive motion Irregular, not rhythmic or oscillatory (rotational around a central plane) Often associated with posturing Head tremor is present in supine position Voice tremor has breaks, strangulation

Dystonic Tremor

Enhanced physiologic tremor Action tremor that most people have (e.g. with stress) Postural and kinetic Faster rate and lower amplitude than ET Not associated head tremor

Drug induced tremor Action tremors: Lithium, depakote, stimulants, prednisone, beta agonists, amiodarone Possible form of enhanced physiologic tremor Rest tremors: Some anti-emetics and anti-psychotics

Primary writing tremor Task specific tremor Only occur with writing Similar frequency to essential tremor Similar to writer s cramp without dystonic posturing

Orthostatic tremor 14 to 16 Hz tremor in legs Instability with standing Improves with walking or sitting Not always visible Evaluate with EMG

Cerebellar tremor Action tremor Worse with intention Slow at 3-4 Hz Overshoot Associated with other cerebellar features: E.g. dysarthria, ataxia

Holmes tremor Midbrain, pontine or thalamic lesion Usually unilateral Action > postural > rest Usually disabling Can occur months to years after onset of stroke Sometimes associated with dystonia or ataxia

Holmes tremor

Other tremors Psychogenic Abrupt onset, variable pattern, distactible, suggestible, entrainable Wilson s disease Fragile X Ataxia Peripheral neuropathy-related

Psychogenic Tremor

Peripheral neuropathy tremor

Other abnormal movements Myoclonus Brief jerk Can occur once or multiple times in a row Chorea Irregular flowing movement transitioning from one body part to another Tics Repeated movements or sounds that are repeatable, can be suppressed and are associated with an urge to produce the movement

Name the disorder - Case 1 CC: bilateral hand tremor 62 year old man Onset of tremor 2 years ago Difficulty eating, drinking and writing h/o lumbar radiculopathy, HTN Meds: GBP, HCTZ, metoprolol FHx of tremor (father)

Case 1

Name the Disorder - Case 2 CC: left hand tremor 67 yo RH man Onset of tremor x years ago, mild imbalance, mild hand slowness FHX: cardiac disease h/o DM, HTN Meds: propranolol, lovastatin, glipizide

Case 2

Name the disorder - Case 3 CC: head tremor 76 yo woman Head tremor x 10 years, no hand tremor, no improvement with primidone Meds: Sybicort inhaler h/o COPD FHx: HTN, DM

Case 3

Name the disorder - Case 4 CC: involuntary body movement 94 yo woman Onset 5 years ago. Symptoms occur in clusters for minutes to hours. Sometimes unilateral limb, sometimes entire body. Better with Valium Meds: tylenol 3, Norco, Effexor PMHx: Arthritis and breast ca

Case 4

Name the disorder - Case 5 CC: gait dysfunction 77 yo man Involuntary head movements, slowed arms and legs, shuffling gait and cognitive decline x 2 years Meds: ASA, metoprolol h/o CAD, aortic valve replacement FHx: Parkinson s mother and MGM

Case 5

Thank you to my patients for allowing me to tape them! References: Louis, E, Diagnosis and Management of Tremor. Continuum 2016;22(4):1143-1158