THE MANAGEMENT of TREMOR Peter G Bain
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Vet Oracle Teleneurology: Client Factsheet
Client Factsheet Paroxysmal Dyskinesia Paroxysmal Dyskinesia: A little bit of background Paroxysmal dyskinesias (PDs) are episodic movement disorders in which abnormal movements are present only during attacks. Although increasingly being recognised, they are often poorly characterised in veterinary literature and are commonly mistaken for an epileptic seizure, both by owners and by vets. The term ‘paroxysmal’ indicates that the signs occur suddenly against a background of normality. The term ‘dyskinesia’ broadly refers to a movement of the body that is involuntary, which means that the animal has no control over the movement and remains fully aware of its surroundings. Between attacks, affected animals are totally normal and there is no loss of consciousness during the attacks, though some animals may find the episodes disconcerting and do not respond normally. The attacks can last anything from a few minutes to a couple of hours and can sometime occur multiple times in a day. What causes Paroxysmal Dyskinesia? Most neurologists consider that PD results from dysfunction an area of the brain called the basal nuclei (often call the basal ganglia) and the cerebellum which is a fundamental part of the brain that involves in coordinating movement. Nerve cells in the basal nuclei play an important role in initiating and controlling movement. It is thought that abnormal signal from the cerebellum causes abnormal activity of the basal nuclei, which results in spontaneous and uncontrolled muscle activity and, therefore, movement and posture. The underlying cause of many PDs is unknown, with the majority being described as idiopathic (meaning of unknown cause) and presumed to be related to abnormal brain signalling between different parts involved with movement or its feedback control. -
Rest Tremor Revisited: Parkinson's Disease and Other Disorders
Chen et al. Translational Neurodegeneration (2017) 6:16 DOI 10.1186/s40035-017-0086-4 REVIEW Open Access Rest tremor revisited: Parkinson’s disease and other disorders Wei Chen1,2, Franziska Hopfner2, Jos Steffen Becktepe2 and Günther Deuschl1,2* Abstract Tremor is the most common movement disorder characterized by a rhythmical, involuntary oscillatory movement of a body part. Since distinct diseases can cause similar tremor manifestations and vice-versa,itischallengingtomakean accurate diagnosis. This applies particularly for tremor at rest. This entity was only rarely studied in the past, although a multitude of clinical studies on prevalence and clinical features of tremor in Parkinson’s disease (PD), essential tremor and dystonia, have been carried out. Monosymptomatic rest tremor has been further separated from tremor-dominated PD. Rest tremor is also found in dystonic tremor, essential tremor with a rest component, Holmes tremor and a few even rarer conditions. Dopamine transporter imaging and several electrophysiological methods provide additional clues for tremor differential diagnosis. New evidence from neuroimaging and electrophysiological studies has broadened our knowledge on the pathophysiology of Parkinsonian and non-Parkinsonian tremor. Large cohort studies are warranted in future to explore the nature course and biological basis of tremor in common tremor related disorders. Keywords: Tremor, Parkinson’s disease, Essential tremor, Dystonia, Pathophysiology Background and clinical correlates of tremor in common tremor re- Tremor is defined as a rhythmical, involuntary oscillatory lated disorders. Some practical clinical cues and ancillary movement of a body part [1]. Making an accurate diagnosis tests for clinical distinction are found [3]. Besides, accu- of tremor disorders is challenging, since similar clinical mulating structural and functional neuroimaging, as well entities may be caused by different diseases. -
Characteristics of Tremor Induced by Lesions of the Cerebellum
The Cerebellum (2019) 18:705–720 https://doi.org/10.1007/s12311-019-01027-3 ORIGINAL PAPER Characteristics of Tremor Induced by Lesions of the Cerebellum Andrea Kovács1,2 & Máté Kiss3 & Nándor Pintér4 & Imre Szirmai5 & Anita Kamondi1,5 Published online: 8 April 2019 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract It is a clinical experience that acute lesions of the cerebellum induce pathological tremor, which tends to improve. However, quantitative characteristics, imaging correlates, and recovery of cerebellar tremor have not been systematically investigated. We studied the prevalence, quantitative parameters measured with biaxial accelerometry, and recovery of pathological tremor in 68 patients with lesions affecting the cerebellum. We also investigated the correlation between the occurrence and characteristics of tremor and lesion localization using 3D T1-weighted MRI images which were normalized and segmented according to a spatially unbiased atlas template for the cerebellum. Visual assessment detected pathological tremor in 19% while accelerometry in 47% of the patients. Tremor was present both in postural and intentional positions, but never at rest. Two types of pathological tremor were distinguished: (1) low-frequency tremor in 36.76% of patients (center frequency 2.66 ± 1.17 Hz) and (2) normal frequency– high-intensity tremor in 10.29% (center frequency 8.79 ± 1.43 Hz). The size of the lesion did not correlate with the presence or severity of tremor. Involvement of the anterior lobe and lobule VI was related to high tremor intensity. In all followed up patients with acute cerebellar ischemia, the tremor completely recovered within 8 weeks. Our results indicate that cerebellar lesions might induce pathological postural and intentional tremor of 2–3 Hz frequency. -
Traumatic Brain Injury(Tbi)
TRAUMATIC BRAIN INJURY(TBI) B.K NANDA, LECTURER(PHYSIOTHERAPY) S. K. HALDAR, SR. OCCUPATIONAL THERAPIST CUM JR. LECTURER What is Traumatic Brain injury? Traumatic brain injury is defined as damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration impact, blast waves, or penetration by a projectile, leading to temporary or permanent impairment of brain function. Traumatic brain injury (TBI) has a dramatic impact on the health of the nation: it accounts for 15–20% of deaths in people aged 5–35 yr old, and is responsible for 1% of all adult deaths. TBI is a major cause of death and disability worldwide, especially in children and young adults. Males sustain traumatic brain injuries more frequently than do females. Approximately 1.4 million people in the UK suffer a head injury every year, resulting in nearly 150 000 hospital admissions per year. Of these, approximately 3500 patients require admission to ICU. The overall mortality in severe TBI, defined as a post-resuscitation Glasgow Coma Score (GCS) ≤8, is 23%. In addition to the high mortality, approximately 60% of survivors have significant ongoing deficits including cognitive competency, major activity, and leisure and recreation. This has a severe financial, emotional, and social impact on survivors left with lifelong disability and on their families. It is well established that the major determinant of outcome from TBI is the severity of the primary injury, which is irreversible. However, secondary injury, primarily cerebral ischaemia, occurring in the post-injury phase, may be due to intracranial hypertension, systemic hypotension, hypoxia, hyperpyrexia, hypocapnia and hypoglycaemia, all of which have been shown to independently worsen survival after TBI. -
Tremor in X-Linked Recessive Spinal and Bulbar Muscular Atrophy (Kennedy’S Disease)
CLINICS 2011;66(6):955-957 DOI:10.1590/S1807-59322011000600006 CLINICAL SCIENCE Tremor in X-linked recessive spinal and bulbar muscular atrophy (Kennedy’s disease) Francisco A. Dias,I Renato P. Munhoz,I Salmo Raskin,II Lineu Ce´sar Werneck,I He´lio A. G. TeiveI I Movement Disorders Unit, Neurology Service, Internal Medicine Department, Hospital de Clı´nicas, Federal University of Parana´ , Curitiba, PR, Brazil. II Genetika Laboratory, Curitiba, PR, Brazil. OBJECTIVE: To study tremor in patients with X-linked recessive spinobulbar muscular atrophy or Kennedy’s disease. METHODS: Ten patients (from 7 families) with a genetic diagnosis of Kennedy’s disease were screened for the presence of tremor using a standardized clinical protocol and followed up at a neurology outpatient clinic. All index patients were genotyped and showed an expanded allele in the androgen receptor gene. RESULTS: Mean patient age was 37.6 years and mean number of CAG repeats 47 (44-53). Tremor was present in 8 (80%) patients and was predominantly postural hand tremor. Alcohol responsiveness was detected in 7 (88%) patients with tremor, who all responded well to treatment with a b-blocker (propranolol). CONCLUSION: Tremor is a common feature in patients with Kennedy’s disease and has characteristics similar to those of essential tremor. KEYWORDS: Kennedy’s disease; X-linked recessive bulbospinal neuronopathy; Spinal and bulbar muscular atrophy; Motor neuron disease; Tremor. Dias FA, Munhoz RP, Raskin S, Werneck LC, Teive HAG. Tremor in X-linked recessive spinal and bulbar muscular atrophy (Kennedy’s disease). Clinics. 2011;66(6):955-957. Received for publication on December 24, 2010; First review completed on January 18, 2011; Accepted for publication on February 25, 2011 E-mail: [email protected] Tel.: 55 41 3019-5060 INTRODUCTION compatible with a long life. -
Part Ii – Neurological Disorders
Part ii – Neurological Disorders CHAPTER 14 MOVEMENT DISORDERS AND MOTOR NEURONE DISEASE Dr William P. Howlett 2012 Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania BRIC 2012 University of Bergen PO Box 7800 NO-5020 Bergen Norway NEUROLOGY IN AFRICA William Howlett Illustrations: Ellinor Moldeklev Hoff, Department of Photos and Drawings, UiB Cover: Tor Vegard Tobiassen Layout: Christian Bakke, Division of Communication, University of Bergen E JØM RKE IL T M 2 Printed by Bodoni, Bergen, Norway 4 9 1 9 6 Trykksak Copyright © 2012 William Howlett NEUROLOGY IN AFRICA is freely available to download at Bergen Open Research Archive (https://bora.uib.no) www.uib.no/cih/en/resources/neurology-in-africa ISBN 978-82-7453-085-0 Notice/Disclaimer This publication is intended to give accurate information with regard to the subject matter covered. However medical knowledge is constantly changing and information may alter. It is the responsibility of the practitioner to determine the best treatment for the patient and readers are therefore obliged to check and verify information contained within the book. This recommendation is most important with regard to drugs used, their dose, route and duration of administration, indications and contraindications and side effects. The author and the publisher waive any and all liability for damages, injury or death to persons or property incurred, directly or indirectly by this publication. CONTENTS MOVEMENT DISORDERS AND MOTOR NEURONE DISEASE 329 PARKINSON’S DISEASE (PD) � � � � � � � � � � � -
Tremor, Abnormal Movement and Imbalance Differential
Types of involuntary movements Tremor Dystonia Chorea Myoclonus Tics Tremor Rhythmic shaking of muscles that produces an oscillating movement Parkinsonian tremor Rest tremor > posture > kinetic Re-emergent tremor with posture Usually asymmetric Pronation-supination tremor Distal joints involved primarily Often posturing of the limb Parkinsonian tremor Other parkinsonian features Bradykinesia Rigidity Postural instability Many, many other motor and non- motor features Bradykinesia Rigidity Essential tremor Kinetic > postural > rest Rest in 20%, late feature, only in arms Intentional 50% Bringing spoon to mouth is challenging!! Mildly asymmetric Gait ataxia – typically mild Starts in the arms but can progress to neck, voice and jaw over time Jaw tremor occurs with action, not rest Neck tremor should resolve when patient is lying flat Essential tremor Many other tremor types Physiologic tremor Like ET but faster rate and lower amplitude Drug-induced tremor – Lithium, depakote, stimulants, prednisone, beta agonists, amiodarone Anti-emetics (phenergan, prochlorperazine), anti-psychotics (except clozapine and Nuplazid) Many other tremor types Primary writing tremor only occurs with writing Orthostatic tremor leg tremor with standing, improves with walking and sitting, causes imbalance Many other tremor types Cerebellar tremor slowed action/intention tremor Holmes tremor mid-brain lesion, unilateral Dystonia Dystonia Muscle contractions that cause sustained or intermittent torsion of a body part in a repetitive -
The Clinical Approach to Movement Disorders Wilson F
REVIEWS The clinical approach to movement disorders Wilson F. Abdo, Bart P. C. van de Warrenburg, David J. Burn, Niall P. Quinn and Bastiaan R. Bloem Abstract | Movement disorders are commonly encountered in the clinic. In this Review, aimed at trainees and general neurologists, we provide a practical step-by-step approach to help clinicians in their ‘pattern recognition’ of movement disorders, as part of a process that ultimately leads to the diagnosis. The key to success is establishing the phenomenology of the clinical syndrome, which is determined from the specific combination of the dominant movement disorder, other abnormal movements in patients presenting with a mixed movement disorder, and a set of associated neurological and non-neurological abnormalities. Definition of the clinical syndrome in this manner should, in turn, result in a differential diagnosis. Sometimes, simple pattern recognition will suffice and lead directly to the diagnosis, but often ancillary investigations, guided by the dominant movement disorder, are required. We illustrate this diagnostic process for the most common types of movement disorder, namely, akinetic –rigid syndromes and the various types of hyperkinetic disorders (myoclonus, chorea, tics, dystonia and tremor). Abdo, W. F. et al. Nat. Rev. Neurol. 6, 29–37 (2010); doi:10.1038/nrneurol.2009.196 1 Continuing Medical Education online 85 years. The prevalence of essential tremor—the most common form of tremor—is 4% in people aged over This activity has been planned and implemented in accordance 40 years, increasing to 14% in people over 65 years of with the Essential Areas and policies of the Accreditation Council age.2,3 The prevalence of tics in school-age children and for Continuing Medical Education through the joint sponsorship of 4 MedscapeCME and Nature Publishing Group. -
Atypical Parkinsonism from Parkinson Disease Is Important
Introduction The diagnosis of Parkinson disease in the early stages can be challenging. Symptoms overlap with other movement disorders such as essential tremor and atypical parkinsonian disorders. Differentiating atypical parkinsonism from Parkinson disease is important. Helps predict how well patients will respond to therapy. How the disease will progress. what the prognosis is compared to idiopathic Parkinson disease. Parkinsonism Diagnostic Criteria Tremor at rest Bradykinesia Rigidity Loss of postural reflexes Flexed posture Freezing (motor blocks) Definite: At least two of these features must be present, one of them being 1 or 2. Probable: Feature 1 or 2 alone is present. Possible: At least two of features 3 to 6 must be present Queen Square Brain Bank Criteria Presence of Bradykinesia and of either: 1- Resting tremor 4-6Hz 2- Extrapyramidal rigidity 3- Postural instability not caused by visual, cerebellar, vestibular, or proprioceptive dysfunction. Features of typical PD At least 3 Unilateral onset Excellent response to levodopa ( 70%-100%) Development of dyskinesia Levodopa response for 5 yrs or more Clinical course of 10 yrs or more Progressive disorder Rest tremor present Persistent asymmetry affecting side of onset most Exclusion Pyramidal signs Stepwise deterioration Repeated head injury History of encephalitis or oculogyric crisis Neuroleptic treatment at onset Strictly unilateral features after 3 yrs Supranuclear gaze palsy Cerebellar signs Early severe autonomic dysfunction Early severe cognitive dysfunction Early freezing & postural falls Negative response to levodopa Imaging evidence of communicating hydrocephalus Parkinson’s Disease Diagnostic Criteria RED FLAGS Early autonomic dysregulation. Early postural instability. Symmetric onset. Brainstem symptoms & signs. Pyramidal signs. Early cognitive decline. -
EXTRAPYRAMIDAL MOVEMENT DISORDERS (GENERAL) Mov1 (1)
EXTRAPYRAMIDAL MOVEMENT DISORDERS (GENERAL) Mov1 (1) Extrapyramidal Movement Disorders (GENERAL) Last updated: July 12, 2019 PATHOPHYSIOLOGY ..................................................................................................................................... 1 CLINICAL FEATURES .................................................................................................................................... 2 DIAGNOSIS ................................................................................................................................................... 3 TREATMENT ................................................................................................................................................. 4 MORPHOLOGIC CORRELATIONS ................................................................................................................... 4 TREMOR ......................................................................................................................................................... 5 ESSENTIAL TREMOR ..................................................................................................................................... 6 ORTHOSTATIC TREMOR ................................................................................................................................ 7 PRIMARY WRITER'S TREMOR ........................................................................................................................ 7 PHYSIOLOGIC TREMOR ................................................................................................................................ -
Hypoxic-Ischemic Brain Injury: Movement Disorders and Clinical Implications
Hypoxic-Ischemic Brain Injury: Movement Disorders and Clinical Implications By: Carolyn Tassini, PT, DPT, CBIS, NCS Supervisor, Rehabilitation Services March 27, 2019 Disclosures • Carolyn Tassini, PT, DPT, CBIS, NCS – Nothing to disclose • Additional credit for this presentation goes to Kimberly Miczak, PT, NCS Following this session: • Participants will appreciate mechanisms underlying motor, cognitive and visual impairments following hypoxic-ischemic brain injury. • Participants will utilize current evidence from movement disorder literature in developing treatment plan for individuals following hypoxic- ischemic brain injury. • Participants will recognize the importance of transdisciplinary team in maximizing treatment and outcomes for individuals recovering from hypoxic- ischemic brain injury. Introduction • What is a hypoxic or anoxic brain injury? ◦ Hypoxic-Ischemic brain injury • Common Causes • Cardiorespiratory arrest • Respiratory failure • Drug overdose • Carbon monoxide poisoning • Drowning/strangulation • Primary vs secondary injury Image from: neurolove.tumblr.com Background Info • No national data available on the prevalence of HI- BI • Peak frequency in males aged 60-years (r/t cardiac) and females in their late 20’s r/t suicide and parasuicide/self-harm attempts (Fitzgerald 2010) • Can range from mild to severe • HI-BI vs TBI rehab course: • slower progress • poorer outcome • more likely to DC to residential facility vs home (Fitzgerald 2010) Mechanism of Injury • Cardiorespiratory- hypoxia with ischemia ◦ Reperfusion -
Pathophysiology and Treatment of Alien Hand Syndrome
Freely available online Reviews Pathophysiology and Treatment of Alien Hand Syndrome 1* 2 3 Harini Sarva , Andres Deik & William Lawrence Severt 1 Department of Neurology, Maimonides Medical Center, New York, NY, USA, 2 Parkinson Disease and Movement Disorders Center, Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA, 3 Department of Neurology, Maimonides Medical Center, Brooklyn, NY, USA Abstract Background: Alien hand syndrome (AHS) is a disorder of involuntary, yet purposeful, hand movements that may be accompanied by agnosia, aphasia, weakness, or sensory loss. We herein review the most reported cases, current understanding of the pathophysiology, and treatments. Methods: We performed a PubMed search in July of 2014 using the phrases ‘‘alien hand syndrome,’’ ‘‘alien hand syndrome pathophysiology,’’ ‘‘alien hand syndrome treatment,’’ and ‘‘anarchic hand syndrome.’’ The search yielded 141 papers (reviews, case reports, case series, and clinical studies), of which we reviewed 109. Non-English reports without English abstracts were excluded. Results: Accumulating evidence indicates that there are three AHS variants: frontal, callosal, and posterior. Patients may demonstrate symptoms of multiple types; there is a lack of correlation between phenomenology and neuroimaging findings. Most pathologic and functional imaging studies suggest network disruption causing loss of inhibition as the likely cause. Successful interventions include botulinum toxin injections, clonazepam, visuospatial coaching techniques, distracting the affected hand, and cognitive behavioral therapy. Discussion: The available literature suggests that overlap between AHS subtypes is common. The evidence for effective treatments remains anecdotal, and, given the rarity of AHS, the possibility of performing randomized, placebo-controlled trials seems unlikely. As with many other interventions for movement disorders, identifying the specific functional impairments caused by AHS may provide the best guidance towards individualized supportive care.