#68: Tremors: One degree of Kevin Bacon?

November 20, 2017 | By Matthew Watto, MD

Steady your hand and annihilate tremors with tips from Neurologist, and Movement Disorder specialist, Andres Deik, MD, Assistant Professor of Clinical Neurology at Kashlak Memorial Hospital (we can’t tell you where he really works: ) We teach you to differentiate benign causes of tremor from Parkinson’s disease with simple history and physical exam skills, plus nonpharmacologic and pharmacologic therapies for tremor.

Special thanks to Beth Garbitelli and Chris Thrash who wrote and produced this episode and the show notes!

Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Case from Kashlak Memorial:
70 year old with history of bipolar disease presents with a postural tremor that interferes with eating and dressing.  He takes Lithium for his bipolar disorder, managed by his psychiatrist.  He presents with a very high amplitude tremor that is quite disabling.  His psychiatrist has reduced his lithium to help with his tremor, which helped, but it is still interfering with his quality of life.

Top Pearls on Tremor

1. Parkinsonian tremor = at rest.  Essential tremor (ET) = with action (intention > postural). Drug induced tremor = enhanced physiologic tremor (postural > intention).
2. Medications and substances commonly cause tremor e.g. SSRIs, valproic acid, bupropion, antipsychotics, lithium, stimulants, β-2 agonists; withdrawal from alcohol, benzodiazepines, opiates
3. Distract patient to unmask a resting tremor.
4. Consider observing patient’s handwriting or spiral drawing.
5. Parkinsonism is misdiagnosed 10% of time by specialists and ~20% by non specialists6
6. Always check a TSH (thyroid stimulating hormone).
7. There are many weighted devices (e.g. utensils) available for patients with tremor.
8. Occupational therapy can be very helpful with these.
9. Pharmacologic management of ET is primarily beta blockers and primidone. Topiramate is 3rd line.

Show Notes

1. Tremor – rhythmic oscillation of a BODY PART (not just the hands).
2. Important to classify as “at rest” or with action.
3. Action tremor:
   • Intention tremor  – increased amplitude when reaching for an object
   • Postural tremor – tremor brought on when lifting arms against gravity.
   • Isometric tremor – when holding an object. (“Gym tremor”)
4. Postural tremor vs. “re-emerging rest tremor”
   • When lifting arms overhead, hands should shake immediately in postural tremor
   • If tremor emerges after a few seconds it’s a re-emerging rest tremor
5. Important questions when taking a history:
   • When did it start? Time frame is important.
   • What activities exacerbate tremor?
     • Handwriting
     • Buttoning shirts
     • Brushing teeth
     • Drinking a cup of coffee
     • Dystonic tremor often highly task specific e.g. violin playing
   • How bothersome is this tremor? Rest tremors tend to be better tolerated.
   • What medications are you taking?
     • Inhalers – beta agonists
     • Steroids
     • Antipsychotics
     • SSRIs, particularly sertraline/fluoxetine
     • Bupropion (especially over 300 mg)
     • Lithium
     • Withdrawal from alcohol, benzodiazepines, or opiates
6. Physical exam techniques:
   • Full neurologic exam helps exclude more ominous reasons for the tremor
   • Have patient sit with arms on arm rests and distract patient (months of year, serial 7s, etc.) to unmask a rest tremor
   • Have patients raise hands to see a postural tremor (e.g. chicken wings with fingers extended, but not quite touching)Consider holding a laser pointer or place paper on hands to observe more subtle tremors
   • Finger-to-nose to reveals intention tremor
   • Assess tone and passive range of motion in elbows, wrist, knees for cogwheel rigidity.
   • Assess rapid alternating movements or have patient repeatedly tap index finger and thumb together. Progressively smaller movements indicate bradykinesia, a key feature of parkinsonism.
7. Bradykinesia: Slowness of movement and decline in amplitude or speed often with halts, hesitations (source UpToDate). Key feature of Parkinsons disease (PD)
8. Distinguishing typical Parkinsonian tremor from essential tremor (ET)
   • ET– usually only with action (BUT eventually seen at rest if present >5 years. Action component still remains > rest component)
   • Parkinsonian tremor – improves or disappear with action
   • ET tends to be fast (7-10 Hz) and Parkinsonian tremor tends to be a slow tremor (3-7 Hz)
   • Parkinsonian tremor is easily controlled with volition, thus it worsens with distraction
   • ET tends to be alcohol responsive
   • ET has an autosomal dominant inheritance pattern. PD has familial inheritance, but not as strong.
   • Micrographia (small handwriting) seen in Parkinsonism while macrographia is observed in ET.
   • Free hand spiral is very small in Parkinsonism and very large in ET.
9. Parkinson’s disease (PD) mimics include progressive supranuclear palsy and multisystem atrophy since initial presentation is similar to idiopathic PD.
10. Tremor workup
    • TSH
    • No reliable biomarkers available
    • PET scans used in research studies (however, doesn’t often change management)
    • DAT scan – can distinguish between PD and ET (looks at dopaminergic system), but NOT between causes of parkinsonism.
11. Essential tremor treatment
    • Non-pharmacologic
      • Special keyboards or utensils (often weighted)
      • Liftware device (spoon/fork that vibrates in opposite direction of tremor)
      • Weighted bracelets
      • Occupational therapy
    • Pharmacologic
      • Beta blockers: Start low and go slow e.g. Propranolol 10 mg once daily and titrate dose as needed. Switch to long acting propranolol once effective dose achieved. Other options include Nadolol, and Atenolol. Metoprolol not helpful.
      • Primidone (a barbiturate): Start 50 mg nightly and increase in 50 mg increments for effect. Pros: Helps with sleep, Long acting. Cons: Many drug interactions e.g. Warfarin
      • Topiramate: Third line. Doses 100-200 mg daily may be effective. Cognitive side effects limit use in many patients.
      • Long acting benzodiazepines: Can be effective since all tremors worsens with anxiety. Concerns for abuse/dependence limit use.

Conclusion: Case from Kashlak Memorial:
70 year old with history of bipolar disease on lithium. Lithium dose was decreased, but tremor still limited his function. Stopping lithium was not an option. Low dose propranolol restored his normal functional capacity.

Disclosures: Dr Deik reports no relevant financial disclosures.

Time Stamps

• 00:00 Intro and disclaimer
• 01:08 Listener feedback – Paul is not fired.
• 02:09 Picks of the week.
• 05:35 Dr. Deik intro
• 07:19 Icebreaker questions
• 12:20 Wikipedia definition
• 13:02 Classifying tremor
• 14:33 Postural tremor vs. reemerging rest tremor
• 15:48 Important history questions
• 17:58 Medications that can induce tremor
• 21:39 Physical exam techniques
• 27:30 Exam characteristics between typical PD tremor and ET
• 28:36 History components to distinguish between PD and ET
• 34:10 Misdiagnosis of Parkinson’s
• 36:54 Imaging workup
• 39:03 Case from Dr Deik
• 41:33 Nonpharmacologic management
• 44:18 Pharmacologic management
• 49:06 Dosing propranolol
• 51:07 Distinguishing between physiologic tremor and pathologic tremor’
• 54:06 Website recommendations
• 55:50 Handwriting
• 59:14 Take home points
• 61:34 Outro

Links from the show:

1. Moby Dick by Herman Melville (book)
2. Stranger Things (TV show) on Netflix
3. Sapiens (book) by Yuval Noah Harari
4. Star Trek: Voyager (TV show)
5. Cosmos: A Spacetime Odyssey (Documentary series) on Netflix
6. Liftware demo (YouTube) vibrating utensils for tremor.
7. Weighted utensils for tremor and specialized keyboard for tremor
8. International Essential Tremor Foundation website for tremor resources
9. Tremors (film) with Kevin Bacon
10. Love and Other Drugs (film) with Anne Hathaway

Recommended reading:

1. Elias WJ. Tremor. JAMA. 2014 Mar 5;311(9):948-54. doi: 10.1001/jama.2014.1397. (Subscription required)
2. Pipis M. Tremor. BMJ. 2013 Dec 12;347:f7200. doi: 10.1136/bmj.f7200. (Subscription required)
3. Tremor Fact Sheet from NIH-National Institute of Neurologic Disorders and Stroke
4. Schrag A. How valid is the clinical diagnosis of Parkinson’s disease in the community? J Neurol Neurosurg Psychiatry. 2002 Nov; 73(5): 529–534. doi:  10.1136/jnnp.73.5.529  (FREE)
5. Letter by KA Jellinger How valid is the clinical diagnosis of Parkinson’s disease in the community? JNNP 2003