21 Questions
What is the most common cause of tremor?
Enhanced Physiologic Tremor
What is the primary treatment for Essential Tremor?
Propranolol & Primidone
What is the characteristic tremor of Parkinson Disease?
Resting tremor
What is the primary neurotransmitter involved in Parkinson Disease?
Dopamine
What is the primary treatment for Tic Disorders?
Habit Reversal Training
What is the pathophysiologic mechanism underlying Restless Leg Syndrome?
Disordered dopamine function
What is a characteristic feature of Essential Tremor?
Action tremor
Which of the following is a characteristic of Enhanced Physiologic Tremor?
Resolves once the cause is removed or absent
What is the typical age of onset for Parkinson Disease?
Age 70
Which of the following is a cardinal feature of Parkinson Disease?
Resting tremor
What is the primary mechanism of action for Dopamine Agonists in the treatment of Parkinson Disease?
Mimicking dopamine action in the brain
What is the typical duration of Tic Disorders?
At least 3 months
Which of the following is a characteristic of Simple Tics?
Involuntary, sudden, and brief movements
What is the primary treatment for Restless Leg Syndrome?
Dopamine Agonists
Which of the following is a common feature of Essential Tremor?
Action tremor
What is the primary reason for the worsening of Essential Tremor with stress, anxiety, and hyperthyroidism?
Increased norepinephrine release
Which of the following is a potential side effect of dopamine agonists in the treatment of Parkinson Disease?
Freezing or off effects
A patient with a 5-year history of intermittent, sudden, and brief movements of the face is most likely to have which of the following?
Tic Disorder
Which of the following medications is used to treat Tic Disorders when function is impaired?
Fluphenazine
Which of the following is a characteristic feature of Restless Leg Syndrome?
Worsening at night
A patient with a 15-year history of bilateral action tremor, with a recent onset of cogwheel phenomenon, is most likely to have which of the following?
Parkinson Disease
Study Notes
Movement Disorders
Enhanced Physiologic Tremor
- Caused by stress, anxiety, excitement, muscle fatigue, fever, hypoglycemia, alcohol or opioid withdrawal, and certain medications
- Short duration, resolves once cause is removed
- Most common cause of tremor
- Risk increases with advanced age
- Affects males and females equally
Essential Tremor
Clinical Features
- Longstanding, progressive
- Kinetic action tremor, bilateral but can be asymmetric
- Worsens with stress, anxiety, hyperthyroidism, caffeine, and certain medications
- Improves with alcohol
- At least 3 years' duration
Diagnostic Criteria
- Bilateral action tremor of hands and forearms, but not resting tremor
- Absence of other neurologic signs, except for cogwheel phenomenon
- May have tremor in other locations (head, voice, lower limbs)
Management
- Pharmacologic: 1st line is propranolol and primidone
Parkinson Disease
Epidemiology
- Mean onset: age 70
- Males > Females
Pathophysiology
- Neurodegenerative disorder
- Genetic and environmental factors
- Pathologic features: Lewy body formation, degeneration of dopaminergic neurons, particularly in substantia nigra
- Dopamine depletion
Clinical Features
- Motor: cardinal features include resting tremor (uni>bilateral), bradykinesia, rigidity (cogwheel>lead pipe)
- Stooped posture, masked facial expression, rigidity, shuffling, short-stepped gait
Diagnosis
- Cardinal features: bradykinesia + resting tremor or rigidity
- MRI brain if atypical presentation
Pharmacologic Management
- Levodopa/carbidopa
- Side effects: motor fluctuations, "freezing" or "off effects"
- Dopamine agonists: early (family history of tics, obsessive compulsive disorder)
Tourette Syndrome
Pathophysiology
- Genetic predisposition
- CNS dis-inhibition of motor and limbic system
Clinical Features
- Tics: involuntary, sudden, brief, intermittent movements (motor) or utterances (vocal or phonic)
- Increase: stress
- Decrease: distraction, focus
- Simple or complex
- Transient remissions
- Do not occur during sleep
Prognosis
- 33-50% of cases resolve by age 18
- Tic types: simple (twitching, blinking, sniffing, grunting), complex (touching, slapping, clapping)
Evaluation
- Clinical diagnosis
- Onset before age 18
- At least 3 months duration
- Treatment: habit reversal training, Rx when function impaired, dopamine agonists (fluphenazine, pimozide), antagonists (tetrabenazine)
Restless Leg Syndrome
General Information
- More common in Caucasians
- Pathophysiology: likely involves disordered dopamine function, associated with iron metabolism abnormality
- Primary RLS: genetic, several loci with AD pattern of inheritance, variable penetrance
- Mean age of onset: 27 years old
- Secondary RLS: associated with pregnancy, anemia, ferritin deficiency, uremia, peripheral neuropathy, spinal cord disease
Clinical Features
- Urge to move legs, usually caused or accompanied by unpleasant sensation in the leg
- Symptoms begin or worsen with rest
- Diagnosis: sleep laboratory assessment, positive response to dopaminergic therapy
Evaluation
- History and physical exam
- Rule out secondary RLS: check ferritin level
Movement Disorders
Enhanced Physiologic Tremor
- Caused by stress, anxiety, excitement, muscle fatigue, fever, hypoglycemia, alcohol or opioid withdrawal, and certain medications
- Short duration, resolves once cause is removed
- Most common cause of tremor
- Risk increases with advanced age
- Affects males and females equally
Essential Tremor
Clinical Features
- Longstanding, progressive
- Kinetic action tremor, bilateral but can be asymmetric
- Worsens with stress, anxiety, hyperthyroidism, caffeine, and certain medications
- Improves with alcohol
- At least 3 years' duration
Diagnostic Criteria
- Bilateral action tremor of hands and forearms, but not resting tremor
- Absence of other neurologic signs, except for cogwheel phenomenon
- May have tremor in other locations (head, voice, lower limbs)
Management
- Pharmacologic: 1st line is propranolol and primidone
Parkinson Disease
Epidemiology
- Mean onset: age 70
- Males > Females
Pathophysiology
- Neurodegenerative disorder
- Genetic and environmental factors
- Pathologic features: Lewy body formation, degeneration of dopaminergic neurons, particularly in substantia nigra
- Dopamine depletion
Clinical Features
- Motor: cardinal features include resting tremor (uni>bilateral), bradykinesia, rigidity (cogwheel>lead pipe)
- Stooped posture, masked facial expression, rigidity, shuffling, short-stepped gait
Diagnosis
- Cardinal features: bradykinesia + resting tremor or rigidity
- MRI brain if atypical presentation
Pharmacologic Management
- Levodopa/carbidopa
- Side effects: motor fluctuations, "freezing" or "off effects"
- Dopamine agonists: early (family history of tics, obsessive compulsive disorder)
Tourette Syndrome
Pathophysiology
- Genetic predisposition
- CNS dis-inhibition of motor and limbic system
Clinical Features
- Tics: involuntary, sudden, brief, intermittent movements (motor) or utterances (vocal or phonic)
- Increase: stress
- Decrease: distraction, focus
- Simple or complex
- Transient remissions
- Do not occur during sleep
Prognosis
- 33-50% of cases resolve by age 18
- Tic types: simple (twitching, blinking, sniffing, grunting), complex (touching, slapping, clapping)
Evaluation
- Clinical diagnosis
- Onset before age 18
- At least 3 months duration
- Treatment: habit reversal training, Rx when function impaired, dopamine agonists (fluphenazine, pimozide), antagonists (tetrabenazine)
Restless Leg Syndrome
General Information
- More common in Caucasians
- Pathophysiology: likely involves disordered dopamine function, associated with iron metabolism abnormality
- Primary RLS: genetic, several loci with AD pattern of inheritance, variable penetrance
- Mean age of onset: 27 years old
- Secondary RLS: associated with pregnancy, anemia, ferritin deficiency, uremia, peripheral neuropathy, spinal cord disease
Clinical Features
- Urge to move legs, usually caused or accompanied by unpleasant sensation in the leg
- Symptoms begin or worsen with rest
- Diagnosis: sleep laboratory assessment, positive response to dopaminergic therapy
Evaluation
- History and physical exam
- Rule out secondary RLS: check ferritin level
Movement Disorders
Enhanced Physiologic Tremor
- Caused by stress, anxiety, excitement, muscle fatigue, fever, hypoglycemia, alcohol or opioid withdrawal, and certain medications
- Short duration, resolves once cause is removed
- Most common cause of tremor
- Risk increases with advanced age
- Affects males and females equally
Essential Tremor
Clinical Features
- Longstanding, progressive
- Kinetic action tremor, bilateral but can be asymmetric
- Worsens with stress, anxiety, hyperthyroidism, caffeine, and certain medications
- Improves with alcohol
- At least 3 years' duration
Diagnostic Criteria
- Bilateral action tremor of hands and forearms, but not resting tremor
- Absence of other neurologic signs, except for cogwheel phenomenon
- May have tremor in other locations (head, voice, lower limbs)
Management
- Pharmacologic: 1st line is propranolol and primidone
Parkinson Disease
Epidemiology
- Mean onset: age 70
- Males > Females
Pathophysiology
- Neurodegenerative disorder
- Genetic and environmental factors
- Pathologic features: Lewy body formation, degeneration of dopaminergic neurons, particularly in substantia nigra
- Dopamine depletion
Clinical Features
- Motor: cardinal features include resting tremor (uni>bilateral), bradykinesia, rigidity (cogwheel>lead pipe)
- Stooped posture, masked facial expression, rigidity, shuffling, short-stepped gait
Diagnosis
- Cardinal features: bradykinesia + resting tremor or rigidity
- MRI brain if atypical presentation
Pharmacologic Management
- Levodopa/carbidopa
- Side effects: motor fluctuations, "freezing" or "off effects"
- Dopamine agonists: early (family history of tics, obsessive compulsive disorder)
Tourette Syndrome
Pathophysiology
- Genetic predisposition
- CNS dis-inhibition of motor and limbic system
Clinical Features
- Tics: involuntary, sudden, brief, intermittent movements (motor) or utterances (vocal or phonic)
- Increase: stress
- Decrease: distraction, focus
- Simple or complex
- Transient remissions
- Do not occur during sleep
Prognosis
- 33-50% of cases resolve by age 18
- Tic types: simple (twitching, blinking, sniffing, grunting), complex (touching, slapping, clapping)
Evaluation
- Clinical diagnosis
- Onset before age 18
- At least 3 months duration
- Treatment: habit reversal training, Rx when function impaired, dopamine agonists (fluphenazine, pimozide), antagonists (tetrabenazine)
Restless Leg Syndrome
General Information
- More common in Caucasians
- Pathophysiology: likely involves disordered dopamine function, associated with iron metabolism abnormality
- Primary RLS: genetic, several loci with AD pattern of inheritance, variable penetrance
- Mean age of onset: 27 years old
- Secondary RLS: associated with pregnancy, anemia, ferritin deficiency, uremia, peripheral neuropathy, spinal cord disease
Clinical Features
- Urge to move legs, usually caused or accompanied by unpleasant sensation in the leg
- Symptoms begin or worsen with rest
- Diagnosis: sleep laboratory assessment, positive response to dopaminergic therapy
Evaluation
- History and physical exam
- Rule out secondary RLS: check ferritin level
This quiz covers the causes, epidemiology, and clinical features of Enhanced Physiologic Tremor, a common movement disorder. Learn about the factors that contribute to this condition and how it differs from Essential Tremor.
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