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Dr. Okun

Post of the Week: Facts on Parkinson's Tremor

18 posts in this topic

Dear Forum members here are a few facts on Parkinson's tremor:

 

Tremor in Parkinson's disease is usually a resting tremor, that improves when performing tasks.

 

Most PD patients have some intentional tremor (tremor at action), but it is usually minor in severity.

 

A very small number of PD patients have co-existent essential tremor.

 

Treatment for PD tremor is usually sinemet (levodopa), a dopamine agonist, or in rare cases an anticholinergic. Anticholinergics are usually avoided because of side effects, but can be useful in difficult to treat tremor.

 

Once patients have tried maximally tolerated doses of sinemet, a dopamine agonist, and an anticholinergics---in a cocktail--if they still have bothersome tremor, many patients will try clozaril (which requires weekly blood monitoring), or deep brain stimulation as a treatment approach.

 

20-40% of patients with PD have a tremor that responds only partially to medications, and in rare cases some tremors do not respond to medications.

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Dear Forum members here are a few facts on Parkinson's tremor:

 

Tremor in Parkinson's disease is usually a resting tremor, that improves when performing tasks.

 

Most PD patients have some intentional tremor (tremor at action), but it is usually minor in severity.

 

A very small number of PD patients have co-existent essential tremor.

 

Treatment for PD tremor is usually sinemet (levodopa), a dopamine agonist, or in rare cases an anticholinergic. Anticholinergics are usually avoided because of side effects, but can be useful in difficult to treat tremor.

 

Once patients have tried maximally tolerated doses of sinemet, a dopamine agonist, and an anticholinergics---in a cocktail--if they still have bothersome tremor, many patients will try clozaril (which requires weekly blood monitoring), or deep brain stimulation as a treatment approach.

 

20-40% of patients with PD have a tremor that responds only partially to medications, and in rare cases some tremors do not respond to medications.

 

Do you mean by "PD" Parkinson's Syndrome or only primary, idiopathic or genetical variety excluding parkinsonisms?

What about the resting tremor unilaterality, in particular, disabling in right-handed patients?

What about its aggravation with emotional states of mind, with cold, exercise, fatigue, sleep and off-states... do these factors have differential dg. value?

What other drugs have been tested and found hopeful for treatment of tremorogenic type of PD?

It is annoying and socially embarrasing feature of PD but it is bradykinesis, fortunately, most responding to Sinemet, which is the most fearful symptom of PD.

gmk

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Dr. Okun, I am one of those who have both essential tremor and pd tremor. My Neurologist suggested that I wean off the primidone and add sinemet to the mirapex to control my tremors. Will this help a person like myself? Please advise. Thank you in advance.

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Do you mean by "PD" Parkinson's Syndrome or only primary, idiopathic or genetical variety excluding parkinsonisms?

 

- I am referring to PD only and not parkinsonisms like PSP, MSA or CBD.

 

What about the resting tremor unilaterality, in particular, disabling in right-handed patients?

 

- The treatment approach is usually the same whether unilateral or bilateral. DBS may be used unilateral and is particularly effective if tremor is resistant to meds only on one side of the body (you can get away with a single lead in some cases)

 

What about its aggravation with emotional states of mind, with cold, exercise, fatigue, sleep and off-states... do these factors have differential dg. value?

 

- All of these features worsen PD tremor, but also worsen many other kinds of tremors.

 

What other drugs have been tested and found hopeful for treatment of tremorogenic type of PD?

 

-Most of the others have not come to fruition in PD (propranolol, primidone, anti-seizure-meds). Some people do anecdotally find one or another that helps. Clozaril has been useful in severe tremor for many PD patients.

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It is a reasonable approach.

 

We have found the resting tremor to be more responsive than the action tremor of PD. Sometimes the action tremor component requires DBS.

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Tremors are non-intentional rhythmic movements of a body part, which are the result of alternating or irregular synchronous contractions of muscles that have an opposite effect on a joint. For example, muscles that, when contracted, result in flexion of the wrist are stimulated synchronously with muscles that result in extension of the wrist. The result is a rhythmic flexion and extension of the wrist. This phenomenon can happen in any part of the body. It is this rhythmic quality that defines and distinguishes tremors from any other abnormal movements.

 

And

In Parkinson's disease, neurons (nerve cells) of the brain area known as the substantia nigra (Latin for "black substance") are primarily affected.

 

When neurons in the substantia nigra degenerate, the brain's ability to generate body movements is disrupted and this disruption produces signs and symptoms characteristic of Parkinson's disease:

 

Tremor

Rigidity

Akinesia (lack of movement or loss of spontaneous movement)

Bradykinesia (slowness of movement)

Problems with walking and posture.

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Thank you for that very clear explanation of tremor. It prompts me to ask about what hypotheses and/or theories have been put forward to explain: 1) why about one-quarter of individuals with Parkinson's never experience tremor, and 2) why the prognosis for this no-tremor group is supposedly less favourable vis a vis disease progression and symptom severity?

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When scientists have examined the brain tissue of PD patients with and without tremor (from post-mortem brain banks) there seems to be differences in which layer of cells is lost in the brain (where the pathology is). That is thought to underpin the clinical difference.

 

Prognosis is more difficult. PD is not one disease. It is a syndrome probably with many causes. We have a lot to learn. Where the cells in the brain are affected by PD may give us a hint of the accompanying symptoms.

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When scientists have examined the brain tissue of PD patients with and without tremor (from post-mortem brain banks) there seems to be differences in which layer of cells is lost in the brain (where the pathology is). That is thought to underpin the clinical difference.

 

Prognosis is more difficult. PD is not one disease. It is a syndrome probably with many causes. We have a lot to learn. Where the cells in the brain are affected by PD may give us a hint of the accompanying symptoms.

 

 

So prognosis for no-tremor PD patients is not necessarily less favorable than PD patients that have tremor?

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I have heard that PD tremors cannot wake someone up from sleep? It is hard for me to tell but I believe I have been awakened from sleep twice from internal tremors but most occur as soon as I awake and are at their worst for a few minutes and then quiet down but still noticeable most of the day.

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Some patients actually do get re-emergence of symptoms at night. The reason underpinning this problem is likely wearing off of dopaminergic drugs. Some people will simply re-dose when they wake up with symptoms which can include tremor. Hope that helps.

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You are correct, it is not an absolute rule.

NOT AN ABSOLUTE RULE. BUT I UNDERSTAND PROBABILITY OF PROGRESSION MUCH GREATER IN NON TREMOR THAN TREMOR.TRUE?

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Probability of progression is not exactly what has been studied. The studies suggest symptoms may be more severe if you do not have a tremor. It is interesting to note however that as the genetics emerge some cases of non-tremor PD behave similarly to tremor predominant PD-- so the stereotype does not always stick.

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If you have PD these can be part of the PD and can be treatable.

 

They can also occur as part of other syndromes and diseases so if you don't have a diagnosis I would urge you to seek one.

 

A sleep study is very helpful!

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