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Increased Tremors with Sinemet

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I have posted this question in another forum but thus far received no response so I thought I'd request your opinion.


My wife developed tremors in her right hand (predominantly her thumb) immediately after hip replacement surgery that also left her right hand numb - apparently from the I.V. drip.


Eventually the numbness disappeared and was replaced with a "tingling" sensation.


Her Internist told her she suspected nerve damage from the I.V. had caused the numbness and tingling as well as the tremor and it hopefully would heal over time. After 6 months, the tingling subsided but the tremors remained and she recommended a consult with an Neurologist.


We briefed the Neurologist on the Hip Replacement (Left Hip), the situation with the I.V., and told him of an initial and 2 repeated injuries to her right shoulder.


The Neurologist looked at her lack of arm swing on the right side (present since the first shoulder injury), the frequency and amplitude of the tremor, and the slightly abnormal gait (brought on by the hip replacement).


In spite of our explanations for the arm swing and gait he told us he suspected early stage Parkinsons.


He told us that the "Gold Standard" for determining if it was indeed PD was to put her on a regimen of slowly increasing doses of Sinemet. He said that if there was a point where the tremors were controlled - as the dosage of Sinemet was increasing - it would show that his diagnosis was correct.


She began the regimen and at low doses there was no effect, as the dosage increased, the tremor remained the same however she became more and more "anxious" and felt as if her motor nerves were firing overtime in several parts of her body.


The Neurologist told her that was a normal initial reaction to Sinemet and to keep going.


As she reached the therapeutic dosage level, her tremor got exponentially worse in amplitude. Her entire hand began shaking and she felt as if bugs were crawling on her body.


The Neurologist told us to ramp the dosage back down but said that he still felt she had PD and he prescribed Azilect.


When I challenged him on his previous claim that Sinemet was the 'Gold Standard' and would stop the tremors if she had PD, he had no answer for me. He said that the Sinemet test was the correct test and he could not explain why she reacted the opposite of expectations but some people react differently to medicine.


From what I can tell, the lack of arm swing as well as the fact she walks differently after the hip replacement are influencing his diagnosis (her leg was lengthened approximately 1" and she overcompensates due to the way she has walked for the previous 67 years.)


Other than what I've explained, she has no other Parkinson symptoms.


We both admit that we are biased towards not wanting to accept this diagnosis because we don't want her to have PD. And we also know that as laymen we're not qualified to challenge an Neurologist's diagnosis.


But something just doesn't feel right about this. (FYI, this Neurologist is not a Movement Disorder Specialist.)


We'd like your views on what happened with the Sinemet and also ask if you feel we should we get a second opinion from a MDS?


Thank you.

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A second opinion is a good idea.


The sinemet test should be done not only to look at tremor, but also at bradykinesia, rigidity and other PD features.


20-40% of PD patients will have an incomplete or alternatively no response to tremor, but often then respond in other areas.


A scale called a UPDRS should be done at baseline and after working up to a reasonable dose (usually 2- 2.5 tabs of 25/100 sinemet taken 3-4 times a day). This may not be the final dose selected but will give a lot of info.


Now, interestingly some patients actually get more tremulous the higher the dose of sinemet, and sometimes also the higher the amount of electricity we use if they have a deep brain stimulator.


I would recommend a second opinion, but the sinemet test was a great idea.


Finally, his diagnosis is probably correct and we see PD emerge after surgeries quite frequently. We believe that most of these patients have PD and the stress of the surgery brings it out. Also, numbness is commonly seen on the side the PD starts on.

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