Parkinsonism and Tremors

Related Subjects:Multiple System Atrophy (MSA) |Parkinson Plus syndromes |Parkinsonism |Idiopathic Parkinson disease |Progressive Supranuclear Palsy |Drug Induced Parkinson disease Multiple System Atrophy (MSA) |Parkinsonism |Acutely Ill Patient with Parkinson's disease |Neuroleptic Malignant Syndrome

🧠 About

Note: It is essential to distinguish between Parkinsonism and Parkinson's Disease (PD). 👉 Parkinsonism is a syndrome – a set of features (tremor, rigidity, akinesia, postural instability). 👉 Parkinson’s Disease is a specific idiopathic neurodegenerative disorder due to dopaminergic cell loss in the substantia nigra. 👉 Parkinsonism can occur in many other conditions: stroke, drugs, toxins, head injury, and atypical neurodegenerative syndromes.

• Classic clinical signs remembered by TRAP: Tremor 🤲, Rigidity 🪢, Akinesia/Bradykinesia 🐢, and Postural Instability 🚶‍♂️⚖️.

📌 Most Common Causes

• Parkinson's Disease (PD): Most frequent cause; due to degeneration of dopaminergic neurons in substantia nigra pars compacta.
• Drug-Induced Parkinsonism: Dopamine-receptor blockers (antipsychotics, metoclopramide) 🚫 dopamine pathways.
• Vascular Parkinsonism: Multiple small strokes in basal ganglia → lower body parkinsonism, poor levodopa response.
• Atypical Parkinsonism: PSP, MSA, CBD — faster progression, extra features, and poor levodopa response.

🧾 Other Causes

• Wilson’s Disease 🟢: Copper accumulation, consider in young patients.
• Carbon Monoxide Poisoning 🛢️: Basal ganglia damage after inhalation.
• Post-Encephalitic Parkinsonism 🦠: Historically after encephalitis lethargica.
• Head Injury 🥊: Chronic trauma (e.g., boxers → “pugilistic parkinsonism”).
• MPTP Toxicity 💉: Synthetic opioid contaminant causing irreversible PD-like syndrome.

⚠️ Symptoms

• Tremor: “Pill-rolling” at rest, unilateral onset.
• Bradykinesia: Slowness in initiating movement; reduced arm swing while walking.
• Rigidity: “Cogwheel” or “lead-pipe” stiffness on exam.
• Postural Instability: Falls, impaired balance, difficulty turning.
• Other features: hypomimia (masked facies 🎭), hypophonia (soft voice), micrographia ✍️.

📊 Causes of Tremor

🧾 Causes of Parkinsonism

💡 Exam Pearl: • PD = asymmetrical, resting tremor, levodopa responsive. • Drug-induced = bilateral, no tremor, reversible. • Vascular = lower limb predominant, gait problems. • PSP = vertical gaze palsy + early falls. • MSA = autonomic failure. • CBD = alien limb + apraxia.

Cases — Parkinsonism & Tremors

• Case 1 — Idiopathic Parkinson’s Disease: A 68-year-old man presents with a 2-year history of slowness and difficulty buttoning shirts. His wife notes a resting “pill-rolling” tremor of the right hand and reduced arm swing when walking. Exam: cogwheel rigidity, bradykinesia, shuffling gait. Diagnosis: Idiopathic Parkinson’s disease. Management: Start levodopa + dopa-decarboxylase inhibitor (co-careldopa), physiotherapy, occupational therapy; later consider dopamine agonists or MAO-B inhibitors.
• Case 2 — Drug-Induced Parkinsonism: A 62-year-old woman with schizophrenia develops bilateral resting tremor, rigidity, and bradykinesia 6 months after starting risperidone. Symptoms are symmetric, unlike typical idiopathic PD. Diagnosis: Antipsychotic-induced parkinsonism. Management: Review psychiatric meds (switch to atypical antipsychotic with lower EPS risk, e.g. quetiapine); symptomatic therapy (anticholinergics like procyclidine in selected cases).
• Case 3 — Essential Tremor (Mimic): A 70-year-old woman complains of long-standing tremor in both hands, worse when holding a cup or writing, and improved with alcohol. Exam: action tremor, no rigidity or bradykinesia. Diagnosis: Essential tremor (not parkinsonism). Management: Propranolol or primidone if functionally disabling; otherwise reassurance.

Teaching Commentary 🤲

Parkinsonism = clinical syndrome of resting tremor, rigidity, bradykinesia, and postural instability. - Causes: idiopathic Parkinson’s disease, drugs (antipsychotics, metoclopramide), vascular parkinsonism, atypical parkinsonian syndromes (MSA, PSP, CBD). - Key exam clue: asymmetry → think Parkinson’s disease; symmetry → drug-induced or other causes. Essential tremor is a common mimic but is an action tremor, not resting, and often improves with alcohol. Management is tailored: dopaminergic therapy in PD, drug review in secondary parkinsonism, beta-blockers/primidone in essential tremor.