Cases reported "Tremor"

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11/68. Quantitative assessment of Parkinson's disease deficits.

    OBJECTIVE: To quantitatively analyze the tremor and rigidity due to Parkinson's disease. methods: 38 patients with Parkinson's disease (PD) ranging in age from 45 to 72 years and 211 normal subjects aged from 16 to 76 years were investigated. The frequency and range of tremor, the muscle tone of the upper limbs in elbow were detected by a computerized video motion detecting system and a new invented apparatus which can detects skeletal muscle tone. RESULTS: For the PD patients, the frequency of resting tremors was detected in 4 to 6 per second. For extensor and flexor in the PD patients, the value of muscle tone was higher than that of normal subjects and the value of muscle tone in flexor was higher than that of extensor. The rigidity increased gradually with repeat passive movement. The curves of rigidity were shown on computer screen or printed out. The data of rigidity were compared with the M-A Scale. A patient who was suspected to suffer from PD above by the equipments and found the muscle tone was higher than normal. In another PD patient the rigidity was obvious at one side and the muscle tone in "normal side" was also high. These equipments were used to record changes of rigidity and tremor in one more PD patient taking with different drugs in order to see the drug effect. CONCLUSION: Quantitative methods are useful to analyse the motion disorders due to PD.
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12/68. Fast orthostatic tremor in Parkinson's disease mimicking primary orthostatic tremor.

    leg tremor during standing is a rare feature in idiopathic Parkinson's disease (PD). Tremor during standing usually has a low frequency (range, 4-6 Hz), similar to PD rest tremor frequency, and is improved by levodopa. We describe three cases of fast orthostatic tremor (FoT) of legs and trunk mimicking primary orthostatic tremor (OT) in patients treated with levodopa for PD. Asymmetrical akinetorigid syndrome was accompanied by a rest tremor in two cases. We obtained electrophysiological parameters by electromyographic (EMG) polygraphic recording after 16 hours withdrawal of antiparkinsonian treatment and at the maximal effect of levodopa in order to investigate the effect of dopaminergic stimulation upon such cases of orthostatic tremor in PD. Electrophysiological parameters of orthostatic tremor, especially frequency (range 14-18 Hz), were similar to that seen in POT. Severity of tremor was independent of seriousness and duration of PD. levodopa had no effect either on the handicap due to OT or on the amplitude and frequency of the EMG OT activity. In contrast, mild improvement of OT was obtained with benzodiazepines in two cases and parkinsonian syndrome was levodopa-sensitive. These findings suggest that FoT in PD would not be directly controlled by the dopaminergic system. However, increased rhythmicities in basal ganglia or in cerebello-thalamic loops at the rapid frequencies range seen in PD could favor the emergence of a primary orthostatic tremor-like tremor in PD patients.
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13/68. Peripheral mechanisms in tremor after traumatic neck injury.

    Tremor is a rare manifestation after neck injury, and its physiological mechanism has not been elucidated. We studied the effects of torque loading and ischaemic nerve block on coarse postural tremor in the right upper extremity, which had developed in association with a C7-C8 radiculopathy after traumatic neck injury in a 55 year old man. Loading reduced the tremor frequency from 6.1 Hz to 4.2 Hz with corresponding electromyography (EMG) bursts at the same frequencies as the tremor. Ischaemic nerve block also reduced the tremor frequency from 6.2 Hz to 2.8 Hz, and the time course of the frequency was not in parallel with that of the size of the maximal M wave. A significant reduction of the tremor frequency by loading and ischaemic nerve block indicates a mechanical reflex mechanism underlying the tremor, and association of synchronous EMG bursts suggests an increase in gain in the stretch reflex loop. The stretch reflex loop plays an important role in generation of oscillation in tremor after neck injury.
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14/68. Control of lithium tremor with propranolol.

    lithium tremor is an irregular, nonrhythmic tremor of the distal extremities, variable in both intensity and frequency. It is clinically differentiated from essential tremor and tremors due to anxiety and neuroleptics. The pathophysiologic mechanisms are hypothesized to be of perpheral origin. Five patients were successfully treated with propranolol. In general, the dosage of propranolol must be individually adjusted and is usually from 30 to 40 mg daily in divided doses. This blocker of beta-adrenergic receptors remains effective with long-term administration and increases in dosage are not required.
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15/68. Bilateral high-frequency synchronous discharges: a new form of tremor in humans.

    OBJECTIVES: To report bilateral high-frequency synchronous discharges in a patient with a sporadic form of olivopontocerebellar atrophy; to investigate the electromyographic pattern, the coherence and cospectral density across limbs, and the resetting effects of electrical stimulation over the posterior fossa; and to highlight the clinical, electrophysiologic, and radiologic features of this new form of tremor associated with posterior fossa disorders. DESIGN: Case study of a patient clinically exhibiting a sporadic form of olivopontocerebellar atrophy associated with cerebellar and brainstem atrophy. SETTING: research unit, university hospital. MAIN OUTCOME MEASURES: Electromyographic studies, coherence and cospectral density analysis, and calculation of a resetting index based on the timing of measured bursts and predicted bursts for an electrical stimulus given over the posterior fossa at increasing delays. RESULTS: Surface electromyographic recordings in forearm muscles revealed a low-frequency postural tremor in the upper limbs, with episodes of highly coherent tremor at a frequency of 14 Hz. Squared coherence and cospectral density was strong between agonist and antagonist muscles in the left and right upper limbs and across limbs for the high-frequency discharges. Electrical stimulation over the posterior fossa reset the explosive high-frequency bursts. The resetting index was 0.82 Hz. CONCLUSIONS: Our results show that bilateral high-frequency synchronous discharges may be associated with the sporadic form of olivopontocerebellar atrophy. Bilateral coherent bursting and resetting of this explosive postural tremor following electrical stimulation over the posterior fossa strongly suggest that the brainstem plays a key role in the network involved in the genesis of rhythmic bursts. We suggest that the high-frequency discharges are due to repetitive discharges in the reverberating cerebello-precerebellar circuits.
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16/68. Treatment of tremors in complex regional pain syndrome.

    A 14-year-old girl presented with Complex Regional pain syndrome, Type I (CRPS-1) of the left ankle after a remote history of sprain. Allodynia, pain, temperature and color changes, and swelling were successfully treated with physical therapy, transcutaneous electrical nerve stimulation (TENS), gabapentin, amitriptyline, and tramadol. Five weeks later, she presented with a continuous, involuntary, intermittent coarse tremor of the left foot causing increased pain. The electromyogram showed rhythmic discharges of 3 Hz frequency lasting 20-80 milliseconds in the left tibialis, peroneus and gastrocnemius, suggestive of either basal ganglia or spinal origin. Tremor and pain were controlled with epidural bupivacaine, but the tremor reappeared after discontinuing epidural blockade. carbidopa/levodopa 25/100 (Sinemet) was started and the tremor disappeared after two days. With continued physical therapy, pain and swelling resolved within two months and carbidopa/levodopa was discontinued after five weeks with no recurrence of the tremor. Our success in the treatment of CRPS-associated tremor in this young girl with carbidopa/levodopa suggests that this patient may have had underlying movement disorder which was unmasked by the peripheral injury.
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17/68. Staged lesions through implanted deep brain stimulating electrodes: a new surgical procedure for treating tremor or dyskinesias.

    Thalamotomy and pallidotomy have been shown to have some efficacy for treating some movement disorders such as disabling tremor or parkinsonian levodopa-induced dyskinesias (LID). Compared to continuous deep brain stimulation (DBS), this surgical procedure has the disadvantage of irreversibility and a lack of adaptability. Making a lesion involves a risk of inducing permanent side effects, especially if the lesion is large, or of observing a resurgence of the symptoms if the lesion is too small. We performed unilateral pallidotomy in one patient suffering from LID and unilateral thalamotomy in two patients suffering from tremor through the lead classically used for DBS. The technique of lead implantation was similar to that used for DBS treatment but, instead of connecting the lead to a pulse generator, it was left in place and used to make a radiofrequency lesion. This technique allowed the lesion to be kept as small as possible, thereby minimizing the risk of permanent side effects and made possible to extend the lesion if the symptoms reappeared. One lesioning session was enough to relieve tremor in the two patients treated by thalamotomy; three lesioning sessions over a 7-month period were required to relieve drug-induced dyskinesias in the patient treated by pallidotomy. In all 3 patients, disabling symptoms were still relieved without any permanent side effects 6 months after the last lesion was performed.
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18/68. Tardive tremor.

    A variety of hyperkinetic movement disorders has been associated with the use of neuroleptics (dopamine receptor blocking drugs), but tardive tremor has not been previously documented. We describe five patients in whom tremor occurred after chronic treatment with neuroleptics, was aggravated by and persisted after neuroleptic withdrawal, and improved after treatment with the dopamine depleting drug tetrabenazine. This involuntary oscillatory movement, with a frequency range of 3-5 Hz, was most prominent during maintenance of a posture, but was also present at rest and during a goal-directed movement. The tremor was accompanied by other tardive movement disorders, including akathisia, chorea, dystonia, myoclonus, and stereotypy. There was no family history or other explanation for tremor in these patients. We suggest that this hitherto unreported movement disorder is best termed "tardive tremor."
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19/68. Effect of stereotactic thalamic lesion on essential tremor.

    The cause of essential (low-frequency) tremor is unknown and its relation to physiological (high-frequency) tremor is unclear. We assessed essential tremor in one patient before and after a stereotactic thalamic lesion. The procedure changed the size of the tremor in the right hand but not in the left. Persistence of a low-frequency component suggested that essential tremor was an additional feature superimposed on physiological tremor in this patient. The focus of essential tremor seems to be an autonomous central generator that is independent of physiological tremor mechanisms.
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20/68. Orthostatic tremor associated with voice tremor.

    We report a 67-year-old female with orthostatic and voice tremor. Her orthostatic tremor mainly affected her lower extremities, alternating between antagonist muscle groups at a frequency of 4.4-4.8 Hz. The voice tremor ranged between 4.8 and 8.8 Hz. In this case, the frequency of voice tremor was same as that of orthostatic tremor, suggesting a common origin from a tremor-generating mechanism. These tremors were diagnosed as 'forme fruste' of the essential tremor, not the incipient stage of Parkinson's disease. Medications including clonazepam, perphenazine, Dopa and trihexyphenidyl hydrochloride had no effect on both the orthostatic and voice tremors, but propranolol was somewhat beneficial on voice tremor.
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