Extrapyramidal / Tremor

Question 1

General Inspection

Answer 1

Poverty of facial expression (mask like face, loss of facial micromovements)

Flexed extrapyramidal posture: cannot lie flat (head off pillow), ‘Simian’ posture on standing (stopped, hands over groins)

Question 2

Tremor

Answer 2

Parkinsonian tremor: hands resting on pillow. ‘Pill-rolling’ quality. Coarse tremor (3-4Hz)

Hands out, fingers spread: parkinsonian tremor should improve

Consider other causes of tremor

Question 3

Rigidity

Answer 3

‘Cogwheeling’ in Parkinsonism

Ask patient to tap knee with other hand: synkinesis - reinforces hypertonia

Question 4

Bradykinesia

Answer 4

Thumb to each finger in turn, as quickly as possible

Pretend to play piano

Question 5

Postural instability

Answer 5

Ask to rise from chair, walk across room, turn and come back

Parkinsonian features: hesitancy, shuffling gait, loss of arm swing, hurried steps, festination, retropulsion

Question 6

Other tests

Answer 6

Glabellar tap
Speech
Writing

Question 7

Function

Answer 7

Motion of turning a tap
Undo and do up a button
Handle some coins

Question 8

To finish

Answer 8

Wash hands and thank pt

I would also like to look for evidence of a Parkinson PLUS syndrome:
Perform full neurological examination
Check erect and supine BP
Assess eye movements

Question 9

Core features of Parkinsonism

Answer 9

Tremor
Rigidity
Akinesia (Brady)
Postural instability

Question 10

Conditions with similar presentations to Parkinsonism

Answer 10

Benign essential tremor

Wilson’s disease: tremor, dyskinesias, psychiatric illness, hepatotoxicity, Kayser-Fleischer rings in eyes

Question 11

Causes of Parkinsonism

Answer 11

Idiopathic Parkinson’s disease
Drug-induced: lithium, antipsychotics (phenothiazine and atypical), metoclopramide
Parkinson PLUS syndrome: Shy-Drager syndrome, multisystem atrophy, progressive supranuclear palsy
Atherosclerotic pseudoparkinsonism
Dementia pugilistica

Question 12

Long term complications of L-dopa therapy

Answer 12

Increasingly severe Parkinsonism
Autonomic neuropathy 
Dysphagia 
Dementia 
Dyskinesias
Motor fluctuations (on-off, end of dose)

Question 13

Treatments used in PD

Answer 13

L-dopa
Dopamine agonists: ropinerole..
Anticholinergics: procyclidine, orphenadrine 
COMT inhibitors: entacapone
MAO-B inhibitors: selegiline 
Glutamate antagonists: amantadine

Question 14

Tremors

Answer 14

Resting: Parkinsonism

Flapping: hepatic failure, respiratory failure, renal failure

Intention: cerebellar lesion

Postural: benign essential tremor, physiological tremor

Question 15

Benign Essential Tremor

Answer 15

Unknown aetiology, genetic component likely

Improvement with alcohol, progressive

Mild asymmetry common, usually slower (4-7Hz), titubation in 50%, postural and action

B-blockers, Gabapentin if CI

Question 16

Exaggerated Physiological Tremor

Answer 16

Fever, hyperthyroidism, anxiety states, medication-induced

Non-progressive

Usually symmetrical, usually faster (8-12Hz), no titubation, usually purely postural

Treat cause if possible, B-blockers / gabapentin