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3/3 PD: Etc

Extra stuff from PD case - Tremor descriptions & Home safety eval

Describe a resting tremor. Slow & coarse tremor at rest. Voluntary movement reduces tremor.
What causes a resting tremor? May be c/b basal ganglia disturbances. Common causes inc. PD, Wilson’s, heavy metal poisoning, & certain drugs (lithium & some anti-psychotics).
Where does a resting tremor normally occur? Affects arms more than legs & can interfere with fine motor activities. Occurs in a body part which is not voluntarily activated & is fully supported by gravity.
How is resting tremor diagnosed? Complete neuro exam looking specifically for Parkinsonism.
Describe an intentional tremor. Slow, broad tremor that occurs when attempting voluntary, fine mvmts. Occurs towards the end of a purposeful mvmt. Absent at rest & during first phase of voluntary mvmt.
What causes an intentional tremor. C/b cerebellar damage which can be d/t MS, stroke, Wilson’s disease, alcoholism, or overuse of sedatives or anticonvulsants.
How is an intentional tremor diagnosed? CT or MRI to check for brain damage, finger-to-nose test.
Describe a flapping tremor. Coarse, slow, nonrhythmic. Occurs when arms are outstretched & hands are extended. The hand will drop d/t sudden loss of sustained muscular contraction & then return to its position suddenly d/t overcompensation by wrist extension muscles.
What causes a flapping tremor? C/b liver, kidney, or metabolic disorders that result in brain damage. Mechanism = sudden, temporary lapse in muscle tone.
How is a flapping tremor diagnosed? Blood tests to evaluate liver & kidney function.
Describe an isometric tremor. Medium frequency & variable amplitude. Occurs upon muscle contraction against stationary objects: holding/squeezing/resisting. Rhythmic muscle contraction in legs & trunk that occurs immediately after standing but stops when seated.
Describe a psychogenic tremor. Occurs at any age & is incredibly variable in presentation & course. Will go away if patient isn’t observed or after administration of a placebo.
How is a psychogenic tremor diagnosed? Ask patient to keep a rhythm (different than the tremor’s rhythm) with an uninvolved body part & see if tremor miraculously starts matching the assigned rhythm.
What is a physiologic tremor? A.k.a. enhanced tremor. Most easily seen by holding arms outstretched, fingers apart. Exaggeration of normal physical response such as fear, anxiety.
What causes a physiologic tremor? Seen in hyperthyroid, hypercortisol, hypoglycemia, extreme physical exertion, alcohol/drug/caffeine withdrawal. Can be induced via IV injection of epinephrine or beta agonists.
How is a physiologic tremor diagnosed? Blood tests from hyperthyroidism, hypercortisol, etc.
What is an orthostatic tremor? A rare tremor where the pt shakes when standing still but it goes away upon walking.
What is a neuropathic tremor? A rare tremor c/b demyelinating neuropathies.
What is a palatal tremor? A rare tremor involving rhythmic, involuntary movements of the soft palate.
How do you treat a tremor? Treat underlying disorder first (PD, etc. if present)& then: β-blockers (esp. propanolol), anti-convulsants (mysoline, primidone, etc.), mild tranquilizers. Avoid stimulants. If surgery is required: thalamotomy or deep brain stimulation.
Describe rigidity. Increased tone present t/o ROM. Affects flexors & extensors equally. Can have cogwheel quality – periodic interruption of rigidity as joint is moved passively. Occurs w/ certain extrapyramidal disorders. Ex: PD.
Describe spasticity. Velocity-dependent, with sudden release after a set maximum. Occurs in flexors of upper limb & extensors of lower limb (the antigravity muscle groups). D/t upper motor neuron disease.
What is an essential tremor? Rapid, fine tremor. A.k.a. senile, tension, or familial. Usually starts early adulthood & slowly worsens w/ age sometimes=> disability. Some forms familial. MC tremor: affects 5-10 million Americans. Usually doesn't indicate disease or neuro condition.
Describe an essential tremor. Usually begins symmetrically in arms (sometimes in dominant arm), f/b head “nodding” tremor, which disappears when head is supported. May also affect vocal cords=>shaky voice. Better at rest, worse when limb outstretched or in uncomfortable position.
How is an essential tremor diagnosed? Ask about medications, anxiety, stress, family history.
PD falling stats: Mostly forward falls. 70% of PD pts fall at least once/year. The risk of falling in PD is ~2x that of community-dwelling older people.
Why do PD pts fall so much? Postural inflexibility (kyphotic position & loss of arm swing), proprioceptive disturbances, gait disorders, transfers, dual tasking.
Describe proprioceptive disturbances in PD. Unable to process changes in peripheral input. Loss of normal sense of limb & trunk position.
Describe gait disturbances in PD. Shuffling, freezing of gait (hard time starting mvmt). Festinating Gait: difficulty initiating walking, then gait possibly speeds up => difficulty stopping.
What are some tests to see if pt is at risk for falling? Retropulsion test: rxn to sudden jolt to shoulders (2+ steps backward is abnormal). Fxnal reach test: reach fwd as far as possible w/ feet in place. Timed Up & Go test: pt gets up from chair, walks 10 ft & returns; based on time (>30 sec abnormal).
What can be done about falling? Reduce # meds if possible (sedatives, etc), treat contributing medical conditions (Bone/muscle degeneration, vision problems, insomnia, etc.), Home Safety Evaluation.
What is a home safety evaluation? Visit by home-health RN, PT or OT to ID a risky environment. Look for: Obstructed paths (throw rugs, extension cords, etc.), Lighting, (change bulbs from 60 to 100 watts, etc), Safety equipment (handrails in bathroom, “booster” on toilets, sofas, etc.)
What else does a Home Health OT assess with a PD pt? Instrumental Activities of Daily Living (IADLs). Transportation, shopping, cooking, using phone, managing $, taking Rx, housecleaning, laundry. Social isolation & loneliness. Family stress. Nutrition problems. Financial concerns. Alcohol abuse.
Created by: 16813610



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