○      This episode we will

         -Take a look into the neurologic system

-Review useful information for the evaluation of tremor

-Walk through differentiating the diagnosis of tremor

-And you know so much more!

 

OK, so if you listen to my last podcast you know that I talk quite a bit about assessment skills and observation skills that lead to excellence in assessing for the unspoken symptoms. There are many valuable clues to be found in observation that will improve your interview skills and what we will call your investigator skills into disease process. I had not planned to begin doing very specific podcast on isolated disease processes yet, but I got so excited with the mention of Parkinson’s disease and neurologic dysfunction in a few areas of The Preassessment Podcast that I could not resist interjecting one very specific disease oriented podcast here!

As I had mentioned in my very first podcast I have a background in neurology. That was my very first position as an advance practice nurse and I can’t begin to express how valuable that position was to the rest of my career thus far!

 

You see, many people are baffled by the neurologic system and diagnosing neurologic disorders. It is very complex, I won’t lie. I spent many hours studying diagrams and books and doing my own homework beyond the education that I was receiving while I was in training. I worked as the triage nurse for the neurology practice while I was completing my Master’s degree to become an advance practice nurse. During that time, I not only had the value of being able to talk to the patients when they contacted the office for medication questions and symptomatology and other issues that need to be addressed, I was able to learn from a top notch neurologist, that loved to educate.

 

 And I sucked up all the knowledge I possibly could! 

 

Because, in case you haven’t figured it out, I am quite a nerd when it comes to the medical field and learning. The more I can learn the better. I am always willing to take another course, read another book, follow another respected provider and learn everything that I can from clinical expertise. The value that I got from seeing things from both sides during the time I was the triage nurse catapulted my ability to manage patients in my primary care practice with neurologic impairments.

 

When I got to the advanced practice level within that neurology practice and was performing the examinations myself, and doing the patient interview prior to the examination, I was blown away at how many things were not addressed in the primary care setting with these patients. 

 

Now that I am in primary care practice myself, I can see that you’re very busy and have so many things to manage, that often something with such perceived complexity should be sent to a specialist. However, I am going to give you some tips and tricks along way on how to manage or at least diagnose common neurologic disorders in your primary care clinic. Then you can decide if they are manageable by you or if you need to refer them on. 

 

So, I have mentioned Parkinson specifically, but what I would like to do is actually give you the assessment related to tremor. Because just the diagnosis of tremor alone, does not make it Parkinson’s. There are many criteria that go into the Parkinson’s diagnosis. The tremor is one of the hallmark signs of Parkinson’s disease, followed by bradykinesia‘s. Just in case you don’t know that terminology, that means the slowing down of muscle movement. So, not all Parkinson’s diagnoses actually start with a tremor. How about that for a tidbit of knowledge?

 

Now tremor.  What exactly is a tremor? A tremor is a repetitive motion, that is uncontrollable of a particular body part.

 

When you look at a tremor you want to be sure to note the location, the amplitude, if it is present at rest or with activity and follow through with your questioning as appropriate to get that information.

 

Many times, a tremor is not a presenting symptom from a patient. There are times that it is not even noticeable to the patient. It is often brought up by someone else. If someone has a tremor of the head, which is also called a head titubation, it can be actually embarrassing to the patient. It can cause the patient to refrain from social activities, increasing isolation and causing the patient much distress.

 

When you are doing your “preassessment”, as we discussed in the last episode, a tremor of the head could’ve been one of the things that you picked up on. If so, this is how I would proceed with that, had the patient not already brought it up. If the patient has brought it up, then you just skip right to the questions. 

 

On examination, I start the conversation with “Were you aware that you had a bit of a tremor of your head?” If they did not, I will let them know what my observation was and that it is a common finding, that is often associated with an excitability of beta receptors. If it does not bother the patient, I simply reassure them, that it is a benign finding and not often associated with Parkinson’s disease. We all know Michael J. Fox made Parkinson’s disease famous, as it also instilled some fear into patients about getting that disease.

 

If the patient has noticed that tremor of the head or “head bobbing” it may be referred as, I will ask more specific questions. Do you notice this more when you are stressed or in front of people? Are you able to control it? Does it get better or worse if you drink alcohol? Do you have a tremor anywhere else?

 

Most often, the Essential tremor will improve with alcohol consumption.

 

Sometimes, head titubation is associated with tremor in other locations, but not always. If so, a tremor of the upper extremity would be the most likely associated location.

 

 I will have already observed for any kind of at rest tremor activity prior to my inquiry for detailed information. If you have not made note of your observations prior to the question, the tremor may increase with their anxiety of addressing the situation. This however, is still another helpful part of the assessment.

 

The specific questioning to help with differential diagnosis is as follows..

  1. Is this tremor in one hand or both?

  2. When do you notice the tremor?

3.        Is the tremor at rest or when you were trying to do something? For example, does the tremor get worse when you were trying to drink a cup of coffee or eat from a spoon or is it just at rest?

4.        Have you noticed that the tremor gets worse when you are anxious?

5.        Do you have any control over the tremor at all?

6.        Did the tremor come on all of a sudden or did you notice it overtime?

7.        Does anyone else in your family have a tremor like this?

8.        How long have you had the tremor?

9.        Does alcohol make the tremor better or worse?

10.  Do you have any other symptoms with the tremor? That may have started at the same time as you notices the tremor.  For example, slurred speech, weakness of the arm?

11.  Have you noticed that it is harder for you to get up out of a chair? Do you have to push off with your hands or grab onto something to get out of the chair?

12.  Do you feel like you’ve maybe slowed down a little bit?

13.  Do you shuffle your feet?

14.  Do you have any trouble with your balance?

 

 

This series of questioning, is to help differentiate between what we call an Intention Tremor and a Parkinsonian Tremor. You see an Intention Tremor is almost always associated with over stimulation of the beta receptors. It can also be a result of a stroke that has occurred in the brain stem in the area of the Substantia nigra in the brain. If you don’t remember that term or you’re not even sure where the heck that is in the brain, don’t worry. This was one of those advance things that I picked up on in the neurology practice. It was not something that I readily recalled from my education. The point of that area’s involvement has to do with the dopamine receptors. 

 

So now that you have asked the questions, you need to follow up with an assessment to support the path you follow for the diagnosis. Giving someone the diagnosis of Parkinson’s is very serious and could be causing a lot of distress and anxiety for the patient. If you give someone the diagnosis of an Intention Tremor and treat that accordingly, while reassuring them of its benign nature, then you have helped that patient incredibly. You have saved them a trip from the neurologist as well as probably a few sleepless nights and unnecessary fear.

 

For the examination phase:

 

First, I would like you to take a look at their facial features. Is there a lot of movement in the face? Or are they a bit flat and blunted? Does their speech seem slow to you? It may not have been quite obvious until you started with a tremor discussion. But now pay close attention. When they walk, do they swing both arms normally as they walk, or do they stay pretty close to their sides? Do they pick up their feet or do they tend to shuffle their feet? As for the tremor, is it in one arm or both? Is it at rest while you were talking to them and distracting them? Or is it when they are doing something? Like, when they are pointing to something or raising their hand to correlate with something you may be discussing. When you do you were actual hands-on assessment, check for something called cogwheeling. The assessment for cogwheeling takes a little bit of practice. But what cogwheeling is, is a bit of an impedance in the loose, natural flow of passive rotation of the wrist in a circular motion. You will notice a little bit of a “sticking“. That is called cogwheeling. The other thing that you want to do, while keeping the hand as relaxed as possible, take the hand inside of your hand, raise the hand up and down. Does it go with ease? Or does it feel a little bit stiff? No check the tone of some other muscles. How about their biceps and their lower extremities? Does there seem to be an increased tone of the muscles?

 

This is very important to your differential diagnosis. Let’s go through the differential diagnosis now that you have collected some data via interview and physical examination.

 

1.  Intention Tremor- and intention tremor is uncontrollable movements,  that is often not perceivable to the patient, unless they are attempting to actively use a specific muscle group that is affected by the tremor. For example, taking a drink from a cup or sipping soup from a spoon. One of the best questions to assess this is do you spill your coffee on you or do you avoid eating soup because you might spill it due to the tremor? And intention tremor is a benign finding related to beta receptor excitability. It does not cause any long-term problems and typically does not involve any other body parts aside from the head or a unilateral extremity. It is very commonly and very effectively treated, with the use of a beta blocker. Typically Inderal. Use a long acting release if possible. Unfortunately, insurance companies will block this long acting formulation.

 

2.         Parkinson’s  Disease - Parkinson’s is often known by its Hallmark presentation of a tremor at rest, often associated with a “pill rolling“ quality and bradykinesia’s.Parkinson’s is more of a systemic, progressive disease, with hypertonicity of muscles and the “slowing down“. The area of the brain that is effective in Parkinson’s disease is the substantia nigra. There are still no definitive causes of Parkinson’s disease. It is hypothesize that it is associated with exposure to heavy metals and pesticides. The treatment is to control symptoms. There is no hard data on preventing the progression and the progression is variable in each person. So symptom management is vital. Should you start the treatment for Parkinson’s, the gold standard is with Sinemet (Carbidopa- Levodopa) which works at dopamine receptors to ease movements and lessen tremor activity. There are also some new patches that are long acting to help with improving function and decreasing symptoms, by decreasing the hypertonicity associated with Parkinson’s and easing up movements. If you do feel sure of the diagnosis of Parkinson’s disease, I encourage you to make that referral to neurology. You can initiate the Sinemet for symptomatic control until they were able to get in with that neurologist, but definitely pass that one along. Also of mention, there are no diagnostic tests for Parkinson’s.

3.        Stroke – this is one of the other possibilities in your differential diagnosis. I would look at thinking of a stroke if the onset was very sudden and not associated with any other bradykinetic symptoms. Sudden onset of anything neurologic, almost always is associated with something that impedes a specific area of the brain.

4.        Anxiety –if the tremor is noted in the bilateral upper extremities, progressive and associated with anxiety causing activities then it is most likely associated with anxiety. Start by treating the anxiety. Once the anxiety is under control, reassess the tremulousness.

5.        Substance Use – sometimes tremor can be associated with the use of subtances that effect a variety of receptors, These substances can include alcohol, cocaine, heroin, amphetamine and methadone.

6.        Substance withdrawal – this kind of goes along with the previous, as well as the anxiety associated with the inability to obtain a substance that the patient was used to receiving on a regular basis.

7.        Musculoskeletal disorders-this is less common, but can occur if there is impairment to the ability of the affected area to withstand the demands placed on it. For example, if you have wasting of the muscles in the lower extremities or a muscle impairment, such as rhabdomyolysis or muscular dystrophy.  The stress of trying to hold the weight of the body can cause tremulousness of the lower extremities.

 

So once again, we have validated the need to do a thorough interview of the patient to correlate with the physical findings. You should almost always have made your diagnosis before you order any diagnostic studies. Get the history. Take the time to investigate the situation. Do not be afraid. If you’re on the fence, no worries go ahead and send to the neurologist. With something as simple as an intention tremor, this can be managed within your scope of practice. Anxiety can be managed by you. If you believe that it is from a musculoskeletal etiology, start the testing. Take a look at the low back. Is there a radiculopathy that may be stopping  innervation to a muscle? Do a CK-MB and a sedimentation rate to see if maybe there is something like a rhabdomyolysis.

 

Specifically ask about substance use. When you do, make the patient aware that sometimes that type of tremor can be seen with withdrawal or excessive use. The patient may or may not answer you honestly.

 

If you have abnormal findings on your exam, order an MRI of the brain without contrast to start. This will let you know if there’s a tumor pressing on the area that can cause tremor, if there has been a stroke in that area or if there is nothing at all to see. The thing with Parkinson’s disease specifically, is it there are really no diagnostic studies for Parkinson’s disease. It is a diagnosis of exclusion. Meaning that you have checked everything else. You have done a panel to look at heavy metals, you have done imaging studies to assess for the things previously mentioned, you have ruled out intention tremor alcoholism and anxiety. And you have put your assessment skills into play.

 

I know this was a very intense and heavy topic for today’s podcast. But I really hope that you’ve learned something. Give me some feedback. Was it helpful? Or was it too much? Do you think that you could put this information into your practice right now? Do you feel more confident? Please let me know! 

 

I just like to give you some of the information I have learned that I didn’t know and wish someone had taught me more of. Our clinical studies and programs are not always able to give us all of these specialized pieces of information. We read what’s in the book, but when we go out into the real world, we don’t always get to practice this. And when you’re trying to learn everything at once it’s impossible to remember everything! 

 

I want to thank you for your time! And if you’re loving it, give me an Itunes review! That will help others find this podcast to help with their practice also! 

 

You can find more of me and what I’m up to on healthinterventions.net,  Facebook and Instagram!

 

Have a great week! May it be filled with many Health Interventions!