Chief Concern Series: The Trouble with Tremors

Ashley Paul, MD joins us to learn more about diagnosing and treating tremors. She shares point to look for in a high‑yield history, physical exam findings, and how to think about medical management among much more.

Please check out more of Dr. Paul's work here: “Parkinson’s Foundation Fundamentals of Parkinson’s Disease” CME video. 

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• 23:16 (Cont.) Chief Concern Series: The Trouble with Tremors

Transcript

Michael Kentris: 0:05

Hello everybody and welcome back to the neurotransmitters. We are continuing today our chief concern series. I am joined by my co-host, Dr. Galena Geikman. How are you doing today, Galena?

SPEAKER_01: 0:16

Hey Michael, so excited to be back and really excited for today's topic.

Michael Kentris: 0:20

Yes, as am I. You know, general neurology is what I practice mostly. Epilepsy is what I'm specially trained in. I always feel like movement disorders in general are my weakest area because it just feels so ephemerally in some ways. But thankfully, we are joined today by someone who is an expert in that, and that is my very good friend, Dr. Ashley Paul, who is an assistant professor of neurology at Johns Hopkins and the clerkship director of neurology rotation there, and a movement disorders specialist. Did I say that twice? I feel it bears repeating. But Ashley, thank you so much for joining us today.

SPEAKER_02: 0:57

Thank you for having me. And I I could be a movement disorder specialist twice. It's complicated to make the clear decision. Yeah, that's right.

Michael Kentris: 1:05

You know, you did that two-year fellowship, so I feel that's only fair.

SPEAKER_02: 1:08

Yeah, right. Credit for each year. I'll take it.

Michael Kentris: 1:12

So where should we start as far as movement disorders? What's the most common one that that we're seeing, generally speaking?

SPEAKER_02: 1:20

So movement disorders is not a disease in itself, right? It there's there's so many different types. And we try to categorize them as hyperkinetic or too much movement or hypokinetic, but I actually feel like it it ends up being more complicated than that. That's a nice simple schema, though, to start with. I would say tremors are extremely common. In fact, I probably don't see every person with a tremor. A lot of it is likely managed by a primary care physician, especially since, as you both know, the wait time to see a neurologist, let alone a movement disorder specialist, is long. I think I was reading somewhere it's upward of eight months across the country. So so yeah, important for our primary care physicians to be able to do the initial workup and management.

Michael Kentris: 2:06

Now I find this, and I know we all have slightly different practice environments, right? A lot of times when I get referred a patient and the reason for referral is tremor, more often than not, the patient does not actually have a tremor. So can we start out? Let's start like very, very fundamental. What do we mean when we say tremor?

SPEAKER_02: 2:26

I do like this question because if you are a purist, which we will be purists today, a tremor is rhythmic and oscillatory. So it should have, you know, a frequency that you can count. It shouldn't have a lot of variability. A lot of things do get called tremors that aren't actually tremor. And uh there was a study published about essential tremors and how it's um kind of like this wastebasket term because a lot of things are called essential tremor when they're not. And when the study showed that when these patients are referred to a movement determined specialist, more than half of these patients end up with a different diagnosis. And that I I mean, I haven't counted my referrals, uh, you know, I haven't looked at the numbers, but I get that feeling too. You know, I I've had tremor referrals that weren't at least they weren't essential tremor. They were maybe some type of tremor, but they weren't always essential tremor.

Michael Kentris: 3:21

Gotcha. So as you were saying, kind of rhythmic oscillatory. And then I I'm gonna dig back into my memory banks here. A lot of times we're talking about like where in the body is the tremor is kind of an important part of defining the syndrome as well. Is that right?

SPEAKER_02: 3:38

Aaron Powell Well, yes, definitely. You want to know if it's affecting a particular limb. Is it unilateral? Is it bilateral? Is there head and neck involvement, leg involvement, which can really influence what we think about the diagnosis. And actually, talking about that, it reminds me of one of my patients who was referred to me as quote unquote essential tremor and had this isolated tremor of the neck with limited range of motion. And, you know, I rediagnosed her as dystonic head tremor. She actually had a um vocal cord involvement too. And the reason why it was not essential tremor was because there was no involvement of her arms. There's no limb involvement. And so although someone with essential tremor could have head tremor, technically, it should still start in the limbs. So she had only isolated head and voice.

Michael Kentris: 4:28

So when we're talking about kind of like your assessments, like I know there's a bunch of like there's our standard, you know, quote unquote neurologic exam that we do. And Galina, stop me if I'm if I'm varying too far off the outline. But well, we should probably start with the history, I guess. I'm rewriting my own question in real time. What what are the what are the most important questions when you're like kind of asking the patient about their tremor or about like what it's affecting, et cetera, et cetera?

SPEAKER_02: 4:56

I will say across all movement disorders, not just tremor, but also for tremor, onset matters. What is the age of onset? How long this has been going on for can really change your differential. So essential tremor, for example, has a bimodal uh age of onset. So maybe someone in their 20s or 30s, but it could be someone in their six Parkinson's disease. So if you if you're concerned about that, which you know, a lot of people with tremor, that's probably their main concern that they come in with. The most common age range is onset in the 60s. Now, of course, there is early onset Parkinson's, juvenile Parkinson's. So it's not obviously by itself diagnostic, but it's a place to start. And in the diagnostic criteria for something like essential tremor, there should be tremor for at least three years uh without other associated neurological conditions, right? Without Parkinsonism, without cerebellary ataxia, without dystonia. So yeah. Then there's a sort of murky term called essential tremor plus where it doesn't quite meet criteria for Parkinson's or other disorders. So they have features of essential tremor, but they do have some other little things. And we I guess we just don't know what to call it, so we call it essential tremor plus. Um I think this is why one of my colleagues actually debates the legitimacy of essential tremors of diagnosis. But it is an accepted term and it's a, you know, it has uh its criteria among movement store specialists, but yeah, it's not uncommon that we monitor for conversion to something else. Other historical questions that you would want to know. So we talked about where in the body it's involved, how long it's been going on for, and I would also want to know about the acuity. Was it sudden onset? Has this been chronic and progressive? That obviously will change your differential greatly too.

Michael Kentris: 6:43

And most of our more common tremors are kind of more on that slow side of things. Is that accurate?

SPEAKER_02: 6:49

Yeah, yeah. I would say so.

Michael Kentris: 6:51

I mean Never say never, never say always.

SPEAKER_02: 6:53

Yeah, you know, exactly. Because now that I'm thinking about it, well, you know, there's also drug-induced tremors could be sudden onset, right? Um functional tremors, which are not uncommon, tend to also be sudden onset. So yeah, I take that back. I'm not sure.

SPEAKER_01: 7:11

One of the things that I found interesting is actually whether or not the tremor bothers the person. I don't know that that is alone distinguishing factor, but I'm curious your experience, Ashley and Michael. But I've had a lot of patients that come in because someone else is bothered by their tremor and they're not so bothered by the tremor. And I'm curious if that has any predictive value for the diagnosis.

SPEAKER_02: 7:34

It's a good question. I think a lot of times by the time they see me, it is bothersome, right? Because now they've gone to their primary care doctor and maybe they've been to now a general neurologist and now they want to see a subspecialist. And so usually by the time I get them, they're on the it's bothersome level. But there are times where people might have movements that they don't particularly notice and other people are around them might notice. I actually find this true for someone who has dyskinesias with Parkinson's, that that's fairly common.

Michael Kentris: 8:02

I've to your earlier point, Ashley, and to your question, Galena, I a lot of times I'll have patients come in, they want to know if they have Parkinson's. And I'll tell them, like, I don't think this is Parkinson's. And they're like, oh, okay. And they're like ready to leave like at that point in time. And they, you know, they're never you know, it's like, oh, do you want any treatment or you know, they're like, nah, I'm good. And then they'll just follow up whenever they decide to.

SPEAKER_01: 8:25

Yeah, I that's why I mentioned that because in, you know, oftentimes I do have patients where once I've done the history and the exam, I'm leaning towards essential tremor, and they've often had it for years, which is what helps with the diagnosis and it's been stable. But, you know, they'll get comments like, oh, well, when I go out, my family or like my family at the family reunion who don't see me as often, you know, are bothered by it by day to day in their life. It doesn't. But it does raise the point about when, as you said, actually gets worse, it can really have an impact on their functional quality of life. And even essential tremor, which we term is benign in the sense of in terms of etiology and kind of prognosis, yes, at some point, if severe, can get in the way of their life. Are there common things that you ask your patients about in terms of assessing function with the tremor? Is it fine motor skills? Is it, you know, is it day-to-day activities? What should primary care doctors be asking about?

SPEAKER_02: 9:18

I'm gonna answer that, but I'm also want to make a comment on on benign. I think we are trying to move away from that term because of how much it can impact a person's day-to-day function. And even though essential tremor is not considered neurodegenerative, people get older, right? And your brain changes. And so there can be some change and progression in how much it interferes with day-to-day activity. And so much really depends on how a person defines their quality of life. I mean, if you are a surgeon, even the smallest bit of tremor is not great to have. But if you're like, hey, you know, I don't do a lot of fine motor activities, then you may not care about the tremor and it doesn't bother you. Some people feel like it's just socially embarrassing. And that is one of the questions we ask. There's something called the tetrascale, which is a formal scale that movement tutorial specialists use to grade essential tremors. And it'll ask about personal hygiene eating. Do they spill, do they have to use two hands to bring a cup of water without spilling to their mouth or bring a spoon to their mouth? Do they need two hands to write? You know, so if their dominant hand has a lot of tremor, do they have to hold it down with their opposite hand? If they're carrying a tray of food, do they have to bring the tray close to their chest, like their center of gravity, to keep it still, or can they hold it out? Putting a key in a lock, actually, is a quite a question on the Tetris scale, right? Because you can imagine if you have tremor and you're trying to approach a small hole with your key. That's that's tricky. And so if they score highly on these on these scales, then you know, of course we still start with oral medications, but we may also consider some more advanced therapies if if those things don't work.

SPEAKER_01: 10:55

Speaking about history questions, how important or how maybe reliable is the family history question? I feel like the teaching is always like essential tremor runs in families, like, you know, period, stop. What's your experience?

SPEAKER_02: 11:10

So I guess this goes back to uh Michael never say never and never say always, right? Um it is supposed to be a reliable history question. Generally speaking, essential tremor does have a strong family history, even though there's not maybe a specific identified genetic marker. That being said, I have had patients who don't necessarily have a strong family history. I think sometimes things are lost in history though, right? If someone, maybe their father or grandfather or whoever might have had some tremor and they just ignored it or didn't get formally diagnosed. And I I just see that to be true, not just for tremor, but for other conditions as well. So it's still worth asking. I don't necessarily anchor on it for a diagnosis, but I think it is worth asking.

Michael Kentris: 11:57

I'm curious. Like we all learn in medical school about like all these kind of like Parkinsonian questions, right? It's like your change of smell or your handwriting, all those kinds of things, like getting well, I guess this is more of a neurology question, like getting stuck when you walk through a doorway or feet sticking to the ground, things like that. Do you find that that those really help you differentiate like a Parkinson, let's say idiopathic Parkinson's versus Parkinsonian versus something else?

SPEAKER_02: 12:24

Yeah. The main things that I focus on, so to call something Parkinsonism, right? It means that they have braidokinesia, slowness of movement with loss of amplitude, and one of the two, at least one of the two, a rest tremor specifically, or and or rigidity, right? So you have to have braidokinesia, and then one of the other two criteria. So if they meet that, then we start diving more into the Parkinsonian questions, right? That's when I might want to know about alpha-synuclein markers, which are not always present, but commonly can be. So do they have signs of REM sleep behavioral disorder, acting out their dreams at night, constipation, hyposmia, loss of smell. Sometimes I'll ask about taste since sometimes people don't recognize when they have loss of smell, or I'll ask them very specifically, are you sure? Like, does your partner say, Hey, do you smell that? And you say, smell what? So I do try to dig because sometimes people just don't realize until it's bad enough, right?

Michael Kentris: 13:18

That's a great point. I find the the one that I've had the most luck with is the is the rum sleep behavior type question. That one seems to, especially if their spouses with them, that really shines a light on things. I find that, yeah, no, I really don't get a lot of hits on the smell and taste, that kind of stuff. Like the more maybe more subtle things, but I don't know, personal experience. Yeah.

SPEAKER_02: 13:39

I think the other issue is that a lot of people can have change like constipation, right? That's very nonspecific. During COVID, if I asked about smell and taste, the first thing people would say is I I don't have COVID. It's like, well, that's not actually why I'm asking, but thank you for letting me know. So when you get all three, that's kind of like a ding-ding-ding. This is really increasing this the pretest probability of some type of nigrostrital degeneration from office nucleanopathy.

Michael Kentris: 14:07

Now, something this may be more uh a manifestation of me working in the Midwest, but I find that I'm asking about occupation a lot. You know, we got a lot of farmers, a lot of former factory workers. I had one guy who worked in a plant with some sort of aluminum chemical thing and it has an association with, you know, kind of some sort of atypical Parkinsonism sort of thing. So I find that I'm asking about like, you know, what kind of work did you do? It's like, oh, I worked in a factory, like, well, front office or you know, in the uh area where the chemicals were. And uh you kind of have to ask about that. I don't know if that's if that's something would you recommend that based on like maybe where you're geographically located, or do you find it helpful if someone has, let's say, you know, long roundup exposure? I shouldn't say branded names on this probably, but that's okay. But uh let's say some sort of chemical exposure, right? I think we we all saw that study uh came out this last year about proximity to a golf course and incidence of Parkinson's disease. Do you find that that's a useful historical feature when you're trying to dope that out at the beginning?

SPEAKER_02: 15:09

I think there is an association, right? There's correlation between certain parts of the US and certain chemical exposures that seem to increase the risk of developing Parkinson's disease. I don't always dive deep into it because um I find then then the patient anchors around it because there's really nothing I could do about their prior history of exposure other than to say, can we reduce it now, right? If it's an ongoing thing.

Michael Kentris: 15:35

Right. Do you find um the other question I I often ask about, and this might be more kind of like verging on like a frontotemporal thing, but like a history of military service as well. Do you find that that's a useful question?

SPEAKER_02: 15:47

Yeah, similarly, I uh a lot of times before I can ask it, I patients ask me that question. Right? Because a lot of people are aware of those links. Um so it comes up quite a bit, and they want to know if we can prove it. And I don't have a good way to prove it, right? We just know historically this increases your risk. But can we say, you know, can we prove it? No, not really.

Michael Kentris: 16:12

Fair enough.

SPEAKER_02: 16:13

Unless they're really actively toxic, I guess.

Michael Kentris: 16:16

Right. Like if you get some blood marker.

SPEAKER_02: 16:18

Yeah.

Michael Kentris: 16:19

Like I know uh I think it was a fellow from your institution. I I've got some pawpaw trees in my backyard here. If you're we talked about this before, I think, off off of recording. Uh I I think it was a a fellow of what uh another mutual friend of ours, Sirajin Raj Rajan, but his co-fellow at the time had written a paper about this chemical in the pawpaw fruit, which uh I think they call them like Appalachian bananas or Appalachian mangoes. It's somewhere between a bang m a banana and a mango flavor-wise. Anyway, it's got this chemical that's been linked loosely with with developing Parkinson's disease. We haven't grown any on our trees, but maybe someday.

SPEAKER_03: 16:55

For better or for worse.

Michael Kentris: 16:56

Right, right. So anyway, uh yeah, active exposure, as you were saying. But uh any other big historical questions that you kind of just incorporate into your routine tremor evaluation.

SPEAKER_02: 17:08

Aaron Ross Powell Medication history is a must. Right? Sometimes that is the easiest way to treat a tremor, and it's something you don't want to miss. We know that dopamine blocking agents can increase risk of tremor, Parkinsonism, other movement disorders, but there are other medications too, certain anti-seizure medications, right, can cause tremor. Michael, I'm sure you're familiar with that.

Michael Kentris: 17:31

I I had someone on Limotragene ask me about that just this last week, and I had to say, because they they asked me, you know, what do you think this is from? I'm like, your meds probably. So yes. Uh and then we have to ask, like, do you want to do anything about it? Which is that's a whole conversation, right? Whether it's for psychiatric reasons or seizures or any other, you know, cardiac reasons, what have you.

SPEAKER_02: 17:54

Yeah, exactly. Yeah. Because there are a a list of medications that can cause tremor. One of your clues that that this might be more drug-induced rather than Parkinson's is that if the tremor is very symmetric and bilateral, people with Parkinson's course can have tremor involving more than one limb, but it tends to start off asymmetric or tends to dominate in one hand in the at least in the beginning.

Michael Kentris: 18:16

Yeah. So let's let's dive more into that like physical exam part, right? Because we we have like the routine parts of the movement or coordination or whatever term you care to use, institution-dependent, I think.

SPEAKER_03: 18:29

Yeah.

Michael Kentris: 18:30

What are the what are the things that everyone should be doing? And then what are the things that you add in that you think are missed opportunities for either someone in primary care or even even general neurology?

SPEAKER_02: 18:40

So oh, that's a good question, because I'm obviously so heavily biased now towards the movement disorder exam. But I wouldn't expect a primary care physician to do a full movement disorder exam. I think looking for signs of braidokinesia, so even if they're not doing, you know, every single type of movement or exam maneuver that you could do to elicit that, at least doing finger taps, right, to see amplitude and speed. And we can do foot taps too. I prefer to do it one hand at a time. Sometimes interesting things come out if you do it one hand at a time, like mirror movements, right? Which is non-specific, but indicative of some kind of underlying process, neurological process going on, right? Like I wouldn't expect to see mirror movements with a central tremor, but I definitely see it in Parkinson's disease. So yeah, again, it's not really very specific, but it is it's interesting. It's it's another clue. Other key maneuver. So specifically for tremor, you want to evaluate tremors in a rest position. Well, three positions at least, right? Or four. So to evaluate for a rest tremor, you have to have your patient fully relaxed, which can be hard to do. So I'd like to have them not on the exam table but in a chair, you know, feet flat on the floor. Ideally, uh, the more formal way to do this is to have their hands dangling off the armrests, but you could also have it resting in their lap. That that's also acceptable. And I Have them close their eyes and I give them some type of cognitive loading test because sometimes a rest tremor doesn't emerge at all until you distract them, basically. So I usually have them do months of the year backwards, but if that's too easy, then I might do serial sevens and go from there. One time I had someone name the presidents backwards and that brought out the rest tremor. But they were really good at math. Like they did serial sevens faster than me. I mean, I guess I'm not that great at math, but it was very impressive. Yeah. So that's rest tremor. And then evaluate for postural tremor, so arms outstretched. And you would want them to keep that position for at least, you know, 20 seconds, because sometimes a tremor doesn't appear right away, but there's something called postural re-emergence tremor, which is basically a rest tremor that emerges when you this becomes their new rest position. So it's worth having them hold their arms out a little bit longer.

Michael Kentris: 20:52

Now, with their with their arms out, are you a palms up or a palms down person?

SPEAKER_02: 20:57

Palms down.

Michael Kentris: 20:58

All right.

SPEAKER_02: 21:00

I feel like I don't even check for pronator drift anymore because it's just not as relevant to my exam as a movement specialist.

Michael Kentris: 21:07

Yes. Now when we're looking for that re-emergence tremor, so for people who aren't familiar with that specifically, what are we looking at in in their hands, their fingers, etc.

SPEAKER_02: 21:17

So it will look similar to the rest tremor that they may have had their hands with their hands in their lap. And again, there should be rhythmic and oscillatory around one joint. I think the common description that people hear is like the the pill rolling tremor, like with a thumb. I think that's a decent description. I mean, but sometimes it's around the wrist. You know, this is one problem with podcasts. I'm just realizing as I'm demonstrating.

Michael Kentris: 21:40

So all right. I mean, but yeah, if we think back to like the pill roll, imagine like like you said, someone holding a pill between their thumb and one of their fingers and they're rolling it back and forth, right? Like that's that's the movement. Yes. And then if we just extend that movement, like it's the same pill, but instead of the fingers moving it, it's the whole wrist moving the around the pill, right? Would that be accurate to say?

SPEAKER_02: 22:02

I think that's fair. It's harder to describe a wrist tremor, but it is. Yeah. Again, I think the the frequency, the oscillation around the wrist joint uh is what makes it a tremor in the first place. Um Go ahead.

Michael Kentris: 22:15

You mentioned frequency. So the what kind of frequency are we are we looking at? And how do you count frequency? Like do you do it by a watch? Or is it just like ingrained in your neurologic sensors now?

SPEAKER_02: 22:28

I think it's just ingrained now. I mean, uh to be honest, I never really measured frequency.

SPEAKER_03: 22:34

I know. Yeah, Roger would be disappointed.

Michael Kentris: 22:40

But I tend to think of like faster tremors and slower tremors. Yes. And what's what's your threshold for considering something a quote unquote faster tremor? Like about what frequency would you ballpark at?

SPEAKER_02: 23:09

You know, it's probably around like 11 Hertz or something like that. Um that would be a pretty fast tremor. More common, I would say, with like enhanced physiologic tremors tend to be fast, low amplitude and fast. So the other thing was the amplitude of the tremor. But there's so there's such a range. Even within Parkinson's, you know, a breast tremor can be very subtle and small. And sometimes I just see it in the thumb. They're not even rolling the pill with two fingers, they're just with one finger, you know. And so And that's why I don't anchor around, you know, the f the frequency and the amplitude so strictly, because severity matters here too. And someone with essential tremor could have a much more severe tremor than someone with a Parkinson's tremor, right? And so I don't like to use it as a way to I just don't want to over-characterize to the point where I'm not actually working on how is this interfering with this person's quality of life, if that makes sense. Yeah. But it it can be fun from a scientific perspective, from an academic perspective, right? Like we do like do characterize. Um, and we can get very nerdy about that.

Michael Kentris: 24:14

So I think as neurologists, we all like our taxonomies more than we probably should.

SPEAKER_03: 24:18

But uh Yeah, exactly.

Michael Kentris: 24:20

I wanted to revisit, if if we may, the term braidokinesia, right? And you mentioned a good point, right? It's not just that it slows down, but it loses amplitude as well.

SPEAKER_03: 24:29

Yeah.

Michael Kentris: 24:29

So I find, right, because a lot of times we're evaluating older patients and they have arthritis or some other joint restriction. How do you assess for braidokinesia in someone like maybe they've got just bad osteo or rheumatoid arthritis or some issue with their hands where they're already slow? Uh how do you deal with that situation?

SPEAKER_02: 24:50

So I think that's where different maneuvers can be helpful. So we talked about finger taps, which again, we're looking at the height, we're looking at the speed. And there's also hand grips, right? Opening and closing the hands. There's pronation, supination, right? So for our non-neurologists, palms up, palms down, repeating that movement over and over again as big as they can and as fast as they can. And examining all limbs, right? So hopefully there are arthritis or other things are not so severe in every limb that all limbs are equally affected and that I can't tell anything, right? We look at things over 10 taps, so 10 finger taps, 10 opening and closing of the hand. Typically, uh more minor disease will decrement, right? There will be loss of speed and amplitude towards the end of 10 taps. Someone who's more severe might not get to a big amplitude. They might start off small. Someone in the middle might decrement in the middle of 10 taps. So you're kind of watching how it changes in 10 taps because a normal person should be able to maintain speed and amplitude across right doing something 10 times. Now, we will all eventually decrement and slow down if you do it long enough. I don't know what the limit is for a person without a neurological condition, but but just thinking about not just one tap, right? But like over the span of 10 finger taps, what that looks like is helpful. Gotcha.

SPEAKER_01: 26:16

When I think of brady kinesia, I actually, and I'm teaching the non-neurologist, I like to comment on all the various ways that you can observe it, especially the ways that are not participatory in the sense of, you know, asking them to finger tap. So I do like to pay attention to the face of my patients and their expression. And of course it can be a little bit challenging if you're meeting someone for the first time, but thinking about expressions and even the speed of the expression, like you may say something funny and they do smile eventually, but there's a delay. Um, I also find that there's more of a not necessarily staring, but because of the reduced blink rate. That's something that you can compare to your own blink rate and you can notice in the exam room without saying anything at all. And I always sort of joke that, you know, I often diagnose or start to consider the Parkinsonism when I get them from the exam room and they're opening their briefcase and they're trying to stand up and and uh you over time start to know what you can observe even before you get to the formal testing and the finger tapping and the toe tapping. Are there other things that you observe, Ashley?

SPEAKER_02: 27:22

I was gonna say, uh sometimes that's your best observation, right, when you're bringing them from the uh from the waiting room to the exam room because they don't realize they're being observed. I think when you specifically ask to do particular maneuvers, I can't tell you the number of times I've had spouses tell me like it's much worse at home. Um because they're performing for you, right? They're trying to do the their best. And so to some degree they're going to consciously or subconsciously suppress the degree of severity of their movements. Yeah. So I love that. I I also use those strategies too. And uh global braidokinesia is something we actually score. So, right, looking at them holistically of how slow they are, looking at mass faces and they reduce blink rate, bradyphrenia, right? Slowness of the eye. Yeah.

SPEAKER_01: 28:06

Can you talk a little bit more about leg tremors? This is something that I have to confess I didn't see very often as a resident and only recently started seeing as a general outpatient neurologist where that might be the first complaint. And I'm realizing that while it might be atypical for Parkinsonism, Parkinsonism is so common that leg presentation can't, you know, is on the differential when they first come in. So how do you look at leg tremor when that's the main presenting complaint? And this is sort of asking for a friend, right? So I can improve for next time.

SPEAKER_02: 28:42

Well, that's a good question. And and I it's probably less common than arm tremor, but you can have leg tremor with Parkinson. So similarly to arm tremor, it's more likely going to be unilateral or it's going to affect one side more than the other. So that's a clue towards Parkinsonism. It can still be a rest tremor, right? So they're doing nothing with their legs and it starts bouncing, right? As opposed to having them extend their legs out and now you're looking for a postural tremor. The other question is if it's more of like an ataxic. So we say a toxic tremor, but again, if you're purist, it's not really a tremor, right? It's not rhythmic and oscillatory. But unfortunately, our terminology is like that. So is it more of a coronation problem than a true tremor problem? Is also a good question to ask when you're looking at someone's leg. Vascular Parkinsonism classically affects the lower extremities, the legs, more than the arms. And so if you have someone that has more symptoms isolated to the legs, that's a clue toward vascular Parkinsonism. Now, I definitely have had patients with vascular Parkinsonism that can look a lot like regular Parkinson's disease. So it's not exclusive, but it's something to think about.

SPEAKER_01: 29:52

Learn you said there were four positions in which to test tremor. I think we got through two.

SPEAKER_02: 29:58

Yeah. So uh postural tremor, we said arms outstretched, but also then, you know, close to the chest. I asked them to bring their arms in. Sometimes that brings out more of a proximal tremor, right? The classic thing that we think about is wing beating where their arms are sort of flapping. I actually have not really seen that very often in my day-to-day practice, but and that might clue you more towards some other disease entirely, uh, away from Parkinson's. I find that people with Parkinson's might just have more postal tremor here in the distal, like in the hands, that maybe didn't emerge out here as much. So I still check both positions and then looking for a kinetic tremor, finger to nose, is the movement smooth? Is there more tremor as they approach the target? Is there tremor throughout? Someone with Parkinson's can have any combination of these tremors, but if we're using the tremor towards a dynastic criteria, we're looking for the rest tremor. Somebody with essential tremor in theory should not have a rest tremor, right? Or drug-induced should not have a rest tremor. So those are some of your key clues there too.

Michael Kentris: 30:59

For finger-to-nose testing, right? It's something that I think is taught very early in medical school, and I think is not taught particularly well. Yes. What are your opinions on that? Uh, what are your pet peeves on finger-to-nose testing and how can we improve it?

SPEAKER_02: 31:15

That's such a funny question. So you're right. We traditionally teach students to move the target, right? I think that's one thing. Um, as a screening exam, just so as a general neuroscreening exam, I think that's perfectly acceptable. If we're more concerned about their coordination, I I have been taught as a movement disorder specialist specifically to hold my finger in one place so that I can examine, focus on the like, is there a kinetic tremor, is there an intention tremor? Um, rather than kind of testing if they can follow where I place my finger at the same time, right? Because you're making that move a lot more complicated, which I think then actually reduces your sensitivity.

Michael Kentris: 31:57

Man, I've been doing it wrong. I need to straighten up and fly right.

SPEAKER_01: 32:00

No, I actually think that's such a good question because there is a difference between kinetic tremor or action tremor and then the intention tremor and the end target. And those are very different.

SPEAKER_02: 32:11

Yeah. We tend to lump those things together, right, in the traditional way of doing it.

SPEAKER_01: 32:17

And that's usually what's mixed up in the reporting by my resident is coming to stop the case. I said, let's do it again together. Yeah, right. It got worse with movement, not that it was uh worse at the end target. Yeah.

SPEAKER_02: 32:30

Those things are easy to miss if you're moving your target.

SPEAKER_01: 32:33

I actually find that some patients will bring in videos of like what's happening at home, or you may want to take one. I feel like movement disorders as a subspecialty is famous for videos. Yes. What's your practice, Ashley? Is that something you do? I some of my colleagues do it regularly for every patient as part of like part of their chart.

SPEAKER_02: 32:53

I have actually thought about that, but I don't have like the dedicated camera equipment and storage to do it. But I've been thinking about doing that. I know uh someone in our division did buy some equipment, which no one seems to know where it is right now.

Michael Kentris: 33:09

Um It's in their trunk.

SPEAKER_02: 33:11

Right, right, exactly. So it's on the move. It's on the move, right? Yes, moving away from the movement disorder division. I do think it's good practice. I actually think even for the general practitioner, it's nice to have video evidence, especially if you're not sure how to characterize the movement, right? And if you can attach it to their chart, which I feel like a lot of EMRs are now allowing short videos and in addition to photos to be attached to the chart, it's nice because then you have something to compare back to as well as things may evolve over time.

Michael Kentris: 33:44

Yeah, I f I found for kind of these episodic things, especially, it's very helpful. Obviously working in the seizure world a little bit there. It doesn't usually happen in the office. So it's let's just say exciting for lack of a better word when it does. But uh yes, I've had some folks upload videos to their my chart and stuff like that, and it it's it's been very helpful.

SPEAKER_02: 34:04

Yeah. Yeah. Um I've had a patient who would refer to me for some type of movement that happens at night. Uh the working diagnosis, um, he had a cardiac arrest, and so there this was thought to be myoclonus from anoxic brain injury. Neas MRI looked fine, which uh doesn't totally rule out any anoxic brain injury whatsoever, but it was a little difficult because he had no abnormal movements in person. Actually, he had a mild Parkinsonism, but he was also on an atypical antipsychotic. So not helpful, but that's where things can get murky and complicated, I guess. But there are tools then that could be helpful in those kind of instances. Sometimes a question comes up if someone's had drug-induced Parkinsonism or drug-induced tremor, or is there underlying Parkinson's and the drug unmasked it? Right.

SPEAKER_01: 34:57

So I actually I actually had that question because I I myself take the practice of trying to follow patients for a little bit of time before I kind of feel like they're leaning more to one way or the other. And I'm wondering, what's your threshold? Is there is there like five years of essential trauma that hasn't changed and okay, done? Or is there is that could practice that can still emerge? Like, do you have a timeline or do you have a practice around counseling patients when you give them that diagnosis? I just I've I've definitely learned that they can coexist or they can evolve, but I've never learned like to what extent or until one timeline.

SPEAKER_02: 35:38

Yeah. So depending on which studies you read, um, essential tremor, people with essential tremor can have a fourfold increased risk of developing Parkinson's disease compared to the general population. So I at least, if I'm seeing this person once a year, I try to at least do a screening exam to make sure they're not developing signs of Parkinsonism, at least, you know, on that basis. Um we talked about earlier about how essential tremor, by definition, you know, if we're looking at the criteria, you expect there to be some tremor without any other neurological, like uh without Parkinsonism, without dystonia, without ataxia, for at least three years. So that's something else I keep in mind in terms of timeline. People with Parkinson's disease tend to slowly evolve over time, right? We know that symptoms probably start decades before their first motor symptom with dream enactment, with constipation, with loss of smell, all of that. And so that back history is helpful too in terms of your pretest probability, your clinical suspicion, and how much you're gonna monitor and how much you want to do as a workup. Because clinically, if they really meet criteria for Parkinson's, right, you don't necessarily have to do a whole lot of scanning and testing. You could initiate treatment. This was actually something I was t just talking about with some of our internal medicine residents uh this morning. You know, a lot of them told me that they wouldn't feel comfortable starting Cinemed, which I find interesting because Cinnamon is pretty well tolerated, right? It's a pretty benign medication. There's no permanent side effects. Like it kind of boggles my mind how I've seen some primary care physicians, and not not my residents, but outside. So obviously I have a referral bias here, but I've I've seen uh some people come with uh drug-induced Parkinsonism. And the first thing that was given to them for depression was an atypical antipsychotic.

SPEAKER_03: 37:32

That's weird.

SPEAKER_02: 37:33

A little disturbing to me. Yeah, right. That doesn't seem like normal practice. Um, but I I have seen that happen. And so to me, like if you're comfortable starting an atypical antipsychotic or other medications, right, that have higher side effects profiles, I don't think there's a good reason to be scared of Cinema.

SPEAKER_01: 37:50

So oh, go ahead, go ahead. I think that you actually hit on something that I was interested in, right? Which is like what is the initial role of, say, the primary care physician seeing the patient? And maybe we'll talk about management, but before that, is there a set of screening labs that you think they should get, or is there imaging that's helpful to get at that stage? Or would you want them to just get their best hit at the exam and then refer if they think there's a tremor or they think there's a movement disorder? Like what are the initial specific labs or imaging and then how can they get started?

SPEAKER_02: 38:24

Yeah, I think because we know that the wait time to see a neurologist can be a while, it would be good for them to start the initial workup and even start some of the initial management treatment. I think that's only fair to our patients who are waiting to be seen. And I do think that it's not always super complicated. So you may not always need, you know, a movement disorder specialist, but of course, if you have one available, it's it's nice to have. And I don't think early referral is ever hurt, right? So it's not a bad thing. But initial workup. So if we're just talking about tremor broadly, if they are on medications like, I don't know, lithium, right? You could check a lithium level and make sure they're not toxic.

unknown: 39:02

Right.

SPEAKER_02: 39:02

And there's seizure medications that are we could check levels too, and for the same reasons. TSH is probably always a good thing to check, and probably something that's being screened anyway by a primary care physician. But we know your diarrhea could do a lot of things. So those are some maybe an initial lab workup that I would think about. Um, I feel like uh Wilson's disease is a lot, you know, those things are caught earlier now these days, because we have better screening at birth. But if you are concerned that a person didn't have all of those screening and maybe they have more than a tremor going on, they might have some combination of odd movements and maybe they have some psychiatric history and they're younger, you know, on the younger side, that might be a good reason to check copper and ceruloplasm. So I think if your suspicion is high enough, that's reasonable. Certainly no one's gonna blame you for checking copper and ceruloplasm anyway. But I guess a word of caution there is if someone's on an oral contraceptive, sometimes that artificially changes your copper levels.

SPEAKER_03: 40:03

That's good to know.

SPEAKER_02: 40:04

Yeah. I learned that as a fellow when I ordered copper levels. And I was like, wait, I didn't really have a high suspicion for Wilson's eye. My attending just told me to order it. Yeah. So you gotta know what. you're going to be doing with that test result, right?

Michael Kentris: 40:19

The eternal curse.

SPEAKER_01: 40:21

This is actually a bit of a side note, but it did remind me I went to a talk recently where the person shared that actually women are more likely to be underdiagnosed with Parkinson's. It can be slightly different presentation. And I'm curious what you've seen and what's the advice to make sure we're catching our women with Parkinson's sufficiently early.

SPEAKER_02: 40:43

Yeah, I've had a patient who's actually she was a retired internist. So that's, you know, feels even more horrible that she was kind of dismissed when her symptoms started. I think it's easy to dismiss early signs as like, oh, you're just getting older or ah, it's not that big of a deal. And so we need to check our biases really. And that can be true for both men and women, but for some reason I think unfortunately, I think you're right that women do tend to fly under the radar more. But I don't necessarily think it's because their symptoms are just more subtle. I think that's just our biases.

Michael Kentris: 41:22

Aaron Ross Powell I mean that kind of bears out across other conditions as well where women are just in general underdiagnosed. I mean for like even just like acute coronary syndrome and you know kind of really common stuff like that.

SPEAKER_02: 41:33

Aaron Ross Powell Right. And I mean we know the origin of the word hysteria, right? So an unfortunate history, but I think that tells you everything there.

Michael Kentris: 41:42

Aaron Ross Powell Should we talk about treatment? I think we I think we should give it a give it a quick stab.

SPEAKER_03: 41:48

Yeah.

Michael Kentris: 41:49

So well before we do that just like if you had to say like overall what are like the three or four most common types of tremor that you that are floating around out there in the in the general population?

SPEAKER_02: 42:01

Ooh, okay.

Michael Kentris: 42:02

Well sorry I didn't mean to ask a stats question.

SPEAKER_02: 42:05

Yeah I don't know if I know s like the actual numbers but I'll just say from my experience.

Michael Kentris: 42:11

Yeah.

SPEAKER_02: 42:11

So I would say essential tremor is common but then I again I raise the question of how many essential tremors are true essential tremors and if you put a room of movement disorder specialists together there might be a lot of variability in that answer. That surprises me not at all right um but Parkinson's disease is on the rise so I would say that's also out of these disorders right I think that would is pretty common too I do see a lot of dystonic tremors that are misdiagnosed as essential tremors. So I would say those are kind of my top three tremors. Enhanced physiologic tremor I think most people capture easily and aren't not worrisome. So I'm sure they're very common but not something we worry too much about.

Michael Kentris: 42:56

So let's let's start with essential tremor if it exists. If you're going to be starting someone who's got let's just say you know it's it's bothering them, they're spilling their drinks they can't eat their soup, what have you they want to take something medication wise. Or I should say what about non-pharmacologic options to begin with?

SPEAKER_02: 43:13

Yeah, that's a good question because I have plenty of patients who are like I take enough medications. I think it never hurts to send someone to occupational therapy to work on strategies to help mitigate the tremors. There are tools that have been designed to help with tremors like weighted utensils. There's something called like liftware at least that's one company I probably shouldn't say a particular brand either but yeah those are some of the common tools out there. There is a stimulatory device that you wear around the wrist that it has been approved for essential tremors and called a Calatrio device. I honestly haven't had huge success with it but it's a it exists. It's also yeah it exists. It's it's um I'm just saying from my personal experience we are not sponsored by Calatrio. Oh yeah clearly not yeah that's my bias though so I've not looked up their uh like any trial data for them.

SPEAKER_01: 44:05

I think actually earlier you made the good point about like what is your functional quality of life because they do have some other devices that maybe have serve a smaller population but for example like a pen for artists or I had a patient who had a special bracelet for playing guitar because it would help steady his hand and so kind of thinking about those as you said I I love to you know get occupational therapy colleagues on board. There's I think also like these utensils that vibrate and they match and counter the exactly stable oscillatory frequency. Yeah yeah pretty cool yeah it's a true tremor you can set it to one page to one frequency and then the the soup ends up still so that's what that can be.

SPEAKER_02: 44:52

I have a patient with Parkinson's disease who has breast tremor and a kinetic tremor who bought some random vibratory product off of Amazon. Luckily it was not something expensive and she's you know anecdotally told me that it's worked really well. So but probably off of those same principles right of something that is emitting vibrations at a particular frequency that counteracts the frequency of the tremor. So it's pretty cool. And there is also another um like there's makeup products too for women with essential tremors to apply mascara. It's like weighted. So yeah there's all kinds of things out there actually which is nice to see that these kind of things are coming out more and more. So yeah there's a I like to get occupational therapy involved for this too. Of course a lot of times patients do also want something that might feel more like a quick fix, right? Which it's not we know that's not always the case even with a medication. But the common medications that we use are propanolol, providone. You could use them in combination because they can have a synergistic effect, although you really do have to watch out for side effects. I like to ask people to you know get a baseline heart rate and blood pressure before starting and have them monitor it when they do start, start low, go up slowly so that we don't I'll just say so we don't cause side effects.

Michael Kentris: 46:12

One of the things I'm running into a lot because again right an older patient population in general is that they're already on a beta blocker, like a tenolol or metoprolol or something else. Do you ever recommend they talk to their their family doctor or their cardiologist about changing to propranolol, assuming they don't have any like asthma or some something like that.

SPEAKER_02: 46:31

Yeah I love that you brought up assuming that you don't have asthma because um that's something I've included in one of my like learning modules as a a thing to think about. Yes. So if you if to answer your question, you definitely would want to work alongside the cardiologist and ensure that this is not going to be detrimental from a cardiac perspective because a heart attack is not worth controlling your tremor.

Michael Kentris: 46:55

Says you. No I'm kidding specialist.

SPEAKER_02: 46:58

I know right normally I'm just like ah heart yeah but no I'm kidding.

Michael Kentris: 47:01

But one of the things I find and I I'll be honest I had kind of a revelation about this but uh dosing is not what we would expect typically right we get a lot of these electronic medical records and for propranolol they recommend a certain dose and Primadone they recommend a certain dose kind of out of the box uh which may not be appropriate. So where are you starting with these medications generally?

SPEAKER_02: 47:24

Generally I still start at the lowest dose and try to work up to something that's therapeutic because and this is just my general practice across medications, right? If we can get away with the lowest dose that helps and avoid side effects, I think that's always better. I want my patients to feel better, obviously but sometimes when you start at a higher dose too quickly and they have side effects then you also kind of lose your patient's trust right they're like oh my God this happened that I don't want to go back and see this doctor. Or even if they do come back they're like well I don't want to try this at a lower dose I just give me something else right and unfortunately there's not a lot of options with high evidence for efficacy for the treatment of essential tremor. Apropranolol and Premadone are your highest people will try Topamax but that has its slew of side effects. Gabapentin is I never really had good success with that. So you start getting into your kind of B level medications and that's yeah it's not as efficacious.

Michael Kentris: 48:21

It always felt like the B level essential tremor meds are really just like well let's just try any of the old seizure medications and see if that does anything. I kind of feel that way too is that accurate or is that just like my impression?

SPEAKER_02: 48:33

Aaron Ross Powell's my impression too.

SPEAKER_01: 48:36

It's there. But it's a B level for a reason. What ranges do you find to be useful actually for perpranol and permidone? Like what I know it varies for every patient with a good therapeutic range.

SPEAKER_02: 48:46

Yeah I was gonna say it really does vary for every patient. So I don't really have a set target range um because it's just it is so variable where they might encounter side effects versus benefit. And so I've had people on as low as you know 10 milligrams three times a day. And then I've had people who I will switch to Inderol when you know they get up to a dose that that's appropriate. But yeah, it's a lot of variability.

Michael Kentris: 49:18

Something I I've seen is a lot of primodone overdosing out of the gate. Yeah. And I I think the problem because I've been reflecting on this a little bit uh recently is that it's seizure it's anti-seizure dosing, not tremor dosing.

SPEAKER_02: 49:33

Okay, yeah.

Michael Kentris: 49:35

So they're starting it at a higher dose than probably to yeah. So like it in our in our hospital system it defaults to 50 milligrams three times a day. Yeah exactly right yeah which for those who aren't familiar is a high dose to start with yeah most people are not going to tolerate particularly well and that has been my experience when people show up from the hospital in the office and be like I'm so tired all the time.

SPEAKER_02: 50:01

Like I bet you are calling because I'm just like yeah yeah right and yeah if I can I try to start with propanolol overprimidone if there's no contraindication properol. But sometimes you can get away with low dose primidone and propranolol together. Um yeah I feel like primadone's feels like a dirty drug to me sometimes. Because even at low doses people do feel its effects. True I've had a patient who did have tremor control with primadone but didn't like the side effects.

Michael Kentris: 50:34

And so probably probably my bias is as an epileptologist I I probably write primadone more than I do perprinolol dirty confessions. But um but yeah I think the problem right a lot of these TID three times a day dosing, primadone, right, it's it's pro-drug and that's about an eight hour half life but but for tremor right you don't have to dose it that way. A lot of times I'm just giving like 50 or 100 milligrams of bedtime and that works for a fair number of people.

SPEAKER_02: 51:04

Yeah um I usually do daytime dosing because that's when their tremors going to bother them but sometimes I'll start with just once a day and like just just try it out right to see if it works at all and how you feel on it before doing multiple times a day dosing. And you can maybe get away with even twice a day because again as they're approaching the evening and if they're sleeping right they they don't really need it. Because most tremors go away in your sleep.

Michael Kentris: 51:28

That's a good point.

SPEAKER_02: 51:29

Yeah. So I'll I'll woke up um I'll I've had some patients maybe take a third dose if they know they're gonna go out, right? And maybe they want to enjoy like a glass of wine and they don't want to spill the glass of wine right because that's a real scenario right people are like thinking I'm drunk and I'm not and you know it's like I just have this tremor, right? And they're worried about judgment. So sometimes I give them a little bit of that flexibility. And once we know that it's working well and that it's not causing side effects. Yeah.

SPEAKER_03: 51:59

Awesome.

SPEAKER_02: 52:01

I had a patient who felt pretty sensitive to effects of even just 10 milligrams of propanolol but basically would use it in only specific scenarios.

Michael Kentris: 52:10

That makes sense.

SPEAKER_02: 52:11

Like giving a presentation. So I maybe that was also performance. Maybe it helped her with two things I don't know. But um she did have a central tremor and it seemed to help. But she just couldn't take it regularly.

Michael Kentris: 52:22

I I know we're kind of running up against our time but I have to ask you about about starting carboidopa levadopa for Parkinson's patients. Because as you said, right, a lot of people I've had plenty of referrals where the the primary care doc accurately diagnoses the patient but then as you said doesn't start the medication. So so my first question is why do the 10 100 tablets exist? What do we do with them?

SPEAKER_02: 52:50

Throw them out I don't know why I I just talked about this with my internal medicine residents this morning. Like you know after I just told them right start low, go slow, the 10 milligrams right represents carbidopa enables more levadopa to cross the blood brain barrier and get converted to dopamine and so that there's less peripheral conversion of levadopa to dopamine and therefore also less nausea right because and that's where the name Cinemat even comes from right like scene without emesis basically right.

Michael Kentris: 53:25

I love a I love a Latin pot.

SPEAKER_02: 53:28

A little trivia there. Yeah I don't know why the 10100 even exist because it does not make sense. Why would you put them at higher risk of having nausea and poor tolerance unless leva dopa crossing into the brain I didn't know if there was a rationale I there's that okay well then I will feel free to continue going on and disliking that it exists. Exactly you can join my club.

Michael Kentris: 53:53

So now this is something I've I've seen some debate about starting like do we start just like right at the gate, you know, three tablets, you know, you know every eight hours throughout the day do we start getting a little ginger you know ramp your way up over a week or two?

SPEAKER_02: 54:08

What's your approach and kind of what what do you think best practices would represent so I think there is going to be some variation even among movement disorder specialists and also of course you always want to tailor your treatment to your patient. So if I have a high suspicion that they have Parkinson's disease and you know we keep talking about Cinemat as a totally benign medication. I mean it does have risk of certain side effects, right? So if someone has a lot of, you know, I only I wish our audience could see your face Michael and your eye roll so uh if our patient has orthostatic hypotension, right, I might be much more cautious about starting Cinemet because we know Cinema can drop the blood pressure a little bit and worsen that. And so maybe in that kind of scenario I'll start at half a tablet. But I usually still start unless it's really bad orthostatic hypotension, you know, I I will still start at three times a day because it is pretty short acting right the half life of cinema is something like 90 minutes. And so if you really want to see a change three times a day I think is a reasonable frequency to start with. And most people I'll start with one tablet three times a day. But yeah, some of these scenarios I might start at half a tablet if I'm just being super cautious. What if they have dementia and I'm worried about worsening that I mean it's hard to know how sensitive they'll be to the dopaminergic effects. So yeah I will have patients ramp up on their own. I'll give them a titration schedule and depending again on the patient, sometimes I'll do it weekly or sometimes I'll do it every two weeks, go up by half a tablet. Usually when they start reaching around two tablets, I'd like to see them back two tablets three times a day. If I can't see them back that quickly I tell them that they can go up to three tablets three times a day. And yeah it's it's good to get another exam in there somewhere though to see what their response is because sometimes they may not notice what's improving, right? Especially depending on what symptoms bothering them the most like for example, sometimes tremors are just stubborn and maybe the tremors not improving as much as they would like but there's some improvement. Or maybe the tremor's not improving but the braidokinia is and so it's really helpful to know if there's any effect at all. Right? Because we do expect in Parkinson's disease to see a response of some sort.

Michael Kentris: 56:25

Yeah it's it's funny you say that because a lot of times I've I've got a few of these uh you know pleasantly cantankerous older gentlemen in my practice and uh they'll come in and they'll say like I don't know that it's doing anything and you know their wife will be sitting next to them like what are you talking about?

SPEAKER_02: 56:40

Like you're walking so much faster you know exactly exactly so helpful to have that additional history and also helpful to have your objective exam. Yeah.

SPEAKER_01: 56:51

Very much I think what's been really nice is getting to know the full kind of person of my patients with Parkinson's as you treat them and they're kind of not not you know they not let's say like that sort of kind of a lie but I had one patient in particular comes to mind where we first met and it wasn't that we weren't building rapport but I was sort of like oh like usually I have you know a little bit more rapport and then as he bec as he was better treated he just had like just a natural connection you know in terms of face like facial expression and kind of was more open as more fluid conversation and it's been really interesting to have that experience of meeting someone you know prior to treatment and then getting to actually know them more as a person throughout the treatment.

SPEAKER_02: 57:37

Yeah. You brought up a good point because I think in Parkinson's disease we tend to think a lot about the motor symptoms but we should also think about non-motor symptoms. Mood, depressed mood anxiety can happen in over half of people with Parkinson's at any stage of the disease, even pre-motor, right? And so we don't want to neglect other things that can also sometimes affect their quality of life even more than the tremor or the braidokinesia. The flip side of that is sometimes because of their reduced facial expression people can look depressed but are not depressed. And so sometimes I have family members saying like oh I think he's so depressed and always good to get the perspective of the patient as well and having good rapport helps know how reliable their own history is too but yeah generally I I try to ask well do you feel depressed? And they'll say well no I'm fine right they just don't smile as much. Absolutely. Yeah and yeah Cinemed could help with that.

Michael Kentris: 58:32

Any any final thoughts that you would have for for a primary care doc or primary care practitioner who's seen tremors in the office? If it's if it's beyond this, just send them your way, send them to their local neurologist. But should they go ahead and just start some of these medications if they think it's reasonable?

SPEAKER_02: 58:49

Yeah I think so as long as they are able to monitor the patients. Again, unlike an atypical antipsychotic right some dopamine blocking agents we know not only can cause secondary movement disorders, but sometimes it's permanent. Like you can remove the offending drug and they can have persistent movement disorders that just doesn't go away and it was from the medication. That doesn't happen with carbidopable yeah prescribing some of these other medications it's I encourage people to not be afraid of cinema.

Michael Kentris: 59:20

Right.

SPEAKER_02: 59:20

The 25100s of course yes yes throw out the 10100s that are worthless.

Michael Kentris: 59:25

Awesome well I I feel like I learned some things today. How about you Galina?

SPEAKER_01: 59:30

Yeah no I'm just wrapped with attention I feel like I got to ask all my you know general neurology to move at disorder specialist questions and hopefully our PCP colleagues learned along the way too because I certainly learned something tonight.

Michael Kentris: 59:46

Yes and we didn't even get like we restrained ourselves I think quite brilliantly inasmuch as not going deep into the weeds of uh all of the various dopaminergic medications that we have in the armamentarium. So despite my my own secret desires to know more about when do I use these strange things. But hopefully at a future date we will we will have you back and talk about just those things for the you know to be announced subspecialty series. You heard it first here. But uh yeah, hopefully at some point in the future, uh, we'll have you back and be able to answer all of these very esoteric neurology questions for us.

SPEAKER_02: 1:00:29

I would love to be back. And in the meanwhile, though, I'm gonna do a uh a shameless plug. I worked with the Parkinson's Foundation on making a fundamentals course. It's the target audience is healthcare professionals, including the non-neurologist. And it goes over a lot of these things in the uh videos like 40 minutes. It was meant to be sort of like crash course style. So it's also CME. I think if you just Google the Parkinson's Foundation fundamentals of Parkinson's disease, it should come up.

Michael Kentris: 1:01:00

We can probably put a link in the show notes if you want.

SPEAKER_01: 1:01:03

Yeah, I know that Ashley Paul, you made some other resources available, so we can put those in the show notes for folks who after this our crash course podcast want the supplementary 40-minute crash course video. They're gonna be able to click right directly.

SPEAKER_02: 1:01:24

Yeah, yeah. I mean, for those out there who are more visual learners, there's some nice graphics in in the video.

Michael Kentris: 1:01:30

Excellent. Well, Dr. Paul, thank you so much. And I I always appreciate the chance to talk with you and pick your brain about uh everything related to tremors. So thank you again.

SPEAKER_02: 1:01:43

Oh, thank you for having me. I love being here.

Michael Kentris: 1:01:46

I nearly forgot. If people want to find you online, where should they look?

SPEAKER_02: 1:01:51

Michael, you know that I'm not good at being online, but I do have a Twitter or whatever we call it now these days. I still the the council exists and it's uh shaking palsy. Palsy spelled like with my last name, P-A-U-L-S-Y. Um that's probably my most online presence right now.

Michael Kentris: 1:02:09

Hey, that's good enough. And as always, you can uh find me online or the podcast uh at neuro underscore podcast, and you can always find our past work at theneurotransmitters.com. Uh Galena, anything to plug today?

SPEAKER_01: 1:02:24

No, just to plug uh Dr. Ashley Paul one more time and thank her so much for the time today. Ashley, you're just not not only a superb movement disorder uh doctor, but also a superb educator. So thank you so much for being with us tonight and demonstrating all of your multiple talents.

SPEAKER_02: 1:02:44

Thank you. I had a blast, and I love these keys to hang out. What's some of my favorite neurologists?

Michael Kentris: 1:02:50

Too kind. Well, we'll have to do this again real soon. All right. Thank you, everybody.