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Mhm. Ok. Ok. Hi, everyone. Um, so it's been a way for everyone to join. My name is Bart. Um, and I'm joined with Niddy today and we're gonna talk all about tremors. Parkinson's um, Wilson's disease and all the other causes of tremor. Um, so we're just going to wait for everyone to join. Mhm. Ok. We'll make a start at about three past six, I think. Mhm. You. Ok, fine. So we'll make a start. Um, so, and if anyone has any questions, just please use the chat or shout out um we'll be happy to stop and we can go over anything. So, like I said today, we're gonna talk about tremors and I'm going to start today by talking about the neurological causes of tremor. But first of all, if you're new to teaching things, there are free tutorials open for everybody and we'll focus on core presentations and diagnostic technique important for the MLA. Um We're all UCL medical students usually fifth or sixth year. Um and we're doing it for medical students, but everyone is welcome to join and we're also reviewed by doctors to ensure that all our content is accurate. Um And you can keep our data via joining our group chat or our email pages. So I'm gonna talk to you now about Parkinson's and neurological causes of tremor. So the sorts of things that you might associate initially when you think of tremors. Ok. Um And it's important to have the distinction of what the different types of tremor are. So you've got resting tremors. So a tremor which is happening at rest and you've got various action tremors. So you can have a postural tremor where you're holding a position against gravity. So for example, if I'm holding my arm out, like, so that's a postural tremor, an intention tremor, which is only going to start when a person is going to move towards a target. So your very common one is your finger pointing, your pass, pointing. So it's the finger, the, the um nose to finger test where the patient might start tremoring. When they're towards the end of that movement, you've got your task specific tremors. So when it's writing or speaking and the patient might start tremoring at that point. So at that point, so they might have poorer handwriting or they might be a bit dis um dysarthric and you call your isometric tremor, which is slightly a difficult one to think about, but it's usually a voluntary muscle contraction that is not accompanied by a movement. So anything like when you're holding something still and you're not moving your arms at all, but you're using your muscles to stay in that position and you start tremoring. That's an isometric tremor. So you can think of it like if you're holding a plank position and your abdomen starts shaking because your, um, you know, you're, you're, you're getting tired, that's your isometric tremor where your body isn't moving, but your muscles are still engaged in um, in emotion and your causes of tremor. So, it's important to think about each of the types of tremor and what they might be caused by. So your essential tremor, which is a very, very common cause um is usually bilateral and there's an absence of any other neurological symptoms. So it's just a tremor, but it's completely benign. There's no reason for the tremor to be there. Um And it's usually inherited. So in about 50 70% of cases that this is an inherited tremor. So the patient might come in, they might have a tremor, but their father, their grandfather, um and the whole family history will also have had that tremor. You've got your function tremors too, which can appear as any form of the tremors that I mentioned previously. And these are usually any tremor and they can have a variety of symptoms which can often get worse with stress. So, if your patient comes into the clinic and they're very tremulous, you can think maybe this is a functional tremor and it can increase the tension and disappear on distraction so much like any other functional disorder where the patient is distracted where the patient isn't thinking about that tremor, that tremor may go away. So you can do this, for example, with a neurological examination and try and test sensation. And when the patient is focused on telling you if they can feel um your stimuli, they can maybe you can, you can look at the tremor and see if the tremor goes away. And then at that point, you can be going more towards a, a functional as opposed to a, an organic cause of the tremor, your dystonic tremors. So, when there's too much stimulation where you're dystonic. So, for example, um in an ocular gt crisis in serotonin syndrome or um any dystonic FF form, there's too much stimulation to those muscles. So your, your body is held in an unnatural position in a dystonic position. Um And it's often in the neck. So sort of your um neck might be pulled to a side torticollis, your vocal cords. So, laryngeal tremor or any limb at all. Um and it's usually a relief by relaxing or touching that affects the body part. So sometimes patients can relax at will if they can't, you can do fur um further things that can help relax. That body part, your physiologic tremors um are the fine amplitude tremors that are in hands and fingers. So usually they're not neurological. Um but anything like hypothyroidism, hypoglycemia, et oh withdrawal. These are your organic causes of tremor that are not neurological. So, these are the ones that nydia is going to go over later. Um, and they usually very fine amplitude hands, fingers very slightly tremulous. So you can imagine somebody who's coming up with an alcohol withdrawal who has this kind of tremor. Your cerebellar tremors are usually slower tremors and they're big wide amplitude movements. So the patient might have very, very large movements. Um, they'll worsen at the end of a movement and it's usually due to a stroke injury or chronic damage to the cerebellum. And again, it can be due to prolonged ethanol use, prolonged alcohol use. And finally, your orthostatic tremor is quite rare. Um and it's due to rapid muscle contractions when a person stands up. So much like orthostatic hypotension where a patient is standing up, moving from one position to another, there's a very quick instant movement and at that point that tremor is also starting, it's usually very fine. Um It may lead to some instability and the patient may have falls as a result of it. Um But if you can't see it, but the patient reports feeling tremulous, you can touch their calves or thighs and feel if there's any movement that shouldn't be there, any questions on any of that, any of those tremors that they're just sort of the general class of what the tremors might be. Ok? If not, I'm gonna move on. Um And so your essential tremor is very common. About 5% of the population will have an essential tremor and it tends to get worse with age and it will predominantly affect your upper limb. So your hands and your arms and it's going to worsen when your arms are outstretched in that postural position. So there's a postural tremor, usually bilateral as well. Um And it's going to worsen again with writing or purposeful action. So your patient may have again, poor handwriting, um or not have very good manual dexterity. Um Like I said, so it's usually symmetrical, unlike Parkinson's many other conditions which are asymmetrical and very much an SBA thing, it's relieved by eth ethanol, alcohol, exacerbated by anxiety and adrenergic stimulation. So, any excitement, anything um where your adrenaline's pumping, that's when the tremor gets worse. Um And your common management is going to be pro propranolol or Primidone similar to any um any of the thyroid tremors. And you can also use Botox or DBS. So deep brain stimulation if it's a very, very um annoying tremor, if it's having a big impact on the patient's quality of life. Um very common, very common in SBA. It's very common in um ACY and patients often come in with this thinking it's Parkinson's, but it's actually nothing. It's completely benign that there, there's no underlying neurological pathology that we should be very worried about. So we've got this question now. So you've got a 63 year old woman visiting her GP with trained hand tremors that worsen when she writes. Um So what kind of tremor is that? And she has a medical history of well controlled diabetes. Asthma managed with inhaled budesonide and Metformin on examination. She has a normal gait and then quickly alternate her hands between pronation and supination. So again, what kind of movement is that? Pronation, supination movement? What, what would we describe that as? Um, and we say the tremors are out are worse when the arms are outstretched and her voice is soft and shaky with the rhythmic changes to loudness. Um So I'm gonna put the pole up uh if you try and answer and then answer my questions. So tell me what um that pronation Super Nation thing is and also let me know what um the the the the worsening is with other things good. So again, so I've got one answer would be let's have a look. So try and vote on the polls, see what you think, intentional movements. Yeah. So it's whenever it's on intentions. So when she's writing, when it, so, so it's an intention tremor, right? Um And then when your arms are going from pronation to Super Nation, what might we call that difference? What is that called? Thinking of your neuro exam? And when you do it, um you know, on patients, especially when they sort of move and kick your arm away or um do this with their hands, what are you testing for which part of the drain would execute those kinds of functions? Ok, great. So, so we've got three votes for essential tremor. So it's an essential tremor. Um Yeah, I agree. Um That is correct. So, you know, a bit of a giveaway. That's what.