davidmeigs wrote:
> I thought I recalled hearing the term.  I have been preparing my journal of
> symptoms for the specialist (when ever my insurance gets off their #*!^$!).

                UNUSUAL SYMPTOMS IN PARKINSON’S DISEASE
(posted to PIEN, August 1994 by Alan Bonander)

By Lisa M. Shulman, MD, Clinical Research Fellow, and William J. Weiner,
MD, Director, Movement Disorders Center, University of Miami School of
Medicine.

Do you ever feel a tremor inside your body that cannot be seen by
others?

Forty-four (44) percent of patients with Parkinson's disease said "yes"
in a recent study conducted at the U. of Miami School of Medicine,
Department of Neurology, Movement Disorders Center.

This "internal tremor" is experienced in either the extremities, chest
or abdomen.  Commonly, it is reported on the same side as the other
parkinsonian symptoms, such as the typical observable tremor.

Internal tremor generally occurs in brief episodes lasting less than
half an hour and with a frequency of several times per week. Eighty (80)
percent of patients describe this as unpleasant, uncomfortable or
painful.

The sensation of internal tremor is the most recent example of a number
of sensory symptoms that have gained increasing recognition in
Parkinson's disease.

A variety of sensory phenomena such as aching, burning, tingling and
numbness have been previously studied.

Approximately 40% of patients report these sensations.

Similar to our findings in internal tremor, these other sensory symptoms
occur intermittently and often correspond in location to the side of the
body more affected by Parkinson's disease.

Internal tremor and other sensory symptoms of Parkinson's disease are
not simply a curiosity; they are a significant source of difficulty and
disability for many patients.

Sensory symptoms may appear early in the course of illness, perhaps
prior to the motor symptoms.

Both patients and physicians are less familiar with the sensory
manifestations of Parkinson's disease, impeding accurate and early
diagnosis.

Sensory symptoms are often not mentioned in descriptions of
parkinsonism.  This may be a source of bewilderment and concern to both
patients and family members. Additionally, both internal tremor and
other Parkinson's related sensations may be uncomfortable and of
sufficient intensity to merit specific treatment.

While sensory symptoms may be of special, or even predominant concern to
the patient, they pose a unique dilemma to the physician.  The doctor
must rely  totally on the historical accuracy and insights of the
patient.

Unlike the assessment of motor symptoms, such as the observable resting
tremor, rigidity, slowing of movement or difficulty walking, sensory
symptoms cannot be observed or objectively evaluated by the physician.

Identification and management will be optimized by precise reporting of
the timing, frequency, location and severity of symptoms.  Information
regarding factors associated with both the exacerbation and relief of
unusual sensation can also be helpful.

Interestingly, when patients with and without internal tremor are
compared, there is no difference in the duration or severity of their
Parkinson's disease symptoms. There also is no observable tremor alone.
The patients with internal tremor are far more likely to experience
other sensory symptoms (aching, tingling, burning, numbness) than their
counterparts without internal tremor.

What is the cause of internal tremor?
The answer to this question remains unclear, but we can speculate that
it may represent a very mild tremor that is too subtle to be detected by
observation.

If this is true, it is indeed surprising that there was no discrepancy
in the presence or severity of resting tremor.  More than 80 percent of
patients with Parkinson's disease have an observable resting tremor.

Alternatively, the sensation of internal tremor may have more in common
with the other Parkinson's related sensory symptoms.

The parts of the brain that are affected by the changes of Parkinson's
disease may play a role in the interpretation of sensory information.
Misinformation in the form of unusual sensory phenomena may be the
result.

In certain patients readjustment of the medications used in the
treatment of their motor symptoms can relieve the sensory symptoms as
well.

Although it is important for both patients and physicians to be aware of
the existence of Parkinson's related sensory symptoms, one must be wary
of developing an overly casual attitude to reports of unusual
sensations. When symptoms suggest other possible causes, appropriate
evaluation should be pursued to exclude these alternatives.

The potential causes of recurring sensory symptoms are numerous, and
need to be approached on an individual basis. While our knowledge of
these symptoms remains incomplete, awareness of the widespread nature of
this problem can be reassuring.

Further studies of the sensation of internal tremor are currently
planned at the U. of Miami to aid in both better understanding and
treatment of this previously undescribed symptom in Parkinson's disease.
-----------------
        Internal tremor in patients with Parkinson's disease
L. M. Shulman, C. Singer, J. A. Bean & W. J. Weiner Department of
Neurology, University of Miami School of Medicine, Florida 33136, USA.

Although sensory symptoms were not originally described in Parkinson's
disease (PD), in recent years it has been increasingly recognized that
painful sensations and paresthesias occur in approximately 40% of
patients.

It has been our observation that PD patients often describe a sensation
of internal tremor, a feeling of tremor inside the chest, abdomen, arms,
or legs that cannot be seen.

We investigated the prevalence and characteristics of internal tremor by
administering a questionnaire to 100 consecutive patients with PD and 50
age-matched controls seen in our movement disorders center.

A sensation of internal tremor was present in 44% of this sample of PD
patients and in 6% of the control population (p < 0.0001).

The presence of internal tremor was unrelated to Unified Parkinson's
Disease Rating Scale score, Hoehn and Yahr stage, duration of disease,
or the presence of observable tremor.

The frequency of other sensory symptoms (aching, tingling, burning) was
higher in the PD patients with internal tremor (73%) than in those
without (45%; p = 0.005).

Internal tremor is associated with anxiety in 64% of patients (p <
0.0001). It was described as uncomfortable and was unrelieved by
antiparkinsonian medication in three quarters of patients.

A sensation of internal tremor is commonly reported by PD patients and
should be recognized as a useful diagnostic factor in PD.

Source:Mov Disord 11:3-7  (1996)[PMID8771060,MUID96366946]

--
Judith Richards, London, Ontario, Canada
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