Hi everyone, the patient with Parkinsonian tremor has returned with vertigo-like symptoms.

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NOTICE: The free trial will expire in 2 weeks, on August 29th.

RECAP (from previous): 72-year-old male with a 9-month history of "Parkinsonian tremor" that was intermittent, right-sided, and large-amplitude, with a flexion pattern affecting the upper extremity more than the lower. Cervical retraction-extension abolished the right upper- and lower-extremity tremor during the session, and this improvement was maintained at subsequent follow-up.

MRI Results

Disc space heights: Preserved

C1-2: Unremarkable.

C2-3: No significant disc herniation, foraminal stenosis or spinal canal stenosis.

C3-4: Mild disc bulge. Right uncovertebral degenerative changes. Moderate bilateral facet arthropathy. Moderate left foraminal stenosis. Severe right foraminal stenosis. No central canal stenosis.

C4-5: No disc herniation. Severe right facet arthropathy and mild left facet arthropathy. Moderate left foraminal stenosis. Severe right foraminal stenosis. No central canal stenosis.

C5-6: Mild disc bulge. Moderate bilateral facet arthropathy. Moderate-severe bilateral foraminal stenosis. No central canal stenosis.

C6-7: Mild disc bulge. Severe right and moderate-severe left foraminal stenosis. No central canal stenosis.

C7-T1: No significant disc herniation, foraminal stenosis or spinal canal stenosis.

IMPRESSION:

• No acute osseous injury of the cervical spine.
• Cervical spine spondylosis as described above.

NEW EVAL: Current Symptoms: off balance and falling backward, 3 falls in the last month, slow and gradual onset. (he is coming off of Wellbutrin and starting Cymbalta, relevance?), intermittent tremors of R>L arm and both legs. Diplopia when watching TV and blurry vision when reading. Facial/forehead/lips paresthesias to the touch (chronic episodic) Onset date: ~July 1, 2026. Method of onset: nothing specific. General Symptom Trend: worsening. Aggravators: going upstairs, turning corners

EXAM:

Walking: needs to lean on the wall or hand on wife for support

Cervical AROM: Baseline: facial paresthesias, dizziness, no pains

Flexion: chin to chest, feels like falling backward somewhat

Extension: 40-50, NE

Rotation R: 80, NE

Rotation L: 80, NE

Lateral Flexion R: 20-30, NE

Lateral Flexion L: 20-30, NE

Strength: 5/5 throughout UEs

DTRS: Bicep (C5-6) Right= 3+ Left = 3+ Brachioradialis (C6) Right= 3+ Left = 3+ Triceps (C7) Right= 2+ Left = 2+ Patellar Right= 3+ Left: 3+ Achilles Right: 3+, with clonus Left: 3+ with clonus

Sensation: both cheekbones and bilateral outer thighs feel "thick"

Tandem: ataxic

Hoffman (UMN): negative bilat

SLS: 5 seconds each with LOB

Rapid Alternating Movements: slow, but accurate, produced dizziness

Brandt-Daroff: no nystagmus, dizziness with R SL without nystagmus

Hallpike: no nystagmus, no dizziness

MOVEMENT TESTING:

Sustained Retraction: Head feels much clearer, vision cleared somewhat

Retraction/Ext: some dizziness, no improvement

Sustained Retraction: Vision clears to near-normal, he is able to stand upright without UE support, ataxia decreased, needs a hand on the wall when walking, but is much better.

TAKE-AWAY: There is still a mechanical cervical contribution. However, I don't like that it returned so quickly with additional balance symptoms (I see this kind of patient regularly). I'm taking it slowly. He's out with sustained cervical retraction and postural correction. He feels much better leaving today. I'll keep everyone posted.

Until next time,

Ryan Tauzell, PT, Cert. MDT

ryan@atlashealth.io

​atlashealth.io​

PS: As always, I'm happy to chat about these patients. I've enjoyed sharing, and thanks so much for your emails!

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