Not long after having a stroke in his cerebellar peduncle, a 73-year-old man with type 2 diabetes mellitus, high blood pressure, and high cholesterol began experiencing progressive, uncontrolled movements of his left arm. The erratic nature of the movements left him with little dexterity, affecting both his fine and gross motor function. He felt very frustrated by his loss of coordination and was embarrassed to be in public.
The patient’s primary care physician referred him to Duke Neurology for post-stroke care and to try to uncover the cause of his arm’s uncontrolled movements.
Question: What were the most important steps in helping this patient?
Answer: Uncovering the likely cause of the movements—rubral tremor due to the stroke—and giving the patient and his family an opportunity to discuss how the stroke had affected him were critical to helping the patient improve his quality of life.
Because rubral tremor is relatively rare and not always caused by stroke, it can be difficult to identify, says Duke neurologist Yasmin Ali O’Keefe, MD. However, she says, it makes sense in this case, given the location of his stroke.
“Most people think of a weak limb, slurred speech, and facial droop as stroke symptoms, so experiencing something very different can be unsettling,” O’Keefe says.
That’s why it was so important to help the patient understand why he was having these movements, she adds: “The movements were bothering him more than the actual stroke was. So, just knowing what was going on and that the stroke was the cause gave him a sense of clarity and relief.”
O’Keefe also discussed potential interventions and preventive measures with the patient. He was already on medication prescribed by his primary care provider for cholesterol, blood pressure, and diabetes. Based on new stroke guidelines for cholesterol, O’Keefe increased his statin dose.
The patient wished to avoid surgical or pharmacologic interventions because there was a chance they would further limit his movements or cause other adverse effects. The data to support the efficacy of surgeries like deep brain stimulation for rubral tremors are also quite weak, O’Keefe says.
Instead, she encouraged him to try non-interventional methods of controlling the tremor, such as putting weights on his wrist. She also gave him the chance to talk about how the stroke and tremor were affecting him. Six months after the stroke, she says he reported that the tremor had improved and it no longer prevented him from engaging in social events.
“The paradigm in stroke care is to focus on preventing another stroke,” O’Keefe says. “This is of paramount importance, but I think it’s just as important to create a safe space for patients to talk about how a stroke has affected them as a person. My intent is to not only take care of each patient physically but to also make sure their emotional state is healthy.”