Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Parkinson's Disease


Related Terms

  • Idiopathic Parkinson's
  • Paralysis Agitans
  • Parkinsonism
  • Shaking Palsy

Differential Diagnosis

  • Alzheimer's disease
  • Cardioembolic stroke
  • Cortical-basal ganglionic degeneration
  • Dementia pugilistica caused by repeated head trauma (“punch-drunk” syndrome)
  • Dementia with Lewy bodies (DLB)
  • Drug-induced parkinsonism
  • Essential tremor
  • Hallervorden-Spatz disease
  • Hepatolenticular degeneration (Wilson's disease)
  • Jakob-Creutzfeldt and other prion diseases
  • Lacunar syndromes
  • Multiple system atrophy
  • Progressive supranuclear palsy
  • Spinocerebellar ataxia type 3 (Machado-Joseph disease)
  • Striatonigral degeneration
  • Vascular parkinsonism secondary to stroke

Specialists

  • Internal Medicine Physician
  • Neurologist
  • Neurosurgeon

Comorbid Conditions

Factors Influencing Duration

The extent and length of disability vary, depending on the severity of symptoms, the rapidity of deterioration, the individual’s choice of treatment, and the individual’s response to treatment; the extent of associated conditions such as dementia, depression, or visual dysfunction; and the demands of the individual's occupation. Parkinson's disease is typically associated with continued deterioration. Recovery is not expected, although some improvement may be shown with effective treatment. Initially, there may be some acute periods of disability while medications are adjusted or surgery is performed.

Medical Codes

ICD-9-CM:
332.0 - Paralysis Agitans; Parkinsonism or Parkinsons Disease NOS, Idiopathic, Primary
332.1 - Parkinsonism, Secondary, Due to Drugs

Overview

Parkinson's disease is a chronic, progressive, neurodegenerative disorder that results from a gradual loss of nerve cells in a part of the brain (substantia nigra) that controls movement. These nerve cells normally communicate with each other using a neurotransmitter called dopamine. In Parkinson's disease, dopamine decreases in the brain as the dopamine-producing cells die out, and as a result, the individual exhibits shaking (resting tremor of the hands), slowness of movement (bradykinesia), reduced spontaneous movement, stiffness (rigidity), balance problems, reduced facial expression (hypomimia), and other symptoms. Parkinson's symptoms begin to appear when approximately 60% to 80% less dopamine is being produced (Hauser). Cognitive impairment associated with Parkinson's disease increases with age and disease progression, occurring in 2.7% of cases per year in those between ages 55 and 64 and 13.7% of cases per year after age 70 (Swanberg).

Idiopathic Parkinson's disease with no known underlying cause accounts for the majority of parkinsonism. Suggested causes include rapid aging, genetic predisposition, environmental toxins, and increased oxidative stress, a complex process that involves cell death from free radicals produced in the oxidation of dopamine (Blackmer). Secondary parkinsonism can result from underlying degenerative disorders, infections, and vascular or structural lesions (Hauser).

Additionally, "Parkinson's plus" syndromes are diseases in which brain cells die in multiple areas of the brain, including those areas responsible for the findings in Parkinson's disease. The Parkinson's plus syndromes are associated with other neurologic symptoms such as dementia, autonomic nervous system dysfunction, and abnormalities involving the cranial nerves that supply the head and neck or the cerebellum and help control movement.

Incidence and Prevalence: The incidence of Parkinson's disease is about 10 to 20 new cases per 100,000 population per year (Blackmer). It is the second most common neurodegenerative disease, following Alzheimer's disease, affecting about 1% of adults older than age 60 (Hauser). About 5% of individuals diagnosed with Parkinson's disease are younger than 40 years of age (early-onset Parkinson's); the prevalence is estimated to be 100 to 200 cases per 100,000, increasing to 300 to 700 cases per 100,000 in the population over age 65, and decreasing again in individuals over age 89 (Blackmer).

The international incidence is estimated to be 4.5 to 21 new cases per 100,000 per year, with prevalence averaging 120 cases per 100,000 (Hauser).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors for Parkinson’s disease include being older than 60, gender, and genetics or combinations of these factors (Blackmer). Environmental risk factors include exposure to pesticides, herbicides, organic solvents, lead, cyanide, manganese, tobacco smoke, and other toxins in air and water; the use of well water; and living in a rural environment or close to industrial plants or quarries (Hauser). Gene abnormalities have been found in familial Parkinson's disease, accounting for about 5% of individuals with Parkinson’s disease (Hauser). The lifetime risk for Parkinson’s is about 6.7% in individuals between the ages of 45 and 100 (Blackmer).

The male to female ratio is 3 to 2. Race does not appear to be a risk factor. This disease affects equal numbers of whites and blacks living in the same geographic area of the US, but black populations in South Africa and Nigeria have a lower incidence; similarly, Asian populations are reported to have a lower incidence, but not Asian Americans (Blackmer).

Source: Medical Disability Advisor



Diagnosis

History: Parkinsonian symptoms may develop slowly, making diagnosis more difficult. Early symptoms are often related to muscle rigidity and include slowness of movements (bradykinesia) and vague heaviness, stiffness, or aching in the limbs. Tremor or rhythmic shaking usually begins in one hand but later may involve all limbs. As the disease progresses, the individual develops a stooped posture, has difficulty maintaining balance, getting up from a seated position, or beginning to walk. The individual walks with small, shuffling steps; experiences loss of the normal automatic arm swing, unsteadiness on turning, and difficulty in stopping; and has a tendency to fall.

The individual may experience depression that may occur prior to physical symptoms. Some individuals may report feelings of indifference, lack of assertiveness, difficulty making decisions, or self-centeredness. Temperamental or demanding behaviors are also characteristic. Sleep disturbances may include daytime drowsiness, frequent napping, a rigidity that makes it difficult to turn in bed, or jerking movements of the body or legs that disrupt sleep. Disruption in the autonomic nervous system that controls bodily functions may lead to constipation, sexual or bladder dysfunction, or a drop in blood pressure upon standing with associated dizziness or light-headedness (orthostatic hypotension).

History may include exposure to environmental toxins. A family history of Parkinson’s disease may be reported.

Physical exam: Voluntary and emotional facial movements are limited and slow and include an expressionless face (hypomimia), decreased eye blinking, and a blank stare (masked facies). Speech is monotonous and of low volume (hypophonia), and as the disease progresses, the individual may become difficult or impossible to understand. Signs of dementia may be noticed in late-stage Parkinson’s, but not usually on initial presentation of symptoms. Drooling, decreased swallowing, increased sweating, and dandruff or oily skin may indicate abnormalities in the nervous system controlling bodily functions. Strength is normal, but rigidity and slowness in starting movement limit both voluntary and spontaneous tasks. Rigidity may initially be confined to one limb but eventually involves most muscles. At first the muscles exhibit only a slight stiffness on movement, which then progresses to a ratchet-like jerking (cogwheeling). Handwriting becomes smaller and shaky (micrographia).

The characteristic parkinsonian tremor may be observed early in disease development; it is described as “pill-rolling” because it looks as if the individual rolls a pill between the thumb and index finger at a speed of 4 to 5 movements per second. The tremor later spreads and involves the wrist and then the entire limb. It is worse at rest and improves or disappears with movement.

Tests: There are no specific diagnostic tests or laboratory biomarkers for Parkinson's disease. Imaging modalities such as MRI and CT reveal little to aid diagnosis but may help rule out other diagnoses. Deficits that can be shown on positron emission tomography (PET) and single-photon emission CT (SPECT) may confirm dopamine deficiency syndrome but cannot differentiate Parkinson’s disease from multiple system atrophy and progressive supranuclear palsy (Hauser). A response to medication that increases brain dopamine supports the diagnosis.

Source: Medical Disability Advisor



Treatment

Although there is no cure for Parkinson's disease, drugs, surgery, and rehabilitation may provide significant symptomatic relief and, in some cases, slow disease progression.

Levodopa therapy has long been the mainstay of antiparkinsonian drug treatment. It combines levodopa (L-dopa), which increases brain dopamine levels, with carbidopa (peripheral decarboxylase inhibitor, or PDI), which interferes with the peripheral metabolism of levodopa to dopamine before it reaches the brain, thereby decreasing side effects. Although levodopa therapy improves all the major features of Parkinson's disease, it does not stop its progression. Over half the individuals taking levodopa eventually experience the “on-off” effect, or fluctuations in their response to the drug; the “wearing-off” effect with shorter duration of action of each dose; and side effects that include uncontrollable twisting or flailing movements.

Other drugs that may be helpful, either alone or in combination, including those that mimic the action of dopamine (dopamine agonists); monoamine oxidase inhibitors; and catechol-O-methyl transferase (COMT) inhibitors that cause dopamine to remain in the brain longer. Co-enzyme Q10 is a scavenger of free radicals that has attracted attention by slowing progression of disability from Parkinson’s disease in recent studies; additional studies are under way (Hauser).

Neuroprotective therapies that slow the loss of dopamine neurons would be the first line of defense for Parkinson’s disease, but these therapies have not been widely available. Selegiline, however, is a medication being researched as a possible neuroprotective drug. Studies have indicated that it protects cultured dopamine neurons from certain toxic effects, and studies of the drug in human subjects indicate that it increases dopamine levels and delays the need for levodopa therapy to relieve symptoms. The conclusion is that selegiline or other neuroprotective therapies could slow disease progression (Hauser).

Surgical treatment may be helpful in selected individuals who are unresponsive to medication or who develop intolerable adverse drug reactions or “on-off” effect. The most widely employed surgery is deep brain stimulation (DBS). It is preferred because it does not destroy brain tissue and is reversible, allowing it to be adjusted as the disease progresses. MRI and CT images allow visualization of the targeted area of the brain and guide performance of the procedure. The DBS system consists of a lead that is implanted into the targeted brain structure (thalamus, globus pallidus interna, subthalamic nucleus) and then connected to an implantable pulse generator (IPG) as the power source. The IPG is implanted in the chest cavity below the collarbone and is connected to the lead by an extension wire running down the neck under the skin. DBS works by resetting abnormal firing patterns in the brain to reduce parkinsonian symptoms. Variations in the DBS system include subthalamic stimulation, pallidal stimulation, and thalamic stimulation.

Subthalamic stimulation is performed more often than other DBS procedures. It involves implanting the DBS lead in the subthalamic nucleus (STN). STN DBS is able to control all the main symptoms of Parkinson’s disease as well as motor fluctuations and dyskinesia; it also often results in significant reductions in the need for antiparkinson medications. Pallidal stimulation involves implanting the DBS lead in the globus pallidus interna (GPI). Pallidal stimulation significantly controls all classic symptoms of Parkinson’s disease (tremor, rigidity, bradykinesia) as well as dyskinesia. Thalamic stimulation involves implanting the DBS lead in the ventral intermediate nucleus of the thalamus (VIM). It has a 90% success rate for controlling Parkinson’s disease tremor (Hauser) but does not affect rigidity, bradykinesia, dyskinesia, or motor fluctuations. Each type of DBS requires regular follow-up so that stimulation parameters can be adjusted as the disease progresses according to symptom changes and / or adverse effects.

Irreversible lesion surgeries have largely been replaced by reversible DBS but may still be an option in selected individuals disabled by refractory tremor. Neuroablative procedures destroy specific deep brain targets using thermocoagulation. A radiofrequency generator selectively creates lesions in the globus pallidus or thalamus (thalamotomy) using a small heated electrode. This type of lesion surgery does not slow disease progression, although it is 80% to 90% successful in reducing tremors (Tagliati). The mortality rate for neuroablation is 0.5% to 1%; death is usually due to uncontrolled hemorrhage (Tagliati).

The transplantation of neurons is a potential treatment for Parkinson’s disease because the neuronal degeneration is specifically related to dopamine production (dopaminergic) and the target area in the brain is well defined. Sources of dopamine-producing cells are being studied, including fetal nigral cells, sympathetic ganglia, carotid body glomus cells, PC-12 cells, and neuroblastoma cells. Porcine fetal cells used in initial studies have been abandoned as possible transplanted cells because they did not prove effective. More recent studies show that transplanted cells survive transplantation, but benefits for Parkinson’s disease symptoms may be limited (Hauser).

Several studies have recently demonstrated the safety of gene therapy as a treatment for Parkinson’s disease, and larger studies have been initiated to examine the efficacy of this procedure (Hauser). The goal of these studies is to modify genes involved in the development of Parkinson’s disease. The use of stem cells is also being studied in the laboratory.

Source: Medical Disability Advisor



Prognosis

Although symptoms of Parkinson's disease can be relieved or controlled for at least the first 4 to 6 years (Hauser), there is no cure and most individuals will continue to deteriorate. However, individuals differ considerably in how severely they are affected and in the rate of progression. Many individuals with late onset have relatively mild symptoms that do not interfere with their lives. As symptoms progress, individuals may notice impairment on both sides of the body, although the first side involved usually remains more severely impaired. Some individuals eventually become completely dependent and wheelchair-bound. In advanced Parkinson's disease, walking and balance become more difficult, leading to falls. Both the “wearing-off” effect, with decreased duration of effect from levodopa therapy, and the “on-off” effect, with fluctuating uncontrolled movements alternating with slow and decreased movements, limit function. Accompanying dementia may be a significant cause of disability in late-stage Parkinson’s disease, affecting 15% to 30% of patients (Hauser); when Parkinson’s disease is accompanied by dementia, mortality and morbidity may be higher (Swanberg). Life expectancy is not significantly reduced unless onset is under the age of 40 (DiMinno).

Source: Medical Disability Advisor



Rehabilitation

Individuals with Parkinson's disease may require physical, occupational, speech, and psychological therapy. The types of services necessary are contingent on the functional limitations present. Generally, none of these therapies should be needed for protracted periods but may be helpful for a brief period of up to several weeks at symptom onset or when the individual deteriorates suddenly.

All therapies should educate individuals and their caregivers about both the disease process and the need to engage in a regular exercise routine. Individuals learn to perform their routine during periods when their medication allows maximum function rather than when it is wearing off. Individuals may take exercise classes designed specifically for those with Parkinson's disease. Exercise requiring mild to moderate exertion, such as walking, aquatic exercise, stretching, yoga, or Tai Chi, has been shown to decrease disability.

Speech therapy may be useful to improve voice volume and intelligibility or to evaluate swallowing ability so that diet can be modified as needed. Speech therapy may be required to strengthen the muscles of the face for improved speech and swallowing. Individuals perform facial expressions necessary for clarified speech with visual cueing through use of a mirror. Individuals perform active and isometric tongue exercises to allow for better speech and eating. Individuals learn to speak with greater volume through activities such as sustained vocal expressions. To assist in the swallowing reflex, individuals first eat semi-moist, pureed food that is easier to swallow and then progress to food rich in taste, smell, and texture. Individuals also learn to achieve sucking control and saliva production.

Because individuals experience weakness and stiffness with resultant decreased function in all joints, a comprehensive stretching program is critical in order to maintain range of motion in the joints. Occupational and physical therapists instruct individuals and their family members how to safely stretch the arms and legs. Individuals also learn to perform range of motion exercises of all body parts, including the trunk, to promote normal gait and posture. For individuals with discomfort associated with stiffness and rigidity, massage, stretching, and modalities such as heat may help.

Individuals also learn a strengthening program in occupational and physical therapy that allows the arms and legs to maintain functional abilities. Individuals are instructed in arm exercises that strengthen the muscles used with crutches or a walker, and leg exercises that promote the ability to get out of a chair and walk. All strengthening exercises are performed to the individual's tolerance.

Parkinson's disease may also result in impaired balance, coordination, and difficulty with alternating movements. Occupational and physical therapists instruct individuals on static and dynamic sitting and standing balance. Occupational therapists instruct individuals to perform fine motor coordination exercises, and physical therapists instruct individuals to work on gross motor coordination with functional skills.

The main focus of physical and occupational therapy is to maximize functional capabilities. Occupational therapists teach individuals skills such as getting in and out of the shower, dressing, and meal preparation, and may order adaptive equipment if needed to facilitate independence with activities of daily living (ADLs). Physical therapists teach skills such as getting in and out of bed, walking, pivoting safely while walking, and rolling in bed. They may order equipment such as a trapeze bar to hang over the bed that aids in getting up from the bed, or a cane or rolling walker to promote balance.

A psychologist or psychiatrist can help individuals and their families adjust to the stresses of a debilitating illness. Additionally, these psychiatric services can help treat the depression and hallucinations that often accompany this disease process. Support groups are useful for both the individual and their families to connect with other people undergoing similar experiences.

Source: Medical Disability Advisor



Complications

Dementia variably occurs in 20% to 40% of individuals with Parkinson's disease, especially in individuals over age 64 (Swanberg). A 2- to 6-fold increase in risk of dementia is noted in Parkinson’s disease compared to the risk in the unaffected population, and it may increase with comorbid neurodegenerative disorders, such as Alzheimer’s disease, and cerebrovascular disease (Swanberg). Dementia is often preceded by depression or drug-induced hallucinations. Depression is seen in many individuals and may even precede parkinsonian symptoms. It may be accompanied by anxiety, panic attacks, loss of energy and initiative, or loss of pleasure in normally enjoyable activities. Loss of balance can cause falls or self-injury. Difficulty swallowing and decreased gastric motility may lead to complications such as weight loss, depletion of body fluids (dehydration), or pneumonia caused by food particles entering the airway (aspiration pneumonia). Sensory problems in Parkinson's disease may include decreased sense of smell, abnormal color vision, and blurred vision related to decreased visual contrast sensitivity. Stiffness and difficulty with movement may eventually cause deconditioning, joint immobility (contractures), or accelerated osteoarthritis.
Complications of deep brain stimulation include adverse events such as hemorrhage, ischemic lesions, seizures, or death, which may occur in 1% to 2% of patients (Hauser). Infection may develop in 3% to 5% of surgical patients, and the lead must be removed until the infection clears (Hauser). Misplacement of the DBS lead occurs in about 10% of patients, requiring repeat surgery to correct placement (Hauser). Other DBS side effects may include paresthesia, muscle spasms, visual disturbances, mood changes, and pain.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Because physical abilities vary among individuals, work restrictions and accommodations must be evaluated on a case-by-case basis. Slowness of movement may limit driving, standing up from a chair, walking, and turning. Balance problems may limit crawling, stooping, kneeling, and working at heights. Decreased fine motor control coordination and tremor may cause difficulties with writing, keyboard operation, or manipulation of small objects. Soft, monotonous speech may impair communication skills. Dementia, depression, and personality change may interfere with judgment, memory, and interpersonal skills. Visual problems may hinder reading or sorting tasks. Urinary urgency may cause frequent interruptions. Accommodations may include grab-bars or railings, well-lit work areas without clutter or scatter rugs, and good color contrast between safety devices and surrounding areas and between the floor and stairs. Use of a cane or walker may be helpful; a wheelchair may be needed eventually.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was diagnosis suspected based on presenting symptoms and clinical presentation?
  • Were other conditions with similar symptoms, such as Wilson's disease, striatonigral degeneration, essential tremor, Creutzfeldt-Jakob disease, Huntington's disease, Shy-Drager syndrome, progressive supranuclear palsy, cortical basal ganglionic degeneration, stroke, and hydrocephalus, ruled out?
  • Has a positive response to a trial of dopaminergic medication (levodopa therapy) supported diagnosis of Parkinson's disease?
  • Because prognosis and treatment differ significantly, it is important to differentiate between idiopathic Parkinson's disease, secondary parkinsonism, and “Parkinson's-plus” syndromes. Has the distinction been made?
  • Would individual benefit from consultation with a specialist?

Regarding treatment:

  • Are individual's symptoms being effectively controlled by medication?
  • Has individual begun to experience “on-off” or “wearing-off” effects? Would individual benefit from use of an alternate medication or combination of medications?
  • Is individual a candidate for surgical intervention?

Regarding prognosis:

  • At what age was individual diagnosed with Parkinson's disease?
  • To what extent do symptoms impair function?
  • Has disease progression slowed with medical or surgical intervention?
  • Would individual benefit from rehabilitation (physical, occupational, speech, or psychological therapy)?
  • Has home health care or other assistance with activities of daily living been considered?
  • Does individual have an underlying condition, such as osteoarthritis, injury, stroke, other neurological disorders, dementia or psychiatric disease, heart failure, obesity, diabetes mellitus, or kidney disease, that could affect prognosis?
  • Has individual experienced any complications that could affect prognosis, such as weight loss, dehydration, or pneumonia? If so, have these conditions been addressed in the treatment plan?
  • What support system does individual have in place? Would individual benefit from psychological counseling or enrollment in a community support group?

Source: Medical Disability Advisor



References

Cited

Blackmer, Jeff. "Parkinson Disease." eMedicine. Eds. Milton J. Klein, et al. 10 Mar. 2009. Medscape. 15 Jul. 2009 <http://emedicine.medscape.com/article/312519-overview>.

DiMinno, Mariann, and Michael J. Aminoff. "Parkinson Primer." National Parkinson Foundation. 15 Jul. 2009 <http://www.parkinson.org>.

Hauser, Robert A., Rajesh Pahwa, and Kelly E. Lyons. "Parkinson Disease." eMedicine. Eds. Rodrigo O. Kuljis, et al. 13 Jan. 2009. Medscape. 15 Jul. 2009 <http://emedicine.medscape.com/neuro/article/1151267-overview>.

Swanberg, Margaret M., and Raj K. Katapatapu. "Parkinson Disease Dementia." eMedicine. Eds. Alan D. Schmetzer, et al. 15 Apr. 2009. Medscape. 15 Jul. 2009 <http://emedicine.medscape.com/article/289595-overview>.

Tagliati, Michele, and Ron Alterman. "Surgical Treatment of Tremor." eMedicine. Eds. Robert A. Hauser, et al. 15 May. 2006. Medscape. 15 Jul. 2009 <http://emedicine.medscape.com/article/1153869-overview>.

Source: Medical Disability Advisor






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