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Familial and essential tremor
Essential tremor is the most commonly occurring movement disorder with a prevalence of five to six per
cent. Familial tremor is identical, apart from having a positive family history. Mean age of onset is in
middle life. Over 90 per cent of affected individuals experience hand tremor, 33 per cent head tremor, 16
per cent voice tremor, and 12 per cent leg tremor. In familial tremor an autosomal dominant pattern is
observed. Tremor progresses very slowly over many years. Handwriting, fine movements such as using a
screwdriver or threading a needle, and drinking soup from a spoon, may be affected. The tremor is present
with intention and maintaining posture.
Essential/familial tremor is most often an annoyance rather than a significant functional disability.
Treatment with aeromedically acceptable beta-adrenergic blocking medicines is often highly effective.
Other agents such as primidone have potential sedating and other central effects, precluding their use in
licence holders.
Operational limitations:
Familial and essential tremor is ordinarily not disqualifying unless significant functional impairment is
present.
Aeromedical considerations:
In many individuals tremor is mild without need for treatment. Identification of the disorder, exclusion of
other potentially serious conditions, and determination of functional impairment may allow immediate
medical certification. In more severe cases with an element of functional impairment, treatment (e.g.
propanolol) may warrant a three month observation for effectiveness prior to medical certification.
Parkinson’s Disease
Parkinson’s disease10 is characterized by three major symptoms: tremor, rigidity, and bradykinesia
(slowness of movement). The disease may progress slowly over many years in some, though disturbingly
rapidly in others. Tremor at rest is a classic feature, giving rise to the term “shaking palsy” in earlier
literature. Medical certification may be considered early in the course of the disease. Therapeutic agents
including carbidopa/levodopa may be acceptable, while the dopamine agonists are unacceptable due to
their sedative potential.
Operational limitations:
A diagnosis of Parkinson’s disease in itself is not disqualifying for any class of medical certification.
Aeromedical considerations:
A diagnosis of Parkinson’s disease should lead to a thorough neurological evaluation, exclusion of
related conditions, and evaluation of need for treatment. Medical certification may be appropriate
10 Parkinson’s disease: paralysis agitans. After James Parkinson, English physician (1755-1824)
ICAO Preliminary Unedited Version — October 2008 III-10-15
immediately in mild conditions. Medication must also be considered. Levodopa agents may be allowed,
but dopamine agonists are prohibitive due to their potentially sedating effects. If certification is granted
following medical evaluation, it should be conditioned upon periodic re-examination and re-evaluation. If
disease progression presents a risk to aviation safety, the Medical Assessment should be revoked.
Multiple Sclerosis
Multiple sclerosis (MS, sclerosis disseminata) is an autoimmune disorder where the immune system
attacks the central nervous system, causing patches or plaques of demyelination in the brain or spinal
cord, with eventual axonal loss and glial scarring (sclerosis).The commonly known form is characterized
by remissions and exacerbations (relapsing and remitting MS), but there are primary progressive and
secondary progressive forms. Age of onset is often between age 20 and 40, and there is slight female
preponderance. Symptoms are myriad and may include localized sensory disturbances, gait abnormalities,
focal motor deficit such as hemiparesis or paraparesis, optic neuritis, speech disturbances, and sphincter
disturbances.
Acute exacerbations are commonly treated with corticosteroids, whereas immuno-modulatory therapy is
commonly employed to reduce the frequency and severity of exacerbations. Therapeutic agents include
the interferons and glatirimer acetate. Chemotherapeutic agents are employed in severe cases.
Medical certification may be considered in licence holders with MS, ordinarily conditioned on stability,
degree of deficit, and nature of deficit. Symptoms such as vertigo and diplopia would clearly compromise
flight safety, while minor paresthesiae in an extremity might be inconsequential.
Operational limitations:
A diagnosis of multiple sclerosis is disqualifying for all classes of medical certification.
Aeromedical considerations:
Some individuals with multiple sclerosis experience rapid progression of disease, and others have lesions
in areas causing severe functional impairment (e.g. brain stem lesion with diplopia and vertigo). Others
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Manual of Civil Aviation Medicine 2(32)
