Reciprocal inhibition in forearm muscles in patients with essential tremor

Non-invasive electrical stimulation of peripheral nerves for the management of tremor

Pathological tremor in patients with essential tremor and Parkinsons disease is typically treated using medication or neurosurgical interventions. There is a widely recognized need for new treatments that avoid the side effects of current medications and do not carry the risks of surgical interventions. Building on decades of research and engineering development, non-invasive electrical stimulation of peripheral nerves has emerged as a safe and effective strategy for reducing pathologic tremor in essential tremor. This review surveys the peripheral electrical stimulation (PES) literature and summarizes effectiveness, safety, clinical translatability, and hypothesized tremor-reduction mechanisms of various PES approaches. The review also proposes guidelines for assessing tremor in the context of evaluating new therapies that combine the strengths of clinician assessments, patient evaluations, and novel motion sensing technology. The review concludes with a summary of future directions for PES, including expanding clinical access for patients with Parkinson's disease and leveraging large, at-home datasets to learn more about tremor physiology and treatment effect that will better characterize the state of tremor management and accelerate discovery of new therapies. Growing evidence suggests that non-invasive electrical stimulation of afferent neural pathways provides a viable new option for management of pathological tremor, with one specific PES therapy cleared for prescription and home use, suggesting that PES be considered along with medication and neurosurgical interventions for treatment of tremor. This article is part of the Special Issue "Tremor" edited by Daniel D. Truong, Mark Hallett, and Aasef Shaikh.

Abnormal vibration induced illusion of movement in essential tremor: evidence for abnormal muscle spindle afferent function

OBJECTIVES

Vibration induced illusion of movement (VIIM) is abnormal in patients with idiopathic focal dystonia, an abnormality which corrects with fatigue of the vibrated muscle. Since dystonia and essential tremor sometimes coexist in families, we investigated the perception of VIIM and the effect of fatigue on VIIM in patients with essential tremor.

METHODS

VIIM in 18 patients with essential tremor was compared with VIIM in 18 healthy control participants before and after volitional fatigue of the vibrated muscles.

RESULTS

Vibration of the immobilised biceps produced a subnormal VIIM in patients with essential tremor (12.81 degrees (SEM 2.15)) compared with healthy control subjects (28.55 degrees (1.66)). The perception increased following volitional fatigue of the vibrated arm in patients with essential tremor (16.23 degrees (2.50)) but not in healthy controls (27.55 degrees (1.66)). No difference was observed in patients with alcohol or non-alcohol responsive tremor.

CONCLUSIONS

The VIIM decreased with increasing age in healthy control subjects. Abnormal VIIM implies abnormal sensorimotor processing in patients with essential tremor, similar to that found in idiopathic focal dystonia, and the change of the perception with age could explain the age related onset of the disorder.

Neurophysiological investigations in patients with primary writing tremor

The pathophysiology of primary writing tremor (PWT) is still unknown: it has been classified as a focal form of essential tremor and as a tremulous form of writer's cramp. We studied cortical and spinal excitability in patients with PWT and compared the results with published data of patients with essential tremor, and writer's cramp. We used electrical stimulation of median and radial nerve to study reciprocal inhibition of forearm antagonist muscles and paired transcranial magnetic stimulation at short and long interstimulus intervals (ISIs) to assess intracortical excitability. Both studies were conducted on patients with PWT and on control subjects. The early (presynaptic) and late (disynaptic) phases of reciprocal inhibition were normal as was intracortical excitability at short and long ISIs. Our study suggests that the pathophysiology of PWT is different from that of writer's cramp and partially also from that of essential tremor.

H-reflex recovery curves differentiate essential tremor, Parkinson's disease, and the combination of essential tremor and Parkinson's disease

The purpose of this study was to examine H-reflex parameters among the pathophysiologic conditions of essential tremor (ET), Parkinson's disease (PD), combined essential tremor with Parkinson's disease (ETPD), and a control group. H-reflex latencies, amplitude of maximum H-reflex to maximum M-response ratio (H:M), vibration H-reflex to control H-reflex (Hv:Hc), and H-reflex recovery curves (HRRCs) were recorded and compared between a control group and patient groups with ET, early-stage PD, and with ETPD. No statistically or clinically significant differences were found between the patient groups and the control group for latency, H:M ratio, or Hv:Hc ratio. Significantly greater ratio values were observed for the PD group over the other groups for the HRRC tests at each interstimulus interval between 200 and 300 msec (p < 0.05), but values were not different between PD and ETPD patients for intervals between 350 and 1,000 msec. Patients with ET, PD, and ETPD apparently have different underlying pathologies. HRRC tests do not distinguish ET patients from normal, but differentiates specifically between PD and ETPD, and normal individuals. HRRC testing may be a useful method for evaluating pathologies between ET, PD, and ETPD patients.

Loss of reflex inhibition following muscle tendon stimulation in essential tremor

Electrical stimulation of human upper limb muscle tendons produces a reflex inhibition (I(1)) in the same muscles. This inhibition is reduced in Parkinson's disease (PD), prompting a similar study of essential tremor (ET). In essential tremor, two of eight subjects had no discernible inhibition, even following supramaximal stimulation (< 80 mA) of the tendons from extensor digitorum communis and extensor pollicis brevis. In the remaining six subjects, the mean thresholds for I(1) in these muscles were increased by 270 and 320%, respectively, relative to controls. The maximal amplitude of the inhibition was significantly reduced in the ET group, as was the following excitation (E(1)). The latency and duration of I(1) were not different in ET subjects and controls. The maximal duration of I(1) was correlated with tremor frequency in individuals, and tendon stimulation was effective in initiating ongoing tremor cycles. These results disclose a peripheral reflex abnormality in ET that is mediated by tendon afferents and can be linked to the coexistent tremor. The response in ET was distinguished from that in PD by its different time-course and by failure of the response to appear in the antagonist muscle. The abnormality may prove a useful marker for ET, which currently lacks a definitive pathological or neurophysiological marker to support objective clinical diagnosis.

Spinal and cortical inhibition in Huntington's chorea

In this article we studied spinal and cortical inhibitory mechanisms in patients with Huntington's disease. To evaluate spinal cord inhibitory circuitries, we assessed reciprocal inhibition between antagonist forearm muscles and the recovery cycle of the H reflex in the flexor carpi radialis. Patients showed a significant decrease in the presynaptic phase of reciprocal inhibition reaching a minimum at the conditioning-test interval of 20 msec and an abnormal facilitation of the test H reflex at the conditioning test interval of 40 to 60 msec. Throughout its time course (10-200 msec), the H reflex recovery cycle showed a more prominent facilitation in patients than in control subjects. To assess whether the observed pathophysiological abnormalities might have arisen from an abnormal motor cortical excitability, we examined the recovery cycle of the motor potentials evoked by paired transcranial magnetic stimuli. We found that the inhibitory mechanisms controlling motor cortical excitability were normal. An interpretation of the spinal cord abnormalities is that the intrinsically normal but deafferentated motor cortex in Huntington's disease partly loses its inhibitory control, thus disinhibiting spinal cord circuitry. Our findings from paired transcranial magnetic stimulation suggest that cortical motor areas are not hyperexcitable in Huntington's disease. Hence, the postulated thalamocortical overactivity in experimental models of Huntington's disease needs to be reappraised.

Botulinum toxin restores presynaptic inhibition of group Ia afferents in patients with essential tremor

We studied the effect of botulinum toxin A injection on the abnormal presynaptic phase of reciprocal inhibition between forearm antagonist muscles in patients with essential tremor. Ten patients with essential tremor were investigated before and 1 month after botulinum injection. Reciprocal inhibition was studied by conditioning the H reflex in forearm flexors with a radial-nerve stimulus delivered at a range of time intervals. Botulinum toxin produced a significant functional improvement in tremor (about 20%). Before botulinum toxin injection, patients had a reduced presynaptic phase of reciprocal inhibition. After botulinum toxin this phase was significantly more pronounced. The normal early disynaptic phase of reciprocal inhibition was normal before and after botulinum treatment. Although botulinum treatment reduced the size of the H reflex and the M wave to a similar extent, it left the H/M ratio unchanged. These findings show that botulinum toxin treatment restores presynaptic inhibition between forearm antagonist muscles. The results are also consistent with botulinum toxin having a beneficial effect in patients with essential tremor. Both effects probably depend upon the toxin's concurrent action on the extrafusal and intrafusal motor end-plates, the latter resulting in decreased spindle afferent input to the spinal cord.