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Hopfner F, Buhmann C, Classen J, Holtbernd F, Klebe S, Koschel J, Kohl Z, Paus S, Pedrosa DJ. Tips and tricks in tremor treatment. J Neural Transm (Vienna) 2024:10.1007/s00702-024-02806-x. [PMID: 39043978 DOI: 10.1007/s00702-024-02806-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 07/04/2024] [Indexed: 07/25/2024]
Abstract
Tremor, whether arising from neurological diseases, other conditions, or medication side effects, significantly impacts patients' lives. Treatment complexities necessitate clear algorithms and strategies. Levodopa remains pivotal for Parkinson's tremor, though response variability exists. Some dopamine agonists offer notable tremor reduction targeting D2 receptors. Propranolol effectively manages essential tremor and essential tremor plus (ET/ET +), sometimes with primidone for added benefits, albeit dose-dependent side effects. As reserve medications anticholinergics and clozapine are used for treatment of parkinsonian tremor, 1-Octanol and certain anticonvulsant drugs for tremor of other orign, especially ET. Therapies such as invasive deep brain stimulation and lesional focused ultrasound serve for resistant cases. A medication review is crucial for all forms of tremor, but it is particularly important if medication may have triggered the tremor. Sensor-based detection and non-drug interventions like wristbands and physical therapy broaden diagnostic and therapeutic horizons, promising future tremor care enhancements. Understanding treatment nuances is a key for tailored tremor management respecting patient needs and tolerability. Successful strategies integrate pharmacological, non-invasive, and technological modalities, aiming for optimal symptom control and improved quality of life.
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Affiliation(s)
- Franziska Hopfner
- Department of Neurology, Neurologische Klinik und Poliklinik mit Friedrich Baur Institut, Ludwig-Maximilians University, Campus Großhadern, Marchioninistraße 15, 81377, Munich, Germany.
| | - Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joseph Classen
- Department of Neurology, Leipzig University Medical Center, Liebigstraße 20, 04103, Leipzig, Germany
| | - Florian Holtbernd
- Department of Neurology, RWTH Aachen University, Pauwelsstraße 30, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Juelich Research Center GmbH and RWTH Aachen University, Aachen, Germany
| | - Stephan Klebe
- Department of Neurology, Essen University Hospital, 45147, Essen, Germany
- Department of Neurology, Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Germany
| | - Jiri Koschel
- Parkinson-Klinik Ortenau, GmbH & Co KG, Kreuzbergstraße 12-16, 77709, Wolfach, Germany
| | - Zacharias Kohl
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - Sebastian Paus
- Department of Neurology, GFO Clinics Troisdorf, Troisdorf, Germany
| | - David J Pedrosa
- Department of Neurology, Philipps University Marburg, Marburg, Germany
- Centre for Mind, Brain and Behaviour, Philipps University Marburg, Marburg, Germany
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Schierscher T, Salzmann L, Singh N, Fischer V, Kobel A, Bauland F, Geistanger A, Risch L, Geletneky C, Seger C, Taibon J. An isotope dilution-liquid chromatography-tandem mass spectrometry (ID-LC-MS/MS)-based candidate reference measurement procedure (RMP) for the quantification of primidone in human serum and plasma. Clin Chem Lab Med 2024; 62:1327-1338. [PMID: 38549258 DOI: 10.1515/cclm-2023-1032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/12/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVES Primidone is an anticonvulsive drug used in the treatment of epilepsy and essential tremor. It offers beneficial effects in controlling seizures, but its usage is also associated with possible side effects. To ensure optimal therapy, it is crucial to measure its concentration through accurate quantification methods. Therefore, our main goal was to develop and validate a new reference measurement procedure (RMP) for accurately measuring primidone levels in human serum and plasma. METHODS In our study, we focused on the separation of primidone from both known and unknown interferences using a C18 column. To achieve accurate sample preparation, we developed a protocol involving protein precipitation followed by a high dilution step. The validation of the assay and determination of measurement uncertainty were carried out following guidelines from organizations such as the Clinical and Laboratory Standards Institute, the International Conference on Harmonization, and the Guide to the Expression of Uncertainty in Measurement. These rigorous validation processes ensure the reliability and accuracy of our method for quantifying primidone levels in human serum and plasma samples. RESULTS The RMP was shown to be highly selective and specific, with no evidence of matrix interference. It can be used to quantify primidone in the range of 0.150-30.0 μg/mL. Intermediate precision was less than 4.0 %, and repeatability CV ranged from 1.0 to 3.3 % across all concentration levels. The relative mean bias ranged from 0.1 to 3.9 % for native serum levels, and from -2.6 to 2.8 % for lithium-heparin plasma levels. The measurement uncertainties for single measurements and target value assignment were 1.5-4.1 % and 0.9-1.0 %, respectively. CONCLUSIONS In this study, we introduce an innovative LC-MS/MS-based candidate RMP specifically designed for primidone in human serum and plasma. Our RMP offers a traceable platform, facilitating the standardization of routine assays and enabling the evaluation of clinically relevant samples. With this novel approach, we aim to enhance the accuracy and reliability of primidone measurements, ultimately benefiting the field of clinical research and patient care.
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Affiliation(s)
| | | | | | | | - Anja Kobel
- Dr. Risch Ostschweiz AG, Buchs, Switzerland
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3
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Wagle Shukla A. Diagnosis and Treatment of Essential Tremor. Continuum (Minneap Minn) 2022; 28:1333-1349. [DOI: 10.1212/con.0000000000001181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Wagle Shukla A. Reduction of neuronal hyperexcitability with modulation of T-type calcium channel or SK channel in essential tremor. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 163:335-355. [PMID: 35750369 DOI: 10.1016/bs.irn.2022.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Essential tremor is one of the most prevalent movement disorders. Propranolol and primidone are the first-line pharmacological therapies. They provide symptomatic control in less than 50% of patients. Topiramate, alprazolam, clonazepam, gabapentin, and botulinum toxin injections are the next line of treatments. These medications lead to modest improvements and are therefore commonly used as add-on agents. Surgical therapies, including deep brain stimulation (DBS) surgery and focused ultrasound beam targeted to the thalamus, are considered for treating tremor refractory to medications and lead to greater than 75% improvements in tremor symptoms. However, DBS is a costly and an invasive procedure; some patients report tolerance to benefits. Focused ultrasound therapy leading to brain lesions is associated with a possibility for permanent clinical deficits. Therefore, research efforts to develop the next generation of oral medications with greater benefits and lesser adverse effects are warranted. There is considerable evidence that the increased functions of calcium channels (P/Q-type and T-type channels) and reduced functions of calcium-activated potassium channels (SK channels) located in the neuronal membranes lead to tremor oscillations. Consequently, many new pharmacological studies have targeted these channels to leverage better clinical outcomes. The current review will discuss the pathophysiology, the specific importance of these channels, and the early clinical experience of using compounds targeting these channels to treat essential tremor.
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Affiliation(s)
- Aparna Wagle Shukla
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States.
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Treatment Patterns in Essential Tremor: A Retrospective Analysis. Tremor Other Hyperkinet Mov (N Y) 2022; 12:10. [PMID: 35415009 PMCID: PMC8954883 DOI: 10.5334/tohm.682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/05/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Although first line therapies for essential tremor have been identified from small clinical trials, responses are variable. We conducted a survey of tremor management in a large sample of ET cases. Methods: The Movement Disorders Clinical Case Registry within a US Veterans Health Administration medical center was used to identify 1468 patients with ET. Results: Of 1468 charts reviewed, 1074 (73.19%) met criteria for ET with characterization of temporal course and treatment; 291/1074 subjects (27.1%) did not receive any treatment. Almost half (500/1074; 46.6%) of the patients received monotherapy, 196/1074 (18.2%) two, 66/1074 (6.1%) three, and 21/1074 (2.0%) four or more medications. Of all prescriptions, primidone was the most used (546/1172; 46.6%), followed by propranolol (419; 35.8%), topiramate (122; 10.4%) and gabapentin (35; 3.0%). Medication response was available for a total of 1030 prescriptions, of which 138 (13.4%) were discontinued due to side effects; 180 (17.5%) prescriptions were ineffective. Furthermore, 52/1074 patients (4.8%) were treated with botulinum toxin injections and 41/1074 (3.8%) underwent deep brain stimulation surgery. Discussion: Our data suggest that more widespread recognition of limitations underlying conventional approaches, as well as increased referrals for nonpharmacological therapies, may be necessary to achieve improved outcomes in ET populations.
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Botulinum Toxin for Essential Tremor and Hands Tremor in the Neurological Diseases: A Meta-Analysis of Randomized Controlled Trials. Toxins (Basel) 2022; 14:toxins14030203. [PMID: 35324700 PMCID: PMC8955110 DOI: 10.3390/toxins14030203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/03/2022] [Accepted: 03/09/2022] [Indexed: 12/04/2022] Open
Abstract
Tremor is a common movement disorder. Essential tremor (ET) is the most common etiology of tremor, while hands tremor is the most disabling type of tremor. This study aimed to explore the effects of Botulinum toxin (BoNT) on tremor within 6 weeks of treatment, and the muscular weakness adverse effect within 6 weeks specifically in randomized controlled trials. PubMed, Embase, and Cochrane Library databases were searched. Tremor severity and grip strength after BoNT treatment were investigated. BoNT significantly attenuated hand tremor severity in patients with either essential tremor (ET), Parkinson’s disease or multiple sclerosis (Standardized mean difference [SMD] = −0.59, 95% confidence interval [CI], −0.95 to −0.24, p = 0.001, I2 = 46%). Regarding people with ET, BoNT significantly reduced their tremor severity, including hands tremor and head tremor within 6 weeks of treatment (SMD = −0.58, 95% CI, −0.28 to −0.88, p = 0.002, I2 = 0%). Electromyography (EMG) but not anatomical guidance BoNT injection provided significant benefit on the relief of tremor in both conditions. The principal adverse event was weakness, but it did not worse within 6 weeks of BoNT treatment (SMD = −0.35, 95% CI, −0.83 to 0.12, p = 0.07, I2 = 57%), as assessed by the subjective grip strength. In conclusion, BoNT was an effective treatment for the hand tremor and ET, and EMG guidance injection was preferred. In addition, the muscular weakness adverse effect was not significant.
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Primidone Intolerance in Essential tremor: Is it More than Just Age? Tremor Other Hyperkinet Mov (N Y) 2021; 11:57. [PMID: 35070493 PMCID: PMC8719469 DOI: 10.5334/tohm.672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background: There are few medications for the treatment of essential tremor (ET). One of these, primidone, which is one of only two front-line agents, is associated with considerable adverse drug reactions (ADRs). It is unclear why some primidone-treated ET patients develop ADRs whereas others do not, and why these ADRs seem to be more prevalent in ET patients than primidone-treated patients with epilepsy. Objective: To review several possible explanations underlying the above-referenced differences. Methods: A literature search was conducted in PubMed in October 2021. Studies reporting the ADRs of primidone in different neurological conditions were comprehensively reviewed. Discussion: Although there were no head-to-head data, a review of the previous studies on ET and epilepsy patients indicates that the former is relatively more intolerant to primidone. Moreover, not all ET patients develop ADR of similar nature or severity. We discuss several potential mechanisms for this variability in the intolerance to primidone. These include: (i) older age (ET vs. epilepsy patients), (ii) cross-tolerance to primidone in patients with epilepsy, (iii) neurobiological (GABA-related) abnormalities associated with ET. Conclusion: We speculate that there are several possible explanations for primidone intolerance in ET. These possibilities should be tested in future studies, and we propose the roadmap for designing these studies. It is of value to obtain detailed insight into these complex issues because primidone remains one of the few frontline anti-tremor medications in ET. Answers to issues we have raised in this article could facilitate more customized formulation of primidone in ET patients.
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Yu JY, Rajagopal A, Syrkin-Nikolau J, Shin S, Rosenbluth KH, Khosla D, Ross EK, Delp SL. Transcutaneous Afferent Patterned Stimulation Therapy Reduces Hand Tremor for One Hour in Essential Tremor Patients. Front Neurosci 2020; 14:530300. [PMID: 33281539 PMCID: PMC7689107 DOI: 10.3389/fnins.2020.530300] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 10/20/2020] [Indexed: 01/25/2023] Open
Abstract
Essential tremor (ET) patients often experience hand tremor that impairs daily activities. Non-invasive electrical stimulation of median and radial nerves in the wrist using a recently developed therapy called transcutaneous afferent patterned stimulation (TAPS) has been shown to provide symptomatic tremor relief in ET patients and improve patients’ ability to perform functional tasks, but the duration of tremor reduction is unknown. In this single-arm, open-label study, fifteen ET patients performed four hand tremor-specific tasks (postural hold, spiral drawing, finger-to-nose reach, and pouring) from the Fahn-Tolosa-Marin Clinical Rating Scale (FTM-CRS) prior to, during, and 0, 30, and 60 min following TAPS. At each time point, tremor severity was visually rated according to the FTM-CRS and simultaneously measured by wrist-worn accelerometers. The duration of tremor reduction was assessed using (1) improvement in the mean FTM-CRS score across all four tasks relative to baseline, and (2) reduction in accelerometer-measured tremor power relative to baseline for each task. Patients were labeled as having at least 60 min of therapeutic benefit from TAPS with respect to each specified metric if all three (i.e., 0, 30, and 60 min) post-therapy measurements were better than that metric’s baseline value. The mean FTM-CRS scores improved for at least 60 min beyond the end of TAPS for 80% (12 of 15, p = 4.6e–9) of patients. Similarly, for each assessed task, tremor power improved for at least 60 min beyond the end of TAPS for over 70% of patients. The postural hold task had the largest reduction in tremor power (median 5.9-fold peak reduction in tremor power) and had at least 60 min of improvement relative to baseline beyond the end of TAPS therapy for 73% (11 of 15, p = 9.8e–8) of patients. Clinical ratings of tremor severity were correlated to simultaneously recorded accelerometer-measured tremor power (r = 0.33–0.76 across the four tasks), suggesting tremor power is a valid, objective tremor assessment metric that can be used to track tremor symptoms outside the clinic. These results suggest TAPS can provide reductions in upper limb tremor symptoms for at least 1 h post-therapy in some patients, which may improve patients’ ability to perform tasks of daily living.
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Affiliation(s)
- Jai Y Yu
- Cala Health, Inc., Burlingame, CA, United States
| | | | | | - Sooyoon Shin
- Cala Health, Inc., Burlingame, CA, United States
| | | | - Dhira Khosla
- Personal Care Neurology, Oakland, CA, United States
| | - Erika K Ross
- Cala Health, Inc., Burlingame, CA, United States
| | - Scott L Delp
- Department of Bioengineering, Stanford University, Stanford, CA, United States
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Abstract
Essential tremor is one of the most common tremor syndromes. According to the recent tremor classification, tremor as a symptom is defined as an involuntary, rhythmic, oscillatory movement of a body part and is classified along two axes: axis 1-defining syndromes based on the clinical features such as historical features, tremor characteristics, associated signs, and laboratory tests; and axis 2-classifying the etiology (Bhatia et al., Mov Disord 33:75-87, 2018). The management of this condition has two major approaches. The first is to exclude treatable etiologies, as particularly during the onset of this condition the presentation of a variety of etiologies can be with monosymptomatic tremor. Once the few etiologies with causal treatments are excluded, all further treatment is symptomatic. Shared decision-making with enabling the patient to knowledgeably choose treatment options is needed to customize the management. Mild to moderate tremor severity can sometimes be controlled with occupational treatment, speech therapy of psychotherapy, or adaptation of coping strategy. First-line pharmacological treatments include symptomatic treatment with propranolol, primidone, and topiramate. Botulinum toxin is for selected cases. Invasive treatments for essential tremor should be considered for severe tremors. They are generally accepted as the most powerful interventions and provide not only improvement of tremor but also a significant improvement of life quality. The current standard is deep brain stimulation (DBS) of the thalamic and subthalamic region. Focused ultrasound thalamotomy is a new therapy attracting increasing interest. Radiofrequency lesioning is only rarely done if DBS or focused ultrasound is not possible. Radiosurgery is not well established. We present our treatment algorithm.
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Affiliation(s)
- Franziska Hopfner
- Department of Neurology, UKSH, Christian-Albrechts-University Kiel, Rosalind-Fraenklinstr. 10, 24105, Kiel, Germany
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Günther Deuschl
- Department of Neurology, UKSH, Christian-Albrechts-University Kiel, Rosalind-Fraenklinstr. 10, 24105, Kiel, Germany.
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Isaacson SH, Peckham E, Tse W, Waln O, Way C, Petrossian MT, Dahodwala N, Soileau MJ, Lew M, Dietiker C, Luthra N, Agarwal P, Dhall R, Morgan J, Calakos N, Zesiewicz TA, Shamim EA, Kumar R, LeWitt P, Shill HA, Simmons A, Pagan FL, Khemani P, Tate J, Maddux B, Luo L, Ondo W, Hallett M, Rajagopal A, Chidester P, Rosenbluth KH, Delp SL, Pahwa R. Prospective Home-use Study on Non-invasive Neuromodulation Therapy for Essential Tremor. Tremor Other Hyperkinet Mov (N Y) 2020; 10:29. [PMID: 32864188 PMCID: PMC7427656 DOI: 10.5334/tohm.59] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/14/2020] [Indexed: 02/07/2023] Open
Abstract
Highlights This prospective study is one of the largest clinical trials in essential tremor to date. Study findings suggest that individualized non-invasive neuromodulation therapy used repeatedly at home over three months results in safe and effective hand tremor reduction and improves quality of life for many essential tremor patients. Background Two previous randomized, controlled, single-session trials demonstrated efficacy of non-invasive neuromodulation therapy targeting the median and radial nerves for reducing hand tremor. This current study evaluated efficacy and safety of the therapy over three months of repeated home use. Methods This was a prospective, open-label, post-clearance, single-arm study with 263 patients enrolled across 26 sites. Patients were instructed to use the therapy twice daily for three months. Pre-specified co-primary endpoints were improvements on clinician-rated Tremor Research Group Essential Tremor Rating Assessment Scale (TETRAS) and patient-rated Bain & Findley Activities of Daily Living (BF-ADL) dominant hand scores. Other endpoints included improvement in the tremor power detected by an accelerometer on the therapeutic device, Clinical and Patient Global Impression scores (CGI-I, PGI-I), and Quality of Life in Essential Tremor (QUEST) survey. Results 205 patients completed the study. The co-primary endpoints were met (p≪0.0001), with 62% (TETRAS) and 68% (BF-ADL) of 'severe' or 'moderate' patients improving to 'mild' or 'slight'. Clinicians (CGI-I) reported improvement in 68% of patients, 60% (PGI-I) of patients reported improvement, and QUEST improved (p = 0.0019). Wrist-worn accelerometer recordings before and after 21,806 therapy sessions showed that 92% of patients improved, and 54% of patients experienced ≥50% improvement in tremor power. Device-related adverse events (e.g., wrist discomfort, skin irritation, pain) occurred in 18% of patients. No device-related serious adverse events were reported. Discussion This study suggests that non-invasive neuromodulation therapy used repeatedly at home over three months results in safe and effective hand tremor reduction in many essential tremor patients.
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Affiliation(s)
- Stuart H. Isaacson
- Parkinson’s Disease and Movement Disorders of Boca Raton, Boca Raton, FL, US
| | | | - Winona Tse
- Mount Sinai Hospital, Department of Neurology, New York, NY, US
| | - Olga Waln
- Houston Methodist, Department of Neurology, Houston, TX, US
| | - Christopher Way
- Parkinson’s Institute and Clinical Center, Mountain View, CA, US
| | - Melita T. Petrossian
- Pacific Neuroscience Institute, Pacific Movement Disorders Center, Santa Monica, CA, US
| | - Nabila Dahodwala
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, US
| | | | - Mark Lew
- University of Southern California, Department of Neurology, Los Angeles, CA, US
| | - Cameron Dietiker
- University of California San Francisco, Movement Disorder and Neuromodulation Center, San Francisco, CA, US
| | - Nijee Luthra
- University of California San Francisco, Movement Disorder and Neuromodulation Center, San Francisco, CA, US
| | - Pinky Agarwal
- EvergreenHealth, Department of Neurology, Kirkland, WA, US
| | - Rohit Dhall
- University of Arkansas for Medical Sciences, Department of Neurology, Little Rock, AR, US
| | - John Morgan
- Augusta University, Department of Neurology, Augusta, GA, US
| | - Nicole Calakos
- Duke University School of Medicine, Department of Neurology, Durham, NC, US
| | | | - Ejaz A. Shamim
- Kaiser Permanente MidAtlantic States, Department of Neurology, MidAtlantic Permanente Research Institute, Largo, MD, US
| | - Rajeev Kumar
- Rocky Mountain Movement Disorders Center, Englewood, CO, US
| | - Peter LeWitt
- Henry Ford Health System, Department of Neurology, West Bloomfield, MI, US
| | - Holly A. Shill
- Barrow Neurological Institute, Department of Neurology, Phoenix, AZ, US
| | - Adam Simmons
- Hospital for Special Care, Department of Research, New Britain, CT, US
| | - Fernando L. Pagan
- Georgetown University Medical Center, Department of Neurology, Washington DC, US
| | - Pravin Khemani
- Swedish Neuroscience Institute, Department of Neurology, Seattle, WA, US
| | - Jessica Tate
- Wake Forest Baptist Health, Department of Neurology, Winston-Salem, NC, US
| | | | - Lan Luo
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Neurology, Boston, MA, US
| | - William Ondo
- Houston Methodist, Department of Neurology, Houston, TX, US
| | - Mark Hallett
- National Institute of Neurological Disorders and Stroke, Human Motor Control Section, Bethesda, MD, US
| | | | | | | | - Scott L. Delp
- Stanford University, Department of Bioengineering, Stanford, CA, US
| | - Rajesh Pahwa
- University of Kansas Medical Center, Department of Neurology, Kansas City, KS, US
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Alonso-Navarro H, García-Martín E, Agúndez JA, Jiménez-Jiménez FJ. Current and Future Neuropharmacological Options for the Treatment of Essential Tremor. Curr Neuropharmacol 2020; 18:518-537. [PMID: 31976837 PMCID: PMC7457404 DOI: 10.2174/1570159x18666200124145743] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/31/2019] [Accepted: 01/23/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Essential Tremor (ET) is likely the most frequent movement disorder. In this review, we have summarized the current pharmacological options for the treatment of this disorder and discussed several future options derived from drugs tested in experimental models of ET or from neuropathological data. METHODS A literature search was performed on the pharmacology of essential tremors using PubMed Database from 1966 to July 31, 2019. RESULTS To date, the beta-blocker propranolol and the antiepileptic drug primidone are the drugs that have shown higher efficacy in the treatment of ET. Other drugs tested in ET patients have shown different degrees of efficacy or have not been useful. CONCLUSION Injections of botulinum toxin A could be useful in the treatment of some patients with ET refractory to pharmacotherapy. According to recent neurochemical data, drugs acting on the extrasynaptic GABAA receptors, the glutamatergic system or LINGO-1 could be interesting therapeutic options in the future.
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Affiliation(s)
| | | | | | - Félix J. Jiménez-Jiménez
- Address correspondence to this author at the Section of Neurology, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain; Tel: +34636968395; Fax: +34913280704; E-mails: ;
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12
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Ferreira JJ, Mestre TA, Lyons KE, Benito-León J, Tan EK, Abbruzzese G, Hallett M, Haubenberger D, Elble R, Deuschl G. MDS evidence-based review of treatments for essential tremor. Mov Disord 2019; 34:950-958. [PMID: 31046186 DOI: 10.1002/mds.27700] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Essential tremor is one of the most prevalent movement disorders. Many treatments for essential tremor have been reported in clinical practice, but it is uncertain which options have the most robust evidence. The International Parkinson and Movement Disorder Society commissioned a task force on tremor to review clinical studies of treatments for essential tremor. OBJECTIVES To conduct an evidence-based review of current pharmacological and surgical treatments for essential tremor, using standardized criteria defined a priori by the International Parkinson and Movement Disorder Society. METHODS We followed the recommendations of the International Parkinson and Movement Disorder Society Evidence Based Medicine Committee. RESULTS Sixty-four studies of pharmacological and surgical interventions were included in the review. Propranolol and primidone were classified as clinically useful, similar to Topiramate, but only for doses higher than 200 mg/day. Alprazolam and botulinum toxin type A were classified as possibly useful. Unilateral Ventralis intermedius thalamic DBS, radiofrequency thalamotomy, and MRI-guided focused ultrasound thalamotomy were considered possibly useful. All the above recommendations were made for limb tremor in essential tremor. There was insufficient evidence for voice and head tremor as well as for the remaining interventions. CONCLUSION Propranolol, primidone, and topiramate (>200 mg/day) are the pharmacological interventions in which the data reviewed robustly supported efficacy. Their safety profile and patient preference may guide the prioritization of these interventions in clinical practice. MRI-guided focused ultrasound thalamotomy was, for the first time, assessed and was considered to be possibly useful. There is a need to improve study design in essential tremor and overcome the limitation of small sample sizes, cross-over studies, short-term follow-up studies, and use of nonvalidated clinical scales. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Joaquim J Ferreira
- Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Portugal.,CNS-Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Tiago A Mestre
- Parkinson's Disease and Movement Disorders Center, Division of Neurology, Department of Medicine, The Ottawa Hospital Research Institute, Brain and Mind Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kelly E Lyons
- Parkinson's Disease and Movement Disorder Center, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Julián Benito-León
- Department of Neurology, University Hospital 12 de Octubre; Center of Biomedical Network Research on Neurodegenerative diseases (CIBERNED), Department of Medicine, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Eng-King Tan
- National Neuroscience Institute, Duke NUS Medical School, Singapore
| | - Giovanni Abbruzzese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health, University of Genoa-IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Mark Hallett
- Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Dietrich Haubenberger
- Clinical Trials Unit, Office of the Clinical Director, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Rodger Elble
- Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Günther Deuschl
- Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Christian Albrechts University Kiel, Kiel, Germany
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Daneault JF. Could Wearable and Mobile Technology Improve the Management of Essential Tremor? Front Neurol 2018; 9:257. [PMID: 29725318 PMCID: PMC5916972 DOI: 10.3389/fneur.2018.00257] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/03/2018] [Indexed: 11/13/2022] Open
Abstract
Essential tremor (ET) is the most common movement disorder. Individuals exhibit postural and kinetic tremor that worsens over time and patients may also exhibit other motor and non-motor symptoms. While millions of people are affected by this disorder worldwide, several barriers impede an optimal clinical management of symptoms. In this paper, we discuss the impact of ET on patients and review major issues to the optimal management of ET; from the side-effects and limited efficacy of current medical treatments to the limited number of people who seek treatment for their tremor. Then, we propose seven different areas within which mobile and wearable technology may improve the clinical management of ET and review the current state of research in these areas.
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Affiliation(s)
- Jean-Francois Daneault
- Motor Behavior Laboratory, Department of Rehabilitation and Movement Sciences, School of Health Professions, Rutgers, The State University of New Jersey, Newark, NJ, United States
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Hopfner F, Deuschl G. Is essential tremor a single entity? Eur J Neurol 2017; 25:71-82. [DOI: 10.1111/ene.13454] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 09/01/2017] [Indexed: 12/18/2022]
Affiliation(s)
- F. Hopfner
- Department of Neurology; Universitätsklinikum Schleswig-Holstein; Kiel Campus Germany
- Christian-Albrechts Universität; Kiel Germany
| | - G. Deuschl
- Department of Neurology; Universitätsklinikum Schleswig-Holstein; Kiel Campus Germany
- Christian-Albrechts Universität; Kiel Germany
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Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, Agoritsas T, Mistry N, Iorio A, Jack S, Sivaramalingam B, Iserman E, Mustafa RA, Jedraszewski D, Cotoi C, Haynes RB. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2014; 2014:CD000011. [PMID: 25412402 PMCID: PMC7263418 DOI: 10.1002/14651858.cd000011.pub4] [Citation(s) in RCA: 671] [Impact Index Per Article: 67.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications. OBJECTIVES The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes. SEARCH METHODS We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles. SELECTION CRITERIA We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome. MAIN RESULTS The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes. AUTHORS' CONCLUSIONS Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.
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Affiliation(s)
- Robby Nieuwlaat
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Nancy Wilczynski
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Tamara Navarro
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Nicholas Hobson
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Rebecca Jeffery
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Arun Keepanasseril
- McMaster UniversityDepartments of Clinical Epidemiology & Biostatistics, and Medicine, Faculty of Health Sciences1280 Main Street WestHamiltonONCanadaL8S 4L8
| | - Thomas Agoritsas
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Niraj Mistry
- St. Michael's HospitalDepartment of Pediatrics30 Bond StreetTorontoONCanadaM5B 1W8
| | - Alfonso Iorio
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Susan Jack
- McMaster UniversitySchool of Nursing, Faculty of Health SciencesHealth Sciences CentreRoom 2J32, 1280 Main Street WestHamiltonONCanadaL8S 4K1
| | | | - Emma Iserman
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Reem A Mustafa
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Dawn Jedraszewski
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Chris Cotoi
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - R. Brian Haynes
- McMaster UniversityDepartments of Clinical Epidemiology & Biostatistics, and Medicine, Faculty of Health Sciences1280 Main Street WestHamiltonONCanadaL8S 4L8
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Hedera P, Cibulčík F, Davis TL. Pharmacotherapy of essential tremor. J Cent Nerv Syst Dis 2013; 5:43-55. [PMID: 24385718 PMCID: PMC3873223 DOI: 10.4137/jcnsd.s6561] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/10/2013] [Accepted: 11/25/2013] [Indexed: 12/11/2022] Open
Abstract
Essential tremor (ET) is a common movement disorder but its pathogenesis remains poorly understood. This has limited the development of effective pharmacotherapy. The current therapeutic armamentaria for ET represent the product of careful clinical observation rather than targeted molecular modeling. Here we review their pharmacokinetics, metabolism, dosing, and adverse effect profiles and propose a treatment algorithm. We also discuss the concept of medically refractory tremor, as therapeutic trials should be limited unless invasive therapy is contraindicated or not desired by patients.
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Affiliation(s)
- Peter Hedera
- Department of Neurology, Vanderbilt University, Nashville, TN
| | - František Cibulčík
- Department of Neurology, Slovak Medical University and University Hospital Bratislava, Slovakia
| | - Thomas L Davis
- Department of Neurology, Vanderbilt University, Nashville, TN
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17
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Shaw JD, Allison KG, Staffetti JS, Zesiewicz TA. Diagnosis and treatment of essential tremor. Neurodegener Dis Manag 2013. [DOI: 10.2217/nmt.13.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Essential tremor (ET) is one of the most prevalent movement disorders in the world, affecting millions of people. Medications that are commonly used to treat ET include antiepileptic or antihypertensive medications. Primidone and propranolol are considered effective, first-line agents for treating ET, while atenolol, alprazolam and topiramate are considered second-line agents. Gabapentin appears to improve ET when used as a monotherapy, although not as an adjunct therapy. Alternatives to pharmacologic treatment for refractory ET include botulinum toxin A injections, deep-brain stimulation of the ventral intermediate nucleus of the thalamus and thalamotomy. Future developments in the treatment of ET will depend on valid animal models and a greater understanding of its pathophysiology.
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Affiliation(s)
- Jessica Davenport Shaw
- University of South Florida, Department of Neurology, Frances J Zesiewicz Center & Foundation for Parkinson’s Disease & University of South Florida Ataxia Research Center, 12901 Bruce B Downs Boulevard, MDC Box 55, Tampa, FL 33612, USA
| | - Kevin G Allison
- University of South Florida, Department of Neurology, Frances J Zesiewicz Center & Foundation for Parkinson’s Disease & University of South Florida Ataxia Research Center, 12901 Bruce B Downs Boulevard, MDC Box 55, Tampa, FL 33612, USA
| | - Joseph S Staffetti
- University of South Florida, Department of Neurology, Frances J Zesiewicz Center & Foundation for Parkinson’s Disease & University of South Florida Ataxia Research Center, 12901 Bruce B Downs Boulevard, MDC Box 55, Tampa, FL 33612, USA
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Abstract
OPINION STATEMENT Essential tremor is one of the most common movement disorders in the world. Although millions of people worldwide are affected by ET, only one medication, propranolol, is approved by the United States Food and Drug Administration to treat it. None of the medications currently used as ET therapy were developed specifically for this purpose, and select antihypertensive and antiepileptic medications remain at the forefront of ET therapy. Propranolol and primidone are considered "effective" agents that treat ET; topiramate, atenolol, and alprazolam are "probably effective", and nimodipine, nadolol, and clonazepam are "possibly effective". Medications that probably do not adequately treat ET include levetiracetam and pregabalin. Gabapentin appears to improve ET when used as monotherapy, but not when used as adjunct therapy. Sotalol has been found to be "probably effective" in treating ET in previous reviews, but it may be associated with arrhythmias and should not be routinely recommended. Botulinum toxin A may reduce limb tremor, but may cause dose dependent weakness. Deep brain stimulation (DBS) of the VIM is used as an alternative to pharmacological therapy of ET in patients who fail to adequately respond to medical therapy. The magnitude of effect from DBS is greater than from medical management, but more severe side effects are possible with surgery. Future treatment options for ET will depend on valid animal models, and a better understanding of its pathophysiology.
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Zappia M, Albanese A, Bruno E, Colosimo C, Filippini G, Martinelli P, Nicoletti A, Quattrocchi G. Treatment of essential tremor: a systematic review of evidence and recommendations from the Italian Movement Disorders Association. J Neurol 2012; 260:714-40. [DOI: 10.1007/s00415-012-6628-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 07/12/2012] [Accepted: 07/12/2012] [Indexed: 10/28/2022]
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Resnick AS, Okun MS, Malapira T, Smith D, Vale FL, Sullivan K, Miller A, Jahan I, Zesiewicz T. Sustained Medication Reduction Following Unilateral VIM Thalamic Stimulation for Essential Tremor. Tremor Other Hyperkinet Mov (N Y) 2012; 2:tre-02-38-193-1. [PMID: 23440408 PMCID: PMC3569968 DOI: 10.7916/d8zg6qz2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Accepted: 07/26/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is an increasingly utilized therapeutic modality for the management of medication refractory essential tremor (ET). The aim of this study was to determine whether DBS allowed for anti-tremor medication reduction within the year after the procedure was performed. METHODS We conducted a retrospective chart review and telephone interviews on 34 consecutive patients who had been diagnosed with ET, and who had undergone unilateral DBS surgery. RESULTS Of the 34 patients in our cohort, 31 patients (91%) completely stopped all anti-tremor medications either before surgery (21 patients, 62%) or in the year following DBS surgery (10 patients, 29%). Patients who discontinued tremor medications before DBS surgery did so because their tremors either became refractory to anti-tremor medication, or they developed adverse events to tremor medications. Patients who stopped tremor medications after DBS surgery did so due to sufficient tremor control. Only three patients (9%) who were taking tremor medications at the time of surgery continued the use of a beta-blocker post-operatively for the purpose of hypertension management in all cases. DISCUSSION The data from this study indicate that medication cessation is common following unilateral DBS for ET.
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Affiliation(s)
- Andrew S. Resnick
- Department of Neurology, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America,UF Center for Movement Disorders and Neurorestoration, Gainesville, Florida, United States of America
| | - Michael S. Okun
- UF Center for Movement Disorders and Neurorestoration, Gainesville, Florida, United States of America
| | - Teresita Malapira
- UF Center for Movement Disorders and Neurorestoration, Gainesville, Florida, United States of America
| | - Donald Smith
- Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America
| | - Fernando L. Vale
- Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America
| | - Kelly Sullivan
- Department of Neurology, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America
| | - Amber Miller
- Department of Neurology, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America
| | - Israt Jahan
- Department of Neurology, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America
| | - Theresa Zesiewicz
- Department of Neurology, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America,*To whom correspondence should be addressed. E-mail:
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Deuschl G, Raethjen J, Hellriegel H, Elble R. Treatment of patients with essential tremor. Lancet Neurol 2011; 10:148-61. [PMID: 21256454 DOI: 10.1016/s1474-4422(10)70322-7] [Citation(s) in RCA: 235] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Benito-León J, Louis ED. Management of essential tremor, including medical and surgical approaches. HANDBOOK OF CLINICAL NEUROLOGY 2011; 100:449-456. [PMID: 21496601 DOI: 10.1016/b978-0-444-52014-2.00034-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Essential tremor (ET) is one of the most common neurological disorders among adults. For many years, ET was viewed as a benign monosymptomatic condition, characterized by a kinetic arm tremor, yet over the last 10 years, a growing body of evidence suggests that this disorder is a progressive condition that is heterogeneous. Tremor may have a negative impact on health-related quality of life in some patients. Pharmacotherapy is initiated when the tremor interferes with the patient's ability to perform daily activities or when the tremor becomes embarrassing or affects health-related quality of life. For severe tremor, deep-brain stimulation of the thalamus may improve function.
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Affiliation(s)
- Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre" and Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain.
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Abstract
Essential tremor (ET) is one of the most common movement disorders in the world. Despite this, only one medication (propranolol) is approved by the Food and Drug Administration (FDA) to treat it. Fortunately, recent studies have identified some additional medications as treatment of ET. Surgical procedures, such as deep brain stimulation of the ventral intermediate nucleus of the thalamus, offer treatment for refractory tremor. The epidemiology, pathogenesis, and medical and surgical treatment of ET will be discussed in this paper.
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Affiliation(s)
- Theresa A Zesiewicz
- Department of Neurology, Parkinson Research Foundation, James A. Haley Veterans Administration Hospital, University of South Florida, Tampa, FL, USA
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Abstract
BACKGROUND People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects. OBJECTIVES To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions. SEARCH STRATEGY We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles. SELECTION CRITERIA Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings. DATA COLLECTION AND ANALYSIS Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis. MAIN RESULTS For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes. AUTHORS' CONCLUSIONS For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.
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Affiliation(s)
- R B Haynes
- McMaster University, Clinical Epidemiology & Biostatistics and Medicine, Faculty of Health Sciences, 1200 Main Street West, Rm. 2C10B, Hamilton, Ontario, Canada L8N 3Z5.
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Martínez C, García-Martín E, Alonso-Navarro H, Jiménez-Jiménez FJ, Benito-León J, García-Ferrer I, Vázquez-Torres P, Puertas I, Zurdo JM, López-Alburquerque T, Agúndez JAG. Changes at the CYP2C locus and disruption of CYP2C8/9 linkage disequilibrium in patients with essential tremor. Neuromolecular Med 2007; 9:195-204. [PMID: 17627038 DOI: 10.1007/bf02685892] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Revised: 10/16/2006] [Accepted: 10/18/2006] [Indexed: 10/22/2022]
Abstract
To identify low-penetrance genes related to sporadic essential tremor (ET) at the CYP2C locus, located in chromosome 10 q23.33. Leukocytary DNA from 200 ET patients and a control group of 300 unrelated healthy individuals with known CYP2C19 genotypes was studied for common CYP2C8 and CYP2C9 allelic variants by using amplification-restriction analyses. Patients with ET showed the following differences compared with healthy subjects: a 1.6-fold reduction in the frequency for CYP2C8*3 (p=0.006), a 1.35-fold reduction of CYP2C9*2 (p=0.05) and a 1.52-fold reduction in the frequency for CYP2C9*3 (p=0.07). The frequency for patients with ET carrying at least one defective allele was 1.33-fold reduced as compared with healthy subjects (p=0.002). In addition, a disruption of the CYP2C8*3/CYP2C9*2 linkage disequilibrium was observed in ET patients, with a 2.1-fold reduction in the percentage for carriers of the haplotype CYP2C8*3 plus CYP2C9*2 in ET patients (p=0.0001). These findings were independent of gender, age, age of onset, or clinical symptoms. These results suggest that alterations at the CYP2C gene locus are associated with the risk for ET.
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Affiliation(s)
- Carmen Martínez
- Department of Pharmacology and Psychiatry, Medical School, University of Extremadura, Badajoz, and Department of Medicine-Neurology, Príncipe de Asturias Hospital, Alcalá de Henares, Madrid, Spain
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Manto M, Rocon E, Pons J, Belda JM, Camut S. Evaluation of a wearable orthosis and an associated algorithm for tremor suppression. Physiol Meas 2007; 28:415-25. [PMID: 17395996 DOI: 10.1088/0967-3334/28/4/007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We describe a wearable orthosis and an associated algorithm for the simultaneous assessment and treatment of essential tremor, one of the most common movement disorders in humans involving an overactivity of the olivo-cerebellar pathways. A motor providing effective viscosity is fixed on a wearable orthosis in the upper limbs. The motor is controlled by a personal computer with software processing in real time the position and rate of rotation of the joint detected by a chip gyroscope. The orthosis can be used in a monitoring mode and in an active mode. The range of tremor suppression of the signals above the orthosis operational limit ranges from about 3% (percentile 5) to about 79% (percentile 95) in relation to energy in the monitoring mode. Considering both postural and kinetic, the mean tremor energy decreased from 55.49 +/- 22.93 rad2 s(-3) in the monitoring mode to 15.66 +/- 7.29 rad2 s(-3) in the active mode. Medians of power reduction were below 60% for the wrist and the elbow. In addition to supplying new information on the interactions between kinematics, dynamics and tremor genesis, this non-invasive technique is an alternative to current therapies. This new approach will provide new insights into the understanding of motor control.
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Affiliation(s)
- Mario Manto
- Service de Neurologie, Hôpital Erasme-ULB, Bruxelles, Belgium.
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Abstract
Essential tremor (ET) is among the most common neurologic disorders. The traditional view of this disorder as a benign, monosymptomatic, familial condition is being replaced by a more complex view of ET as perhaps a family of diseases with etiologic, clinical, and pathologic heterogeneity. This article discusses the major clinical features of ET and approaches to its diagnosis and treatment.
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Affiliation(s)
- Elan D Louis
- Department of Neurology, College of Physicians and Surgeons, Columbia University, 710 West 168th Street, New York, NY 10032, USA.
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Benito-León J, Louis ED. Essential tremor: emerging views of a common disorder. ACTA ACUST UNITED AC 2006; 2:666-78; quiz 2p following 691. [PMID: 17117170 DOI: 10.1038/ncpneuro0347] [Citation(s) in RCA: 194] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Accepted: 09/15/2006] [Indexed: 11/08/2022]
Abstract
Essential tremor (ET) is the most prevalent tremor disorder. ET has traditionally been viewed as a monosymptomatic disorder characterized by a kinetic arm tremor, but this definition is gradually being replaced. The clinical spectrum has come to include several motor features, including tremor and ataxia, and several non-motor features, including possible cognitive impairment and personality disturbances. Postmortem studies are revealing several different patterns of pathology. The emerging view is that ET might be a family of diseases, unified by the presence of kinetic tremor, but further characterized by etiological, clinical and pathological heterogeneity. Effective pharmacological treatments for the disorder remain limited, although new insights into disease mechanisms might result in more-effective therapies. In addition, recent investigations of environmental toxicants that might be linked to ET open the way towards primary disease prevention through a reduction in exposure to these factors.
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Alonso-Navarro H, Martínez C, García-Martín E, Benito-León J, García-Ferrer I, Vázquez-Torres P, Puertas I, López-Alburquerque T, Agúndez JAG, Jiménez-Jiménez FJ. CYP2C19 polymorphism and risk for essential tremor. Eur Neurol 2006; 56:119-23. [PMID: 16960452 DOI: 10.1159/000095702] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Accepted: 07/12/2006] [Indexed: 11/19/2022]
Abstract
Many patients with essential tremor (ET) develop acute adverse effects to primidone. We investigated the association between CYP2C19 polymorphism (possibly related to primidone metabolism) and the risk for developing essential ET and acute adverse effects to primidone. Leukocytary DNA from 200 ET patients and 300 healthy controls was studied for the genotype CYP2C19 and the occurrence of CYP2C19 allelic variants by using allele-specific PCR amplification and Sma I and BamH I RFLP analyses. The frequencies of the genotype CYP2C19*1/CYP2C19*2 and of the allelic variant CYP2C19*2 were significantly higher in ET patients than in controls. The mean age at onset of ET did not differ significantly between patients with genotypes CYP2C19*1/CYP2C19*2andCYP2C19*1/CYP2C19*1. The frequencies of the genotype CYP2C19*1/CYP2C19*2 and the allelic variant CYP2C19*2 were similar in ET patients who developed acute adverse effects to primidone, in those who tolerated primidone and in controls; the frequencies were also similar in patients with head, voice, tongue and chin tremor compared with controls. These results suggest that heterozygosis CYP2C19*1/CYP2C19*2 is associated with the risk for ET, but not with the age at onset of ET, the presentation of acute side effects of primidone, or the existence of head, voice, tongue or chin tremor.
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Affiliation(s)
- Hortensia Alonso-Navarro
- Department of Medicine-Neurology, Hospital Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Spain
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Haynes RB, Yao X, Degani A, Kripalani S, Garg A, McDonald HP. Interventions to enhance medication adherence. Cochrane Database Syst Rev 2005:CD000011. [PMID: 16235271 DOI: 10.1002/14651858.cd000011.pub2] [Citation(s) in RCA: 226] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects. OBJECTIVES To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions. SEARCH STRATEGY Computerized searches were updated to September 2004 without language restriction in MEDLINE, EMBASE, CINAHL, The Cochrane Library, International Pharmaceutical Abstracts (IPA), PsycINFO and SOCIOFILE. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of original and review articles on the topic. SELECTION CRITERIA Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings. DATA COLLECTION AND ANALYSIS Study design features, interventions and controls, and results were extracted by one reviewer and confirmed by at least one other reviewer. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. MAIN RESULTS For short-term treatments, four of nine interventions reported in eight RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient compliance, but did not enhance the clinical outcome. For long-term treatments, 26 of 58 interventions reported in 49 RCTs were associated with improvements in adherence, but only 18 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes. Six studies showed that telling patients about adverse effects of treatment did not affect their adherence. AUTHORS' CONCLUSIONS Improving short-term adherence is relatively successful with a variety of simple interventions. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.
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Affiliation(s)
- R B Haynes
- McMaster University Medical Centre, Clinical Epidemiology and Biostatistics, HSC Room 2C10b, 1200 Main St. West, Hamilton, Ontario, Canada L8N 3Z5.
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Abstract
BACKGROUND Essential tremor (ET) is the most common adult tremor disorder and is characterized by postural and kinetic tremor. Symptoms are typically progressive and potentially disabling, often forcing patients to change jobs or seek early retirement. Proper treatment is contingent on a correct diagnosis, and other possible causes of tremor must be excluded. REVIEW SUMMARY Although primidone and propranolol have been regarded as the mainstays of pharmacologic therapy for ET, additional agents may be useful in reducing tremor. Surgical procedures are available that effectively ameliorate tremor that is refractory to medical management. This article reviews the epidemiology, pathophysiology, and treatment options for ET. CONCLUSIONS Despite a range of treatment options currently available, further research is necessary to manage this syndrome most effectively. Double-blind, controlled trials are needed to determine whether primidone, propranolol, or a combination of these medications is superior in the initial management of ET. Other pharmacologic agents have shown potential to reduce tremor and should be investigated further. Additional studies are also needed to determine the best treatment of head and voice tremor with pharmacologic and surgical interventions. With proper treatment, tremor is sufficiently reduced in the majority of patients.
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Affiliation(s)
- Kelly L Sullivan
- Department of Neurology, Parkinson's Disease and Movement Disorders Center, Tampa General Hospital Healthcare, University of South Florida, Tampa, Florida 33612, USA
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Gatto EM, Roca MCU, Raina G, Micheli F. Low Doses of Topiramate are Effective in Essential Tremor: A Report of Three Cases. Clin Neuropharmacol 2003; 26:294-6. [PMID: 14646607 DOI: 10.1097/00002826-200311000-00006] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We here report on 3 patients with essential tremor, otherwise unresponsive to pharmacological treatment, who greatly benefited from low doses of topiramate (50 mg/d). No side effects were observed and improvement was sustained during a mean of 7 months (range 3-12 months) follow up. Our results suggest that topiramate titration should be performed gradually, so as not to neglect cases responsive to low doses.
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Affiliation(s)
- Emilia M Gatto
- Parkinson's Disease and Movement Disorders Unit, Institute of Applied Neurosciences, José de San Martin Hospital de Clinicas, Buenos Aires, Argentina
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Abstract
PURPOSE OF REVIEW Tremors can be encountered in a variety of disease states but the most common causes are Parkinson disease and essential tremor. This review was undertaken to highlight advances in the field during the last 12 months. RECENT FINDINGS Kinetic tremor may be more prominent in essential tremor than postural tremor. Clinically Parkinson disease and essential tremor may be confused with each other but it may be possible to distinguish between these two nitrites using sophisticated electrophysiology. Monosymptomatic rest tremor has recently been shown to be associated with decreased fluorodopa uptake on the positron emission tomography scan suggesting its relationship to Parkinson disease. SUMMARY Significant advances have been made in the understanding of the pathophysiology, genetics and therapy of tremor disorders during the last 12 months. This review will consider Parkinson disease, essential tremor and other tremors and highlight advances in the field.
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Sethi K. Curr Opin Neurol 2003; 16:481-485. [DOI: 10.1097/00019052-200308000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Abstract
Tremor is a common movement disorder yet many physicians struggle with its terminology as well as with its treatment. Attempts have been made to develop standard terminology and criteria for tremors but this process continues to evolve. In this review, a summary of the currently-proposed phenomenology and syndromic classification of all types of tremor is presented. The diagnosis and management of essential tremor is presented in more detail, as it is the most commonly encountered tremor.
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Affiliation(s)
- D A Grimes
- Parkinson's Disease and Movement Disorders Clinic, The Ottawa Hospital, Ottawa, Canada
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