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Schoeberl F, Dowsett J, Pradhan C, Grabova D, Köhler A, Taylor P, Zwergal A. TMS of the left primary motor cortex improves tremor intensity and postural control in primary orthostatic tremor. J Neurol 2024; 271:2938-2947. [PMID: 38625401 PMCID: PMC11136716 DOI: 10.1007/s00415-024-12376-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/17/2024]
Abstract
A ponto-cerebello-thalamo-cortical network is the pathophysiological correlate of primary orthostatic tremor. Affected patients often do not respond satisfactorily to pharmacological treatment. Consequently, the objective of the current study was to examine the effects of a non-invasive neuromodulation by theta burst repetitive transcranial magnetic stimulation (rTMS) of the left primary motor cortex (M1) and dorsal medial frontal cortex (dMFC) on tremor frequency, intensity, sway path and subjective postural stability in primary orthostatic tremor. In a cross-over design, eight patients (mean age 70.2 ± 5.4 years, 4 female) with a primary orthostatic tremor received either rTMS of the left M1 leg area or the dMFC at the first study session, followed by the other condition (dMFC or M1 respectively) at the second study session 30 days later. Tremor frequency and intensity were quantified by surface electromyography of lower leg muscles and total sway path by posturography (foam rubber with eyes open) before and after each rTMS session. Patients subjectively rated postural stability on the posturography platform following each rTMS treatment. We found that tremor frequency did not change significantly with M1- or dMFC-stimulation. However, tremor intensity was lower after M1- but not dMFC-stimulation (p = 0.033/ p = 0.339). The sway path decreased markedly after M1-stimulation (p = 0.0005) and dMFC-stimulation (p = 0.023) compared to baseline. Accordingly, patients indicated a better subjective feeling of postural stability both with M1-rTMS (p = 0.007) and dMFC-rTMS (p = 0.01). In conclusion, non-invasive neuromodulation particularly of the M1 area can improve postural control and tremor intensity in primary orthostatic tremor by interference with the tremor network.
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Affiliation(s)
- Florian Schoeberl
- Department of Neurology and German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - James Dowsett
- Division of Psychology, University of Stirling, Stirling, UK
| | - Cauchy Pradhan
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - Denis Grabova
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - Angelina Köhler
- Department of Neurology and German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - Paul Taylor
- Faculty of Philosophy, Philosophy of Science and the Study of Religion, LMU Munich, Munich, Germany
| | - Andreas Zwergal
- Department of Neurology and German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany.
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Babeliowsky WA, Bot M, Potters WV, van den Munckhof P, Blok ER, de Bie RM, Schuurman R, van Rootselaar A. Deep Brain Stimulation for Orthostatic Tremor: An Observational Study. Mov Disord Clin Pract 2024; 11:676-685. [PMID: 38586984 PMCID: PMC11145120 DOI: 10.1002/mdc3.14035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 02/09/2024] [Accepted: 03/12/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Primary orthostatic tremor (OT) can affect patients' life. Treatment of OT with deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus (Vim) is described in a limited number of patients. The Vim and posterior subthalamic area (PSA) can be targeted in a single trajectory, allowing both stimulation of the Vim and/or dentatorubrothalamic tract (DRT). In essential tremor this is currently often used with positive effects. OBJECTIVE To evaluate the efficacy of Vim/DRT-DBS in OT-patients, based on standing time and Quality of Life (QoL), also on the long-term. Furthermore, to relate stimulation of the Vim and DRT, medial lemniscus (ML) and pyramidal tract (PT) to beneficial clinical and side-effects. METHODS Nine severely affected OT-patients received bilateral Vim/DRT-DBS. Primary outcome measure was standing time; secondary measures included self-reported measures, neurophysiological measures, structural analyses, surgical complications, stimulation-induced side-effects, and QoL up to 56 months. Stimulation of volume of tissue activated (VTA) were related to outcome measures. RESULTS Average maximum standing time increased from 41.0 s ± 51.0 s to 109.3 s ± 65.0 s after 18 months, with improvements measured in seven of nine patients. VTA (n = 7) overlapped with the DRT in six patients and with the ML and/or PT in six patients. All patients experienced side-effects and QoL worsened during the first year after surgery, which improved again during long-term follow-up, although remaining below age-related normal values. Most patients reported a positive effect of DBS. CONCLUSION Vim/DRT-DBS improved standing time in patients with severe OT. Observed side-effects are possibly related to stimulation of the ML and PT.
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Affiliation(s)
- Wietske A. Babeliowsky
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Maarten Bot
- NeurosurgeryAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Wouter V. Potters
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | | | - Edwin R. Blok
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Rob M.A. de Bie
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
- Amsterdam NeuroscienceNeurodegenerationAmsterdamThe Netherlands
| | - Rick Schuurman
- NeurosurgeryAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
| | - Anne‐Fleur van Rootselaar
- Neurology and Clinical NeurophysiologyAmsterdam UMC location University of AmsterdamAmsterdamThe Netherlands
- Amsterdam NeuroscienceNeurodegenerationAmsterdamThe Netherlands
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Boogers A, Billet A, Vandenberghe W, Nuttin B, Theys T, Mc Laughlin M, De Vloo P. Deep brain stimulation and spinal cord stimulation for orthostatic tremor: A systematic review. Parkinsonism Relat Disord 2022; 104:115-120. [PMID: 36243552 DOI: 10.1016/j.parkreldis.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/24/2022] [Accepted: 10/01/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Orthostatic tremor is a rare and debilitating movement disorder. Its first-line treatment is pharmacological. For pharmaco-refractory patients, surgical treatment options such as deep brain stimulation (DBS) and spinal cord stimulation (SCS) have been investigated recently. OBJECTIVES We conducted a systematic review of all published outcome and safety data on DBS and SCS for orthostatic tremor patients. METHODS We searched Pubmed and Embase for studies describing orthostatic tremor patients treated with DBS or SCS. We collected all available outcome and safety data and our primary endpoint was the change in unsupported stance duration 1 year postoperatively (±6 months). RESULTS We included 15 studies, reporting on 32 orthostatic tremor patients who underwent DBS, 4 patients SCS and 2 both. The ventral intermediate nucleus and the zona incerta were targeted in 25/34 and 9/34 DBS cases, respectively. The median stance time at 1 year follow-up was 240 s compared to 30 s pre-operatively (p < 0.001). Stimulation-induced side effects occurred in the majority of patients, but were often transient. Bilateral stimulation appeared more effective than unilateral and stimulation settings were comparable to thalamic DBS for essential tremor. There were insufficient data available to draw meaningful conclusions on the long-term effects of DBS. Due to insufficient data, no conclusions could be drawn on the effects of SCS on orthostatic tremor. CONCLUSION DBS may be effective to increase stance time in orthostatic tremor patients in the first year, but further research is necessary to evaluate the long-term effects and the role of spinal cord stimulation.
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Affiliation(s)
- Alexandra Boogers
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Research Group Experimental ORL, Department of Neurosciences, The Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Alexine Billet
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Wim Vandenberghe
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Laboratory for Parkinson Research, Department of Neurosciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Bart Nuttin
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Research Group Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Tom Theys
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Research Group Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Myles Mc Laughlin
- Research Group Experimental ORL, Department of Neurosciences, The Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Philippe De Vloo
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Research Group Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Kim E, Kum J, Kim H. Trans-Spinal Focused Ultrasound Stimulation Selectively Modulates Descending Motor Pathway. IEEE Trans Neural Syst Rehabil Eng 2022; 30:314-320. [PMID: 35108206 DOI: 10.1109/tnsre.2022.3148877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Compared to current non-invasive methods utilizing magnetic and electrical means, focused ultrasound provides greater spatial resolution and penetration depth. Despite the broad application of ultrasound stimulation, there is a lack of studies dedicated to the investigation of acoustic neuromodulation on the spinal cord. This study aims to apply focused ultrasound on the spinal cord to modulate the descending pathways in a non-invasive fashion. The application of trans-spinal focused ultrasound (tsFUS) was examined on the motor deficit mouse model. tsFUS was achieved using a single-element focused ultrasound transducer operating at 3 MHz. The sonication was performed on anesthetized 6 week-old mice targeting T12 and L3 vertebrae. The effect was analyzed by comparing electromyography responses from the hindlimb induced by electrical stimulation of the motor cortex. Further, the mouse model with the Harmaline-induced essential tremor was selected to investigate the potential clinical application of tsFUS. The safety was verified by histological assessment. Sonication at the T12 area inhibited motor response, while sonication over the L3 region provided signal enhancement. Sonication of T12 of the ET mouse also showed the ability of ultrasound to suppress tremors. Meanwhile, the histological examination did not show any abnormalities with the highest applied acoustic pressure. In this work, a non-invasive motor signal modulation was achieved using tsFUS. Moreover, the results showed the ability of focused ultrasound to manage tremors in a safe manner. This study provides a stepping stone for the trans-spinal application of focused ultrasound to motor-related disorders.
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Frey J, Hess CW, Kugler L, Wajid M, Wagle Shukla A. Transcranial Magnetic Stimulation in Tremor Syndromes: Pathophysiologic Insights and Therapeutic Role. Front Neurol 2021; 12:700026. [PMID: 34512517 PMCID: PMC8426899 DOI: 10.3389/fneur.2021.700026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/30/2021] [Indexed: 12/12/2022] Open
Abstract
Transcranial magnetic stimulation (TMS) is a painless, non-invasive, and established brain stimulation technique to investigate human brain function. Over the last three decades, TMS has shed insight into the pathophysiology of many neurological disorders. Tremor is an involuntary, rhythmic oscillatory movement disorder commonly related to pathological oscillations propagated via the cerebello-thalamo-cortical pathway. Although tremor is the most common movement disorder and recent imaging studies have enhanced our understanding of the critical pathogenic networks, the underlying pathophysiology of different tremor syndromes is complex and still not fully understood. TMS has been used as a tool to further our understanding of tremor pathophysiology. In addition, repetitive TMS (rTMS) that can modulate brain functions through plasticity effects has been targeted to the tremor network to gain potential therapeutic benefits. However, evidence is available for only a few studies that included small patient samples with limited clinical follow-up. This review aims to discuss the role of TMS in advancing the pathophysiological understanding as well as emerging applications of rTMS for treating individual tremor syndromes. The review will focus on essential tremor, Parkinson's disease tremor, dystonic tremor syndrome, orthostatic tremor, and functional tremor.
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Affiliation(s)
- Jessica Frey
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Christopher W Hess
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Liam Kugler
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Manahil Wajid
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Aparna Wagle Shukla
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
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Hewitt AL, Klassen BT, Lee KH, Van Gompel JJ, Hassan A. Deep brain stimulation for orthostatic tremor: A single-center case series. Neurol Clin Pract 2020; 10:324-332. [PMID: 32983612 DOI: 10.1212/cpj.0000000000000730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/13/2019] [Indexed: 11/15/2022]
Abstract
Background Orthostatic tremor (OT) is a high-frequency weight-bearing tremor of the legs and trunk associated with progressive disability and is often refractory to medications. Case reports suggest that thalamic deep brain stimulation (DBS) is effective. We report 5 female patients with medication-refractory OT who underwent bilateral thalamic DBS at the Mayo Clinic and assess factors associated with a successful DBS outcome. Methods Demographic, clinical, electrophysiology, and DBS data were abstracted. Outcomes were change in tremor-onset latency, standing time, standing ADLs, and patient and clinician global impression of change (PGIC; CGIC). Results All 5 patients had improved standing time (72 vs 408 seconds, p ≤ 0.001) and improved standing ADLs after surgery, without change in tremor-onset latency (16 vs 75 seconds, p = 0.14). Maximal benefit was reached up to 3 years after surgery and sustained for up to 6 years. CGIC was "much improved" in all; PGIC was "much improved" in 4 and "minimally improved" in 1. There were no major complications. Postoperative electrophysiology (n = 1) showed lower tremor amplitude and slower tremor ramp-up on vs off stimulation. Conclusions Bilateral thalamic DBS improved OT symptoms with benefit lasting up to 6 years. A modest increase in standing time of several minutes was associated with meaningful improvement in standing ADLs. Microlesional effect and bilateral stimulation are likely favorable features, while baseline standing time of several minutes may be unfavorable. These findings may inform clinician and patient counseling and require confirmation in larger studies.
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Affiliation(s)
- Angela L Hewitt
- Department of Neurology (ALH, BTK, AH) and Department of Neurosurgery (KHL, JVG), Mayo Clinic, Rochester, MN
| | - Bryan T Klassen
- Department of Neurology (ALH, BTK, AH) and Department of Neurosurgery (KHL, JVG), Mayo Clinic, Rochester, MN
| | - Kendall H Lee
- Department of Neurology (ALH, BTK, AH) and Department of Neurosurgery (KHL, JVG), Mayo Clinic, Rochester, MN
| | - Jamie J Van Gompel
- Department of Neurology (ALH, BTK, AH) and Department of Neurosurgery (KHL, JVG), Mayo Clinic, Rochester, MN
| | - Anhar Hassan
- Department of Neurology (ALH, BTK, AH) and Department of Neurosurgery (KHL, JVG), Mayo Clinic, Rochester, MN
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Krack P, Volkmann J, Tinkhauser G, Deuschl G. Deep Brain Stimulation in Movement Disorders: From Experimental Surgery to Evidence‐Based Therapy. Mov Disord 2019; 34:1795-1810. [DOI: 10.1002/mds.27860] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/01/2019] [Accepted: 08/19/2019] [Indexed: 12/21/2022] Open
Affiliation(s)
- Paul Krack
- Department of Neurology Bern University Hospital and University of Bern Bern Switzerland
| | - Jens Volkmann
- Department of Neurology University Hospital and Julius‐Maximilian‐University Wuerzburg Germany
| | - Gerd Tinkhauser
- Department of Neurology Bern University Hospital and University of Bern Bern Switzerland
| | - Günther Deuschl
- Department of Neurology University Hospital Schleswig Holstein (UKSH), Kiel Campus; Christian‐Albrechts‐University Kiel Germany
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Gilmore G, Murgai A, Nazer A, Parrent A, Jog M. Zona incerta deep-brain stimulation in orthostatic tremor: efficacy and mechanism of improvement. J Neurol 2019; 266:2829-2837. [DOI: 10.1007/s00415-019-09505-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/03/2019] [Accepted: 08/08/2019] [Indexed: 10/26/2022]
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León Ruiz M, Benito-León J. The Top 50 Most-Cited Articles in Orthostatic Tremor: A Bibliometric Review. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2019; 9:tre-09-679. [PMID: 31413901 PMCID: PMC6691913 DOI: 10.7916/tohm.v0.679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/06/2019] [Indexed: 12/20/2022]
Abstract
Background Article-level citation count is a hallmark indicating scientific impact. We aimed to pinpoint and evaluate the top 50 most-cited articles in orthostatic tremor (OT). Methods The ISI Web of Knowledge database and 2017 Journal Citation Report Science Edition were used to retrieve the 50 top-cited OT articles published from 1984 to April 2019. Information was collected by the Analyze Tool on the Web of Science, including number of citations, publication title, journal name, publication year, and country and institution of origin. Supplementary analyses were undertaken to clarify authorship, study design, level of evidence, and category. Results Up to 66% of manuscripts were recovered from five journals: Movement Disorders (n = 18), Brain (n = 4), Journal of Clinical Neurophysiology (n = 4), Neurology (n = 4), and Clinical Neurophysiology (n = 3). Articles were published between 1984 and 2018, with expert opinion as the predominant design (n = 22) and review as category (n = 17). Most articles had level 5 evidence (n = 26). According to their countries of origin, 34% of articles belonged to the United States (n = 17) leading the list, followed by United Kingdom (n = 15). University College London yielded the greater number of articles (n = 12), followed by the University of Kiel (n = 9). Most popular authors were G. Deuschl (n = 10), C.D. Marsden (n = 6), J. Jankovic (n = 5), P.D. Thompson (n = 5), J.C. Rothwell (n = 5), L.J. Findley (n = 4), and P. Brown (n = 4), who together accounted for 48% of them. All papers were in English. Discussion Publishing high-cited OT articles could be facilitated by source journal, study design, category, publication language, and country and institution of origin.
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Affiliation(s)
| | - Julián Benito-León
- Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, ES.,Department of Medicine, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, ES.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, ES
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Evidente VGH, Baker ZJ, Evidente MH, Garrett R, Lambert M, Ponce FA. Orthostatic Tremor is Responsive to Bilateral Thalamic Deep Brain Stimulation: Report of Two Cases Performed Asleep. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2018; 8:566. [PMID: 30191085 PMCID: PMC6125736 DOI: 10.7916/d8ks882g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 07/09/2018] [Indexed: 12/01/2022]
Abstract
Background Orthostatic tremor (OT) is a hyperkinetic movement disorder characterized by rapid tremor in the lower extremities or trunk upon standing. Case Report We report two patients presenting with OT, whose symptoms improved markedly following asleep bilateral thalamic deep brain stimulation (DBS) surgery. Discussion Medically refractory OT can respond favorably to asleep bilateral DBS surgery similar to awake surgery, and may have the advantages of less psychological trauma to the patient, shorter procedure times, and less exposure to anesthesia.
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Affiliation(s)
| | | | | | - Robin Garrett
- Movement Disorders Center of Arizona, Scottsdale, AZ, USA
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Wuehr M, Schlick C, Möhwald K, Schniepp R. Proprioceptive muscle tendon stimulation reduces symptoms in primary orthostatic tremor. J Neurol 2018; 265:1666-1670. [PMID: 29767354 DOI: 10.1007/s00415-018-8902-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 05/03/2018] [Accepted: 05/05/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Primary orthostatic tremor (OT) is characterized by high-frequency lower limb muscle contractions and a disabling sense of unsteadiness while standing. To date, therapeutic options for OT are limited. Here, we examined the effects of proprioceptive leg muscle stimulation via muscle tendon vibration (MTV) on tremor and balance control in patients with primary OT. METHODS Tremor in nine patients with primary OT was examined during four conditions: standing (1), standing with MTV on the bilateral soleus muscles (2), lying (3), and lying with MTV (4). Tremor characteristics were assessed by frequency domain analysis of surface EMG recordings from four leg muscles. Body sway was analyzed using posturographic recordings. RESULTS During standing, all patients showed a coherent high-frequency tremor in leg muscles and body sway that was absent during lying (p < 0.001). MTV during standing did not reset tremor frequency, but resulted in a decreased tremor intensity (p < 0.001; mean reduction: 32.5 ± 7.1%) and body sway (p = 0.032; mean reduction: 37.2 ± 6.8%). MTV did not affect muscle activity during lying. Four patients further reported a noticeable relief from unsteadiness during stimulation. CONCLUSION Proprioceptive stimulation did not reset tremor frequency consistent with the presumed central origin of OT. However, continuous MTV influenced the emergence of OT symptoms resulting in reduced tremor intensity, improved posture, and a relief from unsteadiness in half of the examined patients. These findings indicate that MTV either directly interferes with the peripheral manifestation of the central oscillatory pattern or prevents proprioceptive afferent feedback from becoming extensively synchronized at the tremor frequency.
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Affiliation(s)
- M Wuehr
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - C Schlick
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - K Möhwald
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - R Schniepp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
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Deep brain stimulation in uncommon tremor disorders: indications, targets, and programming. J Neurol 2018; 265:2473-2493. [PMID: 29511865 DOI: 10.1007/s00415-018-8823-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/01/2018] [Accepted: 03/02/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND In uncommon tremor disorders, clinical efficacy and optimal anatomical targets for deep brain stimulation (DBS) remain inadequately studied and insufficiently quantified. METHODS We performed a systematic review of PubMed.gov and ClinicalTrials.gov. Relevant articles were identified using the following keywords: "tremor", "Holmes tremor", "orthostatic tremor", "multiple sclerosis", "multiple sclerosis tremor", "neuropathy", "neuropathic tremor", "fragile X-associated tremor/ataxia syndrome", and "fragile X." RESULTS We identified a total of 263 cases treated with DBS for uncommon tremor disorders. Of these, 44 had Holmes tremor (HT), 18 orthostatic tremor (OT), 177 multiple sclerosis (MS)-associated tremor, 14 neuropathy-associated tremor, and 10 fragile X-associated tremor/ataxia syndrome (FXTAS). DBS resulted in favorable, albeit partial, clinical improvements in HT cases receiving Vim-DBS alone or in combination with additional targets. A sustained improvement was reported in OT cases treated with bilateral Vim-DBS, while the two cases treated with unilateral Vim-DBS demonstrated only a transient effect. MS-associated tremor responded to dual-target Vim-/VO-DBS, but the inability to account for the progression of MS-associated disability impeded the assessment of its long-term clinical efficacy. Neuropathy-associated tremor substantially improved with Vim-DBS. In FXTAS patients, while Vim-DBS was effective in improving tremor, equivocal results were observed in those with ataxia. CONCLUSIONS DBS of select targets may represent an effective therapeutic strategy for uncommon tremor disorders, although the level of evidence is currently in its incipient form and based on single cases or limited case series. An international registry is, therefore, warranted to clarify selection criteria, long-term results, and optimal surgical targets.
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Comprehensive, blinded assessment of balance in orthostatic tremor. Parkinsonism Relat Disord 2018; 47:22-25. [DOI: 10.1016/j.parkreldis.2017.11.335] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 10/31/2017] [Accepted: 11/14/2017] [Indexed: 10/18/2022]
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Abstract
Tremor is a phenomenon observed in a broad spectrum of diseases with different pathophysiologies. While patients with tremor may not complain in the clinic of symptoms of imbalance, gait difficulties, or falls, laboratory research studies using quantitative analysis of gait and posture and neurophysiologic techniques have demonstrated impaired gait and balance across a variety of tremor etiologies. These findings have been supported by careful epidemiologic studies assessing symptoms of imbalance. Imaging and neurophysiologic studies have identified cerebellar networks as important mediators of tremor, and therefore a likely common site of dysfunction to explain the phenomenologic overlap between impaired postural and gait control with tremor. Further understanding of these mechanisms and networks is of crucial importance in the development of new treatments, particularly surgical or minimally invasive lesional therapies.
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Affiliation(s)
- Hugo Morales-Briceño
- Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney, NSW, Australia
| | - Alessandro F Fois
- Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney, NSW, Australia
| | - Victor S C Fung
- Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Lenka A, Pal PK, Bhatti DE, Louis ED. Pathogenesis of Primary Orthostatic Tremor: Current Concepts and Controversies. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2017; 7:513. [PMID: 29204315 PMCID: PMC5712672 DOI: 10.7916/d8w66zbh] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 10/31/2017] [Indexed: 12/01/2022]
Abstract
Background Orthostatic tremor (OT), a rare and complex movement disorder, is characterized by rapid tremor of both legs and the trunk while standing. These disappear while the patient is either lying down or walking. OT may be idiopathic/primary or it may coexist with several neurological conditions (secondary OT/OT plus). Primary OT remains an enigmatic movement disorder and its pathogenesis and neural correlates are not fully understood. Methods A PubMed search was conducted in July 2017 to identify articles for this review. Results Structural and functional neuroimaging studies of OT suggest possible alterations in the cerebello-thalamo-cortical network. As with essential tremor, the presence of a central oscillator has been postulated for OT; however, the location of the oscillator within the tremor network remains elusive. Studies have speculated a possible dopaminergic deficit in the pathogenesis of primary OT; however, the evidence in favor of this concept is not particularly robust. There is also limited evidence favoring the concept that primary OT is a neurodegenerative disorder, as a magnetic resonance spectroscopic imaging study revealed significant reduction in cerebral and cerebellar N-acetyl aspartate (NAA) levels, a marker of neuronal compromise or loss. Discussion Based on the above, it is clear that the pathogenesis of primary OT still remains unclear. However, the available evidence most strongly favors the existence of a central oscillatory network, and involvement of the cerebellum and its connections.
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Affiliation(s)
- Abhishek Lenka
- Department of Clinical Neurosciences, National Institute of Mental Health and Neurosciences, Bangalore, India.,Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Pramod Kumar Pal
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Danish Ejaz Bhatti
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Elan D Louis
- Division of Movement Disorders, Department of Neurology, Yale School of Medicine, Yale University, New Haven, CT, USA.,Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT, USA.,Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, CT, USA
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17
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Lehn AC, O'Gorman C, Olson S, Salari M. Thalamic Ventral Intermediate Nucleus Deep Brain Stimulation for Orthostatic Tremor. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2017; 7:479. [PMID: 28983421 PMCID: PMC5628322 DOI: 10.7916/d8280jhr] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 06/28/2017] [Indexed: 12/02/2022]
Abstract
Background Orthostatic tremor (OT) was first described in 1977. It is characterized by rapid tremor of 13–18 Hz and can be recorded in the lower limbs and trunk muscles. OT remains difficult to treat, although some success has been reported with deep brain stimulation (DBS). Case Report We report a 68‐year‐old male with OT who did not improve significantly after bilateral thalamic stimulation. Discussion Although some patients were described who improved after DBS surgery, more information is needed about the effect of these treatment modalities on OT, ideally in the form of randomized trial data.
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Affiliation(s)
- Alexander C Lehn
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia.,School of Medicine, University of Queensland, Brisbane, Australia
| | - Cullen O'Gorman
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia.,Griffith University, Gold Coast, Australia
| | - Sarah Olson
- Department of Neurosurgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Mehri Salari
- Department of Neurology, School of medicine, Qom University of Medical Science, Qom, Iran
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Merola A, Fasano A, Hassan A, Ostrem JL, Contarino MF, Lyons M, Krauss JK, Wolf ME, Klassen BT, van Rootselaar AF, Regidor I, Duker AP, Ondo W, Guridi J, Volkmann J, Wagle Shukla A, Mandybur GT, Okun MS, Witt K, Starr PA, Deuschl G, Espay AJ. Thalamic deep brain stimulation for orthostatic tremor: A multicenter international registry. Mov Disord 2017. [PMID: 28631862 DOI: 10.1002/mds.27082] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Aristide Merola
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
| | - Alfonso Fasano
- Division of Neurology, Movement disorders center, University of Toronto Canada Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, UHN, Division of Neurology; University of Toronto; Toronto Ontario Canada
- Krembil Research Institute; Toronto Ontario Canada
| | - Anhar Hassan
- Department of Neurology; Mayo Clinic; Rochester Minnesota USA
| | - Jill L. Ostrem
- UCSF Movement Disorders and Neuromodulation Center, Department of Neurology; University of California San Francisco; San Francisco California USA
| | - Maria Fiorella Contarino
- Department of Neurology; Academic Medical Center; Amsterdam The Netherlands
- Department of Neurology; Leiden University Medical Center; Leiden The Netherlands
- Department of Neurology; Haga Teaching Hospital; The Hague The Netherlands
| | - Mark Lyons
- Department of Neurosurgery; Mayo Clinic; Phoenix Arizona USA
| | - Joachim K. Krauss
- Department of Neurosurgery; Medical School Hannover, MHH; Hannover Germany
| | - Marc E. Wolf
- Department of Neurology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim; University of Heidelberg; Mannheim Germany
| | | | | | - Ignacio Regidor
- Functional Neurosurgery Unit; Hospital Universitario Ramón y Cajal; Madrid Spain
| | - Andrew P. Duker
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
| | - William Ondo
- Methodist Neurological Institute; Houston Texas USA
| | - Jorge Guridi
- Neurosurgical Department, Clinica Universidad de Navarra; Navarra Spain
| | - Jens Volkmann
- Department of Neurology; University Hospital Würzburg; Würzburg Germany
| | - Aparna Wagle Shukla
- Department of Neurology, Center for Movement Disorders and Neurorestoration; McKnight Brain Institute; Gainesville Florida USA
| | - George T. Mandybur
- Department of Neurosurgery; University of Cincinnati College of Medicine. Mayfield Clinic- Neurosurgeon; Cincinnati Ohio USA
| | - Michael S. Okun
- Department of Neurology, Center for Movement Disorders and Neurorestoration; McKnight Brain Institute; Gainesville Florida USA
| | - Karsten Witt
- Department of Neurology; University Medical Center Schleswig-Holstein, Christian-Albrechts University; Kiel Germany
- Dept. of Neurology; School of Medicine and Health Sciences - European Medical School, University Oldenburg; Oldenburg Germany
| | - Philip A. Starr
- UCSF Department of Neurological Surgery; University of California San Francisco; San Francisco California USA
| | - Günther Deuschl
- Department of Neurology; University Medical Center Schleswig-Holstein, Christian-Albrechts University; Kiel Germany
| | - Alberto J. Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
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19
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Schöberl F, Feil K, Xiong G, Bartenstein P, la Fougére C, Jahn K, Brandt T, Strupp M, Dieterich M, Zwergal A. Pathological ponto-cerebello-thalamo-cortical activations in primary orthostatic tremor during lying and stance. Brain 2017; 140:83-97. [PMID: 28031220 DOI: 10.1093/brain/aww268] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 04/25/2016] [Accepted: 09/07/2016] [Indexed: 11/14/2022] Open
Abstract
Primary orthostatic tremor is a rare neurological disease characterized mainly by a high frequency tremor of the legs while standing. The aim of this study was to identify the common core structures of the oscillatory circuit in orthostatic tremor and how it is modulated by changes of body position. Ten patients with orthostatic tremor and 10 healthy age-matched control subjects underwent a standardized neurological and neuro-ophthalmological examination including electromyographic and posturographic recordings. Task-dependent changes of cerebral glucose metabolism during lying and standing were measured in all subjects by sequential 18F-fluorodeoxyglucose-positron emission tomography on separate days. Results were compared between groups and conditions. All the orthostatic tremor patients, but no control subject, showed the characteristic 13-18 Hz tremor in coherent muscles during standing, which ceased in the supine position. While lying, patients had a significantly increased regional cerebral glucose metabolism in the pontine tegmentum, the posterior cerebellum (including the dentate nuclei), the ventral intermediate and ventral posterolateral nucleus of the thalamus, and the primary motor cortex bilaterally compared to controls. Similar glucose metabolism changes occurred with clinical manifestation of the tremor during standing. The glucose metabolism was relatively decreased in mesiofrontal cortical areas (i.e. the medial prefrontal cortex, supplementary motor area and anterior cingulate cortex) and the bilateral anterior insula in orthostatic tremor patients while lying and standing. The mesiofrontal hypometabolism correlated with increased body sway in posturography. This study confirms and further elucidates ponto-cerebello-thalamo-primary motor cortical activations underlying primary orthostatic tremor, which presented consistently in a group of patients. Compared to other tremor disorders one characteristic feature in orthostatic tremor seems to be the involvement of the pontine tegmentum in the pathophysiology of tremor generation. High frequency oscillatory properties of pontine tegmental neurons have been reported in pathological oscillatory eye movements. It is remarkable that the characteristic activation and deactivation pattern in orthostatic tremor is already present in the supine position without tremor presentation. Multilevel changes of neuronal excitability during upright stance may trigger activation of the orthostatic tremor network. Based on the functional imaging data described in this study, it is hypothesized that a mesiofrontal deactivation is another characteristic feature of orthostatic tremor and plays a pivotal role in development of postural unsteadiness during prolonged standing.
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Affiliation(s)
- Florian Schöberl
- 1 Department of Neurology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
| | - Katharina Feil
- 1 Department of Neurology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
| | - Guoming Xiong
- 2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
| | - Peter Bartenstein
- 2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,3 Department of Nuclear Medicine, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,4 Munich Cluster of Systems Neurology, SyNergy, Marchioninistr. 15, 81377 Munich, Germany
| | - Christian la Fougére
- 2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,5 Department of Nuclear Medicine, Eberhard Karls University, Röntgenweg 11, 72076 Tübingen, Germany
| | - Klaus Jahn
- 2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,6 Neurology, Schön Klinik Bad Aibling, Kolbermoorer Str. 72, 83043 Bad Aibling, Germany
| | - Thomas Brandt
- 2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,7 Clinical Neurosciences, Ludwig-Maximilians-Unversity, Marchioninistr. 15, 81377 Munich, Germany
| | - Michael Strupp
- 1 Department of Neurology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
| | - Marianne Dieterich
- 1 Department of Neurology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.,4 Munich Cluster of Systems Neurology, SyNergy, Marchioninistr. 15, 81377 Munich, Germany
| | - Andreas Zwergal
- 1 Department of Neurology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany .,2 German Center for Vertigo and Balance Disorders, DSGZ, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
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20
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Merola A, Duker AP, Mandybur G, Tareen TK, Tuazon J, Espay AJ, Fasano A. Thalamic deep brain stimulation and gait in orthostatic tremor. Mov Disord 2017; 32:937-938. [PMID: 28218418 DOI: 10.1002/mds.26958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/11/2017] [Accepted: 01/25/2017] [Indexed: 11/11/2022] Open
Affiliation(s)
- Aristide Merola
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Andrew P Duker
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - George Mandybur
- Department of Neurosurgery, University of Cincinnati College of Medicine. Mayfield Clinic- Neurosurgeon, Cincinnati, Ohio, USA
| | - Tamour Khan Tareen
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jasmine Tuazon
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, UHN, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
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21
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Hassan A, van Gerpen JA. Orthostatic Tremor and Orthostatic Myoclonus: Weight-bearing Hyperkinetic Disorders: A Systematic Review, New Insights, and Unresolved Questions. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2017; 6:417. [PMID: 28105385 PMCID: PMC5233784 DOI: 10.7916/d84x584k] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 10/25/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Orthostatic tremor (OT) and orthostatic myoclonus (OM) are weight-bearing hyperkinetic movement disorders most commonly affecting older people that induce "shaky legs" upon standing. OT is divided into "classical" and "slow" forms based on tremor frequency. In this paper, the first joint review of OT and OM, we review the literature and compare and contrast their demographic, clinical, electrophysiological, neuroimaging, pathophysiological, and treatment characteristics. METHODS A PubMed search up to July 2016 using the phrases "orthostatic tremor," "orthostatic myoclonus," "shaky legs," and "shaky legs syndrome" was performed. RESULTS OT and OM should be suspected in older patients reporting unsteadiness with prolonged standing and/or who exhibit cautious, wide-based gaits. Surface electromyography (SEMG) is necessary to verify the diagnoses. Functional neuroimaging and electrophysiology suggest the generator of classical OT lies within the cerebellothalamocortical network. For OM, and possibly slow OT, the frontal, subcortical cerebrum is the most likely origin. Clonazepam is the most useful medication for classical OT, and levetiracetam for OM, although results are often disappointing. Deep brain stimulation appears promising for classical OT. Rolling walkers reliably improve gait affected by these disorders, as both OT and OM attenuate when weight is transferred from the legs to the arms. DISCUSSION Orthostatic hyperkinesias are likely underdiagnosed, as SEMG is often unavailable in clinical practice, and thus may be more frequent than currently recognized. The shared weight-bearing induction of OT and OM may indicate a common pathophysiology. Further research, including use of animal models, is necessary to better define the prevalence and pathophysiology of OT and OM, in order to improve their treatment, and provide additional insights into basic balance and gait mechanisms.
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Affiliation(s)
- Anhar Hassan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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22
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Athauda D, Georgiev D, Aviles‐Olmos I, Peters A, Day B, Brown P, Zrinzo L, Hariz M, Limousin P, Foltynie T. Thalamic-Caudal Zona Incerta Deep Brain Stimulation for Refractory Orthostatic Tremor: A Report of 3 Cases. Mov Disord Clin Pract 2017; 4:105-110. [PMID: 30713954 PMCID: PMC6353314 DOI: 10.1002/mdc3.12345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/02/2016] [Accepted: 02/02/2016] [Indexed: 11/06/2022] Open
Abstract
Orthostatic tremor (OT) is a rare, disabling movement disorder characterized by the development of a high-frequency tremor of the lower limbs and feelings of unsteadiness upon standing, which compel the patient to sit down or walk. Medical therapy is often unsatisfactory. Previous reports suggest that deep brain stimulation of the ventral intermediate nucleus of the thalamus may improve clinical outcomes. The authors report 3 patients who had intractable orthostatic tremor treated with bilateral deep brain stimulation of the ventral intermediate nucleus of the thalamus-caudal zona incerta, resulting in improved and sustained clinical improvements in symptoms, although there were no apparent changes in the underlying tremor frequency or onset.
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Affiliation(s)
- Dilan Athauda
- Sobell Department of Motor NeuroscienceUniversity College London Institute of Neurology and The National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Dejan Georgiev
- Sobell Department of Motor NeuroscienceUniversity College London Institute of Neurology and The National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Iciar Aviles‐Olmos
- Sobell Department of Motor NeuroscienceUniversity College London Institute of Neurology and The National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Amy Peters
- Sobell Department of Motor NeuroscienceUniversity College London Institute of Neurology and The National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Brian Day
- Sobell Department of Motor NeuroscienceUniversity College London Institute of Neurology and The National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Peter Brown
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordJohn Radcliffe HospitalOxfordUnited Kingdom
| | - Ludvic Zrinzo
- Sobell Department of Motor NeuroscienceUniversity College London Institute of Neurology and The National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Marwan Hariz
- Sobell Department of Motor NeuroscienceUniversity College London Institute of Neurology and The National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Patricia Limousin
- Sobell Department of Motor NeuroscienceUniversity College London Institute of Neurology and The National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Thomas Foltynie
- Sobell Department of Motor NeuroscienceUniversity College London Institute of Neurology and The National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
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Coenen VA, Amtage F, Volkmann J, Schläpfer TE. Deep Brain Stimulation in Neurological and Psychiatric Disorders. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:519-26. [PMID: 26334979 DOI: 10.3238/arztebl.2015.0519] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 05/07/2015] [Accepted: 05/07/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) is the chronic electrical stimulation of selected target sites in the brain through stereotactically implanted electrodes. More than 150 000 patients around the world have been treated to date with DBS for medically intractable conditions. The indications for DBS include movement disorders, epilepsy, and some types of mental illness. METHODS This review is based on relevant publications retrieved by a selective search in PubMed and the Cochrane Library, and on the current guidelines of the German Neurological Society (Deutsche Gesellschaft für Neurologie, DGN). RESULTS DBS is usually performed to treat neurological diseases, most often movement disorders and, in particular, Parkinson's disease. Multiple randomized controlled trials (RCTs) have shown that DBS improves tremor, dyskinesia, and quality of life in patients with Parkinson's disease by 25% to 50%, depending on the rating scales used. DBS for tremor usually involves stimulation in the cerebello-thalamo-cortical regulatory loop. In an RCT of DBS for the treatment of primary generalized dystonia, the patients who underwent DBS experienced a 39.3% improvement of dystonia, compared to only 4.9% in the control group. Two multicenter trials of DBS for depression were terminated early because of a lack of efficacy. CONCLUSION DBS is an established treatment for various neurological and psychiatric diseases. It has been incorporated in the DGN guidelines and is now considered a standard treatment for advanced Parkinson's disease. The safety and efficacy of DBS can be expected to improve with the application of new technical developments in electrode geometry and new imaging techniques. Controlled trials would be helpful so that DBS could be extended to further indications, particularly psychiatric ones.
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Affiliation(s)
- Volker A Coenen
- Abteilung Stereotaktische und Funktionelle Neurochirurgie, Universitätsklinikum der Albert-Ludwigs-Universität Freiburg, Klinik für Neurologie und Neurophysiologie, Albert-Ludwigs-Universität Freiburg, Neurologische Klinik und Poliklinik, Universit7auml;sklinikum Würzburg, Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum
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Benito-León J, Domingo-Santos Á. Orthostatic Tremor: An Update on a Rare Entity. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2016; 6:411. [PMID: 27713855 PMCID: PMC5039949 DOI: 10.7916/d81n81bt] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/22/2016] [Indexed: 12/01/2022]
Abstract
Background Orthostatic tremor (OT) remains among the most intriguing and poorly understood of movement disorders. Compared to Parkinson’s disease or even essential tremor, there are very few articles addressing more basic science issues. In this review, we will discuss the findings of main case series on OT, including data on etiology, pathophysiology, diagnostic approach, treatment strategies, and outcome. Methods Data for this review were identified by searching PUBMED (January 1966 to August 2016) for the terms “orthostatic tremor” or “shaky leg syndrome,” which yielded 219 entries. We did not exclude papers on the basis of language, country, or publication date. The electronic database searches were supplemented by articles in the authors’ files that pertained to this topic. Results Owing to its rarity, the current understanding of OT is limited and is mostly based on small case series or case reports. Despite this, a growing body of evidence indicates that OT might be a progressive condition that is clinically heterogeneous (primary vs. secondary cases) with a broader spectrum of clinical features, mainly cerebellar signs, and possible cognitive impairment and personality disturbances. Along with this, advanced neuroimaging techniques are now demonstrating distinct anatomical and functional changes, some of which are consistent with neuronal loss. Discussion OT might be a family of diseases, unified by the presence of leg tremor, but further characterized by etiological and clinical heterogeneity. More work is needed to understand the pathogenesis of this condition.
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Affiliation(s)
- Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Complutense University, Madrid, Spain
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25
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Blahak C, Sauer T, Baezner H, Wolf ME, Saryyeva A, Schrader C, Capelle HH, Hennerici MG, Krauss JK. Long-term follow-up of chronic spinal cord stimulation for medically intractable orthostatic tremor. J Neurol 2016; 263:2224-2228. [PMID: 27522355 DOI: 10.1007/s00415-016-8239-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/15/2016] [Accepted: 07/16/2016] [Indexed: 10/21/2022]
Abstract
Orthostatic tremor (OT) is a rare form of tremor occurring in the legs when standing upright. Medical treatment frequently is unsatisfactory, thus in selected cases, surgical treatment, such as spinal cord stimulation (SCS) or thalamic deep brain stimulation has been proposed. We report the long-term results (follow-up (FU) 34-133 months) of SCS in four patients with medically intractable OT. Outcome was assessed by recording the time tolerated to stand still pre- and post-operatively and by a patient self-rating (PSR) scale (0 = poor to 6 = excellent). Furthermore, surface electromyography (EMG) recordings of different leg muscles were performed to estimate tremor activity with and without SCS post-operatively. With chronic SCS, all four patients showed an improvement of unsteadiness occurring in the presence of stimulation-induced paraesthesia of the legs. The mean standing time improved from 51 s (SD 47 s, range 4-120 s) pre-operatively to 220 s (SD 184 s, range 10-480 s) with SCS at last available FU. Tremor activity in the EMG of the anterior tibial muscle was reduced by 30-60 % with SCS compared with off SCS. PSR score was 4 or 5 in three patients and 3 in the other. In conclusion, SCS is an effective long-term treatment option in patients with otherwise intractable OT.
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Affiliation(s)
- Christian Blahak
- Department of Neurology, Universitaetsmedizin Mannheim, University of Heidelberg, Mannheim, Germany.
| | - Tamara Sauer
- Department of Neurology, Universitaetsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Hansjoerg Baezner
- Department of Neurology, Universitaetsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Marc E Wolf
- Department of Neurology, Universitaetsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Assel Saryyeva
- Department of Neurosurgery, Medical School Hannover MHH, Hannover, Germany
| | | | | | - Michael G Hennerici
- Department of Neurology, Universitaetsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Medical School Hannover MHH, Hannover, Germany
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Abstract
Surgical procedures for dystonia and tremor have evolved over the past few decades, and our understanding of risk, benefit, and predictive factors has increased substantially in that time. Deep brain stimulation (DBS) is the most utilized surgical treatment for dystonia and tremor, though lesioning remains an effective option in appropriate patients. Dystonic syndromes that have shown a substantial reduction in severity secondary to DBS are isolated dystonia, including generalized, cervical, and segmental, as well as acquired dystonia such as tardive dystonia. Essential tremor is quite amenable to DBS, though the response of other forms of postural and kinetic tremor is not nearly as robust or consistent based on available evidence. Regarding targeting, DBS lead placement in the globus pallidus internus has shown marked efficacy in dystonia reduction. The subthalamic nucleus is an emerging target, and increasing evidence suggests that this may be a viable target in dystonia as well. The ventralis intermedius nucleus of the thalamus is the preferred target for essential tremor, though targeting the subthalamic zone/caudal zona incerta has shown promise and may emerge as another option in essential tremor and possibly other tremor disorders. In the carefully selected patient, DBS and lesioning procedures are relatively safe and effective for the management of dystonia and tremor.
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Affiliation(s)
- Jason L Crowell
- Department of Neurology, University of Virginia, PO Box 800394, Charlottesville, VA, 22908, USA
| | - Binit B Shah
- Department of Neurology, University of Virginia, PO Box 800394, Charlottesville, VA, 22908, USA.
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Gallea C, Popa T, García-Lorenzo D, Valabregue R, Legrand AP, Apartis E, Marais L, Degos B, Hubsch C, Fernández-Vidal S, Bardinet E, Roze E, Lehéricy S, Meunier S, Vidailhet M. Orthostatic tremor: a cerebellar pathology? Brain 2016; 139:2182-97. [PMID: 27329770 PMCID: PMC4958903 DOI: 10.1093/brain/aww140] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/22/2016] [Indexed: 12/24/2022] Open
Abstract
SEE MUTHURAMAN ET AL DOI101093/AWW164 FOR A SCIENTIFIC COMMENTARY ON THIS ARTICLE: Primary orthostatic tremor is characterized by high frequency tremor affecting the legs and trunk during the standing position. Cerebellar defects were suggested in orthostatic tremor without direct evidence. We aimed to characterize the anatomo-functional defects of the cerebellar motor pathways in orthostatic tremor. We used multimodal neuroimaging to compare 17 patients with orthostatic tremor and 17 age- and gender-matched healthy volunteers. Nine of the patients with orthostatic tremor underwent repetitive transcranial stimulation applied over the cerebellum during five consecutive days. We quantified the duration of standing position and tremor severity through electromyographic recordings. Compared to healthy volunteers, grey matter volume in patients with orthostatic tremor was (i) increased in the cerebellar vermis and correlated positively with the duration of the standing position; and (ii) increased in the supplementary motor area and decreased in the lateral cerebellum, which both correlated with the disease duration. Functional connectivity between the lateral cerebellum and the supplementary motor area was abnormally increased in patients with orthostatic tremor, and correlated positively with tremor severity. After repetitive transcranial stimulation, tremor severity and functional connectivity between the lateral cerebellum and the supplementary motor area were reduced. We provide an explanation for orthostatic tremor pathophysiology, and demonstrate the functional relevance of cerebello-thalamo-cortical connections in tremor related to cerebellar defects.
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Affiliation(s)
- Cécile Gallea
- 1 Centre de NeuroImagerie de Recherche - Institut du Cerveau et de la Moelle épinière, ICM, Paris, France 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France 5 AP-HP, Hôpital de la Pitié Salpêtrière, Département de Neuroradiologie, Paris, France
| | - Traian Popa
- 1 Centre de NeuroImagerie de Recherche - Institut du Cerveau et de la Moelle épinière, ICM, Paris, France 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France
| | - Daniel García-Lorenzo
- 1 Centre de NeuroImagerie de Recherche - Institut du Cerveau et de la Moelle épinière, ICM, Paris, France 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France 5 AP-HP, Hôpital de la Pitié Salpêtrière, Département de Neuroradiologie, Paris, France
| | - Romain Valabregue
- 1 Centre de NeuroImagerie de Recherche - Institut du Cerveau et de la Moelle épinière, ICM, Paris, France 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France 5 AP-HP, Hôpital de la Pitié Salpêtrière, Département de Neuroradiologie, Paris, France
| | | | - Emmanuelle Apartis
- 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France 7 AP-HP, Hôpital de Saint-Antoine, Département de Neurologie, Paris, France
| | - Lea Marais
- 1 Centre de NeuroImagerie de Recherche - Institut du Cerveau et de la Moelle épinière, ICM, Paris, France 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France 5 AP-HP, Hôpital de la Pitié Salpêtrière, Département de Neuroradiologie, Paris, France
| | - Bertrand Degos
- 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France 8 AP-HP, Hôpital de la Pitié Salpêtrière, Département de Neurologie, Paris, France
| | - Cecile Hubsch
- 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France 8 AP-HP, Hôpital de la Pitié Salpêtrière, Département de Neurologie, Paris, France
| | - Sara Fernández-Vidal
- 1 Centre de NeuroImagerie de Recherche - Institut du Cerveau et de la Moelle épinière, ICM, Paris, France 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France
| | - Eric Bardinet
- 1 Centre de NeuroImagerie de Recherche - Institut du Cerveau et de la Moelle épinière, ICM, Paris, France 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France
| | - Emmanuel Roze
- 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France 8 AP-HP, Hôpital de la Pitié Salpêtrière, Département de Neurologie, Paris, France
| | - Stéphane Lehéricy
- 1 Centre de NeuroImagerie de Recherche - Institut du Cerveau et de la Moelle épinière, ICM, Paris, France 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France 5 AP-HP, Hôpital de la Pitié Salpêtrière, Département de Neuroradiologie, Paris, France
| | - Sabine Meunier
- 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France
| | - Marie Vidailhet
- 2 Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Paris, France 3 CNRS, UMR 7225, Paris, France 4 Inserm, U 1127, Paris, France 8 AP-HP, Hôpital de la Pitié Salpêtrière, Département de Neurologie, Paris, France
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di Biase L, Munhoz RP. Deep brain stimulation for the treatment of hyperkinetic movement disorders. Expert Rev Neurother 2016; 16:1067-78. [DOI: 10.1080/14737175.2016.1196139] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Introduction: Deep brain stimulation (DBS) has become a standard therapy for the treatment of select cases of medication refractory essential tremor and Parkinson’s disease however the effectiveness and long-term outcomes of DBS in other uncommon and complex tremor syndromes has not been well established. Traditionally, the ventralis intermedius nucleus (VIM) of the thalamus has been considered the main target for medically intractable tremors; however alternative brain regions and improvements in stereotactic techniques and hardware may soon change the horizon for treatment of complex tremors. Areas covered: In this article, we conducted a PubMed search using different combinations between the terms ‘Uncommon tremors’, ‘Dystonic tremor’, ‘Holmes tremor’ ‘Midbrain tremor’, ‘Rubral tremor’, ‘Cerebellar tremor’, ‘outflow tremor’, ‘Multiple Sclerosis tremor’, ‘Post-traumatic tremor’, ‘Neuropathic tremor’, and ‘Deep Brain Stimulation/DBS’. Additionally, we examined and summarized the current state of evolving interventions for treatment of complex tremor syndromes. Expertcommentary: Recently reported interventions for rare tremors include stimulation of the posterior subthalamic area, globus pallidus internus, ventralis oralis anterior/posterior thalamic subnuclei, and the use of dual lead stimulation in one or more of these targets. Treatment should be individualized and dictated by tremor phenomenology and associated clinical features.
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Affiliation(s)
| | - Michael S Okun
- b Department of Neurology , University of Florida Center for Movement Disorders and Neurorestoration , Gainesville FL , USA
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Eligibility Criteria for Deep Brain Stimulation in Parkinson’s Disease, Tremor, and Dystonia. Can J Neurol Sci 2016; 43:462-71. [DOI: 10.1017/cjn.2016.35] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIn this review, the available evidence to guide clinicians regarding eligibility for deep brain stimulation (DBS) in the main conditions in which these forms of therapy are generally indicated—Parkinson’s disease (PD), tremor, and dystonia—is presented. In general, the literature shows that DBS is effective for PD, essential tremor, and idiopathic dystonia. In these cases, key points in patient selection must include the level of disability and inability to manage symptoms using the best available medical therapy. Results are, however, still not optimal when dealing with other aetiologies, such as secondary tremors and symptomatic dystonia. Also, in PD, issues such as age and neuropsychiatric profile are still debatable parameters. Overall, currently available literature is able to guide physicians on basic aspects of patient selection and indications for DBS; however, a few points are still debatable and controversial. These issues should be refined and clarified in future studies.
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Adebayo PB. Orthostatic tremor: current challenges and future prospects. Degener Neurol Neuromuscul Dis 2016; 6:17-24. [PMID: 30050365 PMCID: PMC6053087 DOI: 10.2147/dnnd.s84742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This review provides an outlook of orthostatic tremor (OT), a rare adult-onset tremor characterized by subjective unsteadiness during standing that is relieved by sitting or walking. Recent case series with a long-time follow-up have shown that the disease is slowly progressive, spatially spreads to the upper limbs, and other neurological disorders may develop in about one-third of the patients. The diagnosis of OT hinges on the typical history of unsteadiness during standing, which is confirmed by electromyographic findings of a 13–18 Hz tremor that is typically absent during tonic activation while the patient is sitting and lying. Although the tremor is generated by a central oscillator, cerebellar and/or basal ganglia dysfunction are needed for its manifestation (double lesion hypothesis). However, functional neuroimaging findings have not consistently implicated the dopaminergic system in its pathogenesis. Drug treatments have been largely disappointing with no sustained benefits, although thalamic deep brain stimulation has helped some patients. Large-scale follow-up studies, more drug trials, and novel therapies are urgently needed.
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Affiliation(s)
- Philip Babatunde Adebayo
- Neurology Unit, Department of Medicine, Faculty of Clinical Sciences, Ladoke Akintola University of Technology, Ogbomoşo, Oyo State, Nigeria,
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Coleman RR, Starr PA, Katz M, Glass GA, Volz M, Khandhar SM, Ostrem JL. Bilateral Ventral Intermediate Nucleus Thalamic Deep Brain Stimulation in Orthostatic Tremor. Stereotact Funct Neurosurg 2016; 94:69-74. [PMID: 27002536 DOI: 10.1159/000444127] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 01/19/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Orthostatic tremor (OT) is characterized by high-frequency leg tremor when standing still, resulting in a sense of imbalance, with limited treatment options. Ventral intermediate (Vim) nucleus thalamic deep brain stimulation (DBS) has been reported as beneficial in a few cases. OBJECTIVE To report clinical outcomes, lead locations, and stimulation parameters in 2 patients with severe medication-refractory OT treated with Vim DBS. METHODS The patients underwent surface electromyography (EMG) to confirm the OT diagnosis. Outcomes were measured as change in tolerated standing time at the last follow-up. Lead locations were quantified using postoperative MRI. RESULTS Vim DBS was well tolerated and resulted in improvement in standing time (patient 1: 50 s at baseline to 15 min 16 months after surgery; patient 2: 34 s at baseline to 4.2 min 7 months after surgery). Postoperative surface EMG for patient 1 demonstrated a delayed onset of tremor, lower-amplitude tremor, and periods of quiescence, but an unchanged tremor frequency. CONCLUSION These cases provide further support for Vim DBS to improve standing time in severe medication-refractory OT. The location of the effective thalamic target for OT does not differ from the effective target for essential tremor.
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Affiliation(s)
- Robert R Coleman
- Neurology, University of California San Francisco, San Francisco, Calif., USA
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Ganos C, Maugest L, Apartis E, Gasca-Salas C, Cáceres-Redondo MT, Erro R, Navalpotro-Gómez I, Batla A, Antelmi E, Degos B, Roze E, Welter ML, Mestre T, Palomar FJ, Isayama R, Chen R, Cordivari C, Mir P, Lang AE, Fox SH, Bhatia KP, Vidailhet M. The long-term outcome of orthostatic tremor. J Neurol Neurosurg Psychiatry 2016; 87:167-72. [PMID: 25770124 DOI: 10.1136/jnnp-2014-309942] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 02/16/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Orthostatic tremor is a rare condition characterised by high-frequency tremor that appears on standing. Although the essential clinical features of orthostatic tremor are well established, little is known about the natural progression of the disorder. We report the long-term outcome based on the largest multicentre cohort of patients with orthostatic tremor. METHODS Clinical information of 68 patients with clinical and electrophysiological diagnosis of orthostatic tremor and a minimum follow-up of 5 years is presented. RESULTS There was a clear female preponderance (76.5%) with a mean age of onset at 54 years. Median follow-up was 6 years (range 5-25). On diagnosis, 86.8% of patients presented with isolated orthostatic tremor and 13.2% had additional neurological features. At follow-up, seven patients who initially had isolated orthostatic tremor later developed further neurological signs. A total 79.4% of patients reported worsening of orthostatic tremor symptoms. These patients had significantly longer symptom duration than those without reported worsening (median 15.5 vs 10.5 years, respectively; p=0.005). There was no change in orthostatic tremor frequency over time. Structural imaging was largely unremarkable and dopaminergic neuroimaging (DaTSCAN) was normal in 18/19 cases. Pharmacological treatments were disappointing. Two patients were treated surgically and showed improvement. CONCLUSIONS Orthostatic tremor is a progressive disorder with increased disability although tremor frequency is unchanged over time. In most cases, orthostatic tremor represents an isolated syndrome. Drug treatments are unsatisfactory but surgery may hold promise.
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Affiliation(s)
- Christos Ganos
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK Department of Neurology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Lucie Maugest
- Department of Neurology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France CRICM UPMC/INSERM UMR 1127 CNRS UMR7225 Brain and Spine Institute, Paris, France
| | - Emmanuelle Apartis
- CRICM UPMC/INSERM UMR 1127 CNRS UMR7225 Brain and Spine Institute, Paris, France Neurophysiology Unit, AP-HP, Saint-Antoine Hospital, Paris, France Pierre Marie Curie Paris-6 University, Paris, France
| | - Carmen Gasca-Salas
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Canada
| | - María T Cáceres-Redondo
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Seville, Spain
| | - Roberto Erro
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK
| | - Irene Navalpotro-Gómez
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK Department of Neurology, Hospital del Mar, Barcelona, Spain
| | - Amit Batla
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK
| | - Elena Antelmi
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK
| | - Bertrand Degos
- Department of Neurology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France Pierre Marie Curie Paris-6 University, Paris, France
| | - Emmanuel Roze
- Department of Neurology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France CRICM UPMC/INSERM UMR 1127 CNRS UMR7225 Brain and Spine Institute, Paris, France Pierre Marie Curie Paris-6 University, Paris, France
| | - Marie-Laure Welter
- Department of Neurology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France CRICM UPMC/INSERM UMR 1127 CNRS UMR7225 Brain and Spine Institute, Paris, France Pierre Marie Curie Paris-6 University, Paris, France
| | - Tiago Mestre
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Canada Parkinson's Disease and Movement Disorder Centre, division of Neurology, department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Canada
| | - Francisco J Palomar
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Seville, Spain
| | - Reina Isayama
- Department of Medicine, University of Toronto, Toronto, Canada Division of Brain, Imaging and Behavior-Systems Neuroscience, Toronto Western Research Institute, Toronto, Canada
| | - Robert Chen
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Canada Department of Medicine, University of Toronto, Toronto, Canada Division of Brain, Imaging and Behavior-Systems Neuroscience, Toronto Western Research Institute, Toronto, Canada
| | - Carla Cordivari
- Department of Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Pablo Mir
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Seville, Spain Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Spain
| | - Anthony E Lang
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Canada
| | - Susan H Fox
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Canada
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK
| | - Marie Vidailhet
- Department of Neurology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France CRICM UPMC/INSERM UMR 1127 CNRS UMR7225 Brain and Spine Institute, Paris, France Pierre Marie Curie Paris-6 University, Paris, France
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Hassan A, Ahlskog JE, Matsumoto JY, Milber JM, Bower JH, Wilkinson JR. Orthostatic tremor: Clinical, electrophysiologic, and treatment findings in 184 patients. Neurology 2016; 86:458-64. [PMID: 26747880 DOI: 10.1212/wnl.0000000000002328] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 10/07/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the clinical, electrophysiologic, and treatment outcome features of orthostatic tremor (OT) in a large case series. METHODS We performed medical record review of 184 patients who met clinical and electrodiagnostic criteria for OT from 1976 to 2013 at the Mayo Clinic. Demographic, clinical, electrophysiologic, and treatment data were extracted. RESULTS The majority of OT cases were female (63.6%) and mean age at onset was 59.3 years (range 13-85 years). Diagnosis was delayed by a mean of 7.2 years (range 0-44 years). The average tremor frequency was 15.7 Hz (range 12.5-20 Hz), and transmitted to the arms on weight-bearing (95.5%). Patients reported a spectrum of progressive orthostatic leg symptoms, relieved by sitting or leaning. Falls were reported in 24.1%. Coexistent neurologic disorders included essential tremor (22.8%), other tremor (4.9%), and parkinsonism (8.7%). Family history of OT was noted in 4.9%. Of 46 medications trialed, 24 failed to provide any benefit. Benzodiazepines provided at least mild benefit in 55.9%, and moderate to marked benefit in 31.5%; β-blockers (31.0%) and anticonvulsants (25.0%) provided mild benefit, and the remainder were largely ineffective. Medication benefit waned over time. Deep brain stimulation (DBS) was effective in 2 cases. CONCLUSION OT predominantly affects female seniors, and the diagnosis should be considered with any orthostatic-induced leg symptoms, and confirmed by surface EMG. Benzodiazepines are the most efficacious treatment, followed by β-blockers and anticonvulsants. DBS should be further explored for treatment.
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Affiliation(s)
- Anhar Hassan
- From the Department of Neurology (A.H., J.E.A., J.Y.M., J.H.B.), Mayo Clinic, Rochester, MN; SUNY Downstate College of Medicine (J.M.M.), Brooklyn, NY; University of Pennsylvania (J.R.W.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (PADRECC) (J.R.W.), Philadelphia VA Medical Center, PA.
| | - J Eric Ahlskog
- From the Department of Neurology (A.H., J.E.A., J.Y.M., J.H.B.), Mayo Clinic, Rochester, MN; SUNY Downstate College of Medicine (J.M.M.), Brooklyn, NY; University of Pennsylvania (J.R.W.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (PADRECC) (J.R.W.), Philadelphia VA Medical Center, PA
| | - Joseph Y Matsumoto
- From the Department of Neurology (A.H., J.E.A., J.Y.M., J.H.B.), Mayo Clinic, Rochester, MN; SUNY Downstate College of Medicine (J.M.M.), Brooklyn, NY; University of Pennsylvania (J.R.W.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (PADRECC) (J.R.W.), Philadelphia VA Medical Center, PA
| | - Joshua M Milber
- From the Department of Neurology (A.H., J.E.A., J.Y.M., J.H.B.), Mayo Clinic, Rochester, MN; SUNY Downstate College of Medicine (J.M.M.), Brooklyn, NY; University of Pennsylvania (J.R.W.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (PADRECC) (J.R.W.), Philadelphia VA Medical Center, PA
| | - James H Bower
- From the Department of Neurology (A.H., J.E.A., J.Y.M., J.H.B.), Mayo Clinic, Rochester, MN; SUNY Downstate College of Medicine (J.M.M.), Brooklyn, NY; University of Pennsylvania (J.R.W.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (PADRECC) (J.R.W.), Philadelphia VA Medical Center, PA
| | - Jayne R Wilkinson
- From the Department of Neurology (A.H., J.E.A., J.Y.M., J.H.B.), Mayo Clinic, Rochester, MN; SUNY Downstate College of Medicine (J.M.M.), Brooklyn, NY; University of Pennsylvania (J.R.W.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (PADRECC) (J.R.W.), Philadelphia VA Medical Center, PA
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Contarino MF, Bour LJ, Schuurman PR, Blok ER, Odekerken VJJ, van den Munckhof P, de Bie RMA, van Rootselaar AF. Thalamic deep brain stimulation for orthostatic tremor: Clinical and neurophysiological correlates. Parkinsonism Relat Disord 2015; 21:1005-7. [PMID: 26096797 DOI: 10.1016/j.parkreldis.2015.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/15/2015] [Accepted: 06/05/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Maria Fiorella Contarino
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands; Department of Neurology, Haga Teaching Hospital, Leyweg 275, 2545 CH, The Hague, The Netherlands.
| | - Lo J Bour
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - P Richard Schuurman
- Department of Neurosurgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Erik R Blok
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Vincent J J Odekerken
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Rob M A de Bie
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Anne-Fleur van Rootselaar
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Mahlknecht P, Limousin P, Foltynie T. Deep brain stimulation for movement disorders: update on recent discoveries and outlook on future developments. J Neurol 2015; 262:2583-95. [PMID: 26037016 DOI: 10.1007/s00415-015-7790-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 12/18/2022]
Abstract
Modern deep brain stimulation (DBS) has become a routine therapy for patients with movement disorders such as Parkinson's disease, generalized or segmental dystonia and for multiple forms of tremor. Growing numbers of publications also report beneficial effects in other movement disorders such as Tourette's syndrome, various forms of chorea and DBS is even being studied for Parkinson's-related dementia. While exerting remarkable effects on many motor symptoms, DBS does not restore normal neurophysiology and therefore may also have undesirable side effects including speech and gait deterioration. Furthermore, its efficacy might be compromised in the long term, due to progression of the underlying disease. Various programming strategies have been studied to try and address these issues, e.g., the use of low-frequency rather than high-frequency stimulation or the targeting of alternative brain structures such as the pedunculopontine nucleus. In addition, further technical developments will soon provide clinicians with an expanded choice of hardware such as segmented electrodes allowing for a steering of the current to optimize beneficial effects and reduce side effects as well as the possibility of adaptive stimulation systems based on closed-loop concepts with or without accompanying advances in programming and imaging software. In the present article, we will provide an update on the most recent achievements and discoveries relevant to the application of DBS in the treatment of movement disorder patients and give an outlook on future clinical and technical developments.
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Affiliation(s)
- Philipp Mahlknecht
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK.,Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Patricia Limousin
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK.
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Bötzel K, Tronnier V, Gasser T. The differential diagnosis and treatment of tremor. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:225-35; quiz 236. [PMID: 24739887 DOI: 10.3238/arztebl.2014.0225] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 01/15/2014] [Accepted: 01/15/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Essential tremor is the most common type of tremor, with a prevalence of 0.4% in the overall population and 4-7% in persons over age 65. In general, tremor is so common that patients with tremor are frequently treated not only by neurologists, but also by physicians from other specialties. METHOD This review is based on publications retrieved by a selective PubMed search and on guidelines from Germany and abroad. RESULTS Particular tremor syndromes are usually diagnosed on the basis of their typical clinical presentation and whatever accompanying manifestations may be present. Ancillary tests are usually unnecessary. Unilateral rest tremor accompanied by rigidity and bradykinesia is typical of Parkinson's disease. Essential tremor is a bilateral postural tremor. The most common cause of intention tremor is multiple sclerosis. Mild tremor syndromes can often be treated satisfactorily with drugs. In case of severe tremor, which is rarer, a stereotactic operation can be considered. The usual outcome of such procedures is the complete suppression of tremor. CONCLUSION Most patients with tremor can be given a precise diagnosis and offered specific treatment. It is important for the physician to inform the patient about the expected course of tremor over time, its possible genetic causes, and the various available treatments.
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Affiliation(s)
- Kai Bötzel
- Department of Neurology, Institute for Clinical Neurosciences, Ludwig-Maximilians University of Munich, Klinikum Großhadern, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Department of Neurosurgery, German Center for Neurodegenerative Diseases, Tübingen University
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Erro R, Bhatia KP, Cordivari C. Shaking on Standing: A Critical Review. Mov Disord Clin Pract 2014; 1:173-179. [PMID: 30363785 DOI: 10.1002/mdc3.12053] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 04/19/2014] [Accepted: 04/24/2014] [Indexed: 11/06/2022] Open
Abstract
Orthostatic tremor is a rare condition, though its exact prevalence is unknown, which is clinically characterized by a feeling of unsteadiness or being about to fall on standing and which disappears on walking, sitting, or lying down. It is generally accepted that classic orthostatic tremor manifests with a high-frequency tremor (>13 Hz) of the legs when standing. However, a number of patients initially reported as orthostatic tremor did not actually have such electrophysiological features. It is our experience that there is a clinical spectrum of different conditions presenting as shaking on standing, and this highlights the importance of the electrophysiology to aid the differential diagnosis of these disorders. Here, we provide a critical review of the clinical spectrum of shaking on standing, along with demonstrative electrophysiological recordings of some of these conditions.
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Affiliation(s)
- Roberto Erro
- Sobell Department of Motor Neuroscience and Movement Disorders UCL Institute of Neurology London United Kingdom.,Dipartimento di Scienze Neurologiche e del Movimento Università di Verona Verona Italy.,Department of Clinical Neurophysiology National Hospital for Neurology and Neurosurgery, Queen Square London United Kingdom
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders UCL Institute of Neurology London United Kingdom
| | - Carla Cordivari
- Department of Clinical Neurophysiology National Hospital for Neurology and Neurosurgery, Queen Square London United Kingdom
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Abstract
Tremor is a hyperkinetic movement disorder characterized by rhythmic oscillations of one or more body parts. It can be disabling and may impair quality of life. Various etiological subtypes of tremor are recognized, with essential tremor (ET) and Parkinsonian tremor being the most common. Here we review the current literature on tremor treatment regarding ET and head and voice tremor, as well as dystonic tremor, orthostatic tremor, tremor due to multiple sclerosis (MS) or lesions in the brainstem or thalamus, neuropathic tremor, and functional (psychogenic) tremor, and summarize main findings. Most studies are available for ET and only few studies specifically focused on other tremor forms. Controlled trials outside ET are rare and hence most of the recommendations are based on a low level of evidence. For ET, propranolol and primidone are considered drugs of first choice with a mean effect size of approximately 50 % tremor reduction. The efficacy of topiramate is also supported by a large double-blind placebo-controlled trial, while other drugs have less supporting evidence. With a mean effect size of about 90 % deep brain stimulation in the nucleus ventralis intermedius or the subthalamic nucleus may be the most potent treatment; however, there are no controlled trials and it is reserved for severely affected patients. Dystonic limb tremor may respond to anticholinergics. Botulinum toxin improves head and voice tremor. Gabapentin and clonazepam are often recommended for orthostatic tremor. MS tremor responds only poorly to drug treatment. For patients with severe MS tremor, thalamic deep brain stimulation has been recommended. Patients with functional tremor may benefit from antidepressants and are best be treated in a multidisciplinary setting. Several tremor syndromes can already be treated with success. But new drugs specifically designed for tremor treatment are needed. ET is most likely covering different entities and their delineation may also improve treatment. Modern study designs and long-term studies are needed.
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Affiliation(s)
- Susanne A. Schneider
- Department of Neurology, Christian-Albrechts-University Kiel, University-Hospital Schleswig-Holstein, Campus Kiel, Schittenhelmstr. 10, 24105 Kiel, Germany
| | - Günther Deuschl
- Department of Neurology, Christian-Albrechts-University Kiel, University-Hospital Schleswig-Holstein, Campus Kiel, Schittenhelmstr. 10, 24105 Kiel, Germany
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Muthuraman M, Hellriegel H, Paschen S, Hofschulte F, Reese R, Volkmann J, Witt K, Deuschl G, Raethjen J. The central oscillatory network of orthostatic tremor. Mov Disord 2013; 28:1424-30. [PMID: 23926026 DOI: 10.1002/mds.25616] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 06/06/2013] [Accepted: 06/14/2013] [Indexed: 11/08/2022] Open
Abstract
Orthostatic tremor (OT) is a movement disorder of the legs and trunk that is present in the standing position but typically absent when sitting. The pathological central network involved in orthostatic tremor is still unknown. In this study we analyzed 15 patients with simultaneous high-resolution electroencephalography and electromyography recording to assess corticomuscular coherence. In 1 patient we were able to simultaneously record the local field potential in the ventrolateral thalamus and electroencephalography. Dynamic imaging of coherent source analysis was used to find the sources in the brain that are coherent with the peripheral tremor signal. When standing, the network for the tremor frequency consisted of unilateral activation in the primary motor leg area, supplementary motor area, primary sensory cortex, two prefrontal/premotor sources, thalamus, and cerebellum for the whole 30-second segment recorded. The source coherence dynamics for the primary leg area and the thalamic source signals with the tibialis anterior muscle showed that they were highly coherent for the whole 30 seconds for the contralateral side but markedly decreased after 15 seconds for the ipsilateral side. The source signal and the recorded thalamus signal followed the same time frequency dynamics of coherence in 1 patient. The corticomuscular interaction in OT follows a consistent pattern with an initially bilateral pattern and then a segregated unilateral pattern after 15 seconds. This may add to the feeling of unsteadiness. It also makes the thalamus unlikely as the main source of orthostatic tremor.
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Affiliation(s)
- Muthuraman Muthuraman
- Department of Neurology, University Hospital Schleswig-Holstein, University of Kiel, Kiel, Germany
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Abstract
Deep brain stimulation (DBS) is a well established treatment for essential tremor and for the tremor associated with Parkinson's disease. The efficacy of DBS in these common tremors has led some investigators to apply the technique to rarer tremors such as such as Holmes' tremor, posttraumatic tremor, orthostatic tremor, and the tremor associated with multiple sclerosis. Likewise, DBS of the thalamus and globus pallidus directly suppresses levodopa-induced dyskinesias in Parkinson's disease, suggesting the application of DBS to other hyperkinetic states such as Huntington's disease, tardive dyskinesia, and hemiballism. Myoclonus has also been treated with DBS, especially in cases where it is associated with dystonia. This chapter reviews the reported results of DBS for these conditions. Due to the rarity of these indications, most of the literature reviewed takes the form of case reports or small single-center case series.
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Affiliation(s)
- Philip A Starr
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
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Abstract
Movement disorders are neurological conditions affecting speed, fluency, quality, and ease of movement. Deep brain stimulation (DBS) is used to treat advanced Parkinson's disease, essential tremor, and dystonia. Possible target sites for DBS include the ventral intermediate nucleus of the thalamus, the globus pallidus internus, and the subthalamic nucleus. High-frequency DBS leads to a kind of functional deafferentation of the stimulated structure and to the modulation of cortical activity. This has a profound effect on the efficiency of movement. Indications for the use of DBS include the need to improve function, reduce medication dependency, and avoid ablative neurosurgery. Appropriate patient selection is critical for success. The implantation technique is briefly described. Programming stimulation parameters are performed via telemetry. The adverse effects of DBS are discussed. The future should see the development of “closed-loop” systems. Its use has promoted interdisciplinary team work and provided an improved understanding of the complex neurocircuitry associated with these disorders. DBS is a highly effective, safe, and reversible surgical treatment for advanced Parkinson's disease, tremor, and dystonia. It is a useful therapeutic option in carefully selected patients that significantly improves motor symptoms, functional status, and quality of life.
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Treatment of motor and non-motor features of Parkinson's disease with deep brain stimulation. Lancet Neurol 2012; 11:429-42. [DOI: 10.1016/s1474-4422(12)70049-2] [Citation(s) in RCA: 266] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Lyons MK, Behbahani M, Boucher OK, Caviness JN, Evidente VGH. Orthostatic tremor responds to bilateral thalamic deep brain stimulation. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2012; 2. [PMID: 23439685 PMCID: PMC3569976 DOI: 10.7916/d8tq608k] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 05/27/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Orthostatic tremor (OT) is a disabling movement disorder manifested by postural and gait disturbance. Primarily a condition of elderly people, it can be progressive in up to 15% of patients. The primary treatments are medications that are often ineffective. CASE REPORT A 75-year-old male presented with a 10-year history of progressive and disabling OT. He had tried various medications without significant benefits. He underwent bilateral thalamic Vim deep brain stimulation (DBS). At 30-month follow-up, he has had continued significant improvement of his OT. DISCUSSION Bilateral thalamic DBS may be a viable option for medically refractory OT.
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Affiliation(s)
- Mark K Lyons
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, Unites States of America
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Schiefer TK, Matsumoto JY, Lee KH. Moving forward: advances in the treatment of movement disorders with deep brain stimulation. Front Integr Neurosci 2011; 5:69. [PMID: 22084629 PMCID: PMC3211039 DOI: 10.3389/fnint.2011.00069] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 10/07/2011] [Indexed: 11/13/2022] Open
Abstract
The modern era of stereotactic and functional neurosurgery has ushered in state of the art technologies for the treatment of movement disorders, particularly Parkinson's disease (PD), tremor, and dystonia. After years of experience with various surgical therapies, the eventual shortcomings of both medical and surgical treatments, and several serendipitous discoveries, deep brain stimulation (DBS) has risen to the forefront as a highly effective, safe, and reversible treatment for these conditions. Idiopathic advanced PD can be treated with thalamic, globus pallidus internus (GPi), or subthalamic nucleus (STN) DBS. Thalamic DBS primarily relieves tremor while GPi and STN DBS alleviate a wide range of Parkinsonian symptoms. Thalamic DBS is also used in the treatment of other types of tremor, particularly essential tremor, with excellent results. Both primary and various types of secondary dystonia can be treated very effectively with GPi DBS. The variety of anatomical targets for these movement disorders is indicative of the network-level dysfunction mediating these movement disturbances. Despite an increasing understanding of the clinical benefits of DBS, little is known about how DBS can create such wide sweeping neuromodulatory effects. The key to improving this therapeutic modality and discovering new ways to treat these and other neurologic conditions lies in better understanding the intricacies of DBS. Here we review the history and pertinent clinical data for DBS treatment of PD, tremor, and dystonia. While multiple regions of the brain have been targeted for DBS in the treatment of these movement disorders, this review article focuses on those that are most commonly used in current clinical practice. Our search criteria for PubMed included combinations of the following terms: DBS, neuromodulation, movement disorders, PD, tremor, dystonia, and history. Dates were not restricted.
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Affiliation(s)
| | | | - Kendall H. Lee
- Department of Neurologic Surgery, Mayo ClinicRochester, MN, USA
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Affiliation(s)
- Hrishikesh Kumar
- Movement Disorders Program, Division of Neurology, University of Western Ontario, London, Ont.
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Abstract
Tremor is one of the most frequent movement disorders and covers a wide spectrum of entities summarized in the 1998 consensus statement of the Movement Disorder Society. Essential tremor and Parkinson tremor are most common and are also the most thoroughly studied. Major progress has occurred in the clinical semiology, neuroimaging, epidemiology, and pathophysiology of tremors. Pathology and genetic research are rapidly growing fields of study. Recently described tremor entities include orthostatic tremor, dystonic tremor, cortical tremor, and thalamic tremor. Treatment research methodology has improved substantially, but few double-blind controlled trials have been published. Deep brain stimulation is the most effective treatment for most tremors but is reserved for advanced cases.
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Affiliation(s)
- Rodger Elble
- Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
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Hellriegel H, Raethjen J, Deuschl G, Volkmann J. Levetiracetam in primary orthostatic tremor: a double-blind placebo-controlled crossover study. Mov Disord 2011; 26:2431-4. [PMID: 21953629 DOI: 10.1002/mds.23881] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 06/10/2011] [Accepted: 06/15/2011] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND In a double-blind crossover study we evaluated the antitremor effect of a 4-week treatment with either escalating dosages of levetiracetam or placebo in orthostatic tremor. METHODS Twelve patients with orthostatic tremor participated in the study. Primary end point was improvement in stance duration. Secondary end points were total track length of the sway path and tremor total power. The patients' impression of impairment was assessed by a visual analog scale and quality of life by the SF-36. RESULTS We found no significant effect of dosage or treatment on stance duration (P = .175), total track length (P = .690), total power (P = .280), or visual analog scale (P =.735). Neither was SF-36 differentially changed by levetiracetam or placebo (SF-36, Physical Component Summary: P = .079; SF-36, Mental Component Summary: P = .073). Side effects like dizziness, fatigue, or nausea were only mild to moderate. CONCLUSIONS Levetiracetam is ineffective in the treatment of orthostatic tremor.
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Affiliation(s)
- Helge Hellriegel
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
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