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An unusual initial presentation of Parkinson's disease: unilateral standing leg tremor. Acta Neurol Belg 2020; 120:415-416. [PMID: 29728905 DOI: 10.1007/s13760-018-0920-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
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Hassan A, Caviness J. Slow Orthostatic Tremor: Review of the Current Evidence. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2019; 9:tre-09-721. [PMID: 31832265 PMCID: PMC6886496 DOI: 10.7916/tohm.v0.721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/07/2019] [Indexed: 12/01/2022]
Abstract
Background Orthostatic tremor (OT) is defined as tremor in the legs and trunk evoked during standing. While the classical description is tremor of ≥13 Hz, slower frequencies are recognized. There is disagreement as to whether the latter represents a slow variant of classical OT, or different tremor disorder(s) given frequent coexistent neurological disease. Methods A systematic literature search of PubMed was performed in February 2019 for “slow orthostatic tremor” and related terms which generated 573 abstracts, of which 61 were included. Results Between 1970 and 2019, there were 70 cases of electrophysiologically confirmed slow OT. Two-thirds were female, of mean age 60 years (range 26–86), and mean disease duration 6 years (range 0–32). One-third of cases were isolated, and two-thirds had a coexistent disorder(s), including parkinsonism (30%), ataxia (12%), and dystonia (10%). Postural arm tremor was present in 34%. Median tremor frequency was 6–7 Hz (range 3–12). Tremor bursts ranged from 50 to 150 ms duration, and were alternating or synchronous in antagonistic and/or analogous muscles. Low and high coherences were reported. Five cases (7%) had coexistent classical OT. Clonazepam was the most effective medication across all frequencies, and levodopa was effective for 4–7 Hz OT with coexistent parkinsonism. Two cases resolved with the treatment of Graves’ disease. Electrophysiology and imaging predominantly support a central tremor generator. Discussion While multiple lines of evidence separate slow OT from classical OT, clinical and electrophysiological overlap may occur. Primary and secondary causes are identified, similar to classical OT. Further exploration to clarify these slow OT subtypes, clinically and neurophysiologically, is proposed.
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Affiliation(s)
- Anhar Hassan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - John Caviness
- Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
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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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Benito-León J, Louis ED, Mato-Abad V, Dydak U, Álvarez-Linera J, Hernández-Tamames JA, Molina-Arjona JA, Malpica N, Matarazzo M, Romero JP, Sánchez-Ferro Á. In vivo neurometabolic profiling in orthostatic tremor. Medicine (Baltimore) 2016; 95:e4848. [PMID: 27631243 PMCID: PMC5402586 DOI: 10.1097/md.0000000000004848] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 06/17/2016] [Accepted: 08/22/2016] [Indexed: 11/29/2022] Open
Abstract
The pathogenesis of orthostatic tremor (OT) remains unclear, although some evidence points to dysfunction in the brainstem or cerebellum. We used single voxel proton magnetic resonance spectroscopy (1H-MRS) (3 T) to investigate whether neurochemical changes underlie abnormal cerebellar or cortical function in OT. Fourteen OT patients and 14 healthy controls underwent 1H-MRS studies with voxels placed in midparietal gray matter and cerebellum (vermis and central white matter). Spectral analysis was analyzed using the software package LCModel (version 6.3). The absolute metabolite concentrations and ratios of total N-acetylaspartate + N-acetylaspartyl glutamate (NAA), choline-containing compounds, myoinositol, and glutamate + glutamine to creatine were calculated. In midparietal gray matter spectra, we found a significant decrease in the absolute concentration of NAA in OT patients versus healthy controls (7.76 ± 0.25 vs 8.11 ± 0.45, P = 0.017). A similar decrease in NAA was seen in the cerebellar vermis (7.33 ± 0.61 vs 8.55 ± 1.54, P = 0.014) and cerebellar white matter (8.54 ± 0.79 vs 9.95 ± 1.57, P = 0.010). No differences in the other metabolites or their ratios were observed. Reductions in both cerebral cortical and cerebellar NAA suggest that there is neuronal damage or loss in OT, raising the intriguing question as to whether OT is a neurodegenerative disease. Along with clinical history and electrophysio0logical examination, 1H-MRS could serve as a useful diagnostic aid for OT.
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Affiliation(s)
- Julián Benito-León
- Department of Neurology, University Hospital “12 de Octubre”
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED)
- Department of Medicine, Complutense University, Madrid, Spain
| | - Elan D. Louis
- Department of Neurology, Yale School of Medicine
- Department of Chronic Disease Epidemiology, Yale School of Public Health
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine and Yale School of Public Health, New Haven, CT
| | - Virginia Mato-Abad
- Neuroimaging Laboratory, Center for Biomedical Technology, Rey Juan Carlos University, Madrid, Spain
| | - Ulrike Dydak
- School of Health Sciences, Purdue University, West Lafayette
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN
| | | | | | | | - Norberto Malpica
- Neuroimaging Laboratory, Center for Biomedical Technology, Rey Juan Carlos University, Madrid, Spain
| | | | - Juan Pablo Romero
- Department of Neurology, University Hospital “12 de Octubre”
- Faculty of Biosanitary Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Madrid, Spain
| | - Álvaro Sánchez-Ferro
- Department of Neurology, University Hospital “12 de Octubre”
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, MA
- HM CINAC, HM Hospitales, Madrid, Spain
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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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Rigby HB, Rigby MH, Caviness JN. Orthostatic Tremor: A Spectrum of Fast and Slow Frequencies or Distinct Entities? Tremor Other Hyperkinet Mov (N Y) 2015; 5:324. [PMID: 26317042 PMCID: PMC4548762 DOI: 10.7916/d8s75fhk] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/15/2015] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Orthostatic tremor (OT) is defined by the presence of a high-frequency (13-18 Hz) tremor of the legs upon standing associated with a feeling of unsteadiness. However, some patients have discharge frequencies of <13 Hz, so-called "slow OT". The aim of this study was to characterize patients with unsteadiness upon standing found to have <13 Hz tremor discharges on neurophysiologic testing. METHODS A retrospective review was performed on all subjects with a diagnosis of OT who were referred to the Mayo Clinic, Scottsdale, AZ, between 1999 and 2013 for confirmation using neurophysiology. RESULTS Fourteen of 28 subjects (50%) had OT discharges of <13 Hz, of whom eight had frequencies of <10 Hz and six had frequencies of 10-13 Hz. Lower frequency discharges tended to have a broader spectral peak, greater variability in discharge duration, and lower inter-muscular coherence. Subjects with <13 Hz OT had shorter mean disease duration at time of neurophysiology testing (2.00 years in <10 Hz group, 7.96 years 10-13 Hz group, and 11.43 years >13 Hz; p = 0.002). The proportion of subjects who experienced gait unsteadiness (85.7% vs. 66.6% vs. 21.4%; p = 0.016), falls (37.5% vs. 50% vs. 0%; p = 0.010), and had abnormal gait on examination (71.4% vs. 66.0% vs. 14.3%; p = 0.017) was greater in those with low and intermediate frequencies. DISCUSSION Slow tremor electromyography frequencies (<13 Hz) may characterize a substantial proportion of patients labeled as OT. These subjects may have greater gait involvement and higher likelihood of falls leading to earlier presentation to subspecialty care.
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Affiliation(s)
- Heather B. Rigby
- Department of Neurology, Movement Disorders Center, Mayo Clinic, Scottsdale, AZ, USA
- Division of Neurology, Dalhousie University, Halifax, NS, Canada
| | - Matthew H. Rigby
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - John N. Caviness
- Department of Neurology, Movement Disorders Center, Mayo Clinic, Scottsdale, AZ, USA
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Yaltho TC, Ondo WG. Orthostatic tremor: A review of 45 cases. Parkinsonism Relat Disord 2014; 20:723-5. [PMID: 24736049 DOI: 10.1016/j.parkreldis.2014.03.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/04/2014] [Accepted: 03/15/2014] [Indexed: 10/25/2022]
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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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Lee SY, Chung EJ, Kim YJ, Kim SJ. Dopa responsive slow orthostatic tremor in Parkinson's disease. J Mov Disord 2011; 4:82-4. [PMID: 24868403 PMCID: PMC4027687 DOI: 10.14802/jmd.11019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 10/24/2011] [Indexed: 11/24/2022] Open
Abstract
Slow orthostatic tremor (OT) occurred to longer and lower frequency regular rhythmic bursts in leg muscle upon standing. The slow OT was often able to clinically confused with orthostatic myoclonus. We described a Parkinson's disease patient with levodopa responsive slow OT. She showed abnormal movements of more regular rhythms and stable frequency on both legs on standing. These symptoms were aggravated at off state and improved by increasing levodopa.
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Affiliation(s)
- Suk Yoon Lee
- Department of Neurology, Inje University College of Medicine, Busan, Korea
| | - Eun Joo Chung
- Department of Neurology, Inje University College of Medicine, Busan, Korea
| | - Yeo Jung Kim
- Department of Neurology, Inje University College of Medicine, Busan, Korea
| | - Sang Jin Kim
- Department of Neurology, Inje University College of Medicine, Busan, Korea
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Abstract
Orthostatic tremor (OT) is a rare syndrome characterized by unsteadiness on standing due to a high-frequency tremor involving the legs. Symptoms usually start in the sixth decade. Typically, the symptoms rapidly improve on sitting or walking, and the need to sit down or to move can be so strong that patients avoid situations where they have to stand still. A polygraphic recording of a fast and synchronous tremor of the legs, between 13 and 18Hz, is mandatory to confirm the diagnosis of OT. Many patients also suffer from tremor, often involving lower frequencies, of the face, hands, or trunk. Recent studies suggest that this is perhaps due to subharmonics of the high-frequency tremor spreading through the body. Most cases of OT seem to be idiopathic, though symptomatic forms have been occasionally described. Several cases of OT have been reported in Parkinson's disease (PD), either preceding the onset of OT or developing in long-standing PD, suggesting a dopaminergic control of the central oscillator, possibly in the posterior fossa. The response to treatment is often disappointing. Clonazepam is widely used as a first-line agent, but gabapentin and dopaminergic drugs may be helpful in some patients.
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11
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12
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Kang SY, Song SK, Kim JS, Sohn YH. Unilateral standing leg tremor as the initial manifestation of Parkinson disease. J Mov Disord 2009; 2:29-32. [PMID: 24868349 PMCID: PMC4027702 DOI: 10.14802/jmd.09007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 04/06/2009] [Accepted: 03/29/2009] [Indexed: 11/24/2022] Open
Abstract
Background: The aim of this study was to analyze the different forms of leg tremors exhibited while standing in patients with Parkinson disease (PD), and to determine if the type of leg tremor exhibited is indicative of prognosis or treatment response in PD patients. Methods: We studied the clinical characteristics of five PD patients (all women; mean age, 59 years, range, 53–64 years) with unilateral standing leg tremor as the initial manifestation of PD, including their electrophysiological findings and the results of long-term follow-up. Results: For each patient, parkinsonism either existed at the time of onset of the initial symptoms or developed later. Patient responses to drugs were generally good, but one patient showed a poor response to drugs, even though she had only a low frequency leg tremor. For two patients whom we could observe during the 10-year follow-up period, neither the leg tremor nor parkinsonism was aggravated. Conclusions: There are two forms of unilateral standing leg tremor in PD. One form is high frequency, similar to the primary orthostatic tremor. The other is low frequency and similar to the parkinsonian resting tremor. Based on these observations, it appears that progression might be slow if PD patients have standing leg tremor as the initial manifestation.
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Affiliation(s)
- Suk Yun Kang
- Department of Neurology and Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea ; Department of Neurology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sook-Keun Song
- Department of Neurology and Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jin-Soo Kim
- Department of Neurology and Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Ho Sohn
- Department of Neurology and Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Leu-Semenescu S, Roze E, Vidailhet M, Legrand AP, Trocello JM, Cochen V, Sangla S, Apartis E. Myoclonus or tremor in orthostatism: an under-recognized cause of unsteadiness in Parkinson's disease. Mov Disord 2008; 22:2063-9. [PMID: 17674413 DOI: 10.1002/mds.21651] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Patients with Parkinson's disease (PD) often complain of unsteadiness. This can occur as the result of various neurological dysfunctions, including changes in postural adjustments, loss of postural reflexes, axial akinesia and rigidity, freezing and/or postural hypotension. In some cases these symptoms remain unexplained, and rare cases of unsteadiness have been attributed to tremor on standing. To delineate this condition, we investigated 11 consecutive PD patients with unexplained unsteadiness because of tremor on standing, seen in our department over a 6-year period. All the patients had detailed clinical and electrophysiological investigations based on surface polygraphic electromyographic recordings. Four patients had fast orthostatic tremor (13-18 Hz), one had intermediate orthostatic tremor (8-9 Hz), and three had slow orthostatic tremor (4-6 Hz). The remaining 3 patients had orthostatic myoclonus, a condition that has not previously been reported in PD. Patients with fast tremor improved on clonazepam. Patients with slow tremor and myoclonus improved on levodopa and sometimes benefited further when clonazepam was added. These observations show the usefulness of neurophysiological investigations for diagnosing and treating unexplained unsteadiness in Parkinson's disease.
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Thomas A, Bonanni L, Antonini A, Barone P, Onofrj M. Dopa-responsive pseudo-orthostatic tremor in parkinsonism. Mov Disord 2007; 22:1652-6. [PMID: 17579364 DOI: 10.1002/mds.21621] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In four patients an inabilitating standing tremor appeared years before that parkinsonian symptoms were evidenced. This tremor was refractory to gabapentin and dramatically responded to Levodopa administration. Its dominant frequency was 6.2 to 6.9 Hz with sporadic subharmonics at 8 to 18 Hz. Three patients were affected by different genetic mutations (Park 2, Park 6, mtDNA deletion) in one no genetic or metabolic alterations could be evidenced. All patients had dopamine transporter abnormalities. We suggest that the term "Pseudo-Orthostatic Tremor" could be used to define this Dopa responsive, 6 to 7 Hz standing tremor.
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Affiliation(s)
- Astrid Thomas
- Department of Oncology and Neuroscience, Neurophysiopathology, University G. D'Annunzio Chieti-Pescara, Italy
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Garosi LS, Rossmeisl JH, Lahunta A, Shelton GD, Lennox G. Primary Orthostatic Tremor in Great Danes. J Vet Intern Med 2005. [DOI: 10.1111/j.1939-1676.2005.tb02736.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Katzenschlager R, Costa D, Gerschlager W, O'Sullivan J, Zijlmans J, Gacinovic S, Pirker W, Wills A, Bhatia K, Lees AJ, Brown P. [123I]-FP-CIT-SPECT demonstrates dopaminergic deficit in orthostatic tremor. Ann Neurol 2003; 53:489-96. [PMID: 12666116 DOI: 10.1002/ana.10475] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is increasing evidence of a potential role of the dopaminergic system in orthostatic tremor (OT): Association with parkinsonism and treatment effects of L-dopa and dopamine agonists have been reported. Eleven patients with isolated OT had single-photon emission computed tomography (SPECT) using (123)I-FP-CIT ([(123)I]-2 beta-carbomethoxy-3beta-(-4-iodophenyl)-N-(3-fluoropropyl)-nortropane) as dopamine transporter tracer. Results were compared with 12 age-matched normal controls and 12 patients with Parkinson's disease (PD). A marked reduction in striatal tracer binding was found in OT compared to normal controls (p < 0.001). Tracer uptake was significantly higher and more symmetrical than in PD, and caudate and putamen were equally affected. L-dopa challenges, performed in seven patients, showed a small but non-significant improvement on EMG and a small but significant improvement in clinical parameters on blinded video rating. Two-month open-label L-dopa treatment (600 mg/day) led to a small improvement in two of five patients but no significant overall change. Olfactory function on University of Pennsylvania Smell Identification Test was normal. Our finding of a marked tracer uptake reduction on dopamine transporter SPECT supports a role of the dopaminergic system in OT. Lack of evidence of a clinically relevant therapeutic response to L-dopa suggests that other mechanisms must also be involved in the pathogenesis.
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Affiliation(s)
- Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas 77030, USA.
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Apartis E, Tison F, Arné P, Jedynak CP, Vidailhet M. Fast orthostatic tremor in Parkinson's disease mimicking primary orthostatic tremor. Mov Disord 2001; 16:1133-6. [PMID: 11748748 DOI: 10.1002/mds.1218] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Leg tremor during standing is a rare feature in idiopathic Parkinson's disease (PD). Tremor during standing usually has a low frequency (range, 4-6 Hz), similar to PD rest tremor frequency, and is improved by levodopa. We describe three cases of fast orthostatic tremor (FoT) of legs and trunk mimicking primary orthostatic tremor (OT) in patients treated with levodopa for PD. Asymmetrical akinetorigid syndrome was accompanied by a rest tremor in two cases. We obtained electrophysiological parameters by electromyographic (EMG) polygraphic recording after 16 hours withdrawal of antiparkinsonian treatment and at the maximal effect of levodopa in order to investigate the effect of dopaminergic stimulation upon such cases of orthostatic tremor in PD. Electrophysiological parameters of orthostatic tremor, especially frequency (range 14-18 Hz), were similar to that seen in POT. Severity of tremor was independent of seriousness and duration of PD. Levodopa had no effect either on the handicap due to OT or on the amplitude and frequency of the EMG OT activity. In contrast, mild improvement of OT was obtained with benzodiazepines in two cases and parkinsonian syndrome was levodopa-sensitive. These findings suggest that FoT in PD would not be directly controlled by the dopaminergic system. However, increased rhythmicities in basal ganglia or in cerebello-thalamic loops at the rapid frequencies range seen in PD could favor the emergence of a primary orthostatic tremor-like tremor in PD patients.
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Affiliation(s)
- E Apartis
- Neurophysiologie, Centre Hospitalo Universitaire Saint-Antoine, Paris, France
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Abstract
Tremors other than those associated with Parkinson's disease are commonly encountered in clinical practice. The differentiation of tremor subtypes depends primarily on the presence of distinct clinical characteristics and is facilitated by the use of consistent nomenclature. Such differentiation can be helpful in determining the etiology of the tremor and assist in its management. In this review, the authors outline recently proposed changes to classification and review the clinical features, differential diagnosis, and current therapy for nonparkinsonian tremors.
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Affiliation(s)
- J D O'Sullivan
- The National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Evidente VG, Adler CH, Caviness JN, Gwinn KA. Effective treatment of orthostatic tremor with gabapentin. Mov Disord 1998; 13:829-31. [PMID: 9756154 DOI: 10.1002/mds.870130513] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We report seven patients with orthostatic tremor (OT) who were successfully treated with the anticonvulsant gabapentin. Five of the patients had been previously tried on clonazepam, the most commonly used drug for OT, four without any benefit. The degree of improvement perceived by the patients with gabapentin varied from 60-80% (mean 73%). The effective dose of gabapentin ranged from 300-1800 mg/day (mean 1030 mg/day). The side effects were generally mild, transient, and dose-related. Duration of response has so far ranged from 2-22 months (mean 11 months) with all patients still currently benefiting from gabapentin. We conclude that gabapentin may be an effective treatment for OT. Further trials are indicated.
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Affiliation(s)
- V G Evidente
- Parkinson's Disease and Movement Disorders Center, Mayo Clinic Scottsdale, Arizona 85259, USA
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Burleigh A, Horak F, Nutt J, Frank J. Levodopa reduces muscle tone and lower extremity tremor in Parkinson's disease. Can J Neurol Sci 1995; 22:280-5. [PMID: 8599770 DOI: 10.1017/s0317167100039470] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE We have quantified the effects of levodopa treatment in Parkinsonian subjects during maintained stance. METHODS Electromyographic muscle activity during quiet stance was assessed in subjects with Parkinson's disease, who exhibited a fluctuating response to levodopa, and in age-matched control subjects. Stance stability was also assessed from mean displacement and velocity of the center of pressure excursions during stance. RESULTS Lower extremity and trunk muscles showed high amplitude activity in all Parkinson's subjects when "off", and a 4-5 Hz tremor in three of these subjects. When "on", the amplitude of muscle activity was reduced in the distal muscles more than the proximal, while tremor was suppressed in all muscles. Corresponding to the excessive muscle activity, the Parkinson's subjects had increased velocity and variability of velocity in the anterior-posterior center of foot pressure excursions, but the mean displacement of the center of pressure excursion was not different from the controls. The velocity of center of pressure excursions in the Parkinson's subjects "on", approached those of the control subjects suggesting that the excessive distal muscle amplitude and tremor contributed to the high velocity of the center of pressure. CONCLUSIONS These findings suggest that dopaminergic systems are involved in the regulation of muscle tone during stance. Depletion of dopaminergic transmission results in increased muscle tone and tremor in the lower extremities which may contribute to changes in posture and stability.
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Affiliation(s)
- A Burleigh
- Dow Neurological Sciences Institute of GSH & MC, Portland, OR 97209-1595, USA
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