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Habibollahi Z, Zhou Y, Jenkins ME, Jayne Garland S, Friedman E, Naish MD, Trejos AL. Tremor Suppression Using Functional Electrical Stimulation. IEEE Trans Neural Syst Rehabil Eng 2024; 32:3289-3298. [PMID: 39222447 DOI: 10.1109/tnsre.2024.3453222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Parkinson's disease (PD) and essential tremor are two major causes of pathological tremor among people over 60 years old. Due to the side effects and complications of traditional tremor management methods such as medication and deep brain surgery, non invasive tremor suppression methods have become more popular in recent years. Functional electrical stimulation (FES) is one of the methods used to reduce tremor in several studies. However, the effect of different FES parameters on tremor suppression and discomfort level, including amplitude, the number of pulses in each stimulation burst, frequency, and pulse width is yet to be studied for longer stimulation durations. Therefore, in this work, experiments were performed on 14 participants with PD to evaluate the effect of thirty seconds of out-of-phase electrical stimulation on wrist tremor at rest. Trials were conducted by varying the stimulation amplitude and the number of pulses while keeping the frequency and pulse width constant. Each test was repeated three times for each participant. The results showed an overall tremor suppression for 11 out of 14 participants and no average positive effects for three participants. It is concluded that despite the effectiveness of FES in tremor suppression, each set of FES parameters showed different suppression levels among participants due to the variability of tremor over time. Thus, for this method to be effective, an adaptive control system would be required to tune FES parameters in real time according to changes in tremor during extended stimulation periods.
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2
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Huang Y, Yao K, Zhang Q, Huang X, Chen Z, Zhou Y, Yu X. Bioelectronics for electrical stimulation: materials, devices and biomedical applications. Chem Soc Rev 2024; 53:8632-8712. [PMID: 39132912 DOI: 10.1039/d4cs00413b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Bioelectronics is a hot research topic, yet an important tool, as it facilitates the creation of advanced medical devices that interact with biological systems to effectively diagnose, monitor and treat a broad spectrum of health conditions. Electrical stimulation (ES) is a pivotal technique in bioelectronics, offering a precise, non-pharmacological means to modulate and control biological processes across molecular, cellular, tissue, and organ levels. This method holds the potential to restore or enhance physiological functions compromised by diseases or injuries by integrating sophisticated electrical signals, device interfaces, and designs tailored to specific biological mechanisms. This review explains the mechanisms by which ES influences cellular behaviors, introduces the essential stimulation principles, discusses the performance requirements for optimal ES systems, and highlights the representative applications. From this review, we can realize the potential of ES based bioelectronics in therapy, regenerative medicine and rehabilitation engineering technologies, ranging from tissue engineering to neurological technologies, and the modulation of cardiovascular and cognitive functions. This review underscores the versatility of ES in various biomedical contexts and emphasizes the need to adapt to complex biological and clinical landscapes it addresses.
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Affiliation(s)
- Ya Huang
- Department of Biomedical Engineering, City University of Hong Kong, Hong Kong, China
| | - Kuanming Yao
- Department of Biomedical Engineering, City University of Hong Kong, Hong Kong, China
| | - Qiang Zhang
- Department of Biomedical Engineering, City University of Hong Kong, Hong Kong, China
| | - Xingcan Huang
- Department of Biomedical Engineering, City University of Hong Kong, Hong Kong, China
| | - Zhenlin Chen
- Department of Biomedical Engineering, City University of Hong Kong, Hong Kong, China
| | - Yu Zhou
- Department of Electronic and Computer Engineering, The Hong Kong University of Science and Technology, Hong Kong, China.
| | - Xinge Yu
- Department of Biomedical Engineering, City University of Hong Kong, Hong Kong, China
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3
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Evancho A, Tyler WJ, McGregor K. A review of combined neuromodulation and physical therapy interventions for enhanced neurorehabilitation. Front Hum Neurosci 2023; 17:1151218. [PMID: 37545593 PMCID: PMC10400781 DOI: 10.3389/fnhum.2023.1151218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/30/2023] [Indexed: 08/08/2023] Open
Abstract
Rehabilitation approaches for individuals with neurologic conditions have increasingly shifted toward promoting neuroplasticity for enhanced recovery and restoration of function. This review focuses on exercise strategies and non-invasive neuromodulation techniques that target neuroplasticity, including transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), and peripheral nerve stimulation (PNS). We have chosen to focus on non-invasive neuromodulation techniques due to their greater potential for integration into routine clinical practice. We explore and discuss the application of these interventional strategies in four neurological conditions that are frequently encountered in rehabilitation settings: Parkinson's Disease (PD), Traumatic Brain Injury (TBI), stroke, and Spinal Cord Injury (SCI). Additionally, we discuss the potential benefits of combining non-invasive neuromodulation with rehabilitation, which has shown promise in accelerating recovery. Our review identifies studies that demonstrate enhanced recovery through combined exercise and non-invasive neuromodulation in the selected patient populations. We primarily focus on the motor aspects of rehabilitation, but also briefly address non-motor impacts of these conditions. Additionally, we identify the gaps in current literature and barriers to implementation of combined approaches into clinical practice. We highlight areas needing further research and suggest avenues for future investigation, aiming to enhance the personalization of the unique neuroplastic responses associated with each condition. This review serves as a resource for rehabilitation professionals and researchers seeking a comprehensive understanding of neuroplastic exercise interventions and non-invasive neuromodulation techniques tailored for specific diseases and diagnoses.
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Affiliation(s)
- Alexandra Evancho
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
| | - William J. Tyler
- Department of Biomedical Engineering, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- Department of Physical Medicine and Rehabilitation, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Keith McGregor
- Department of Clinical and Diagnostic Studies, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
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Trout MA, Harrison AT, Brinton MR, George JA. A portable, programmable, multichannel stimulator with high compliance voltage for noninvasive neural stimulation of motor and sensory nerves in humans. Sci Rep 2023; 13:3469. [PMID: 36859464 PMCID: PMC9977866 DOI: 10.1038/s41598-023-30545-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Most neural stimulators do not have a high enough compliance voltage to pass current through the skin. The few stimulators that meet the high compliance voltage necessary for transcutaneous stimulation are typically large benchtop units that are not portable, and the stimulation waveforms cannot be readily customized. To address this, we present the design and validation of a portable, programmable, multichannel, noninvasive neural stimulator that can generate three custom bipolar waveforms at ± 150 V with microsecond temporal resolution. The design is low-cost, open-source, and validated on the benchtop and with a healthy population to demonstrate its functionality for sensory and motor stimulation. Sensory stimulation included electrocutaneous stimulation targeting cutaneous mechanoreceptors at the surface of the skin and transcutaneous nerve stimulation targeting the median nerve at the wrist. Both electrocutaneous stimulation on the hand and transcutaneous stimulation at the wrist can elicit isolated tactile percepts on the hand but changes in pulse frequency are more discriminable for electrocutaneous stimulation. Also, neuromuscular electrical stimulation of the flexor digiti profundus is evoked by applying electrical stimulation directly above the muscle in the forearm and to the median and ulnar nerves in the upper arm. Muscle and nerve stimulation evoked similar grip forces and force rise times, but nerve stimulation had a significantly slower fatigue rate. The development and validation of this noninvasive stimulator and direct comparison of common sensory and motor stimulation targets in a human population constitute an important step towards more widespread use and accessibility of neural stimulation for education and research.
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Affiliation(s)
- Marshall A Trout
- Department of Electrical and Computer Engineering, University of Utah, Salt Lake City, USA.
| | - Abigail T Harrison
- Department of Biomedical Engineering, University of Utah, Salt Lake City, USA
| | - Mark R Brinton
- Department of Engineering and Physics, Elizabethtown College, Elizabethtown, USA
| | - Jacob A George
- Department of Electrical and Computer Engineering, University of Utah, Salt Lake City, USA.
- Department of Biomedical Engineering, University of Utah, Salt Lake City, USA.
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, USA.
- Department of Mechanical Engineering, University of Utah, Salt Lake City, USA.
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5
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Zhang B, Huang F, Liu J, Zhang D. Bilateral transcranial direct current stimulation may be a feasible treatment of Parkinsonian tremor. Front Neurosci 2023; 17:1101751. [PMID: 36908793 PMCID: PMC9998710 DOI: 10.3389/fnins.2023.1101751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023] Open
Abstract
Background Parkinsonian tremor is a common pathological tremor that affects over 6 million people worldwide. It lowers patients' quality of life and threatens their career development, especially when patients' occupation requires dexterous manipulation. In spite of current available treatments in clinics, there is a lack of low-cost, low side-effect, effective solutions for Parkinsonian tremor. Transcranial direct current stimulation (tDCS) may be an alternative treatment. Objective In this research, we explored the immediate effect of tDCS with a novel bilateral electrode setup over Parkinsonian tremor. In such a bilateral setup, the cathode was placed over the primary cortex contralateral to the more affected side of Parkinsonian tremor while the anode symmetrically over the other hemisphere. It was designed as a modification to the traditional cathodal setup. The performance of this bilateral setup was compared with three other setups including anodal setup, cathodal setup, and sham (control). Methods A randomized, sham-controlled, double-blind, crossover experiment was carried out over 13 qualified patients diagnosed with idiopathic Parkinson's disease (PD). Before and after the stimulus of each tDCS setup, subjects were tested before and after tDCS with four measures, including the Unified Parkinson's Disease Rating Scale (UPDRS), Fahn-Tolosa-Marin Tremor Rating Scale (FTMTRS), Purdue Pegboard Test (PPT) and a self-design Continuous Tremor Signal Assessment (CTSA). Tremor intensity calculated from CTSA data were regarded as the primary outcome of the experiment. Results Statistical results of CTSA, FTMTRS and PPT showed both bilateral tDCS and cathodal tDCS effectively suppressed Parkinsonian tremor. A quantitative comparison of the effect in tremor suppression indicated the optimal suppressive effect was obtained with bilateral tDCS. Based on the results of UPDRS, anodal tDCS was found to benefit subjects' overall performance the most, however, it had little effect in improving Parkinsonian tremor, as revealed by the results of other evaluations. Conclusion Our study suggests a beneficial immediate effect of bilateral tDCS in Parkinsonian tremor suppression. In addition, we assume there may be an underlying interhemispheric unbalance of cortical excitability which contributes to Parkinsonian tremor genesis. Clinical trial registration Identifier: ChiCTR2100054804.
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Affiliation(s)
- Bin Zhang
- State Key Laboratory of Mechanical Systems and Vibrations, Robotics Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Feifei Huang
- Department of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Liu
- Department of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dingguo Zhang
- Department of Electronic and Electrical Engineering, University of Bath, Bath, United Kingdom
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6
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Standring DJ, Pigg AC, Thompson-Westra J, Mente K, Maurer CW, Haubenberger D, Hallett M, Charles SK. Distribution of tremorogenic activity among the major superficial muscles of the upper limb in persons with Essential tremor. Clin Neurophysiol 2022; 142:20-32. [PMID: 35930890 PMCID: PMC9529895 DOI: 10.1016/j.clinph.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/13/2022] [Accepted: 07/01/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Peripheral tremor suppression has the potential to reduce tremor, but we do not currently know where best to intervene. The purpose of this study was to characterize the distribution of tremorogenic activity among upper-limb muscles. METHODS Surface electromyography was recorded from the 15 major superficial muscles of the upper limb while 25 patients with Essential Tremor performed postural and kinetic tasks. We defined tremorogenic activity as power in the tremor band (4-8 Hz) and determined the distribution of this power among muscles. RESULTS The distribution varied considerably between patients (mean r = 0.58), but on average, the greatest power was found in the anterior deltoid and extensor carpi ulnaris muscles. Other muscles with high power included the extensor carpi radialis, pectoralis major, lateral deltoid, and brachialis muscles. This distribution was similar (mean r ≥ 0.88) for postural and kinetic tremor, various limb configurations, repetitions, and patient characteristics (sex, tremor severity, age of onset, and duration). CONCLUSIONS We identified a rough pattern in which muscles opposing gravity appeared to have the highest tremor-band power; we hypothesize that the distribution of tremorogenic muscle activity depends in part on the distribution of voluntary activity required by the task. SIGNIFICANCE Understanding which muscles exhibit the most tremorogenic activity is one of the steps in the pursuit of optimizing peripheral tremor suppression.
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Affiliation(s)
- David J Standring
- Mechanical Engineering, Brigham Young University, Provo, UT 84602, USA
| | - Adam C Pigg
- Mechanical Engineering, Brigham Young University, Provo, UT 84602, USA
| | - Johanna Thompson-Westra
- Clinical Trials Unit, Office of the Clinical Director, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
| | - Karin Mente
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
| | - Carine W Maurer
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
| | - Dietrich Haubenberger
- Clinical Trials Unit, Office of the Clinical Director, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
| | - Steven K Charles
- Mechanical Engineering, Brigham Young University, Provo, UT 84602, USA; Neuroscience, Brigham Young University, Provo, UT 84602, USA.
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7
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Popović‐Maneski L, Mateo S. MotiMove: Multi‐purpose transcutaneous functional electrical stimulator. Artif Organs 2022. [DOI: 10.1111/aor.14379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Sébastien Mateo
- Trajectoires Team, Lyon Neuroscience Research Center, CNRS UMR5292, INSERM U1028 Université Lyon 1, Université de Lyon Lyon France
- Plate‐forme Mouvement et Handicap Hospices Civils de Lyon, Hôpital Henry Gabrielle Lyon France
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8
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Popović-Maneski L, Došen S, Popovic MR, Azevedo C, Keller T, Ferrante S, Bergeron V, Milosevic M. TRIBUTE: Dejan B. Popović (1950-2021). Artif Organs 2022. [PMID: 35894805 DOI: 10.1111/aor.14356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Strahinja Došen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Milos R Popovic
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada.,KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada.,CRANIA, University Health Network & University of Toronto, Toronto, Ontario, Canada
| | - Christine Azevedo
- National Institute for Research in Digital Science and Technology (INRIA), CAMIN, Montpellier, France
| | - Thierry Keller
- Neuroengineering Department, TECNALIA, Basque Research and Technology Alliance (BRTA), Donostia - San Sebastian, Spain
| | - Simona Ferrante
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Vance Bergeron
- Laboratoire de Physique, Ecole normale superieure de Lyon, Lyon Cedex 07, France
| | - Matija Milosevic
- Graduate School of Engineering Science, Department of Mechanical Science and Bioengineering, Osaka University, Osaka, Japan
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9
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Rationale and Evidence for Peripheral Nerve Stimulation for Treating Essential Tremor. Tremor Other Hyperkinet Mov (N Y) 2022; 12:20. [PMID: 35949227 PMCID: PMC9205368 DOI: 10.5334/tohm.685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/08/2022] [Indexed: 01/15/2023] Open
Abstract
Background: There is growing recognition of peripheral stimulation techniques for controlling arm symptoms in essential tremor (ET). Recently, the FDA gave clearance to the Cala system, a device worn around the wrist to treat arm tremors. The Cala system stimulates the sensory afferents of the peripheral nerves with high-frequency pulses. These pulses are delivered to the median and radial nerves alternately at the tremor frequency of the individual patient. Methods: The PubMed database was searched using the terms (“Essential Tremor”[Mesh] OR “essential tremor” [Title/Abstract] OR “tremor” [Title/Abstract]) AND (“peripheral arm stimulation” [Title/Abstract] OR “Cala device” [Title/Abstract] OR “sensory afferent stimulation” [Title/Abstract] OR “afferent stimulation” [Title/Abstract] OR “arm stimulation” [Title/Abstract] OR “peripheral nerve stimulation” [Title/Abstract]). Results: The search yielded 54 articles. Many studies discussed the rationale and various strategies for peripheral modulation of tremor. While the Cala system was found to be safe and well-tolerated in ET, data on efficacy revealed mixed findings. In a large randomized, blinded trial (n = 77), the primary outcome evaluated with spiral drawing task did not improve but the secondary outcomes reflected by the arm tremor severity and the activities of the daily living score revealed 20–25% improvements. A subsequent trial (n = 323) found that the in-home use of the Cala device led to improvements of similar magnitude lasting for at least three months but the clinical assessments were open-labeled. Discussion: Peripheral stimulation techniques are promising therapeutic modalities for treating ET symptoms. Stimulation of sensory afferent nerve fibers at the wrist can potentially modulate the peripheral and central components of the tremor network. Although the Cala system is user-friendly, safe, and well-tolerated, the current clinical evidence on the efficacy is inconsistent and insufficient. Thus, more data is warranted for implementing peripheral nerve stimulation as a standard of care for ET. Highlights The current review discusses the rationale, background, and potential mechanisms for using peripheral arm stimulation devices for treating ET. The Cala system is a wrist-worn peripheral nerve stimulation device that received FDA clearance to treat arm tremors. The current review evaluates the evidence for the safety and efficacy of using the Cala system and similar devices in clinical practice.
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Zhou Y, Box D, Hardy KG, Jenkins ME, Garland J, Naish MD, Trejos AL. Survey-based identification of design requirements and constraints for a wearable tremor suppression device. J Rehabil Assist Technol Eng 2022; 9:20556683221094480. [PMID: 35548101 PMCID: PMC9083043 DOI: 10.1177/20556683221094480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/30/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Parkinsonian tremor has severely impacted the lives of 65% of individuals with Parkinson’s disease, and nearly 25% do not respond to traditional treatments. Although wearable tremor suppression devices (WTSDs) have become a promising alternative approach, this technology is still in the early stages of development, and no studies have reported the stakeholders’ opinions on this technology and their desired design requirements. Methods An online survey was distributed to affected Canadians and Canadian movement disorder specialists (MDS) to acquire information on demographics, the current state of treatments, opinions on the WTSDs, and the desired design requirements of future WTSDs. Results A total of 101 affected individuals and 24 MDS completed the survey. It was found that both groups are generally open to using WTSDs to manage tremor. The most important design requirement to end users is the adaptability to lifestyle, followed by weight and size, accurate motion, comfort, safety, quick response, and cost. Lastly, most of the participants (65%) think that the device should cost under $500. Conclusions The findings from this study can be used as guidelines for the development of future WTSDs, such that the future generations could be evaluated and accepted by the end users.
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Affiliation(s)
- Yue Zhou
- School of Biomedical Engineering, Western University, London, ON, Canada
| | - Devin Box
- School of Kinesiology, Western University, London, ON, Canada
| | - Kenneth G Hardy
- Ivey Business School, Western University, London, ON, Canada
| | - Mary E Jenkins
- Movement Disorders Program, Clinical Neurological Sciences, Western University, London, ON, Canada
| | - Jayne Garland
- Faculty of Health Sciences, Western University, London, ON, Canada
| | - Michael D Naish
- School of Biomedical Engineering, Western University, London, ON, Canada
- Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
- Department of Electrical and Computer Engineering, Western University, London, ON, Canada
| | - Ana Luisa Trejos
- School of Biomedical Engineering, Western University, London, ON, Canada
- Department of Electrical and Computer Engineering, Western University, London, ON, Canada
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11
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Fujikawa J, Morigaki R, Yamamoto N, Oda T, Nakanishi H, Izumi Y, Takagi Y. Therapeutic Devices for Motor Symptoms in Parkinson’s Disease: Current Progress and a Systematic Review of Recent Randomized Controlled Trials. Front Aging Neurosci 2022; 14:807909. [PMID: 35462692 PMCID: PMC9020378 DOI: 10.3389/fnagi.2022.807909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background Pharmacotherapy is the first-line treatment option for Parkinson’s disease, and levodopa is considered the most effective drug for managing motor symptoms. However, side effects such as motor fluctuation and dyskinesia have been associated with levodopa treatment. For these conditions, alternative therapies, including invasive and non-invasive medical devices, may be helpful. This review sheds light on current progress in the development of devices to alleviate motor symptoms in Parkinson’s disease. Methods We first conducted a narrative literature review to obtain an overview of current invasive and non-invasive medical devices and thereafter performed a systematic review of recent randomized controlled trials (RCTs) of these devices. Results Our review revealed different characteristics of each device and their effectiveness for motor symptoms. Although invasive medical devices are usually highly effective, surgical procedures can be burdensome for patients and have serious side effects. In contrast, non-pharmacological/non-surgical devices have fewer complications. RCTs of non-invasive devices, especially non-invasive brain stimulation and mechanical peripheral stimulation devices, have proven effectiveness on motor symptoms. Nearly no non-invasive devices have yet received Food and Drug Administration certification or a CE mark. Conclusion Invasive and non-invasive medical devices have unique characteristics, and several RCTs have been conducted for each device. Invasive devices are more effective, while non-invasive devices are less effective and have lower hurdles and risks. It is important to understand the characteristics of each device and capitalize on these.
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Affiliation(s)
- Joji Fujikawa
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
| | - Ryoma Morigaki
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
- *Correspondence: Ryoma Morigaki,
| | - Nobuaki Yamamoto
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
- Department of Neurology, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
| | - Teruo Oda
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
| | - Hiroshi Nakanishi
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
| | - Yuishin Izumi
- Department of Neurology, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
| | - Yasushi Takagi
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima, Japan
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12
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Puttaraksa G, Muceli S, Barsakcioglu DY, Holobar A, Clarke AK, Charles SK, Pons JL, Farina D. Online tracking of the phase difference between neural drives to antagonist muscle pairs in essential tremor patients. IEEE Trans Neural Syst Rehabil Eng 2022; 30:709-718. [PMID: 35271447 DOI: 10.1109/tnsre.2022.3158606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Transcutaneous electrical stimulation has been applied in tremor suppression applications. Out-of-phase stimulation strategies applied above or below motor threshold result in a significant attenuation of pathological tremor. For stimulation to be properly timed, the varying phase relationship between agonist-antagonist muscle activity during tremor needs to be accurately estimated in real-time. Here we propose an online tremor phase and frequency tracking technique for the customized control of electrical stimulation, based on a phase-locked loop (PLL) system applied to the estimated neural drive to muscles. Surface electromyography signals were recorded from the wrist extensor and flexor muscle groups of 13 essential tremor patients during postural tremor. The EMG signals were pre-processed and decomposed online and offline via the convolution kernel compensation algorithm to discriminate motor unit spike trains. The summation of motor unit spike trains detected for each muscle was bandpass filtered between 3 to 10 Hz to isolate the tremor related components of the neural drive to muscles. The estimated tremorogenic neural drive was used as input to a PLL that tracked the phase differences between the two muscle groups. The online estimated phase difference was compared with the phase calculated offline using a Hilbert Transform as a ground truth. The results showed a rate of agreement of 0.88 ± 0.22 between offline and online EMG decomposition. The PLL tracked the phase difference of tremor signals in real-time with an average correlation of 0.86 ± 0.16 with the ground truth (average error of 6.40° ± 3.49°). Finally, the online decomposition and phase estimation components were integrated with an electrical stimulator and applied in closed-loop on one patient, to representatively demonstrate the working principle of the full tremor suppression system. The results of this study support the feasibility of real-time estimation of the phase of tremorogenic neural drive to muscles, providing a methodology for future tremor-suppression neuroprostheses.
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13
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Kaneko N, Fok KL, Nakazawa K, Masani K. Motor point stimulation induces more robust F-waves than peripheral nerve stimulation. Eur J Neurosci 2022; 55:1614-1628. [PMID: 35178805 DOI: 10.1111/ejn.15625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 02/11/2022] [Accepted: 02/13/2022] [Indexed: 11/27/2022]
Abstract
The F-wave is a motor response induced by electrical stimulation of peripheral nerves via the antidromic firing of motor nerves, which reflects the motoneuron excitability. To induce F-waves, transcutaneous peripheral nerve stimulation (PNS) is used, which activates nerve branches via transcutaneous electrodes over the nerve branches. An alternative method to activate peripheral nerves, i.e., motor point stimulation (MPS) which delivers electrical stimulation over the muscle belly, has not been used to induce F-waves. In our previous studies, we observed that MPS induced F-wave like responses, i.e., motor responses at the latency of F-waves at a supramaximal stimulation. Here we further investigated the F-wave like responses induced by MPS in comparison to PNS in the soleus muscle. Thirteen individuals participated in this study. We applied MPS and PNS on the participant's left soleus muscle. Using a monopolar double-pulse stimulation, the amplitude of the second H-reflex induced by PNS decreased, while the amplitude of the motor response at the F-wave latency induced by MPS did not decrease. These results suggest that the motor response at the F-wave latency induced by MPS was not an H-reflex but an F-wave. We also found that the F-wave induced by MPS had a greater amplitude, higher persistence, and caused less pain when compared to the F-waves induced using PNS. We conclude that MPS evokes antidromic firing inducing F-waves more consistently compared to PNS.
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Affiliation(s)
- Naotsugu Kaneko
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada.,KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Life Sciences, Graduate School of Arts and Sciences, The University of Tokyo, Tokyo, Japan.,Japan Society for the Promotion of Science, Tokyo, Japan
| | - Kai Lon Fok
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada.,KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Kimitaka Nakazawa
- Department of Life Sciences, Graduate School of Arts and Sciences, The University of Tokyo, Tokyo, Japan
| | - Kei Masani
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada.,KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
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14
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Meng L, Jin M, Zhu X, Ming D. Peripherical Electrical Stimulation for Parkinsonian Tremor: A Systematic Review. Front Aging Neurosci 2022; 14:795454. [PMID: 35197841 PMCID: PMC8859162 DOI: 10.3389/fnagi.2022.795454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/03/2022] [Indexed: 11/30/2022] Open
Abstract
Parkinsonian tremor is one of the most common motor disorders in patients with Parkinson's disease (PD). Compared to oral medications and brain surgery, electrical stimulation approaches have emerged as effective and non-invasive methods for tremor reduction. The pathophysiology, detection and interventions of tremors have been introduced, however, a systematic review of peripherical electrical stimulation approaches, methodologies, experimental design and clinical outcomes for PD tremor suppression is still missing. Therefore, in this paper, we summarized recent studies on electrical stimulation for tremor suppression in PD patients and discussed stimulation protocols and effectiveness of different types of electrical stimulation approaches in detail. Twenty out of 528 papers published from 2010 to 2021 July were reviewed. The results show that electrical stimulation is an efficient intervention for tremor suppression. The methods fall into three main categories according to the mechanisms: namely functional electrical stimulation (FES), sensory electrical stimulation (SES) and transcutaneous electrical nerve stimulation (TENS). The outcomes of tremor suppression were varied due to various stimulation approaches, electrode locations and stimulation parameters. The FES method performed the best in tremor attenuation where the efficiency depends mainly by the control strategy and accuracy of tremor detection. However, the mechanism underlying tremor suppression with SES and TENS, is not well-known. Current electrical stimulation approaches may only work for a number of patients. The potential mechanism of tremor suppression still needs to be further explored.
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Affiliation(s)
- Lin Meng
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Mengyue Jin
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Xiaodong Zhu
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
- Xiaodong Zhu
| | - Dong Ming
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
- Department of Biomedical Engineering, Tianjin University, Tianjin, China
- *Correspondence: Dong Ming
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15
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Pascual-Valdunciel A, Rajagopal A, Pons JL, Delp S. Non-invasive electrical stimulation of peripheral nerves for the management of tremor. J Neurol Sci 2022; 435:120195. [PMID: 35220113 PMCID: PMC9590374 DOI: 10.1016/j.jns.2022.120195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/06/2021] [Accepted: 02/17/2022] [Indexed: 12/22/2022]
Abstract
Pathological tremor in patients with essential tremor and Parkinsons disease is typically treated using medication or neurosurgical interventions. There is a widely recognized need for new treatments that avoid the side effects of current medications and do not carry the risks of surgical interventions. Building on decades of research and engineering development, non-invasive electrical stimulation of peripheral nerves has emerged as a safe and effective strategy for reducing pathologic tremor in essential tremor. This review surveys the peripheral electrical stimulation (PES) literature and summarizes effectiveness, safety, clinical translatability, and hypothesized tremor-reduction mechanisms of various PES approaches. The review also proposes guidelines for assessing tremor in the context of evaluating new therapies that combine the strengths of clinician assessments, patient evaluations, and novel motion sensing technology. The review concludes with a summary of future directions for PES, including expanding clinical access for patients with Parkinson's disease and leveraging large, at-home datasets to learn more about tremor physiology and treatment effect that will better characterize the state of tremor management and accelerate discovery of new therapies. Growing evidence suggests that non-invasive electrical stimulation of afferent neural pathways provides a viable new option for management of pathological tremor, with one specific PES therapy cleared for prescription and home use, suggesting that PES be considered along with medication and neurosurgical interventions for treatment of tremor. This article is part of the Special Issue "Tremor" edited by Daniel D. Truong, Mark Hallett, and Aasef Shaikh.
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Affiliation(s)
- Alejandro Pascual-Valdunciel
- Northwestern University, Evanston, IL, USA; E.T.S. Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Spain
| | | | - Jose L Pons
- Northwestern University, Evanston, IL, USA; Shirley Ryan AbilityLab, Chicago, IL, USA.
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16
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Arruda BS, Reis C, Sermon JJ, Pogosyan A, Brown P, Cagnan H. Identifying and modulating distinct tremor states through peripheral nerve stimulation in Parkinsonian rest tremor. J Neuroeng Rehabil 2021; 18:179. [PMID: 34953492 PMCID: PMC8709974 DOI: 10.1186/s12984-021-00973-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Resting tremor is one of the most common symptoms of Parkinson's disease. Despite its high prevalence, resting tremor may not be as effectively treated with dopaminergic medication as other symptoms, and surgical treatments such as deep brain stimulation, which are effective in reducing tremor, have limited availability. Therefore, there is a clinical need for non-invasive interventions in order to provide tremor relief to a larger number of people with Parkinson's disease. Here, we explore whether peripheral nerve stimulation can modulate resting tremor, and under what circumstances this might lead to tremor suppression. METHODS We studied 10 people with Parkinson's disease and rest tremor, to whom we delivered brief electrical pulses non-invasively to the median nerve of the most tremulous hand. Stimulation was phase-locked to limb acceleration in the axis with the biggest tremor-related excursion. RESULTS We demonstrated that rest tremor in the hand could change from one pattern of oscillation to another in space. Median nerve stimulation was able to significantly reduce (- 36%) and amplify (117%) tremor when delivered at a certain phase. When the peripheral manifestation of tremor spontaneously changed, stimulation timing-dependent change in tremor severity could also alter during phase-locked peripheral nerve stimulation. CONCLUSIONS These results highlight that phase-locked peripheral nerve stimulation has the potential to reduce tremor. However, there can be multiple independent tremor oscillation patterns even within the same limb. Parameters of peripheral stimulation such as stimulation phase may need to be adjusted continuously in order to sustain systematic suppression of tremor amplitude.
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Affiliation(s)
- Beatriz S Arruda
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Mansfield Road, Oxford, OX1 3TH, UK
| | - Carolina Reis
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Mansfield Road, Oxford, OX1 3TH, UK
| | - James J Sermon
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Mansfield Road, Oxford, OX1 3TH, UK
| | - Alek Pogosyan
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Mansfield Road, Oxford, OX1 3TH, UK
| | - Peter Brown
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Mansfield Road, Oxford, OX1 3TH, UK
| | - Hayriye Cagnan
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Mansfield Road, Oxford, OX1 3TH, UK.
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17
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Phokaewvarangkul O, Vateekul P, Wichakam I, Anan C, Bhidayasiri R. Using Machine Learning for Predicting the Best Outcomes With Electrical Muscle Stimulation for Tremors in Parkinson's Disease. Front Aging Neurosci 2021; 13:727654. [PMID: 34566628 PMCID: PMC8461308 DOI: 10.3389/fnagi.2021.727654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022] Open
Abstract
Recent studies have identified that peripheral stimulation in Parkinson’s disease (PD) is effective in tremor reduction, indicating that a peripheral feedback loop plays an important role in the tremor reset mechanism. This was an open-label, quasi-experimental, pre- and post-test design, single-blind, single-group study involving 20 tremor-dominant PD patients. The objective of this study is to explore the effect of electrical muscle stimulation (EMS) as an adjunctive treatment for resting tremor during “on” period and to identify the best machine learning model to predict the suitable stimulation level that will yield the longest period of tremor reduction or tremor reset time. In this study, we used a Parkinson’s glove to evaluate, stimulate, and quantify the tremors of PD patients. This adjustable glove incorporates a 3-axis gyroscope to measure tremor signals and an EMS to provide an on-demand muscle stimulation to suppress tremors. Machine learning models were applied to identify the suitable pulse amplitude (stimulation level) in five classes that led to the longest tremor reset time. The study was registered at the www.clinicaltrials.gov under the name “The Study of Rest Tremor Suppression by Using Electrical Muscle Stimulation” (NCT02370108). Twenty tremor-dominant PD patients were recruited. After applying an average pulse amplitude of 6.25 (SD 2.84) mA and stimulation period of 440.7 (SD 560.82) seconds, the total time of tremor reduction, or tremor reset time, was 329.90 (SD 340.91) seconds. A significant reduction in tremor parameters during stimulation was demonstrated by a reduction of Unified Parkinson’s Disease Rating Scale (UPDRS) scores, and objectively, with a reduction of gyroscopic data (p < 0.05, each). None of the subjects reported any serious adverse events. We also compared gyroscopic data with five machine learning techniques: Logistic Regression, Random Forest, Support Vector Machine (SVM), Neural Network (NN), and Long-Short-Term-Memory (LSTM). The machine learning model that gave the highest accuracy was LSTM, which obtained: accuracy = 0.865 and macro-F1 = 0.736. This study confirms the efficacy of EMS in the reduction of resting tremors in PD. LSTM was identified as the most effective model for predicting pulse amplitude that would elicit the longest tremor reset time. Our study provides further insight on the tremor reset mechanism in PD.
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Affiliation(s)
- Onanong Phokaewvarangkul
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Peerapon Vateekul
- Department of Computer Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Itsara Wichakam
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chanawat Anan
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Roongroj Bhidayasiri
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,The Academy of Science, The Royal Society of Thailand, Bangkok, Thailand
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18
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Essential tremor amplitude modulation by median nerve stimulation. Sci Rep 2021; 11:17720. [PMID: 34489503 PMCID: PMC8421420 DOI: 10.1038/s41598-021-96660-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 08/05/2021] [Indexed: 11/08/2022] Open
Abstract
Essential tremor is a common neurological disorder, characterised by involuntary shaking of a limb. Patients are usually treated using medications which have limited effects on tremor and may cause side-effects. Surgical therapies are effective in reducing essential tremor, however, the invasive nature of these therapies together with the high cost, greatly limit the number of patients benefiting from them. Non-invasive therapies have gained increasing traction to meet this clinical need. Here, we test a non-invasive and closed-loop electrical stimulation paradigm which tracks peripheral tremor and targets thalamic afferents to modulate the central oscillators underlying tremor. To this end, 9 patients had electrical stimulation delivered to the median nerve locked to different phases of tremor. Peripheral stimulation induced a subtle but significant modulation in five out of nine patients-this modulation consisted mainly of amplification rather than suppression of tremor amplitude. Modulatory effects of stimulation were more pronounced when patient's tremor was spontaneously weaker at stimulation onset, when significant modulation became more frequent amongst subjects. This data suggests that for selected individuals, a more sophisticated control policy entailing an online estimate of both tremor phase and amplitude, should be considered in further explorations of the treatment potential of tremor phase-locked peripheral stimulation.
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19
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Lora-Millan JS, Delgado-Oleas G, Benito-León J, Rocon E. A Review on Wearable Technologies for Tremor Suppression. Front Neurol 2021; 12:700600. [PMID: 34434161 PMCID: PMC8380769 DOI: 10.3389/fneur.2021.700600] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/28/2021] [Indexed: 12/29/2022] Open
Abstract
Tremor is defined as a rhythmic, involuntary oscillatory movement of a body part. Although everyone exhibits a certain degree of tremor, some pathologies lead to very disabling tremors. These pathological tremors constitute the most prevalent movement disorder, and they imply severe difficulties in performing activities of daily living. Although tremors are currently managed through pharmacotherapy or surgery, these treatments present significant associated drawbacks: drugs often induce side effects and show decreased effectiveness over years of use, while surgery is a hazardous procedure for a very low percentage of eligible patients. In this context, recent research demonstrated the feasibility of managing upper limb tremors through wearable technologies that suppress tremors by modifying limb biomechanics or applying counteracting forces. Furthermore, recent experiments with transcutaneous afferent stimulation showed significant tremor attenuation. In this regard, this article reviews the devices developed following these tremor management paradigms, such as robotic exoskeletons, soft robotic exoskeletons, and transcutaneous neurostimulators. These works are presented, and their effectiveness is discussed. The article also evaluates the different metrics used for the validation of these devices and the lack of a standard validation procedure that allows the comparison among them.
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Affiliation(s)
- Julio S. Lora-Millan
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas – Universidad Politécnica de Madrid, Madrid, Spain
| | - Gabriel Delgado-Oleas
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas – Universidad Politécnica de Madrid, Madrid, Spain
- Ingeniería Electrónica, Universidad del Azuay, Cuenca, Ecuador
| | - Julián Benito-León
- Department of Neurology, University Hospital “12 de Octubre”, Madrid, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Madrid, Spain
- Department of Medicine, Complutense University, Madrid, Spain
| | - Eduardo Rocon
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas – Universidad Politécnica de Madrid, Madrid, Spain
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20
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Mo J, Priefer R. Medical Devices for Tremor Suppression: Current Status and Future Directions. BIOSENSORS-BASEL 2021; 11:bios11040099. [PMID: 33808056 PMCID: PMC8065649 DOI: 10.3390/bios11040099] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 01/14/2023]
Abstract
Tremors are the most prevalent movement disorder that interferes with the patient’s daily living, and physical activities, ultimately leading to a reduced quality of life. Due to the pathophysiology of tremor, developing effective pharmacotherapies, which are only suboptimal in the management of tremor, has many challenges. Thus, a range of therapies are necessary in managing this progressive, aging-associated disorder. Surgical interventions such as deep brain stimulation are able to provide durable tremor control. However, due to high costs, patient and practitioner preference, and perceived high risks, their utilization is minimized. Medical devices are placed in a unique position to bridge this gap between lifestyle interventions, pharmacotherapies, and surgical treatments to provide safe and effective tremor suppression. Herein, we review the mechanisms of action, safety and efficacy profiles, and clinical applications of different medical devices that are currently available or have been previously investigated for tremor suppression. These devices are primarily noninvasive, which can be a beneficial addition to the patient’s existing pharmacotherapy and/or lifestyle intervention.
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21
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Pascual-Valdunciel A, Hoo GW, Avrillon S, Barroso FO, Goldman JG, Hernandez-Pavon JC, Pons JL. Peripheral electrical stimulation to reduce pathological tremor: a review. J Neuroeng Rehabil 2021; 18:33. [PMID: 33588841 PMCID: PMC7885254 DOI: 10.1186/s12984-021-00811-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/11/2021] [Indexed: 01/02/2023] Open
Abstract
Interventions to reduce tremor in essential tremor (ET) and Parkinson’s disease (PD) clinical populations often utilize pharmacological or surgical therapies. However, there can be significant side effects, decline in effectiveness over time, or clinical contraindications for these interventions. Therefore, alternative approaches must be considered and developed. Some non-pharmacological strategies include assistive devices, orthoses and mechanical loading of the tremorgenic limb, while others propose peripheral electrical stimulation. Specifically, peripheral electrical stimulation encompasses strategies that activate motor and sensory pathways to evoke muscle contractions and impact sensorimotor function. Numerous studies report the efficacy of peripheral electrical stimulation to alter tremor generation, thereby opening new perspectives for both short- and long-term tremor reduction. Therefore, it is timely to explore this promising modality in a comprehensive review. In this review, we analyzed 27 studies that reported the use of peripheral electrical stimulation to reduce tremor and discuss various considerations regarding peripheral electrical stimulation: the stimulation strategies and parameters, electrodes, experimental designs, results, and mechanisms hypothesized to reduce tremor. From our review, we identified a high degree of disparity across studies with regard to stimulation patterns, experimental designs and methods of assessing tremor. Having standardized experimental methodology is a critical step in the field and is needed in order to accurately compare results across studies. With this review, we explore peripheral electrical stimulation as an intervention for tremor reduction, identify the limitations and benefits of the current state-of-the-art studies, and provide ideas to guide the development of novel approaches based on the neural circuitries and mechanical properties implied in tremor generation.
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Affiliation(s)
- Alejandro Pascual-Valdunciel
- Neural Rehabilitation Group, Cajal Institute, Spanish National Research Council (CSIC), Madrid, Spain.,E.T.S. Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Grace W Hoo
- Legs + Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, 60611, USA
| | - Simon Avrillon
- Legs + Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, 60611, USA.,Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Filipe Oliveira Barroso
- Neural Rehabilitation Group, Cajal Institute, Spanish National Research Council (CSIC), Madrid, Spain
| | - Jennifer G Goldman
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Parkinson's Disease and Movement Disorders, Shirley Ryan AbilityLab, Chicago, IL, USA.,Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Julio C Hernandez-Pavon
- Legs + Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, 60611, USA.,Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - José L Pons
- Legs + Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, 60611, USA. .,Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Department of Biomedical Engineering and Mechanical Engineering, McCormick School of Engineering, Northwestern University, Chicago, IL, USA.
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22
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Kang N. Quantitative Evidence of Pathological Tremor Suppression after Functional Electrical Stimulation. IRANIAN JOURNAL OF PUBLIC HEALTH 2020; 49:2428-2430. [PMID: 34178753 PMCID: PMC8215052 DOI: 10.18502/ijph.v49i12.4835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Nyeonju Kang
- Division of Sport Science & Sport Science Institute, Incheon National University, Incheon, South Korea
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23
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Pigg AC, Thompson-Westra J, Mente K, Maurer CW, Haubenberger D, Hallett M, Charles SK. Distribution of tremor among the major degrees of freedom of the upper limb in subjects with Essential Tremor. Clin Neurophysiol 2020; 131:2700-2712. [PMID: 33010725 DOI: 10.1016/j.clinph.2020.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 07/06/2020] [Accepted: 08/06/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Although Essential Tremor is one of the most common movement disorders, we do not currently know which muscles are most responsible for tremor. Determining this requires multiple steps, one of which is characterizing the distribution of tremor among the degrees of freedom (DOF) of the upper limb. METHODS Upper-limb motion was recorded while 22 subjects with ET performed postural and kinetic tasks involving a variety of limb configurations. We calculated the mean distribution of tremor among the seven DOF from the shoulder to the wrist, as well as the effect of limb configuration, repetition, and subject characteristics (sex, tremor onset, duration, and severity) on the distribution. RESULTS On average, kinetic tremor was greatest in forearm pronation-supination and wrist flexion-extension, intermediate in shoulder internal-external rotation and wrist radial-ulnar deviation and then shoulder flexion-extension and elbow flexion-extension, and least in shoulder abduction-adduction. The average distribution of postural tremor was similar except for forearm pronation-supination, which played a smaller role than in kinetic tremor. Limb configuration and subject characteristics did significantly affect tremor, but practically only in forearm pronation-supination and wrist flexion-extension. There were no significant differences between repetitions, indicating that the distribution was consistent over the duration of the experiment. CONCLUSIONS This paper presents a thorough characterization of tremor distribution from the shoulder to the wrist. SIGNIFICANCE Understanding which DOF exhibit the most tremor may lead to more targeted peripheral tremor suppression.
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Affiliation(s)
- Adam C Pigg
- Mechanical Engineering, Brigham Young University, Provo, UT 84602, USA
| | - Johanna Thompson-Westra
- Clinical Trials Unit, Office of the Clinical Director, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
| | - Karin Mente
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
| | - Carine W Maurer
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
| | - Dietrich Haubenberger
- Clinical Trials Unit, Office of the Clinical Director, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
| | - Steven K Charles
- Mechanical Engineering, Brigham Young University, Provo, UT 84602, USA; Neuroscience, Brigham Young University, Provo, UT 84602, USA.
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24
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SHAH VRUTANGKUMARV, GOYAL SACHIN, PALANTHANDALAM-MADAPUSI HARISHJ. COMPARISON OF THEORIES OF REST TREMOR MECHANISM IN PARKINSON’S DISEASE: CENTRAL OSCILLATOR (SOURCE-TRIGGERED OSCILLATIONS) AND FEEDBACK-INDUCED INSTABILITY IN THE SENSORIMOTOR LOOP (SELF-SUSTAINED OSCILLATIONS). J MECH MED BIOL 2020. [DOI: 10.1142/s0219519419500751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Rest tremor is one of the most common and disabling symptoms of Parkinson’s disease (PD). The exact neural origin of rest tremor is still not clearly understood. Understanding the origin of rest tremor is important as it may aid in optimizing existing treatment strategies such as Deep Brain Stimulation or in developing new treatment strategies for rest tremor reduction. There are broadly two theories that are gaining prominence for rest tremor generation in PD. The first theory is the central oscillator theory that states that the rest tremor is triggered by an oscillatory source in the brain. The second theory is the feedback-induced instability theory that states that the rest tremor arises out of a feedback-induced instability in the sensorimotor loop. This paper analyzes validity of the two theories based on established clinical observations of Parkinsonian rest tremor by using representative simulation examples. Finally, based on our analysis, we propose two test-worthy experiments for further validation.
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Affiliation(s)
- VRUTANGKUMAR V. SHAH
- Balance Disorder Lab, Department of Neurology, Oregon Health and Science University, OR 97239, USA
- SysIDEA Lab, Mechanical Engineering, Indian Institute of Technology Gandhinagar, Gandhinagar, GJ-382355, India
| | - SACHIN GOYAL
- Department of Mechanical Engineering, Health Science Research Institute, University of California, Merced, CA-95343, USA
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25
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Shahtalebi S, Atashzar SF, Samotus O, Patel RV, Jog MS, Mohammadi A. PHTNet: Characterization and Deep Mining of Involuntary Pathological Hand Tremor using Recurrent Neural Network Models. Sci Rep 2020; 10:2195. [PMID: 32042111 PMCID: PMC7010677 DOI: 10.1038/s41598-020-58912-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/17/2020] [Indexed: 12/04/2022] Open
Abstract
The global aging phenomenon has increased the number of individuals with age-related neurological movement disorders including Parkinson's Disease (PD) and Essential Tremor (ET). Pathological Hand Tremor (PHT), which is considered among the most common motor symptoms of such disorders, can severely affect patients' independence and quality of life. To develop advanced rehabilitation and assistive technologies, accurate estimation/prediction of nonstationary PHT is critical, however, the required level of accuracy has not yet been achieved. The lack of sizable datasets and generalizable modeling techniques that can fully represent the spectrotemporal characteristics of PHT have been a critical bottleneck in attaining this goal. This paper addresses this unmet need through establishing a deep recurrent model to predict and eliminate the PHT component of hand motion. More specifically, we propose a machine learning-based, assumption-free, and real-time PHT elimination framework, the PHTNet, by incorporating deep bidirectional recurrent neural networks. The PHTNet is developed over a hand motion dataset of 81 ET and PD patients collected systematically in a movement disorders clinic over 3 years. The PHTNet is the first intelligent systems model developed on this scale for PHT elimination that maximizes the resolution of estimation and allows for prediction of future and upcoming sub-movements.
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Affiliation(s)
- Soroosh Shahtalebi
- Concordia Institute for Information Systems Engineering, Concordia University, Montreal, H3G 1M8, QC, Canada
| | - Seyed Farokh Atashzar
- Departments of Electrical and Computer Engineering, and Mechanical and Aerospace Engineering, New York University, New York, 10003, NY, USA
- NYU WIRELESS center, New York University (NYU), New York, USA
| | - Olivia Samotus
- London Movement Disorders Centre, London Health Sciences Centre, London, ON, Canada
| | - Rajni V Patel
- Department of Electrical and Computer Engineering, University of Western Ontario, London, N6A 5B9, ON, Canada
| | - Mandar S Jog
- London Movement Disorders Centre, London Health Sciences Centre, London, ON, Canada
| | - Arash Mohammadi
- Concordia Institute for Information Systems Engineering, Concordia University, Montreal, H3G 1M8, QC, Canada.
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26
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Castrillo-Fraile V, Peña EC, Gabriel Y Galán JMT, Delgado-López PD, Collazo C, Cubo E. Tremor Control Devices for Essential Tremor: A Systematic Literature Review. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2019; 9:tre-09-688. [PMID: 31867136 PMCID: PMC6898897 DOI: 10.7916/tohm.v0.688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 11/04/2019] [Indexed: 12/01/2022]
Abstract
Background There is a growing interest in nonpharmacological approaches for essential tremor (ET), including tremor cancelation devices. However, the true efficacy of such devices in ET remains unclear. Methods A systematic literature review was conducted using standardized criteria regarding efficacy and comfortability. Devices focused on design or experimental testing in which tremor was simulated in a robot were excluded. Results Out of 324 articles initially identified, 12 articles were included. Orthoses using biomechanical loading and neuromodulation with electrical stimulation, and external tremor cancelation devices, were the main interventions used to suppress tremor. All devices were designed to control tremor of the upper limbs at different anatomical locations. Overall, an average tremor attenuation of 50–98% was reported (level of evidence III). Interference with voluntary movements and portability was described as the main drawback. Discussion In conclusion, this review highlights the growing interest in emerging tremor control devices and the importance of assessing comfort without affecting voluntary movements. However, the level of evidence regarding the efficacy of these tremor control devices remains low. An integrated multidisciplinary combination approach of engineering, robotics, physiology, physiotherapy, and clinical assessment is needed to improve the quality of non-pharmacological interventions for ET.
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Affiliation(s)
- Victoria Castrillo-Fraile
- Department of Rehabilitation, Burgos University Hospital, Burgos, ES.,Department of Health Science, University of Valladolid, Valladolid, ES
| | | | | | | | - Carla Collazo
- Department of Health Science, University of Burgos, Burgos, ES
| | - Esther Cubo
- Department of Neurology, Burgos University Hospital, Burgos, ES.,Department of Health Science, University of Burgos, Burgos, ES
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Puttaraksa G, Muceli S, Gallego JÁ, Holobar A, Charles SK, Pons JL, Farina D. Voluntary and tremorogenic inputs to motor neuron pools of agonist/antagonist muscles in essential tremor patients. J Neurophysiol 2019; 122:2043-2053. [PMID: 31509467 PMCID: PMC6998026 DOI: 10.1152/jn.00407.2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pathological tremor is an oscillation of body parts at 3–10 Hz, determined by the output of spinal motor neurons (MNs), which receive synaptic inputs from supraspinal centers and muscle afferents. The behavior of spinal MNs during tremor is not well understood, especially in relation to the activation of the multiple muscles involved. Recent studies on patients with essential tremor have shown that antagonist MN pools receive shared input at the tremor frequency. In this study, we investigated the synaptic inputs related to tremor and voluntary movement, and their coordination across antagonist muscles. We analyzed the spike trains of motor units (MUs) identified from high-density surface electromyography from the forearm extensor and flexor muscles in 15 patients with essential tremor during postural tremor. The shared synaptic input was quantified by coherence and phase difference analysis of the spike trains. All pairs of spike trains in each muscle showed coherence peaks at the voluntary drive frequency (1–3 Hz, 0.2 ± 0.2, mean ± SD) and tremor frequency (3–10 Hz, 0.6 ± 0.3) and were synchronized with small phase differences (3.3 ± 25.2° and 3.9 ± 22.0° for the voluntary drive and tremor frequencies, respectively). The coherence between MN spike trains of antagonist muscle groups at the tremor frequency was significantly smaller than intramuscular coherence. We predominantly observed in-phase activation of MUs between agonist/antagonist muscles at the voluntary frequency band (0.6 ± 48.8°) and out-of-phase activation at the tremor frequency band (126.9 ± 75.6°). Thus MNs innervating agonist/antagonist muscles concurrently receive synaptic inputs with different phase shifts in the voluntary and tremor frequency bands. NEW & NOTEWORTHY Although the mechanical characteristics of tremor have been widely studied, the activation of the affected muscles is still poorly understood. We analyzed the behavior of motor units of pairs of antagonistic wrist muscle groups in patients with essential tremor and studied their activity at voluntary movement- and tremor-related frequencies. We found that the phase relation between inputs to antagonistic muscles is different at the voluntary and tremor frequency bands.
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Affiliation(s)
| | - Silvia Muceli
- Department of Bioengineering, Imperial College London, London, United Kingdom.,Division of Signal Processing and Biomedical Engineering, Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Juan Álvaro Gallego
- Neural and Cognitive Engineering Group, Centre for Automation and Robotics, Spanish National Research Council, Arganda del Rey, Spain
| | - Ales Holobar
- Faculty of Electrical Engineering and Computer Science, University of Maribor, Maribor, Slovenia
| | - Steven K Charles
- Department of Mechanical Engineering and Neuroscience Center, Brigham Young University, Provo, Utah
| | - Jose L Pons
- Legs & Walking AbilityLab, Shirley Ryan AbilityLab, Chicago, Illinois.,Department of Physical Medicine & Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Biomedical Engineering and Department of Mechanical Engineering, McCormick School of Engineering, Northwestern University, Chicago, Illinois.,Neural Rehabilitation Group, Cajal Institute, Spanish National Research Council, Madrid, Spain
| | - Dario Farina
- Department of Bioengineering, Imperial College London, London, United Kingdom
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ALLEN BRENDONC, CHARLES STEVENK. EFFECT OF GYROSCOPE PARAMETERS ON GYROSCOPIC TREMOR SUPPRESSION IN A SINGLE DEGREE OF FREEDOM. J MECH MED BIOL 2019. [DOI: 10.1142/s0219519419500246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although tremor is one of the most common movement disorders, there are few effective tremor-suppressing options available to patients. Gyrostabilization is a potential option, but we do not currently know how to optimize gyrostabilization for tremor suppression. To address this gap, we present a systematic investigation of how gyrostabilizer parameters affect tremor suppression in a single degree of freedom (DOF). A simple model with a single DOF at the wrist and a gyroscope mounted on the back of the hand was used to focus on the most basic effects. We simulated the frequency response of the system (hand + gyroscope) to a tremorogenic input torque at the wrist. Varying system parameters one at a time, we determined the effect of individual parameters on the system’s frequency response. To minimize the bandwidth without adding significant inertia, the inertia and spin speed of the flywheel should be as high as design constraints allow, whereas the distance from the wrist joint axis to the gyroscope and the precession stiffness and damping should be kept as low as possible. The results demonstrate the potential of gyroscopic tremor suppression and can serve as foundation for further investigations of gyroscopic tremor suppression in the upper limb.
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Affiliation(s)
- BRENDON C. ALLEN
- Mechanical Engineering, Brigham Young University, 350 EB, Provo, UT 84602, USA
| | - STEVEN K. CHARLES
- Mechanical Engineering and Neuroscience, Brigham Young University, 350 EB, Provo, UT 84602, USA
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29
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Hu Z, Xu S, Hao M, Xiao Q, Lan N. The impact of evoked cutaneous afferents on voluntary reaching movement in patients with Parkinson’s disease. J Neural Eng 2019; 16:036029. [DOI: 10.1088/1741-2552/ab186f] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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30
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Corie TH, Charles S. Simulated Tremor Propagation in the Upper Limb: From Muscle Activity to Joint Displacement. J Biomech Eng 2019; 141:2730753. [PMID: 30964940 DOI: 10.1115/1.4043442] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Indexed: 12/19/2022]
Abstract
Although tremor is the most common movement disorder, there are few non-invasive treatment options. Creating effective tremor suppression devices requires a knowledge of where tremor originates mechanically (which muscles) and how it propagates through the limb (to which degrees of freedom, DOF). To simulate tremor propagation, we created a simple model of the upper limb, with tremorogenic activity in the 15 major superficial muscles as inputs and tremulous joint displacement in the 7 major DOF as outputs. The model approximated the muscle excitation-contraction dynamics, musculoskeletal geometry, and mechanical impedance of the limb. From our simulations, we determined fundamental principles for tremor propagation: 1) The distribution of tremor depends strongly on musculoskeletal dynamics. 2) The spreading of tremor is due to inertial coupling (primarily) and musculoskeletal geometry (secondarily). 3) Tremorogenic activity in a given muscle causes significant tremor in only a small subset of DOF, though these affected DOF may be distant from the muscle. 4) Assuming uniform distribution of tremorogenic activity among muscles, tremor increases proximal-distally, and the contribution from muscles increases proximal-distally. 5) Although adding inertia (e.g. with weighted utensils) is often used to suppress tremor, it is possible to increase tremor by adding inertia to the wrong DOF. 6) Similarly, adding viscoelasticity to the wrong DOF can increase tremor. Based solely on the musculoskeletal system, these principles indicate that tremor treatments targeting muscles should focus first on the distal muscles, and devices targeting DOF should focus first on the distal DOF.
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Affiliation(s)
| | - Steven Charles
- Mechanical Engineering, Neuroscience, Brigham Young University
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31
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Herrnstadt G, McKeown MJ, Menon C. Controlling a motorized orthosis to follow elbow volitional movement: tests with individuals with pathological tremor. J Neuroeng Rehabil 2019; 16:23. [PMID: 30709409 PMCID: PMC6359763 DOI: 10.1186/s12984-019-0484-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 01/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a need for alternative treatment options for tremor patients who do not respond well to medications or surgery, either due to side effects or poor efficacy, or that are excluded from surgery. The study aims to evaluate feasibility of a voluntary-driven, speed-controlled tremor rejection approach with individuals with pathological tremor. The suppression approach was investigated using a robotic orthosis for suppression of elbow tremor. Importantly, the study emphasizes the performance in relation to the voluntary motion. METHODS Nine participants with either Essential Tremor (ET) or Parkinson's disease (PD) were recruited and tested off medication. The participants performed computerized pursuit tracking tasks following a sinusoid and a random target, both with and without the suppressive orthosis. The impact of the Tremor Suppression Orthosis (TSO) at the tremor and voluntary frequencies was determined by the relative power change calculated from the Power Spectral Density (PSD). Voluntary motion was, in addition, assessed by position and velocity tracking errors. RESULTS The suppressive orthosis resulted in a 94.4% mean power reduction of the tremor (p < 0.001) - a substantial improvement over reports in the literature. As for the impact to the voluntary motion, paired difference tests revealed no statistical effect of the TSO on the relative power change (p = 0.346) and velocity tracking error (p = 0.283). A marginal effect was observed for the position tracking error (p = 0.05). The interaction torque with the robotic orthosis was small (0.62 Nm) when compared to the maximum voluntary torque that can be exerted by adult individuals at the elbow joint. CONCLUSIONS Two key contributions of this work are first, a recently proposed approach is evaluated with individuals with tremor demonstrating high levels of tremor suppression; second, the impact of the approach to the voluntary motion is analyzed comprehensively, showing limited inhibition. This study also seeks to address a gap in studies with individuals with tremor where the impact of engineering solutions on voluntary motion is unreported. This study demonstrates feasibility of the wearable technology as an effective treatment that removes tremor with limited impediment to intentional motion. The goal for such wearable technology is to help individuals with pathological tremor regain independence in activities affected by the tremor condition. Further investigations are needed to validate the technology.
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Affiliation(s)
- Gil Herrnstadt
- Menrva Research Group, Schools of Mechatronic Systems Engineering and Engineering Science, Simon Fraser University, Burnaby, Canada
| | - Martin J McKeown
- Department of Medicine (Neurology) and Pacific Parkinson's Research Centre, University of British Columbia, Vancouver, Canada
| | - Carlo Menon
- Menrva Research Group, Schools of Mechatronic Systems Engineering and Engineering Science, Simon Fraser University, Burnaby, Canada.
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Caba V, Borgese L, Agnelli S, Depero LE. A green and simple process to develop conductive polyurethane foams for biomedical applications. INT J POLYM MATER PO 2018. [DOI: 10.1080/00914037.2018.1525732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Valentina Caba
- INSTM and Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Laura Borgese
- INSTM and Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Silvia Agnelli
- INSTM and Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Laura E. Depero
- INSTM and Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
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HEO JAEHOON, JEON HYEONGMIN, CHOI EUIBUM, KWON DOYOUNG, EOM GWANGMOON. CONTINUOUS SENSORY ELECTRICAL STIMULATION FOR THE SUPPRESSION OF PARKINSONIAN REST TREMOR. J MECH MED BIOL 2018. [DOI: 10.1142/s0219519418400067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This paper aims to investigate the effect of continuous sensory electrical stimulation (SES) on the suppression of a Parkinsonian rest tremor. Fourteen patients with Parkinson’s disease participated in this study. Three wrist muscles were electrically stimulated on sensory level under motor threshold. Intensity of stimulation was determined for each muscle of each patient as the maximum tolerable current amplitude that does not induce muscle contraction. Tri-axial gyro sensors were attached to three upper limb segments. The angular velocity of each segment was measured for each of the three sessions, i.e., PRE-, ON- and POST- stimulations. Outcome measures were the tremor amplitude and main frequency of each axis in the power spectrum. Decrease in tremor amplitude was significant at ON and POST sessions in finger and at POST session in hand and forearm. Decrease in main frequency was significant mainly at ON session. About one-third of patients showed reduction in tremor power at ON-stimulation and at POST-stimulation. Subjects with suppression of tremor showed greater initial tremor amplitude than those without suppression. Continuous SES suppressed the Parkinsonian rest tremor. The results suggest that the properties of tremor-generating loop may be altered by continuous SES and the effect lasts temporarily.
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Affiliation(s)
- JAE-HOON HEO
- School of Biomedical Engineering, Konkuk University, Chungju 27478, Korea
| | - HYEONG-MIN JEON
- School of Biomedical Engineering, Konkuk University, Chungju 27478, Korea
| | - EUI-BUM CHOI
- School of Biomedical Engineering, Konkuk University, Chungju 27478, Korea
| | - DO-YOUNG KWON
- Department of Neurology, College of Medicine, Korea University, Ansan 15355, Korea
| | - GWANG-MOON EOM
- School of Biomedical Engineering, Konkuk University, Chungju 27478, Korea
- BK21plus Research Institute of Biomedical Engineering, Konkuk University, Chungju, Korea
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34
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Zhou Y, Jenkins ME, Naish MD, Trejos AL. Characterization of Parkinsonian Hand Tremor and Validation of a High-Order Tremor Estimator. IEEE Trans Neural Syst Rehabil Eng 2018; 26:1823-1834. [PMID: 30047891 DOI: 10.1109/tnsre.2018.2859793] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent progress in wearable technology has made wearable tremor suppression devices (WTSDs) for Parkinson's patients a potentially viable alternative solution for tremor management. So far, in contrast to wrist and elbow tremor, finger tremors have not been studied in depth despite the huge impact that they have on a patient's daily life. In addition, more evidence has been found showing that the performance of current tremor estimators may be limited by their model order due to the multiple harmonics present in tremor. The aim of this paper is to characterize finger and wrist tremor in both the time and frequency domains, and to propose a high-order tremor estimation algorithm. Tremor magnitudes are reported in the forms of linear acceleration, angular velocity, and angular displacement. The activation of forearm flexor and extensor muscles is also investigated. The frequency analysis shows that Parkinsonian tremors produce oscillations of the hand with pronounced harmonics. At last, a high-order weighted-frequency Fourier linear combiner (WFLC)-based Kalman filter is proposed. The percentage estimation accuracy achieved from the proposed estimator is 96.3 ± 1.7%, showing average improvements of 28.5% and 48.9% over its lower-order counterpart and the WFLC. The proposed estimator shows promise for use in a WTSD.
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Abbasi M, Afsharfard A, Arasteh R, Safaie J. Design of a noninvasive and smart hand tremor attenuation system with active control: a simulation study. Med Biol Eng Comput 2018; 56:1315-1324. [PMID: 29297138 DOI: 10.1007/s11517-017-1769-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 12/13/2017] [Indexed: 11/30/2022]
Abstract
This paper presents the design and simulation of a handheld device for people with hand tremor, such as Parkinson's and essential tremor patients. This device can be used as a pen for smartphones or as a spoon. The designed system includes two links, which are connected to two servomotors, which are mounted in orthogonal directions. To attenuate the effect of hand tremor on the tip of device, PID and computed torque methods are used to actively control the system. These controllers are used to control the rotation of the motors for moving the links in opposite directions of the hand tremor. Performance of the device with mentioned controllers is studied for different applications and finally, the results of both controllers are discussed and compared. Based on the presented results in this study, the designed device is able to suppress the hand tremor up to 75% during eating and 65% during following a spiral pattern. Graphical abstract Design of a noninvasive and smart hand tremor attenuation system: a simulation study.
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Affiliation(s)
- Mahdi Abbasi
- Mechanical Engineering Department, Faculty of Engineering, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Aref Afsharfard
- Mechanical Engineering Department, Faculty of Engineering, Ferdowsi University of Mashhad, Mashhad, Iran.
| | - Roya Arasteh
- Electrical Engineering Department, Faculty of Engineering, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Javad Safaie
- Electrical Engineering Department, Faculty of Engineering, Ferdowsi University of Mashhad, Mashhad, Iran
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Buki E, Katz R, Zacksenhouse M, Schlesinger I. Vib-bracelet: a passive absorber for attenuating forearm tremor. Med Biol Eng Comput 2017; 56:923-930. [PMID: 29101536 DOI: 10.1007/s11517-017-1742-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 10/20/2017] [Indexed: 11/29/2022]
Abstract
Tremor is a rhythmic, involuntary, oscillatory movement of a limb produced by alternating contractions of reciprocally innervated muscles. More than 4% of the population over 40 years old suffer from tremor. There is no cure for most tremors, and while psychological therapy is sometimes helpful, tremors are usually treated with either medication or invasive surgery including thalamotomy and deep brain stimulation. Both medications and surgery may have adverse effects, and thus, there is a growing interest in developing non-invasive vibration attenuation devices. This paper presents a passive absorber device for attenuating pronation/supination tremor, dubbed Vib-bracelet. It is based on the principles of dynamic vibration absorption and is tuned to the frequency of the tremor. Prototypes were manufactured and tested on a mechanical model of the human forearm. Simulations and experiments demonstrate the efficiency of the device in attenuating vibrations in the range of 4-6 Hz, which is the range of frequency of observed tremor, with maximum amplitude attenuation of 85%.
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Affiliation(s)
- Eran Buki
- Mechanical Engineering Department, Technion Israel Institute for Technology, Haifa, Israel
| | - Reuven Katz
- Mechanical Engineering Department, Technion Israel Institute for Technology, Haifa, Israel
| | - Miriam Zacksenhouse
- Mechanical Engineering Department, Technion Israel Institute for Technology, Haifa, Israel.
| | - Ilana Schlesinger
- Movement Disorders Clinic, Department of Neurology, Rambam Medical Center, Haifa, Israel
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Xu FL, Hao MZ, Xu SQ, Hu ZX, Xiao Q, Lan N. Development of a closed-loop system for tremor suppression in patients with Parkinson's disease. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:1782-1785. [PMID: 28268673 DOI: 10.1109/embc.2016.7591063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
More than 70% of patients suffering Parkinson's disease (PD) exhibit resting tremor in their extremities, hampering their ability to perform daily activities. Based on our earlier studies on corticospinal transmission of tremor signals [10,11], we hypothesize that cutaneous afferents evoked by surface stimulation can produce an inhibitory effect on propriospinal neurons (PN), which in turn will suppress tremor signals passing through the PN. This paper presents the development of a closed-loop system for tremor suppression by transcutaneous electrical nerve stimulation (TENS) of sensory fibers beneath the skin. The closed-loop system senses EMGs of forearm muscles, and detects rhythmic bursting in the EMG signal. When a tremor is detected by the system, a command signal triggers a stimulator to output a train of bi-phasic, current regulated pulses to a pair of surface electrodes. The stimulation electrode is placed on the dorsal hand skin near the metacarpophalangeal joint of index finger, which is innervated by the superficial radial nerve that projects an inhibitory afferent to PNs of forearm muscles. We tested the closed-loop system in 3 normal subjects to verify the algorithm and in 2 tremor dominated PD subjects for feasibility of tremor detecting and suppression. Preliminary results indicate that the closed-loop system can detect tremor in all subjects, and tremor in PD patients was suppressed significantly by electrical stimulation of cutaneous afferents.
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Shah VV, Goyal S, Palanthandalam-Madapusi HJ. A Possible Explanation of How High-Frequency Deep Brain Stimulation Suppresses Low-Frequency Tremors in Parkinson's Disease. IEEE Trans Neural Syst Rehabil Eng 2017; 25:2498-2508. [PMID: 28866595 DOI: 10.1109/tnsre.2017.2746623] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Parkinson's disease (PD) is a neurodegenerative disorder of the central nervous system and one of its key symptoms is rest tremor. Deep brain stimulation (DBS) effectively suppresses rest tremor in Parkinson's disease. Despite being a successful treatment option, its underlying principle and the mechanism by which it attenuates tremors is not yet fully understood. Since existing methods for tuning DBS parameters are largely trial and error, understanding how DBS works can help to reduce time and costs, and could also ultimately lead to better treatment strategies for PD. In this paper, we set out to analyze how a high-frequency stimulation applied through DBS can help reduce the low-frequency rest tremors observed in PD patients. We identify key elements in the sensorimotor loop (the feedback loop consisting of sensory feedbacks and motor responses) that play a role in the interaction of high-frequency DBS signal and the low-frequency tremor. Based on the analysis of these elements, we draw insights about the working of DBS and the role of frequency and the nature of stimulation. We verify these observations with numerical examples and a bench top experimental example.
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Jitkritsadakul O, Thanawattano C, Anan C, Bhidayasiri R. Tremor's glove-an innovative electrical muscle stimulation therapy for intractable tremor in Parkinson's disease: A randomized sham-controlled trial. J Neurol Sci 2017; 381:331-340. [PMID: 28991711 DOI: 10.1016/j.jns.2017.08.3246] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/08/2017] [Accepted: 08/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Medically refractory resting tremor is a debilitating symptom of Parkinson's disease (PD) patients. In our pilot study, modulation of peripheral reflex mechanism by electrical muscle stimulation (EMS) temporarily suppressed tremor. OBJECTIVES To investigate the efficacy of EMS, delivered using Tremor's glove, as a treatment of resting hand tremor. PATIENTS AND METHODS Thirty PD patients with medically refractory resting tremor were randomly allocated to a Tremor's glove group (n=15) or a sham glove group (n=15). Gloves were placed on the most tremulous hand for 30min per testing session. Demographics, clinical rating scales, and tremor parameters (RMS of angular velocity and angular displacement, peak magnitude, and frequency) were assessed before and during stimulation. Correlations with validated clinical rating scales were performed. RESULTS There were no statistically significant differences between groups in demographics, rating scales, or tremor parameters. During stimulation, significant reduction in RMS angular velocity (as percentage) in every axis and peak magnitude in axis (x-, y-) and UPDRS tremor score, were found with Tremor's glove compared to the sham groups (p<0.05, each). Significant moderate correlations were observed between a percentage reduction of RMS angular velocity in every axis and UPDRS tremor scores. Mean duration of tremor reduction after stimulation was 107.78±104.15s. No serious adverse events were observed. CONCLUSION In this study, EMS-based Tremor's glove was effective in suppressing resting hand tremor in PD patients. Tremor's glove is light-weight with a good safety profile, making it a future potential therapeutic option for PD patients with medically refractory tremor.
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Affiliation(s)
- Onanong Jitkritsadakul
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Chusak Thanawattano
- National Electronics and Computer Technology Center (NECTEC), Pathumthani, Thailand
| | - Chanawat Anan
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Roongroj Bhidayasiri
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand; Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan.
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40
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Hao MZ, Xu SQ, Hu ZX, Xu FL, Niu CXM, Xiao Q, Lan N. Inhibition of Parkinsonian tremor with cutaneous afferent evoked by transcutaneous electrical nerve stimulation. J Neuroeng Rehabil 2017; 14:75. [PMID: 28705167 PMCID: PMC5513246 DOI: 10.1186/s12984-017-0286-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 06/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent study suggests that tremor signals are transmitted by way of multi-synaptic corticospinal pathway. Neurophysiological studies have also demonstrated that cutaneous afferents exert potent inhibition to descending motor commands by way of spinal interneurons. We hypothesize in this study that cutaneous afferents could also affect the transmission of tremor signals, thus, inhibit tremor in patients with PD. METHODS We tested this hypothesis by activating cutaneous afferents in the dorsal hand skin innervated by superficial radial nerve using transcutaneous electrical nerve stimulation (TENS). Eight patients with PD having tremor dominant symptom were recruited to participate in this study using a consistent experimental protocol for tremor inhibition. Resting tremor and electromyogram (EMG) of muscles in the upper extremity of these subjects with PD were recorded, while surface stimulation was applied to the dorsal skin of the hand. Fifteen seconds of data were recorded for 5 s prior to, during and post stimulation. Power spectrum densities (PSDs) of tremor and EMG signals were computed for each data segment. The peak values of PSDs in three data segments were compared to detect evidence of tremor inhibition. RESULTS At stimulation intensity from 1.5 to 1.75 times of radiating sensation threshold, apparent suppressions of tremor at wrist, forearm and upper arm and in the EMGs were observed immediately at the onset of stimulation. After termination of stimulation, tremor and rhythmic EMG bursts reemerged gradually. Statistical analysis of peak spectral amplitudes showed a significant difference in joint tremors and EMGs during and prior to stimulation in all 8 subjects with PD. The average percentage of suppression was 61.56% in tremor across all joints of all subjects, and 47.97% in EMG of all muscles. The suppression appeared to occur mainly in distal joints and muscles. There was a slight, but inconsistent effect on tremor frequency in the 8 patients with PD tested. CONCLUSIONS Our results provide direct evidence that tremor in the upper extremity of patients with PD can be inhibited to a large extent with evoked cutaneous reflexes via surface stimulation of the dorsal hand skin area innervated by the superficial radial nerve.
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Affiliation(s)
- Man-Zhao Hao
- Laboratory of Neurorehabilitation Engineering, School of Biomedical Engineering, Shanghai Jiao Tong University, 1954 Hua Shan Road, Shanghai, 200030, China
| | - Shao-Qin Xu
- Department of Neurology, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zi-Xiang Hu
- Laboratory of Neurorehabilitation Engineering, School of Biomedical Engineering, Shanghai Jiao Tong University, 1954 Hua Shan Road, Shanghai, 200030, China
| | - Fu-Liang Xu
- Laboratory of Neurorehabilitation Engineering, School of Biomedical Engineering, Shanghai Jiao Tong University, 1954 Hua Shan Road, Shanghai, 200030, China
| | - Chuan-Xin M Niu
- Laboratory of Neurorehabilitation Engineering, School of Biomedical Engineering, Shanghai Jiao Tong University, 1954 Hua Shan Road, Shanghai, 200030, China.,Department of Rehabilitation, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qin Xiao
- Department of Neurology, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ning Lan
- Laboratory of Neurorehabilitation Engineering, School of Biomedical Engineering, Shanghai Jiao Tong University, 1954 Hua Shan Road, Shanghai, 200030, China. .,Division of Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, USA.
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41
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Dideriksen JL, Laine CM, Dosen S, Muceli S, Rocon E, Pons JL, Benito-Leon J, Farina D. Electrical Stimulation of Afferent Pathways for the Suppression of Pathological Tremor. Front Neurosci 2017; 11:178. [PMID: 28420958 PMCID: PMC5378793 DOI: 10.3389/fnins.2017.00178] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 03/20/2017] [Indexed: 11/13/2022] Open
Abstract
Pathological tremors are involuntary oscillatory movements which cannot be fully attenuated using conventional treatments. For this reason, several studies have investigated the use of neuromuscular electrical stimulation for tremor suppression. In a recent study, however, we found that electrical stimulation below the motor threshold also suppressed tremor, indicating involvement of afferent pathways. In this study, we further explored this possibility by systematically investigating how tremor suppression by afferent stimulation depends on the stimulation settings. In this way, we aimed at identifying the optimal stimulation strategy, as well as to elucidate the underlying physiological mechanisms of tremor suppression. Stimulation strategies varying the stimulation intensity and pulse timing were tested in nine tremor patients using either intramuscular or surface stimulation. Significant tremor suppression was observed in six patients (tremor suppression > 75% was observed in three patients) and the average optimal suppression level observed across all subjects was 52%. The efficiency for each stimulation setting, however, varied substantially across patients and it was not possible to identify a single set of stimulation parameters that yielded positive results in all patients. For example, tremor suppression was achieved both with stimulation delivered in an out-of-phase pattern with respect to the tremor, and with random timing of the stimulation. Overall, these results indicate that low-current stimulation of afferent fibers is a promising approach for tremor suppression, but that further research is required to identify how the effect can be maximized in the individual patient.
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Affiliation(s)
- Jakob L Dideriksen
- SMI, Department of Health Science and Technology, Aalborg UniversityAalborg, Denmark
| | - Christopher M Laine
- Brain-Body Dynamics Lab, University of Southern CaliforniaLos Angeles, CA, USA
| | - Strahinja Dosen
- Institute of Neurorehabilitation Systems, University Medical Center GöttingenGöttingen, Germany.,Clinic for Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center GöttingenGöttingen, Germany
| | - Silvia Muceli
- Institute of Neurorehabilitation Systems, University Medical Center GöttingenGöttingen, Germany.,Clinic for Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center GöttingenGöttingen, Germany
| | - Eduardo Rocon
- Center for Automation and Robotics, Consejo Superior de Investigaciones CientíficasArganda del Rey, Spain
| | - José L Pons
- Neural Rehabilitation Group, Instituto Cajal, Consejo Superior de Investigaciones CientíficasMadrid, Spain
| | | | - Dario Farina
- Department of Bioengineering, Imperial College LondonLondon, UK
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42
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HEO JAEHOON, KWON YURI, JEON HYEONGMIN, KWON DOYOUNG, LEE CHANNYEONG, PARK KEONWOO, MANTO MARIO, KIM JIWON, EOM GWANGMOON. SUPPRESSION OF ACTION TREMOR BY SENSORY ELECTRICAL STIMULATION IN PATIENTS WITH ESSENTIAL TREMOR. J MECH MED BIOL 2016. [DOI: 10.1142/s0219519416400261] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Essential tremor (ET) is the most common movement disorder that includes postural tremor and action tremor. This study investigates whether sensory electrical stimulation (SES) is effective on the action tremor in patients with ET. One task in the clinical testing of action tremor, “Archimedes spiral drawing”, was performed in 18 patients for three sessions, which were named as pre-stimulation (PRE), stimulation on (ON), and 5[Formula: see text]min after stimulation (POST). SES (sub-motor threshold) was applied on the muscles of the elbow and wrist only at ON session. Three-dimensional (3D) angular velocities were measured on three segments (index finger, hand, and forearm) from which movements of metacarpophalangeal (MP) and wrist joints were derived. Average tremor intensity in each session was represented by root mean square of the vector sum of 3D angular velocities. Tremor intensities in ON session were smaller than in PRE session in one segment (finger) and two joints (MP and wrist) ([Formula: see text]). Tremor intensities in POST session were even smaller than in ON session in all segments and one joint (wrist) ([Formula: see text]). The results indicate that SES suppresses action tremor and the effect continues and even improves 5[Formula: see text]min after the termination of stimulation. The findings of this study may contribute to the improvement of the quality of life in patients with ET.
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Affiliation(s)
- JAE-HOON HEO
- School of Biomedical Engineering, Konkuk University, Chungju 380-701, Korea
| | - YURI KWON
- School of Biomedical Engineering, Konkuk University, Chungju 380-701, Korea
| | - HYEONG-MIN JEON
- School of Biomedical Engineering, Konkuk University, Chungju 380-701, Korea
| | - DO-YOUNG KWON
- Department of Neurology, College of Medicine, Korea University, Anam, Seoul, Korea
| | - CHAN-NYEONG LEE
- Department of Neurology, College of Medicine, Korea University, Anam, Seoul, Korea
| | - KEON-WOO PARK
- Department of Neurology, College of Medicine, Korea University, Anam, Seoul, Korea
| | - MARIO MANTO
- Unité d’Etude du Mouvement, Université Libre de Bruxelles, Erasme, Bruxelles, 1070, Belgium
| | - JI-WON KIM
- School of Biomedical Engineering, Konkuk University, Chungju 380-701, Korea
| | - GWANG-MOON EOM
- School of Biomedical Engineering, Konkuk University, Chungju 380-701, Korea
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43
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Shah A, Coste J, Lemaire JJ, Taub E, Schüpbach WMM, Pollo C, Schkommodau E, Guzman R, Hemm-Ode S. Intraoperative acceleration measurements to quantify improvement in tremor during deep brain stimulation surgery. Med Biol Eng Comput 2016; 55:845-858. [PMID: 27631560 DOI: 10.1007/s11517-016-1559-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 08/08/2016] [Indexed: 11/25/2022]
Abstract
Deep brain stimulation (DBS) surgery is extensively used in the treatment of movement disorders. Nevertheless, methods to evaluate the clinical response during intraoperative stimulation tests to identify the optimal position for the implantation of the chronic DBS lead remain subjective. In this paper, we describe a new, versatile method for quantitative intraoperative evaluation of improvement in tremor with an acceleration sensor that is mounted on the patient's wrist during surgery. At each anatomical test position, the improvement in tremor compared to the initial tremor is estimated on the basis of extracted outcome measures. This method was tested on 15 tremor patients undergoing DBS surgery in two centers. Data from 359 stimulation tests were acquired. Our results suggest that accelerometric evaluation detects tremor changes more sensitively than subjective visual ratings. The effective stimulation current amplitudes identified from the quantitative data (1.1 ± 0.8 mA) are lower than those identified by visual evaluation (1.7 ± 0.8 mA) for similar improvement in tremor. Additionally, if these data had been used to choose the chronic implant position of the DBS lead, 15 of the 26 choices would have been different. These results show that our method of accelerometric evaluation can potentially improve DBS targeting.
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Affiliation(s)
- Ashesh Shah
- Institute for Medical and Analytical Technologies, University of Applied Sciences and Arts Northwestern Switzerland, Gruendenstrasse 40, 4132, Muttenz, Switzerland
| | - Jérôme Coste
- Image-Guided Clinical Neuroscience and Connectomics (EA 7282), Université Clermont Auvergne, Clermont-Ferrand, France.,Service de Neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Jacques Lemaire
- Image-Guided Clinical Neuroscience and Connectomics (EA 7282), Université Clermont Auvergne, Clermont-Ferrand, France.,Service de Neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ethan Taub
- Departments of Neurosurgery and Biomedicine, University of Basel, Basel, Switzerland
| | - W M Michael Schüpbach
- Department of Neurology, University Hospital Bern and University of Bern, Bern, Switzerland.,Assistance Publique Hôpitaux de Paris, Institut National de Santé et en Recherche Médicale, Institut du Cerveau et de la Moelle Epinière, Centre d'Investigation Clinique 1422, Département de Neurologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Claudio Pollo
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Erik Schkommodau
- Institute for Medical and Analytical Technologies, University of Applied Sciences and Arts Northwestern Switzerland, Gruendenstrasse 40, 4132, Muttenz, Switzerland
| | - Raphael Guzman
- Departments of Neurosurgery and Biomedicine, University of Basel, Basel, Switzerland
| | - Simone Hemm-Ode
- Institute for Medical and Analytical Technologies, University of Applied Sciences and Arts Northwestern Switzerland, Gruendenstrasse 40, 4132, Muttenz, Switzerland.
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Herrnstadt G, Menon C. Voluntary-Driven Elbow Orthosis with Speed-Controlled Tremor Suppression. Front Bioeng Biotechnol 2016; 4:29. [PMID: 27066477 PMCID: PMC4814799 DOI: 10.3389/fbioe.2016.00029] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 03/17/2016] [Indexed: 12/04/2022] Open
Abstract
Robotic technology is gradually becoming commonplace in the medical sector and in the service of patients. Medical conditions that have benefited from significant technological development include stroke, for which rehabilitation with robotic devices is administered, and surgery assisted by robots. Robotic devices have also been proposed for assistance of movement disorders. Pathological tremor, among the most common movement disorders, is one such example. In practice, the dissemination and availability of tremor suppression robotic systems has been limited. Devices in the marketplace tend to either be non-ambulatory or to target specific functions, such as eating and drinking. We have developed a one degree-of-freedom (DOF) elbow orthosis that could be worn by an individual with tremor. A speed-controlled, voluntary-driven suppression approach is implemented with the orthosis. Typically tremor suppression methods estimate the tremor component of the signal and produce a canceling counterpart signal. The suggested approach instead estimates the voluntary component of the motion. A controller then actuates the orthosis based on the voluntary signal, while simultaneously rejecting the tremorous motion. In this work, we tested the suppressive orthosis using a one DOF robotic system that simulates the human arm. The suggested suppression approach does not require a model of the human arm. Moreover, the human input along with the orthosis forearm gravitational forces, of non-linear nature, are considered as part of the disturbance to the suppression system. Therefore, the suppression system can be modeled linearly. Nevertheless, the orthosis forearm gravitational forces can be compensated by the suppression system. The electromechanical design of the orthosis is presented, and data from an essential tremor patient is used as the human input. Velocity tracking results demonstrate an RMS error of 0.31 rad/s, and a power spectral density shows a reduction of the tremor signal by 99.8%, while the intentional component power was reduced by <1%.
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Affiliation(s)
- Gil Herrnstadt
- MENRVA Lab, Engineering Science Department, Simon Fraser University , Burnaby, BC , Canada
| | - Carlo Menon
- MENRVA Lab, Engineering Science Department, Simon Fraser University , Burnaby, BC , Canada
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45
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Murphy MD, Guggenmos DJ, Bundy DT, Nudo RJ. Current Challenges Facing the Translation of Brain Computer Interfaces from Preclinical Trials to Use in Human Patients. Front Cell Neurosci 2016; 9:497. [PMID: 26778962 PMCID: PMC4702293 DOI: 10.3389/fncel.2015.00497] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 12/10/2015] [Indexed: 12/13/2022] Open
Abstract
Current research in brain computer interface (BCI) technology is advancing beyond preclinical studies, with trials beginning in human patients. To date, these trials have been carried out with several different types of recording interfaces. The success of these devices has varied widely, but different factors such as the level of invasiveness, timescale of recorded information, and ability to maintain stable functionality of the device over a long period of time all must be considered in addition to accuracy in decoding intent when assessing the most practical type of device moving forward. Here, we discuss various approaches to BCIs, distinguishing between devices focusing on control of operations extrinsic to the subject (e.g., prosthetic limbs, computer cursors) and those focusing on control of operations intrinsic to the brain (e.g., using stimulation or external feedback), including closed-loop or adaptive devices. In this discussion, we consider the current challenges facing the translation of various types of BCI technology to eventual human application.
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Affiliation(s)
- Maxwell D Murphy
- Bioengineering Graduate Program, University of KansasLawrence, KS, USA; Department of Rehabilitation Medicine, University of Kansas Medical CenterKansas City, KS, USA
| | - David J Guggenmos
- Department of Rehabilitation Medicine, University of Kansas Medical Center Kansas City, KS, USA
| | - David T Bundy
- Department of Rehabilitation Medicine, University of Kansas Medical Center Kansas City, KS, USA
| | - Randolph J Nudo
- Department of Rehabilitation Medicine, University of Kansas Medical CenterKansas City, KS, USA; Landon Center on Aging, University of Kansas Medical CenterKansas City, KS, USA
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46
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Chalah MA, Lefaucheur JP, Ayache SS. Non-invasive Central and Peripheral Stimulation: New Hope for Essential Tremor? Front Neurosci 2015; 9:440. [PMID: 26635516 PMCID: PMC4649015 DOI: 10.3389/fnins.2015.00440] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/01/2015] [Indexed: 12/31/2022] Open
Abstract
Essential tremor (ET) is among the most frequent movement disorders. It usually manifests as a postural and kinematic tremor of the arms, but may also involve the head, voice, lower limbs, and trunk. An oscillatory network has been proposed as a neural correlate of ET, and is mainly composed of the olivocerebellar system, thalamus, and motor cortex. Since pharmacological agents have limited benefits, surgical interventions like deep brain stimulation are the last-line treatment options for the most severe cases. Non-invasive brain stimulation techniques, particularly transcranial magnetic or direct current stimulation, are used to ameliorate ET. Their non-invasiveness, along with their side effects profile, makes them an appealing treatment option. In addition, peripheral stimulation has been applied in the same perspective. Hence, the aim of the present review is to shed light on the emergent use of non-invasive central and peripheral stimulation techniques in this interesting context.
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Affiliation(s)
- Moussa A Chalah
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil Créteil, France ; Service de Physiologie - Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris Créteil, France
| | - Jean-Pascal Lefaucheur
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil Créteil, France ; Service de Physiologie - Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris Créteil, France
| | - Samar S Ayache
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil Créteil, France ; Service de Physiologie - Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris Créteil, France ; Neurology Division, University Medical Center Rizk Hospital Beirut, Lebanon
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47
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Jitkritsadakul O, Thanawattano C, Anan C, Bhidayasiri R. Exploring the effect of electrical muscle stimulation as a novel treatment of intractable tremor in Parkinson's disease. J Neurol Sci 2015; 358:146-52. [PMID: 26342942 DOI: 10.1016/j.jns.2015.08.1527] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Revised: 08/21/2015] [Accepted: 08/23/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND As the pathophysiology of tremor in Parkinson disease (PD) involves a complex interaction between central and peripheral mechanisms, we propose that modulation of peripheral reflex mechanism by electrical muscle stimulation (EMS) may improve tremor temporarily. OBJECTIVES To determine the efficacy of EMS as a treatment for drug resistant tremor in PD patients. METHODS This study was a single-blinded, quasi-experimental study involving 34 PD patients with classic resting tremor as confirmed by tremor analysis. The EMS was given at 50Hz over the abductor pollicis brevis and interrosseus muscles for 10s with identified tremor parameters before and during stimulation as primary outcomes. RESULTS Compared to before stimulation, we observed a significant reduction in the root mean square (RMS) of the angular velocity (p<0.001) and peak magnitude (p<0.001) of resting tremor while tremor frequency (p=0.126) and dispersion (p=0.284) remained unchanged during stimulation. The UPDRS tremor score decreased from 10.59 (SD=1.74) before stimulation to 8.85 (SD=2.19) during stimulation (p<0.001). The average percentage of improvement of the peak magnitude and RMS angular velocity was 49.57% (SD=38.89) and 43.81% (SD=33.15) respectively. 70.6% and 61.8% of patients experienced at least 30% tremor attenuation as calculated from the peak magnitude and RMS angular velocity respectively. CONCLUSIONS Our study demonstrated the efficacy of EMS in temporarily improving resting tremor in medically intractable PD patients. Although tremor severity decreased, they were not completely eliminated and continued with a similar frequency, thus demonstrating the role of peripheral reflex mechanism in the modulation of tremor, but not as a generator. EMS should be further explored as a possible therapeutic intervention for tremor in PD.
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Affiliation(s)
- Onanong Jitkritsadakul
- Chulalongkorn Center of Excellence for Parkinson Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Chusak Thanawattano
- Biomedical Signal Processing Laboratory, National Electronics and Computer Technology Center (NECTEC), and National Science and Technology Development Agency (NSTDA), Pathumthani, Thailand
| | - Chanawat Anan
- Chulalongkorn Center of Excellence for Parkinson Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Roongroj Bhidayasiri
- Chulalongkorn Center of Excellence for Parkinson Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand; Department of Rehabilitation Medicine, Juntendo University, Tokyo, Japan.
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48
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Abstract
BACKGROUND Treatment options for essential (ET) and Parkinson disease (PD) tremor are suboptimal, with significant side effects. Botulinum toxin type A (BoNT A) is successfully used in management of various focal movement disorders but is not widely used for tremor. METHOD This study examines complexity of wrist tremor in terms of involvement of its three anatomical degrees of freedom (DOF) in two common situations of rest and posture. The study examines tremor in 11 ET and 17 PD participants by kinematic decomposition of motion in 3-DOF. RESULTS Tremor decomposition showed the motion involved more than one DOF (<70% contribution in one DOF) in most ET (rest: 100%, posture: 64%) and PD (rest: 77%, posture: 77%) patients. Task variation resulted in change in both amplitude and composition in ET, but not in PD. Amplitude significantly increased from rest to posture in ET. Directional bias was observed at the wrist for ET (pronation), and PD (extension, ulnar deviation, pronation). Average agreement between clinical visual and kinematic selection of muscles was 55% across all subjects. CONCLUSION This study shows the complexity of tremor and the difficulty in visual judgment of tremor, which may be key to the success of targeted focal treatments such as BoNT A.
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Lambrecht S, Gallego JA, Rocon E, Pons JL. Automatic real-time monitoring and assessment of tremor parameters in the upper limb from orientation data. Front Neurosci 2014; 8:221. [PMID: 25120424 PMCID: PMC4110507 DOI: 10.3389/fnins.2014.00221] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 07/07/2014] [Indexed: 11/13/2022] Open
Abstract
Upper limb tremor is the most prevalent movement disorder and, unfortunately, it is not effectively managed in a large proportion of the patients. Neuroprostheses that stimulate the sensorimotor pathways are one of the most promising alternatives although they are still under development. To enrich the interpretation of data recorded during long-term tremor monitoring and to increase the intelligence of tremor suppression neuroprostheses we need to be aware of the context. Context awareness is a major challenge for neuroprostheses and would allow these devices to react more quickly and appropriately to the changing demands of the user and/or task. Traditionally kinematic features are used to extract context information, with most recently the use of joint angles as highly potential features. In this paper we present two algorithms that enable the robust extraction of joint angle and related features to enable long-term continuous monitoring of tremor with context awareness. First, we describe a novel relative sensor placement identification technique based on orientation data. We focus on relative rather than absolute sensor location, because in many medical applications magnetic and inertial measurement units (MIMU) are used in a chain stretching over adjacent segments, or are always placed on a fixed set of locations. Subsequently we demonstrate how tremor parameters can be extracted from orientation data using an adaptive estimation algorithm. Relative sensor location was detected with an accuracy of 94.12% for the 4 MIMU configuration, and 100% for the 3 MIMU configurations. Kinematic tracking error values with an average deviation of 8% demonstrate our ability to estimate tremor from orientation data. The methods presented in this study constitute an important step toward more user-friendly and context-aware neuroprostheses for tremor suppression and monitoring.
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Affiliation(s)
- Stefan Lambrecht
- Neurorehabilitation group, Cajal Institute, Spanish National Research Council (CSIC) Madrid, Spain
| | - Juan A Gallego
- Neurorehabilitation group, Cajal Institute, Spanish National Research Council (CSIC) Madrid, Spain
| | - Eduardo Rocon
- Neurorehabilitation group, Cajal Institute, Spanish National Research Council (CSIC) Madrid, Spain
| | - Jose L Pons
- Neurorehabilitation group, Cajal Institute, Spanish National Research Council (CSIC) Madrid, Spain
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50
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Dosen S, Muceli S, Dideriksen JL, Romero JP, Rocon E, Pons J, Farina D. Online tremor suppression using electromyography and low-level electrical stimulation. IEEE Trans Neural Syst Rehabil Eng 2014; 23:385-95. [PMID: 25051555 DOI: 10.1109/tnsre.2014.2328296] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Tremor is one of the most prevalent movement disorders. There is a large proportion of patients (around 25%) in whom current treatments do not attain a significant tremor reduction. This paper proposes a tremor suppression strategy that detects tremor from the electromyographic signals of the muscles from which tremor originates and counteracts it by delivering electrical stimulation to the antagonist muscles in an out of phase manner. The detection was based on the iterative Hilbert transform and stimulation was delivered above the motor threshold (motor stimulation) and below the motor threshold (sensory stimulation). The system was tested on six patients with predominant wrist flexion/extension tremor (four with Parkinson disease and two with Essential tremor) and led to an average tremor reduction in the range of 46%-81% and 35%-48% across five patients when using the motor and sensory stimulation, respectively. In one patient, the system did not attenuate tremor. These results demonstrate that tremor attenuation might be achieved by delivering electrical stimulation below the motor threshold, preventing muscle fatigue and discomfort for the patients, which sets the basis for the development of an alternative treatment for tremor.
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