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Roth N, Salih A, Rosenblum S. Subjective and Objective Day-to-Day Performance Measures of People with Essential Tremor. SENSORS (BASEL, SWITZERLAND) 2024; 24:4854. [PMID: 39123901 PMCID: PMC11315051 DOI: 10.3390/s24154854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/19/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024]
Abstract
This paper aims to map the daily functional characteristics of people diagnosed with essential tremor (ET) based on their subjective self-reports. In addition, we provide objective measurements of a cup-drinking task. This study involved 20 participants diagnosed with ET who completed the Columbia University Assessment of Disability in Essential Tremor (CADET) questionnaire that included five additional tasks related to digital equipment operation we wrote. Participants also described task-performance modifications they implemented. To create objective personal performance profiles, they performed a cup-drinking task while being monitored using a sensor measurement system. The CADET's subjective self-report results indicate that the most prevalent tasks participants reported as having difficulty with or requiring modifications were writing, threading a needle, carrying a cup, using a spoon, pouring, and taking a photo or video on a mobile phone. Analysis of participants' modifications revealed that holding the object with two hands or with one hand supporting the other were the most prevalent types. No significant correlation was found between the CADET total scores and the cup drinking objective measures. Capturing patients' perspectives on their functional disability, alongside objective performance measures, is envisioned to contribute to the development of custom-tailored interventions aligned with individual profiles, i.e., patient-based/smart healthcare.
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Affiliation(s)
- Navit Roth
- The Laboratory of Complex Human Activity and Participation (CHAP), Department of Occupational Therapy, University of Haifa, Haifa 3498838, Israel;
- Department of Mechanical Engineering, Braude College of Engineering, Karmiel 2161002, Israel;
| | - Adham Salih
- Department of Mechanical Engineering, Braude College of Engineering, Karmiel 2161002, Israel;
| | - Sara Rosenblum
- The Laboratory of Complex Human Activity and Participation (CHAP), Department of Occupational Therapy, University of Haifa, Haifa 3498838, Israel;
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2
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Kosmowska B, Paleczna M, Biała D, Kadłuczka J, Wardas J, Witkin JM, Cook JM, Sharmin D, Marcinkowska M, Kuter KZ. GABA-A Alpha 2/3 but Not Alpha 1 Receptor Subunit Ligand Inhibits Harmaline and Pimozide-Induced Tremor in Rats. Biomolecules 2023; 13:biom13020197. [PMID: 36830567 PMCID: PMC9953228 DOI: 10.3390/biom13020197] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/11/2023] [Accepted: 01/15/2023] [Indexed: 01/20/2023] Open
Abstract
Treatment of tremors, such as in essential tremor (ET) and Parkinson's disease (PD) is mostly ineffective. Exact tremor pathomechanisms are unknown and relevant animal models are missing. GABA-A receptor is a target for tremorolytic medications, but current non-selective drugs produce side effects and have safety liabilities. The aim of this study was a search for GABA-A subunit-specific tremorolytics using different tremor-generating mechanisms. Two selective positive allosteric modulators (PAMs) were tested. Zolpidem, targeting GABA-A α1, was not effective in models of harmaline-induced ET, pimozide- or tetrabenazine-induced tremulous jaw movements (TJMs), while the novel GABA-A α2/3 selective MP-III-024 significantly reduced both the harmaline-induced ET tremor and pimozide-induced TJMs. While zolpidem decreased the locomotor activity of the rats, MP-III-024 produced small increases. These results provide important new clues into tremor suppression mechanisms initiated by the enhancement of GABA-driven inhibition in pathways controlled by α2/3 but not α1 containing GABA-A receptors. Tremor suppression by MP-III-024 provides a compelling reason to consider selective PAMs targeting α2/3-containing GABA-A receptors as novel therapeutic drug targets for ET and PD-associated tremor. The possibility of the improved tolerability and safety of this mechanism over non-selective GABA potentiation provides an additional rationale to further pursue the selective α2/3 hypothesis.
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Affiliation(s)
- Barbara Kosmowska
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smetna St., 31-343 Krakow, Poland
| | - Martyna Paleczna
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smetna St., 31-343 Krakow, Poland
| | - Dominika Biała
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smetna St., 31-343 Krakow, Poland
| | - Justyna Kadłuczka
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smetna St., 31-343 Krakow, Poland
| | - Jadwiga Wardas
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smetna St., 31-343 Krakow, Poland
| | - Jeffrey M. Witkin
- Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI 53211, USA
- RespireRx Pharmaceuticals Inc., Glen Rock, NJ 07452, USA
| | - James M. Cook
- Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI 53211, USA
- RespireRx Pharmaceuticals Inc., Glen Rock, NJ 07452, USA
| | - Dishary Sharmin
- Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI 53211, USA
| | - Monika Marcinkowska
- Department of Pharmaceutical Chemistry, Jagiellonian University, Medical College, 9 Medyczna St., 30-688 Krakow, Poland
| | - Katarzyna Z. Kuter
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smetna St., 31-343 Krakow, Poland
- Correspondence: ; Tel.: +48-12-662-32-26
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3
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Ray A, Biswas DA. Association of Diet With Essential Tremor: A Narrative Review. Cureus 2022; 14:e29168. [PMID: 36258958 PMCID: PMC9567235 DOI: 10.7759/cureus.29168] [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: 08/06/2022] [Accepted: 09/14/2022] [Indexed: 11/09/2022] Open
Abstract
Essential tremor is a neurological disorder categorized by the rhythmic shaking of the upper limbs, lower limbs, neck, or head. The etiology of essential tremor is believed to be genetic variations, environmental factors, lifestyle, etc. Poor lifestyle and diet are important factors contributing to the onset of various disorders. Environment and lifestyle play a significant part in the dietary habits of an individual. Some diet components may probably be associated with the etiopathogenesis or progression of the essential tremor. Dietary habits may be a key influence on the commencement of tremors in healthy individuals. Typically, the diet of essential tremor patients is not supervised. It may also intensify the tremors in essential tremor patients. Association of the diet with the essential tremor can shed light on the root of tremor aggravating aspect and aid in diet modification in essential tremor patients. The aim of the review is to establish a relation between the diet with etiopathogenesis and the progression of essential tremor. The review includes studies providing information about essential tremor and correlating essential tremor with diet, lifestyle, environment, and genetic factors. Studies that did not provide a link to the association of essential tremor were excluded. The interpretation of the research indicated that genetic variations might be triggered due to enzymatic changes triggered by dietary patterns. Dietary components showed ambiguous, weak, strong, or no association. Essential tremor may be influenced by diet. Further research must be carried out on essential tremor patients in the nutritional domain. Physicians may monitor the diet of the essential tremor patients and record the progress of the disorder on its basis to manage the patients with essential tremor and provide better services.
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Heimburg T. The thermodynamic soliton theory of the nervous impulse and possible medical implications. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2022; 173:24-35. [PMID: 35640761 DOI: 10.1016/j.pbiomolbio.2022.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/05/2022] [Accepted: 05/22/2022] [Indexed: 06/15/2023]
Abstract
The textbook picture of nerve activity is that of a propagating voltage pulse driven by electrical currents through ion channel proteins, which are gated by changes in voltage, temperature, pressure or by drugs. All function is directly attributed to single molecules. We show that this leaves out many important thermodynamic couplings between different variables. A more recent alternative picture for the nerve pulse is of thermodynamic nature. It considers the nerve pulse as a soliton, i.e., a macroscopic excited region with properties that are influenced by thermodynamic variables including voltage, temperature, pressure and chemical potentials of membrane components. All thermodynamic variables are strictly coupled. We discuss the consequences for medical treatment in a view where one can compensate a maladjustment of one variable by adjusting another variable. For instance, one can explain why anesthesia can be counteracted by hydrostatic pressure and decrease in pH, suggest reasons why lithium over-dose may lead to tremor, and how tremor is related to alcohol intoxication. Lithium action as well as the effect of ethanol and the anesthetic ketamine in bipolar patients may fall in similar thermodynamic patterns. Such couplings remain obscure in a purely molecular picture. Other fields of application are the response of nerve activity to muscle stretching and the possibility of neural stimulation by ultrasound.
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Affiliation(s)
- T Heimburg
- Niels Bohr Institute, University of Copenhagen, Blegdamsvej 17, 2100, Copenhagen Ø, Denmark.
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Bolton TAW, Van De Ville D, Régis J, Witjas T, Girard N, Levivier M, Tuleasca C. Graph Theoretical Analysis of Structural Covariance Reveals the Relevance of Visuospatial and Attentional Areas in Essential Tremor Recovery After Stereotactic Radiosurgical Thalamotomy. Front Aging Neurosci 2022; 14:873605. [PMID: 35677202 PMCID: PMC9168220 DOI: 10.3389/fnagi.2022.873605] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Essential tremor (ET) is the most common movement disorder. Its pathophysiology is only partially understood. Here, we leveraged graph theoretical analysis on structural covariance patterns quantified from morphometric estimates for cortical thickness, surface area, and mean curvature in patients with ET before and one year after (to account for delayed clinical effect) ventro-intermediate nucleus (Vim) stereotactic radiosurgical thalamotomy. We further contrasted the observed patterns with those from matched healthy controls (HCs). Significant group differences at the level of individual morphometric properties were specific to mean curvature and the post-/pre-thalamotomy contrast, evidencing brain plasticity at the level of the targeted left thalamus, and of low-level visual, high-level visuospatial and attentional areas implicated in the dorsal visual stream. The introduction of cross-correlational analysis across pairs of morphometric properties strengthened the presence of dorsal visual stream readjustments following thalamotomy, as cortical thickness in the right lingual gyrus, bilateral rostral middle frontal gyrus, and left pre-central gyrus was interrelated with mean curvature in the rest of the brain. Overall, our results position mean curvature as the most relevant morphometric feature to understand brain plasticity in drug-resistant ET patients following Vim thalamotomy. They also highlight the importance of examining not only individual features, but also their interactions, to gain insight into the routes of recovery following intervention.
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Affiliation(s)
- Thomas A. W. Bolton
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Connectomics Laboratory, Department of Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Dimitri Van De Ville
- Institute of Bioengineering, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
- Department of Radiology and Medical Informatics, University of Geneva (UNIGE), Geneva, Switzerland
| | - Jean Régis
- Stereotactic and Functional Neurosurgery Service and Gamma Knife Unit, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire de la Timone, Marseille, France
| | - Tatiana Witjas
- Neurology Department, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire de la Timone, Marseille, France
| | - Nadine Girard
- Department of Diagnostic and Interventional Neuroradiology, Centre de Résonance Magnétique Biologique et Médicale, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire de la Timone, Marseille, France
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Constantin Tuleasca
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
- Signal Processing Laboratory (LTS5), École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
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6
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Pandey S. Is essential tremor a family of diseases or a syndrome? A syndrome. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 163:31-59. [PMID: 35750367 DOI: 10.1016/bs.irn.2022.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In a consensus statement, a task force of the "International Parkinson and Movement Disorder Society" (IPMDS) has recently proposed a two axes classification for tremor: axis I (clinical manifestations) and axis II (etiology). In the axis, I, the clinical features of tremor in a given patient are specified in terms of medical history, tremor characteristics, associated signs, and laboratory tests for some tremors leading to the discovery of axis 2 etiologies. Based on axis I sign and symptoms a specific clinical syndrome is diagnosed which have been categorized as isolated tremor syndrome (a syndrome consisting only of tremor) and combined tremor syndrome (consisting of tremor and other systemic or neurological signs). The IPMDS task force defined essential tremor as an isolated tremor syndrome of bilateral upper limb action tremor of at least 3years duration with or without a tremor in other locations (e.g., head, voice or lower limbs) in absence of other neurological signs, such as dystonia, ataxia, or parkinsonism. Patients with neurological signs of uncertain significance (such as impaired tandem gait, questionable dystonic posturing, or memory impairment) are classified as essential tremor plus. In this paper, the author will make the argument that essential tremor is a syndrome with multiple causes.
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Affiliation(s)
- Sanjay Pandey
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India.
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7
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An Updated Overview of the Magnetic Resonance Imaging of Brain Iron in Movement Disorders. Behav Neurol 2022; 2022:3972173. [PMID: 35251368 PMCID: PMC8894064 DOI: 10.1155/2022/3972173] [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: 08/03/2021] [Accepted: 01/29/2022] [Indexed: 01/12/2023] Open
Abstract
Brain iron load is one of the most important neuropathological hallmarks in movement disorders. Specifically, the iron provides most of the paramagnetic metal signals in the brain and its accumulation seems to play a key role, although not completely explained, in the degeneration of the basal ganglia, as well as other brain structures. Moreover, iron distribution patterns have been implicated in depicting different movement disorders. This work reviewed current literature on Magnetic Resonance Imaging for Brain Iron Detection and Quantification (MRI-BIDQ) in neurodegenerative processes underlying movement disorders.
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8
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Liao C, Castonguay CE, Heilbron K, Vuokila V, Medeiros M, Houle G, Akçimen F, Ross JP, Catoire H, Diez-Fairen M, Kang J, Mueller SH, Girard SL, Hopfner F, Lorenz D, Clark LN, Soto-Beasley AI, Klebe S, Hallett M, Wszolek ZK, Pendziwiat M, Lorenzo-Betancor O, Seppi K, Berg D, Vilariño-Güell C, Postuma RB, Bernard G, Dupré N, Jankovic J, Testa CM, Ross OA, Arzberger T, Chouinard S, Louis ED, Mandich P, Vitale C, Barone P, García-Martín E, Alonso-Navarro H, Agúndez JAG, Jiménez-Jiménez FJ, Pastor P, Rajput A, Deuschl G, Kuhlenbaümer G, Meijer IA, Dion PA, Rouleau GA. Association of Essential Tremor With Novel Risk Loci: A Genome-Wide Association Study and Meta-analysis. JAMA Neurol 2022; 79:185-193. [PMID: 34982113 PMCID: PMC8728658 DOI: 10.1001/jamaneurol.2021.4781] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Question Can common genetic variants associated with essential tremor (ET) be identified? Findings In this genome-wide association study and meta-analysis including genetic data on 483 054 individuals, 5 genome-wide significant loci were associated with risk of ET and common variants were associated with approximately 18% of ET heritability. Meaning Findings of this study may help identify new genes and inform ET biology. Importance Essential tremor (ET) is one of the most common movement disorders, affecting 5% of the general population older than 65 years. Common variants are thought to contribute toward susceptibility to ET, but no variants have been robustly identified. Objective To identify common genetic factors associated with risk of ET. Design, Setting, and Participants Case-control genome-wide association study. Inverse-variance meta-analysis was used to combine cohorts. Multicenter samples collected from European populations were collected from January 2010 to September 2019 as part of an ongoing study. Included patients were clinically diagnosed with or reported having ET. Control individuals were not diagnosed with or reported to have ET. Of 485 250 individuals, data for 483 054 passed data quality control and were used. Main Outcomes and Measures Genotypes of common variants associated with risk of ET. Results Of the 483 054 individuals included, there were 7177 with ET (3693 [51.46%] female; mean [SD] age, 62.66 [15.12] years), and 475 877 control individuals (253 785 [53.33%] female; mean [SD] age, 56.40 [17.6] years). Five independent genome-wide significant loci and were identified and were associated with approximately 18% of ET heritability. Functional analyses found significant enrichment in the cerebellar hemisphere, cerebellum, and axonogenesis pathways. Genetic correlation (r), which measures the degree of genetic overlap, revealed significant common variant overlap with Parkinson disease (r, 0.28; P = 2.38 × 10−8) and depression (r, 0.12; P = 9.78 × 10−4). A separate fine-mapping of transcriptome-wide association hits identified genes such as BACE2, LRRN2, DHRS13, and LINC00323 in disease-relevant brain regions, such as the cerebellum. Conclusions and Relevance The results of this genome-wide association study suggest that a portion of ET heritability can be explained by common genetic variation and can help identify new common genetic risk factors for ET.
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Affiliation(s)
- Calwing Liao
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada.,Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Charles-Etienne Castonguay
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada.,Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | | | - Veikko Vuokila
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Miranda Medeiros
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Gabrielle Houle
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada.,Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Fulya Akçimen
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada.,Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Jay P Ross
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada.,Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Helene Catoire
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Monica Diez-Fairen
- Fundació Docència i Recerca Mútua Terrassa, University Hospital Mútua de Terrassa, Terrassa, Barcelona, Spain.,Movement Disorders Unit, Department of Neurology, University Hospital Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Jooeun Kang
- Division of Genetic Medicine, Department of Medicine, Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stefanie H Mueller
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Simon L Girard
- Département des Sciences Fondamentales, Université du Québec à Chicoutimi, Saguenay, Quebec, Canada.,Montreal Neurological Institute, Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | | | - Delia Lorenz
- University Children's Hospital, University of Würzburg, Wurzburg, Germany
| | - Lorraine N Clark
- Department of Pathology and Cell Biology, Taub Institute, Columbia University, New York, New York
| | | | - Stephan Klebe
- Department of Neurology, University Hospital Würzburg, Wurzburg, Germany.,Department of Neurology, University Hospital Essen, Essen, Germany
| | - Mark Hallett
- National Institute of Neurological Disorders and Stroke Intramural Research Program, National Institutes of Health, Bethesda, Maryland
| | | | - Manuela Pendziwiat
- Institute of Clinical Molecular Biology, University of Kiel, Kiel, Germany.,Department of Neuropediatrics, University Medical Center Schleswig-Holstein, University of Kiel, Kiel, Germany
| | - Oswaldo Lorenzo-Betancor
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Neurology, University of Washington School of Medicine, Seattle
| | - Klaus Seppi
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Daniela Berg
- Department of Neurology, University Hospital Schleswig-Holstein, University of Kiel, Kiel, Germany
| | - Carles Vilariño-Güell
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ronald B Postuma
- Montreal Neurological Institute, Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Geneviève Bernard
- Montreal Neurological Institute, Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.,Division of Pediatric Neurology, Departments of Pediatrics, Neurology and Neurosurgery, Montreal Children's Hospital, Montreal, Quebec, Canada.,Child Health and Human Development Program, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Division of Medical Genetics, Department of Specialized Medicine, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nicolas Dupré
- Faculté de Médecine, Université Laval, Centre Hospitalier Universitaire de Québec (l'Enfant-Jésus), Quebec, Canada
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas
| | - Claudia M Testa
- Parkinson's and Movement Disorders Center, Department of Neurology, Virginia Commonwealth University, Richmond
| | - Owen A Ross
- Departments of Neuroscience and Clinical Genomics, Mayo Clinic Florida, Jacksonville
| | - Thomas Arzberger
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.,Center for Neuropathology and Prion Research, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sylvain Chouinard
- Unité des troubles du mouvement André Barbeau, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Elan D Louis
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas
| | - Paola Mandich
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genova, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico Policlinico, San Martino, Genova, Italy
| | - Carmine Vitale
- Department of Motor Sciences and Wellness, University Parthenope, Naples, Italy
| | - Paolo Barone
- Center for Neurodegenerative Disease (CEMAND), Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, Baronissi, Salerno, Italy
| | - Elena García-Martín
- University Institute of Molecular Pathology Biomarkers, UNEx, ARADyAL Instituto de Salud Carlos III, Caceres, Spain
| | | | - José A G Agúndez
- University Institute of Molecular Pathology Biomarkers, UNEx, ARADyAL Instituto de Salud Carlos III, Caceres, Spain
| | | | - Pau Pastor
- Fundació Docència i Recerca Mútua Terrassa, University Hospital Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Alex Rajput
- University of Saskatchewan, Saskatoon Health Authority, Saskatoon, Saskatchewan, Canada
| | - Günther Deuschl
- Department of Neurology, University Medical Center Schleswig Holstein, University of Kiel, Kiel, Germany
| | - Gregor Kuhlenbaümer
- Department of Neurology, University Hospital Schleswig-Holstein, University of Kiel, Kiel, Germany
| | - Inge A Meijer
- Department of Neuroscience and Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Patrick A Dion
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Guy A Rouleau
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada.,Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
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Vetterick C, Lyons KE, Matthews LG, Pendal R, Ravina B. The Hidden Burden of Disease and Treatment Experiences of Patients with Essential Tremor: A Retrospective Claims Data Analysis. Adv Ther 2022; 39:5546-5567. [PMID: 36239902 PMCID: PMC9618517 DOI: 10.1007/s12325-022-02318-8] [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: 08/05/2022] [Accepted: 09/06/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Essential tremor (ET) affects approximately 7 million people in the USA, yet public recognition of the disease and its impact remain low. METHODS A retrospective observational study examined US claims data from 2015 to 2019 using the Compile database. ET diagnoses were captured using longitudinal data from 2015 to 2019 and for the year 2019, with diagnosis estimates extrapolated to the general US population. Confirmed ET was identified by an ET diagnosis code with at least two relevant prescriptions or by two diagnosis codes for ET and unspecified tremor at least 90 days apart. Comorbidity and treatment use data were extracted, and medication compliance and 2-year treatment persistence were assessed as measures of treatment adherence. RESULTS A total of 1,336,183 patients with ET diagnoses codes were identified from 2015 through 2019, corresponding to 2,226,971 projected US diagnoses. In 2019, 128,263 patients had a confirmed ET diagnosis, corresponding to 213,772 projected US confirmed diagnoses. Of these, 96% had at least one comorbidity, and 64% received at least one pharmacologic treatment. Propranolol (24%) and primidone (20%) comprised the most common ET prescriptions. Two-year medication discontinuation rates were approximately 40%. CONCLUSION Our findings revealed that 1 million people were diagnosed and sought treatment for ET in the USA from 2015 to 2019. Projected population estimates of approximately 2 million people diagnosed suggest a further 1 million remain untreated. Our findings highlight the complexity of patient care in ET, complicated by delayed diagnoses, multiple comorbidities, and lack of effective and tolerable therapies that can mitigate treatment adherence limitations.
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Affiliation(s)
- Christine Vetterick
- Praxis Precision Medicines, 99 High Street, 30th Floor, Boston, MA, 02110, USA
| | - Kelly E Lyons
- University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Lillian G Matthews
- Praxis Precision Medicines, 99 High Street, 30th Floor, Boston, MA, 02110, USA
| | - Robert Pendal
- Praxis Precision Medicines, 99 High Street, 30th Floor, Boston, MA, 02110, USA
| | - Bernard Ravina
- Praxis Precision Medicines, 99 High Street, 30th Floor, Boston, MA, 02110, USA.
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10
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Kosmowska B, Wardas J. The Pathophysiology and Treatment of Essential Tremor: The Role of Adenosine and Dopamine Receptors in Animal Models. Biomolecules 2021; 11:1813. [PMID: 34944457 PMCID: PMC8698799 DOI: 10.3390/biom11121813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/25/2021] [Accepted: 11/30/2021] [Indexed: 12/13/2022] Open
Abstract
Essential tremor (ET) is one of the most common neurological disorders that often affects people in the prime of their lives, leading to a significant reduction in their quality of life, gradually making them unable to independently perform the simplest activities. Here we show that current ET pharmacotherapy often does not sufficiently alleviate disease symptoms and is completely ineffective in more than 30% of patients. At present, deep brain stimulation of the motor thalamus is the most effective ET treatment. However, like any brain surgery, it can cause many undesirable side effects; thus, it is only performed in patients with an advanced disease who are not responsive to drugs. Therefore, it seems extremely important to look for new strategies for treating ET. The purpose of this review is to summarize the current knowledge on the pathomechanism of ET based on studies in animal models of the disease, as well as to present and discuss the results of research available to date on various substances affecting dopamine (mainly D3) or adenosine A1 receptors, which, due to their ability to modulate harmaline-induced tremor, may provide the basis for the development of new potential therapies for ET in the future.
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Affiliation(s)
| | - Jadwiga Wardas
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology Polish Academy of Sciences, 31-343 Kraków, Poland;
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11
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Roth N, Rosenblum S. Does Cup-Grip Type Affect Tremor among People with Essential Tremor? SENSORS 2021; 21:s21237797. [PMID: 34883799 PMCID: PMC8659972 DOI: 10.3390/s21237797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 12/02/2022]
Abstract
Essential tremor (ET) is a movement disorder that may cause functional disability in daily activities, such as drinking from a cup or drawing. This study aims to characterize effects of varied cup-grip types and measured axes on the actual performance of people with ET and find correlations between cup-grip type and measured axes, and spiral drawing measures. Participants (20 with ET and 18 controls) held a cup of water in a steady position in three grip types and drew a spiral. The cup acceleration was measured by the cup triaxial accelerometer, analyzed in X, Y and Z axes (directions); deviation of the measured acceleration from the desired steady position acceleration was computed. Significant group differences were found for outcome measures in all grip types. Among participants with ET, significantly higher measured values were found in the cup’s horizontal plane (X and Y axes) compared to the vertical direction (Z axis) and for on-the-handle versus around-the-cup grips in the X and Y axes. Significant correlations were found between this grip’s measures and spiral-drawing actual performance measures, indicating the measurement axis and grip type may affect actual performance. These findings may support the future development of assistive devices for tremor suppression and personalized supportive therapy.
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Affiliation(s)
- Navit Roth
- The Laboratory of Complex Human Activity and Participation (CHAP), Department of Occupational Therapy, University of Haifa, Haifa 3498838, Israel;
- Department of Mechanical Engineering, ORT Braude Academic College of Engineering, Karmiel 2161002, Israel
- Correspondence:
| | - Sara Rosenblum
- The Laboratory of Complex Human Activity and Participation (CHAP), Department of Occupational Therapy, University of Haifa, Haifa 3498838, Israel;
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12
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Roth N, Braun-Benyamin O, Rosenblum S. Drawing Direction Effect on a Task's Performance Characteristics among People with Essential Tremor. SENSORS (BASEL, SWITZERLAND) 2021; 21:5814. [PMID: 34502703 PMCID: PMC8433857 DOI: 10.3390/s21175814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 08/25/2021] [Accepted: 08/25/2021] [Indexed: 12/26/2022]
Abstract
Essential tremor (ET) is a common movement disorder affecting the performance of various daily tasks, including drawing. While spiral-drawing task characteristics have been described among patients with ET, research about the significance of the drawing direction of both spiral and lines tasks on the performance process is scarce. This study mapped inter-group differences between people with ET and controls related to drawing directions and the intra-effect of the drawing directions on the tremor level among people with ET. Twenty participants with ET and eighteen without ET drew spirals and vertical and horizontal lines on a digitizer with an inking pen. Time-based outcome measures were gathered to address the effect of the drawing directions on tremor by analyzing various spiral sections and comparing vertical and horizontal lines. Significant group differences were found in deviation of the spiral radius from a filtered radius curve and in deviation of the distance curve from a filtered curve for both line types. Significant differences were found between defined horizontal and vertical spiral sections within each group and between both line types within the ET group. A significant correlation was found between spiral and vertical line deviations from filtered curve outcome measures. Achieving objective measures about the significance of drawing directions on actual performance may support the clinical evaluation of people with ET toward developing future intervention methods for improving their functional abilities.
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Affiliation(s)
- Navit Roth
- The Laboratory of Complex Human Activity and Participation (CHAP), Department of Occupational Therapy, University of Haifa, Haifa 3498838, Israel;
- Department of Mechanical Engineering, ORT Braude Academic College of Engineering, Karmiel 2161002, Israel;
| | - Orit Braun-Benyamin
- Department of Mechanical Engineering, ORT Braude Academic College of Engineering, Karmiel 2161002, Israel;
| | - Sara Rosenblum
- The Laboratory of Complex Human Activity and Participation (CHAP), Department of Occupational Therapy, University of Haifa, Haifa 3498838, Israel;
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13
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Abstract
Essential tremor (ET) is one of the most common movement disorders and can occur unexpectedly and develop indefinitely to any population unit. According to the recorded statistics of people suffering from ET, the disorder affects 5% of people worldwide, thus creating an ever-increasing need to investigate ways for its suppression and treatment. In this article, we investigate the capability of Pneumatic Artificial Muscles (PAMs) to reduce or even suppress ET leading to the relief of the sufferers. In our work, we designed and constructed two iterations of a glovelike setup and attempted to explore the possibility of suppressing ET on different parts of the hand by exerting force on the index finger and metacarpal region. For both glove iterations, we established an experimental protocol based on the adjustment of a force controller. Finally, we evaluated exhaustively the performance of our setup under multiple motion scenarios with the participation of an ET-diagnosed volunteer.
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14
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Weerasinghe G, Duchet B, Bick C, Bogacz R. Optimal closed-loop deep brain stimulation using multiple independently controlled contacts. PLoS Comput Biol 2021; 17:e1009281. [PMID: 34358224 PMCID: PMC8405008 DOI: 10.1371/journal.pcbi.1009281] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/30/2021] [Accepted: 07/15/2021] [Indexed: 11/18/2022] Open
Abstract
Deep brain stimulation (DBS) is a well-established treatment option for a variety of neurological disorders, including Parkinson’s disease and essential tremor. The symptoms of these disorders are known to be associated with pathological synchronous neural activity in the basal ganglia and thalamus. It is hypothesised that DBS acts to desynchronise this activity, leading to an overall reduction in symptoms. Electrodes with multiple independently controllable contacts are a recent development in DBS technology which have the potential to target one or more pathological regions with greater precision, reducing side effects and potentially increasing both the efficacy and efficiency of the treatment. The increased complexity of these systems, however, motivates the need to understand the effects of DBS when applied to multiple regions or neural populations within the brain. On the basis of a theoretical model, our paper addresses the question of how to best apply DBS to multiple neural populations to maximally desynchronise brain activity. Central to this are analytical expressions, which we derive, that predict how the symptom severity should change when stimulation is applied. Using these expressions, we construct a closed-loop DBS strategy describing how stimulation should be delivered to individual contacts using the phases and amplitudes of feedback signals. We simulate our method and compare it against two others found in the literature: coordinated reset and phase-locked stimulation. We also investigate the conditions for which our strategy is expected to yield the most benefit. In this paper we use computer models of brain tissue to derive an optimal control algorithm for a recently developed new generation of deep brain stimulation (DBS) devices. DBS is a treatment for a variety of neurological disorders including Parkinson’s disease, essential tremor, depression and pain. There is a growing amount of evidence to suggest that delivering stimulation according to feedback from patients, or closed-loop, has the potential to improve the efficacy, efficiency and side effects of the treatment. An important recent development in DBS technology are electrodes with multiple independently controllable contacts and this paper is a theoretical study into the effects of using this new technology. On the basis of a theoretical model, we devise a closed-loop strategy and address the question of how to best apply DBS across multiple contacts to maximally desynchronise neural populations. We demonstrate using numerical simulation that, for the systems we consider, our methods are more effective than two well-known alternatives, namely phase-locked stimulation and coordinated reset. We also predict that the benefits of using multiple contacts should depend strongly on the intrinsic neuronal response. The insights from this work should lead to a better understanding of how to implement and optimise closed-loop multi-contact DBS systems which in turn should lead to more effective and efficient DBS treatments.
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Affiliation(s)
- Gihan Weerasinghe
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Benoit Duchet
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Christian Bick
- Department of Mathematics, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Systems and Network Neuroscience, Amsterdam Neuroscience, Amsterdam, The Netherlands
- Mathematical Institute, University of Oxford, Oxford, United Kingdom
- Department of Mathematics, University of Exeter, Exeter, United Kingdom
| | - Rafal Bogacz
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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15
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Shukla S, Thirugnanasambandam N. Tapping the Potential of Multimodal Non-invasive Brain Stimulation to Elucidate the Pathophysiology of Movement Disorders. Front Hum Neurosci 2021; 15:661396. [PMID: 34054449 PMCID: PMC8149895 DOI: 10.3389/fnhum.2021.661396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/30/2021] [Indexed: 11/18/2022] Open
Abstract
This mini-review provides a detailed outline of studies that have used multimodal approaches in non-invasive brain stimulation to investigate the pathophysiology of the three common movement disorders, namely, essential tremor, Parkinson’s disease, and dystonia. Using specific search terms and filters in the PubMed® database, we finally shortlisted 27 studies in total that were relevant to this review. While two-thirds (Brittain et al., 2013) of these studies were performed on Parkinson’s disease patients, we could find only three studies that were conducted in patients with essential tremor. We clearly show that although multimodal non-invasive brain stimulation holds immense potential in unraveling the physiological mechanisms that are disrupted in movement disorders, the technical challenges and pitfalls of combining these methods may hinder their widespread application by movement disorder specialists. A multidisciplinary team with clinical and technical expertise may be crucial in reaping the fullest benefits from such novel multimodal approaches.
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Affiliation(s)
- Sakshi Shukla
- National Brain Research Centre (NBRC), Manesar, India
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16
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Sedov A, Usova S, Semenova U, Gamaleya A, Tomskiy A, Beylergil SB, Jinnah HA, Shaikh AG. Pallidal Activity in Cervical Dystonia with and Without Head Tremor. THE CEREBELLUM 2021; 19:409-418. [PMID: 32095996 DOI: 10.1007/s12311-020-01119-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The relationship between two common movement disorders, dystonia and tremor, is controversial. Both deficits have correlates in the network that includes connections between the cerebellum and the basal ganglia. In order to assess the physiological relationship between tremor and dystonia, we measured the activity of 727 pallidal single-neurons during deep brain stimulation surgery in patients with cervical dystonia without head oscillations, cervical dystonia plus jerky oscillations, and cervical dystonia with sinusoidal oscillations. Cluster analyses of spike-train recordings allowed classification of the pallidal activity into burst, pause, and tonic. Burst neurons were more common, and number of spikes within spike and inter-burst intervals was shorter in pure dystonia and jerky oscillation groups compared to the sinusoidal oscillation group. Pause neurons were more common and irregular in pure tremor group compared to pure dystonia and jerky oscillation groups. There was bihemispheric asymmetry in spontaneous firing discharge in pure dystonia and jerky oscillation groups, but not in sinusoidal oscillation group. These results demonstrate that the physiology of pallidal neurons in patients with pure cervical dystonia is similar to those who have cervical dystonia combined with jerky oscillations, but different from those who have cervical dystonia combined with sinusoidal oscillations. These results imply distinct mechanistic underpinnings for different types of head oscillations in cervical dystonia.
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Affiliation(s)
- Alexey Sedov
- Semenov Institute of chemical physics, Russian Academy of Sciences, Moscow, Russia.,Moscow Institute of physics and technology, Moscow, Dolgoprudny, Russia
| | - Svetlana Usova
- Semenov Institute of chemical physics, Russian Academy of Sciences, Moscow, Russia
| | - Ulia Semenova
- Semenov Institute of chemical physics, Russian Academy of Sciences, Moscow, Russia
| | - Anna Gamaleya
- N .N. Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia
| | - Alexey Tomskiy
- N .N. Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia
| | - Sinem B Beylergil
- Departments of Neurology and Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - H A Jinnah
- Department of Neurology, Pediatrics, and Genetics, Emory University, Atlanta, GA, USA
| | - Aasef G Shaikh
- Departments of Neurology and Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA. .,Neurological Institute, University Hospitals, Cleveland, OH, USA. .,Neurology Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA. .,Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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17
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The Problem of Questionable Dystonia in the Diagnosis of 'Essential Tremor-Plus'. Tremor Other Hyperkinet Mov (N Y) 2020; 10:27. [PMID: 32864186 PMCID: PMC7427675 DOI: 10.5334/tohm.539] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
In a recent consensus statement on tremor, the task force of the International Parkinson and Movement Disorder Society proposed a new term, ‘essential tremor-plus (ET-plus)’ which includes patients with the characteristics of essential tremor (ET) and additional soft neurological signs of uncertain significance such as questionable dystonic posturing. The clinical interpretation of questionable dystonia has been left to the investigator. The consensus statement also stated that the ET-plus syndrome does not include other clearly defined syndromes like dystonic tremor. However, the boundary between questionable dystonia and definite dystonia is not distinct leading to diagnostic uncertainty in a clinical setting. A similar case may be classified as ET-plus by one observer and dystonic tremor by another. Following the new definition, many studies have reclassified their ET cohort, and they have highlighted the problem of defining questionable dystonia in the diagnosis of ET plus. ET-plus is likely to be a mixture of patients that actually have dystonia and those that don’t, and clinically all we can do is to be suspicious that there might be dystonia. For example, it is not clear whether we should consider spooning and index finger pointing as a sign of questionable or definite dystonia. There are major research and possible therapeutic implications of questionable dystonia in the diagnosis of ET-plus. The concept of ET-plus is extremely difficult to implement without definite guidelines. The resolution will need a biomarker such as physiology or imaging.
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Liao C, Sarayloo F, Vuokila V, Rochefort D, Akçimen F, Diamond S, Houle G, Laporte AD, Spiegelman D, He Q, Catoire H, Dion PA, Rouleau GA. Transcriptomic Changes Resulting From STK32B Overexpression Identify Pathways Potentially Relevant to Essential Tremor. Front Genet 2020; 11:813. [PMID: 32849812 PMCID: PMC7413243 DOI: 10.3389/fgene.2020.00813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/06/2020] [Indexed: 12/18/2022] Open
Abstract
Objective: Essential tremor (ET) is a common movement disorder that has a high heritability. A number of genetic studies have associated different genes and loci with ET, but few have investigated the biology of any of these genes. STK32B was significantly associated with ET in a large genome-wide association study (GWAS) and was found to be overexpressed in ET cerebellar tissue. The objective of this study is to determine the effects of overexpressed STK32B in cerebellar DAOY cells. Methods: Here, we overexpressed STK32B RNA in human cerebellar DAOY cells and used an RNA-Seq approach to identify differentially expressed genes (DEGs) by comparing the transcriptome profile of these cells to one of the control DAOY cells. Results: Pathway and gene ontology enrichment identified axon guidance, olfactory signaling, and calcium-voltage channels as significant. Additionally, we show that overexpressing STK32B affects transcript levels of previously implicated ET genes such as FUS. Conclusion: Our results investigate the effects of overexpressed STK32B and suggest that it may be involved in relevant ET pathways and genes.
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Affiliation(s)
- Calwing Liao
- Department of Human Genetics, McGill University, Montreal, QC, Canada.,Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Faezeh Sarayloo
- Department of Human Genetics, McGill University, Montreal, QC, Canada.,Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Veikko Vuokila
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Daniel Rochefort
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Fulya Akçimen
- Department of Human Genetics, McGill University, Montreal, QC, Canada.,Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Simone Diamond
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Gabrielle Houle
- Department of Human Genetics, McGill University, Montreal, QC, Canada.,Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | | | - Dan Spiegelman
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Qin He
- Department of Biomedical Sciences, Université de Montréal, Montreal, QC, Canada
| | - Hélène Catoire
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Patrick A Dion
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Guy A Rouleau
- Department of Human Genetics, McGill University, Montreal, QC, Canada.,Montreal Neurological Institute, McGill University, Montreal, QC, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
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Kosmowska B, Ossowska K, Wardas J. Pramipexole Reduces zif-268 mRNA Expression in Brain Structures involved in the Generation of Harmaline-Induced Tremor. Neurochem Res 2020; 45:1518-1525. [PMID: 32172399 PMCID: PMC7297825 DOI: 10.1007/s11064-020-03010-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/11/2020] [Accepted: 03/04/2020] [Indexed: 11/25/2022]
Abstract
Essential tremor is one of the most common neurological disorders, however, it is not sufficiently controlled with currently available pharmacotherapy. Our recent study has shown that pramipexole, a drug efficient in inhibiting parkinsonian tremor, reduced the harmaline-induced tremor in rats, generally accepted to be a model of essential tremor. The aim of the present study was to investigate brain targets for the tremorolytic effect of pramipexole by determination of the early activity-dependent gene zif-268 mRNA expression. Tremor in rats was induced by harmaline administered at a dose of 15 mg/kg ip. Pramipexole was administered at a low dose of 0.1 mg/kg sc. Tremor was measured by Force Plate Actimeters where four force transducers located below the corners of the plate tracked the animal's position on a Cartesian plane. The zif-268 mRNA expression was analyzed by in situ hybridization in brain slices. Harmaline induced tremor and increased zif-268 mRNA levels in the inferior olive, cerebellar cortex, ventroanterior/ventrolateral thalamic nuclei and motor cortex. Pramipexole reversed both the harmaline-induced tremor and the increase in zif-268 mRNA expression in the inferior olive, cerebellar cortex and motor cortex. Moreover, the tremor intensity correlated positively with zif-268 mRNA expression in the above structures. The present results seem to suggest that the tremorolytic effect of pramipexole is related to the modulation of the harmaline-increased neuronal activity in the tremor network which includes the inferior olive, cerebellar cortex and motor cortex. Potential mechanisms underlying the above pramipexole action are discussed.
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Affiliation(s)
- Barbara Kosmowska
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smętna Street, 31-343, Kraków, Poland
| | - Krystyna Ossowska
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smętna Street, 31-343, Kraków, Poland
| | - Jadwiga Wardas
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smętna Street, 31-343, Kraków, Poland.
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20
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van Brummelen EMJ, Ziagkos D, de Boon WMI, Hart EP, Doll RJ, Huttunen T, Kolehmainen P, Groeneveld GJ. Quantification of tremor using consumer product accelerometry is feasible in patients with essential tremor and Parkinson's disease: a comparative study. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2020; 7:4. [PMID: 32280482 PMCID: PMC7137336 DOI: 10.1186/s40734-020-00086-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/10/2020] [Indexed: 11/10/2022]
Abstract
Background To quantify pharmacological effects on tremor in patients with essential tremor (ET) or Parkinson’s Disease (PD), laboratory-grade accelerometers have previously been used. Over the last years, consumer products such as smartphones and smartwatches have been increasingly applied to measure tremor in an easy way. However, it is unknown how the technical performance of these consumer product accelerometers (CPAs) compares to laboratory-grade accelerometers (LGA). This study was performed to compare the technical performance of CPAs with LGA to measure tremor in patients with Parkinson’s Disease (PD) and essential tremor (ET). Methods In ten patients with PD and ten with ET, tremor peak frequency and corresponding amplitude were measured with 7 different CPAs (Apple iPhone 7, Apple iPod Touch 5, Apple watch 2, Huawei Nexus 6P, Huawei watch, mbientlabMetaWear (MW) watch, mbientlab MW clip) and compared to a LGA (Biometrics ACL300) in resting and extended arm position. Results Both in PD and ET patients, the peak frequency of CPAs did not significantly differ from the LGA in terms of limits of agreement. For the amplitude at peak frequency, only the iPhone and MW watch performed comparable to the LGA in ET patients, while in PD patients all methods performed comparable except for the iPod Touch and Huawei Nexus. Amplitude was higher when measured with distally-located CPAs (Clip, iPhone, iPod) compared with proximally-located CPAs (all watches). The variability between subjects was higher than within subjects for frequency (25.1% vs. 13.4%) and amplitude measurement (331% vs. 53.6%). Resting arm position resulted in lower intra-individual variability for frequency and amplitude (13.4 and 53.5%) compared to extended arm position (17.8 and 58.1%). Conclusions Peak frequencies of tremor could be measured with all tested CPAs, with similar performance as LGA. The amplitude measurements appeared to be driven by anatomical location of the device and can therefore not be compared. Our results show that the tested consumer products can be used for tremography, allowing at-home measurements, in particular in studies with a cross-over or intra-individual comparison design using the resting arm position. Trial registration This trial was registered in the Dutch Competent Authority (CCMO) database with number NL60672.058.17 on May 30th 2017.
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Affiliation(s)
| | - Dimitrios Ziagkos
- 1Centre for Human Drug Research, Zernikedreef 8, Leiden, 2333 CL The Netherlands
| | - Wadim M I de Boon
- 1Centre for Human Drug Research, Zernikedreef 8, Leiden, 2333 CL The Netherlands
| | - Ellen P Hart
- 1Centre for Human Drug Research, Zernikedreef 8, Leiden, 2333 CL The Netherlands
| | - Robert J Doll
- 1Centre for Human Drug Research, Zernikedreef 8, Leiden, 2333 CL The Netherlands
| | | | | | - Geert Jan Groeneveld
- 1Centre for Human Drug Research, Zernikedreef 8, Leiden, 2333 CL The Netherlands.,4Department of Anesthesiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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21
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Kosmowska B, Ossowska K, Konieczny J, Lenda T, Berghauzen-Maciejewska K, Wardas J. Inhibition of Excessive Glutamatergic Transmission in the Ventral Thalamic Nuclei by a Selective Adenosine A1 Receptor Agonist, 5′-Chloro-5′-Deoxy-(±)-ENBA Underlies its Tremorolytic Effect in the Harmaline-Induced Model of Essential Tremor. Neuroscience 2020; 429:106-118. [DOI: 10.1016/j.neuroscience.2019.12.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/16/2019] [Accepted: 12/28/2019] [Indexed: 12/20/2022]
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22
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Forman CR, Svane C, Kruuse C, Gracies JM, Nielsen JB, Lorentzen J. Sustained involuntary muscle activity in cerebral palsy and stroke: same symptom, diverse mechanisms. Brain Commun 2019; 1:fcz037. [PMID: 33033798 PMCID: PMC7531180 DOI: 10.1093/braincomms/fcz037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 12/12/2022] Open
Abstract
Individuals with lesions of central motor pathways frequently suffer from sustained
involuntary muscle activity. This symptom shares clinical characteristics with dystonia
but is observable in individuals classified as spastic. The term spastic dystonia has been
introduced, although the underlying mechanisms of involuntary activity are not clarified
and vary between individuals depending on the disorder. This study aimed to investigate
the nature and pathophysiology of sustained involuntary muscle activity in adults with
cerebral palsy and stroke. Seventeen adults with cerebral palsy (Gross Motor Function
Classification System I–V), 8 adults with chronic stroke and 14 control individuals
participated in the study. All individuals with cerebral palsy or stroke showed increased
resistance to passive movement with Modified Ashworth Scale >1. Two-minute surface EMG
recordings were obtained from the biceps muscle during attempted rest in three positions
of the elbow joint; a maximally flexed position, a 90-degree position and a maximally
extended position. Cross-correlation analysis of sustained involuntary muscle activity
from individuals with cerebral palsy and stroke, and recordings of voluntary isometric
contractions from control individuals were performed to examine common synaptic drive. In
total, 13 out of 17 individuals with cerebral palsy and all 8 individuals with stroke
contained sustained involuntary muscle activity. In individuals with cerebral palsy, the
level of muscle activity was not affected by the joint position. In individuals with
stroke, the level of muscle activity significantly (P < 0.05)
increased from the flexed position to the 90 degree and extended position. Cumulant
density function indicated significant short-term synchronization of motor unit activities
in all recordings. All groups exhibited significant coherence in the alpha (6–15 Hz), beta
(16–35 Hz) and early gamma band (36–60 Hz). The cerebral palsy group had lower alpha band
coherence estimates, but higher gamma band coherence estimates compared with the stroke
group. Individuals with increased resistance to passive movement due to cerebral palsy or
stroke frequently suffer sustained involuntary muscle activity, which cannot exclusively
be described by spasticity. The sustained involuntary muscle activity in both groups
originated from a common synaptic input to the motor neuron pool, but the generating
mechanisms could differ between groups. In cerebral palsy it seemed to originate more from
central mechanisms, whereas peripheral mechanisms likely play a larger role in stroke. The
sustained involuntary muscle activity should not be treated simply like the spinal stretch
reflex mediated symptom of spasticity and should not either be treated identically in both
groups.
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Affiliation(s)
| | - Christian Svane
- Department of Neuroscience, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Christina Kruuse
- Department of Neurology, Neurovascular Research Unit, Herlev Gentofte Hospital, 2730 Herlev Gentofte, Denmark
| | - Jean-Michel Gracies
- EA 7377 BIOTN, Université Paris-Est Creteil, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, APHP, Créteil, France
| | - Jens Bo Nielsen
- Department of Neuroscience, University of Copenhagen, 2200 Copenhagen, Denmark.,Elsass Institute, 2830 Charlottenlund, Denmark
| | - Jakob Lorentzen
- Department of Neuroscience, University of Copenhagen, 2200 Copenhagen, Denmark.,Elsass Institute, 2830 Charlottenlund, Denmark
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Lee J, Chang SY. Altered Primary Motor Cortex Neuronal Activity in a Rat Model of Harmaline-Induced Tremor During Thalamic Deep Brain Stimulation. Front Cell Neurosci 2019; 13:448. [PMID: 31680866 PMCID: PMC6803555 DOI: 10.3389/fncel.2019.00448] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 09/19/2019] [Indexed: 01/30/2023] Open
Abstract
Although deep brain stimulation (DBS) is a clinically effective surgical treatment for essential tremor (ET), and its neurophysiological mechanisms are not fully understood. As the motor thalamus is the most popular DBS target for ET, and it is known that the thalamic nucleus plays a key role in relaying information about the external environment to the cerebral cortex, it is important to investigate mechanisms of thalamic DBS in the context of the cerebello-thalamo-cortical neuronal network. To examine this, we measured single-unit neuronal activities in the resting state in M1 during VL thalamic DBS in harmaline-induced tremor rats and analyzed neuronal activity patterns in the thalamo-cortical circuit. Four activity patterns - including oscillatory burst, oscillatory non-burst, irregular burst, and irregular non-burst - were identified by harmaline administration; and those firing patterns were differentially affected by VL thalamic DBS, which seems to drive pathologic cortical signals to signals in normal status. As specific neuronal firing patterns like oscillation or burst are considered important for information processing, our results suggest that VL thalamic DBS may modify pathophysiologic relay information rather than simply inhibit the information transmission.
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Affiliation(s)
- Jihyun Lee
- Laboratory of Brain & Cognitive Sciences for Convergence Medicine, College of Medicine, Hallym University, Anyang, South Korea
| | - Su-Youne Chang
- Department of Neurologic Surgery, Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
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24
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Beylergil SB, Singh AP, Zee DS, Jinnah HA, Shaikh AG. Relationship between jerky and sinusoidal oscillations in cervical dystonia. Parkinsonism Relat Disord 2019; 66:130-137. [PMID: 31345708 DOI: 10.1016/j.parkreldis.2019.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/17/2019] [Accepted: 07/20/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Dystonia is often associated with repetitive jerky oscillations (i.e. dystonic tremor), while tremor is characterized by sinusoidal oscillations. We propose two competing predictions for dystonic tremor and sinusoidal tremor relationship. In any given patient, (1) the oscillation could be characterized as either sinusoidal or jerky based on the degree of distortion in the waveforms, (2) the oscillation consists of both sinusoidal and jerky waveforms mixed in a certain proportion that varies among individuals. We objectively test these predictions in patients with cervical dystonia. METHODS We recorded head oscillations in 14 subjects with cervical dystonia using a high-resolution magnetic field search coil system. Distortion in the signal was used as a measure of jerkiness. A hierarchical clustering classified the oscillations based on distortion characteristics. RESULTS Signal analysis in the frequency domain allowed identification of the components of the waveforms at frequencies other than the fundamental frequency. The distortion from the component at fundamental frequency was present in both low and high frequency range. Based on varying levels of distortions, i.e. jerkiness, the head oscillations were grouped into 4 clusters: one cluster with lowest distortion (sinusoidal waveforms), one cluster with highest distortion (jerky waveforms), and two intermediate clusters - one with distortion at low frequency and another with distortion at high frequency. The distribution of 4 clusters varied across subjects suggesting co-existence of sinusoidal and jerky waveforms. CONCLUSION These results support the prediction that jerky and sinusoidal waveforms concur in cervical dystonia. Amount of concurrence varies amongst patients.
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Affiliation(s)
- Sinem Balta Beylergil
- Department of Biomedical Engineering, Case Western University School of Medicine, Cleveland, OH, USA
| | - Aditya P Singh
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX, USA
| | - David S Zee
- Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA
| | - Hyder A Jinnah
- Departments of Neurology and Human Genetics, Emory University, Atlanta, GA, USA
| | - Aasef G Shaikh
- Department of Biomedical Engineering, Case Western University School of Medicine, Cleveland, OH, USA; Department of Neurology, Case Western University School of Medicine, Cleveland, OH, USA; Neurological Institute, University Hospitals, Cleveland, OH, USA; Neurology Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.
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25
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Rajput AH, Rajput EF, Bocking SM, Auer RN, Rajput A. Parkinsonism in essential tremor cases: A clinicopathological study. Mov Disord 2019; 34:1031-1040. [PMID: 31180613 PMCID: PMC6771898 DOI: 10.1002/mds.27729] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/07/2019] [Accepted: 05/09/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Essential tremor and Parkinson's syndrome are two common movement disorders that may co-occur in some individuals. There is no diagnostic neuropathology for essential tremor, but in PD and other Parkinson's syndrome variants, the neuropathology is well known. The spectrum of Parkinson's syndrome variants associated with essential tremor, their clinical features, and course have not been determined in autopsy-confirmed cases. OBJECTIVES To identify: diagnostic features of essential tremor/Parkinson's syndrome, different Parkinson's syndrome variants, and long-term clinical profile in such cases. METHODS Patients that had an essential tremor diagnosis and a subsequent clinical or pathological diagnosis of Parkinson's syndrome seen in our clinic during 50 years were included. The diagnosis of parkinsonism was made when bradykinesia, rigidity, and resting tremor were all clinically evident. RESULTS Twenty-one cases were included. All the common variants of parkinsonism co-occurred with essential tremor. The most common was PD (67%) followed by PSP. The pathological findings were not predicted clinically in 2 cases that had essential tremor/PD and in all 5 essential tremor/PSP cases. CONCLUSION In most essential tremor/Parkinson's syndrome patients, the main motor features of parkinsonism-bradykinesia, rigidity, and resting tremor-were identifiable. All known degenerative Parkinson's syndrome variants co-occurred in essential tremor patients. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Ali H. Rajput
- Saskatchewan Movement Disorders ProgramUniversity of Saskatchewan/ Saskatchewan Health AuthoritySaskatoonSaskatchewanCanada
| | - Emma F. Rajput
- Saskatchewan Movement Disorders ProgramUniversity of Saskatchewan/ Saskatchewan Health AuthoritySaskatoonSaskatchewanCanada
| | - Sarah M. Bocking
- Saskatchewan Movement Disorders ProgramUniversity of Saskatchewan/ Saskatchewan Health AuthoritySaskatoonSaskatchewanCanada
| | - Roland N. Auer
- Department of PathologySaskatchewan Health AuthoritySaskatoonSaskatchewanCanada
| | - Alex Rajput
- Saskatchewan Movement Disorders ProgramUniversity of Saskatchewan/ Saskatchewan Health AuthoritySaskatoonSaskatchewanCanada
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26
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Luft F, Sharifi S, Mugge W, Schouten AC, Bour LJ, van Rootselaar AF, Veltink PH, Heida T. Deficits in tapping accuracy and variability in tremor patients. J Neuroeng Rehabil 2019; 16:54. [PMID: 31064378 PMCID: PMC6505201 DOI: 10.1186/s12984-019-0528-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background The basal ganglia and cerebellum are brain structures involved in movement initiation, execution and termination. They are thought to be involved in the tremor generation and movement deficits in Parkinson’s disease (PD) and essential tremor (ET). Especially in PD, maintaining cyclic movement, such as walking or tapping can be significantly disturbed. Providing external cues improves timing of these movements in PD but its effect on ET has not yet been studied in depth. The aim of this study is to evaluate the usefulness of a bimanual tapping task as a tool during clinical decision making. Method Hand movements and tremor was recorded using accelerometers and EMG (m. extensor carpi ulnaris) from PD and ET patients and healthy controls during a bimanual tapping task as a way to distinguish PD from ET. All subjects performed the tapping task at two different frequencies, 2 Hz and 4 Hz, with and without the presence of auditory cues. Results No significant intra-group differences were found in the patient groups. Acceleration data revealed significantly less accurate tapping and more variable tapping in PD than in ET and healthy controls. ET subjects tapped less accurate and with a greater variability than healthy controls during the 4 Hz tapping task. Most interestingly the tapping accuracy improved in PD patients when kinetic tremor was recorded with EMG during the task. Conclusion Providing ET and PD patients with an external cue results in different tapping performances between patient groups and healthy controls. Furthermore, the findings suggest that kinetic tremor in PD enables patients to perform the task with a greater accuracy. So far this has not been shown in other studies.
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Affiliation(s)
- Frauke Luft
- Department of Biomedical Signals and Systems, University of Twente, Enschede, The Netherlands.
| | - Sarvi Sharifi
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Winfred Mugge
- Department of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, The Netherlands
| | - Alfred C Schouten
- Department of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, The Netherlands
| | - Lo J Bour
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne-Fleur van Rootselaar
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter H Veltink
- Department of Biomedical Signals and Systems, University of Twente, Enschede, The Netherlands
| | - Tijtske Heida
- Department of Biomedical Signals and Systems, University of Twente, Enschede, The Netherlands
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27
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Crevecoeur F, Gevers M. Filtering Compensation for Delays and Prediction Errors during Sensorimotor Control. Neural Comput 2019; 31:738-764. [DOI: 10.1162/neco_a_01170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Compensating for sensorimotor noise and for temporal delays has been identified as a major function of the nervous system. Although these aspects have often been described separately in the frameworks of optimal cue combination or motor prediction during movement planning, control-theoretic models suggest that these two operations are performed simultaneously, and mounting evidence supports that motor commands are based on sensory predictions rather than sensory states. In this letter, we study the benefit of state estimation for predictive sensorimotor control. More precisely, we combine explicit compensation for sensorimotor delays and optimal estimation derived in the context of Kalman filtering. We show, based on simulations of human-inspired eye and arm movements, that filtering sensory predictions improves the stability margin of the system against prediction errors due to low-dimensional predictions or to errors in the delay estimate. These simulations also highlight that prediction errors qualitatively account for a broad variety of movement disorders typically associated with cerebellar dysfunctions. We suggest that adaptive filtering in cerebellum, instead of often-assumed feedforward predictions, may achieve simple compensation for sensorimotor delays and support stable closed-loop control of movements.
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Affiliation(s)
- F. Crevecoeur
- Institute of Information and Communication Technologies, Electronics and Applied Mathematics, University of Louvain, Louvain-la-Neuve 1348, Belgium, and Institute of Neuroscience, University of Louvain, Brussels 1200, Belgium
| | - M. Gevers
- Institute of Information and Communication Technologies, Electronics and Applied Mathematics, University of Louvain, Louvain-la-Neuve 1348, Belgium
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28
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Patel PN, Kabagambe EK, Starkweather JC, Keller M, Ahmed ZA, Gruber SC, Akins JS, Garrett CG, Francis DO. Defining differences in patient characteristics between spasmodic dysphonia and laryngeal tremor. Laryngoscope 2018; 129:170-176. [PMID: 30426500 DOI: 10.1002/lary.27245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 03/10/2018] [Accepted: 03/26/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare presenting characteristics of patients with adductor spasmodic dysphonia (ADSD), ADSD with laryngeal tremor (ADSD + LT), and laryngeal tremor without ADSD (LT). DESIGN Cross-sectional analysis. METHODS Patients treated for laryngeal movement disorders (1990-2016) were included. Analysis of variance and chi square tests measured differences in patient characteristics across the three disease groups. Using ADSD as the referent, multivariable logistic regression models were used to determine whether potential risk factors including patient demographics, family history, presence of potential inciting events prior to disease onset, and coprevalent movement disorders were associated with ADSD + LT or LT. RESULTS In all, 652 patients with ADSD (n = 377), ADSD + LT (n = 98), and LT (n = 177) were included. ADSD patients were significantly younger than those with ADSD + LT and LT (52.5 ± 13.4, 63.9 ± 11.3, and 69.3 ± 10.5 years, respectively; P < 0.001). Coprevalent movement disorders were more common in ADSD + LT (38.7%) and LT (57.1%) groups than in the ADSD group (11.5%; P < 0.001). Compared to ADSD, patients with ADSD + LT and LT were more likely to develop an additional movement disorder during follow-up. In multivariable analyses, increasing age, female gender, and having a movement disorder at presentation were associated with significantly greater odds of having ADSD + LT or LT when compared to ADSD. CONCLUSION ADSD + LT patients demonstrate intermediate gender composition and age distributions between those with ADSD and LT. These findings suggest that ADSD + LT may be a distinct phenotype in the spectrum of laryngeal movement disorders. LEVEL OF EVIDENCE 4 Laryngoscope, 129:170-176, 2019.
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Affiliation(s)
- Priyesh N Patel
- Vanderbilt Voice Center, Department of Otolaryngology, Nashville, Tennessee
| | - Edmond K Kabagambe
- Vanderbilt Voice Center, Department of Otolaryngology, Nashville, Tennessee.,Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Matthew Keller
- Saint Louis University School of Medicine, St. Louis, Missouri
| | | | | | | | - C Gaelyn Garrett
- Vanderbilt Voice Center, Department of Otolaryngology, Nashville, Tennessee
| | - David O Francis
- Division of Otolaryngology, Wisconsin Surgical Outcomes Research, Department of Surgery, University of Wisconsin, Madison, Wisconsin, U.S.A
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29
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Vasechkin SV, Levin OS. [Diagnosis and management of essential tremor]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:64-72. [PMID: 30346436 DOI: 10.17116/jnevro201811806264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Essential tremor (ET) is the most common extrapyramidal disease and one of the most frequent neurological diseases. The main presentation of ET is a progressive bilateral (kinetic-postural) hand tremor. The prevalence in people over 65 years is 5%, it increases with age up to 22% in people over 95 years. About half of patients with ET have family history. The modern concepts of the pathogenesis, clinical features and differential diagnosis are considered. Possible methods of medical and surgical management are described.
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Affiliation(s)
- S V Vasechkin
- Centre of Extrapyramidal Diseases Department of Neurology, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - O S Levin
- Centre of Extrapyramidal Diseases Department of Neurology, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
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30
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Roy A, Coombes SA, Chung JW, Archer DB, Okun MS, Hess CW, Wagle Shukla A, Vaillancourt DE. Cortical dynamics within and between parietal and motor cortex in essential tremor. Mov Disord 2018; 34:95-104. [PMID: 30345712 DOI: 10.1002/mds.27522] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 09/08/2018] [Accepted: 09/12/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Evidence from functional imaging in essential tremor suggests that activity within parietal and motor cortices may be associated with worsening of tremor at increased visual feedback. OBJECTIVES Examine how cortical oscillations within these regions and the connectivity between these regions is associated with worsening of tremor in essential tremor in response to high visual feedback. METHOD The study included 24 essential tremor participants and 17 controls. We measured cortical activity and tremor magnitude at low and high feedback conditions. Cortical activity was measured using high-density electroencephalogram and isolated using source localization. RESULTS Changes in power across feedback in the 4-12 Hz and 12-30 Hz bands were reduced within the contralateral motor cortex of essential tremor patients compared to controls. The 12-30 Hz bidirectional connectivity between the parietal and contralateral motor cortex was decreased in essential tremor patients. Worsening of tremor from low to high visual feedback was associated with 4-12 Hz activity in contralateral motor cortex. The greatest separation between groups was found when using the difference of the contralateral motor cortex activity at high and low feedback, rather than either feedback condition alone. CONCLUSION Our findings provide new evidence that tremor in essential tremor is associated with reduced power across feedback in the motor cortex and reduced connectivity between the parietal and motor cortices. Combined with previous work on the cerebellar-thalamo-cortical motor circuit, our findings suggest that the network level disturbances associated with essential tremor extend to the cortico-cortical pathway between the parietal cortex and motor cortex. © 2018 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Arnab Roy
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Stephen A Coombes
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Jae Woo Chung
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Derek B Archer
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Michael S Okun
- Department of Neurology and Fixel Center for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Florida, USA
| | - Christopher W Hess
- Department of Neurology and Fixel Center for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Florida, USA
| | - Aparna Wagle Shukla
- Department of Neurology and Fixel Center for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Florida, USA
| | - David E Vaillancourt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA.,Department of Neurology and Fixel Center for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Florida, USA.,Department of Biomedical Engineering, University of Florida, Gainesville, Florida, USA
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31
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Langford BE, Ridley CJA, Beale RC, Caseby SCL, Marsh WJ, Richard L. Focused Ultrasound Thalamotomy and Other Interventions for Medication-Refractory Essential Tremor: An Indirect Comparison of Short-Term Impact on Health-Related Quality of Life. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1168-1175. [PMID: 30314617 DOI: 10.1016/j.jval.2018.03.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/21/2018] [Accepted: 03/25/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Up to 50% of essential tremor patients are refractory to medication and require alternative treatment to achieve tremor relief. This study aimed to identify and analyze evidence supporting the use of the emerging magnetic resonance-guided focused ultrasound (MRgFUS) compared to alternative stimulatory and ablative interventions for the treatment of medication-refractory essential tremor: radiofrequency thalamotomy, unilateral deep brain stimulation (DBS), and stereotactic radiosurgery. METHODS A systematic literature review was conducted to identify clinical, health-related quality of life (HRQoL), and economic evidence for each intervention. Because of the lack of comparative evidence captured, a feasibility assessment was performed to determine possible comparisons between interventions, and newly established matching-adjusted indirect comparison and simulated treatment comparison techniques were used to conduct a comparison between unilateral DBS aggregate data and MRgFUS individual patient data. RESULTS The systematic literature review identified 1,559 records, and screening yielded 46 relevant articles. The captured studies demonstrated that radiofrequency thalamotomy, DBS, stereotactic radiosurgery, and MRgFUS all exhibit clinical efficacy, with variation in onset and duration of tremor relief, and are each associated with a unique safety profile. The matching-adjusted indirect comparison and simulated treatment comparison results demonstrated no evidence of a difference in efficacy (measured by Clinical Rating Scale for Tremor Total) and HRQoL (measured by Clinical Rating Scale for Tremor Part C) outcomes between MRgFUS and unilateral DBS in the short term (≤12 months). CONCLUSIONS This study provides preliminary evidence that MRgFUS could elicit similar short-term tremor- and HRQoL-related benefits to DBS, the current standard of care, and allowed for the first robust statistical comparison between these interventions.
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Samotus O, Lee J, Jog M. Transitioning from Unilateral to Bilateral Upper Limb Tremor Therapy for Parkinson's Disease and Essential Tremor Using Botulinum Toxin: Case Series. Toxins (Basel) 2018; 10:toxins10100394. [PMID: 30262746 PMCID: PMC6215170 DOI: 10.3390/toxins10100394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 09/20/2018] [Accepted: 09/22/2018] [Indexed: 11/21/2022] Open
Abstract
Botulinum toxin type A (BoNT-A) injections guided by kinematic analysis for unilateral upper limb essential tremor (ET) and Parkinson’s disease (PD) tremor therapy has demonstrated efficacy, improvements in quality of life (QoL) and arm functionality. In this open-label pilot trial, 5 ET and 2 PD participants decided to switch from receiving long-term unilateral arm treatment to now bilateral BoNT-A arm therapy in their other tremulous arm which worsened over time. Injection patterns were based on kinematic analysis. Efficacy endpoints including kinematic analysis, Fahn-Tolosa-Marin tremor rating scale, QoL questionnaire, and maximal grip strength were collected over 2 treatments and 2 follow-up visits totaling 18-weeks. BoNT-A decreased wrist tremor amplitude by 84.6% and 89.6% 6-weeks following the 1st injection in the newly-treated limb in ET and PD participants, respectively. PD participants started with worse QoL but demonstrated an additional improvement in QoL by 29.9% for switching to bilateral treatment, whereas ET participants did not. Left and right arm tremor also did not share commonalities in severity or dose. This preliminary finding suggests trends for transitioning to bilateral therapy and warrants further studies to evaluate efficacy of bilateral tremor BoNT-A therapy in a larger cohort of PD and ET patients.
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Affiliation(s)
- Olivia Samotus
- Department of Clinical Neurological Sciences, London Health Sciences Centre-Lawson Health Research Institute, 339 Windermere Road, A10-026, London, ON N6A 5A5, Canada.
- Schulich School of Medicine and Dentistry, University of Western, 1151 Richmond Street, London, ON N6A 3K7, Canada.
| | - Jack Lee
- Department of Clinical Neurological Sciences, London Health Sciences Centre-Lawson Health Research Institute, 339 Windermere Road, A10-026, London, ON N6A 5A5, Canada.
| | - Mandar Jog
- Department of Clinical Neurological Sciences, London Health Sciences Centre-Lawson Health Research Institute, 339 Windermere Road, A10-026, London, ON N6A 5A5, Canada.
- Schulich School of Medicine and Dentistry, University of Western, 1151 Richmond Street, London, ON N6A 3K7, Canada.
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Alonso-Juarez M, Baizabal-Carvallo JF. Distinguishing features between valproate-induced tremor and essential tremor. Acta Neurol Scand 2018; 138:177-181. [PMID: 29749618 DOI: 10.1111/ane.12953] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tremor frequently occurs in patients taking valproate and may resemble that observed in patients with essential tremor (ET). We aimed to compare the distribution, severity, and functional impact of both types of tremor. METHODS Among 118 consecutive individuals taking valproate, we identified 28 patients with valproate-induced tremor severe enough to require pharmacological treatment; through evaluations using the Clinical Rating Scale for Tremor (CRST), they were compared with 29 consecutive patients with ET. RESULTS Patients with valproate-induced tremor were significantly younger than those with ET: 35.6 ± 15.4 vs 58.8 ± 20.5 years (P < .001), with a shorter evolution time of tremor (P < .001). Total CRST scores did not differ between groups (P = .164), neither in subscores of Parts A (P = .321), B (P = .094), and C (P = .386). Patients with valproate-induced tremor had a higher proportion of postural tongue tremor compared with ET patients: 22 (79%) vs 15 (52%) (P = .034). A frank tremor axis in the Archimedes spirals was observed in a higher proportion of patients with ET compared to valproate-induced tremor: 31% vs 3.6% (P = .006). CONCLUSIONS Patients with valproate-induced tremor requiring pharmacological treatment have similar distribution, CRST scores, and functional impact than those with ET.
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Affiliation(s)
| | - J. F. Baizabal-Carvallo
- University of Guanajuato; Guanajuato México
- Baylor College of Medicine; Houston TX USA
- Hospital Regional de Alta Especialidad del Bajio; Leon Mexico
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34
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Patel A, Deeb W, Okun MS. Deep Brain Stimulation Management of Essential Tremor with Dystonic Features. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2018; 8:557. [PMID: 29971197 PMCID: PMC6026276 DOI: 10.7916/d8p85vbq] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/22/2018] [Indexed: 12/04/2022]
Abstract
Clinical Vignette A 64-year-old female with essential tremor (ET) presents for evaluation of deep brain stimulation (DBS) candidacy. Examination revealed subtle dystonic features as well as a disabling postural-action tremor. Clinical Dilemma Can dystonia occur in the setting of the diagnosis of ET and can its presence alter DBS target selection? Clinical Solution Unilateral DBS implantation of the ventralis intermedius (Vim) led to improvement in both tremor and dystonic posturing. Gap in Knowledge Case reports of DBS in dystonic tremor suggest Vim, globus pallidus internus (GPi), and subthalamic targets may all be effective, to varying degrees, in improving both tremor and dystonia. More rigorous studies are needed to identify the optimal target(s). Expert Commentary This case underscores the limited evidence available to guide a clinician’s choice of DBS targets in patients with ET and dystonia. The severity of the dystonia and the presence of more generalized dystonia may alter the thinking about optimal targeting. Vim, GPi, and subthalamic targets appear potentially acceptable options, though Vim is usually the first target attempted when postural-action tremor is the chief complaint. Occasionally, a second rescue DBS lead may be necessary.
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Affiliation(s)
- Amar Patel
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Wissam Deeb
- Fixel Center for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Fixel Center for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, USA
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Abstract
INTRODUCTION Essential tremor is the most common form of pathologic tremor. Surgical therapies disrupt tremorogenic oscillation in the cerebellothalamocortical pathway and are capable of abolishing severe tremor that is refractory to available pharmacotherapies. Surgical methods are raspidly improving and are the subject of this review. Areas covered: A PubMed search on 18 January 2018 using the query essential tremor AND surgery produced 839 abstracts. 379 papers were selected for review of the methods, efficacy, safety and expense of stereotactic deep brain stimulation (DBS), stereotactic radiosurgery (SRS), focused ultrasound (FUS) ablation, and radiofrequency ablation of the cerebellothalamocortical pathway. Expert commentary: DBS and SRS, FUS and radiofrequency ablations are capable of reducing upper extremity tremor by more than 80% and are far more effective than any available drug. The main research questions at this time are: 1) the relative safety, efficacy, and expense of DBS, SRS, and FUS performed unilaterally and bilaterally; 2) the relative safety and efficacy of thalamic versus subthalamic targeting; 3) the relative safety and efficacy of atlas-based versus direct imaging tractography-based anatomical targeting; and 4) the need for intraoperative microelectrode recordings and macroelectrode stimulation in awake patients to identify the optimum anatomical target. Randomized controlled trials are needed.
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Affiliation(s)
- Rodger J Elble
- a Neuroscience Institute , Southern Illinois University School of Medicine , Springfield , Illinois , USA
| | - Ludy Shih
- b Department of Neurology , Beth Israel Deaconess Medical Center, Harvard Medical School , Boston , Massachusetts USA
| | - Jeffrey W Cozzens
- a Neuroscience Institute , Southern Illinois University School of Medicine , Springfield , Illinois , USA
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Bhatia KP, Bain P, Bajaj N, Elble RJ, Hallett M, Louis ED, Raethjen J, Stamelou M, Testa CM, Deuschl G. Consensus Statement on the classification of tremors. from the task force on tremor of the International Parkinson and Movement Disorder Society. Mov Disord 2018; 33:75-87. [PMID: 29193359 PMCID: PMC6530552 DOI: 10.1002/mds.27121] [Citation(s) in RCA: 811] [Impact Index Per Article: 135.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 05/03/2017] [Accepted: 06/04/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Consensus criteria for classifying tremor disorders were published by the International Parkinson and Movement Disorder Society in 1998. Subsequent advances with regard to essential tremor, tremor associated with dystonia, and other monosymptomatic and indeterminate tremors make a significant revision necessary. OBJECTIVES Convene an international panel of experienced investigators to review the definition and classification of tremor. METHODS Computerized MEDLINE searches in January 2013 and 2015 were conducted using a combination of text words and MeSH terms: "tremor", "tremor disorders", "essential tremor", "dystonic tremor", and "classification" limited to human studies. Agreement was obtained using consensus development methodology during four in-person meetings, two teleconferences, and numerous manuscript reviews. RESULTS Tremor is defined as an involuntary, rhythmic, oscillatory movement of a body part and is classified along two axes: Axis 1-clinical characteristics, including historical features (age at onset, family history, and temporal evolution), tremor characteristics (body distribution, activation condition), associated signs (systemic, neurological), and laboratory tests (electrophysiology, imaging); and Axis 2-etiology (acquired, genetic, or idiopathic). Tremor syndromes, consisting of either isolated tremor or tremor combined with other clinical features, are defined within Axis 1. This classification scheme retains the currently accepted tremor syndromes, including essential tremor, and provides a framework for defining new syndromes. CONCLUSIONS This approach should be particularly useful in elucidating isolated tremor syndromes and syndromes consisting of tremor and other signs of uncertain significance. Consistently defined Axis 1 syndromes are needed to facilitate the elucidation of specific etiologies in Axis 2. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Kailash P. Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, University College London (UCL) Institute of Neurology, London, United Kingdom
| | - Peter Bain
- Department of Neurosciences, Charing Cross Hospital, Imperial College London, United Kingdom
| | - Nin Bajaj
- Division of Neurology, Nottingham University Hospital, Nottingham, United Kingdom
| | - Rodger J. Elble
- Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland, USA
| | - Elan D. Louis
- Division of Movement Disorders, Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA, and Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Jan Raethjen
- Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Christian Albrechts University Kiel, Kiel, Germany
| | - Maria Stamelou
- Department of Neurology, Philipps University, Marburg, Germany; Department of Neurology, Attikon Hospital, University of Athens, Athens, Greece
| | | | - Guenther Deuschl
- Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Christian Albrechts University Kiel, Kiel, Germany
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Botulinum Toxin Type A Injections as Monotherapy for Upper Limb Essential Tremor Using Kinematics. Can J Neurol Sci 2017; 45:11-22. [DOI: 10.1017/cjn.2017.260] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AbstractBackground:There is a significant need for a targeted therapy for essential tremor (ET), as medications have not been developed specifically for ET, and the ones prescribed are often not well-tolerated, so that many patients remain untreated. Recent work has shown that, unlike previous experience, kinematically guided individualized botulinum toxin type A (BoNT-A) injections provide benefit along with minimal weakness. Ours is the first long-term (96-week) safety and efficacy study of BoNT-A as monotherapy for ET using kinematically driven injection parameters.Methods:Ten ET patients were administered six serial BoNT-A treatments every 16 weeks and were assessed at 6 weeks following treatment. During each study visit, the Fahn–Tolosa–Marin (FTM) scale, the Unified Parkinson’s Disease Rating Scale, and the Quality of Life for Essential Tremor Questionnaire (QUEST) were administered along with kinematic assessment of the treated limb. Participants performed scripted tasks with motion sensors placed over each arm joint. Dosing patterns were determined using the movement disorder neurologist’s interpretation of muscles contributing to the kinematically analyzed upper limb tremor biomechanics.Results:There was a 33.8% (p<0.05) functional improvement (FTM part C) and a 39.8% (p<0.0005) improvement in QUEST score at week 96 compared to pretreatment scores at week 0. Although there was a 44.6% (p<0.0005) non-dose-dependent reduction in maximal grip strength, only 2 participants complained of mild weakness. Following the fourth serial treatment, mean action tremor score was reduced by 62.9% (p=0.001) in the treated and by 44.4% (p=0.03) in the untreated arm at week 96 compared to week 48.Conclusions:Individualized BoNT-A dosing patterns to each individual’s tremor biomechanics provided an effective monotherapy for ET as function improved without functionally limiting muscle weakness.
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Morgan S, Kellner S, Gutierrez J, Collins K, Rohl B, Migliore F, Cosentino S, Huey ED, Louis ED, Monin JK. The Experience of Essential Tremor Caregivers: Burden and Its Correlates. Front Neurol 2017; 8:396. [PMID: 28855888 PMCID: PMC5557742 DOI: 10.3389/fneur.2017.00396] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/25/2017] [Indexed: 11/15/2022] Open
Abstract
Background Essential tremor (ET) is associated with physical and cognitive impairments, as well as embarrassment, avoidance of social settings, and related difficulties that negatively impact the lives of patients. In similar disease contexts, burden on friends and relatives acting as caregivers has been noted and has well-documented implications. There has been no study examining caregiver burden related to ET. Methods Data were gathered from 55 ET participants enrolled in a clinical study and their caregivers. The Zarit Burden Interview was used to assess caregiver burden. To assess clinical features that may be associated with burden, we collected several variables including the Montreal Cognitive Assessment, self-reported tremor disability, a videotaped neurological examination, questionnaires assessing ET participants’ suffering, caregivers’ perceptions of that suffering, and both caregiver and ET participant depressive symptoms. Spearman’s correlations were performed between caregiver burden and clinical features, and we created a multivariate linear regression model predicting caregiver burden. Results Many ET caregivers provide little to no care and experience little to no burden. However, some caregivers (11%) provide over 25 h of care/week, and 13% experience high levels of burden. Caregivers most commonly provided assistance with writing and cooking. Increased burden was associated with the ET participants’ decreased cognition, more caregiving tasks, more hours/week of caregiving activities, a longer duration of care, more ET participant falls/year, more medications taken by the ET participant, and more depressive symptoms in both the ET participant and the caregiver (all p < 0.05). ET participants’ suffering and their caregivers’ perceptions of suffering were both associated with increased burden. Neither tremor severity score nor self-reported tremor disability score was associated with increased caregiver burden. Using a multivariate linear regression model, we found that caregivers’ increased perception of their partners’ suffering was the best predictor of caregiver burden. Conclusion While not all relatives and friends of ET patients provide extensive care or experience high burden, there is a group reporting high levels of caregiver burden that requires the attention and counseling of clinicians. This burden is associated with primarily non-tremor symptoms of ET and with caregivers’ perception that their partners are suffering.
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Affiliation(s)
- Sarah Morgan
- Department of Neurology, Division of Movement Disorders, Yale School of Medicine, Yale University, New Haven, CT, United States
| | - Sarah Kellner
- Department of Neurology, Division of Movement Disorders, Yale School of Medicine, Yale University, New Haven, CT, United States
| | - Jesus Gutierrez
- Department of Neurology, Division of Movement Disorders, Yale School of Medicine, Yale University, New Haven, CT, United States
| | - Kathleen Collins
- Department of Neurology, Division of Movement Disorders, Yale School of Medicine, Yale University, New Haven, CT, United States
| | - Brittany Rohl
- Department of Neurology, Division of Movement Disorders, Yale School of Medicine, Yale University, New Haven, CT, United States
| | - Fanny Migliore
- Department of Neurology, Division of Movement Disorders, Yale School of Medicine, Yale University, New Haven, CT, United States
| | - Stephanie Cosentino
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, United States.,Taub Institute for Research on Alzheimer's Disease and the Aging Brain, College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Edward D Huey
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, United States.,Taub Institute for Research on Alzheimer's Disease and the Aging Brain, College of Physicians and Surgeons, Columbia University, New York, NY, United States.,Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Elan D Louis
- Department of Neurology, Division of Movement Disorders, Yale School of Medicine, Yale University, New Haven, CT, United States.,Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT, United States.,Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, CT, United States
| | - Joan K Monin
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, United States
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Becker J, Barbe MT, Hartinger M, Dembek TA, Pochmann J, Wirths J, Allert N, Mücke D, Hermes A, Meister IG, Visser-Vandewalle V, Grice M, Timmermann L. The Effect of Uni- and Bilateral Thalamic Deep Brain Stimulation on Speech in Patients With Essential Tremor: Acoustics and Intelligibility. Neuromodulation 2017; 20:223-232. [DOI: 10.1111/ner.12546] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/13/2016] [Accepted: 10/13/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Johannes Becker
- Department of Neurology; University Hospital Cologne; Cologne Germany
| | - Michael T. Barbe
- Department of Neurology; University Hospital Cologne; Cologne Germany
- Cognitive Neuroscience; Institute of Neuroscience and Medicine (INM3), Research Centre Jülich; Jülich Germany
| | | | - Till A. Dembek
- Department of Neurology; University Hospital Cologne; Cologne Germany
| | - Jil Pochmann
- Department of Neurology; University Hospital Cologne; Cologne Germany
| | - Jochen Wirths
- Department of Stereotaxy and Functional Neurosurgery; University Hospital Cologne; Cologne Germany
| | - Niels Allert
- Neurological Rehabilitation Center Godeshöhe; Bonn Germany
| | - Doris Mücke
- Institute of Linguistics - Phonetics; University of Cologne; Cologne Germany
| | - Anne Hermes
- Institute of Linguistics - Phonetics; University of Cologne; Cologne Germany
| | - Ingo G. Meister
- Department of Neurology; University Hospital Cologne; Cologne Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotaxy and Functional Neurosurgery; University Hospital Cologne; Cologne Germany
| | - Martine Grice
- Institute of Linguistics - Phonetics; University of Cologne; Cologne Germany
| | - Lars Timmermann
- Department of Neurology; University Hospital Cologne; Cologne Germany
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Espay AJ, Lang AE, Erro R, Merola A, Fasano A, Berardelli A, Bhatia KP. Essential pitfalls in "essential" tremor. Mov Disord 2017; 32:325-331. [PMID: 28116753 DOI: 10.1002/mds.26919] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/11/2016] [Accepted: 12/19/2016] [Indexed: 12/13/2022] Open
Abstract
Although essential tremor has been considered the most common movement disorder, it has largely remained a diagnosis of exclusion: many tremor and nontremor features must be absent for the clinical diagnosis to stand. The clinical features of "essential tremor" overlap with or may be part of other tremor disorders and, not surprisingly, this prevalent familial disorder has remained without a gene identified, without a consistent natural history, and without an acceptable pathology or pathophysiologic underpinning. The collective evidence suggests that under the rubric of essential tremor there exists multiple unique diseases, some of which represent cerebellar dysfunction, but for which there is no intrinsic "essence" other than a common oscillatory behavior on posture and action. One approach may be to use the term essential tremor only as a transitional node in the deep phenotyping of tremor disorders based on historical, phenomenological, and neurophysiological features to facilitate its etiologic diagnosis or serve for future gene- and biomarker-discovery efforts. This approach deemphasizes essential tremor as a diagnostic entity and facilitates the understanding of the underlying disorders to develop biologically tailored diagnostic and therapeutic strategies. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Alberto J Espay
- UC Gardner Neuroscience Institute, Department of Neurology, Gardner Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Ohio, USA
| | - Anthony E Lang
- Morton and Gloria Shulman Movement Disorders Center, Toronto Western Hospital and The Edmond J. Safra Program in PD, Toronto, Ontario, Canada, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
| | - Roberto Erro
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
| | - Aristide Merola
- UC Gardner Neuroscience Institute, Department of Neurology, Gardner Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Ohio, USA
| | - Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Center, Toronto Western Hospital and The Edmond J. Safra Program in PD, Toronto, Ontario, Canada, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
| | - Alfredo Berardelli
- Department of Neurology and Psychiatry, "Sapienza" University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli, IS, Italy
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, London, UK
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Abdulrahman AA, Faisal K, Meshref AAA, Arshaduddin M. Low-dose acute vanillin is beneficial against harmaline-induced tremors in rats. Neurol Res 2017; 39:264-270. [DOI: 10.1080/01616412.2016.1275456] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
| | - Kunnathodi Faisal
- Scientific Research Center, Medical Services Department, Riyadh, Saudi Arabia
| | - Ali Al Amri Meshref
- Department of Pharmacy and Pharmaceutical Sciences, Medical Services Department, Riyadh, Saudi Arabia
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Knowledge gaps and research recommendations for essential tremor. Parkinsonism Relat Disord 2016; 33:27-35. [PMID: 27769649 DOI: 10.1016/j.parkreldis.2016.10.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 08/29/2016] [Accepted: 10/01/2016] [Indexed: 12/17/2022]
Abstract
Essential tremor (ET) is a common cause of significant disability, but its etiologies and pathogenesis are poorly understood. Research has been hampered by the variable definition of ET and by non-standardized research approaches. The National Institute of Neurological Disorders and Stroke (USA) invited experts in ET and related fields to discuss current knowledge, controversies, and gaps in our understanding of ET and to develop recommendations for future research. Discussion focused on phenomenology and phenotypes, therapies and clinical trials, pathophysiology, pathology, and genetics. Across all areas, the need for collaborative and coordinated research on a multinational level was expressed. Standardized data collection using common data elements for genetic, clinical, neurophysiological, and pathological studies was recommended. Large cohorts of patients should be studied prospectively to collect bio-samples, characterize the natural history of the clinical syndrome including patient-oriented outcomes, investigate potential etiologies of various phenotypes, and identify pathophysiological mechanisms. In particular, cellular and system-level mechanisms of tremor oscillations should be elucidated because they may yield effective therapeutic targets and biomarkers. A neuropathology consortium was recommended to standardize postmortem analysis and further characterize neuropathological observations in the cerebellum and elsewhere. Furthermore, genome-wide association studies on large patient cohorts (>10,000 patients) may allow the identification of common genes contributing to risk, and whole exome or genome sequencing may enable the identification of genetic risk and causal mutations in cohorts and well-characterized families.
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Gövert F, Becktepe JS, Deuschl G. Current concepts of essential tremor. Rev Neurol (Paris) 2016; 172:416-422. [PMID: 27561441 DOI: 10.1016/j.neurol.2016.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/18/2016] [Indexed: 01/27/2023]
Abstract
Essential tremor is clinically defined but there is increasing evidence that it is not a unique entity. Its pathophysiology has been studied with many methods but may also vary between subtypes. Neurophysiologically, there is strong evidence that a specific cerebello-thalamo-cortical loop is abnormally oscillating. The cause of its uncontrolled oscillation is not yet understood. The clear proof of a degenerative cause is still lacking and abnormal receptors or other causes of altered non-progressive functional disturbance cannot be excluded. Strong evidence supports the major involvement of the cerebellum and there is ample evidence that GABA is the main neurotransmitter involved in the pathophysiology in ET. Genetics have provided so far only a few rare subtypes which are due to specific mutations but there is no doubt that it is mostly a hereditary condition. There is evidence that the large subgroup of late onset tremor is a separate condition and this tremor is an independent risk factor for earlier mortality and comes with signs of premature aging (aging-related tremor). It will be important to improve phenotyping of patients in more detail possibly to include not only features of the tremor itself but also other clinical assessments like force measurements or cognitive testing. Based on these variables, we may be able to better understand the presumably different mechanisms underlying different variants of the disease.
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Affiliation(s)
- F Gövert
- Department of Neurology, Christian-Albrecht University of Kiel, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Schittenhelmstrasse 10, 24105 Kiel, Germany
| | - J S Becktepe
- Department of Neurology, Christian-Albrecht University of Kiel, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Schittenhelmstrasse 10, 24105 Kiel, Germany
| | - G Deuschl
- Department of Neurology, Christian-Albrecht University of Kiel, Universitätsklinikum Schleswig-Holstein, Kiel Campus, Schittenhelmstrasse 10, 24105 Kiel, Germany.
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Fabbri M, Abreu L, Santos T, Ferreira JJ. Resting and Reemergent Tongue Tremor as Presenting Symptoms of Parkinson's Disease. Mov Disord Clin Pract 2016; 4:273-274. [PMID: 30838267 DOI: 10.1002/mdc3.12408] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/08/2016] [Accepted: 06/10/2016] [Indexed: 11/08/2022] Open
Affiliation(s)
- Margherita Fabbri
- Clinical Pharmacology Unit Instituto de Medicina Molecular Faculty of Medicine University of Lisbon Lisbon Portugal
| | - Luis Abreu
- Department of Neurosciences Hospital Santa Maria Centro Hospitalar Lisboa Norte Lisbon Portugal
| | - Telma Santos
- Neurology Department Centro Hospitalar de Vila Nova de Gaia/Espinho Nova de Gaia Portugal
| | - Joaquim J Ferreira
- Clinical Pharmacology Unit Instituto de Medicina Molecular Faculty of Medicine University of Lisbon Lisbon Portugal.,Department of Neurosciences Hospital Santa Maria Centro Hospitalar Lisboa Norte Lisbon Portugal.,Laboratory of Clinical Pharmacology and Therapeutics Faculty of Medicine University of Lisbon Lisbon Portugal
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Albanese A, Sorbo FD. Dystonia and Tremor: The Clinical Syndromes with Isolated Tremor. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2016; 6:319. [PMID: 27152246 PMCID: PMC4850743 DOI: 10.7916/d8x34xbm] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 02/21/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Dystonia and tremor share many commonalities. Isolated tremor is part of the phenomenological spectrum of isolated dystonia and of essential tremor. The occurrence of subtle features of dystonia may allow one to differentiate dystonic tremor from essential tremor. Diagnostic uncertainty is enhanced when no features of dystonia are found in patients with a tremor syndrome, raising the question whether the observed phenomenology is an incomplete form of dystonia. METHODS Known forms of syndromes with isolated tremor are reviewed. Diagnostic uncertainties between tremor and dystonia are put into perspective. RESULTS The following isolated tremor syndromes are reviewed: essential tremor, head tremor, voice tremor, jaw tremor, and upper-limb tremor. Their varied phenomenology is analyzed and appraised in the light of a possible relationship with dystonia. DISCUSSION Clinicians making a diagnosis of isolated tremor should remain vigilant for the detection of features of dystonia. This is in keeping with the recent view that isolated tremor may be an incomplete phenomenology of dystonia.
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Affiliation(s)
- Alberto Albanese
- Istituto Clinico Humanitas, Rozzano, Italy; Istituto di Neurologia, Università Cattolica del Sacro Cuore, Milan, Italy
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Elkouzi A, Kattah JC, Elble RJ. Hypertrophic Olivary Degeneration Does Not Reduce Essential Tremor. Mov Disord Clin Pract 2015; 3:209-211. [PMID: 30713917 DOI: 10.1002/mdc3.12275] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 08/11/2015] [Accepted: 08/17/2015] [Indexed: 12/20/2022] Open
Affiliation(s)
- Ahmad Elkouzi
- Southern Illinois University School of Medicine Springfield Illinois USA
| | - Jorge C Kattah
- University of Illinois College of Medicine at Peoria Peoria Illinois USA
| | - Rodger J Elble
- Southern Illinois University School of Medicine Springfield Illinois USA
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Shaikh AG, Zee DS, Jinnah HA. Oscillatory head movements in cervical dystonia: Dystonia, tremor, or both? Mov Disord 2015; 30:834-42. [PMID: 25879911 DOI: 10.1002/mds.26231] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 02/14/2015] [Accepted: 03/05/2015] [Indexed: 11/09/2022] Open
Abstract
Cervical dystonia is characterized by abnormal posturing of the head, often combined with tremor-like oscillatory head movements. The nature and source of these oscillatory head movements is controversial, so they were quantified to delineate their characteristics and develop a hypothetical model for their genesis. A magnetic search coil system was used to measure head movements in 14 subjects with cervical dystonia. Two distinct types of oscillatory head movements were detected for most subjects, even when they were not clinically evident. One type had a relatively large amplitude and jerky irregular pattern, and the other had smaller amplitude with a more regular and sinusoidal pattern. The kinematic properties of these two types of oscillatory head movements were distinct, although both were often combined in the same subject. Both had features suggestive of a defect in a central neural integrator. The combination of different types of oscillatory head movements in cervical dystonia helps to clarify some of the current debates regarding whether they should be considered as manifestations of dystonia or tremor and provides novel insights into their potential pathogenesis.
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Affiliation(s)
- Aasef G Shaikh
- Department of Neurology, Emory University, Atlanta, GA, USA
| | - David S Zee
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - H A Jinnah
- Department of Neurology, Emory University, Atlanta, GA, USA
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Are patients with limb and head tremor a clinically distinct subtype of essential tremor? Can J Neurol Sci 2015; 42:181-6. [PMID: 25857448 DOI: 10.1017/cjn.2015.23] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Essential tremor (ET) is the most common tremor disorder in adults. In addition to upper limbs, the tremor in ET may also involve head, jaw, voice, tongue, and trunk. Though head tremor (HT) is commonly present in patients with ET, large comparative studies of ET patients with HT (HT+) and without HT (HT-) are few. METHODS To determine whether ET with HT is a distinct clinical subtype by comparing ET patients with and without HT, a chart review of 234 consecutive patients with ET attending the neurology clinics of the National Institute of Mental Health and Neurosciences, India, was done. A movement disorder specialist confirmed the diagnosis of ET in all patients using the National Institutes of Health collaborative genetic criteria. RESULTS HT was present in 44.4% of the patients. Comparison between HT+ and HT- showed that the HT+ group patients: (1) were older, (2) had later onset of tremor, (3) had unimodal distribution of age at onset with a single peak in the fifth decade, (4) had more frequent voice tremor, and (5) were more likely to have mild cervical dystonia. HT was part of presenting symptoms in nearly two thirds of the ET patients and in the rest it was detected during clinical examination. CONCLUSIONS Several demographic and clinical variables suggest that ET patients with HT have a distinct clinical phenotype.
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Boyar K. Essential tremor versus Parkinson disease: Make the right diagnosis. Nurse Pract 2014; 39:13-16. [PMID: 25140846 DOI: 10.1097/01.npr.0000452984.51256.1a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Karyn Boyar
- Karyn Boyar is a full-time faculty clinical instructor at New York University College of Nursing, New York, N.Y
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50
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Mücke D, Becker J, Barbe MT, Meister I, Liebhart L, Roettger TB, Dembek T, Timmermann L, Grice M. The effect of deep brain stimulation on the speech motor system. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2014; 57:1206-1218. [PMID: 24686442 DOI: 10.1044/2014_jslhr-s-13-0155] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE Chronic deep brain stimulation of the nucleus ventralis intermedius is an effective treatment for individuals with medication-resistant essential tremor. However, these individuals report that stimulation has a deleterious effect on their speech. The present study investigates one important factor leading to these effects: the coordination of oral and glottal articulation. METHOD Sixteen native-speaking German adults with essential tremor, between 26 and 86 years old, with and without chronic deep brain stimulation of the nucleus ventralis intermedius and 12 healthy, age-matched subjects were recorded performing a fast syllable repetition task (/papapa/, /tatata/, /kakaka/). Syllable duration and voicing-to-syllable ratio as well as parameters related directly to consonant production, voicing during constriction, and frication during constriction were measured. RESULTS Voicing during constriction was greater in subjects with essential tremor than in controls, indicating a perseveration of voicing into the voiceless consonant. Stimulation led to fewer voiceless intervals (voicing-to-syllable ratio), indicating a reduced degree of glottal abduction during the entire syllable cycle. Stimulation also induced incomplete oral closures (frication during constriction), indicating imprecise oral articulation. CONCLUSION The detrimental effect of stimulation on the speech motor system can be quantified using acoustic measures at the subsyllabic level.
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