1
|
Frey J, Hess CW, Kugler L, Wajid M, Wagle Shukla A. Transcranial Magnetic Stimulation in Tremor Syndromes: Pathophysiologic Insights and Therapeutic Role. Front Neurol 2021; 12:700026. [PMID: 34512517 PMCID: PMC8426899 DOI: 10.3389/fneur.2021.700026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/30/2021] [Indexed: 12/12/2022] Open
Abstract
Transcranial magnetic stimulation (TMS) is a painless, non-invasive, and established brain stimulation technique to investigate human brain function. Over the last three decades, TMS has shed insight into the pathophysiology of many neurological disorders. Tremor is an involuntary, rhythmic oscillatory movement disorder commonly related to pathological oscillations propagated via the cerebello-thalamo-cortical pathway. Although tremor is the most common movement disorder and recent imaging studies have enhanced our understanding of the critical pathogenic networks, the underlying pathophysiology of different tremor syndromes is complex and still not fully understood. TMS has been used as a tool to further our understanding of tremor pathophysiology. In addition, repetitive TMS (rTMS) that can modulate brain functions through plasticity effects has been targeted to the tremor network to gain potential therapeutic benefits. However, evidence is available for only a few studies that included small patient samples with limited clinical follow-up. This review aims to discuss the role of TMS in advancing the pathophysiological understanding as well as emerging applications of rTMS for treating individual tremor syndromes. The review will focus on essential tremor, Parkinson's disease tremor, dystonic tremor syndrome, orthostatic tremor, and functional tremor.
Collapse
Affiliation(s)
- Jessica Frey
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Christopher W Hess
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Liam Kugler
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Manahil Wajid
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Aparna Wagle Shukla
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| |
Collapse
|
2
|
Abstract
Tremor is a phenomenon observed in a broad spectrum of diseases with different pathophysiologies. While patients with tremor may not complain in the clinic of symptoms of imbalance, gait difficulties, or falls, laboratory research studies using quantitative analysis of gait and posture and neurophysiologic techniques have demonstrated impaired gait and balance across a variety of tremor etiologies. These findings have been supported by careful epidemiologic studies assessing symptoms of imbalance. Imaging and neurophysiologic studies have identified cerebellar networks as important mediators of tremor, and therefore a likely common site of dysfunction to explain the phenomenologic overlap between impaired postural and gait control with tremor. Further understanding of these mechanisms and networks is of crucial importance in the development of new treatments, particularly surgical or minimally invasive lesional therapies.
Collapse
Affiliation(s)
- Hugo Morales-Briceño
- Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney, NSW, Australia
| | - Alessandro F Fois
- Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney, NSW, Australia
| | - Victor S C Fung
- Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| |
Collapse
|
3
|
Bhatti D, Thompson R, Hellman A, Penke C, Bertoni JM, Torres-Russotto D. Smartphone Apps Provide a Simple, Accurate Bedside Screening Tool for Orthostatic Tremor. Mov Disord Clin Pract 2017; 4:852-857. [PMID: 30363432 DOI: 10.1002/mdc3.12547] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/23/2017] [Accepted: 08/18/2017] [Indexed: 11/07/2022] Open
Abstract
Background Orthostatic Tremor (OT) is characterized by the presence of a sensation of instability while standing, associated with high frequency (13-18 Hz) lower extremity tremor. Diagnosis is confirmed with surface electromyography (EMG). An accurate screening tool that could be used in the routine clinical setting, without any specialized equipment, would be useful in earlier detection of OT and judicial use of additional testing. Objective The objective of this study was to evaluate OT diagnostic test characteristics at bedside using iPhone's built-in accelerometer and available applications for tremor recordings. Methods We obtained recordings using iPhones (Model 5, 5s, and 6) and free Applications ("LiftPulse" by LiftLabs [App1] and "iSeismometer" by ObjectGraph LLC [App2]) at default settings. Results 24 EMG-confirmed OT subjects (mostly females, 22/24) and 15 age-matched controls (mostly males, 11/15) were evaluated. App1 detected OT range tremor in 22/24 patients and none of the controls. (Sensitivity = 92%, Specificity = 100%, NPV = 88%). App2 detected OT range tremor in 21/24 patients and in 1/13 controls (Sensitivity = 88%, Specificity = 92%, NPV = 80%). When combined, 24/24 patients and 1/13 controls had OT range tremor (Sensitivity = 100%, Specificity = 92%, NPV = 100%). Conclusions Smartphone apps that use the built-in accelerometer provide a simple, accurate and inexpensive bedside screening diagnostic tool for patients with OT.
Collapse
Affiliation(s)
- Danish Bhatti
- Department of Neurological Sciences University of Nebraska Medical Center Omaha Nebraska
| | - Rebecca Thompson
- Department of Neurological Sciences University of Nebraska Medical Center Omaha Nebraska
| | - Amy Hellman
- Department of Neurological Sciences University of Nebraska Medical Center Omaha Nebraska
| | - Cynthia Penke
- Department of Neurological Sciences University of Nebraska Medical Center Omaha Nebraska
| | - John M Bertoni
- Department of Neurological Sciences University of Nebraska Medical Center Omaha Nebraska
| | - Diego Torres-Russotto
- Department of Neurological Sciences University of Nebraska Medical Center Omaha Nebraska
| |
Collapse
|
4
|
Hassan A, van Gerpen JA. Orthostatic Tremor and Orthostatic Myoclonus: Weight-bearing Hyperkinetic Disorders: A Systematic Review, New Insights, and Unresolved Questions. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2017; 6:417. [PMID: 28105385 PMCID: PMC5233784 DOI: 10.7916/d84x584k] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 10/25/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Orthostatic tremor (OT) and orthostatic myoclonus (OM) are weight-bearing hyperkinetic movement disorders most commonly affecting older people that induce "shaky legs" upon standing. OT is divided into "classical" and "slow" forms based on tremor frequency. In this paper, the first joint review of OT and OM, we review the literature and compare and contrast their demographic, clinical, electrophysiological, neuroimaging, pathophysiological, and treatment characteristics. METHODS A PubMed search up to July 2016 using the phrases "orthostatic tremor," "orthostatic myoclonus," "shaky legs," and "shaky legs syndrome" was performed. RESULTS OT and OM should be suspected in older patients reporting unsteadiness with prolonged standing and/or who exhibit cautious, wide-based gaits. Surface electromyography (SEMG) is necessary to verify the diagnoses. Functional neuroimaging and electrophysiology suggest the generator of classical OT lies within the cerebellothalamocortical network. For OM, and possibly slow OT, the frontal, subcortical cerebrum is the most likely origin. Clonazepam is the most useful medication for classical OT, and levetiracetam for OM, although results are often disappointing. Deep brain stimulation appears promising for classical OT. Rolling walkers reliably improve gait affected by these disorders, as both OT and OM attenuate when weight is transferred from the legs to the arms. DISCUSSION Orthostatic hyperkinesias are likely underdiagnosed, as SEMG is often unavailable in clinical practice, and thus may be more frequent than currently recognized. The shared weight-bearing induction of OT and OM may indicate a common pathophysiology. Further research, including use of animal models, is necessary to better define the prevalence and pathophysiology of OT and OM, in order to improve their treatment, and provide additional insights into basic balance and gait mechanisms.
Collapse
Affiliation(s)
- Anhar Hassan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
5
|
Benito-León J, Domingo-Santos Á. Orthostatic Tremor: An Update on a Rare Entity. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2016; 6:411. [PMID: 27713855 PMCID: PMC5039949 DOI: 10.7916/d81n81bt] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/22/2016] [Indexed: 12/01/2022]
Abstract
Background Orthostatic tremor (OT) remains among the most intriguing and poorly understood of movement disorders. Compared to Parkinson’s disease or even essential tremor, there are very few articles addressing more basic science issues. In this review, we will discuss the findings of main case series on OT, including data on etiology, pathophysiology, diagnostic approach, treatment strategies, and outcome. Methods Data for this review were identified by searching PUBMED (January 1966 to August 2016) for the terms “orthostatic tremor” or “shaky leg syndrome,” which yielded 219 entries. We did not exclude papers on the basis of language, country, or publication date. The electronic database searches were supplemented by articles in the authors’ files that pertained to this topic. Results Owing to its rarity, the current understanding of OT is limited and is mostly based on small case series or case reports. Despite this, a growing body of evidence indicates that OT might be a progressive condition that is clinically heterogeneous (primary vs. secondary cases) with a broader spectrum of clinical features, mainly cerebellar signs, and possible cognitive impairment and personality disturbances. Along with this, advanced neuroimaging techniques are now demonstrating distinct anatomical and functional changes, some of which are consistent with neuronal loss. Discussion OT might be a family of diseases, unified by the presence of leg tremor, but further characterized by etiological and clinical heterogeneity. More work is needed to understand the pathogenesis of this condition.
Collapse
Affiliation(s)
- Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Complutense University, Madrid, Spain
| | | |
Collapse
|
6
|
Benito-León J, Louis ED, Puertas-Martín V, Romero JP, Matarazzo M, Molina-Arjona JA, Domínguez-González C, Sánchez-Ferro Á. Cognitive and neuropsychiatric features of orthostatic tremor: A case-control comparison. J Neurol Sci 2016; 361:137-43. [PMID: 26810532 PMCID: PMC5469211 DOI: 10.1016/j.jns.2015.12.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 11/30/2015] [Accepted: 12/20/2015] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Evidence suggests that the cerebellum could play a role in the pathophysiology of orthostatic tremor. The link between orthostatic tremor and the cerebellum is of interest, especially in light of the role the cerebellum plays in cognition, and it raises the possibility that orthostatic tremor patients could have cognitive deficits consistent with cerebellar dysfunction. Our aim was to examine whether orthostatic tremor patients had cognitive deficits and distinct personality profiles when compared with matched controls. METHODS Sixteen consecutive orthostatic tremor patients (65.7 ± 13.3 years) and 32 healthy matched controls underwent a neuropsychological battery and the Personality Assessment Inventory. In linear regression models, the dependent variable was each one of the neuropsychological test scores or the Personality Assessment Inventory subscales and the independent variable was orthostatic tremor vs. RESULTS Adjusted for age in years, sex, years of education, comorbidity index, current smoker, and depressive symptoms, diagnosis (orthostatic tremor vs. healthy control) was associated with poor performance on tests of executive function, visuospatial ability, verbal memory, visual memory, and language tests, and on a number of the Personality Assessment Inventory subscales (somatic concerns, anxiety related disorders, depression, and antisocial features). Older-onset OT (>60 years) patients had poorer scores on cognitive and personality testing compared with their younger-onset OT counterparts. CONCLUSION Orthostatic tremor patients have deficits in specific aspects of neuropsychological functioning, particularly those thought to rely on the integrity of the prefrontal cortex, which suggests involvement of frontocerebellar circuits. Cognitive impairment and personality disturbances could be disease-associated nonmotor manifestations of orthostatic tremor.
Collapse
Affiliation(s)
- Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, (CIBERNED), Madrid, Spain; Department of Medicine, Complutense University, Madrid, Spain.
| | - Elan D Louis
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA; Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA; Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine and Yale School of Public Health, New Haven, CT, USA
| | | | - Juan Pablo Romero
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Faculty of Biosanitary Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Madrid, Spain
| | - Michele Matarazzo
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain
| | | | | | - Álvaro Sánchez-Ferro
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, MA, USA; HM CINAC, HM Hospitales, Móstoles, Madrid, Spain
| |
Collapse
|
7
|
Lin FC, Wu MN, Chen CH, Huang P. Slow orthostatic tremor as the first manifestation of Grave's disease. Mov Disord 2013; 28:1158-9. [PMID: 23468171 DOI: 10.1002/mds.25313] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Feng-Cheng Lin
- Department of Neurology; Kaohsiung Medical University; Hospital Kaohsiung Medical University; Kaohsiung Taiwan Republic of China
- Department of Neurology; Pingtung Hospital; Department of Health Executive Yuan; Taiwan Republic of China
| | - Meng-Ni Wu
- Department of Neurology; Kaohsiung Medical University; Hospital Kaohsiung Medical University; Kaohsiung Taiwan Republic of China
| | - Chun-Hung Chen
- Department of Neurology; Kaohsiung Medical University; Hospital Kaohsiung Medical University; Kaohsiung Taiwan Republic of China
| | - Poyin Huang
- Department of Neurology; Kaohsiung Medical University; Hospital Kaohsiung Medical University; Kaohsiung Taiwan Republic of China
- Department of Neurology; Kaohsiung Municipal Hsiao-Kang Hospital Kaohsiung Medical University; Kaohsiung Taiwan Republic of China
| |
Collapse
|
8
|
Labiano-Fontcuberta A, Benito-León J. Letter with reference to the article “Importance of electromyographic studies in the diagnosis of orthostatic tremor”. NEUROLOGÍA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.nrleng.2011.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
9
|
Carta en relación con el artículo «Importancia del estudio electromiográfico en el diagnóstico del temblor ortostático». Neurologia 2012; 27:121-2; author reply 122. [DOI: 10.1016/j.nrl.2011.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 03/26/2011] [Indexed: 11/22/2022] Open
|
10
|
Importancia del estudio electromiográfico en el diagnóstico del temblor ortostático. Neurologia 2011; 26:53-5. [DOI: 10.1016/j.nrl.2010.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 06/05/2010] [Accepted: 06/20/2010] [Indexed: 11/22/2022] Open
|
11
|
Yagüe S, Veciana M, Pedro J, Campdelacreu J. Importance of electromyography studies in the diagnosis of orthostatic tremor. NEUROLOGÍA (ENGLISH EDITION) 2011. [DOI: 10.1016/s2173-5808(11)70009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
12
|
|
13
|
Krauss JK, Weigel R, Blahak C, Bäzner H, Capelle HH, Grips E, Rittmann M, Wöhrle JC. Chronic spinal cord stimulation in medically intractable orthostatic tremor. J Neurol Neurosurg Psychiatry 2006; 77:1013-6. [PMID: 16735398 PMCID: PMC2077764 DOI: 10.1136/jnnp.2005.086132] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Orthostatic tremor with its sense of unsteadiness when standing may have a devastating effect on affected persons. Currently, there are no other treatment options in those who do not respond or who do not tolerate medical treatment. OBJECTIVES To report on a pilot study on spinal cord stimulation in medically intractable orthostatic tremor. METHODS Chronic spinal cord stimulation (SCS) was performed in two patients with medically-intractable orthostatic tremor via quadripolar plate electrodes implanted at the lower thoracic spine. The electrodes were connected to implantable pulse generators. RESULTS Subjective and objective improvement of unsteadiness was achieved within a frequency range of 50 to 150 Hz, and occurred in the presence of stimulation-induced paraesthesia. With optimized stimulation settings polygraphic electromyelogram (EMG) recordings continued to show the typical 14-16 Hz EMG activity. The beneficial effect of SCS was maintained at long-term follow-up. CONCLUSIONS The results of this pilot study indicate that SCS may be an option in patients with otherwise intractable orthostatic tremor.
Collapse
Affiliation(s)
- J K Krauss
- Department of Neurosurgery, Medical University, MHH, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Karlberg M, Fransson PA, Magnusson M. Posturography Can Be Used to Screen for Primary Orthostatic Tremor, a Rare Cause of Dizziness. Otol Neurotol 2005; 26:1200-3. [PMID: 16272942 DOI: 10.1097/01.mao.0000194891.26097.e0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Primary orthostatic tremor is a rare neurologic condition of unknown origin characterized by a 10- to 20-Hz tremor in the legs while standing. Patients with primary orthostatic tremor usually complain of dizziness and unsteadiness that is relieved if they sit down or start to walk around. These patients might be referred to neurotology clinics. Previously, the only way to make the diagnosis has been by means of surface electromyographic recordings from the lower limbs during standing. The authors wanted to study whether posturography can be used to screen for primary orthostatic tremor. STUDY DESIGN Retrospective case review. SETTING Balance clinic at a tertiary referral center. PATIENTS From September 2000 to August 2002, 701 patients were investigated at the authors' balance clinic. INTERVENTION Static posturography on a force platform with 50-Hz sampling frequency. Recordings were made during 120 seconds of quiescent stance with open or closed eyes. MAIN OUTCOME MEASURE Fast-Fourier transformation (FFT) analysis of recorded torque in the fore-to-aft direction to quantify the spectral power distribution in the range of 0 to 25 Hz. Visual inspection of power spectrum plots was performed. RESULTS Five patients (0.7%) were identified (1 man and 4 women; mean age, 56 yr; age range, 36-73 yr) with narrow peaks at 8.5 to 18 Hz in the power spectra of their posturographic recordings. Surface electromyographic recordings during standing confirmed their diagnosis of primary orthostatic tremor. CONCLUSION Analysis of power spectra from posturographic recordings is a simple, quick method to screen for primary orthostatic tremor. The condition might be more common than previously assumed. It is important to identify patients with primary orthostatic tremor because they might be misdiagnosed and left without treatment.
Collapse
Affiliation(s)
- Mikael Karlberg
- Department of Otorhinolaryngology-Head and Neck Surgery, Lund University Hospital, Lund, Sweden.
| | | | | |
Collapse
|
15
|
Garosi LS, Rossmeisl JH, Lahunta A, Shelton GD, Lennox G. Primary Orthostatic Tremor in Great Danes. J Vet Intern Med 2005. [DOI: 10.1111/j.1939-1676.2005.tb02736.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
16
|
Piboolnurak P, Yu QP, Pullman SL. Clinical and neurophysiologic spectrum of orthostatic tremor: Case series of 26 subjects. Mov Disord 2005; 20:1455-61. [PMID: 16037915 DOI: 10.1002/mds.20588] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Orthostatic tremor (OT) is a condition described as high-frequency tremors predominantly in the legs and trunk, which are present not only in the standing position but also during isometric contraction of the limb muscles. This report is one of the largest OT series describing clinical and neurophysiologic findings in 26 subjects with OT. The main findings included 13.0 to 18.6 Hz leg tremors while standing with varied patterns of phase relationships between the antagonists of the ipsilateral leg and between the homologous muscles of the contralateral leg, short latency tremor onset upon standing with abrupt cessation after sitting, coexistence of tremors in the cranial structures and the arms, and sense of unsteadiness without actual falls. Although the oscillator of OT is most likely located in the brainstem, cerebral cortex, basal ganglia, and cerebellum may also be involved in its pathogenesis.
Collapse
Affiliation(s)
- Panida Piboolnurak
- Department of Neurology, Clinical Motor Physiology Laboratory, Columbia University Medical Center, New York, New York, USA
| | | | | |
Collapse
|