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Bhidayasiri R. Old problems, new solutions: harnessing technology and innovation in Parkinson's disease-evidence and experiences from Thailand. J Neural Transm (Vienna) 2024; 131:721-738. [PMID: 38189972 DOI: 10.1007/s00702-023-02727-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/09/2023] [Indexed: 01/09/2024]
Abstract
The prevalence of Parkinson's disease (PD) is increasing rapidly worldwide, but there are notable inequalities in its distribution and in the availability of healthcare resources across different world regions. Low- and middle-income countries (LMICs), including Thailand, bear the highest burden of PD so there is an urgent need to develop effective solutions that can overcome the many regional challenges associated with delivering high-quality, and equitable care to a diverse population with limited resources. This article describes the evolution of healthcare delivery for PD in Thailand, as a case example of a LMIC. The discussions reflect the author's presentation at the Yoshikuni Mizuno Lectureship Award given during the 8th Asian and Oceanian Parkinson's Disease and Movement Disorders Congress in March 2023 for which he was the 2023 recipient. The specific challenges faced in Thailand are reviewed along with new solutions that have been implemented to improve the knowledge and skills of healthcare professionals nationally, the delivery of care, and the outcomes for PD patients. Technology and innovation have played an important role in this process with many new tools and devices being implemented in clinical practice. Without any realistic prospect of a curative therapy in the near future that could halt the current PD pandemic, it will be necessary to focus on preventative lifestyle strategies that can help reduce the risk of developing PD such as good nutrition (EAT), exercise (MOVE), good sleep hygiene (SLEEP), and minimizing environmental risks (PROTECT), which should be initiated and continued (REPEAT) as early as possible.
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Affiliation(s)
- Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, 1873 Rama 4 Road, Bangkok, 10330, Thailand.
- The Academy of Science, The Royal Society of Thailand, Bangkok, 10330, Thailand.
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Varalta V, Righetti A, Evangelista E, Vantini A, Martoni A, Tamburin S, Fonte C, Di Vico IA, Tinazzi M, Waldner A, Picelli A, Filippetti M, Smania N. Effects of upper limb vibratory stimulation training on motor symptoms in Parkinson's disease: an observational study. J Rehabil Med 2024; 56:jrm19495. [PMID: 38407431 PMCID: PMC10910977 DOI: 10.2340/jrm.v56.19495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/13/2023] [Indexed: 02/27/2024] Open
Abstract
OBJECTIVES Parkinson's disease is characterized by motor and non-motor symptoms. Tremor is one of the motor symptoms that can affect manual skills and have an impact on daily activities. The aim of the current study is to investigate the effect of upper limb training provided by a specific vibratory device (Armshake®, Move It GmbH - Bochum, Germany) on tremor and motor functionality in patients with Parkinson's disease. Furthermore, the training effect on global cognitive functioning is assessed. DESIGN An uncontrolled before-after clinical trial. PATIENTS Individuals with diagnosis of Parkinson's disease, motor upper limbs deficits, and absence of dementia. METHODS Participants underwent a 3-week programme (3 times a week) and was evaluated before, after, and at 1 month follow-up by motor (Fahn Tolosa Marin Tremor Rating Scale, Unified Parkinson's Disease Rating Scale - part III, Purdue Pegboard Test, Disability of the Arm, Shoulder and Hand Questionnaire) and cognitive (Montreal Cognitive Assessment) scales. RESULTS Twenty subjects are included. After treatment a statistically significant improvement in tremor, manual dexterity and activities of daily living was found. The data indicated no effects on global cognitive functioning. CONCLUSION These findings suggest positive effects of vibratory stimulation training on upper limb motor symptoms in Parkinson's disease.
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Affiliation(s)
- Valentina Varalta
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona; Neurorehabilitation Unit, University Hospital of Verona, Verona
| | - Anna Righetti
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona; Neurorehabilitation Unit, University Hospital of Verona, Verona
| | - Elisa Evangelista
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Alberto Vantini
- Neurorehabilitation Unit, University Hospital of Verona, Verona, Italy
| | - Alessandro Martoni
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona
| | - Stefano Tamburin
- Section of Neurology, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona
| | - Cristina Fonte
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona; Neurorehabilitation Unit, University Hospital of Verona, Verona
| | - Ilaria Antonella Di Vico
- Section of Neurology, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona
| | - Michele Tinazzi
- Section of Neurology, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona; Neurology Unit, USD Parkinson e Disturbi del Movimento, University Hospital of Verona, Verona
| | - Andreas Waldner
- Department of Neurological Rehabilitation, Private Hospital "Villa Melitta", Bolzano. andre
| | - Alessandro Picelli
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona; Neurorehabilitation Unit, University Hospital of Verona, Verona; Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada.
| | - Mirko Filippetti
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona; Neurorehabilitation Unit, University Hospital of Verona, Verona
| | - Nicola Smania
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona; Neurorehabilitation Unit, University Hospital of Verona, Verona
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Hosseini SM, Farashi S, Bashirian S. Electromagnetic radiation therapy for Parkinson's disease tremor reduction- systematic reviews and Bayesian meta-analyses for comparing the effectiveness of electric, magnetic and light stimulation methods. J Neuroeng Rehabil 2023; 20:129. [PMID: 37752553 PMCID: PMC10521577 DOI: 10.1186/s12984-023-01255-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 09/19/2023] [Indexed: 09/28/2023] Open
Abstract
PURPOSE Tremor is one of the key characteristics of Parkinson's disease (PD), leading to physical disabilities and often showing limited responses to pharmacological treatments. To suppress tremors in PD patients, several types of non-invasive and non-pharmacological methods have been proposed so far. In the current systematic review, three electromagnetic-based radiation strategies including electrical stimulation, magnetic stimulation, and light stimulation methods were reviewed and compared. METHODS Major databases were searched to retrieve eligible studies. For the meta-analysis, a random-effect Bayesian framework was used. Also, heterogeneity between studies was assessed using I2 statistic, prediction interval, and tau2. Publication bias was assessed using funnel plot, and the effectiveness of methods for reducing tremor was compared using network Bayesian meta-analysis. RESULTS AND CONCLUSION Thirty-one studies were found for qualitative analysis, and 16 studies were found for quantitative synthesis. Based on the suppression ratio, methods can be ordered as electrical stimulation, light therapy, and magnetic stimulation. Furthermore, the results showed that electrical and magnetic stimulation were more effective for tremor suppression at early stages of PD, while light therapy was found to be more effective during the later stages of PD.
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Affiliation(s)
- Seyedeh Marzieh Hosseini
- Autism Spectrum Disorders Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Sajjad Farashi
- Neurophysiology Research Centre, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Saeid Bashirian
- Autism Spectrum Disorders Research Center, Hamadan University of Medical Sciences, Hamadan, Iran.
- Social Determinants of Health Research Center, Hamadan University of Medical Sciences, Hamadan, Iran.
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Shahien M, Elaraby A, Gamal M, Abdelazim E, Abdelazeem B, Ghaith HS, Negida A. Physical therapy interventions for the management of hand tremors in patients with Parkinson's disease: a systematic review. Neurol Sci 2023; 44:461-470. [PMID: 36205810 DOI: 10.1007/s10072-022-06420-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/19/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Several physical therapy modalities have been used to improve hand tremors in patients with Parkinson's disease (PD). However, little is known about the efficacy of these techniques. Therefore, we conducted this study to synthesize evidence from published studies on the efficacy of physical therapy techniques for hand tremors in PD patients. METHODS We followed the PRISMA statement and Cochrane handbook guidelines when conducting this study. We conducted an electronic literature search of PubMed, Cochrane Central Register of Clinical Trials, Web of Science, Ovid, and Embase, and then we selected clinical trials assessing the efficacy of any physical therapy intervention for hand tremors in patients with PD. Study outcomes were extracted, and evidence was synthesized narratively. RESULTS A total of six modalities described in six studies were included in this systematic review. Out of the six interventions, the tremor's glove and electrical stimulation showed significant improvements in root mean square angular velocity (59% and 43.8%, respectively) and UPDRS tremor score (P < 0.05 for both). Also, eccentric exercises were associated with significant reductions in the mean resting tremor amplitude (P < 0.05). These data were dependent on single studies; therefore, a meta-analysis was not feasible. CONCLUSION Several physical therapy interventions, such as electrical stimulation, exercises, transcranial low voltage pulsed electromagnetic fields, weights, and virtual reality showed promising results in reducing hand tremors. However, this evidence was based on a limited number of included studies, and more RCTs with larger sample sizes are required to confirm the efficacy of these interventions.
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Affiliation(s)
- Mostafa Shahien
- Faculty of Physical Therapy, Cairo University, Cairo, Egypt
- Medical Research Group of Egypt, Cairo, Egypt
| | - Abdelrahman Elaraby
- Faculty of Physical Therapy, Cairo University, Cairo, Egypt
- Medical Research Group of Egypt, Cairo, Egypt
| | - Mohamed Gamal
- Faculty of Medicine, Tanta University, Tanta, Egypt
- Medical Research Group of Egypt, Cairo, Egypt
| | - Eslam Abdelazim
- Faculty of Medicine, Misr University for Science and Technology, 6Th of October City, Egypt
- Medical Research Group of Egypt, Cairo, Egypt
| | - Basel Abdelazeem
- McLaren Health Care, Flint, MI, USA
- Michigan State University, East Lansing, MI, USA
- Medical Research Group of Egypt, Cairo, Egypt
| | - Hazem S Ghaith
- Facutly of Medicine, Al-Ahzar University, Cairo, Egypt
- Medical Research Group of Egypt, Cairo, Egypt
| | - Ahmed Negida
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA.
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK.
- Faculty of Medicine, Zagazig University, Zagazig, Egypt.
- Medical Research Group of Egypt, Cairo, Egypt.
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Zhang B, Huang F, Liu J, Zhang D. Bilateral transcranial direct current stimulation may be a feasible treatment of Parkinsonian tremor. Front Neurosci 2023; 17:1101751. [PMID: 36908793 PMCID: PMC9998710 DOI: 10.3389/fnins.2023.1101751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023] Open
Abstract
Background Parkinsonian tremor is a common pathological tremor that affects over 6 million people worldwide. It lowers patients' quality of life and threatens their career development, especially when patients' occupation requires dexterous manipulation. In spite of current available treatments in clinics, there is a lack of low-cost, low side-effect, effective solutions for Parkinsonian tremor. Transcranial direct current stimulation (tDCS) may be an alternative treatment. Objective In this research, we explored the immediate effect of tDCS with a novel bilateral electrode setup over Parkinsonian tremor. In such a bilateral setup, the cathode was placed over the primary cortex contralateral to the more affected side of Parkinsonian tremor while the anode symmetrically over the other hemisphere. It was designed as a modification to the traditional cathodal setup. The performance of this bilateral setup was compared with three other setups including anodal setup, cathodal setup, and sham (control). Methods A randomized, sham-controlled, double-blind, crossover experiment was carried out over 13 qualified patients diagnosed with idiopathic Parkinson's disease (PD). Before and after the stimulus of each tDCS setup, subjects were tested before and after tDCS with four measures, including the Unified Parkinson's Disease Rating Scale (UPDRS), Fahn-Tolosa-Marin Tremor Rating Scale (FTMTRS), Purdue Pegboard Test (PPT) and a self-design Continuous Tremor Signal Assessment (CTSA). Tremor intensity calculated from CTSA data were regarded as the primary outcome of the experiment. Results Statistical results of CTSA, FTMTRS and PPT showed both bilateral tDCS and cathodal tDCS effectively suppressed Parkinsonian tremor. A quantitative comparison of the effect in tremor suppression indicated the optimal suppressive effect was obtained with bilateral tDCS. Based on the results of UPDRS, anodal tDCS was found to benefit subjects' overall performance the most, however, it had little effect in improving Parkinsonian tremor, as revealed by the results of other evaluations. Conclusion Our study suggests a beneficial immediate effect of bilateral tDCS in Parkinsonian tremor suppression. In addition, we assume there may be an underlying interhemispheric unbalance of cortical excitability which contributes to Parkinsonian tremor genesis. Clinical trial registration Identifier: ChiCTR2100054804.
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Affiliation(s)
- Bin Zhang
- State Key Laboratory of Mechanical Systems and Vibrations, Robotics Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Feifei Huang
- Department of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Liu
- Department of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dingguo Zhang
- Department of Electronic and Electrical Engineering, University of Bath, Bath, United Kingdom
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Zhou Y, Jenkins ME, Naish M, Trejos AL. Preliminary Assessment of the Safety of a Fault-Tolerant Control-based Wearable Tremor Suppression Glove . ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:2874-2877. [PMID: 36086514 DOI: 10.1109/embc48229.2022.9871546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The advent of wearable tremor suppression de-vices (WTSDs) has provided a promising alternative approach for parkinsonian tremor management, especially for individuals whose tremors are not managed by conventional treatment options. Currently, research in WTSDs has shown successful results with a tremor suppression ratio of up to 99 %; however, the user safety of WTSDs has not been properly considered, especially in the occurrence of unexpected events, such as faults and disturbances. In this study, a fault-tolerant control system was developed and integrated into the control system of a WTSD for the first time. The safety and tremor suppression performance of the proposed system under the influence of a measurement loss fault were tested and evaluated on 18 tremor motion datasets, specifically by quantifying the tremor power suppression ratio and the error when tracking voluntary motion. The experimental evaluation showed that the proposed system could remain functional and safe to use in the existence of the fault, with an average user motion tracking error of 1.5º. It was also found that the proposed system achieved significantly improved performance in both metrics when compared to the system without a fault-tolerant controller. Clinical Relevance-This work improves the safety and robustness of WTSDs making them more suitable for use as an additional treatment for parkinsonian tremor.
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Zhou Y, Box D, Hardy KG, Jenkins ME, Garland J, Naish MD, Trejos AL. Survey-based identification of design requirements and constraints for a wearable tremor suppression device. J Rehabil Assist Technol Eng 2022; 9:20556683221094480. [PMID: 35548101 PMCID: PMC9083043 DOI: 10.1177/20556683221094480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/30/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Parkinsonian tremor has severely impacted the lives of 65% of individuals with Parkinson’s disease, and nearly 25% do not respond to traditional treatments. Although wearable tremor suppression devices (WTSDs) have become a promising alternative approach, this technology is still in the early stages of development, and no studies have reported the stakeholders’ opinions on this technology and their desired design requirements. Methods An online survey was distributed to affected Canadians and Canadian movement disorder specialists (MDS) to acquire information on demographics, the current state of treatments, opinions on the WTSDs, and the desired design requirements of future WTSDs. Results A total of 101 affected individuals and 24 MDS completed the survey. It was found that both groups are generally open to using WTSDs to manage tremor. The most important design requirement to end users is the adaptability to lifestyle, followed by weight and size, accurate motion, comfort, safety, quick response, and cost. Lastly, most of the participants (65%) think that the device should cost under $500. Conclusions The findings from this study can be used as guidelines for the development of future WTSDs, such that the future generations could be evaluated and accepted by the end users.
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Affiliation(s)
- Yue Zhou
- School of Biomedical Engineering, Western University, London, ON, Canada
| | - Devin Box
- School of Kinesiology, Western University, London, ON, Canada
| | - Kenneth G Hardy
- Ivey Business School, Western University, London, ON, Canada
| | - Mary E Jenkins
- Movement Disorders Program, Clinical Neurological Sciences, Western University, London, ON, Canada
| | - Jayne Garland
- Faculty of Health Sciences, Western University, London, ON, Canada
| | - Michael D Naish
- School of Biomedical Engineering, Western University, London, ON, Canada
- Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
- Department of Electrical and Computer Engineering, Western University, London, ON, Canada
| | - Ana Luisa Trejos
- School of Biomedical Engineering, Western University, London, ON, Canada
- Department of Electrical and Computer Engineering, Western University, London, ON, Canada
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Meng L, Jin M, Zhu X, Ming D. Peripherical Electrical Stimulation for Parkinsonian Tremor: A Systematic Review. Front Aging Neurosci 2022; 14:795454. [PMID: 35197841 PMCID: PMC8859162 DOI: 10.3389/fnagi.2022.795454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/03/2022] [Indexed: 11/30/2022] Open
Abstract
Parkinsonian tremor is one of the most common motor disorders in patients with Parkinson's disease (PD). Compared to oral medications and brain surgery, electrical stimulation approaches have emerged as effective and non-invasive methods for tremor reduction. The pathophysiology, detection and interventions of tremors have been introduced, however, a systematic review of peripherical electrical stimulation approaches, methodologies, experimental design and clinical outcomes for PD tremor suppression is still missing. Therefore, in this paper, we summarized recent studies on electrical stimulation for tremor suppression in PD patients and discussed stimulation protocols and effectiveness of different types of electrical stimulation approaches in detail. Twenty out of 528 papers published from 2010 to 2021 July were reviewed. The results show that electrical stimulation is an efficient intervention for tremor suppression. The methods fall into three main categories according to the mechanisms: namely functional electrical stimulation (FES), sensory electrical stimulation (SES) and transcutaneous electrical nerve stimulation (TENS). The outcomes of tremor suppression were varied due to various stimulation approaches, electrode locations and stimulation parameters. The FES method performed the best in tremor attenuation where the efficiency depends mainly by the control strategy and accuracy of tremor detection. However, the mechanism underlying tremor suppression with SES and TENS, is not well-known. Current electrical stimulation approaches may only work for a number of patients. The potential mechanism of tremor suppression still needs to be further explored.
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Affiliation(s)
- Lin Meng
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Mengyue Jin
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Xiaodong Zhu
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
- Xiaodong Zhu
| | - Dong Ming
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
- Department of Biomedical Engineering, Tianjin University, Tianjin, China
- *Correspondence: Dong Ming
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Bhidayasiri R, Maytharakcheep S, Phumphid S, Maetzler W. Improving functional disability in patients with tremor: A clinical perspective of the efficacies, considerations, and challenges of assistive technology. J Neurol Sci 2022; 435:120197. [DOI: 10.1016/j.jns.2022.120197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/06/2021] [Accepted: 02/17/2022] [Indexed: 11/24/2022]
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Pascual-Valdunciel A, Rajagopal A, Pons JL, Delp S. Non-invasive electrical stimulation of peripheral nerves for the management of tremor. J Neurol Sci 2022; 435:120195. [PMID: 35220113 PMCID: PMC9590374 DOI: 10.1016/j.jns.2022.120195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/06/2021] [Accepted: 02/17/2022] [Indexed: 12/22/2022]
Abstract
Pathological tremor in patients with essential tremor and Parkinsons disease is typically treated using medication or neurosurgical interventions. There is a widely recognized need for new treatments that avoid the side effects of current medications and do not carry the risks of surgical interventions. Building on decades of research and engineering development, non-invasive electrical stimulation of peripheral nerves has emerged as a safe and effective strategy for reducing pathologic tremor in essential tremor. This review surveys the peripheral electrical stimulation (PES) literature and summarizes effectiveness, safety, clinical translatability, and hypothesized tremor-reduction mechanisms of various PES approaches. The review also proposes guidelines for assessing tremor in the context of evaluating new therapies that combine the strengths of clinician assessments, patient evaluations, and novel motion sensing technology. The review concludes with a summary of future directions for PES, including expanding clinical access for patients with Parkinson's disease and leveraging large, at-home datasets to learn more about tremor physiology and treatment effect that will better characterize the state of tremor management and accelerate discovery of new therapies. Growing evidence suggests that non-invasive electrical stimulation of afferent neural pathways provides a viable new option for management of pathological tremor, with one specific PES therapy cleared for prescription and home use, suggesting that PES be considered along with medication and neurosurgical interventions for treatment of tremor. This article is part of the Special Issue "Tremor" edited by Daniel D. Truong, Mark Hallett, and Aasef Shaikh.
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Affiliation(s)
- Alejandro Pascual-Valdunciel
- Northwestern University, Evanston, IL, USA; E.T.S. Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Spain
| | | | - Jose L Pons
- Northwestern University, Evanston, IL, USA; Shirley Ryan AbilityLab, Chicago, IL, USA.
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Kim J, Wichmann T, Inan OT, DeWeerth SP. Analyzing the Effects of Parameters for Tremor Modulation via Phase-Locked Electrical Stimulation on a Peripheral Nerve. J Pers Med 2022; 12:76. [PMID: 35055390 PMCID: PMC8779889 DOI: 10.3390/jpm12010076] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/30/2021] [Accepted: 12/31/2021] [Indexed: 12/18/2022] Open
Abstract
(1) Background: Non-invasive neuromodulation is a promising alternative to medication or deep-brain stimulation treatment for Parkinson's Disease or essential tremor. In previous work, we developed and tested a wearable system that modulates tremor via the non-invasive, electrical stimulation of peripheral nerves. In this article, we examine the proper range and the effects of various stimulation parameters for phase-locked stimulation. (2) Methods: We recruited nine participants with essential tremor. The subjects performed a bean-transfer task that mimics an eating activity to elicit kinetic tremor while using the wearable stimulation system. We examined the effects of stimulation with a fixed duty cycle, at different stimulation amplitudes and frequencies. The epochs of stimulation were locked to one of four phase positions of ongoing tremor, as measured with an accelerometer. We analyzed stimulation-evoked changes of the frequency and amplitude of tremor. (3) Results: We found that the higher tremor amplitude group experienced a higher rate of tremor power reduction (up to 65%) with a higher amplitude of stimulation when the stimulation was applied at the ±peak of tremor phase. (4) Conclusions: The stimulation parameter can be adjusted to optimize tremor reduction, and this study lays the foundation for future large-scale parameter optimization experiments for personalized peripheral nerve stimulation.
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Affiliation(s)
- Jeonghee Kim
- Department of Engineering Technology and Industrial Distribution, Texas A&M University, College Station, TX 77843, USA
- Department of Multidisciplinary Engineering, Texas A&M University, College Station, TX 77843, USA
- Department of Electrical and Computer Engineering, Texas A&M University, College Station, TX 77843, USA
| | - Thomas Wichmann
- Department of Neurology, Emory University, Atlanta, GA 30322, USA;
- Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center at Emory University, Atlanta, GA 30329, USA
| | - Omer T. Inan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (O.T.I.); (S.P.D.)
| | - Stephen P. DeWeerth
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (O.T.I.); (S.P.D.)
- Department of Biomedical Engineering, Lehigh University, Bethlehem, PA 18015, USA
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Phokaewvarangkul O, Vateekul P, Wichakam I, Anan C, Bhidayasiri R. Using Machine Learning for Predicting the Best Outcomes With Electrical Muscle Stimulation for Tremors in Parkinson's Disease. Front Aging Neurosci 2021; 13:727654. [PMID: 34566628 PMCID: PMC8461308 DOI: 10.3389/fnagi.2021.727654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022] Open
Abstract
Recent studies have identified that peripheral stimulation in Parkinson’s disease (PD) is effective in tremor reduction, indicating that a peripheral feedback loop plays an important role in the tremor reset mechanism. This was an open-label, quasi-experimental, pre- and post-test design, single-blind, single-group study involving 20 tremor-dominant PD patients. The objective of this study is to explore the effect of electrical muscle stimulation (EMS) as an adjunctive treatment for resting tremor during “on” period and to identify the best machine learning model to predict the suitable stimulation level that will yield the longest period of tremor reduction or tremor reset time. In this study, we used a Parkinson’s glove to evaluate, stimulate, and quantify the tremors of PD patients. This adjustable glove incorporates a 3-axis gyroscope to measure tremor signals and an EMS to provide an on-demand muscle stimulation to suppress tremors. Machine learning models were applied to identify the suitable pulse amplitude (stimulation level) in five classes that led to the longest tremor reset time. The study was registered at the www.clinicaltrials.gov under the name “The Study of Rest Tremor Suppression by Using Electrical Muscle Stimulation” (NCT02370108). Twenty tremor-dominant PD patients were recruited. After applying an average pulse amplitude of 6.25 (SD 2.84) mA and stimulation period of 440.7 (SD 560.82) seconds, the total time of tremor reduction, or tremor reset time, was 329.90 (SD 340.91) seconds. A significant reduction in tremor parameters during stimulation was demonstrated by a reduction of Unified Parkinson’s Disease Rating Scale (UPDRS) scores, and objectively, with a reduction of gyroscopic data (p < 0.05, each). None of the subjects reported any serious adverse events. We also compared gyroscopic data with five machine learning techniques: Logistic Regression, Random Forest, Support Vector Machine (SVM), Neural Network (NN), and Long-Short-Term-Memory (LSTM). The machine learning model that gave the highest accuracy was LSTM, which obtained: accuracy = 0.865 and macro-F1 = 0.736. This study confirms the efficacy of EMS in the reduction of resting tremors in PD. LSTM was identified as the most effective model for predicting pulse amplitude that would elicit the longest tremor reset time. Our study provides further insight on the tremor reset mechanism in PD.
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Affiliation(s)
- Onanong Phokaewvarangkul
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Peerapon Vateekul
- Department of Computer Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Itsara Wichakam
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chanawat Anan
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Roongroj Bhidayasiri
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,The Academy of Science, The Royal Society of Thailand, Bangkok, Thailand
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13
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Lora-Millan JS, Delgado-Oleas G, Benito-León J, Rocon E. A Review on Wearable Technologies for Tremor Suppression. Front Neurol 2021; 12:700600. [PMID: 34434161 PMCID: PMC8380769 DOI: 10.3389/fneur.2021.700600] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/28/2021] [Indexed: 12/29/2022] Open
Abstract
Tremor is defined as a rhythmic, involuntary oscillatory movement of a body part. Although everyone exhibits a certain degree of tremor, some pathologies lead to very disabling tremors. These pathological tremors constitute the most prevalent movement disorder, and they imply severe difficulties in performing activities of daily living. Although tremors are currently managed through pharmacotherapy or surgery, these treatments present significant associated drawbacks: drugs often induce side effects and show decreased effectiveness over years of use, while surgery is a hazardous procedure for a very low percentage of eligible patients. In this context, recent research demonstrated the feasibility of managing upper limb tremors through wearable technologies that suppress tremors by modifying limb biomechanics or applying counteracting forces. Furthermore, recent experiments with transcutaneous afferent stimulation showed significant tremor attenuation. In this regard, this article reviews the devices developed following these tremor management paradigms, such as robotic exoskeletons, soft robotic exoskeletons, and transcutaneous neurostimulators. These works are presented, and their effectiveness is discussed. The article also evaluates the different metrics used for the validation of these devices and the lack of a standard validation procedure that allows the comparison among them.
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Affiliation(s)
- Julio S. Lora-Millan
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas – Universidad Politécnica de Madrid, Madrid, Spain
| | - Gabriel Delgado-Oleas
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas – Universidad Politécnica de Madrid, Madrid, Spain
- Ingeniería Electrónica, Universidad del Azuay, Cuenca, Ecuador
| | - Julián Benito-León
- Department of Neurology, University Hospital “12 de Octubre”, Madrid, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Madrid, Spain
- Department of Medicine, Complutense University, Madrid, Spain
| | - Eduardo Rocon
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas – Universidad Politécnica de Madrid, Madrid, Spain
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14
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Pascual-Valdunciel A, Hoo GW, Avrillon S, Barroso FO, Goldman JG, Hernandez-Pavon JC, Pons JL. Peripheral electrical stimulation to reduce pathological tremor: a review. J Neuroeng Rehabil 2021; 18:33. [PMID: 33588841 PMCID: PMC7885254 DOI: 10.1186/s12984-021-00811-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/11/2021] [Indexed: 01/02/2023] Open
Abstract
Interventions to reduce tremor in essential tremor (ET) and Parkinson’s disease (PD) clinical populations often utilize pharmacological or surgical therapies. However, there can be significant side effects, decline in effectiveness over time, or clinical contraindications for these interventions. Therefore, alternative approaches must be considered and developed. Some non-pharmacological strategies include assistive devices, orthoses and mechanical loading of the tremorgenic limb, while others propose peripheral electrical stimulation. Specifically, peripheral electrical stimulation encompasses strategies that activate motor and sensory pathways to evoke muscle contractions and impact sensorimotor function. Numerous studies report the efficacy of peripheral electrical stimulation to alter tremor generation, thereby opening new perspectives for both short- and long-term tremor reduction. Therefore, it is timely to explore this promising modality in a comprehensive review. In this review, we analyzed 27 studies that reported the use of peripheral electrical stimulation to reduce tremor and discuss various considerations regarding peripheral electrical stimulation: the stimulation strategies and parameters, electrodes, experimental designs, results, and mechanisms hypothesized to reduce tremor. From our review, we identified a high degree of disparity across studies with regard to stimulation patterns, experimental designs and methods of assessing tremor. Having standardized experimental methodology is a critical step in the field and is needed in order to accurately compare results across studies. With this review, we explore peripheral electrical stimulation as an intervention for tremor reduction, identify the limitations and benefits of the current state-of-the-art studies, and provide ideas to guide the development of novel approaches based on the neural circuitries and mechanical properties implied in tremor generation.
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Affiliation(s)
- Alejandro Pascual-Valdunciel
- Neural Rehabilitation Group, Cajal Institute, Spanish National Research Council (CSIC), Madrid, Spain.,E.T.S. Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Grace W Hoo
- Legs + Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, 60611, USA
| | - Simon Avrillon
- Legs + Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, 60611, USA.,Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Filipe Oliveira Barroso
- Neural Rehabilitation Group, Cajal Institute, Spanish National Research Council (CSIC), Madrid, Spain
| | - Jennifer G Goldman
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Parkinson's Disease and Movement Disorders, Shirley Ryan AbilityLab, Chicago, IL, USA.,Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Julio C Hernandez-Pavon
- Legs + Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, 60611, USA.,Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - José L Pons
- Legs + Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, 60611, USA. .,Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Department of Biomedical Engineering and Mechanical Engineering, McCormick School of Engineering, Northwestern University, Chicago, IL, USA.
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15
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Kang N. Quantitative Evidence of Pathological Tremor Suppression after Functional Electrical Stimulation. IRANIAN JOURNAL OF PUBLIC HEALTH 2020; 49:2428-2430. [PMID: 34178753 PMCID: PMC8215052 DOI: 10.18502/ijph.v49i12.4835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Nyeonju Kang
- Division of Sport Science & Sport Science Institute, Incheon National University, Incheon, South Korea
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16
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Caba V, Borgese L, Agnelli S, Depero LE. A green and simple process to develop conductive polyurethane foams for biomedical applications. INT J POLYM MATER PO 2018. [DOI: 10.1080/00914037.2018.1525732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Valentina Caba
- INSTM and Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Laura Borgese
- INSTM and Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Silvia Agnelli
- INSTM and Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Laura E. Depero
- INSTM and Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
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17
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Zhang B, Huang F, Liu J, Zhang D. A Novel Posture for Better Differentiation Between Parkinson's Tremor and Essential Tremor. Front Neurosci 2018; 12:317. [PMID: 29867328 PMCID: PMC5966572 DOI: 10.3389/fnins.2018.00317] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 04/24/2018] [Indexed: 11/13/2022] Open
Abstract
Due to a lack of reliable non-invasive bio-markers, misdiagnosis between Parkinson's disease and essential tremor is common. Although some assistive engineering approaches have been proposed, little acceptance has been obtained for these methods lack well-studied mechanisms and involve operator-dependent procedures. Aiming at a better differentiation between the two tremor causes, we present a novel posture, termed arm-rested posture, to ameliorate the quality of recorded tremor sequences. To investigate its efficacy, the posture was compared with another common posture, called arm-stretching posture, in fundamental aspects of tremor intensity and dominant frequency. A tremor-affected cohort comprising 50 subjects (PD = 26, ET = 24) with inhomogeneous tremor manifestation were recruited. From each subject, acceleration data of 5 min in terms of each posture were recorded. In the overall process, no operator-dependent procedures, such as data screening, was employed. The differentiation performance of the two postures were assessed by the index of discrimination coefficient and a receiver operating characteristic analysis based on binary logistic regression. The results of the differentiation assessment consistently demonstrate a better performance with the arm-rested posture than with the arm-stretching posture. As a by-product, factors of disease stage (incipient, progressed stage), spectrum estimate (PSD, bispectrum) and recording length (5-300s) were investigated. The significant effect of disease stage was only found in PD in terms of tremor intensity [F(1, 516) = 7.781, P < 0.05]. The bispectrum estimate was found to have better performance than the PSD estimate in extracting dominant frequency in terms of the discrimination coefficient. By extending the recording length, we noticed an increase in the performance of dominant frequency. The best result of the arm-rested posture was obtained with the maximum recording length of 300 s (area under the curve: 0.944, sensitivity: 92%, 1-specificity: 0%, accuracy: 96%), which is better than that of the arm-stretching posture in the same condition (area under the curve: 0.734, sensitivity: 54%, 1-specificity: 12%, accuracy: 72%). Thus, we conclude that the arm-rested posture can assist in improving tremor differentiation between Parkinson's disease and essential tremor and may act as a universal tool to analyze tremor for both clinical and research purpose.
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Affiliation(s)
- Bin Zhang
- State Key Laboratory of Mechanical Systems and Vibrations, Robotics Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Feifei Huang
- Department of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Liu
- Department of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dingguo Zhang
- State Key Laboratory of Mechanical Systems and Vibrations, Robotics Institute, Shanghai Jiao Tong University, Shanghai, China
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18
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Jitkritsadakul O, Thanawattano C, Anan C, Bhidayasiri R. Tremor's glove-an innovative electrical muscle stimulation therapy for intractable tremor in Parkinson's disease: A randomized sham-controlled trial. J Neurol Sci 2017; 381:331-340. [PMID: 28991711 DOI: 10.1016/j.jns.2017.08.3246] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/08/2017] [Accepted: 08/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Medically refractory resting tremor is a debilitating symptom of Parkinson's disease (PD) patients. In our pilot study, modulation of peripheral reflex mechanism by electrical muscle stimulation (EMS) temporarily suppressed tremor. OBJECTIVES To investigate the efficacy of EMS, delivered using Tremor's glove, as a treatment of resting hand tremor. PATIENTS AND METHODS Thirty PD patients with medically refractory resting tremor were randomly allocated to a Tremor's glove group (n=15) or a sham glove group (n=15). Gloves were placed on the most tremulous hand for 30min per testing session. Demographics, clinical rating scales, and tremor parameters (RMS of angular velocity and angular displacement, peak magnitude, and frequency) were assessed before and during stimulation. Correlations with validated clinical rating scales were performed. RESULTS There were no statistically significant differences between groups in demographics, rating scales, or tremor parameters. During stimulation, significant reduction in RMS angular velocity (as percentage) in every axis and peak magnitude in axis (x-, y-) and UPDRS tremor score, were found with Tremor's glove compared to the sham groups (p<0.05, each). Significant moderate correlations were observed between a percentage reduction of RMS angular velocity in every axis and UPDRS tremor scores. Mean duration of tremor reduction after stimulation was 107.78±104.15s. No serious adverse events were observed. CONCLUSION In this study, EMS-based Tremor's glove was effective in suppressing resting hand tremor in PD patients. Tremor's glove is light-weight with a good safety profile, making it a future potential therapeutic option for PD patients with medically refractory tremor.
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Affiliation(s)
- Onanong Jitkritsadakul
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Chusak Thanawattano
- National Electronics and Computer Technology Center (NECTEC), Pathumthani, Thailand
| | - Chanawat Anan
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Roongroj Bhidayasiri
- Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand; Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan.
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19
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Dideriksen JL, Laine CM, Dosen S, Muceli S, Rocon E, Pons JL, Benito-Leon J, Farina D. Electrical Stimulation of Afferent Pathways for the Suppression of Pathological Tremor. Front Neurosci 2017; 11:178. [PMID: 28420958 PMCID: PMC5378793 DOI: 10.3389/fnins.2017.00178] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 03/20/2017] [Indexed: 11/13/2022] Open
Abstract
Pathological tremors are involuntary oscillatory movements which cannot be fully attenuated using conventional treatments. For this reason, several studies have investigated the use of neuromuscular electrical stimulation for tremor suppression. In a recent study, however, we found that electrical stimulation below the motor threshold also suppressed tremor, indicating involvement of afferent pathways. In this study, we further explored this possibility by systematically investigating how tremor suppression by afferent stimulation depends on the stimulation settings. In this way, we aimed at identifying the optimal stimulation strategy, as well as to elucidate the underlying physiological mechanisms of tremor suppression. Stimulation strategies varying the stimulation intensity and pulse timing were tested in nine tremor patients using either intramuscular or surface stimulation. Significant tremor suppression was observed in six patients (tremor suppression > 75% was observed in three patients) and the average optimal suppression level observed across all subjects was 52%. The efficiency for each stimulation setting, however, varied substantially across patients and it was not possible to identify a single set of stimulation parameters that yielded positive results in all patients. For example, tremor suppression was achieved both with stimulation delivered in an out-of-phase pattern with respect to the tremor, and with random timing of the stimulation. Overall, these results indicate that low-current stimulation of afferent fibers is a promising approach for tremor suppression, but that further research is required to identify how the effect can be maximized in the individual patient.
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Affiliation(s)
- Jakob L Dideriksen
- SMI, Department of Health Science and Technology, Aalborg UniversityAalborg, Denmark
| | - Christopher M Laine
- Brain-Body Dynamics Lab, University of Southern CaliforniaLos Angeles, CA, USA
| | - Strahinja Dosen
- Institute of Neurorehabilitation Systems, University Medical Center GöttingenGöttingen, Germany.,Clinic for Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center GöttingenGöttingen, Germany
| | - Silvia Muceli
- Institute of Neurorehabilitation Systems, University Medical Center GöttingenGöttingen, Germany.,Clinic for Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center GöttingenGöttingen, Germany
| | - Eduardo Rocon
- Center for Automation and Robotics, Consejo Superior de Investigaciones CientíficasArganda del Rey, Spain
| | - José L Pons
- Neural Rehabilitation Group, Instituto Cajal, Consejo Superior de Investigaciones CientíficasMadrid, Spain
| | | | - Dario Farina
- Department of Bioengineering, Imperial College LondonLondon, UK
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