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Schoeberl F, Dowsett J, Pradhan C, Grabova D, Köhler A, Taylor P, Zwergal A. TMS of the left primary motor cortex improves tremor intensity and postural control in primary orthostatic tremor. J Neurol 2024; 271:2938-2947. [PMID: 38625401 PMCID: PMC11136716 DOI: 10.1007/s00415-024-12376-3] [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: 02/21/2024] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/17/2024]
Abstract
A ponto-cerebello-thalamo-cortical network is the pathophysiological correlate of primary orthostatic tremor. Affected patients often do not respond satisfactorily to pharmacological treatment. Consequently, the objective of the current study was to examine the effects of a non-invasive neuromodulation by theta burst repetitive transcranial magnetic stimulation (rTMS) of the left primary motor cortex (M1) and dorsal medial frontal cortex (dMFC) on tremor frequency, intensity, sway path and subjective postural stability in primary orthostatic tremor. In a cross-over design, eight patients (mean age 70.2 ± 5.4 years, 4 female) with a primary orthostatic tremor received either rTMS of the left M1 leg area or the dMFC at the first study session, followed by the other condition (dMFC or M1 respectively) at the second study session 30 days later. Tremor frequency and intensity were quantified by surface electromyography of lower leg muscles and total sway path by posturography (foam rubber with eyes open) before and after each rTMS session. Patients subjectively rated postural stability on the posturography platform following each rTMS treatment. We found that tremor frequency did not change significantly with M1- or dMFC-stimulation. However, tremor intensity was lower after M1- but not dMFC-stimulation (p = 0.033/ p = 0.339). The sway path decreased markedly after M1-stimulation (p = 0.0005) and dMFC-stimulation (p = 0.023) compared to baseline. Accordingly, patients indicated a better subjective feeling of postural stability both with M1-rTMS (p = 0.007) and dMFC-rTMS (p = 0.01). In conclusion, non-invasive neuromodulation particularly of the M1 area can improve postural control and tremor intensity in primary orthostatic tremor by interference with the tremor network.
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Affiliation(s)
- Florian Schoeberl
- Department of Neurology and German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - James Dowsett
- Division of Psychology, University of Stirling, Stirling, UK
| | - Cauchy Pradhan
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - Denis Grabova
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - Angelina Köhler
- Department of Neurology and German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany
| | - Paul Taylor
- Faculty of Philosophy, Philosophy of Science and the Study of Religion, LMU Munich, Munich, Germany
| | - Andreas Zwergal
- Department of Neurology and German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany.
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Möhwald K, Wuehr M, Schenkel F, Feil K, Strupp M, Schniepp R. The gait disorder in primary orthostatic tremor. J Neurol 2020; 267:285-291. [PMID: 32915312 PMCID: PMC7718181 DOI: 10.1007/s00415-020-10177-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To uncover possible impairments of walking and dynamic postural stability in patients with primary orthostatic tremor (OT). METHODS Spatiotemporal gait characteristics were quantified in 18 patients with primary OT (mean age 70.5 ± 5.9 years, 10 females) and 18 age-matched healthy controls. One-third of patients reported disease-related fall events. Walking performance was assessed on a pressure-sensitive carpet under seven conditions: walking at preferred, slow, and maximal speed, with head reclination or eyes closed, and while performing a cognitive or motor dual-task paradigm. RESULTS Patients exhibited a significant gait impairment characterized by a broadened base of support (p = 0.018) with increased spatiotemporal gait variability (p = 0.010). Walking speed was moderately reduced (p = 0.026) with shortened stride length (p = 0.001) and increased periods of double support (p = 0.001). Gait dysfunction became more pronounced during slow walking (p < 0.001); this was not present during fast walking. Walking with eyes closed aggravated gait disability as did walking during cognitive dual task (p < 0.001). CONCLUSION OT is associated with a specific gait disorder with a staggering wide-based walking pattern indicative of a sensory and/or a cerebellar ataxic gait. The aggravation of gait instability during visual withdrawal and the normalization of walking with faster speeds further suggest a proprioceptive or vestibulo-cerebellar deficit as the primary source of gait disturbance in OT. In addition, the gait decline during cognitive dual task may imply cognitive processing deficits. In the end, OT is presumably a complex network disorder resulting in a specific spino-cerebello-frontocortical gait disorder that goes beyond mere tremor networks.
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Affiliation(s)
- Ken Möhwald
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany. .,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany
| | - Fabian Schenkel
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany
| | - Katharina Feil
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Strupp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Roman Schniepp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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Wuehr M, Schlick C, Möhwald K, Schniepp R. Walking in orthostatic tremor modulates tremor features and is characterized by impaired gait stability. Sci Rep 2018; 8:14152. [PMID: 30237442 PMCID: PMC6147915 DOI: 10.1038/s41598-018-32526-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/06/2018] [Indexed: 11/13/2022] Open
Abstract
Primary orthostatic tremor (OT) is characterized by high-frequency lower-limb muscle contractions and a disabling sense of unsteadiness while standing. Patients consistently report a relief of symptoms when starting to ambulate. Here, we systematically examined and linked tremor and gait characteristics in patients with OT. Tremor and gait features were examined in nine OT patients and controls on a pressure-sensitive treadmill for one minute of walking framed by two one-minute periods of standing. Tremor characteristics were assessed by time-frequency analysis of surface EMG-recordings from four leg muscles. High-frequency tremor during standing (15.29 ± 0.17 Hz) persisted while walking but was consistently reset to higher frequencies (16.34 ± 0.25 Hz; p < 0.001). Tremor intensity was phase-dependently modulated, being predominantly observable during stance phases (p < 0.001). Tremor intensity scaled with the force applied during stepping (p < 0.001) and was linked to specific gait alterations, i.e., wide base walking (p = 0.019) and increased stride-to-stride fluctuations (p = 0.002). OT during walking persists but is reset to higher frequencies, indicating the involvement of supraspinal locomotor centers in the generation of OT rhythm. Tremor intensity is modulated during the gait cycle, pointing at specific pathways mediating the peripheral manifestation of OT. Finally, OT during walking is linked to gait alterations resembling a cerebellar and/or sensory ataxic gait disorder.
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Affiliation(s)
- M Wuehr
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.
| | - C Schlick
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany
| | - K Möhwald
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - R Schniepp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Munich, Germany
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Abstract
Tremor is clinically defined as a rhythmic, oscillating movement of parts of the body, which functionally leads to impairment of the coordination and execution of targeted movements. It can be a symptom of a primary disease, such as resting tremor in Parkinson's disease or occur as an independent disease, such as essential or orthostatic tremor. For the development of tremor, cerebral components as well as mechanisms at the spinal and muscular level play an important role. This review presents the results of new imaging and electrophysiological studies that have led to important advances in our understanding of the pathophysiology of tremor. We discuss pathophysiological models for the development of resting tremor in Parkinson's disease, essential and orthostatic tremor. We describe recent developments starting from the classical generator model, with an onset of pathological oscillations in distinct cerebral regions, to a network perspective in which tremor arises and spreads through existing anatomical or newly emerged pathological brain networks. In particular translational approaches are presented and discussed. These could serve in the future as a basis for the development of new therapeutic strategies.
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Affiliation(s)
- M Muthuraman
- Sektion für Bewegungsstörungen und Neurostimulation, Biomedizinische Statistik und multimodale Signalverarbeitung, Klinik und Poliklinik für Neurologie, Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - A Schnitzler
- Klinik für Neurologie, Universitätsklinik Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - S Groppa
- Sektion für Bewegungsstörungen und Neurostimulation, Biomedizinische Statistik und multimodale Signalverarbeitung, Klinik und Poliklinik für Neurologie, Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
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Maugest L, McGovern EM, Mazalovic K, Doulazmi M, Apartis E, Anheim M, Bourdain F, Benchetrit E, Czernecki V, Broussolle E, Bonnet C, Falissard B, Jahanshahi M, Vidailhet M, Roze E. Health-Related Quality of Life Is Severely Affected in Primary Orthostatic Tremor. Front Neurol 2018; 8:747. [PMID: 29379467 PMCID: PMC5775514 DOI: 10.3389/fneur.2017.00747] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/27/2017] [Indexed: 12/17/2022] Open
Abstract
Background Primary orthostatic tremor (POT) is a movement disorder characterized by unsteadiness upon standing still due to a tremor affecting the legs. It is a gradually progressive condition with limited treatment options. Impairments in health-related quality of life (HQoL) seem to far exceed the physical disability associated with the condition. Methods A multi-center, mixed-methodology study was undertaken to investigate 40 consecutive patients presenting with POT to four movement disorder centers in France. HQoL was investigated using eight quantitative scales and a qualitative study which employed semi-structured interviews. Qualitative data were analyzed with a combination of grounded-theory approach. Results Our results confirm that HQoL in POT is severely affected. Fear of falling was identified as the main predictor of HQoL. The qualitative arm of our study explored our initial results in greater depth and uncovered themes not identified by the quantitative approach. Conclusion Our results illustrate the huge potential of mixed methodology in identifying issues influencing HQoL in POT. Our work paves the way for enhanced patient care and improved HQoL in POT and is paradigmatic of this modern approach for investigating HQoL issues in chronic neurological disorders.
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Affiliation(s)
- Lucie Maugest
- Département de Neurologie, EA 4184, Hôpital universitaire de Dijon, Dijon, France
| | - Eavan M McGovern
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Katia Mazalovic
- Département de Médecine générale, Faculté de Médecine, Université de Bourgogne, Dijon, France
| | - Mohamed Doulazmi
- Sorbonne Universités, UPMC Univ Paris 06, UMR8256, INSERM, CNRS, Institut de Biologie Paris Seine, Adaptation Biologique et Vieillissement, Paris, France
| | - Emmanuelle Apartis
- Département de Neurophysiologie, Hôpital de Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mathieu Anheim
- Département de Neurologie, Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Strasbourg, France.,Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Illkirch-Graffenstaden, France.,Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
| | - Frédéric Bourdain
- Département de Neurologie, Centre médico-chirurgical Foch, Suresnes, France
| | - Eve Benchetrit
- Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Virginie Czernecki
- Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Emmanuel Broussolle
- Département de Neurologie, Service de Mouvements anormaux, Hôpital Neurologique et Neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Université Lyon I, Faculté de Médecine Lyon Sud Charles Mérieux, Institut des Sciences Cognitives Marc Jeannerod, CNRS UMR 5229, Lyon, France
| | - Cecilia Bonnet
- Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bruno Falissard
- CESP, Univ. Paris-Sud, Université Paris-Saclay, UVSQ, INSERM U1178, Paris, France
| | - Marjan Jahanshahi
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, The National Hospital for Neurology and Neurosurgery, University College London, London, United Kingdom
| | - Marie Vidailhet
- Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UMR S 975, CNRS UMR 7225, ICM, Sorbonne Universités, UPMC Université Paris, Paris, France
| | - Emmanuel Roze
- Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UMR S 975, CNRS UMR 7225, ICM, Sorbonne Universités, UPMC Université Paris, Paris, France
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Chiosa V, Groppa SA, Ciolac D, Koirala N, Mişina L, Winter Y, Moldovanu M, Muthuraman M, Groppa S. Breakdown of Thalamo-Cortical Connectivity Precedes Spike Generation in Focal Epilepsies. Brain Connect 2017; 7:309-320. [DOI: 10.1089/brain.2017.0487] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Vitalie Chiosa
- Department of Neurology, Neuroimaging and Neurostimulation, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Neurology and Neurosurgery, National Center of Epileptology, Institute of Emergency Medicine, Chisinau, Moldova
- Laboratory of Neurobiology and Medical Genetics, State University of Medicine and Pharmacy “Nicolae Testemiţanu,” Chisinau, Moldova
| | - Stanislav A. Groppa
- Department of Neurology and Neurosurgery, National Center of Epileptology, Institute of Emergency Medicine, Chisinau, Moldova
- Laboratory of Neurobiology and Medical Genetics, State University of Medicine and Pharmacy “Nicolae Testemiţanu,” Chisinau, Moldova
| | - Dumitru Ciolac
- Department of Neurology, Neuroimaging and Neurostimulation, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Neurology and Neurosurgery, National Center of Epileptology, Institute of Emergency Medicine, Chisinau, Moldova
- Laboratory of Neurobiology and Medical Genetics, State University of Medicine and Pharmacy “Nicolae Testemiţanu,” Chisinau, Moldova
| | - Nabin Koirala
- Department of Neurology, Neuroimaging and Neurostimulation, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Liudmila Mişina
- Department of Neurology and Neurosurgery, National Center of Epileptology, Institute of Emergency Medicine, Chisinau, Moldova
- Laboratory of Neurobiology and Medical Genetics, State University of Medicine and Pharmacy “Nicolae Testemiţanu,” Chisinau, Moldova
| | - Yaroslav Winter
- Department of Neurology, Neuroimaging and Neurostimulation, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Muthuraman Muthuraman
- Department of Neurology, Neuroimaging and Neurostimulation, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sergiu Groppa
- Department of Neurology, Neuroimaging and Neurostimulation, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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