Combination therapy of extrapyramidal disease with trihexyphenidyl and L-dopa: an electromyographic study with specific reference to tremor

Anticholinergic drugs for parkinsonism and other movement disorders

Anticholinergic (AC) drugs, a medication class that acts by blocking nicotinic and muscarinic acetylcholine receptors, were first utilized for therapeutic purposes in the mid-19th century. Initial applications were as symptomatic therapy for Parkinson disease (PD), a practice continuing to the present. Initially, the AC drugs used were naturally-occurring plant compounds. Synthetic AC drugs were developed in the late 1940s and predominated in neurological therapeutics. Until the advent of pharmaceuticals acting upon striatal dopaminergic motor pathways, AC drugs provided the only effective means for lessening tremors and other clinical problems of the PD patient. However, because dopaminergic compounds are so effective at meeting the needs of the typical PD patient, AC medications are far less utilized by clinicians today. In recent years, there has been only a few investigations of AC drugs as neurological treatments. This review will revisit the clinical landscape of AC pharmacology and application for movement disorders along with recent research in search of improving therapeutics with AC drugs.

Tremor in dystonia

Tremor has been recognized as an important clinical feature in dystonia. Tremor in dystonia may occur in the body part affected by dystonia known as dystonic tremor or unaffected body regions known as tremor associated with dystonia. The most common type of tremor seen in dystonia patients is postural and kinetic which may be mistaken for familial essential tremor. Similarly familial essential tremor patients may have associated dystonia leading to diagnostic uncertainties. The pathogenesis of tremor in dystonia remains speculative, but its neurophysiological features are similar to dystonia which helps in differentiating it from essential tremor patients. Treatment of tremor in dystonia depends upon the site of involvement. Dystonic hand tremor is treated with oral pharmacological therapy and dystonic head, jaw and voice tremor is treated with injection botulinum toxin. Neurosurgical interventions such as deep brain stimulation and lesion surgery should be an option in patients not responding to the pharmacological treatment.

The treatment of dystonic tremor: a systematic review

Tremor is one of the clinical manifestations of dystonia; however, there are no specific therapeutic trials evaluating the efficacy of treatments for dystonic tremor (DT), tremor associated with dystonia or primary writing tremor (PWT). We systematically reviewed the literature available up to July 2013 on the treatment of these tremors and retrieved the data of 487 patients published in 43 papers detailing the effects of given interventions on tremor severity. Treatment outcome was highly variable, depending on the specific type of intervention and tremor distribution. No specifically designed studies were available for the treatment of tremor associated with dystonia. As for the other tremors, drug efficacy was generally disappointing and a moderate effect was only found with anticholinergics, tetrabenazine, clonazepam, β-blockers and primidone; levodopa was only efficacious on tremor due to dopa-responsive dystonia. The largest amount of data was available for botulinum toxin injections, which provided a marked improvement, particularly for the management of axial tremors (head or vocal cords). In refractory DTs, deep brain stimulation of several targets was attempted. Deep brain stimulation of globus pallidus internus, thalamus or subthalamic area led to a marked improvement of dystonic axial or appendicular tremors in most cases refractory to other treatments. Few other non-invasive treatments, for example, orthotic device in PWT, have been used with anecdotal success. In conclusion, considering the lack of good-quality studies, future randomised controlled trials are needed. In absence of evidence-based guidelines, we propose an algorithm for the treatment of DT based on currently available data.

Spectral analysis of tremorine and cold tremor electromyograms in animal species of different size

In 14 mice (36.2 +/- 5.4 g), 17 rats (425 +/- 46.4 g), and 11 rabbits (3,200 +/- 340 g) a comparative electromyographic analysis of tremorine tremor and cold tremor was performed in gastrocnemius and tibialis anterior muscles using spectral analysis. The mean frequency of cold tremor decreased with increasing body weight (mice: 40.2 +/- 4.5 Hz; rats: 31.3 +/- 4.9 Hz; rabbits: 16.4 +/- 3.2 Hz). With tremorine tremor no such allometric correlation was found for tremor frequency and body weight (mice: 17.7 +/- 3.6 Hz; rats: 19.6 +/- 5.1 Hz; rabbits: 15.9 +/- 2.1 Hz). Cross spectral analysis revealed that during cold tremor the flexor muscle (tibialis anterior) and the extensor muscle (gastrocnemius) of rabbits are activated alternately. The mean phase shift between the activation of flexor and extensor muscle was -155.5 degrees. Stronger activation was observed in the flexor muscle. Tremorine tremor was characterized by synchronous activation of flexor and extensor muscles with a mean phase angle of 3.0 degrees and a predominance of the extensor muscle. The results suggest that the nervous mechanisms for the generation of tremorine tremor and cold tremor are different.