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Khatoun A, Asamoah B, Boogers A, Mc Laughlin M. Epicranial Direct Current Stimulation Suppresses Harmaline Tremor in Rats. Neuromodulation 2022:S1094-7159(22)01223-5. [DOI: 10.1016/j.neurom.2022.08.448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/19/2022] [Accepted: 08/01/2022] [Indexed: 10/14/2022]
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A MULTIFACTORIAL APPROACH FOR IMPROVING THE SURGICAL PERFORMANCE OF NOVICE VITREORETINAL SURGEONS. Retina 2021; 41:2163-2171. [PMID: 34543245 DOI: 10.1097/iae.0000000000003147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To quantitatively analyze and compare the novice vitreoretinal surgeons' performance after various types of external exposures. METHODS This prospective, self-controlled, cross-sectional study included 15 vitreoretinal fellows with less than 2 years of experience. Surgical performance was assessed using the Eyesi simulator after each exposure: Day 1, placebo, 2.5, and 5 mg/kg caffeine; Day 2, placebo, 0.2, and 0.6 mg/kg propranolol; Day 3, baseline simulation, breathalyzer reading of 0.06% to 0.10% and 0.11% to 0.15% blood alcohol concentration; Day 4, baseline simulation, push-up sets with 50% and 85% repetition maximum; Day 5, 3-hour sleep deprivation. Eyesi-generated total scores were the main outcome measured (0-700, worst to best). RESULTS Performances worsened after increasing alcohol exposure based on the total score (χ2 = 7; degrees of freedom = 2; P = 0.03). Blood alcohol concentration 0.06% to 0.10% and 0.11% to 0.15% was associated with diminished performance compared with improvements after propranolol 0.6 and 0.2 mg/kg, respectively (∆1 = -22 vs. ∆2 = +13; P = 0.02; ∆1 = -43 vs. ∆2 = +23; P = 0.01). Propranolol 0.6 mg/kg was positively associated with the total score, compared with deterioration after 2.5 mg/kg caffeine (∆1 = +7 vs. ∆2 = -13; P = 0.03). CONCLUSION Surgical performance diminished dose dependently after alcohol. Caffeine 2.5 mg/kg was negatively associated with dexterity, and performance improved after 0.2 mg/kg propranolol. No changes occurred after short-term exercise or acute 3-hour sleep deprivation.
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Roizenblatt M, Dias Gomes Barrios Marin V, Grupenmacher AT, Muralha F, Faber J, Jiramongkolchai K, Gehlbach PL, Farah ME, Belfort R, Maia M. Association of Weight-Adjusted Caffeine and β-Blocker Use With Ophthalmology Fellow Performance During Simulated Vitreoretinal Microsurgery. JAMA Ophthalmol 2021; 138:819-825. [PMID: 32525517 DOI: 10.1001/jamaophthalmol.2020.1971] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance Vitreoretinal surgery can be technically challenging and is limited by physiologic characteristics of the surgeon. Factors that improve accuracy and precision of the vitreoretinal surgeon are invaluable to surgical performance. Objectives To establish weight-adjusted cutoffs for caffeine and β-blocker (propranolol) intake and to determine their interactions in association with the performance of novice vitreoretinal microsurgeons. Design, Settings, and Participants This single-blind cross-sectional study of 15 vitreoretinal surgeons who had less than 2 years of surgical experience was conducted from September 19, 2018, to September 25, 2019, at a dry-laboratory setting. Five simulations were performed daily for 2 days. On day 1, performance was assessed after sequential exposure to placebo, low-dose caffeine (2.5 mg/kg), high-dose caffeine (5.0 mg/kg), and high-dose propranolol (0.6 mg/kg). On day 2, performance was assessed after sequential exposure to placebo, low-dose propranolol (0.2 mg/kg), high-dose propranolol (0.6 mg/kg), and high-dose caffeine (5.0 mg/kg). Interventions Surgical simulation tasks were repeated 30 minutes after masked ingestion of placebo, caffeine, or propranolol pills during the 2 days. Main Outcomes and Measures An Eyesi surgical simulator was used to assess surgical performance, which included surgical score (range, 0 [worst] to 700 [best]), task completion time, intraocular trajectory, and tremor rate (range, 0 [worst] to 100 [best]). The nonparametric Friedman test followed by Dunn-Bonferroni post hoc test was applied for multiple comparisons. Results Of 15 vitreoretinal surgeons, 9 (60%) were male, with a mean (SD) age of 29.6 (1.4) years and mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) of 23.15 (2.9). Compared with low-dose propranolol, low-dose caffeine was associated with a worse total surgical score (557.0 vs 617.0; difference, -53.0; 95% CI, -99.3 to -6.7; P = .009), a lower antitremor maneuver score (55.0 vs 75.0; difference, -12.0; 95% CI, -21.2 to -2.8; P = .009), longer intraocular trajectory (2298.6 vs 2080.7 mm; difference, 179.3 mm; 95% CI, 1.2-357.3 mm; P = .048), and increased task completion time (14.9 minutes vs 12.7 minutes; difference, 2.3 minutes; 95% CI, 0.8-3.8 minutes; P = .048). Postcaffeine treatment with propranolol was associated with performance improvement; however, surgical performance remained inferior compared with low-dose propranolol alone for total surgical score (570.0 vs 617.0; difference, -51.0; 95% CI, -77.6 to -24.4; P = .01), tremor-specific score (50.0 vs 75.0; difference, -16.0; 95% CI, -31.8 to -0.2; P = .03), and intraocular trajectory (2265.9 mm vs 2080.7 mm; difference, 166.8 mm; 95% CI, 64.1-269.6 mm; P = .03). Conclusions and Relevance The findings suggest that performance of novice vitreoretinal surgeons was worse after receiving low-dose caffeine alone but improved after receiving low-dose propranolol alone. Their performance after receiving propranolol alone was better than after the combination of propranolol and caffeine. These results may be helpful for novice vitreoretinal surgeons to improve microsurgical performance.
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Affiliation(s)
- Marina Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil.,Vision Institute, Universidade Federal de São Paulo, São Paulo, Brazil.,Johns Hopkins University School of Medicine, The Wilmer Eye Institute, Baltimore, Maryland
| | | | | | - Felipe Muralha
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jean Faber
- Department of Neurology and Neurosurgery, Neuroengineering and Neurocognition Laboratory, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Kim Jiramongkolchai
- Johns Hopkins University School of Medicine, The Wilmer Eye Institute, Baltimore, Maryland
| | - Peter Louis Gehlbach
- Johns Hopkins University School of Medicine, The Wilmer Eye Institute, Baltimore, Maryland
| | - Michel Eid Farah
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil.,Vision Institute, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rubens Belfort
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil.,Vision Institute, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mauricio Maia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil.,Vision Institute, Universidade Federal de São Paulo, São Paulo, Brazil
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Samotus O, Lee J, Jog M. Transitioning from Unilateral to Bilateral Upper Limb Tremor Therapy for Parkinson's Disease and Essential Tremor Using Botulinum Toxin: Case Series. Toxins (Basel) 2018; 10:toxins10100394. [PMID: 30262746 PMCID: PMC6215170 DOI: 10.3390/toxins10100394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 09/20/2018] [Accepted: 09/22/2018] [Indexed: 11/21/2022] Open
Abstract
Botulinum toxin type A (BoNT-A) injections guided by kinematic analysis for unilateral upper limb essential tremor (ET) and Parkinson’s disease (PD) tremor therapy has demonstrated efficacy, improvements in quality of life (QoL) and arm functionality. In this open-label pilot trial, 5 ET and 2 PD participants decided to switch from receiving long-term unilateral arm treatment to now bilateral BoNT-A arm therapy in their other tremulous arm which worsened over time. Injection patterns were based on kinematic analysis. Efficacy endpoints including kinematic analysis, Fahn-Tolosa-Marin tremor rating scale, QoL questionnaire, and maximal grip strength were collected over 2 treatments and 2 follow-up visits totaling 18-weeks. BoNT-A decreased wrist tremor amplitude by 84.6% and 89.6% 6-weeks following the 1st injection in the newly-treated limb in ET and PD participants, respectively. PD participants started with worse QoL but demonstrated an additional improvement in QoL by 29.9% for switching to bilateral treatment, whereas ET participants did not. Left and right arm tremor also did not share commonalities in severity or dose. This preliminary finding suggests trends for transitioning to bilateral therapy and warrants further studies to evaluate efficacy of bilateral tremor BoNT-A therapy in a larger cohort of PD and ET patients.
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Affiliation(s)
- Olivia Samotus
- Department of Clinical Neurological Sciences, London Health Sciences Centre-Lawson Health Research Institute, 339 Windermere Road, A10-026, London, ON N6A 5A5, Canada.
- Schulich School of Medicine and Dentistry, University of Western, 1151 Richmond Street, London, ON N6A 3K7, Canada.
| | - Jack Lee
- Department of Clinical Neurological Sciences, London Health Sciences Centre-Lawson Health Research Institute, 339 Windermere Road, A10-026, London, ON N6A 5A5, Canada.
| | - Mandar Jog
- Department of Clinical Neurological Sciences, London Health Sciences Centre-Lawson Health Research Institute, 339 Windermere Road, A10-026, London, ON N6A 5A5, Canada.
- Schulich School of Medicine and Dentistry, University of Western, 1151 Richmond Street, London, ON N6A 3K7, Canada.
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Samotus O, Lee J, Jog M. Long-term tremor therapy for Parkinson and essential tremor with sensor-guided botulinum toxin type A injections. PLoS One 2017; 12:e0178670. [PMID: 28586370 PMCID: PMC5460844 DOI: 10.1371/journal.pone.0178670] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 05/17/2017] [Indexed: 12/14/2022] Open
Abstract
Objective Current pharmacological agents used to treat Parkinson disease (PD) tremor and essential tremor (ET) provide suboptimal benefit and are commonly associated with significant adverse effects. Botulinum toxin type A (BoNT-A) has been shown to be effective for wrist tremor though functionally bothersome muscle weakness frequently occurs. This is the longest study to date demonstrating that BoNT-A therapy coupled with kinematic guidance can provide efficacious outcomes for upper limb tremor with minimized unwanted weakness. Methods A total of 28 PD and 24 ET participants with bothersome, disabling tremor, received six serial BoNT-A treatments every 16 weeks starting at week 0 with a follow-up visit 6 weeks following a treatment, totaling 96 weeks. Clinical scales, including Fahn-Tolosa-Marin tremor rating scale (FTM), and sensor-based tremor assessments were conducted at each visit. Kinematics was utilized to identify which arm muscles contributed to the tremulous movements and the experienced injector used clinical expertise in determining BoNT-A dosages. Results Following BoNT-A treatment, clinical ratings of tremor severity and functional ability (FTM) showed significant improvements following the first treatment which was maintained up to week 96 in PD and ET. Kinematics detected a significant reduction in PD and ET tremor amplitudes by 70% and 76% over the treatment course, respectively. By objectively distinguishing tremulous muscles and tremor severity, adverse effects were limited to mild perceived weakness by participants in injected muscles during follow-ups. Following the fourth treatment, BoNT-A dosages in flexor and extensor wrist muscles and biceps were reduced for those experiencing residual weakness which ultimately did not interfere with tremor relief or arm function. Conclusions Kinematics is an objective method that can aid clinicians in assessing and determining optimal BoNT-A parameters to alleviate both PD and ET tremor. BoNT-A injections are tolerable and effective when focal therapy regimens are determined and optimized kinematically over a long-term.
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Affiliation(s)
- Olivia Samotus
- London Health Sciences Centre – Lawson Health Research Institute, Department of Clinical Neurological Sciences, London, Ontario, Canada
- University of Western, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Jack Lee
- London Health Sciences Centre – Lawson Health Research Institute, Department of Clinical Neurological Sciences, London, Ontario, Canada
| | - Mandar Jog
- London Health Sciences Centre – Lawson Health Research Institute, Department of Clinical Neurological Sciences, London, Ontario, Canada
- University of Western, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- * E-mail:
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Abstract
BACKGROUND Treatment options for essential (ET) and Parkinson disease (PD) tremor are suboptimal, with significant side effects. Botulinum toxin type A (BoNT A) is successfully used in management of various focal movement disorders but is not widely used for tremor. METHOD This study examines complexity of wrist tremor in terms of involvement of its three anatomical degrees of freedom (DOF) in two common situations of rest and posture. The study examines tremor in 11 ET and 17 PD participants by kinematic decomposition of motion in 3-DOF. RESULTS Tremor decomposition showed the motion involved more than one DOF (<70% contribution in one DOF) in most ET (rest: 100%, posture: 64%) and PD (rest: 77%, posture: 77%) patients. Task variation resulted in change in both amplitude and composition in ET, but not in PD. Amplitude significantly increased from rest to posture in ET. Directional bias was observed at the wrist for ET (pronation), and PD (extension, ulnar deviation, pronation). Average agreement between clinical visual and kinematic selection of muscles was 55% across all subjects. CONCLUSION This study shows the complexity of tremor and the difficulty in visual judgment of tremor, which may be key to the success of targeted focal treatments such as BoNT A.
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Rahimi F, Samotus O, Lee J, Jog M. Effective Management of Upper Limb Parkinsonian Tremor by IncobotulinumtoxinA Injections Using Sensor-based Biomechanical Patterns. Tremor Other Hyperkinet Mov (N Y) 2015; 5:348. [PMID: 26566459 PMCID: PMC4636031 DOI: 10.7916/d8bp0270] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 10/06/2015] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND Focal treatment of Parkinson's disease tremor by botulinum toxin type A incobotulinumtoxinA (BoNT-A) injections has been inadequately investigated and at best provides modest relief with significant muscle weakness. Complexity of multi-joint tremulous movements results in non-individualized dosing regimens. This 38-week open-label study used kinematic technology to guide muscle selection and improve efficacy of incobotulinumtoxinA (BoNT-A) injections for Parkinson's disease tremor. METHODS Participants (n=28) attended study visits at weeks 0, 6, 16, 22, 32, and 38, and were injected with BoNT-A at weeks 0, 16, and 32. During each visit, clinical tremor scales, the Unified Parkinson's Disease Rating Scale (UPDRS) and the Fahn-Tolosa-Marin (FTM), and kinematic assessments were conducted. Participants performed rest and postural scripted tasks with motion sensors placed over the wrist, elbow, and shoulder joints where tremor was quantified by angular root mean square (RMS) amplitude in multiple degrees of freedom at each joint. Injection parameters were determined using the clinician's interpretation of which muscles would contribute to the upper limb tremor biomechanics analyzed kinematically. RESULTS Kinematic measures of tremor amplitude allowed detailed segmentation of tremor into directional components at each arm joint permitting a statistically significant decrease in mean UPDRS item 20 (rest tremor) at week 16 (p=0.006) and at week 32 (p=0.014), and in FTM tremor severity scores at week 6 (p=0.024). Ten participants perceived mild muscle weakness following the third treatment, which did not interfere with performing activities of daily living. DISCUSSION Kinematics is a simple method for standardizing assessments and treatment of upper limb Parkinson's disease tremor, thereby personalizing tremor therapy and optimizing the effect of BoNT-A injections for Parkinson's disease tremor.
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Affiliation(s)
- Fariborz Rahimi
- Department of Electrical and Computer Engineering, University of Bonab, Bonab, Iran
- †Represents F.R and O.S are co-authors
| | - Olivia Samotus
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Lawson Health Research Institute, London, ON, Canada
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
- †Represents F.R and O.S are co-authors
| | - Jack Lee
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Lawson Health Research Institute, London, ON, Canada
| | - Mandar Jog
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Lawson Health Research Institute, London, ON, Canada
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
- *To whom correspondence should be addressed. E-mail:
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Abstract
OBJECTIVE One the greatest challenges of BoNT A therapy for tremor lies in the complexity and variation of components involved in tremor movement, and the lack of objective measures to determine these components. This 3 month open-label single injection study aims to couple clinician best judgment with kinematics to improve effect of BoNT A (incobotulinumtoxinA) injection in 7 patients with upper limb Parkinson's disease (PD) tremor. METHODS Injection was guided with clinical and kinematic assessment of tremor using angular wrist position in 3 degrees of freedom: flexion/extension, pronation/supination, and radial/ulnar deviation. Overall tremor severity and change were measured by linear finger acceleration. RESULTS Kinematic data from static and functional tasks demonstrate no improvement at one month post-injection, but significant improvement at two and three months. Clinical scales across UPDRS Items 20 (1, 2, 3 months post) and 21 (2 months), and spiral drawings (3 months) showed significant improvement from baseline, while line drawings did not. CONCLUSIONS This study suggests injection of BoNT A as a viable focal management option for upper limb PD tremor. In addition to clinical judgment, objective quantification of tremor dynamics by kinematics may be a feasible assessment and guidance tool which can be used to optimize injection conditions for focal tremor therapy. Kinematic analysis of tremor across a variety of joints in all degrees of movement may provide important insight into tremor dynamics, allowing optimized, targeted focal therapy.
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Resnick AS, Okun MS, Malapira T, Smith D, Vale FL, Sullivan K, Miller A, Jahan I, Zesiewicz T. Sustained Medication Reduction Following Unilateral VIM Thalamic Stimulation for Essential Tremor. Tremor Other Hyperkinet Mov (N Y) 2012; 2:tre-02-38-193-1. [PMID: 23440408 PMCID: PMC3569968 DOI: 10.7916/d8zg6qz2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Accepted: 07/26/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is an increasingly utilized therapeutic modality for the management of medication refractory essential tremor (ET). The aim of this study was to determine whether DBS allowed for anti-tremor medication reduction within the year after the procedure was performed. METHODS We conducted a retrospective chart review and telephone interviews on 34 consecutive patients who had been diagnosed with ET, and who had undergone unilateral DBS surgery. RESULTS Of the 34 patients in our cohort, 31 patients (91%) completely stopped all anti-tremor medications either before surgery (21 patients, 62%) or in the year following DBS surgery (10 patients, 29%). Patients who discontinued tremor medications before DBS surgery did so because their tremors either became refractory to anti-tremor medication, or they developed adverse events to tremor medications. Patients who stopped tremor medications after DBS surgery did so due to sufficient tremor control. Only three patients (9%) who were taking tremor medications at the time of surgery continued the use of a beta-blocker post-operatively for the purpose of hypertension management in all cases. DISCUSSION The data from this study indicate that medication cessation is common following unilateral DBS for ET.
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Affiliation(s)
- Andrew S. Resnick
- Department of Neurology, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America,UF Center for Movement Disorders and Neurorestoration, Gainesville, Florida, United States of America
| | - Michael S. Okun
- UF Center for Movement Disorders and Neurorestoration, Gainesville, Florida, United States of America
| | - Teresita Malapira
- UF Center for Movement Disorders and Neurorestoration, Gainesville, Florida, United States of America
| | - Donald Smith
- Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America
| | - Fernando L. Vale
- Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America
| | - Kelly Sullivan
- Department of Neurology, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America
| | - Amber Miller
- Department of Neurology, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America
| | - Israt Jahan
- Department of Neurology, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America
| | - Theresa Zesiewicz
- Department of Neurology, University of South Florida College of Medicine, Parkinson's Disease and Movement Disorders Center, Tampa, Florida, United States of America,*To whom correspondence should be addressed. E-mail:
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Abstract
Postural tremor is the most common movement disorder in psychiatry, and often a difficult problem for clinicians. It can be classified as physiological, essential, drug-induced, and postural tremor in Parkinson's disease. Drugs used in psychiatry that can produce postural tremor, include lithium, valproic acid, lamotrigine, antidepressants, and neuroleptics. Clinical characteristics of postural tremor induced by each of these drugs are described. Pharmacological strategies for therapy in disabling drug-induced tremor include beta-blockers, primidone, gabapentin, topiramate, and benzodiazepines; their utility, doses and side-effects are also discussed.
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Laser Literature Watch. Photomed Laser Surg 2006; 24:222-48. [PMID: 16706704 DOI: 10.1089/pho.2006.24.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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