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Essential tremor amplitude modulation by median nerve stimulation. Sci Rep 2021; 11:17720. [PMID: 34489503 PMCID: PMC8421420 DOI: 10.1038/s41598-021-96660-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 08/05/2021] [Indexed: 11/08/2022] Open
Abstract
Essential tremor is a common neurological disorder, characterised by involuntary shaking of a limb. Patients are usually treated using medications which have limited effects on tremor and may cause side-effects. Surgical therapies are effective in reducing essential tremor, however, the invasive nature of these therapies together with the high cost, greatly limit the number of patients benefiting from them. Non-invasive therapies have gained increasing traction to meet this clinical need. Here, we test a non-invasive and closed-loop electrical stimulation paradigm which tracks peripheral tremor and targets thalamic afferents to modulate the central oscillators underlying tremor. To this end, 9 patients had electrical stimulation delivered to the median nerve locked to different phases of tremor. Peripheral stimulation induced a subtle but significant modulation in five out of nine patients-this modulation consisted mainly of amplification rather than suppression of tremor amplitude. Modulatory effects of stimulation were more pronounced when patient's tremor was spontaneously weaker at stimulation onset, when significant modulation became more frequent amongst subjects. This data suggests that for selected individuals, a more sophisticated control policy entailing an online estimate of both tremor phase and amplitude, should be considered in further explorations of the treatment potential of tremor phase-locked peripheral stimulation.
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Price JB, Rusheen AE, Barath AS, Rojas Cabrera JM, Shin H, Chang SY, Kimble CJ, Bennet KE, Blaha CD, Lee KH, Oh Y. Clinical applications of neurochemical and electrophysiological measurements for closed-loop neurostimulation. Neurosurg Focus 2021; 49:E6. [PMID: 32610297 DOI: 10.3171/2020.4.focus20167] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 04/16/2020] [Indexed: 12/21/2022]
Abstract
The development of closed-loop deep brain stimulation (DBS) systems represents a significant opportunity for innovation in the clinical application of neurostimulation therapies. Despite the highly dynamic nature of neurological diseases, open-loop DBS applications are incapable of modifying parameters in real time to react to fluctuations in disease states. Thus, current practice for the designation of stimulation parameters, such as duration, amplitude, and pulse frequency, is an algorithmic process. Ideal stimulation parameters are highly individualized and must reflect both the specific disease presentation and the unique pathophysiology presented by the individual. Stimulation parameters currently require a lengthy trial-and-error process to achieve the maximal therapeutic effect and can only be modified during clinical visits. The major impediment to the development of automated, adaptive closed-loop systems involves the selection of highly specific disease-related biomarkers to provide feedback for the stimulation platform. This review explores the disease relevance of neurochemical and electrophysiological biomarkers for the development of closed-loop neurostimulation technologies. Electrophysiological biomarkers, such as local field potentials, have been used to monitor disease states. Real-time measurement of neurochemical substances may be similarly useful for disease characterization. Thus, the introduction of measurable neurochemical analytes has significantly expanded biomarker options for feedback-sensitive neuromodulation systems. The potential use of biomarker monitoring to advance neurostimulation approaches for treatment of Parkinson's disease, essential tremor, epilepsy, Tourette syndrome, obsessive-compulsive disorder, chronic pain, and depression is examined. Further, challenges and advances in the development of closed-loop neurostimulation technology are reviewed, as well as opportunities for next-generation closed-loop platforms.
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Affiliation(s)
| | - Aaron E Rusheen
- 1Department of Neurologic Surgery.,2Medical Scientist Training Program
| | | | | | | | | | | | - Kevin E Bennet
- 1Department of Neurologic Surgery.,3Division of Engineering, and
| | | | - Kendall H Lee
- 1Department of Neurologic Surgery.,4Department of Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Yoonbae Oh
- 1Department of Neurologic Surgery.,4Department of Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
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3
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Al-Shorafat DM, Bhowmick S, Espay AJ, Fasano A. β-Blocker-Induced Tremor. Mov Disord Clin Pract 2021; 8:449-452. [PMID: 33816676 DOI: 10.1002/mdc3.13176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/23/2020] [Accepted: 01/16/2021] [Indexed: 11/11/2022] Open
Abstract
Background Although the β-blocker propranolol is considered one of the most effective tremor treatments and other β-blockers are often prescribed to patients with tremor, those with partial β-agonist activity on β-adrenoreceptors can theoretically induce or exacerbate tremor. Here we report 2 patients with tremor induced or worsened by such β-blockers. Cases Case 1 is a 38-year-old man with worsening of tremor in both upper extremities after the introduction of pindolol as an adjunct treatment for severe depression. The tremor improved 1 month after discontinuing this medication. Case 2 is a 77-year-old woman with new bilateral hand tremor after receiving labetalol for the management of hypertension during a hospital admission. Tremor markedly attenuated after eliminating labetalol. Conclusion β-Blockers with partial agonist activity can induce or exacerbate tremor.
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Affiliation(s)
- Duha M Al-Shorafat
- The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Division of Neurology, Department of Medicine University of Toronto Toronto Ontario Canada
| | - Suvorit Bhowmick
- The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Division of Neurology, Department of Medicine University of Toronto Toronto Ontario Canada
| | - Alberto J Espay
- James J. and Joan A. Gardner Center for Parkinson's Disease and Movement Disorders, UC Gardner Neuroscience Institute, Department of Neurology University of Cincinnati Cincinnati Ohio USA
| | - Alfonso Fasano
- The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Division of Neurology, Department of Medicine University of Toronto Toronto Ontario Canada.,Krembil Brain Institute Toronto Ontario Canada
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Lenka A, Louis ED. Do We Belittle Essential Tremor by Calling It a Syndrome Rather Than a Disease? Yes. Front Neurol 2020; 11:522687. [PMID: 33178097 PMCID: PMC7594521 DOI: 10.3389/fneur.2020.522687] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 08/26/2020] [Indexed: 12/23/2022] Open
Abstract
Essential tremor (ET) is among the most prevalent neurological diseases. Appreciation in recent years of a richer tremor phenomenology, additional motor and non-motor features, variability in the natural course of tremor, associations with a host of other neurological conditions, and etiological and pathophysiological heterogeneity have resulted in general awareness of the clinical richness of ET. Along with this evolving view of ET have surfaced several conundrums regarding nomenclature. One of these is whether ET should be labeled a "syndrome" or "disease." Here, we revisit the classical definitions of "syndrome" and "disease" and discuss ET in this context. Considering the characteristics of "disease" and "syndrome" and evaluating the characteristics of ET, it seems to fit more into the "disease" construct. There are several reasons: There is considerable knowledge of the underlying etiologies and pathophysiology of ET, in numerous studies ET has been linked with other neurological conditions, the condition is progressive and deteriorative, and therapeutic approaches are grounded in an understanding of disease mechanisms and its associated neuroanatomy. Moreover, the etiological-pathological-clinical heterogeneity suggests that ET should be regarded as a "family of diseases" more appropriately termed "the essential tremors." This nomenclatural issue is not a mere matter of words; public health implications are numerous. A condition with the label "syndrome" may not be recognized as a serious problem, may be plagued by diminished public awareness, and may not garner funds for research that a condition with the label "disease" or "diseases" would. ET should be regarded as a family of diseases.
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Affiliation(s)
- Abhishek Lenka
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Elan D. Louis
- Department of Neurology, University of Texas Southwestern, Dallas, TX, United States
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Kuo SH, Louis ED, Faust PL, Handforth A, Chang SY, Avlar B, Lang EJ, Pan MK, Miterko LN, Brown AM, Sillitoe RV, Anderson CJ, Pulst SM, Gallagher MJ, Lyman KA, Chetkovich DM, Clark LN, Tio M, Tan EK, Elble RJ. Current Opinions and Consensus for Studying Tremor in Animal Models. CEREBELLUM (LONDON, ENGLAND) 2019; 18:1036-1063. [PMID: 31124049 PMCID: PMC6872927 DOI: 10.1007/s12311-019-01037-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Tremor is the most common movement disorder; however, we are just beginning to understand the brain circuitry that generates tremor. Various neuroimaging, neuropathological, and physiological studies in human tremor disorders have been performed to further our knowledge of tremor. But, the causal relationship between these observations and tremor is usually difficult to establish and detailed mechanisms are not sufficiently studied. To overcome these obstacles, animal models can provide an important means to look into human tremor disorders. In this manuscript, we will discuss the use of different species of animals (mice, rats, fruit flies, pigs, and monkeys) to model human tremor disorders. Several ways to manipulate the brain circuitry and physiology in these animal models (pharmacology, genetics, and lesioning) will also be discussed. Finally, we will discuss how these animal models can help us to gain knowledge of the pathophysiology of human tremor disorders, which could serve as a platform towards developing novel therapies for tremor.
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Affiliation(s)
- Sheng-Han Kuo
- Department of Neurology, Columbia University, 650 West 168th Street, Room 305, New York, NY, 10032, USA.
| | - Elan D Louis
- Department of Neurology, Yale School of Medicine, Yale University, 800 Howard Avenue, Ste Lower Level, New Haven, CT, 06519, USA.
- Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT, USA.
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, CT, USA.
| | - Phyllis L Faust
- Department of Pathology and Cell Biology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, NY, USA
| | - Adrian Handforth
- Neurology Service, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Su-Youne Chang
- Department of Neurologic Surgery and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - Billur Avlar
- Department of Neuroscience and Physiology, New York University School of Medicine, New York, NY, USA
| | - Eric J Lang
- Department of Neuroscience and Physiology, New York University School of Medicine, New York, NY, USA
| | - Ming-Kai Pan
- Department of Medical Research and Neurology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Lauren N Miterko
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
- Program in Developmental Biology, Baylor College of Medicine, Houston, TX, USA
- Jan and Dan Duncan Neurological Research Institute of Texas Children's Hospital, Houston, TX, USA
| | - Amanda M Brown
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
- Jan and Dan Duncan Neurological Research Institute of Texas Children's Hospital, Houston, TX, USA
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, USA
| | - Roy V Sillitoe
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
- Program in Developmental Biology, Baylor College of Medicine, Houston, TX, USA
- Jan and Dan Duncan Neurological Research Institute of Texas Children's Hospital, Houston, TX, USA
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, USA
| | - Collin J Anderson
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Stefan M Pulst
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | | | - Kyle A Lyman
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Lorraine N Clark
- Department of Pathology and Cell Biology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, NY, USA
- Taub Institute for Research on Alzheimer's Disease and the Aging Brain, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Murni Tio
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Eng-King Tan
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Rodger J Elble
- Department of Neurology, Southern Illinois University School of Medicine, Springfield, IL, USA
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Wadhwa A, Schaefer SM. Successful Treatment of Primary Orthostatic Tremor Using Perampanel. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2019; 9:tre-09-681. [PMID: 31413897 PMCID: PMC6691907 DOI: 10.7916/tohm.v0.681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/08/2019] [Indexed: 12/02/2022]
Abstract
Background Primary orthostatic tremor (POT) remains a therapeutic conundrum. Various medication classes have been tried, yielding modest results at best. Case Report A 62-year-old female with a 13-year history of POT, refractory to clonazepam up to 20 mg/day, was treated with perampanel 1–2 mg/day. She reported 90% subjective symptomatic improvement. Discussion This case highlights the potential for use of perampanel, a novel AMPA (α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) receptor antagonist for the treatment of POT. There has been one prior report citing its use for POT with complete resolution of symptoms. We encourage further studies to highlight its efficacy for POT.
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Affiliation(s)
- Anant Wadhwa
- Division of Movement Disorders, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Sara M Schaefer
- Division of Movement Disorders, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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Differential effects of propranolol on head and upper limb tremor in patients with essential tremor and dystonia. J Neurol 2018; 265:2695-2703. [PMID: 30209649 DOI: 10.1007/s00415-018-9052-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 01/19/2023]
Abstract
Propranolol is used as the first-line treatment in essential tremor and it has also been proposed as a treatment for tremor in dystonia. However, several issues remain uncertain. For example, it is still not clear whether propranolol exerts a beneficial effect on head tremor. Moreover, no studies have investigated whether the effect of propranolol on head and upper limb tremor in essential tremor differs from that in dystonia. We aimed to assess the effects of propranolol on tremor in different body parts in essential tremor and in patients with tremor and dystonia. Twenty-nine patients with head and upper limb tremor were enrolled in the study, 14 with essential tremor, and 15 with dystonia. Participants underwent a clinical and kinematic analysis of tremor in two sessions, i.e., without (baseline) and 'on therapy' with propranolol. We found that head tremor was more severe in patients with dystonia, while upper limb tremor was more evident in patients with essential tremor (P < 0.05). Propranolol had no effect on head tremor in either group (all Ps > 0.05), but it did reduce upper limb tremor in patients with essential tremor. The present study demonstrates differential effects of propranolol on head and upper limb tremor in patients with essential tremor. The lack of effect on head and upper limb tremor in patients with dystonia suggests that the pathophysiological mechanisms underlying tremor in these two conditions and in different body parts may be distinct.
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Nestrasil I, Svatkova A, Rudser KD, Chityala R, Wakumoto A, Mueller BA, Bednařík P, Tuite P, Wu X, Bushara K. White matter measures correlate with essential tremor severity-A pilot diffusion tensor imaging study. Brain Behav 2018; 8:e01039. [PMID: 29964316 PMCID: PMC6085909 DOI: 10.1002/brb3.1039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND An evolving pathophysiological concept of essential tremor (ET) points to diffuse brain network involvement, which emphasizes the need to investigate white matter (WM) changes associated with motor symptoms of ET. OBJECTIVES To investigate ET-related WM changes and WM correlates of tremor severity using tremor clinical rating scales and accelerometry. METHODS Tract-based spatial statistics (TBSS) approach was utilized to compare 3 Tesla diffusion tensor imaging (DTI) data from 12 ET patients and 10 age- and gender-matched healthy individuals. Clinical scales, tremor frequency and amplitude as measured by accelerometry were correlated with DTI data. RESULTS ET patients demonstrated mean (MD) and radial diffusivity (RD) abnormalities in tracts involved in primary and associative motor functions such as bilateral corticospinal tracts, the superior longitudinal fascicles, and the corpus callosum but also in nonmotor regions including the inferior fronto-occipital and longitudinal fascicles, cingulum bundles, anterior thalamic radiations, and uncinate fascicles. A combined tremor frequency and amplitude score correlated with RD and MD in extensive WM areas, which partially overlapped the regions that were associated with tremor frequency. No significant relationship was found between DTI measures and clinical rating scales scores. CONCLUSIONS The results show that ET-related diffusion WM changes and their correlates with tremor severity are preferentially located in the primary and associative motor areas. In contrast, a relationship between WM was not detected with clinical rating scales. Accelerometry parameters may, therefore, serve as a potentially useful clinical measures that relate to WM deficits in ET.
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Affiliation(s)
- Igor Nestrasil
- Division of Clinical Behavioral NeuroscienceDepartment of PediatricsUniversity of MinnesotaMinneapolisMinnesota
| | - Alena Svatkova
- Division of Clinical Behavioral NeuroscienceDepartment of PediatricsUniversity of MinnesotaMinneapolisMinnesota
- Department of Medicine III, Clinical Division of Endocrinology and MetabolismMedical University of ViennaViennaAustria
- Multimodal and Functional Neuroimaging Research GroupCentral European Institute of TechnologyMasaryk UniversityBrnoCzech Republic
| | - Kyle D. Rudser
- Division of BiostatisticsUniversity of MinnesotaMinneapolisMinnesota
| | | | - Amy Wakumoto
- Division of Clinical Behavioral NeuroscienceDepartment of PediatricsUniversity of MinnesotaMinneapolisMinnesota
| | - Bryon A. Mueller
- Department of PsychiatryUniversity of MinnesotaMinneapolisMinnesota
| | - Petr Bednařík
- Multimodal and Functional Neuroimaging Research GroupCentral European Institute of TechnologyMasaryk UniversityBrnoCzech Republic
- Department of RadiologyCenter for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesota
- High Field MR CentreDepartment of Biomedical Imaging and Image‐guided TherapyMedical University of ViennaViennaAustria
| | - Paul Tuite
- Department of NeurologyUniversity of MinnesotaMinneapolisMinnesota
| | - Xiang Wu
- Psychology DepartmentSun Yet‐Sen UniversityGuangzhouGuangdongChina
| | - Khalaf Bushara
- Department of NeurologyUniversity of MinnesotaMinneapolisMinnesota
- Neurology ServiceVeterans Affairs Medical CenterMinneapolisMinnesota
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Lee S, Asaad WF, Jones SR. Computational modeling to improve treatments for essential tremor. ACTA ACUST UNITED AC 2016; 19:19-25. [PMID: 29167694 DOI: 10.1016/j.ddmod.2017.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Essential tremor (ET) is a neurological disorder of unknown etiology that is typically characterized by an involuntary periodic movement of the upper limbs. No longer considered monosymptomatic, ET patients often have additional motor and even cognitive impairments. Although there are several pharmacological treatments, no drugs have been developed specifically for ET [1], and 30-70% of patients are medication-refractory [2]. A subset of medication-refractory patients may benefit from electrical deep brain stimulation (DBS) of the ventral intermediate nucleus of the thalamus (VIM), which receives cerebellar inputs. Abnormal cerebellar input to VIM is presumed to be a major contributor to tremor symptoms, which is alleviated by DBS. Computational modeling of the effects of DBS in VIM has been a powerful tool to design DBS protocols to reduce tremor activity. However, far less is known about how these therapies affect non-tremor symptoms, and more experimental and computational modeling work is required to address these growing considerations. Models capable of addressing multiple facets of ET will lead to novel, more efficient treatment.
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Affiliation(s)
- Shane Lee
- Department of Neuroscience and Brown Institute for Brain Science, Brown University, United States
| | - Wael F Asaad
- Department of Neuroscience and Brown Institute for Brain Science, Brown University, United States
- Department of Neurosurgery, Brown University Alpert Medical School, United States
- Department of Neurosurgery, Rhode Island Hospital, United States
- Norman Prince Neurosciences Institute, Lifespan, United States
| | - Stephanie R Jones
- Department of Neuroscience and Brown Institute for Brain Science, Brown University, United States
- Providence Veteran's Affairs Medical Center, Center for Neurorestoration and Neurotechnology, United States
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