Tremor analysis in two normal cohorts

OBJECTIVE

Quantitative tremor analyses using almost identical methods were compared between two independent large normal cohorts, to separate robust measures that may readily be used diagnostically from more critical ones needing lab-specific normalization.

METHODS

Hand accelerometry and surface EMG from forearm flexors and extensors were recorded with (500 and 1000 g) and without weight loading under postural conditions in 117 and 67 normal volunteers in two different specialty centers for movement disorders in Germany.

RESULTS

Tremor amplitude (total power) and frequency fell within a similar range but differed significantly. A significant reduction of tremor frequency under 1000 g weight load (>1 Hz), and a lack of rhythmic EMG activity at the tremor frequency in around 85-90% of the recordings were robust findings in both centers.

CONCLUSIONS

The differences in frequency and total power indicate that these measures critically depend on the details of the recording conditions being slightly different between the two centers. Thus each lab needs to establish its own normative data. We estimate that at least 25 normal subjects have to be recorded to obtain normal values. The reduction of tremor frequency under load and lacking tremor-related EMG activity were well reproducible allowing a differentiation of physiological from low amplitude pathological tremor.

SIGNIFICANCE

This study provides a framework for more standardized tremor analyses in clinical neurophysiology.

Estimation of Delay Times in Biological Systems

The problem of delay time estimation in biological systems is addressed with the focus on practical applicability of methods. Four delay time estimators are described: a cross correlation method and three increasingly sophisticated interpretations of the phase spectrum, ranging from a pointwise interpretation of the phase spectrum in terms of a delay to a Hilbert transform method. The four methods are compared through simulation studies showing that, in general, the Hilbert transform method performs best. The methods are then used to estimate delay times in three physiological systems: vestibular stimulation, cerebral autoregulation, and human orthostatic tremor. In all three cases, the Hilbert transform method yields the best results, leading in some cases to physiologically more sensible interpretations of experiments than the other methods.

Essential tremor and cerebellar dysfunction: abnormal ballistic movements

BACKGROUND

Clinical characteristics reminiscent of cerebellar tremor occur in patients with advanced essential tremor. Ballistic movements are known to be abnormal in cerebellar disease. The hypothesis was proposed that ballistic movements are abnormal in essential tremor, reflecting cerebellar dysfunction.

OBJECTIVE

To elucidate the role of the cerebellum in the pathophysiology of essential tremor.

METHODS

Kinematic parameters and the triphasic electromyographic (EMG) components of ballistic flexion elbow movements were analysed in patients assigned to the following groups: healthy controls (n = 14), pure essential postural tremor (ET(PT); n = 17), and essential tremor with an additional intention tremor component (ET(IT); n = 15).

RESULTS

The main findings were a delayed second agonist burst (AG(2)) and a relatively shortened deceleration phase compared with acceleration in both the essential tremor groups. These abnormalities were most pronounced in the ET(IT) group, which had additional prolongation of the first agonist burst (AG(1)) and a delayed antagonist burst (ANT).

CONCLUSIONS

Abnormalities of the triphasic pattern and kinematic parameters are consistent with a disturbed cerebellar timing function in essential tremor. These abnormalities were most pronounced in the ET(IT) group. The cerebellar dysfunction in essential tremor could indicate a basic pathophysiological mechanism underlying this disorder. ET(PT) and ET(IT) may represent two expressions within a continuous spectrum of cerebellar dysfunction in relation to the timing of muscle activation during voluntary movements.

Variability of frequency and phase between antagonistic muscle pairs in pathological human tremors

We investigated the electromyographic activity (EMG) of flexor and extensor muscles with different hand positions in patients with essential (ET) and parkinsonian (PD) tremor. Using a previously developed bootstrap method and standard cross-spectral analysis, we performed statistical tests to assess the effect of hand position on: (1) the frequency of the EMG; and (2) the phase between the EMGs recorded from antagonistic muscle pairs. Frequency as well as phases changed significantly with different positions of the hands but not during the recordings when the position was left unchanged. Besides confirmation that frequency and phase are stationary and reliable parameters during short-term recordings under controlled laboratory conditions, these results are of particular interest for ambulatory long-term tremor measurements. A higher variability of the estimated parameters reported in long-term recordings may perhaps reflect a patient's mobility only. Our study shows that long-term recording systems should have the means to monitor the patient's movements to provide reliable results.

Evaluation of impaired dynamic cerebral autoregulation by the Mueller manoeuvre

Arterial blood pressure (ABP) shows polyphasic changes during the Mueller manoeuvre (voluntary negative intrathoracic pressure). The aim of the present study was to investigate (1) whether these changes could be applied to detect impaired dynamic cerebral autoregulation (dCA) in carotid stenosis and (2) whether the degree of indicated impairment correlates with transfer function phase as another current measure for dCA (deep breathing method) and CO2-reactivity. We examined 13 patients with severe unilateral carotid artery stenosis and 16 age-matched controls during 15-s Mueller manoeuvres (MM) at -30 mmHg using bilateral transcranial Doppler sonography and non-invasive ABP recordings (Finapres, 2300, Ohmeda, Englewood, CO, USA). After an initial biphasic oscillation, cerebral blood flow velocity (CBFV) and ABP decreased to below baseline. CBFV reincreased in controls and on contralateral sides in patients 6.0 s (3.8-9.5 s, median and range) after the onset of the decrease, despite a further fall in ABP. CBFV over the affected side revealed a significantly delayed reincrease (8.0 (5.6-10.3) s; P<0.01) combined with a relatively flat and inertial amplitude behaviour. An applied autoregulation index derived from the MM (mROR), phase shift and CO2-reactivity were severely reduced on the affected side in patients (P<0.01). Reduction of the mROR correlated significantly with reduction of phase shift (r=0.69; P=0.002) and CO2-reactivity (r=0.78; P=0.002). In conclusion, the different cerebral haemodynamic pattern during the MM in patients is likely to reflect impaired dCA. The degree of indicated impairment correlates with that of transfer function phase and CO2-reactivity. Therefore, the MM represents a convenient method for grading of compromised cerebral haemodynamics in patients with carotid artery stenosis.

Tremor-correlated cortical activity in essential tremor

BACKGROUND

In patients with parkinsonian resting tremor, tremor-correlated activity in the contralateral sensorimotor cortex has been studied by both magnetoencephalography (MEG) and electroencephalography (EEG). In essential tremor, MEG failed to detect cortical involvement. The objective of this study was to investigate whether EEG recording can reveal tremor-correlated cortical activity in patients with essential tremor or enhanced physiological tremor.

METHODS

Seven patients with essential tremor and three patients with enhanced physiological tremor participated in the study. Unilateral postural tremor was activated by wrist extension on the right or on the left side. Electromyography (EMG) signals arising from the wrist extensor and flexor muscles, and a high-resolution EEG were recorded simultaneously. Coherences between the time series of the rectified tremor EMG and the EEG were estimated.

FINDINGS

In five of nine arms with essential tremor, we found highly significant coherences at the tremor frequency between the tremor EMG and the EEG. Isocoherence maps illustrating the topography of significant coherences over the scalp showed that the maximum coherences were located over the contralateral sensorimotor cortex. In the patients with enhanced physiological tremor, we were unable to detect consistent significant corticomuscular coherences at the tremor frequency.

INTERPRETATION

Using simultaneous EEG-EMG recordings, we showed that significant corticomuscular coherences at the tremor frequency can be found in essential tremor. This finding contrasts with a recent study based on MEG recordings. The results suggest that the sensorimotor cortex is involved in the generation of essential tremor, in a similar way to that previously shown in parkinsonian resting tremor.

Dynamic cerebral autoregulation testing as a diagnostic tool in patients with carotid artery stenosis

Evaluation of dynamic cerebral autoregulation might yield a physiologically more adequate measure of cerebral hemodynamic impairment in carotid artery stenosis than CO2-reactivity. This study re-evaluates and compares the Valsalva maneuver (VM) and phase shift during deep breathing. Nineteen patients with severe carotid artery stenosis and 17 age-matched controls were examined using transcranial Doppler sonography and non-invasive blood pressure recordings (Finapres). Phase shift was determined by cross-spectral analysis, responses to VM were graded by the formerly-introduced autoregulation slope index (ASI) and the new Valsalva time index (VTI). Phase shift and autoregulatory indices were significantly reduced on the affected side (p < 0.001). Correlations with CO2-reactivity were significant when pooling values of controls and patients (r from 0.54 to 0.78; p < 0.001). Correlations except for the VTI (r = -0.65; p = 0.002) were not significant considering only the affected side in patients. Correlations of pooled values between phase shift and VM-derived indices were significant (VTI r = -0.62; p < 0.001; ASI r = 0.49; p < 0.001), within patients only when comparing side-to-side differences (VTI r = -0.58; p = 0.009; ASI r = 0.52; p = 0.023). In conclusion, detection of impaired cerebral autoregulation is possible both by deep breathing and VM. The new VTI seems to be more suitable than the conventional ASI. Inter-method agreement concerning the extent of impairment is only acceptable for intra-individual side-to-side differences. Since absolute values of one autoregulation testing method or CO2-reactivity alone might fail, various tests should be combined for comprehensive assessment of cerebral hemodynamic impairment.

Tremor-correlated cortical activity detected by electroencephalography

OBJECTIVE

In this study we investigated whether cortical activity related to Parkinsonian resting tremor can be detected by electroencephalography (EEG).

METHODS

Seven patients with idiopathic Parkinson's disease suffering from unilateral tremor participated in the study. Electromyography (EMG) signals arising from the wrist extensor and flexor muscles as well as a high resolution EEG were recorded simultaneously. Coherencies between EEG and EMG were calculated.

RESULTS

In all patients, we found highly significant coherencies at the tremor frequency or its first harmonic between the tremor EMG and contralateral EEG channels. There were no significant coherencies between the tremor EMG and ipsilateral EEG channels. Isocoherency maps illustrating the topography of the coherencies over the scalp showed that the maximum coherencies were situated over the cortical motor areas. In one case, a high coherency was also found over the parietal cortex.

CONCLUSIONS

The results show for the first time that tremor-correlated cortical activity can be detected by electroencephalography. The findings underline that motor areas of the cerebral cortex are involved in the neuronal network generating resting tremor in Parkinson's disease.

Pathological tremors: Deterministic chaos or nonlinear stochastic oscillators?

Pathological tremors exhibit a nonlinear oscillation that is not strictly periodic. We investigate whether the deviation from periodicity is due to nonlinear deterministic chaotic dynamics or due to nonlinear stochastic dynamics. To do so, we apply various methods from linear and nonlinear time series analysis to tremor time series. The results of the different methods suggest that the considered types of pathological tremors represent nonlinear stochastic second order processes. Finally, we evaluate whether two earlier proposed features capturing nonlinear effects in the time series allow for a discrimination between two pathological forms of tremor for a much larger sample of time series than previously investigated. (c) 2000 American Institute of Physics.

Side-to-side correlation of muscle activity in physiological and pathological human tremors

OBJECTIVE

Many tremors occur always or often bilaterally. The question arises whether this could be explained by a common source or commonly transmitting pathways or by bilaterally represented, independent structures with the same oscillatory properties. A similar tremor frequency does not provide sufficient information to clarify this question.

METHODS

We analyze coherencies between surface electromyographies (EMG) to investigate if bilateral physiologic (PT), essential (ET), Parkinsonian (PD) and orthostatic (OT) tremors originate from a common source for both sides of the body. We show that commonly used techniques to test whether coherencies are significant could lead to false positive results for tremor EMGs. A new estimation procedure is proposed to test EMG tremor time series on their linear independence. We apply this test to bilateral tremors.

RESULTS

All measured EMG-pairs in OT (n = 7) were highly coherent between both sides with reproducible coherency values of up to 0.99. All other investigated tremors, i.e. PT and enhanced physiological tremors (EPT, n = 117), ET (n = 76) and PD resting and postural tremors (n = 70) do not show a significant side-to-side correlation.

CONCLUSIONS

This finding shows that the pathophysiologies of OT and other pathological tremors are definitely different. Either they have different origins or different kinds of transmitting pathways. The proposed method might also be used to investigate other electrophysiological data and is a helpful, easy to use investigation for a daily clinical routine.

Classical conditioning of the electrically elicited blink reflex in humans: a new method of data analysis

The eyeblink conditioning paradigm is a well-established model to study learning processes in humans and animals. Especially results from animal studies have supplied new insight into physiological pathways and brain structures involved in associative motor learning and memory. An important role of the cerebellum and its afferent fiber systems could be shown. Recent studies in humans have given evidence that results of animal experiments can be applied directly to the human condition. A high variation of baseline EMG activity and/or spontaneous blinks may influence the analysis of classical conditioning of the electrically elicited blink reflex in humans. To optimize differentiation between real conditioned responses and stimulus-independent EMG activity, we developed an algorithm which is fully automated and independent of a possible bias of an examiner. In a first step the algorithm decides whether a subject fulfills the criteria of a successful learning process or not. The second step quantifies the learning process. For quantification of the learning process, the following parameters were calculated: number of conditioned responses, onset of conditioning, time and amount of maximal conditioning, speed of conditioning and speed of habituation. According to our criteria, 80% of the healthy volunteers acquired conditioned responses. There is an age-related decline in eyeblink classical conditioning. Analysis of patient groups with different types of lesions will further improve our knowledge and understanding of pathways involved in learning processes in humans. The proposed new algorithm of data analysis takes less than 10 s on a standard computer, is more sensitive and more specific in detecting conditioned responses and, therefore, may further improve the value and reliability of the eyeblink conditioning paradigm in clinical research.

A software for recording and analysis of human tremor

For many diseases various methods for the diagnosis and treatment monitoring are available. Presently, such methods are not established for an investigation of tremor diseases, although the different forms of tremor are common neurological symptoms and occur frequently in various neurological diseases and also other conditions. We developed an easy-to-use application for tremor-analysis and recording, running under MS-Windows, that allows us to investigate different forms of tremor by advanced mathematical methods of time series analysis. The application is also applicable for users who are not familiar with these kind of advanced data analysis methods. It provides tools for the diagnosis and treatment monitoring under laboratory conditions, based on previously developed and established methods of spectral and cross spectral analysis of tremor and electromyographic time series.

Assessing muscle stiffness from quiet stance in Parkinson's disease

In previous studies, we developed a postural stiffness measure that is extracted from foot center-of-pressure (COP) trajectories from quietly standing individuals and is based on an analytical mechanical model of posture control. Here we apply this measure to patients with Parkinson's disease (PD). We correlated the postural stiffness measure with different clinical rating scales, obtained from patients. Kendall's rank correlation was highly significant between the stiffness measure and rigidity, bradykinesia, posture impairment, gait, and leg agility, respectively, as rated by the Unified Parkinson's Disease Rating Scale. These results provide further evidence that a higher intrinsic muscle stiffness may contribute to the aforementioned clinically defined symptoms. From a clinical standpoint, this work indicates that the proposed postural stiffness measure may be useful as an assessment tool for the evaluation of PD patients subsequent to pharmacological and surgical treatment.

Involvement of cranial muscles and high intermuscular coherence in orthostatic tremor

Electromyographic recordings were conducted from limb, trunk, and cranial muscles in 6 patients with orthostatic tremor. Spectral analysis revealed a high-frequency tremor not only in the muscles of the limbs and trunk, but also in cranial muscles. The cross spectra were analyzed between various pairs of muscles that displayed a high-frequency tremor pattern. The resulting peak correlations were uniformly very high (near one) suggesting a high level of coherence. The involvement of cranial muscles suggests that supraspinal mechanisms are involved in the generation of orthostatic tremor. The high intermuscular coherence between all muscles indicates the existence of either a unique oscillator that generates tremor in all involved muscles on both sides of the body or a linking mechanism probably at a supraspinal level. The high-frequency tremor was only found when the muscles were contracted isometrically, irrespective of body posture. Thus, tremor generation might be more closely linked to mechanisms responsible for isometric force control than to those involved in stance regulation.

The effects of stochastic galvanic vestibular stimulation on human postural sway

Galvanic vestibular stimulation serves to modulate the continuous firing level of the peripheral vestibular afferents. It has been shown that the application of sinusoidally varying, bipolar galvanic currents to the vestibular system can lead to sinusoidally varying postural sway. Our objective was to test the hypothesis that stochastic galvanic vestibular stimulation can lead to coherent stochastic postural sway. Bipolar binaural stochastic galvanic vestibular stimulation was applied to nine healthy young subjects. Three different stochastic vestibular stimulation signals, each with a different frequency content (0-1 Hz, 1-2 Hz, and 0-2 Hz), were used. The stimulation level (range 0.4-1.5 mA, peak to peak) was determined on an individual basis. Twenty 60-s trials were conducted on each subject - 15 stimulation trials (5 trials with each stimulation signal) and 5 control (no stimulation) trials. During the trials, subjects stood in a relaxed, upright position with their head facing forward. Postural sway was evaluated by using a force platform to measure the displacements of the center of pressure (COP) under each subject's feet. Cross-spectral measures were used to quantify the relationship between the applied stimulus and the resulting COP time series. We found significant coherency between the stochastic vestibular stimulation signal and the resulting mediolateral COP time series in the majority of trials in 8 of the 9 subjects tested. The coherency results for each stimulation signal were reproducible from trial to trial, and the highest degree of coherency was found for the 1- to 2-Hz stochastic vestibular stimulation signal. In general, for the nine subjects tested, we did not find consistent significant coherency between the stochastic vestibular stimulation signals and the anteroposterior COP time series. This work demonstrates that, in subjects who are facing forward, bipolar binaural stochastic galvanic stimulation of the vestibular system leads to coherent stochastic mediolateral postural sway, but it does not lead to coherent stochastic anteroposterior postural sway. Our finding that the coherency was highest for the 1- to 2-Hz stochastic vestibular stimulation signal may be due to the intrinsic dynamics of the quasi-static postural control system. In particular, it may result from the effects of the vestibular stimulus simply being superimposed upon the quiet-standing COP displacements. By utilizing stochastic stimulation signals, we ensured that the subjects could not predict a change in the vestibular stimulus. Thus, our findings indicate that subjects can act as "responders" to galvanic vestibular stimulation.

Cross-spectral analysis of physiological tremor and muscle activity. II. Application to synchronized electromyogram

We investigated the relationship between synchronized muscle activity and tremor time series in (enhanced) physiological tremor by cross-spectral analysis. Special attention was directed to the phase spectrum and its potential to clarify the contribution of reflex mechanisms to physiological tremor. The phase spectra are investigated assuming that the electromyogram (EMG) synchronization was caused by a reflex or a central oscillator. Comparing these results to phase spectra of measured data, we found a significant contribution of reflexes. But reflexes only modify existing peaks in the power spectrum. The main agents of physiological tremor are an efferent pace and the resonant behavior of the biomechanical system.

Cross-spectral analysis of physiological tremor and muscle activity. I. Theory and application to unsynchronized electromyogram

We investigate the relationship between the extensor electromyogram (EMG) and tremor times series in physiological hand tremor by cross-spectral analysis. Special attention is directed to the phase spectrum and the effects of observational noise. We calculate the theoretical phase spectrum for a second-order linear stochastic process and compare the results to measured tremor data recorded from subjects who did not show a synchronized EMG activity in the corresponding extensor muscle. The results show that physiological tremor is well described by the proposed model and that the measured EMG represents a Newtonian force by which the muscle acts on the hand.

Central mechanisms in human enhanced physiological tremor

The sites of the central nervous structures involved in enhanced physiological tremor (EPT) are still unclear. The syndrome of persistent mirror movements (PMM) is characterized by abnormal bilateral corticospinal projections. If a supraspinal mechanism is involved in EPT, the activity of EPT should be coherent between both sides in subjects with this abnormality. We investigated three PMM subjects and three normal controls. Focal transcranial magnetic stimulation (TMS) resulted in contralateral hand muscle responses in the controls. The PMM subjects, in contrast, had bilateral responses. Similarly, long-latency reflexes (LLR) in PMM could be recorded bilaterally, while the control subjects showed responses only on the stimulated side. EPT was evoked by intravenous salbutamol. EMG time series were recorded bilaterally from the wrist extensor muscles and cross spectra were calculated. If there was a significant right-left-coherence, phase analysis was performed. No control subject showed a significant right-left-coherence of tremor activity. In contrast, a significant coherence was found in PMM between 8 and 12 Hz. When the mechanical tremor frequency of one hand was reduced by loading, coherences and phase spectra of the EMGs remained unchanged. By comparing the results from TMS, LLR and cross spectral analysis we come to the conclusion, that the 8 to 12 Hz component of EPT is transmitted transcortically, most likely originating from two separate generators for both sides.

Quantitative analysis of tremor time series

Spectral analysis is applied to tremor time series in basic research and treatment monitoring. The estimation of the spectra from the data is usually done by averaging the squared modulus of the Fourier transform of segments of the data. We discuss drawbacks of this method and propose an alternative procedure to estimate the spectra adaptively based on the data. Thus, the method can be applied to all types of tremor. Applying the theory of spectral estimation, we propose a method to decide whether a spectrum exhibits multiple significant peaks and discuss different approaches to determine the amplitude of the tremor from the spectrum.

Clinical neurophysiology of tremor

The neurophysiological analysis of tremor has a long tradition. These attempts were directed to understand the mechanisms underlying tremor, on the one hand, and to develop tools to better diagnose the different types of tremor, on the other. Meanwhile, reasonable criteria are available to distinguish between centrally and peripherally mediated tremors. However, no generally accepted means exist to differentiate the different forms of central tremors. Frequency is a useful classifier for cerebellar tremor, rubral tremor, and orthostatic tremor. Although the highest amplitudes are found in Parkinson's disease, this parameter does not well distinguish between the different tremors. Waveform analysis of tremor is a promising tool to separate between the different tremors. Polymyography is pathognomonic for some rare forms of tremor. New approaches to classify tremors are based on positron emission tomography scanning, analysis of ballistic movement, and reflex testing. The means to separate myoclonias from tremors include EEG/EMG correlation techniques, long-latency reflexes, and polymyography. Provided these techniques are applied in the setting of careful clinical analysis of tremor syndromes, they may prove to be helpful in clinical practice.