Abstract
Botulinum toxin type A (BoNT-A) injection patterns customized to each patient’s unique tremor characteristics produce better efficacy and lower adverse effects compared to the fixed-muscle-fixed-dose approach for Essential Tremor (ET) and Parkinson’s disease (PD) tremor therapy. This article outlined how a kinematic-based dosing method to standardize and customize BoNT-A injections for tremors was developed. Seven ET and eight PD participants with significant tremor reduction and minimal perceived weakness using optimized BoNT-A injections determined by clinical and kinematic guidance were retrospectively selected to develop the kinematic-based dosing method. BoNT-A dosages allocated per joint were paired to baseline tremor amplitudes per joint. The final kinematic-based dosing method was prospectively utilized to validate BoNT-A injection pattern selection without clinical/visual assessments in 31 ET and 47 PD participants with debilitating arm tremors (totaling 122 unique tremor patterns). Whole-arm kinematic tremor analysis was performed at baseline and 6-weeks post-injection. Correlation and linear regression analyses between baseline tremor amplitudes and the change in tremor amplitude 6-weeks post-injection, with BoNT-A dosages per joint, were performed. Injection patterns determined using clinical assessment and interpretation of kinematics produced significant associations between baseline tremor amplitudes and optimized BoNT-A dosages in all joints. The change in elbow tremor was only significantly associated with the elbow total dose as the change in the wrist and shoulder tremor amplitudes were not significantly associated with the wrist and shoulder dosages from the selected 15 ET and PD participants. Using the kinematic-based dosing method, significant associations between baseline tremor amplitudes and the change (6-weeks post-first treatment) in tremor at each joint with BoNT-A dosages for all joints was observed in all 78 ET and PD participants. The kinematic-based dosing method provided consistency in dose selection and subsequent tremor reduction and can be used to standardize tremor assessments for whole-arm tremor treatment planning.
Highlights
Introduction conditions of the Creative CommonsDebilitating upper limb tremor resistant to oral pharmacological interventions [1,2,3]can be treated using local injections of botulinum toxin type A (BoNT-A) in EssentialTremor (ET) and Parkinson’s disease (PD) patients [4,5,6]
A range of baseline tremor amplitudes at each joint corresponding to BoNT-A joint dosages that produced significant tremor reduction with minimal perceived weakness in a retrospective selection of Essential Tremor (ET) and PD participants were established using injection patterns determined by clinical and kinematic guidance [12]
In this article, a linear relationship between dose selection and tremor severity per joint was established from participants with significant tremor reduction and minimal weakness using injection patterns optimized by integrating visual assessments and clinical interpretation of kinematics
Summary
Introduction conditions of the Creative CommonsDebilitating upper limb tremor resistant to oral pharmacological interventions [1,2,3]can be treated using local injections of botulinum toxin type A (BoNT-A) in EssentialTremor (ET) and Parkinson’s disease (PD) patients [4,5,6]. Needle-guided techniques (e.g., electromyography [EMG], electrical stimulation), ultrasound, or surface EMG and anatomy are used for more accurate targeting of muscles contributing to tremor motion. Using such techniques aid the injector to select muscles for injection, which has improved functional outcomes and minimized excessive arm weakness [10,11,12,13,14,15,16,17]. There is no available software for tremor analysis to customize BoNT-A dosing for the selection of muscle groups without substantial clinical judgment [18,19]. Newer comprehensive technology-based injection techniques, such as the Yale method (EMG needle-probing of forearm muscles) [10,11] and whole-arm kinematic tremor assessments by Jog et al [12,13,14,15] can guide clinical customization of BoNT-A dose and muscle selections based on each patient’s tremor characteristics [19]
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