Abstract
ObjectiveCurrent 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.MethodsA 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.ResultsFollowing 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.ConclusionsKinematics 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.
Highlights
Tremor greatly affects Parkinson disease (PD) patients during rest and is a functional interference and social embarrassment for essential tremor (ET) patients; many seek therapy
Kinematics detected a significant reduction in PD and ET tremor amplitudes by 70% and 76% over the treatment course, respectively
botulinum toxin type A (BoNT-A) dosages in flexor and extensor wrist muscles and biceps were reduced for those experiencing residual weakness which did not interfere with tremor relief or arm function
Summary
Tremor greatly affects Parkinson disease (PD) patients during rest and is a functional interference and social embarrassment for essential tremor (ET) patients; many seek therapy. The treatment of tremor is a significant unmet need as traditional pharmacotherapy, such as levodopa and dopamine agonists for PD tremor and beta-blockers and anticonvulsants for ET, produces suboptimal benefit and is frequently associated with significant adverse events, such as fatigue, cognitive and neuropsychiatric side effects [1,2,3] Surgical interventions such as deep brain stimulation and thalamotomy are effective for treating oral drug resistant ET and PD tremor, but are highly invasive procedures and further studies are required to establish guidelines for optimizing device programming and decreasing frequent side-effects [4,5,6,7]. The current study reports the 2 year longitudinal results on the efficacy and tolerability of kinematicallyguided, individualized BoNT-A injections for management of debilitating upper limb ET and PD tremors
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