Transitioning from Unilateral to Bilateral Upper Limb Tremor Therapy for Parkinson's Disease and Essential Tremor Using Botulinum Toxin: Case Series.

Mandar Jog,Jack Lee,Olivia Samotus

doi:10.3390/toxins10100394

Mandar Jog, Jack Lee + Show 1 more

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https://doi.org/10.3390/toxins10100394

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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.

Highlights

One-third of Parkinson’s disease (PD) patients experience tremor-related quality of life (QoL)problems that interfere with daily activities, such as eating and dressing, which induce psychosocial stress in more than 25% of patients [1]
As this study demonstrates a glimpse to the possible benefits of bilateral Botulinum toxin type A (BoNT-A) therapy, tremor patients with worse QoL and more severe bilateral tremor may benefit more from bilateral rather than unilateral arm treatment
essential tremor (ET) participants had been treated for their right arm tremor and already experienced significant functional and quality of life (QoL) improvement in their arm function as reported by all FTM and QUEST scores with sustained benefit over 96 weeks [17]

Summary

Introduction

One-third of Parkinson’s disease (PD) patients experience tremor-related quality of life (QoL)problems that interfere with daily activities, such as eating and dressing, which induce psychosocial stress in more than 25% of patients [1]. Toxins 2018, 10, 394 tremor severity over the disease progression where ET severity increase is correlated to patient age and duration of tremor and severity gradually worsens with time [4]. Assessed, targeted therapy by botulinum toxin type A (BoNT-A) injections for one arm have been shown to produce reasonable reduction of ET and PD wrist tremor severities significant muscle weakness and limited functional benefit has warranted many patients to discontinue treatment [10,11,12,13,14].

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