Feeling Of Unsteadiness Research Articles

Thalamic Local Field Potentials and Closed-Loop Deep Brain Stimulation in Orthostatic Tremor.

Orthostatic tremor (OT) is a rare movement disorder characterized by a feeling of unsteadiness and a high-frequency tremor in the legs (13-18 Hz) relieved by sitting or walking. The aims were to study the brain electrophysiology captured chronically in a person with medication-refractory OT while standing and walking and in the semi-recumbent position using bilateral ventral intermedius nucleus deep brain stimulation (DBS) (Medtronic Percept PC) and to describe the clinical use of closed-loop DBS. A sensing survey was used to capture baseline local field potentials (LFPs) while standing. Livestreamed LFPs were synchronized with data collected from two accelerometers (legs) and gait analysis during OFF stimulation and continuous and closed-loop DBS. Strong oscillatory coupling between thalamic LFP and leg tremor with significant coherence at 14.65 Hz was found during weight-bearing. Single-threshold adaptive DBS (sensing at this frequency) was superior to continuous stimulation in reducing tremor and stimulation-related gait ataxia. This study provides new insights into both the pathophysiology and management of OT. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

AHP and GCA Combined Approach to Green Design Evaluation of Kindergarten Furniture

Kindergarten furniture is an important part of children’s furniture. However, in sharp contrast with the high level of concern about the color, shape, structure, and modularity of kindergarten furniture, the research on green design and green evaluation of kindergarten furniture has not been given due attention. Through understanding the concept and principles of green design, this paper presents an objective approach to evaluate the green design of kindergarten furniture. An evaluation method based on the analytic hierarchy process (AHP) integrating gray correlation analysis (GCA) for kindergarten furniture green design was proposed. By using the AHP to determine the green design elements of kindergarten furniture, five standard layer indicators were obtained in aspects of environmental friendliness of the materials, color, technological structure, size, and interestingness, as well as 11 criterion layer indicators: environmental friendliness of structural materials, environmental friendliness of adhesives, environmental friendliness of paint, stimulate creativity or enhance concentration, avoid the feelings of unsteadiness, structural stability, rounding the edges, comfortable to use, size adjustable, interesting decorative patterns, and modular. Afterward, GCA was used to evaluate the green design of five kindergarten furniture schemes and a comprehensive evaluation score was obtained. Taking the design scheme represented by five desk and chair sets in kindergarten as an example, the effectiveness of this method was verified, and the advantages and disadvantages of the five desk and chair sets were analyzed and compared. The results showed that the third desk and chair sets at kindergarten made of New Zealand pine ranks first in the comprehensive green evaluation indicators, followed by the fourth sets made of rubber and wood. After the green design evaluation, we studied the carbon footprint of five furniture products and analyzed their carbon emissions at the production stage, the packaging stage, the transportation stage, and the storage stage. The results show that the amount of carbon emission is generally consistent with the evaluation results of the green scheme, which verifies the effectiveness of the green design evaluation method. This study provides an effective and feasible reference for kindergarten furniture designers. Hence, a greener kindergarten furniture design is expected to improve the learning and living environment for kindergarten-age children.

Fall risk question-based tools for fall screening in community-dwelling older adults: a systematic review of the literature.

Fall screening tools aim to accurately identify the high fall risk individuals. To increase ease of administration and cost-effectiveness many studies focus on question-based tools. The purpose of this systematic review was to identify question-based tools for fall risk assessment in community-dwelling older adults over the age of 60 and the risk factors that are covered by these tools. The PRISMA guidelines were followed. A literature search was conducted in PubMed/MEDLINE, Web of Science and Google Scholar. Data quality assessment was performed with the Ottawa-Newcastle scale. The results identified 20 studies that used 22 question-based tools to assess fall risk. The number of questions per tool varied from 1 to 41 questions. Data quality varied greatly, with values 3-9 for cohort and 2-7 for cross-sectional studies. The most commonly reported fall risk factors were fall history, feeling of unsteadiness, fear of falling, muscle strength, gait limitation and incontinence. Healthcare providers should use the above tools with caution regarding the limitations of each tool. Further studies should be designed to address individuals with high fall risk, such as individuals with cognitive impairment, as they are under-represented or excluded from most of the existing studies.

Orthostatic tremor as initial presentation of Parkinson's disease.

Orthostatic tremor is rare and is defined as tremor that occurs when standing and affects the lower limbs and trunk, with a frequency of 14-16 Hz. It disappears when leaning on objects and walking. Patients with orthostatic tremor usually have a subjective feeling of unsteadiness. Although orthostatic tremor occurs predominantly in isolation, it has been reported in association with Parkinson's disease, although rarely. We described a patient who presented initially with history and clinical examination which are strongly suggestive of primary orthostatic tremors, but developed parkinsonism features 10 months after the onset of tremor and responded well to levodopa therapy.

Gait Function after High-Intensity Focused Ultrasound Thalamotomy for Essential Tremor: Searching for Technique Optimization

Introduction: Essential tremor (ET) is one of the most prevalent movement disorders in adults and may be highly disabling for some. Magnetic resonance image-guided high-intensity focused ultrasound (MRIgFUS) has been shown to control tremor efficaciously and with acceptable risk. To date, paresthesia and ataxia are the most common adverse effects (AE). Nevertheless, the impact of MRIgFUS thalamotomy on balance is not well established. Methods: Thirty-two patients underwent MRIgFUS for ET and completed 6 months of follow-up. Tremor severity and functional disability were assessed using the Essential Tremor Rating Scale and the Quality of Life in Essential Tremor Questionnaire. The Berg Balance Scale (BBS) was applied to objectively measure balance status. Results: All treatments were successful. The sonication target was 1–2 mm above the depth of the intercommissural line. Procedures lasted less the 2 h, with an average of 8 sonications per patient. Twenty-four patients were included in the tremor analysis. The hand tremor score was improved by 76% after 6 months of follow-up and 87% of patients self-reported marked improvement (≥75%). Disability scores showed marked improvement (78%), leading to a significant improvement in quality of life. At the final follow-up, 48% of the patients reported no side effects. When present, AE were generally transient and were considered mild in 96% of affected patients. Paresthesia and subjective feeling of unsteadiness were the most common persistent complaints (23% and 20%, respectively). Regarding objective ataxia, BBS scores remained stable throughout follow-up for most patients. Only 2 patients suffered a mild worsening of balance although no patients experienced moderate or severe ataxia. Conclusions: Subjective feeling of unsteadiness is one of the most frequent AE after MRIgFUS, although objective ataxia is infrequent and mild. Selecting the most appropriate lesion location and procedural parameters should increase treatment benefits while reducing side effects.

Impact of Common Dizziness Associated Symptoms on Dizziness Handicap in Older Adults.

Background: A cross-sectional observational study was designed to determine the impact of dizziness associated symptoms on the dizziness handicap inventory (DHI) in older adults (≥60 years).Methods: In total, 785 individuals referred to a multidisciplinary dizziness unit were assessed. Participants completed self-report questionnaires with general questions about symptoms of dizziness as well as the DHI. The DHI subscores (physical, functional, emotional) were calculated. Medical diagnoses were collected from the medical records of the patients. One-way MANOVA and networking analysis were used to analyze the impact of dizziness associated symptoms on dizziness handicap.Results: Most patients reported swaying dizziness (60.6%) and feeling of unsteadiness (59.8%) with substantial overlap between the types of dizziness. Most frequent dizziness associated symptoms were ear noise/tinnitus, visual problems, and nausea/vomiting. Network analysis revealed that visual disturbances, headache, and hearing impairment were associated with higher DHI and explained 12% of the DHI variance in the linear regression. In the one-way MANOVA visual problems and headache had an effect on all three DHI subscores, while hearing impairment was associated with the functional and emotional subscores of DHI.Conclusion: Distinct dizziness associated symptoms have substantial impact on dizziness handicap in older adults. A multifactorial assessment including these symptoms may assist in tailoring therapies to alleviate dizziness handicap in this group.

Combination psychotropic medicine use in older adults and risk of hip fracture.

SUMMARYOlder people might be embarrassed to talk about falling as they worry this may be judged as a loss of their ability to live independently. Ask older patients, at least yearly, if they ever feel unsteady on their feet or if they have fallenConsider whether medicines may be contributing to feelings of unsteadiness or falling. Drugs such as benzodiazepines and selective serotonin reuptake inhibitors, particularly if taken together, are associated with a risk of falling and hip fractureReview the patient’s treatment regimen to see if there are drugs that are no longer required. Psychotropic drugs should usually be tapered gradually so that adverse effects can be minimisedInvolve a range of health professionals to identify and manage the risk of falls. Help patients stay physically active, independent and socially connected

Persistent postural perceptual dizziness of the elderly

Persistent postural perceptual dizziness (PPPD) is a common cause of complaints to dizziness and unitability among patients of all-ages. The disease is characterized by a permanent feeling of non-rotatory dizziness or unsteadiness that at first can be caused by an acute vestibular dizziness, somatic disturbance that causes sudden unsteadiness and loss of balance or, for example, by a panic attack. Despite the permanent feeling of unsteadiness and dizziness, a regular instrumental examination cannot reveal important changes that can explain personal feeling. The diagnosis can be made according to the diagnostic criteria developed by the International Barani Society. Treatment consists of psychotherapy, drug therapy and vestibular rehabilitation.

Orthostatic Tremor: Pathophysiology Guiding Treatment.

Orthostatic tremor (OT) is a rare disorder characterized by tremor and a feeling of unsteadiness while standing that resolve upon walking or sitting. A pathognomonic 13-18Hz tremor is seen on surface EMG while standing. Though its clinical features have been better defined over time, much of its pathophysiology remains unknown and treatment options are limited. We review here recent developments in both of these areas. Several recent studies have furthered our understanding of the central oscillatory network involved in OT. fMRI and 18F-FDG-PET studies have identified a ponto-cerebello-thalamo-cortical network underlying OT, though the nature of its dysfunction remains unknown. Randomized trials of treatments for OT are few, so most data are from case reports or small case series. Clonazepam and gabapentin are likely the most effective medical therapies, while bilateral ventral intermediate nucleus deep brain stimulation shows promise for refractory cases. Though much about OT remains unknown, our understanding of its pathophysiology has improved through recent studies. Treatment benefit is overall modest and inconsistent, though better understanding of the disease could lead to new avenues for treatment.

Cerebello-cortical networks in orthostatic tremor.

This scientific commentary refers to ‘Orthostatic tremor: a cerebellar pathology?’ by Gallea et al. (doi:10.1093/brain/aww140). There is no tremor as clinically uncontroversial as orthostatic tremor with its unique symptom of shaking in the legs and trunk at a pathognomonic frequency of 13–20 Hz. It is present only during standing and absent while sitting, but rare patients can trigger orthostatic tremor with isometric contraction of limb muscles. The presenting complaint of the patient is a feeling of unsteadiness in the standing position, despite an unremarkable neurological examination. Later in the disease, a quarter of patients have sudden falls. The tremor is hardly visible unless the patient presents with subharmonics but it is regularly palpable and can be auscultated with a normal stethoscope (helicopter sign). The diagnosis is confirmed with EMG from at least one leg muscle (Deuschl et al. , 1998). The cause of orthostatic tremor is unknown. Rare symptomatic causes have been proposed in patients with cerebellar atrophy or lesions in the pons or midbrain together with orthostatic tremor (Vetrugno et al. , 2013). An autoimmune aetiology has also been proposed because of concomitant Graves’ disease, stiff person syndrome or simply because immunoglobulins were helpful in selected patients (Hassan et al. , 2016). In this issue of Brain , Gallea and co-workers present anatomical and functional connectivity data suggesting that orthostatic tremor may be a cerebellar pathology (Gallea et al. , 2016). Metabolic imaging studies of orthostatic tremor have shown intact serotonergic and dopaminergic pathways (Trocello et al. , 2008) and further biochemical analyses have been fruitless. A few peculiar observations are associated with this condition. The first is that all muscles of the body tremble at the main tremor frequency and only during stance. While for other tremors the coherence between different muscles changes over time, …

Orthostatic Tremor: A Spectrum of Fast and Slow Frequencies or Distinct Entities?

BackgroundOrthostatic tremor (OT) is defined by the presence of a high-frequency (13–18 Hz) tremor of the legs upon standing associated with a feeling of unsteadiness. However, some patients have discharge frequencies of <13 Hz, so-called “slow OT”. The aim of this study was to characterize patients with unsteadiness upon standing found to have <13 Hz tremor discharges on neurophysiologic testing.MethodsA retrospective review was performed on all subjects with a diagnosis of OT who were referred to the Mayo Clinic, Scottsdale, AZ, between 1999 and 2013 for confirmation using neurophysiology.ResultsFourteen of 28 subjects (50%) had OT discharges of <13 Hz, of whom eight had frequencies of <10 Hz and six had frequencies of 10–13 Hz. Lower frequency discharges tended to have a broader spectral peak, greater variability in discharge duration, and lower inter-muscular coherence. Subjects with <13 Hz OT had shorter mean disease duration at time of neurophysiology testing (2.00 years in <10 Hz group, 7.96 years 10–13 Hz group, and 11.43 years >13 Hz; p = 0.002). The proportion of subjects who experienced gait unsteadiness (85.7% vs. 66.6% vs. 21.4%; p = 0.016), falls (37.5% vs. 50% vs. 0%; p = 0.010), and had abnormal gait on examination (71.4% vs. 66.0% vs. 14.3%; p = 0.017) was greater in those with low and intermediate frequencies.DiscussionSlow tremor electromyography frequencies (<13 Hz) may characterize a substantial proportion of patients labeled as OT. These subjects may have greater gait involvement and higher likelihood of falls leading to earlier presentation to subspecialty care.

Shaking on Standing: A Critical Review.

Orthostatic tremor is a rare condition, though its exact prevalence is unknown, which is clinically characterized by a feeling of unsteadiness or being about to fall on standing and which disappears on walking, sitting, or lying down. It is generally accepted that classic orthostatic tremor manifests with a high-frequency tremor (>13Hz) of the legs when standing. However, a number of patients initially reported as orthostatic tremor did not actually have such electrophysiological features. It is our experience that there is a clinical spectrum of different conditions presenting as shaking on standing, and this highlights the importance of the electrophysiology to aid the differential diagnosis of these disorders. Here, we provide a critical review of the clinical spectrum of shaking on standing, along with demonstrative electrophysiological recordings of some of these conditions.

Drżenie ortostatyczne – łatwa diagnostyka, trudna diagnoza? Opis przypadku

Abstract Objectives Orthostatic tremor is a specific form of tremor which is characterized by a subjective feeling of unsteadiness during stance, not present in other positions. The diagnosis can be confirmed in the electromyographic or accelerometric study by recording the tremor ( e.g. in the quadriceps muscle) of frequency 13–18 Hz occurring exclusively in the upright position. Case report In the present case, despite the presence of the classic features of orthostatic tremor the proper diagnosis has been much delayed. Conclusions The paper presents the characteristic features of this rare movement disorder, indicates some diagnostic possibilities, and emphasizes the need for disseminating the knowledge about the disease which can be treated successfully.

The central oscillatory network of orthostatic tremor

Orthostatic tremor (OT) is a movement disorder of the legs and trunk that is present in the standing position but typically absent when sitting. The pathological central network involved in orthostatic tremor is still unknown. In this study we analyzed 15 patients with simultaneous high-resolution electroencephalography and electromyography recording to assess corticomuscular coherence. In 1 patient we were able to simultaneously record the local field potential in the ventrolateral thalamus and electroencephalography. Dynamic imaging of coherent source analysis was used to find the sources in the brain that are coherent with the peripheral tremor signal. When standing, the network for the tremor frequency consisted of unilateral activation in the primary motor leg area, supplementary motor area, primary sensory cortex, two prefrontal/premotor sources, thalamus, and cerebellum for the whole 30-second segment recorded. The source coherence dynamics for the primary leg area and the thalamic source signals with the tibialis anterior muscle showed that they were highly coherent for the whole 30 seconds for the contralateral side but markedly decreased after 15 seconds for the ipsilateral side. The source signal and the recorded thalamus signal followed the same time frequency dynamics of coherence in 1 patient. The corticomuscular interaction in OT follows a consistent pattern with an initially bilateral pattern and then a segregated unilateral pattern after 15 seconds. This may add to the feeling of unsteadiness. It also makes the thalamus unlikely as the main source of orthostatic tremor.

Safety and efficacy of botulinum toxin in primary orthostatic tremor

Primary orthostatic tremor (POT) is a rapid 13–18Hertz tremor that produces a subjective feeling of unsteadiness when standing, and is absent when seated or supine. It predominantly affects the legs during isometric contraction though a similar tremor can be seen in the arms and jaw. When present in the jaw this rapid tremor has been successfully treated with botulinum toxin. We sought to test whether symptoms of POT improved following injection of abobotulinumtoxinA to muscles in the legs. This randomised, double blind, placebo controlled cross-over design study enrolled eight patients with electrophysiologically confirmed POT. Each patient received injections of either 200mU abobotulinumtoxinA or 0.9% saline in the tibialis anterior bilaterally, with cross-over after 20weeks. Electrophysiological and clinical assessments were performed before and 6weeks after each injection. Seven patients completed the study. No significant differences were seen in the primary outcome measures of time from standing to unsteadiness or symptom diary scores. Electrophysiological characteristics of POT remained remarkably constant throughout the study in all patients with variability of less than 1Hertz in the frequency recorded. Falls were common, with one patient experiencing a fall with upper limb fracture whilst on the placebo. The frequency of falls correlated with both the severity of the self-rated symptoms and a shorter time to feeling unsteady with eyes closed. In conclusion, treatment with 200mU of abobotulinumtoxinA in the tibialis anterior does not alter subjective experience of unsteadiness in POT. Postural instability and falls are common.

A case of atypical neurosjogren with cranial MRG and clinical findings

Sjogren's syndrome is a chronic inflammatory autoimmune exocrinopathy, which is characterised by infiltration of mononuclear cells of secretory glands. 10-40% of patients also have neurological involvement, either in the central nervous system or in peripheral nervous system. We present a 60-years-old female patient diagnosed as Sjogren’s syndrome 8 years ago. Patient's chief complaints were gase diturbance, feeling of unsteadiness and incresed sleep, which started 3-4 days ago. Her neurological examination revealed tendency to fall asleep (somnolance) and when was awakened she had vertical gase palsy, ataxia and impairment of attention and close memory at mental examination. There were hyperintensities in posterior part of left gyrus rectus, periaquaductal region, posterior parts of superior cerebral pedincules, left sub-basal ganglionic region, mamillary bodies and bilateral medial thalamic pars on T2 and FLAIRweighted sequences of cranial MRI. Here we dicussed an atypical neurosjogren case, which had not any clinical improvement despite intensive immunosuppressive therapy, with clinical and MRI findings along with literature.

PATH55 Characterising orthostatic tremor: a study of 56 patients

Orthostatic tremor (OT) is a rarely reported condition defined as a subjective feeling of unsteadiness on standing, accompanied by a 13- to 18-Hz leg tremor that is relieved during sitting....

Balance-related efficacy compared with balance function in patients with acute stroke

It is well known that patients who have suffered a stroke have problems with balance and have feelings of unsteadiness. The aim of this study was to analyse the correlation between how patients estimate their perceived confidence in task performance without falling and the objective assessment of balance made by a physiotherapist, and whether the Falls Efficacy Scale (FES(S)) is to be recommended for use in patients in the acute phase of stroke. Sixty patients divided into two groups assessed their belief to perform daily life activities without fear of falling using the FES(S) and were assessed by using the Berg Balance Scale (BBS) and Timed Up and Go (TUG) by a physiotherapist. Group 1 assessed themselves before, whereas Group 2 assessed themselves after the objective assessment. The correlation between the FES(S) and the TUG was moderate to good, but these two scales consider different aspects and dimensions of balance, ability, and belief and are therefore not interchangeable. The correlation between FES(S) and BBS was low to moderate. The conclusion of this study was that the FES(S) is not to be recommended as a single measurement in the acute phase of stroke because it does not measure actual balance function.

Disequilibrium and gait disorders in older people

Disequilibrium, or imbalance, is a type of dizziness typically described as a feeling of unsteadiness when standing or walking that is not present while sitting or lying down. Patients with disequilibrium often complain of vertigo, lightheadedness, or a similar ‘head’ sensation as the main symptom, but disequilibrium also occurs in isolation. The first step in determining the cause is to define exactly what the patient is experiencing, and any associated symptoms. The complaint of imbalance is very common among older people. Since the population is quickly aging, we can only expect the number of patients presenting with it to increase. As a result of this frequent presentation and the many potential causes of the symptom, some authors even argue that disequilibrium should be considered part of a geriatric syndrome. Further complicating the evaluation is the fact that most elderly people have at least one chronic disease and are taking several medications, factors that could contribute to, or even cause, disequilibrium. Signs on examination that could indicate early features of neurodegenerative disorders are also common in older people. Because dizziness and imbalance have a strong association with falls, searching for a reversible disorder and directing attention to fall-prevention strategies are paramount. Falls themselves are a major source of morbidity and mortality in the elderly population.

Subependymal nodular heterotopia

29-year-old woman complained of episodic dizziness with a feeling of unsteadiness. She was referred to the ear, nose and throat clinic. Examination was normal and a pure tone audiogram was within normal limits. Although her symptoms improved with vestibular rehabilitation exercises, they did not resolve entirely and so magnetic resonance (MR) imaging of the brain was requested. Imaging changes (Figure 1a) prompted an urgent referral to the neurology clinic. In her past medical history, the patient had developed seizures at the age of 5 years, initially brief ‘absences’ (eye blinking, head nodding, mouth twitching) with very occasional generalized tonic-clonic seizures. She was the product of a normal full-term vaginal delivery, with normal developmental milestones. There was no family history of seizure disorder. Formal testing at the age of 7 years showed that she was of average intellectual ability and above average ability on the arithmetic subtest. An electroencephalogram showed right temporal slow and sharp wave features. A diagnosis of ‘idiopathic’ temporal lobe epilepsy was made and she was commenced on carbamazepine with reduction in seizure frequency. A computed tomography brain scan performed at the age of 13 years after a further generalized seizure was reported to show a large cerebellar cistern but was otherwise normal. Family history was negative for seizure disorder. Her neurological examination was normal. MR brain imaging (Figure 1b) showed multiple bilateral subependymal nodules of grey matter, lining both lateral ventricles, appearances diagnostic of subependymal nodular heterotopia. No other cerebral or cortical malformation was seen.