Management Of Tremor Research Articles

The Pharmacological Management of Essential Tremor and Its Long-Term Effects on Patient Quality of Life: A Systematic Review.

Essential tremor (ET) is one of the most prevalent nerve-related movement disorders, most commonly affecting the hands during voluntary movements or while maintaining posture. Unlike tremors in neurodegenerative conditions, ET is not observed at rest. Continued research is essential to optimize treatment strategies and address the unmet need for sustainable, patient-centered therapies that minimize side effects and enhance long-term quality of life (QoL) for individuals with ET. Five medical databases were searched for content relevant to this study's topic, utilizing the guidelines set forth by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). These databases searched include Web of Science, PubMed, Cochrane Library, ScienceDirect, and Google Scholar for publications between 2010 and 2024. The review analyzed studies including adult patients with ET, focusing on efficacy, safety, and QoL outcomes, with priority given to studies from the Middle East or Saudi Arabia. We included 10 studies that met our inclusion criteria for a full review. Based on the studies, pharmacological treatments such as alprazolam, primidone, propranolol, and CX-8998 were found to be efficient in the management of ET. Emerging medications, including CX-8998 and alprazolam, showed mixed results with significant adverse events. Surgical interventions like deep brain stimulation (DBS) demonstrated long-term motor control benefits, although functional declines occurred due to disease progression. Novel approaches like low-intensity focused ultrasound (LIFU), transcutaneous afferent patterned stimulation (TAPS), and incobotulinumtoxinA injections presented promising results with improved tremor control and minimal side effects. In conclusion, pharmacological treatments for ET provide symptomatic relief but are limited by side effects and reduced long-term efficacy, significantly impacting QoL. Surgical and novel therapeutic options offer enhanced motor control and durability of effects, though they are not universally applicable.

Combining Transcranial Direct Current Stimulation with Exercise to Improve Mobility, Stability, and Tremor Management in 25 Individuals with Parkinson's Disease.

Parkinson's disease (PD) is a neurodegenerative disorder characterized by tremors, balance impairments, and mobility limitations. Innovative approaches like combining transcranial direct current stimulation (tDCS) with exercise show promise in addressing these symptoms. This study investigates the effects of exercise combined with tDCS on mobility and tremor management in PD patients. Twenty-five individuals aged 60-75 (66.6 ± 7.33), diagnosed with PD (Hoehn and Yahr stage 2-3), were assigned to three groups in a randomized controlled design: exercise with active tDCS (n = 8), exercise with sham tDCS (n = 8), and a control group (n = 9). Dual-task training sessions focusing on walking speed, balance, and force control were conducted over ten sessions. No significant differences were detected across the groups for grip strength or force control measures (p > 0.05). Significant improvements were observed in the intervention group: the Timed Up and Go (TUG) test showed a significant reduction in time (mean difference = 2.498 s, p < 0.001, ηp2 = 0.331); anterior-posterior displacement significantly increased (mean difference = 21.375 mm, p = 0.0269, ηp2 = 0.303); and force-tremor decoupling improved, with coherence in the 1-4 Hz band significantly decreasing (p = 0.0067). Finally, changes in TUG from post- to pre-treatment values were significantly positively correlated with the changes in coherence (R = 0.468, p = 0.018). Combining tDCS with exercise enhances mobility and tremor management in PD patients. These findings support the potential for such interventions to improve functional outcomes and quality of life for individuals with PD.

A Wearable Multichannel Electrical Stimulator for Tremor Suppression

Abstract Pathological wrist and finger tremors can be mitigated by out-of-phase stimulation of the sensory nerves in the flexor and extensor muscles. This study endeavors to develop a portable, multichannel electrical stimulator designed to deliver high-frequency, low-intensity, biphasic charge-balanced current pulses within a practical load range to effectively suppress wrist and finger tremors. The circuit architecture integrates an Arduino Nanomicrocontroller, a four-channel digital potentiometer, and four Howland current pumps. The Howland current pump, employing an operational amplifier, generates bipolar currents by accepting bipolar voltages, whereas the digital potentiometer offers programmable bipolar voltages via its wiper terminals. Experimental results indicate that the pulse frequency can be adjusted between 50 Hz and 200 Hz, and the current level can be modulated within a range of −10 mA to +10 mA, with load resistance spanning 100 Ω to 1.3 kΩ. This portable and multichannel device is effective in delivering high-frequency, low-intensity sensory nerve stimulation through programmable biphasic charge-balanced current pulses. The proposed stimulator has the potential to enable adaptive muscle activation, thereby initiating, promoting, and generating movements, and facilitating interactive in-home neurorehabilitation for disabled patients. The portability and programmability of this device make it a promising tool for personalized tremor management and rehabilitation, enhancing the quality of life for individuals with motor impairments.

Simultaneous radiofrequency VIM thalamotomy and Posteroventral pallidotomy for management of dystonic tremors

Simultaneous radiofrequency VIM thalamotomy and Posteroventral pallidotomy for management of dystonic tremors

Four-tract tractography: multiparametric direct targeting of the dentatorubrothalamic tract

This video article presents a case study of a 70-year-old male with medically refractory essential tremor treated with magnetic resonance–guided focused ultrasound (MRgFUS). Following an initial successful ablation of the right thalamus, the patient underwent left-sided thalamotomy. After two tractography-guided sonications, the authors observed a significant reduction in his right-hand tremor with no immediate side effects. Postprocedure evaluation revealed sustained tremor reduction with minimal side effects, showcasing bilateral MRgFUS as an effective, noninvasive option for essential tremor management. The video can be found here: https://stream.cadmore.media/r10.3171/2024.7.FOCVID2483

Stereotactic radiofrequency lesioning of caudal zona incerta for parkinsonian tremor.

This video showcases stereotactic radiofrequency lesioning of the caudal zona incerta (CZi) for parkinsonian tremor in a 70-year-old patient. The preoperative evaluation, including imaging and frame placement, is detailed. The surgical procedure involves meticulous targeting and trajectory planning. Intraoperative stimulation is utilized for motor response assessment. Two temporary lesioning phases precede the final procedure at 75°C. The postoperative CT scan highlights the lesion site. Immediate tremor relief is observed postoperatively, with the effect persisting at the 1-month follow-up. Supporting readings underscore the efficacy and safety of CZi for tremor management. The video can be found here: https://stream.cadmore.media/r10.3171/2024.7.FOCVID2462.

Research hotspots and frontiers of essential tremor from 2013 to 2023: a visualization analysis based on CiteSpace.

ET, one of the most prevalent neurological disorders, presents a significant challenge in terms of disability. Despite the growing focus on ET in recent years, comprehensive bibliometric analysis has been lacking. This study delves into essential tremor research covering the period from 2013 to 2023, utilizing the Web of Science (WOS) database. Employing CiteSpace for quantitative analysis, it examines an array of metrics including annual publication trends, contributions from countries and institutions, authorship patterns, key terminologies, and patterns of reference co-citation. The primary objective is to use CiteSpace for a detailed visual exploration of the literature over the last decade, pinpointing the evolving landscape and key areas of focus in essential tremor research, and thus providing a foundation for future investigative endeavors. There were 2,224 literary works included in all. The amount of published works has been steadily rising in recent years. Of them, the majority originate from the United States, Louis, Elan D. is the publisher of the most publications (161 articles), and Movement Disorders is the journal that receives the most citations. The key words contribution and co-cited literatures suggest that the main research hotspots in recent years are the physiological and pathological mechanism of essential tremor, the determination of optimal targets for deep brain stimulation (DBS) and surgery transcranial magnetic resonance-guided focused ultrasound (MRgFUS) in the surgical management of essential tremor and the innovative research of botulinum toxin administration method.

Ayurvedic Management of Kampavata

Kampavata is one among Vataja nanatmaja vyadhis. Acharya Charaka, Susrutha, Vagbhata, Madhavakara, Kashyapa mentioned Kampavata as Vepathu. It can be correlated with “Tremors” in modern science which is the most common movement disorder. The total number of people suffering from ET worldwide was 24.91 million in 2020 and incidence increases with age. Kampa is the prominent feature in Kampavata which is categorized as Sarvanga-kampa and Shiro-kampa. Kampa occurs due to Prakopa of Chalaguna which is the inherent quality of Vata dosha. The management of essential tremors in the conventional system of medicine is decreasing quality of life of patient with certain side effects like fatigue, impotence, bradycardia, reduced blood pressure, drowsiness, nausea, dizziness, ataxia, confusion, vertigo, paresthesia etc. By Ayurvedic intervention patient quality of life can be preserved. In the present clinical study patient was treated with Snehana and Brmhana line of management in the form of Shirodhara, Nasya and Samana oushadies like Sarvamayantakaghrta etc. The outcome of the study revealed good therapeutic efficacy and patient got remarkable relief in symptoms, that are assessed by TRG Essential tremor rating assessment scale (TETRAS©) V 3.1.

Radiosurgical thalamotomy for the management of tremors: a systematic review and meta-analysis.

Medical treatment for tremors may include beta-blockers, primidone, dopaminergic, and anticholinergic drugs but it frequently leads to pharmacoresistance. Therefore, surgical treatment gained relevance as an alternative for those patients.We aim to evaluate radiosurgical thalamotomy as an effective and safe alternative to manage tremors.Pubmed (MEDLINE), Embase, Web of Science, and the Cochrane Library databases were systematically searched for potential articles that evaluated radiosurgical thalamotomy for the management of tremor.Our analysis included 12 studies with 545 patients, 226 of whom were female. Of these, 64.6% of patients were diagnosed with essential tremor (ET), 34.6% with Parkinson's disease (PD), and 0.8% with both ET and PD. The FTM-TRS global score (MD -5.46; 95% CI [-10.44]-[-0.47]; I2 = 52%) and the drawing (MD -1.40; 95% CI [-2.03]-[-0.76]; I2 = 93%), drinking (MD -1.60; 95% CI [-1.82]-[-1.37]; I2 = 40%), and writing (MD -1.51; 95% CI [-1.89]-[-1.13]; I2 = 89%) grades showed significantly lower mean differences, favoring radiosurgical thalamotomy. A pooled proportion of 12% presented with tremor unchanged, while 38% presented with total elimination of tremor. Adverse events included: major paresis, minor paresis, dysarthria, and numbness. Thus, radiosurgical thalamotomy is a safe alternative for tremors resistant to medication, particularly in high-risk patients for RF or DBS procedures. The recommended dose of 130 to 150Gy is effective and well-tolerated. However, randomized controlled trials (RCTs) are needed to understand the unpredictability of tissue response to radiation.

Egg membrane as a training model for microsurgery

Teaching microsurgery is limited by the availability of appropriate training models. In-vivo models, such as rats, remain the gold standard, but ethical and economic limitations restrict their use for initial training. This study investigated the feasibility of using egg membrane as an inert model, an accessible and economical alternative for introduction to microsurgery.The specifications for inert models include ease of access, low cost, high reproducibility and realistic reproduction of relevant characteristics. Fourteen microsurgery students assessed egg membrane as an inert training model on a 10-item questionnaire evaluating the specifications for use in microsurgery teaching.Easy access to the material and the ease with which it could be set up were evaluated positively. Dissection of the membrane added an educational dimension, distinguishing this model from other inert alternatives. On the other hand, the flexibility of the egg membrane and its resistance to the passage of the needle or the tightening of the thread were generally considered to be different from the in-vivo arterial wall.In conclusion, egg membrane as an inert model offers a practical, economical alternative in microsurgery training despite a lack of fidelity in reproducing the most relevant characteristics of the arterial wall. This model is more suited to the initial phase of learning microsurgery: in particular, working under a microscope, eye/hand coordination, tremor management and digital dexterity.

Standardized Pre-clinical Surgical Animal Model Protocol to Investigate the Cellular and Molecular Mechanisms of Ischemic Flap Healing

BackgroundSome of the most complex surgical interventions to treat trauma and cancer include the use of locoregional pedicled and free autologous tissue transfer flaps. While the techniques used for these reconstructive surgery procedures have improved over time, flap complications and even failure remain a significant clinical challenge. Animal models are useful in studying the pathophysiology of ischemic flaps, but when repeatability is a primary focus of a study, conventional in-vivo designs, where one randomized subset of animals serves as a treatment group while a second subset serves as a control, are at a disadvantage instigated by greater subject-to-subject variability. Our goal was to provide a step-by-step methodological protocol for creating an alternative standardized, more economical, and transferable pre-clinical animal research model of excisional full-thickness wound healing following a simulated autologous tissue transfer which includes the primary ischemia, reperfusion, and secondary ischemia events with the latter mimicking flap salvage procedure.ResultsUnlike in the most frequently used classical unilateral McFarlane’s caudally based dorsal random pattern skin flap model, in the herein described bilateral epigastric fasciocutaneous advancement flap (BEFAF) model, one flap heals under normal and a contralateral flap—under perturbed conditions or both flaps heal under conditions that vary by one within-subjects factor. We discuss the advantages and limitations of the proposed experimental approach and, as a part of model validation, provide the examples of its use in laboratory rat (Rattus norvegicus) axial pattern flap healing studies. ConclusionsThis technically challenging but feasible reconstructive surgery model eliminates inter-subject variability, while concomitantly minimizing the number of animals needed to achieve adequate statistical power. BEFAFs may be used to investigate the spatiotemporal cellular and molecular responses to complex tissue injury, interventions simulating clinically relevant flap complications (e.g., vascular thrombosis) as well as prophylactic, therapeutic or surgical treatment (e.g., flap delay) strategies in the presence or absence of confounding risk factors (e.g., substance abuse, irradiation, diabetes) or favorable wound-healing promoting activities (e.g., exercise). Detailed visual instructions in BEFAF protocol may serve as an aid for teaching medical or academic researchers basic vascular microsurgery techniques that focus on precision, tremor management and magnification.Graphical

Present and Prospective Advancements in the Field of Deep Brain Stimulation Technology

Deep brain stimulation (DBS) in the neurosurgery domain allows for precise control of particular neural circuits. DBS has shown significant therapeutic effectiveness in the management of essential tremor, dystonia, and Parkinson's disease (PD). Moreover, ongoing research is investigating the potential of DBS as a therapy modality for several additional conditions characterized by aberrant circuitry, including depression and dementia. Over the last two decades, there has been a gradual improvement in DBS (Deep Brain Stimulation) devices, which today integrate an extension wire, pulse generator, and intracranial electrode. These components have been borrowed from the field of cardiology. The present paradigm of DBS is expected to undergo significant changes due to recent breakthroughs in technology and imaging, as well as a more comprehensive understanding of brain illnesses. Anticipated advancements in the tolerability and efficacy of DBS may be attributed to progress made in several areas, including battery and electrodes designing, stimulation systems, on-demand and closed-loop stimulation, including sensor technologies. This review provides a comprehensive examination of the historical and projected trajectory of DBS technology. By retrospectively examining the progress of DBS, we may enhance our understanding and recognition of our current position, as well as proactively forecast the next obstacles and prospects.

Cerebral Metabolism Analysis for Predicting Response to Radiosurgical Thalamotomy in Tremor Management: A Retrospective Pre-Therapeutic PET-FDG Assessment

Cerebral Metabolism Analysis for Predicting Response to Radiosurgical Thalamotomy in Tremor Management: A Retrospective Pre-Therapeutic PET-FDG Assessment

Tremor in Spinocerebellar Ataxia: A Scoping Review.

Spinocerebellar ataxia (SCA) denotes an expanding list of autosomal dominant cerebellar ataxias. Although tremor is an important aspect of the clinical spectrum of the SCAs, its prevalence, phenomenology, and pathophysiology are unknown. This review aims to describe the various types of tremors seen in the different SCAs, with a discussion on the pathophysiology of the tremors, and the possible treatment modalities. The authors conducted a literature search on PubMed using search terms including tremor and the various SCAs. Relevant articles were included in the review after excluding duplicate publications. While action (postural and intention) tremors are most frequently associated with SCA, rest and other rare tremors have also been documented. The prevalence and types of tremors vary among the different SCAs. SCA12, common in certain ethnic populations, presents a unique situation, where the tremor is typically the principal manifestation. Clinical manifestations of SCAs may be confused with essential tremor or Parkinson's disease. The pathophysiology of tremors in SCAs predominantly involves the cerebellum and its networks, especially the cerebello-thalamo-cortical circuit. Additionally, connections with the basal ganglia, and striatal dopaminergic dysfunction may have a role. Medical management of tremor is usually guided by the phenomenology and associated clinical features. Deep brain stimulation surgery may be helpful in treatment-resistant tremors. Tremor is an elemental component of SCAs, with diverse phenomenology, and emphasizes the role of the cerebellum in tremor. Further studies will be useful to delineate the clinical, pathophysiological, and therapeutic aspects of tremor in SCAs.

Tremor Suppression Using Functional Electrical Stimulation.

Parkinson's disease (PD) and essential tremor are two major causes of pathological tremor among people over 60 years old. Due to the side effects and complications of traditional tremor management methods such as medication and deep brain surgery, non invasive tremor suppression methods have become more popular in recent years. Functional electrical stimulation (FES) is one of the methods used to reduce tremor in several studies. However, the effect of different FES parameters on tremor suppression and discomfort level, including amplitude, the number of pulses in each stimulation burst, frequency, and pulse width is yet to be studied for longer stimulation durations. Therefore, in this work, experiments were performed on 14 participants with PD to evaluate the effect of thirty seconds of out-of-phase electrical stimulation on wrist tremor at rest. Trials were conducted by varying the stimulation amplitude and the number of pulses while keeping the frequency and pulse width constant. Each test was repeated three times for each participant. The results showed an overall tremor suppression for 11 out of 14 participants and no average positive effects for three participants. It is concluded that despite the effectiveness of FES in tremor suppression, each set of FES parameters showed different suppression levels among participants due to the variability of tremor over time. Thus, for this method to be effective, an adaptive control system would be required to tune FES parameters in real time according to changes in tremor during extended stimulation periods.

Research on Tremor Suppression Strategies Under a Constant Current Peripheral Electrical Stimulation Device for Parkinson's Disease.

Tremor, a prevalent symptom in Parkinson's patients, is conventionally treated with medications and craniotomy. However, the associated side effects and high surgical costs pose challenges for some individuals. In this study, a lightweight constant current electrical stimulator was developed, which is driven by the FPGA to control the underlying logic and has multiple programmable stimulation parameters. Clinical experiments involving patients with Parkinson's-related resting tremor symptoms were conducted to assess the efficacy of peripheral electrical stimulation. Two Co-contraction Avoidance Stimulation (CAS) strategies targeting nerves and muscles were proposed to reduce tremors. Four Parkinson's disease (PD) patients were recruited to verify the effectiveness of these strategies. Kinematic data recorded by inertial sensors showed that the radial nerve and muscle intervention strategies reduced the average angular velocity amplitude of finger joints during resting tremor by 75.92% and 82.41%, respectively. Notably, under low-frequency pulse stimulation (100 Hz) focused on muscle interference, a low-intensity current of no more than 8 mA maintained a tremor suppression rate of 59.91% even 5 minutes post-stimulation. Based on the experimental results, it is concluded that the constant current electrical stimulator developed in this study can effectively suppress tremor under specific stimulation strategies. These findings have significant implications for the development of lightweight, wearable tremor suppression devices. The stimulator's adaptability, coupled with its precise control parameters, demonstrates promise for advancing non-invasive and cost-effective tremor management in Parkinson's patients.

Factors affecting temperature prediction in essential tremor management using magnetic resonance imaging-guided high-intensity focused ultrasound.

Factors affecting temperature prediction in essential tremor management using magnetic resonance imaging-guided high-intensity focused ultrasound.

Transcutaneous afferent patterned stimulation therapy at the wrist for essential tremor relief

Transcutaneous afferent patterned stimulation (TAPS), also referred to as non-invasive peripheral nerve stimulation, at the wrist provides a promising option for the management of essential tremor. This new wrist-worn neuromodulation method avoids the risks of surgical interventions and can be easily used at home. TAPS therapy is indicated to aid in the temporary relief of hand tremors following stimulation in adults with essential tremor. No serious device-related side effects have been reported. Future studies will be needed to determine the optimal parameters of stimulation. This article introduces a wrist-worn TAPS device and reviews the tremor-reducing mechanism and the clinical effectiveness of TAPS therapy for essential tremor.

Tremor in Parkinson’s Disease: From Pathophysiology to Advanced Therapies

Background:Tremor is one of the most prevalent symptoms in Parkinson’s Disease (PD). The progression and management of tremor in PD can be challenging, as response to dopaminergic agents might be relatively poor, particularly in patients with tremor-dominant PD compared to the akinetic/rigid subtype. In this review, we aim to highlight recent advances in the underlying pathogenesis and treatment modalities for tremor in PD.Methods:A structured literature search through Embase was conducted using the terms “Parkinson’s Disease” AND “tremor” OR “etiology” OR “management” OR “drug resistance” OR “therapy” OR “rehabilitation” OR “surgery.” After initial screening, eligible articles were selected with a focus on published literature in the last 10 years.Discussion:The underlying pathophysiology of tremor in PD remains complex and incompletely understood. Neurodegeneration of dopaminergic neurons in the retrorubral area, in addition to high-power neural oscillations in the cerebello-thalamo-cortical circuit and the basal ganglia, play a major role. Levodopa is the first-line therapeutic option for all motor symptoms, including tremor. The addition of dopamine agonists or anticholinergics can lead to further tremor reduction. Botulinum toxin injection is an effective alternative for patients with pharmacological-resistant tremor who are not seeking advanced therapies. Deep brain stimulation is the most well-established advanced therapy owing to its long-term efficacy, reversibility, and effectiveness in other motor symptoms and fluctuations. Magnetic resonance-guided focused ultrasound is a promising modality, which has the advantage of being incisionless. Cortical and peripheral electrical stimulation are non-invasive innovatory techniques that have demonstrated good efficacy in suppressing intractable tremor.

Preliminary Assessment of the Safety of a Fault-Tolerant Control-based Wearable Tremor Suppression Glove.

The advent of wearable tremor suppression de-vices (WTSDs) has provided a promising alternative approach for parkinsonian tremor management, especially for individuals whose tremors are not managed by conventional treatment options. Currently, research in WTSDs has shown successful results with a tremor suppression ratio of up to 99 %; however, the user safety of WTSDs has not been properly considered, especially in the occurrence of unexpected events, such as faults and disturbances. In this study, a fault-tolerant control system was developed and integrated into the control system of a WTSD for the first time. The safety and tremor suppression performance of the proposed system under the influence of a measurement loss fault were tested and evaluated on 18 tremor motion datasets, specifically by quantifying the tremor power suppression ratio and the error when tracking voluntary motion. The experimental evaluation showed that the proposed system could remain functional and safe to use in the existence of the fault, with an average user motion tracking error of 1.5º. It was also found that the proposed system achieved significantly improved performance in both metrics when compared to the system without a fault-tolerant controller. Clinical Relevance-This work improves the safety and robustness of WTSDs making them more suitable for use as an additional treatment for parkinsonian tremor.