Voice Tremor Research Articles

Somatosensory temporal discrimination in essential tremor and isolated head and voice tremors.

The aim of this study was to investigate the somatosensory temporal discrimination threshold in patients with essential tremor (sporadic and familial) and to evaluate whether somatosensory temporal discrimination threshold values differ depending on the body parts involved by tremor. We also investigated the somatosensory temporal discrimination in patients with isolated voice tremor. We enrolled 61 patients with tremor: 48 patients with essential tremor (31 patients with upper limb tremor alone, nine patients with head tremor alone, and eight patients with upper limb plus head tremor; 22 patients with familial vs. 26 sporadic essential tremor), 13 patients with isolated voice tremor, and 45 healthy subjects. Somatosensory temporal discrimination threshold values were normal in patients with familial essential tremor, whereas they were higher in patients with sporadic essential tremor. When we classified patients according to tremor distribution, somatosensory temporal discrimination threshold values were normal in patients with upper limb tremor and abnormal only in patients with isolated head tremor. Temporal discrimination threshold values were also abnormal in patients with isolated voice tremor. Somatosensory temporal discrimination processing is normal in patients with familial as well as in patients with sporadic essential tremor involving the upper limbs. By contrast, somatosensory temporal discrimination is altered in patients with isolated head tremor and voice tremor. This study with somatosensory temporal discrimination suggests that isolated head and voice tremors might possibly be considered as separate clinical entities from essential tremor.

17. Clinical distinctions between essential and dystonic voice tremor

17. Clinical distinctions between essential and dystonic voice tremor

Bilateral Gamma Knife thalamotomy for treatment of axial tremor

Objective: The objective of this report is to describe the effect of both unilateral and bilateral Gamma Knife thalamotomy (GKT) on axial tremor. Methods: Sixty-eight patients with essential tremor (ET) either only or predominantly affecting axial structures, including the head and neck, voice or lower jar, underwent staged bilateral GKT using previously described methods. A single lesion was made during each GKT procedure in the ventral intermediate (VIM) thalamic nucleus using one 4-mm collimator isocenter, and a maximum radiosurgical dose of 140 Gy. All patients had failed prior medical management. Tremor was graded on a five step scale [0-4] by a comprehensive movement disorder team before treatment, after unilateral thalamotomy and again after bilateral thalamotomy. Results: There were statistically significant improvements in head, voice and lower jaw tremor after bilateral GKT (P<0.05 or better). The average amount of improvement in tremor score was 60.86%. Two patients experienced complications which included speech, balance and gait problems of the total 136 procedures (1.5%). Minimum follow up was 18 months and mean follow up was 65 months. Conclusions: Although bilateral radiofrequency thalamotomy (RFT) carries a high risk of complications, bilateral GKT can be performed safely with appropriate safe guards. Improvements in axial tremor following bilateral GKT are comparable to those seen after bilateral deep brain stimulation (DBS) but with a lower complication rate.

Distinct phenotypes of speech and voice disorders in Parkinson's disease after subthalamic nucleus deep brain stimulation

ObjectivesTo elucidate the phenotypes and pathophysiology of speech and voice disorders in Parkinson's disease (PD) with subthalamic nucleus deep brain stimulation (STN-DBS).MethodsWe conducted a cross-sectional study on 76 PD patients...

Validity of a Screening Question for Head Tremor: An Analysis of Four Essential Tremor Case Samples

Background: The goal of this study was to assess the validity of a screening question for head tremor in essential tremor (ET). There are no published data on this topic, and the knowledge will guide future epidemiological investigations of this disorder. Methods: These analyses utilized four distinct patient samples: a population-based study in northern Manhattan, a study of the environmental epidemiology of ET, a genetics study, and a brain repository. Sensitivity was the proportion of ET cases with head tremor on examination who self-reported head tremor. Results: The sensitivity of the screening question for head tremor was lowest in the population-based study (31.6%), and higher as well as somewhat similar across the remaining studies (46.7 to 62.2%). Higher sensitivity was associated with tremor of longer duration, presence of voice tremor on examination, female gender, and lower education. The use of the screening question would have increased case ascertainment during the screening phase of these four studies by 1.9, 4.1, 10.2, and 20.3%. Conclusions: A screening question for head tremor had low-to-moderate sensitivity in ET. The use of such a screening questionnaire, however, has the potential to increase case ascertainment by as much as 20% in some screening settings.

Novel DYT11 gene mutation in patients without dopaminergic deficit (SWEDD) screened for dystonia.

To test the hypothesis that adult-onset primary dystonia may be the underlying etiology of tremulous patients with clinical diagnosis of Parkinson disease (PD) but without evidence of dopaminergic deficit at nigrostriatal SPECT imaging. We retrospectively reviewed clinical and imaging data of patients with clinical diagnosis of PD assessed at our tertiary movement disorder clinic, who underwent dopamine transporter SPECT imaging consecutively between 2002 and 2011. Molecular screening for DYT1, DYT5, DYT6, DYT11, and DYT16 dystonia genes was performed in all cases who met the following criteria at the time of SPECT scan: (1) clinical diagnosis of PD; (2) normal dopamine transporter SPECT; (3) asymmetric rest tremor, with or without postural/kinetic component; (4) ≥ 12-month follow-up; and (5) normal brain MRI. We excluded subjects with (6) overt dystonic features, and (7) head or voice tremor. Twenty-three subjects were eligible for molecular analysis. Positive family history for tremor or PD was present in 45% of probands. We found one patient with a novel heterozygous frameshift mutation in the DYT11 gene (c.1058-1062 delCACCA/p.Gln352fsX376). Electrophysiologic study of tremor revealed that the main contributor was 5- to 6-Hz pseudo-rhythmic myoclonus, primarily involving extensor muscles. In 2 brothers, we found a missense variant in the DYT5 gene (c.334A>G; p.Thr112Ala) of uncertain pathogenicity in humans. Our findings provide further support to the hypothesis that adult-onset monogenic dystonia may underlie a "PD look-alike" clinical phenotype. In addition to dystonic tremor, pseudo-rhythmic myoclonus may be mischaracterized as "rest tremor."

The treatment of tremor.

Tremor is a hyperkinetic movement disorder characterized by rhythmic oscillations of one or more body parts. It can be disabling and may impair quality of life. Various etiological subtypes of tremor are recognized, with essential tremor (ET) and Parkinsonian tremor being the most common. Here we review the current literature on tremor treatment regarding ET and head and voice tremor, as well as dystonic tremor, orthostatic tremor, tremor due to multiple sclerosis (MS) or lesions in the brainstem or thalamus, neuropathic tremor, and functional (psychogenic) tremor, and summarize main findings. Most studies are available for ET and only few studies specifically focused on other tremor forms. Controlled trials outside ET are rare and hence most of the recommendations are based on a low level of evidence. For ET, propranolol and primidone are considered drugs of first choice with a mean effect size of approximately 50 % tremor reduction. The efficacy of topiramate is also supported by a large double-blind placebo-controlled trial, while other drugs have less supporting evidence. With a mean effect size of about 90 % deep brain stimulation in the nucleus ventralis intermedius or the subthalamic nucleus may be the most potent treatment; however, there are no controlled trials and it is reserved for severely affected patients. Dystonic limb tremor may respond to anticholinergics. Botulinum toxin improves head and voice tremor. Gabapentin and clonazepam are often recommended for orthostatic tremor. MS tremor responds only poorly to drug treatment. For patients with severe MS tremor, thalamic deep brain stimulation has been recommended. Patients with functional tremor may benefit from antidepressants and are best be treated in a multidisciplinary setting. Several tremor syndromes can already be treated with success. But new drugs specifically designed for tremor treatment are needed. ET is most likely covering different entities and their delineation may also improve treatment. Modern study designs and long-term studies are needed.

Differences in Botulinum Toxin Dosing Between Patients With Adductor Spasmodic Dysphonia and Essential Voice Tremor

To explore possible dose differences in average botulinum toxin (BTX) given to patients with adductor spasmodic dysphonia (ADSD) compared with patients with essential voice tremor (EVT). A retrospective study compared the average BTX dose injected in equal doses to the thyroarytenoid (TA) muscles of 51 patients with ADSD with 52 patients with EVT. Those with ADSD received significantly higher total doses (6.80±2.79 units) compared with those with EVT (5.02±1.65 units). Dose at time of first injection, age at time of first injection, gender, year of first injection, and average time between injections were included in multivariate analysis but did not interact with total average dose findings. Patients with ADSD may need relatively higher doses of BTX injections to bilateral TA muscles compared with patients with EVT.

Balance in essential tremor during tandem gait: Is the first mis-step an important finding?

Essential tremor (ET) is the most commonly diagnosed movement disorder. ET may cause substantial loss of motor skills and balance with advanced age. We compared abnormalities in tandem gait with daily activity and Fahn–Tolosa–Marin Tremor Rating Scale (FTMTRS) scores in 90 ET patients. All patients performed a 15-step tandem three times. The mean of first mis-steps was accepted as the tandem index (TI). The mean age was 61.4±17years; the mean duration of tremor was 6.7±4years; and there were 36 men and 54 women. There was no significant difference for age or sex between patients and controls. Head (24.6%), jaw (5.5%), voice (11%), and tongue tremors (1.5%) were identified in ET patients. Rest (2.5%), postural (95%), and kinetic tremors (54%) were detected in the upper extremities. Postural tremor was found in the lower extremities of 5%. The mean TI was 8.3±4 (median, 8) in ET patients, and 10.6±3.9 (median, 10) in controls (p=0.04). Correlation analysis of TI and FTMTRS scores showed tandem gait was significantly correlated with age, total tremor score, postural and kinetic extremity tremor, writing, drawing, pouring, feeding, and working scores. Linear regression showed a significant effect of age and FTMTRS score on TI. The decrease in balance control is apparent with advancing age. Balance disorders were more pronounced in ET patients. Although first mis-step in tandem gait is not as detailed as dynamic balance tests, it can be a simple method for detecting balance disorders.

음성신호 분석에 의한 판소리의 음성학적 특징 연구

판소리는 우리나라 전통 성악곡이며 소리, 대화, 몸짓이 어울린 종합 예술로 독창성과 우수성을 세계적으로 인정받은 세계무형유산이다. 특히, 판소리는 소리꾼의 해학적 표현과 청중의 참여도가 높은 점에서 예술적 가치가 있으며 모든 계층이 두루 즐기는 예술로서 사회적 통합의 기능을 담당한 것으로 평가되고 있다. 따라서 본 논문에서는 사회와 시대를 표현한 판소리의 음향학적 특징을 분석하기 위해 판소리 다섯 마당을 대상으로 음성신호 분석 기술을 적용한 상관성 추출 연구를 수행하였다. 이를 위해 판소리 다섯 마당에 대한 스펙트로그램, 피치, 안정도 및 강도 분석을 실험하였다. 실험 결과를 통해 판소리는 청중들에게 집중과 흥미를 지속적으로 유지시키면서 이야기를 풀어가는 특징을 잘 반영하기 위해 목소리의 파동 및 성대 떨림의 변화 폭이 크고 안정적이며 음성 에너지가 큰 소리로 표현하고 있는 것으로 분석되었다. Pansori is our traditional vocal sound, originality and excellence in the art of conversation, gesture general became a globally recognized world intangible heritage. Especially, Pansori as shrews and humorous representation of audience participation with a high degree of artistic value and enjoy the arts throughout all layers to be responsible for the social integration of functions is evaluated. Therefore, in this paper, Pansori five yard target speech signal analysis techniques applied to analyze the Pansori acoustic features of a representation of a society and era correlation extraction studies were performed. Pansori on the five yard spectrogram, pitch, stability and strength analysis for this experiment. Pansori through experimental results Comical story while keeping the audience focused and interested to better reflect the characteristics of energy for the wave of voice and vocal cord tremor change the width of a large, stable and voice with a loud voice, that expresses were analyzed.

A new paradigm for the management of essential vocal tremor with botulinum toxin

1) To clarify essential voice tremor (EVT) phenomenology; 2) To report a management paradigm for essential voice tremor using botulinum toxin. Retrospective analysis of prospectively collected data. Phenomenology from patients diagnosed with EVT between April 1996 and March 2012 was recorded, charted, and analyzed. A paradigm for treatment of EVT using botulinum toxin based on individualized clinical findings is discussed. Sixteen patients were included. Fewer than 50% patients were responsive to centrally acting oral medications. Fifteen patients analyzed had horizontal laryngeal tremor and received botulinum toxin injections to bilateral thyroarytenoid muscles. Thirteen patients had a vertical laryngeal tremor, and these patients underwent additional strap muscle injections. All patients had symptomatic improvement with reduced tremor amplitude. Dose adjustments over time depended on degree of symptomatic improvement. Management of essential voice tremor with botulinum toxin is optimized by individualizing treatment based on the tremor phenomenology observed during clinical examination. 4.

An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions

Botulinum toxin (Botox) is an exotoxin produced from Clostridium botulinum. It works by blocking the release of acetylcholine from the cholinergic nerve end plates leading to inactivity of the muscles or glands innervated. Botox is best known for its beneficial role in facial aesthetics but recent literature has highlighted its usage in multiple non-cosmetic medical and surgical conditions. This article reviews the current evidence pertaining to Botox use in the head and neck. A literature review was conducted using The Cochrane Controlled Trials Register, Medline and EMBASE databases limited to English Language articles published from 1980 to 2012. The findings suggest that there is level 1 evidence supporting the efficacy of Botox in the treatment of spasmodic dysphonia, essential voice tremor, headache, cervical dystonia, masticatory myalgia, sialorrhoea, temporomandibular joint disorders, bruxism, blepharospasm, hemifacial spasm and rhinitis. For chronic neck pain there is level 1 evidence to show that Botox is ineffective. Level 2 evidence exists for vocal tics, trigeminal neuralgia, dysphagia and post-laryngectomy oesophageal speech. For stuttering, ‘first bite syndrome’, facial nerve paresis, Frey's syndrome, oromandibular dystonia and palatal/stapedial myoclonus the evidence is level 4. Thus, the literature highlights a therapeutic role for Botox in a wide range of non-cosmetic conditions pertaining to the head and neck (mainly level 1 evidence). With ongoing research, the spectrum of clinical applications and number of people receiving Botox will no doubt increase. Botox appears to justify its title as ‘the poison that heals’.

Voice Handicap in Essential Tremor: A Comparison with Normal Controls and Parkinson’s Disease

<strong>Background:</strong> Although voice tremor is one of the most commonly noted clinical features of essential tremor (ET), there are nearly no published data on the handicap associated with it. <strong>Methods:</strong> The Voice Handicap Index (VHI) was self-administered by participants enrolled in a research study at Columbia University Medical Center. The VHI quantifies patients’ perceptions of handicap due to voice difficulties. Data from 98 ET cases were compared with data from 100 controls and 85 patients with another movement disorder (Parkinson’s disease, PD). <strong>Results:</strong> Voice tremor was present on examination in 25 (25.5%) ET cases; 12 had mild voice tremor (ET_{Mild VT}) and 13 had marked voice tremor (ET_{Marked VT}). VHI scores were higher in ET cases than controls (p=0.02). VHI scores among ET_{Marked VT} were similar to those of PD cases; both were significantly higher than controls (pMarked VT, with values that were similar to those observed in PD. <strong>Discussion:</strong> The voice handicap associated with ET had multiple (i.e., physical, functional, and emotional) dimensions. Moreover, ET cases with marked voice tremor on examination had a level of self-reported voice handicap that was similar to that observed in patients with PD.

Voice handicap in essential tremor: a comparison with normal controls and Parkinson's disease.

Although voice tremor is one of the most commonly noted clinical features of essential tremor (ET), there are nearly no published data on the handicap associated with it. The Voice Handicap Index (VHI) was self-administered by participants enrolled in a research study at Columbia University Medical Center. The VHI quantifies patients' perceptions of handicap due to voice difficulties. Data from 98 ET cases were compared with data from 100 controls and 85 patients with another movement disorder (Parkinson's disease, PD). Voice tremor was present on examination in 25 (25.5%) ET cases; 12 had mild voice tremor (ETMildVT) and 13 had marked voice tremor (ETMarkedVT). VHI scores were higher in ET cases than controls (p = 0.02). VHI scores among ETMarkedVT were similar to those of PD cases; both were significantly higher than controls (p<0.001). The three VHI subscale scores (physical, functional, emotional) were highest in ETMarkedVT, with values that were similar to those observed in PD. The voice handicap associated with ET had multiple (i.e., physical, functional, and emotional) dimensions. Moreover, ET cases with marked voice tremor on examination had a level of self-reported voice handicap that was similar to that observed in patients with PD.

Defining Dystonic Tremor

A strong association between dystonia and tremor has been known for more than a century. Two forms of tremor in dystonia are currently recognized: 1) dystonic tremor, which is tremor produced by dystonic muscle contraction and 2) tremor associated with dystonia, which is tremor in a body part that is not dystonic, but there is dystonia elsewhere. Both forms of tremor in dystonia frequently resemble essential tremor or another pure tremor syndrome (e.g., isolated head and voice tremors and task-specific writing tremor), and relationships among these tremor disorders have long been debated. Misdiagnosis is common because mild dystonia is frequently overlooked in patients with tremor. It is now clear that essential tremor is a syndrome, not a specific disease, and the use of essential tremor as a specific clinical diagnosis is arguably an impediment to elucidating this and other pure tremor syndromes and their relationship to dystonia. A new classification, primary tremor, is proposed and would be used for any disorder in which tremor is the sole or principal abnormality with no identifiable etiology other than possible genetic inheritance. This classification scheme would facilitate tremor research by moving the focus from the narrow question “Is it essential tremor?” to a broader consideration of what genetic and environmental factors cause primary tremor disorders, and how do they relate to dystonia and other neurological disorders.

Defining Dystonic Tremor

A strong association between dystonia and tremor has been known for more than a century. Two forms of tremor in dystonia are currently recognized: 1) dystonic tremor, which is tremor produced by dystonic muscle contraction and 2) tremor associated with dystonia, which is tremor in a body part that is not dystonic, but there is dystonia elsewhere. Both forms of tremor in dystonia frequently resemble essential tremor or another pure tremor syndrome (e.g., isolated head and voice tremors and task-specific writing tremor), and relationships among these tremor disorders have long been debated. Misdiagnosis is common because mild dystonia is frequently overlooked in patients with tremor. It is now clear that essential tremor is a syndrome, not a specific disease, and the use of essential tremor as a specific clinical diagnosis is arguably an impediment to elucidating this and other pure tremor syndromes and their relationship to dystonia. A new classification, primary tremor, is proposed and would be used for any disorder in which tremor is the sole or principal abnormality with no identifiable etiology other than possible genetic inheritance. This classification scheme would facilitate tremor research by moving the focus from the narrow question “Is it essential tremor?” to a broader consideration of what genetic and environmental factors cause primary tremor disorders, and how do they relate to dystonia and other neurological disorders. Keywords: Dystonia, essential tremor, tremor

음성진전 유무에 따른 내전형 연축성 발성장애의 보툴리눔 독소-A 주입 후 음성 특성 변화 양상

As BTX-A, which has been known to be the most effective treatment for ADSD, is not effective in treating vocal tremors, voice assessment must be employed to perform differential diagnosis of SD and vocal tremor in an accurate fashion. In this study, the characteristics of vocal changes after botulinum toxin injection were compared by analyzing the voice characteristics resulting from the presence of vocal tremors using objective analysis devices, with the aim of helping to provide prognoses and to determine remedial effects in clinical cases comprising patients with adductor spasmodic dysphonia accompanied by voice tremors. Respiratory function tests, aerodynamic analysis, electroglottography (EGG), acoustic analysis, auditory perception tests, and K-VHI had been conducted at intervals of four, eight, and twelve weeks before and after injection, targeting a group of 17 ADSD female patients (a ADSD group of four with vocal tremor and a ADSD group of 13 without voice tremor). For average FVC and FEV1, the T group showed statistically significant low averages compared with the NT group, whereas the T group showed statistically significant high average ATRI compared with the NT group. In addition, the T group showed a statistically significant Fatr, lower than that of the NT group. For the ADSD group of patients with voice tremor, their vocal tremor remained unchanged despite noticeable decrease in wringing voices. In other words, as the vocal tremor and wringing voices are two distinctive features, there is a need for the two features to be targeted separately for differential diagnosis.

H1-MAPT and the Risk for Familial Essential Tremor

The most frequent MAPT H1 haplotype is associated with the risk for developing progressive supranuclear palsy and other neurodegenerative diseases such as Parkinson’s disease. A recent report suggests that the MAPT H1 is associated with the risk for developing essential tremor. We wanted to confirm this association in a different population. We analyzed the distribution of allelic and genotype frequencies of rs1052553, which is an H1/H2 SNP, in 200 subjects with familial ET and 291 healthy controls. rs1052553 genotype and allelic frequencies did not differ significantly between subjects with ET and controls and were unrelated with the age at onset of tremor or gender, and with the presence of head, voice, chin, and tongue tremor. Our study suggests that the MAPT H1 rs1052553 is not associated with the risk for developing familial ET in the Spanish population.

Deep Brain Stimulation for Treatment of Voice Disorders

Vocal tremor is a common, troublesome disorder that is difficult to treat. Efficacy of deep brain stimulation (DBS) was reported more than a decade ago. Most laryngologists are not familiar with the technique or its potential. This review was undertaken to assemble relevant literature written over the past decade and assess the clinical implications of that literature. Literature review. PubMed search from 2002 through 2011. A small number of articles on the topic have been identified, some of which appear to provide information of potential clinical importance for voice patients. A review of the literature from 2002 through 2011 has revealed several studies supporting the efficacy of DBS as well as adverse consequences of specific technical approaches (such as high-frequency DBS). In the aging population, the prevalence of this voice tremor is likely to increase. We suspect that DBS may be underused; and laryngologists should collaborate with neurosurgeons, speech-language pathologists, and voice scientists to study more extensively the safety and efficacy of DBS for treatment of voice disorders.

ACOUSTIC STRUCTURE OF THE VOICE IN CHILDREN CONSIDERED FOR PARTIAL DEAFNESS TREATMENT

BackgroundPartial deafness (PD) is a condition in which normal hearing is preserved in the low frequency range, while severe to profound hearing loss is observed in the middle and high frequency ranges. The aim of this study was to assess the acoustic structure of the voice in children considered for partial deafness treatment (PDT).Material and MethodsThe material included 127 children aged from 5 to 12 years old. The study group included children with partial deafness (PD). Depending on age, patients in the study group were divided into 2 groups. The first included 40 children aged 5–6 years, and the second consisted of 44 school-age children aged 7–12 years. The control group included 20 healthy normally hearing children aged 5–6 years and 23 healthy, normally hearing children with clear voices, aged 7–12 years. Children’s voices were assessed subjectively by the physician and objectively with the use of a digital CSL KAY Multidimensional Voice Profile analyser (MDVP). The sustained vowel “a” was used for analysis.ResultsAcoustic features of PD vs. normally hearing children were different. Statistically significant parameters differentiating voices in the group of younger children were fundamental frequency (Fo); shimmer, a parameter describing changes in amplitude (ShdB); and noise-to-harmonic-ratio (NHR). In the group of older children more acoustic parameters characterizing voices of PD children were defined. They included fundamental frequency (Fo); fundamental frequency variation (vFo); amplitude change (vAm, sAPQ); noise-to-harmonic-ratio (NHR); and voice tremor (FTRI).ConclusionsThe acoustic structure of the voice in children with partial deafness is different from that in children with normal hearing.