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Enhancement by agonist or antagonist muscle vibration of tremor at the elastically loaded human elbow.

1. Human subjects attempted to maintain a constant force by flexing their elbow against a spring which was attached to a force transducer at one end and the subject's wrist at the other. The tremor at 8-12 Hz which develops in this situation was enhanced in amplitude with negligible change of frequency by applying vibration at 100 Hz to the tendon either of an agonist muscle (biceps brachii) or of the antagonist (triceps brachii). The tremor was assessed by spectral analysis of the force records and measurement of the peaks in the spectra. The compliance of the spring was normally 2.8 N/mm and target forces of 40-120 N were used. 2. The percentage increase in the tremor on applying vibration was relatively independent of target force, although the absolute amounts of tremor increased markedly with increasing target force. The average increase was greater for vibration of triceps than for biceps (70% as opposed to 37%, averaged between subjects and over a range of forces). 3. When the spring was replaced by a rigid connexion there was usually no clear tremor peak either in the presence or absence of vibration. Vibration, however, tended to increase the general noisiness of the force signal. 4. Qualitatively similar effects were seen when the elbow exerted an extending force so that triceps became the agonist and biceps the antagonist. 5. The tremor peak present in the spectrum of the demodulated electromyogram during vigorous tremor increased in size when vibration made the tremor larger. 6. The effect of a rhythmic afferent input was studied by modulating the amplitude of the vibration at 8-9 Hz, to correspond to the tremor frequency, while the subject pulled against a rigid attachment. Both the e.m.g. and the tension spectra contained peaks at the modulation frequency. The raw force records showed that, with reference to the modulation, the effects of biceps and of triceps vibration were approximately 180 degrees out of phase with each other, as would occur if vibration of one were having an excitatory action, and vibration of the other an inhibitory action. Moreover, in each case the effect on force (whether excitatory or inhibitory) lagged about half a cycle on the vibration envelope, as required for such reflexes to help in the generation of tremor. 7. It is suggested that vibration increases the modulation of Ia firing elicited by a given movement tremor and this, by means of the stretch reflex arc, enhanced the tremor. The powerful action of vibration of the antagonist illustrates, it would seem, the functional effectiveness under normal conditions of a spinal inhibitory pathway, most probably the Ia disynaptic route. The findings are also discussed in relation to the increase in stretch reflex gain that occurs in association with increasing strength of voluntary contraction.

Adolescent↗

Bilateral thalamic deep brain stimulation: midline tremor control.

OBJECTIVES: To determine the efficacy of bilateral deep brain stimulation (DBS) for management of midline tremor (head, voice, tongue, trunk) in patients with essential tremor. DESIGN: Prospective assessment of tremor at baseline (presurgical), and postoperatively at 1, 3, and 12 months, and annually thereafter. METHODS: A clinical series of 22 individuals undergoing staged, bilateral DBS for treatment of essential tremor. The tremor rating scale was the primary outcome measure. RESULTS: Midline tremor showed significant improvement with stimulation "on" at nearly every postoperative interval when compared with stimulation "off" and with baseline tremor. Bilateral stimulation was associated with a significant incremental improvement in midline tremor control compared with unilateral stimulation: average "stimulation on" percentage change in midline tremor from the unilateral to bilateral period was 81%. Head and voice tremor showed the most consistent improvement. Among those requiring a change in stimulation parameters because of side effects, dysarthria, disequilibrium, motor disturbances, and paraesthesiae were the most common. Dysarthria was more common with bilateral (n = 6; 27%) than with unilateral (n = 0) stimulation. Stimulation parameters remained largely unchanged after the first three months. Nine of 44 leads placed (20%) required subsequent repositioning or replacement. CONCLUSIONS: Unilateral thalamic stimulation significantly improves midline tremor, and subsequent bilateral thalamic stimulation offers an additional incremental improvement in midline tremor control.

Aged↗

Evaluation of three different ways of assessing tremor in multiple sclerosis.

OBJECTIVES: To examine the comparative reliability and validity of three simple ways of rating upper limb tremor in patients with multiple sclerosis. METHODS: Three examiners independently rated severity of upper limb tremor in patients with multiple sclerosis on a 0-10 scale by studying videotape recordings of patients' examinations, spiral drawings, and handwriting samples. The correlations of the tremor severity scores with scores from arm dexterity tests and a tremor related disability scale were also assessed. RESULTS: Rating tremor on posture had a good intrarater and interrater reliability. However, these reliabilities decreased when kinetic tremor was assessed, in part because dysmetria was a confounding factor. The intrarater reliabilities of rating tremor from spirals and handwriting were also good but the interrater reliabilities were only fair to moderate. Tremor severity scored by all three methods correlated highly with scores obtained from the nine hole peg test, finger tapping test, and a tremor related activities of daily living (ADL) questionnaire, indicating that all three methods were valid ways of assessing tremor in multiple sclerosis. CONCLUSION: Multiple sclerosis tremors in posture can be scored using a clinical rating scale in a valid and reliable way, and from spirals and handwriting samples if the ratings are carried out by the same examiner. However, scoring kinetic tremor was less reliable. In addition, the nine hole peg and finger tapping tests provide useful objective assessments of upper limb function in tremulous patients with multiple sclerosis.

Activities of Daily Living↗

Posture-related oscillations in human cerebellar thalamus in essential tremor are enabled by voluntary motor circuits.

The mechanism of essential tremor (ET) is unclear. Animal models of tremor and functional imaging studies in ET predict that the cerebellum and a cerebellar recipient thalamic nucleus (ventral intermediate, Vim) should exhibit oscillatory activity during rest and during tremor due to abnormal olivo-cerebellar activity. Physiologic responses of 152 single neurons were recorded during awake mapping of the ventral thalamus in seven patients with ET prior to thalamotomy. During postural tremor, spectral cross-correlation analysis demonstrated that 51% of the neurons studied exhibited a concentration of power at tremor frequency that was correlated with electromyography, i.e., tremor neurons. During rest, thalamic neurons did not exhibit tremor-frequency activity. Among the three thalamic nuclei surveyed, Vim had a significantly higher proportion of tremor neurons than did the principal somatic sensory nucleus (ventral caudal, Vc) or a pallidal recipient thalamic nucleus (ventral oral posterior, Vop). Neurons related to active movement (voluntary neurons) had significantly greater tremor-related activity than did nonvoluntary neurons. These findings are not consistent with a model of continuous olivo-cerebellar driving of the motor cortex through thalamic connections. Instead ET may be facilitated by motor circuits that enable tremor-related thalamic activity during voluntary movement. Additionally, a subgroup of tremor neurons with proprioceptive inputs were identified that may allow sensory feedback to access the central tremor network.

Action Potentials↗

Occurrence of widespread motor-unit firing correlations in muscle contractions: their role in the generation of tremor and time-varying voluntary force.

The firing behavior of motor units (MUs) of the first dorsal interrosseus muscle of the hand was examined during both constant-force and varying-force (sinusoidal or broadband random variations) isometric contractions in healthy adults. The emphasis was on the analysis of MU synchrony with an efficient and sensitive method. In static contractions, widespread and strong MU firing correlations, with the MUs in phase, were present at the frequency of muscle tremor, when the tremor was regular (narrowband) and large. MU correlations could also exist in contractions where the tremor of a subject was irregular (broadband) overall, but they were generally weak. These correlations were at the frequency of the subject's regular tremor, and the corresponding distinct tremor component was sometimes discernible within the broad tremor-band. In contrast, the MUs did not show any such correlations in the case of purely irregular and small tremor. On the basis of these observations, it is concluded that the rhythms in the force contributions of the last- recruited, large MUs, which fire near their threshold rate, compose the broadband frequency content of physiological muscle tremor in every contraction. Within this band, there is an additional distinct tremor component when MU correlations are present. For widespread and strong MU correlations, this component dominates and constitutes the observed regular tremor. In dynamic contractions, the firing of all MUs was modulated in the frequency band of both the sinusoidal and the complex variations of the force. The MU modulations showed a time-lead over the force variations and were strongly correlated both to these variations and among themselves. Thus widespread and strong correlations of MU firing modulations seem to provide a mechanism for generation of time-varying voluntary force, under general dynamic conditions. Finally, when regular tremor was present in dynamic contractions, widespread and fairly strong MU correlations also existed at the tremor frequency. It is concluded that at least two mechanisms can cause widespread MU synchrony, and they can act in parallel. They involve two types of correlated inputs to the alpha-motoneurons (presumably from the muscle spindles and the cortex), whose effects combine at the level of the membrane potential of the cells.

Adult↗

Factor structure of motor signs in essential tremor.

Motor signs in essential tremor (ET) are varied. Patients may have limb tremors, including postural, kinetic (e.g. writing, pouring), and rest tremors, head tremor, voice tremor, or chin tremor. Factor analysis allows one to determine whether these signs fall into a smaller number of discrete domains. Such an analysis has not been performed on a group of ET cases. ET cases (n = 168) were recruited from the Neurological Institute of New York and a videotaped examination was performed. A factor analysis was performed on 17 motor items. Four distinct factors emerged, explaining 68.7% of the total variance. These were factor I (action tremor in the dominant arm), factor II (action tremor in the nondominant arm), factor III (tremor at rest) and factor IV (chin tremor, head tremor, and voice tremor). The demonstration of these four factors will be of potential use for pathological and genetic studies as well as interventional studies, as will be discussed.

Aged↗

Genetic essential tremor in gamma-aminobutyric acidA receptor alpha1 subunit knockout mice.

Essential tremor is the most common movement disorder and has an unknown etiology. Here we report that gamma-aminobutyric acidA (GABA(A)) receptor alpha1-/- mice exhibit postural and kinetic tremor and motor incoordination that is characteristic of essential tremor disease. We tested mice with essential-like tremor using current drug therapies that alleviate symptoms in essential tremor patients (primidone, propranolol, and gabapentin) and several candidates hypothesized to reduce tremor, including ethanol; the noncompetitive N-methyl-D-aspartate receptor antagonist MK-801; the adenosine A1 receptor agonist 2-chloro-N6-cyclopentyladenosine (CCPA); the GABA(A) receptor modulators diazepam, allopregnanolone, and Ro15-4513; and the L-type Ca2+ channel antagonist nitrendipine. Primidone, propranolol, and gabapentin reduced the amplitude (power) of the pathologic tremor. Nonsedative doses of ethanol eliminated tremor in mice. Diazepam, allopregnanolone, Ro15-4513, and nitrendipine had no effect or enhanced tremor, whereas MK-801 and CCPA reduced tremor. To understand the etiology of tremor in these mice, we studied the electrophysiological properties of cerebellar Purkinje cells. Cerebellar Purkinje cells in GABA(A) receptor alpha1-/- mice exhibited a profound loss of all responses to synaptic or exogenous GABA, but no differences in abundance, gross morphology, or spontaneous synaptic activity were observed. This genetic animal model elucidates a mechanism of GABAergic dysfunction in the major motor pathway and potential targets for pharmacotherapy of essential tremor.

Adrenergic beta-Antagonists↗

Ventralis intermedius plus ventralis oralis anterior and posterior deep brain stimulation for posttraumatic Holmes tremor: two leads may be better than one: technical note.

OBJECTIVE AND IMPORTANCE: To describe the effects of ventralis oralis anterior (VOA) and posterior (VOP), as well as ventralis intermedius (VIM), deep brain stimulation (two ipsilateral thalamic leads implanted) on posttraumatic Holmes tremor. Results of both thalamic lesioning and thalamic deep brain stimulation for Holmes tremor and tremors due to posttraumatic lesions in the region of the midbrain have been disappointing. In 2001, the use of two electrodes implanted in parallel for severe essential tremor was reported. We propose the use of a similar technique for posttraumatic Holmes tremor. One rationalization for the placement of two leads was to affect both the cerebellar receiving area (VIM) and the pallidal receiving area (VOA/VOP). A second rationalization was that the placement of a second electrode may affect somatotopy, and may, therefore, be beneficial for the treatment of more difficult to control tremor subtypes. CLINICAL PRESENTATION: A 24-year-old man with intractable posttraumatic Holmes tremor presented for consideration of a surgical intervention. INTERVENTION: A high-resolution, volumetric magnetic resonance imaging scan was obtained 1 day before the procedure. Microelectrode recording was used in addition to stereotactic computed tomography, image fusion, and stereotactic targeting to map the locations of the VIM, VOP, and VOA nuclei of the thalamus. A deep brain stimulation electrode was then implanted on the border between the left VIM and VOP thalamic nuclei, and a second ipsilateral deep brain stimulation lead was placed on the VOA and VOP border, 2 mm anterior to the first. Fourteen videotaped tremor rating scales were evaluated by two blinded reviewers. CONCLUSION: The patient experienced tremor rebound with VIM-VOP monotherapy. However, when the second lead (VOA/VOP) was activated, he experienced sustained improvement in tremor and tremor disability at a 12-month follow-up examination. This case elucidates a potential new approach for the treatment of patients with posttraumatic Holmes tremor. Additional study and longer follow-up periods will be needed to further evaluate this promising therapy.

Adult↗

Oxcarbazepine use in essential tremor.

OBJECTIVE: To report the novel finding of a significant improvement in essential tremor symptoms with oxcarbazepine in a patient with a suboptimal response to propranolol. CASE SUMMARY: A 40-year-old woman with a history of substance abuse complicated by essential tremor and neuropathic pain was admitted to our addictions unit with altered mental state due to escalating use of alprazolam. Alprazolam had been prescribed several months prior to admission for treatment of anxiety. The doses had risen to 5-10 mg/day during that period. Apparently, her essential tremor had responded inadequately to propranolol, but had responded well to alprazolam. She was started on a sedative/hypnotic withdrawal protocol, but did not require treatment with phenobarbital. She subsequently rated her tremor as "moderately severe." On discontinuation of the withdrawal protocol, oxcarbazepine 450 mg twice daily was initiated to treat her neuropathic pain, and the tremor improved, with a clinically significant reduction in tremor and a decreased pain score. DISCUSSION: Essential tremor is a common neurologic disorder with uncertain pathophysiology. Practice guidelines advocate the use of propranolol or primidone as first-line agents to treat essential tremor. Unfortunately, primidone has abuse potential and propranolol has variable pharmacokinetics; these characteristics limit their effectiveness in treating tremor. Our patient experienced a significant and sustained improvement in her tremor following the initiation of oxcarbazepine. To our knowledge, as of September 2, 2006, this is the first report of the use of oxcarbazepine in essential tremor. While the exact therapeutic action remains unclear, oxcarbazepine offers significant advantages compared with current first-line agents, including its good tolerability profile, the extended half-life of its metabolite, and lack of abuse potential. CONCLUSIONS: We report a case of essential tremor responding to oxcarbazepine. This drug offers several potential advantages over current first-line agents. Further research is warranted to test the robustness of this preliminary finding.

Adult↗

Selective attenuation of afferent synaptic transmission as a mechanism of thalamic deep brain stimulation-induced tremor arrest.

Deep brain stimulation (DBS) of the ventrolateral thalamus stops several forms of tremor. Microelectrode recordings in the human thalamus have revealed tremor cells that fire synchronous with electromyographic tremor. The efficacy of DBS likely depends on its ability to modify the activity of these tremor cells either synaptically by stopping afferent tremor signals or by directly altering the intrinsic membrane currents of the neurons. To test these possibilities, whole-cell patch-clamp recordings of ventral thalamic neurons were obtained from rat brain slices. DBS was simulated (sDBS) using extracellular constant current pulse trains (125 Hz, 60-80 micros, 0.25-5 mA, 1-30 s) applied through a bipolar electrode. Using a paired-pulse protocol, we first established that thalamocortical relay neurons receive converging input from multiple independent afferent fibers. Second, although sDBS induced homosynaptic depression of EPSPs along its own pathway, it did not alter the response from a second independent pathway. Third, in contrast to the subthalamic nucleus, sDBS in the thalamus failed to inhibit the rebound potential and the persistent Na+ current but did activate the Ih current. Finally, in eight patients undergoing thalamic DBS surgery for essential tremor, microstimulation was most effective in alleviating tremor when applied in close proximity to recorded tremor cells. However, stimulation could still suppress tremor at distances incapable of directly spreading to recorded tremor cells. These complementary data indicate that DBS may induce a "functional deafferentation" of afferent axons to thalamic tremor cells, thereby preventing tremor signal propagation in humans.

Afferent Pathways↗

[Transient improvement of writing tremor by holding breath in volition: a case report].

We report a 76-year-old Japanese woman who had tremor of her hand during writing. Her past and family histories were unremarkable. On neurological examination, there was no abnormal finding except the writing tremor and the postural tremor of her lips and jaw. Surface EMG studies revealed that regular grouped discharges, at a frequency of about 5 Hz, appeared in the wrist flexor and extensor muscles soon after she start writing; these grouped discharges were inhibited while holding breath. Her postural tremor improved after consumption of a small amount of alcohol, suggesting that she had essential tremor. Thus, she may be diagnosed as having a variant of essential tremor. On the other hand, this tremor may be interpreted as a variant of writer's cramp, since her writing tremor transiently improved when she hold breath, just like a trick. In patients with dystonia, it is well known that dystonic symptoms can be temporally ameliorated by geste movement like a "trick". Although the pathophysiological relationship between primary writing tremor and writer's cramp are unclear, the unique characters of this tremor may suggest that a focal task-specific tremor and essential tremor can co-exist.

Aged↗

Orthostatic tremor: report of a case and review of the literature.

Orthostatic tremor is a rare movement disorder characterized by tremulousness of the lower limbs on standing that disappears on walking, sitting or on lying down and a distinctive electromyographic burst of 14 to 16 Hz. On inspection, fine ripples can sometimes be seen over the quadriceps on standing. The tremor has a tendency to reappear even in the supine posture if the lower limb muscles are put to an isometric contraction state, indicating thereby that in spite of the fact that the tremor occurs on standing, it is essentially 'orthostasis independent' and the central factor is the contraction of the muscles. As a matter of fact, the tremor is abolished if the subject is suspended by harness, thus relieving him of muscle contraction. Doubts are being cast whether it is a variant of essential tremor since a number of families are being reported to be suffering from this disease as well. Positron emission tomography reveals hyperactivity of cerebellum in orthostatic tremor as it shows in essential tremor, therefore lending credence to such a hypothesis. However, lack of response to alcohol, propranolol and primidone in orthostatic tremor stands out as a serious challenge to such a view. Lack of positive family history, synchrony of contracting group of muscles and negative 'resetting' of the tremor by increasing peripheral load-phenomena consistently observed in orthostatic tremor and not in essential tremor, are other features that often help to distinguish between the two conditions. We report a case of orthostatic tremor that presented with the classical clinical and electromyographic features. Relevant literature in this regard is also being reviewed.

Aged↗

Pathological oscillatory coupling within the human motor system in different tremor syndromes as revealed by magnetoencephalography.

Whole-head MEG-systems and modern spatial-filter-based analysis tools recently provided new possibilities to analyze non-invasively cerebral networks of human tremor syndromes. We compared tremor syndromes in Parkinsonian patients with a typical resting tremor as well as in patients with hepatic encephalopathy (HE) with a postural tremor called "mini-asterixis". In 6 patients with idiopathic Parkinson's disease (PD) we found strong coherence between the electromyography (EMG) of forearm muscles and activity in the contralateral primary motor cortex (M1) at tremor frequency but also at double tremor frequency. Furthermore, significant coherences were observed between M1 and medial wall areas (CMA/SMA), lateral premotor cortex, diencephalon, SII cortex, posterior parietal cortex and the contralateral cerebellum at tremor and, stronger, at double tremor frequency. In contrast, in 6 patients with "mini-asterixis" and HE due to chronic liver cirrhosis excessive corticomuscular coherence occurred at the individual tremor frequency between EMG and M1 activity. Interestingly, thalamus-M1 coupling was significantly altered towards lower frequencies matching the individual frequency of the mini-asterixis. Cerebro-muscular or cerebro-cerebral coupling at double tremor frequency was not observed. Therefore, "mini-asterixis" reflects most likely a pathologically decelerated and augmented synchronized rhythmical motor cortical output. This could be due to functional alterations in the M1-basal-ganglia-thalamo-cortical loops in severe HE. In summary, tremor syndromes in PD as well as in patients with HE and "mini-asterixis" are characterized by pathological oscillatory activity within cerebral networks of motor areas. However, the present study shows different mechanisms of tremor generation in PD and HE patients.

Evoked Potentials, Motor↗

[Voice change and acoustic character of essential voice tremor].

OBJECTIVE: To discuss the voice change and acoustic character of essential voice tremor. METHOD: Observations and acoustic studies were performed about clinical manifestations and voice of 18 patients with essential voice tremor. RESULT: In 18 patients with essential voice tremor, female accounts for 72% (13/18 cases). The mean age at tremor onset was 57 years old . And 8900 of them had no neurologic abnormalities. The clinical manifestation includes voice tremor, dysphonia, even frequent voice interruption. The laryngeal body happens to regular tremor in automatically. Bilateral vocal cords, ventricular cords and arytenoid cartilages also tremble regularly open and closed, together with the tremor of voice-producing organs(soft palate, tongue and lateral pharyngeal wall). The frequency of voice tremor is 4-6 Hz. The acoustic analysis characteristics of voice is the obvious increasing of Shimmer, presenting the specific change of the parameters such as soft phonation index (SPI), degree of voiceless (DUV), degree of voice breaks (DVB), FO tremor intensity index (FTRI) and Amplitude Tremor Intensity Index (ATRI). CONCLUSION: The voice change of essential voice tremor is a kind of regular tremor with low frequency. For the severe patients, it shows dysphonia and frequent voice interruption.

Acoustics↗

[The involvement of the cholinergic system in the tremor induced by phenol].

The effect of cholinergic drugs on the tremor induced by subcutaneous (s.c.) injection of a 1 v/v% phenol solution was investigated. Male dd-Y strain mice weighing 18-24 g were used in all experiments. Intraperitoneal (i.p.) administration of physostigmine (0.05-0.1 mg/kg) did not alter the tremor. Neostigmine (0.05-0.1 mg/kg i.p.) increased the strength of the tremor weakly and shortened the latency of the tremor. I.p. administrations of methacholine, atropine, methylatropine, and scopolamine did not produce significant effects on the tremor. I.p. injection of nicotine (0.5-1 mg/kg) shortened the duration of the tremor. Intracerebro-ventricular (i.c.v.) infusions of nicotine (4 micrograms/mouse) and carbachol (5 micrograms/mouse) prolonged the latency of the tremor. Furthermore, i.c.v. infusion of nicotine (4 micrograms/mouse) reduced the strength of the tremor slightly. On the contrary, i.p. (10-20 mg/kg) or i.c.v. (20-60 micrograms/mouse) administration of mecamylamine potentiated the strength and prolonged the duration of the tremor in a dose dependent manner. Hexamethonium (10-20 micrograms/mouse, i.c.v.) also potentiated the strength and prolonged the duration of the tremor. These results suggest that a peripheral increase of acetylcholine level may potentiate the tremor induced by phenol, and the tremor may be suppressed by a negative feedback mechanism involving the nicotinic cholinergic system of the central nervous system.

Animals↗

Acoustic and airflow spectral analysis of voice tremor.

Acoustic spectral analysis has been used to describe voice tremor with some success, but no feature distinguishing pathological from normal tremor has been clearly identified. To assist in monitoring voice tremor associated with neurological diseases, objective and quantifiable measures that can distinguish between normal and pathological tremor are desired. This study explored the plausibility of using airflow and acoustic signals to quantify the frequency and amplitude of voice tremor and potentially to distinguish pathological from normal tremor. Subjects were 10 individuals with pathological tremor, most of them individuals with Parkinson's disease, and 10 gender and age-matched individuals with no voice disorder. Simultaneous acoustic and airflow signals were recorded during sustained vowel phonation. The acoustic intensity contours and the airflow signals were submitted to spectral analysis. A peak prominence ratio, defined as the ratio of the spectral peak energy to the overall signal energy, was calculated for each spectral peak below 30 Hz. For each subject, the 6 spectral peaks with the highest peak prominence ratios were selected. Frequency values of the 6 selected acoustic or airflow spectral peaks failed to distinguish tremor group from control group. Peak prominence ratios of the 6 selected acoustic spectral peaks were significantly higher for tremor group than for control group. Although spectral analysis of airflow signals was not useful in differentiating tremor group from control group, acoustic intensity contours and airflow time waveforms were highly and positively correlated in more tremor subjects (90%) than control subjects (40%). This finding suggests that the relationship between acoustic intensity contours and airflow time waveforms may reflect the presence and the source of voice tremor.

Adult↗

Multicentre European study of thalamic stimulation in parkinsonian and essential tremor.

OBJECTIVES: Thalamic stimulation has been proposed to treat disabling tremor. The aims of this multicentre study were to evaluate the efficacy and the morbidity of thalamic stimulation in a large number of patients with parkinsonian or essential tremor. METHODS: One hundred and eleven patients were included in the study and 110 were implanted either unilaterally or bilaterally. Patients were evaluated with clinical scales, before and up to 12 months after surgery. RESULTS: Upper and lower limb tremor scores were reduced in both groups. Eighty five per cent of the electrodes satisfied the arbitrary criteria of two point reduction in rest tremor reduction in the parkinsonian tremor group and 89% for postural tremor reduction in the essential tremor group. In the parkinsonian tremor group, limb akinesia and limb rigidity scores were moderately but significantly reduced. Axial scores were unchanged. In the essential tremor group, head tremor was significantly reduced only at 3 months and voice tremor was non-significantly reduced. Activities of daily living were improved in both groups. Changes in medication were moderate. Adverse effects related to the surgery were mild and reversible. CONCLUSIONS: Thalamic stimulation was shown to be an effective and relatively safe treatment for disabling tremor. This procedure initially applied in a very limited number of centres has been successfully used in 13 participating centres.

Activities of Daily Living↗

Peripherally induced tremor and parkinsonism.

OBJECTIVE: Trauma to the peripheral nervous system is a well-recognized cause of dystonia and tremor, but peripherally induced parkinsonism has not previously been documented. We seek to characterize peripherally induced tremor and parkinsonism and propose possible mechanisms for this phenomenon. DESIGN: Review of records of patients evaluated in the Movement Disorders Clinic between 1977 and 1993. In addition to demographic and clinical information, the records were screened for any potential predisposing factors. PATIENTS: Twenty-eight patients in whom the onset of tremor, parkinsonism, or both was anatomically and temporally related to local injury. INTERVENTION: The type and site of injury were verified by history and examination of records whenever possible. Severity of tremor and parkinsonism was assessed by clinical rating scales. Three patients with tremor and parkinsonism had their striatal [18F]-fluorodopa uptake and raclopride binding measured with positron emission tomography. MAIN OUTCOME MEASURE: Response to conventional antitremor and antiparkinsonian medication was assessed by a clinical rating scale. RESULTS: Severe local injury preceded the onset of movement disorder by 47.5 +/- 74.7 days (mean +/- SD). The mean age at onset of movement disorder was 46.5 +/- 14.1 years. Tremor was present in all 28 patients, 11 of whom exhibited additional parkinsonian features. In 20 patients, the movement disorder spread beyond the original site. Possible predisposing factors were identified in 13 patients; nine had essential tremor or a family history of essential tremor. In addition to tremor, dystonia and myoclonus were evident in 13 and three patients, respectively. Reflex sympathetic dystrophy was present in six patients. Tremor did not improve with medications, and only seven patients with parkinsonism responded to therapy with levodopa. CONCLUSION: Central reorganization in response to peripheral injury may give rise to a motor disturbance, including tremor and parkinsonism.

Adult↗