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PubMed2000

The many forms of tremor. Precise classification guides selection of therapy.

Tremor is a common, potentially disabling symptom that occurs with a variety of neurologic conditions. Rational therapy is enhanced by correct identification of the tremor type and, when possible, of its cause. In this review, the basic phenomenology of tremor is presented, followed by an examination of the most common tremor types and their treatment. Surgical therapy for medically refractory tremor is discussed.

Humans↗
PubMedDate not supplied

Weighted wrist cuffs for tremor reduction during eating in adults with static brain lesions.

OBJECTIVE: This study examined whether weighting the forearm during feeding decreased tremors and increased functional feeding in adults with intention tremor caused by static brain lesions. METHOD: Five individuals with various diagnoses, ages 30-81, were videotaped during 8 or 16 meal sessions, alternating treatment and control conditions within each meal. In this single-case design, treatment consisted of application of a weighted fabric wrist cuff and the baseline (control) condition employed an identical cuff with the weights removed. Dependent variables studied were time to acquire and deliver a bite, grams of food eaten, number of times food was spilled, number of times a compensatory technique was used, participant self-rating, and investigator rating of the severity of the tremor. RESULTS: All five participants demonstrated improvement during treatment in one or more of the dependent variables. t Tests of the means of baseline and treatment half-sessions incorporating conservative control of Type I error revealed the following statistically significant improvements under the weighted condition: Participants 3, 4, and 5 took less time to acquire a bite; Participants 4 and 5 made fewer spills; Participants 3 and 5 showed a diminished tremor. There were no statistically significant decreases in function on any variable for any participants during the weighted condition. CONCLUSION: The application of weight to the wrist of a person with upper-extremity tremor is accompanied by some functional improvement in self-feeding for some individuals. The size of benefit seems to be sensitive to the amount of weight used.

Adult↗
PubMed1998

Effects of long-term organophosphate exposures on neurological symptoms, vibration sense and tremor among South African farm workers.

OBJECTIVES: This study assessed the relationship between long-term exposure to organophosphate insecticides and neurological symptoms, vibration sense, and motor tremor after control for the effect of past poisoning and acute exposure. METHODS: This cross-sectional study included 164 pesticide applicators and 83 nonspraying reference workers on deciduous fruit farms. The workers were tested on the Vibratron II, on tests of dynamic and static tremor, and for a set of neurological and "dummy" symptoms. Exposure was derived with the use of a job-exposure matrix for pesticides in agriculture. RESULTS: Compared with nonapplicators, current applicators reported significantly more dizziness, sleepiness, and headache and had a higher overall neurological symptom score. This association remained statistically significant after multiple logistic regression analyses controlling for a range of confounders and effect modifiers [odds ratio (OR) 2.25, for current applicators having high neurological score, 95% confidence interval (95% CI) 1.15-4.39]. The average lifetime intensity of organophosphate exposure was nonsignificantly associated with both neurological (OR 1.98, 95% CI 0.49-7.94) and "dummy" symptoms (OR 2.37, 95% CI 0.54-10.35). Previous pesticide poisoning was significantly associated with the neurological scores (OR 4.08, 95% CI 1.48-11.22) but not with the "dummy" symptoms. Vibration sense outcomes were associated with age and height, but not with the organophosphate exposure measures. In the multiple linear regression modeling for tremor intensity in the dominant hand, recent organophosphate exposure in the past 10 days was a significant predictor (partial correlation coefficient = 0.04), but none of the long-term organophosphate exposure measures were significant. CONCLUSIONS: Strong evidence was found for an association between symptom outcomes and past organophosphate poisoning and between symptom outcomes and current spray activity. In contrast to symptoms, there was no association between either past poisoning or current spray activity and vibration sense or tremor outcome. Long-term organophosphate exposure did not appear to predict symptoms, vibration sense, or tremor outcome.

Adult↗
PubMedDate not supplied

Pramipexole, a nonergot dopamine agonist, is effective against rest tremor in intermediate to advanced Parkinson's disease.

We evaluated the efficacy of the nonergot dopamine receptor agonist pramipexole in 16 patients with advanced Parkinson's disease and marked rest tremor during an "on" period. The patients were drawn from a larger placebo-controlled, double-blind, randomized trial, which was not originally designed to investigate the effect of pramipexole on tremor. Eleven patients received pramipexole. The first effects were seen with a pramipexole dose of 0.75 mg/d with a reduction of the tremor item A of Unified Parkinson's Disease Rating Scale (UPDRS III, "on" state) by 25% and of rigidity and akinesia by 22%. Under the highest dose, 4.5 mg/d, the tremor score was improved by 61% over baseline (p < 0.0056, Wilcoxon signed rank) and the sum of rigidity and akinesia items by 66% (p < 0.0038, Wilcoxon signed rank). Five patients received placebo and did not improve. Based on this sample of patients, the nonergot dopamine receptor agonist pramipexole appears to have a potent anti-rest tremor action while being effective against akinesia and rigidity.

Aged↗
PubMed2000

Diagnostic criteria for essential tremor and differential diagnosis.

Classic essential tremor (ET) is a condition in which the upper limbs (approximately 95% of patients) and, less commonly, the head (approximately 34%), face (approximately 5%), voice (approximately 12%), trunk (approximately 5%), and lower limbs (approximately 20%) exhibit a mixed postural and kinetic tremor without other neurologic abnormalities. Most patients with ET probably inherit the disease through an autosomal dominant gene, but the true ratio of hereditary versus sporadic ET is unknown. Isolated focal, position-specific, and task-specific tremors are probably not ET in most patients and are often due to subtle dystonia. Unilateral tremor, gait disturbance, rigidity, bradykinesia, rest tremor, and rapid onset of symptoms are indications of other tremorogenic disorders.

Biomechanical Phenomena↗
PubMed2000

Surgical treatment of essential tremor.

Surgical treatment for essential tremor (ET) has been used since the early 1950s. Initially, different areas were targeted for tremor control. However, the optimal target was eventually determined to be the ventralis intermedius (VIM) nucleus of the thalamus. Thalamotomy improves contralateral tremor in more than 90% of patients. Long-term studies of thalamotomy indicate that the benefits continue in most patients. Persistent morbidity associated with thalamotomy, which occurs in less than 10% of patients, includes dysarthria, dysequilibrium, weakness, and cognitive impairment. Bilateral thalamotomy is associated with substantial morbidity and is usually avoided. Studies demonstrate that chronic stimulation of the VIM is safe and effective for tremor. Adverse effects of chronic stimulation include paresthesia, dysarthria, dysequilibrium, and localized pain. In many patients, bilateral thalamic stimulation is performed without a substantial increase in morbidity. ET patients with disabling medication-resistant tremor are reasonable candidates for these stereotactic procedures.

Essential Tremor↗
PubMedDate not supplied

[Acute pharmacological test with clonidine for the tremor in patients with Parkinson disease].

INTRODUCTION: Idiopathic Parkinson's disease has a prevalence of 1/1,000 and in 70-75% of these patients tremor is the commonest symptom. Of all the typical symptoms of this disease, the tremor is the most difficult to control. It is therefore necessary to seek drugs to solve this serious problem. OBJECTIVE: To evaluate the usefulness of clonidine in the acute treatment of resting and postural tremor in patients with idiopathic Parkinson's disease. PATIENTS AND METHODS: Acute pharmacological test (administration of 0.3 mg of clonidine chlorhydrate intramuscularly). The evaluation was done using a clinical protocol before administration and 30, 60, 120 and 240 minutes afterwards. Statistical comparison was done by variance analysis, taking a value of p < 0.0025 as significant. We included 28 patients (15 men and 13 women) of an average age of 66.9 years, and average duration of the disease of 5.53 years. Diagnosis followed the strict criteria of UKDDDSBB. RESULTS: There was no difference in the evaluations before and after the first dose of L-dopa. For both types of tremor, from 60 minutes onwards there were significant differences, with the maximum 120 minutes after administration (p < 0.0001). CONCLUSIONS: Clonidine is useful in the acute treatment of postural and intention tremor in patients with idiopathic Parkinson's disease. Its action is that of reducing the liberation of noradrenaline, synergically with the exciting dopaminergic system. It also seems to reduce the activity of spontaneous discharge at both thalamic and cortical levels.

Adolescent↗
PubMedDate not supplied

Assistive technology to improve PC interaction for people with intention tremor.

Many patients with upper limb intention tremor encounter difficulties in mouse-driven interaction with the personal computer (PC). An assistive technology system ("the Tremor Control System"), consisting of a motion-filtering software program that supports multiple interfaces, was developed and validated with 36 persons with Multiple Sclerosis in a multi-center trial. PC-tests, requiring basic functions such as cursor placement and click and drag function, were able to differentiate between patients and control subjects (ANOVA: p<0.05). A significant time improvement on the PC-tests was found when using an optimal alternative interface instead of the standard PC-mouse (paired t-tests: p<0.01 for Point & Click test, p<0.05 for Drag & Drop test and p<0.1 for Double Click test). A significant time improvement was found for the Double Click test (paired t-tests: p<0.05) when the motion-filtering program was implemented. The number of patients able to perform fully the PC-tests increased with the Tremor Control System. Patients with marked intention tremor seemed to profit especially from this assistive technology. These users reported that working with the Tremor Control System was less fatiguing and more comfortable compared to the use of the standard PC-mouse.

Computers↗
PubMed2001

Single-pulse transcranial magnetic stimulation reset the rhythm of essential tremor but not heart beat.

BACKGROUND: Human oscillator is observed in and outside the nervous system. Cardiac rhythm is generated by heart itself but can be modulated by brain. Using the technique of transcranial magnetic stimulation (TMS) and resetting index, we studied if single-pulse TMS could reset the cardiac rhythm and help differentiate oscillator of neurogenic or non-neurogenic origin. METHODS: In addition to the study of 4 patients with essential tremor, cardiac rhythm was studied in 6 normal subjects. The magnetic intensity was initiated from motor threshold of hand muscle, and then with an increment of 10% up to the maximal output of magnetic stimulator. We used the resetting index (RI) to quantify the influence of the TMS. RESULTS: The resetting phenomenon was observed in essential tremor (RI = 0.92) but not in cardiac rhythm (RI = 0.02). CONCLUSIONS: Single-pulse TMS is able to reset the rhythm of essential tremor but not heart beat. The pacing mechanism is different between essential tremor and heart beat. The cardiac rhythm is regulated and modulated chiefly by heart itself. Essential tremor should not share the same mechanism with heart beat.

Adult↗
PubMed2001

[Tremor and abnormal movement in multiple sclerosis: symptomatic therapeutic indications].

Tremor and movement disorders in multiple sclerosis (MS) patients cause a severe functional impairment. The different types of tremor observed in MS are: cerebellor tremor with a dominant intention component, Holmes tremor characterized by the addition of rest and postural components and palatal tremor. When no medication can improve the functional status, it is acceptable to discuss the deep brain stimulation in the VIM thalamus, thus making possible a partial attenuation of the rest and postural component, mainly affecting the proximal part of the affected limb. Among the movement disorders, paroxysmal dyskinesias are not rare and a good therapeutic response is obtained with carbamazepine: dystonia and parkinsonism are usually coincidental features during MS.

Electric Stimulation Therapy↗
PubMed2001

[Treatment of dyskinetic disorders with tremor by lesioning and DBS of Vim].

OBJECTIVE: To explore the effect of stereotactic operation in treatment of dyskinetic disorders with tremor as the main symptom and to study the value of anatomic location and microelectrode functional location. METHODS: Surgiplan system and microelectrode direction technique were used to locate the Vim, and then target lesioning and deep brain simulation (DBS) were performed in 22 patients with dyskinetic disorders with tremor. After the operation, a follow-up was conducted for 6 approximately 12 months. RESULTS: After the operation, tremor disappeared in 21 patients and hypermyotonia was improved in 13 cases. During the follow-up tremor completely disappeared in 18 patients, including 3 cases treated with DBS, was markedly alleviated in 3 cases and was slightly improved in one case. Typical cell firing at tremor was recorded in 17 cases during the operation. CONCLUSION: The surgiplan system and microelectrode recording technique play an important role in location of Vim. Accurate location is crucial for success of operation. The curative effect of DBS is similar as lesioning operation.

Adult↗
PubMed2002

The metabolic substrates of bradykinesia and tremor in uncomplicated Parkinson's disease.

The pathophysiological mechanisms of bradykinesia and resting tremor, i.e., two major features of Parkinson's disease (PD), remain incompletely understood despite extensive studies, including functional imaging investigations. Using high-resolution positron emission tomography (PET) and [(18)F]fluoro-2-deoxyglucose (FDG) in 17 nondemented patients with uncomplicated PD on a stable therapeutic regimen, we measured the resting-state cerebral metabolic rate of glucose (CMRGlc), a validated marker of synaptic density/activity. Following formulation of distinct a priori hypotheses about potentially involved brain regions based on previous experimental and clinical literature, correlations between CMRGlc and objective scores of bradykinesia and tremor were searched in a voxel-based fashion using SPM99. Bradykinesia scores were significantly positively correlated with bilateral putamen and globus pallidum CMRGlc, while tremor scores were negatively correlated with bilateral putamen and cerebellar vermis CMRGlc. There was a large overlap of putamenal voxels significantly but inversely correlated with both extrapyramidal features. For both bradykinesia and tremor, the observed patterns of subcortical correlations largely concurred with our a priori hypotheses, and point to the major role of disruption of the striatofrontal and corticocerebellar pathways in the genesis of these extrapyramidal features. The direction of these correlations was not entirely expected, however, which may be due to the patients' being studied on medication, contrary to most studies performed to date. The observation that overlapping portions of the putamen inversely correlated with bradykinesia and tremor was a novel and striking finding which points to the complexity of the underlying pathophysiology of PD. Because it allows greater control of the neurological status, studying patients on medication may partly explain our findings. Voxel-based analysis of resting FDG-PET holds considerable potential for assessing the neural substrates of motor impairment in PD.

Aged↗
PubMed1992

Activity of serum creatine kinase, lactate dehydrogenase and LD isoenzymes in piglets affected with congenital tremor: a case report.

The activities of serum creatine kinase (CK), lactate dehydrogenase (LD) and LD isoenzymes were studied in 14 Prestice black pied pigs from a herd affected with congenital tremor. Mean CK activity was 19.57 +/- 3.56 mu kat.l-1 for 6 adult pigs, and it was 21.03 +/- 1.33 mu kat.l-1 and 20.42 +/- 1.23 mu kat.l-1 for the affected (n = 5) and control (n = 3) piglets, respectively. No significant differences were demonstrable between the groups in CK activity. Total serum LD and LD-4 as well as LD-5 isoenzyme activities were higher in sows. Piglets affected with congenital tremor showed an increase in total LD enzyme and LD-5 isoenzyme activity. It is concluded that no relationship exists between congenital tremor and serum CK activity in piglets. At the same time, there is a positive relationship between congenital tremor and significantly (P < 0.01) elevated LD enzyme and LD-5 isoenzyme activity. The results allow us to suggest that total lactate dehydrogenase and LD-5 isoenzyme activities could be used as biological markers of congenital tremor in piglets.

Animals↗
PubMed1992

Effect of increasing dosage of an inhaled beta-2 specific agonist on pulmonary function, tremor, and cardiovascular indices.

In this investigation we evaluated the effect of increasing dosage, using an inhaled beta-2 specific agonist, pirbuterol, administered by a metered dose inhaler on pulmonary function, tremor, and cardiovascular parameters in nonacute adult asthmatic patients. This study was conducted with a randomized crossover study design in which each individual was administered a single dose of pirbuterol (0.4, 0.8 and 1.2 mg) [corrected] on separate days. Measurements of pulmonary function, tremor (by accelerometer readings), electrocardiogram, blood pressure and pulse were obtained at 0, 15, 30, 60, 90, 120, and 180 minutes following test drug administration where appropriate. These measurements were performed until there had been no change from baseline in tremor by 60 minutes or return of tremor measurements to within 15% of baseline for up to six hours. The data demonstrated that the onset of bronchodilator effectiveness had occurred by 15 minutes after test drug administration (the first testing time). The peak percent change from baseline for the FEV1 occurred at 60 minutes after administration for all three test doses. The duration of activity was never truly established as there was no significant difference between any of the potential side effects for any of the three test drugs at any testing time period. This study demonstrated that with the beta-2 specific agent pirbuterol, administered as a metered dose inhaler, there is little risk of development of skeletal muscle or cardiovascular toxicity when as much as three times the recommended dose is used in a single usage, and that there is no direct correlation between the onset, peak, and/or duration of tremor with the onset and peak of bronchodilator efficacy with this agent.

Adolescent↗
PubMedDate not supplied

A case of psychogenic tremor associated with blepharospasm and myoclonus: an analysis with surface electromyogram.

We report a 25-year-old woman with an unusual complex psychogenic movement disorders consisting of blepharospasm, tremor, and myoclonus. The tremor appeared in both arms and legs with resting, kinetic, and postural tremor of a variable amplitude, direction, and frequency. The analysis of the arm tremor with surface electromyogram revealed that it consisted of reciprocal and alternating contraction of the wrist flexor and extensor. No apparent co-activation of agonist-antagonist muscles could be seen at the onset of the tremor at rest or at its appearance while performing diadochokinesis.

Adult↗
PubMedDate not supplied

[Treatment of a case of essential tremor with subthalamic stimulation].

INTRODUCTION: Chronic stimulation of the subthalamic nucleus (STN) has proved itself to be useful in treating Parkinson's disease and especially in dealing with the tremor suffered by patients. Yet there is very little experience to support the use of STN as an alternative therapy in non Parkinsonian tremors. CASE REPORT: Our study considered the case of a patient who had been diagnosed as suffering from drug resistant essential tremor which was predominant in the distal region of the upper right limb and was treated by unilateral stimulation of the STN. RESULTS: The patient's clinical state improved significantly from the first weeks onwards. After a year and a half of therapy, the patient had achieved a stable improvement of 82.4% on the tremor scale and medication was reduced by 41.7%. CONCLUSIONS: SNT stimulation appears as a suitable target for the treatment of drug resistant essential tremor.

Aged↗
PubMedDate not supplied

Effects of topical anesthesia on essential tremor.

In a single-blinded study, the effects of skin desensitization by topical anesthesia (4% xylocaine) on six patients who had essential tremor were investigated. Resting hand tremor was monitored using an accelerometer and multiple surface electromyograms. The amplitude and frequency characteristics of the oscillations were determined using spectral analysis. Topical anesthesia significantly suppressed the tremor amplitude and the associated electrical activity in all patients: the mean tremor amplitude was reduced by 40%. No changes in the frequencies of the essential tremors were detected.

Administration, Cutaneous↗
PubMed2005

Clinical and magnetic resonance imaging manifestations of Holmes tremor.

Holmes tremor is a rare symptomatic slow tremor in the proximal parts of the limbs. It may be present at rest or maintenance of a posture, or during the movement of the affected limb. We describe herein three patients of Holmes tremor with possible etiologies of brainstem infarction and head injury. The intervals between the causal events and the appearance of tremor range from 1 month to 12 months. Magnetic resonance imaging studies reveal hypertrophy of the inferior olivary nucleus in all of the three patients, although only one of them has palatal myoclonus. The surface electromyographic recordings reveal characteristic slow oscillation with frequencies of 3.5 to 4.2 Hz. These features suggest that perturbation of the dentato-rubral-olivary circuitry may play a pivotal role for the generation of Holmes tremor. However, no tight correlation is observed between the presence of inferior olivary nuclear hypertrophy and the appearance of symptomatic palatal myoclonus in the current report.

Adult↗