Decreasing the Symptoms of Essential Tremor With Medical Painting Therapy.

Introduction Essential tremor (ET) is a common movement disorder in the elderly. Bilateral postural tremor usually involves the hands and forearms; the primary diagnostic criteria can be with or without a kinetic tremor. Anticonvulsants are frequently prescribed as a primary medication, and botulinum toxin and deep brain stimulation as secondary options. In this case report, a patient with ET received medical painting therapy guided by the principles of anthroposophy and the work of Liane Collot d´Herbois. Case Presentation A 78-year-old woman presented ET, depression and bipolar symptoms. Additionally, she reported insomnia, constipation, lumbar pain, and sciatic pain. Current medications included lithium carbonate, folic acid, levothyroxine, and zinc, and she had refused to take propranolol for her ET. She agreed to begin medical painting therapy. Over 5 months, she had 16 sessions of medical painting therapy, carried out in 2 stages. The first stage consisted of 6 free painting sessions for patient evaluation, followed by the second stage of 10 therapeutic sessions. Conclusion The patient reported an increased quality of life (including emotional aspects) and a decrease in her ET, as evidenced by the patient's handwriting. Further research is needed to understand the strengths and limitations of this therapy for ET and related conditions.

Wernekinck Commissure Syndrome with Holmes Tremor: A Report of Two Cases and Review of Literature.

Wernekinck commissure syndrome is a rare midbrain infarction, it consists of several symptoms including bilateral cerebellar ataxia, ophthalmoplegia, and palatal tremor. Holmes tremor is a rare clinical syndrome characterized by a combination of resting, postural, and action tremors. We describe two cases of Wernekinck commissure syndrome with Holmes tremor. To the best of our knowledge, it has been rarely reported in the literature to date. Both of the cases were presented with acute onset of bilateral cerebellar ataxia, dysarthria, and Holmes tremor. In the treatment, one patient was given "clonazepam and benheisol," the other was received acupuncture therapy, both of them showed a marked improvement in ataxia and tremor.

Trace Element Status in Children with Infantile Tremor Syndrome: An Inductively Coupled Plasma-Mass Spectrometry Based Study.

The primary objective of the study was to compare the trace element status in children with infantile tremor syndrome (ITS) with healthy controls. Blood counts, serum vitamin B12, plasma homocysteine, plasma ferritin and trace elements - magnesium, zinc and selenium were compared. Twenty-six children (11 with tremors, 14 boys, mean age 11.5 ± 3.5 mo) and 19 controls were enrolled for this study. Low vitamin B12 levels (67% vs. 5%) and elevated plasma homocysteine 96% vs. 26%) was significantly more (P < 0.001) in cases. Eight controls had hypoferritinemia, while none with ITS had it (p < 0.001). None of the children in either group had low serum levels of zinc or magnesium. Low levels of selenium were seen in six cases and five controls. This study did not show any association between the studied nutrients/ trace elements and ITS while, it showed a strong association of ITS with vitamin B12 deficiency supporting that it is a Neurocutaneous Infantile B-12 deficiency (NIB) syndrome.

Effects of acute cannabidiol administration on anxiety and tremors induced by a Simulated Public Speaking Test in patients with Parkinson's disease.

BACKGROUND: Cannabidiol (CBD) is one of the main components of Cannabis sativa and has anxiolytic properties, but no study has been conducted to evaluate the effects of CBD on anxiety signs and symptoms in patients with Parkinson's disease (PD). This study aimed to evaluate the impacts of acute CBD administration at a dose of 300 mg on anxiety measures and tremors induced by a Simulated Public Speaking Test (SPST) in individuals with PD. METHODS: A randomised, double-blinded, placebo-controlled, crossover clinical trial was conducted. A total of 24 individuals with PD were included and underwent two experimental sessions within a 15-day interval. After taking CBD or a placebo, participants underwent the SPST. During the test, the following data were collected: heart rate, systemic blood pressure and tremor frequency and amplitude. In addition, the Visual Analog Mood Scales (VAMS) and Self-Statements during Public Speaking Scale were applied. Statistical analysis was performed by repeated-measures analysis of variance (ANOVA) while considering the drug, SPST phase and interactions between these variables. RESULTS: There were statistically significant differences in the VAMS anxiety factor for the drug; CBD attenuated the anxiety experimentally induced by the SPST. Repeated-measures ANOVA showed significant differences in the drug for the variable related to tremor amplitude as recorded by the accelerometer. CONCLUSION: Acute CBD administration at a dose of 300 mg decreased anxiety in patients with PD, and there was also decreased tremor amplitude in an anxiogenic situation.

Randomised controlled trial of escitalopram for cervical dystonia with dystonic jerks/tremor.

OBJECTIVE: Trials for additional or alternative treatments for cervical dystonia (CD) are scarce since the introduction of botulinum neurotoxin (BoNT). We performed the first trial to investigate whether dystonic jerks/tremor in patients with CD respond to the selective serotonin reuptake inhibitor (SSRI) escitalopram. METHODS: In a randomised, double-blind, crossover trial, patients with CD received escitalopram and placebo for 6 weeks. Treatment with BoNT was continued, and scores on rating scales regarding dystonia, psychiatric symptoms and quality of life (QoL) were compared. Primary endpoint was the proportion of patients that improved at least one point on the Clinical Global Impression Scale for jerks/tremor scored by independent physicians with experience in movement disorders. RESULTS: Fifty-threepatients were included. In the escitalopram period, 14/49 patients (29%) improved on severity of jerks/tremor versus 11/48 patients (23%) in the placebo period (P=0.77). There were no significant differences between baseline and after treatment with escitalopram or placebo on severity of dystonia or jerks/tremor. Psychiatric symptoms and QoL improved significantly in both periods compared with baseline. There were no significant differences between treatment with escitalopram and placebo for dystonia, psychiatric or QoL rating scales. During treatment with escitalopram, patients experienced slightly more adverse events, but no serious adverse events occurred. CONCLUSION: In this innovative trial, no add-on effect of escitalopram for treatment of CD with jerks was found on motor or psychiatric symptoms. However, we also did not find a reason to withhold patients treatment with SSRIs for depression and anxiety, which are common in dystonia. TRIAL REGISTRATION NUMBER: NTR2178.

Exploring the effect of electrical muscle stimulation as a novel treatment of intractable tremor in Parkinson's disease.

BACKGROUND: As the pathophysiology of tremor in Parkinson disease (PD) involves a complex interaction between central and peripheral mechanisms, we propose that modulation of peripheral reflex mechanism by electrical muscle stimulation (EMS) may improve tremor temporarily. OBJECTIVES: To determine the efficacy of EMS as a treatment for drug resistant tremor in PD patients. METHODS: This study was a single-blinded, quasi-experimental study involving 34 PD patients with classic resting tremor as confirmed by tremor analysis. The EMS was given at 50Hz over the abductor pollicis brevis and interrosseus muscles for 10s with identified tremor parameters before and during stimulation as primary outcomes. RESULTS: Compared to before stimulation, we observed a significant reduction in the root mean square (RMS) of the angular velocity (p<0.001) and peak magnitude (p<0.001) of resting tremor while tremor frequency (p=0.126) and dispersion (p=0.284) remained unchanged during stimulation. The UPDRS tremor score decreased from 10.59 (SD=1.74) before stimulation to 8.85 (SD=2.19) during stimulation (p<0.001). The average percentage of improvement of the peak magnitude and RMS angular velocity was 49.57% (SD=38.89) and 43.81% (SD=33.15) respectively. 70.6% and 61.8% of patients experienced at least 30% tremor attenuation as calculated from the peak magnitude and RMS angular velocity respectively. CONCLUSIONS: Our study demonstrated the efficacy of EMS in temporarily improving resting tremor in medically intractable PD patients. Although tremor severity decreased, they were not completely eliminated and continued with a similar frequency, thus demonstrating the role of peripheral reflex mechanism in the modulation of tremor, but not as a generator. EMS should be further explored as a possible therapeutic intervention for tremor in PD.

Morphometric and functional MRI changes in essential tremor with and without resting tremor.

The etiopathogenesis of essential tremor (ET) is still debated, since the predominant role of circuit dysfunction or brain degenerative changes has not been clearly established. The relationship with Parkinson's Disease (PD) is also controversial and resting tremor occurs in up to 20 % of ET. We investigated the morphological and functional changes associated with ET and we assessed potential differences related to the presence (ET+R) or absence (ET-R) of resting tremor. 32 ET patients (18 ET+R; 14 ET-R) and 12 healthy controls (HC) underwent 3T-MRI protocol including Spoiled Gradient T1-weighted sequence for Voxel-Based Morphometry (VBM) analysis and functional MRI during continuous writing of "8" with right dominant hand. VBM analysis revealed no gray and white matter atrophy comparing ET patients to HC and ET+R to ET-R patients. HC showed a higher BOLD response with respect to ET patients in cerebellum and other brain areas pertaining to cerebello-thalamo-cortical circuit. Between-group activation maps showed higher activation in precentral gyrus bilaterally, right superior and inferior frontal gyri, left postcentral gyrus, superior and inferior parietal gyri, mid temporal and supramarginal gyri, cerebellum and internal globus pallidus in ET-R compared to ET+R patients. Our findings support that the dysfunction of cerebello-thalamo-cortical network is associated with ET in absence of any morphometric changes. The dysfunction of GPi in ET+R patients, consistently with data reported in PD resting tremor, might suggest a potential role of this structure in this type of tremor.

Dystonia and tremor secondary to thalamic infarction successfully treated with thalamotomy of the ventralis intermedius nucleus.

BACKGROUND: Focal thalamic lesions have been associated with a variety of involuntary movements such as tremor, dystonia, and chorea-ballism. METHODS: We describe a patient with severe hyperkinesias of the right arm secondary to a thalamic infarction in the left postero-ventral region of the thalamus. RESULTS: The dystonia and tremor of the right upper limb were subsequently controlled with another surgical lesion of the ventralis intermedius nucleus of the thalamus. CONCLUSION: This observation suggests that ablative surgery might be applied to treat a movement disorder induced by the lesion of the same nucleus, which in addition lead to interesting pathophysiological conjectures.

Cannabis (medical marijuana) treatment for motor and non-motor symptoms of Parkinson disease: an open-label observational study.

OBJECTIVE: The use of cannabis as a therapeutic agent for various medical conditions has been well documented. However, clinical trials in patients with Parkinson disease (PD) have yielded conflicting results. The aim of the present open-label observational study was to assess the clinical effect of cannabis on motor and non-motor symptoms of PD. METHODS: Twenty-two patients with PD attending the motor disorder clinic of a tertiary medical center in 2011 to 2012 were evaluated at baseline and 30 minutes after smoking cannabis using the following battery: Unified Parkinson Disease Rating Scale, visual analog scale, present pain intensity scale, Short-Form McGill Pain Questionnaire, as well as Medical Cannabis Survey National Drug and Alcohol Research Center Questionnaire. RESULTS: Mean (SD) total score on the motor Unified Parkinson Disease Rating Scale score improved significantly from 33.1 (13.8) at baseline to 23.2 (10.5) after cannabis consumption (t = 5.9; P < 0.001). Analysis of specific motor symptoms revealed significant improvement after treatment in tremor (P < 0.001), rigidity (P = 0.004), and bradykinesia (P < 0.001). CONCLUSIONS: There was also significant improvement of sleep and pain scores. No significant adverse effects of the drug were observed. The study suggests that cannabis might have a place in the therapeutic armamentarium of PD. Larger, controlled studies are needed to verify the results.

Short circuit in deep brain stimulation.

OBJECT: The authors undertook this study to investigate the incidence, cause, and clinical influence of short circuits in patients treated with deep brain stimulation (DBS). METHODS: After the incidental identification of a short circuit during routine follow-up, the authors initiated a policy at their institution of routinely evaluating both therapeutic impedance and system impendence at every outpatient DBS follow-up visit, irrespective of the presence of symptoms suggesting possible system malfunction. This study represents a report of their findings after 1 year of this policy. RESULTS: Implanted DBS leads exhibiting short circuits were identified in 7 patients (8.9% of the patients seen for outpatient follow-up examinations during the 12-month study period). The mean duration from DBS lead implantation to the discovery of the short circuit was 64.7 months. The symptoms revealing short circuits included the wearing off of therapeutic effect, apraxia of eyelid opening, or dysarthria in 6 patients with Parkinson disease (PD), and dystonia deterioration in 1 patient with generalized dystonia. All DBS leads with short circuits had been anchored to the cranium using titanium miniplates. Altering electrode settings resulted in clinical improvement in the 2 PD cases in which patients had specific symptoms of short circuits (2.5%) but not in the other 4 cases. The patient with dystonia underwent repositioning and replacement of a lead because the previous lead was located too anteriorly, but did not experience symptom improvement. CONCLUSIONS: In contrast to the sudden loss of clinical efficacy of DBS caused by an open circuit, short circuits may arise due to a gradual decrease in impedance, causing the insidious development of neurological symptoms via limited or extended potential fields as well as shortened battery longevity. The incidence of short circuits in DBS may be higher than previously thought, especially in cases in which DBS leads are anchored with miniplates. The circuit impedance of DBS should be routinely checked, even after a long history of DBS therapy, especially in cases of miniplate anchoring.

Cerebral causes and consequences of parkinsonian resting tremor: a tale of two circuits?

Tremor in Parkinson's disease has several mysterious features. Clinically, tremor is seen in only three out of four patients with Parkinson's disease, and tremor-dominant patients generally follow a more benign disease course than non-tremor patients. Pathophysiologically, tremor is linked to altered activity in not one, but two distinct circuits: the basal ganglia, which are primarily affected by dopamine depletion in Parkinson's disease, and the cerebello-thalamo-cortical circuit, which is also involved in many other tremors. The purpose of this review is to integrate these clinical and pathophysiological features of tremor in Parkinson's disease. We first describe clinical and pathological differences between tremor-dominant and non-tremor Parkinson's disease subtypes, and then summarize recent studies on the pathophysiology of tremor. We also discuss a newly proposed 'dimmer-switch model' that explains tremor as resulting from the combined actions of two circuits: the basal ganglia that trigger tremor episodes and the cerebello-thalamo-cortical circuit that produces the tremor. Finally, we address several important open questions: why resting tremor stops during voluntary movements, why it has a variable response to dopaminergic treatment, why it indicates a benign Parkinson's disease subtype and why its expression decreases with disease progression.

Surgical therapy for multiple sclerosis tremor: a 12-year follow-up study.

BACKGROUND AND PURPOSE: Severe multiple sclerosis (MS) tremor causes disability poorly responsive to medication. Deep brain stimulation (DBS) or thalamotomy can suppress tremor, but long-term outcomes are unclear. METHODS: Nine patients with MS tremor underwent disability measures at baseline and 12 months post-surgery (six thalamotomy, three DBS) in 1997-1998 (previously reported, Matsumoto et al., Neurology 2001;57:1876-82). We report the prospective 12-year follow-up of this cohort for tremor, disability, and death. RESULTS: Surgery was initially successful in all. Tremor recurred in all patients within median 3 months, although two DBS patients were tremor-free for 5 years. Median tremor-free survival (tremor-free time/survival time) was 4.3%. At 12-year follow-up, four survivors (two thalamotomy, two DBS) (Expanded Disability Status Scale scores 8-8.5) were severely disabled. Five patients were dead (four thalamotomy, one DBS) median 5.8 years post-operative. CONCLUSIONS: Surgery benefit for severe tremor was overall short-lived (median 3 months), with long-term poor prognosis. Although two DBS patients had sustained 5-year tremor-suppression, the observed progressive disability and death in this cohort bear importance for long-term success in future MS tremor surgery trials.

Permanent tremor reduction during thalamic stimulation in multiple sclerosis.

BACKGROUND: Unlike thalamic lesioning, thalamic stimulation is considered a reversible treatment for tremor. However, tremor in multiple sclerosis (MS) can sometimes permanently improve during thalamic stimulation. Such 'permanent tremor reduction' (PTR) has been attributed to limb weakness preventing tremor expression. In this study, 11 consecutive patients with MS tremor treated with thalamic stimulation were assessed for PTR. Eighteen upper limbs had tremor, of which 16 received contralateral stimulation. METHODS: Tremor severity and limb strength were assessed preoperatively, early postoperatively (within 1 year) and late postoperatively (after 3 years). Tremor severity was rated using validated clinical scales both on and off stimulation. Following explantation, the parenchyma surrounding three electrode tracts was examined with MRI. RESULTS: At final review (mean 5.2 years) PTR was evident in 11 of the 18 upper limbs with tremor. PTR often rendered stimulation redundant. PTR could occur when limb strength was conserved and could arise remotely from the initial surgery. PTR was significant (and universal) in limbs that received long-term (>2 years) effective (tremor suppressing) stimulation. PTR was not a significant finding in limbs that had not received long-term, effective stimulation. Contralateral to a limb with PTR, MRI revealed a thalamic lesion adjacent to the electrode tract. Thalamic lesions were not identified contralateral to two limbs without PTR. CONCLUSIONS: MS tremor often permanently improves during thalamic stimulation, even when limb strength is conserved. PTR may simply reflect natural history. Alternatively, these findings appear consistent with the recent proposal that thalamic stimulation in MS might promote local 'demyelinative lesioning.'

Successful thalamic deep brain stimulation for orthostatic tremor.

We report a patient with severe orthostatic tremor (OT) unresponsive to pharmacological treatments that was successfully controlled with thalamic (Vim, ventralis intermedius nucleus) deep brain stimulation (DBS) over a 4-year period. Cortical activity associated with the OT revealed by EEG back-averaging and fluoro-deoxi-glucose PET were also suppressed in parallel with tremor arrest. This case suggests that Vim-DBS may be a useful therapeutic approach for patients highly disabled by OT.

Effects on cognition of stereotactic lesional surgery for the treatment of tremor in multiple sclerosis.

OBJECTIVE: To assess the effect of stereotactic lesional surgery for treatment of tremor in multiple sclerosis on cognition. METHODS: Eleven patients (3 males, 8 females) with multiple sclerosis participated in the study. Six subjects comprised the surgical group and five the matched control group. All patients were assessed at baseline and three months using a neuropsychological test battery that included measures of intellectual ability, memory, language, perception and executive function. RESULTS: There were no significant differences between the surgical and control groups and no change from pre to post testing except for a decline in scores on the Mini-Mental State Examination (MMSE), WAIS-R Digit Span and Verbal Fluency in the surgical group. CONCLUSIONS: The results indicate that stereotactic lesional surgery does not result in major cognitive impairment in multiple sclerosis. However, the decline in MMSE scores, digit span and verbal fluency require further investigation in a larger sample.