Abstract:Objective:One the greatest challenges of BoNT A therapy for tremor lies in the complexity and variation of components involved in tremor movement, and the lack of objective measures to determine these components. This 3 month open-label single injection study aims to couple clinician best judgment with kinematics to improve effect of BoNT A (incobotulinumtoxinA) injection in 7 patients with upper limb Parkinson's disease (PD) tremor.Methods:Injection was guided with clinical and kinematic assessment of tremor using angular wrist position in 3 degrees of freedom: flexion/extension, pronation/supination, and radial/ulnar deviation. Overall tremor severity and change were measured by linear finger acceleration.Results:Kinematic data from static and functional tasks demonstrate no improvement at one month post-injection, but significant improvement at two and three months. Clinical scales across UPDRS Items 20 (1, 2, 3 months post) and 21 (2 months), and spiral drawings (3 months) showed significant improvement from baseline, while line drawings did not.Conclusions:This study suggests injection of BoNT A as a viable focal management option for upper limb PD tremor. In addition to clinical judgment, objective quantification of tremor dynamics by kinematics may be a feasible assessment and guidance tool which can be used to optimize injection conditions for focal tremor therapy. Kinematic analysis of tremor across a variety of joints in all degrees of movement may provide important insight into tremor dynamics, allowing optimized, targeted focal therapy.
While many studies have reported on the use of kinematic analysis on well-controlled, in-laboratory mobility tasks, few studies have examined the challenges of recording dynamic mobility in home environments. This preliminary study evaluated whole body mobility in eleven patients with Parkinson disease (H&Y 2-4). Patients were recorded in their home environment during scripted and non-scripted mobility tasks while wearing a full-body kinematic recording system using 11 inertial motion sensors (IMU). Data were analyzed with principal component analysis (PCA) in order to identify kinematic variables which best represent mobility tasks. Results indicate that there was a large degree of variability within subjects for each task, across tasks for individual subjects, and between scripted and non-scripted tasks. This study underscores the potential benefit of whole body multi-sensor kinematic recordings in understanding the variability in task performance across patients during daily activity which may have a significant impact on rehabilitation assessment and intervention.
Background: Treatment options for essential (ET) and Parkinson disease (PD) tremor are suboptimal, with significant side effects. Botulinum toxin type A (BoNT A) is successfully used in management of various focal movement disorders but is not widely used for tremor. Method: This study examines complexity of wrist tremor in terms of involvement of its three anatomical degrees of freedom (DOF) in two common situations of rest and posture. The study examines tremor in 11 ET and 17 PD participants by kinematic decomposition of motion in 3-DOF. Results: Tremor decomposition showed the motion involved more than one DOF (<70% contribution in one DOF) in most ET (rest: 100%, posture: 64%) and PD (rest: 77%, posture: 77%) patients. Task variation resulted in change in both amplitude and composition in ET, but not in PD. Amplitude significantly increased from rest to posture in ET. Directional bias was observed at the wrist for ET (pronation), and PD (extension, ulnar deviation, pronation). Average agreement between clinical visual and kinematic selection of muscles was 55% across all subjects. Conclusion: This study shows the complexity of tremor and the difficulty in visual judgment of tremor, which may be key to the success of targeted focal treatments such as BoNT A.RÉSUMÉ: Décomposition dynamique du mouvement dans le tremblement essential et le tremblement parkinsonien. Contexte : Les options de traitement du tremblement essentiel (TE) et du tremblement dû à la maladie de Parkinson (MP) sont sous-optimales et comportent des effets secondaires importants. La toxine botulique de type A (BoNT A) est utilisée avec succès dans le traitement de différents troubles focaux du mouvement, mais elle n'est pas utilisée couramment pour traiter le tremblement. Méthode : Cette étude examine la complexité du tremblement du poignet en termes de ses trois degrés anatomiques de liberté (DDL) dans deux situations fréquentes soit le tremblement de repos et le tremblement postural. L'étude examine le tremblement chez 11 patients atteints de TE et 17 patients atteints de MP au moyen de la décomposition cinématique du mouvement en 3 DDL. Résultats: La décomposition du tremblement a montré que le mouvement impliquait plus d'un DDL (contribution <70% dans un DDL) chez la plupart des patients atteints de TE (de repos : 100% ; postural : 64%) et chez les patients atteints de MP (de repos : 77% ; postural : 77%). Une variation des tâches provoquait un changement tant de l'amplitude que de la composition dans le TE, mais non dans la MP. L'amplitude augmentait significativement du repos à la situation du maintien d'une posture dans le TE. Un biais directionnel a été observé au niveau du poignet dans le TE (pronation) et dans la MP (extension, déviation cubitale, pronation). La concordance moyenne entre la sélection visuelle clinique et cinématique des muscles était de 55% pour l'ensemble des sujets. Conclusion : Cette étude montre la complexité du tremblement et la difficulté de porter un jugement visuel sur le tremblement, un élément c...
Previous, studies have demonstrated variability in the frequency and amplitude in tremor between subjects and between trials in both healthy individuals and those with disease states. However, to date, few studies have examined the composition of tremor. Efficacy of treatment for tremor using techniques such as Botulinum neurotoxin type A (BoNT A) injection may benefit from a better understanding of tremor variability, but more importantly, tremor composition. In the present study, we evaluated tremor variability and composition in 8 participants with either essential tremor or Parkinson disease tremor using kinematic recording methods. Our preliminary findings suggest that while individual patients may have more intra-trial and intra-task variability, overall, task effect was significant only for amplitude of tremor. Composition of tremor varied among patients and the data suggest that tremor composition is complex involving multiple muscle groups. These results may support the value of kinematic assessment methods and the improved understanding of tremor composition in the management of tremor.
Background: Functional motor impairments including mobility are major reasons for clinical intervention and medication adjustment in symptomatic therapy for Parkinson's disease (PD). Outcome measures used to assess the impact of medication are mostly based on patients' memory or diaries which, considering the gaps between visits, are neither objective nor very reliable. Objective: Investigating the feasibility of using movement features extracted from ecological whole-body kinematics recordings to measure the quantitative and qualitative changes in multiple aspects of mobility after medication changes in PD. Methods: Eleven patients with PD (PwPD) performed mobility tasks in their own home, wearing a full body wireless inertial sensing based motion capture system. Three scripted walking tasks (walking, fast walking, and walk turns) were examined at baseline and two weeks after medication changes. Clinical scales, including investigator-rated clinical global impression of improvement (CGI-I), were collected at both visits. Results: Out of 59 recorded body joint variables, five were identified as pertinent. Changes were represented in vector space as a plot of mean versus peak amplitude. Regression analysis was used to predict clinical improvement or worsening based on these vector features. The predictors were able to explain (>98.5% of variance) patients' clinical global impression of improvement, thus correctly predicting 5 cases of improvement and 2 cases of worsening. Conclusions: This study provided a method of extracting clinically meaningful reports from ecological kinematic data showing changes after drug adjustments. The results are presented using a novel concept called change space that may be more understandable for clinical staff.
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