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Objective: To evaluate the safety and efficacy of unilateral Gamma Knife thalamotomy (GKT) for treatment of severe tremor with a prospective blinded assessment.Methods: Fifty patients (mean age: 74.5 years; 32 men) with severe refractory tremor (36 essential, 14 parkinsonian) were treated with unilateral GKT. Targeting of the ventral intermediate nucleus (Vim) was achieved with Leksell Gamma Knife with a single shot through a 4-mm collimator helmet. The prescription dose was 130 Gy. Neurologic and neuropsychological assessments including a single-blinded video assessment of the tremor severity performed by a movement disorders neurologist from another center were performed before and 12 months after treatment. MRI follow-up occurred at 3, 6, and 12 months. Results:The upper limb tremor score improved by 54.2% on the blinded assessment (p , 0.0001). All tremor components (rest, postural, and intention) were improved. Activities of daily living were improved by 72.2%. Cognitive functions remained unchanged. Following GKT, the median delay of improvement was 5.3 months (range 1-12 months). The only side effect was a transient hemiparesis associated with excessive edema around the thalamotomy in one patient. Conclusion:This blinded prospective assessment demonstrates that unilateral GKT is a safe and efficient procedure for severe medically refractory tremor. Side effects were rare and transient in this study. Classification of evidence:This study provides Class IV evidence that for patients with severe refractory tremor, GKT is well tolerated and effective in reducing tremor impairment. The pharmacologic treatment for severe tremor can be disappointing.

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In the current study, we adopted the hypothesis that the body scheme disturbances occurring during adolescence might lead subjects to transiently neglect proprioceptive information and that adolescents might rely more strongly on vision to control their orientation and stabilize their body. To check this point, we asked adolescents 14-15 years to maintain vertical stance while very slow sinusoidal oscillations in the frontal plane were applied to the supporting platform at 0.01 Hz (below the detection threshold of the semicircular canal system) and at 0.06 Hz (above) with the eyes open and closed. Two postural components, orientation and segmental stabilization, were analyzed at the head, shoulder, trunk, and pelvis levels. At the lowest frequency without vision, the performances of adolescents were much less efficient than those of adults. Moreover, this study showed that vision plays a predominant role in adolescents' control of orientation and body stabilization. At 0.06 Hz without vision, a clearcut difference was observed between the strategies used by girls and boys; specifically, the maturation of the segmental stabilization processes was found to be more advanced in girls than in boys. However, no such difference was observed at 0.01 Hz. Lastly, comparisons between the data obtained in adolescents and those previously obtained in young adults (Vaugoyeau, Viel, Amblard, Azulay, & Assaiante, 2008) clearly show that adolescents use different postural strategies and that they are not yet capable of reaching comparable postural performance levels to those observed in adults. Because adolescents were not able to use the proprioceptive information available to improve their postural control, we concluded that they showed a maturational lag in comparison with adults. This suggests that the mechanisms underlying postural control are still maturing during adolescence, which might constitute a transient period of proprioceptive neglect in sensory integration of postural control.

The study examined, in children aged 7 and adults, the postural control when a cognitive task (modified Stroop) of varying level of difficulty is executed simultaneously. Postural difficulty also varied (with or without vibrations of the ankle joint). We hypothesized that children's performance was more affected than adults', when the difficulty of the cognitive and postural tasks increased. Results (i) demonstrated that the presence of a concurrent cognitive task affected postural sway at all ages; (ii) confirmed that the interference between mental activity and postural control can be attributed mainly to general capacity limitations and (iii) showed a degradation of the postural criteria in children but not of the cognitive ones, when the postural condition was constraining.

In this study, we investigated the sensory integration to postural control in children and adolescents from 5 to 15 years of age. We adopted the working hypothesis that considerable body changes occurring during these periods may lead subjects to under-use the information provided by the proprioceptive pathway and over-use other sensory systems such as vision to control their orientation and stabilize their body. It was proposed to determine which maturational differences may exist between the sensory integration used by children and adolescents in order to test the hypothesis that adolescence may constitute a specific phase in the development of postural control. This hypothesis was tested by applying an original protocol of slow oscillations below the detection threshold of the vestibular canal system, which mainly serves to mediate proprioceptive information, to the platform on which the subjects were standing. We highlighted the process of acquiring an accurate sensory and anatomical reference frame for functional movement. We asked children and adolescents to maintain a vertical stance while slow sinusoidal oscillations in the frontal plane were applied to the support at 0.01 Hz (below the detection threshold of the semicircular canal system) and at 0.06 Hz (above the detection threshold of the semicircular canal system) with their eyes either open or closed. This developmental study provided evidence that there are mild differences in the quality of sensory integration relative to postural control in children and adolescents. The results reported here confirmed the predominance of vision and the gradual mastery of somatosensory integration in postural control during a large period of ontogenesis including childhood and adolescence. The youngest as well as the oldest subjects adopted similar qualitative damping and segmental stabilization strategies that gradually improved with age without reaching an adult's level. Lastly, sensory reweighting for postural strategies as assessed by very slow support oscillations presents a linear development without any qualitative turning point between childhood and adolescence.

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