Discuss about the Treatment of Essential, Dystonic and Parkinsonian Tremor.
The term tremor can be described as the uncontrolled rhythmic movement of the limbs or any part of the body. It has been estimated that, there are more than 100 million patients worldwide who suffers from tremor (Baumann 2012). The disease can be evidently seen among the older individuals who often suffer from many motor symptom disorders such as Parkinson’s disease, Alzheimer’s and Huntington’s disease. Many individual of young age can also suffer from tremor due to many reasons such as psychological trauma, tension, depression and anxiety (Gallego et al 2013). Apart from the neurological disorders, tremor can also happen due to thyroid disorders, stroke, multiple sclerosis, substance abuse, mercury poisoning and anxiety.
Many keywords such as tremor, Parkinson’s disease, psychogenic tremor, task specific tremor, beta-blocking drugs, dystonic tremor, physiologic tremor, psychogenic tremor, cerebeller tremor and essential tremor have been used to search some online database such as CINAHL, Cochrane, Medline and Scholarly. Searching all these sites was helpful as it presented more than 800 articles regarding tremor to access. All the relevant materials are accessed and three articles from the database were chosen based on the relevance. These articles are Treatment of essential tremor: a systematic review of evidence and recommendations from the Italian Movement Disorders Association (Article 1), The treatment of dystonic tremor: a systematic review (Article -2), and Beta- Blocker therapy for tremor in Parkinson’s disease ( Article 3) respectively.
All three articles has discussed about the types of tremor and broadly described about different aspects of the treatment of tremor. From these articles, this is evident that there are varieties of treatment options for tremor. Beta-blockers are used to treat essential tremor and anxiety related tremors. All three of the articles discuses the use of Beta-blocker as the treatment of tremor caused by Parkinson’s disease. These articles also discuss using other drugs such as anticholinergies, primidone, tetrabenazine and clonazepam as the treatment of dystonic tremor (Kim et al 2014). All these studies compare the efficacy and safety of the drugs used for the treatment of tremor. Results of these studies have been found after experimenting with very small number of population, so it is difficult to make a conclusion. The quality of evidence of these drugs with respect to the controlled study with placebo was found to be very low to moderate.
Tremor:
Tremor can be defined as oscillatory, uncontrolled rhythmical movement of any body part such as limbs. The involuntary contracting movement of the innervated muscles causes tremor. Many types of tremors can be identified by using many parameters such as location, frequency and rthythmicity.
Physiologic tremor:
This is one of the kinetic action tremors, which happens to the normal individuals. This can be seen to the individuals suffering from physical exhaustion or is experiencing strong psychological emotion such as anxiety and withdrawal symptoms.
It can happen to any condition, at rest or in kinetic movement. This type of tremor onsets and stops suddenly. This generally happens due to the occurrence of stress and suddenly relapses when the patient is distracted from the stress.
Dystonic tremor:
This type of tremor can be seen in individuals of every age affected with dystonia ( a disease in which the muscles of the body twitches and twirls repetitively). Dystonic tremor may affect any of the body muscles and causes painful postures (Fasano, Bove and Lang 2013).
Essential tremor:
This is the most common part of tremor, which can be seen in normal individuals. This tremor is commonly non-progressive but it might be progressive for some people (Song et al, 2015). This type of tremor is most commonly seen in the hands, but it can affect the other body parts such as tongue, legs and voice and head. Severity of this type of tremor essentially increases with the age of the person experiencing this.
Parkinson’s disease:
Parkinson’s disease is one of the most common degenerative disorders, which can be seen in the elderly. The central nervous system of the body gradually degenerates along with the age of the person and affects the central nervous system of the body (Jiménez, and Vingerhoets 2012). Resting tremor is often a precursor of Parkinson’s disease.
Beta-Blocking drugs:
These are a class of drugs, which blocks many beta- adrenergic substances such as epinephrine and nor-epinephrine. The main principle of action of the Beta-blockers is the action of the sympathetic nerves of the body (Crosby, Deane and Clarke 2003). As beta-blockers relieves the stress of the heart, it commonly used as the treatment of trachycardia and bradycardia.
The article assesses the current state of knowledge of ET therapy. To assess it correctly, the authors categorized all the studies they found into many categories according to the GRADE evidence. The GRADE evidence is used to grade the evidence quality and strength (Louis 2012). The study exclusively included the patients suffering from essential tremors (Patients with Parkinsonian tremor, dystonic tremor and other tremors were exclusively excluded from the study). The article successfully assesses the effects of drugs such as beta-blockers, botulinas toxins, calcium-channel blockers, dopamine agonists and antidepressants and many more drugs on these chosen patients suffering from essential tremor. Randomized control trial methodology was performed on the patients and the data were recorded in the hoc-created collecting form which as described in the Cochrane’s reviewer’s handbook. The authors of the article categorized the results into four categories- very low, low, moderate and high according to GRADE (Zesiewicz et al 2010). Efficacy, safety and recommendation of every drugs used in this article was vastly discussed in this article. The research methodology and findings used in this study is relatively accurate.
The article is a systematic review, which includes a total number of 43 studies which includes a total of 487 patients with the problem of dystonic tremor and primary writing tremor has been included. The authors of this article could not find the studies with Meta analysis of randomized control trial (Fasano, Bove and Lang 2013). Therefore, they included all the relevant available studies to review. The authors also considered only those cases of tremors, which are confined in just one region of the body. The article reviews many cases in which various combinations of drugs were used, such as Beta-blockers, baclofen, carbamazepine, fluvoxamine and sulpriride. The study discusses the effects of drugs on the patients with dystonia but as no studies with random control trials were used in this study, the interpretation remains incomplete.
Mainly, the tremor in Parkinson’s disease happens when the person is resting and mainly starts when the person is under stress (Noyce et al 2012). There are many anti-parkinsonian drugs such as levodopa which mainly affects the bradykinesia, rather than helping with the tremors. Beta- blockers are mainly used as the treatment of the tremors related to anxiety and thyroid toxicity along with essential tremors. This article included all studies with randomized controlled trial for beta- blocker therapy and for the placebo patients (Crosby, Deane and Clarke 2003). The study tries to review the safety and efficacy of the beta-blockers as the treatment drug of Parkinson’s. The study includes all the patients with idiopathic Parkinson’s in two groups, one group included 72 patients who received placebo drugs and the other group was receiving Beta-blockers as drugs. The study used many cross-over trials for the beta-controlled drug (Zappia et al 2013). The study only used a very small number of patients for the trial and the effects of the drugs in comparison with the placebo drugs were low to moderate. Very small number of patients who reported the effect of the beta- control drugs as effective.
The article has taken a vast number of studies, patients and drugs for the study and has used many randomized control trials for interpreting the results. They have also used the GRADE method to categorize the safety and efficacy of the drugs used for the randomized control trial. The research of this study is well designed( Thenganatt and Jankovic 2014). The studies were designed to obtain data on which the people can rely on. The study describes which drug should be used as the first line treatment and second line treatment for the management of essential tremors. The whole article is well-defined and complete.
Many additional controls were needed for defining the other possible treatments for the management of Essential Tremor.
The study discusses many aspects of the treatment of dystonic tremor on a significant number of studies with significant number of patients. The whole finding of the study is well written and the use of the graphs were relevant.
The main limitation of the study is the lack of the studies with randomized controlled trial. The study only considers those patients suffering from tremor in only one region. The study also excludes the patients who are on combination treatment (Fasano, Bove and Lang 2013). The results on the effects of many drugs such as carbazepine, fluvomaxine, acetazolamine, amitriptyline, baclofen and sulpriride was not very good, so the authors of the paper could not draw any conclusion on this study (Zappia et al 2013).
The study were based on the randomized controlled trial over the use of the combination of Beta blocker drugs which were compared with placebo drugs placed on the people suffering from Parkinson’s (Yu et al 2012).
The number of the patients used was too small to interpret a result. In addition, no significant results were found.
The study is one of the most relevant studies one can found on the treatment of Essential tremor. The study successfully interprets the drugs, which can be used as the first line and second line therapy for Parkinson’s (Louis et al 2012). The study is also skillfully determines the safety and efficacy of drugs such as Primidone and propranolol (PRP).
The impact of this study over the etratment of Essential tremor would be huge as the physicians could rely only on these kinds of work.
The only gap of the finding is that the effects of the drugs were only low to moderate. The study could not find any drug, which can definitely be used as the effective treatment for tremor.
The article is not very relevant and is not able give a significant impact on the other studies. There was no study available with randomized control trial and they just included studies with limited result. The authors even excluded many results as it was scattered.
The article is also lacks relevancy as there they used very limited number of people to conduct their study and it is not expected to have a correctly interpretive result from such a small study. The main gap of the study is also the usage of the small number of people (Zappia et al 2013).
As discussed in Article 1, drugs such as Primidone, and propranolol (PRP) can be used as the first line therapy to treat essential tremor, though it cannot be used on to the people with young and old age. Drugs like artinolol and sotalol can be used as the second linen treatment for essential tremor. Beta blockers could be used as the first line treatment only in people with definite Essential Tremor. Article 2 discusses the combined effect of surgery and drug such as VIM-DBS (Ventralis Intermedious Nuclei- Different Brain Nuclei) and GPi (Schneider and Deuschl 2014) (Yamamoto et al 2013). The study discusses that the subthalamic area of the brain should be considered for stimulation. According to article 3, all the reporting which includes the adverse report of treatment were reported very poorly, but the use of Beta blockers in the patients leaves some concerns about the efficacy of beta blockers because of the report of the frequency of heart rate decrease.
Conclusion:
After reviewing the three articles, it can be concluded that, there are not many treatments available for tremor, which depends on the cause. The treatment of tremor depends on the level of severity and disability experienced by the patients. Moreover, the overall effectiveness of the medicines used for tremor remains moderate to very low and the patients frequently discontinues the treatments.
References:
Baumann, C.R., 2012. Epidemiology, diagnosis and differential diagnosis in Parkinson’s disease tremor. Parkinsonism & related disorders, 18, pp.S90-S92.
Crosby NJ, Deane K, and Clarke CE. 2003 Beta-blocker therapy for tremor in Parkinson’s disease. Cochrane Database of Systematic Review (3) pp.1-8
Fasano, A., Bove, F. and Lang, A.E., 2013. The treatment of dystonic tremor: a systematic review. J Neurol Neurosurg Psychiatry, pp.jnnp-2013.
Gallego, J.Á., Rocon, E., Belda-Lois, J.M. and Pons, J.L., 2013. A neuroprosthesis for tremor management through the control of muscle co-contraction. Journal of neuroengineering and rehabilitation, 10(1), p.36.
Jiménez, M.C. and Vingerhoets, F.J., 2012. Tremor revisited: treatment of PD tremor. Parkinsonism & related disorders, 18, pp.S93-S95.
Kim, S.D., Yiannikas, C., Mahant, N., Vucic, S. and Fung, V.S., 2014. Treatment of proximal upper limb tremor with botulinum toxin therapy. Movement Disorders, 29(6), pp.835-838.
Louis, E.D., 2012. Treatment of essential tremor: are there issues we are overlooking?. Frontiers in neurology, 2, p.91.
Louis, E.D., Huey, E.D., Gerbin, M. and Viner, A.S., 2012. Depressive traits in essential tremor: impact on disability, quality of life, and medication adherence. European journal of neurology, 19(10), pp.1349-1354.
Noyce, A.J., Bestwick, J.P., Silveira?Moriyama, L., Hawkes, C.H., Giovannoni, G., Lees, A.J. and Schrag, A., 2012. Meta?analysis of early nonmotor features and risk factors for Parkinson disease. Annals of neurology, 72(6), pp.893-901.
Schneider, S.A. and Deuschl, G., 2014. The treatment of tremor. Neurotherapeutics, 11(1), pp.128-138.
Song, I.U., Ha, S.W., Yang, Y.S. and Chung, Y.A., 2015. Differences in regional glucose metabolism of the brain measured with F-18-FDG-PET in patients with essential tremor according to their response to beta-blockers. Korean journal of radiology, 16(5), pp.967-972.
Thenganatt, M.A. and Jankovic, J., 2014. Parkinson disease subtypes. JAMA neurology, 71(4), pp.499-504.
Yamamoto, T., Katayama, Y., Ushiba, J., Yoshino, H., Obuchi, T., Kobayashi, K., Oshima, H. and Fukaya, C., 2013. On?demand control system for deep brain stimulation for treatment of intention tremor. Neuromodulation: Technology at the Neural Interface, 16(3), pp.230-235.
Yu, X., He, G.R., Sun, L., Lan, X., Shi, L.L., Xuan, Z.H. and Du, G.H., 2012. Assessment of the treatment effect of baicalein on a model of Parkinsonian tremor and elucidation of the mechanism. Life sciences, 91(1), pp.5-13.
Zappia, M., Albanese, A., Bruno, E., Colosimo, C., Filippini, G., Martinelli, P., Nicoletti, A., Quattrocchi, G. 2013, Italian Movement Disorders Association and Essential Tremor Committee,. Treatment of essential tremor: a systematic review of evidence and recommendations from the Italian Movement Disorders Association. Journal of neurology, 260(3), pp.714-740.
Zesiewicz, T.A., Chari, A., Jahan, I., Miller, A.M. and Sullivan, K.L., 2010. Overview of essential tremor. Neuropsychiatric disease and treatment, 6, p.401.
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