Objective:

To assess the role of ultrasound-guided (US) Onabotulinumtoxin-A (BoNT-A) injections for various types of hand and head tremor.

Background:

Focal treatment of head and limb tremor by onabotulinumtoxin-A (BoNT-A) injections has been inadequately investigated. Though few reports showed promising effects; yet, absence of wide scale studies, heterogeneous tremor presentation and diverse regimens to target a multi-joint tremulous movement make it difficult to reach an objective consensus regarding its value.

Methods:

This was a 12-week open-label study that include 23 participants with different tremors types [essential head tremor (n=4), head tremors related to Khat chewing (n=2), Parkinsonian head tremors (n=2), essential limb tremor (n=7), Holme’s tremor (n=3), Parkinsonian limb tremor (n=5)]. All patients received maximum medical treatment with unsatisfactory response. Study visits were at weeks 0, 4, 6 and 12. During each visit, patients were subjected to standardized videotaping (during rest, posture and motion), Fahn-Tolosa-Marin (FTM) tremor motor scale and spiral drawings. Injection paradigm was determined using surface EMG (tremor frequency) and ultrasonography of muscles that may contribute to the tremor across various joints in all degrees of movement (degrees of freedom of motion). All patients were injected with BoNT-A at baseline by US-guidance.

Results:

A significant decrease in FTM tremor severity score at week 6 (p< 0.01) with improvement in spiral drawing (P<0.05). In PD tremor, though some improvement was detected; yet, it was not statistically significant (P=0.06). Head tremor showed statistically significant improvement compared to those with limb tremor (P=0.04). Muscle weakness was detected in 2/15 patients with limb tremor.

Conclusions:

BoNT-A could be a promising option for treatment of resistant-to-treat tremor. Precise directional assessment of tremor at each arm joint using US allowed for a better outcome in arm tremor.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/ultrasonography-guided-botulinum-toxin-type-a-injection-in-tremor-an-open-label-study/