Tremor predominant Parkinson's disease

Tremor-predominant Parkinson's disease is characterised by prominent tremor of one or more limbs with a relative lack of significant rigidity and bradykinesia. Despite the lack of other disabling motor symptoms, the tremor of tremor-predominant Parkinson's disease can be very disabling, especially if a postural and kinetic component exists.

Treatment include use of oral medications, injections with botulinum toxin and neurosurgical procedures. Some of the first line medications (levodopa, dopamine agonists, anticholinergics) are very effective in controlling tremor. However, some patients with Parkinson's disease tremors are unresponsive to first line drugs and treatment with second line medications (clozapine, amantadine, clonazepam, propranolol, neurontin) should be attempted. In the small number of patients with disabling tremor that is refractory to all medications, neurosurgical intervention should be considered. Both thermocoagulation and deep brain stimulation at several different neuroanatomical sites (thalamus, globus pallidus, subthalamic nucleus) offer good to excellent tremor control with relatively low risk to the patient 1).

Patients with tremor predominant Parkinson's disease (PD) achieve more improvement in tremor control after Combined Unilateral Posteroventral Pallidotomy and Ventral Intermediate Nucleus Thalamotomy 2).

Focused ultrasound thalamotomy for patients with TDPD demonstrated improvements in medication-refractory tremor by CRST assessments, even in the setting of a placebo response 3).

Marjama-Lyons J, Koller W. Tremor-predominant Parkinson's disease. Approaches to treatment. Drugs Aging. 2000 Apr;16(4):273-8. Review. PubMed PMID: 10874522.
Fayed ZY, Radwan H, Aziz M, Eid M, Mansour AH, Nosseir M, Anwer H, Elserry T, Abdel Ghany WA. Combined Unilateral Posteroventral Pallidotomy and Ventral Intermediate Nucleus Thalamotomy in Tremor-Dominant Parkinson's Disease versus Posteroventral Pallidotomy Alone: A Prospective Comparative Study. Stereotact Funct Neurosurg. 2018 Sep 18;96(4):1-6. doi: 10.1159/000492229. [Epub ahead of print] PubMed PMID: 30227440.
Bond AE, Shah BB, Huss DS, Dallapiazza RF, Warren A, Harrison MB, Sperling SA, Wang XQ, Gwinn R, Witt J, Ro S, Elias WJ. Safety and Efficacy of Focused Ultrasound Thalamotomy for Patients With Medication-Refractory, Tremor-Dominant Parkinson Disease: A Randomized Clinical Trial. JAMA Neurol. 2017 Oct 30. doi: 10.1001/jamaneurol.2017.3098. [Epub ahead of print] PubMed PMID: 29084313.
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