Kinematic-guided BoNT-A Treatment for ET and PD Tremor
Kinematic-guided BoNT-A Treatment for ET and PD Tremor
The present study attempts to fill a critical knowledge gap of BoNT A in tremor management by
 studying the efficacy of IncobotulinumtoxinA (Xeomin®) injection for hand tremor in essential
 tremor and idiopathic Parkinson disease using data regarding composition of tremor obtained
 through sophisticated, yet clinically accessible multi-sensor based kinematic information.
Current pharmacological agents used to treat Parkinson disease (PD) tremor and essential
 tremor (ET) provide suboptimal benefit and are commonly associated with significant adverse
 effects. Botulinum toxin type A (BoNT-A) has been shown to be effective for wrist tremor
 though functionally bothersome muscle weakness frequently occurs. This is the longest study
 to date demonstrating that BoNT-A therapy coupled with kinematic guidance can provide
 efficacious outcomes for upper limb tremor with minimized unwanted weakness. A total of 28 PD
 and 24 ET participants with bothersome, disabling tremor, received six serial BoNT-A
 treatments every 16 weeks starting at week 0 with a follow-up visit 6 weeks following a
 treatment, totaling 96 weeks. Clinical scales, including Fahn-Tolosa-Marin tremor rating
 scale (FTM), and sensor-based tremor assessments were conducted at each visit. Kinematics was
 utilized to identify which arm muscles contributed to the tremulous movements and the
 experienced injector used clinical expertise in determining BoNT-A dosages. Following BoNT-A
 treatment, clinical ratings of tremor severity and functional ability (FTM) showed
 significant improvements following the first treatment which was maintained up to week 96 in
 PD and ET. Kinematics detected a significant reduction in PD and ET tremor amplitudes by 70%
 and 76% over the treatment course, respectively. By objectively distinguishing tremulous
 muscles and tremor severity, adverse effects were limited to mild perceived weakness by
 participants in injected muscles during follow-ups. Following the fourth treatment, BoNT-A
 dosages in flexor and extensor wrist muscles and biceps were reduced for those experiencing
 residual weakness which ultimately did not interfere with tremor relief or arm function.
 Kinematics is an objective method that can aid clinicians in assessing and determining
 optimal BoNT-A parameters to alleviate both PD and ET tremor. BoNT-A injections are tolerable
 and effective when focal therapy regimens are determined and optimized kinematically over a
 long-term
Inclusion Criteria:

 -  Consenting male and female participants, aged 18 years to 80 years

 -  PD individuals diagnosed by UK Brain Bank Criteria with stage H&Y2-3 disease or ET
 with hand tremor in their motor dominant hand

 -  Stable IPD/ET medication management for the 6 month duration prior to their enrollment
 in the study

 -  Individuals with IPD will be eligible for the study only if tremor is their primary
 and most bothersome symptom as determined by clinical exam and patient report

 -  Participants who are botulinum toxin naïve for tremor management

 Exclusion Criteria:

 -  History of stroke

 -  Muscle weakness or any related compartmental muscle syndrome

 -  Smoking

 -  Offending medications (Lithium, valproate, steroids, amiodarone, beta-adrenergic
 agonists (e.g. salbutamol))

 -  Contradictions per the Xeomin® drug monograph

 -  Patients prescribed zonisamide