title: A neuroprosthesis for tremor management through the control of muscle co-contraction.
abstract: BACKGROUND
  Pathological tremor is the most prevalent movement disorder. Current treatments do not attain a significant tremor reduction in a large proportion of patients, which makes tremor a major cause of loss of quality of life. For instance, according to some estimates, 65% of those suffering from upper limb tremor report serious difficulties during daily living. Therefore, novel forms for tremor management are required. Since muscles intrinsically behave as a low pass filter, and tremor frequency is above that of volitional movements, the authors envisioned the exploitation of these properties as a means of developing a novel treatment alternative. This treatment would rely on muscle co-contraction for tremor management, similarly to the strategy employed by the intact central nervous system to stabilize a limb during certain tasks.
  
  
  METHODS
  We implemented a neuroprosthesis that regulated the level of muscle co-contraction by injecting current at a pair of antagonists through transcutaneous neurostimulation. Co-contraction was adapted to the instantaneous parameters of tremor, which were estimated from the raw recordings of a pair of solid state gyroscopes with a purposely designed adaptive algorithm. For the experimental validation, we enrolled six patients suffering from parkinsonian or essential tremor of different severity, and evaluated the effect of the neuroprosthesis during standard tasks employed for neurological examination.
  
  
  RESULTS
  The neuroprosthesis attained significant attenuation of tremor (p<0.001), and reduced its amplitude up to a 52.33±25.48%. Furthermore, it alleviated both essential and parkinsonian tremor in spite of their different etiology and symptomatology. Tremor severity was not a limiting factor on the performance of the neuroprosthesis, although there was a subtle trend towards larger attenuation of more severe tremors. Tremor frequency was not altered during neurostimulation, as expected from the central origin of Parkinson's disease and essential tremor. All patients showed a good tolerance to neurostimulation in terms of comfort and absence of pain, and some spontaneously reported that they felt that tremor was reduced when the neuroprosthesis was activated.
  
  
  CONCLUSIONS
  The results presented herein demonstrate that the neuroprosthesis provides systematic attenuation of the two major types of tremor, irrespectively from their severity. This study sets the basis for the validation of the neuroprosthesis as an alternative, non-invasive means for tremor management.
authors.affiliation: Bioengineering Group, Consejo Superior de Investigaciones Científicas (CSIC), Ctra Campo Real km 0.2-La Poveda, 28500 Arganda del Rey, Spain. ja.gallego@csic.es
authors.forename: Juan Álvaro
authors.initials: JÁ
authors.lastname: Gallego
authors.forename: Eduardo
authors.initials: E
authors.lastname: Rocon
authors.forename: Juan Manuel
authors.initials: JM
authors.lastname: Belda-Lois
authors.forename: José Luis
authors.initials: JL
authors.lastname: Pons
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D020329:Essential Tremor / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009119:Muscle Contraction / Q000502:physiology; D018482:Muscle, Skeletal / Q000502:physiology; D058117:Neural Prostheses; D010300:Parkinson Disease / Q000628:therapy*; D004561:Transcutaneous Electric Nerve Stimulation / Q000295:instrumentation / Q000379:methods*