title: Effective Management of Upper Limb Parkinsonian Tremor by IncobotulinumtoxinA Injections Using Sensor-based Biomechanical Patterns.
abstract: BACKGROUND
  Focal treatment of Parkinson's disease tremor by botulinum toxin type A incobotulinumtoxinA (BoNT-A) injections has been inadequately investigated and at best provides modest relief with significant muscle weakness. Complexity of multi-joint tremulous movements results in non-individualized dosing regimens. This 38-week open-label study used kinematic technology to guide muscle selection and improve efficacy of incobotulinumtoxinA (BoNT-A) injections for Parkinson's disease tremor.
  
  
  METHODS
  Participants (n=28) attended study visits at weeks 0, 6, 16, 22, 32, and 38, and were injected with BoNT-A at weeks 0, 16, and 32. During each visit, clinical tremor scales, the Unified Parkinson's Disease Rating Scale (UPDRS) and the Fahn-Tolosa-Marin (FTM), and kinematic assessments were conducted. Participants performed rest and postural scripted tasks with motion sensors placed over the wrist, elbow, and shoulder joints where tremor was quantified by angular root mean square (RMS) amplitude in multiple degrees of freedom at each joint. Injection parameters were determined using the clinician's interpretation of which muscles would contribute to the upper limb tremor biomechanics analyzed kinematically.
  
  
  RESULTS
  Kinematic measures of tremor amplitude allowed detailed segmentation of tremor into directional components at each arm joint permitting a statistically significant decrease in mean UPDRS item 20 (rest tremor) at week 16 (p=0.006) and at week 32 (p=0.014), and in FTM tremor severity scores at week 6 (p=0.024). Ten participants perceived mild muscle weakness following the third treatment, which did not interfere with performing activities of daily living.
  
  
  CONCLUSIONS
  Kinematics is a simple method for standardizing assessments and treatment of upper limb Parkinson's disease tremor, thereby personalizing tremor therapy and optimizing the effect of BoNT-A injections for Parkinson's disease tremor.
authors.affiliation: Department of Electrical and Computer Engineering, University of Bonab, Bonab, Iran.
authors.forename: Fariborz
authors.initials: F
authors.lastname: Rahimi
authors.affiliation: Department of Clinical Neurological Sciences, London Health Sciences Centre, Lawson Health Research Institute, London, ON, Canada ; Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.
authors.forename: Olivia
authors.initials: O
authors.lastname: Samotus
authors.affiliation: Department of Clinical Neurological Sciences, London Health Sciences Centre, Lawson Health Research Institute, London, ON, Canada.
authors.forename: Jack
authors.initials: J
authors.lastname: Lee
authors.affiliation: Department of Clinical Neurological Sciences, London Health Sciences Centre, Lawson Health Research Institute, London, ON, Canada ; Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.
authors.forename: Mandar
authors.initials: M
authors.lastname: Jog
keywords: Parkinson’s disease; biomechanics; botulinum toxin; kinematics; movement disorders; tremor