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Classification of Tremor and Update on Treatment

P. DAVID CHARLES, M.D., GREGORY J. ESPER, B.S., THOMAS L. DAVIS, M.D., ROBERT J. MACIUNAS, M.D., and DAVID ROBERTSON, M.D.
Vanderbilt University School of Medicine
Nashville, Tennessee

Tremor is a symptom of many disorders, including Parkinson's disease, essential tremor, orthostatic tremor, cerebellar disease, peripheral neuropathy and alcohol withdrawal. Tremors may be classified as postural, rest or action tremors. Symptomatic treatment is tailored to the tremor type. Combination therapy with carbidopa and levodopa remains the first-line approach for parkinsonian tremor. Essential tremor may be amenable to propranolol or primidone. Propranolol may be useful in treating alcohol withdrawal tremor, and isoniazid may control the cerebellar tremor associated with multiple sclerosis. Clonazepam may relieve orthostatic tremor. Other agents are also available for the treatment of tremor. When medical therapy fails to control the tremor, surgical options such as thalamotomy, pallidotomy and thalamic stimulation should be considered in severe cases. Thalamic stimulation, the most recent of these surgical approaches, offers the advantage over ablative procedures of alleviating tremor without the creation of a permanent lesion.

Tremor is the involuntary, rhythmic oscillation of reciprocally innervated, antagonistic muscle groups, causing movement of a body part about a fixed plane in space.1,2 Effective treatment of tremor requires distinguishing this type of movement disorder from other movement disorders.

Rhythmicity distinguishes tremor from disorders in which tremor may be a component, such as choreoathetosis and dystonia, and its biphasic nature distinguishes tremor from clonus.1 The frequency and amplitude of a tremor vary to the degree that the tremor may be hardly noticeable or severely disabling. Frequency can be divided into three categories of oscillations per second: slow (3 to 5 Hz), intermediate (5 to 8 Hz) or rapid (9 to 12 Hz).3 Amplitude may be classified as fine, medium or coarse, depending on the displacement produced by the tremor about the fixed plane.3 A coarse tremor has a large displacement, whereas a fine tremor is barely noticeable. Tremor may be unifocal, multifocal or generalized, and may affect the head, face, jaw, voice, tongue, trunk or extremities.

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TABLE 1
Classification of Tremors, and Their Characteristics and Treatment

Type of tremor
Frequency
Occurrence
Etiology
Treatment*
Postural tremor 5 to 9 Hz When limb is positioned against gravity Physiologic tremor, essential tremor, alcohol or drug withdrawal, metabolic disturbances, drug-induced tremor, psychogenic tremor Beta blockers, primidone (Mysoline), acetazolamide (Diamox), clonazepam (Klonopin), botulinum toxin, brain gabapentin (Neurontin), deep stimulation, thalamotomy
Rest tremor 3 to 6 Hz When limb is fully supported against gravity and the muscles are not voluntarily activated Parkinson's disease, multiple- systems atrophy, progressive supranuclear palsy, drug-induced tremor, rubral tremor, psychogenic tremor Levodopa­carbidopa (Sinemet), anticholinergics and other antiparkinsonian agents, deep brain stimulation, pallidotomy, thalamotomy
Action tremor† 3 to 10 Hz During any type of movement Cerebellar lesions, rubral tremor, psychogenic tremor Wrist weights, isoniazid

*--Drugs and other treatments are generally listed in the order in which they should be tried. An adequate trial of each medication must be tried before the agent is judged to be ineffective. Many of these drugs are not specifically labeled for the treatment of tremor or have not undergone extensive studies to support their use in the treatment of tremor.

†--Action tremor includes intention tremor (exacerbation toward the end of goal-directed movement), kinetic tremor (during any type of movement) and task-specific tremor (only during performance of highly skilled activities, such as writing or playing a musical instument).

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Classification: Postural, Rest and Action Tremors

Tremor is primarily classified on the basis of when it occurs, either with a certain posture, at rest or during action (Table 1). A resting tremor occurs when the patient is attempting to maintain the position of a body part at rest (e.g., when the patient's hands exhibit a tremor as they are resting in the patient's lap). Postural tremor is observed when the patient tries to maintain a posture against gravity, such as holding the arms out in front of the body. An action tremor (kinetic or intention tremor) occurs during movement of the affected body part from one point to another. A task-specific tremor occurs only when the patient begins to perform a highly skilled activity, such as writing or speaking.2

Tremor may be either physiologic or pathologic. Physiologic tremor is a normal variant, occurring at a frequency of 8 to 12 Hz in the hands yet as slow as 6.5 Hz in other body parts during maintenance of a posture.2,4 It can be increased by emotions such as anxiety, stress or fear, by exercise and fatigue, hypoglycemia, hypothermia, hyperthyroidism and alcohol withdrawal. When such an increase occurs, physiologic tremor is then called enhanced or exaggerated physiologic tremor.1,4 Certain drugs can also exacerbate physiologic tremor5 (Table 2). Pathologic tremor is either idiopathic or occurs secondary to some disorders (Table 3). Essential tremor and parkinsonian tremor are two common types of pathologic tremor.

Identification of the type of tremor depends on keen observation. The location of the tremor or the patient's position when it occurs should be identified first, and special attention must be paid to other signs of illness. Careful observation will reveal if the tremor occurs at rest, during posture maintenance or during movement. The patient should be asked what produces or modulates the amplitude and frequency of the tremor.2,3 A correct diagnosis is essential for proper treatment of the disorder, because different types of tremor require different treatments.

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TABLE 2
Commonly Used Agents That Exacerbate Physiologic Tremor

• Caffeine
• Fluoxetine (Prozac)
• Haloperidol (Haldol)
• Lithium
• Methylphenidate (Ritalin)
• Metoclopramide (Reglan)
• Phenylpropanolamine
• Pseudoephedrine
• Theophylline
• Valproic acid
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TABLE 3
Selected Secondary Causes of Tremor

• Alcohol or drug withdrawal
• Brain abscess
• Brain tumor
• Multiple sclerosis
• Peripheral neuropathy
• Pheochromocytoma
• Psychogenic disorders
• Thyrotoxicosis
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Tremor Types Based on Etiology

Parkinsonian Tremor
The tremor in Parkinson's disease occurs at rest and is characterized by a frequency of 4 to 6 Hz and a medium amplitude. It is classically referred to as a "pill rolling" tremor of the hands but can also affect the head, trunk, jaw and lips.2,3 Although rare, a rest tremor may also be found in patients with other neurodegenerative diseases, such as multiple-systems atrophy and progressive supranuclear palsy. The tremor associated with these disorders is usually symmetric and not as prominent as the tremor that accompanies Parkinson's disease.

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A physiologic tremor occurs in the hands at a frequency of 8 to 12 Hz during maintenance of a posture.
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Parkinson's disease results from a slow degeneration of a small area in the midbrain, called the substantia nigra. Specifically, excitatory and inhibitory dopaminergic neurons degenerate in the substantia nigra pars compacta. These neurons project to the striatum and then to the globus pallidus. From there, multiple connections in the basal ganglia project to one another, to the thalamus and, finally, to the cortex, which makes up the extrapyramidal system. This system regulates the initiation and control of movement, and dysfunction of any of these connections can lead to various types of movement disorders.6 As a consequence of neuronal degeneration in the substantia nigra pars compacta, the ventral intermediate nucleus of the thalamus becomes overactive, possibly producing the tremor of Parkinson's disease. The neurons in the ventral intermediate nucleus of the thalamus fire at a rate that matches the tremor.7

Essential Tremor
Essential tremor is the most common movement disorder.2,3,8 This postural tremor may have its onset anywhere between the second and sixth decades of life and its prevalence increases with age.8 It is slowly progressive over a period of years.3

The specific pathophysiology of essential tremor remains unknown. Essential tremor occurs sporadically or can be inherited. While the exact genetic defect has not been identified, familial transmission seems to be autosomal dominant with variable penetrance.4

The frequency of essential tremor is 4 to 11 Hz, depending on which body segment is affected. Proximal segments are affected at lower frequencies, and distal segments are affected at higher frequencies.3 Although typically a postural tremor, essential tremor may occur at rest in severe and very advanced cases.2 It most commonly affects the hands but can also affect the head, voice, tongue and legs.2,3,9 In some patients essential tremor is alleviated by small amounts of alcohol, an effect not found in Parkinson's disease.

Cerebellar Tremor
The most common type of cerebellar tremor is kinetic, or goal directed. Cerebellar tremors are due to lesions of the lateral cerebellar nuclei or superior cerebellar peduncle, or its connections. Classically, a lesion within a cerebellar hemisphere or nuclei leads to an action tremor on the ipsilateral side of the body. Midline cerebellar disease may cause tremor of both arms, the head and the trunk.2 Lesions in the location of the red nucleus produce a wing-beating type of tremor (called rubral tremor), which is also present to a lesser degree with rest and posture.

During examination, a cerebellar tremor increases in severity as the extremity approaches its target. Other signs of cerebellar pathology, such as abnormalities of gait, speech and ocular movements, and the ability to perform rapidly alternating movements, may be present and may help to confirm the diagnosis of cerebellar tremor.3

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Propranolol (Inderal) and primidone (Mysoline) are both effective in the treatment of essential tremor.
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Another type of tremor may also be associated with damage to the cerebellum. Termed "cerebellar postural tremor," it is prominent with both action and posture.4 In its most severe form, cerebellar postural tremor has a frequency of 2.5 to 4 Hz and may wax and wane in amplitude, increasing progressively with prolonged posture. It persists and worsens with goal-directed movement.4 The milder form of the tremor has a more rapid frequency, approaching 10 Hz, and appears more distally, making it harder to identify than the severe type.4

Multiple sclerosis is the most common cause of the cerebellar postural tremor.4 Other causes of this tremor include tumors and strokes, as well as neural degeneration in the cerebellum.

Alcohol Withdrawal Tremor
Alcohol withdrawal tremor is similar to essential tremor on examination but with subtle differences. Alcohol withdrawal tremor has a frequency between 6 and 10.5 Hz. In one study,10 74 percent of the patients with alcohol withdrawal tremors had tremors at a frequency above 8 Hz. In this same series, tremors in all of the patients who had essential tremor were at a frequency below 8 Hz. Thus, the tremor of alcohol withdrawal tends to be more rapid than essential tremor.

A family history of tremor was found in only 1 percent of the patients with alcohol withdrawal tremor, as compared with almost one half of the patients with essential tremor.10 In addition, severity and degree of functional disability were less with alcohol withdrawal tremor.

Only the hands are affected in patients with alcohol withdrawal tremor, but multiple sites of involvement are possible in patients with essential tremor. Overactivity of the sympathetic nervous system is thought to be responsible for alcohol withdrawal tremor, and prolonged alcohol abuse can result in a chronic tremor disorder.10

Psychogenic Tremor
Psychogenic tremor is a complex tremor that can occur at rest, during postural movement and during kinetic movement. The etiology and pathophysiology of psychogenic tremor are likely to differ from patient to patient, and the main focus of treatment should be psychotherapy, not medication.

Clinical features of psychogenic tremor include an abrupt onset, a static course, spontaneous remission and unclassifiable tremors.11 Unresponsiveness to antitremor drugs, an increase in frequency and amplitude with attention and a decrease in frequency and amplitude with distraction, responsiveness to placebo, absence of other neurologic signs and remission with psychotherapy are also signs of psychogenic tremor.11 Clinical inconsistencies, such as being able to write words yet not being able to draw a spiral, and changing characteristics, such as direction and affected body part, are also representative of psychogenic tremor.11

Other Tremors
Other types of tremor occur much less commonly than the previously described tremors. Orthostatic tremor is defined as a postural tremor of the legs, occurring at a frequency of 13 to 18 Hz, initiated on standing and alleviated by walking or sitting.12 It is more readily noticeable during palpation than by sight and is not influenced by peripheral feedback.13 Unsteadiness, feelings of imbalance or weakness, and trembling and shaking in the lower limbs are associated features of orthostatic tremor.14 The etiology of orthostatic tremor is unknown, but it is currently regarded as an entity separate from essential tremor.12-14

Tremor associated with peripheral neuropathy is clinically similar to essential tremor. Its etiology is diverse. Not only can it be idiopathic, it can also be caused by demyelination from immunoglobulin M paraproteinemic neuropathies.2 Tremor in association with peripheral neuropathy can also result from Charcot-Marie-Tooth disease, diabetes mellitus, uremia and porphyria.2

Drug Treatment of Tremor

Parkinsonian Tremor
Treatment of Parkinson's disease includes both medical and surgical intervention. Dopamine replacement therapy by means of levodopa clearly revolutionized the treatment of Parkinson's disease. Levodopa is almost exclusively given in combination with the peripheral decarboxylase inhibitor carbidopa (Sinemet). Carbidopa blocks the peripheral metabolism of levodopa to dopamine, decreasing the peripheral adverse effects of levodopa, such as nausea and vomiting, while increasing levodopa's availability in the brain.15,16 In addition to modulating the tremor associated with Parkinson's disease, levodopa improves bradykinesia, rigidity and other commonly associated symptoms. Carbidopa­levodopa is available in formulations of 10/100 mg, 25/100 mg and 25/250 mg. It is advantageous to begin treatment of mild disease with the 25/100-mg dosage, one tablet three times a day, and then increase the dosage as symptoms become less manageable.

When tremor is the predominant presenting symptom of Parkinson's disease or when tremor persists despite adequate control of other parkinsonian symptoms with low dosages of levodopa, an anticholinergic agent such as trihexyphenidyl (Artane) or benztropine (Cogentin) may be the treatment of choice. In most patients, however, anticholinergics do not significantly improve bradykinesia and rigidity. Trihexyphenidyl dosages necessary to improve tremor are between 4 and 10 mg per day (maximum: 32 mg), and useful benztropine dosages range from 1 to 4 mg per day. The side effects of these agents are their limiting factor, particularly in the elderly. Side effects include memory impairment, hallucinations, dry mouth, urinary difficulties and blurred vision.15

Other antiparkinsonian drugs--for example, amantadine (Symmetrel), tolcapone (Tasmar) and dopamine agonists such as pergolide (Permax), bromocriptine (Parlodel), ropinirole (Requip) and pramipexole (Mirapex)--are most helpful in patients whose tremor responds poorly to levodopa alone.

Essential Tremor
As with other tremors, effective treatment of essential tremor is not found in a single, universal agent. Some therapies may be satisfactory in some patients and ineffective in others. The most widely used drugs for essential tremor are the beta-adrenergic blocker propranolol (Inderal) and the anticonvulsant primidone (Mysoline). The typical dosage range for propranolol is 80 to 320 mg per day and for primidone, 25 to 750 mg per day.3 Other beta-adrenergic receptor antagonists used in the treatment of essential tremor include metoprolol (Lopressor) and nadolol (Corgard).2 Alcohol is also effective in relieving essential tremor, but abuse may be an adverse consequence.3

In our experience, propranolol and primidone are equally effective in the treatment of essential tremor. Patients who do not respond to one medication after a few weeks of therapy should be tried on the other one. Primidone may be preferred, because of the exercise intolerance associated with high-dose beta blockade. Patients who have a very-low-amplitude rapid tremor are generally more responsive to these agents than those who have a slower tremor with greater amplitude. Patients who have tremor of the head and voice may also be more resistant to treatment than patients with essential tremor of the hands.

Other Tremors
There is no established treatment for cerebellar tremor.2 In patients with multiple sclerosis, severe cerebellar tremor may be improved with isoniazid, in a dosage of 600 to 1,200 mg per day, given together with pyridoxine.4

Propranolol in a dosage of 160 mg per day is very effective in reducing the tremor associated with alcohol withdrawal.10

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Thalamic stimulation by means of an implanted electrode may effectively control tremor in patients with essential tremor or Parkinson's disease.
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Treatment of orthostatic tremor should first be attempted with clonazepam (Klonopin). In one small study,14 eight of nine patients responded to clonazepam in dosages ranging from 0.5 to 2.0 mg per day. The patient who did not respond to clonazepam responded to chlordiazepoxide (Librium), in a dosage of 30 mg twice a day. In another study,12 10 of 18 patients had sustained improvement with clonazepam, and valproic acid was effective in the remaining eight patients. However, propranolol in daily dosages of up to 320 mg had no effect on controlling orthostatic tremor.

Tremor due to peripheral neuropathy may be ameliorated with propranolol, primidone, benzodiazepines or baclofen (Lioresal), but the underlying cause of the neuropathy itself should be treated as well.2

Other medications have been shown to be helpful in the management of tremor but should probably only be tried in consultation with a neurologist, when the previously mentioned drugs have failed to control the tremor.

Surgical Treatment of Tremor

Thalamotomy
Surgical therapy for tremor should only be considered if drug therapy fails to produce adequate relief. Stereotactic thalamotomy is the surgical procedure most often used to quell essential tremor. Before the introduction of levodopa, thalamotomy was an often-selected option in the treatment of Parkinson's disease. Because the benefits of levodopa wane after four to seven years of therapy, this procedure remains an option in some patients with severe parkinsonian tremor refractory to drug therapy. However, problems associated with bilateral thalamotomy, such as dysphagia and dysarthria, limit its use. Thalamotomy is usually only considered in patients with severe, drug-resistant essential tremor and in a very small subset of patients with Parkinson's disease who have severe, disabling, predominantly unilateral tremor.

In one study of the use of stereotactic thalamotomy in the treatment of tremor,17 86 percent of the 42 patients with parkinsonian tremor and 83 percent of the six patients with essential tremor had cessation of tremor or moderate to marked improvement in tremor after the procedure. Follow-up in some patients was as long as 13 years (mean follow-up: 53.4 months). The investigators used three criteria for patient selection: (1) predominantly unilateral, severe and incapacitating tremor, (2) a poor response to or intolerance of optimal medical therapy and (3) no potentially serious risk factors for surgery. Postoperative complications included weakness, dysarthria and confusion, but these problems subsided with time.

Catastrophic complications in the perioperative period include bleeding in the thalamus or the subdural or epidural area, which can lead to death, paralysis, aphasia or significant cognifive deficits.

Pallidotomy
Producing lesions in the globus pallidus by means of pallidotomy is an alternative to thalamotomy in the treatment of parkinsonian tremor. Pallidotomy also improves other symptoms of Parkinson's disease, such as bradykinesia and levodopa-induced dyskinesias.18 As with thalamotomy, pallidotomy should only be considered in cases of severe tremor unresponsive to medical treatment.

In a series of 259 patients who underwent pallidotomy for parkinsonian tremor,18 complete relief of all symptoms on the side contralateral to the procedure occurred in 212 patients (81.9 percent). Of the remaining 47 patients, 36 experienced substantial improvement and 11 had only minor or no improvement. In many of the patients, pallidotomy also produced a significant reduction in bradykinesia, rigidity and levodopa-induced dyskinesias. The side effects associated with the procedure were similar to those of thalamotomy and included visual field defects, such as lower central visual field scotomas, and hemiparesis. Cognitive deficits, dysarthria and foot apraxia occurred in less than 1 percent.

If the pallidal lesion is large enough and placed at the posteroventral margin of the lateral pallidum, it abolishes the tremor as often as thalamotomy. However, because of theoretic concerns that bilateral pallidotomy may cause cognitive deficits, this approach must be explored before it is comonly used in the treatment of tremor.

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Figure 1
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FIGURE 1. Thalamic stimulation, showing position of the electrode within the thalamus and path of the wire to the pulse generator in the subclavicular pouch.

Thalamic Stimulation
During physiologic localization in preparation for thalamotomy, the observation that high-frequency stimulation of the ventral intermediate nucleus of the thalamus abolished tremor led to investigation of thalamic stimulation as a treatment for tremor. The first study of this technique as a long-term therapy for tremor was reported in 1993.19

Thalamic stimulation involves implanting an electrode in the thalamic area found to be responsible for the tremor. After the wire of the electrode leaves the skull, it is tunneled under the scalp and down the neck to a purse generator located in the subclavicular pouch (Figure 1). The implanted stimulating device is much like a modified pacemaker, and its electrical impulses can suppress tremor indefinitely. The stimulator can be reprogrammed by using a small portable computer that communicates with the device by radio frequency. Moreover, the patient can turn the device on and off with a magnet. Patients usually turn the device on in the morning, leave it on during waking hours and turn it off at bedtime, since most tremors cease during sleep.

In the first study of this technique,19 as many as 88 percent of the patients with Parkinson's disease had either good or excellent relief of tremor. The operative risk of implanting the device is proving to be similar to that of thalamotomy; death, paralysis, aphasia and significant cognitive deficits are possible complications.

Tremor recurrence after placement of the electrode can be controlled by adjusting the stimulation parameter rather than by reoperation.20 The U.S. Food and Drug Administration has approved thalamic stimulation as an accepted therapy for unilateral suppression of uncontrolled essential tremor or parkinsonian tremor in an upper extremity. As with the other surgical techniques, thalamic stimulation is an option that should be chosen only after medical therapy has failed.

Promising Surgical Approaches
At the forefront of new surgical therapies for tremor are pallidal stimulation and subthalamic nucleus stimulation.21-23 With new advances in deep brain stimulation, procedures can be performed bilaterally to relieve tremor in patients with bilateral involvement. Either a combination of thalamotomy and stimulation or bilateral stimulation without ablation is now a possibility.23 Targets in the brain that are too dangerous to approach for producing a lesion by means of thalamotomy may be treated with stimulation instead, and electrical stimulation can be modified to alleviate tremor as it progresses.22 Thus, deep brain stimulation has become a promising option for abolishing tremors that cannot be controlled by medical therapy.

The authors have received honoraria from Allergen, Inc., Medtronic, Inc., Roche Laboratories, SmithKline and Beecham Pharmaceuticals, and Upjohn Company, and research support for clinical trials from Allergen, Inc., Roche Laboratories and Medtronic, Inc.

The authors thank Dominick Doyle, Medical Arts Group, Vanderbilt University, Nashville, Tenn., for providing the drawing in Figure 1.


The Authors

P. DAVID CHARLES, M.D.,
is assistant professor of neurology and director of the movement disorders clinic at Vanderbilt University School of Medicine, Nashville, Tenn. Dr. Charles received a medical degree from Vanderbilt University School of Medicine, where he also completed a residency in neurology and a fellowship in movement disorders and neurophysiology.

GREGORY J. ESPER, B.S.,
is currently a fourth-year medical student at Vanderbilt University School of Medicine. He completed a bachelor's degree in neuroscience at the University of Pittsburgh, Pittsburgh, Pa.

THOMAS L. DAVIS, M.D.,
is associate professor of neurology at Vanderbilt University School of Medicine. Dr. Davis graduated from the University of Mississippi School of Medicine, Jacksonville, and completed a residency in neurology at Vanderbilt University and a postdoctoral fellowship in neuropharmacology at the National Institutes of Health, Bethesda, Md.

ROBERT J. MACIUNAS, M.D.,
is professor of neurosurgery at Vanderbilt University School of Medicine. Dr. Maciunas graduated from the University of Illinois, Abraham Lincoln School of Medicine, Chicago, and completed an internship in general surgery and a residency in neurosurgery at the Mayo Graduate School of Medicine, Rochester, Minn.

DAVID ROBERTSON, M.D.,
is professor of medicine, neurology and pharmacology, and director of the General Clinical Research Center at Vanderbilt University School of Medicine. Dr. Robertson graduated from Vanderbilt University and completed a residency in internal medicine at Johns Hopkins Hospital, Baltimore.

Address correspondence to P. David Charles, M.D., Director, Movement Disorders Clinic, Vanderbilt University Medical Center, 2100 Pierce Ave., Suite 352, Nashville, TN 37212. Reprints are not available from the authors.

REFERENCES

  1. Adams RD, Victor M, Ropper AH. Principles of neurology. 6th ed. New York: McGraw-Hill, 1997:94-113.
  2. Anouti A, Koller WC. Tremor disorders: diagnosis and management. West J Med 1995;162:510-3.
  3. Sandroni P, Young RR. Tremor: classification, diagnosis and management. Am Fam Physician 1994;50: 1505-12.
  4. Hallet M. Classification and treatment of tremor. JAMA 1991;266:1115-7.
  5. Physicians' desk reference: companion guide. 52nd ed. Montvale, N.J.: Medical Economics, 1998:1263-528.
  6. Burchiel KJ. Thalamotomy for movement disorders. Neurosurg Clin North Am 1995;6:55-71.
  7. Lenz FA, Normand SL, Kwan HC, Andrews D, Rowland LH, Jones MW, et al. Statistical prediction of the optimal site for thalamotomy in parkinsonian tremor. Mov Disord 1995;10:318-28.
  8. Louis ED, Ottman R, Hauser WA. How common is the most common adult movement disorder? Estimates of essential tremor throughout the world. Mov Disord 1998;13:5-10.
  9. Britton TC. Essential tremor and its variants. Curr Opin Neurol 1995;8:314-9.
  10. Koller WC, O'Hara R, Dorus W, Bauer J. Tremor in chronic alcoholism. Neurology 1985;35:1660-2.
  11. Koller WC, Lang A, Vetere-Overfield B, Findley L, Cleeves L, Factor S, et al. Psychogenic tremors. Neurology 1989;39:1094-9.
  12. McManis PG, Sharbrough FW. Orthostatic tremor: clinical and electrophysiologic characteristics. Muscle Nerve 1993;16:1254-60.
  13. Britton TC, Thompson PD, van der Kamp W, Rothwell JC, Day BL, Findley LJ, et al. Primary orthostatic tremor: further observations in six cases. J Neurol 1992;239:209-17.
  14. Gates PC. Orthostatic tremor (shaky legs syndrome). Clin Exp Neurol 1993;30:66-71.
  15. Cutson TM, Laub KC, Schenkman M. Pharmacological and nonpharmacological interventions in the treatment of Parkinson's disease. Phys Ther 1995; 75:363-73.
  16. Aminoff MJ. Treatment of Parkinson's disease. West J Med 1994;161:303-8.
  17. Jankovic J, Cardoso F, Grossman RG, Hamilton WJ. Outcome after stereotactic thalamotomy for parkinsonian, essential and other types of tremor. Neurosurgery 1995;37:680-7.
  18. Laitinen LV. Pallidotomy for Parkinson's disease. Neurosurg Clin North Am 1995;6:105-12.
  19. Benabid AL, Pollak P, Seigneuret E, Hoffman D, Gay E, Perret J. Chronic VIM thalamic stimulation in Parkinson's disease, essential tremor and extra-pyramidal dyskinesias. Acta Neurochir Suppl 1993;58:39-44.
  20. Tasker RR. Deep brain stimulation is preferable to thalamotomy for tremor suppression. Surg Neurol 1998;49:145-53.
  21. Krack P, Pollak P, Limousin P, Benazzouz A, Benabid AL. Stimulation of the subthalamic nucleus alleviates tremor in Parkinson's disease [Letter]. Lancet 1997;350:1675.
  22. Pollak P, Benabid AL, Limousin P, Benazzouz A. Chronic intracerebral stimulation in Parkinson's disease. Adv Neurol 1997;74:213-20.
  23. Jankovic J, Hamilton WJ, Grossman RG. Thalamic surgery for movement disorders. Adv Neurol 1997;74:221-33.

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 We take 15  minutes to fix any pain disorder     The Lahore Facility uses Nanotechnology

                    Read The Flame within a guide to prevent & treat autoimmune diseases by Dr Imran Khan

                                                    

                 (Nanotech trains doctors in a autoimmune fellowship, pain fellowship, & joint disease management)

                                                                         Quran states this is the book for those who can understand.

  1.            Nanotech  manufacture their own radiofrequency units for  neuralgic pain control. 2007
  2.          Nanotech develops,  Cranio Electric Stimulator to stop depression, anxiety and reverses neuropsychiatry disorders 2007
  3.                    Nanotech develops Bone Pulser for quickly increasing strength in fractured bones and healing fractures.  2008
  4.               Nanotech develops  the worlds first external epilepsy stimulator to control Epilepsy.          2008
  5.                     Nanotech develops the first Parkinsonism external deep brain stimulator                         2008
  6.         Nanotech developed electropolation  will fix any infection, wound tumor swelling in a few days  2008

                        (We are the Largest Medical  electronic equipment developer out side the Western World) Nanotech Lahore

   We learned to tame the autoimmune disease by attacking their causes, after 25  years of research in USA.  Read our e-book for details (the research is based upon published scientific papers). We  treat the root cause of the disease not the symptoms. Resulting in a end to the disease. You can request  references of the patients who are disease free or improved, from arthritis, heart disease, Parkinson, epilepsy, pains, fatigue, multiple sclerosis, fibromyalgia, hearing disorders, CIDP.

 We are light years ahead of any autoimmune clinic in the world. They way we infuse IVIg subcutaneously not only to reduce the dose but to make it more potent. Zero IVIg related side effects at our facility. The only IVIg pump being manufactured in the USA is in part by our consultation. We know how to quickly tame any autoimmune disorder by ways others doctors cannot even dream about. (Knowledge is power). Nanotech gets patients from all over the world.

Today, autoimmune conditions are causing diseases like anemia, weakness, joint pains, skin rashes, heart diseases, stomach problems, psychiatric disorders , multiple sclerosis, kidney disorders, epilepsy, Parkinsons.  Many doctors are not well informed to diagnose and treat the root cause of these conditions.  We are the first organization ready to solve autoimmune related planning and health care issues. We  have twenty years of clinical research at our finger tips and experience from the United States Public Health Service at N.I.H . The media shows infectious diseases like Bird flu, Mad Cow, SARS as greater dangers when all of them can be treated, the real problem is autoimmune diseases. The gulf war syndrome is autoimmune too! Nanotech medical Center has cured autoimmune diseases in two weeks .

 Kids with behavior disorder, drug seeking behavior or sexual devious behavior successfully treated at Nanotech.

 The first facility to treat the root cause of autoimmune disorders, with the most modern treatments is available in Lahore. No waiting you are seen in a VIP environment, in a carpeted facility at Nanotech Medical Center  in Lahore. ( 56-E2 WAPDA Town Lahore 0322-4569778 ) (seen by appointment only) Call us before coming.

Since January 2007 we announced the brand new addition of the first anti-ageing and life extension clinic in Lahore. Skin and beauty rejuvenation, brain enhancement , improved memory retrieval. Stronger bones and muscle mass. Improved libido and sexual strength.  We bypass the heart surgery and give you a stronger new heart and brain. We provide treatment for Alzheimer's  or any other autoimmune diseases. You wake up fresh everyday. Natural shiny skin without any makeup.  We grow your natural hair. We wake up the Cleopatra and Tarzan within you. Guaranteed results. The most amazing recovery is of a married young girl in Islamabad who could not here a phone ring, she went to the USA and the Los Angles hearing center told her they can only offer her a experimental replacement of the stapes bone. Then she contacted us. Within six months her hearing is back to normal, she also has no muscle pains and her skinny face now looks full and beautiful.

                                                                                  If you are planning to come to Lahore Clinic please note that in $70 a day you can get a 4-star hotel called PC-1 near our facility, the cost will include food for the day. In local currency that is about Rs. 4000 a day bed & breakfast. In Euros roughly 60 a day. This is a branch of Pearl Continental Hotels. Excellent food and outstanding rooms. Delivery and pickup from our clinic. A cab to the hotel and clinic from the airport costs Rupees 500 or dollar 10, Euro 8.

In December 2007 we have added a addiction treatment center, Memory clinic and psychiatric treatment.

Men do you have a  low libido, low general and sexual drive, erection problems, high weight, mood swings, depression and difficulty in the ability to concentrate. Then call us for HELP. Open 7 days a week  at Nanotech.

We remove kidney stones without a stone busters or surgery just plain old herbs. Guaranteed results.

Do not remove a Cataract call us for non surgical treatment and no surgery. Did I tell you cataract surgery can be followed by vision loss!

Women who have constant fatigue, pains, stiff joints, loss of sleep or stress we can help you right away.

                                                                                                  Kalash  women   More pictures of Women in Pakistan

Homeopathic, alternative, allopathic, holistic, aroma treatment, light therapy, magnetic treatment, (we have them all)

We have completely reversed Parkinson  disease in a prominent businessman in Lahore.

Fixed Epilepsy in children , women and men. A man who used to jerk all the time stopped jerking and got married.

Complete reversal of Vasculitis, Multiple Sclerosis, Depression, Epilepsy, Headaches, Alzheimers

Complete reversal of CIDP , neuropathy, GBS,

Complete reversal of arthritis, joint disorders, muscle weakness

Complete reversal of skin lesions , make your face more beautiful

Complete reversal of fatigue, pains, epilepsy, tremors, anxiety , depression by our unique ECT & CMS treatments. These treatments would cost you a 100.000 in USA we provide these at a fraction of their cost here.


We provide internet based medical consultations. Main office located in 56-E2 WAPDA TOWN LAHORE. Pakistan tele: 0322-4569778 

NO unnecessary tests like labs, MRI or CT scans . A diagnosis on the first visit! Treatment starts from the day you visit. Every patient saves money as our physicians are USA trained Board Certified with 20 years experience. We provide cancer treatment, kidney stone removal, joint treatment all without any surgery. If no other doctor can diagnose you the please visit us and get a diagnosis. We treat psychiatric and anxiety, tension related problems.

If you have weakness, skin problems, fatigue, sex disorders, sleep disorders this is the place to come.

We have received Multiple awards, including one from the President of USA, another from  surgeon General of USA. From university of Arizona and other one for helping poor farm workers and other awards for teaching from government institutions.


                     We offer Treatment for  All Autoimmune disorders. Specially Fibromyalgia, Chronic Fatigue syndrome, CIDP, joint pains, cardiac and skin diseases. We make you young again . If you have a undiagnosed condition then we have an answer for you. 

FibromyaIgia, Chronic Fatigue, weakness, tiredness, forgetfulness are all treated.

Satisfaction Guaranteed. Most western Insurance companies will cover the cost. Our cost is lower then the deductible of most insurance companies in the USA. Get a internet based consultation.

Central Location for easy access for patients in Dubai, Africa, Middle East , Asia and Australia

Evaluation, Examination, Blood Tests, Medications, Supplements, Diet recommendations in one place, at one price. No lines no waiting you get VIP treatment. Buy our e-book for complete treatment guidelines with FDA approved drugs. (From literature available in the National Library of Medicine Washington DC.

Twisted ankle, locked knee, ankle , frozen shoulder and spinal pain fixed within 24 hours without surgery in 99% of our cases.

More advanced than any clinic in Singapore, Dubai , UK or USA.   Why , we can treat MRSA, Alzheimers, Hepatitis, all autoimmune disorders, complete heart disease and stroke prevention, Complete diet guidelines, all in one place. No second opinion needed, no poly pharmacy, no testing just treatment.

 
    American Board Certified Physicians

Lahore Clinic activities

In our clinic at Lahore we have treated patients who were could not be helped by doctors in many western countries suffering from autoimmune disorders..

 

 
    Following are true reports

Case 1: A young girl from UK, who was not diagnosed doctors in UK thought she has  MS. She is doing well and her diagnosis was Fibromyalgia.

Case 2: A girl from USA who could not hear, she  was told to get a transplant in the House Ear Institute is a world-renowned hearing center in Los Angles USA, she has recovered without surgery,  on anti inflammatory treatment.

Case 3: A boy from UK who was suffering from muscle spasms and odd movements in the calf, e had seen several doctors in UK was without a diagnosis.  He was diagnosed as muscle fasciculation syndrome. His left calf muscle would have rippling movements.

Case 4: A girl from Dubai who was diagnosed as Myofacial pain. She is back to normal.

Case 5: A girl from Lahore who had not been to school for a year as she had fatigue and daily fevers she was diagnosed as Takayasu and is back at school within two weeks of treatment.

Case 6: A 9 year old from Lahore who had poor grades at school and was not doing well. Within two weeks he is among the best students in his class. He had attention deficit disorder.

Case 7: A old man with Parkinson's and multiple stokes who could not walk. He is active and walks.

Case 8: A old woman from Lahore who could not walk due to arthritis and had intention tremor. She is back at walking without any tremor  or joint problems.

Case 9 : A young man suffering from Anxiety who could not work. Is currently fully recovered and got a promotion.

Case 10: A 75 year old with multi vessel disease cardiac disease is fully recovered and independent with our oral chelation.

Case 11: A Alzheimer's patient from Germany.

Case 12 : A CIDP patient from Bangladesh who responded to intramuscular IVIG.

Case 13: A wheelchair bound woman from Sahiwal who was told by every neurologist in the City that she could not walk. She stood up one month after we started her treatment.

Case 14: 82 year old retired man who came in wearing two neck collars, treated with a TP injection and he threw away his neck collars.

Case 15: Three uncontrolled epilepsy patients, one a child all are doing well. The first one with Myoclonic epilepsy went one month without any drugs on a electrical stimulator. The second a child with

Case 16 Woman with swelling around eyes due to Thyroiditis resolved in 30 minutes

Case 17 Novartis Medical Doctor in Pakistan intense eye pain and severe red eye resolved in 30 minutes

Case 18 CIDP In a young pharmacy rep of USB in Pakistan resolved with drug cost of 1000 rupees.

Case 19 A basket ball player with severe neck pain which came on after a dunk, resolved in one hour. (NBA take note) We have the technology to heal  a severely hurt athlete in 30 minutes.

Case 20 A young man with low neck pain and weakness in arms, came with a MRI showing disc disease and was thinking of ozone surgery as recommended by a neurosurgeon. The pain and weakness resolved with trigger point injection in 5 minutes.

Case 21 A 45 year old who was not walking for 3 years due to knee pain, fixed in 15 minutes and the patient walked out of the clinic. Her husband is a mechanical engineer in a local grid station. If you want to talk to him send us a email.

Case 22 A girl with skin disorder walked in, she had not been diagnosed for last 10 years. She got a diagnosis Scleroderma. Is on treatment.

Case 23 A 18 year old who would not obey his parents and would not go to college. Was turned around in one month.

Case 24  A 50 year old well built laborer who had neck pain and numb index & middle finger of left hand and  could not work  for 3 months while under treatment by doctors in Jinnah hospital Lahore. With nano pulse and TPI  at Nanotech after two days he has been released to return to work.

Case 24 A 57 year old Income Tax Commissioner from Lahore , who was diagnosed by a Mayo Hospital neurologist as a L-4 disc on examination had Transverse Myelitis, with nanotech pulser he improved within 30 minutes.

 
                  We treat all joint disorders without surgery.  You can send us a email asking us if we can help you please provide all details. Until the doctor has examined you and gone over your history we cannot say if we can help you or not. There are patients who cannot afford to travel to Lahore, for them we will do a remote consultation if they pay by paypal or bank draft in advance. See our services section. For a full consultation from overseas a $ 50 consult fees is charged. Rupees 500 for first 15 minute consultation for local population. For remote consultation we cannot examine or provide physical treatment, for that we depend on local doctors. Trigger point injection Rs 500 each point.

    Diseases Treated at our facility include the following.

If you have any chronic diseases then we have a treatment, does the disease come in attacks and do you sometimes feel better?

                    Arteriosclerosis Heart Disease, preventative treatment and we reduce cholesterol without drugs!

                    Neuropathies including CIDP GBS ( weakness , numbness in hands and  feet)

                    Memory Disorders , Alzheimers , forget names of people, forget keys, wallet, forgets to take medicine

                    ALS, Parkinsons, Multiple Sclerosis

                    AIED autoimmune hearing loss, vertigo or noises in the ear

                    Chronic Fatigue and Fibromyalgia, Arthritis, Gulf war Syndrome

                    Myocarditis, Heart Failure, swelling in legs, difficulty breathing

                    PTSD, stress, tension,  Neuropsychiatric Disorders, depression, anxiety, attention deficit disorder

                    Epilepsy (treat the cause, with the least medication.) odd feelings ,

                    Chronic Pain, Back pain , twisted ankle, frozen shoulder, wrist pain, (No need of surgery)

                    Sleep Disorders, Narcolepsy (excessive sleep disorder). dreams, sudden onset of sleep while driving,

                    Sexual disorders ( Male erectile dysfunction) premature ejaculation,

                    Asthma, chronic bronchitis, difficulty breathing

                    Hepatitis inflammation of the Liver

                    Prostates inflammation and enlargement , bladder inflammation (without surgery)

                    Gall bladder stones

                    Inflammation in the stomach, intestines or rectum,  Crohn's disease or Ulcerative colitis

                    Irritable Bowel Syndrome  ( alternating constipation and diarrhea)

                            For appointment please contact

                    Chronic Lyme disease 

                   Obsessive compulsive disorder ( is a autoimmune disorder)

                   Sudden onset of hearing disorders, vertigo- dizziness, nausea, buzzing sounds in ear

                    Multiple Sclerosis     ( Brand new protocol , low cost)  without interferon's or IVIg!

                   Sudden onset of visual disorders

                   Lambert-Eaton Syndrome

                   Myasthenia Gravis, weakness

                   Stiff-Person Syndrome, feeling of tightness and stiffness in muscles

                   Parkinsons disease any stage

                   Sydenham chorea rapid uncontrolled hand and arm movements

                   Huntington chorea, uncontrolled movements

                   Rheumatoid arthritis & all of arthritis variants

                   Ankylosing Spondylitis (AS)  Back pain

                   Scleroderma tight skin, weakness

                   Osteoarthritis (OA), is currently considered a autoimmune disorder ( read our e-book)

                   Psoriasis , skin rash, joint pains, numbness, dry tongue

                   Reactive Arthritis and Reiter's Syndrome, joint pains

                   Scleroderma CREST  ( skinny women who have difficulty swallowing) tight skin, skinny

                   Autoimmune Vasculitis , strokes, headaches

                   Giant Cell Arteritis ( old woman with headaches)

                  Takayasu arteritis ( blue hands and feet, reduced pulses) weakness

                  Behcet's Disease   anal or mouth ulcers , weakness

                  Churg-Strauss Syndrome (CSS)  rash, weakness

                  Wegeners  sinus problems, kidney problems, strawberry gums

                  Dermatomyositis & Polymyositis  weakness shoulders / legs

                  Sjogren's  (dry mouth and dry eyes, dry vagina may cause the husband to have penile lesions after sex)

                  SLE or Lupus  red rash on face

                  Antiphospholipid syndrome (Infertility, recurrent abortion)

                  Porphyria  Do you have passing out spells, abdominal pain

                  We treat MRSA, Hepatitis, or whatever infection you may have.  Do you have a untreatable infection?

                 We treat all types of Medical, psychiatric and physical disorders.

                 We cover all autoimmune disorders including skin conditions and infertility.

                 Clinic Time  9-am  - 1 PM morning       5pm- 8 pm evening

                 Charge for consultation  Rs 500/ per 15 minutes  consultation.  Injection of Trigger point is 200/ per trigger point. If we inactivate five trigger points in one injection the cost is 1000 rupees.

   Please check the contents of the E-Book,  and Dr Khans picture" The Flame Within" Published by CIDPUSA press.

  Our treatments in Lahore are based upon Quranic Shifa.  Please read the link.

 Tele Medicine is used to provide our expertise, so we will do remote consultations based upon the internet or phone by prepayment anywhere .

  For more information please contact    (Quran says mankind is poor,  Allama Iqbal states help the poor, no money we still help)

 Call us for references: Our doctors have delivered talks worldwide, call us before coming to the center.

www.cidpusa.org  www.cidpusa.org/P/ivig.htm  http://www.cidpusa.org/disease.html http://www.cidpusa.org/Lahore.html   hair loss tips