Objective: To assess the functional benefit of ultrasound-guided treatment with botulinum toxin type A in patients with action tremor of the upper limb.

Background: Action tremor of the upper limbs can be extremely disabling. Current oral treatments are often unsatisfactory, either because of limited benefit, contraindications for usage or adverse events. Botulinum toxin treatment is recommended for treatment of essential tremor of the upper limb in selected cases and has been reported to be useful for other types of tremor, including that of  Parkinson’s disease. Ultrasound-assisted injections increase the accuracy of muscle targeting while minimizing damage to adjacent structures.

Method: Nine patients with bilateral upper limb tremor, aged 27 to 91 years (median 74 years), were referred for treatment with botulinum toxin, after failure of or contraindications to oral medication. 
Six patients suffered from essential tremor, two from a cerebellar-type tremor and one from Holmes tremor.
Patients were treated with botulinum toxin type A delivered to selected muscles of one of the upper limbs under ultrasound guidance. Specific goals of treatment were discussed and established with each patient before treatment. Selection of muscles was performed according to the segment(s) and pattern of movement associated with tremor. Pre-and post-treatment evaluations were performed through Goal attainment scaling (GAS) after 1 to 3 treatments (not less than 12 weeks apart) with botulinum toxin.

Results: The average total dose of 119U for Abobotulinumtoxin A (5 cases) and 81U for Onabotulinumtoxin A (4 cases). 
Treatment resulted in funcional benefit for patients in all but one case (average GAS change 18,7, ranging from 0 to 24,8). One patient suffered mild transient paresis of one finger, with no functional repercussion.
In two patients with essential tremor, who suffered from previous paresis of the treated upper limb (due to myeloradiculopathy or  surgery for intracranial tumor), treatment was effective with no worsening of paresis.

Conclusion: Ultrasound-guided botulinum toxin treatment of action tremor may be an effective treatment for disabling action tremor of the uper limb. The authors suggest that, in carefully selected cases,  this treatment may be useful even in the presence of previous weakness from other causes.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/ultrasound-guided-treatment-of-action-tremor-of-the-upper-limb-with-botulinum-toxin/