Case Study 2
Subject: The patient is a 52-year–old right-handed woman with no relevant medical history, besides the specified below, who complains of tremor in both hands since 5 years ago. She is referred from neurology outpatients' clinic to NeuroTREMOR Clinic.
History of present illness: The patient states she has always had some degree of tremor in her hands and that this tremor increases when she performs activities like holding a cup of water or holding anything with some weight. Initially she had tremor just in her left hand but since 2 years ago she notices tremor in her both hands and some times in her head.
She does not have any problems walking or with her balance, she does not have any parkinsonian symptom. She has been treated sith some medications but had to quit to take them because they worsened her asthma symptoms (beta blockers) or caused excessive drowsiness and sleepiness (primidone and pregabaline). She is very anxious because she works cleaning in a house and she says that her symptoms are very evident for her boss and she is afraid this could impair her in the future.
Past medical history: 1. Dyslpemia 2. Asthma Medications: - Salbutamol inhaler QD - Ipatropium Bromure inhaler QD Allergies:None. Social history:The patient lives with her couple and one 15-year-old kid. She works as house cleaner. Smoker of 10 units /day /year. Family history: Her mother had strong postural tremor, probably essential tremor. Review of systems: Non relevant. General physical examination: The patient is thin and well appearing. Temperature is 36.5, blood pressure is 135/80, and pulse is 70. There is no proptosis, lid swelling, conjunctival injection, or chemosis. Cardiac exam shows a regular rate and no murmur. Neurologic examination Mental status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming. She recalls 3/3 objects at 5 minutes. Cranial nerves: CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 4 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally. CN III, IV, VI: At primary gaze, there is no eye deviation. Normal ocular movements. Pupils symmetric and reactive. CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact. CN VII: Face is symmetric with normal eye closure and smile. CN VII: Hearing is normal to rubbing fingers CN IX, X: Palate elevates symmetrically. Phonation is normal. CN XI: Head turning and shoulder shrug are intact CN XII: Tongue is midline with normal movements and no atrophy.
Motor: There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally.
Deltoid | Biceps | Triceps | Wrist extension | Finger abduction | Hip flexion | Hip extension | Knee flexion | Knee extension | Ankle flexion | Ankle extension | |
L |
5 |
5 |
5 |
5 |
5 |
5 |
5 |
5 |
5 |
5 |
5 |
R |
5 |
5 |
5 |
5 |
5 |
5 |
5 |
5 |
5 |
5 |
5 |
Reflexes: Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles. Plantar responses are flexor. Sensory: Light touch, pinprick, position sense, and vibration sense are intact in fingers and toes. Coordination: Fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. Romberg is absent. Gait/Stance: Posture is normal. Gait is steady with normal steps, base normal, arm swing normal, turning normal. Heel and toe walking are normal. Tandem gait is normal when the patient closes one of her eyes. Extrapiramidal exam: Moderate postural tremor in both arms when outstretched, increases with weights and tasks. Rapid alternating movements normal, finger tapping normal but slightly interfered by tremor in left hand. No rigidity in passive movements of left arm. Laboratory Data: - Blood tests: blood cells count normal, blood lipidic profile normal, thyroid hormones normal. - MRI: No pathological findings. There are no signal abnormalities in the brain stem or in the corpus callosum. No abnormalities in orbits, sinuses, or venous structures. Initial Assessment: In summary, the patient is a 52-year-old woman with postural tremor in both hands not accompanied with any Parkinsonian symptom. The patient fulfils all the criteria for Essential tremor diagnosis at the moment but she has not experienced any benefit form current treatments available because she has asthma that may be aggravated by beta-blockers intake. She has tried primidone and some other antiepileptic drugs with well known anti tremoric effect but she has suspended the treatment due to adverse effects and lack of efficacy. We proposed her to try a new therapeutic approach for her problem and she accepted excited this new possibility. Plan: Patient was included in NeuroTREMOR Study for tremor assessment and treatment with afferent stimulation.
Hospital Based Platform Impact
This patient had a clear diagnosis of Essential tremor and was not analysed in our system. We did not have doubts about her diagnosis.
Neuroprosthetic Platform Impact
The clinical assessment of the neuroprosthetic system usage in this patient showed that there was not a remarkable and clinically evident suppression from the neurostimulation
|
Diagnosis |
Phase 1 |
Phase 2 |
Phase 1 - Phase 2 % score change |
Tremor items score |
Patient 3 |
ET |
29(EFT) |
29(EFT) |
0 |
8 |
The effect of stimulation of this patient was very mild, but the patient was very happy with the usability and wearability of the system, she did not experienced any discomfort or pain during stimulation and was willing to collaborate in further experiments.
Conclusion In this case the diagnostic platform was not necessary because we had a clear diagnosis but instead we had a patient that had no effect from all the prescribed medications. She was willing to collaborate and happy to se the interest of our group in offering her a less invasive option for treatment. She was offered to be a deep brain stimulation candidate, but is reluctant to the invasiveness of the procedure. This is a good example of the type of patients that our system could help when the efficacy in the clinical level is achieved.