Peripheral electrical stimulation to reduce pathological tremor: a review

Alejandro Pascual-Valdunciel, Grace W Hoo, Simon Avrillon, Filipe Oliveira Barroso, Jennifer G Goldman, Julio C Hernandez-Pavon, José L Pons, Alejandro Pascual-Valdunciel, Grace W Hoo, Simon Avrillon, Filipe Oliveira Barroso, Jennifer G Goldman, Julio C Hernandez-Pavon, José L Pons

Abstract

Interventions to reduce tremor in essential tremor (ET) and Parkinson's disease (PD) clinical populations often utilize pharmacological or surgical therapies. However, there can be significant side effects, decline in effectiveness over time, or clinical contraindications for these interventions. Therefore, alternative approaches must be considered and developed. Some non-pharmacological strategies include assistive devices, orthoses and mechanical loading of the tremorgenic limb, while others propose peripheral electrical stimulation. Specifically, peripheral electrical stimulation encompasses strategies that activate motor and sensory pathways to evoke muscle contractions and impact sensorimotor function. Numerous studies report the efficacy of peripheral electrical stimulation to alter tremor generation, thereby opening new perspectives for both short- and long-term tremor reduction. Therefore, it is timely to explore this promising modality in a comprehensive review. In this review, we analyzed 27 studies that reported the use of peripheral electrical stimulation to reduce tremor and discuss various considerations regarding peripheral electrical stimulation: the stimulation strategies and parameters, electrodes, experimental designs, results, and mechanisms hypothesized to reduce tremor. From our review, we identified a high degree of disparity across studies with regard to stimulation patterns, experimental designs and methods of assessing tremor. Having standardized experimental methodology is a critical step in the field and is needed in order to accurately compare results across studies. With this review, we explore peripheral electrical stimulation as an intervention for tremor reduction, identify the limitations and benefits of the current state-of-the-art studies, and provide ideas to guide the development of novel approaches based on the neural circuitries and mechanical properties implied in tremor generation.

Keywords: Afferent fibers; Electrical stimulation; Essential tremor; Neural circuitry; Parkinson’s disease; Stimulation parameters; Tremor.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flow diagram of screening process and identifying final papers included in this review
Fig. 2
Fig. 2
Stimulation strategies. a Out-of-phase stimulation. Tremorgenic bursts are detected in the recording window EMG (gray lines) and future tremorgenic bursts are predicted during the stimulation window (red and blue lines). Stimulation is then applied to the antagonist (red and blue colored rectangles) out-of-phase with respect to the activity in each target muscle during a stimulation window (adapted figure from Dosen et al. [16]). b Continuous stimulation. Electrical stimulation is applied during the entire stimulation window (green colored rectangle) without following any time pattern
Fig. 3
Fig. 3
Stimulation parameter scatter plot. a Frequency vs. stimulation intensity. b Pulse width vs. stimulation intensity. Red dots represent studies using electrical stimulation of afferent pathways. Yellow dots represent studies using FES. Studies testing multiple stimulation parameters are represented by multiple dots. Studies performed by the same research group or replicating the same conditions are represented by the same dot. Note that four studies used stimulation of afferent pathways with stimulation intensity above motor threshold. ***Not described in paper
Fig. 4
Fig. 4
a The tremorgenic input is generated by a central brain oscillator and projected to the motor neuron pools monosynaptically via the corticospinal tract and disynaptically via interneurons. Several strategies to reduce tremors have been proposed: b functional electrical stimulation on the nerve or the muscle belly to elicit antagonist muscle forces and increase the joint impedance, c stimulation of Ia afferent fibers to decrease the excitability of the antagonist pool of motor neurons and alter the transmission of the tremorgenic input, and d stimulation of cutaneous afferent fibers to inhibit the interneurons and alter the disynaptic transmission of the tremorgenic input

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