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Therapeutic Advances in the Treatment of Holmes Tremor: Systematic Review
Kai-Liang Wang1, Joshua K Wong2, Robert S Eisinger2
1Department of Neurology, Program for Movement Disorders and Neurorestoration, Fixel Institute for Neurological Diseases at the University of Florida, Gainesville, FL, USA; Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
Insights
Deep brain stimulation (DBS) offers superior tremor suppression for Holmes tremor (HT) compared to medical treatments. This review proposes a practical algorithm for managing HT, highlighting the need for further collaborative research due to variable treatment responses.
Area of Science:
- Neurology
- Neurosurgery
Background:
- Holmes tremor (HT) presents a management challenge due to variable responses to current treatments.
- A lack of randomized controlled trials complicates clinical decision-making for HT.
Purpose of the Study:
- To develop a practical clinical treatment algorithm for Holmes tremor (HT).
- To systematically review and synthesize evidence on pharmacological and surgical interventions for HT.
Main Methods:
- A systematic review of 58 studies (1990-2018) examining 89 HT patients.
- Data analysis focused on pharmacological treatments and deep brain stimulation (DBS) outcomes.
- Clinical outcomes were assessed using a 1-10 ranked scale.
Main Results:
- Deep brain stimulation (DBS) demonstrated superior tremor suppression compared to medical interventions (p=0.025).
- Globus pallidus internus (GPi) DBS showed greater efficacy for resting tremor (p=0.042) and overall tremor reduction (p=0.022).
- Levetiracetam, trihexyphenidyl, and levodopa were common medical treatments; VIM and GPi were primary DBS targets.
Conclusions:
- A range of medical and surgical options exist for HT management, with DBS showing significant benefits.
- The variable response to treatments underscores the need for collaborative research to advance understanding and treatment strategies for HT.
- A practical treatment algorithm for HT is proposed based on current evidence.
Objective:
We aimed to formulate a practical clinical treatment algorithm for Holmes tremor (HT) by reviewing currently published clinical data.
Materials And Methods:
We performed a systematic review of articles discussing the management of HT published between January 1990 and December 2018. We examined data from 89 patients published across 58 studies detailing the effects of pharmacological or surgical interventions on HT severity. Clinical outcomes were measured by a continuous 1-10 ranked scale. The majority of studies addressing treatment response were case series or case reports. No randomized control studies were identified.
Results:
Our review included 24 studies focusing on pharmacologic treatments of 25 HT patients and 34 studies focusing on the effect of deep brain stimulation (DBS) in 64 patients. In the medical intervention group, the most commonly used drugs were levetiracetam, trihexyphenidyl, and levodopa. In the surgically treated group, the thalamic ventralis intermedius nucleus (VIM) and globus pallidus internus (GPi) were the most common brain targets for neuromodulation. The two targets accounted for 57.8% and 32.8% of total cases, respectively. Overall, compared to the medically treated group, DBS provided greater tremor suppression (p = 0.025) and was more effective for the management of postural tremor in HT. Moreover, GPi DBS displayed greater benefit in the resting tremor component (p = 0.042) and overall tremor reduction (p = 0.022).
Conclusions:
There is a highly variable response to different medical treatments in HT without randomized clinical trials available to dictate treatment decisions. A variety of medical and surgical treatment options can be considered for the management of HT. Collaborative research between different institutions and researchers are warranted and needed to improve our understanding of the pathophysiology and management of this condition. In this review, we propose a practical treatment algorithm for HT based on currently available evidence.
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