Journal of Clinical Medicine Article Treatment of Dystonic Tremor of the Upper Limbs: A Single-Center Retrospective Study Belén González-Herrero 1,2, *,† , Ilaria Antonella Di Vico 3,† , Erlick Pereira 1 , Mark Edwards 4 and Francesca Morgante 1,5 1 Neurosciences Research Centre, Molecular and Clinical Sciences Institute, St. George’s University of London, London SW17 0RE, UK 2 Departamento de Medicina, Universidad Autónoma de Barcelona (UAB), 08193 Barcelona, Spain 3 Neurology Unit, Movement Disorders Division, Department of Neurosciences Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy 4 Department of Clinical and Basic Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK 5 Dipartimento di Medicina Clinica e Sperimentale, University of Messina, 98122 Messina, Italy * Correspondence: bgonzale@sgul.ac.uk † These authors contributed equally to this work. Abstract: Tremor is part of the phenomenological spectrum of dystonia. Treatments available for tremor in dystonia are oral medications (OM), botulinum neurotoxin (BoNT), and brain surgery (deep brain stimulation or thalamotomy). There is limited knowledge regarding the outcome of different treatment options, and evidence is especially scarce for the tremor of the upper limbs occurring in people with dystonia. In this single-center retrospective study, we evaluated the outcome of different treatments in a cohort of people with upper limb dystonic tremors. Demographic, clinical, and treatment data were analyzed. Dropout rates and side effects were specifically assessed, as well as the 7-point patient-completed clinical global impression scale (p-CGI-S, 1: very much improved; 7: very much worse) as outcome measures. A total of 47 subjects (46.8% female) with dystonic tremor, tremor associated with dystonia, or task-specific tremor were included, with a median age at onset of 58 years (7–86). A total of 31 subjects were treated with OM, 31 with BoNT, and 7 with surgery. Dropout rates with OM were 74.2% due to either lack of efficacy (n = 10) or side effects (n = 13). A total of Citation: González-Herrero, B.; Di 7 patients treated with BoNT (22.6%) had mild weakness, causing dropout in 2. P-CGI-S was ≤3 Vico, I.A.; Pereira, E.; Edwards, M.; (improvement) in 39% with OM, compared to 92% with BoNT and 100% with surgery. These findings Morgante, F. Treatment of Dystonic suggest good symptom control of the tremor of the upper limb in dystonia with BoNT and surgery, Tremor of the Upper Limbs: A with higher rates of dropout and side effects with OM. Randomized controlled studies are needed to Single-Center Retrospective Study. J. confirm our findings and provide further insight into better selecting suitable patients for BoNT or Clin. Med. 2023, 12, 1427. https:// doi.org/10.3390/jcm12041427 brain surgery. Academic Editor: Felix Rosenow Keywords: dystonia; tremor; dystonic tremor; botulinum toxin; deep brain stimulation Received: 23 December 2022 Revised: 5 February 2023 Accepted: 7 February 2023 Published: 10 February 2023 1. Introduction Tremor is an involuntary, rhythmic, oscillatory movement of a body part [1], and it is one of the phenomenological manifestations of dystonia. Tremor in dystonia is classified into two types: dystonic tremor (Dys-T), which occurs in body parts affected by dystonia, Copyright: © 2023 by the authors. and tremor associated with dystonia (TAD) that appears in a body part not affected by Licensee MDPI, Basel, Switzerland. dystonia in a person with dystonia located elsewhere. Classically, tremor in dystonia This article is an open access article (whether Dys-T or TAD) is variable in frequency and amplitude and exacerbated in specific distributed under the terms and conditions of the Creative Commons positions. While generally a postural and kinetic tremor, it may also occur at rest and is Attribution (CC BY) license (https:// frequently asymmetric [2,3]. Task-specific tremor (TST) is a form of action tremor that creativecommons.org/licenses/by/ occurs only or mostly when performing a specific skilled task [4], most commonly seen 4.0/). J. Clin. Med. 2023, 12, 1427. https://doi.org/10.3390/jcm12041427 https://www.mdpi.com/journal/jcm J. Clin. Med. 2023, 12, 1427 2 of 10 during writing, called primary writing tremor (PWT). Although the pathophysiology of TST is still debated, growing data favors its dystonic nature [5,6]. There are no formal guidelines for the treatment of Dys-T, TAD, and TST. In a recent placebo-controlled, parallel-group, randomized clinical trial [7] conducted on 30 subjects with dystonic hand tremor, onabotulinum toxin A significantly improved the Fahn–Tolosa– Marin Tremor Rating Scale total score. A systematic review of the available data on the treatment of Dys-T and PWT concluded that botulinum neurotoxin (BoNT) and functional neurosurgery (deep brain stimulation, DBS, and thalamotomy by radiofrequency) might be more effective than oral medications; however, there was no data on the treatment of upper limb Dys-T with BoNT and no data at all for TAD [8]. Moreover, there are no long-term follow-up data regarding the treatment of different types of tremors in dystonia. The present retrospective study aimed to evaluate the short and long-term clinical outcomes of people with Dys-T, TAD, and TST affecting the upper limbs and treated with oral medications, BoNT, and functional neurosurgery in a tertiary referral center for movement disorders. 2. Methods This is a retrospective cohort study including consecutive patients diagnosed with Dys-T, TAD, or TST affecting the upper limbs at the Movement Disorders Clinic at St. George’s Hospital, London, UK, between August 2016 and October 2021. Medical records of all participants were systematically reviewed and included all documents available from two movement disorder specialists (FM and ME) at St. George’s Hospital, London. Patients were excluded from the study if comprehensive medical records throughout follow-up were unavailable. We included all patients whose upper extremity tremor was classified as an idiopathic dystonic tremor and excluded individuals whose tremor was considered secondary. Demographic and medical history data were recorded, including sex, age at the onset of tremor, duration at first assessment, follow-up duration, and family history of movement disorders. Clinical examination was standardized and included the following aspects: assessment at resting, postural and kinetic tremor with eyes open and closed; and assessment of tremor while performing different manual tasks, including writing, using cutlery, holding a cup, typing on a keyboard and cell phone, or playing an instrument. The following clinical features were retrieved: type of tremor (Dys-T, TAD and TST), distribution (restricted to the upper limbs or present in other body districts), side of tremor, if asymmetric, presence of resting component, and predominant pattern of tremor. Patients were also asked about the daily tasks most impacted by the tremor. Data on oral treatment included the number and type of medications prescribed, side effects, and dropout rates due to inefficacy. Inefficacy was determined when patients had been on the maximum dose for at least six months, without benefit. All patients undergoing surgical and botulinum toxin treatment were treated by the same movement disorder specialist (FM). Electromyography and/or electrical stimulation guidance was used when injecting botulinum toxin whenever clinical examination did not disclose a consistent pattern of tremor, or to inject fingers, forearm flexors, or extensors. Incobotulinum toxin A (Merz Pharma GmbH & Co. KGaA, Frankfurt, Germany) was prepared by adding 1 or 2 mL of preservative-free saline into 100 U vials, and abobotulinum toxin A (Ipsen Biopharm limited, Wrexham, UK) by adding 2.5 mL of preservative-free saline into 500 U vials. We collected the following data on BoNT treatment: tremor duration at first injection, the number of injections received, treatment duration, injection interval, type of BoNT, the dose of BoNT at first and last injection, muscles injected, side effects, and dropout rates. Data from patients treated with surgery included: the type of procedure (deep brain stimulation, DBS, or radiofrequency thalamotomy), type of device, age at surgery, DBS settings, and side effects. J. Clin. Med. 2023, 12, 1427 3 of 10 A patient-completed Clinical Global Impression (CGI) rating scale was assessed for all patients, regardless of the treatment received. Our study included the modified patient- rated CGI-improvement (p-CGI-I) at the follow-up visits as an outcome measure. The scale measures improvement on a 7-point scale (1: Very much improved, 2: Much improved, 3: Minimally improved, 4: No change, 5: Minimally worse, 6: Much worse, 7: Very much worse) based on the perception of the patient regarding how much he or she had improved or worsened relative to a baseline state at the beginning of the intervention. 3. Statistical Analysis Comparisons between groups were performed using Fisher’s exact test for categorical variables and the U Mann–Whitney test for continuous variables. Grading scores were analyzed using the U Mann–Whitney test and the Wilcoxon signed-rank test for ordinal variables. The results were considered statistically significant at a 2-tailed p < 0.05. SPSS software version 28 (IBM Corp., Armonk, NY, USA) was used to perform the analysis. All data are reported as mean ± standard deviation, unless otherwise stated. 4. Results A total of 47 patients (22 female, 46.8%) were included in the study, with a median (interquartile range, IQR) age at the first assessment of 70.9 (62.3–75.9) years and tremor duration of 8.8 (3.8–28.6) years. They were followed up for a median (IQR) of 24.8 (5.3–35.6) months. A total of 33 patients had Dys-T (70.2%), 4 patients had TAD (8.5%), and 10 TST (21.3%). The tremor was postural or kinetic in all the patients, with 4 (8.5%) also having a rest component. The tremor was typically restricted to the upper limbs (70.2%), bilateral (66%), and asymmetric (96.8%). Complete demographic and clinical data are presented in Table 1. Table 1. Demographic and clinical data of subjects with dystonic tremor, tremor associated with dystonia, and task-specific tremor. n = 47 Sex (n, %) Male 25 (53.4) Female 22 (46.8) Family history of movement disorders (n, %) Negative 33 (70.2) Tremor 13 (27.7) Parkinsonism 1 (2.1) Age at onset, median (IQR), years 58.0 [41.5–67.7] Age at first assessment, median (IQR), years 70.9 [62.3–75.9] Total time follow-up, median (IQR), months 24.8 [5.3–35.6] Tremor duration at first assessment, median (IQR), years 8.8 [3.8–28.6] Type of tremor (n, %) Dystonic tremor (Dys-T) 33 (70.2) Tremor associated with dystonia (TAD) 4 (8.5) Task-specific tremor (TST) 10 (21.3) Body districts involved (n, %) Only UL 13 (27.7) UL + Legs 3 (6.4) UL + Head/Neck 11 (23.4) UL + Oromandibular 1 (2.1) UL + Voice 4 (8.5) Laterality (n, %) Monolateral 31 (66) Bilateral 16 (34) Asymmetric 30 (97.9) Data are presented as numbers (n, %) for categorical variables and median (interquartile range, IQR) for contin- uous variables. Dys-T = dystonic tremor; TAD = tremor associated with dystonia; TST = task specific tremor; UL = upper limbs. J.J. Clin. Clin. Med. Med. 2023, 2023, 12, 12, 1427 x FOR PEER REVIEW 44 of 10 of 10 A total A total of of 43 43 patients patients (91.5%) (91.5%) received received treatment treatment of of multiple multiple types; types; 44 did did not, not, due due to to personal preference or mild presentation. Throughout the period of follow-up, 31 personal preference or mild presentation. Throughout the period of follow-up, 31 (72.1%) (72.1%) received oral medications, received medications, 3131 (72.1%) (72.1%)BoNT, BoNT,and and77(16.3%) (16.3%)underwent underwentsurgery surgery(6(6DBS, DBS,1 1thalamotomy). thalamotomy). 4.1. 4.1. Treatment Treatment with with Oral OralMedication Medication AA total totalofof3131patients patients(72.1%) (72.1%) were were treated with treated at least with one one at least oral oral medication ± 1.1). (1.74 (1.74 medication ± Considering 1.1). Considering patients utilizing patients all oral utilizing allmedications together, oral medications 23 (74.2%) together, dropped 23 (74.2%) out dueout dropped to either due toside effects either side(41.9%), effects most commonly (41.9%), drowsiness most commonly and lightheadedness, drowsiness or inefficacy and lightheadedness, or (32.3%). Still, despite some improvement, 5 patients required combined therapy inefficacy (32.3%). Still, despite some improvement, 5 patients required combined therapy with BoNT (4, with 12.9%) BoNTor(4,surgery 12.9%) (1, 3.2%) to(1, or surgery achieve 3.2%) to satisfactory benefits. Individualized achieve satisfactory benefits benefits. Individualized and side-effect percentages resulting from the different oral medications are benefits and side-effect percentages resulting from the different oral medications are sum- summarized in Figure in marized 1. Figure 1. Figure 1. Effect Figure 1. Effectofoforal medications oral for dystonic medications tremor tremor for dystonic of the upper limbs. of the Thelimbs. upper most frequently The most prescribed frequently oral medications prescribed for tremor were oral medications propranolol for tremor (64.5%), primidone were propranolol (38.7%), and (64.5%), primidone gabapentin (38.7%), (25.8%). and gabapen- Benefits were tin (25.8%). only reported Benefits with were only propranolol reported with (35%) and primidone propranolol (35%) and (8%). Topiramate, primidone (8%). clonazepam, Topiramate, clonazepam, trihexyphenidyl, trihexyphenidyl, and levodopa, and levodopa, were were either either ineffective or ineffective caused sideoreffects caused(topiramate side effectsin(topir- 20%, amate in 20%, clonazepam in clonazepam in 25%, and trihexyphenidyl 25%, and trihexyphenidyl in 25%). in 25%). 4.2. 4.2. Treatment Treatment with with BoNT BoNT The decision to treatwith The decision to treat withBoNT BoNTwas wasmade made inin3131 patients patients (72.1%), (72.1%), andand 19them 19 of of them had had taken taken oral oral medication medication previously, previously, without without satisfactory satisfactory outcomes. outcomes. OutOut of subjects, of 31 31 subjects,26 26 (83.9%) (83.9%) were were stillstill receiving receiving thisthis treatment treatment at theatlast thefollow-up. last follow-up. A totalAoftotal of 2 patients 2 patients showed showed handgriphandgrip weaknessweakness and did not and didtonot want want the continue to continue treatment,the treatment, 1 had 1 had an an intercurrent in- stroke tercurrent stroke affecting the previously injected arm, and 2 patients were affecting the previously injected arm, and 2 patients were lost to the follow-up. Figure 2 re- lost to the follow-up. ports the mainFigure 2 reports tremor patternthe mainthe during tremor pattern execution during of the the tasks manual execution of the identified asmanual goals of tasks identified as goals of the BoNT treatment in each patient. These therapeutical the BoNT treatment in each patient. These therapeutical goals included high dexterity activi- goals included high dexterity activities (19.2%), holding a cup (65.4%), writing ties (19.2%), holding a cup (65.4%), writing (34.5%), and using cutlery (19.2%). (34.5%), and using cutlery (19.2%). The median (IQR) tremor duration at first injection was 8.8 (4.9–23.7) years, and the median (IQR) treatment duration with BoNT was 27.7 (4.8–34.5) months. The mean interval within injections was 4.8 ± 1.7 months. EMG and/or electrical stimulation were employed to optimize the injection in 8 subjects (25.8%). Abobotulinum and incobotulinum toxins were similarly used (57.5% vs. 42.3%, re- spectively). Patients underwent, on average, 4.5 ± 3.3 injection sessions. Table 2 shows the muscles injected. The incobotulinum toxin dose was significantly higher at the last injection (68.6 ± 35.7) compared to the first injection (50.8 ± 26.1) (p = 0.03). The dose of the first (271.3 ± 196.8) and last injection (250 ± 164.1) with abobotulinum toxin was comparable (p = 0.43). Figure 2. Main pattern of dystonic tremor of the upper limbs. Pronosupination was the most frequent tremor pattern observed while performing the most affected manual task. taken oral medication previously, without satisfactory outcomes. Out of 31 subjects, 26 (83.9%) were still receiving this treatment at the last follow-up. A total of 2 patients showed handgrip weakness and did not want to continue the treatment, 1 had an intercurrent stroke affecting the previously injected arm, and 2 patients were lost to the follow-up. Figure 2 re- J. Clin. Med. 2023, 12, 1427 ports the main tremor pattern during the execution of the manual tasks identified as goals of 5 of 10 the BoNT treatment in each patient. These therapeutical goals included high dexterity activi- ties (19.2%), holding a cup (65.4%), writing (34.5%), and using cutlery (19.2%). Figure2.2. Main Figure Mainpattern pattern ofofdystonic dystonictremor tremorofofthe theupper upperlimbs. limbs.Pronosupination Pronosupination was was the themost mostfrequent frequent tremor pattern observed while performing the most affected manual task. tremor pattern observed while performing the most affected manual task. Table 2. Type of botulinum toxin, injected muscles, and botulinum toxin dose. Abobotulinum Toxin/A (Units) Incobotulinum Toxin/A (Units) Muscles injected (n, %) n = 31 Pronator teres 18 (58.0) 78.0 ± 26.9 23.1 ± 9.6 Longus supinator 21 (67.7) 76.7 ± 26.7 22.8 ± 9.0 Biceps 8 (25.8) 83.7 ± 41.4 30.0 ± 10.0 Triceps 11 (35.5) 101.7 ± 28.6 20 ± 0.0 Flexor carpi radialis 3 (9.7) 20 30 ± 14.14 Flexor carpi ulnaris 3 (9.7) 55 ± 7.0 30 Extensor carpi radialis 2 (6.4) - 30 ± 20 Teres major/minor 3 (9.7) 80 ± 40 - Flexor superficialis digitorum 3 (9.7) 40 30 ± 0.0 Flexor profundus digitorum 3 (9.7) - 30 ± 17.32 Data are presented as numbers (n, %) for categorical variables and mean ± SD for continuous variables. The most frequently injected muscles were the pronator teres, longus supinator biceps, and triceps. A total of 7 subjects (22.6%) exhibited transitory weakness (4 with abobotulinum toxin, causing dropout in one, and 3 with incobotulinum toxin, causing dropout in one). The duration of side effects was comparable between the two formulations of BoNT (abobotulinum toxin: 20 (IQR, 10–90) days; incobotulinum toxin: 20 (IQR, 7–60) days, U Mann–Whitney p = 0.4). 4.3. Treatment with Functional Neurosurgery A total of 7 patients (14.9%) were treated with brain surgery, 6 with DBS, and 1 with unilateral radiofrequency thalamotomy in the VIM nucleus. St. Jude Medical Infinity direc- tional DBS leads (Abbott Neuromodulation, Austin, TX, USA), spaced at 1.5 mm apart, were implanted bilaterally in all patients receiving DBS. The ventralis intermedius (VIM) nucleus of the thalamus and caudal zona incerta (cZI) were dual-targeted using classic anterior com- missure, posterior commissure (ACPC) stereotactic coordinates (x = +/−13, y = −4, z = 0). The tips of the electrodes were positioned in the cZI (posterior subthalamic area). The rationale for deciding to use unilateral thalamotomy instead of DBS in the 1 patient was age (she was over 80 years old), and the tremor predominantly affected the right side of the body. She had some balance difficulties predating the surgery, and her expectations were gaining independence in the basic activities of daily living, such as holding cutlery and holding a stick when walking. The increased risk of bilateral DBS surgery and the unnecessary burden of attending subsequent programming sessions favored thalamotomy over DBS. All patients treated with brain surgery had previously received treatment with oral medications, without benefit. None of them had received BoNT injections before surgery. J. Clin. Med. 2023, 12, 1427 6 of 10 The average age at surgery was 70.8 ± 8.5 years, and the median (IQR) tremor duration was 23 (9–42) years. The follow-up median (IQR) time was 29.1 (14.9–47.9) months. A total of 2 patients had chronic stimulation-induced side effects (dysarthria and balance disturbances). The patient with thalamotomy exhibited balance disturbances predating surgery, which transitorily worsened after surgery. She recovered and reached her baseline three weeks after surgery. Clinical data and DBS settings at the last follow-up are collated in Table 3. Table 3. Subjects with dystonic tremor and task-specific tremor treated with functional neurosurgery. Disease Side Effects with Current Age at Onset Gender/Age Type of Tremor Duration at DBS Settings DBS Settings or after (Years) Surgery (Years) Thalamotomy Left: 1-, case+, Mild stimulation induced Dystonic 60 mcs,130 Hz, 2 mA Male, 63 20 43 dysarthria and Tremor Right: 9-, case+, balance difficulties. 60 mcs,130 Hz, 2.7 mA Left: 2(abc)-, case+, Dystonic 60 mcs, 130 Hz, 2.6 mA Male, 66 57 9 None Tremor Right: 9-, case+, 60 mcs, 130 Hz, 1.4 mA Left 1-, 2(abc)+, 50 mcs, Dystonic 170 Hz, 2.5 mA Male, 73 50 23 None Tremor Right 9-, 10(abc)+, 60 mcs, 170 Hz, 3.0 mA Left 2a-, case+, 60 mcs, Dystonic 130 Hz, 4.0 mA Male, 70 60 10 None Tremor Right 11c-, case+, 60 mcs, 130 Hz, 3.0 mA Left 3c-, case+, 60 mcs, Task-specific 190 Hz, 3.5 mA, Female, 60 56 4 None Tremor Right 12-, case+, 60 mcs, 130 Hz, 2.1 mA Left 1-, case+, 60 mcs, Mild stimulation induced Dystonic 130 Hz 3.4 mA Female, 81 7 74 dysarthria and Tremor Right 9-, case+, 30 mcs, balance difficulties. 190 Hz, 4.0 mA Dystonic Mild balance disturbance Female, 82 50 32 Not applicable Tremor (present before surgery). DBS = deep brain stimulation; mcs = microseconds; Hz = hertz; mA: milliampere. Subjects 1–6 were treated with DBS. Subject 7 was treated with a thalamotomy. 4.4. Clinical Global Improvement (CGI-I) The patient-reported outcomes with the different therapies are represented in Figure 3. With oral medication, 40% of patients reported a p-CGI-I ≤ 3 (improvement) compared to 92% after optimized treatment with BoNT (at the last injection) and 100% after surgery. The percentage of p-CGI-I ≤ 3 was significantly higher when comparing the first and last injection of BoNT (71% vs. 92%, Fisher’s exact test; p = 0.04). There were no significant differences in p-CGI scores in regards to botulinum toxin type (Mann–Whitney U test; p = 0.82) or the usage of EMG guidance (p = 0.4). J.J.Clin. Clin.Med. 2023,12, Med.2023, 12,1427 x FOR PEER REVIEW 77 of of 10 10 Figure3.3.Patient-based Figure Patient-basedClinical ClinicalGlobal GlobalImprovement Improvement(p-CGI-I) (p-CGI-I)as asper pertreatment treatmentfor fortremor. tremor.More Morepatients patients reported improvement on the p-CGI-I with botulinum toxin (BoNT) injections and neurosurgery reported improvement on the p-CGI-I with botulinum toxin (BoNT) injections and neurosurgery com- compared to oral medications. The percentage of p-CGI-I ≤ 3 was significantly higher when com- pared to oral medications. The percentage of p-CGI-I ≤ 3 was significantly higher when comparing paring the first and last injection of BoNT (74% vs. 92%, Fisher’s exact test p = 0.04). P-CGI = 1: Very the first and last injection of BoNT (74% vs. 92%, Fisher’s exact test p = 0.04). P-CGI = 1: Very much much improved, 2: Much improved, 3: Minimally improved, 4: No change, 5: Minimally worse, 6: improved, Much worse, 2: Much 7: Veryimproved, 3: Minimally improved, 4: No change, 5: Minimally worse, 6: Much much worse. worse, 7: Very much worse. 5. Discussion In the group of patients that received both oral medications and BoNT at any time during There is an unmet the entire need(16, follow-up for evidence-based 37.2%), the pCGI-Iguidelines to treat tremor was significantly higherin dystonia with BoNT [8]. The different criteria and labeling used by clinicians for compared to oral medications (Wilcoxon Rank Squares; p = 0.001). isolated upper limb tremors and the lack of biomarkers to distinguish between tremor syndromes have made it difficult to 5.draw definitive conclusions about how best to treat dystonic tremors of the upper limb. Discussion Here, iswe There anreviewed unmet needthree forvery different approaches evidence-based guidelinestototreating patients treat tremor with tremor in dystonia [8]. in dystonia: The differentoral medication, criteria BoNT, and labeling or brain used surgery. for by clinicians While oral medication isolated upper limbhas a systemic tremors and effect, the lackBoNT is administered of biomarkers by local intramuscular to distinguish between tremor injections syndromesin thehave muscles, madeand deep brain it difficult to stimulation or thalamotomy require brain surgery. Oral medications for tremor draw definitive conclusions about how best to treat dystonic tremors of the upper limb. more com- monly produce sickness, lightheadedness, or drowsiness and may be contraindicated if the patient has other comorbidities or if there is interaction with other medications; BoNT can J. Clin. Med. 2023, 12, 1427 8 of 10 Here, we reviewed three very different approaches to treating patients with tremor in dystonia: oral medication, BoNT, or brain surgery. While oral medication has a systemic effect, BoNT is administered by local intramuscular injections in the muscles, and deep brain stimulation or thalamotomy require brain surgery. Oral medications for tremor more commonly produce sickness, lightheadedness, or drowsiness and may be contraindicated if the patient has other comorbidities or if there is interaction with other medications; BoNT can produce bruising and weakness in the injected muscles, and brain surgery can result in a hemorrhagic stroke or a brain infection, to side effects ultimately related to the stimulation, more commonly in the target for tremor, balance, and speech disturbances. Our study suggests that commonly used oral medications for tremor are less effective than BoNT and surgery in treating any type of tremor of the upper limbs occurring in people with dystonia and task-specific tremors. Dropout rates and side effects were higher with oral medications. BoNT appeared to be an effective and safe therapy, leading to improvement in 71% of the patients after the first injection; this percentage increased to 92% when the injection protocol was optimized at subsequent follow-up visits. In patients who received both oral medications and BoNT at any time during their follow-up, improvement based on the p-CGI-I was significantly greater with BoNT. These results are in keeping with those of Fasano et al. in their systematic review [8], in which they found BoNT to be superior to oral medication for axial dystonic tremor and task-specific tremor, as well as with the results from the placebo-controlled trial from Rajan et al. [7], in which BoNT significantly improved the outcome of 30 subjects with dystonic hand tremor. The outcome of any tremor treatment is often assessed with validated rating scales developed for essential tremor, such as The Fahn–Tolosa–Marin [9] or the Tetras scale [10], as well as instruments measuring the quality of life, such as QUEST [11]. However, such outcome measures were not designed for subjects whose tremor occurs in the context of dystonia or for those having a purely task-specific tremor. In our study, from medical history and clinical examination, we identified the manual tasks most affected by tremor, similar to the goal attainment scale employed in spasticity studies [12]. The p-CGI was based on their satisfaction with the treatment regarding the manual task most impacted by the tremor, which was most commonly holding a cup. This also allowed us to identify the pattern of tremor (clinically or by EMG) while executing that specific action and injecting the botulinum toxin accordingly. Most frequently, there was a pronosupination of the forearm and flexion-extension at the elbow. Therefore, the most injected muscles were the supinator longus, pronator teres, biceps, and triceps (Table 2). Previous studies using BoNT in the treatment of upper limb tremor only injected either the wrist flexors/extensors [13,14] or selected the muscles by the clinical and electrophysio- logical assessment of patients with arms at rest, outstretched in front of the subject, and while performing finger-to-nose action [7,15]. Injecting the wrist extensors increases the possibility of handgrip weakness [14,16], and typically, tremor in dystonia changes with different positions. This makes it imperative, in our opinion, that the selection of muscles for injection takes place in reference to specific task performance. Given our retrospective data, prospective controlled studies are warranted to test this approach in subjects with Dys-T, DAT, or TST. Deep brain surgery was the most effective treatment for those failing first, second, and third-line oral medications for tremor. None of the patients treated with brain surgery had received BoNT. They were selected for brain surgery based on the severity of the tremor, which determined functional impairment and significant disability in the absence of exclusion criteria. Data on DBS for tremor in dystonia are scanty, with different targets proposed in addition to the globus pallidus pars interna11 , such as the VIM, ventralis oralis anterior12 , and caudal ZI13 . Our cohort was implanted, positioning the most inferior contact in cZI/PSA, allowing for the targeting of two different structures (cZI and VIM), previously demonstrated to be effective for Dys-T [17]. Several limitations of this study should be considered. The results should be cau- tiously interpreted, as the data were analyzed retrospectively, and the sample number is J. Clin. Med. 2023, 12, 1427 9 of 10 relatively small in some analyses. Treatment decisions were based on clinical expertise and patients’ preferences. Moreover, some data were not included due to incomplete reports. A standardized dystonia rating scale was not employed to formally assess tremor and dystonia symptoms. A clinical examination was not always accompanied by EMG or kinematic assessment. Lastly, the p-CGI-I is a subjective measure of improvement based on the patient’s perception, which could have been supplemented by objective measures. Despite these limitations, our data suggest that oral medications employed for essential tremor are often ineffective or not tolerated in people with dystonic tremors of the upper limbs. Botulinum toxin appears to be a safe and effective therapeutic option that warrants testing in randomized controlled trials with open-label, long-term follow-up. This seems to be particularly true if the tremor has a predominant pattern of pronosupination of the forearm or flexion-extension at the elbow when performing the most-affected manual tasks. Therefore, there is a need to develop specific rating scales for dystonic tremors that also consider essential manual tasks commonly affected. Finally, functional neurosurgery also seems to be a very effective procedure. Large randomized controlled trials are needed to confirm our findings and provide further insight into selecting patients best suited to receive BoNT, DBS, or thalamotomy. Author Contributions: Research project—conceptualization and organization: B.G.-H., I.A.D.V. and F.M.; execution: B.G.-H. and I.A.D.V.; Statistical analysis—design and execution: B.G.-H.; review and critique: B.G.-H., I.A.D.V., E.P., M.E. and F.M.; Manuscript—writing of the first draft: B.G.-H.; review and critique: B.G.-H., I.A.D.V., E.P., M.E. and F.M. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: The study was conducted following the Declaration of Helsinki. This study is based on retrospective clinical data obtained during routine clinical care. Patients data were anonymized. This study reports on a clinical audit approved by St George’s University Hospital. Informed Consent Statement: Individualized informed consent was not required for this retrospec- tive study as it was part of a clinical audit approved by St George’s University Hospital. Data Availability Statement: Supporting data is not publicly available. Acknowledgments: B.G.-H. is grateful to the Alfonso Martin Escudero Foundation, Spain, for supporting her research activity. Conflicts of Interest: E.P.: speaking honoraria from Boston Scientific; research support from NIHR, UKRI, Life after Paralysis, and the Rosetrees Trust. M.E.: grant income from NIHR and royalties from the Oxford University Press; honoraria from the International Parkinson’s Disease and Movement Disorder Society and Wiley Publishing. F.M.: research support from NIHR and UKRI; speaking hono- raria from Abbvie, Medtronic, Boston Scientific, Bial, and Merz; travel grants from the International Parkinson’s Disease and Movement Disorder Society; advisory board fees from Merz and Boston Scientific; consultancies fees from Boston Scientific, Merz, and Bial; research support from Boston Scientific, Merz, and Global Kynetic; royalties for the book “Disorders of Movement”, from Springer; member of the editorial board of Movement Disorders, Movement Disorders Clinical Practice, and the European Journal of Neurology. Sandy Maria Cartella has no disclosures to report. B.G.-H.: research support from the Alfonso Martin Escudero Foundation, Madrid, Spain. I.A.D.V.: no disclosures. References 1. Bhatia, K.P.; Bain, P.; Bajaj, N.; Elble, R.J.; Hallett, M.; Louis, E.D.; Raethjen, J.; Stamelou, M.; Testa, C.M.; Deuschl, G.; et al. Consensus Statement on the classification of tremors. from the task force on tremor of the International Parkinson and Movement Disorder Society. Mov. Disord. 2018, 33, 75–87. [CrossRef] [PubMed] 2. Albanese, A.; Bhatia, K.; Bressman, S.B.; Delong, M.R.; Fahn, S.; Fung, V.S.; Hallett, M.; Jankovic, J.; Jinnah, H.A.; Klein, C.; et al. Phenomenology and classification of dystonia: A consensus update. Mov. Disord. 2013, 28, 863–873. [CrossRef] [PubMed] 3. Erro, R.; Rubio-Agusti, I.; Saifee, T.A.; Cordivari, C.; Ganos, C.; Batla, A.; Bhatia, K.P. Rest and other types of tremor in adult-onset primary dystonia. J. Neurol. Neurosurg. Psychiatry 2014, 85, 965–968. [CrossRef] [PubMed] 4. Bain, P.G. Task-specific tremor. Handb. Clin. Neurol. 2011, 100, 711–718. [CrossRef] [PubMed] J. Clin. Med. 2023, 12, 1427 10 of 10 5. Latorre, A.; Rocchi, L.; Batla, A.; Berardelli, A.; Rothwell, J.C.; Bhatia, K.P. The Signature of Primary Writing Tremor Is Dystonic. Mov. Disord. 2021, 36, 1715–1720. [CrossRef] [PubMed] 6. Lenka, A.; Jankovic, J. Tremor Syndromes: An Updated Review. Front. Neurol. 2021, 12, 684835. [CrossRef] [PubMed] 7. Rajan, R.; Srivastava, A.K.; Anandapadmanabhan, R.; Saini, A.; Upadhyay, A.; Gupta, A.; Vishnu, V.Y.; Pandit, A.K.; Vibha, D.; Singh, M.B.; et al. Assessment of Botulinum Neurotoxin Injection for Dystonic Hand Tremor: A Randomized Clinical Trial. JAMA Neurol. 2021, 78, 302–311. [CrossRef] [PubMed] 8. Fasano, A.; Bove, F.; Lang, A.E. The treatment of dystonic tremor: A systematic review. J. Neurol. Neurosurg. Psychiatry 2014, 85, 759–769. [CrossRef] [PubMed] 9. Stacy, M.A.; Elble, R.J.; Ondo, W.G.; Wu, S.C.; Hulihan, J. Assessment of interrater and intrarater reliability of the Fahn-Tolosa- Marin Tremor Rating Scale in essential tremor. Mov. Disord. 2007, 22, 833–838. [CrossRef] [PubMed] 10. Elble, R.; Comella, C.; Fahn, S.; Hallett, M.; Jankovic, J.; Juncos, J.L.; Lewitt, P.; Lyons, K.; Ondo, W.; Pahwa, R.; et al. Reliability of a new scale for essential tremor. Mov. Disord. 2012, 27, 1567–1569. [CrossRef] [PubMed] 11. Tröster, A.I.; Pahwa, R.; Fields, J.A.; Tanner, C.M.; Lyons, K.E. Quality of life in Essential Tremor Questionnaire (QUEST): Development and initial validation. Park. Relat. Disord. 2005, 11, 367–373. [CrossRef] [PubMed] 12. Kiresuk, T.J.; Sherman, R.E. Goal attainment scaling: A general method for evaluating comprehensive community mental health programs. Community Ment. Health J. 1968, 4, 443–453. [CrossRef] [PubMed] 13. Brin, M.F.; Lyons, K.E.; Doucette, J.; Adler, C.H.; Caviness, J.N.; Comella, C.L.; Dubinsky, R.M.; Friedman, J.H.; Manyam, B.V.; Matsumoto, J.Y.; et al. A randomized, double masked, controlled trial of botulinum toxin type A in essential hand tremor. Neurology 2001, 56, 1523–1528. [CrossRef] [PubMed] 14. Jankovic, J.; Schwartz, K.; Clemence, W.; Aswad, A.; Mordaunt, J. A randomized, double-blind, placebo-controlled study to evaluate botulinum toxin type A in essential hand tremor. Mov. Disord. 1996, 11, 250–256. [CrossRef] [PubMed] 15. van der Walt, A.; Sung, S.; Spelman, T.; Marriott, M.; Kolbe, S.; Mitchell, P.; Evans, A.; Butzkueven, H. A double-blind, randomized, controlled study of botulinum toxin type A in MS-related tremor. Neurology 2012, 79, 92–99. [CrossRef] [PubMed] 16. Anandan, C.; Jankovic, J. Botulinum Toxin in Movement Disorders: An Update. Toxins 2021, 13, 42. [CrossRef] [PubMed] 17. Tsuboi, T.; Jabarkheel, Z.; Zeilman, P.R.; Barabas, M.J.; Foote, K.D.; Okun, M.S.; Wagle Shukla, A. Longitudinal follow-up with VIM thalamic deep brain stimulation for dystonic or essential tremor. Neurology 2020, 94, e1073–e1084. [CrossRef] [PubMed] Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.