Clinical short communication| Volume 367, P122-127, August 15, 2016

Reduction in DBS frequency improves balance difficulties after thalamic DBS for essential tremor


      • Cerebellar features including imbalance are increasingly recognized symptoms in ET
      • The effects of thalamic DBS on imbalance in ET are contradictory
      • Reduction in DBS frequency to the lowest effective settings for tremor, provided benefit in disequilibrium in our patients
      • Larger, prospective, well conducted clinical trials are warranted to validate these initial results


      Essential tremor (ET) is a syndrome characterized by the presence of symmetric, moderate to high frequency postural and action tremors of the limbs. Additionally, increasing evidence indicates the occurrence of associated cerebellar features in ET patients including impaired gait and balance. Deep brain stimulation (DBS) of the ventralis intermedius (VIM) nucleus of the thalamus has been shown to be an effective treatment for medically-refractory ET tremor but its effects on balance remain unclear with conflicting results reported. In this article, we report the effects of frequency modification in four patients with disequilibrium after DBS and review available literature regarding the effects of neurostimulation on balance in ET. Reduction in DBS frequency (10–20 Hz reduction intervals) to the lowest effective settings for tremor control was conducted followed by immediate and 4-week assessment of disequilibrium. All patients reported improvement in balance ranging from mild to marked benefit on clinical global impression scale and in the posture and gait disturbance sub-scores of the International Cooperative Ataxia Rating Scale (ICARS). There was no significant difference in tremor control with DBS frequency adjustments. Our results suggest a relationship between the effects of high-frequency stimulation and disequilibrium in ET patients treated with bilateral or unilateral DBS. Additional larger, prospective studies are warranted to validate these results and discern the relationship between DBS stimulation settings and cerebellar findings in ET.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Neurological Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Louis E.D.
        • Ferreira J.J.
        How common is the most common adult movement disorder? Update on the worldwide prevalence of essential tremor.
        Mov. Disord. 2010; 25: 534-541
        • Chandran V.
        • Pal P.K.
        Essential tremor: beyond the motor features.
        Parkinsonism Relat. Disord. 2012; 18: 407-413
        • Arkadir D.
        • Louis E.D.
        The balance and gait disorder of essential tremor: what does this mean for patients?.
        Ther. Adv. Neurol. Disord. 2013; 6: 229-236
        • Kronenbuerger M.
        • Konczak J.
        • Ziegler W.
        • Buderath P.
        • Frank B.
        • Coenen V.A.
        • et al.
        Balance and motor speech impairment in essential tremor.
        Cerebellum. 2009; 8: 389-398
        • Hoskovcova M.
        • Ulmanova O.
        • Sprdlik O.
        • Sieger T.
        • Novakova J.
        • Jech R.
        • et al.
        Disorders of balance and gait in essential tremor are associated with midline tremor and age.
        Cerebellum. 2013; 12: 27-34
        • Parisi S.L.
        • Heroux M.E.
        • Culham E.G.
        • Norman K.E.
        Functional mobility and postural control in essential tremor.
        Arch. Phys. Med. Rehabil. 2006; 87: 1357-1364
        • Pahwa R.
        • Lyons K.E.
        • Wilkinson S.B.
        • Simpson Jr., R.K.
        • Ondo W.G.
        • Tarsy D.
        • et al.
        Long-term evaluation of deep brain stimulation of the thalamus.
        J. Neurosurg. 2006; 104: 506-512
        • Pedrosa D.J.
        • Auth M.
        • Eggers C.
        • Timmermann L.
        Effects of low-frequency thalamic deep brain stimulation in essential tremor patients.
        Exp. Neurol. 2013; 248: 205-212
        • Fasano A.
        • Herzog J.
        • Raethjen J.
        • Rose F.E.
        • Muthuraman M.
        • Volkmann J.
        • et al.
        Gait ataxia in essential tremor is differentially modulated by thalamic stimulation.
        Brain. 2010; 133: 3635-3648
        • Ondo W.G.
        • Almaguer M.
        • Cohen H.
        Computerized posturography balance assessment of patients with bilateral ventralis intermedius nuclei deep brain stimulation.
        Mov. Disord. 2006; 21: 2243-2247
        • Earhart G.M.
        • Clark B.R.
        • Tabbal S.D.
        • Perlmutter J.S.
        Gait and balance in essential tremor: variable effects of bilateral thalamic stimulation.
        Mov. Disord. 2009; 24: 386-391
        • Hwynn N.
        • Hass C.J.
        • Zeilman P.
        • Romrell J.
        • Dai Y.
        • Wu S.S.
        • et al.
        Steady or not following thalamic deep brain stimulation for essential tremor.
        J. Neurol. 2011; 258: 1643-1648
        • Barbe M.T.
        • Liebhart L.
        • Runge M.
        • Deyng J.
        • Florin E.
        • Wojtecki L.
        • et al.
        Deep brain stimulation of the ventral intermediate nucleus in patients with essential tremor: stimulation below intercommissural line is more efficient but equally effective as stimulation above.
        Exp. Neurol. 2011; 230: 131-137
        • Blomstedt P.
        • Sandvik U.
        • Fytagoridis A.
        • Tisch S.
        The posterior subthalamic area in the treatment of movement disorders: past, present, and future.
        Neurosurgery. 2009; 64 (discussion 38-42): 1029-1038
        • Anderson T.R.
        • Hu B.
        • Iremonger K.
        • Kiss Z.H.
        Selective attenuation of afferent synaptic transmission as a mechanism of thalamic deep brain stimulation-induced tremor arrest.
        J. Neurosci. 2006; 26: 841-850
        • Deuschl G.
        • Bain P.
        • Brin M.
        Consensus statement of the Movement Disorder Society on Tremor. Ad Hoc Scientific Committee.
        Mov Disord. 1998; 13: 2-23
        • Pilitsis J.G.
        • Metman L.V.
        • Toleikis J.R.
        • Hughes L.E.
        • Sani S.B.
        • Bakay R.A.
        Factors involved in long-term efficacy of deep brain stimulation of the thalamus for essential tremor.
        J. Neurosurg. 2008; 109: 640-646
        • Favilla C.G.
        • Ullman D.
        • Wagle Shukla A.
        • Foote K.D.
        • Jacobson C.E.
        • Okun M.S.
        Worsening essential tremor following deep brain stimulation: disease progression versus tolerance.
        Brain. 2012; 135: 1455-1462
        • Moro E.
        • Esselink R.J.
        • Xie J.
        • Hommel M.
        • Benabid A.L.
        • Pollak P.
        The impact on Parkinson's disease of electrical parameter settings in STN stimulation.
        Neurology. 2002; 59: 706-713
        • Kronenbuerger M.
        • Gerwig M.
        • Brol B.
        • Block F.
        • Timmann D.
        Eyeblink conditioning is impaired in subjects with essential tremor.
        Brain. 2007; 130: 1538-1551
        • Stolze H.
        • Petersen G.
        • Raethjen J.
        • Wenzelburger R.
        • Deuschl G.
        The gait disorder of advanced essential tremor.
        Brain. 2001; 124: 2278-2286
        • Bermejo-Pareja F.
        Essential tremor–a neurodegenerative disorder associated with cognitive defects?.
        Nat. Rev. Neurol. 2011; 7: 273-282
        • Troster A.I.
        • Woods S.P.
        • Fields J.A.
        • Lyons K.E.
        • Pahwa R.
        • Higginson C.I.
        • et al.
        Neuropsychological deficits in essential tremor: an expression of cerebello-thalamo-cortical pathophysiology?.
        Eur. J. Neurol. 2002; 9: 143-151
        • Bove M.
        • Marinelli L.
        • Avanzino L.
        • Marchese R.
        • Abbruzzese G.
        Posturographic analysis of balance control in patients with essential tremor.
        Mov. Disord. 2006; 21: 192-198
        • Kiss Z.H.
        • Mooney D.M.
        • Renaud L.
        • Hu B.
        Neuronal response to local electrical stimulation in rat thalamus: physiological implications for mechanisms of deep brain stimulation.
        Neuroscience. 2002; 113: 137-143
        • Baier B.
        • Vogt T.
        • Rohde F.
        • Cuvenhaus H.
        • Conrad J.
        • Dieterich M.
        Deep brain stimulation of the nucleus ventralis intermedius: a thalamic site of graviceptive modulation.
        Brain Struct. Funct. 2015;
        • Herzog J.
        • Hamel W.
        • Wenzelburger R.
        • Potter M.
        • Pinsker M.O.
        • Bartussek J.
        • et al.
        Kinematic analysis of thalamic versus subthalamic neurostimulation in postural and intention tremor.
        Brain. 2007; 130: 1608-1625