Today, we're going to be talking about tremor treatment and updates over the past year as part of our Special Congress Series for 2024. Thanks for joining us today. So let's start with just general year in review. What do you think was particularly notable about the things that came out or the things that you are aware of over the past year.
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So one is, of course, utilization of technology in treatment, in outcome measures. in characterization. And so we can start with characterization, or we can start with outcome measurements. So one big thing that I can see already is Inclusion of machine learning, artificial intelligence video frame based analysis of different types of oscillatory movement disorders such as tremor, and big data analytics utilizing data from thousands and thousands of patients to come up with finding a hidden trend.
So these are the main big things that is happening now and more or less hot in the field for tremor. And it has, of course, direct implication for deciding right treatment, come up with a classification first, classifying in the right category and then doing more treatment. And of course precision medicine, again, falls along the same lines that you have a specific class of a movement disorder.
or a tremor, and that would fit. It's not one treatment that fits all, one size fits all, but it's more precise, these are the big things. The other interesting thing which is very near and dear to my heart is physiology, electrophysiology, neurophysiology of oscillatory movement disorder.
And I'm specifically using the word oscillatory movement disorder because I don't want to call it tremor or a dystonia, which is rhythmic or myoclonus, which is rhythmic a lot of times. They are more or less tremulous or, appears like tremor, but what we are finding more and more is that
Differences, subtle differences in the phenomenology that we see of these movement disorders, they are reflected into the physiology.
So, let's take an example. Something which is what we use to call dystonic tremor, for example. A jerky yet rhythmic movements compared to sinusoidal oscillations, classic tremor. And if you look at the field potentials in the GPI, for example, those who have more prominent sinusoids would have a different physiological character signature compared to the other types.
So these are the other, we are finding not just the differences in their appearance, but also the differences in physiology in human which has now direct implication to the treatment then.
[00:03:49] Dr. Sara Schaefer:
Right, you can use all of this new technology and new data in order to inform your treatments, assess treatment, efficacy, and all of those things moving forward.
So it sounds like we're well on our way.
Okay, I'm sure a lot of this stuff was talked about at the Congress.
I certainly heard rumblings of a few of the things that you mentioned. What do you think has been particularly notable as presentations or posters at the conference regarding this?
[00:04:16] Dr. Aasef Shaikh:
So the big trend that I saw amongst the abstracts and the posters on Tremor this year was involvement of dentatorubrothalamic fibers.
So there are several poster repeatedly touching base upon this theme of dentatorubrothalamic fibers or tract and different applications of that in different disease classes. There were posters on targeting these fibers to treat different forms of tremors. There was one for, we know that for outflow tremor, of course but again, coming down to the precision medicine, right?
Again, along that lines, if there is a certain type of tremor and targeting these fibers, there were other posters which were more atypical forms of essential tremor, so to speak, looking at these fibers. So that reminds us that tremor is not really a problem of a node. Tremor is a problem of multiple nodes connected to each other.
It's more of a network disorder, and it seems like this year, a lot of posters covered one connection of the network, and that was dentatorubrothalamic fibers.
[00:05:30] Dr. Sara Schaefer: And I mentioned that you are the co chair of the MDS Tremor Study Group. What projects are you all working on at the moment? And what are you excited about from the past year and, and upcoming?
[00:05:44] Dr. Aasef Shaikh: There are several projects which are up and are going. The rating scale is one, the habituation of DBS, treatment and essential tremor is another ongoing project. We have envisioned a project to classify some forms of, I'm gonna say, quote, tremor. For example, oculopalatal tremor or myarrhythmias.
This is something. That my partner, Dr. Fasano, and I are envisioning to put together a little panel to further enlighten our understanding of whether this is really a tremor or this is something else, especially for the oculopalatal tremor, which some of, some of my colleagues call myoclonus.
Probably it is neither of them. So these disorder inocular facial myarrhythmias. This is another category which is more blurred. So we are looking into digging deep into these special categories of rather rare oscillatory movement disorders and trying to come up with more, not just the semiology and phenomenology, but also pathophysiology for them.
That, that excites me the most. The other interesting thing that we accomplished not too long ago is a relationship between dystonia and tremor. So as we know, we call something Dystonic tremor. We call something tremor associated with dystonia. Sometimes we call tremulous dystonia. There are lots of names, but we think that there is dystonia and there is tremor.
And sometimes both can be present together in one patient. So, So what we suggest, we call dystonia with tremor and if you really have to use the term dystonic tremor, then you should really classify, you should really clarify in that paper or the note or whatever context you are using that term, that what is that that you are calling dystonic tremor.
So we need more clarity on this term and this is something which we had worked very hard over the last two, three years and hopefully we will have a paper soon.
[00:07:50] Dr. Sara Schaefer:
I mentioned to you before we started recording that I've gone rogue and just started calling it the tremor dystonia continuum and telling patients they're either more on the tremor side or more on the dystonic side.
So it will be nice to have a little bit of a of direction going forward on that.
[00:08:08] Dr. Aasef Shaikh:
In fact, you probably read our mind because the way we have presented this in papers is that it's like a Venn diagram, a Venn diagram of a tremor and Venn diagram of a dystonia. And this Venn diagram, two circles when they meet, it is dystonia with tremor.
People call it dystonic tremor. You can call it dystonia with tremor. And then there is another alternative to the Venn diagram, which is a gray to white shade. If white is tremor, if a black is dystonia, and then there is a gray, and that is the continuum. So is that really a continuum or it's a Venn diagram?
And that's the million dollar question that we still have to answer. And we need more physiology to answer that question.
[00:08:54] Dr. Sara Schaefer:
Well, it all gets back to our favorite thing in the world, which is basic phenomenology, right? It's amazing that there are still so many things out there that we don't yet understand on a deep phenomenological level, and there's so much debate still in the field, which I find very exciting.
[00:09:11] Dr. Aasef Shaikh:
Of course, likewise.
[00:09:13] Dr. Sara Schaefer: Thank you very much for joining us.