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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 4  |  Page : 462-463

Upper limbs spread of orthostatic tremor following hip replacement surgery


1 Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey; Department of Medicine, Neurology Unit, Ladoke Akintola University of Technology, Ogbomoso, Nigeria
2 Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey

Date of Web Publication19-Sep-2014

Correspondence Address:
Philip B Adebayo
Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey; Department of Medicine, Neurology Unit, Ladoke Akintola University of Technology, Ogbomoso, Nigeria

Philip B Adebayo
Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey; Department of Medicine, Neurology Unit, Ladoke Akintola University of Technology, Ogbomoso, Nigeria

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.141280

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How to cite this article:
Adebayo PB, Gunduz A, Kiziltan ME, Kiziltan G, Adebayo PB, Gunduz A, Kiziltan ME, Kiziltan G. Upper limbs spread of orthostatic tremor following hip replacement surgery . Neurol India 2014;62:462-3

How to cite this URL:
Adebayo PB, Gunduz A, Kiziltan ME, Kiziltan G, Adebayo PB, Gunduz A, Kiziltan ME, Kiziltan G. Upper limbs spread of orthostatic tremor following hip replacement surgery . Neurol India [serial online] 2014 [cited 2019 Dec 15];62:462-3. Available from: http://www.neurologyindia.com/text.asp?2014/62/4/462/141280


Sir,

Orthostatic tremor (OT) is characterized by a high frequency (13-18 Hz), which causes a great deal of unsteadiness while standing and is most obvious in the legs. It can occasionally be seen in the trunk and upper limbs when these regions are used to support body weight or when they contract isometrically. [1] Total hip replacement (THR) is the treatment option for severe hip osteoarthritis often with generally good prognosis. However, postoperative posturography shows evidence of some residual gait and balance deficit. [2],[3],[4] While OT of the upper extremities is an unusual phenomenon, its appearance post-THR is rather uncommon.

A 57-year-old female was diagnosed as a case of OT since five years with good response to 2 mg daily of clonazepam. She had a right THR in April, 2013. Following the surgery, she admitted that her lower limb OT worsened. She could use a brace walker minimally but noted tremor of the upper extremities on doing so. In January 2014, polymyographic recordings were performed with the Ag-AgCl pair of cutaneous recording electrodes placed on rectus femoris, anterior tibialis, gastrocnemius, biceps brachii, forearm flexorand extensor muscles as well as paraspinal muscles during sitting, standing and walking. During sitting, polymyographic recordings showed a 10 Hz postural tremor of the upper extremities with no tremor in the lower extremities [Figure 1]a. Upon standing, a rapidly developed 16 Hz tremor was noted over the rectus femoris, anterior tibialis, gastrocnemius and paraspinal muscles [Figure 1]b and c. Simultaneously, we noted the same high frequency tremor in the forearm extensor muscles [Figure 1]b. Immediately on initiation of the swing phase of gait, the lower extremities tremor disappeared [Figure 1]d.
Figure 1: Polymyographic recordings: Channels are right-sided biceps brachii, forearm flexor muscle, forearm extensor muscle, rectus femoris, anterior tibialis and gastrocnemius respectively. (a) A 10 Hz postural tremor of the upper extremity with no lower extremity tremor during sitting (sensitivity 200 ƒÊV/div, 0.1 ms/div). (b) A 16 Hz tremor over the rectus femoris, anterior tibialis, gastrocnemius muscles during standing (sensitivity 200 ƒÊV/div, 0.1 ms/div). A very high frequency tremor also appears on the upper extremity.(c) A 16 Hz tremor over lower extremity muscles similar to the Figure b, but this fi gure shows a longer period due to longer sweep time (sensitivity 200 ƒÊV/div, 0.5 ms/div). (d) Disappearance of high frequency tremor during swing phase of gait and its reappearance during stance phase with sweep time similar to the Figure c (sensitivity 200 ƒÊV/div, 0.5 ms/div)

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Altered weight-bearing seems to explain this observation even though the upper extremities could be involved in about 15% of patients with OT. [5] Theoretically, post-THR patients are prone to balance and gait abnormalities due to factors such as damage to proprioceptive fibers resulting from excision of the capsules, weakened abductor muscles, unequal length, shortened abductors lever arm and restricted range of motions in addition to altered weight bearing. [3] Consequent upon these, trunk compensatory mechanism ensues to help compensate for weakened abductor muscles and to maintain body balance in the frontal plain. Unfortunately, this compensatory mechanism persists between 6 months to 3 years after surgery. [4] Because the trunk compensatory strategy causes a mechanical disadvantage with increased energy demand during walking, [2],[3] the additional exertion can produce extra tremors. The 10 Hz postural tremor observed during sitting is most likely a concomitant essential tremor. The co-existence of OT and essential tremor (ET) has been well documented. [5] Patients with OT should be informed of the possible worsening of their symptoms, especially after surgeries that may impact their balance.

 
  References Top

1.Wu YR, Ashby P, Lang AE. Orthostatic tremor arises from an oscillator in the posterior fossa. Mov Disord 2001;16:272-9.  Back to cited text no. 1
    
2.Nankaku M, Tsuboyama T, Kakinoki R, Kawanabe K, Kanzaki H, Mito Y, et al. Gait analysis of patients in early stages after total hip athroplasty: Effect of lateral trunk displacmemnt on walking efficiency. J Orthop Sci 2007;12:550-4.  Back to cited text no. 2
    
3.Nallegowda M, Singh U, Bhan S, Wadhwa S, Handa G, Dwivedi SN. Balance and gait in total hip replacement: A pilot study. Am J Phys Med Rehabil 2003;82:669-77.  Back to cited text no. 3
    
4.Iida H, Yamamuro T. Kinetic analysis of the centre of gravity of the human body in normal and pathological gaits. J Biomech 1987;20:987-95.  Back to cited text no. 4
    
5.Gerschlager W, Münchau A, Katzenschlager R, Brown P, Rothwell JC, Quinn N, et al. Natural history and syndromic associations of orthostatic tremor: A review of 41 patients. Mov Disord 2004;19:788-95.  Back to cited text no. 5
    


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