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Physical Therapy Denver - Blue Sky Physical Therapy

Blue Sky Physical Therapy of Denver

We are located between Bayaud and Alameda on South Madison Street. We are easily accessible from a variety of places. You can reach us in the following ways:

  • From Colorado Boulevard travel West on Alameda Avenue. Take a Right onto Madison Street, and then you will find us ½ way down the block on the left.
  • From Cherry Creek, take 1st Avenue East through Cherry Creek. 1st Avenue turns into Steele Street as it curves South around Cherry Creek Mall. Take a Left onto Bayaud Street, then a Right onto Madison. You will find us ½ way down the block on the right.
  • From Downtown, head towards Speer Boulevard, then head East towards Cherry Creek. Speer turns into 1st Ave as it crosses York. Follow the above directions from Cherry Creek.
  • From Aurora, take Parker Road, which turns into Leetsdale. Take Leetsdale and then go West on Alameda. Cross Colorado Boulevard and follow above directions from Colorado Blvd.

Parking

Blue Sky Physical Therapy has assigned parking for our patients/clients. Turn into one of two driveways for the building and you will find a number of spots labeled “Blue Sky” under the building. There is also ample free street parking on the east side of the building.

  • Back Pain & Sciatica Pain

    Have you got a back injury that causes you pure agony? Maybe you have not just back pain but also other symptoms like a pins and needles sensation in your back, buttocks, or legs.

  • Neck Pain

    Do you dread having to look up, down, or to one side because of the pain you know you’ll experience? Do you struggle for hours to find a sleeping position that doesn’t torture your neck?

  • Manual Therapy

    Are you struggling with a recent injury that seems slow to heal — or an old injury that never healed properly? Do you feel as if some part of your body is “stuck” or otherwise unable to function as it should?

Denver Physical Therapists

Meet Our Team!

Our dedicated team at Blue Sky Physical Therapy is made up of the Denver physical therapy community’s leading experts.

Our physical therapists at Blue Sky Physical Therapy are compassionate, caring, and ambitious when it comes to assisting you in reaching your peak performance while causing the least amount of discomfort.

They will work to identify the underlying cause of your issues and provide quality treatment for any type of pain, injury, or condition you are experiencing. They will also use their expertise to teach you how to avoid future injuries, which is an added benefit!

  • Hillary L Joseph
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  • Karen L Lewis
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  • Katherine Koch
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  • Shawna Olsen
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  • Natalie Ormond
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Find long-lasting relief with Blue Sky Physical Therapy

At Blue Sky Physical Therapy, we have one mission: to see our patients excel in every area of their wellness journey. Our treatment plans are designed to help you achieve your goals, taking into account your symptoms, medical history, and any health restrictions you may have.

If you are in the Denver, CO area, or in any of the surrounding areas, and you are looking for relief, look no further. Blue Sky Physical Therapy is here to help as one of the most favored Flint, MI physical therapy practices.

We look forward to seeing you achieve your recovery, health, and fitness goals! With our care and commitment, we know that it is possible for anyone who walks through our doors. We know what works best, and we're eager to help you discover the treatments for your needs!

What Denver Thinks About Blue Sky Physical Therapy

I’ve had pain in my left hip area ever since a fall on cement two years ago. My sports medicine doc recommended physical therapy to strengthen the muscles in the area. I started working with Alan Zidek and have been going two times a week. After five weeks, I am very pleased with my progress in improving my strength, endurance, and balance. I am very happy with Blue Sky.

Helen P.

Blue Sky PT is #1. I was referred to this clinic in 2017 when I was diagnosed with a labral tear and FAI in my right hip. Prior to surgery, we did strengthening exercises in order to strengthen the muscle groups around the hip pre-surgery. Post-op we progressed beautifully until I found out that I had the same issue in my left hip in 2018. I was then diagnosed with bilateral borderline hip dysplasia. Finally, in 2020, I had the left tear and FAI repaired. Lindsay was my PT in 2017 and Hilary in 2020. Both are seriously *amazing.* Really – you can’t get any better. Hilary is informative, goal-oriented, knowledgeable, flexible, and kind. She really knows her stuff, and we have worked together over the past four months post-op to attain my goals. She also does dry needling, and I HIGHLY recommend you try it. She is an inspiration, and I am truly grateful for the progress we have made together. The way I am progressing from my second surgery is seriously indescribable. The way my body was functions from 2017-June 2020 has completely changed for the better now. I am eternally grateful for this place and its staff. Thank you, Blue Sky!

Maya J.

Sammi Harmon was amazing! My son is a passionate ballet student and she understood exactly what his problems were and what he needed to do to get them better. It’s hard to find a PT who understands ballet. When he complains that something is tight or he can’t do something or when he’s having problems from a ballet- specific problem such as sickling his foot, an average PT wouldn’t be able to help. I’d highly recommend Sammie to any ballet student!

Robin D.

Katherine has been a godsend. She is knowledgeable and skilled and creative in her approach to physical therapy. She is very engaged and listens well and addresses my concerns and my issues with skill and talent. I am very grateful to have her help as I recover from my injuries.

Val M.

I have had the pleasure of dealing with Blue Sky for one thing or another for more than 12 years. First for Pilates which I have continued to this date. Then for a badly strained back and later sciatica. In all instances, I have been treated professionally with great skill and care. The therapists at Blue Sky have not just felt with the injury but have been concerned with my whole wellness. Also, Pilates is wonderful because teachers are all PT professionals as well and so they understand my body. You can have complete confidence in this outfit. Incidentally, their COVID protocols are excellent.

Garry H.

Blue Sky PT is an outstanding, professional healthcare facility with caring and extremely competent therapists. I have worked with several physical therapists and Pilates reformer classes. Highest recommendation!

Beverly M.
Are you suffering from pain or limited range of motion?

If you’re suffering, fill out the form to request a consult.

Physical Therapy Services | Physical Therapy Clinic Near You

What is Physical Therapy? 

Physical Therapy (PT) also known as physiotherapy helps to restore mobility, strength and endurance while alleviating pain, loss of motion or lack of coordination.  

Physical Therapy Services

Without a Doctor's Visit

If you think you need physical therapy, you don't need a doctor's visit to confirm it. Thanks to Direct Access, our clinics can help you with your body pains and conditions without a physician's referral. This service is beneficial for those who want to save time and start their healing process immediately. There's also the added benefit of saving money you would otherwise have to pay for that initial visit to your doctor. 

Physical Therapy Where You Prefer


When your body is in pain, you may struggle to move around the house, let alone get in a car and drive to a physical therapy clinic. At our clinics, we provide accommodating physical therapy options so you can enjoy your visit — no matter where it takes place.

At the Physical Therapy Clinic

We take an individualized approach to every patient. When you come to a clinic for your appointment, trust that our team of physical therapists will treat you with the utmost respect and the personalized care you need. We provide physical therapy services that help you live to the fullest. We have all the tools and equipment you need to keep your body healthy and functioning right.

Teletherapy

Teletherapy is a service we are proud to offer patients. Whether you are unable to leave your house on a regular basis due to your condition or would prefer teletherapy due to COVID-19, our teletherapy services connect you to your physical therapist through virtual communication. With the use of technological devices, we bring physical therapy to you at your current location. This way, our physical therapists can maintain regular contact with you, and you can keep giving your body the treatment it needs.

Physical Therapy in Your Home

Whether you live in your own home or in an assisted living home, you can take advantage of our in-home therapy services. A physical therapist can come to you and provide the necessary treatment you need to continue on your road to recovery or maintain the healthy life you live. We come prepared with any tools and information you need, and we will work with you on your schedule.

Services We Specialize In

At our clinics, we understand the various ways people can become injured and then require medical attention. That's why we specialize in a range of efficient services to help you recover and get back to your daily routine. Some of these services include:

  • Aquatic therapy: The pool is an excellent place for patients to use muscles that need strengthening. The water adds support to these muscles and facilitates body movement that may be painful outside of the pool.
  • Back pain: Almost every American will experience back pain at some point in their life. Our clinic can identify the cause of your pain and develop a treatment plan that reduces the pain over time.
  • Sports medicine: Athletes endure incredibly intense periods of activity. Our clinic can sit down with you and create a program that helps you maintain your performance and manage the exhaustion your body experiences after games and practices.

Our Physical Therapists Empower Patients and Help Them Recover

The Blue Sky Therapy family consists of over 584 active employees, including hundreds of physical therapists specializing in different areas. Regardless of their different specialties, however, every therapist in our network has one thing in common: Their primary goal is to provide patients with personalized treatment to help them realize their full potential and live the most functional, rewarding lives possible.

Find a Physical Therapy Clinic Near You

Don't let your body keep you from living life to its full potential. We have clinics located in Florida and Ohio. Find a clinic near you and begin treatment with a physical therapist today.

Specific disorders for which Physical Therapists provide treatment include, but are not limited to:

  • Low back and neck pain
  • Joint arthroplasty surgeries
  • Joint pain/surgery (shoulder, hip, knee, ankles)
  • Plantar fasciitis
  • Generalized weakness/balance impairments
  • Carpal tunnel
  • Rotator cuff injuries

We Offer the Following Physical Therapy Services:

Aquatic

Therapy

Back, Lumbar Pain,

Sciatica & Spine

Pre & Post-Operative

Orthopedic

Outpatient Specific Therapies:

Auto & Work

Injuries

Sports Medicine
Wellness Solutions

Women’s Health & Pelvic Floor Rehabilitation

One on One Customized Treatment Plans

Our physical therapists work one on one with each patient and their family (where applicable) to develop a customized treatment plan to accomplish their goals.

Restore

Function

Our goal is to help patients who are challenged by everyday life to restore function and regain independence, so that they can live productive and fulfilling lives.

Regain Daily-Living Abilities

Our physical therapists focus on helping patients return to function and work/home activities after surgey, illness or injury.

Pain

Relief

Our therapists work to implement hands on treatments that help relieve acute or chronic pain.

Where can you find

Physical Therapy Services?


Skilled Nursing Facilities


Assisted Living Facilities


Home Health Agencies


Physical Therapy Clinics

Interested in Our Physical Therapy Services?

Modern approaches to the diagnosis and treatment of essential tremor

Modern approaches to the diagnosis and treatment of essential tremor

Website of the publishing house "Media Sfera"
contains materials intended exclusively for healthcare professionals. By closing this message, you confirm that you are a registered medical professional or student of a medical educational institution.

Vasechkin S.V.

Levin O.S.

Russian Medical Academy of Postgraduate Education

Modern approaches to the diagnosis and treatment of essential tremor

Authors:

Vasechkin S.V., Levin O.S.

More about the authors

Magazine: Journal of Neurology and Psychiatry. S.S. Korsakov. Special issues. 2018;118(6‑2): 64‑72

DOI: 10.17116/jnevro201811806264

How to quote:

Vasechkin S.V., Levin O.S. Modern approaches to the diagnosis and treatment of essential tremor. Journal of Neurology and Psychiatry. S.S. Korsakov. Special issues. 2018;118(6‑2):64‑72.
Vasechkin SV, Levin OS. Diagnosis and management of essential tremor. Zhurnal Nevrologii i Psikhiatrii imeni S.S. Korsakova. 2018;118(6‑2):64‑72. (In Russ.)
https://doi. org/10.17116/jnevro201811806264

Read metadata

Essential tremor (ET) is the most common extrapyramidal and one of the most common neurological diseases, the main manifestation of which is a progressive bilateral action (kinetic-postural) hand tremor. The prevalence of ET in the population older than 65 years is 5%, it increases with age, reaching 22% among people older than 95 years. In / of cases, ET is familial. Modern concepts of pathogenesis, features of the clinical picture and differential diagnosis of ET are considered. Possible methods of conservative and surgical treatment of ET are given.

Keywords:

essential tremor

movement disorders

extrapyramidal diseases

neurodegenerative diseases

Authors:

Vasechkin S.V.

Levin O.S.

Russian Medical Academy of Postgraduate Education

Close metadata

Essential tremor (ET) is the most common extrapyramidal disease and one of the most common neurological diseases, the main manifestation of which is a progressive bilateral action (kinetic-postural) hand tremor. Probably, this is a heterogeneous condition in terms of etiology and pathogenesis, which can be a manifestation of a whole spectrum of diseases that differ in the role of hereditary factors, the time of onset, the rate of progression, and concomitant syndromes [1].

Epidemiology

A meta-analysis of 28 epidemiological studies [2] showed a median prevalence of 0.9%. In the group of patients older than 65 years, the prevalence of ET was 5%, and in the group of patients older than 95 years it reached 21.7%. However, ET should not be considered exclusively a disease of the elderly. Family forms of ET with onset at the age of 6 years have been described [3]. Mortality in ET has not been sufficiently studied, although the presence of severe functional limitations in some patients, cognitive impairment up to dementia can affect life expectancy. In one of the retrospective studies, the mortality of patients with ET was consistent with that in the control group.

Etiology

Familial character is detected in ½ of cases of ET [4, 5]. However, to date, only in a very small number of cases have three loci associated with ET been found: 3q13 (FET1; ETM1), 2p24.1 (ETM2), and 6p23 (ETM3) [6]. Analysis of familial cases indicates an autosomal dominant inheritance with variable penetrance and gene expression.

There are few studies investigating the possibility of a non-genetic origin of E.T. Among the proposed environmental factors, special attention [7] is paid to β-carboline alkaloids, which are powerful tremorogenic substances that are often found in food, especially in meat cooked at high temperature for a long time. The concentration of these substances in the blood was higher in patients with ET than in the control group.

Genetic and ecological theories cannot be regarded as mutually exclusive. For example, in some cases, environmental factors may be agents of gene expression, and in other cases, the genotype may predetermine susceptibility to certain environmental factors. Sporadic cases are clinically indistinguishable from familial cases and may also be based on a genetic defect. The only relative difference may be the age of onset of ET: familial cases for the most part appear before 60 years of age (more often at 35–45 years, but sometimes up to 10–20 years), sporadic diseases occur later. Most cases of so-called senile tremor, which is considered as a variant of ET occurring over the age of 65 (late-onset ET), are sporadic.

Pathogenesis and pathomorphology

The pathogenesis of ET also remains poorly understood. A pathomorphological study of the brain of 100 patients with ET made it possible to distinguish two groups: those with degenerative changes in the cerebellum and those with Lewy bodies in the brainstem [8].

In the cerebellum, an increase in the number of glial cells and the so-called "torpedoes" was noted, the number of which turned out to be 10 times higher compared to the control group [8]. A torpedo is a fusiform extension of the proximal segment of the axon of Purkinje cells, consisting of massive accumulations of disoriented neurofilaments. They are found in degenerating and possibly regenerating Purkinje cells and have been described in other pathological processes causing destruction of cerebellar tissue. In addition, ET revealed changes involving the dentate nucleus: a decrease in the number of neurons, microglial accumulations, white matter blanching [8].

In other cases, Lewy bodies were found in the bluish spot, less often in the innominate substance ( substantia innominata ) and the dorsal nucleus of the vagus nerve, even more rarely in the substantia nigra [8]. The relationship between the appearance of Lewy bodies in the blue spot and ET is not entirely clear. It is known that locus coeruleus neurons are the main source of norepinephrine in the CNS, and their axons form synapses with Purkinje cells in the cerebellum. It is possible that damage to the cells of the coeruleus reduces the stimulating effect on Purkinje cells and, as a result, leads to a decrease in the concentration of gamma-aminobutyric acid.

Clinical and morphological studies indicate the involvement of the cerebellum in the pathogenesis of ET [9-14]. This is also evidenced by the data of MR spectroscopy, which revealed a decrease in the ratio of N-acetyl-aspartate and creatinine in the cerebellum, indicating a decrease in the number of neurons [15–17].

The data available to date suggest that trembling is the result of central oscillations that occur in the system that combines the red nuclei, cerebellum, inferior olives (Guillain-Mollare triangle). The tremor generator can be hyperactive neurons of the inferior olive or cerebellum, the impulses from which “bombard” the motor cortex through the thalamus [18]. The result is alternating or synchronous contractions of the agonist and antagonist muscles, leading to trembling. The role of the cerebellum in the pathogenesis of tremor is confirmed by the unilateral decrease in tremor after infarction of the ipsilateral cerebellar hemisphere. It is also important to note that neuropsychological examination reveals moderate cognitive impairment in some patients [19—21], presumably also associated with impaired functioning of the cerebellar-thalamo-frontal systems.

The results of studies [17] show that dysfunction of GABAergic systems has a certain effect on the pathogenesis of ET. Thus, in a number of patients with ET, a reduced level of GABA in the cerebrospinal fluid is detected, and using positron emission tomography with 11 C-flumazenil, changes in the state of GABA receptors in the thalamus were detected. Recent genome screening linked ET predisposition to polymorphism in gene LINGO 1 , which encodes a protein that inhibits cell differentiation during brain development, as well as axonal regeneration and synaptic plasticity [22, 23]. It is suggested that dysfunction of the climbing fibers that follow from the inferior olives to Purkinje cells and form numerous synapses on their dendrites may be one of the key links in the pathogenesis of ET, at least in some of its cases.

Clinical manifestations

The main clinical manifestation of the disease is a bilateral action tremor in the hands, which appears when moving (kinetic tremor) and / or while arbitrarily holding a certain position (postural tremor).

Tremor usually appears in both hands at once or first in one, and then with a slight delay (no more than several months) in the other, however, its amplitude in one hand may be higher than in the other, so the symmetry of the tremor is relative [24] . Moreover, in a number of familial cases (4.4%) with autosomal dominant inheritance, patients with both bilateral and unilateral tremor were observed. However, sporadic cases of unilateral action tremor are not usually attributed to E.T. Initially, the distal parts of the arms are involved in the tremor, then the trembling spreads in the proximal direction and to the axial parts (head, larynx, rarely trunk).

ET is considered to have a benign, slowly progressive course [25, 26], but it leads to severe disability in 15% of cases [4]. It is worth noting that in more than 80% of patients who sought medical help, tremor caused difficulties in daily activities, for example, limited the ability to independently eat or dress. About ¼ of patients who came to the diagnostic center were forced to quit their jobs due to tremor [4].

Kinetic hand tremors can occur during various voluntary movements, including drinking or pouring water from a glass, using eating utensils, or writing. Kinetic tremor often intensifies at the last point of a purposeful movement (the so-called “terminal amplification”), but sometimes it has a clearer intentional character, growing as it approaches the target. Postural tremor of the arms (for example, when holding the upper limbs in an extended horizontal position in front of the body) usually has a lower amplitude than kinetic tremor. Trembling in the hands most often includes flexion / extension of the hands, mixing / spreading of the fingers, much less often it has a rotatory character (pronation / supination), which is more characteristic of parkinsonian tremor. The frequency of oscillations during ET is 6–10 Hz. With increasing age of the patient, there is a tendency to reduce the frequency of tremor to 4 Hz.

Head tremor occurs in approximately 30% of patients with ET [27]. Head trembling can be represented by a “yes-yes” or “no-no” wavering. Isolated head tremor, previously considered a special variant of ET, is currently not included in ET. However, this issue has not been finally resolved. Head tremor that occurs against the background of her dystonic posture, as a rule, is a variant of focal dystonia. It is usually more pronounced when turning the head to one side (opposite to the direction of dystonic traction).

At a later stage, the tremors involve the vocal cords (about 20% of cases), the face/jaw (about 10%), the tongue (about 20%), the trunk (about 5%), and the lower extremities (about 10%) [27 ]. Due to the tremor of the tongue, soft palate, vocal folds, patients may experience mild dysarthria, but it is rarely observed before 65 years of age.

During the day, due to the daily rhythms of physiological processes and changes in the emotional state, fluctuations in the amplitude (but not frequency) of the tremor are possible. Under the influence of stress, overwork, with an increase in temperature, taking psychostimulants, the severity of trembling may temporarily increase. Like other extrapyramidal syndromes, trembling decreases or disappears completely during sleep.

In classic ET, there are no other neurological manifestations; however, there are often cases in the clinic when trembling similar to ET is accompanied by other neurological symptoms. Among them are cerebellar (impaired tandem walking, intentional tremor, dysmetria), dystonic symptoms (head position, writing spasm, blepharospasm), symptoms of parkinsonism (rest tremor, hypomimia, bradykinesia, tendency to achirokinesis). Usually these are “mild symptoms” that do not have clinical significance, that is, they do not reach a degree of severity that allows diagnosing one or another neurological syndrome. In recent years, it is customary to diagnose ET-plus in such cases [28, 29]. The recently published criteria for diagnosing ET, developed by the International Society for Parkinson's Disease and Movement Disorders, contain the definition of ET-plus for the first time (see table).

Diagnostic criteria for E. T. International Parkinson's and Movement Disorders Society (MDS, 2018)

In addition to kinetic-postural tremor, some patients with ET have resting tremor in the absence of rigidity or bradykinesia [30, 31]. In these patients, there is a more pronounced and widespread postural-kinetic tremor. It should be taken into account that the resting tremor in ET has some features, being only a continuation of the pronounced postural-kinetic trembling, has the same frequency characteristics, and does not decrease with movement. In this regard, it is more correct to define this type of tremor as “tremor at rest”.

Difficulties in differential diagnosis also arise in cases where postural tremor is detected in patients in the classical clinic of Parkinson's disease [32, 33]. An important characteristic of this type of tremor is the presence of a short pause in trembling after the start of movement or after the limb is placed in a certain position, the so-called re-emergent tremor [32]. Postural trembling in Parkinson's disease does not appear immediately after stretching the arms, but after a few seconds and then gradually increases in amplitude. This variant of tremor has clinical characteristics similar to resting tremor, including the same frequency and a positive response to levodopa.

Thus, although in practice patients with ET are often diagnosed with parkinsonism, it is not difficult to distinguish classic ET from parkinsonian tremor in the vast majority of cases. But often in the clinic there are borderline cases, when trembling, similar to ET, is accompanied by minimal signs of parkinsonism. In this case, the diagnosis helps to establish long-term observation of the patient. A relatively rapid increase in signs of parkinsonism indicates Parkinson's disease or another disease that manifests itself as parkinsonism.

Many authors [34, 35] have recently pointed out that some patients with ET are predisposed to the development of Parkinson's disease. In these cases, in addition to resting tremor, patients have bradykinesia, rigidity, postural instability, and gait changes.

Misdiagnosis of ET is common in patients with dystonic tremor. In patients with focal or generalized forms of muscular dystonia, 2 variants of tremor can be observed. In some patients, a postural-kinetic tremor in the hands is observed, reminiscent of E.T. Along with this, in dystonia, there is also a special variant of tremor - dystonic, in which there is a local, variable in amplitude, asymmetric, low-frequency, often arrhythmic trembling. It usually occurs in the same region as the dystonic posture and is often accompanied by myoclonus. Dystonic tremor of the head is especially common as a manifestation of cervical dystonia (spastic torticollis). Dystonic head tremor is more often horizontal (“no-no”) and usually slower than in ET (about 5 Hz). It depends on the posture, increases when turning the head in the direction opposite to the direction of dystonic traction, and decreases with corrective gestures (for example, when touching the chin). Diagnosis of dystonic tremor can be difficult because sometimes a rather gross tremor occurs against the background of a minimally pronounced pathological posture (for example, torticollis) or long before more obvious dystonic hyperkinesis. In some cases, dystonic tremor occurs in a different region than dystonic hyperkinesis proper and may be more pronounced than the latter. For example, a patient with barely noticeable torticollis may be disturbed by a rather coarse dystonic tremor in the hand.

Disorder of walking and postural stability

Approximately 1/3 of patients with ET have impaired tandem walking, which may indicate cerebellar dysfunction [9, 11]. The frequency of erroneous lateral steps during the tandem walking test positively correlated with the age of the patients, the age of onset of the disease, and the presence and severity of axial tremor (tremor of the head, jaw, and vocal cords). At the same time, there was no correlation with the severity of trembling in the limbs. Alcohol, which reduces hand tremor in 60% of patients with ET, can also improve gait disorders with a decrease in the number of lateral steps [11, 36].

Non-motor manifestations

In recent years, a special interest of researchers has been directed to the study of non-motor manifestations in ET.

Many studies [19, 28, 35] have identified mild cognitive impairment in ET. The profile of cognitive impairment indicates a possible dysfunction of the frontostriate or cerebellar-thalamocortical systems. In addition, a relationship was established between cognitive impairment and late onset of the disease and the severity of dementia: at the onset of the disease at the age of 65, 70% of patients had a cognitive defect [35]. Some elderly develop dementia, the risk of which in patients with ET is 2-3 times higher than the average for the population (“trembling” dementia). Just as in the case of the delayed development of the Parkinson's disease clinic against the background of a long-term course of ET, it can be assumed that the pathogenetic mechanisms underlying ET (for example, associated with axonal dysfunction), in the presence of additional factors, can contribute to the development of a degenerative process in the subcortical or temporo-limbic structures. On the other hand, it cannot be ruled out that ET may be the debut syndrome of one or another neurodegenerative disease.

Patients with ET have a more pronounced level of anxiety compared to the population level [37]. The lack of correlation between the severity of tremor and anxiety disorders probably indicates that an anxious personality profile may be the primary manifestation of the disease, and not a consequence of psychological disorders caused by severe disabling tremor [37].

Several studies38,39 have reported mild olfactory dysfunction among ET patients, but this is less common than in Parkinson's disease. Olfactory disturbances were observed at an early stage and did not correlate with the duration of the disease or its severity. It is possible that this feature is characteristic of ET associated with Lewy bodies. Separate studies [35] reported a high percentage of ET patients with hearing loss.

ET has been shown to be associated with arterial hypertension, coronary heart disease, cerebrovascular disease, migraine, but these associations have not been confirmed in all studies and their relationship to the pathogenesis of the disease remains unclear. Observation of the outstanding domestic neurologist L.S. Minor, who believed that families of patients with tremor are characterized by increased fertility and a large number of centenarians ( status macrobioticus multiparus ), was also not confirmed in subsequent studies, at least in most cases.

Although ET is currently considered as a separate entity, genetic studies and clinical experience suggest that it is rather a combination of several conditions with similar clinical manifestations, with different genetic basis, pathogenesis, unequal rate of development and response to drugs.

Treatment approaches

The aim of ET treatment is to minimize the functional limitations associated with tremor and reduce social maladjustment. The choice of treatment is based on the needs of the patient, the severity of the tremor, comorbidity, and previous therapy. Therapy may include physical interventions, behavioral interventions, lifestyle changes, medications, and surgery. Therapy for essential tremor is symptomatic and does not cure, prevent, or slow the rate of progression of the disease. In cases where the patient does not have functional or psychosocial impairments, treatment is not required [40].

In a significant number of cases, especially at an early stage, drug treatment is not required: it is enough to calm patients who often experience discomfort not so much in connection with the tremor itself, but with fears about the expected onset of a severe disabling disease (most often Parkinson's disease).

Most patients with moderate tremor are able to minimize functional and social disability by mastering adaptive techniques: use pens, knives or eating utensils with comfortable thick handles, scissors with safety blunt ends, voice control telephone, etc. To methods physical impact include the use of special orthoses, with which you can limit the range of motion of the wrist joint [40, 41].

In cases where tremor leads to a limitation of professional or household activities, medical treatment is indicated, the choice of drugs for which is based on their expected safety and effectiveness. The safest and most effective drugs (level of evidence, A, according to the American Academy of Neurology Expert Committee) include the β-blocker propranolol and the anticonvulsant primidone. The effectiveness of propranolol and primidone, which are traditionally referred to as first choice drugs, is approximately equal [42-44].

Propranolol is a non-selective β-adrenergic receptor blocker primarily acting on postural and kinetic hand tremor. As accelometry shows, the amplitude of oscillations decreased by 50%. According to the results of controlled studies, the average effective dose of the drug was 185 mg / day. Most often, the dosage varies from 80 to 320 mg / day (in 2-3 doses). The most convenient drug with a long release, but it is not registered in Russia. In the initial stages of the disease, propranolol can be taken not constantly, but occasionally, for example, when visiting public places or before a performance. In these cases, long-acting preparations are especially convenient. Propranolol can also be used to treat head tremor in E.T. Side effects occurred in 12-66% of patients and were represented by dizziness, fatigue, bradycardia, and impaired attention. The mechanism of the antitremor action of propranolol remains unknown. It is assumed that it can be associated with both peripheral action (on muscle β2-adrenergic receptors) and central action of the drug (possibly with increased GABAergic transmission). Propranolol is effective in about 75% of patients, but only in a small proportion of them is it able to completely or almost completely suppress tremor. Relative contraindications to its appointment are: heart failure (in the phase of decompensation or subcompensation), atrioventricular blockade of the 2nd-3rd degree, severe bronchial asthma, insulin-dependent diabetes mellitus. In a significant proportion of patients, especially the elderly, due to side effects, the dose of the drug cannot be increased to an effective one.

Primidone is a barbiturate anticonvulsant that, like propranolol, reduces the amplitude of postural and kinetic hand tremors by about 50%. Range of effective dosages: from 125 to 500 mg/day. The average therapeutic dose is 482 mg / day. Adverse events were more often observed at the initiation of treatment and were represented by drowsiness, fatigue, nausea, vomiting, ataxia, dizziness. These reactions usually lasted for several days, and then, due to the induction of liver enzymes and changes in drug metabolism, decreased. Empirically, slow initial dose titration of primidone has been shown to improve tolerability, but controlled studies suggest otherwise. The mechanism of the antitremor effect of primidone seems to be related to the action of the drug itself, and not to its metabolites. In the body, primidone breaks down into a number of compounds, including phenobarbital. But phenobarbital itself, although it can reduce tremor, has a much less pronounced effect than primidone. A combination of propranolol and primidone is possible, which is effective in some patients who do not respond well to monotherapy with each of the drugs.

Second choice drugs (Evidence B) include alprazolam, sotalol, atenolol, gabapentin, topiramate.

Alprazolam is a short-acting, high potency benzodiazepine that reduces limb tremor by 25-34%. Therapeutic dose - 0.125-3 mg / day in 2-4 doses. According to the mechanism of action, alprazolam is close to clonazepam, but the latter has a greater effect on axial and dystonic tremor. Clonazepam and alprazolam are recommended to be used with caution due to the potential risk of dependence syndrome.

Sotalol is a non-selective β-adrenergic blocker, the closest in mechanism of action to propranolol, reduces the amplitude of limb trembling by 28%.

Atenolol is a selective β1-blocker, effective at a dose of 50-150 mg/day, but its antitremor effect is lower than that of non-selective β-blockers.

Gabapentin is an anticonvulsant with a structure similar to GABA, but its main mechanism is related to the action on voltage-gated calcium channels. The results of the 90 years of a large placebo-controlled study showed that monotherapy with gabapentin at an average dose of 1200 mg / day for 15 days leads to a decrease in tremor, according to accelometry, by more than 70%, which is higher than the antitremor effect of propranolol and primidone. However, this has not been confirmed in clinical practice. Currently, gabapentin is rarely used in ET, usually in combination with other agents and when first-line agents have failed.

Topiramate is an anticonvulsant that blocks sodium channels and potentiates GABA activity. According to several placebo-controlled studies, it was found that the drug at a dosage of up to 400 mg / day reduces tremor by an average of 20%. Practice shows that when topiramate is used in ½ of patients, adverse events occur (weight loss, paresthesia, cholelithiasis, impaired attention), which prevent the achievement of an effective dose of the drug.

The β-blocker nadolol, the calcium antagonist nimodipine, or the anticonvulsant zonisamide can be used as second-choice agents for limb tremor. The atypical antipsychotic clozapine, which blocks 5HT-2c receptors, is recommended only in refractory cases of tremor of the extremities in ET due to the risk of agranulocytosis (when prescribing the drug, the number of leukocytes in the blood should be determined weekly).

Botulinum toxin A injections for the treatment of ET are indicated in cases refractory to conservative treatment, more often with severe tremor of the head and voice. It should be borne in mind that the use of botulinum toxin for the treatment of voice tremors can cause impaired breathing, articulation and swallowing. The effectiveness of botulinum toxin A in the treatment of limb tremor in ET is usually moderate and is often accompanied by dose-dependent hand extensor weakness. To maintain the effect, repeated injections are required after 3-6 months.

In the most severe cases of hand tremor resistant to pharmacological treatment, stereotaxic intervention on the ventral intermediate nucleus of the thalamus is used: implantation of electrodes on one or both sides, followed by chronic stimulation, or thalamotomy [45-47]. Each procedure is accompanied by a certain risk of complications [46]. Safer pacing is preferred, and some of its adverse effects may be offset over time or by adjusting stimulator settings. Stimulation is not indicated for the treatment of axial tremor (of the head and vocal cords). With asymmetric tremor, a thalamotomy is possible on the corresponding side, but on both sides, due to the threat of side effects, it is not allowed. There is insufficient evidence for the long-term efficacy of thalamotomy using the Gamma Knife. A promising neurosurgical method is MRI-guided ultrasound thalamotomy [48–50]. Overall, additional prospective controlled studies are needed to determine the efficacy and safety of surgical treatment for ET. The ET treatment algorithm is shown in the figure.

ET treatment algorithm.

Treatment of non-motor disorders in ET is poorly developed. When correcting cognitive impairment, it should be borne in mind that almost all drugs recommended for the correction of trembling can exacerbate cognitive decline. To date, only memantine is able to improve cognitive function while reducing tremor, although more research is also needed to confirm this.

In the presence of anxiety disorders, it should be borne in mind that the use of antidepressants (primarily selective serotonin reuptake inhibitors) may increase trembling, and mirtazapine is more preferable in the treatment of this category of patients.

The authors declare no conflict of interest.

e-mail: [email protected]

effective treatment, symptoms and causes

Parapsoriasis is a relatively rare disease. In the article we will talk about its forms, causes and symptoms, as well as approaches to diagnosis and treatment.

Parapsoriasis includes a group of chronic non-contagious dermatoses of unknown origin, which are characterized by skin rashes similar to psoriatic.

The causes and mechanism of development of parapsoriasis are poorly understood. Parapsoriasis includes lichen planus, rosacea, and "dry" eczema. All these dermatoses are similar to psoriasis, except for such symptoms as:

  • the effect of stearin stain when trying to scrape off the scales;

  • varnished terminal film;

  • pinpoint bleeding like dew drops.

Despite the fact that parapsoriasis is considered a rare disease, due to the deterioration of the environment and the increase in the number of allergies, parapsoriasis occurs more and more often.

What forms does it take?

Basic forms of parapsoriasis :

  • Teardrop or spotted;

  • Plaque or Broca's disease;

  • Lichenoid.

Due to the fact that the disease is little studied, at the moment there is no generally accepted classification. Many doctors consider forms of parapsoriasis as separate diseases.

Guttate parapsoriasis

Or superficial infectious-allergic vasculitis (inflammation of the inner lining of small vessels). It often develops in the spring and autumn due to a sore throat, flu or pneumonia. Women are more susceptible to the disease than men. There are chronic, most frequent, subacute and acute types of the course.

The disease is manifested by small dense papules (nodules) of a rounded shape with a smooth surface, light pink, less often brownish-red. For rashes, fusion is not characteristic.

The main localization is the chest, the inner surface of the shoulders and forearms, the back, the lower abdomen, the inner thighs, the area of ​​the sacrum and popliteal fossae. At the base of the nodules, there is a slight swelling (infiltration). Itching and pain are absent.

In parallel with the papules, a bright red rash sometimes appears, covered with small lamellar scales.

This type of disease is also called "parapsoriasis spotted". The rash is similar to the rash in secondary syphilis, so differential diagnosis is important here.

Chronic form

Eruptions go through four stages of development:

  • "Hidden" peeling : small scales appear on the surface of the papule when scraped.

  • "Purpura" : as a result of scratching, papules begin to bleed like purpura.

  • "Collodion" film: occurs during the period of symptom reduction - the scale is located in the center of the papule, slightly separating from it along the edges;

  • "Washer" : the flake is completely detached without being damaged.

The total duration of these stages is about 3-4 weeks, after which whitish depigmented spots remain on the skin. Mucosal involvement is rare.

The chronic form is characterized by a long course with exacerbations in the autumn and winter and remissions in the summer.

If the therapy is properly prescribed and the patient follows all the recommendations of the attending physician, the exacerbations are less pronounced, and the periods of remission become longer.

Acute parapsoriasis

As a rule, acute parapsoriasis develops suddenly, accompanied by fever, deterioration of health and sometimes - enlargement of peripheral lymph nodes.

During the period of exacerbation, bloody edematous papules with a diameter of up to 1 cm predominate. They go through the same stages of development as in the chronic course, the difference is that necrosis (tissue necrosis) and suppuration are noted in the center of the papules, the papule becomes a pustule, leaving after hem yourself.

Acute parapsoriasis is often accompanied by a rash on the mucous membranes of the oral cavity, genital organs. The degree of severity of the process is indicated by the predominance of one or another type of rash:

  • vesicular - vesicles with clear liquid;

  • atrophic - with a tendency to regress elements within a short time;

  • purplish - the predominance of bloody rashes distinguishes the process with the most acute course.

The disease may recur. At the site of the rash, there are areas of depigmentation or excessive pigmentation, as well as scars.

Subacute form

Symptoms of the subacute form are similar to those of chronic parapsoriasis, they are distinguished by elements with increased bleeding, as well as small papular rashes on the mucous membranes up to 3 mm in size. Painful sensations are absent. At the site of the rash, hyperpigmented and depigmented areas remain.

Habermann-Fly varioliform parapsoriasis (pox-like)

May occur at any age both in men and women.

During the prodromal period, malaise, weakness, fever, enlargement of peripheral lymph nodes are noted. Then a widespread symmetrical rash appears, which is localized on the chest, abdomen, limbs, including the palms and feet, rarely on the scalp. This is its similarity with chickenpox.

Eruptions do not tend to coalesce or cluster.

Elements with central necrosis join papules, up to 5-8 mm in size, at different stages of development. Pustules with purulent and vesicles with bloody contents may appear on the surface of the papules, which, when dried, form crusts. In place of the crusts, pigmented spots and scars remain, similar to the consequences of chicken pox.

Very rarely whitish rash on the tongue, hard palate and buccal mucosa.

The acute phase of varioliform parapsoriasis lasts from 1 to 1.5 months. If the rash does not go away within six months, the disease becomes chronic.

Plaque parapsoriasis

Most patients with this disease have gastrointestinal or genitourinary pathologies. Therefore, effective treatment of concomitant disorders and proper nutrition help to reduce skin manifestations.

Plaque parapsoriasis is manifested by single or multiple spots, which may remain unchanged for a long time (up to several years).

There are two forms of the disease:

Plaque parapsoriasis is more common in middle-aged and older men.

Large plaque parapsoriasis

Foci of inflammation are very thin plaques or flat spots of irregular or oval shape. Rashes are not accompanied by pain, in some cases there is a slight itching. The elements of the rash have clear boundaries, do not increase over time, but their number increases.

Localization - lower chest, thighs, flexion surfaces, areas of the body subject to frequent friction. It is not excluded the appearance of a rash on the skin of the mammary glands. The color of the rashes can be red-brown, whitish-pink, blue-red, brown.

Foci are characterized by atrophic vascular poikiloderma, which is characterized by:

As a rule, large-plaque parapsoriasis has a chronic course (up to several decades). In about a quarter of cases, the disease turns into mycosis fungoides. With a long course, infiltration of the focus of inflammation occurs, papules appear, itching may appear.

A rare form of large-plaque parapsoriasis - retiform, or reticular parapsoriasis - is characterized by widespread rashes in the form of papules or spots with a scaly surface. Almost all cases of the mesh form end in mycosis fungoides.

Small-plaque parapsoriasis

Appears as smooth, slightly rough or wrinkled patches up to 5 cm in diameter, yellowish brown, yellowish pinkish, reddish blue or yellow. Their shape can be elliptical, elongated or like stripes with pointed ends.

In the absence of correct treatment or if the skin is irritated by clothes, the spots begin to acquire a more juicy, bright color. Elements cover transparent thin scales.

Eruptions are localized mainly on the chest parallel to the location of the ribs, limbs, in the region of the mammary glands, sacrum, along the inner surface of the shoulders and thighs.

Small plaque parapsoriasis has a chronic course.

Lichenoid parapsoriasis

The rarest of all types of parapsoriasis. It is characterized by high resistance to the ongoing treatment.

Rash elements include flat small vesicles, pink or brownish-red papules, covered with small scales in the center, and plaques up to 5 mm in size.

Over time, the process spreads to the lateral surfaces of the chest, head, face, limbs. On the face, papules are often arranged in groups, scattered or as stripes, on the legs they tend to merge. Papules on the lips are grayish-white in color and tend to merge. Separate elements may appear on the mucous membranes.

Eruptions are at different stages of development, in their place often remain foci of hyper- and hypopigmentation and small scars.

Causes of parapsoriasis

Many questions regarding the causes of parapsoriasis are not fully understood. In patients with parapsoriasis, disorders are revealed in the form of a decrease in capillary resistance and an increase in their permeability. Similar violations are detected with influenza, tonsillitis, meningococcal meningitis, scarlet fever, measles, chicken pox and many other infectious diseases.

However, parapsoriasis is not a contagious disease, since the presence of pathogens of the above infections is not diagnosed in the body of patients.

It is believed that the main reason for the development of parapsoriasis is a skin inflammatory autoimmune reaction of the body caused by antigens as a result of the action of infectious toxic agents (viruses of acute infectious diseases, intoxications of a different nature, chronic foci of infection, allergens, etc.).

An inflammatory autoimmune reaction can be caused by somatic diseases (chronic disorders of the liver, stomach, intestines), seasonal acute respiratory viral infections, excessive insolation, endocrinological disorders and diseases of the endocrine glands, etc.

Symptoms of parapsoriasis

Symptoms depend on the form of the disease. For example, guttate parapsoriasis can develop at any time of the year, occur in several forms - acute, chronic and subacute and not be accompanied by itching or pain.

In the acute form, skin rashes appear suddenly. The process begins with a small spot, in the center of which is a scaly papule. Rashes can appear on any part of the body. Parapsoriasis is characterized by staging: first redness, then papule, vesicle and atrophic elements of the rash. At the last stage, scars and age spots form.

Subacute parapsoriasis has symptoms similar to the acute stage, but occurs against a background of more pronounced redness in the lesions. The rash is localized mainly on the arms and legs.

Lichenoid parapsoriasis is characterized by a round-shaped rash and has a chronic course. Rashes can merge with each other, increasing the lesions.

Plaque parapsoriasis appears as yellowish patches with smooth edges. The size of the spots is from 5 mm to 1.5 cm. Aggravation occurs in winter.

Diagnosis and treatment of parapsoriasis

The main method of diagnosis is a clinical examination.

Dermatologist determines the nature of the rashes, their localization and shape, and performs dermatoscopy.

Dermatoscopy – Examination of the skin with the Dermatoscope, which, thanks to its multiple magnification, reveals the smallest details of the structure and shape of the rash and accurately determines the form of the disease.

As an additional method, diagnostics can be carried out to identify concomitant diseases.

Chronic parapsoriasis is difficult to treat, so it is important to follow all the doctor's recommendations. This will allow you to achieve a long-term remission.

Basic principles of parapsoriasis therapy

PUVA-therapy - ultraviolet treatment that slows down the growth of papules and activates the reproduction of healthy cells.

Learn more