Tremor Interdisciplinary Clinic
The mission of the Tremor Interdisciplinary Clinic is to provide an educational, consultative set of assessments and recommendations to participants and their local, referring care teams who seek to better understand the nature of and management options for their tremor syndromes.
Essential tremor (ET) and Parkinson disease (PD) remain the most commons movement disorders and also the top 2 etiologies of pathophysiologic tremor. Clinically differentiating between these tremor phenomenologies—let alone other causes of tremor—can prove difficult even for movement disorder specialists who attempt to characterize and classify them, let alone other healthcare professionals. Tremor in ET and PD are often rendered medically-refractory within as little as 1 year of initiating available pharmacotherapies on the market. Patients suffering from tremor are only occasionally referred by their healthcare providers to allied health professionals like occupational therapists for adaptive training: a lost opportunity considering a growing number of adaptive and wearable devices on the market. Deep brain stimulation (DBS) and focused ultrasound ablation (FUSA) surgeries are approved for tremor reduction in both conditions, but require dedicated teams of neurologists, neurosurgeons, and other healthcare professionals to effectively communicate expectations to patients and the referring community at large, let alone coordinate the procedures effectively. Lastly, investigating future insights into tremor management clearly requires collaboration with the basic science researchers who are only occasionally asked to engage in translational research opportunities within clinical settings, despite a number of diagnostic tools at their disposal for tremor analysis (e.g. inertial measurement units, electromyography, accelerometry).
With so many professionals independently studying and treating tremor, we hypothesize that a model for integrated, interdisciplinary care could provide the same benefits as its individual components, while developing emergent properties useful to the study and management of multiple tremor types within real-world patient populations. With so much data already gathered for the utility of interdisciplinary care models across multiple other movement disorders and neurological conditions, we propose a consultative rubric that aims to offer unique clinical opportunities to participants and referring providers, while keeping in mind the limited availability of the highly-trained specialists and the high, global volumes of tremor patients.
Tremor Interdisciplinary Clinic Team Members and Roles
|Team Member||Role||Duration of Visit||Visit Frequency|
|Movement Disorders Specialist||•History and physical
•Complete tremor performance scales
•Clarify tremor etiology and briefly review treatment options
|•History and physical
•Discuss functional neurosurgical options and general surgical candidacy for each procedure
|Occupational Therapist||•History and physical
•Complete ADL rating scales based on proposed tremor etiology
•Offer adaptive technique and equipment options for personal and vocational considerations
|Nurse Educator||With provider direction, offer more in-depth education of:
•Deep brain stimulation surgery
•Focused ultrasound ablation
•Fitting for adaptive equipment
|30 minutes||As appropriate|
|Research Coordinator||With MDS direction:
•Review available studies for which patient may qualify (as possible, contact patient using telephone screening afforded by study protocols)
•Obtain any necessary consents, including for biomedical engineering
|10-20 minutes||As appropriate|
|Biomedical Engineer||•Use combination of IMUs to analyze tremor characteristics per upper limb.||20 minutes||Regularly (unless declined by patient)|
Half-Day Session Make Up
During a 4-hour block of time, 4 participants are scheduled for evaluation. Each participant is seen in tandem by the minimum 3 providers mentioned, making up largely 3 hours of patient-provider-facing time. The last hour of evaluation for each participant is flexible and designed to cater to the needs and interests of the individual patients; such that they may be offered opportunities to participate in available research and be provided with additional education regarding their individual diagnosis and/or treatment options available to them. Though it is the intent of this clinic to objectively measure all tremors with the assistance of our biomedical engineering colleague, this is not a standard of care practice and so requires participants to opt in to testing during that last hour of evaluation/care.
Interdisciplinary Discussion and Recommendations
Once all in-person evaluations have occurred, an hour is spent by all team members discussing individual evaluations per participating patient. Subjective reports, objective findings, clinical opinions, and treatment considerations are reviewed through collaborative discussion. Clinical and ethical questions and concerns are raised as appropriate, resulting in a series of recommendations (whether concordant or not) which are then published in a comprehensive clinic document drafted by the lead movement disorders specialist for the use of patients and referring providers.
As mentioned, it is largely the intent of this clinic to be consultative in nature and as such patients would return to their previously-treating healthcare professionals. Given the fact that our center does offer more advanced therapeutic options (including deep brain stimulation surgery, focused ultrasound ablation surgery, professional connections to adaptive equipment manufacturers, and research opportunities), ongoing professional relationships with these participants are certainly possible but not the primary goal of TIC evaluations.
Analysis of Effect
Through tracked but anonymized data, we hope to better understand short-term and long-term impacts of the TIC on tremor patients and referring providers alike. Variables to be collected will include pre-visit survey responses and post-visit questionnaire responses by participants, focusing on self-perceived utility of the evaluations, education, and treatment recommendations. 6 months later we aim to send out a second survey geared towards understanding whether any recommendations were followed by the patient with their local care team or through ongoing professional relationships at our center. Lastly, we aim to survey referring providers regarding the utility of this service, alongside any self-perceived competency in subsequent evaluation and management of tremor patients after receiving our clinical documentation.
Challenges and Responses for Tremor ID Care
|> 10.7 million persons with tremor||Consultative model; provide referring provider and patient with expectations ahead of visit|
|Higher community misdiagnosis rate||Accept referrals from any neurologist; screen referrals from other HCPs|
|Traditional time and resource constraints||Flexible ID visits with multiple providers on same date of service to allow for redundancies, reducing chances of missed opportunities to educate and provide a comprehensive evaluation|
|Disjointed communication between more traditional multidisciplinary care members||Visits with all care members on same date of service, with ID meeting immediately following all visits|
|Integration of the basic sciences and research||Submit IRB proposal to allow for anonymized, direct measurement of tremor characteristics per participant in an effort to develop group analyses of these objective measures alongside other group analyses planned for TIC outcomes|