The Cerebellum

, Volume 12, Issue 1, pp 27–34 | Cite as

Disorders of Balance and Gait in Essential Tremor Are Associated with Midline Tremor and Age

  • Martina Hoskovcová
  • Olga Ulmanová
  • Otakar Šprdlík
  • Tomáš Sieger
  • Jana Nováková
  • Robert Jech
  • Evžen RůžičkaEmail author
Original Paper


Disorders of balance and gait have been observed in patients with essential tremor (ET), but their association with tremor severity remains unclear. This study aimed to evaluate postural instability and gait changes in ET patients and to investigate their relationship to tremor characteristics with regard to cerebellar dysfunction as a possible common pathogenetic mechanism in ET. Thirty ET patients (8F, mean (SD) age 55.8 (17.8), range 19–81 years) and 25 normal controls (7F, 53.0 (17.7), 19–81) were tested with the scales of Activities-specific Balance Confidence (ABC), Fullerton Advanced Balance (FAB), and International Cooperative Ataxia Rating Scale (ICARS). Posturography and gait were assessed using a Footscan® system. Tremor was evaluated by the Fahn–Tolosa–Marin Tremor Rating Scale (TRS) and accelerometry in five upper limb positions. A mean (SD) TRS sum score of 27.0 (13.2) corresponded to mild to moderate tremor severity in most patients. In comparison with controls, ET subjects exhibited lower tandem gait velocity (0.21 vs. 0.26 m/s, P = 0.028), more missteps (0.57 vs. 0.12, P = 0.039), and increased postural sway in tandem stance (sway area 301.1 vs. 202.9 mm2, P = 0.045). In normal gait, step width increased with the midline tremor subscore of TRS (Pearson r = 0.60, P = 0.046). Moreover, significant correlations were found between age and quantitative measures of normal and tandem gait in ET patients but not in controls. ABC, FAB, and ICARS scores did not significantly differ between patients and controls. In conclusion, gait and balance alterations in ET patients occur even without subjective complaints. Their relationship with midline tremor and dependence on age suggest a connection with cerebellar dysfunction.


Essential tremor Posturography Gait Accelerometry Aging 



The authors wish to thank Klára Plichtová; Martina Puršová, M.Sc.; Marie Vinopalová, MD; and František Zahálka, M.Sc. for their technical help and Aaron Rulseh, MD for his correction of English. This study was supported by the Czech Ministry of Health, NS10336-3/2009; by the Czech Ministry of Education, MSM 0021620849; and by the Czech Technical University in Prague, SGS10/279/OHK3/3T/13.

Conflict of Interest

None of the authors report a conflict of interest with respect to financial or personal relationships with organizations that may have influence on this work.


  1. 1.
    Elble RJ. Diagnostic criteria for essential tremor and differential diagnosis. Neurology. 2000;54 suppl 4:S2–6.PubMedGoogle Scholar
  2. 2.
    Ondo WG, Almaguer M, Cohen H. Computerized posturography balance assessment of patients with bilateral ventralis intermedius nuclei deep brain stimulation. Mov Disord. 2006;21:2243–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Bove M, Marinelli L, Avanzino L, Marchese R, Abruzzese G. Posturographic analysis of balance control in patients with essential tremor. Mov Disord. 2006;21:192–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Parisi SL, Heroux ME, Culham EG, Norman KE. Functional mobility and postural control in essential tremor. Arch Phys Med Rehabil. 2006;87:1357–64.PubMedCrossRefGoogle Scholar
  5. 5.
    Earhart GM, Clark BR, Tabbal SD, Perlmutter JS. Gait and balance in essential tremor: variable effects of bilateral thalamic stimulation. Mov Disord. 2009;24:386–91.PubMedCrossRefGoogle Scholar
  6. 6.
    Singer C, Sanchez-Ramos J, Weiner WJ. Gait abnormality in essential tremor. Mov Disord. 1994;9:193–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Hubble JP, Busenbark KL, Pahwa R, Lyons K, Koller WC. Clinical expression of essential tremor: effects of gender and age. Mov Disord. 1997;12:969–72.PubMedCrossRefGoogle Scholar
  8. 8.
    Stolze H, Petersen G, Raethjen J, Wenzelburger R, Deuschl G. The gait disorder of advanced essential tremor. Brain. 2001;124:2278–86.PubMedCrossRefGoogle Scholar
  9. 9.
    Kronenbuerger M, Konczak J, Ziegler W, Buderath P, Frank B, Coenen VA, et al. Balance and motor speech impairment in essential tremor. Cerebellum. 2009;8:389–98.PubMedCrossRefGoogle Scholar
  10. 10.
    Louis ED, Rios E, Rao AK. Tandem gait performance in essential tremor: clinical correlates and association with midline tremors. Mov Disord. 2010;25:1633–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Fasano A, Herzog J, Raethjen J, Rose FEM, Muthuraman M, Volkmann J, et al. Gait ataxia in essential tremor is differentially modulated by thalamic stimulation. Brain. 2010;133:3635–48.PubMedCrossRefGoogle Scholar
  12. 12.
    Rao AK, Gillman A, Louis ED. Quantitative gait analysis in essential tremor reveals impairments that are maintained into advanced age. Gait Posture. 2011;34:65–70.PubMedCrossRefGoogle Scholar
  13. 13.
    Louis ED. Essential tremor as a neuropsychiatric disorder. J Neurol Sci. 2010;289:144–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Louis ED, Benito-León J, Vega-Quiroga S, Bermejo-Pareja F. Faster rate of cognitive decline in essential tremor cases than controls: a prospective study. Eur J Neurol. 2010;17:1291–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Louis ED. Essential tremors: a family of neurodegenerative disorders? Arch Neurol. 2009;66:1202–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Deuschl G, Elble R. Essential tremor—neurodegenerative or nondegenerative disease towards a working definition of ET. Mov Disord. 2009;24:2033–41.PubMedCrossRefGoogle Scholar
  17. 17.
    Louis ED, Faust PL, Vonsattel JP, Honig LS, Rajput A, Robinson CA, et al. Neuropathological changes in essential tremor: 33 cases compared with 21 controls. Brain. 2007;130:3297–307.PubMedCrossRefGoogle Scholar
  18. 18.
    Deuschl G, Bain P, Brin M. Consensus statement of the Movement Disorder Society on Tremor. Ad Hoc Scientific Committee. Mov Disord. 1998;13 suppl 3:2–23.PubMedGoogle Scholar
  19. 19.
    Powell LE, Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 1995;50:M28–34.CrossRefGoogle Scholar
  20. 20.
    Rose DJ, Lucchese N, Wiersma LD. Development of a multidimensional balance scale for use with functionally independent older adults. Arch Phys Med Rehabil. 2006;87:1478–85.PubMedCrossRefGoogle Scholar
  21. 21.
    Trouillas P, Takayanagi T, Hallett M, Currier RD, Subramony SH, Wessel K, et al. International Cooperative Ataxia Rating Scale for pharmacological assessment of the cerebellar syndrome. The Ataxia Neuropharmacology Committee of the World Federation of Neurology. J Neurol Sci. 1997;145:205–11.PubMedCrossRefGoogle Scholar
  22. 22.
    Fahn S, Tolosa E, Marin C. Clinical rating scale for tremor. In: Jankovic J, Tolosa E, editors. Parkinson’s disease and movement disorders. 2nd ed. Baltimore: Williams & Wilkins; 1993. p. 271–80.Google Scholar
  23. 23.
    Šprdlík O, Hurák Z, Hoskovcová M, Ulmanová O, Růžička E. Tremor analysis by decomposition of acceleration into gravity and inertial acceleration using inertial measurement unit. Biomed Signal Process Control. 2011;6:269–79.CrossRefGoogle Scholar
  24. 24.
    Rocchi L, Chiari L, Cappello A. Feature selection of stabilometric parameters based on principal component analysis. Med Biol Eng Comput. 2004;42:71–9.PubMedCrossRefGoogle Scholar
  25. 25.
    R Development Core Team (2009) R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna. ISBN 3-900051-07-0.
  26. 26.
    Louis ED, Rao AK, Gerbin M. Functional correlates of gait and balance difficulty in essential tremor: balance confidence, near misses and falls. Gait Posture. 2012;35:43–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Stolze H, Klebe S, Petersen G, Raethjen J, Wenzelburger R, Witt K, et al. Typical features of cerebellar ataxic gait. J Neurol Neurosurg Psychiatry. 2002;73:310–2.PubMedCrossRefGoogle Scholar
  28. 28.
    Morton SM, Bastian AJ. Mechanisms of cerebellar gait ataxia. Cerebellum. 2007;6:79–86.PubMedCrossRefGoogle Scholar
  29. 29.
    Quattrone A, Cerasa A, Messina D, Nicoletti G, Hagberg GE, Lemieux L, et al. Essential head tremor is associated with cerebellar vermis atrophy: a volumetric and voxel-based morphometry MR imaging study. Am J Neuroradiol. 2008;29:1692–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Louis ED, Faust PL, Ma KJ, Yu M, Cortes E, Vonsattel JP. Torpedoes in the cerebellar vermis in essential tremor cases vs. controls. Cerebellum. 2011;10:812–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Louis ED, Okun MS. It is time to remove the ‘benign’ from the essential tremor label. Parkinsonism Relat Disord. 2011;17:516–20.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Martina Hoskovcová
    • 1
  • Olga Ulmanová
    • 1
  • Otakar Šprdlík
    • 2
  • Tomáš Sieger
    • 1
    • 3
  • Jana Nováková
    • 2
  • Robert Jech
    • 1
  • Evžen Růžička
    • 1
    Email author
  1. 1.Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine and General University Hospital in PragueCharles University in PraguePragueCzech Republic
  2. 2.Department of Control Engineering, Faculty of Electrical EngineeringCzech Technical University in PraguePragueCzech Republic
  3. 3.Department of Cybernetics, Faculty of Electrical EngineeringCzech Technical University in PraguePragueCzech Republic

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