Peripheral Therapies for Tremor: Botulinum Toxins, Electrical Stimulation, Mechanical Dampening, Vibration, Cooling, and Adaptive Devices

This manuscript discusses nonpharmacological, nonsurgical interventions for tremor, mostly essential tremor, predominantly arm tremor. We will review botulinum toxin injections (BoNT), transcutaneous electrical stimulation (TES), multiple orthotic/mechanical devices, vibration strategies, cooling, and adaptive utensils. BoNT has copious but inconsistent efficacy data, the optimal tremor phenotypes, muscle selection, and injection techniques remain debated. The TES section discusses mostly peripheral nerve stimulation at the wrist, including commercially available open-loop systems and closed-loop systems (Felix), as well as spinal and cerebellar TNS. Orthotic devices, which physically dampen tremor, include the STIL B.P. orthosis, the Tremulo,GyroGlove,WOTAS exoskeleton, liquid harmonic dampeners, Steadi-3, and Readi-Steady. Vibration devices include the Encora Pulse and Vilim ball. Adaptive devices include weighted spoons, deep cavity spoons, counter-balance utensils, and electrical actuator devices.