Successful Therapy of Holmes Tremor with a Silicone Hand-Wrist Orthesis and Botulinum Toxin A

Background: We report a 15-year-old boy, who had a cerebral bleeding in the thalamus and basal ganglia area with a consecutive hemiparesis. The patient suffered from a persisting weakness of underarm and hand and a increasing intention and postural tremor of the whole arm (Holmes tremor). In the tremor analysis, we saw a tremor of low frequency and high amplitude, especially of the upper arm (abduction/elevation) and the hand/dorsal extension/palmar flexion). The hand could not be stabilized—causing a loss of hand function. The tremor was trigged by the “trembling” wrist. Therapy goals (in brackets the ICF domain): Reduction of the amplitude in wrist and upper arm (structure and function), better precision in bimanual tasks (activity), reduction of social abnormality (participation). Results: As an interdisciplinary team (orthopedic technician, occupational therapist, and child neurologist), we manufactured a silicone wrist/hand orthosis. This led to a substantial reduction of tremor frequency and amplitude. The patient gave the school grade 2+ (1–6). Clinically and sonographically, we identified M. deltoideus as one of the triggering muscles. After a therapy with 25 U Onabotulinum toxin A (Botox [0.3 U/kg]), a further reduction of the tremor was described for 4 weeks. In this first injection, a low dose was chosen to reduce the risk of worsening the paresis. Conclusion: An orthotic stabilization of the wrist and a treatment with Botulinum toxin can lead to a remarkable improvement of hand function and reduction of the tremor.