OBJECTIVE: Transcranial brain parenchyma sonography (TCS) has been recommended as a tool for the early and differential diagnosis of Parkinson\'s disease (PD) in German and European clinical guidelines. Still, the brain structures to be examined for the diagnostic questions and the requirements for being a qualified investigator were not specified in detail. These issues have now been addressed in the 2023 update of the clinical guideline on PD by the German Society of Neurology (DGN).
METHODS: The recommendations were based on a systematic literature review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.
RESULTS: Three diagnostic questions were defined: (1) What is the accuracy of TCS in the differential diagnosis of PD versus atypical and secondary Parkinsonian syndromes? (2) What is the accuracy of TCS in the differential diagnosis of PD versus essential tremor? (3) What is the accuracy of TCS in the diagnosis of PD in persons with typical early symptoms, compared with the diagnosis established by clinical follow-up? The brain structures to be assessed and the level of recommendation were formulated for these questions. The training requirements for being regarded as qualified TCS investigator were stipulated by the responsible medical societies (German Society of Ultrasound in Medicine, DEGUM; German Society for Clinical Neurophysiology and Functional Imaging, DGKN). Finally, the recommendations for these diagnostic questions reached strong consensus (each ≥ 97%) of the guideline committee. Here, the details of review and recommendations are presented.
CONCLUSIONS: The updated guideline clarifies the diagnostic uses and limitations of TCS in PD.

Essential tremor (ET) is the most prevalent movement disorder with poorly understood etiology. Some neuroimaging studies report cerebellar involvement whereas others do not. This discrepancy may stem from underpowered studies, differences in statistical modeling or variation in magnetic resonance imaging (MRI) acquisition and processing. To resolve this, we investigated the cerebellar structural differences using a local advanced ET dataset augmented by matched controls from PPMI and ADNI. We tested the hypothesis of cerebellar involvement using three neuroimaging biomarkers: VBM, gray/white matter volumetry and lobular volumetry. Furthermore, we assessed the impacts of statistical models and segmentation pipelines on results. Results indicate that the detected cerebellar structural changes vary with methodology. Significant reduction of right cerebellar gray matter and increase of the left cerebellar white matter were the only two biomarkers consistently identified by multiple methods. Results also show substantial volumetric overestimation from SUIT-based segmentation-partially explaining previous literature discrepancies. This study suggests that current estimation of cerebellar involvement in ET may be overemphasized in MRI studies and highlights the importance of methods sensitivity analysis on results interpretation. ET datasets with large sample size and replication studies are required to improve our understanding of regional specificity of cerebellum involvement in ET. PROTOCOL REGISTRATION: The stage 1 protocol for this Registered Report was accepted in principle on 21 March 2022. The protocol, as accepted by the journal, can be found at: https://doi.org/10.6084/m9.figshare.19697776 .

The aim of this consensus paper is to discuss the roles of the cerebellum in human gait, as well as its assessment and therapy. Cerebellar vermis is critical for postural control. The cerebellum ensures the mapping of sensory information into temporally relevant motor commands. Mental imagery of gait involves intrinsically connected fronto-parietal networks comprising the cerebellum. Muscular activities in cerebellar patients show impaired timing of discharges, affecting the patterning of the synergies subserving locomotion. Ataxia of stance/gait is amongst the first cerebellar deficits in cerebellar disorders such as degenerative ataxias and is a disabling symptom with a high risk of falls. Prolonged discharges and increased muscle coactivation may be related to compensatory mechanisms and enhanced body sway, respectively. Essential tremor is frequently associated with mild gait ataxia. There is growing evidence for an important role of the cerebellar cortex in the pathogenesis of essential tremor. In multiple sclerosis, balance and gait are affected due to cerebellar and spinal cord involvement, as a result of disseminated demyelination and neurodegeneration impairing proprioception. In orthostatic tremor, patients often show mild-to-moderate limb and gait ataxia. The tremor generator is likely located in the posterior fossa. Tandem gait is impaired in the early stages of cerebellar disorders and may be particularly useful in the evaluation of pre-ataxic stages of progressive ataxias. Impaired inter-joint coordination and enhanced variability of gait temporal and kinetic parameters can be grasped by wearable devices such as accelerometers. Kinect is a promising low cost technology to obtain reliable measurements and remote assessments of gait. Deep learning methods are being developed in order to help clinicians in the diagnosis and decision-making process. Locomotor adaptation is impaired in cerebellar patients. Coordinative training aims to improve the coordinative strategy and foot placements across strides, cerebellar patients benefiting from intense rehabilitation therapies. Robotic training is a promising approach to complement conventional rehabilitation and neuromodulation of the cerebellum. Wearable dynamic orthoses represent a potential aid to assist gait. The panel of experts agree that the understanding of the cerebellar contribution to gait control will lead to a better management of cerebellar ataxias in general and will likely contribute to use gait parameters as robust biomarkers of future clinical trials.

In 2018, the new Consensus Statement on the Classification of Tremors, by the Task Force on Tremor of the International Parkinson Movement Disorder Society, was published. So far, the article has been cited more than 400 times in peer-reviewed international journals and commonly debated in conferences and meetings due to an enthusiastic welcome from the community. Compared to the previous Consensus Statement (1998), the main novelties are: 1) the classification of tremor according to clinical manifestation (Axis 1) and etiology (Axis 2), and therefore the use of a syndromic approach; 2) the definition of essential tremor as a syndrome; 3) the recognition of the new category essential tremor plus, that derives from the uncertain significance of the soft neurological signs often associated with essential tremor. In this paper, we summarise and explain the most important aspects of the new classification of tremors, highlighting the main novelties, their relevance, and application in clinical practice. Moreover, we discuss its possible weakness and reflect on the critical comments made so far. We believe that this new tremor classification is comprehensive, rigorous, and consistent and, considering our current knowledge of tremor syndromes, it is the best we can do at present. This article is part of the Special Issue \"Tremor\" edited by Daniel D. Truong, Mark Hallett, and Aasef Shaikh.

OBJECTIVE: This study characterized the clinical phenotypes of individuals with vocal tremor (VT) using tremor classification criteria published by the International Parkinson and Movement Disorder Society (IPMDS) including laryngeal features from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS).
METHODS: VT phenotypic descriptors were extracted from participant medical records from 2017 to 2019. Clinical phenotype descriptors included the: (a) chief complaint and discipline for the first appointment, (b) demographics, (c) tremor body distribution, condition, frequency, and progression, (d) exacerbating/alleviating factors, (e) treatment approaches, and (g) neurologic comorbidities. Descriptive statistics were conducted.
RESULTS: Of 179 meeting inclusion criteria, 2/3 were female; tremor onset affected voice (43%) or extremity (32%) and 2/3 were documented with tremor duration of 3 years or more. Those with primary VT first saw otolaryngology or speech language pathology (59%), whereas those with primary extremity/head tremor first saw neurology (36%). Documentation commonly omitted tremor clinical features such as (a) observed conditions of tremor (64%), (b) laryngeal features (64%), and (c) tremor frequency (92%). Thus, VT classification was based on comorbidity in 49% of patients (ie, essential tremor (48%), dystonia (72%), and Parkinson\'s disease (100%)) and 32% had inadequate documentation to classify.
CONCLUSIONS: The majority of individuals with VT were unable to be classified based on documented clinical features highlighting the need for consistent multidisciplinary assessment of tremor affecting speech structures. The primary site of tremor determined the first discipline seen. Most commonly classified VT categories included essential tremor (47%), dystonia (28%), Parkinsonism (7%), and isolated VT (19%).
METHODS: 4.

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BACKGROUND: This evidence-based guideline is an update of the 2005 American Academy of Neurology practice parameter on the treatment of essential tremor (ET).
METHODS: A literature review using MEDLINE, EMBASE, Science Citation Index, and CINAHL was performed to identify clinical trials in patients with ET published between 2004 and April 2010.
CONCLUSIONS: Conclusions and recommendations for the use of propranolol, primidone (Level A, established as effective); alprazolam, atenolol, gabapentin (monotherapy), sotalol, topiramate (Level B, probably effective); nadolol, nimodipine, clonazepam, botulinum toxin A, deep brain stimulation, thalamotomy (Level C, possibly effective); and gamma knife thalamotomy (Level U, insufficient evidence) are unchanged from the previous guideline. Changes to conclusions and recommendations from the previous guideline include the following: 1) levetiracetam and 3,4-diaminopyridine probably do not reduce limb tremor in ET and should not be considered (Level B); 2) flunarizine possibly has no effect in treating limb tremor in ET and may not be considered (Level C); and 3) there is insufficient evidence to support or refute the use of pregabalin, zonisamide, or clozapine as treatment for ET (Level U).

In Germany, deep brain stimulation (DBS) of the thalamic ventralis intermedius nucleus (VIM) is licensed for treatment of essential tremor in cases unresponsive to pharmacotherapy. Especially a bothersome hand tremor interfering with activities of daily living will improve, whereas head, tongue or vocal tremor shows less response. DBS was proven to be superior to lesional thalamotomy with better functional outcome and less adverse effects. The consensus statement presented here reflects the current recommendations of the German Deep Brain Stimulation Study Group for inclusion and exclusion criteria as well as for peri-, intra- and postoperative neurological management.

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