HHS Public Access Author manuscript Author Manuscript
Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01. Published in final edited form as: Mov Disord Clin Pract. 2016 ; 3(3): 282–284. doi:10.1002/mdc3.12295.
Ultrasound as Diagnostic Tool for Diaphragmatic Myoclonus Vesper Fe Marie Llaneza Ramos, MD1, Elaine Considine, RN1, Barbara I. Karp, MD2, Codrin Lungu, MD3, Katharine Alter, MD4, and Mark Hallett, MD1 1Human 2CNS,
Motor Control Section, National Institutes of Health, Bethesda, MD
IRB, National Institutes of Health, Bethesda, MD
Author Manuscript
3Office
of the Clinical Director, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 4Functional
and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD and Mount Washington Pediatric Hospital, Washington, DC
Abstract Background—Diaphragmatic myoclonus is a rare disorder of repetitive diaphragmatic contractions, acknowledged to be a spectrum that includes psychogenic features. Electromyography has been the diagnostic tool most commonly used in the literature.
Author Manuscript
Methods—To test if we could perform a noninvasive technique to delineate the diaphragm as the source of abnormal movements and demonstrate distractibility and entrainability, we used Bmode ultrasound in a patient with diaphragmatic myoclonus. Results—Ultrasound imaging clearly delineated the diaphragm as the source of her abdominal movements. We were able to demonstrate entrainability of the diaphragm to hand tapping to a prescribed rhythm set by examiner. Conclusion—We recommend the use of ultrasound as a noninvasive, convenient diagnostic tool for further studies of diaphragmatic myoclonus. We agree with previous findings that diaphragmatic myoclonus may be a functional movement disorder, as evidenced by distractibility and entrainability demonstrated on real-time video with ultrasonography.
Author Manuscript
Corresponding author: Vesper Fe Marie Llaneza Ramos, Highest Degree: MD, Institution: National Institutes of Health, Address: Human Motor Control Section Building, 10, Room 7D42, 10 Center Drive, Bethesda, MD, 20814, Phone number: 301 4023496, Fax number: 301 4802286, [email protected]. Authors’ Roles Dr. Ramos - Study concept and design, acquisition of data, analysis and interpretation, manuscript preparation and critical revision of the manuscript for important intellectual content. Elaine Considine, RN—Study concept and design, acquisition of data, manuscript preparation and critical revision of the manuscript for important intellectual content. Dr. Karp - Study concept and design, analysis and interpretation, and critical revision of the manuscript for important intellectual content. Dr. Lungu- Study concept and design, acquisition of data, analysis and interpretation, and critical revision of the manuscript for important intellectual content. Dr. Alter- Study concept and design, acquisition of data, analysis and interpretation, and critical revision of the manuscript for important intellectual content. Dr. Hallett - Study concept and design, analysis and interpretation, and critical revision of the manuscript for important intellectual content.
Llaneza Ramos et al.
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Keywords ultrasound; myoclonus; motor control; conversion
Introduction Diaphragmatic myoclonus is a rare disorder of repetitive contractions of the diaphragm. Previous reports with electromyography demonstrated distractibility with hand-tapping tasks, suggesting that the movements share mechanisms used also for volitional control. 1 To test if we could perform a noninvasive technique to delineate the diaphragm as the source of abnormal movements and demonstrate distractibility and entrainability, we used B-mode ultrasound in a patient with diaphragmatic myoclonus.
Author Manuscript
Methods We studied an 82-year old woman, referred for sudden-onset abdominal excursions after a stressful period, associated with anxiety and hyperventilation. Her abdominal excursions were severe enough to interfere with her balance, prompting cane use, but disappeared during sleep. She was examined by three Movement Disorders neurologists and found to have irregular, repetitive, distractible abdominal and chest wall excursions, consistent with diaphragmatic myoclonus. These movements appeared to entrain inconsistently, with noted poor effort on entrainment tasks. The patient had other psychogenic features on exam, such as developing new onset right leg tremor when presented to the senior attending physician.
Author Manuscript Author Manuscript
We imaged the patient, using B-mode ultrasound, lying supine at rest (Figure 1) and with hand tapping tasks. We followed the technique similar to that used for ultrasound-guided needle EMG of the diaphragm.2 We identified the 7th, 8th, and 9th ribs at the mid-axillary line. The transducer was then placed perpendicular to the ribs, centered over the 8th intercostal space (ICS). After initial identification of the anatomy perpendicular to the long axis of the ribs, the transducer was rotated to orient it parallel to the ribs overlying the ICS. Real-time imaging of structures within the 7th ICS was followed by scanning of the 7th and 9th ICS to identify the ICS that provided the best visualization of the diaphragm. Once optimal visualization of the diaphragm was achieved, we then proceeded with entrainment techniques, instructing the patient to tap her left hand following the examiner’s hand tapping rhythm at her bedside. Examiner then varied tapping rhythm while recording real-time imaging of the diaphragm (Video 1). Videos for ultrasound and hand tapping were synchronized using a time stamp on the ultrasound machine and on the camera. The accuracy of the synchronization is to the nearest second. The National Institutes of Health CNS IRB approved the use of human subjects for this study. Written informed consent was obtained prior to the start of the study.
Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01.
Llaneza Ramos et al.
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Author Manuscript
Results Ultrasound imaging clearly delineated the diaphragm as the source of her abdominal movements (Video 1). We were able to demonstrate distractibility and some entrainability of the diaphragm to hand tapping to a prescribed rhythm set by examiner.
Discussion
Author Manuscript
Diaphragmatic myoclonus is puzzling, acknowledged to be a spectrum of disorders, with psychogenic features.1 Other names include diaphragmatic flutter, respiratory myoclonus, and Leeuwenhoek’s disease (after the famed microscope inventor, Antony van Leeuwenhoek, who wrote an excellent description of his own ailment).3 Epigastric pulsation is the most common manifestation,4 disappearing in sleep,5–7 as in our patient. The majority have diaphragmatic contractions of 0.5 to 15 Hz, usually two to five Hz,5 characteristically irregular. 7 Other common symptoms include dyspnea, hyperventilation, hiccups or belching. 5
Author Manuscript
Diaphragmatic myoclonus is well associated with postencephalitic illness, intrathoracic lesions,7 and cervical spine lesions. A tardive form, related to prochlorperazine, has also been reported.8 Phillips and Eldridge failed to reproduce electromyography patterns in a healthy volunteer instructed to reproduce patient’s movement disorder. 9 However, Espay et al. used electromyography to demonstrate in two cases that the movements were influenced by distracting tasks such as hand tapping, Valsalva or abdomen pressure. 1 Kondo et al. showed in one of three cases that placebo controlled symptoms and abnormal contractions never occurred in one patient when electrophysiological recording was anticipated, suggesting that emotional states influenced movement attacks. 6 The interpretation of the signs of distractibility and entrainability as being psychogenic are derived from skeletal muscles, and the diaphragm is different in that it has intrinsic involuntary control as well as voluntary control. One caveat is that the interpretation of the signs of distractibility and entrainability as being psychogenic are derived from skeletal muscles, and the diaphragm is different in that it has intrinsic involuntary control as well as voluntary control. This does raise caution since it is theoretically possible for distraction and entrainment to influence an involuntary generator, but this physiology is not known.
Author Manuscript
Previous diagnostic tools used include fluoroscopy, phonocardiogram, strain gauge pneumogram, phrenic nerve interruption, and electromyography. 10 Surface electromyography is imprecise, contaminated by chest wall musculature. Needle electromyography of the diaphragm is invasive and uncomfortable. Ultrasound offers realtime direct visualization, particularly useful because of the diaphragm’s dynamic nature, 2 and especially relevant as a noninvasive, painless diagnostic tool for diaphragmatic myoclonus. Accelerometry of the left hand tapping task may be used in future studies to more objectively quantify frequency and entrainment effort. Further, we recognize that the time resolution of ultrasound is less than that for electromyography, which remains more accurate for assessment of entrainment and coherence.
Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01.
Llaneza Ramos et al.
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Author Manuscript
Reported successful treatments for diaphragmatic myoclonus include phenytoin, carbamazepine, haloperidol and clonazepam; the latter was demonstrated to be highly effective and particularly chosen because of its success in other cases of segmental myoclonus. 5
Conclusion We recommend the use of ultrasound as a noninvasive, convenient diagnostic tool for further studies of diaphragmatic myoclonus. We agree with previous findings that diaphragmatic myoclonus may have features inconsistent with purely organic myoclonus syndromes, here demonstrated on real-time video with ultrasonography.
Supplementary Material Author Manuscript
Refer to Web version on PubMed Central for supplementary material.
Acknowledgments Disclosures: Funding Sources and Conflicts of Interest: The study was supported by the NINDS Intramural Program. The authors acknowledge that this manuscript was prepared as part of their official duties as employees of the Department of Health and Human Services (DHHS). Work presented here does not officially express the opinion of DHHS. Financial Disclosures for the Previous 12 Months: Dr. Ramos is a federal government employee, working for the National Institutes of Health. This work was undertaken as part of her official duty. Her research at the NIH is supported by the NIH Intramural Program.
Author Manuscript
Elaine Considine, RN is a federal government employee, working for the National Institutes of Health. This work was undertaken as part of her official duty. Her research at the NIH is supported by the NIH Intramural Program. Dr. Karp is a federal government employee, working for the National Institutes of Health. This work was undertaken as part of her official duty. Her research at the NIH is supported by the NIH Intramural Program. Dr. Karp is an investigator on a study that receives research support from Allergan via a Clinical Trials Agreements (CTA) with NIH. Dr. Lungu is a federal government employee, working for the National Institutes of Health. This work was undertaken as part of his official duty. Dr. Lungu’s research at the NIH is supported by the NIH Intramural Program. Dr. Alter is an employee of Mount Washington Pediatric Hospital and a federal government contractor, working for the National Institutes of Health. This work was undertaken as part of her official duty at NIH. She has received consulting honoraria from Allergan, and speaking honoraria from Ipsen. She has received royalties from Demos Medical Publishing.
Author Manuscript
Dr. Hallett is a federal government employee, working for the National Institutes of Health. This work was undertaken as part of his official duty. Dr. Hallett's research at the NIH is largely supported by the NIH Intramural Program. Dr. Hallett serves as Chair of the Medical Advisory Board for and receives honoraria and funding for travel from the Neurotoxin Institute. He may accrue revenue on US Patent #6,780,413 B2 (Issued: August 24, 2004): Immunotoxin (MAB-Ricin) for the treatment of focal movement disorders, and US Patent #7,407,478 (Issued: August 5, 2008): Coil for Magnetic Stimulation and methods for using the same (H-coil); in relation to the latter, he has received license fee payments from the NIH (from Brainsway) for licensing of this patent. He is on the Editorial Board of 22 journals, and received royalties from publishing from Cambridge University Press, Oxford University Press, John Wiley & Sons, Wolters Kluwer, and Elsevier. He has received honoraria for lecturing from Columbia. Supplemental research funds came from the Kinetics Foundation, for studies of instrumental methods to
Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01.
Llaneza Ramos et al.
Page 5
Author Manuscript
monitor Parkinson’s disease, BCN Peptides, S.A., for treatment studies of blepharospasm, and Medtronics, Inc., for studies of deep brain stimulation, via Clinical Trials Agreements (CTA) with NIH.
References
Author Manuscript
1. Espay AJ, Fox SH, Marras C, Lang AE, Chen R. Isolated diaphragmatic tremor: is there a spectrum in "respiratory myoclonus"? Neurology. 2007; 69:689–692. [PubMed: 17698791] 2. Boon AJ, Alsharif KI, Harper CM, Smith J. Ultrasound-guided needle EMG of the diaphragm: technique description and case report. Muscle Nerve. 2008; 38:1623–1626. [PubMed: 19016552] 3. Larner AJ. Antony van Leeuwenhoek and the description of diaphragmatic flutter (respiratory myoclonus). Mov Disord. 2005; 20:917–918. [PubMed: 16007667] 4. Rigatto M, de MN. Diaphragmatic flutter. Report of a case and review of literature. Am J Med. 1962; 32:103–109. [PubMed: 14492224] 5. Chen R, Remtulla H, Bolton CF. Electrophysiological study of diaphragmatic myoclonus. J Neurol Neurosurg Psychiatry. 1995; 58:480–483. [PubMed: 7738561] 6. Kondo T, Tamaya S, Ohta Y, Yamabayashi H. Dual-respiratory rhythms. A key to diagnosis of diaphragmatic flutter in patients with HVS. Chest. 1989; 96:106–109. [PubMed: 2500305] 7. Corbett CL. Diaphragmatic flutter. Postgrad Med J. 1977; 53:399–402. [PubMed: 882482] 8. Burn DJ, Coulthard A, Connolly S, Cartlidge NE. Tardive diaphragmatic flutter. Mov Disord. 1998; 13:190–192. [PubMed: 9452356] 9. Phillips JR, Eldridge FL. Respiratory myoclonus (Leeuwenhoek's disease). N Engl J Med. 1973; 289:1390–1395. [PubMed: 4753939] 10. Hoffman R, Yahr W, Krieger B. Diaphragmatic flutter resulting in failure to wean from mechanical ventilator support after coronary artery bypass surgery. Critical care medicine. 1990; 18:499–501. [PubMed: 2328594]
Author Manuscript Author Manuscript Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01.
Llaneza Ramos et al.
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Author Manuscript Author Manuscript Author Manuscript
Figure 1.
Ultrasound snapshot of the diaphragm and surrounding structures.
Author Manuscript Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01.
Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01. Published in final edited form as: Mov Disord Clin Pract. 2016 ; 3(3): 282–284. doi:10.1002/mdc3.12295.
Ultrasound as Diagnostic Tool for Diaphragmatic Myoclonus Vesper Fe Marie Llaneza Ramos, MD1, Elaine Considine, RN1, Barbara I. Karp, MD2, Codrin Lungu, MD3, Katharine Alter, MD4, and Mark Hallett, MD1 1Human 2CNS,
Motor Control Section, National Institutes of Health, Bethesda, MD
IRB, National Institutes of Health, Bethesda, MD
Author Manuscript
3Office
of the Clinical Director, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 4Functional
and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD and Mount Washington Pediatric Hospital, Washington, DC
Abstract Background—Diaphragmatic myoclonus is a rare disorder of repetitive diaphragmatic contractions, acknowledged to be a spectrum that includes psychogenic features. Electromyography has been the diagnostic tool most commonly used in the literature.
Author Manuscript
Methods—To test if we could perform a noninvasive technique to delineate the diaphragm as the source of abnormal movements and demonstrate distractibility and entrainability, we used Bmode ultrasound in a patient with diaphragmatic myoclonus. Results—Ultrasound imaging clearly delineated the diaphragm as the source of her abdominal movements. We were able to demonstrate entrainability of the diaphragm to hand tapping to a prescribed rhythm set by examiner. Conclusion—We recommend the use of ultrasound as a noninvasive, convenient diagnostic tool for further studies of diaphragmatic myoclonus. We agree with previous findings that diaphragmatic myoclonus may be a functional movement disorder, as evidenced by distractibility and entrainability demonstrated on real-time video with ultrasonography.
Author Manuscript
Corresponding author: Vesper Fe Marie Llaneza Ramos, Highest Degree: MD, Institution: National Institutes of Health, Address: Human Motor Control Section Building, 10, Room 7D42, 10 Center Drive, Bethesda, MD, 20814, Phone number: 301 4023496, Fax number: 301 4802286, [email protected]. Authors’ Roles Dr. Ramos - Study concept and design, acquisition of data, analysis and interpretation, manuscript preparation and critical revision of the manuscript for important intellectual content. Elaine Considine, RN—Study concept and design, acquisition of data, manuscript preparation and critical revision of the manuscript for important intellectual content. Dr. Karp - Study concept and design, analysis and interpretation, and critical revision of the manuscript for important intellectual content. Dr. Lungu- Study concept and design, acquisition of data, analysis and interpretation, and critical revision of the manuscript for important intellectual content. Dr. Alter- Study concept and design, acquisition of data, analysis and interpretation, and critical revision of the manuscript for important intellectual content. Dr. Hallett - Study concept and design, analysis and interpretation, and critical revision of the manuscript for important intellectual content.
Llaneza Ramos et al.
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Author Manuscript
Keywords ultrasound; myoclonus; motor control; conversion
Introduction Diaphragmatic myoclonus is a rare disorder of repetitive contractions of the diaphragm. Previous reports with electromyography demonstrated distractibility with hand-tapping tasks, suggesting that the movements share mechanisms used also for volitional control. 1 To test if we could perform a noninvasive technique to delineate the diaphragm as the source of abnormal movements and demonstrate distractibility and entrainability, we used B-mode ultrasound in a patient with diaphragmatic myoclonus.
Author Manuscript
Methods We studied an 82-year old woman, referred for sudden-onset abdominal excursions after a stressful period, associated with anxiety and hyperventilation. Her abdominal excursions were severe enough to interfere with her balance, prompting cane use, but disappeared during sleep. She was examined by three Movement Disorders neurologists and found to have irregular, repetitive, distractible abdominal and chest wall excursions, consistent with diaphragmatic myoclonus. These movements appeared to entrain inconsistently, with noted poor effort on entrainment tasks. The patient had other psychogenic features on exam, such as developing new onset right leg tremor when presented to the senior attending physician.
Author Manuscript Author Manuscript
We imaged the patient, using B-mode ultrasound, lying supine at rest (Figure 1) and with hand tapping tasks. We followed the technique similar to that used for ultrasound-guided needle EMG of the diaphragm.2 We identified the 7th, 8th, and 9th ribs at the mid-axillary line. The transducer was then placed perpendicular to the ribs, centered over the 8th intercostal space (ICS). After initial identification of the anatomy perpendicular to the long axis of the ribs, the transducer was rotated to orient it parallel to the ribs overlying the ICS. Real-time imaging of structures within the 7th ICS was followed by scanning of the 7th and 9th ICS to identify the ICS that provided the best visualization of the diaphragm. Once optimal visualization of the diaphragm was achieved, we then proceeded with entrainment techniques, instructing the patient to tap her left hand following the examiner’s hand tapping rhythm at her bedside. Examiner then varied tapping rhythm while recording real-time imaging of the diaphragm (Video 1). Videos for ultrasound and hand tapping were synchronized using a time stamp on the ultrasound machine and on the camera. The accuracy of the synchronization is to the nearest second. The National Institutes of Health CNS IRB approved the use of human subjects for this study. Written informed consent was obtained prior to the start of the study.
Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01.
Llaneza Ramos et al.
Page 3
Author Manuscript
Results Ultrasound imaging clearly delineated the diaphragm as the source of her abdominal movements (Video 1). We were able to demonstrate distractibility and some entrainability of the diaphragm to hand tapping to a prescribed rhythm set by examiner.
Discussion
Author Manuscript
Diaphragmatic myoclonus is puzzling, acknowledged to be a spectrum of disorders, with psychogenic features.1 Other names include diaphragmatic flutter, respiratory myoclonus, and Leeuwenhoek’s disease (after the famed microscope inventor, Antony van Leeuwenhoek, who wrote an excellent description of his own ailment).3 Epigastric pulsation is the most common manifestation,4 disappearing in sleep,5–7 as in our patient. The majority have diaphragmatic contractions of 0.5 to 15 Hz, usually two to five Hz,5 characteristically irregular. 7 Other common symptoms include dyspnea, hyperventilation, hiccups or belching. 5
Author Manuscript
Diaphragmatic myoclonus is well associated with postencephalitic illness, intrathoracic lesions,7 and cervical spine lesions. A tardive form, related to prochlorperazine, has also been reported.8 Phillips and Eldridge failed to reproduce electromyography patterns in a healthy volunteer instructed to reproduce patient’s movement disorder. 9 However, Espay et al. used electromyography to demonstrate in two cases that the movements were influenced by distracting tasks such as hand tapping, Valsalva or abdomen pressure. 1 Kondo et al. showed in one of three cases that placebo controlled symptoms and abnormal contractions never occurred in one patient when electrophysiological recording was anticipated, suggesting that emotional states influenced movement attacks. 6 The interpretation of the signs of distractibility and entrainability as being psychogenic are derived from skeletal muscles, and the diaphragm is different in that it has intrinsic involuntary control as well as voluntary control. One caveat is that the interpretation of the signs of distractibility and entrainability as being psychogenic are derived from skeletal muscles, and the diaphragm is different in that it has intrinsic involuntary control as well as voluntary control. This does raise caution since it is theoretically possible for distraction and entrainment to influence an involuntary generator, but this physiology is not known.
Author Manuscript
Previous diagnostic tools used include fluoroscopy, phonocardiogram, strain gauge pneumogram, phrenic nerve interruption, and electromyography. 10 Surface electromyography is imprecise, contaminated by chest wall musculature. Needle electromyography of the diaphragm is invasive and uncomfortable. Ultrasound offers realtime direct visualization, particularly useful because of the diaphragm’s dynamic nature, 2 and especially relevant as a noninvasive, painless diagnostic tool for diaphragmatic myoclonus. Accelerometry of the left hand tapping task may be used in future studies to more objectively quantify frequency and entrainment effort. Further, we recognize that the time resolution of ultrasound is less than that for electromyography, which remains more accurate for assessment of entrainment and coherence.
Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01.
Llaneza Ramos et al.
Page 4
Author Manuscript
Reported successful treatments for diaphragmatic myoclonus include phenytoin, carbamazepine, haloperidol and clonazepam; the latter was demonstrated to be highly effective and particularly chosen because of its success in other cases of segmental myoclonus. 5
Conclusion We recommend the use of ultrasound as a noninvasive, convenient diagnostic tool for further studies of diaphragmatic myoclonus. We agree with previous findings that diaphragmatic myoclonus may have features inconsistent with purely organic myoclonus syndromes, here demonstrated on real-time video with ultrasonography.
Supplementary Material Author Manuscript
Refer to Web version on PubMed Central for supplementary material.
Acknowledgments Disclosures: Funding Sources and Conflicts of Interest: The study was supported by the NINDS Intramural Program. The authors acknowledge that this manuscript was prepared as part of their official duties as employees of the Department of Health and Human Services (DHHS). Work presented here does not officially express the opinion of DHHS. Financial Disclosures for the Previous 12 Months: Dr. Ramos is a federal government employee, working for the National Institutes of Health. This work was undertaken as part of her official duty. Her research at the NIH is supported by the NIH Intramural Program.
Author Manuscript
Elaine Considine, RN is a federal government employee, working for the National Institutes of Health. This work was undertaken as part of her official duty. Her research at the NIH is supported by the NIH Intramural Program. Dr. Karp is a federal government employee, working for the National Institutes of Health. This work was undertaken as part of her official duty. Her research at the NIH is supported by the NIH Intramural Program. Dr. Karp is an investigator on a study that receives research support from Allergan via a Clinical Trials Agreements (CTA) with NIH. Dr. Lungu is a federal government employee, working for the National Institutes of Health. This work was undertaken as part of his official duty. Dr. Lungu’s research at the NIH is supported by the NIH Intramural Program. Dr. Alter is an employee of Mount Washington Pediatric Hospital and a federal government contractor, working for the National Institutes of Health. This work was undertaken as part of her official duty at NIH. She has received consulting honoraria from Allergan, and speaking honoraria from Ipsen. She has received royalties from Demos Medical Publishing.
Author Manuscript
Dr. Hallett is a federal government employee, working for the National Institutes of Health. This work was undertaken as part of his official duty. Dr. Hallett's research at the NIH is largely supported by the NIH Intramural Program. Dr. Hallett serves as Chair of the Medical Advisory Board for and receives honoraria and funding for travel from the Neurotoxin Institute. He may accrue revenue on US Patent #6,780,413 B2 (Issued: August 24, 2004): Immunotoxin (MAB-Ricin) for the treatment of focal movement disorders, and US Patent #7,407,478 (Issued: August 5, 2008): Coil for Magnetic Stimulation and methods for using the same (H-coil); in relation to the latter, he has received license fee payments from the NIH (from Brainsway) for licensing of this patent. He is on the Editorial Board of 22 journals, and received royalties from publishing from Cambridge University Press, Oxford University Press, John Wiley & Sons, Wolters Kluwer, and Elsevier. He has received honoraria for lecturing from Columbia. Supplemental research funds came from the Kinetics Foundation, for studies of instrumental methods to
Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01.
Llaneza Ramos et al.
Page 5
Author Manuscript
monitor Parkinson’s disease, BCN Peptides, S.A., for treatment studies of blepharospasm, and Medtronics, Inc., for studies of deep brain stimulation, via Clinical Trials Agreements (CTA) with NIH.
References
Author Manuscript
1. Espay AJ, Fox SH, Marras C, Lang AE, Chen R. Isolated diaphragmatic tremor: is there a spectrum in "respiratory myoclonus"? Neurology. 2007; 69:689–692. [PubMed: 17698791] 2. Boon AJ, Alsharif KI, Harper CM, Smith J. Ultrasound-guided needle EMG of the diaphragm: technique description and case report. Muscle Nerve. 2008; 38:1623–1626. [PubMed: 19016552] 3. Larner AJ. Antony van Leeuwenhoek and the description of diaphragmatic flutter (respiratory myoclonus). Mov Disord. 2005; 20:917–918. [PubMed: 16007667] 4. Rigatto M, de MN. Diaphragmatic flutter. Report of a case and review of literature. Am J Med. 1962; 32:103–109. [PubMed: 14492224] 5. Chen R, Remtulla H, Bolton CF. Electrophysiological study of diaphragmatic myoclonus. J Neurol Neurosurg Psychiatry. 1995; 58:480–483. [PubMed: 7738561] 6. Kondo T, Tamaya S, Ohta Y, Yamabayashi H. Dual-respiratory rhythms. A key to diagnosis of diaphragmatic flutter in patients with HVS. Chest. 1989; 96:106–109. [PubMed: 2500305] 7. Corbett CL. Diaphragmatic flutter. Postgrad Med J. 1977; 53:399–402. [PubMed: 882482] 8. Burn DJ, Coulthard A, Connolly S, Cartlidge NE. Tardive diaphragmatic flutter. Mov Disord. 1998; 13:190–192. [PubMed: 9452356] 9. Phillips JR, Eldridge FL. Respiratory myoclonus (Leeuwenhoek's disease). N Engl J Med. 1973; 289:1390–1395. [PubMed: 4753939] 10. Hoffman R, Yahr W, Krieger B. Diaphragmatic flutter resulting in failure to wean from mechanical ventilator support after coronary artery bypass surgery. Critical care medicine. 1990; 18:499–501. [PubMed: 2328594]
Author Manuscript Author Manuscript Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01.
Llaneza Ramos et al.
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Author Manuscript Author Manuscript Author Manuscript
Figure 1.
Ultrasound snapshot of the diaphragm and surrounding structures.
Author Manuscript Mov Disord Clin Pract. Author manuscript; available in PMC 2017 May 01.
