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Tremor
THE BASIC FAC TS
MULTIPLE SCLEROSIS
Some people with MS experience tremor,
an involuntary rhythmic shaking movement
of the muscles. The most common type of
tremor seen in people with MS is caused
by loss of myelin on nerve fibers in the
pathways that coordinate voluntary muscle
movement and balance.
Tremor can affect the limbs, head, body,
or the muscles needed for speech or sexual
functioning. Some tremors are slight and
don’t interfere with daily living while other
tremors can significantly affect important
basic activities. Gross tremor is characterized
by wide back and forth motions, usually
of the arms or legs. Intention or action
tremors
are activated when a person reaches
for something. When tremor is severe, it can
prevent a person from eating, writing, speaking
clearly, or walking.
There is no cure for tremor, and it remains
one of the most frustrating MS symptoms.
Options for management include physical
and occupational therapy techniques,
medications, stress management, neuro-
surgery, and electrode implants. Some of
these options will work for one individual;
others will not. Coping with tremor requires
patience, good communication with
healthcare professionals, and some creative
problem-solving.
JUDY
DIAGNOSED IN 1982
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Don Denton, of Lubbock, Texas, has been
dealing with intention tremors due to his
MS for over 20 years. He’s worked as a peer
counselor with his chapter of the Society.
When he talks to people who have problems
with MS tremor, he tells them frankly that
there is no easy answer. However, he also
reassures them that they may be able to reduce
their problems. Don has found some relief with
medication. He has also learned strategies
that allow him to perform daily tasks better,
and he plans ahead so that tremor-related
problems don’t take him by surprise. For
Don, tremor has become just one more
piece of this challenging chronic disease.
Occupational and
physical therapy
techniques
An occupational therapist or physical therapist
is the recommended source for both practical
strategies and adaptive aids that can reduce
the negative impact of tremor on daily life.
Your doctor should be able to refer you to a
professional with MS experience — or, call
the National MS Society.
Some tremor can be controlled through the
use of braces. A rigid brace can support an
affected limb while a person performs a specific
activity. Afterwards, the brace can be removed.
In some cases, however, bracing may actually
increase other problems such as spasticity.
Consult a rehabilitation specialist to explore
this option.
Some people find it helpful to hold their
arms close to the body or to prop an
elbow against the chest in order to gain
more control over forearm movements.
Weights fastened to the wrists or ankles
with Velcro strips can stabilize an affected
limb. Weighted boots are also used. Putting
weights on canes or walkers, or using
weighted spoons or forks can make these
tools easier to use when tremor is active.
The use of weighted devices has to be
balanced against the added fatigue they
might cause. Therapists commonly offer
samples for a try-out.
Adaptive equipment, such as wrist rests that
facilitate writing or typing, and plates and
cups with lips to minimize food spills, are
also helpful to some people.
Physical or occupational therapists may
be able to reduce the effects of tremor by
teaching specific positions for some activities
or by balance and coordination exercises.
These might include repeating a series of
movements related to an activity like eating,
for example, until those muscles “learn” a
pattern sufficiently well to override disruptions
of the nervous system. Rehab therapists may
also teach exercises that focus on stimulating
the balance centers of the brain. Computers
can provide biofeedback that teaches people
to recognize balance problems in time to
compensate for them.
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Tremor and
speech problems
If tremor affects the muscles necessary for
speech, a person will want to consult a speech
therapist. A speech therapist can show a person
how to slow down or concentrate on phrasing
so that speech is more intelligible. If this is
not possible, a person with speech tremor may
need to learn alternative communication skills.
Electronic aids, communication charts, or
computer-assisted alternative communication
systems are available. However, tremor this
severe is not common for people with MS.
Stress management
and tremor
People with MS-related tremor may find
that the unwanted muscle movements are
worse in stressful situations. As Dr. Robert
R. Young, former professor of neurology
at the University of Southern California,
explains, “Stress, excitement, and anxiety all
result in the body releasing adrenalin which
produces a temporary aroused condition.
All of us experience this at some time. Stage
fright is one example.” For people with MS
tremor, this temporary condition can make
the existing tremor worse.
Stress management techniques can be an
essential tool for such situations. Dr. Young
would also prescribe a beta-adrenergic
blocking agent such as propranolol
(Inderal®) in pill form for someone who is
facing a particularly stressful event such as
giving a speech or appearing in public.
Medications for
the management
of tremor
At present, there are no medications
specifically for tremor, but several
medications have been shown to have
secondary effects that can be more or
less helpful. Some people respond well
to one medication; some benefit from a
combination; some find no benefit. People
with tremor will have to work patiently
with their physicians in investigating which
therapy might be useful to them.
(The following list is adapted from
Managing the Symptoms of MS,
6th
Edition, Randall T. Schapiro, MD, 2014,
Demos Medical Publishing Co., Inc.)
n
Hydroxyzine (Atarax, Vistaril
®
)
Antihistamine that can help minor tremor
worsened by stress
n
Clonazepam (Klonopin
®
)
Anti-anxiety agent with sedative effect
n
Propranolol (Inderal
®
)
Beta-blocker with modest relief for
some tremor
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n
Buspirone (Buspar
®
)
Anti-anxiety agent with some antitremor effect
n
Ondansetron (Zofran
®
)
Anti-nausea medication with anti-tremor
effect, but very expensive
n
Primidone (Mysoline
®
)
Anti-epileptic medication with some anti-
tremor effect in low doses; sedating effect
n
Acetazolamide (Diamox)
Diuretic; some help for postural tremor
n
OnabotulinumtoxinA (Botox
®
)
Neurotoxin that temporarily paralyzes targeted
muscles; may be effective for tremor in the arms
and hands
Other medications that may be tried
include gabapentin (Neurontin®), isoniazid
(Laniazid, in the US; Isotamine in Canada);
and trihexyphenidyl (Artane). Some gross
tremor can also be treated with baclofen,
which is primarily an agent for treating
spasticity.
The question of whether marijuana —
produced from the flowering top of the
hemp plant, cannabis sativa — should
be used for symptom management in
MS is a complex one. More and better
therapies are needed for tremor; still, there
are uncertainties about the benefits of
marijuana relative to its side effects.
The National MS Society recommends that
people diagnosed with a relapsing form of
MS begin treatment with one of the disease
modifying therapies. These medications
may not have any direct effect on existing
symptoms, including tremor, but they
may slow down the progress of the disease
and help avoid additional damage to central
nervous system tissues.
Thalamotomy
and deep brain
stimulation
Tremor in MS occurs when there is damage
to nerve fibers in a section of the brain
called the thalamus. Tremor is sometimes
treated with a neuro-surgical technique
called thalamotomy which involves
permanently destroying targeted nerve
tissue in the thalamus.
There has been some success reported in
the treatment of MS tremor from using
electrode stimulation of areas in the thalamus.
This is called deep brain stimulation or DBS.
A tiny electrode is implanted in a targeted area
of the thalamus during open-skull surgery.
The electrode is connected to a wire lead
that is inserted under the skin of the neck. It
connects to a control device inserted under
the skin in the chest area. This device is
programmed to send impulses to the electrode
in the brain. These impulses interfere with
the nerve signals that are causing muscles to
make involuntary tremor movements.
DBS was originally developed for the
treatment of tremor due to Parkinson’s
disease. It is still a new therapy and is
not yet FDA-approved for MS tremor.
The Center for Neurological Restoration
at The Cleveland Clinic Foundation
has performed approximately 40 DBS
operations for people with MS. The Center
is enthusiastic about this new neurosurgical
technology but cautions people to have
reasonable expectations. Tremor in MS is
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often associated with poor coordination
(also called ataxia) and loss of the ability
to judge distances (dysmetria). DBS may
reduce tremor, but it doesn’t abolish these
disabling symptoms.
Like any surgery, the DBS procedure has
risks — a 2–3% risk of serious complications
due to the surgery itself. Then, over time,
DBS recipients tend to build up tolerance
to a particular electronic signal. This means
that they must frequently return to their
doctor’s office to have the impulse generator
reset, either to a higher or lower level. This
is done using non-invasive radio signals.
Andrea Kool-Tucker of Columbus, OH
made the assessment and decided that
the benefits would outweigh the risk of
complications or the bother of frequent office
visits. She was often unable to feed herself
or to write due to the intention tremors
in her arms. Her doctors had prescribed
medications, but none had provided relief
for her. The fact that the DBS procedure
is reversible helped her decide to try it. In
2000, Kool-Tucker had the operation. Since
then, she has been able to feed herself and
write again. At first, it was necessary to get
her impulse generator reset every few months,
but now this occurs less frequently. She does
not find her implanted device noticeable
or intrusive, but she has noticed that her
problems with gait seem to increase when
the device is turned on, so she simply turns
it off when she needs to walk.
In 2008, Kool-Tucker began to experience
essential tremors in her left arm. She had
another DBS in 2009 to address this problem
and then had additional surgery to implant
a new implantable pulse generator. Unlike
persons with Parkinson’s who always receive
Bilateral DBS, persons with MS generally
only get Unilateral DBS. Therefore, Kool-
Tucker had to have the second surgery.
Coping over
the long term
It can be maddening to feel that your own
body is no longer in your control. Many
people feel painfully embarrassed when
other people witness their tremor. Simple
changes — like grasping a glass with two
hands instead of one — can be a big help.
Don Denton handles embarrassment by
being upfront with people about all his
MS symptoms, including tremor. When
ordering coffee at a restaurant, he’ll tell
the server, “I can’t always control my hand
shaking, so pour me half a cup — otherwise,
I’m going to spill some.” Denton also knows
that his tremor can increase with fatigue, so
he’ll try to plan certain activities for early in
the day.
If tremor is having an impact on your social
life or making you wary about going out in
public, a professional therapist or counselor
may help you arrive at solutions more
acceptable than simply staying at home.
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Keep trying
It’s hard to predict which strategies will
work for an individual’s tremor. Tremor can
be discussed with a physical or occupational
therapist, or other healthcare provider. If
balance exercises fail, try biofeedback. If
one medication has no effect, or the side
effects are too troublesome, talk to your
doctor about other options. Celebrate every
moment of progress — whether it’s learning
the exact angle needed to sign your name
clearly or reaping benefits from Swiss ball
balance exercises.
In dealing with this frustrating symptom,
make use of all the available resources. These
include a responsive healthcare team —
therapists, nurses, and counselors as well
as your physician, your family and friends,
and the National MS Society. Educate
yourself and those closest to you about
tremor and all the possible therapies for it,
including creative coping. And try to keep
tremor in perspective.
Medications and neurosurgical technologies
now offer somewhat better outcomes for
long-term management of tremor in MS.
New developments are expected from
research. There is hope for the future. But
until improvements come to fruition,
people who live with tremor will continue
to piece together the strategies that best
address their own individual situations.
For additional
information
Educational videos
n
national
MS
society.org/videos
In the Symptom Management category,
look for feature presentation called
Managing Your Symptoms in MS:
Tremors, Seizures, and Loss of Balance.
Society publications:
n
Managing MS through Rehabilitation
n
Taming Stress in Multiple Sclerosis
For more information on deep brain
stimulation, go to clevelandclinic.org and
search the site for deep brain stimulation.
By Lorna Smedman, PhD.
Botox
®
is a registered trademark of Allergan, Inc.
Buspar is a registered trademark of Bristol-Myer
Squibb, Co.
Inderal is a registered trademark of Wyeth Corp.
Klonopin is a registered trademark of Hoffman
LaRoche Inc., Corp.
Mysoline is a registered trademark of Valeant
Pharmaceuticals
Neurontin is a registered trademark of Parke Davis
Division of Pfizer
Vistaril is a registered trademark of Pfizer, Inc.
Zofran is a registered trademark of Glaxo Group Ltd.
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* The National Multiple Sclerosis Society is
proud to be a source of information about
multiple sclerosis. Our comments are based on
professional advice, published experience and
expert opinion, but do not represent individual
therapeutic recommendation or prescription.
For specific information and advice, consult your
personal physician.
national
MS
society.org
1-800-344-4867
© 2016 National MS Society.
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