Ms and tremors. Multiple Sclerosis and Tremors: A Comprehensive Overview and Future Outlook
How does tremor affect individuals with Multiple Sclerosis. What are the different types of tremors associated with MS. How can tremors in MS patients be effectively managed and treated. What are the latest research developments in understanding and addressing MS-related tremors.
Understanding Multiple Sclerosis and Its Relationship with Tremors
Multiple Sclerosis (MS) is a complex neurological disorder that affects millions of people worldwide. One of the lesser-known but significant symptoms of MS is tremor, which can significantly impact a patient’s quality of life. Tremors in MS were first described by Jean-Martin Charcot in 1877, highlighting the long-standing recognition of this symptom in the medical community.
Tremors can manifest in various forms in MS patients, ranging from subtle shaking to more pronounced, disabling movements. These involuntary movements can affect different parts of the body, including the arms, legs, head, and even the eyes and vocal cords.
Prevalence and Impact of Tremors in MS Patients
Studies have shown that tremors affect a significant portion of MS patients. According to a cross-sectional survey conducted through the NARCOMS multiple sclerosis registry, approximately 45% of MS patients reported experiencing tremors. Of these, about 6% described their tremors as severe enough to interfere with daily activities.
The impact of tremors on MS patients can be profound. They can interfere with basic tasks such as eating, writing, and dressing, leading to decreased independence and quality of life. In some cases, tremors can be so severe that they limit a person’s ability to work or participate in social activities.
Types of Tremors Observed in Multiple Sclerosis
MS-related tremors can manifest in various forms, each with its unique characteristics and challenges. Understanding these different types is crucial for accurate diagnosis and effective treatment.
Postural Tremor
Postural tremor occurs when a person maintains a position against gravity, such as holding their arms outstretched. This type of tremor is common in MS patients and can significantly affect their ability to perform tasks that require maintaining a steady posture.
Intention Tremor
Intention tremor, also known as cerebellar tremor, is particularly characteristic of MS. It occurs during purposeful movement, becoming more pronounced as the individual approaches their target. This type of tremor can make tasks like reaching for objects or touching one’s nose extremely challenging.
Rest Tremor
While less common in MS compared to conditions like Parkinson’s disease, rest tremor can occur in some MS patients. This type of tremor is present when the affected body part is completely supported against gravity and the muscles are not voluntarily activated.
Nystagmus and Oscillopsia
MS can also cause tremor-like movements of the eyes, known as nystagmus. In some cases, this can lead to oscillopsia, a condition where objects in the visual field appear to oscillate or jump. These visual disturbances can significantly impact a person’s ability to read, drive, or navigate their environment safely.
The Neurological Basis of Tremors in Multiple Sclerosis
The exact mechanisms underlying tremors in MS are not fully understood, but research suggests that damage to specific areas of the central nervous system plays a crucial role. The cerebellum, which is responsible for coordinating movement, is often implicated in MS-related tremors.
Demyelination and axonal loss in the cerebellum and its connections to other parts of the brain can disrupt the normal processing of sensory information and motor commands, leading to tremors. Additionally, lesions in other areas of the brain, such as the thalamus and basal ganglia, may contribute to the development of tremors in MS patients.
The Role of the Cerebellum
The cerebellum plays a central role in the manifestation of tremors in MS. This part of the brain is responsible for fine-tuning motor movements, maintaining balance, and coordinating complex movements. When the cerebellum is damaged by MS lesions, it can lead to various types of tremors, particularly intention tremors.
Research has shown that the extent of cerebellar damage often correlates with the severity of tremors in MS patients. This understanding has led to targeted treatments that focus on modulating cerebellar activity to alleviate tremor symptoms.
Diagnostic Approaches for Tremors in Multiple Sclerosis
Accurately diagnosing tremors in MS patients is crucial for developing effective treatment plans. The diagnostic process typically involves a combination of clinical assessment, neurological examination, and imaging studies.
Clinical Assessment and Neurological Examination
A thorough clinical assessment involves taking a detailed medical history and performing a comprehensive neurological examination. Physicians may use standardized rating scales, such as the Fahn-Tolosa-Marin Tremor Rating Scale, to assess the severity and impact of tremors on daily activities.
Imaging Studies
Magnetic Resonance Imaging (MRI) plays a crucial role in diagnosing MS and can also help identify lesions that may be contributing to tremors. Advanced imaging techniques, such as functional MRI and diffusion tensor imaging, can provide insights into the neural pathways affected by MS and their relationship to tremor symptoms.
Electrophysiological Studies
In some cases, electrophysiological studies such as electromyography (EMG) and accelerometry may be used to characterize the nature and frequency of tremors. These tests can help differentiate MS-related tremors from other movement disorders and guide treatment decisions.
Treatment Strategies for Managing Tremors in MS Patients
Managing tremors in MS patients often requires a multifaceted approach, combining pharmacological interventions, rehabilitation techniques, and in some cases, surgical options.
Pharmacological Interventions
Several medications have shown promise in treating MS-related tremors, although their efficacy can vary significantly between patients. Some commonly used medications include:
- Beta-blockers (e.g., propranolol)
- Anticonvulsants (e.g., gabapentin, carbamazepine)
- Benzodiazepines (e.g., clonazepam)
- Cannabinoids (in some jurisdictions)
It’s important to note that while these medications can be effective, they may also have side effects that need to be carefully considered and managed.
Rehabilitation and Physical Therapy
Rehabilitation plays a crucial role in managing tremors and improving overall function in MS patients. Physical therapy techniques may include:
- Strengthening exercises
- Balance and coordination training
- Use of assistive devices and adaptive equipment
- Occupational therapy to improve daily living skills
These interventions can help patients develop strategies to compensate for tremors and maintain independence in daily activities.
Surgical Interventions
For patients with severe, treatment-resistant tremors, surgical options may be considered. Deep Brain Stimulation (DBS) has shown promise in treating MS-related tremors, particularly when targeting the thalamus or other specific brain regions. However, the effectiveness of DBS can vary, and careful patient selection is crucial.
Other surgical approaches, such as thalamotomy or gamma knife radiosurgery, have also been used in some cases, but these are generally considered less reversible and potentially riskier than DBS.
Emerging Therapies and Future Perspectives in MS Tremor Management
As our understanding of MS and its associated tremors continues to evolve, new treatment approaches are being developed and tested. These emerging therapies offer hope for improved tremor management in the future.
Noninvasive Brain Stimulation Techniques
Transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) are being investigated as potential noninvasive treatments for MS-related tremors. These techniques aim to modulate brain activity in specific regions associated with tremor generation, potentially offering a safer alternative to surgical interventions.
Targeted Drug Delivery Systems
Researchers are exploring the use of targeted drug delivery systems, such as intrathecal pumps, to deliver medications directly to the central nervous system. This approach could potentially allow for more effective tremor control with fewer systemic side effects.
Regenerative Medicine and Stem Cell Therapy
While still in the early stages of research, regenerative medicine approaches, including stem cell therapy, hold promise for repairing damaged neural pathways in MS patients. These therapies could potentially address the underlying causes of tremors by promoting remyelination and axonal repair.
The Impact of Tremors on Quality of Life in MS Patients
Tremors can have a profound impact on the daily lives of individuals with MS, affecting various aspects of their physical, emotional, and social well-being. Understanding these impacts is crucial for developing comprehensive care plans that address not just the physical symptoms but also the broader implications of tremors on patients’ lives.
Physical and Functional Limitations
Tremors can significantly impair a person’s ability to perform basic tasks, leading to:
- Difficulties with fine motor skills (e.g., writing, using utensils)
- Challenges in maintaining balance and walking
- Increased fatigue due to constant muscle activation
- Difficulties with personal care and hygiene
These physical limitations can lead to decreased independence and increased reliance on caregivers or assistive devices.
Emotional and Psychological Impact
The presence of visible tremors can also have significant emotional and psychological consequences, including:
- Increased anxiety and depression
- Lowered self-esteem and confidence
- Social isolation due to embarrassment or difficulty participating in activities
- Frustration and anger at the loss of control over one’s body
Addressing these psychological aspects is crucial for comprehensive tremor management in MS patients.
Social and Occupational Consequences
Tremors can also have broader social and occupational impacts, including:
- Difficulties maintaining employment or pursuing career goals
- Challenges in social interactions and relationships
- Reduced participation in leisure activities and hobbies
- Financial strain due to medical expenses and potential loss of income
Recognizing these far-reaching consequences underscores the importance of effective tremor management strategies that go beyond symptom control to address the overall quality of life for MS patients.
Tremor in Multiple Sclerosis—An Overview and Future Perspectives
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MS Tremors (Postural, Intention, Nystagmus) Causes & Treatment
Written by WebMD Editorial Contributors
- What Is a Tremor?
- What Are the Types of Tremors?
- Why Does MS Cause Tremors?
- Medicines That Treat MS Tremors
- Nonmedicinal Tremor Treatments
- Tremors and Depression
- More
A tremor is when a body part moves or shakes and you can’t control it. Many people with multiple sclerosis (MS) have some form of tremor they can’t control, in different parts of their bodies, like their head, arms, or legs.
- Intention tremor. There’s no shaking when you’re at rest. It starts when you try to reach or grasp something or move your hand or foot to a precise spot. This is the most common form of MS tremor, and it usually causes the most problems in day-to-day life.
- Postural tremors. You shake when you sit or stand, but not when you lie down.
- Resting tremor. You move more when you’re sitting still and less when you move. This is more common with Parkinson’s disease than MS.
- Nystagmus. This type causes jumpy eye movements.
This disease damages the protective sheath (myelin) that covers the nerves in your brain and spinal cord. Tremors result from damage to a part of your brain called the cerebellum. It controls your balance and coordination and smooths out the actions that you make when you move your limbs and eyes or speak.
These problems are one of the hardest MS symptoms to treat. There aren’t any drugs made just to treat MS tremors. Your doctors may prescribe drugs for another condition that could help, like:
- Acetazolamide (Diamox), which treats a type of glaucoma and altitude sickness
- Buspirone (Buspar) and clonazepam (Klonopin), which are anti-anxiety drugs
- Hydroxyzine (Atarax, Vistaril), an antihistamine
- Isoniazid (INH), a drug for tuberculosis
- Primidone (Mysoline), a seizure medicine
- Propranolol (Inderal), which treats heart problems, high blood pressure, and migraines
- Braces: These can hold your joint still and stop extra movement. A brace on your ankle or foot can make it easier to walk. They can help control your arm, hand, or neck, too.
- Deep brain stimulation: This experimental approach is mostly used for people who have tremors from Parkinson’s disease. A doctor implants electrodes into your brain. Wires connect them to a gadget in your chest. You use it to send your brain signals that stop the tremors.
- Medical cannabis: There’s little evidence that cannabis can help with tremors, but study results are mixed and usually only include small numbers of people.
- Physical therapy: It can show you exercises that increase your range of motion, improve your posture and balance, and make your body more stable
- Speech therapy: If you have tremors in your lips, tongue, or jaw, a health professional can work with you to slow your speech, make it clearer, and control the volume.
- Occupational therapist: This person will set you up with special tools called adaptive or assistive devices. They can help you grab things from up high or off the floor, pull up a zipper, or hold a fork more easily.
- Weights: Adding extra weight to a body part can help keep it still. You can also add weights to commonly used items like forks, pencils, pens, eating utensils, canes, and walkers.
Tremors can be tough to handle in social situations. You may feel like you want to be alone, but that can make you feel lonely and depressed. A psychologist or counselor can help you find ways to feel more comfortable in public and keep the tremors from changing how you live your life.
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Tremor – causes, diagnosis and treatment
Tremor is a movement disorder, which is manifested by involuntary rhythmic fluctuations in various parts of the body, arising from the stereotypically repeated contraction and relaxation of the muscles. Most often, hyperkinesis covers the hands, head, feet, severe trembling limits the physical, social and professional activity of patients. Diagnosis is based on anamnesis data, neurological examination, results of additional studies (laboratory tests, neurophysiological and neuroimaging methods). Tremor treatment involves eliminating the cause, symptomatic correction.
General characteristics
Tremulous hyperkinesis is a common variant of involuntary movements. Although symptoms occur at any age, including childhood, higher rates are found in people over 65 years of age. The tremor is felt as a rhythmic trembling. It is often observed in the hands, reminiscent of counting coins or rolling pills, but can also affect other parts of the body: the head (movements like “yes-yes” or “no-no”), torso, feet. Sometimes the chin, tongue, vocal cords are involved in the pathological process, which interferes with eating, disrupts the function of speech production.
An isolated tremor is not life-threatening, but violent movements make daily activities much more difficult. Hand trembling creates difficulty in writing, drawing, holding cutlery and other activities that require the participation of fine motor skills (dressing, manual labor). Tremor limits professional and social activity, creates psychological discomfort, and reduces the quality of life. Some types of hyperkinesis progress with time, accompanied by a neurological deficit, while others disappear with the elimination of the causative factor.
Classification
Tremor or trembling is a movement disorder, which in the structure of neurological syndromes belongs to hyperkinesis. By origin, it is primary (essential) and secondary, which is a sign of the underlying disease, intoxication or the action of medications. Taking into account etiopathogenetic features, two types of tremor are distinguished:
- Physiological. Occurs in healthy individuals, characterized by low amplitude, not visually determined. Physiological tremor is a normal motor control mechanism, exacerbated by external factors, but may be consciously reduced by the patient himself.
- Pathological. Due to various disorders in the central or peripheral parts of the nervous system. The most common variants are parkinsonian, cerebellar, essential tremor. There are also dystonic, neuropathic, orthostatic and some other types.
Considering the clinical and morphological features, there are slow (in the range from 3 to 5 Hz) and fast trembling (6-12 Hz), low- and high-amplitude (small or large-scale), intermittent or constant. An important criterion for systematization is the conditions of development, in accordance with which the tremor of rest and action (action) is distinguished. The latter has several varieties:
- Postural (static). Caused by maintaining a stationary position of body parts (stretched forward and parted to the sides of the arms, head). Its variety is considered positional tremor, characteristic of strictly defined postures.
- Kinetic. Associated with motor acts. Simple kinetic tremor occurs during any non-purposeful movements. Intentional trembling intensifies as a goal is achieved.
- Kinesiology specific. Only observed during certain narrow actions. A characteristic example is writing tremor, which is absent in other situations involving the same muscles.
- Isometric. Occurs under conditions of isometric muscle tension, with a strong contraction without movement. Such trembling is observed when clenching the hand into a fist, holding a heavy object.
Topographic classification involves the division of tremor depending on location. The focal one affects only one anatomical zone (hand, head, soft palate, etc.), the segmental one covers adjacent areas (bibrachial), if several areas are affected, hemitremor is noted on one side, and involuntary movements throughout the body allow us to talk about generalized trembling. When making a diagnosis, the time of the first appearance of the symptom, family history, connection with the intake of certain substances are taken into account.
Why tremor occurs
Causes of hand tremor
Hands are the most typical localization of tremor. Considering the physiological mechanisms of tremor development, note the ability to increase with muscle fatigue, hypothermia, the action of psychogenic factors (emotional upheaval, anxiety). The spectrum of pathological causes is very extensive – the main positions in it are assigned to essential tremor and Parkinson’s disease, but there are many other conditions that can cause hand trembling:
- Endocrinopathy : thyrotoxicosis, pheochromocytoma, hypoglycemia, hyperparathyroidism.
- Metabolic disorders : Wilson-Konovalov disease (tremulous, trembling-rigid forms), Hallervorden-Spatz.
- Massive lesions : subdural hematoma, tumors, cavernous angiomas.
- Vascular lesions of the brain : ischemic and hemorrhagic strokes.
- Infectious diseases : neurosyphilis, epidemic encephalitis.
- Hereditary pathology : Fragile X-associated tremor and ataxia syndrome (FXTAS), Kennedy’s bulbar-spinal amyotrophy, Sensitive Ataxia-Neuropathy-Dysarthria-Ophthalmoplegia Syndrome (SANDO).
- Polyneuropathies : metabolic (diabetic, paraproteinemic, toxic), chronic inflammatory demyelinating, hereditary motor-sensory.
- Withdrawal syndrome : withdrawal of alcohol, drugs (cocaine, heroin), medications (opioids, benzodiazepines).
- Intoxications : salts of heavy metals (mercury, arsenic, lead), carbon monoxide, carbon disulfide.
- Taking tremorogenic drugs : tricyclic antidepressants, neuroleptics, sympathomimetics.
The development of physiological tremor is largely due to mechanical factors – the weight of the limb, muscle tone, stiffness of the articular apparatus. The leading role in the formation of pathological trembling is occupied by changes in the central nervous system associated with the appearance of so-called tremor generators (central oscillators) with spontaneous or induced rhythmic activity. The second important point is the loss of control over voluntary movements from the cerebellar system.
Causes of head tremor
Rhythmic nodding and turning of the head are quite common, but usually included in the picture of mixed trembling, when involuntary motor acts cover several parts of the body. Often we are talking about parkinsonian (primary, secondary) or essential tremor. The following diseases are recognized as other causes of hyperkinesis:
- Cervical dystonia.
- Multiple sclerosis.
- Holmes tremor (mesencephalic).
- Prion diseases: Kuru disease.
- Paraneoplastic syndromes : opsoclonus-myoclonus syndrome.
- Metabolic encephalopathies : hypoxic-ischemic, uremic, hepatic.
- Hereditary diseases : olivopontocerebellar atrophy, leukodystrophies (Peliceus-Merzbacher disease), ataxia with vitamin E deficiency.
Tremor of central origin is caused by damage to the neural ring of the extrapyramidal system, in which there are subcortical structures – basal, stem, cerebellar nuclei. An important place is given to changes in the striopallidar system, rubrospinal tract, and thalamic connections. Head trembling occurs in the pathology of the cervical spine, which is associated with impaired blood circulation, compression of the spinal nerves.
Causes of chin tremor
Mandibular trembling may be an early symptom of Parkinson’s disease or neuroleptic parkinsonism (rabbit syndrome). Tremor of the chin is due to other causes that require attention in the differential diagnosis. Increased alertness is traditionally caused by conditions characteristic of early childhood:
- Neonatal tremor .
- Perinatal CNS damage : hypoxic encephalopathy, intrauterine infections, birth trauma.
- Cerebral palsy .
- Hydrocephalus .
- Family chin tremor (geniospasm) .
Physiological tremor of the neonatal period occurs against the background of crying, when undressing or getting a child out of the water, under the influence of fear, cold. Risk factors for damage to cerebral structures are infectious diseases, obstetric and somatic pathology in a pregnant woman. It is impossible to exclude the development of intoxication and withdrawal syndrome in a child when the mother uses psychoactive drugs.
Diagnosis
Diagnostic search begins with the analysis of complaints, anamnestic information and neurological examination. To objectify the intensity of trembling allows the scale of clinical assessment of tremor. If the syndromic diagnosis usually does not cause difficulties, then certain difficulties may arise with the nosological verification of the pathology. Additional methods are used for differentiation:
- Laboratory tests. Some causes of tremor can be determined by the results of a biochemical blood test with the determination of thyroid-stimulating hormones, glucose, calcium, kidney tests and other indicators. Toxicological tests allow you to determine the concentration of toxic substances, drugs, medicines. If hepatolenticular degeneration is suspected, ceruloplasmin levels and urinary copper excretion are examined.
- Tomography. Neuroimaging is indicated for sudden onset, rapid progression, tremor associated with other neurological disorders. MRI of the brain reveals atrophic, ischemic lesions or other structural damage. Functionally active zones are examined with positron emission tomography.
- Computer stabilography . A stabiloanalyzer (stabilometric platform) with biofeedback helps to assess the characteristics of postural tremor. During the study, support reactions are studied, including when performing diagnostic tests – static and dynamic.
- Tremorometry. The most widespread method of registration of involuntary rhythmic fluctuations using a computer polygraph that evaluates the frequency and amplitude of trembling. To record a tremorogram, tenso-, piezo-, accelerometric methods are used.
- Electroneuromyography. It makes it possible to indirectly judge the parameters of trembling by the tension and relaxation of individual muscles. Electromyography helps to differentiate tremor from other movement disorders, to identify individual causes of trembling (polyneuropathy).
Cerebral vascular pathology is detected by transcranial ultrasound and angiography. The displacement of the median structures and the state of the ventricular system are visible on the echoencephalogram. It is possible to confirm the hereditary nature of some diseases with molecular genetic tests. Conditions accompanied by tremors are differentiated among themselves and with other hyperkinesias.
Ergotherapy
Treatment
Conservative therapy
Treatment of tremor is designed to reduce the functional limitations and social exclusion of patients. The basis of therapy is conservative methods, which are usually symptomatic. If a secondary tremor is detected, treatment involves the elimination of the causes of its occurrence, the correction of the underlying pathology. Among the therapeutic measures are used:
- Lifestyle optimization. Avoid situations that increase jitter intensity. In the early stages of the development of the disease, patients are advised to master adaptive methods – use fountain pens and cutlery with thick handles, blunt scissors and knives, telephones with voice control, etc.
- Physical methods. The methods of physical influence include the use of special orthoses that limit the mobility of the hand in the wrist joint. Assistance in the development of simple motor models is provided by physiotherapy exercises and occupational therapy, which are complemented by massage, reflexology and balneotherapy.
- Pharmacotherapy. Several groups of drugs are indicated for the treatment of tremor. Based on clinical expediency, anticonvulsants (primidone, topiramate, gabapentin), antiparkinsonian drugs (levodopa, amantadine, pramipexole), beta-blockers (propranolol, atenolol, nadolol) are prescribed. With severe tremor of the head and voice, injections of botulinum toxin A are performed.
Surgical treatment
The failure of conservative therapy is a reason to consider options for surgical treatment of tremor. In severe disabling forms, it is possible to implant electrodes in the ventrolateral thalamic or subthalamic nuclei, followed by deep brain stimulation with high-frequency electrical impulses. Promising methods are radiofrequency ablation, ultrasound or cryotalamotomy under MRI control.
Tremor in multiple sclerosis
What is a tremor?
Tremor is a medical term for treperine and other tremors, in a known degree of rhythmic, involuntarily twisting and releasing on a group of muscles. Tezhyk tremor ima at about 30% of chorat with MS.
Pathological tremor se divided into two groups: static tremor (at rest) and tremor during movement.
Static tremor (tremor at rest, Parkinson’s tremor) is asymmetrical, low frequency (3 – 6 Hz) and rhythmic. Disappeared with movement and sleep, suffocated with stress and anxiety, not affected by alcohol. Showing it in extreme parts on the extreme. Movements in his presence are understandably befitting on the “armour on a bet”.
Tremor during movement two types:
- postural – developing a set of trembling during the experience, the position is determined in advance, for example, moving forward;
- intentional – an oscillating (trembling) tremor, manifesting itself during purposeful movement, especially at the edges of a motor act, for example, appearing on a treper on a rkat when encroaching on the bowl, some of it is silva from reaching the rakat to the bowl. Trepteniyata with tosi tremors is uncoordinated and with a different amplitude.
Osventova, nystagmus, a kind of tremor, please clear it up.
What causes the tremor?
Tremors caused by lesions in the brain, especially in the brain and nerves involved in motor coordination. You are nervous, participating in coordinating muscle movements, serving many muscle groups, dealing with various functions. People with tremors may develop ataxia, speech problems (dysarthria) or problems with speech (dysphagia).
What is the typical tremor in MS?
Two best forms of tremor in MS sa intentional tremor and orthostatic tremor. Orthostatic tremor is characterized by rhythmic muscle contractions, which appear in the area on the margin of the vednag, a trace of the right from the sednal or legal position. Usually the patient complains about the feeling of instability and cannot but appreciate what you are talking about for tremor. With multiple sclerosis, for the difference from Parkinson’s pain, sometimes observing a tremor at rest.
Tremor in case of multiple sclerosis oath to burn the extremes and may vary from slightly trembling to difficultly perverted on the daily activities of kato writing, storage, denunciation, personal hygiene, etc. Ordinary person with tremor standing by avoidance of movement, for example. refusal to keep and drink in a public place or compensatory strategy. K’m compensatory strategies for all of them, for example, squeezing on lakta kam tyaloto, some of the right tremors are weakly visible, with tremor on the head of the bolniyat, you can drink and stabilize the glavata through the belt on the belt, squeezed on the ramenet kam garba on the table and fixed on the lakta under right ygl usually drive to better control on rkat.
Tremor tests can be increased from anxiety and stress. Tremor and nay-unfavorable for the therapeutic effect of the symptom on MS.
What is the main therapeutic approach for tremor?
Treatment options include balance and coordination exercises, mechanical approach and medications.