Getting a Handle on MS Tremors and Shakes

Many people with multiple sclerosis (MS) develop tremors, or shaking, in various body parts. Tremors can be mild, but they can also be severe and disabling.

“MS tremors are rhythmic, back-and-forth muscle movements that you can’t control,” says Alessandro Serra, MD, PhD, a neurologist at University Hospitals Cleveland Medical Center in Ohio. “The tremor can affect your hands, arms, legs, or even your head and vocal cord muscles.”

People with MS get tremors when plaques, or damaged areas, develop along the nerve pathways responsible for voluntary muscle movement and balance.

How much of an impact they have on a person’s life varies from one individual to another.

Dario Anastasio, 62, of Newington, Connecticut, had to give up his job as a computer systems engineer because of his tremors.

“Before I was diagnosed with MS, I would have tremors in my hands, but I could still write and use a computer,” Anastasio says. The tremors worsened after his 2007 diagnosis with MS.

Linda Roudebush, 62, of Austin, Texas, is not so troubled by the tremors in her left hand. “I am right-handed,” she says. “So the tremor in my left hand is an inconvenience, but not all that bothersome. I don’t take anything for it, and I use the shaking hand to scratch an itch or give a back massage,” she jokes.

Different Types of Tremors

Tremors are commonly classified by appearance and cause or origin:

Cerebellar tremor, the kind most often associated with MS, is a slow tremor of the extremities “caused by lesions in or damage to the cerebellum in the brain,” says Harold Gutstein, MD, a MS neurologist at NYU Langone Health in New York City.

“In MS, these tremors reflect more aggressive or long-lasting disease,” Dr. Gutstein says. Cerebellar tremors tend to occur at the end of purposeful movement, such as pressing an elevator button with a finger.

Tremors are also described according to the situations in which they occur:

Intention tremor tends to occur at the end of a purposeful movement, such as touching a finger to the tip of your nose.  “These occur when you reach for something and start to shake,” Dr. Serra says.

Postural tremor occurs when you’re holding a position against gravity, such as holding your arms outstretched. “With these tremors, you shake when you sit or stand,” Gutstein says, “but not when you’re lying down.”

Resting tremor occurs at rest and is more common in Parkinson’s disease than in MS, but it does occur in MS.

How to Prevent MS Tremors

Gutstein often tells his patients: “The brain is like time: Once it disappears, you’re not getting it back.”

The important thing is to get diagnosed and get early, aggressive treatment with available disease-modifying MS drugs that can prevent most tremors from ever occurring, he says. “There are about 15 medications now for the treatment of MS, and some of them are very effective.”

To minimize tremors, “you should also eliminate contributing factors that can be controlled, like fatigue, stress, or too much coffee,” Gutstein says. “There are no great treatments for MS tremors once they start, which is why prevention is so important.”

How to Cope With MS Tremors

For those who have already developed tremors, treatment may include the following:

Occupational or physical therapy can help you manage tremors that interfere with daily life. These therapies may include the use of braces, weighted devices, wrist rests, and exercises to increase control and balance, Serra says.

Medication, including anti-anxiety drugs, antihistamines, beta-blockers, anti-nausea medication, and anti-seizure drugs have all been used for tremors caused by MS. “No drug has been specifically approved for MS tremors,” Serra says. “None of the available MS drugs treat tremors, either.”

Deep brain stimulation, a therapy often used to treat Parkinson’s disease, may also be helpful for cases of severe MS tremor. It involves implanting electrodes into the brain to block involuntary muscle movement, Serra explains.

Anastasio underwent deep brain stimulation on the left side of his brain to control the tremors on the right side of his body. “I can now hold my right hand without shaking, but my left one still has tremors,” he says. He has not decided whether to have the treatment on the other side of his brain.

“Deep brain stimulation shows promise,” Serra says, “but the improvements are not always dramatic enough to justify the risks.” Those include infection and bleeding in the brain, he says.

Botox, which is approved to treat MS-related spasticity in the upper and lower limbs, as well as overactive bladder, may also help treat MS-related limb tremors. In a study published in the journal Neurology, 23 people with MS showed improvement in tremor severity in their arms as well as in their writing and drawing ability six weeks and three months after Botox shots.

When injected into a muscle, Botox blocks nerve signals that cause tightening and movements of the muscle. Its effects last between two and six months.

What About Medical Marijuana for MS Tremors?

Medical marijuana has not yet been proven to help with tremors, Gutstein says.

Indeed, a review of clinical and preclinical research on marijuana and other chemicals (cannabinoids) derived from the cannabis plant published in February 2015 in the journal Movement Disorders found that cannabinoid-based therapies probably had no benefit for tremors in MS.

“There is a lot of noise out there,” Gutstein says, “but [no evidence directly related to] cerebellar lesions. It’s a step I wouldn’t cross at this point.”

Additional reporting by Susan Jara.

Causes and effects of tremor

What causes tremor?

MS tremors are usually caused by damage to myelin in an area of the brain known as the ‘cerebellum’, and the nerves leading to and from it. The cerebellum is the part of the brain that controls your balance and coordination. It ‘smoothes out’ the movement of your limbs, eyes and speech. Tremor can also be the result of demyelination in other areas of the brain – including the thalamus and the basal ganglia, which are both involved in controlling movement.

Like other MS symptoms, tremor can come and go, or it could be progressive. If you experience tremor as the result of a relapse, you might find that you are still left with some level of tremor once the relapse is over.

Other reasons for tremor

If you have intention or postural tremor because of your MS, you will probably find that while your muscles are completely relaxed – such as when you are lying down or asleep – your tremor goes away. If it doesn’t, there may be another reason for it.

Tremor can be the result of muscle weakness and problems with posture, or a side effect of some medications (such as drugs for asthma). It could also be caused by other neurological conditions, such as Parkinson’s.

The effects of tremor

For some people, their tremor is so mild they’re the only person aware of it. For others, it’s more obvious. It might be difficult to carry a drink without spilling it, or to hold a pen steady to write. For a few people, it can be so severe that everyday activities like eating, drinking or getting dressed are difficult or impossible without help.

Getting help and support

If your tremor is severe, it can have a significant impact on your independence. It can also directly affect your general well-being, work and social life. You might feel embarrassed about your tremor, and may be avoiding situations which make you feel self-conscious about it. Or it might make you feel anxious, and that anxiety may be making your tremor worse.

Whatever you feel – and it may be different at different times – you don’t have to cope alone. You might find that talking to other people with tremor helps. Your MS nurse, for example, may know about any support groups in your area and may be able to find further support for you and your family. Your local branch of the MS Society may also be able to offer support as well as other activities.

If you think that counselling might help, you can ask your GP or MS nurse for a referral. This may be particularly helpful if anxiety is making your tremor worse. Bear in mind, though, that the availability of counselling on the NHS is quite limited, so you may have to wait a while and may only get a certain number of appointments. You can also ask your GP to recommend a private counsellor, or if counselling is available from any voluntary organisations in your area. Many MS National Therapy Centres offer counselling services.

> Read more about treating and managing tremor

Tremor in multiple sclerosis

Abstract

Tremor is estimated to occur in about 25 to 60 percent of patients with multiple sclerosis (MS). This symptom, which can be severely disabling and embarrassing for patients, is difficult to manage. Isoniazid in high doses, carbamazepine, propranolol and gluthetimide have been reported to provide some relief, but published evidence of effectiveness is very limited. Most trials were of small size and of short duration. Cannabinoids appear ineffective. Tremor reduction can be obtained with stereotactic thalamotomy or thalamic stimulation. However, the studies were small and information on long-term functional outcome is scarce. Physiotherapy, tremor reducing orthoses, and limb cooling can achieve some functional improvement. Tremor in MS remains a significant challenge and unmet need, requiring further basic and clinical research.

Keywords: multiple sclerosis, treatment, tremor, ataxia

Search strategy and selection criteria

References for this review were identified from searches of Pubmed (from 1966 to 2005) and the Cochrane Library (2005, Issue 2) with the search terms “multiple sclerosis”, “tremor”, “ataxia”, “disability”, “prevalence”, “surgery”, “thalamotomy”, “deep brain stimulation” and “treatment”. Articles were also identified through searches of the reference tables of identified papers. Furthermore we searched the ISI Science Citation Index for relevant articles citing identified papers. Only articles in English and German were included in the review; publications in abstract form were not considered.

Introduction

Tremor is such a common problem in multiple sclerosis (MS) that the famous French neurologist Charcot (1825–1893) described it as a part of his triad of characteristic symptoms in MS, together with nystagmus, and scanning speech.

Tremor of the upper limbs can be very disabling and seriously impair many activities of daily living and quality of life. In practice the treatment of tremor in MS is often frustrating. In this review we discuss medical, surgical and other treatment options.

Epidemiology

Although the epidemiology of symptoms in MS has been studied extensively, it remains difficult to ascertain the prevalence of tremor in historic study populations, mostly because Kurtzke’s functional systems scale for cerebellar function, which is most widely used in clinical studies in MS, does not record tremor [55]. In a large long-term follow-up study, Weinshenker and colleagues found functionally relevant cerebellar deficits in one third of 259 patients [94]. In another study, disability and dependency of patients with MS were shown to correlate with the severity of ataxia [95].

Two newer studies assessed the prevalence of tremor in MS. One study by Alusi and coworkers examined 100 patients randomly selected from a London MS-clinic and found tremor in 58% of patients. The tremor was minimal in 27%, mild in 16% and moderate to severe in 15% of all patients [6]. As patients were selected from a specialist clinic, the relatively high prevalence and severity of tremor might be due to selection bias.

In a prevalence cohort study by Pittock and colleagues, 200 MS patients living in Olmsted County, Minnesota, USA were assessed for tremor and measures of disability. Tremor was found in 25.5% and severe tremor in 3% of the study population [74]. Probably the community based population in the latter study gives a more realistic estimate of tremor prevalence in MS. In both studies, however, tremor was associated with greater disability as measured on the expanded disability status scale (EDSS). In the Olmsted County population, patients with tremor of any severity were more likely to be unemployed or retired early because of disability.

Tremor subtypes

Tremor in MS can involve the head, neck, vocal cords, trunk and limbs, whereas involvement of the tongue, jaw or palate has not been reported [5].

The different types of tremor are currently classified according to a working consensus of the Movement Disorder Society [29]. In MS, the two most prevalent tremor forms are postural tremor (tremor present whilst voluntarily maintaining a position against gravity) and intention tremor (tremor occurring during target directed movement where tremor amplitude increases during visually guided movements towards the target). True rest tremor (tremor present in a body part that is not voluntarily activated and is completely supported against gravity) is unusual in patients with MS, and Holmes (or “rubral”) tremor is also very uncommon.

In the two main prevalence studies, [6, 74] rest tremor was observed only in the Olmsted County survey (1% of patients), whereas Holmes tremor was observed in neither study. An overview of the affected body parts observed in both studies is given in Table . In both studies tremor was most commonly found in the arms. In the London study population, 36% of patients suffered from bilateral arm tremor, making this the most common pattern of limb involvement.

Table 1

Details of the two main prevalence studies on tremor in MS

	London [6] (n = 100)	Olmsted County [74] (n = 200)
Total patients with tremor	58 (58%)	51 (25.5%)
Patients with severe tremor	15 (15%)	6 (3%)
Arm tremor	56 (56%)	47 (23. 5%)
Bilateral arm tremor	36 (36%)	not reported
Leg tremor	10 (10%)	12 (6%)
Head tremor	9 (9%)	7 (3.5%)
trunk tremor	7 (7%)	not reported

Pathophysiology of tremor

The pathophysiology of tremor in MS is a difficult area of investigation, partly because MS is by definition a multifocal disease, so that tremor occurrence cannot easily be linked to a single neuroanatomical site. Systematic postmortem studies on the link between lesion site and the clinical phenomenon of tremor have never been undertaken.

The predominance of action tremors (postural and intention) in patients with MS point to the cerebellum and its connections as the most likely source of tremor production, whereas the rarity of rest tremor argues against an involvement of the basal ganglia. The common occurrence of bilateral tremor might indicate that damage to the cerebellum and its connections is often multifocal.

Another link to the cerebellum in the pathophysiology of tremor in MS is the effect of peripheral cooling on intention tremor. Intention tremor is thought to be modulated through increased long latency stretch reflexes [30]. Cooling has been shown to decrease the sensitivity of muscle spindles [64] and the velocity of peripheral nerve conduction [56]. In two experimental studies, cooling of the arms markedly reduced intention tremor severity in patients with MS [77, 35]. The authors argue that this effect might have been partly due to decreased muscle spindle function and decreased nerve conduction velocity, which in turn resulted in decreased input into tremor producing cerebellar circuits.

Alusi and coworkers drew attention to the placement site of deep brain stimulation (DBS) electrodes to help understand the neuronal circuits involved in tremor production. They stated that neurosurgeons increasingly chose the nucleus ventralis oralis posterior (VOP) of the thalamus rather than the classic target, the nucleus ventralis intermedius (VIM). This is interesting because the VOP is the basal ganglia output nucleus of the thalamus [6], suggesting that the cerebellar tremors seen in MS might actually be generated by the basal ganglia. The standard electrode placement site reported in the literature, however, is the VIM and no studies comparing placement sites have been published. Whittle and coworkers comment on the difficulty of electrode placement in MS patients: in most patients there are major brain distortions due to demyelination, plaque formation and e vacuo hydrocephalus, and it is therefore uncertain whether the anatomy of these patients conforms to standard stereotactic atlasses [100]. Keeping these comments in mind, it seems unwise to base pathophysiological theories purely on DBS electrode placement site.

A range of animal experiments have been undertaken to indentify the anatomical structures involved in tremor production (for review [101]). It has been shown that damage or removal of the cerebellar cortex does not induce intention tremor in monkeys, [31, 76] whereas partial or complete cerebellectomy leads to tremor during movement and posture [75, 42, 40]. A slow, 3–5 Hz tremor during target directed movements can also be induced by reversible cooling of the dentate nucleus (the origin of most cerebellar efferents) in monkeys [22].

Most cerebellar efferents project from the dentate nucleus via the superior cerebellar peduncle (brachium conjunctivum) to the red nucleus and the thalamus. According to some studies, transection of the superior cerebellar peduncle causes intention tremor in monkeys [34, 93], whereas other authors do not mention this effect.

Interestingly, Carpenter and colleagues report that tremor induced by transection of the superior cerebellar peduncle can be alleviated by a second lesion in the lateroventral or centromedian thalamus. [19, 20] The results of these animal studies suggest that damage to cerebellar efferents (through lesions of the dentate nucleus or superior cerebellar peduncle) may cause disinhibition of thalamic nuclei which are the main producers of intention tremor.

Although this is an interesting pathophysiologic model of intention tremor production, it remains uncertain whether the results of animal studies can be generalized to patients with MS.

In summary, clinical observation, animal studies and some experimental evidence in humans favour the cerebellum and the thalamic nuclei connected to it as the major locus of intention tremor production, but more research is needed to evaluate the role of the basal ganglia and other systems in tremor production in MS.

Assessment of tremor

Depending on the subtype of tremor, several methods for the assessment of tremor severity and its impact on the lives of patients have been developed. Rest tremor is often assessed with the tremor subscale of the Unified Parkinson’s Disease Rating Scale (UPDRS). Fahn and colleagues devised the most comprehensive tremor scale for non-parkinsonian tremor in 1984 [33]. This instrument measures tremor in nine body parts at rest, while maintaining a posture and during goal directed movements. It also includes an assessment of arm tremor while writing and pouring water as well as a subscale for functional disability (interference of tremor with dressing, writing, eating etc.). Some studies included in this review use a modified and heavily abbreviated version of this scale, but most studies assess tremor by clinical examination only (e.g. by finger-to-nose testing, drinking from a cup, nine-hole-peg-test or writing and drawing tasks) or use a simple ordinal severity scale, often classifying tremor as absent, mild, moderate or severe. A simple 0–10 tremor severity scale devised by Bain and coworkers [11] has been shown to be a valid and reliable measurement tool in patients with MS [7], but has so far only been used in few clinical studies [6, 4, 15].

Accelerometry and polarized light goniometry are neurophysiologic methods of tremor assessment. While these methods offer an objective measurement of tremor severity, they can only measure one aspect of an often complex movement problem at a time, and e.g. cannot measure the ataxia which often complicates tremor in MS.

Matsumoto and colleagues devised a more complex “quantitative movement analysis technique”, which records the patients’ goal directed movements in three dimensions using an electromagnetic tracking device, but the complexity of this method [62] as well as the computer aided tracking tasks employed by Aisen and coworkers [2] prohibit their widespread use.

One of the most important aspects of tremor in MS is its impact on the daily life of the patients. Functional status in MS-patients is often measured by asking the patients to complete questionnaires assessing activities of daily living such as writing, eating or dressing. Often these scales are self-devised and not validated. Validated scales used in the studies reviewed in this article include the Frenchay Activities Index [85] and the quality of life subscale of the Functional Assessment of Multiple Sclerosis Scale (FAMS) [62].

Medical treatment

A summary of the published studies on medical treatment of tremor in MS is given in Table . Most of the published literature on medical treatment consists of case reports and uncontrolled open label studies. The few randomized controlled trials comprised small numbers of patients and very likely lacked the power to reveal small treatment effects.

Table 2

Studies on medical treatment of tremor in MS

Study	n*	study design	intervention(s)	tremor assessment	patients with tremor reduction (%)	patients with improved functional status (%)	adverse effects (n)
Koller, 1984 [52]	3	double-blind placebo-controlled crossover	propranolol (not specified) isoniazid (po. ) 1200mg/d ethanol (iv.) 50ml of 10% solution	writing tasks, patient self assessment, clinical examination, accelerometry	no effect		hepatitis while on isoniazid treatment (1)
Sabra et al. 1982 [80]	4	case reports	isoniazid (po.) 400 to 1200mg/d	clinical examination	4 (100%)	4 (100%)	abnormal liver function tests (1)
Duquette et al. 1985 [32]	12	open label	isoniazid (po. ) 500–1000mg/d	patient self assessment, clinical examination, blinded evaluation of video tapes	10 (83%)	0	drowsiness, dysphagia, increased bronchial secretions (6) abnormal liver function tests (2) fatigue (2)
Morrow et al. 1985 [67]	5	open label	isoniazid (po.) 700–1200 mg/d	clinical examination	4 (80%)	4 (80%)	increased weakness (2) drowsiness (1)
Francis et al. 1986 [38]	5	open label	isoniazid (po. ) 1200 mg/d	clinical examination, polarised light goniometry	4 (80%)	0	anorexia and nausea (3)
Hallet et al. 1985 [44]	6	double-blind placebo-controlled crossover	isoniazid (po.) 1200 mg/d	self-rating scales, accelerometry, blinded evaluation of video tapes	6 (100%)	0	None
Bozek et al. 1987 [16]	8	double-blind placebo-controlled crossover	isoniazid (po. ) 12 or 20 mg/kg	clinical examination, accelerometry, blinded evaluation of video tapes	6 (75%)	4 (50%)	somnolence (3) **
Sechi et al. 1989 [86]	7	single-blind placebo controlled	carbamazepine (po.) 400 or 600 mg/d	clinical tremor rating scale, accelerometry	7 (100%)	not reported	none reported
Rice et al. 1997 [78]	16	double-blind placebo-controlled crossover	ondansetron (iv. ) 8 mg (single dose)	nine-hole peg-test, writing tasks, patient self assessment	12 (75%)	not reported	short-lasting foot dystonia (1)
Gbadamosi et al. 2001 [39]	14	open label	ondansetron (iv.) 8 mg (single dose)	nine-hole peg-test, writing tasks, patient self assessment	no effect		none reported
Aisen et al. 1991 [2]	6	open label	Gluthetimide 750 to 1250 mg	blinded functional assessment by occupational therapist, computer-aided tracking tasks	5 (83%)	5 (83%)	sedation (4)
Clifford, 1983 [21]	8	open label	Δ9-THC (po. ) 5 to 15 mg	clinical examination	5 (63%)	2 (25%)	none
Zajicek et al. 2003 [103]	365†	double-blind randomized placebo controlled	cannabis extract (po.) Δ9-THC (po.)	patient self assessment	no effect		cannabis extract: adverse events in 12 Δ9-THC: adverse events in18 placebo: adverse events in 20
Wade et al. 2004 [92]	13‡	double-blind randomized placebo controlled	cannabis extract (po. )	visual analogue scale symptom reduction	no effect		cannabis extract:$ 112 adverse events in 80 patients placebo:$ 53 adverse events in 80 patients
Fox et al. 2004 [37]	14	double-blind randomized placebo controlled crossover	cannabis extract (po.)	tremor rating scale	no effect		cannabis extract: adverse events in 10 placebo: adverse events in 2

Beneficial effects have been reported for a variety of drugs: case reports and small uncontrolled open label studies claim a positive effect of primidone [47], gluthetimide [2], intrathecal baclofen [96] and isoniazid. [80, 32, 67, 38] Controlled clinical trials have been published on the use of propranolol [52], ethanol [52], isoniazid, [52, 44, 16] carbamazepine [86], ondansetron [78] and dolasetron [65].

Koller evaluated the effect of propranolol, isoniazid and ethanol on tremor in three tremulous MS patients in a double blind crossover trial and found no treatment effect for any of the treatments [52]. To the best of our knowledge, no further trials with propranolol have been published, but it is interesting to note that Alusi and coworkers excluded two tremulous MS patients from a thalamotomy trial because they had achieved functional improvement after propranolol use [4].

In an open study the hypnotic-sedative drug glutethimide exhibited visible functional benefit in six of eight MS patients with tremor [2]. Apparently, a controlled trial to confirm these findings was never undertaken.

Two double-blind placebo-controlled trials using isoniazid were published. In the first study reduction of tremor occurred in six of eight patients [16], with functional improvement in four patients. In the second study all six patients had measurable tremor reduction after treatment with isoniazid but this did not lead to functional improvement [44]. Doses of isoniazid used to treat MS-related tremor were very high (up to 1200 mg a day), and treatment was in some patients associated with anorexia and nausea [38] or with a combination of drowsiness, dysphagia and increased bronchial secretion. [32, 67] Other reported side effects were abnormal liver function tests, [80, 32] fatigue [32] and increased weakness [67]. Isoniazid inhibits GABA aminotransferase activity and increases GABA in the central nervous system, but no correlation was found between the degree of GABA elevation in the cerebrospinal fluid and clinical response [16].

Sechi and coworkers published a small single-blind placebo-controlled trial with carbamazepine [86]. They reported improvement of tremor as assessed by clinical examination and accelerometry in all seven included patients, but failed to report whether this translated into functional improvement.

A placebo controlled, double-blind, crossover study, suggested that a single intravenous dose of the 5-HT₃ receptor antagonist ondansetron led to tremor reduction in twelve, and to functional improvement in nine of the sixteen included tremulous MS patients [78]. A subsequent open label study by Gbadamosi and colleagues which used the same intervention found no significant treatment effect [39]. Likewise, a small clinical trial with dolasetron, another 5-HT₃ receptor antagonist, showed no significant treatment effect on cerebellar ataxia [65].

Weiss and coworkers reported a positive effect of intrathecal baclofen in a single patient with bilateral arm tremor [96]. The tremor amplitude decreased almost linearly as the dosage increased and tremor was abolished at a dosage of 250 µg per day. This possible treatment option has, however, not been observed or evaluated in other studies.

In recent years, there has been growing interest in cannabis as a possible therapeutic in MS. In the 1980’s a case report [63] and a small uncontrolled study [21] on the beneficial effects of cannabis on tremor and spasticity in MS were published and a survey taken among MS patients revealed that many patients experienced positive effects of smoked cannabis on MS-related symptoms [23].

Baker and colleagues reported a decrease of tremor and spasticity in an animal model of MS after treatment with Δ⁹-tetrahydrocannabinol, the active ingredient of cannabis [12]. All this furthered hopes of cannabis as a possible new treatment option for tremor in MS, but much to the disappointment of tremulous MS patients, several well conducted randomized controlled trials did not show a significant effect of orally administered cannabis extracts [103, 37, 92] or oral Δ⁹-tetrahydrocannabinol [103] on tremor.

Surgical treatment

The surgical treatment options for tremor in MS are stereotactic thalamotomy and DBS. An overview of the published studies on surgical treatment is given in Tables  and . Most of the studies are small observational retrospective studies. When reviewing the literature on surgical treatment, it is surprising as well as disappointing that the majority of studies are remarkably imprecise in providing basic information on the length of follow-up, on adverse effects and-most importantly-on the effect on functional status and tremor associated disability.

Table 3

Studies on stereotactic surgery for the treatment of tremor in MS

Study	n*	patient characteristics**	lesion site	follow-up	tremor and disability assessment	patients with tremor reduction (%)§	patients with improved functional status (%)§	patients with permanent adverse effects (n)
Cooper, 1960a [25]	2	disabling intention tremor	VL	3 to 12 mo	clinical examination	2 (100%)	not reported	none
Cooper, 1960b [24]	6	disabling intention tremor	unilateral (n = 5) or bilateral (n = 1) VL	Not specifically reported	clinical examination, assessment of filmed tremor	5 (83%)	not reported	increase of contralateral hemiparesis (1)
Krayenbühl et al. 1962 [54]	4	disabling bilateral intention tremor	unilateral (n = 3) or bilateral (n = 1) VL	3 weeks to 6 mo	clinical examination	4 (100%)	4 (100%)	none
Broager and Fog, 1962 [18]	4	severe intention tremor	unilateral VL	1 to 6 mo	clinical examination	4 (100%)	2 (50%)	generalized seizure (1) mental change (1)
Cooper et al. 1967 [26]	32	disabling bilateral intention tremor	unilateral or bilateral VL	12 to 96 mo	clinical examination	27 (85%)	not reported	increase of contralateral hemiparesis (2)
Samra et al. 1970 [81]	25	disabling bilateral arm intention tremor	unilateral or bilateral VL	not specifically reported	clinical examination, assessment of filmed tremor	22 (88%)	not reported	increase of contralateral hemiparesis (1)
Riechert and Richter, 1972 [79]	29	disabling intention (n = 29) and postural (n = 18) tremor	unilateral (n = 28) or bilateral (n = 1) VL	not specifically reported	clinical examination, patient self assessment questionnaires	29 (100%)	“two thirds” of patients	increase of leg paresis (2)
Arsalo et al. 1973 [10]	26	disabling bilateral intention tremor	unilateral VL and subthalamus	3 to 97 mo	clinical examination	21 (80%)	not reported	subdural haematoma (1)
Andrew et al. 1974 [8]	4	disabling postural (n = 2) and intention (n = 4) tremor	unilateral VIM	6 to 36 mo	clinical examination	4 (100%)	not reported	hemiplegia (1)
Van Manen, 1974 [91]	4	severe intention tremor	unilateral VL	3 to 86 mo†	clinical examination	2 (50%)	not reported	not reported separately for MS subgroup
Hauptvogel et al. 1975 [45]	11	severe intention tremor	unilateral (n = 10) or bilateral (n = 1) VL	15 to 86 mo	clinical examination	7 (63%)	4 (36%)	not reported
Mundinger and Kuhn 1982 [68]	84	severe action tremor	ZI, VOP	36 to 120 mo	clinical examination filmed tremor patient self assessment questionnaire	70 (83%)	not reported	not specifically reported
Speelman and van Manen, 1984 [89]	11	severe intention tremor	unilateral VL	3 weeks to 132 mo	clinical tremor and functional rating scales	8 (73%)	0 (0%)	hemiparesis (4) micturition disturbance (2) speech disorder (1)
Kandel and Hondcarian, 1985 [51]	20	severe intention tremor	unilateral (n = 15) or bilateral (n = 5) VL (ZI, FF)	12 to 120 mo	not reported	14 (70%)	not reported	none
Hitchcock et al. 1987 [48]	30	tremor	Thalamus	24 mo	clinical examination functional rating scales	50%	25%	not reported
Wester et al. 1990 [97]	9	severe intention tremor	unilateral VOA and VOP	3 to 89 mo mean: 24 mo†	questionnaire sent to treating neurologist	6 (66%)	6 (66%)	hemiparesis (5) mental changes (3) dysphasia (3) dysarthria (2) subdural haematoma (1)
Goldman et al. 1992 [43]	2	severe intention tremor unresponsive to medication	unilateral VL	3 mo 34 mo	clinical tremor rating scale	2 (100%)	0 (0%)	dysarthria (1)
Whittle and Haddow, 1995 [98]	9	severe rest, kinetic, postural or intention tremor	unilateral VL	12 mo	clinical examination and evauation of video tapes	9 (100%)	2 (22%)	depression (2)
Shahzadi et al. 1995 [87]	33	severe tremor	unilateral VIM	3 to 120 mo	clinical examination ability to drink from a waterfilled cup	22 (67%)	17 (51%)	not reported
Hooper and Whittle, 1998 [50]	6	severe postural (n = 4) or intention tremor (n = 2)	unilateral VL	14 to 73 mo mean: 51 mo	Barthel Index	1 (16%)	1 (16%)	not reported
Critchley and Richardson, 1998 [27]	24	disabling intention tremor	unilateral (n = 22) or bilateral (n = 2) VIM	mean: 26 mo	clinical tremor and functional rating scales	18 (75%)	2 (8%)	hemiparesis (1) seizure (2) MS relapse (3) dysarthria (1)
Schuurman et al. 2000 [85]	5	severe arm tremor	unilateral VIM‡	6 mo	clinical tremor and functional rating scales	5 (100%)	0 (0%)	severe gait or balance disturbance (2)
Niranjan et al. 2000 [72]***	3	severe action tremor	unilateral VIM	2 to 11 mo median 6 mo†	clinical tremor rating scale, patient self assessment of functional improvement	3 (100%)	3 (100%)	none
Alusi et al. 2001 [4]	11	severe postural and intention tremor	unilateral VOP (n = 7), ZI (n = 3), STN (n = 1)	12 mo	clinical tremor and functional rating scales	11 (100%)	7 (64%)	depression (3) seizures (2) hemiparesis (1) dysphasia (1)
Matsumoto et al. 2001 [62]	6	severe tremor	unilateral VIM	3 to 12 mo	clinical tremor and functional rating scales, novel movement analysis tool	6 (100%)	0 (0%)	MS relapse (2)
Bittar et al. 2005 [15]	10	disabling postural and intention arm tremor	unilateral VOP (distal tremor), unilateral ZI (proximal tremor) or unilateral VOP and ZI (mixed tremor)	12 to 50 mo: mean 16 mo	clinical tremor rating scale	not individually reported, overall improvement of mean tremor scores: postural: 78% intention: 72%	not reported	hemiparesis (3) seizures (1)

Table 4

Studies on DBS for the treatment of tremor in MS

Study	N*	patient characteristics	stimulation site	follow-up	tremor and disability assessment	patients with tremor reduction (%)§	patients with improved functional status (%)§	patients with permanent adverse effects (n)
Brice and McLellan, 1980 [17]	2	severe bilateral arm intention tremor	bilateral subthalamic	5 mo 6 mo	clinical examination	2 (100%)	2 (100%)	**
Nguyen and Degos, 1993 [71]	1	severe unilateral distal postural arm tremor	unilateral VIM	17 mo	clinical tremor and functional rating scales	1 (100%)	1 (100%)	not reported
Siegfried and Lippitz, 1994 [88]	9	severe intention tremor	unilateral (n = 8) or bilateral (n = 1) VIM	not reported	not reported	9 (100%)	not reported	not reported
Benabid et al. 1996 [13]	4	severe arm tremor†	VIM†	≥ 6 mo	clinical tremor rating scale	0 (0%)‡	no detailed report†	intracerebral haemorrhage (1)
Geny et al. 1996 [41]	13	severe postural tremor (n = 12), moderate intention tremor (n = 1)	unilateral VIM	8 to 26 mo mean: 13 mo	clinical tremor and functional rating scales	9 (69%)	12 (92%)	MS relapse (3)
Whittle et al. 1998 [99]***	5	severe arm tremor	VL	not reported	not reported	not reported	not reported	not reported
Hay, 1999 [46]	1	head and limb tremor	unilateral thalamus	2 mo	not reported	1 (100%)	not reported	not reported
Montgomery et al, 1999 [66]	14	disabling arm tremor	unilateral VIM	variable	clinical tremor rating scale	15 (100%)	not reported	MS relapse (1)#
Schulder et al. 1999 [83]	5	severe bilateral postural and intention arm tremor	unilateral VIM	>6 mo	clinical tremor rating scale, patient self assessment of functional improvement	5 (100%)	3 (60%)	Ms relapse (2)
Taha et al. 1999 [90]	2	bilateral limb, head or voice tremor†	bilateral VIM (bilateral DBS or unilateral DBS plus contralateral thalamotomy)	mean: 10 mo	clinical tremor rating scale	2 (100%)	not reported	not reported separately for MS subgroup†
Schuurman et al. 2000 [85]	5	severe arm tremor	unilateral or bilateral VIM	6 mo	clinical tremor and functional rating scales	3–5 (60–100%)$	0 (0%)	dysarthria (2) severe gait or balance disturbance (1) arm ataxia (1)
Krauss et al. 2001 [53] Loher et al. 2003 [61]$$	2	severe tremor	unilateral or bilateral VIM†	3 to 24 mo, mean: 12 mo†	clinical tremor rating scales, assessment of video tapes	2 (100%)	not reported	not reported separately for MS subgroup†
Matsumoto et al. 2001 [62]	3	severe tremor	unilateral VIM	3 to 12 mo	clinical tremor and functional rating scales, novel movement analysis tool	3 (100%)	0 (0%)	none
Hooper et al. 2002 [49]	10	disabling arm tremor	unilateral thalamus	12 mo	clinical tremor and functional rating scales	10 (100%)	0 (0%)	intracerebral haemorrhage (2) generalized seizure (2)
Nandi et al. 2002 [70]	1	severe bilateral postural and intention tremor	unilateral ZI	12 mo	clinical examination	1 (100%)	1 (100%)	increased dystonic posturing of left foot impairing ambulation (1)
Berk et al. 2002 [14]	12	disabling arm tremor	unilateral VIM	12 mo	clinical tremor and functional rating scales, patient self assessment questionnaire	significant tremor reduction, not individually reported	no significant improvement	wound infection (2)
Wishart et al. 2003 [102]	4	bilateral arm tremor	bilateral VL	15 to 31 mo	clinical tremor rating scale	4 (100%)	4 (100%)	MS relapse (1) dysarthria (1)
Schulder et al. 2003 [84]	9	disabling arm tremor	unilateral thalamus	9 to 48 mo,	clinical tremor and functional rating scales, patient self assessment	8 (88%)	3 (33%)	MS relapse (3)
Nandi et al. 2004 [69]	10	disabling arm tremor	unilateral (n = 6) or bilateral (n = 4) VOP and ZI	3 to 23 mo	computer-aided tracking tasks	significant tremor reduction, not individually reported	not reported	seizure (1) dysarthria (1) wound infection (1)
Bittar et al. 2005 [15]y	10	disabling postural and intention arm tremor	unilateral VOP (distal tremor), unilateral ZI (proximal tremor) or unilateral VOP and ZI (mixed tremor)	3 to 23 mo:	clinical tremor rating scale	not individually reported, overall improvement of mean tremor scores: postural: 64% intention: 36%	not reported	monoparesis (1)

The first study on thalamotomy for tremor in MS was published by Cooper in 1960 [25]. Brice and colleagues were the first to report improvement of tremor through continuous thalamic DBS in 1980 [17].

Strategies for patient and treatment site selection

The earlier studies on thalamotomy used the thalamic nucleus ventralis lateralis (VL) as the target, whereas the nucleus VIM was chosen in most DBS studies and most later thalamotomy studies. This preference for the VIM is probably due to the experience with this thalamic nucleus in the treatment of tremor in Parkinson’s disease (PD) and essential tremor (ET). Research groups in Oxford and London used the nucleus VOP and the zona incerta (ZI) as targets for both lesional surgery and DBS, but the results yielded with these targets [4, 69, 15] were not different from those reported for VIM or VL thalamotomy or stimulation.

The same researchers advocate the use of tremor frequency analysis during movement tasks as a method to identify patients likely to benefit from surgery [60]. This may be a valuable tool for patient selection, although it has only been validated in a small number of patients and studies in which this technique is used [4, 69, 15] do not report better results than studies without this selection method.

The site for lesional surgery or electrode placement is classically chosen relative to the site of the anterior and posterior commissures using a standardized atlas. More recently, surgeons tried to refine this placement strategy with microelectrode recording within the target area. Neurons discharging synchronous to peripheral tremor are identified and the treatment site is placed in an area where the most tremor related neuronal activity is found. [73, 59, 57, 58]

This method of treatment site selection is often used in studies on tremulous patients with PD and ET, but only a small number of MS-patients were included in these studies. [87, 13, 66, 62, 84] Since this method offers a theoretical advantage over the classical methods of treatment site selection, it should be further evaluated.

Outcome after surgical treatment

Because of the many shortcomings of the published studies, the results need to be interpreted with great caution. It does, however, seem as if almost all patients experience tremor reduction immediately after thalamotomy, and roughly 70% of patients continue to benefit from thalamotomy beyond a follow-up period of one year (Table ). In the three studies on thalamic DBS with a follow-up period longer than one year, 69% to 100% of the patients experienced reduced tremor [41, 84, 102]. Functional improvement after both thalamotomy and DBS is much more variable and unfortunately not reported in many studies (Tables  and ).

Niranjan published an interesting study on gamma-knife thalamotomy as a possible alternative to neurosurgery. In this study all three patients with MS-related tremor experienced marked improvement of tremor after radiosurgery. Unfortunately, no further studies have been published to evaluate this interesting non-invasive treatment option [72].

There are two trials in which thalamotomy and DBS were compared in patients with MS. In a randomized controlled trial conducted by Schuurman and colleagues [85] patients with ET, tremor due to PD and tremulous MS patients were randomized to undergo either VIM thalamotomy or DBS. Five tremulous MS patients were randomized to each group. After a short follow-up period of six months, there were no significant differences between thalamotomy and DBS in functional outcome for the MS subgroup. In the same study, fewer adverse effects were observed in the DBS group, except for the subgroup of MS patients, where adverse effects were about equal for both interventions (Tables  and ). Bittar and colleagues compared cumulative tremor scores for intention and postural tremor between patients undergoing VOP/ZI thalamotomy or DBS in a non-randomized study [15]. Ten patients were in each group. Interestingly, after a mean follow-up period of 15 to 16 months, patients in the thalamotomy group had a better outcome (tremor reduction: 78% for postural tremor and 72% for intention tremor) than patients in the DBS group (tremor reduction: 64% for postural tremor and 36% for intention tremor). However, as there were more adverse effects in the thalamotomy group, no clear recommendations could be given.

Adverse events reported for the neurosurgical interventions comprised increase of hemiparesis, dysarthria, dysphasia, mental changes, depression, seizures, intracerebral haemorrhage, subdural haematoma, wound infection and MS relapse. Thalamotomy was associated with a higher risk of adverse events than DBS. Bilateral thalamotomy carries such a high risk of adverse effects, that it is no longer recommended. If bilateral treatment is necessary, either bilateral DBS or unilateral thalamotomy followed by contralateral DBS are possible treatment options.

Other treatment options

Electromagnetic fields, limb cooling, physiotherapy, weight bracelets, orthoses and specialized software have been advocated as additional treatment options.

Sandyk and Dann reported a reduction of intention as well as postural tremor in three tremulous MS patients treated with pulsed electromagnetic fields [82], but these interesting findings have not been substantiated in a larger trial.

Albrecht and coworkers published a small clinical trial on the effect of arm cooling on intention tremor [3]. In their study, patients achieved significantly better results on a clinical testing battery after immersion of the tremulous arm in ice water. As this effect lasted for about 45 minutes the authors recommend limb cooling to achieve transient tremor control for activities such as working with a PC, signing a document or self-catherisation. In a similar study, Feys and colleagues report tremor reduction lasting for about 30 minutes after limb cooling with a special cooling device [35].

Weighted wrist cuffs are a mechanical tool to reduce tremor amplitude, and one article reported their beneficial effects in three MS patients [28]. Although wearing bracelets decrease tremor amplitude and therefore may offer some benefit to tremulous patients, their effect on intention tremor is small and their use is therefore unlikely to yield important functional improvement. A more advanced computer aided tremor reducing orthosis provided functional benefit in a small case series including patients with MS [1].

Physiotherapy aimed at improving ataxia in MS was evaluated by Armutlu and coworkers. In their small pilot study they found that rehabilitative physiotherapy using Johnstone pressure splints was superior to physiotherapy alone [9]. Unfortunately no larger trials followed this pilot study, so that it remains uncertain which patients may benefit from which form of physiotherapy.

The use of a mouse driven computer system is a special challenge for tremulous MS patients. Feys and colleagues published a study on the use of specialized software developed to aid computer use in 36 tremulous MS patients and found significant improvement in the time needed to complete some basic mouse driven computer operations [36].

Tremor in multiple sclerosis | Journal of Neurology, Neurosurgery & Psychiatry

Tremor, which is an involuntary rhythmic oscillatory movement of a body part, is estimated to occur in 75% of patients diagnosed as having multiple sclerosis.1
2 It can be severely disabling and is extremely difficult to treat.3-23 The tremor of multiple sclerosis is frequently embedded in a complex movement disorder, which often includes dysmetria and other ataxic features.8 There is considerable controversy surrounding the precise definition and identification of the different components of this movement (tremor, dysmetria, and other ataxic features). 1
24-26 Resolution of this controversy is critical to treatment because these separate components respond differently to various interventions.7
8
17
19
21

Incidence and prevalence

The incidence and prevalence of tremor in multiple sclerosis is difficult to estimate accurately, although tremor of moderate and severe magnitudes were found in 32% and 6% respectively of patients in one study.22 In part this is because of the problem of distinguishing intention tremor from serial dysmetria, which is the result of the voluntary sequential correction of movement errors, and some types of postural tremor from other postural instabilities.27 In addition, the natural history of multiple sclerosis and in particular the transience of the neurological signs during the relapsing and remitting phase make prevalence studies difficult. This problem is compounded by the structure of the Kurtzke functional systems deployed for the assessment of patients with multiple sclerosis, because subscale part B (cerebellar function) does not isolate tremor. 28 In a 3 year follow up study of multiple sclerosis, cerebellar deficits of functional importance were found to occur in 33% of 259 patients and to be predictive of a worse prognosis.29
30 A similar proportion was found to have ataxic symptoms in an extensive epidemiological survey undertaken in the United Kingdom and involving over 300 patients with multiple sclerosis.26 There are no published quantitative studies of the contribution of tremor to the disabilities and handicaps caused by the disease.

Types of tremor

Tremor of the head, neck, vocal cords, trunk and limbs have all been described in association with multiple sclerosis, but there have been no reports of tremor of the palate, tongue or jaw.7
8
10-13
16
19
20
31-35

In the past there have been some confusion and disagreement about the nomenclature for the various types of tremor found in multiple sclerosis, although a working consensus has recently been reached on the classification and definition of tremor in general, which will be adopted here. 1
27
36 In multiple sclerosis true rest tremor (tremor which is present in a body part that is not voluntarily activated and that is completely supported against gravity) is not seen; a point appreciated by Charcot in 1875.1
27
37However, apparent “rest” tremor—for example, shoulder tremor when a patient is sitting upright—has been inaccurately termed rest tremor in some previous surgical papers.22
38 Furthermore, not one example of rest or “rubral” tremor was encountered in a recent study of 100 patients with clinically definite multiple sclerosis.39

Various forms of action tremor have been found in multiple sclerosis.

POSTURAL TREMOR

Postural tremor can affect the head, neck, trunk, and limbs.1 Head tremor (titubation) can be in any or all directions. It may persist on lying because of continuing tonic contractions of neck and trunk muscles.36 A large amplitude “wing beating” postural tremor that increases progressively on maintained posture is well described. 7-9
27 In the legs postural tremors are encountered but primary orthostatic (14–18 Hz) tremor is not, although spastic ataxia can be mistaken for orthostatic tremor.3
40 Leg clonus can also be misinterpreted as tremor but the first is increased by applying passive stretch to the muscles whereas the second is not.1

KINETIC TREMOR

At least two forms of kinetic tremor occur in multiple sclerosis. Firstly, intention tremor is seen when tremor amplitude increases during visually guided movements towards a target. This tremor has a tendency to worsen with increasing precision requirements and is influenced by non-rhythmic disorders of movement and hypotonia.36
27 Secondly, it is common to find an action tremor that is seen as a rhythmic oscillation around the movement trajectory. This form of action tremor has two components—a terminal kinetic tremor and a postural tremor of the shoulder girdle—which variably interact and has been termed “hyperkinetic” tremor.3
41

Simple kinetic tremor that occurs during voluntary non-target directed actions—for example, opening and closing a fist—is characteristic of essential tremor and has also been described in parkinsonism but not multiple sclerosis. 1
36 Similarly, task specific tremors (for example, primary writing tremor) have not been documented in multiple sclerosis.

Features associated with tremor in multiple sclerosis

The tremor of multiple sclerosis should be considered in the context of ataxia, which literally means disorder or confusion.42 However, in practice the term ataxia is used loosely to describe irregularities in voluntary movement.43 In 1917 Holmes drew attention to the fact that in cerebellar disorders there are, in addition to tremor, decomposition of voluntary movement, asynergia (failure of smooth fusion of the movement’s component parts), rebound phenomena, and dysdiadochokinesia. He also noted that at times the active muscles involved in a movement are initially harmonious but after a time develop phase errors that cause further irregularity of movement.43

Goal directed movements illustrate the interplay between ataxia and tremor. There are several problems that can induce an oscillation in the terminal component of such movements—namely, true intention tremor, serial dysmetria, low frequency sway movements resulting from proximal postural instability, and postural tremor that has been inhibited by motion. 27
43
44

Pathophysiology

In multiple sclerosis the mechanisms of production of tremor are poorly understood because of the presence of multiple CNS lesions, which prevent precise neuroanatomical correlation of structure to function. Lesions from various causes involving the cerebellum, its connections, and the midbrain have all been documented to cause action tremors.31
37
44
45 There are no postmortem studies in multiple sclerosis linking tremor to a discrete lesion. However, one patient who presented with an isolated severe action tremor affecting the arms was found at postmortem examination to have plaques in the periventricular regions, pons, optic chiasm, superior and middle cerebellar peduncles, cerebellar white matter, and around the dentate nuclei but notably not the red nucleus.46 In addition, a single case study using MRI showed that a plaque in the superior cerebellar peduncle resulted in severe postural tremor with alternating activation of the agonist-antagonist muscles. 31 This causal relation is supported by primate experiments in which tremor was produced by section of the superior cerebellar peduncle.47There are no data available from PET studies of tremulous patients with multiple sclerosis.

Struppler et al considered that cerebellar lesions caused postural and intention tremor but not simple kinetic tremor; attributing intention tremor, hypotonia, and dysenergia to neocerebellar disturbances and postural tremor to both archicerebellar and neocerebellar pathology.36 Lesions of the archicerebellum result in a 3–5 Hz postural tremor of the trunk and limb girdle, whereas lesions of the neocerebellum produce an intention tremor of the limb, which varies in frequency (according to the intended accuracy), in addition to the postural component.36

EMG studies of multiple sclerosis tremor

It is established that action tremors are caused by segregation of EMG activity, or more accurately the insertion of silent epochs into what would have been continuous activity in an active muscle. 48 This segregation of EMG activity in tremulous patients with multiple sclerosis was shown by Altenburger in 1930, and has subsequently been corroborated.44 In a study of 11 patients with multiple sclerosis with alternating EMG pattern in the agonist-antagonist pairs, the oscillatory movements were subdivided into two groups physiologically: The first had low amplitude tremor, with frequencies between 5–8 Hz with 75–100 ms burst duration, that was only apparent on goal directed movement. The second had disabling wide amplitude tremor, with lower frequencies of 2.5–4 Hz and longer (125–250 ms) burst duration on postural activity which persisted or worsened on intention. Both types of tremor were accompanied by dysmetria.27

CAN TREMOR BE DISTINGUISHED FROM OTHER COMPONENTS OF ATAXIA?

A crucial question is whether or not tremor can be distinguished from the other components of ataxia by physiological means. This problem is complicated by the finding that the manifestations of ataxia differ according to the complexity of movement. Nevertheless, analysis of simple voluntary movements may provide a way of distinguishing these movement disorders.

When rapid simple voluntary movements are performed by healthy subjects there is a symmetric kinematic profile with acceleration and deceleration phases of equal duration. This is accompanied by a triphasic EMG pattern consisting of an agonist burst (initiating motion), an antagonist burst that checks it, and a second agonist burst that makes a terminal adjustment.49

In patients with cerebellar deficits there is start delay, a slow and prolonged acceleration phase, and lack of uniform deceleration, causing an asymmetric kinematic profile.50 Analysis by EMG of fast stereotyped elbow flexion movements in dysmetric patients showed that the duration of the initial biceps or triceps bursts were prolonged, although this was less evident when the same patients performed smooth movements slowly.51 In some hypermetric patients a delayed first antagonist EMG burst has been reported during simple ballistic movements. However, in fact the antagonist burst may have two components (an initial task invariable and late task dependent component, which varies with movement distance and load), so that an apparent delay may be caused by an absent first component. Furthermore, delay of the second component may contribute to hypermetria.52 In a compound movement there is the additional problem of positional error when the movement reverses direction, as manifest by dysdiadochokinesia, which is reflected physiologically by the abnormal, late, timing of the antagonist deactivation before initiation of agonist activity.51

Studies of voluntary ballistic movements in essential tremor (a pure action tremor) have shown that the second antagonist burst is delayed, a finding that may be relevant to tremor production.53Thus it may be possible to distinguish tremor from dysmetria by looking at the timing and size of the EMG bursts accompanying rapid simple movements.

It has also been suggested that in ataxia there is additional adventitious motion resulting from purposeless contractions of other muscle groups. 43

Assessment of multiple sclerosis tremor

Conventional tremor rating scales are often chosen for the assessment of tremor severity in multiple sclerosis because the Kurtzke functional systems scale lacks a tremor specific subscale.28 However, these scales were designed primarily for evaluating rest and postural tremors, whereas the accompanying ataxia makes clinical rating of tremors in multiple sclerosis more difficult.3 The ferocity of some tremors limits the applicability of quantifying tremor in spirals, maze drawings, handwriting specimens, and measuring the volume of water spilt from a cup to patients with mild action tremors. The same applies to measures of upper limb function such as the nine hole pegboard test and finger tapping. Assessments with EMG, accelerometry, computerised tracking tests, and kinematic studies all have associated difficulties: EMG can only provide a surrogate marker of limb movement; whereas accelerometric signals of intention tremor are inaccurate because the finger-nose-finger test provides a non-stationary signal consisting of at most 10 tremor cycles and both the tremor and intended limb movement frequencies overlap, reducing the signal to noise ratio. Tracking tests can be useful for quantifying tremor involving a single joint but are unsuitable for the assessment of tremors that appear in free limb movements which involve multiple joints.54
55 Kinematic studies can circumvent this difficulty but analysis of the derived signal is complex and limits their widespread deployment.56
57 It is also important to make an overall assessment of patient disability because there can be major interactions between tremor and the other neurological deficits found in multiple sclerosis, and the differential contribution of tremor to the overall disability may influence treatment.

Treatment

patients with multiple sclerosis adapt to tremor by reaching with both hands, bracing an arm during manual tasks, or restraining it to prevent self injury. As restoration of normal posture and movement is rarely attained, the use of compensatory techniques are encouraged by therapists, although good results are scarce.44
58 These methods include giving choreographic advice, altering the patient’s environment—for example, using a barber’s chair for postural head tremor—and weighting a tremulous limb with bracelets and heavy utensils. 59 The second is of limited value to patients with either proximal muscle weakness or savage tremors because relatively high loads (750–1000 g) are required for tremor control, and this can exacerbate fatigue and weakness.58Furthermore, Manto et al elegantly demonstrated that limb weighting increased hypermetria in patients with cerebellar lesions, but not normal subjects, because in the former the size of the antagonist EMG burst (which checks movement) did not increase.60 Dynamic systems with multidegree of freedom orthoses and robotic arms based on virtual reality have been developed to assist tremulous patients with multiple sclerosis but are not widely deployed.61

Medical treatments for multiple sclerosis tremors, or ataxia, or both are empirical and generally unrewarding, although the following medications have been reported to have some beneficial effect: hyoscine, isoniazid, glutethimide, clonazepam, carbamazepine, primidone, tetra-hydrocannibol, and ondansetron. 3
6-15However, for this group of patients their benefit to side effect ratio is generally low and most of these studies did not employ double blind controlled protocols. Ethyl alcohol and propranalol, which reduce the magnitude of some other action tremors, for example essential tremor, have not been shown to be effective.3
6 Extracranial application of brief AC pulsed electromagnetic fields in the pico Tesla range was reported to decrease the amplitude of tremor in three patients with chronic progressive multiple sclerosis, although this promising finding needs further exploration.2

In selected patients with multiple sclerosis thalamotomy has been reported to alleviate contralateral limb tremor initially in between 65% and 96% of cases, although in about 20% tremor returns within 12 months and functional improvement of the relevant arm is estimated to occur in only 25% to 70% of patients.19
20
22
23
62
63 Nevertheless, some patients have regained their capacity to eat and drink independently. 63 Cooper also noted that head tremor was improved by thalamotomy in five out of six patients.16Despite the relief of tremor afforded, there are several reservations about this procedure for patients with multiple sclerosis. These include moderation of benefit by the remaining ataxia, immediate postoperative side effects, and a possible negative influence on the rate of progression of the underlying disease.19 In no prospective study has the influence of thalamotomy on overall disability, handicap, and quality of life of tremulous patients with multiple sclerosis been measured; nor have side effects been quantified. The incidence of reported side effects varies from 0% to 45% of cases in different studies.16-23
62
63 This probably reflects variation in case selection and improved surgical techniques, which now utilise better imaging and intraoperative electrophysiology. Experience has shown that optimal results are obtained in patients with (a) relatively stable disease, (b) good mobility, (c) minimal overall disability status, and (d) minimal ataxia in the tremulous limb, although the last is difficult to establish preoperatively when it may be submerged by severe tremor. 19
20
22
23

A recent thalamotomy series involving nine patients and utilising CT/MRI guidance, showed no significant long term complications.62 It is notable that in this cohort of patients with multiple sclerosis stimulation at the expected coordinate location for the nucleus ventralis lateralis of the thalamus did not elicit the expected responses—a finding that may be related to the focal and diffuse cerebral atrophy caused by multiple sclerosis.62 Relevantly, other groups have reported that lesions centred on the classic target (lower part of the nucleus ventralis intermedius) need to be large to alleviate (a) kinetic type tremors, (b) low frequency/high amplitude tremors, and (c) tremor involving proximal or widely distributed muscle groups.64 As the incapacitating tremors seen in multiple sclerosis usually have these three characteristics a more optimal surgical target may be the nucleus ventralis oralis posterior.65 The most often reported complications of thalamotomy are worsening of gait, hemiparesis, and dysarthria. In addition, epilepsy, sensory disturbances, dysphagia, and transient bladder disturbance, depression, confusion, lethargy, and somnolence have also been, albeit rarely, described.16-23
63Recently three papers, on a total of 23 patients, have shown that thalamic stimulation can also alleviate multiple sclerosis tremor in up to 69% of patients but in one series tremor recurred in 20%.35
66
67 The relative merits of thalamic stimulation versus lesion placement remain controversial, as there have been no comparative trials of the two techniques. Nevertheless, if a second procedure was contemplated deep brain stimulation may be preferable because some side effects are potentially reversible.67

Conclusion

The action tremors seen in patients with multiple sclerosis can be among the most severely disabling encountered in clinical practice. Alas, the mechanisms producing these tremors are poorly understood. In part this is because they are often embedded within complex movement disorders, which makes them difficult to study. Disabling tremors in multiple sclerosis rarely respond sufficiently to medical treatment. Thus stereotaxic surgery remains the treatment of choice. However, this form of surgery has immediate and potential long term risks. The question of whether thalamic stimulation is preferable to lesioning awaits a definitive answer. In addition the optimal intrathalamic target site requires clarification. Consequently there is a strong case for entering patients with multiple sclerosis who are disabled by their tremor into scrupulous clinical trials, with multidimensional outcome measures. Although inevitably the degree of success will depend on case selection, surgical technique and postoperative physiotherapy, aimed at optimising functional gain.

MS Tremors & Shaking |

What causes tremors?

Tremors are a common MS symptom, often appearing alongside problems with coordination. An MS tremor is an involuntary shaking or trembling movement. The tremors are variable from person to person. They might be strong enough to cause you to spill a drink, or it might be so mild that no one would notice you having one. For some people it can be severe, making it hard to eat a meal for example, but this is less common. The tremors can be progressive, or they can come and go. 

MS tremors are caused by damage to the myelin sheath in an area of the brain called the cerebellum, and the nerves leading to and from it. The cerebellum controls your coordination and balance. 

Tremors can also be a result of demyelination in other parts of the brain such as the basal ganglia and the thalamus — these areas of the brain control movement.

If you have MS tremors, it is likely that they disappear as soon as you are completely relaxed, for example in bed at night. If the tremors don’t go away when you are lying down in bed then there may be another cause, such as another neurological condition or the side effect from some medications like asthma inhalers.

The effects of MS tremors

MS tremors are mild for most people with MS. A small number of PwMS find that it is more severe. 

The tremor can affect your balance and gait and also can affect your hands, arms and head. This can make daily tasks, from writing to dressing, more challenging, and can make working very difficult. Doing a job which requires delicate handiwork such as a decorator or a surgeon can be impacted by this particular symptom. The tremors can affect your whole body, or just one part. 

Getting help and support

It is vital that you get the right help and support as if they are severe, MS tremors can have a major impact on your self-esteem and your sense of independence. You might find that talking to others who are experiencing MS tremors helps. By connecting with others in an MS community where people have positive stories and tips to share, can help you to develop a positive mindset and learn how you can best deal with this symptom.   

Anxiety can make your tremors worse, so making sure that you find ways of relaxing such as meditation can help you to relieve stress. You might find that you also want to speak to a counsellor for some coping strategies. 

The OMS 7-Step Recovery Program includes meditation to reduce stress, as well as an exercise routine to help strengthen your muscles and improve your mobility and body confidence.

You can also become part of the OMS community in a number of ways:

An occupational therapist will be able to advise you on how you can adapt your home to help deal with tremors, and the possible assistive devices which might make your daily activities easier — things to help with activities such as writing or cooking. 

Physical therapists can help advise you if tremors affect your mobility, and they will be able to advise on specific exercises to increase your muscle strength. 

What are the next steps?

If it seems like there is too much information and you don’t know where to start, read through our next steps – we are here to support you.

Multiple Sclerosis Foundation – Symptoms of MS

What causes MS symptoms?

Imagine you run a delivery service in a busy city. Each time you receive a package, you assign it to a driver to deliver. Along some drivers’ routes, there may be potholes or detours that slow them down. They may deliver the packages eventually, but not at the speed you would have liked. Another driver may find his way completely blocked and be unable to deliver their package. You, however, have no control over the road damage or dead-ends along their routes, nor can you predict where they will be.

This illustrates MS and its symptoms. Your nervous system is like a network of “roads” running to every part of your body. Your brain uses these “roads” to sends “packages” – nerve signals that instruct the body what to do – throughout your body every second of the day. But due to the “road damage” caused by MS, some signals will be slowed down, and some may not get delivered at all.  

What kind of symptoms can MS cause?

Because this network of nerves delivers instructions throughout your system, MS can affect you in dozens of different ways. The symptoms can affect your senses, mind, and body.

Affected

Name

Description

Your senses

Vision

Double vision, blurred vision, partial vision loss

Hearing

Central auditory processing impairment

Smell

Diminished sense of smell

Taste

Diminished or altered sense of taste

Touch

Numbness, tingling, burning sensations, itching

Your mind

Thoughts

Impaired short-term memory or concentration, slower processing of information

Feelings

Depression, personality changes, inappropriate laughing or crying

Your body

Face

Facial pain (neuralgias), partial paralysis (Bell’s palsy), headaches, speech changes

Muscles

Muscle spasms, squeezing sensation (“MS hug”), foot drop, swallowing difficulties

Positioning

Vertigo, dizziness, balance changes

Elimination

Incontinence, constipation, urinary retention

Nervous System

Tremor, weakness, fatigue, heat sensitivity, seizures

Sex

Erectile dysfunction, diminished sensation, decreased desire

Unfortunately, since MS damage is unpredictable, it is impossible to determine what symptoms you will have and how severe any of them will be. However, just as a delivery service can pay attention to which roads are more likely to have damage from heavy traffic, you can learn which symptoms are the most common for people with MS and be prepared to deal with them should they arise.

Common symptoms explained

Fatigue

A feeling of exhaustion that is not caused by lack of sleep or overexertion, and may not improve with rest. Fatigue is the most common and persistent symptom of MS, affecting nearly 80 percent of those with MS.

Treated by: Modifying activities, occupational therapy, and medications.

Dysesthesias

Up to 55 percent of people with MS experience these altered sensations, including numbness, tingling (a ‘pins and needles’ feeling), burning, or sensitivity to touch. These sensations are often the earliest symptoms of MS.

Treated by: Medication, exercise, healthy diet, body cooling,  or acupuncture.

Impaired coordination

Difficulties with balance and a person’s manner of walking (gait) are common with MS. Balance problems may cause a person to sway or stagger. Gait impairment may make it difficult to lift the foot or leg.

Treated by: Exercises, physical therapy, occupational therapy.

Tremors

Shaking or trembling of a limb, or occasionally the head. Up to 50 percent report extremity ataxia (shaky movements or unsteady gait) or tremors. 

Treated by: Exercise, physical therapy, occupational therapy, adaptive equipment, and medications.

Depression

In MS, depression is common both as a symptom of the disease itself, and as a common reaction to the onset of a chronic illness.

Treated by: Medications, counseling, and complementary alternative treatments.

Spasticity 

Affecting up to 60 percent of people diagnosed, this often painful symptom occurs when opposing groups of muscles contract and relax at the same time.

Treated by: Exercise, stretching, physical therapy, mechanical aids, and medications.

Bladder dysfunction

Signs of bladder dysfunction can include frequent urination, urgency, dribbling, and incontinence. Conversely, it can also include hesitancy or urinary retention.

Treated by: Modifying activities, medications, catheterization.

Bowel dysfunction

About two-thirds of people with MS experience bowel dysfunction, most frequently constipation, but  diarrhea and incontinence can also occur. 

Treated by: Diet management, adequate fluid intake, and medications.

Optic neuritis

While it rarely affects both eyes simultaneously, optic neuritis is a common symptom that can cause blurred vision, double vision, or vision loss. Vision often returns, at least to some degree. 

Treated by: Medications, eye patch.

Cognitive dysfunction

Changes in cognition (thinking ability) typically affect short-term memory, verbal fluency, and speed of information processing. Memory and reasoning problems may affect between two-thirds and three-fourths of those diagnosed with MS to varying degrees.

Treated by: Occupational therapy, cognitive rehabilitation, medications

Sexual Dysfunction

More than 90 percent of men and 70 percent of women with MS report some change in their sexual life after the onset of the disease. Some problems include decreased sexual drive, impaired sensation, diminished orgasmic response, and loss of sexual interest.

Treated by: Counseling, medications.

Proactive symptom management

These are only a few of the dozens of symptoms that MS can present. While they are the most commonly reported symptoms, not every person with MS is guaranteed to experience them. Some individuals may experience many symptoms associated with the disease, others only a few. And the severity of symptoms varies from person to person as well, ranging from mildly bothersome to life-altering. With such an unpredictable condition, what can you do to manage your symptoms? Quite a lot.

• Slow MS down by starting a disease-modifying treatment and sticking to your dosing schedule.
• Consider healthy sleep, exercise, and diet habits as an important part of your treatment routine. 
• Bring up new or worsening symptoms with your doctor as early as possible, and follow through with treatment recommendations.
• Reach out for social support. Join a support group or open up to trusted friends.

These common sense steps have been shown time and again to improve outcomes, either by decreasing your chance of relapses and new symptoms, or by giving you the resilience to recover or adapt.

For more on managing symptoms, visit our MS Focus Magazine Symptom Management archive.

Multiple Sclerosis Symptoms, Diagnosis, and Treatments

Multiple sclerosis (MS) is a disease which affects the lining of nerve fibres within the brain and spinal cord. It usually affects females aged 20-40 years.

MS usually causes episodes of neurological problems, such as blurred vision, slurred speech, numbness, or weakness.

The underlying pathological process is known as “demyelination.” Relapses are usually treated with medications, such as interferon or corticosteroids.

HOW COMMON IS TREMOR IN MS?

15% of MS patients experience significant tremor, usually involving one or both arms. This tremor frequently causes significant disability.

WHAT PROBLEMS DOES MS TREMOR CAUSE?

MS tremor causes problems such as difficulty opening doors, writing, feeding, and taking care of personal hygiene. In many cases the affected arm is completely useless.

In the worst cases, there is so much tremor that the arm flails about violently, making it difficult for carers to administer basic nursing.

HOW IS IT TREATED?

MS tremor is notoriously difficult to treat. There is usually no effective medication available.

Some patients are suitable for surgery, usually deep brain stimulation (DBS).

WHAT IS DEEP BRAIN STIMULATION?

Deep brain stimulation is a highly specialised technique in which a fine electrode (wire) is passed with precision into deep structures within the brain, and a small pulse of electric current is used to inactivate these regions.

WHO MAY BENEFIT FROM SURGERY?

Patients with disabling MS tremor may be candidates for surgery. It is critical to differentiate tremor (which can be treated with surgery) from ‘ataxia’ (incoordination). Ataxia is seen commonly in MS patients, and unfortunately is not treatable with surgery.

MS patients who suffer from a predominant tremor, with only a small or no element of ataxia, may benefit from DBS.

WHAT ARE THE RISKS OF SURGERY?

The greatest risk in surgery for MS tremor is weakness of the arm, leg or both. This is frequently temporary following surgery, however may be permanent in a small number of patients. There is a 2-3% risk of infection and haemorrhage (bleeding). The risk that the surgery could cause death is extremely small (less than 1 in 100 patients).

WHAT ARE THE BENEFITS OF SURGERY?

The majority of well-selected patients improved following surgery. The reduction in tremor severity may be up to 80%. In addition to a reduction in the tremor itself, patients often experience a substantial improvement in function.

MS TREMOR SURGERY AT PRECISION BRAIN, SPINE AND PAIN CENTRE

Professor Richard Bittar is a neurosurgeon with specific training and expertise in movement disorder surgery. He is experienced in the surgical treatment of MS tremor, using deep brain stimulation. He has published research into this technique, and has lectured internationally on surgery for MS tremor.

90,000 Why are my hands shaking?

2020.04.27

Why are my hands shaking?

Anxiety, agitation, these are normal causes that could lead to trembling of the fingers or hands. Even if you are in excellent health, you may notice a slight tremor by simply stretching your arms out and keeping them straight (your fingers will start to shake a little).

This is the natural state of your body. Another similar example is offered by piercing needles.This is an action that requires concentration, concentration and tension, causing the hands to shake. It is worth worrying when you notice that your hands are shaking more often than usual.

Involuntary handshake is a problem that complicates even the most basic daily activities. Eating, writing, or drinking water becomes extremely difficult and demanding. Actions that require more precision or diligence may be forgotten altogether. And this is the everyday life of people with shaking hands.A person begins to think – why? Maybe the earthquake started recently? Or maybe it gets worse. It probably started gradually? Could this have happened when I was under stress, I was very angry?

Whatever the cause, “tremor” is the name experts attribute to these trembling hands (and sometimes the voice, head, mouth, and legs). This happens to people more often than you think, and the causes and consequences can be very different.

Essential tremor (tremor)

Essential tremor (ET) is the most common tremor disorder.It usually starts in the fingers, but can spread to the hands, head, voice, or other parts of the body.

The

ET is different in that it affects your hands, especially when they move. Many other tremors occur even when we are at rest.

This may be related to inheritance. This means that if one of your parents is shaking, you are more likely to start one someday.

In some cases, vibration can be caused by toxic substances in the environment.Age is another risk factor. Although significant tremors can occur at any age, it is more likely in people over 40. The odds increase with age.

ET is not life threatening, but may deteriorate over time. Stress, fatigue, and excess caffeine can make the situation worse. At some point, eating, drinking, writing, and all the other daily tasks we do manually can become more challenging.

This condition is difficult to cure. There are medications, but none of them work consistently.There is a possibility of so-called deep brain stimulation, in which doctors implant a device in your brain to help control tremors. If shaky hands are causing problems, ask your doctor, if this treatment can help you.

Parkinson’s disease

Tremor is an early symptom of Parkinson’s disease, which affects 10 million people worldwide. Not everyone with the disease suffers from tremors, but most notice tremors in an arm, leg, or even one toe in the early stages.

Shivers usually affect only one side of your body. This usually happens when you relax your muscles. That is why it is called the trembling of the world.

When you move, the tremor stops. Even a little flexion of the fingers can help. Like other types of tremors, stress or anxiety can make the situation worse. Shivers can spread from one side of the body to the other.

Multiple sclerosis.

This condition affects the immune system, brain, nerves and spinal cord, and can also cause hand tremors.There is trembling in the arm or leg. MS can cause various tremors. Most often, for example, significant tremors are observed during movement.

Refusal from alcohol

Tremor is one of the first signs. If you are not too hooked, tremors can only last for a few days. If you drink a lot or for a long time, they can last a year or even longer.

It is not always a disease

A handshake does not always mean that you are sick.Sometimes a tremor is your body’s response to something:

Drugs – Block a chemical in the brain called dopamine (it transfers information from one part of your brain to another). These medicines are used to maintain your mood. When the drug is stopped, the tremor will subside.

Disadvantage of B12 : Without it, your nervous system won’t function properly. It can be found in meat, fish, poultry, eggs, and dairy products.If you are getting so little that your hands are shaking, your doctor will prescribe you an injection of this medication.

Caffeine: A cup of coffee or tea can cause hand shake.

Stress: From financial and work worries to relationship and health problems, stress makes you shiver. Severe anger, intense hunger, or lack of sleep can make you shiver. This is known as physiological tremor.

Low blood sugar : Your doctor will call this hypoglycemia.It activates your body’s natural response to stress and makes you shiver.

Overactive Thyroid : This gland is on your neck just above the collar. When this is stimulated, your entire body is mobilized for stress. You have trouble sleeping, your heart may beat faster, and your hands start to shake.

Nerve damage : Injury, injury, illness, or problems with the central nervous system can also cause tremors. Your doctor will call this peripheral neuropathy.It can affect the arms and legs.

If you think your hand tremors are caused by chronic stress, excessive coffee consumption, hunger or lack of sleep, your lifestyle change is likely the best solution. Relax, try to sleep, trade coffee for water, grab a snack and watch the shaking subside.

But if you think that your condition is not improving and has more serious consequences, be sure to consult your family doctor for advice and a plan for further treatment.

Treatment of essential hand tremor in Yekaterinburg

Hand tremor is a fairly common syndrome in which tremors of the fingers and hands are observed. Many believe that such a disease can be found in the elderly and the elderly, but hands are shaking no less often in young girls and boys, and even in adolescents.

Nervous tremors in the hands are not necessarily a symptom of a serious neurological disorder. Such a reaction in the body can be caused by strong fear, an overabundance of emotions, and taking certain medications.But if trembling in the hands with excitement and without it becomes a constant companion, then this indicates serious disturbances in the body. In this case, it is imperative to consult a doctor at the medical center, where the problem will be diagnosed and the appropriate treatment selected.

Why does hand tremor appear?

The causes of hand tremor in adults can be varied. If your hands began to shake strongly, this means that there are two reasons:

• psycho-emotional, when the hands shake involuntarily, sometimes they do not obey under the influence of increased nervous excitability, after the release of emotions, the trembling of the hands usually disappears;
• physical, when the hands began to shake constantly, the fingers tremble upon contact with small objects, or even in the case of complete calmness.The reasons in this case are associated with disorders and diseases of the body.

Sometimes the cause of tremors on the right and left hand can be a hangover syndrome.

Treatment

Treatment for each patient is selected individually:

• surgical procedures to get rid of essential tremor;
• diet therapy – sometimes a sudden tremor may appear due to the abuse of coffee, fatty and spicy foods;
• apitherapy – a standard method of influencing the disease with the help of bees;
• hydrotherapy, in particular a contrast shower – a service that enhances immunity, improves blood circulation and strengthens the nervous system;
• drug treatment – taking antidepressants, inhibitors, anticonvulsants.

Sometimes shaking hands and dizziness combined can be a sign of overwork. But if the symptoms appear regularly, then you will need an appointment with the clinic for the doctor to diagnose the disease.

Endocrinologist in Yaroslavl | Medical Center MiR

Endocrinologist , a doctor who diagnoses and treats diseases of the endocrine system (thyroid and parathyroid glands, pancreas, adrenal glands, male and female reproductive glands, pituitary gland, hypothalamus), is receiving appointments at the MiR Medical Center.

The correct functioning of the endocrine system is a prerequisite for the health of the whole organism; in case of insufficiency or excessive amount of hormones, serious disorders occur:

• thyroid gland diseases (hyperthyroidism, hypothyroidism)
• type I and II diabetes mellitus
• overweight, obese
• growth and physical development disorders
• delayed sexual development (girls over 13.5 years old and boys over 14 years old)
• premature sexual development (in girls under 8 years old and boys under 9 years old)
• adrenal diseases
• diseases of the parathyroid glands
• Menstrual dysfunction
• age-related hormonal disorders

The endocrinologist will conduct an examination, listen to your complaints, and, if necessary, prescribe additional examinations: biochemical blood tests, blood and urine tests for hormones.All this will make it possible to make the correct diagnosis and choose the most effective individual course of treatment.

When should I see an endocrinologist?

Usually a general practitioner or pediatrician directs an appointment with an endocrinologist. However, some symptoms directly indicate a possible endocrine pathology:

• Frequent feeling of weakness, rapid fatigability for no apparent reason
• heart palpitations
• excessive sweating and / or swelling
• trembling hands and / or legs
• sudden weight gain or loss, sudden loss of appetite
• persistent dry mouth, thirsty
• Unreasonable violation of the menstrual cycle
• impaired attention and decreased concentration
• Male pattern hair loss or overgrowth in women
• deterioration of the condition of nails and hair
• dryness and / or discoloration of the skin, itching
• muscle pain, limb cramps

In addition, regular preventive examinations by an endocrinologist are necessary in the following cases:

• if your close relatives have diabetes, thyroid diseases, etc.p.
• in the treatment of infertility
• during planning and during pregnancy

90,107 post-menopausal women 90,108

You can also clarify the specialist’s work schedule and make an appointment by phone:

(4852) 233-170

90,000 Which doctor to go to with a tremor of the head – doctors treating the disease

Neurologists of Moscow – latest reviews

A wonderful doctor.Polite, reasonable, interested in his business and the patient’s problem. He explained everything, answers even my strangest questions. The procedures are comfortable, the pain symptoms disappear, the treatment plan is scheduled.

Moderation,

13 November 2021

The reception went very well.I came with severe headaches, I told all my problems, the doctor listened to me. prescribed medicine and gave the necessary recommendations. In principle, I liked everything, I had no questions left. Alina Nikolaevna is attentive, very professional, everything was aimed at solving my problem.

Moderation,

13 November 2021

She explained everything well.Good doctor.

Moderation,

13 November 2021

The reception went well.This is not the first time I come to a specialist, I really like everything. He prescribes the correct treatment, explains everything in an accessible way. From this reception, I received treatment, I was prescribed injections, physiotherapy.

Moderation,

13 November 2021

I liked the reception, the doctor is good.The doctor examined me, figured out my problem, prescribed the appropriate medicine. Alexey Sergeevich is calm, polite, explains all information clearly and understandably for me. Enough time was given to me at the reception. I can recommend a specialist to my friends.

Anonymous,

November 11, 2021

A very competent doctor, he immediately made a diagnosis and correct treatment.And he explained how and how? I am very pleased, I advise everyone to visit this doctor from a pure heart. I got to him on the advice of a relative

Moderation,

November 14, 2021

My problem has not been fully resolved yet.Service was ok, attentive. The doctor at the reception conducted a survey, found out what problem I came with. As a result, Alexander Ivanovich gave the necessary prescriptions and prescribed medicine. I don’t feel the effect of the pills yet. I would recommend this specialist to my friends.

Moderation,

November 14, 2021

I know this specialist.I have been treating him for several years already. Natalya Aleksandrovna is a professional, attentive and kind doctor. Everything looks thoroughly. The doctor made an accurate diagnosis, although I had others in mind. A wonderful specialist. Now there are very few of them. I will recommend this doctor to my friends.

Moderation,

12 November 2021

Irina Ivanovna is a professional in her field.He speaks directly and honestly about problems and health problems. I was very surprised at the competence of the doctor. For two years we go to the doctors, no one can really say anything. The doctor immediately diagnosed, consulted, explained everything in an accessible way, prescribed tests and prescribed the necessary medications. Everything we wanted, we got it. We were very pleased with the reception. We will come back to this doctor. I will recommend this specialist to my friends.

Irina,

November 11, 2021

Responsible, knowledgeable doctor, good approach to the patient.Natalya Anatolyevna listened to me attentively, conducted an examination, explained what exercises should be done and made recommendations. I was pleased with the reception. I recommend a doctor. I wish her every success and prosperity in her work.

Moderation,

12 November 2021

Show 10 reviews of 15,680 90,000 Myasnikov named the main causes of tremors

“Everyone’s hands are shaking – this is a physiological tremor, but it is invisible.It is so low-amplitude and high-frequency that we do not see it, “says Dr. Alexander Myasnikov. On the air of the Russia 1 channel, he named the main causes of hand tremors and explained in which cases it can become a symptom of a dangerous disease.

According to the specialist, in order to diagnose, doctors often use a blank sheet of paper over which the patient holds his hand under a beam of directed light and looks at the shadow.

“Primary tremor can be harmless, or it can be a manifestation of a disease – from Parkinson’s to a brain tumor,” says Alexander Leonidovich.

In the case of Parkinson’s disease, tremors are primarily associated with a lack of dopamine in certain areas of the brain. The doctor recalled that four thousand years ago in Indian Ayurveda, cases of tremor treatment with the help of special herbs were described, in which they found levodopa, the predecessor of the modern drug for Parkinson’s therapy.

This disease is rarely encountered by people under 45 years of age, and in 20% of cases, its occurrence is associated with a genetic predisposition.Risk factors for Parkinson’s include brain injury, insufficient levels of vitamin D, which is produced by direct sunlight, and migraines. According to statistics, farmers living in remote rural areas and people who regularly consume spring water and milk are more susceptible to the disease. Excess magnesium and iron, being overweight, and inadequate muscle strength (especially in childhood) are also powerful risk factors. In addition, it has been proven: the higher the level of education, the more often Parkinson’s occurs, which is sometimes called “the disease of smart people.”

It is believed that smokers and coffee lovers suffer from Parkinson’s less often: due to the lack of dopamine, “Parkinson’s” simply do not enjoy cigarettes, and they do not develop bad habits. Regular exercise can also help reduce your risk of getting sick.

In addition to Parkinson’s disease, there is the so-called essential tremor, which in 70% of cases is due to heredity. This is the most common type of movement disorder in which patients may experience tremors of the hands, head, and other parts of the body.

Other common causes of tremor are medication (including lithium), encephalopathy, and alcohol use. However, Parkinson’s and essential tremor remain the main diagnoses.

90,000 Garnі, stop … – International Shooting Fitness Federation

Run and shoot.
If the participants of the Fit & Shooting shooting matches received a demobilized album at the end, its cover would have the motto “… shoot like a cowboy, and run like his horse.” tournaments.And if in the first match, running was just one of the exercises, then in the fifth, each exercise began with a 100-meter race with obstacles. And the sixth match was a continuous race, interrupted by only ten compulsory physical training exercises and the shooting unit itself. The timer sounded at the first turn and turned off with the last shot of the fifth exercise. If you want, you walk calmly from line to line, drink water and save energy. If you want, you run, catch your breath and fly into the slot.Freestyle as it is. Does not matter. Anyway, on the fourth exercise, the shooter is waiting for burpees, which will burn all the remaining forces and break all game plans. And the July sun in Odeshchina is especially harsh. And then not only the game plan flies out of my head, there is no time to even count replays …
This hell is called “Odessa carbine marathon” and is held at the training ground of the Odessa Military Academy. The officers and cadets of the Academy take part in the marathon on a par with civilians, and if there is any place to compare the shooting training of the military and athletes, it is at the Fit and Shooting match.In addition to the cadets, for example, the match was attended by employees of some Ukrainian special forces. As always, there were many active bodyguards at the match. But the most attention was, of course, drawn to himself by the multiple champion of Ukraine and Europe, the owner of many IPSC presidential medals, the legendary Vitaly Vasin with his champion carbine. According to him, the Odessa match was unlike any competition in which he had to participate. By the way, judging by Vitaly’s Facebook, the shooter began to pay more attention to CrossFit in his training.This means that the result of the next match will be even better.
Physical activity in such matches is intended not so much to complicate the passage of the exercises, but to equalize the chances of the participants. Sometimes, after going through several drills, you notice how the shooter uses the wrong stance, puts the stock incorrectly, forgets to breathe and makes other mistakes when shooting. This is how almost every shooter shoots after a good load. The body itself turns off what it considers superfluous and ceases to control much of what is considered important for a good shot.Many experienced shooters did not hesitate to admit later that before the match they did not even suspect that their body would behave this way in extreme conditions. And even long and difficult IPSC matches do not match the level of physical and nervous load on the shooter to the shooting marathon. Simply due to the fact that at any matches there is a break between exercises, but at Fit and Shooting matches they either do not exist at all, or the time for rest is minimal and it is spent, for example, on loading the store.
Shooting exercises are simple, but go for a run under the scorching sun, do 10 jerks of a one and a half pound kettlebell, sit down 10 times with a carabiner in your arms outstretched and you will see for yourself which one of you is Jason Stethem.It’s useless to compose a game plan in such conditions. Simply because you cannot predict in what physical condition you will find yourself on the next frontier. And here you will be visited by tunnel vision, and hand tremors and high blood pressure. To reach the end of any Fit & Shooting match, shooters will need not only strength and skills, but also strong-willed efforts. And they often play a bigger role than anything else.
Special requirements apply to judges. They provide not only the shooting unit, but also monitor the correctness and purity of physical exercises.I was lucky to judge the fourth, penultimate exercise, and I want to say that participation in such a match puts an end to the disputes between “athletes” and “tacticals” in about 15 minutes – this is how long the average passage of the entire match by one participant lasts. And at the same time, he answers the question of what will happen to the shooting results after intense physical activity, which is inevitable in any real situation.

In addition to demonstrating the actual shooting training, the shooters in the match have to adapt to different conditions of the exercises.For example, some targets had to be hit with two shots, and some with three. After three barely visible cardboard targets in the trench, it is necessary to hit a metal gong through the port at 50 meters. This ability to adapt directly on the line and makes the match closer to reality. The judges are not forbidden to tell the shooters the conditions of passage simply because it is unrealistic to keep them all in their heads, and the shooters pass the briefing once for all exercises at once. So reminders like “All targets – two shots each” or “we hit the extreme targets with two feet in the wheel” are not prohibited.For most shooters, after burpee and tire pulling, there is simply a manifestation of “tunnel vision” and therefore it even comes to explanations where to put the carbine during the exercise. It’s OK. The stress on the nervous system and thinking abilities is already high. By the way, many military men simply did not immediately understand the civilian word “carbine”, because they always had machine guns.

Shooters also have to count the cartridges. For the match, it was allowed to use no more than 4 loaded magazines, which forced the shooters to save ammunition and calculate their consumption during the exercise.As expected, military shooters often compensated for their accuracy by literally “bombarding” targets with bullets. But after one of the cadets, right on the fifth exercise, recharged the magazine with cartridges, there were fewer people who wanted to “cheat”. As practice has shown, transparent windows in stores to control ammunition cannot be used directly when shooting. Their only plus is that the shooter knows exactly how many cartridges are in the store when replacing it. Sports and belt pouches were not used at the match – too large a fine for the loss of a magazine with cartridges forced everyone to decide in favor of their chest placement.
Another prerequisite is that the shooter will wear individual body armor for the entire match, weighing at least 6 kilograms. As a rule, civilian shooters used lighter and more comfortable plate carryers, while the cadets used standard body armor from the Temp and Osprey already available. a practical shooter with a “race gun”, hung with sights and tactical grips.As a person who counted glasses in one of the exercises, I can confidently say that none of the collimators had a decisive advantage over the standard AK mechanical sight. On the gong at 50 meters, both of them hit with approximately the same accuracy and speed. I saw how a simple shabby AK hit the gong from the first time and how the ARC with optics missed several times. Because to hit it, it was not so much the cost of the sight that was important as the breath and readiness of the shooter.
Since we are talking about weapons, the main thing that should be said about the match is that the weapon always comes second after the shooting and physical qualities of the participant.No collimator compensates for lost breathing. The cadets, for example, used standard Kalashnikov assault rifles in caliber 5.45 with standard sights and only occasionally in the minimum body kit. Believe it or not, the holes in the targets were no different from the holes left by the more expensive and modified civilian sportsmen’s carbines. And sometimes they were more heaped. I was struck by the Israeli Tavor carbine of one of the shooters. He showed amazing accuracy, sometimes the distance between hits was no more than a centimeter.True, he also had problems with reliability, which is why the shooter did not manage to take a higher place in the rating. I was unpleasantly surprised by the civilian AK chambered for 7.62, which once sent the cartridge to the chamber. The regular AKS-74 of cadets and active military personnel showed excellent accuracy, in no way inferior to the civilian carbines of the AR. At least at the distance of the match, the American system did not have any advantages. But my personal favorite is the Zbroyar Z-15 carbines in caliber 223 with a 10 barrel.5 inches. These carbines were in the hands of the shooters of the Center A team and did not lose in the accuracy of the longer barrels at all, while significantly gaining in maneuverability. Despite the tense conditions of the match (and all the carbines had to lie on the ground), there were no failures and delays in the weapons based on the AR in my exercise.
It was interesting to compare the two worlds of shooting – the army and the “sports-civil”. The results turned out to be interesting, although the conclusions from them are obvious. But after all, every match proves them, so welcome to reality… Firstly, the AK 5.45 cartridge is an excellent weapon with good accuracy and unsurpassed reliability. It turned out to be an easy task for him to hit the standard “saucer” at 100 meters from the first try. Secondly, when it comes to a well-aimed shot, guys in vests and sophisticated athletes stand in the same stance and hit the targets in the same order. The same guys from the second or third years often showed the best result precisely thanks to daily marches and excellent physical training. At standard IPSC matches, they would have little chance.
I was pleasantly impressed by the paratroopers. Many of these guys have participated in hostilities behind their backs and they spoke with great respect about the innovations that have occurred due to the introduction of practical shooting and crossfit elements into fire and physical training. It is good that the leadership and officers of the Land Forces Academy are not standing still and are not afraid of changes.
After every match, I ask the shooters what their participation in it gave them. According to the reviews of the majority of the participants of “Fit & Shooting”, these matches provide an opportunity to test their strengths precisely in conditions that are as close to reality as possible.Because it is mixed matches that are characterized by the maximum manifestation of all possible negative factors that affect the shooter, preventing him from aiming and making the right decisions. Therefore, the “Fit and Shooting” format has long been chosen for themselves by people for whom shooting is a part of their profession. Starting from the creator of the format Denis Bezvershenko – a professional bodyguard and an excellent athlete, and ending with physical protection teams and special forces. Now there is already a whole group of shooters who have chosen just such competitions.It is believed that, unlike IPSC matches, it is the skills of the shooter as a fighter that are more fully manifested here, which are not limited by speed, power and accuracy. Will you try your hand?

Tremor as a symptom of multiple sclerosis

Tremor that you cannot control is a common symptom of multiple sclerosis (MS) that usually develops at least five years after the illness, although this is not a hard rule.1 Tremors can occur when you try to do something with your hands, while standing or sitting, and their severity can range from subtle to significant interference with your daily tasks.

Signs and symptoms

Tremors are involuntary muscle contractions that lead to rhythmic reciprocating movements of a specific part of the body. Although the arms are most commonly affected, tremors can also affect the legs, vocal cords, head, and trunk. It can come and go, or it gets worse over time.

There are a number of different types of tremor, but the two main types in MS include: 2

• Intentional tremor: This is a type of tremor that occurs when you reach for something and your hand starts to tremble.The closer you get to your goal or the less movement is required, the more your hand or arm will tremble. This is the most common type of tremor in multiple sclerosis.

• Postural tremor: This is a tremor that occurs when you are sitting or standing and your muscles try to hold parts of your body still against gravity. Another example is shaking when you stretch your arms out in front of you.

If your jaw, lip or tongue is trembling, 3 this may affect your ability to swallow (dysphagia) or speak clearly (dysarthria).

For most people, tremors are mostly annoying and can complicate daily tasks and be uncomfortable. However, a small percentage of people may experience tremors so severe that it becomes impossible to perform essential tasks such as eating, drinking or dressing.

It is important to note that you should not experience intentional or postural tremors when you are asleep or even just lying down and your muscles are relaxed. If you experience tremors while resting, it could be the result of something else, as resting tremors are rare in multiple sclerosis, so be sure to talk to your doctor about this.

Reasons

Like other symptoms of multiple sclerosis, most tremors in multiple sclerosis are caused by demyelination – damage by the body’s immune system to myelin, the protective sheath of nerves. In the case of tremor, demyelination occurs in the cerebellum or the nerves leading to or from it. The cerebellum is the part of your brain that controls balance and coordination and helps make the movements of your limbs, mouth, and eyes smooth and fluid.

Tremors can also result from demyelination of the thalamus, the part of your brain that controls the motor systems in your body, and the basal ganglia, which are located on either side of the thalamus in your brain and help control movement.

Tremor may occur as a symptom of relapse and resolve on its own or after a course of corticosteroids, although residual tremor often persists.

The severity of the tremor is not related to the duration of your multiple sclerosis.

According to a 2015 study, 45% to 47% of MS patients experience tremors, with 5.5% to 5.9% reporting severe tremors.

Leaving

Since there is no official recommendation for the treatment of tremors associated with multiple sclerosis, it can be difficult to treat.It is often trial and error to see which approaches work best for you, and as your symptoms change, you may need to explore different treatment options.

Keep in mind that while treatment can reduce your tremors, it probably won’t completely eliminate them.

Medicines

There are no specific drugs for treating tremors, so doctors usually prescribe the following off-label drugs, which means they are not FDA-approved for treating tremors associated with MS.

Medicines your doctor may prescribe include: 7

• Benzodiazepines: eg clonopin (clonazepam)

• Anticonvulsant: eg Neurontin (gabapentin), mizoline (primidone) or keppra (levetiracetam).

• Antihistamines: For example, Atarax or Vistaril (hydroxyzine).

• Beta-blockers: e.g. Inderal (propranolol).

• Antispasmodics: e.g. baclofen or Zanaflex (tizanidine) 8.

• Antiemetics: e.g. Zofran (ondansetron) 9.

• An antibiotic called nidrazide (isoniazid) 10

Efficacy

A 2016 study8 of 567 participants with multiple sclerosis tremors found that 47% used drugs to treat them. Most of those taking the medication said they had moderate (54 percent) or severe (51 percent) tremors, while others described their tremors as mild (37 percent) or completely disabling (35 percent).

Of the patients who reported moderate to severe tremors, only about half said the medication helped reduce their tremors. Anticonvulsants were the most commonly used drug class (51 percent), followed by benzodiazepines (46 percent). While most of the participants only used one medication, some used two or three medications for relief.

A 2018 review of 10 studies on the treatment of upper limb tremor in patients with multiple sclerosis found that nidrazide (isoniazid) is the most studied pharmacological treatment for tremor and helps relieve it in 60-80 percent of patients.However, all of the studies were fairly small and took place in the 1980s.

The review also noted that a 2014 study of the effect of disease-modifying therapy on tremor showed that patients taking Tisabri (natalizumab) were more likely to report an improvement in tremor than patients taking other forms of drug that modify disease.

In addition, the researchers found that the most commonly reported side effects for all tremor treatment options were fatigue and weakness.

Treatment methods

For many people with MS, a rehabilitation plan that includes one or more forms of therapy can reduce tremors.

Occupational Therapy

An occupational therapist can help you find and learn how to use special equipment that will help you with your daily activities, such as braces for affected joints, weights for affected areas or items you need to use, and other aids for writing, cooking, eating, and dressing. …

Occupational Therapy can also help you learn strategies for dealing with tremors and maintaining good posture and alignment as you go about your life.

Physiotherapy

If tremors are affecting your balance, coordination, and walking ability, physiotherapy may be especially helpful. A physical therapist can give you exercises that will strengthen your core, improve your balance and keep you active and flexible, and help you develop correct posture and balance, all of which can reduce your tremors.

Speech therapy

For tremors that affect your jaw, lips and / or tongue, a speech therapist can help. A speech therapist can teach you to speak more slowly and clearly by adjusting the position of your jaw, tongue, and lips. He can also advise you on communication tools if you need them.

Operation

If you have severe tremors and other treatment options have not worked for you, surgery may be possible. There are two types of surgeries that can be used to treat multiple sclerosis tremors.

Deep brain stimulation (DBS)

This technique, also known as thalamic stimulation, has been the surgery of choice for tremors associated with multiple sclerosis over the past several decades. In DBS, the surgeon places battery-operated electrodes in the thalamus that deliver a small electric current to stimulate specific areas, reducing your shaking.

Stereotactic thalamotomy

In stereotactic thalamotomy, also known as lesion surgery, a specific area of ​​the thalamus is destroyed using radio frequency or focused ultrasound.These precise locations are found before surgery on magnetic resonance imaging (MRI) or computed tomography (CT). Basically, this destruction prevents your brain from transmitting signals that cause tremors.

Thalamotomy is permanent and can cause side effects such as weakness, fatigue and seizures, although these may disappear over time.

A 2019 review of 15 studies of DBS and thalamotomies in patients with tremor. The researchers also conducted a subgroup analysis that showed that thalamotomies performed with focused ultrasound could improve quality of life even more than other types of thalamotomies or DBS.

Botulinum toxin

There have been only two small studies to date, 16 one in 1997 and the other in 2012, on the effect of botulinum toxin injections on MS tremor.

A 2012 study used electromyography (EMG) guidelines to administer Botox (Onabotulinotoxin A) or placebo to 23 participants in targeted areas of one or both hands where their tremors appeared. After 12 weeks, the participants received reverse treatment.

Researchers found that botox significantly improved hand tremors and coordination problems called ataxia, which in turn reduced the amount of disability caused by tremors. And although about 42 percent of the participants developed mild to moderate weakness after the Botox injection, it completely disappeared within two weeks.

Botulinum toxin injections can help reduce tremors, especially if you are unable to take medications, do not experience sufficient relief with other treatments, or are not a candidate for surgery.Talk to your doctor about if this option is right for you.

Cope

You can take practical steps to stay healthy so that you can more effectively manage tremors and other symptoms of multiple sclerosis. Try the following. 17

• Minimize stress: delegate tasks to others whenever possible, take time for yourself, and learn relaxation techniques such as aromatherapy and deep breathing that can help you cope with stressful situations.

• Choose a Healthy Diet: A diet rich in vegetables, fruits and whole grains gives you the nutrition you need to stay healthy.

• Exercise as much as possible: movement is good for your muscles and waist, and can also help with symptoms of multiple sclerosis.

• Eliminate or reduce your intake of caffeine and medications that cause tremors: If you are taking medications that make your tremors worse (such as stimulants or certain asthma medications), talk to your doctor about looking for other options.And if caffeine is making you jittery, try to cut back on it and possibly eliminate it entirely from your daily routine.

• Talk to a Counselor: Depression and anxiety are common in any chronic illness, and multiple sclerosis is no exception. And since mental health affects your physical health, seeing a therapist when you have difficulty can dramatically improve not only your mental health but also your overall quality of life.

Word from Verywell

Tremor can be one of the most serious symptoms of MS, and like each of them, the way tremor affects you is very personal. If you encounter this, try to be patient and maintain communication while you and your doctor figure out which treatment options work best. Do one at a time each day and be kind to yourself by making space for activities you enjoy and stay healthy. Your body and your mind will be grateful to you.

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