Understanding Tremors in Multiple Sclerosis
Tremors are one of the more common symptoms of multiple sclerosis. This uncontrollable shaking can be especially bothersome, embarrassing, and debilitating at times, but there are ways to help manage it.
When tremors in multiple sclerosis occur, which they do in about 75 percent of patients with MS, they tend to be mild and transient. However, some people experience more severe shaking called gross tremors, which can be severe and debilitating.
Tremors in multiple sclerosis and spasticity are not the same. While the former involves shaking, the latter refers to involuntary muscle spasms and feelings of pain and stiffness that may be mild to severe. Spasticity most often occurs in the legs, although it can present in and round the joints and may even affect the vocal cord muscles.
Tremors in multiple sclerosis typically are one of three types. All of them are associated with damage (demyelination) along the nerve pathways that are involved with coordination of movement. Demyelination is the loss of the protective coating (myelin) on nerve fibers, which results in an interruption of nerve signals from the brain to the muscles.
- Intention tremor, which is the most common type. People with intention tremor will shake when they reach for or pick up an object or more their foot to a precise spot. If you experience intention tremor, you know how frustrating it can be.
- Postural tremors occur when you are standing or sitting but not when you are lying down. These tremors occur because your body is attempting to fight gravity.
- Nystamus is a tremor that causes jerky movements of the eye
In addition, a condition known as dystonia frequently occurs along with MS-related tremor. Dystonia is characterized by involuntary muscle contractions that result in abnormal postures or slow, repetitive movements. The movements can be painful and may affect one or more muscles throughout the body.
A new study (May 2015) published in Multiple Sclerosis explored the presence of dystonia in patients with MS tremor. Considering the 54 participants in the study, the authors found that upper limb dystonia is common among MS patients, indicating that the pathophysiology of tremor in multiple sclerosis involves very specific sites in the brain (the “cerebello-pallido-thalamo-cortical network”).
This finding indicates that dystonia and tremor may need to be treated at the same time. Some of the treatments used for tremor also are prescribed for dystonia (see below).
Treating tremors in multiple sclerosis
All tremors in multiple sclerosis, whether they are mild or severe, may respond to steps such as eliminating coffee (caffeine) and reducing stress and fatigue. Mild to moderate tremors are more likely to respond to these attempts than is more serious shaking.
Other treatment options include occupational therapy (e.g., use of braces, exercises to improve balance, wrists rests) and medications, although no specific drugs have been approved by the Food and Drug Administration for treatment of tremors in multiple sclerosis, and none of them are especially effective.
Of the drugs frequently prescribed, the anti-tuberculosis agent, isoniazid, has provided some relief. Other drugs administered include the antihistamines Atarax and Vistaril, the beta-blocker Inderal, the anticonvulsant Mysoline, and the anti-anxiety drugs Buspar and Klonopin.
Another approach is deep brain stimulation. This method, which has been used in patients who have Parkinson’s disease, is typically reserved for individuals who have severe tremor.
The procedure involves implanting electrodes into the brain, which are designed to block involuntary tremor muscle activity. Unfortunately, deep brain stimulation usually provides only temporary relief. (This approach also can be used for dystonia.)
Yet another possibility is botulinum toxin (Botox). This neurotoxin paralyzes muscles by preventing the release of acetylcholine, a neurotransmitter involved with nerve signal transmission.
Injections of minute amounts of botulinum toxin can temporarily control tremor and dystonia. This approach has been found to be helpful for select patients with MS and upper extremity tremors.
In Australia, 23 patients with MS (33 upper limbs evaluated) participated in a randomized cross-over study in which they received botulinum toxin type A or placebo at baseline and then the reverse treatment at 12 weeks. The participants experienced significant improvement after botulinum toxin treatment when compared with placebo.
Specifically, patients did significantly better after treatment with the neurotoxin regarding severity of tremor, writing, and drawing at both 6 and 12 weeks. Weakness was more common after botulinum toxin (42.1%) than after placebo (6.1%), but it was mild and resolved within two weeks.
Psychological help with tremors
Along with the physical challenges of tremors in multiple sclerosis, patients often experience feelings of embarrassment, depression, loneliness and isolation. These challenges can have a life-altering impact on individuals and should be addressed with either a counselor, psychologist, support group, or other assistance.
Also read about alternative treatments for multiple sclerosis
Cameron MH et al. Botulinum toxin for symptomatic therapy in multiple sclerosis. Current Neurology and Neuroscience Reports 2014 Aug; 14(8): 463
Van der Walt A et al. A double-blind, randomized, controlled study of botulinum toxin type A in MS-related tremor. Neurology 2012 Jul 3; 79(1): 92-99
Van der Walt A. The occurrence of dystonia in upper-limb multiple sclerosis tremor. Multiple Sclerosis 2015 May 26.