What exactly is MS Tremor?

Tremor is relatively common in MS with possibly as many as 75% of people with MS experiencing it. It is recognised as an involuntary, rhythmical, alternating movement that can affect the muscles of any part of the body.

It can also vary in terms of speed, severity, location, and duration and can tend to come and go affecting the limbs, trunk, head, or even voice and speech.

Tremor may simply be annoying, or can be extremely disabling depending on its severity. An affected area may experience tremor while at rest, or may shake only when a purposeful movement is made. Backwards and forwards motion may be observed with gross tremor, while others with MS may experience fine tremor, where shaking is barely visible and so mild it is not obvious to anyone else.

For others, tremor may be more pronounced, causing a drink to spill when the cup is full, for example, or it can affect handwriting. For a small percentage of people, it is more severe, causing limbs to shake so that it becomes difficult or even impossible to eat, drink, or get dressed without help. Tremor can be frustrating and embarrassing whichever form it takes.

If tremor develops in a person with MS, it tends appear many years after the original symptoms, typically between 5 and 15 years, though it can also develop earlier or later than this. Tremor may become gradually noticeable or develop quite swiftly.

Some will develop a tremor during relapses and like other symptoms it will often lessen when a relapse is over. However, some level of tremor does tend to remain after a relapse. Even with almost complete recovery, it sometimes remains noticeable because it is associated with such precise, fine movements that are involved in reaching for and picking up objects, for example coins, amongst many other things.

Those who develop the Secondary Progressive phase of MS may experience a tremor which gradually becomes more severe over time.

What causes Tremor?

The exact cause of tremor is unknown but is thought to be due to lesions in the cerebellum, the area of the brain responsible for balance, coordination and a ‘fluidity’ of movements of limbs, speech and eyes. Tremor can also be the result of demyelination in other parts of the brain such as the thalamus and the basal ganglia. Similar to many other MS symptoms, emotions, stress, and fatigue are known to worsen tremor.

Types of MS Tremor

a) Intention Tremor
This is characterised by a slow, broad shaking that occurs at the end of an intended movement, most noticeably in the hands. It is also known as Kinetic, Action and Cerebellar Tremor.

The automatic action of picking up an object can be described in the following way: When you move your fingers to perform a fine task, for example putting a coin into a slot, you subconsciously tell your arm muscles to move by sending nerve transmissions down the motor nerve pathways. The brain gets feedback about the movement from sensors in the joints and muscles which it uses to control the movement and gently guide the coin into its correct place.

People with intention tremor get the feedback more slowly, and therefore the hand or fingercan overshoot its target resulting in tremor. Intention Tremor is more obvious when performing delicate fine movements than broad sweeping ones, for example handwriting or sewing.

Intention Tremor is detected by neurologists using finger to nose tests. The neurologist holds up his or her finger and you move your finger from your nose to his or her finger and back to your nose.

b) Other Tremors: Some people experience jaw, lip, or tongue tremor which may affect their ability to speak efficiently.

Postural tremors occur when the limbs are outstretched.

How can Tremor be managed or treated?

In examples of fine tremor, minor adjustments to posture, such as holding an arm close to the body, may be enough to make the condition tolerable.

Adaptation and planning ahead are the key words in coping with tremor; for example, fatigue and heat makes tremor worse, so planning the day’s activities appropriately, using aids or tools is important.

Another example is to stabilise the head against a headrest to reduce head tremor; holding the wrist of the active hand with the other hand may help with functions such as combing or brushing hair.

The use of weights can benefit in dampening tremor. Adding extra weight to a limb, especially at the ankles or wrists, promotes more control. Conversely however, sometimes adding weight can worsen cerebellar tremor and prolonged use should be avoided as it has been shown to increase the tremor after the weights have been removed.

Adding weights to household items not just the limbs may make them easier to control. These include pens and pencils, eating utensils, brushes and walking aids Equipment around the house, especially kitchen utensils may also be adapted with easy-to-grip handles and non-skid surfaces to assist with tremor.

Drug Therapies

Medications which have a calming effect are sometimes prescribed, for example tranquilisers which reduce a tremor by relaxing the individual and calming stress which may have provoked the tremor.

Clonazepam works efficiently but care must be taken however, to prescribe a dose which is effective but not so strong as to sedate the patient excessively. This drug can cause tolerance and dependency.

Propranolol (Inderal®) is a beta blocker – an agent which blocks the nerve flow along certain nerves. It is typically given for high blood pressure or angina. Propranolol is usually effective in treating only physiologic tremors. Doses should be started low and gradually increased until an optimal level is reached.

Amantadine (Symmetrel®) helps to reduce shaking for some individuals. This medication also has antiviral properties and is sometimes prescribed for people with MS to alleviate fatigue.

Baclofen (Lioresal®) is a drug often taken by people with MS to treat spasticity. It also helps to slow tremor, but the dosage must be carefully watched because Baclofen produces weakness as a side effect.

Unlike many MS symptoms, tremor responds minimally to steroid treatment.

Physiotherapy

Certain exercises may be taught by a physiotherapist to increase stability. Exercises for the shoulders, body, pelvis, and hips are particularly helpful for tremor in these areas.

"Patterning" is sometimes used by physiotherapists to promote muscle control and development. This technique uses repeated movements to increase muscle coordination. As the patient repeats these guided movements, the physiotherapist adds increasing amounts of resistance, helping the movements to become strengthened. Eventually, these movements become automatic, and tremor may be decreased.

Orthopaedic Equipment

When a tremor becomes significant enough to interfere with the ability to perform a task, a person may choose to use a brace to immobilise the affected region. Special braces are available to go across a joint, preventing random movement and allowing for the wearer to regain control.

Arm and hand braces work well and may be used when performing a task, such as eating or writing. Braces for the foot and ankle enable the wearer to walk more steadily. Head and neck braces are also available.

Thalamotomy and Thalamic Stimulation

This kind of surgery is only considered for tremor when the condition has been severe and chronic, with no other options for treatment.

A thalamotomy may be performed to give relief from a chronic cerebellar tremor. This surgical process cuts or freezes the thalamus gland in order to destroy the part of the gland that produces tremor.

For others with incapacitating tremor, thalamic stimulation may also be an option. This procedure uses surgically implanted electrodes to stimulate the thalamus, the part of the brain that helps to control movement. Stimulation to this part of the brain may reduce or stop tremor.

Thalamic stimulation is safer than thalamotomy, but still carries risks, and the cost is very high. This procedure should only be considered for severely affected individuals.

Cannabis

Many MS patients are adamant that cannabis relieves their tremors and muscle spasms.

Personal Experiences

“I get intention tremor in both legs. This can get quite violent when I am under stress, i.e. when I think someone is looking at me. I can suppress it to a degree by putting all my weight (quite considerable these days!) on the offending foot/heel.

“I have Intention Tremor in my right hand, my dominant one, but it's not there all the time because various things trigger it off e.g. heat, fatigue, virus etc. “

“I had an embarrassing moment the other week, paying for a meal in a restaurant I had trouble with the chip 'n pin machine and had to actually hold my right wrist with my left hand in order to press the buttons on the pad.”

© Multiple Sclerosis Resource Centre (MSRC)