A tremor is an intense, uncontrollable, and involuntary trembling or shaking that can affect a specific part of the body or the whole body.

Tremors are one of the most common symptoms of multiple sclerosis (MS), affecting 25% to 58% of patients.

Causes of tremor

The myelin sheath — an insulating protein layer that covers nerve fibers — is often damaged in MS patients. Tremors are caused by damage to the nerve fibers that are responsible for controlling movement and coordination. They can also be caused by lesions in the cerebellum — a specialized region of the brain that controls movement and coordination.

Consequences of tremors

The consequences of tremors can vary greatly depending on their severity. Tremors can be very mild and barely noticeable or very strong. For many MS patients, tremors can be debilitating enough to severely affect quality of life.

Tremors commonly affect the head, neck, vocal cords, trunk, and limbs. Based on which part of the body it affects, tremors can cause a wide range of problems. For instance, a tremor in the arms may affect a patient’s ability to do certain tasks with their hands whereas tremors in the legs can cause them to lose their balance and lead to mild-to-severe walking problems. Tremors affecting the neck and vocal cords can cause speaking (dysarthria) or swallowing (dysphagia) difficulties.

In most cases, tremors occur without warning and can greatly affect a patient’s well-being. They can occur during an ongoing activity that requires focus and motor control, such as driving, which may result in serious accidents.

Types of tremors

There are four main types of tremors:

  • Intention tremors happen when a patient is trying to or about to initiate an activity such as reaching for an object.
  • Postural tremors occur when the person is doing an activity that requires resisting gravity, such as standing up. These tremors may subside when the person lies down.
  • Resting tremors happen when the affected person or the body part is at rest. The tremor can diminish when the body is in motion.
  • Nystagmus tremors affect the eyes and can cause jerky eye movements.

Management of tremors

There are no targeted treatments that address the underlying cause of tremors, which can be managed with physical therapy and pharmaceuticals.

Physical management of tremors

MS patients can perform different types of exercises to reduce the incidence of tremors:

  • patterning, which involves repeating a specific pattern of movement to train the mind and improve coordination. Repeated movements can reinforce the connections between nerve circuits and improve coordination.
  • vestibular stimulation techniques, which employ repetitive swinging, rocking, and spinning motions to train and acclimatize the balance centers in the brain.
  • special equipment such as a Swiss ball can be used for balance exercises to improve overall movement and coordination.
  • computerized balance stimulation where the patient listens to instructions and carries out specific movements while standing on a platform and receiving feedback.

Weights, stabilizing braces, and other devices that attach to the body to immobilize limbs can also create natural resistance against tremors.

Pharmaceutical management of tremors

Medications commonly used to manage tremors include:

Patient responses to these medications can vary substantially, so prior consultation with a physician is highly recommended.

Research into treatment of tremors

Deep brain stimulation is a technique that involves electrically stimulating the brain region that initiates tremors and temporarily blocking its activity. It is being investigated for the management of MS tremors following some success with Parkinson’s disease.

The use of cannabis and its active ingredient tetrahydrocannabinol is also being investigated for the treatment of tremors.

MRI guided focussed ultrasound (NCT02614989), gamma knife radiosurgery (NCT03339908), and robot-assisted arm training (NCT03561155) are some other approaches that are being investigated to treat and manage tremors in MS patients.

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