Tremor as a Symptom of Multiple Sclerosis

Tremor—shaking that you can't control—is a common symptom of multiple sclerosis (MS) that usually develops after at least five years of having the disease, though this isn't a hard-and-fast rule. Tremors can occur when you're trying to do something with your hands, whether you're standing or sitting, and their severity can range from being barely noticeable to significantly interfering with your daily tasks.

Signs and Symptoms

Tremors are involuntary muscular contractions that result in a rhythmic, back-and-forth movement of a specific body part. While your hands are most often affected, tremor also can affect your legs, vocal cords, head, and trunk. It can come and go or get progressively worse with time.

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

• Intention tremor: This is the kind of tremor that occurs when you reach for something and your hand starts shaking. The closer you get to your target or the smaller the movement required, the more your hand or arm will shake. This is the most common type of tremor in MS.
• Postural tremor: This is a shaking that occurs while you're sitting or standing and your muscles are trying to hold parts of your body still against the force of gravity. Another example is shakiness when you hold your arms out in front of you.

If you have a tremor in your jaw, lip, or tongue, this may affect your ability to swallow (dysphagia) or to speak clearly (dysarthria).

For the majority of people, tremor is mostly annoying, may make everyday tasks more difficult, and can be embarrassing. However, a small percentage of people may experience tremor so severe that it becomes impossible to perform necessary tasks like eating, drinking, or getting dressed.

Causes

Like other MS symptoms, most MS tremors are caused by demyelination—damage by the body's immune system to myelin, the protective sheath around your nerves. In the case of tremors, the demyelination takes place in your cerebellum or the nerves leading to or away from it. The cerebellum is the part of your brain that controls balance and coordination, and it helps to make the movements of your limbs, mouth, and eyes smooth and fluid.

Tremor can also be the result of demyelination in 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 can occur as a relapse symptom and disappear on its own or after a course of corticosteroids, though it's also common for a residual tremor to remain.

The severity of tremor is not linked to how long you've had MS.

Around 45 percent to 47 percent of MS patients experience tremors, with 5.5 percent to 5.9 percent reporting severe tremor, according to a 2015 study.

Treatment

Because there are no official treatment guidelines for MS-related tremor, it can be a tricky symptom to treat. It's often a trial-and-error process 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 even though treatment can reduce your tremors, it most likely won't eliminate them completely.

Medications

There aren't any specific medications for treating tremors, so healthcare providers usually prescribe the following drugs off-label, which means they're not approved by the U.S. Food and Drug Administration (FDA) for treating MS-related tremor.

Medications your healthcare provider may prescribe include:

• Benzodiazepines: e.g., Klonopin (clonazepam)
• Anticonvulsant: e.g., Neurontin (gabapentin), Mysoline (primidone), or Keppra (levetiracetam)
• Antihistamines: e.g., Atarax or Vistaril (hydroxyzine)
• Beta blockers: e.g., Inderal (propranolol)
• Antispasmodics: e.g., baclofen or Zanaflex (tizanidine)
• Antiemetics: e.g., Zofran (ondansetron)
• An antibiotic called Nydrazid (isoniazid)

Effectiveness

A 2016 study of 567 participants with MS tremors found that 47 percent used medication to treat them. The majority of those using medication said they had moderate (54 percent) or severe (51 percent) tremor, while the others characterized their tremors as mild (37 percent) or completely disabling (35 percent).

In the patients who reported moderate or severe tremor, only around half said that medication helped reduce their tremors. Anticonvulsants were the most often used class of medications (51 percent), followed closely by benzodiazepines (46 percent). Though most participants only used one medication, some used two or three medications for relief.

A 2018 review of studies on treatments for upper-limb tremors in patients with MS showed that Nydrazid (isoniazid) has been the most-studied pharmacologic intervention to treat tremor and helped relieve it in 60 percent to 80 percent of patients. However, the studies were all quite small and conducted in the 1980s.

The review also noted that a 2014 study of the effect of disease-modifying therapies on tremor established that patients taking Tysabri (natalizumab) were more likely to report improvement in their tremor than those on other forms of disease-modifying drugs.

Additionally, the researchers found that the most commonly noted side effects across the board for all the medication options for tremor were fatigue and weakness.

Therapies

For many MS patients, a rehabilitative plan that involves one or more forms of therapy can reduce tremor.

Occupational Therapy

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

Occupational therapy can also help you learn strategies for coping with tremor and maintaining good posture and alignment when you're carrying out your activities of living.

Physical Therapy

If your tremors affect your balance, coordination, and ability to walk, you may especially benefit from physical therapy. A physical therapist can give you exercises that strengthen your core, improve your balance, and keep you active and flexible, as well as help you develop good posture and alignment, all of which can reduce your tremor.

Speech Therapy

In cases of tremors that affect your jaw, lips, and/or tongue, speech therapy may be helpful. A speech therapist can teach you how to speak more slowly and clearly by adjusting the placement of your jaw, tongue, and lips. He or she can also advise you on communication aids if you need them.

Surgery

If your tremor is severe and other treatment options haven't worked for you, surgery may be an option. There are two types of surgeries that can be used to treat MS tremors.

Deep Brain Stimulation (DBS)

This method, also known as thalamic stimulation, has been the surgery of choice for MS-related tremors for the last couple of decades. In DBS, the surgeon places battery-operated electrodes in your thalamus that deliver small electric currents to stimulate certain areas, lessening your tremors.

Stereotactic Thalamotomy

In stereotactic thalamotomy, also known as lesion surgery, a specific area in your thalamus is destroyed using radiofrequency or focused ultrasound. These precise locations are located before the surgery on a magnetic resonance imaging (MRI) scan or a computerized tomography (CT) scan. Essentially, this destruction prevents your brain from transmitting signals that cause your tremors.

Thalamotomy is permanent and can cause side effects like weakness, fatigue, and seizures, though these may go away with time.

A 2019 review of studies on DBS and thalamotomy in patients with tremor, some of which included MS-related tremor, concluded that both types of surgery are equally effective in successfully reducing tremor and improving quality of life. The researchers also did a subgroup analysis that indicated that thalamotomy that's performed with focused ultrasound may improve quality of life even more than other types of thalamotomy or DBS.

Botulinum Toxin

Only two small studies, one from 1997 and another from 2012, have been done so far on the effects of botulinum toxin injections on MS tremor.

The 2012 study utilized electromyography (EMG) guidance to inject the 23 participants with either Botox (onabotulinumtoxinA) or placebo in targeted areas of one or both arms where their tremors appeared. After 12 weeks, the participants received the reverse treatment.

The researchers found that Botox significantly improved hand tremors and coordination difficulties, called ataxia, which in turn decreased the amount of disability the tremors caused. And though around 42 percent of the participants developed mild to moderate weakness after the Botox injection, this went away completely within two weeks.

Coping

You can take practical steps to keep yourself healthy, which can help you cope with your tremors and other MS symptoms more effectively. Consider trying the following.

• Minimize stress: Delegate tasks to others whenever possible, make time for yourself, and learn relaxation techniques like aromatherapy and deep breathing, which can help you deal with stressful situations.
• Choose a healthy diet: A diet that's rich in vegetables, fruits, and whole grains gives you the nutrition you need to stay healthy.
• Exercise as much as you're able: Moving around is good for your muscles and your waistline, and it can help with MS symptoms.
• Eliminate or reduce caffeine and tremor-inducing medications: If you're on medications that make your tremor worse (think stimulants or certain asthma medications), talk to your healthcare provider about finding other options. And if caffeine gives you the jitters, work on reducing your intake and potentially eliminating it from your routine altogether.
• See a counselor: Depression and anxiety are common in any chronic illness, and MS is no exception. And since mental health affects your physical health, seeing a therapist when you're having difficulties can greatly improve not only your mental state, but your overall quality of life too.

Tremor can be one of the more challenging symptoms in MS, and, like every one of them, how tremor affects you is very personal. If you find yourself dealing with it, try to be patient and keep communication open as you and your healthcare provider figure out what treatment options work best.

Take each day one at a time and be good to yourself by carving out space for activities you enjoy and keeping yourself healthy. Your body and your mind will both thank you.