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Luitel P, Neupane N, Paudel S, Adhikari N, Timilsina B, Suryabanshi A, Gyawali P, Ojha R. Prevalence and Clinical Types of Tremor in Multiple Sclerosis and its Associated Disability: A Systematic Review. Tremor Other Hyperkinet Mov (N Y) 2023; 13:34. [PMID: 37719089 PMCID: PMC10503526 DOI: 10.5334/tohm.776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/26/2023] [Indexed: 09/19/2023] Open
Abstract
Objective To describe the state of literature regarding prevalence, clinical types of tremor in Multiple Sclerosis and associated disability. Background Tremor has long been recognized as an important symptom of multiple sclerosis. This can be intention and postural tremor that affects the upper limbs. Patients with multiple sclerosis who experience tremor of any severity typically retire early or lose their jobs due to disability. Methods This systematic review was performed up to September 9, 2022. Article selection was performed by searching the MEDLINE (PubMed) and EMBASE electronic bibliographic databases. The search strategy was not limited by study design but only for articles in the English language. Results A total of nine full-text articles were included in the analysis. Six studies were cross-sectional studies; one each was a prospective observational study, a case-control study, a community-based cohort. The prevalence of tremor in the multiple sclerosis (MS) population among studies ranged widely, between 12.5% and 68.9%. The presence of severe tremor ranged from 3% to 33%. Younger age was a significant predictor of tremor in two studies. The most common tremor subtype was action tremor. Upper extremities were the most common site involved in the majority of our studies, followed by head and neck. Conclusions Prevalence of tremor ranged from 12.5% to 68.9% in the MS population with severe tremor being an infrequent complication. Severity of tremor correlated with increasing disability. Upper limb action tremor was the most common with rare occurrences of resting and rubral tremor.
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Affiliation(s)
- Prajjwol Luitel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Nischal Neupane
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Sujan Paudel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Niranjan Adhikari
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Binita Timilsina
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Anil Suryabanshi
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
| | - Prakash Gyawali
- Emergency Department, Sukraraj Tropical and Infectious Disease Hospital, Teku 44600, Kathmandu, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Institute of Medicine, Maharajgunj 44600, Kathmandu, Nepal
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Shalash A, Elhodeby AM, Saad M, Abdelzaher Ibrahim Y, Hamid E, Nasef A. Tremor in Patients with Relapsing-Remitting Multiple Sclerosis: Clinical Characteristics and Impact on Quality of Life. Mov Disord Clin Pract 2023; 10:1099-1106. [PMID: 37476314 PMCID: PMC10354614 DOI: 10.1002/mdc3.13784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 03/21/2023] [Accepted: 05/02/2023] [Indexed: 07/22/2023] Open
Abstract
Background Little is known about the prevalence and clinical characteristics of tremors in patients with multiple sclerosis (MS), their associated clinical disability, and their impact on quality of life (QoL). Objective This study aimed to investigate the frequency and types of tremors in patients with relapsing remitting MS (RRMS) in remission, and their impact on patients' QoL. Methods A total of 250 patients with RRMS in remission were examined for tremors. All patients were assessed using the Expanded Disability Status Scale (EDSS). Patients with tremors underwent further assessment using the Fahn-Tolosa-Marin Tremor Rating Scale (FTMTRS), the Beck Depression Inventory (BDI), the Montreal Cognitive Assessment (MoCA) scale, and the Short Form 36 Health Survey Questionnaire (SF-36). Brain MRI was obtained for a subgroup of patients. Results Tremors were detected in 36 patients (14.4%) and were associated with significantly worse EDSS scores, BDI (P = 0.021), MoCA, most SF-36 domains, higher total and last year relapses (P < 0.001) and longer disease duration (P = 0.027). Patients with tremors showed higher lesion load (P = 0.007), more infratentorial (P ≤ 0.001), cerebellar and diencephalic lesions (P = 0.024), and cortical atrophy (P = 0.012). Total FTMTRS was significantly correlated to age, EDSS, and physical functioning. Dystonia was associated with tremors in 17 patients (6.8% of total RRMS patients and 47.2% of patients with tremors). Conclusion The current study confirms the common occurrence of tremors and their subtypes among patients with RRMS with mild disability and demonstrates their association with increased disability and impaired QoL.
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Affiliation(s)
- Ali Shalash
- Department of Neurology, Faculty of MedicineAin Shams UniversityCairoEgypt
| | | | - Mahmoud Saad
- Department of Neurology, Faculty of MedicineAin Shams UniversityCairoEgypt
| | | | - Eman Hamid
- Department of Neurology, Faculty of MedicineAin Shams UniversityCairoEgypt
| | - Ayman Nasef
- Department of Neurology, Faculty of MedicineAin Shams UniversityCairoEgypt
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Movement Disorders in Multiple Sclerosis: An Update. Tremor Other Hyperkinet Mov (N Y) 2022; 12:14. [PMID: 35601204 PMCID: PMC9075048 DOI: 10.5334/tohm.671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 04/13/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Multiple sclerosis (MS), a subset of chronic primary inflammatory demyelinating disorders of the central nervous system, is closely associated with various movement disorders. These disorders may be due to MS pathophysiology or be coincidental. This review describes the full spectrum of movement disorders in MS with their possible mechanistic pathways and therapeutic modalities. Methods: The authors conducted a narrative literature review by searching for ‘multiple sclerosis’ and the specific movement disorder on PubMed until October 2021. Relevant articles were screened, selected, and included in the review according to groups of movement disorders. Results: The most prevalent movement disorders described in MS include restless leg syndrome, tremor, ataxia, parkinsonism, paroxysmal dyskinesias, chorea and ballism, facial myokymia, including hemifacial spasm and spastic paretic hemifacial contracture, tics, and tourettism. The anatomical basis of some of these disorders is poorly understood; however, the link between them and MS is supported by clinical and neuroimaging evidence. Treatment options are disorder-specific and often multidisciplinary, including pharmacological, surgical, and physical therapies. Discussion: Movements disorders in MS involve multiple pathophysiological processes and anatomical pathways. Since these disorders can be the presenting symptoms, they may aid in early diagnosis and managing the patient, including monitoring disease progression. Treatment of these disorders is a challenge. Further work needs to be done to understand the prevalence and the pathophysiological mechanisms responsible for movement disorders in MS.
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Quantifying the impact of upper limb tremor on the quality of life of people with multiple sclerosis: a comparison between the QUEST and MSIS-29 scales. Mult Scler Relat Disord 2022; 58:103495. [DOI: 10.1016/j.msard.2022.103495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/12/2021] [Accepted: 01/01/2022] [Indexed: 11/19/2022]
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Makhoul K, Ahdab R, Riachi N, Chalah MA, Ayache SS. Tremor in Multiple Sclerosis-An Overview and Future Perspectives. Brain Sci 2020; 10:brainsci10100722. [PMID: 33053877 PMCID: PMC7601003 DOI: 10.3390/brainsci10100722] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/01/2020] [Accepted: 10/08/2020] [Indexed: 11/16/2022] Open
Abstract
Tremor is an important and common symptom in patients with multiple sclerosis (MS). It constituted one of the three core features of MS triad described by Charcot in the last century. Tremor could have a drastic impact on patients' quality of life. This paper provides an overview of tremor in MS and future perspectives with a particular emphasis on its epidemiology (prevalence: 25-58%), clinical characteristics (i.e., large amplitude 2.5-7 Hz predominantly postural or intention tremor vs. exaggerated physiological tremor vs. pseudo-rhythmic activity arising from cerebellar dysfunction vs. psychogenic tremor), pathophysiological mechanisms (potential implication of cerebellum, cerebello-thalamo-cortical pathways, basal ganglia, and brainstem), assessment modalities (e.g., tremor rating scales, Stewart-Holmes maneuver, visual tracking, digitized spirography and accelerometric techniques, accelerometry-electromyography coupling), and therapeutic options (i.e., including pharmacological agents, botulinum toxin A injections; deep brain stimulation or thalamotomy reserved for severe, disabling, or pharmaco-resistant tremors). Some suggestions are provided to help overcome the unmet needs and guide future therapeutic and diagnostic studies in this complex disorder.
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Affiliation(s)
- Karim Makhoul
- Neurology Division, Lebanese American University Medical Center Rizk Hospital, Beirut 113288, Lebanon; (K.M.); (R.A.); (N.R.)
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon
| | - Rechdi Ahdab
- Neurology Division, Lebanese American University Medical Center Rizk Hospital, Beirut 113288, Lebanon; (K.M.); (R.A.); (N.R.)
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon
- Hamidy Medical Center, Tripoli 1300, Lebanon
| | - Naji Riachi
- Neurology Division, Lebanese American University Medical Center Rizk Hospital, Beirut 113288, Lebanon; (K.M.); (R.A.); (N.R.)
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon
| | - Moussa A. Chalah
- Service de Physiologie-Explorations Fonctionnelles, Henri Mondor Hospital, AP-HP, 94010 Créteil, France;
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, 94010 Créteil, France
| | - Samar S. Ayache
- Service de Physiologie-Explorations Fonctionnelles, Henri Mondor Hospital, AP-HP, 94010 Créteil, France;
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, 94010 Créteil, France
- Correspondence:
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Boonstra FMC, Perera T, Noffs G, Marotta C, Vogel AP, Evans AH, Butzkueven H, Moffat BA, van der Walt A, Kolbe SC. Novel Functional MRI Task for Studying the Neural Correlates of Upper Limb Tremor. Front Neurol 2018; 9:513. [PMID: 30013508 PMCID: PMC6036145 DOI: 10.3389/fneur.2018.00513] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/11/2018] [Indexed: 01/06/2023] Open
Abstract
Introduction: Tremor of the upper limbs is a disabling symptom that is present during several neurological disorders and is currently without treatment. Functional MRI (fMRI) is an essential tool to investigate the pathophysiology of tremor and aid the development of treatment options. However, no adequately or standardized protocols for fMRI exists at present. Here we present a novel, online available fMRI task that could be used to assess the in vivo pathology of tremor. Objective: This study aims to validate the tremor-evoking potential of the fMRI task in a small group of tremor patients outside the scanner and assess the reproducibility of the fMRI task related activation in healthy controls. Methods: Twelve HCs were scanned at two time points (baseline and after 6-weeks). There were two runs of multi-band fMRI and the tasks included a “brick-breaker” joystick game. The game consisted of three conditions designed to control for most of the activation related to performing the task by contrasting the conditions: WATCH (look at the game without moving joystick), MOVE (rhythmic left/right movement of joystick without game), and PLAY (playing the game). Task fMRI was analyzed using FSL FEAT to determine clusters of activation during the different conditions. Maximum activation within the clusters was used to assess the ability to control for task related activation and reproducibility. Four tremor patients have been included to test ecological and construct validity of the joystick task by assessing tremor frequencies captured by the joystick. Results: In HCs the game activated areas corresponding to motor, attention and visual areas. Most areas of activation by our game showed moderate to good reproducibility (intraclass correlation coefficient (ICC) 0.531–0.906) with only inferior parietal lobe activation showing poor reproducibility (ICC 0.446). Furthermore, the joystick captured significantly more tremulous movement in tremor patients compared to HCs (p = 0.01) during PLAY, but not during MOVE. Conclusion: Validation of our novel task confirmed tremor-evoking potential and reproducibility analyses yielded acceptable results to continue further investigations into the pathophysiology of tremor. The use of this technique in studies with tremor patient will no doubt provide significant insights into the treatment options.
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Affiliation(s)
| | - Thushara Perera
- The Bionics Institute, East Melbourne, VIC, Australia.,Department of Medical Bionics, University of Melbourne, Melbourne, VIC, Australia
| | - Gustavo Noffs
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Centre for Neuroscience of Speech, University of Melbourne, Melbourne, VIC, Australia
| | - Cassandra Marotta
- Centre for Neuroscience of Speech, University of Melbourne, Melbourne, VIC, Australia.,Redenlab, Melbourne, VIC, Australia
| | - Adam P Vogel
- The Bionics Institute, East Melbourne, VIC, Australia.,Centre for Neuroscience of Speech, University of Melbourne, Melbourne, VIC, Australia.,Redenlab, Melbourne, VIC, Australia.,Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Andrew H Evans
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Helmut Butzkueven
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, Melbourne Brain Centre, University of Melbourne, Melbourne, VIC, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Clayton, VIC, Australia
| | - Bradford A Moffat
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anneke van der Walt
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, Melbourne Brain Centre, University of Melbourne, Melbourne, VIC, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Clayton, VIC, Australia
| | - Scott C Kolbe
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
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Boonstra F, Florescu G, Evans A, Steward C, Mitchell P, Desmond P, Moffat B, Butzkueven H, Kolbe S, van der Walt A. Tremor in multiple sclerosis is associated with cerebello-thalamic pathology. J Neural Transm (Vienna) 2017; 124:1509-1514. [PMID: 29098451 PMCID: PMC5686246 DOI: 10.1007/s00702-017-1798-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 10/13/2017] [Indexed: 01/21/2023]
Abstract
Tremor in people with multiple sclerosis (MS) is a frequent and debilitating symptom with a relatively poorly understood pathophysiology. To determine the relationship between clinical tremor severity and structural magnetic resonance imaging parameters. Eleven patients with clinically definite MS and right-sided upper limb tremor were studied. Tremor severity was assessed using the Bain score (overall severity, writing, and Archimedes spiral drawing). Cerebellar dysfunction was assessed using the Scale for the Assessment and Rating of Ataxia. Dystonia was assessed using the Global Dystonia Scale adapted for upper limb. For all subjects, volume was calculated for the thalamus from T1-weighted volumetric scans using Freesurfer. Superior cerebellar peduncle (SCP) cross-sectional areas were measured manually. The presence of lesions was visually determined and the lesion volumes were calculated by the lesion growth algorithm as implemented in the Lesion Segmentation Toolbox. Right thalamic volume negatively correlated with Bain tremor severity score (ρ = - 0.65, p = 0.03). Left thalamic volume negatively correlated with general Bain tremor severity score (ρ = - 0.65, p = 0.03) and the Bain writing score (ρ = - 0.65, p = 0.03). Right SCP area negatively correlated with Bain writing score (ρ = - 0.69, p = 0.02). Finally, Bain Archimedes score was significantly higher in patients with lesions in the contralateral thalamus. Whole brain lesion load showed no relationship with tremor severity. These results implicate degeneration of key structures within the cerebello-thalamic pathway as pathological substrates for tremor in MS patients.
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Affiliation(s)
- Frederique Boonstra
- Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Australia
| | - Grace Florescu
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Andrew Evans
- Department of Neurology, The Royal Melbourne Hospital, Level 4 South, 300 Grattan Street, Parkville, VIC, 3052, Australia
| | - Chris Steward
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
- Department of Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Patricia Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Brad Moffat
- Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Australia
| | - Helmut Butzkueven
- Department of Neurology, The Royal Melbourne Hospital, Level 4 South, 300 Grattan Street, Parkville, VIC, 3052, Australia
- Melbourne Brain Centre at Royal Melbourne Hospital, Department of Medicine, University of Melbourne, Melbourne, Australia
- Multiple Sclerosis Unit, Box Hill Hospital, Box Hill, Australia
- Department of Neuroscience, Alfred Central Clinical School, Monash University, Melbourne, Australia
| | - Scott Kolbe
- Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Australia
| | - Anneke van der Walt
- Department of Neurology, The Royal Melbourne Hospital, Level 4 South, 300 Grattan Street, Parkville, VIC, 3052, Australia.
- Melbourne Brain Centre at Royal Melbourne Hospital, Department of Medicine, University of Melbourne, Melbourne, Australia.
- Department of Neuroscience, Alfred Central Clinical School, Monash University, Melbourne, Australia.
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