Tremor and Balance
Reviewed by Randall T. Schapiro, MD
President, The Schapiro MS Advisory Group
Clinical Professor of Neurology, University of Minnesota (retired)
Tremor is a difficult symptom to manage. This is a back-and-forth or “oscillating” movement that usually affects the arms or legs, but can also (less frequently) affect the head or body (trunk). Individuals experiencing tremor may find that this symptom varies and is not always present. However, when tremor does occur, it can interfere with one’s balance and coordination. To follow are examples of how tremors vary:
- Size of movements: ranging from very small movements (fine tremor) to large movements (gross tremor)
- Areas affected: limbs, head, or truck; can also affect speech
- When they occur: when the muscle is at rest or when intentionally moving
- Speed of tremor: ranging from slow to fast
- Impact of tremor: some may be barely noticeable and more of an annoyance; others may be significant, interfering with normal function and daily activities
- Response to treatment: some tremors may respond well to treatment, others do not
With so many variables, having the tremor evaluated by a neurologist or other healthcare professional is critical for determining the most effective treatment plan.
With MS, the most frequently seen tremor is caused by demyelination in the cerebellum, which is located in the lower-back region of the brain. This area of the brain helps to control movement, coordination, balance, and muscle tone. This type of tremor tends to be a slow, gross tremor affecting a limb when moving intentionally (purposeful movement). Unfortunately, this type of tremor is the most challenging to treat. Additionally, stress and anxiety can worsen this type of tremor, which may improve when treated with a sedating type of medication.
Different strategies may be used in an effort to reduce tremors. These include:
Bracing: Braces can immobilize a joint and control extra movement. Bracing the ankle and foot can add stability for standing or walking; braces may also be used for the arm, hand, or neck.
Weighting: Adding extra weight to an affected area can help to stabilize a part of the body, such as the feet, ankles, wrists, and hands. Items can also be weighted, including pens, pencils, eating utensils, a cane, or a walker.
Speech therapy: When tremors around the mouth (lips, tongue, and jaw) interfere with speaking, speech therapy may help. Strategies include techniques to slow speech, increase clarity, and control loudness.
Adaptive equipment: Employing special household items designed to be used in daily activities can be helpful. These can be easy to hold or keep in place with everyday activities – such as writing, dressing, and eating.
Medications: Several medications (listed below) are available to treat certain types of tremor; a healthcare professional can prescribe the one that is best suited for his or her patient.
Treatment plans will often include a combination of strategies to minimize the effects of tremors, but do not eliminate them. The following medications may be used to treat tremor (as listed on MSAA’s website at mymsaa.org under symptoms).
- Atarax®, Vistaril® (hydroxyzine)
- Klonopin® (clonazepam) and Buspar® (buspirone)
- Neurontin® (gabapentin)
- Inderal® (propranolol)
- Zofran® (ondansetron)
- Keppra® (levetiracetam)
- Mysoline® (primidone)
- Laniazid®, Nydrazid® (isoniazid)
Balance Problems in MS
The cerebellum is located in the lower-back region of the brain, and helps to control movement, coordination, balance, and muscle tone. While demyelination in this area can cause tremor for some individuals, it can cause balance problems as well. Other components, such as vision, hearing, and movement of the arms and legs, are also involved in balance. Problems with the functioning of any of these areas can worsen balance, but conversely, some of these areas may be able to compensate for other deficits in balance.
Unlike tremor, balance cannot be treated with medication. The only therapy for balance is through exercise. Physical and occupational therapists will often use an exercise known as patterning when treating balance issues. With patterning, the therapist guides the patient through repeated movements with the idea of retraining the muscles to gain more control and coordination while moving in that same pattern.
Another technique, known as vestibular stimulation, uses motion such as rocking, swinging, or spinning to challenge the brain stem where balance can be affected. This added stimulation helps the balance centers of the brain to function better. Another therapy that may be helpful for individuals who can stand is the SMART Balance Master®. Using a computer, this balance stimulation program tracks the movements of the patient’s feet on the screen and helps to teach the patient how to improve his or her balance.
Schapiro, R. T., Managing the Symptoms of Multiple Sclerosis, 5th edition, (Demos Medical Publishing, 2007)