Saturday, 24 August 2013

Clinic speak: levetiracetam and tremor

Do you suffer from tremor? A new drug to try for cerebellar tremor. #MSBlog #MSResearch #ClinicSpeak

"Tremor, in my opinion is one of the most disabling symptoms in MS. When it involves the pathways to and from  the cerebellum it is called a cerebellar tremor."

"Are there any anatomists out there? The following is for you. A particular type of cerebellar tremor is one that affects the nerve fibres that leave the cerebellum in the so called superior cerebellar peduncles and pass through the midbrain to the thalamus. This tremor has been called a rubral, or red, tremor in the past as the fibres pass through and adjacent to red nucleus in the midbrain. The term we use to describe this tremor now is a cerebellar outflow tremor."

"A cerebellar outflow tremor causes wild flapping movements that prevents you doing any fine motor tasks, for example doing up your buttons and bra clips, or using a pen. Even using a knife and a fork becomes difficult. The occupational therapists are able to give you eating utensils with big handles that may help. Drinking is a problem and this has to be done using a baby cup with a spout or a sealed container with a straw. Getting the spout and straw into your mouth can be difficult. Associated with this tremor is a slurred speech called a dysarthria and shaking or bobbing of the head; this is called titubation. Most MSers who have this type of tremor have unsteadiness of gait called ataxia and are at risk of frequent falls. They may also complain of oscillopsia, which is when your vision bobs up and down due to brain being unable to fix your eyes on a target."

"The following is a video giving you an example of a cerebellar tremor. This person does not have MS, but shows a very mild tremor on the left side that can be compared to the right side that is normal."

"Treating cerebellar tremor is very difficult; medications that we try seldom work and are typically very sedating. Therefore this study below is significant and provides me with another potential drug to try in clinic; levetiracetam. I have not previously tried levetiracetam for cerebellar tremor. Other drugs I use are a combination of baclofen and gabapentin (very sedating), clonazepam (extremely sedating), propranolol (may reduce the amplitude but does not help the intention component), mirtazapine (I am unimpressed with this drug's efficacy), isoniazid (I stopped using this more than a decade ago), etc."

"Diving or sports weights worn at the wrist helps reduce the amplitude of the tremor so that it become less flapping, but this does little to improve the intention component of the tremor, i.e. when you get close to the target the tremor gets worse. If all else fails I refer some MSers to my neurosurgical colleagues for an opinion about having a neurostimulator inserted into a small area of the brain to block the tremor. This only works if the movements that control fine coordination remain intact under the tremor. To assess the latter I grab the arm and hold it so that it is not bobbing up and down from the flapping component of the tremor and I then ask the MSers to do rapid alternating movements of the hand, for example touching the thumb on each finger in turn and repeating the cycle. If this can be done quickly and accurately then a surgical opinion is warranted. Functional neurosurgery works well for a time (3-5 years), but in my experience the tremor usually returns. Why? This type of tremor is typical of progressive MS and as MS progresses the tremor re-emerges. Is it worthwhile having surgery then? Yes having another 3-5 years with good upper limb function can improve your quality of life and allow you to things you want to do. For example, changing your babies nappies or diapers. In 3-5 years time you won't need to do this. And who knows what will happen in the future? What if a DMT emerges for SPMS and PPMS and these can extend the window to 10 years?" 

"I have a policy of spreading the hope. There is always something we can try, and do, for MSers with symptomatic problems. I don't believe in saying there is nothing I can do for you. Making sure MSers with disabilities have hope is very important; remove hope and you destroy their joie de vivre."

Chitsaz et al. Does levetircetam decrease of the rubral tremor in patients with multiple sclerosis. J Res Med Sci. 2013 Mar;18(Suppl 1):S78-80.

BACKGROUND: One of the most disabling MS symptoms is tremor which can cause severe disability and handicap. Treatment of tremor in MSers is still very challenging to manage. In this study, they sought to determine the efficacy of Levetiracetam on treatment of MS-related tremor. Levetiracetam is an anti-convulsant that is used to treat epilepsy. 

MATERIALS AND METHODS: This clinical trial study was conducted among 22 MSers from July 2012 to April 2012 in Alzahra-Hospital, Isfahan, Iran. Patients were given 500 mg Levetiracetam twice a day for 1 week. The drug dosage increased 1000 mg per week until reaching the peak dose of 50 mg/kg. After a 2 week period of washout, first phase was repeated. The subjects were assessed at baseline, after first intervention, after wash-out period, and after second intervention.

RESULTS: A total of 20 MSers(17 females and 3 males) were enrolled in our study. There was a significant difference among tremor rate before and after intervention (P = 0.001). The drug was well tolerated and without any serious side effect during follow-up.

CONCLUSION: Our findings suggest that although Levetiracetam caused a decrease tremor rate in MS, which surged again after washout period.

Other posts on tremor

09 Jul 2012
The 3 main outcomes were the median changes in Bain tremor rating scores for tremor severity, writing, and drawing an Archimedes spiral from baseline to 6 and 12 weeks after treatment with botulinum toxin type A compared ...
29 Jul 2012
OBJECTIVES: Cerebellar tremor is a very disabling sign of MS, and various kinds of treatments have been proposed with different results. Primidone is one of the medications, mostly advised for essential tremor. The aim of ...
19 Jan 2012
Background and purpose: Severe multiple sclerosis (MS) tremor causes disability poorly responsive to medication. Deep brain stimulation (DBS) or thalamotomy can suppress tremor, but long-term outcomes are unclear.
20 Jul 2011
The following NMSS video explains the types of tremors MS'ers may get. The one that is the most disabling is called a cerebellar outflow tremor (aka rubral tremor); this is a course flapping tremor that when severe prevents the ...

22 Jul 2011
Re: "The fewer medicines you take, the better off you'll be." No not really; it is always a trade off between symptoms and their impact on your functioning (activities of daily living, social and occupational) and how effective they ...
24 Jul 2011
What does it mean if a MS symptom (intention tremor) improves in the first few months and then becomes worse than before treatment started? “The expectation of Natalizumab therapy is to prevent future attacks; it does little to ...
02 Jan 2013
People with cerebellar dysfunction have poor balance and co-ordination, slurred speech, jumping eyes or nystagmus and a tremor." Objective: In this study the investigators correlated the anatomical abnormalities in RRMSers ...


  1. Prof G, watch this video and tell me if these kids have what I have:

    You see, I too need a wheelchair at times, but these kids with Ataxia have slurred speech and facial paralysis, things my progressive MS luckily does not feature. Is their Ataxia a different version of MS, or is it pathologically an entirely different ball game? The thing is I m a similar age to the people in the video clip but I have been diagnosed with MS not Ataxia, yet I see similarities.

  2. Prof G, Thank you for the detailed explanation of this troubling symptom. I now understand why touching my nose is part of the neurological examination. Would you give some thought to explaining the 'physical' aspects of a neurological consultation - the tests, the tapping of body parts etc- I would like to know what exactly the neurologist is looking for when each of these tests are performed.

  3. Are there types of tremor in MS that are not as disabling as cerebellar tremor?

  4. There are several Benign essential tremor herbal treatment have been recognized that are effective for recovery of this condition. These herbal remedies are mention as: Fava Beans, Mucuna Pruriens, Lecithin, etc.


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