Thursday, 29 August 2013

Tremor and deep brain stimulation

DBS or deep brain stimulation for MS tremor. #MSBlog #MSResearch

"This is a follow-on post from my recent ClinicSpeak post on tremor and describes a study on the effectiveness of deep brain stimulation on severe MS-related tremor. The results are what they are and should be interpreted in the light of how disabled these MSers are. In short DBS improved self-care (feeding, hygiene, dressing) writing and working. The fact DBS improves feeding tells you how disabling MS-related tremor can be; the majority of the MSers having DBS can't feed themselves. The problem with DBS is that it is very expensive and it is not always possible to get funding to cover the cost of the stimulator and the procedure. You have to request funding on a MSer by MSer basis and MSers are often left in limbo for several months waiting for the outcome of their IFR (individual funding request). The other problem we face is that the threshold for doing the procedure varies from neurosurgeon to neurosurgeon. I have recently had one surgeon say no to one of my MSers, this not only devastated her mood and morale, but questioned my clinical judgement. Fortunately, another neurosurgeon from another center said yes. However, to get this second opinion took months. These are the kinds of trials and tribulations we put our MSers through under the NHS; clearly not an ideal arrangement."

BACKGROUND: Tremor is an important cause of disability and poor quality of life amongst MSers. This study assessed the outcomes of ventral intermediate (VIM) nucleus deep brain stimulation for the treatment of MS-associated tremor at a single centre in a prospective fashion.

METHODS: Sixteen MSers (9 female, 7 male) with a mean age of 41.7 years (range 24-59) underwent surgery. The median duration of MS prior to surgery was 6.5 years and median duration of tremor prior to surgery was 4 years. Case selection was by multidisciplinary assessment with carers, therapists, neurosurgeons and movement disorder neurologists. Tremor was scored pre-operatively and at 6 to 12 months post-operatively using Bain and/or Fahn-Tolosa-Marin systems. The Euro-Qol 5D tool was used to assess quality of life before and after surgery.

RESULTS: The mean tremor reduction was 39 % with a range between 0 and 87 %. Five of 16 MSers achieved at least 50 % tremor reduction and 11 of 16 achieved at least 30 % tremor reduction at last follow up, mean 11.6 months (range 3-80). Tremor was significantly reduced as rated by Bain scores (Wilcoxon matched pairs, Z = 3.07, p = .002) and tended to significance as rated by Fahn scores (Wilcoxon matched pairs, Z = 1.85, p = 0.06). Sub-analysis of activities of daily living measures from the Fahn system showed post-operative improvement in feeding (statistically significant), hygiene, dressing, writing and working. Mean visual analogue scores (0-100) of MSer reported well-being increased from 54.6 to 57.4 post-operatively with a trend to significance (Student's t-test, t = 1.26, p = 0.2). Euro-Qol 5D utility values increased following surgery with a trend to significance which was greater in the group with at least 50 % tremor reduction than in those with none or at least 30 % tremor reduction.

CONCLUSIONS: VIM DBS may reduce severe, disabling tremor in MSers. This tremor reduction tends to be associated with improved quality of life and function in those who respond. MSer reported outcome measures may not correlate with physician rated clinical outcome such as tremor scoring systems and more subtle assessment of these MSers is required.

Other posts on tremor:

24 Aug 2013
"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 ...
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 ...
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 ...
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 ...

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