Multiple Sclerosis Research Unit
Management of Ataxia and Tremor

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Prevalence

Ataxia and tremor are present to some degree in about one third of patients who have MS. About 5% of patients have it as their only or most significant symptom. In these patients the level of disability is particularly high, resulting in loss of independence in even the basic activities of daily life.
Of all the varied symptoms that may occur in MS, ataxia is one of the most disabling. It has an effect on many aspects of daily life such as walking, feeding, eating and dressing. Patients with severe ataxia are often forced to use a wheelchair even though they have sufficient strength in their muscles for walking.

Studies have shown that the degree of ataxia directly relates to the amount of disability the patient has and to their level of dependence:- the greater the level of ataxia, the more disabled the patient and the more dependent the patient is on others for support.

Problems Caused

Ataxic symptoms may be due to lesions affecting sensory pathways leading to loss or inappropriate sensory feedback for movement control or as a result of damage to parts of the brain that control movemenet (cerebellar pathways). It may impair upper limb function leading to a loss of co-ordination and dexterity, and a difficulty in reaching out and grasping accurately. The sufferer will have difficulty managing everyday activities such as writing, dressing, handling money and shopping and caring for their own dependants. Lower limb and truncal ataxia are also common causing difficulty in balance and walking. Some patients have a constant tremor of the head and their speech is affected causing it to be slow and difficult. MS sufferers who have the problems described often feel socially isolated. They are reluctant to integrate in public as every day activities such as eating, talking and shopping ( handling money, writing cheques ) accentuate their symptoms.

Current practice

1. Physiotherapy. The techniques used by the physiotherapist are aimed at improving balance and stability and retraining co-ordinated movement to improve function.
2. Weights. These may be useful for short periods e.g. wearing a weighted wrist band during eating to improve control of cutlery from plate to mouth. When worn for longer periods there is evidence of some increase in ataxic movements after the weights are removed.
3. Riding therapy- for balance and confidence.
4. EMG feedback for re-education of movement.
5. Surgical management- not generally recommended in MS.
6. Medication. Some patients gain some relief of their symptoms by the use of pharmacological treatment but no specific agent is generally used.
   

   Assessment of ataxia

   Ataxia is difficult to assess. It is possible to demonstrate that ataxia is present and where it is present (arms, trunk or legs,) but it is difficult to measure the degree of ataxia. It would be very helpful to be able to measure small changes in ataxia to indicate improvement or deterioration and which factors / therapies affect the degree of ataxia.
   We have been studying a series of timed tests with 25 MS patients with varying degree of upper limb ataxia and with 8 control subjects. Subjects were asked to complete a battery of tests as follows:-

• Timed Tap Test - tapping a computer keyboard
• Timed Reach/ Retrieve Test
• Timed Pronation/ Supination - rotating the forearm as quick as possible
• Finger to Nose Test
• Finger to Target Test
• Jebsen Test of Hand Function - tests everyday activities
• Measurement of Hand Grip Strength

Assessments of upper limb spasticity (Ashworth Scale), range of movement and muscle strength (MRC Scale) were carried out to see whether other symptoms may have an effect on the results. In addition the subjects completed a questionnaire looking at general health, level of function and problems caused by ataxia. We have analysed and written up the results and it would seem that some of the tests used are sensitive to changes in ataxia in patients with MS. Even small changes can be detected and the tests were not affected by muscle weakness.

In view of the serious disability caused by ataxia we plan to continue to develop the assessment and then to use it to measure the efficacy of various treatments aimed at improving ataxia in the hope that further effective strategies may be developed.

Assessment of Tremor
TREMOR. EU TIDE Project No 3216

Description of the project for people with MS or those with an interest in MS.

This programme of work, carried out under the Technology for the Disabled and Elderly (TIDE) programme of the EU has the stated aim: "to improve the treatment of disability caused by tremor through the development of new assistive devices"
Tremor and ataxia (uncoordinated movement) are symptoms of MS, which although not common, can, when they are present, cause considerable difficulties in every-day life. One of the problems in managing tremor is that few drugs that can help, and most of these have unwanted side effects which, although not serious, can give rise to other problems. The European Union (EU) encourages projects that, if successful, can significantly improve the quality of life for people with disabling conditions, and the seriousness of some disabling problems in MS is well recognised. The strength of EU projects is that they bring together the expertise of people from all over Europe so that the greatest possible effort can be applied to solving a problem. The TREMOR project brings together people who have expertise in measurement, treatment and research into MS and tremor. This includes research and development departments of manufacturers who have expertise in developing medical devices.

The project is arranged so that there are groups involved in developing the devices and clinical centres for testing them. The devices themselves- a "jacket" to measure and control arm movement and a joy-stick based device that can be attached to any number of other household or communication devices such as computers, wheelchairs or methods for the remote control of household items etc.-are intended to be affordable easy-to-use systems making the best use of modern electronic expertise. The MS Research Unit in Bristol is one of the centres involved in representing the views of people with MS as possible users of such a system, and in testing the devices.

In conjunction with other MS organisations across Europe we will be trying to gather the views of as many people with MS as possible about the sort of things that would help them most in their daily lives. We will let you have more news of this and of the trials in due course, but in the meantime, if you have any queries, or would like to complete the TREMOR questionnaire please contact us.