Skip to main content

Tremor reduction and quality of life after deep brain stimulation for multiple sclerosis–associated tremor

Abstract

Background

Tremor is an important cause of disability and poor quality of life amongst multiple sclerosis (MS) patients. We assessed the outcomes of ventral intermediate (VIM) nucleus deep brain stimulation for the treatment of multiple sclerosis (MS)–associated tremor at a single centre in a prospective fashion.

Methods

Sixteen patients (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 patients 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 patient 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 patients with MS. This tremor reduction tends to be associated with improved quality of life and function in those who respond. Patient reported outcome measures may not correlate with physician rated clinical outcome such as tremor scoring systems and more subtle assessment of these patients is required.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. Alusi SH, Worthington J, Glickman S, Bain PG (2001) A study of tremor in multiple sclerosis. Brain: J Neurol 124(Pt 4):720–730

    Article  CAS  Google Scholar 

  2. Alusi SH, Worthington J, Glickman S, Findley LJ, Bain PG (2000) Evaluation of three different ways of assessing tremor in multiple sclerosis. J Neurol Neurosurg Psychiatry 68(6):756–760

    PubMed  Article  CAS  Google Scholar 

  3. Bain PG, Findley LJ, Atchison P, Behari M, Vidailhet M, Gresty M, Rothwell JC, Thompson PD, Marsden CD (1993) Assessing tremor severity. J Neurol Neurosurg Psychiatry 56(8):868–873

    PubMed  Article  CAS  Google Scholar 

  4. Benabid AL, Pollak P, Gao D, Hoffmann D, Limousin P, Gay E, Payen I, Benazzouz A (1996) Chronic electrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders. J Neurosurg 84(2):203–214

    PubMed  Article  CAS  Google Scholar 

  5. Berk C, Carr J, Sinden M, Martzke J, Honey CR (2002) Thalamic deep brain stimulation for the treatment of tremor due to multiple sclerosis: a prospective study of tremor and quality of life. J Neurosurg 97(4):815–820

    PubMed  Article  Google Scholar 

  6. Berk C, Carr J, Sinden M, Martzke J, Honey CR (2004) Assessing tremor reduction and quality of life following thalamic deep brain stimulation for the treatment of tremor in multiple sclerosis. J Neurol Neurosurg Psychiatry 75(8):1210, author reply 1210–1

    PubMed  CAS  Google Scholar 

  7. Brooks R (1996) EuroQol: the current state of play. Health Policy (Amsterdam, Netherlands) 37(1):53–72

    Article  CAS  Google Scholar 

  8. Cacciola F, Farah JO, Eldridge PR, Byrne P, Varma TK (2010) Bilateral deep brain stimulation for cervical dystonia: long-term outcome in a series of 10 patients. Neurosurgery 67(4):957–963

    PubMed  Article  Google Scholar 

  9. Craig BM, Busschbach JJV, Salomon JA (2009) Modeling ranking, time trade-off, and visual analog scale values for EQ-5D health states: a review and comparison of methods. Med Care 47(6):634–641

    PubMed  Article  Google Scholar 

  10. Dolan P (1997) Modeling valuations for EuroQol health states. Med Care 35(11):1095–1108

    PubMed  Article  CAS  Google Scholar 

  11. Euroqol group monographs volume 2 (2007) EQ-5D Value Sets: Inventory, Comparative Review and User Guide. 102

  12. Fahn S, Tolosa E, Marin C (1987) Clinical rating scale for tremor. In: Jankovic J, Tolosa E (eds) Parkinson’s disease and movement disorders. Urban and Schwarzenberg, Baltimore, pp 225–234

    Google Scholar 

  13. Fisk JD, Brown MG, Sketris IS, Metz LM, Murray TJ, Stadnyk KJ (2005) A comparison of health utility measures for the evaluation of multiple sclerosis treatments. J Neurol Neurosurg Psychiatry 76(1):58–63

    PubMed  Article  CAS  Google Scholar 

  14. Geny C, Nguyen JP, Pollin B, Feve A, Ricolfi F, Cesaro P, Degos JD (1996) Improvement of severe postural cerebellar tremor in multiple sclerosis by chronic thalamic stimulation. Mov Disord Off J Mov Disord Soc 11(5):489–494

    Article  CAS  Google Scholar 

  15. Hassan A, Ahlskog JE, Rodriguez M, Matsumoto JY (2012) Surgical therapy for multiple sclerosis tremor: a 12-year follow-up study. Eur J Neurol Off J Eur Fed Neurol Soc 19(5):764–768

    CAS  Google Scholar 

  16. Hooper J, Taylor R, Pentland B, Whittle IR (1998) Rater reliability of Fahn’s tremor rating scale in patients with multiple sclerosis. Arch Phys Med Rehabil 79(9):1076–1079

    PubMed  Article  CAS  Google Scholar 

  17. Hooper J, Taylor R, Pentland B, Whittle IR (2002) A prospective study of thalamic deep brain stimulation for the treatment of movement disorders in multiple sclerosis. Br J Neurosurg 16(2):102–109

    PubMed  Article  CAS  Google Scholar 

  18. Hooper J, Whittle IR (2003) Costs of thalamic deep brain stimulation for movement disorders in patients with multiple sclerosis. Br J Neurosurg 17(1):40–45

    PubMed  CAS  Google Scholar 

  19. Hosseini H, Mandat T, Waubant E, Agid Y, Lubetzki C, Lyon-Caen O, Stankoff B, Jedynak P, Cesaro P, Palfi S, Nguyen JP (2012) Unilateral thalamic deep brain stimulation for disabling kinetic tremor in multiple sclerosis. Neurosurgery 70(1):66–69

    PubMed  Article  Google Scholar 

  20. Koch M, Mostert J, Heersema D, De Keyser J (2007) Tremor in multiple sclerosis. J Neurol 254(2):133–145

    PubMed  Article  Google Scholar 

  21. Krauss JK, Simpson RK, Ondo WG, Pohle T, Burgunder JM, Jankovic J (2001) Concepts and methods in chronic thalamic stimulation for treatment of tremor: technique and application. Neurosurgery 48(3):535–541, discussion 541–3

    PubMed  Article  CAS  Google Scholar 

  22. Mandat T, Koziara H, Tutaj M, Rola R, Bonicki W, Nauman P (2010) Thalamic deep brain stimulation for tremor among multiple sclerosis patients. Neurologia i neurochirurgia polska 44(6):542–5

    Google Scholar 

  23. Matsumoto J, Morrow D, Kaufman K, Davis D, Ahlskog JE, Walker A, Sneve D, Noseworthy J, Rodriguez M (2001) Surgical therapy for tremor in multiple sclerosis: an evaluation of outcome measures. Neurology 57(10):1876–1882

    PubMed  Article  CAS  Google Scholar 

  24. McKenna SP, Doward LC, Twiss J, Hagell P, Oprandi NC, Fisk J, Grand’Maison F, Bhan V, Arbizu T, Brassat D, Kohlmann T, Meads DM, Eckert BJ (2010) International development of the patient-reported outcome indices for multiple sclerosis (PRIMUS). Value Health: J Int Soc Pharmacoeconomics Outcome Res 13(8):946–951

    Article  Google Scholar 

  25. Montgomery EB, Baker KB, Kinkel RP, Barnett G (1999) Chronic thalamic stimulation for the tremor of multiple sclerosis. Neurology 53(3):625–628

    PubMed  Article  Google Scholar 

  26. Nguyen JP, Degos JD (1993) Thalamic stimulation and proximal tremor. A specific target in the nucleus ventrointermedius thalami. Arch Neurol 50(5):498–500

    PubMed  Article  CAS  Google Scholar 

  27. Pittock SJ, McClelland RL, Mayr WT, Rodriguez M, Matsumoto JY (2004) Prevalence of tremor in multiple sclerosis and associated disability in the Olmsted County population. Mov Disord: Off J Mov Disord Soc 19(12):1482–1485

    Article  Google Scholar 

  28. Sandyk R, Dann LC (1994) Weak electromagnetic fields attenuate tremor in multiple sclerosis. Int J Neurosci 79(3–4):199–212

    PubMed  Article  CAS  Google Scholar 

  29. Schulder M, Sernas T (1999) Thalamic stimulation in patients with multiple sclerosis. Stereotact Funct Neurosurg 72(2–4):196–201

    PubMed  Article  CAS  Google Scholar 

  30. Schuurman PR, Bosch DA, Merkus MP, Speelman JD (2008) Long-term follow-up of thalamic stimulation versus thalamotomy for tremor suppression. Mov Disord: Off J Mov Disord Soc 23(8):1146–1153

    Article  Google Scholar 

  31. Siegfried J, Lippitz B (1994) Chronic electrical stimulation of the VL-VPL complex and of the pallidum in the treatment of movement disorders: personal experience since 1982. Stereotactic Funct Neurosurg 62(1–4):71–75

    Article  CAS  Google Scholar 

  32. Taha JM, Janszen MA, Favre J (1999) Thalamic deep brain stimulation for the treatment of head, voice, and bilateral limb tremor. J Neurosurg 91(1):68–72

    PubMed  Article  CAS  Google Scholar 

  33. The EuroQol Group (1990) EuroQol–a new facility for the measurement of health-related quality of life. Health Policy (Amsterdam, Netherlands) 16(3):199–208

    Article  Google Scholar 

  34. Thevathasan W, Schweder P, Joint C, Ray N, Pretorius P, Gregory R, Aziz T (2011) Permanent tremor reduction during thalamic stimulation in multiple sclerosis. J Neurol Neurosurg Psychiatry 82(4):419–422

    PubMed  Article  Google Scholar 

  35. Torres CV, Moro E, Lopez-Rios A-L, Hodaie M, Chen R, Laxton AW, Hutchison WD, Dostrovsky JO, Lozano AM (2010) Deep brain stimulation of the ventral intermediate nucleus of the thalamus for tremor in patients with multiple sclerosis. Neurosurgery 67(3):646–651, discussion 651

    PubMed  Article  Google Scholar 

  36. Varma TRK, Eldridge P (2006) Use of the NeuroMate stereotactic robot in a frameless mode for functional neurosurgery. Int J Med Robot Comput Assist Surg: MRCAS 2(2):107–113

    Article  CAS  Google Scholar 

  37. Varma TR, Fox SH, Eldridge PR, Littlechild P, Byrne P, Forster A, Marshall A, Cameron H, McIver K, Fletcher N, Steiger M (2003) Deep brain stimulation of the subthalamic nucleus: effectiveness in advanced Parkinson’s disease patients previously reliant on apomorphine. J Neurol Neurosurg Psychiatry 74(2):170–174

    PubMed  Article  CAS  Google Scholar 

  38. Van Der Walt A, Sung S, Spelman T, Marriott M, Kolbe S, Mitchell P, Evans A, Butzkueven H (2012) A double-blind, randomized, controlled study of botulinum toxin type A in MS-related tremor. Neurology 79(1):92–99

    Article  Google Scholar 

Download references

Acknowledgments

With thanks to Ms P Byrne, theatre nurse, and Ms B Hammersley, clinical nurse specialist

Conflicts of interest

None.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Rasheed Zakaria.

Additional information

Comment

Tremor is a very common and disabling problem in multiple sclerosis (MS). Charcot described tremor as a part of a triad of characteristic symptoms in MS, together with nystagmus, and scanning speech. In MS, tremor can be "postural", namely present whilst voluntarily maintaining an antigravity position or "intention" tremor, occurring during voluntary and visually guided movement directed towards a target object. On the other hand, a true resting tremor present in a body part that is supported against gravity and not voluntarily activated, is unusual in patients with MS.

The pathophysiology of tremor in MS is not entirely known, also because MS is a multifocal disease and tremor cannot always be linked to a specific lesion site. The predominance of action tremors (postural and intention) suggests that the cerebellum and its connections play a main role in tremor production, whereas the rarity of rest tremor argues against an involvement of the basal ganglia. It is likely that lesions of the dentate nucleus or superior cerebellar peduncle may determine the activation of thalamic nuclei, which are the main producers of intention tremor.

Ventral intermediate nucleus (VIM) deep brain stimulation (DBS) is commonly used to treat essential or rubral tremor and has been proposed to treat also tremor in MS. The study of Zakaria and colleagues is a very interesting and well-balanced study on this modern, but controversial topic of functional neurosurgery. Similarly to few other relevant series on this issue, authors recorded a significant early post-operative reduction of tremor, particularly the postural and intentional aspects, but very limited durability of relief and modest impact on quality of life in all patients. This and other studies suggest that the duration of benefit may be as short as 3 months, raising concerns about the cost/benefit ratio of this procedure. Furthermore, as stated by the authors themselves, tremor reduction may sometimes occur spontaneously as a serendipitous consequence of a disease progression, perhaps induced by thalamic lesioning.

Alfredo Conti

Messina, Italy

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Zakaria, R., Vajramani, G., Westmoreland, L. et al. Tremor reduction and quality of life after deep brain stimulation for multiple sclerosis–associated tremor. Acta Neurochir 155, 2359–2364 (2013). https://doi.org/10.1007/s00701-013-1848-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-013-1848-0

Keywords

  • Deep brain stimulation
  • Multiple sclerosis
  • Tremor
  • Quality of life