Unsteady gaze fixation enhances the severity of MS intention tremor

Binocular, Accommodative and Oculomotor Alterations In Multiple Sclerosis: A Review

Multiple sclerosis (MS) is an acquired demyelinating and inflammatory neurodegenerative disease affecting the central nervous system (CNS). Clinical and subclinical ocular disturbances occur in almost all patients with MS. The objective of this narrative review was to collect and summarize the available scientific information on oculomotor, accommodative and binocular alterations that have been reported in MS. A systematic search strategy with the following descriptors was carried out: multiple sclerosis, ocular motility disorders, internuclear ophthalmoplegia, nystagmus, vergences, fixation, pupil reflex, accommodation and stereopsis. According to the search, some oculomotor alterations were found to be commonly reported in MS, such as alterations in saccades and nystagmus. In contrast, accommodative, vergence and stereopsis alterations have not been comprehensively studied despite their relevance, with only minimal evidence showing a potential negative impact of the disease on these aspects. In conclusion, oculomotor impairment is a common component of disability in MS patients and should be considered when managing this type of patients. More research is still needed to know the real impact of this disease on binocular vision and accommodation.

Upper Limb Intention Tremor in Multiple Sclerosis: An Evidence-Based Review of Assessment and Treatment

Background

To present the current knowledge on the characteristics, assessment, and treatment of upper limb intention tremor to inform and improve future intervention studies in patients with multiple sclerosis (MS), we conducted a literature review for articles on upper limb intention tremor in patients with MS.

Methods

Two reviewers conducted searches in PubMed, Web of Science, and MEDLINE (Ovid). Relevant articles, sorted on inclusion criteria, were examined for descriptions and assessments of upper limb intention tremor, and intervention studies were evaluated based on treatment type.

Results

Eight descriptive studies were found reporting on the incidence and severity of tremor, impairments, and lesion load. Ten studies focused on measurement of tremor using various assessments. Intervention studies included eight articles using a diverse set of noninvasive techniques mainly showing transient reduction in tremor amplitude and temporary increase in function. Eighteen studies on pharmacologic interventions were found, with most displaying positive outcomes and mediation of tremor; others showed little to no benefit. Surgical interventions included 17 studies on thalamotomy and 20 on deep brain stimulation. Most studies showed tremor improvement after surgery; however, most sample sizes were small, and interventions were highly invasive, with potential adverse effects resulting from surgery.

Conclusions

The literature on upper limb intention tremor in MS is relatively sparse. More studies are required to determine mechanism of action and to provide more suitable and sustainable interventions to decrease upper limb intention tremor and improve quality of life of individuals with MS.

Efficacy of Balance and Eye-Movement Exercises for Persons With Multiple Sclerosis (BEEMS)

Objective

To determine whether a multifaceted vestibular-related rehabilitation program (Balance and Eye-Movement Exercises for Persons with Multiple Sclerosis; BEEMS) improves balance in persons with MS and whether there are differences in outcomes based on brainstem/cerebellar lesion involvement.

Methods

A 2-arm, examiner-blinded, stratified (involvement vs no involvement of brainstem/cerebellar structures), randomized controlled trial was implemented. Eighty-eight participants were allocated to BEEMS or no treatment control. Computerized Dynamic Posturography-Sensory Organization Test (CDP-SOT) measured balance control. The Dizziness Handicap Inventory (DHI), Modified Fatigue Impact Scale (MFIS), and Short Form-36 Health Status Questionnaire (SF-36) were also administered. Linear mixed models were used to investigate the primary and secondary aims.

Results

From baseline to 6 weeks, BEEMS participants experienced greater improvements compared to control participants in CDP-SOT composite (model-estimated difference in change 4.9, 95% confidence interval 1.39–8.38, p = 0.006), DHI total (−13.5, −17.7 to −7.25, p < 0.0001), MFIS total (−11.4, −15.7 to −7.0, p < 0.0001), SF-36 Mental (5.6, 2.43–8.71, p = 0.0006), and SF-36 Physical (3.5, 1.12–5.81, p = 0.004) scores and from baseline to 14 weeks in CDP-SOT composite (8.3, 4.73–11.9, p < 0.0001), DHI total (−13.9, −19.3 to −8.62, p < 0.0001), MFIS total (−12.3, −16.7 to −7.79, p < 0.0001), SF-36 Mental (3.9, 0.70–7.16, p = 0.02), and SF-36 Physical (3.2, 0.79–5.62, p = 0.01) scores. From baseline to 6 weeks, BEEMS participants with brainstem/cerebellar lesion involvement experienced greater improvements compared to those without in CDP-SOT composite (5.26, 0.34–10.2, p = 0.04) and MFIS total (−7.6, −14.0 to −1.33, p = 0.02) scores.

Conclusion

BEEMS improved multiple outcomes regardless of whether brainstem/cerebellar lesions were present, supporting the generalizability of BEEMS for ambulatory people with MS who have at least minimally impaired balance and fatigue.

Clinical trials.gov identifier

NCT01698086.

Classification of evidence

This study provides Class I evidence that BEEMS training improves dynamic posturography-based balance, dizziness, fatigue, and quality of life in persons with MS.

Cerebellar ataxia: pathophysiology and rehabilitation

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is 'The trainee consistently demonstrates a knowledge of management approaches for specific impairments including spasticity, ataxia.'

Multiple sclerosis. Part I: neuro-ophthalmic manifestations

PURPOSE OF REVIEW

This update includes topics relating to multiple sclerosis (MS) for the ophthalmologist.

RECENT FINDINGS

Interest in the ophthalmology of MS is highlighted by the substantial amount of original research presented at recent medical conferences. At the 2008 World Congress on Treatment and Research in Multiple Sclerosis, 33 of 898 abstract presentations related to ophthalmology. The most represented topics were optical coherence tomography (OCT) and radiology of the visual system (19/33 posters). The 2009 North American neuro-ophthalmologic society (NANOS) conference featured MS-related topics in 6 of 24 platform presentations. This article reviews recent advancements in the neuro-ophthalmology of MS.

SUMMARY

Multiple sclerosis results in various ophthalmic abnormalities. Optic neuritis is the most widely studied visual disturbance in MS, but other unusual visual manifestations such as Charles Bonnet syndrome or the Pulfrich phenomenon also occur. OCT is used to measure thickness of the retinal nerve fiber layer. Because thinning of this layer in MS represents axonal loss, OCT is being used to evaluate neuroprotective treatments. The efferent visual system, in particular the medial longitudinal fasciculus pathway, may be a way to measure body temperature-induced changes in MS.

The effect of levetiracetam on tremor severity and functionality in patients with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) intention tremor is a disabling symptom, which is difficult to treat.

OBJECTIVES

To investigate the effects of levetiracetam, an antiepileptic drug, on tremor severity and related functionality in MS.

METHODS

A randomized, double-blind, placebo-controlled, cross-over study examined the effects of 6 weeks of oral levetiracetam administration (starting dose=250 mg/day, maximal dose=2000 mg/day) in 18 MS patients with disabling intention tremor. Primary outcome was Fahn's Tremor Rating Scale (FTRS) A&B. Secondary outcome measures were the nine-hole peg test, patient's opinion rated with the visual analog scale, FTRS C, and an activities of daily life questionnaire and validated tremor indexes derived during the performance of a digitized spiral drawing task and a wrist step-tracking task. Repeated measures analysis of variance and Friedman tests were applied.

RESULTS

In all, 14 patients completed the trial. Maximal dose intake ranged from 1000 to most commonly 2000 mg, depending on patients' tolerance level. No significant effects of levetiracetam were found for any outcome measure. Further analyses on subgroups with different tremor severity showed no differential effects. Eight patients reported adverse events such as fatigue and stomach ache.

CONCLUSIONS

Levetiracetam intake of 2000 mg/day did not affect tremor severity or functionality in patients with MS.