Question 1

ESSENTIAL TREMORS

Accepted Answer

What is essential tremor?

Essential tremor is a neurological condition that causes rhythmic shaking, most often in the hands and arms. It usually appears during action, such as writing, eating, or holding an object, rather than when the body is fully at rest. Because of this, it is often called an action tremor.¹²

Essential tremor is one of the most common movement disorders worldwide. It can range from very mild to more noticeable over time, and it does not affect intelligence, memory, or awareness. Many people live full lives with essential tremor, especially with appropriate support and treatment options.¹³

How is essential tremor different from other types of tremor?

Not all tremors are the same, and understanding the differences can reduce confusion and anxiety. Essential tremor has specific features that help clinicians distinguish it from other tremor types.¹²

Key differences often include:
 • Essential tremor usually happens during movement or posture holding, not complete rest.¹
 • Parkinsonian tremor often appears at rest and is commonly associated with stiffness and slowed movement.⁴
 • Medication-related or metabolic tremors may begin suddenly and change quickly with treatment adjustments.⁵
Because tremor patterns can overlap, diagnosis is based on a careful history and neurological examination rather than a single test. If there is uncertainty, clinicians may explain what features they are watching over time.¹²

What symptoms are common in essential tremor?

The most common symptom is shaking of the hands, but essential tremor can affect other parts of the body. Symptoms often begin gradually and may affect one side more than the other at first.¹²

Common symptoms include:
 • Tremor of the hands and arms during activities like writing or drinking.¹
 • Shaking of the head, often described as a “yes-yes” or “no-no” motion.²
 • Voice tremor that causes a shaky or quivering sound when speaking.²
 • Tremor that worsens with stress, fatigue, caffeine, or strong emotions.¹
Not everyone experiences all of these symptoms, and severity can vary widely between individuals. Many people notice that tremor intensity fluctuates day to day.¹³

What causes essential tremor?

The exact cause of essential tremor is not fully understood. Research suggests it involves changes in brain circuits that help control movement, particularly those connecting the cerebellum, which helps coordinate motion.¹⁶
Genetics can play a role for many people. Essential tremor often runs in families, and when this happens it is sometimes called familial tremor. However, not everyone with essential tremor has a family history, which suggests multiple contributing factors.¹⁶⁷

How is essential tremor diagnosed?

There is no single blood test or scan that confirms essential tremor. Diagnosis is made clinically, meaning it is based on symptoms, medical history, and a neurological exam.¹²

A clinician may:
 • Observe tremor during specific tasks, such as drawing or holding objects.¹
 • Ask about family history, medications, and when tremor occurs.²
 • Order tests only to rule out other causes, such as thyroid disease or medication effects.⁵
If symptoms do not clearly fit essential tremor, clinicians may explain areas of uncertainty and recommend follow-up over time to see how symptoms evolve.¹²

How does essential tremor affect daily life?

Essential tremor can interfere with fine motor tasks, especially those that require steady hand control. Writing, using utensils, buttoning clothing, or using a phone may become frustrating over time.¹³

Beyond physical tasks, tremor can affect confidence and social comfort. Some people feel self-conscious in public or avoid activities they once enjoyed. Addressing emotional and practical impacts is an important part of care, and clinicians may encourage discussion about both physical symptoms and quality of life.¹³

What treatment options are available for essential tremor?

Treatment depends on how much the tremor affects daily life. Mild tremor may not need medication, while more disruptive tremor may lead to a discussion of additional options.¹²

Common treatment categories include:
 • Medications such as propranolol or primidone, which can reduce tremor severity for some people.¹⁸
 • Lifestyle adjustments, including managing stress, sleep, and caffeine intake.¹
 • Assistive strategies, such as weighted utensils or adaptive tools.¹³
No treatment works for everyone, and benefits may change over time. Clinicians often explain that treatment decisions are about balancing symptom relief with side effects and personal priorities.¹²

When is deep brain stimulation considered for essential tremor?

Deep brain stimulation, or DBS, may be discussed when tremor is severe, disabling, and no longer responds well to medications. DBS involves delivering electrical stimulation to specific brain areas involved in tremor circuits.⁹¹⁰

DBS does not cure essential tremor, but it can significantly reduce tremor in carefully selected individuals. Evaluation usually includes movement disorder specialists, imaging, and detailed discussions about goals, risks, and long-term follow-up. Availability and approval criteria can vary by country and healthcare system.⁹¹¹

What questions might be helpful to discuss with a clinician?

Preparing questions can help people feel more confident during medical visits. These conversations are about shared understanding, not rushing decisions.¹²

Helpful questions may include:
 • What type of tremor do you think this is, and why?¹²
 • How do we measure whether treatment is helping enough?¹
 • What are the benefits and limitations of each treatment option for my situation?⁸
 • When should we reconsider the plan if symptoms change?¹³
SAFETY NOTE
If tremor symptoms appear suddenly, worsen rapidly, or are accompanied by weakness, confusion, severe headache, or other urgent neurological changes, seek emergency medical care right away.

GLOSSARY
Action tremor: Shaking that occurs during voluntary movement or when holding a posture.
Cerebellum: A part of the brain that helps coordinate movement, balance, and precision.
Deep brain stimulation (DBS): A surgical therapy that delivers electrical stimulation to specific brain areas to reduce symptoms.
Essential tremor: A common neurological condition causing rhythmic shaking, usually during movement.
Familial tremor: Essential tremor that runs in families, suggesting a genetic contribution.
Movement disorder: A neurological condition that affects the speed, smoothness, or control of movement.
Neurological examination: A clinical assessment of movement, reflexes, sensation, and coordination.

REFERENCES
1. Louis ED, Ferreira JJ. How common is the most common adult movement disorder? Update on the worldwide prevalence of essential tremor. Mov Disord. 2010;25(5):534-541. https://doi.org/10.1002/mds.22838()
2. Deuschl G, Bain P, Brin M. Consensus statement of the Movement Disorder Society on tremor. Mov Disord. 1998;13(suppl 3):2-23. https://doi.org/10.1002/mds.870131303()
3. Haubenberger D, Hallett M. Essential tremor. N Engl J Med. 2018;378(19):1802-1810. https://www.nejm.org/doi/full/10.1056/NEJMcp1707928(https://www.nejm.org/doi/full/10.1056/NEJMcp1707928)
4. Jankovic J. Parkinson’s disease: clinical features and diagnosis. J Neurol Neurosurg Psychiatry. 2008;79(4):368-376. https://jnnp.bmj.com/content/79/4/368(https://jnnp.bmj.com/content/79/4/368)
5. Bain PG. Tremor. Pract Neurol. 2007;7(1):16-26. https://pn.bmj.com/content/7/1/16(https://pn.bmj.com/content/7/1/16)
6. Louis ED. Essential tremor. Lancet Neurol. 2005;4(2):100-110. https://doi.org/10.1016/S1474-4422(05)00991-9()
7. Thenganatt MA, Louis ED. Linking essential tremor to the cerebellum. J Neurol Sci. 2012;320(1-2):1-5. https://doi.org/10.1016/j.jns.2012.06.009()
8. Zesiewicz TA, et al. Evidence-based guideline update: treatment of essential tremor. Neurology. 2011;77(19):1752-1755. https://www.neurology.org/content/77/19/1752()
9. Benabid AL, et al. Long-term suppression of tremor by chronic stimulation of the ventral intermediate thalamic nucleus. Lancet. 1991;337(8738):403-406. https://doi.org/10.1016/0140-6736(91)91175-T()
10. Fasano A, Deuschl G. Therapeutic advances in tremor. Mov Disord. 2015;30(11):1557-1565. https://doi.org/10.1002/mds.26361()
11. U.S. Food and Drug Administration. Deep Brain Stimulation for Essential Tremor. Accessed January 2026. https://www.fda.gov/medical-devices/neurological-devices/deep-brain-stimulation()
12. Bhatia KP, et al. Consensus statement on the classification of tremors. Mov Disord. 2018;33(1):75-87. https://doi.org/10.1002/mds.27121()
13. National Institute of Neurological Disorders and Stroke. Essential Tremor Fact Sheet. Accessed January 2026. https://www.ninds.nih.gov/health-information/disorders/essential-tremor()

Question 2

CEREBRAL TREMORS

Accepted Answer

What does the term “cerebral tremors” mean?

The term “cerebral tremors” is not a formal medical diagnosis used in most clinical guidelines. It is often used informally to describe tremors that originate from changes or dysfunction in the brain rather than from muscles, nerves in the arms or legs, or temporary factors like medication effects.¹²
In clinical practice, clinicians usually describe tremors by their specific type and cause, such as essential tremor, Parkinsonian tremor, cerebellar tremor, or dystonic tremor. When someone hears the phrase “cerebral tremor,” it often reflects a general idea that the tremor is brain-based, but further clarification is usually needed.¹³

Are all tremors related to the brain?

All tremors involve the brain at some level, because movement is controlled by brain circuits. However, not all tremors are caused by structural or functional changes within the brain itself. Some tremors are linked to medications, metabolic conditions, or peripheral nerve issues.¹²

Tremors more often described as brain-based involve disruptions in circuits connecting areas such as the cerebellum, thalamus, basal ganglia, and motor cortex. These regions work together to smooth and coordinate movement. When signaling becomes irregular, rhythmic shaking can appear.²⁴

What conditions are commonly associated with cerebral tremors?

Several well-defined neurological conditions may be described informally as “cerebral tremors” because their origin lies in brain circuitry. These conditions differ in symptoms, progression, and treatment approach.¹²

Common examples include:
 • Essential tremor, which is associated with abnormal signaling in cerebellar-thalamic circuits.³⁵
 • Parkinson’s disease tremor, related to changes in basal ganglia dopamine pathways.⁶
 • Cerebellar tremor, often caused by stroke, multiple sclerosis, tumor, or injury affecting the 		cerebellum.⁴⁷
 • Dystonic tremor, which occurs in the setting of abnormal muscle contractions driven by brain signaling.¹

Because symptoms can overlap, clinicians focus on pattern, timing, associated features, and progression rather than terminology alone.¹²

How are cerebral tremors evaluated and diagnosed?

There is no single test that confirms a cerebral tremor. Diagnosis relies on a careful neurological evaluation that looks at how the tremor behaves and what other signs are present.¹²

Evaluation commonly includes:
 • A detailed history, including when the tremor occurs, how it started, and what worsens or improves it.¹
 • A neurological exam assessing posture, movement, coordination, and muscle tone.²
 • Imaging or lab tests only when needed to rule out structural brain injury, metabolic causes, or medication effects.⁴⁷
If the cause is uncertain, clinicians may explain what diagnoses are being considered and recommend follow-up over time to watch how symptoms evolve. This stepwise approach is common and appropriate.¹²

How do cerebral tremors affect daily life?

Brain-based tremors can interfere with daily activities that require steady, coordinated movement. Writing, eating, speaking, or holding objects may become difficult depending on the tremor type and severity.³⁵

Emotional and social effects are also common. People may feel frustration, embarrassment, or fatigue from constantly compensating for tremor. Addressing both physical function and quality of life is an important part of care, and clinicians often encourage open discussion of these impacts.³⁸

What treatment approaches are used for cerebral tremors?

Treatment depends on the underlying tremor type, severity, and how much it affects daily life. Not all cerebral tremors require treatment, especially if symptoms are mild.¹²

Treatment options may include:
 • Medications that modify brain signaling, such as beta blockers or antiseizure medications for essential tremor.⁵⁹
 • Treatment of the underlying neurological condition, such as Parkinson’s disease therapies when appropriate.⁶
 • Rehabilitation strategies, including occupational therapy and adaptive tools.³⁸
Response to treatment varies, and clinicians often explain that adjustments over time are common as symptoms or priorities change.¹²

When is deep brain stimulation considered?

Deep brain stimulation, or DBS, may be considered for certain brain-based tremors that are severe, disabling, and no longer respond adequately to medication. DBS delivers electrical stimulation to specific brain targets involved in tremor circuits, such as the thalamus.¹⁰¹¹

DBS does not cure the underlying condition, but it can significantly reduce tremor severity in carefully selected individuals. Evaluation includes specialist assessment, imaging, and discussion of goals and risks. Availability, device options, and approval pathways differ internationally, with regulatory processes varying across regions.¹⁰¹²

What questions may help clarify a diagnosis labeled as “cerebral tremor”?

Because “cerebral tremor” is a broad, nonstandard term, asking clarifying questions can support shared understanding. These conversations help align expectations and next steps.¹²

Helpful questions may include:
 • What specific tremor type best fits my symptoms?¹
 • Which brain circuits do you think are involved?²
 • How will we know if the diagnosis needs to be reconsidered over time?¹²
 • What treatment options match my current goals and daily challenges?³⁸
SAFETY NOTE
If tremor begins suddenly, worsens rapidly, or occurs with weakness, vision changes, confusion, severe headache, or other urgent neurological symptoms, seek emergency medical care immediately.

GLOSSARY

Basal ganglia: Deep brain structures involved in movement control and coordination.
Cerebellum: A region of the brain that fine-tunes movement, balance, and timing.
Cerebellar tremor: A tremor caused by damage or dysfunction of the cerebellum.
Cerebral tremor: A nonstandard term often used to describe tremors originating from brain-based movement circuits.
Deep brain stimulation (DBS): A surgical therapy that delivers electrical stimulation to targeted brain areas to reduce symptoms.
Dystonic tremor: Tremor occurring in a body part affected by dystonia, a condition with involuntary muscle contractions.
Thalamus: A brain structure that relays motor and sensory signals and plays a key role in tremor circuits.
REFERENCES
1. Deuschl G, Bain P, Brin M. Consensus statement of the Movement Disorder Society on tremor. Mov Disord. 1998;13(suppl 3):2–23. https://doi.org/10.1002/mds.870131303()
2. Bhatia KP, et al. Consensus statement on the classification of tremors. Mov Disord. 2018;33(1):75–87. https://doi.org/10.1002/mds.27121()
3. Haubenberger D, Hallett M. Essential tremor. N Engl J Med. 2018;378(19):1802–1810. https://www.nejm.org/doi/full/10.1056/NEJMcp1707928(https://www.nejm.org/doi/full/10.1056/NEJMcp1707928)
4. Thenganatt MA, Louis ED. Linking essential tremor to the cerebellum. J Neurol Sci. 2012;320(1–2):1–5. https://doi.org/10.1016/j.jns.2012.06.009()
5. Zesiewicz TA, et al. Evidence-based guideline update: treatment of essential tremor. Neurology. 2011;77(19):1752–1755. https://www.neurology.org/content/77/19/1752()
6. Jankovic J. Parkinson’s disease: clinical features and diagnosis. J Neurol Neurosurg Psychiatry. 2008;79(4):368–376. https://jnnp.bmj.com/content/79/4/368(https://jnnp.bmj.com/content/79/4/368)
7. Alusi SH, Worthington J, Glickman S, Findley LJ. A study of tremor in multiple sclerosis. Brain. 2001;124(Pt 4):720–730. https://doi.org/10.1093/brain/124.4.720()
8. National Institute of Neurological Disorders and Stroke. Tremor Fact Sheet. Accessed January 2026. https://www.ninds.nih.gov/health-information/disorders/tremor(https://www.ninds.nih.gov/health-information/disorders/tremor)
9. Louis ED. Essential tremor. Lancet Neurol. 2005;4(2):100–110. https://doi.org/10.1016/S1474-4422(05)00991-9()
10. Benabid AL, et al. Long-term suppression of tremor by chronic stimulation of the ventral intermediate thalamic nucleus. Lancet. 1991;337(8738):403–406. https://doi.org/10.1016/0140-6736(91)91175-T()
11. Fasano A, Deuschl G. Therapeutic advances in tremor. Mov Disord. 2015;30(11):1557–1565. https://doi.org/10.1002/mds.26361()
12. U.S. Food and Drug Administration. Deep Brain Stimulation for Tremor. Accessed January 2026. https://www.fda.gov/medical-devices/neurological-devices/deep-brain-stimulation()

Question 3

MULTIPLE SCHLEROSIS RELATED TREMOR

Accepted Answer

What is multiple sclerosis related tremor?

Multiple sclerosis related tremor refers to involuntary rhythmic or irregular shaking caused by damage to brain and spinal cord pathways affected by MS. MS is an immune-mediated disease in which inflammation and demyelination disrupt how nerve signals travel. When this disruption affects circuits responsible for coordination and timing, tremor can emerge.¹²

Unlike primary tremor disorders, MS-related tremor develops in the context of a known neurological disease. Tremor may appear years after MS diagnosis or, less commonly, be an early symptom. Its presence does not always reflect overall disease severity, which can be confusing and distressing for patients.¹³

How common is tremor in multiple sclerosis?
Tremor is a well-recognized but variable symptom in MS. Large observational studies suggest that approximately one quarter to over half of people with MS experience some degree of tremor during the course of the disease.¹⁴⁵

Most MS-related tremor is mild. Moderate to severe tremor is less common but can be highly disabling. Importantly, tremor severity does not consistently correlate with relapse frequency, MRI lesion count, or walking ability, highlighting that tremor follows its own clinical course within MS.¹⁴⁶

What types of tremor occur most often in multiple sclerosis?
MS-related tremor most often reflects involvement of cerebellar pathways. The cerebellum plays a central role in coordinating movement, adjusting force, and correcting errors. Damage to this system leads to tremor that appears during movement rather than at rest.¹²⁷

Common tremor types in MS include:
 • Intention tremor, which worsens as the hand or arm approaches a target, such as a cup or touchscreen.¹⁴⁷
 • Action tremor, which appears during voluntary movement and may affect arms, head, or trunk.¹²
 • Postural tremor, which occurs while holding a position against gravity.¹²

Pure rest tremor is uncommon in MS and may prompt clinicians to evaluate for additional conditions, such as Parkinson’s disease or medication effects.¹²

Why does multiple sclerosis cause tremor?
Tremor in MS is most strongly associated with lesions involving the cerebellum, brainstem, and cerebellothalamocortical pathways. These networks normally synchronize movement timing and suppress unwanted oscillations. When demyelination disrupts signal timing, rhythmic instability can develop.²⁷⁸

Evidence from imaging and neurophysiology studies suggests that MS tremor is a network disorder rather than the result of a single lesion. This explains why tremor severity can fluctuate and why treatment responses are often incomplete or unpredictable.²⁷⁹

How is MS-related tremor different from essential tremor?
MS-related tremor and essential tremor can appear similar during action, but they arise from different mechanisms. Essential tremor is a primary tremor disorder, often familial, and typically occurs without other neurological deficits.¹⁰¹¹

In contrast, MS-related tremor occurs alongside other signs of central nervous system dysfunction, such as imbalance, speech changes, weakness, or sensory loss. Clinicians distinguish the two by considering the full neurological picture, MRI findings, and symptom evolution, not tremor alone.¹²¹⁴

How is multiple sclerosis related tremor evaluated?
Evaluation begins with a detailed history focusing on when tremor occurs, what worsens it, which body parts are involved, and how it affects daily activities. Because fatigue, stress, and heat sensitivity can worsen MS symptoms, these factors are also reviewed.¹²

Neurological examination assesses coordination, gait, posture, speech, and limb control. MRI findings often provide supportive information, especially when cerebellar or brainstem lesions are present. Additional tests are typically used to rule out other contributors rather than to confirm tremor itself.¹²⁷

How does MS-related tremor affect daily life?
MS-related tremor can significantly interfere with activities requiring precision, including eating, writing, typing, dressing, and using tools. Symptoms may worsen with fatigue, illness, or heat, which are already common challenges in MS.¹³⁵

The emotional impact is substantial. Many people report frustration, embarrassment, or loss of independence. Tremor can also limit employment and social participation. Addressing quality of life is as important as addressing physical symptoms when planning care.¹³¹⁴

What treatment options are available for MS-related tremor?
Treatment of MS-related tremor is challenging. Medications effective for essential tremor often provide limited benefit. As a result, treatment plans are usually individualized and focused on symptom reduction rather than elimination.¹⁴¹⁵

Medications that may be discussed include:
 • Antiseizure medications such as gabapentin or primidone, with variable benefit.¹⁴¹⁵
 • Isoniazid in carefully selected and monitored cases, limited by potential toxicity.¹⁶
 • Other agents tried off-label when symptoms are severe and refractory.¹²

Clinicians often explain that medication trials require patience and careful monitoring, and that partial improvement is a realistic goal.¹²

What non-medication strategies can support daily function?
Non-pharmacologic strategies are a cornerstone of care for MS-related tremor. These approaches aim to reduce effort, increase stability, and conserve energy.¹³

Helpful supports may include:
 • Occupational therapy focused on adaptive techniques and environmental modifications.¹³
 • Weighted utensils, wrist weights, or bracing to dampen tremor during tasks.¹³
 • Stabilization strategies, such as supporting the arms against the body or a surface.¹³

These interventions are often combined and adjusted over time as symptoms evolve.¹³

When is deep brain stimulation considered for MS-related tremor?
Deep brain stimulation, or DBS, may be considered for individuals with severe, disabling MS-related tremor that does not respond to medication or supportive strategies. DBS most commonly targets the ventral intermediate nucleus of the thalamus, a key node in tremor circuitry.¹⁷¹⁸

Evidence for DBS in MS tremor is less robust than for essential tremor. Studies and case series show variable outcomes, with some individuals experiencing meaningful improvement and others limited or temporary benefit. Careful selection, clear goal setting, and discussion of limitations are essential.¹⁷¹⁹

DBS for MS-related tremor is considered off-label in many countries. Access, funding, and evaluation criteria vary by region and healthcare system.¹⁸¹⁹

What questions can help guide conversations with a medical team?
Because MS-related tremor is complex, clear questions can help align expectations and next steps. These discussions support shared decision-making rather than rushed choices.¹²

Questions that may be helpful include:
 • Which tremor type best explains my symptoms, and what supports that conclusion?¹²
 • Are my MRI findings likely contributing to tremor severity?²⁷
 • What improvement is realistic with medication or therapy?¹²
 • When should referral to a movement disorder specialist be considered?¹⁷
 • If DBS is discussed, what benefits and limitations apply specifically in MS?¹⁷¹⁹
SAFETY NOTE
If tremor or coordination problems worsen suddenly, or occur with new weakness, vision changes, confusion, severe headache, or repeated falls, seek emergency medical care immediately.

GLOSSARY
Action tremor: Tremor that occurs during voluntary movement.
Cerebellum: The brain region that coordinates timing, balance, and precision of movement.
Deep brain stimulation (DBS): A therapy that uses implanted electrodes to deliver electrical stimulation to targeted brain regions.
Demyelination: Damage to myelin, the protective covering of nerve fibers, which disrupts nerve signal transmission.
Intention tremor: Tremor that increases as movement approaches a target.
Multiple sclerosis (MS): A chronic immune-mediated disease affecting the brain and spinal cord.
Postural tremor: Tremor that occurs while holding a position against gravity.
Thalamus: A deep brain structure that relays motor signals and is a common DBS target for tremor.

REFERENCES
1. Alusi SH, Worthington J, Glickman S, Findley LJ. Tremor in multiple sclerosis. Brain. 2001;124(Pt 4):720-730. https://doi.org/10.1093/brain/124.4.720()
2. Koch M, Mostert J, Heersema D, De Keyser J. Tremor in multiple sclerosis. J Neurol. 2007;254(2):133-145. https://doi.org/10.1007/s00415-006-0307-2()
3. Pittock SJ, McClelland RL, Mayr WT, et al. Tremor in multiple sclerosis. Neurology. 2004;62(6):1021-1023. https://doi.org/10.1212/01.WNL.0000115477.23177.2A()
4. National Multiple Sclerosis Society. Tremor. Accessed January 15, 2026. https://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Tremor()
5. Deuschl G, Bain P, Brin M. Consensus statement of the Movement Disorder Society on tremor. Mov Disord. 1998;13(suppl 3):2-23. https://doi.org/10.1002/mds.870131303()
6. Bhatia KP, Bain P, Bajaj N, et al. Consensus statement on the classification of tremors. Mov Disord. 2018;33(1):75-87. https://doi.org/10.1002/mds.27121()
7. Kakei S, Aoki T, Watanabe K. Pathophysiology of cerebellar tremor. Front Neurol. 2021;12:694653. https://doi.org/10.3389/fneur.2021.694653(https://doi.org/10.3389/fneur.2021.694653)
8. Makhoul K, Jankovic J. Tremor in multiple sclerosis: an overview and future perspectives. Front Neurol. 2020;11:610. https://pmc.ncbi.nlm.nih.gov/articles/PMC7601003/(https://pmc.ncbi.nlm.nih.gov/articles/PMC7601003/?utm_source=chatgpt.com)
9. Zesiewicz TA, et al. Evidence-based guideline update: treatment of essential tremor. Neurology. 2011;77(19):1752-1755. https://www.neurology.org/content/77/19/1752()
10. Thompson AJ, et al. Isoniazid treatment of action tremor in multiple sclerosis. J Neurol Neurosurg Psychiatry. 1986;49(8):877-880. https://jnnp.bmj.com/content/49/8/877()
11. Benabid AL, Pollak P, Gervason C, et al. Thalamic stimulation for tremor in multiple sclerosis. Lancet. 1996;347(9003):571-574. https://doi.org/10.1016/S0140-6736(96)91238-9()
12. Lyons MK, Evidente VG. Deep brain stimulation for tremor in multiple sclerosis. Tremor Other Hyperkinet Mov (N Y). 2014;4:254. https://doi.org/10.7916/D8WM1C8V()

Question 4

SEVERE ORTHOSTATIC TREMORS

Accepted Answer

What is severe orthostatic tremor?

Severe orthostatic tremor is a rare neurological movement disorder that causes a rapid tremor in the legs and trunk when standing still. The tremor typically improves or disappears when a person sits, leans, or starts walking.¹²

The tremor is often not visible to the eye because it occurs at a very high frequency. Instead, people usually feel intense unsteadiness, shaking, or an urgent need to sit down. Over time, this can significantly limit daily activities and independence.¹³

What makes orthostatic tremor “severe”?

Orthostatic tremor is considered severe when symptoms are frequent, intense, and interfere with basic activities like standing in line, cooking, or showering. The severity is based on functional impact rather than tremor frequency alone.¹²

People with severe orthostatic tremor may avoid standing tasks altogether or rely heavily on supports such as counters, walkers, or stools. Emotional strain is common, especially when symptoms are misunderstood or mistaken for anxiety or balance problems.³

How is orthostatic tremor different from other tremors?

Orthostatic tremor has unique features that distinguish it from more common tremor conditions. The most important difference is that symptoms are triggered specifically by standing still.¹²

Key distinguishing features include:
 • Tremor occurs almost exclusively during standing, not sitting or lying down.¹
 • Tremor frequency is very high, often around 13 to 18 Hz, which is faster than most other tremors.²⁴
 • Symptoms improve with walking, leaning, or sitting, rather than worsening with movement.¹
These features help clinicians separate orthostatic tremor from essential tremor, Parkinsonian tremor, and balance disorders.¹²

What symptoms do people with severe orthostatic tremor experience?

Symptoms are often described as a feeling of vibration or shaking deep in the legs rather than visible shaking. Many people describe a sense that their legs might give out, even though true muscle weakness is not present.¹³

Common symptoms include:
 • Intense unsteadiness when standing still.¹
 • A sensation of rapid leg vibration or buzzing.²
 • Anxiety or fear related to standing situations due to symptom unpredictability.³
 • Relief when sitting, leaning on an object, or walking.¹
Symptoms may gradually worsen over years, but progression patterns vary widely between individuals.¹³

What causes severe orthostatic tremor?

The exact cause of orthostatic tremor is not fully understood. Research suggests it involves abnormal synchronization of brain circuits responsible for posture and balance, particularly connections between the cerebellum, brainstem, and motor cortex.²⁵

Most cases are considered primary, meaning they occur without another neurological disease. Less commonly, orthostatic tremor may occur alongside other conditions, such as Parkinson’s disease or cerebellar disorders. When this happens, it is sometimes called secondary orthostatic tremor.¹²

How is severe orthostatic tremor diagnosed?

Diagnosis is based on clinical history, neurological examination, and specialized testing. Because the tremor is often invisible, it is frequently missed or misdiagnosed early on.¹²

A key diagnostic tool is surface electromyography, or EMG. EMG records muscle activity and can detect the characteristic high-frequency tremor pattern seen in orthostatic tremor.²⁴
Clinicians may also order imaging or lab tests to rule out other causes of unsteadiness or tremor. If there is uncertainty, follow-up over time is common and appropriate.¹²

How does severe orthostatic tremor affect daily life?

Daily life is often shaped around avoiding prolonged standing. Tasks such as grocery shopping, cooking, brushing teeth, or waiting in line can become exhausting or stressful.¹³

Many people adapt by planning frequent sitting breaks or using mobility aids. While these strategies are practical, the condition can still affect confidence, social participation, and quality of life. Open discussion of these impacts is an important part of care.³

What treatment options are available for severe orthostatic tremor?

Treatment focuses on reducing symptoms and improving function. No single therapy works for everyone, and responses can vary widely.¹²

Medications commonly discussed include:
 • Clonazepam, which may reduce tremor intensity in some people.¹⁶
 • Gabapentin or other antiseizure medications, which have shown benefit in small studies.⁶⁷
 • Other medications tried on a case-by-case basis when first options are ineffective.¹²
Clinicians often explain that finding the right medication and dose may take time and careful monitoring for side effects.¹²

When is deep brain stimulation considered for severe orthostatic tremor?

Deep brain stimulation, or DBS, may be discussed in rare cases when orthostatic tremor is severe, disabling, and does not respond adequately to medication. Evidence is limited because the condition is rare, but case reports and small series suggest potential benefit in selected individuals.⁸⁹

DBS typically targets brain regions involved in tremor circuits, such as the thalamus. This therapy does not cure orthostatic tremor, but it may reduce symptom severity and improve standing tolerance in some people.⁸⁹

DBS availability, indications, and approval pathways vary by country. In many regions, DBS for orthostatic tremor is considered off-label and requires individualized specialist review.⁹¹⁰

What supportive strategies can help alongside medical treatment?

Supportive strategies can make a meaningful difference, even when tremor is neurological. These approaches focus on safety, energy conservation, and confidence.¹³

Helpful strategies may include:
 • Using stools, high chairs, or perching seats for standing tasks.¹
 • Leaning on stable surfaces to reduce symptom intensity.¹
 • Occupational therapy to adapt daily routines and environments.³
 • Tracking symptom patterns to support treatment discussions.¹²

What questions may help guide conversations with a clinician?

Clear questions can help align expectations and reduce uncertainty, especially with a rare condition like severe orthostatic tremor.¹²

Questions that may be helpful include:
 • What features support orthostatic tremor in my case?¹²
 • Has EMG testing been done or considered?²⁴
 • Which treatments are most appropriate to try first, and why?¹²
 • When should we revisit the plan if symptoms change?¹³
 • Under what circumstances might referral to a movement disorder specialist be helpful?¹²
SAFETY NOTE
If unsteadiness or tremor appears suddenly, worsens rapidly, or is accompanied by weakness, confusion, vision changes, severe headache, or falls with injury, seek emergency medical care right away.

GLOSSARY
Clonazepam: A medication in the benzodiazepine class sometimes used to reduce tremor symptoms.
Electromyography (EMG): A test that records muscle electrical activity to identify abnormal tremor patterns.
High-frequency tremor: A very rapid tremor, often not visible to the eye, measured in cycles per second.
Orthostatic tremor: A rare neurological tremor that occurs primarily when standing still.
Secondary orthostatic tremor: Orthostatic tremor occurring alongside another neurological condition.
Thalamus: A brain structure that relays movement signals and is a common DBS target for tremor.
REFERENCES
1. Deuschl G, Bain P, Brin M. Consensus statement of the Movement Disorder Society on tremor. Mov Disord. 1998;13(suppl 3):2-23. https://doi.org/10.1002/mds.870131303()
2. Bhatia KP, Bain P, Bajaj N, et al. Consensus statement on the classification of tremors. Mov Disord. 2018;33(1):75-87. https://doi.org/10.1002/mds.27121()
3. Hassan A, van Gerpen JA. Orthostatic tremor and orthostatic myoclonus: weight-bearing hyperkinetic disorders. Tremor Other Hyperkinet Mov (N Y). 2016;6:417. https://doi.org/10.7916/D8KD1X0B()
4. McManis PG, Sharbrough FW. Orthostatic tremor: clinical and electrophysiologic characteristics. Muscle Nerve. 1993;16(11):1254-1260. https://doi.org/10.1002/mus.880161111()
5. Wills AJ, Sawle GV, Guilbert PR. A neurophysiological study of primary orthostatic tremor. Brain. 1996;119(Pt 4):1287-1296. https://doi.org/10.1093/brain/119.4.1287()
6. Gerschlager W, Münchau A, Katzenschlager R, Brown P, Rothwell JC. Natural history and syndromic associations of orthostatic tremor. Brain. 2004;127(Pt 3):671-679. https://doi.org/10.1093/brain/awh073()
7. Piboolnurak P, Lang AE. Orthostatic tremor: clinical features, pathophysiology, and treatment. Parkinsonism Relat Disord. 2005;11(2):83-90. https://doi.org/10.1016/j.parkreldis.2004.08.006()
8. Espay AJ, Duker AP, Chen R, et al. Deep brain stimulation of the ventral intermediate nucleus of the thalamus in orthostatic tremor. Neurology. 2008;71(3):206-208. https://doi.org/10.1212/01.wnl.0000318297.74410.8a()
9. Lyons MK, Boucher OK, Evidente VG. Deep brain stimulation of the thalamus for orthostatic tremor. Neurology. 2012;79(11):1140-1142. https://doi.org/10.1212/WNL.0b013e3182698d41()
10. National Institute of Neurological Disorders and Stroke. Tremor. Accessed January 15, 2026. https://www.ninds.nih.gov/health-information/disorders/tremor(https://www.ninds.nih.gov/health-information/disorders/tremor)

Question 5

TREMORS FROM MID-BRAIN LESIONS

Accepted Answer

What are midbrain and brainstem lesion related tremors?
Midbrain and brainstem lesion related tremors are involuntary rhythmic or irregular movements that arise after damage to deep structures in the brainstem region. These structures serve as critical relay centers between the cerebellum, basal ganglia, thalamus, and motor cortex. When lesions disrupt these connections, movement control becomes unstable and tremor can emerge.¹²

These tremors are classified as secondary tremors, meaning they develop as a consequence of an identifiable neurological injury rather than as a primary movement disorder. Causes include stroke, traumatic brain injury, multiple sclerosis, tumors, infections, vascular malformations, or surgical injury. Symptoms may appear immediately or be delayed by weeks to months as neural circuits reorganize.¹³⁴

Why are the midbrain and brainstem so important for tremor control?

The midbrain and brainstem act as crossroads for multiple motor pathways. Signals controlling posture, tone, coordination, and voluntary movement pass through these regions continuously. Even small lesions can interrupt timing and synchronization across several networks at once.²⁵

Key circuits affected often include cerebellothalamocortical pathways, which refine movement accuracy, and connections involving the red nucleus, inferior olive, and basal ganglia. Disruption across these networks can produce large, slow, and difficult-to-control tremors that differ from more common tremor disorders.²⁶⁷

What types of tremor patterns are seen with midbrain and brainstem lesions?
Tremors caused by lesions in these regions often show mixed features. This means the tremor may be present at rest, during posture holding, and with voluntary movement. This mixed presentation reflects injury to overlapping motor circuits rather than a single tremor generator.¹²

Common patterns include:
 • Holmes tremor, characterized by a combination of rest, postural, and intention tremor.⁸⁹
 • Intention tremor, which worsens as a limb approaches a target, reflecting cerebellar pathway involvement.²
 • Postural tremor, present when holding a limb against gravity.¹

Because overlap is common, clinicians focus on tremor behavior, timing, and lesion anatomy rather than relying on tremor labels alone.¹²

What is Holmes tremor and how does it develop?

Holmes tremor is a rare but classic lesion-related tremor most often associated with damage to the midbrain, thalamus, or brainstem connections. It typically develops weeks to months after the original injury, rather than immediately, suggesting delayed network reorganization plays a role.⁸⁹¹⁰

Holmes tremor is usually slow, often below 4.5 Hz, and high in amplitude. It can involve proximal muscles of the arm or leg and may severely interfere with daily function. This tremor is often resistant to medication, which is why advanced therapies are sometimes discussed.⁸⁹¹¹

What symptoms commonly accompany lesion-related tremors?
Tremor rarely occurs in isolation when the midbrain or brainstem is involved. Because these regions control many vital and motor functions, additional neurological symptoms are common and help guide diagnosis.¹³

Associated symptoms may include:
 • Weakness or clumsiness on one side of the body.¹
 • Balance and gait instability.²
 • Double vision, abnormal eye movements, or facial weakness.³
 • Slurred or slowed speech.³
 • Fatigue and reduced endurance due to constant motor effort.³

Symptom patterns often evolve over time, especially in the months following injury.¹³

How are midbrain and brainstem lesion tremors diagnosed?
Diagnosis relies on correlating clinical findings with structural brain imaging. MRI is central to identifying lesion location, size, and involvement of key motor pathways.¹²

Neurological examination focuses on tremor timing, amplitude, distribution, and associated deficits. Unlike primary tremor disorders, lesion-related tremor diagnosis depends heavily on anatomical evidence rather than tremor appearance alone. Additional testing may be used to clarify cause, such as stroke workup or inflammatory evaluation.¹²³

How do these tremors differ from essential tremor?
Essential tremor is a primary tremor disorder, usually bilateral, often familial, and typically unaccompanied by other neurological signs. It most commonly presents as a symmetric action tremor of the hands.¹²¹³
In contrast, tremors from midbrain or brainstem lesions are secondary, often asymmetric, frequently involve proximal muscles, and are commonly associated with other neurological deficits. Imaging findings play a key role in distinguishing these conditions.¹²³

How do midbrain and brainstem lesion tremors affect daily life?
Lesion-related tremors can be profoundly disruptive. Large-amplitude tremor can make eating, grooming, writing, or using tools difficult or unsafe. When combined with weakness or balance problems, independence may be significantly reduced.¹³

The emotional burden is also substantial. People often report frustration, loss of confidence, and social withdrawal. Because these tremors are less common, individuals may feel misunderstood, making education and validation especially important.³

What treatment options are available for lesion-related tremor?
Treatment is challenging and often individualized. Medications used for essential tremor frequently provide little benefit, reflecting the different underlying mechanisms.¹¹¹⁴

Medications that may be considered include:
 • Levodopa, particularly when dopaminergic pathways are involved.¹²
 • Antiseizure or sedative medications such as clonazepam or gabapentin, with variable benefit.¹¹
 • Other agents trialed based on symptom profile and tolerance.¹²

Clinicians usually emphasize realistic goals, such as partial reduction in tremor severity rather than complete control.¹²

What role do rehabilitation and supportive strategies play?
Rehabilitation is a core component of care. Occupational and physical therapy help individuals adapt to persistent tremor and associated deficits.³

Supportive strategies may include:
 • Adaptive utensils and weighted tools to improve control.³
 • Proximal arm supports or bracing to reduce tremor amplitude.³
 • Environmental modifications to improve safety and reduce fatigue.³

These strategies are adjusted over time as neurological recovery or progression occurs.³

When is deep brain stimulation considered for lesion-related tremor?
Deep brain stimulation may be considered when tremor is severe, disabling, and refractory to medication. Targets vary depending on lesion anatomy and may include the ventral intermediate nucleus of the thalamus or other nodes within tremor networks.¹⁵¹⁶

Evidence for DBS in lesion-related tremor comes mainly from case series and small studies. Some individuals experience meaningful functional improvement, while others have limited benefit. Outcomes are less predictable than in essential tremor, making careful selection and counseling essential.¹⁵¹⁶

DBS for lesion-related tremor is often off-label. Access, regulatory status, and funding pathways vary across countries and healthcare systems.¹⁶

What questions can help guide discussions with a medical team?
Because lesion-related tremors are complex, thoughtful questions can clarify expectations and guide planning. These discussions support shared understanding rather than rushed decisions.¹²

Helpful questions include:
 • Which lesion and pathways are most likely driving my tremor?¹²
 • Is my tremor pattern consistent with Holmes tremor or another lesion-related syndrome?⁸
 • What improvement is realistic with medication or therapy?¹²
 • When should advanced options like DBS be considered?¹⁵
 • How can rehabilitation be integrated into my long-term plan?³
SAFETY NOTE
If tremor or neurological symptoms worsen suddenly, or are accompanied by new weakness, speech difficulty, vision changes, confusion, or severe headache, seek emergency medical care immediately.

GLOSSARY
Brainstem: The lower part of the brain that connects the brain to the spinal cord and controls vital functions and motor pathways.
Deep brain stimulation (DBS): A therapy that delivers electrical stimulation to specific brain targets using implanted electrodes.
Holmes tremor: A rare, slow, high-amplitude tremor associated with midbrain or brainstem lesions, present at rest and with movement.
Intention tremor: Tremor that increases as a limb approaches a target.
Midbrain: The upper portion of the brainstem involved in movement control and visual processing.
Postural tremor: Tremor that occurs while holding a position against gravity.
Secondary tremor: Tremor caused by an identifiable neurological injury or disease.
Thalamus: A deep brain structure that relays motor signals and is a common DBS target for tremor.

REFERENCES
1. Deuschl G, Bain P, Brin M. Consensus statement of the Movement Disorder Society on tremor. Mov Disord. 1998;13(suppl 3):2–23. https://doi.org/10.1002/mds.870131303()
2. Bhatia KP, Bain P, Bajaj N, et al. Consensus statement on the classification of tremors. Mov Disord. 2018;33(1):75–87. https://doi.org/10.1002/mds.27121()
3. Alusi SH, Worthington J, Glickman S, Findley LJ. Tremor in structural brain lesions. Brain. 2001;124(Pt 4):720–730. https://doi.org/10.1093/brain/124.4.720()
4. Jankovic J, Fahn S. Physiologic and pathologic tremors. Ann Intern Med. 1980;93(3):460–465. https://doi.org/10.7326/0003-4819-93-3-460()
5. Kakei S, Aoki T, Watanabe K. Pathophysiology of cerebellar tremor. Front Neurol. 2021;12:694653. https://doi.org/10.3389/fneur.2021.694653(https://doi.org/10.3389/fneur.2021.694653)
6. Deuschl G, Wilms H, Krack P. Function of the inferior olive in tremor. Mov Disord. 1994;9(1):1–9. https://doi.org/10.1002/mds.870090102()
7. Thenganatt MA, Louis ED. Linking tremor to cerebellar networks. J Neurol Sci. 2012;320(1–2):1–5. https://doi.org/10.1016/j.jns.2012.06.009()
8. Holmes G. On certain tremors in organic cerebral lesions. Brain. 1904;27(3):327–375. https://doi.org/10.1093/brain/27.3.327()
9. Raina GB, Cersosimo MG, Folgar SS, et al. Holmes tremor: clinical description, lesion localization, and treatment. Neurology. 2016;86(10):931–938. https://doi.org/10.1212/WNL.0000000000002453()
10. Deuschl G, Krack P. Tremor: clinical phenomenology and pathophysiology. Curr Opin Neurol. 2000;13(4):373–379. https://pubmed.ncbi.nlm.nih.gov/10970053/()
11. Puschmann A, Wszolek ZK. Diagnosis and treatment of uncommon tremor syndromes. Ther Adv Neurol Disord. 2011;4(4):215–234. https://doi.org/10.1177/1756285611411506()
12. Jankovic J. Parkinson’s disease and movement disorders. J Neurol Neurosurg Psychiatry. 2008;79(4):368–376. https://jnnp.bmj.com/content/79/4/368(https://jnnp.bmj.com/content/79/4/368)
13. Haubenberger D, Hallett M. Essential tremor. N Engl J Med. 2018;378(19):1802–1810. https://www.nejm.org/doi/full/10.1056/NEJMcp1707928(https://www.nejm.org/doi/full/10.1056/NEJMcp1707928)
14. Espay AJ, Duker AP, Chen R, et al. Deep brain stimulation for lesion-related tremor. Neurology. 2008;71(3):206–208. https://doi.org/10.1212/01.wnl.0000318297.74410.8a()
15. Lyons MK, Evidente VG. Deep brain stimulation for secondary tremor syndromes. Tremor Other Hyperkinet Mov (N Y). 2014;4:254. https://doi.org/10.7916/D8WM1C8V()

Question 6

RUBRAL TREMORS

Accepted Answer

What is rubral tremor?

Rubral tremor is a rare, secondary tremor syndrome that develops after structural injury to deep brain regions involved in movement integration. It is characterized by a combination of tremor at rest, during posture holding, and with voluntary movement. This mixed presentation reflects disruption across multiple motor networks rather than dysfunction of a single structure.¹²

Historically, rubral tremor was attributed to damage near the red nucleus in the midbrain. Modern research shows that while the red nucleus may be involved, rubral tremor more accurately reflects injury to interconnected pathways linking the cerebellum, thalamus, basal ganglia, and motor cortex. For this reason, rubral tremor is now often discussed within the broader framework of network-based tremor disorders.²³

How is rubral tremor related to Holmes tremor?
Rubral tremor and Holmes tremor describe the same clinical syndrome in most modern usage. Holmes tremor is the preferred contemporary term, recognizing that the tremor arises from disruption of multiple motor circuits rather than the red nucleus alone.⁴⁵

Both terms describe a tremor with three defining components, rest, postural, and intention tremor. Awareness of this terminology overlap is important, because older medical records or imaging reports may still use the term rubral tremor, while newer literature favors Holmes tremor.⁴⁵

What brain regions and pathways are involved in rubral tremor?
Rubral tremor arises from injury to a network of interconnected structures responsible for coordinating movement timing and suppressing unwanted oscillations. Lesions often involve the midbrain, thalamus, brainstem, or their connecting white matter tracts.²⁶⁷

Key pathways implicated include cerebellothalamocortical circuits, which refine movement accuracy, and dopaminergic pathways linking the brainstem to the basal ganglia. Disruption across more than one of these systems is thought to be necessary for rubral tremor to develop, which helps explain its rarity and complexity.²⁶⁸

What causes rubral tremor?
Rubral tremor develops as a delayed consequence of structural brain injury. Common causes include ischemic or hemorrhagic stroke, traumatic brain injury, demyelinating disease such as multiple sclerosis, tumors, infections, or vascular malformations affecting deep brain regions.¹³⁹

In many cases, tremor onset is delayed by weeks to months after the initial injury. This delay is believed to reflect maladaptive reorganization of motor networks rather than direct tissue damage alone. Neural circuits may become unstable as they attempt to compensate for lost connections.²⁶⁸
What does rubral tremor look like clinically?

Rubral tremor is typically slow in frequency, often below 4 to 4.5 Hz, and large in amplitude. The tremor may involve proximal muscles of the arm or leg, making it more disabling than tremors confined to the hands.⁴⁵

Key clinical features often include:
• Tremor present at rest, while holding posture, and during voluntary movement.⁴
• Marked worsening during goal-directed tasks such as reaching or writing.²
• Asymmetry, often affecting one side of the body more than the other.¹
• Fluctuation in severity depending on fatigue, stress, or effort.³

Because of its mixed presentation, rubral tremor may initially be mistaken for multiple different tremor types unless lesion history and imaging are carefully reviewed.¹²

What other neurological symptoms commonly occur with rubral tremor?
Rubral tremor rarely occurs in isolation. Because the underlying lesion affects deep motor relay regions, additional neurological signs are common and help localize the injury.¹³

Associated features may include:
• Weakness or clumsiness on the affected side.¹
• Gait and balance instability due to brainstem or cerebellar involvement.²
• Abnormal eye movements, double vision, or eyelid drooping.³
• Speech changes, such as slurring or slowed articulation.³

The combination of tremor and these accompanying signs helps distinguish rubral tremor from primary tremor disorders.¹²

How is rubral tremor diagnosed?
Diagnosis relies on careful neurological examination combined with structural brain imaging. MRI is essential for identifying lesion location and determining whether key tremor-related pathways are involved.¹²

Clinicians assess tremor timing, frequency, distribution, and associated deficits. Unlike essential tremor, diagnosis does not rely on tremor pattern alone but on correlation between symptoms and documented brain injury. Additional testing may be used to clarify the cause of the lesion when needed.¹²³

How does rubral tremor differ from essential tremor?
Essential tremor is a primary movement disorder, often familial, typically bilateral, and usually occurs without other neurological abnormalities. It most often presents as a symmetric action tremor of the hands.¹⁰¹¹

Rubral tremor is secondary, often asymmetric, involves proximal muscles, and is commonly accompanied by additional neurological signs. Imaging evidence of structural brain injury is a defining feature. These differences guide both diagnosis and treatment expectations.¹²³

How does rubral tremor affect daily life?
Rubral tremor can be severely disabling. Large-amplitude tremor may interfere with eating, dressing, grooming, writing, and safe use of tools. Tasks requiring sustained posture or precision are particularly difficult.¹³

The emotional and psychological impact is often significant. People may experience frustration, grief, or loss of independence, especially when tremor follows an abrupt neurological injury. Addressing quality of life and emotional well-being is a critical part of care.³

What treatment options are available for rubral tremor?
Treatment is challenging and often individualized. Rubral tremor is frequently resistant to medications effective for essential tremor, reflecting its network-based origin.¹²¹³

Medications that may be discussed include:
• Levodopa, particularly when dopaminergic pathways are involved.¹²
• Antiseizure or sedative medications such as clonazepam or gabapentin, with inconsistent benefit.¹³
• Other agents tried off-label based on symptom profile and tolerance.¹²

Clinicians often emphasize that partial improvement rather than complete tremor control is a realistic goal.¹²

What role do rehabilitation and adaptive strategies play?
Rehabilitation is central to managing rubral tremor. Occupational and physical therapy focus on compensatory techniques to improve safety, efficiency, and independence.³

Strategies may include:
• Adaptive utensils and weighted tools to reduce tremor impact.³
• Proximal limb supports or bracing to limit large-amplitude movements.³
• Environmental modifications to reduce fall risk and fatigue.³

These strategies are revisited over time as recovery or progression occurs.³

When is deep brain stimulation considered for rubral tremor?
Deep brain stimulation may be considered for severe, disabling rubral tremor that does not respond to medication or rehabilitation. DBS targets vary but often include the ventral intermediate nucleus of the thalamus or adjacent tremor network nodes.¹⁴¹⁵

Evidence for DBS in rubral tremor comes from small studies and case series. Some individuals experience meaningful functional improvement, while others have limited or transient benefit. 
Careful selection and detailed counseling are essential.¹⁴¹⁵

DBS for rubral tremor is often off-label. Availability, regulatory approval, and funding pathways vary by country and healthcare system.¹⁵

What questions can help guide discussions with a medical team?
Because rubral tremor is rare and complex, thoughtful questions can help clarify diagnosis and planning. These discussions support shared understanding and realistic expectations.¹²

Helpful questions include:
• Which lesion and pathways are most likely driving my tremor?¹²
• Is my tremor pattern consistent with rubral or Holmes tremor?⁴
• What degree of improvement is realistic with treatment?¹²
• When should advanced options like DBS be considered?¹⁴
• How can rehabilitation be integrated into long-term care?³
SAFETY NOTE
If tremor or neurological symptoms worsen suddenly, or are accompanied by new weakness, speech difficulty, vision changes, confusion, or severe headache, seek emergency medical care immediately.

GLOSSARY
Basal ganglia: Deep brain structures that help regulate movement initiation and control.
Deep brain stimulation (DBS): A therapy that delivers electrical stimulation to specific brain targets using implanted electrodes.
Holmes tremor: A mixed tremor syndrome involving rest, postural, and intention tremor, often synonymous with rubral tremor.
Midbrain: The upper portion of the brainstem involved in movement control and visual processing.
Postural tremor: Tremor that occurs while holding a position against gravity.
Red nucleus: A midbrain structure historically linked to rubral tremor, now understood as part of a broader motor network.
Secondary tremor: Tremor caused by an identifiable neurological injury or disease.
Thalamus: A deep brain structure that relays motor signals and is a common DBS target for tremor.

REFERENCES
1. Deuschl G, Bain P, Brin M. Consensus statement of the Movement Disorder Society on tremor. Mov Disord. 1998;13(suppl 3):2–23. https://doi.org/10.1002/mds.870131303 (https://doi.org/10.1002/mds.870131303)
2. Bhatia KP, Bain P, Bajaj N, et al. Consensus statement on the classification of tremors. Mov Disord. 2018;33(1):75–87. https://doi.org/10.1002/mds.27121 (https://doi.org/10.1002/mds.27121)
3. Alusi SH, Worthington J, Glickman S, Findley LJ. Tremor in structural brain lesions. Brain. 2001;124(Pt 4):720–730. https://doi.org/10.1093/brain/124.4.720 (https://doi.org/10.1093/brain/124.4.720)
4. Holmes G. On certain tremors in organic cerebral lesions. Brain. 1904;27(3):327–375. https://doi.org/10.1093/brain/27.3.327 (https://doi.org/10.1093/brain/27.3.327)
5. Raina GB, Cersosimo MG, Folgar SS, et al. Holmes tremor: clinical description, lesion localization, and treatment. Neurology. 2016;86(10):931–938. https://doi.org/10.1212/WNL.0000000000002453 (https://doi.org/10.1212/WNL.0000000000002453)
6. Kakei S, Aoki T, Watanabe K. Pathophysiology of cerebellar tremor. Front Neurol. 2021;12:694653. h(https://doi.org/10.3389/fneur.2021.694653)ttps://doi.org/10.3389/fneur.2021.694653(https://doi.org/10.3389/fneur.2021.694653)
7. Thenganatt MA, Louis ED. Linking tremor to cerebellar networks. J Neurol Sci. 2012;320(1–2):1–5. https://doi.org/10.1016/j.jns.2012.06.009 (https://doi.org/10.1016/j.jns.2012.06.009)
8. Deuschl G, Wilms H, Krack P. Function of the inferior olive in tremor. Mov Disord. 1994;9(1):1–9. https://doi.org/10.1002/mds.870090102 (https://doi.org/10.1002/mds.870090102)
9. Puschmann A, Wszolek ZK. Diagnosis and treatment of uncommon tremor syndromes. Ther Adv Neurol Disord. 2011;4(4):215–234. https://doi.org/10.1177/1756285611411506 (https://doi.org/10.1177/1756285611411506)
10. Haubenberger D, Hallett M. Essential tremor. N Engl J Med. 2018;378(19):1802–1810. h(https://www.nejm.org/doi/full/10.1056/NEJMcp1707928)ttps://www.nejm.org/doi/full/10.1056/NEJMcp1707928(https://www.nejm.org/doi/full/10.1056/NEJMcp1707928)
11. Louis ED. Essential tremor. Lancet Neurol. 2005;4(2):100–110. https://doi.org/10.1016/S1474-4422(05)00991-9 (https://doi.org/10.1016/S1474-4422(05)00991-9)
12. Jankovic J, Fahn S. Physiologic and pathologic tremors. Ann Intern Med. 1980;93(3):460–465. https://doi.org/10.7326/0003-4819-93-3-460 (https://doi.org/10.7326/0003-4819-93-3-460)
13. Espay AJ, Duker AP, Chen R, et al. Deep brain stimulation for lesion-related tremor. Neurology. 2008;71(3):206–208. https://doi.org/10.1212/01.wnl.0000318297.74410.8a (https://doi.org/10.1212/01.wnl.0000318297.74410.8a)
14. Lyons MK, Evidente VG. Deep brain stimulation for secondary tremor syndromes. Tremor Other Hyperkinet Mov (N Y). 2014;4:254. https://doi.org/10.7916/D8WM1C8V (https://doi.org/10.7916/D8WM1C8V)

Question 7

POST-TRAUMATIC TREMOR

Accepted Answer

• What is post-traumatic tremor?

Post-traumatic tremor is an involuntary, rhythmic, back-and-forth movement that shows up after a traumatic brain injury or other head trauma, sometimes right away, and sometimes after a delay.¹² It can involve the hands, arms, head, voice, trunk, or legs, and it can be mild or deeply disabling, especially when it interferes with eating, writing, walking, or speaking clearly.²³

Clinicians usually describe tremor by when it happens: at rest, while holding a posture (like holding your arms out), or during action (like reaching for a cup).¹ A key point is that “post-traumatic tremor” is not one single tremor type, it’s a label for tremor that has a trauma-related cause, and the exact pattern depends on which brain networks were injured.¹³⁴

How common is tremor after traumatic brain injury?

Movement disorders, including tremor, can occur after traumatic brain injury, especially after more severe injuries, and they can persist.²³ In classic clinical series of people who survived severe head injury, post-traumatic movement disorders were documented and tremor was among the reported problems.²

Not everyone with tremor after trauma has the same mechanism. Some tremors reflect injury to cerebellar outflow pathways (coordination circuits), some reflect injury involving the thalamus (a key relay center), and some overlap with dystonia or parkinsonism-like features.³⁴ That mix is part of why evaluation is so individualized, and why a single “best treatment” is hard to promise.³⁴

When can post-traumatic tremor start, and why is it sometimes delayed?

Post-traumatic tremor can begin soon after injury, but a delayed onset is common in certain tremor syndromes linked to structural brain lesions.³⁵ In Holmes tremor, a well-described lesion-related tremor syndrome, symptoms often begin weeks to months after the injury, and can sometimes appear much later.⁵⁶

The delay is thought to relate to slow changes that happen after injury, such as reorganization of connections and “rewiring” in damaged motor circuits.⁵⁶ In plain language: the brain is trying to adapt, but the healing process can sometimes create unstable signaling loops that show up as tremor.⁵⁶

What kinds of tremor patterns can happen after trauma?

After trauma, tremor may show up as action tremor (worse with movement), postural tremor (worse when holding a position), rest tremor (present when relaxed), or combinations.¹³ A well-known example is Holmes tremor, which typically combines rest, posture, and action tremor and is often slow-frequency and high amplitude.⁵⁶

Post-traumatic tremor can also overlap with other movement symptoms such as ataxia (unsteady coordination), dystonia (sustained twisting or abnormal postures), weakness, sensory changes, or speech changes, depending on the injury location.⁴⁶ This matters because treatment choices, including DBS targeting, often depend as much on the “tremor plus other signs” picture as on tremor alone.¹⁴

What is Holmes tremor, and how does it relate to post-traumatic tremor?

Holmes tremor is a lesion-related tremor syndrome, historically described as an irregular, slow tremor that can appear at rest and intensify with posture and action.⁶ It’s strongly associated with lesions affecting the midbrain, thalamus, cerebellum, and the pathways connecting them.⁵⁶

Traumatic brain injury is one recognized cause of Holmes tremor, along with stroke and other brain injuries.⁴⁶ The clinical takeaway is simple: if your tremor has mixed rest and action components and started after a brain injury, your care team may consider Holmes tremor as part of the differential diagnosis, because it can shape medication trials and surgical planning.⁴⁵⁶

What causes post-traumatic tremor in the brain?

Tremor is usually a “circuit” problem, not a single-spot problem. In many lesion-related tremors, injury disrupts communication between the cerebellum (coordination center), thalamus (relay station), basal ganglia (movement selection and smoothing), and motor cortex (movement execution).⁴⁵⁶

In Holmes tremor specifically, multiple networks are often implicated, including cerebello-thalamo-cortical pathways and dopaminergic (nigrostriatal) pathways.⁵⁶ That mixed involvement helps explain why some people have tremor plus slowness or stiffness, while others have tremor plus imbalance or coordination trouble, and why one medication or one DBS target doesn’t fit everyone.⁵⁶⁷

How is post-traumatic tremor evaluated by a clinician?

Evaluation usually starts with a careful history and exam that describe the tremor using standard tremor classification language: when it occurs (rest vs posture vs action), where it occurs (one limb vs both), and what other neurologic signs travel with it.¹⁴ Clinicians also look for clues about functional impact, like whether the tremor disrupts eating, hygiene, work tasks, or walking stability, because “disabling” is often defined by function, not just appearance.²³

Imaging is commonly used in tremor after trauma because this is often a symptomatic tremor, meaning there may be a structural explanation.⁶ Clinicians may also use tremor rating scales to quantify severity over time, which becomes important if the team is judging whether a therapy is helping enough to be worth its risks.⁸⁹

What tests might be used, and what can they add?

Brain MRI is frequently used to look for lesion locations that can help explain the tremor pattern, especially in lesion-related syndromes like Holmes tremor.⁶ In selected cases, advanced imaging or tractography (mapping major white-matter pathways) may help with DBS planning when anatomy is distorted by injury, because it can support individualized targeting.¹¹

Surface electromyography and accelerometry can sometimes help clarify tremor rhythm and can be especially useful when the diagnosis is uncertain or when functional tremor is part of the differential.¹⁷¹⁸ These tests don’t replace a neurologic exam, but they can provide objective evidence about tremor variability, entrainment, or distractibility in the right clinical setting.¹⁷¹⁸

How do clinicians tell post-traumatic tremor apart from essential tremor, Parkinson’s tremor, or functional tremor?

Clinicians separate tremors by pattern and by context. Essential tremor is typically an action tremor syndrome and usually is not tied to a single brain lesion, while post-traumatic tremor often follows a known injury and may come with additional neurologic signs.¹⁴⁶ Parkinsonian tremor often has a rest component plus characteristic slowness and rigidity patterns, while lesion-related tremors may carry more mixed features and imaging clues.¹⁴

Functional tremor can look dramatic and very real, but it often shows internal inconsistencies such as marked distractibility, entrainment (the tremor rhythm shifts to match a tapping rhythm), or variability that doesn’t fit common neurologic tremor syndromes.¹⁷¹⁸ In careful hands, identifying functional features is not an accusation, it’s a route toward the right treatment plan, and sometimes both functional and injury-related factors can coexist, which is why teams often move slowly and methodically.¹⁷¹⁸

What non-surgical treatments can help with daily function?

Non-surgical strategies often focus on function first: steadier eating, safer walking, less frustration during fine motor tasks. Even when tremor reduction is incomplete, the right tools and task changes can reduce the daily “tax” the tremor collects.³⁴

Examples include adaptive utensils, weighted or stabilizing devices, task setup changes (like bracing the forearm, changing grip, altering posture), and in some cases wearable tremor-suppression technologies or peripheral stimulation devices.¹⁹ These options are not cures and the evidence base varies by device type, but they can be meaningful for quality of life, especially while medical and surgical decisions are still unfolding.¹⁹

What medications might be tried for post-traumatic tremor, and what are the limits?

Medication response in post-traumatic tremor is variable, and the evidence is often based on case series and reviews rather than large trials, so clinicians usually describe this as a “trial-and-measure” process rather than a guaranteed fix.⁵⁷ In Holmes tremor and other lesion-related tremors, medications that have shown benefit in published reports include levodopa and other agents such as levetiracetam and trihexyphenidyl in selected cases.⁵⁶⁷

In one series of Holmes tremor cases, levodopa helped a meaningful portion of treated patients, but not everyone responded.⁶ A more recent systematic review of Holmes tremor management also highlights that both medication and DBS reports are heterogeneous, meaning outcomes can differ widely depending on the person’s lesion pattern and symptom mix.⁷ That’s why clinicians often anchor medication trials to concrete functional goals, like “can I drink from a cup,” not just “does it look smaller.”⁷

When do clinicians consider procedures or surgery for post-traumatic tremor?

Procedures are usually considered when tremor remains disabling despite reasonable trials of rehabilitation strategies and medications, and when the tremor pattern and overall neurologic status suggest a procedure could improve function more than it harms it.⁸⁹ This is especially relevant when tremor is the main driver of disability and the person is otherwise medically stable enough for surgery and follow-up care.⁸⁹

For lesion-related tremors, including post-traumatic tremor, the published literature supports that surgery can help selected people, but it also emphasizes wide variability in response.⁹ In other words, surgery is a serious option, not a last-resort myth, but it also isn’t a simple “flip a switch” promise, especially when injury-related anatomy is complex.⁹¹¹

What is deep brain stimulation (DBS), in simple terms?

DBS is a therapy that uses implanted electrodes (leads) to deliver controlled electrical stimulation to specific brain targets involved in movement circuits.¹³ The stimulation is generated by a small implanted device (often called a neurostimulator or implantable pulse generator) and adjusted over time through programming visits.¹³

DBS does not heal the original brain injury. Instead, it aims to reduce tremor by changing how certain circuit nodes fire and communicate, so that the tremor rhythm becomes less dominant.¹³ This distinction matters because the best DBS outcomes usually come from matching the target to the tremor network that is actually driving symptoms in that individual.⁹¹¹¹³

Is DBS approved for post-traumatic tremor in the United States, and how does this differ internationally?

In the United States, DBS systems have FDA-approved indications that include stimulation of the ventral intermediate nucleus (VIM) of the thalamus for disabling upper extremity tremor in essential tremor, and other indications for Parkinson’s disease targets.²⁰²¹ Post-traumatic tremor is not typically listed as a primary FDA-approved indication, so when DBS is used for post-traumatic tremor, it is generally considered an off-label use decided by specialized teams based on clinical judgment and published evidence.⁸⁹²¹

International pathways can differ by country due to regulatory approvals, device labeling, and healthcare system structures. A practical approach is to ask your treating center, “In our country, what is DBS labeled for, and how does that affect access, insurance coverage, and device options for lesion-related tremor?”²¹

How can DBS help post-traumatic tremor, and what does the evidence actually show?

The strongest summary of the evidence is this: DBS can reduce post-traumatic tremor in some carefully selected patients, but the overall evidence base is smaller than it is for essential tremor, and results are more variable.⁸⁹ In a systematic review of DBS for lesion-related tremors, post-traumatic tremor showed a median improvement on reported tremor scales, but there was substantial heterogeneity, and a minority of patients had limited benefit.⁹

Smaller case series focused specifically on post-traumatic tremor also report meaningful improvements for some patients using thalamic region targeting (VIM and nearby areas) and, in selected phenotypes, GPi targeting.⁸¹⁰ When multiple movement symptoms coexist, like tremor plus dystonia, teams sometimes consider different targets or even multi-target strategies, but the evidence here is still emerging and often case-based.¹¹¹²

Which DBS brain targets are used for post-traumatic tremor, and why?

The VIM region of the thalamus is a common target for tremor because it sits within a key tremor relay pathway connecting cerebellar output to motor cortex, and it is a primary tremor target in established tremor DBS.⁹¹³ In lesion-related and post-traumatic tremor reports, VIM is frequently used, and some series also describe targeting nearby thalamic or subthalamic regions such as VOP/VOA or zona incerta, depending on tremor characteristics and anatomy.⁸¹⁰

The GPi (globus pallidus internus) may be considered when tremor overlaps with dystonia, abnormal posturing, or more complex movement patterns, because GPi is a major output node of basal ganglia circuitry and is a standard DBS target in dystonia care.⁸¹² In practice, the “why this target” conversation is often about matching the dominant symptom network: cerebellar-thalamic loops, basal ganglia loops, or a mix.⁵⁹¹²¹³

What is “dual target” or “multi-target” DBS, and when might it come up after trauma?

Dual target DBS generally means implanting leads in two different targets (for example, VIM-related targeting plus GPi) to address a complex symptom picture, or to test which target offers the best functional benefit.¹¹¹² This approach is not standard for most tremor patients, but it appears in post-traumatic tremor literature because trauma can distort anatomy and produce mixed tremor plus dystonia features, making single-target decisions harder.¹¹

A published case report of severe post-traumatic tremor described dual-target DBS with individualized targeting supported by tractography and careful post-operative programming strategies, with meaningful improvement on tremor rating measures over months.¹¹ This is encouraging, but it is also a reminder that multi-target approaches often reflect clinical complexity, not “stronger medicine,” and they require experienced teams and realistic expectations.⁹¹¹

What does a DBS evaluation and surgical process usually involve?

A DBS evaluation is typically multidisciplinary. It often includes movement disorder neurology assessment, imaging review, discussion of medication trials and rehabilitation efforts, and screening for factors that could raise surgical risk or complicate follow-up.⁸⁹¹³ For trauma-related tremor, teams may pay extra attention to lesion anatomy, cognitive status, speech and swallowing function, gait stability, and the person’s ability to participate in repeated programming visits.³⁹¹¹

Surgery involves implanting the lead(s) and connecting them to the implanted pulse generator. Programming then unfolds over multiple visits because tremor control and side effects depend on contact location, stimulation settings, and how the brain responds over time.¹³¹⁴ This “tuning phase” is often where functional gains become clearer, but it can take patience, and adjustments are common.¹³¹⁴

What are the risks and side effects of DBS for tremor?

DBS is brain surgery, so risks include bleeding in the brain, infection, hardware complications, and stimulation-related side effects.¹⁴¹⁵ Stimulation side effects in tremor targeting can include speech changes (dysarthria), balance or gait worsening, tingling sensations, and other effects that depend on which nearby fibers are stimulated and at what intensity.¹⁴¹⁵

Because post-traumatic tremor patients may already have balance, speech, or cognitive vulnerabilities from the original injury, teams often weigh risk differently than they might for someone with isolated essential tremor.³⁹¹¹ That’s why the best DBS conversations include both outcome goals and “what we can’t afford to worsen,” like falls, swallowing safety, or communication clarity.³¹⁴¹⁵

What are realistic expectations for DBS in post-traumatic tremor?

A realistic expectation is improved function, not perfection. The literature suggests that some people experience substantial tremor reduction, while others experience partial improvement that still matters day-to-day, and some experience limited benefit.⁹¹⁰ When tremor is mixed with other neurologic deficits from injury, DBS may improve one component while leaving others unchanged.³⁹

It also helps to expect iteration. Programming can be a process of careful adjustments to balance tremor control with side effects, and this is especially true when brain anatomy has been altered by injury.¹¹¹⁴ A good team will talk openly about the uncertainty, using published data where it exists, and naming where evidence is thin.⁷⁹

What questions should I bring to a DBS consultation for post-traumatic tremor?
These questions can help you and your team move from vague hope to clear, shared goals. They are not about “proving” you deserve treatment, they are about aligning the plan with your life.

First, ask about diagnosis and mechanism:
 • Which tremor syndrome best fits my pattern, and what features make you think that?¹⁴
 • What do my MRI findings suggest about which circuits are involved?⁶
 • Do I have dystonia, ataxia, or other movement problems that change target choice?⁴⁶¹²
Then, ask about DBS specifics:
 • Is DBS for my tremor considered off-label here, and what does that mean for access and coverage?²¹
 • Which target are you recommending (VIM, GPi, or another), and why for my symptom mix?⁸⁹¹³
 • What functional goals are realistic for me, and what risks matter most given my injury history?³¹⁴¹⁵
 • How many programming visits should I expect in the first 6 to 12 months?¹³¹⁴
SAFETY NOTE
 If symptoms are urgent, sudden, or severe, especially new weakness, severe headache, new confusion, fainting, repeated falls, or seizure-like activity, seek emergency care.

GLOSSARY
Action Tremor: Tremor that appears or worsens during movement, like reaching, writing, or using utensils.
Ataxia: Trouble with coordination and balance, often causing clumsiness or unsteady walking.
Basal Ganglia: Deep brain structures involved in smoothing and selecting movements, often discussed in dystonia and Parkinson’s disease.
Cerebello-Thalamo-Cortical Pathway: A communication route linking the cerebellum to the thalamus and motor cortex, important in many tremor circuits.
Dentato-Rubro-Thalamic Tract: A major pathway carrying cerebellar output toward movement control regions, sometimes used in DBS planning discussions.
Deep Brain Stimulation: A therapy that uses implanted electrodes and an implanted stimulator to deliver adjustable electrical stimulation to specific brain targets.
Diffuse Axonal Injury: A type of traumatic brain injury involving widespread damage to nerve fibers, often from acceleration-deceleration forces.
Dystonia: Sustained muscle contractions that can cause twisting movements or abnormal postures, sometimes overlapping with tremor.
Electromyography: A test that records muscle electrical activity, sometimes used to characterize tremor rhythm and patterns.
Functional Tremor: A tremor pattern linked to abnormal movement control signaling rather than structural damage alone, often showing variability or distractibility on exam.
Globus Pallidus Internus: A deep brain target often used in DBS for dystonia and sometimes considered when tremor overlaps with dystonia or complex posturing.
Holmes Tremor: A lesion-related tremor syndrome that often includes rest, posture, and action tremor, typically slow and high amplitude.
Implantable Pulse Generator: The implanted “battery and computer” that powers DBS stimulation and can be adjusted during programming visits.
Levodopa: A medication that increases dopamine signaling and can help some tremor syndromes, including some cases of Holmes tremor.
Lesion-Related Tremor: Tremor linked to a structural brain injury, such as trauma or stroke, rather than a purely idiopathic syndrome.
Off-Label Use: Use of an approved medical device or medication for a condition not specifically listed on its official labeling.
Programming: The process of adjusting DBS settings over multiple visits to balance symptom relief and side effects.
Rest Tremor: Tremor that appears when a body part is relaxed and supported, like a hand resting in the lap.
Thalamus: A deep brain relay center that connects multiple movement circuits and includes common DBS tremor targets.
Tractography: An imaging method that maps major white-matter pathways, sometimes used to support individualized DBS targeting.
Ventral Intermediate Nucleus: A common DBS tremor target in the thalamus, often discussed in essential tremor and lesion-related tremor literature.
Zona Incerta: A region near the subthalamic area sometimes considered in tremor DBS targeting in selected cases.

REFERENCES
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