Botox for hand tremors

B
Tremor as a Symptom of Multiple Sclerosis
Image from Verywell Health

Hand tremor in MS can be very debilitating leading to an inability to hold things, as well as leading to hand weakness. In many instances, this is due to involvement of the cerebellum (part of the brain dealing with coordination), rather than the basal ganglia that is involved in Parkinson’s.

MS-related tremors tend to respond poorly to oral medications used for tremor control (for example, propranolol, primidone, gabapentin etc.). Deep-brain stimulation (see diagram below) was popular as a treatment option when it came out, but outcomes have been variable especially when there is an ataxic (swaying side to side) component, suggesting it’s originating from the cerebellum.

Deep Brain Stimulation – Advantages, Risks and Conditions Treated
Deep brain stimulation for hand tremor

However, all is not lost. It would seem that there may be place for botox in the treatment of tremor in MS.

In analysis of all publications for tremor Zheng and colleagues noted that botox into the forearms significantly ameliorated tremor (see Figure below); a similar response was not observed in Parkinson’s-related tremor.

Sub-group analysis of botox on tremor severity in meta-analysis

The only draw back of using botox is the secondary weakness that occurs with muscle relaxation; with 30-70% of individuals experiencing hand weakness in the low-dose to high-dose botox group, respectively.

Abstract

Neurol Neurochir Pol. 2020 Oct 13. doi: 10.5603/PJNNS.a2020.0079. Online ahead of print.

Botulinum toxin type A for hand tremor: a meta-analysis of randomised controlled trials

Xiaoyan Zheng Wenjing WeiPeidong LiuChunxiao Wu Liming Lu Chunzhi Tang

Background: Tremor is one of the most common movement disorders. It does not usually respond to first-line drug treatments (e.g. propranolol, primidone, anticholinergics, gabapentin and clonazepam) due to side effects and frequent dose limitations. Botulinum toxin type A (BoNT-A) has been widely used to treat tremor, but its efficacy and safety are uncertain.

Aims: To evaluate the efficacy and safety of BoNT-A in the treatment of hand tremor.

Methods: We searched the MEDLINE, EMBASE, PsycINFO and Cochrane Library databases for relevant randomised controlled trials of the effects of BoNT-A injections on tremors, up to 20 February 2020. A meta-analysis of comparative effects was performed using R studio software, and publication bias was examined using Egger’s test.

Results: Six studies examining a total of 245 participants with tremor were included in the meta-analysis. The primary outcome of meta-analysis showed no difference in clinical tremor scale scores between the BoNT-A group versus the placebo group (standardised mean difference (SMD): -0.42, 95% confidence interval (CI): -1.94 to 1.10; I2 = 96%). For clinical tremor scale scores, subgroup analyses suggested that the BoNT-A group may differ in terms of multiple sclerosis (MS) related tremor (SMD: -1.10; 95% CI: -2.17 to -0.04; I2 = 79%) compared to a placebo, but the difference did not exist in the outcome of essential tremor (ET) or hand tremor (MD: -1.31; 95% CI: -3.39; 1.31; I2 = 97%). Grip strength (MD: -1.25, 95% CI: -5.99 to 3.50, I2 = 97%) was slightly lower in the BoNT-A group, but the difference was not significant. The incidence of adverse events (AEs), including hand weakness (RR: 2.96, 95% CI: 1.40 to 6.24, I2 = 37%), was significantly greater in the BoNT-A group than in the placebo group. Two studies were assessed as having an overall low risk of bias.

Conclusions: Our study confirms that BoNT-A injections are unlikely to have an impact on patients with hand tremors. However, subgroup analysis suggested that BoNT-A injections could have possible benefits in MS-related tremor. While moderate to severe hand weakness AEs often limits their use in clinical practice, additional well-designed double-blind, placebo-controlled trials are needed to provide more robust conclusions.

About the author

Neuro Doc Gnanapavan

7 comments

  • So Botox could help with my hand tremors? If so, that would be unbelievably exciting for me. My hands themselves aren’t weak though. My left hand is much worse than my right hand. But when I’m trying to do anything with my left hand (even just hold out a piece of paper) it tremors so hard that it can make my whole body shake even after taking medication for it. It’s incredibly embarrassing, but it makes everything so much harder to do than it is anyway.

      • No one has ever even me mentioned it to me. I’ve even brought up having holes drilled into my skull and metal electrodes put in my brain (no go because because it would make MRI’s complicated) and even having part of my dang brain removed with ultrasound or thalmonectomy (probably misspelled that) but apparently that’s very complicated because they can’t even determine what parts of my brain causes it.

        I don’t have a resting tremor. If I’m sitting down or lying still without holding anything my hands don’t shake at all. When I’m trying to hold onto something or move around, crazy shaking happens.

        My doctor always does the close your eyes and touch your nose with your right index finger and then your left. My right finger does it pretty smoothly. My left finger makes it to my nose or really close, but when it gets there it’ll try to shake my nose off of my face or smash it into my head :/

        How much Botox can you actually have? It’s already being considered for my bladder. and legs. Could they do it on bladder, legs, and hand? If only 2 areas, I think I’d probably pick legs and hand…not sure though because I really don’t wanna wear adult diapers or have an internal catheter with a tube draining pee to a bag on my leg. It’s a lot to think about. Plus I’m assuming that there aren’t many doctors who have experience with injecting Botox in hands..

        Anyway, could I have it in all places or no?,

  • I had resting tremors in my feet during a severe relapse. Laying in bed resting, one foot would swing left and right, then the other foot would join in swinging left and right, it made me laugh at the time. Then I would get a vibration feeling in my feet sometimes and now it’s resolved, tremors and sensations gone.

  • Interesting – I have Botox injections for bladder problems, it is very effective. Is this an example of repurposing a drug? Do you know of any patients who have it for both upper limb tremor and bladder spasms. Is the effective treatment period of the Botox different in each case

    • No Patrick, Botox for tremor has existed for some time, more recent than its development for use in bladder instability

    • Patrick – In my experience you are only allowed so much Botox, so if you are receiving it for various different reasons, it is best to allow some time between injections. For example, injections in January for one issue then wait 3-4 months before the next injection for the other issue. Plus, I have found the effects start to last longer after a few rounds of injections.

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