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Ask the Doc: Q & A with Edward Kasarskis, MD, PhD

Edward Kasarskis, M.D., Ph.D. is Director of the multidisciplinary ALS Center at the University of Kentucky Neuroscience Center in Lexington, Kentucky, professor in the Department of Neurology at the University of Kentucky, and Chief of Neurology at the VA Medical Center in Lexington KY. 

Dr Kasarskis
Dr. Kasarskis 

Q: I’m a little confused about muscle pain and tremors. I think that I experience both. What is the difference between them and the best way to treat each of them?

A: Muscle pain and tremors have only one thing in common: they involve muscles. But they are, in fact, very different.

In the pure sense of the word, a tremor is a very rhythmic movement. You may have seen tremor in people with Parkinson’s disease. It’s a back-and-forth, somewhat rhythmic, involuntary movement. In other conditions, a tremor can occur if you try to perform some very coordinated, fine activity such as threading a needle. Some ALS patients use the term "tremor" when they are actually having muscle failure.

When people push their muscles to the limit, they can see their muscles react. It can look like a tremor because the muscle cannot generate any more force. You see this phenomenon every four years in the Olympic power weight lifting event as the contestants reach the limit of their muscle strength. For people with ALS, reaching that limit may not seem to take a lot of effort. For example, just raising your wrist up from a table top against gravity can be challenging, and the muscle response may look like a tremor because the action can't be sustained.

The source of muscle pain in ALS, on the other hand, tends to be a little more complex. People often get discomfort in their muscles from cramping or spasticity. Everyone has had muscle cramps from time to time, perhaps after sitting or lying in an awkward position. Some people get leg cramps at night. That sort of phenomenon is commonly seen in people with ALS.

Another kind of muscle pain occurs when people are trying to move, using almost all their power. This can occur in people with ALS in an activity that may seem very basic, like brushing their hair. Others may experience joint pain from their shoulder, as an example.

Treatments for muscle pain are aimed at essentially reducing the muscle tension or tone and spasticity. Oral drugs like baclofen and tizanadine (Zanaflex) are often used, starting at a low dose and gradually increasing the dose as needed. These medications are gradually adjusted to reduce the muscle tension just to the point that it reduces your pain but not so much that the reduced muscle tone makes it hard to stand, get out of a chair, or walk. Baclofen usually has very few side effects, while tizanadine can cause drowsiness and some mouth dryness, which can be a plus for those with difficulty managing saliva. Unfortunately, some people have trouble tolerating these drugs at all. If these two drugs don’t work for muscle pain, other drugs can be used -- cyclobenzaprinte (Flexeril) and metaxalone (Skelaxen).

People with ALS sometimes fail to drink enough fluids, often avoiding liquids because of mobility challenges. But hydration (getting enough fluids)  can sometimes help reduce muscle cramps and spasticity. It’s also important to make sure your body’s electrolytes are in a healthy range.

Sometimes people benefit from being instructed often by a physical therapist about how to overcome muscle cramping. For example, if your calf muscle goes into a cramp, lifting your foot and toe up pulls the muscle in the opposite direction that caused the cramp, which can overcome the tension. There’s a way to provide a counter-force to most of the muscles that “cramp up.”

Occupational therapy can also be helpful because you can learn how to use adaptive equipment or other strategies to overcome the difficulties your muscle problems are causing.

Even though a drug may work for a while, over time it can sometimes become less effective. It’s important to be reassessed regularly to see if the therapy or treatment you are using is still the best approach for you.

The complexity of muscle problems and the tremendous impact those issues can have on the daily lives of people with ALS point to the importance of being seen in an ALS Association Certified Clinic. At the clinic, there are a team of experts representing many disciplines — medicine, respiratory therapy, physical therapy, occupational therapy and nursing — will work together to address your problems.

If you would like to submit questions for a future Q & A, please send your questions to Please understand that we won't be able to address all questions and we won’t be able to respond to individuals personally.




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