Spiral Drawing Research Articles

A digital assessment system for evaluating kinetic tremor in essential tremor and Parkinson\u2019s disease

BackgroundSpiral drawing on papers is a common tremor evaluation tool for diagnosing patients with essential tremor (ET) or Parkinson’s disease (PD). No standard drawing methods and parameters that use graphic tablets are yet available for objective evaluation.MethodsThis study established a tremor assessment system for tremor severity by using graphic tablets. Twelve patients with ET and twelve patients with PD were tested to establish system algorithms, and six additional patients were tested with the developed system to evaluate its performance. The patients also performed spiral drawing with three guiding paradigms on a graphic tablet: traced along a given spiral (S1), performed freehand drawing (S2), and traced along a guiding point (S3). Three parameters were calculated to quantify tremor severity: the means of radial difference per radian (|dr/dθ|), the means of radial difference per second (|dr/dt|), and the area under curve (AUC) of the frequency spectrum of the velocity. Each patient’s drawing was also evaluated using a visual rating scale (VRS) by experienced physicians. The interrater reliability was examined to identify the most consistent test paradigm.ResultsThe parameter |dr/dθ| and AUC correlated well with the VRS (R > 0.8) in S1, S2 and S3 tests. The S1 test presented the best interrater reliability (Weighted Kappa coefficient, k = 0.80) among three tests. The Weighted Kappa coefficients are 0.67 and 0.71 in S2 and S3 tests, respectively.ConclusionsWe developed three different guiding paradigms for spiral drawing on a digital graphic tablet for clinical tests. Three parameters were calculated to represent the tremor severity in spiral drawing and used to quantify temporal and spatial characteristics of tremor, and provided good correlation with current clinical assessments. The test “traced along a given spiral” is recommended due to its good interrater reliability.

Tremor in multiple sclerosis is associated with cerebello-thalamic pathology

Tremor in people with multiple sclerosis (MS) is a frequent and debilitating symptom with a relatively poorly understood pathophysiology. To determine the relationship between clinical tremor severity and structural magnetic resonance imaging parameters. Eleven patients with clinically definite MS and right-sided upper limb tremor were studied. Tremor severity was assessed using the Bain score (overall severity, writing, and Archimedes spiral drawing). Cerebellar dysfunction was assessed using the Scale for the Assessment and Rating of Ataxia. Dystonia was assessed using the Global Dystonia Scale adapted for upper limb. For all subjects, volume was calculated for the thalamus from T1-weighted volumetric scans using Freesurfer. Superior cerebellar peduncle (SCP) cross-sectional areas were measured manually. The presence of lesions was visually determined and the lesion volumes were calculated by the lesion growth algorithm as implemented in the Lesion Segmentation Toolbox. Right thalamic volume negatively correlated with Bain tremor severity score (ρ = − 0.65, p = 0.03). Left thalamic volume negatively correlated with general Bain tremor severity score (ρ = − 0.65, p = 0.03) and the Bain writing score (ρ = − 0.65, p = 0.03). Right SCP area negatively correlated with Bain writing score (ρ = − 0.69, p = 0.02). Finally, Bain Archimedes score was significantly higher in patients with lesions in the contralateral thalamus. Whole brain lesion load showed no relationship with tremor severity. These results implicate degeneration of key structures within the cerebello-thalamic pathway as pathological substrates for tremor in MS patients.

Verification of a Method for Measuring Parkinson's Disease Related Temporal Irregularity in Spiral Drawings.

Parkinson’s disease (PD) is a progressive movement disorder caused by the death of dopamine-producing cells in the midbrain. There is a need for frequent symptom assessment, since the treatment needs to be individualized as the disease progresses. The aim of this paper was to verify and further investigate the clinimetric properties of an entropy-based method for measuring PD-related upper limb temporal irregularities during spiral drawing tasks. More specifically, properties of a temporal irregularity score (TIS) for patients at different stages of PD, and medication time points were investigated. Nineteen PD patients and 22 healthy controls performed repeated spiral drawing tasks on a smartphone. Patients performed the tests before a single levodopa dose and at specific time intervals after the dose was given. Three movement disorder specialists rated videos of the patients based on the unified PD rating scale (UPDRS) and the Dyskinesia scale. Differences in mean TIS between the groups of patients and healthy subjects were assessed. Test-retest reliability of the TIS was measured. The ability of TIS to detect changes from baseline (before medication) to later time points was investigated. Correlations between TIS and clinical rating scores were assessed. The mean TIS was significantly different between healthy subjects and patients in advanced groups (p-value = 0.02). Test-retest reliability of TIS was good with Intra-class Correlation Coefficient of 0.81. When assessing changes in relation to treatment, TIS contained some information to capture changes from Off to On and wearing off effects. However, the correlations between TIS and clinical scores (UPDRS and Dyskinesia) were weak. TIS was able to differentiate spiral drawings drawn by patients in an advanced stage from those drawn by healthy subjects, and TIS had good test-retest reliability. TIS was somewhat responsive to single-dose levodopa treatment. Since TIS is an upper limb high-frequency-based measure, it cannot be detected during clinical assessment.

Efficacy of Guided Spiral Drawing in the Classification of Parkinson's Disease.

Change of handwriting can be an early marker for severity of Parkinson's disease but suffers from poor sensitivity and specificity due to inter-subject variations. This study has investigated the group-difference in the dynamic features during sketching of spiral between PD and control subjects with the aim of developing an accurate method for diagnosing PD patients. Dynamic handwriting features were computed for 206 specimens collected from 62 Subjects (31 Parkinson's and 31 Controls). These were analyzed based on the severity of the disease to determine group-difference. Spearman rank correlation coefficient was computed to evaluate the strength of association for the different features. Maximum area under ROC curve (AUC) using the dynamic features during different writing and spiral sketching tasks were in the range of 0.67 to 0.79. However, when angular features ($\boldsymbol{\varphi }$ and ${\boldsymbol{p}_{\boldsymbol{n}}}$) and count of direction inversion during sketching of the spiral were used, AUC improved to 0.933. Spearman correlation coefficient was highest for ϕ and ${\boldsymbol{p}_{\boldsymbol{n}}}$. The angular features and count of direction inversion which can be obtained in real-time while sketching the Archimedean guided spiral on a digital tablet can be used for differentiating between Parkinson's and healthy cohort.

New insight in spiral drawing analysis methods – Application to action tremor quantification

ObjectiveSpiral drawing is one of the standard tests used to assess tremor severity for the clinical evaluation of medical treatments. Tremor severity is estimated through visual rating of the drawings by movement disorders experts. Different approaches based on the mathematical signal analysis of the recorded spiral drawings were proposed to replace this rater dependent estimate. The objective of the present study is to propose new numerical methods and to evaluate them in terms of agreement with visual rating and reproducibility. MethodsSeries of spiral drawings of patients with essential tremor were visually rated by a board of experts. In addition to the usual velocity analysis, three new numerical methods were tested and compared, namely static and dynamic unraveling, and empirical mode decomposition. The reproducibility of both visual and numerical ratings was estimated, and their agreement was evaluated. ResultsThe statistical analysis demonstrated excellent agreement between visual and numerical ratings, and more reproducible results with numerical methods than with visual ratings. ConclusionsThe velocity method and the new numerical methods are in good agreement. Among the latter, static and dynamic unravelling both display a smaller dispersion and are easier for automatic analysis. SignificanceThe reliable scores obtained through the proposed numerical methods allow considering that their implementation on a digitized tablet, be it connected with a computer or independent, provides an efficient automatic tool for tremor severity assessment.

14 Analysis of spiral drawings as a means of exploring differences between functional and essential tremor: an ink and paper approach

Objective To compare spiral drawings between essential tremor (ET) and functional tremor (FT); exploring spiral size, axis, density and tremor severity score for parameters to potentially distinguish ET from FT. Method Spiral drawing data of 29 patients with either ET or FT were acquired from ASPH using the NHs patient database and patient notes. Using a ruler spiral size was represented as the horizontal diameter, and it was also measured to 3-loops (3-turn diameter/3TD). Spiral density was determined using total loop number and the horizontal diameter of each spiral. Tremor severity score was determined using a validated tremor scale (Bain). The spirals were also rated for the presence of single or multiple axes. An independent t-test was used to compare tremor severity, 3TD and size and a Mann-Whitney test was used to compare spiral density between both groups. Results Spirals drawn by ET patients had significantly higher tremor severity scores than FT patients (4.18 vs 2.82 p=0.03). Spiralaxis is significantly affected by tremor type (p=0.03); there was a significantly greater proportion of patients in the ET group that demonstrate a single axis on spirography compared to those in the FT group (57% vs 14.3%; p=0.02). In two patients with FT and ET there were variable degrees of change in tremor severity over time, with the change in severity in FT being greater than in ET. Conclusion ET and FT can be distinguished by tremor severity and the presence of a single vs multiple axis on analysis of handwritten spiral drawings.

Task-dependent variability of Essential Tremor

IntroductionIn Essential Tremor (ET), tremor characteristics and the impairment caused by tremor may vary from task to task. A variability of tremor frequency between postural and kinetic tasks has been proposed in ET, suggesting either multiple central oscillating networks, or peripheral or proprioceptive feedback-mechanisms. This electrophysiological study aimed to assess tremor frequencies and amplitudes in tasks involving postural and kinetic tremor, and compare findings within and across tasks, to delineate physiological differences underlying individually affected manual tasks in ET. Methods40 ET patients were included in the study. Tremor was characterized clinically, as well as electrophysiologically using accelerometry and digitizing tablet tasks. Tremor amplitude measures and frequencies were extracted for tasks involving kinetic (digital spiral drawing, handwriting), as well as postural tremor. Tremor was compared between and within tasks. ResultsDigital spiral tremor frequencies were significantly higher compared to postural tremor frequencies, as measured by accelerometry, with a mean difference of >2 Hz (p < 0.001). Within-task variability of repeated digital spirals revealed a significant amplitude reduction over time in both hands (p < 0.001), with an up to 32% reduction compared to the first spiral. ConclusionET exhibited a frequency variability, which was dependent on activation condition, suggesting neurophysiologically distinct pathways between postural and kinetic tremor. The reduction of tremor amplitudes observed in repeated digital spiral drawing may be explained by a learning effect or adaptation, and should be considered as non-random factor of variability when using spirals in ET to assess effects of interventions.

Feasibility of spirography features for objective assessment of motor function in Parkinson's disease.

Parkinson's disease (PD) is currently incurable, however proper treatment can ease the symptoms and significantly improve the quality of life of patients. Since PD is a chronic disease, its efficient monitoring and management is very important. The objective of this paper was to investigate the feasibility of using the features and methodology of a spirography application, originally designed to detect early Parkinson's disease (PD) motoric symptoms, for automatically assessing motor symptoms of advanced PD patients experiencing motor fluctuations. More specifically, the aim was to objectively assess motor symptoms related to bradykinesias (slowness of movements occurring as a result of under-medication) and dyskinesias (involuntary movements occurring as a result of over-medication). This work combined spirography data and clinical assessments from a longitudinal clinical study in Sweden with the features and pre-processing methodology of a Slovenian spirography application. The study involved 65 advanced PD patients and over 30,000 spiral-drawing measurements over the course of three years. Machine learning methods were used to learn to predict the "cause" (bradykinesia or dyskinesia) of upper limb motor dysfunctions as assessed by a clinician who observed animated spirals in a web interface. The classification model was also tested for comprehensibility. For this purpose a visualisation technique was used to present visual clues to clinicians as to which parts of the spiral drawing (or its animation) are important for the given classification. Using the machine learning methods with feature descriptions and pre-processing from the Slovenian application resulted in 86% classification accuracy and over 0.90 AUC. The clinicians also rated the computer's visual explanations of its classifications as at least meaningful if not necessarily helpful in over 90% of the cases. The relatively high classification accuracy and AUC demonstrates the usefulness of this approach for objective monitoring of PD patients. The positive evaluation of computer's explanations suggests the potential use of this methodology in a decision support setting.

Wavelength tuning of the spirally drawn whispering gallery mode microfiber lasers and the perspectives for sensing applications.

Facile and cost-efficient microcavities, as well as the tuning of the optical modes, especially for the application of top-grade optical devices, have been emerging as attractive research fields. In this work, controllable fabrication of the microfiber laser arrays in polymer matrix is achieved by employing the advanced spiral drawing technique. Besides the high-quality whispering gallery mode (WGM) lasing, wavelength tuning is also realized by applying external forces on the polymer matrix, which induce slightly enlarged cavity sizes. Furthermore, the perspectives of utilizing the microfiber arrays as force and strain sensors are discussed and demonstrated.

SUPPRESSION OF ACTION TREMOR BY SENSORY ELECTRICAL STIMULATION IN PATIENTS WITH ESSENTIAL TREMOR

Essential tremor (ET) is the most common movement disorder that includes postural tremor and action tremor. This study investigates whether sensory electrical stimulation (SES) is effective on the action tremor in patients with ET. One task in the clinical testing of action tremor, “Archimedes spiral drawing”, was performed in 18 patients for three sessions, which were named as pre-stimulation (PRE), stimulation on (ON), and 5[Formula: see text]min after stimulation (POST). SES (sub-motor threshold) was applied on the muscles of the elbow and wrist only at ON session. Three-dimensional (3D) angular velocities were measured on three segments (index finger, hand, and forearm) from which movements of metacarpophalangeal (MP) and wrist joints were derived. Average tremor intensity in each session was represented by root mean square of the vector sum of 3D angular velocities. Tremor intensities in ON session were smaller than in PRE session in one segment (finger) and two joints (MP and wrist) ([Formula: see text]). Tremor intensities in POST session were even smaller than in ON session in all segments and one joint (wrist) ([Formula: see text]). The results indicate that SES suppresses action tremor and the effect continues and even improves 5[Formula: see text]min after the termination of stimulation. The findings of this study may contribute to the improvement of the quality of life in patients with ET.

Digitized Spiral Drawing: A Possible Biomarker for Early Parkinson's Disease.

IntroductionPre-clinical markers of Parkinson’s Disease (PD) are needed, and to be relevant in pre-clinical disease, they should be quantifiably abnormal in early disease as well. Handwriting is impaired early in PD and can be evaluated using computerized analysis of drawn spirals, capturing kinematic, dynamic, and spatial abnormalities and calculating indices that quantify motor performance and disability. Digitized spiral drawing correlates with motor scores and may be more sensitive in detecting early changes than subjective ratings. However, whether changes in spiral drawing are abnormal compared with controls and whether changes are detected in early PD are unknown.Methods138 PD subjects (50 with early PD) and 150 controls drew spirals on a digitizing tablet, generating x, y, z (pressure) data-coordinates and time. Derived indices corresponded to overall spiral execution (severity), shape and kinematic irregularity (second order smoothness, first order zero-crossing), tightness, mean speed and variability of spiral width. Linear mixed effect adjusted models comparing these indices and cross-validation were performed. Receiver operating characteristic analysis was applied to examine discriminative validity of combined indices.ResultsAll indices were significantly different between PD cases and controls, except for zero-crossing. A model using all indices had high discriminative validity (sensitivity = 0.86, specificity = 0.81). Discriminative validity was maintained in patients with early PD.ConclusionSpiral analysis accurately discriminates subjects with PD and early PD from controls supporting a role as a promising quantitative biomarker. Further assessment is needed to determine whether spiral changes are PD specific compared with other disorders and if present in pre-clinical PD.

Three-Dimensional Versus Two-Dimensional Neuroendoscopy: A Preclinical Laboratory Study

Use of traditional two-dimensional (2-D) neuroendoscopy is limited by lack of depth perception. The advent of next-generation three-dimensional (3-D) endoscopes potentially compensates for this limitation. The aim of this study was to objectively compare the 2 modalities in a controlled laboratory environment. Using 2-D and 3-D endoscopes, 8 participants performed simple and complex motor tasks. Participants were divided into 3 groups: novice (n= 3), beginner (n= 4), and expert (n= 1), based on prior neuroendoscopy training. Efficiency of completing simple motor tasks in an allocated time and time to complete complex motor tasks were recorded for both visualization methods with demerits for inaccuracy. Inaccuracy was reduced with increasing experience in the use of the 3-D endoscope for simple motor tasks such as spiral drawing (P= 0.04), but there was no statistical difference in completion time for complex motor tasks pertaining to depth perception among the groups (P>0.05) or within groups for simple or complex tasks. To assess the impact on the learning curve, we analyzed the performance improvement in use of the other endoscope based on which endoscope each participant used first. There was marked improvement in accuracy and efficiency of 2-D scope use in the "3-D first" group for performing simple motor tasks such as dotted-line drawing (P= 0.002), but no benefit was observed for complex motor tasks. Our data do not support the superiority of the 3-D endoscope over its conventional 2-D congener, although its use may shorten the learning curve associated with neuroendoscopy, regardless of subjects' prior experience with neuroendoscopy.

Selection of Entropy Based Features for Automatic Analysis of Essential Tremor

Biomedical systems produce biosignals that arise from interaction mechanisms. In a general form, those mechanisms occur across multiple scales, both spatial and temporal, and contain linear and non-linear information. In this framework, entropy measures are good candidates in order provide useful evidence about disorder in the system, lack of information in time-series and/or irregularity of the signals. The most common movement disorder is essential tremor (ET), which occurs 20 times more than Parkinson’s disease. Interestingly, about 50%–70% of the cases of ET have a genetic origin. One of the most used standard tests for clinical diagnosis of ET is Archimedes’ spiral drawing. This work focuses on the selection of non-linear biomarkers from such drawings and handwriting, and it is part of a wider cross study on the diagnosis of essential tremor, where our piece of research presents the selection of entropy features for early ET diagnosis. Classic entropy features are compared with features based on permutation entropy. Automatic analysis system settled on several Machine Learning paradigms is performed, while automatic features selection is implemented by means of ANOVA (analysis of variance) test. The obtained results for early detection are promising and appear applicable to real environments.

Repeated Spiral Drawings Can Distinguish Motor Learning from Tremor Changes in Patients with Essential Tremor (P4.300)

Repeated Spiral Drawings Can Distinguish Motor Learning from Tremor Changes in Patients with Essential Tremor (P4.300)

Re-Emergent Tremor of Parkinson's Disease Masquerading as Essential Tremor.

BackgroundThe re-emergent tremor of Parkinson’s disease (PD) is generally recognized as a postural tremor.Phenomenology ShownA PD patient with a re-emergent tremor occurring during a task (spiral drawing), which on the surface produced a tremor that resembled that of essential tremor (ET).Educational ValueResearchers and clinicians should be aware of features of this re-emergent tremor to help distinguish it from that of ET.

본태성 진전 환자의 진전특성에 대한 수행과제 및 부위의 영향

Abstract: Essential tremor is a neurological disorder with a tremor of the arms and hands. It is well known thatessential tremor is characterized by the postural tremor and the action tremor. There has been no report on the quan-titative difference in the characteristics of two tremor types. The purpose of this study was to investigate the possibledifference in tremor characteristics of postural and action tremors. Seventeen patients with essential tremor (68.9± 7.9years, 7 men, 10 women) participated in this study. Patients performed the tasks of postural maintenance (armsoutstretched) and daily actions (spiral drawing). Three-axes (pitch, roll and yaw) gyro sensors were attached on indexfinger, back of hand and forearm, from which the segment and the joint angular velocities were calculated. Outcomemeasure was the tremor amplitude defined as the root-mean-square mean of the vector-sum angular velocity at seg-ments and joints. Two-way ANOVA showed that task and joint had main factor on the tremor amplitude (p 0.05). However, tremor amplitude at the wrist joint differed among the tasks (p < 0.05), and it was greater inthe action tasks than in postural task. Tremor was greater at finger segments than at hand and forearm and itincreased in action tasks. The results of this study would be helpful for the understanding and task-specific treat-ments of the essential tremor.Key words: essential tremor, task specific, angular velocity, action tremor, postural tremor

Linking Essential Tremor to the Cerebellum: Clinical Evidence.

Essential tremor (ET) might be a family of diseases unified by the presence of kinetic tremor, but also showing etiological, pathological, and clinical heterogeneity. In this review, we will describe the most significant clinical evidence, which suggests that ET is linked to the cerebellum. Data for this review were identified by searching PUBMED (January 1966 to May 2015) crossing the terms "essential tremor" (ET) and "cerebellum," which yielded 201 entries, 11 of which included the term "cerebellum" in the article title. This was supplemented by articles in the author's files that pertained to this topic. The wide spectrum of clinical features of ET that suggest that it originates as a cerebellar or cerebellar outflow problem include the presence of intentional tremor, gait and balance abnormalities, subtle features of dysarthria, and oculomotor abnormalities, as well as deficits in eye-hand coordination, motor learning deficits, incoordination during spiral drawing task, abnormalities in motor timing and visual reaction time, impairment of social abilities, improvement in tremor after cerebellar stroke, efficacy of deep brain stimulation (which blocks cerebellar outflow), and cognitive dysfunction. It is unlikely, however, that cerebellar dysfunction, per se, fully explains ET-associated dementia, because the cognitive deficits that have been described in patients with cerebellar lesions are generally mild. Overall, a variety of clinical findings suggest that in at least a sizable proportion of patients with ET, there is an underlying abnormality of the cerebellum and/or its pathways.

Automatic Spiral Analysis for Objective Assessment of Motor Symptoms in Parkinson's Disease.

A challenge for the clinical management of advanced Parkinson’s disease (PD) patients is the emergence of fluctuations in motor performance, which represents a significant source of disability during activities of daily living of the patients. There is a lack of objective measurement of treatment effects for in-clinic and at-home use that can provide an overview of the treatment response. The objective of this paper was to develop a method for objective quantification of advanced PD motor symptoms related to off episodes and peak dose dyskinesia, using spiral data gathered by a touch screen telemetry device. More specifically, the aim was to objectively characterize motor symptoms (bradykinesia and dyskinesia), to help in automating the process of visual interpretation of movement anomalies in spirals as rated by movement disorder specialists. Digitized upper limb movement data of 65 advanced PD patients and 10 healthy (HE) subjects were recorded as they performed spiral drawing tasks on a touch screen device in their home environment settings. Several spatiotemporal features were extracted from the time series and used as inputs to machine learning methods. The methods were validated against ratings on animated spirals scored by four movement disorder specialists who visually assessed a set of kinematic features and the motor symptom. The ability of the method to discriminate between PD patients and HE subjects and the test-retest reliability of the computed scores were also evaluated. Computed scores correlated well with mean visual ratings of individual kinematic features. The best performing classifier (Multilayer Perceptron) classified the motor symptom (bradykinesia or dyskinesia) with an accuracy of 84% and area under the receiver operating characteristics curve of 0.86 in relation to visual classifications of the raters. In addition, the method provided high discriminating power when distinguishing between PD patients and HE subjects as well as had good test-retest reliability. This study demonstrated the potential of using digital spiral analysis for objective quantification of PD-specific and/or treatment-induced motor symptoms.

Validity and Responsiveness of At-Home Touch Screen Assessments in Advanced Parkinson's Disease.

The aim of this study was to investigate if a telemetry test battery can be used to measure effects of Parkinson's disease (PD) treatment intervention and disease progression in patients with fluctuations. Sixty-five patients diagnosed with advanced PD were recruited in an open longitudinal 36-month study; 35 treated with levodopa-carbidopa intestinal gel (LCIG) and 30 were candidates for switching from oral PD treatment to LCIG. They utilized a test battery, consisting of self-assessments of symptoms and fine motor tests (tapping and spiral drawings), four times per day in their homes during week-long test periods. The repeated measurements were summarized into an overall test score (OTS) to represent the global condition of the patient during a test period. Clinical assessments included ratings on unified PD rating scale (UPDRS) and 39-item PD questionnaire (PDQ-39) scales. In LCIG-naïve patients, the mean OTS compared to baseline was significantly improved from the first test period on LCIG treatment until month 24. In LCIG-nonnaïve patients, there were no significant changes in the mean OTS until month 36. The OTS correlated adequately with total UPDRS (rho = 0.59) and total PDQ-39 (0.59). Responsiveness measured as effect size was 0.696 and 0.536 for OTS and UPDRS, respectively. The trends of the test scores were similar to the trends of clinical rating scores but the dropout rate was high. Correlations between OTS and clinical rating scales were adequate indicating that the test battery contains important elements of the information of well-established scales. The responsiveness and reproducibility were better for OTS than for total UPDRS.

The occurrence of dystonia in upper-limb multiple sclerosis tremor

Background: The pathophysiology of multiple sclerosis (MS) tremor is uncertain with limited phenotypical studies available. Objective: To investigate whether dystonia contributes to MS tremor and its severity. Methods: MS patients (n = 54) with and without disabling uni- or bilateral upper limb tremor were recruited (39 limbs per group). We rated tremor severity, writing and Archimedes spiral drawing; cerebellar dysfunction (SARA score); the Global Dystonia Scale (GDS) for proximal and distal upper limbs, dystonic posturing, mirror movements, geste antagoniste, and writer’s cramp. Results: Geste antagoniste, mirror dystonia, and dystonic posturing were more frequent and severe (p < 0.001) and dystonia scores were correlated with tremor severity in tremor compared to non-tremor patients. A 1-unit increase in distal dystonia predicted a 0.52-Bain unit (95% confidence interval (CI) 0.08–0.97), p = 0.022) increase in tremor severity and a 1-unit (95% CI 0.48–1.6, p = 0.001) increase in drawing scores. A 1-unit increase in proximal dystonia predicted 0.93-Bain unit increase (95% CI 0.45–1.41, p < 0.001) in tremor severity and 1.5-units (95% CI 0.62–2.41, p = 0.002) increase in the drawing score. Cerebellar function in the tremor limb and tremor severity was correlated (p < 0.001). Conclusions: Upper limb dystonia is common in MS tremor suggesting that MS tremor pathophysiology involves cerebello-pallido-thalamo-cortical network dysfunction.