Cooling away the tremors: A case of peripheral cooling in MS rehabilitation

By Rishika Balani, physiotherapist, Ascot Rehab

Multiple sclerosis (MS) is the most common cause of non-traumatic neurological disability in young adults.

Charcot originally identified the classic triad of symptoms as nystagmus, intention tremor, and scanning speech.

Among these, intention tremor can be particularly disabling for many patients.

According to the Movement Disorder Society, intention tremor refers to any tremor resulting from voluntary muscle contraction, including postural, isometric, and kinetic forms.

More simply, it can be understood as a tremor that appears during goal-directed activities such as reaching for an object, dressing, or bathing.

Tremors are reported in roughly 25 per cent to 60 per cent  of individuals with MS, usually caused by lesions affecting the cerebellum or its neural connections, which disrupt smooth coordination of movement.

Unlike resting tremors seen in Parkinson’s disease, intention tremors become more pronounced when the individual actively tries to move.

For many patients, this means a constant battle with basic daily activities.

When it comes to managing tremor in MS, the evidence for pharmacological interventions remains inconclusive, and no single therapy has shown clear effectiveness.

Overall, treatment of intention tremor in MS has been challenging, as both medication and physical interventions have produced limited results.

Therefore, understanding the peripheral mechanisms involved in tremor generation is important because it may lead to new therapeutic approaches.

Recently, the Physiotherapy team at Ascot Rehabilitation Centre worked with a 25-year-old gentleman with early-onset MS whose tremors were so intrusive that even holding cutlery or using his phone became a challenge.

In exploring ways to support him, we came across a novel yet simple approach — peripheral cooling.

Applying this technique provided him with temporary but meaningful relief, highlighting how small interventions can make a big difference in rehabilitation.

Studies suggested that the cooling induced tremor reduction was related to a decrease in the sensory input provided by muscle spindle afferences.

This temporary slowing of neuromuscular activity can dampen the severity of tremors, providing a “window” of improved control for the patient.

The Case: Applying Peripheral Cooling

In this case, our patient presented with disabling intention tremors affecting his ability to perform fine motor tasks.

After discussing potential strategies with him, we introduced the idea of peripheral cooling as a trial intervention.

In line with published research (Feys et al., 2023), we applied a peripheral cooling technique by immersing the patient’s upper limb in multiple cooling packs for 15 minutes.

This reduced the skin temperature from around 32 °C to approximately 16–18 °C, which temporarily dampened tremor severity.

The arm was protected from potential freezing wounds by placing paper tissues between the cold pack and skin.

To evaluate the impact, we used the Nine Hole Peg Test (NHPT) at four time points: before cooling, immediately after (0 minutes), 25 minutes post, and 50 minutes post.

Consistent with research findings, his performance improved most noticeably immediately after cooling, with functional benefits still observable at 25 minutes and partially maintained at 50 minutes.

For him, this meant tasks like drinking, using his phone and writing were achievable with greater control and confidence during that window of time.

Reflection and Wider Implications

What struck us most in this case was the immediacy and tangibility of the results.

For a patient struggling with the frustration of tremors, even 50 minutes of improved function can have a significant psychological and practical impact.

This approach also reflects a wider truth in neuro-rehabilitation: sometimes small, low-tech interventions can open doors that medication or complex equipment cannot.

While peripheral cooling is not a cure, it empowers patients with a safe, accessible strategy they can incorporate into daily routines.

Of course, this technique has its limitations.

The benefits are temporary, and prolonged or repeated cooling must be monitored carefully to avoid skin irritation or discomfort.

More research is also needed to fully understand its long-term efficacy and the best ways to integrate it into rehabilitation programmes.

Peripheral cooling is one such option — inexpensive, non-invasive, and adaptable.

With further exploration, it could become a valuable tool in the neuro-rehab toolkit, particularly for younger patients who are keen to maintain independence in education, work, and social life.

For more information about the neurorehabilitation offered at Ascot Rehab, please visit their website: https://www.ascotrehab.com