A cerebellar-like terminal and postural tremor induced in normal man by transcranial magnetic stimulation

Trains of repetitive transcranial magnetic stimulation (TMS) at 10-30 Hz an d intensities of 90-120% motor threshold were delivered through a figure of eight coil over the motor cortex while normal subjects made either rapid, self-terminated (ballistic) wrist movements or maintained the position of t heir wrist at a fixed angle. Movement kinematics and EMG activity in antago nistic forearm muscles were analysed. In the ballistic task, repetitive TMS had little effect on the velocity or acceleration of the initial segment o f the movement, although it induced large terminal oscillations (tremor) ar ound the target position at frequencies between 4.4 and 7.2 Hz. The likelih ood that tremor would occur increased with increasing stimulus intensities or frequencies. It was maximal with stimulation over the forearm area, and decreased with stimulation over the leg area, or over parietal sites; there was no tremor during stimulation of cervical nerve roots. The frequency of the induced tremor was independent of the rate of stimulation and did not depend on the presence of excitatory and inhibitory motor responses to the stimulus. Stimulation could also induce tremor of the same frequency in the fixed task, but only during co-contraction of forearm muscles. The amplitu de of tremor was proportional to the level of co-contraction. Clinically, t he tremor induced by repetitive TMS appeared very similar to cerebellar tre mors. In order to confirm this we investigated two cerebellar patients, one with autosomal dominant cerebellar ataxia and the other with multiple scle rosis. Both of them had a terminal tremor of 6-7 Hz in the wrist movement t ask. In the holding task, the amplitude of their postural tremor increased with the level of co-contraction in forearm muscles. Since the frequency of repetitive TMS-induced tremor was independent of stimulus parameters, we c onclude that it represents some intrinsic property of the CNS. We suggest t hat the tremor is caused by disruption of cortical processes involved in te rminating a voluntary movement or maintaining a posture. Similarities to ce rebellar patients suggest that repetitive TMS may cause tremor by interferi ng with adaptive cerebellar afferent inflow to motor cortex. Repetitive TMS -induced tremor, therefore, may represent a model of some forms of cerebell ar tremor in man.