Shake, Rattle, and Roll

Abnormal Hand Movements

It’s time for another physical diagnosis discussion. Four weeks ago we talked about abnormal gait. Today let’s discuss abnormal movements of the hands, and let’s limit the discussion to tremor. There are other abnormal movements of the hands, but most of them will occur in people with severe neurological or metabolic disorders, and not in people who are out in public, committing crimes, or solving crimes, i.e. characters in your stories. There are also tics, habits, and “unusual” movements of the hands which are under voluntary control, and are therefore “normal.”

Hopefully this discussion will be of value with description, and being specific.

So, let’s get started. What is tremor? The medical definition is “rhythmic involuntary movements.” Note that it can involve other parts of the body besides the hands.

In practice, when a physician sees someone with “the shakes,” the first thing he/she will do is to differentiate between Parkinsonian tremor and Benign Familial Tremor. They are two different neurological disorders, with far different prognoses and treatment.

 

Parkinson Tremor

The Parkinsonian tremor has a regular rhythm of four to six cycles per second. It is best seen when the patient is moderately relaxed, and disappears during sleep and complete relaxation. It also decreases with voluntary movement. It has been called a “rest tremor.” It can affect the hands, the feet, and the mouth. It is most commonly seen in the hand, where the thumb beats rhythmically against the flexed fingers, thus called a “pill rolling tremor.”

The onset of the tremor is often asymmetric, affecting one limb more that the other. Other clues that this is Parkinson’s disease include slow movement, shuffling while walking, flat facial expression, and rigidity to flexion and extension of the affected limb. Parkinson’s disease is also associated with dementia.

 

Benign Familial Tremor (now coded as “essential tremor”)

I prefer the old name, because it is more descriptive of the cause and the prognosis. This is a very common condition, affecting about four percent of the population. It is often mild and goes undiagnosed. And there is often a family history of the same tremor.

The tremor is described as affecting the fingers, particularly in the outstretched hand. It can also cause rhythmic oscillations of the head (titubation, or “head bob”). The tremor is fine, rapid, and accentuated by activity or emotional stress. I like to call it a “vibratory” tremor. And, because it is worse with activity or trying to suppress it, it is also described as an “intentional” tremor. It is not associated with dementia. And, unlike Parkinson’s Disease, it may not progress.

 

Others

Other common conditions that may be associated with a similar tremor, and may actually be uncovered, otherwise asymptomatic, Benign Familial Tremor, are the following:

  • Excessive thyroid – either hyperthyroidism or excessive thyroid replacement
  • Excessive caffeine intake – we’ve all seen that one
  • Sleep deprivation
  • Decongestant use such as pseudoephedrine (Sudafed)
  • Use of stimulant drugs – either for attention deficit or illicit drug use
  • Anxiety
  • And any combination of the above

 

So, now you are prepared to describe in detail the tremor of that suspect sitting across the interrogation table from you. If you get a chance, grab his wrist and see how smoothly his arm flexes and extends at the elbow. Make him reach for something and see if the tremor ceases or is accentuated. And if his tremor is bizarre, get a neurological consultation. If that doesn’t yield a diagnosis, call a psychiatrist.

 

Okay, it’s your turn: What memorable characters with a tremor have you read about in a novel, or seen in a movie? What characters have you created with a tremor? Or, if you prefer, what would be an ideal situation to display a character with tremor? And, hopefully, it’s not your hero trying to aim his gun.

 

 

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33 thoughts on “Shake, Rattle, and Roll

  1. Good morning, Steve!

    Thank you so much for this discussion. I have a neighbor who was recently evaluated for hand tremors. He, fortunately, has benign familial tremors instead of those secondary to Parkinson’s.

    I had never heard the term “benign familial tremors” before this morning. Thanks for broadening my knowledge once again.

    Have a great weekend, which apparently in these parts will literally be the calm before the storm. Be well, Steve!

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  2. Thanks, Joe. I hope your neighbor found some medicine that helped control the tremor. Benign Familial Tremor is common, but often not reported or treated.

    Yes, Sunday evening to Tuesday afternoon is supposed to deliver another 4″ – 8.” Just what we need. Stay safe. Stay well.

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  3. Morning ~

    As Mr. H said – thanks for the discussion ~

    I saw Parkinson’s “up close” in my granddad,
    who was forced to retire when he could no longer work as an airline sheet metal fine fabricator. It was a long ten or so years, but your descriptions brought bittersweet pictures of him to mind ~

    On a (much) lighter note, the character I think of most readily is Gene Wilder’s Waco Kid in Blazing Saddles –
    “See this hand?” He says, holding out his right arm steadily.
    “Well, I shoot with this one,” he says, holding out a very shaky left hand.

    Stay warm and well.

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    • Thanks, George. Yes, it is bittersweet when we see Parkinson’s disease in a relative. My father developed dementia with the disease, and ended up in a dementia unit. Really sad to watch that progression.

      Thanks for the reminder of the Waco Kid. I’m not sure which side of the fight it would be better to be on, if one of the shooters had tremor.

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  4. Very interesting, Steve, thanks.

    I agree that “essential” tremor is a poor descriptor. Anyone who suffers from it will be quick to say it is anything BUT essential, esp. for a writer trying to type.

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    • Thanks, Debbie, for reminding us of a different perspective, the writer, and daily activities. There are various treatments available. So, if anyone is struggling with it, they should talk to their doctor about options. And, looking through the “other” list, avoiding excess caffeine, getting enough sleep, avoiding stimulants (such as decongestants), can help.

      Have a great weekend.

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  5. One of my mom’s cousins (which would make him one of mine, too, I guess), suffered from Parkinson’s. I think Michael J. Fox would come to mind for most of us. And, loosely coincidental–Hubster and I were watching Bull last night, and the story line revolved around someone finding a cure for Parkinson’s.

    Thanks for the character ideas.

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    • Thanks, Terry. I agree, Michael J Fox was the name I expected to be mentioned the most. He has also brought attention to the need for research for finding a cure, and has continued to work in spite of the disease. Sadly, many people, in many professions, withdraw to hide their disability.

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  6. Awesome, Steve! A diagnosis of “Essential” tremor might anger a patient, no? There’s nothing essential about it. I wonder why they renamed Benign Familial Tremor, which is clear and easy to understand.

    Question: Would a shaky voice fall under Benign Familial Tremor or Parkinsons? It’s not for a character. Just curious.

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    • Thanks for your comments, Sue. Yes, a diagnosis of “essential” tremor might anger a patient, but most of the time patients are just relieved that it is not Parkinson’s disease.

      I don’t know why the “experts” changed the name. In 2015 the diagnosis codes changed from ICD 9 to ICD 10. I believe subspecialists in each specialty had a hand in devising the code. In some areas, the changes made sense. In other areas the differentiation between codes is (to be kind) excessive. In any case, the change was expensive, a huge disruption, and added to profit for the computer people and more control for the government.

      A shaky voice could occur in Benign Familial Tremor or Parkinson disease. It could also occur in many other medical conditions.

      Thanks for your comments and questions.

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  7. An interesting and informative post, Joe. I’ve heard there’s a type of tremor caused by medication also. The sister of a good friend of mine was discovered to have Parkinson’s. Unfortunately, it was after she fell on her face doing damage to her jaw, teeth, and nose. The doctor wondered why she hadn’t been able to put her hands out to break her fall. She’s now on medication which my friend tells me is helping her. My daughter’s father-in-law has also been diagnosed with it. —- Suzanne

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    • Thanks, Suzanne. You’re correct. Tremor can be caused by medication. Antipsychotics, anticonvulsants, and antidepressants are listed. In my primary care practice, the most common medicine I saw as a culprit was thyroid replacement. Too much thyroid can cause tremor, but it also gives the patient more energy and makes it easier to lose weight. Some of the (I won’t mention which sex) patients were happy to put up with the tremor in exchange for keeping their weight down.

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  8. Interesting stuff, Steve. I haven’t written tremor action into any characters, but I do have to say that I was in for cataract surgery two weeks ago and was very happy that my ophthalmologist didn’t display any rhythmic involuntary movements. Enjoy your weekend!

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    • Thanks, Garry. Yes, that would be an interesting antagonist, coming at your face with an instrument of torture…and a tremor.

      Hope you had excellent results with your cataract surgery and healing.

      Your comment about the ophthalmologist reminded me of a urologist story. (Story rated G, for all audiences). When I was in residency, back in the dark ages, I did a rotation with a urologist who was pioneering vas deferens re-anastomosis. He was practicing, working under an operating scope, with a needle so small you could barely see it (except with the scope). He let me try my hand. After a few stitches, he said, “You didn’t have any coffee this morning.”

      I believe, when I have my cataract surgery, I’ll ask the surgeon to skip his/her coffee that morning.

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    • Hey, Garry…just a word. And Steve, have you heard of this?

      I had cataract surgery in April 2019, with lens implants. This upcoming April, I have to go in for laser surgery on both eyes because my immune system doesn’t like the “foreign bodies” in my eyes, and is encasing the new lenses in a cellophane-like substance. The doc’s going to clean them off and hope it doesn’t happen again…who knew?

      It makes it kinda hard to see…

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      • Deb, according to my research (Google), the incidence of posterior capsule opacification is 20%. I knew it was common. Didn’t know it was that high. I suppose that’s good for the docs doing the laser surgery. (Just kidding). You’d think they would come up with something to reduce the incidence.

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  9. Steve, you’ve given me an idea.

    In a current WIP, the MC has an elderly man for a neighbor…I think I’ll consider afflicting him with a hand tremor.

    So mean…

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    • Thanks, Deb. Great idea. The tremor will make the neighbor “real” and more memorable. And, maybe the “affliction” will give you some other options for plot. And, what if, this elderly shaky neighbor likes to shoot ground hogs that get into his garden.

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      • Or his neighbor’s dandelions. The MC’s husband keeps his lawn neat and tidy, but the elderly neighbor always criticizes…if there’s one weed, he says something.

        Shooting a dandelion would make for an amusing scene, I think. 🙂

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  10. Another great post, Steve. Like many of the other commenters, my experience with tremors comes from real-life rather than fiction. I can’t recall a character off the top of my head who experienced tremors, though I probably have seen it in a movie or read it a novel at some point. I do recall the tremors that afflicted my father before he died.

    In 1999 he was diagnosed with idiopathic pulmonary fibrosis, probably caused by a combination of work environment and repeated bouts of pneumonia when he was younger. By early 2003, he had lost a lot of weight and began to show a Parksonian-like tremor–I recall his neurologist saying it was Parksonism brought on by his illness. He was placed on supplemental oxygen later that spring, with the tremors worsening. He passed away in June, 2003.

    On a lighter note, I’ve experienced caffeine tremors. One of my hobbies is stargazing, and holding binoculars can be frustrating if you’ve had too much caffeine or are fatigued, plus people’s hands naturally shake, just barely perceptibly. It can be a real challenge to steady the image in higher power binoculars, say 10x, or especially 12x or higher ones–the stars seem to dance. On the other hand, the image in the ultra-low magnification “constellation” binoculars which are in the 2x magnification range can appear very steady.

    Thanks for another informative post! Happy Saturday!

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    • Thanks, Dale. It is really sad to see loved ones develop tremor in their late years. It’s bad enough that they often lose cognitive function and become weaker, but when they lose function of their hands they become dependent on others. I’ve seen many elderly struggle to get their hearing aids back into their ears, or worse, try to replace tiny batteries in their hearing aids.

      Your comments on star gazing are interesting. And, yes, when my hands begin to shake, I know I’ve had too much coffee.

      Happy Saturday, Dale!

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  11. Thanks so much for this post, Steve. My dad passed away from Parkinson’s last August, and we were all shocked because although he was very unsteady and immobilized by the tremors, weakness and instability, he went to doctors frequently and seemed to have been in good condition otherwise. Then one night he sat down in his favorite chair to watch the news, went to sleep and never woke up. It was very peaceful, I was grateful to hear.

    For writing, I would imagine having a detective observe an essential tremor in a suspect, and seeing him debate whether the tremor is genuine or not. (And if the detective had a medical background, he/she might be able to spot some “tell” that indicates the suspect is faking the condition.

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    • Thanks, Kathryn. I’m sorry for your loss. I’m glad it was peaceful. My father died in 2015. He had severe dementia with his Parkinson’s disease. 2015 was a bad year for influenza. My father had the flu, then a severe pneumonia, from which he never recovered. It was one of the worst events I’ve ever experienced.

      You’re correct about a detective deciding whether a tremor is faked or real. Hopefully, today’s post will give the writer some basic clues to look for. And, in reality, a physician exam will probably be necessary.

      Thanks for stopping by. Have a good weekend!

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  12. In early elementary school (2nd grade, I think) one of my classmates (a boy) suffered from a tremor (I think that’s what it was) that I have never seen since. He would nod his head continuously. I’m talking gross movement here, with his chin rocking to his chest, and then his nose going vertical. It was continuous, cycling once every two or three seconds, I guess. He could do school work by resting his head on his hand, but that was the only time it stopped. Any ideas?

    I haven’t seen him since then. I believe his family moved away.

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    • That’s a very interesting story. And I’m only guessing here. The boy would certainly be motivated to control such embarrassing movements, so they were most likely not voluntary movement. I’ve never heard of tremor with that type of movement. That sounds more like seizure activity. A Jacksonian seizure can cause seizure activity, even while the patient is aware. And the Jacksonian seizure could be caused by cerebral palsy (brain damage at birth).

      That’s just a guess.

      Thanks for stopping by, John. Have a good weekend.

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  13. My father suffered from Parkinsonism for the last five years of his life, finally succumbing to pneumonia. It was terrible to witness a strong and decent man having to deal with it.

    After I retired, I had the opportunity to help out with a Parkinson’s Disease exercise class (exercise does help) twice a week. I met many folks, patients and spouses, who were bravely fighting for every inch. I even recorded an exercise video starring 85-year-old Alta Mae who had led the class for years ever since her husband died of the disease! We made DVDs and patients used them to keep up with the exercises at home.

    I don’t know if I could ever include a Parkinson’s patient in one of my books. It’s just too close to me. But I might create a character based on the brave and faithful Alta Mae. Thanks for reminding me.

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    • Thanks, Kay, for sharing your experience. Some things are too precious to put in a story. But you followed Alta Mae, providing service that was truly meaningful and created memories that will last a lifetime. An Alta Mae – based character would be a tribute to a worthy woman.

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