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.
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.
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
- 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.