Important Clinical Note First

• Wilson's disease (hepatolenticular degeneration - treatable and must not be missed)
• Juvenile Parkinson's disease
• Essential tremor (action > resting, but can present at this age)
• Drug-induced tremor

• Improve voluntary motor control and precision
• Strengthen the visuomotor feedback loop
• Reduce functional disability despite tremor

Core Principles of Frenkel's Exercises

1. Voluntary concentration - Patient focuses full attention on the movement
2. Slow and deliberate motion - No rushing; precision over speed
3. Visual feedback - Eyes on the target at all times
4. Auditory cues - Therapist counts cadence aloud ("1-2-3-4")
5. Gradual progression - Simple to complex; supported to unsupported
6. Repetition - 3-5 sets of each exercise per session

Frenkel's Upper Limb Exercises for Right Hand - Progressive Protocol

Phase 1 - Sitting, Supported (Week 1-2)

• Patient sits upright with back supported
• With eyes open, slowly touch the tip of the right index finger to the nose
• Return to starting position (arm outstretched)
• Repeat 10 times
• Progression: Increase speed gradually, then try with eyes closed

• Therapist holds a finger at shoulder height
• Patient slowly reaches and touches the therapist's finger with the right index finger
• Therapist changes the target position each repetition
• 10 repetitions per set

• Patient touches thumb to each finger in sequence (index, middle, ring, little)
• Perform slowly with visual focus on the fingers
• 3 sets x 10 repetitions
• Progress to rhythmic counting (1-2-3-4 and back)

• Elbow bent to 90°, forearm resting on table
• Slowly rotate forearm: palm up (supination) to palm down (pronation)
• Eyes on the hand throughout
• 10 repetitions, slow and controlled

Phase 2 - Sitting, Unsupported (Week 3-4)

• Place 5-6 objects (cup, pen, block) on the table at different positions
• Patient reaches out and touches/picks up each object in sequence with right hand
• Focus: smooth trajectory, no overshooting
• 3 rounds

• Provide a printed sheet with lines, dots, or simple shapes
• Patient traces with a pen using the right hand as slowly and accurately as possible
• Provides continuous visual biofeedback of motor accuracy

• Stack small blocks or place pegs in holes
• Graded by hole size (larger to smaller)
• Excellent for fine motor control

• Extend right arm forward at shoulder height
• Move arm slowly laterally to the side (keeping elbow straight)
• Return to center, then move arm down
• Perform each direction separately, eyes tracking the hand
• 10 repetitions per direction

Phase 3 - Dynamic and Functional (Week 5-6)

• Alternate tapping right hand on alternating targets (left and right of midline)
• Use a metronome at slow pace (30-40 bpm), gradually increase
• Trains rhythm and coordination together

• Both hands performing a mirrored task (e.g., folding paper, clapping at target points)
• Helps the right side "learn" from the left via bilateral transfer

• Pouring water from one cup to another
• Buttoning and unbuttoning a shirt
• Writing tasks with templates and guidelines
• These generalize gains to real function

Session Structure (Suggested)

Key Modifications for Resting Tremor Specifically

• Weight cuffs (100-200g) on the right wrist can dampen tremor amplitude during exercises
• Begin each movement with a slight postural shift to "activate" voluntary motor control
• Avoid cold temperatures in the therapy room (cold worsens tremor)
• If the tremor is more prominent, start in a semi-reclining position to reduce basal ganglia input via postural tone
• Combine with proprioceptive neuromuscular facilitation (PNF) diagonal patterns for the upper limb

Contraindications / Caution

• Do NOT progress to unsupported phases if significant muscle weakness is present
• Discontinue if tremor worsens significantly during activity (suggests cerebellar component - different treatment approach)
• Reassess regularly since a 17-year-old with resting tremor needs ongoing neurological workup