Introduction: During the seventeenth century, figurines of Buddha and other religious figures called "temple nodders" were produced in Asia.[3] The earliest known Western reference to a bobblehead is thought to be in Nikolai Gogol's 1842 short story "The Overcoat," in which the main character's neck was described as being "like the necks of plaster cats that wag their heads.
Thanjavur dolls are a type of Indian bobblehead doll known as "Thanjavur Thalayatti Bommai" in the Tamil language, meaning "Tanjore Head-Shaking Doll." They are a native art form in the Thanjavur region of Tamil Nadu.
CC licence: https://commons.m.wikimedia.org/wiki/File:A_Tanjore_doll.jpg#mw-jump-to-licenseProject thoughts beginning from our first tryst with the patient seen in 2004 in Vydehi medical college, Bangalore although at that time we didn't even realise what his symptoms were and he googled us ten years later to show us again in another city where we documented our first observation of this syn in a reflective note as fished out from that time in an email sent on 2013 below:
Date: Thu, 10 Jan 2013, 12:35
Subject: re: Bobble head Doll history
To
I met this 39 year old man yesterday after a gap of 7 years since our first meeting in Bangalore. At the time i had simply taken his history and prescribed some non specific medications based on his history without actually witnessing the movements (which at the time was reported to be of a momentary duration). The physician-placebo effect had probably brought him back to me in Bhopal after he managed to locate me through an internet search and sent me an email.
His symptoms had gradually progressed in duration and frequency such that i could easily witness it for myself now. It was a stereotypical head movement that appeared to say no-no.He also had a badly impaired tandem walk among other positive findings. His head movements appeared to increase while lying down and this made us have to resort to a good dose of IV diazepam to sedate him during the cranial MRI (attached).
Copying this also to our neurosurgeon so that it helps to evaluate him soon by the next working day.
There is not much evidence on how to go about the further management of such patients other than convincing reports of improvement following endoscopic third ventriculostomy in different case series. http://www.ncbi.nlm.nih.gov/pubmed/22886034
The other unique feature of our patient was the manifestation of this syndrome in adult life. The oldest patient (among the 57 patients reported till date) is 13 years http://www.neuroscience.org.np/Rana2.pdf
Also why were his symptoms increasing with lying supine? Is it because the normal third ventricular pressure increases during supine? http://www.ncbi.nlm.nih.gov/pubmed/9402598
best,
Subsequently again lost him to follow up for nearly another 7 years before he again got in touch through Facebook and our students in Hyderabad prepared the case reports below through telephonic data capture:
case report link from a student's online learning portfolio linked below:
Hand written case report from another student's online learning portfolio:
Video of patient 2 taken in an OPD follow up encounter in 15th October 2024:
CBBLE and PaJR conversations also at the description box in the YouTube link above.
Got the content below from his PaJR description box possibly added in June 2023 during first encounter:
Sequence of events:
1993:He was born by NVD and cry after birth (+)with no H/o birth insult
He is the youngest in the family with four sisters elder than him who are apparently healthy
2015- For the first time patient noticed involuntary movements of head and neck as insisted by his friends which were mild,he visited a hospital in Karimnagar where he was prescribed Tab Clonazepam 0.25 mg +propranolol 20 mg and ?one more medication at night (which he was even using now)
2016- He was married to a woman with some ?spine deformity and had a kid in 2017,born by LSCS and no H/o birth insult and he is healthy now
2017-He consulted a Neurologist in Hyderabad and used medication for 6 months ,but symptoms did not subside and stopped the medication
2018-By this time his involuntary movements of head increased and he visited a hospital in Nalgonda where he was prescribed with some medication which he almost 3-4 months ,but symptoms did not subside
2019-2020: His symptoms gradually increased despite using different medications
2021:He Visited our hospital with pain abdomen and was diagnosed with liver abscess and the abscess was drained and he was relieved
2022: There if further increase in head and neck movements associated with tremulous speech and movements of left upper limb and after 6 months he developed similar complaints in the right upper limb.
No involuntary movements of lower limbs till now
2023:He consulted a physician in February where he used Vit B12 and thiamine along with some other medication after which he felt his symptoms decreased a bit
Initially he felt the symptoms relieved on taking alcohol but gradually didn’t find any difference on consumption of alcohol
These abnormal movements are absent during rest or sleep
No H/o Loss of consciousness
No H/o seizure activity
No H/o giddiness,falls
Last alcohol intake was 15 days back(90ml whiskey)
Consumes around 90ml/day since 12 years
O/E:
Pt is conscious,coherent and cooperative
Pt maintained eye contact through out the examination
HMF
EMR summary of second patient from June 2023:
Age/Gender : 27 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 06/05/2023 11:18 AM
Diagnosis
TREMOR PLUS SYNDROME
SPASTIC CEREBELLAR ATAXIA ?GENETIC CAUSE ?OTHER CAUSES
Case History and Clinical Findings
PATIENT CAME WITH C/O INVOLUNTARY MOVEMENTS OF NECK SINCE 4 YEARS INVOLUNTARY MOVEMENTS OF UPPER LIMBS SINCE 1 YEAR
HOPI
PATIENT WAS APPARENTLY NORMAL 4 YEARS BACK THEN HE DEVELOPED INVOLUNTARY MOVEMENTS OF NECK SINCE 4 YEARS WHICH WAS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE , INITIALLY STARTED AS FINE MOVEMENTS / TREMORS THEN GRADUALLY INCREASED IN INTENSITY
HE ALSO DEVELOPED INVOLUNTARY MOVEMENTS OF UPPER LIMBS SINCE 1 YEAR INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE
INITIALLY LEFT UPPER LIMB THEN PROGRESSED TO RIGHT UPPER LIMB
PATIENT C/O INCREASE ININTENSITY OF INVOLUNTARY MOVEMENTS SINCE 1 WEEK NO C/O HEADACHE,SEIZURES , LOC , GIDDINESS , WEAKNESS, VISION DISTURBANCE , FEVER , VOMITINGS.
TREMORS ARE SEEN ONLY IN WORKING CONDITION AND RELIEVED IN RESTING STATE PAST HISTORY:
H/O LIVER ABSCESS 1 YEAR BACKDRAINED AND ADVISED FOR ALCOHOL ABSTINENCE N/K/C/O DM , HTN ,TB , EPILEPSY , HTN,CAD,CVA , THYROID.
PERSONAL HISTORY ; DIET : MIXED
APPETITE : DECREASED SLEEP : NORMAL
BOWEL AND BLADDER : REGULAR
ADDICTIONS: ALCOHOL : OCCASIONAL (STOPPED 15 DAYS BACK) NO ALLERGIES
FAMILY HISTORY :
INSIGNIFICANT
GENERAL EXAMINATION :
PATIENT IS
MODERATELY BUILT AND NOURISHED .
NO SIGNS OF ICTERUS , CYANOSIS , CLUBBING ,LYMPHADENOPATHY, EDEMA.
VITALS : TEMPERATURE:98.6 F PR - 54 BPM
BP - 100/60 MMHG RR - 21 CPM
SPO2 - 98% ON RA GRBS - 92 MG/DL
SYSTEMIC EXAMINATION : PER ABDOMEN : INSPECTION :
ABDOMEN IS SCAPHOID UMBILICUS IS CENTRAL
ALL QUADRANTS ARE MOVING EQUALLY WITH RESPIRATION NO SINUSES , ENGORGED VEINS, VISIBLE PULSATIONS . HERNIAL ORIFICES ARE FREE.
PALPATION :
NO LOCAL RISE OF TEMPERATURE NO TENDERNESS
LIVER AND SPLEEN - NOT PALPABLE
PERCUSSION : TYMPANIC NOTE HEARD OVER THE ABDOMEN. FLUID THRILL ABSENT
SHIFTING DULLNESS ABSENT AUSCULTATION :
BOWEL SOUNDS ARE HEARD.
CARDIOVASCULAR SYSTEM :
INSPECTION:
SHAPE OF CHEST IS ELLIPTICAL. NO RAISED JVP
NO VISIBLE PULSATIONS, SCARS , SINUSES , ENGORGED VEINS. PALPATION :
APEX BEAT - FELT AT LEFT 5TH INTERCOSTAL SPACE NO THRILLS AND PARASTERNAL HEAVES AUSCULTATION :
S1 AND S2 HEARD.
RESPIRATORY SYSTEM:
INSPECTION:
SHAPE- ELLIPTICAL B/L SYMMETRICAL
BOTH SIDES MOVING EQUALLY WITH RESPIRATION . NO SCARS, SINUSES, ENGORGED VEINS, PULSATIONS PALPATION:
TRACHEA - CENTRAL
EXPANSION OF CHEST IS SYMMETRICAL. VOCAL FREMITUS - NORMAL
PERCUSSION: RESONANT BILATERALLY AUSCULTATION:
BILATERAL AIR ENTRY PRESENT
CENTRAL NERVOUS SYSTEM:
PATIENT IS DROWSY E4V5M6
SPEECH- SLURRED
NO SIGNS OF MENINGEAL IRRITATION.
CRANIAL NERVES- 11 TH CRANIAL NERVE - DIFFICULTY IN SHRUGGING OF SHOULDERS SENSORY SYSTEM- NORMAL
MOTOR SYSTEM:
TONE- NORMAL
POWER- BILATERALLY 5/5 REFLEXES RIGHTLEFT BICEPS - -
TRICEPS. - - SUPINATOR - - KNEE. - - ANKLE - -
BILATERAL PLANTAR EXTENSOR CEREBELLUM EXAMINATION :
INTENTIONAL TREMORS PRESENT GAIT - NORMAL
NYSTAGMUS - ABSENT FINGER NOSE TEST - NORMAL
DYSDIADOKOKINESIA - ABSENT ROMBERGS TEST - EQUIVOCAL
COURSE IN HOSPITAL:A 26 YEAR OLD MALE CAME WITH C/O INVOLUNTARY MOVEMENTS OF NECK SINCE 4 YEARS AND INVOLUNTARY MOVEMENTS OF UPPER LIMBS SINCE 1 YEAR.MRI BRAIN SHOWED NO ABNORMALITIY.NEUROLOGY REFERRAL WAS DONE AND ADVISED MRI CERVICAL SPINE AND ADVISED CAP. BETACAP 40 MG PO/BD , TAB.VITAMIN E 400 MG PO/OD, INJ.METHYLCOBALAMIN 1500MCG IN 100ML NS FOR 1 WEEK.
PATIENT WAS DISCHARGED AND WAS ASKED TO REVIEW WITH MRI CERVICAL SPINE REPORT.
Investigation
ECG -
USG ABDOMEN - MILD SPLENOMEGALY ( 7-5-23) 2 D ECHO -6-5-23
NO MR /AR/TR
NO RWMA . NO AS /MS
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC FUNCTION . NO PAH/PE/LV CLOTS HEMOGRAM:6/05/23
HB 12.2gm/dl
TLC:5700 CELLS/CUMM PLT: 2.15 LAKHS/CUMM MRI BRAIN(11/5/23)
NO ABNORMALITY DETECTED
Treatment Given(Enter only Generic Name)
IV FLUIDS @ 75 ML/HR
INJ.METHYLCOBALAMIN 1500 MCG/IV/OD IN 100 ML NS FOR 1 WEEK CAP.BETACAP TR 40MG PO/BD
TAB.TETRABENZENE 12.5 MG PO/OD TAB.EVION PO O/D
Advice at Discharge
INJ.METHYLCOBALAMIN 1500 MCG/IV/OD IN 100 ML NS FOR 1 WEEK ONCE WEEKLY FOR 4 WEEKS.
CAP.BETACAP TR 40MG PO/BD TAB.EVION PO/ OD
Follow Up
REVIEW TO GENERAL MEDICINE OPD WITH MRI CERVICAL SPINE AFTER 2 WEEKS OR REVIEW SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date:12/5/23 Ward:AMC
Unit:6
Video of third patient taken in OPD on April 2024 and patient lost to follow up:
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