Essential Tremor and my user experience

We have just emerged from National Essential Tremor Awareness Month 2025, which means this is a good time to share my journey with this condition and describe how it affects my use of technology.

What is Essential Tremor?

You may well be wondering just what ET is. That’s quite normal, it turns out — ET has been called “the most common neurological condition that nobody has ever heard of”. Among the various movement disorders, including Parkinson’s and dystonia, Essential Tremor is the most common, and although it can run in families (mine didn‘t, as best I can tell) nobody knows exactly what causes it. A variety of symptoms can be present, and an article in the British Medical Journal says that ET is now considered a syndrome rather than a single disorder.

Whatever it is, I’ve got it. And it increasingly affects my use of technology.

How I got to where I am with ET

How it started

I noticed the first sign in the summer of 1994. I had stuck my head forward to drink from a full cup of coffee without spilling any on myself. Weirdly, as my mouth came near the cup, my head started shaking uncontrollably from side to side, as if I were frantically signalling “no, no!” To make it stop, I had to draw my head back so that my neck was upright. Eventually I managed to drink the coffee, but not with my head sticking forward.

The scenario repeated itself a couple of times during the weekend. Needless to say, I was mystified.

For a while the shakiness more or less disappeared, but over the next few years it cropped up again from time to time. I could usually make it subside by pulling my head back and straightening my neck, but that became less and less effective as time went on. At some point — sometime about 1998, I think — I noticed that my hands were shaking a bit too. It was time to get myself checked out. So I made an appointment with a neurologist.

Getting a diagnosis

The neurologist watched whilst I wrote my name, drew a spiral, walked to the examining room door and back, and so forth. “Good news,” she told me — “it’s not Parkinson’s, and it’s not MS.” (Good, I thought; it sounded as though it wasn’t life threatening.) Then she said, “You have Essential Tremor.”

What?? I had heard of the other two, of course, but this one was completely new to me. The neurologist told me that the shaking and quivering would gradually grow worse, but she couldn’t tell me how quickly that would happen or how severe it would become; both the progression and the severity vary widely from person to person. Medications were available for it, she said, but my symptoms were so mild at that point that it wasn’t worth the side effects. So I had a diagnosis but nothing much to do for it — except to minimise my consumption of caffeine.

How things are now

25 years after diagnosis, my tremors continue to increase (very gradually), and I’m still not taking any medication or considering any surgical treatment. My left arm, hand, and fingers shake somewhat more than my right ones do; my head shakes a bit; my singing voice can quaver a little (especially around E just above Middle C). It’s this last one that disturbs me the most — singing Renaissance music is vital to my well-being.

On the whole, though, I’m very fortunate: my tremors are not strong. I know people who shake far more than I do; some cannot drive, for example, and some have even had to abandon careers that required steadiness, such as surgery or teaching dance.

Available treatments

I’m not going to go into detail about treatments here; I’ll only mention that modern medicine offers medical and surgical approaches to controlling tremors, and I’ve chosen not to have any treatment for now. Although I know people who are very pleased with the treatments they’ve chosen, my shaking is still not severe enough to induce me to put up with drug side effects or invasive brain surgery.

How Essential Tremor affects my use of technology

But enough about my symptoms. You’re here to read about user experience, aren’t you? So it’s time for me to tell you how ET affects mine.

Keyboards

The effect of ET that shows up most clearly, not only to me but surely to others as well, is that I make quite a lot of typos on my mobile’s on-screen keyboard. Since my left hand and fingers are shakier than my right, I tend to operate the keyboard almost entirely with my right thumb (see Figure 1). This helps reduce the number of times I tap the wrong key or tap the same key multiple times. Sadly, though, it doesn’t eliminate these errors altogether, and I find myself correcting typos in roughly half of my text messages and social media posts. I do have Apple’s “Ignore Repeat” enabled, but I’m going to have to play with the settings a bit before I’ll be able to persuade my iPhone to stop inserting “ee” when I think I’ve typed a single “e”. As someone who has always taken pride in my spelling, I find such typos in my content not only annoying but embarrassing. “It’s not me!” I want to shout. “It’s my tremor!”

For simple things, I find it faster and easier just to ask Siri. :-)

Physical keyboards are much easier. Compared with a mobile’s virtual keyboard, the larger size of the physical keys and the greater force they require make it much less likely that I will accidentally type the same key twice or type a key next to the one I want. I learned touch-typing at age 13, and although I’m not as fast as I once was I’m still pretty good.

Mice

I can usually do a halfway decent job with a mouse, although sometimes my hand wiggles a bit from side to side when I’m trying to click something, and I find myself unable to hold the mouse steady. I can easily make largish and even medium movements, but fine precision is quite another matter.

When an interaction requires me to hover the pointer over, say, a mega-menu or (worse) one of those little reaction-emoji thingies next to a Teams or WhatsApp message, I may have to try three or four times before I can click the right spot. It can get really embarrassing — mortifying, even — if someone has just told of something dreadful that happened to them and I accidentally hit the “laugh” emoji instead of the “wow” one.

Sliders can be difficult if their range is continuous or very fine grained. I’d prefer to enter the values from the keyboard rather than slide a handle along a line. And please don’t try to solve the problem with increment/decrement buttons! For a large range with fine granularity, those buttons can be excruciatingly slow.

Another product that can require extreme precision is Adobe Photoshop. Being a keen amateur photographer, I’ve been using Photoshop since version 4 on MacOS (1996). My increasing tremor has caused me to modify the way I use it. To make detailed selections, for example, I have to zoom in a couple of levels, which means that sometimes I lose sight of the bigger picture. I also select smaller areas at one time and add them to the existing selection, so that if I accidentally select more than I wanted I can “Undo” without undoing a large selection.

Trackpads

My tremor affects mousing and trackpadding (is that a word?). The real problem, though, comes when I don’t have a mouse handy (say, I’m on a train) and I have to use my laptop’s trackpad. Tapping is easy enough, but holding and dragging can be a nightmare if my tremor is acting up. Sometimes I simply cannot avoid inadvertently double-tapping something, and I may end up opening a file (for example) rather than dragging it to another folder. Don’t even think of asking me about tap-and-drag with the trackpad.

Touchscreens

If you think my fingers are shaky, wait until you see me try to use a touchscreen that’s not lying on a surface. When I can rest my arm on something nearby, as I always make sure I do when using my tablet, I can usually manage it fine. But if the device is mounted vertically and I have to hold my arm out to touch it, no way. Shaky fingers plus shaky arm = don’t even think about it.

Other key technologies and procedures

Cameras. Shaky hands can be annoying enough when I’m operating a computer, but when I’m trying to take a photo they can make it really difficult. I’m grateful for vibration reduction / image stabilisation technology, and for camera sensors that can capture sharp images even in low(ish) light without needing a very low shutter speed.

Contact lenses. Inserting my lenses is easier than removing them, because my fingers tremble more when two of them are trying to pinch together (and at the end of the day, as well) than when one by itself is pointing or poking. The process of plucking my lenses from my corneas sometimes takes several tries, and I always have to rest my elbows on a surface to stabilise my arms.

Cutlery. Food that comes in small bits — garden peas and sweet corn, for example — falls off my fork, so I eat those things with a spoon. Thin soup spills easily as well, so I drink that from a mug. Maybe I’ll look into weighted cutlery, although I’d have to carry it with me whenever I went out to eat, and it would be rather heavy in my handbag.

Containers. When someone hands me a glass or cup that’s full to the brim, I ask for help in carrying it to my table. If I’ll be carrying it myself, I take a sip or two before I start off, to reduce the level and prevent it from spilling. I know people who don’t accept containers that are more than about two-thirds full.

Cataract surgery. “You have a tremor”, observed the ophthalmologist. “Yes”, I replied. “I’m going to sedate you”, she informed me. “Good!” I agreed. “I don’t want a moving target”, she explained. “Nope!” I grinned.

Climbing stairs. I simply must have a handrail. This is more important for descending than ascending, but I feel unstable without one. For indoor stairways where I can lean against a wall, it's manageable, but outdoors it is downright scary. Fortunately I haven't fallen — yet…

Crafts. (Sewing, actually, but everything else in this list starts with “C”… J) Many  years ago I made a lot of my clothes, and I always enjoyed sewing. Now I would be hard pressed to mend a ripped seam. Not so much because of threading the needle (I think I could probably manage a needle threader), but because I don’t think I could sew a straight line or avoid pricking a finger.

Managing Tremor with Technologies

Assistive Technologies for Tremors

A number of technologies can provide assistance in working around a tremor. These items hold things still; they make things less susceptible to errors due to shakiness; they provide alternative interaction techniques. Some of them are hardware, and some are software.

For life in general, the International Essential Tremor Foundation (IETF) provide a list of assistive hardware and software for people with tremors. For computers in particular, AbilityNet provide some advice on adapting a computer to accommodate a tremor. (Note: AbilityNet say “voice recognition” when they really mean speech recognition. Voice recognition involves recognising who is speaking, and this article is talking about recognising what is being said.) And Gotechtor offer a list of iPhone settings for people with hand tremors.

Designing to Accommodate Tremor

The main area of tremor that affects digital design exists in the fingers, hands, and arms. It’s difficult to offer design suggestions for tremor, though, because people vary quite widely in the amount of movement that their tremor causes. Probably the most useful thing you can do is to provide alternative interaction techniques that do not require smooth, stable movement — as does the MacOS colour picker previously mentioned — so that people with tremors can type or even use speech to enter data and commands when they are unable to drag something on the screen. For inclusive usability testing, consider recruiting at least one test participant who has a tremor, whether it be ET, Parkinson’s, or something else. And add one or two tremor-assistive devices to your assistive technology toolkit.

I’m afraid I can’t tell you how to design for tremor; there is no general case. I can tell you, though, that for someone with a tremor it’s frustrating and time wasting to have to start something all over again just because your hand or finger wiggled and what you were doing slipped away. So please pay attention to that in designing digital products and services.

Conclusion

As I mentioned earlier, we’ve recently come out of National Essential Tremor Awareness Month. I’m delighted to note that this programme is starting to raise the public’s awareness of ET and how it affects daily life for millions of people, here in the UK and in other countries as well. I have my own goal of raising awareness in the user experience profession about the access needs that ET brings —and about some of the assistive technologies and design strategies that can help in meeting those needs. I hope that what I’ve written here will serve as a reminder that access needs take many shapes and forms and that engaging users with diverse abilities and needs can help in addressing barriers to access.

I’d like to give a shout-out to Jackie Farrell, the former dance teacher mentioned earlier, who serves as the Support Group Coordinator of the UK’s National Tremor Foundation (NTF). Jackie is a powerhouse. She coordinates support groups throughout the UK, including at least one Facebook group, and she runs in-person and online meetups herself. Each day throughout Awareness Month 2025, she posted on Facebook a link to a different bit of helpful information about ET. My favourite was the podcast that has singer Terri Hendrix talking about how she manages her voice tremor — and of course I saved it.

I find ET annoying and frustrating, and it can be embarrassing when other people notice it… but it isn’t going to kill me. When and if I can no longer sing with my choir or manage my contact lenses, then I will consider treatment. Until then, I’ll stay on the lookout for new assistive technologies that might be able to help me. And I’ll keep doing my own part to raise awareness. Thanks for reading.