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Soft signs in movement disorders: friends or foes?
  1. Conor Fearon1,
  2. Alberto J Espay2,
  3. Anthony E Lang3,4,
  4. Timothy Lynch1,
  5. Davide Martino5,
  6. Francesca Morgante6,
  7. Niall P Quinn7,
  8. Marie Vidailhet8,9,10,11,12,13,
  9. Alfonso Fasano3,4
  1. 1 Dublin Neurological Institute at the Mater Misericordiae University Hospital, Dublin, Ireland
  2. 2 Department of Neurology, UC Neuroscience Institute, Gardner Center for Parkinson’s Disease and Movement Disorders, University of Cincinnati, Cincinnati, Ohio, USA
  3. 3 Edmond J. Safra Program in Parkinson’s Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital – UHN, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
  4. 4 Krembil Brain Institute, Toronto, Ontario, Canada
  5. 5 Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  6. 6 Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italy
  7. 7 UCL Institute of Neurology, London, UK
  8. 8 AP-HP, Department of Neurology, Hôpital Salpetriere, Paris, France
  9. 9 Institut du Cerveau et de la Moelle, ICM, Paris, France
  10. 10 INSERM U1127, Paris, France
  11. 11 CNRS UMR 7225, Paris, France
  12. 12 Medical School, Pierre Marie Curie University, Paris, France
  13. 13 Sorbonne Université, Paris, France
  1. Correspondence to Dr Alfonso Fasano, Morton and Gloria Shulman Movement Disorders Center, Toronto Western Hospital, Toronto, ON M5T 2S8, Canada; alfonso.fasano{at}

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In movement disorders, emphasis on pure phenomenology to make diagnoses can lead to significant variability and diagnostic disagreement.1 2 This is illustrated by difficulty among experts in deciding whether possibly equivocal signs (‘soft’ signs) are present or absent. A tight pen grip, slightly asymmetric arm swing, or hyperextended fingers may be judged by some to be within the broad spectrum of normal. Others may consider such signs to be pathological. Hence, the relevance of such signs can be uncertain. Furthermore, we are often asked to judge on the presence and clinical relevance of soft signs in ‘neurologically healthy’ individuals and this can be challenging (eg, in clinical genetic studies). Although classification systems tend to include clinical signs to define boundaries of disease, the relevance of soft signs may be questionable if inter-rater reliability is variable.

Initially introduced in the psychiatric literature,3 the term ‘soft signs’ has also recently been applied to movement disorders. In the recent Consensus Statement on the Classification of Tremor, the detection of soft signs has, for the first time, become an integral part of tremor classification.4 Because of the uncertainty surrounding the interpretation of soft signs, we asked movement disorders experts (MDE) and experts in fields other than movement disorders (non-MDE) to rate videos of patients and healthy control subjects to assess inter-rater reliability on the presence or absence of soft signs.


We asked seven MDE (AJE, AEL, TL, DM, FM, NPQ, MV) and six non-MDE (listed in the Acknowledgements section) to rate 30 videos for the presence or absence of soft signs. Raters were advised that videos may feature control subjects or patients, but no other clinical information was provided. Twenty-five control subjects were recorded (9 …

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  • Contributors All authors have made substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data, drafting the work or revising it critically for important intellectual content. All have given final approval of the version published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Individual author roles: CF: organisation and execution of research project, design and execution of statistical analysis, writing of the first draft of manuscript; AJE, AEL, TL, DM, FM, NPQ, MV: execution of research project, review and critique of manuscript; AF: conception and organisation of research project, execution of statistical analysis, review and critique of manuscript.

  • Funding AJE: Consultancies in Abbvie, TEVA, Impax, Acadia, Acorda, Cynapsus/Sunovion, Lundbeck and USWorldMeds, Expert Testimony, Advisory Boards, in Abbvie, TEVA, Impax, Acadia, Cynapsus/Sunovion, Lundbeck and USWorldMeds, Honoraria in Abbvie, UCB, USWorldMeds, Lundbeck, Acadia, Royalties in Lippincott Williams & Wilkins, Cambridge University Press, Springer, Grants in NIH, Great Lakes Neurotechnologies and Michael J Fox Foundation; AF: Consultancies in Abbvie, Medtronic, Boston Scientific, Sunovion, Chiesi farmaceutici, UCB, Ipsen, Advisory Boards in Abbvie, Boston Scientific, Ipsen, Honoraria in Abbvie, Medtronic, Boston Scientific, Sunovion, Chiesi farmaceutici, UCB, Ipsen, Grants University of Toronto, Weston foundation, Abbvie, Medtronic, Boston Scientific.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.