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Tremor: so common, so difficult
  1. María Carolina Sepúlveda Soto1,
  2. Alfonso Fasano2,3,4,5
  1. 1 Department of Neurology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
  2. 2 Edmond J. Safra Program in Parkinson’s Disease and the Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, UHN, Toronto, Ontario, Canada
  3. 3 Division of Neurology, University of Toronto, Toronto, ON, Canada
  4. 4 Krembil Brain Institute, Toronto, ON, Canada
  5. 5 The Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
  1. Correspondence to Prof Alfonso Fasano, Department of Neurology, Toronto Western Hospital Krembil Neuroscience Centre, Toronto, ON M5T 0S8, Canada; alfonso.fasano{at}

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Is a step-by-step approach to diagnosis enough?

Whether you are a general practitioner or a movement disorders specialist, you have seen patients with tremor, the most frequent movement disorder and the most common sign in clinical neurology.1 In spite of its prevalence, tremor is a complex and often misdiagnosed disorder, especially by non-specialists. Furthermore, a number of false beliefs still populate our textbooks and are taught in medical schools (box 1). In this context, the review by van de Wardt et al 2 is a very timely exercise in light of the recent new classification of tremor.3

Box 1

Common false beliefs and pitfalls in tremor

  • Any patient with mild tremor has ET.

  • Diagnosing ET is a way to sweeten a diagnosis of PD.

  • Electrophysiology in patients with tremor is only used for research purposes.

  • ET always responds to alcohol (ie, it is an ET-specific feature).

  • ET is always familial.

  • Functional tremor cannot coexist with other tremor disorders.

  • Functional tremor is a diagnosis of exclusion.

  • Isolated voice and/or head tremor are usually caused by ET.

  • Jerky/variable tremor always indicates dystonic tremor (ie, it might be functional or myoclonus).

  • Lower limbs and/or trunk tremor always indicate ‘orthostatic tremor’.

  • Myoclonic tremor is a neurological entity.

  • Patients may have ET in the context of another neurological disorder (eg, dystonia and ET).

  • Tremor is always a benign condition.

  • Tremor is indicative of PD.

  • Unilateral tremor is possible in ET.

ET, …

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  • Twitter @DrAlfonsoFasano

  • Contributors MCSS: research project execution and writing of the first draft of the manuscript. AF: research project conception and organisation; review and critique of the manuscript.

  • Funding AF received honoraria for consultancies from Abbvie, Abbott, BrainLab, Boston Scientific, Chiesi farmaceutici, Ipsen, Medtronic, Sunovion and UCB; honaria for participation in advisory boards from Abbvie, Boston Scientific and Ipsen; research grants from Abbvie, Boston Scientific, Cummings Foundation, Dystonia Medical Research Foundation Canada, Michael J. Fox Foundation, Medtronic, University of Toronto and Weston Foundation.

  • Competing interests AF received honoraria and research support from Abbott, Boston Scientific and Medtronic.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

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