Focused neurological assessment to differentiate essential tremor from functional tremor

A 64-year-old female patient presented with a 20-year history of right upper limb tremors, significantly affecting her daily tasks. She was previously diagnosed with essential tremor and reported no response to propranolol (maximum tolerated dose of 80 mg/day). The neurological examination revealed amplitude and frequency variability, distractibility ([Video 1]), entrainment, and distinctive looping patterns in the Archimedes spiral drawing and handwriting ([Figure 1])—a phenomenon known as the "stretched slinky sign," described in a previous study as distinctive of functional tremor, although it has not been formally assessed in control groups.[1] The diagnosis of functional tremor was made based on these positive signs, emphasizing the importance of a focused neurological examination to distinguish it from other tremor disorders.[2] [3]