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Diagnosis of functional movement disorders and specifically functional tremor (FT) (representing 50% of them) remains demanding. Additionally, due to heterogeneity of the disorders, structured concepts and guidelines for diagnosis and therapy are difficult to establish. Ascertaining the state of knowledge to derive instructions for operating procedures is the aim of this review.

Imaging studies in general are mostly underpowered and imaging cannot be used on an individual basis. Therapeutic studies in FT often have a diagnostic component. Cognitive behavioral therapy should be the preferred psychological treatment independent of additional psychiatric symptoms. Other psychotherapeutic methods show lack of evidence concerning FT. Relaxation techniques and physiotherapy are an important additional feature, especially in children and adolescents. In regard to drug therapy, randomized and blinded trials are not available. A significant decrease in rating scales could be detected after active, not sham repetitive transcranial magnetic stimulation with a long-lasting effect. Also root magnetic stimulation seems to be effective. The clinical feature of tremor entrainment in FT can be used in combination with biofeedback as so-called tremor retrainment, using self-modulation of frequency and severity, to bring the movements under volitional control.

Our systematic research identified 19 studies on diagnostic methods and their individual clinical value including 11 studies on patients (methods shown in Table 2). Conventional features (see Table 3) of functional tremor are variability of frequency and amplitude. The response to distraction is a key diagnostic feature in the differential diagnosis between organic and functional movement disorders. Distraction can be achieved by a variety of motor and cognitive tasks.

Recording muscle pairs (wrist and elbow extensors) with EMG and performing coherence and synchronicity measurements seems to be an additional tool in the assessment of postural upper limb tremor, showing a higher synchronicity pattern in Parkinson as well as functional tremor than in essential tremor forms [32] (HR).

In 10 patients and 5 healthy controls functional brain imaging identified tremor as essential (ET) or functional (FT) with different distributions of cerebral blood flow between the groups to distinguish the tremor forms. SPECT imaging at rest and during a tremor inducing motor task was performed. In ET, rest imaging revealed increased rCBF (relative cerebral blood flow) in cerebellar hemi- spheres and left inferior frontal gyrus. During the motor task, ET patients demonstrated increased rCBF in the supplementary motor area (SMA) and contralateral motor cortex and reduced rCBF in the cerebellum and visual cortex. In contrast, In FT imaging at rest revealed an increased relative cerebral blood flow (rCBF) in the left inferior frontal gyrus as well as left insula. Imaging during motor task revealed increased rCBF in the cerebellum and reduced rCBF in the anterior regions of the default mode network [8] (HR).

Objective criteria useful for a positive diagnosis of functional movement disorders are highly recommended. A specific recording strategy should be applied. Polymyography coupled to accelerometry can be used to demonstrate the major electrophysiological criteria of FT, like spontaneous variability of tremor frequency and frequency entrainment during motor tasks of the contralateral side. Further, paradoxical increase of tremor amplitude during mass loading tests, a co-activation preceding the tremor onset, and an alteration of voluntary contralateral motor tasks are characteristics of FT [2] (HR).

The influence of suggestibility on tremor amplitude, frequency or direction should be included in the clinical examination. In functional disorders cognitive behavioral therapy should be the first line treatment irrespective of the evidence of additional psychiatric symptoms [15].

The differential diagnosis is o


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