An accurate diagnosis in Neurology, possibly more than any other specialty in Medicine, relies on astute observation. I tell students that a good many diagnoses are made before you even lay a hand on a patient. Neurologists are also an unusual group of people. Around 15 years ago when I was a wannabe neurologist, I remember sitting in a café in Hobart, Tasmania, while attending a conference. I was with a number of more senior colleagues for whom downtown Hobart provided a rich source of clinical material. Movement disorders in particular seemed to be everywhere. A shuffling gait, a tremulous head, troublesome tics, perhaps the odd focal dystonia. This is not something that is specific to Tasmania, but really can be seen anywhere in the world. Neurology is all around.

However from a patient perspective, the visual nature of neurological disease means that a patient’s disability can be there for the whole world to witness, leading to considerable distress. I recall a patient with an inherited disorder, episodic ataxia, who had episodes of imbalance. Between episodes he had slurred speech that was present even when his other symptoms were at bay. On one occasion, he was pulled over for by police for random breath testing and they simply refused to believe that he had not been drinking. When the breath test was normal, they drove him to a police station for further investigation, completely convinced that he was drunk.

While episodic ataxia is rare, essential tremor, another movement disorder, is not. It remains one of the most prevalent neurological disorders in the community. These patients develop disabling tremors of their hands, voice and even head which can lead to intense social embarrassment. Patients often avoid social situations due to severe tremulousness. As neurologists know, some patients respond to medication well, while others do not. For these patients, deep brain stimulation has proved to be a very useful form of treatment. In this issue of JNNP, Baizabal-Carvallo and colleagues have assessed the long-term effectiveness of DBS for essential tremor http://jnnp.bmj.com/content/85/5/567.full . Their findings suggest that DBS is a safe and effective long-term treatment for patients with essential tremor.

This is an interesting study which provides further evidence that this may be a useful treatment option in patients who suffer from this disabling condition.