The applause sign in frontotemporal lobar degeneration and related conditions


The applause sign, i.e., the inability to execute the same amount of claps as performed by the examiner, was originally reported as a sign specific for progressive supranuclear palsy (PSP). Recent research, however, has provided evidence for the occurrence of the applause sign in various conditions. The aim of this study was to determine the prevalence of the applause sign and correlate its presence with neuropsychological and MRI volumetry findings in frontotemporal lobar degeneration and related conditions. The applause sign was elicited with the three clap test (TCT), with a higher score indicating poorer performance. Data were recorded from 272 patients from the cohort of the German consortium for frontotemporal lobar degeneration (FTLDc): 111 with behavioral variant frontotemporal dementia (bvFTD), 98 with primary progressive aphasia (PPA), 30 with progressive supranuclear palsy Richardson’s syndrome, 17 with corticobasal syndrome (CBS) and 16 with amyotrophic lateral sclerosis with frontotemporal dementia (ALS/FTD). For comparison, 29 healthy elderly control subjects (HC) were enrolled in the study. All subjects underwent detailed language and neuropsychological assessment. In a subset of 156 subjects, atlas-based volumetry was performed. The applause sign occurred in all patient groups (40% in PSP, 29.5% in CBS, 25% in ALS/FTD, 13.3% in PPA and 9.0% in bvFTD) but not in healthy controls. The prevalence was highest in PSP patients. It was significantly more common in PSP as compared to bvFTD, PPA and HC. The comparison between the other groups failed to show a significant difference regarding the occurrence of the applause sign. The applause sign was highly correlated to a number of neuropsychological findings, especially to measures of executive, visuospatial, and language function as well as measures of disease severity. TCT scores showed an inverse correlation with the volume of the ventral diencephalon and the pallidum. Furthermore the volume of the ventral diencephalon and pallidum were significantly smaller in patients displaying the applause sign. Our study confirms the occurrence of the applause sign in bvFTD, PSP and CBS and adds PPA and ALS/FTD to these conditions. Although still suggestive of PSP, clinically it must be interpreted with caution. From the correlation with various cognitive measures we suggest the applause sign to be indicative of disease severity. Furthermore we suggest that the applause sign represents dysfunction of the pallidum and the subthalamic nucleus, structures which are known to play important roles in response inhibition.

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Fig. 1
Fig. 2



Amyotrophic lateral sclerosis with frontotemporal dementia


Behavioral variant frontotemporal dementia


Clinical Dementia Rating Scale Sum of Boxes


Corticobasal syndrome


Frontotemporal lobar degeneration


Healthy control


Laterality index


Primary progressive aphasia


Progressive supranuclear palsy


Statistical parametric mapping 12


Subthalamic nucleus


Three clap test


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Correspondence to Sonja Schönecker.

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Schönecker, S., Hell, F., Bötzel, K. et al. The applause sign in frontotemporal lobar degeneration and related conditions. J Neurol 266, 330–338 (2019) doi:10.1007/s00415-018-9134-y

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  • Applause sign
  • Frontotemporal lobar degeneration
  • Progressive supranuclear palsy
  • Atlas-based MRI volumetry
  • Subthalamic nucleus
  • Pallidum