China
Africa
Explore chapters and articles related to this topic
Neurological Examination of Malingering
Published in Alan R. Hirsch, Neurological Malingering, 2018
Jose L. Henao, Khurram A. Janjua, Alan R. Hirsch
Patients that present with the inability to stand on their own—but drove themselves to the office—should be evaluated for secondary gain. The Hoover sign examines the effort of the patient when moving with lower extremity weakness. This is based on the fact that muscles work as levers and pulleys focusing on the push and pull of the lower extremities. In this test, the examiner places his or her hand under the heel of the nonparetic leg and pushes downward on the paretic leg shin while asking the patient to try and lift the affected leg. In normal circumstances, as patients are lifting one of their legs against gravity or pressure the natural tendency is for the other leg to counteract the movement by pushing down and creating a good balance. When patients lift their legs they are incorporating their hip flexors and quadriceps femoris and—to counteract that movement—the gluteus maximus and iliopsoas muscles contract in the opposite leg. Therefore, both the gluteus maximus and the iliopsoas muscles would be contracting and forcing the unaffected limb to push downward against the examiner’s hand. This downward force on the examiner’s hand suggests that the patient is providing maximum effort. On the other hand, malingerers will not demonstrate full effort. The good leg does not push opposite of the impaired leg’s movement.
H
Published in Anton Sebastian, A Dictionary of the History of Medicine, 2018
Hoover, Charles Franklin (1865–1927) Born in Cleveland, graduated from Harvard. A physician who investigated pulmonary and hepatic disease and the ventilatory functions of the diaphragm. He described Hoover sign where pressure on one leg caused slight lifting movement of the other leg in cases of paralysis of lower limbs. This sign was also used to distinguish organic hemiplegia from malingering or hysteria.
Psychiatry and Neurological Disorders
Published in John W. Scadding, Nicholas A. Losseff, Clinical Neurology, 2011
On the other hand, certain patterns of symptoms are almost pathognomonic of conversion disorder. Tunnel vision in which the same physical area, e.g. a circle two feet in diameter, is the limit of the visual field whether at three feet or ten feet from the patient, is almost certainly due to conversion disorder. Likewise hemi-anaesthesia, which involves the whole body from head to toe right down the midline. The Hoover sign may be telling in a patient with psychogenic paralysis of a leg; when lying on the couch and asked to raise the paralysed leg, there is no downward force exerted by the healthy side as would be found in somebody with a hemiplegia due to neurological disease. On the other hand, when the patient is asked to lift the healthy leg, a normal downward force, hip extension, is produced by the paralysed leg.
Functional Gait Disorders: Clinical presentations, Phenotypes and Implications for treatment
Published in Brain Injury, 2023
Sara Issak, Richard Kanaan, Glenn Nielsen, Natalie A. Fini, Gavin Williams
The diagnosis of FND is usually made by neurologists, especially when motor symptoms are the dominant presentation (43,50). Psychiatrists may have a role in diagnosis, especially for psychological formulation (51). Where possible, the diagnosis should be made based on the identification of positive clinical signs, such as Hoover’s sign for functional weakness, as well as inconsistency of the presentation or incongruency with structural disease (38,52). Examples of inconsistency include a disparity between gait patterns in different environments; variability of symptoms over short periods of time; sudden changes in the frequency or amplitude of a tremor; and a difference between clinical assessment and function, for instance, an inability to access movement during a formal assessment that returns to normal during spontaneous movement (53–55). An example of incongruency is a delayed onset of motor symptoms following minor injury (41). Information from the subjective history provides supporting evidence for the diagnosis, such as transitory episodes of spontaneous remission (41).
Clinical examination practices and perceptions in the era of COVID-19
Published in Expert Review of Respiratory Medicine, 2021
Konstantinos G Kyriakoulis, Garyphallia Poulakou, Thomas Nitsotolis, Konstantinos N Syrigos
Based on the above, a common strategy regarding clinical evaluation was followed by all physicians in our department. An initial detailed clinical examination was performed once, upon admission of each COVID-19 patient in the emergency department. Then, on a daily basis, vital signs were checked four to six times. Arterial blood gases and further laboratory and imaging tests were ordered as appropriate. BP was obtained with validated automated BP monitors, allowing physicians to keep safe distances from patients during measurement. Auscultatory method with aneroid devices were used only in certain cases (e.g. very large arm circumference or severe hypotension-shock), due to higher risk of exposure. Physicians tried to examine patients during other necessary procedures (e.g. blood sampling) and assess signs mainly through inspection that could imply respiratory distress (e.g. suprasternal retraction, nasal flaring, or Hoover sign) [26]. A suggested clinical examination algorithm is presented in Figure 1. This algorithm was developed and implemented mainly in our 30-bed COVID-19 dedicated general ward, where more than 500 patients were hospitalized with a mortality rate of about 3%. Patients hospitalized in our ward have been non-intubated patients with respiratory failure of varying severity requiring supplemental oxygen therapy (nasal cannula, oxygen masks, high-flow nasal cannula). The abovementioned algorithm has been widely used in this context. In our experience, knowledge, and perception, this strategy for selective implementation of clinical examination was well-accepted by most physicians, while it served as a safe approach for both patients and physicians, apparently not leading to significantly misleading or false decisions considering patient outcomes. The impact, significance, and validation of this algorithm in terms of decision leading and patient outcomes improvement is currently under investigation in our center.
Current challenges in the pathophysiology, diagnosis, and treatment of paroxysmal movement disorders
Published in Expert Review of Neurotherapeutics, 2021
Cécile Delorme, Camille Giron, David Bendetowicz, Aurélie Méneret, Louise-Laure Mariani, Emmanuel Roze
The largest series of FPMD consisted of 26 patients, which accounted for 10% of a PMD cohort [180]. This study highlighted several important clues to FPMD in the setting of PMD. The mean age of symptom onset was 38.7 years. This is in contrast with previous reports of PKD, PNKD, and PED, which classically manifest at much earlier ages and begin exceptionally after age 20 years [181]. Conversely, FPMD are rare in children, although pediatric forms of functional neurological disorders are reported [182]. The patients did not have a family history of PMD[*183]. The presence of a family history of PMD is a clue for an organic PMD, although a family history is quite often lacking in organic PMD and has been occasionally reported in cases of functional movement disorders. Eight patients (30.7%) had only one type of movement disorder during episodes: dystonia was the most common, followed by isolated tremor or jerks [180]. Tremor has never been reported in organic PMD and is thus a major clue to FPMD. Seven patients (26.9%) had a combination of two distinct movement disorders, typically dystonia, and tremor. Eleven patients (42.3%) had generalized complex movements. The phenomenology was consistently incongruent with an organic PMD. Variation of the phenomenology from one episode to another was found in 26,9% of the patients, whereas organic PMD are often stereotyped and patterned. Classical functional neurological signs such as distractibility, entrainment, and placebo response were also observed. Six cases had speech disturbances during attacks. Four reported pain and five additional somatic complaints such as breathlessness, rapid breathing, light-headedness, drowsiness, fatigue, chest tightness, or blurring vision. In addition to movement disorders, three patients had occasional unresponsiveness during attacks, and four cases had episodes of collapse without loss of consciousness. Duration of the episodes ranged between a few minutes to several hours or even days, with only 3 patients reporting short attacks (< 5 minutes). Attack frequency between patients ranged from several in a day to one every three months. The disease course was also variable, with some patients experiencing a static course while others rather had a waxing and waning course with periods of complete remission followed by sudden relapses. Interictal functional neurological features were found in nine (34.6 %) patients, mostly gait difficulties, motor weakness, sensory disturbances, and fixed dystonic postures of the feet. This item might be especially relevant as certain patterns of motor weakness such as Hoover sign have been shown to be reliable clues for the diagnosis of functional disorders [180]. Medically unexplained somatic symptoms such as diffuse abdominal symptoms, chest pain, palpitations, dizziness, and headaches were found in 13 patients (50%). Organic PMD often have typical triggers: classic PKD is induced by sudden movement, PED by prolonged exercise, and PNKD is usually favored by coffee or alcohol intake and emotional stress. The triggers in functional cases were atypical and involved ‘increased stress’, alcohol intake, walking, loud noises, feeling frightened, or thirsty. Nine patients (34.6%) experienced attacks of their PMD during examination.