functional weakness and sensory disturbance

by:Kenwei      2019-08-20
In the diagnosis of functional weakness and sensory impairment, positive physical signs are as important as no signs of disease.
The car logo, especially the Hoover logo, is more reliable than the sensory logo, but any one should not be used alone and must be explained in the overall context of the display.
It should be remembered that patients may have both functional and instrumental diseases at the same time.
Careful history is essential before physical diagnosis.
In particular, there are many symptoms, depression or anxiety (
Special panic)
, Or a history of several previous functional symptoms, or a surgical procedure without a positive pathology, increases the likelihood of functional major symptoms.
1 bad childhood experience, personality factors, models of illness, recent life events, secondary harvest (
Financial and other aspects)
, Disease beliefs may all be related to management, but there is not enough knowledge of these factors to use them for diagnosis.
The history of the onset of symptoms may be particularly helpful.
Patients with functional weakness usually describe the symptoms that prompt withdrawal at the onset of the disease
Either with panic, physical trauma (often minor)
Or spontaneous.
In this case, \"separation\" refers to the weakening or loss of a person\'s sense of normal ownership of behavior and feeling.
The description of the implied removal includes: \"The leg feels as if it is not connected to me\", \"I feel far away\" or \"I am in my own place \".
Functional defect observation physical assessment of functional defects should start with the patient standing up from the chair in the waiting room and end when they leave the consultation room (Or hospital).
The main purpose is to find evidence of inconsistency.
It may be particularly helpful to observe patients: Take off your clothes or put on them.
Take things out of the bag and replace it (
List of drugs, for example).
Walk into the room compared to walk out of the room (
Out of the clinic sometimes).
Hoover\'s logo testHoover\'s logo is the most useful test for functional defects, and the only test to be tested for scientific research in conjunction with the neural control group.
This is a simple, repeatable test that requires no skilled secret observation.
The test relies on the principle that almost everyone, whether or not there is a disease, will stretch the hips when bending the lateral hips.
This finding is considered to be the result of cross-extension reflex described by Sherrington, which 4 is able to walk normally, even in decorative animals.
The test described by Hoover in 1908 can be done in two ways: hip extension-
In patients with weak functioning, it can be observed that they voluntarily extend the hip joint (
Often weak
When the opposite hips bend against resistance, they unconsciously extend their hips (This is normal. .
Figure 1 illustrates this test.
When testing involuntary hip extension, it is important to ask the patient to try to concentrate on a good leg. Hip flexion—
The opposite test was also described, where the hip bend of the weak leg was tested, while the examiner\'s hand was held under a good heel, although not fully assessed.
In this test, there is no downward pressure on the good legs, which indicates that there is no effort to pass on to any leg.
Download the signs of new tabDownload figureOpen powerpointFigure month Hoover. (A)
The hip extension was weak during direct testing. (B)
The hip extension is normal when the patient is asked to bend the opposite hip.
Head describes an additional variant where patients lie in front of them and are asked to stretch their good hips while the weak legs are testing the hip flexion.
6 due to attention phenomena, the CaveatsFalse positive espain of the affected hip may produce greater weaknesses in the direct test than in the indirect test (
Related to pain rather than weakness).
Patients with organic illness may try to \"help\" you or \"convince\" you that they are sick.
There is not enough data to rule out the possibility that similar phenomena can sometimes be caused directly by organic brain diseases (such as MS.
False negatives when you test the involuntary extension of the weak hip joint, the patient may not be able to focus enough on showing their good hip joint.
If this is the case, you should find that when you remove your hand from under the weak leg, the bending of the good leg will be stronger.
The following points should also be kept in mind: Hoover\'s test did not distinguish functional or hysterical problems from the weakness of pretending or simulating.
Your patient may have a combination of organic and functional defects.
In fact, organic disease is a risk factor for the development of functional symptoms.
Seven or eight validity hoover tests have been examined in two control studies.
First, computer myometry showed a significant difference in \"involuntary hip extension rate\" among 7 non-hip patients
Compared to the 10 organic weaknesses, organic weaknesses.
2 An equivalent study, conducted using a simple weighing scale, compared nine subjects with a control group of organic weakness, back pain, or no weakness to achieve similar results.
These studies are not blind and do not measure the reliability of the test as they are used in the real world, but provide initial support for its use.
Hoover\'s weapon test?
Hoover described similar \"complementary opposites\" in weapons.
In this test, the resistance bending of the arm stretched in front of the patient produces involuntary stretching of the other arm.
The phenomenon was analyzed by Ziv et al, and the results were similar to those of the legs.
2 The relevant test of shoulder collection is also described based on such a principle, that is, when one side tests shoulder collection, the opposite side will also be combined.
9 The common finding of collapsed weaknessA in functional defects is the \"weakness of collapse\" in which the limb collapses from the normal position through a slight touch (
Or occasionally, even before your hand hits the limb).
Normal power can often be achieved temporarily with encouragement.
Instructions, \"count to three and stop me from pushing down. . . .
\"It is often helpful in this regard.
The intuitive explanation of the breakdown weakness is that the patient did not try at all.
While this is certainly the case at times, in our experience, the performance of most patients with weak functioning seems to get worse as they work harder and focus more on their limbs.
The problem with the breakdown weakness is that, like the Hoover logo, it may also be due to reasons unrelated to the functional weakness.
These include inability to understand guidance, associated joint pain, general discomfort, and the mistaken desire of some patients to \"help a doctor\" or \"persuade a doctor\", \"even though they actually have an organic condition.
Fold effectively or give-
The weakness of way \"has been studied from a neurophysiological perspective.
10-12 Van der Ploeg shows that when the examiner overcomes muscle strength when the function is weak, the strength produced by the limb is abnormally high compared to the strength produced by normal resistance.
11 Another study confirmed that patients with functional weakness had significantly different forces in the limbs compared to the control group.
The study also showed that subjects with weak functioning would produce less strength in the event of slower movements.
12 in a \"real-life\" controlled clinical study, the weakness of collapse was not tested.
Goshould et al found that in 30 patients with acute neuropathy (mostly stroke)
, 10 weaknesses that have collapsed.
They stressed the need to be cautious about the sign.
Other signs of WeaknessCo functionality
Contraction when the excited muscle bicep is tested, it may feel the contraction of the opponent\'s muscles, such as triceps.
Of the 12 patients with functional weakness, Knutsson and Martensson showed that knee flexion was weaker than if they had let the weight of the lower leg run, indicating that the opponent was activated. 12The “arm-
In this test, an allegedly paralyzed arm was dropped on the patient\'s face to see if they would protect themselves from falling.
This is also described as a test for unconscious patients.
However, arm must be very weak in order for this test to be explained, and we suggest that it add little information.
A less positive change is to observe the speed and smoothness of the arm falling from the position stretching to the knee.
Weakness in functionality, which may be slower and trickier.
This has not been verified yet.
Occasionally, a patient complaining about weakness may find that if their limbs are placed in a certain position --
For example, the arm is stretched out.
They will somehow keep their position, even if they can\'t let them down again.
This phenomenon is similar to what is seen in people who are hypnotized at the receiving stage.
Recently, Diukova and others reported that 24 out of 30 patients (80%)
Patients with functional hemiparesis have a chest-lock lacotus-like weakness, usually on the cervical side, while only 3 out of 27 patients (11%)
Weakness of the sternoastoid muscle with vascular anemia (
This is dominated by bilateral nerves, so it is rarely weak in the upper motor neuron damage).
We highlight the importance of finding positive signs of functional weakness and sensory impairment.
It is also important that there are no signs.
Although there may be slight asymmetry, tone and reflection should be normal especially if the patient has attention disturbances. 15 Pseudo-
At the turn of the century, array us is described as array clon with irregular and variable amplitude.
15, 16 although Janet17 describes this, functional defects rarely affect the motor function of the face, which we have observed. Pseudo-
In addition, the upper sagging is also described, and when the eye wheel eye muscles are excessively contracted and the frontal muscles are obviously weak, there will be obvious upper sagging.
Functional gait disorders these are ever-changing in their performance, but some types are common.
Three useful series, 19-21, have been published, but there is no control study.
Perhaps the most common gait disorder is \"dragging and paralyzing gait \"(fig 2).
In this gait, the whole leg is dragged like a bag of potatoes, like a unit behind the patient.
The rotation of the hip joint found in the angle cone-shaped half milk is usually not present.
The hips can be rotated and the ankles can be held in an inverted or flipped position.
Patients with this gait often report that the legs feel as if they are hardly part of them, and may also suggest that they would be better off if amputated.
Table 1 gives a description of other common gait phenomena described by Lempert et al in 20 of 37 patients.
View this table: View common varieties of functional gait disorders in inline View pop-up table 1 (
From Lempert et al, 199120)
Download the new tabDownload figureOpen powerpointFigure month feature monoplegic gait.
In both cases, the legs are dragged to the hips.
External or internal rotation of the hip or ankle joint reversal/flip is common.
Looking back on some very unusual gait disorders, it is only recently beneficial to find an organic home --
For example, there is a sudden onset of kinesogenic.
In the follow-up study of 64 patients with functional motor symptoms at the National Hospital in London, all three false diagnoses occurred in patients with gait disorders.
8 patients with functional sensory impairment may notice functional sensory impairment, or in general, the examiner will detect functional sensory impairment, which surprised the patient.
It usually affects all sensory patterns, whether in a semi-sensory distribution (
\"I feel like I\'m cut in half \")
Or affect the entire body.
In the latter case, the boundary between the shoulder and the groin is very clear.
17, 22 if the trunk is involved, the front is more common than the back.
Patients with semi-visual impairment often complain about intermittent blurred vision of the affected side eyes (asthenopia)
Sometimes there will be hearing problems on the affected side.
If someone has a functional defect, they usually also have a functional sensory impairment --
Maybe it\'s a common pathology.
Although various functional sensory signs have been described, none of them appear to be specific and should therefore not be used for diagnosis.
In organic diseases, it is often believed that the feeling of the midline cannot be precisely divided.
The reason usually given is that the branches of the interrib nerves overlap with the opposite side, so the sensory loss should be a parameter-
That is, 1 or 2 cm from the midline.
However, when several sensory patterns are seriously lost, midline division may occur in a stroke of the hippocampus in a manner similar to functional sensory loss.
Recent imaging work by Vuilleumier et al has demonstrated in this respect that functional pimple lesions in semi-brain loss are interesting.
23 Rolak reported 6 cases of midline division in 80 patients with quality disease.
The split of the 24 vibration sensation means that the sensation of the tuning fork placed on the left and right side of the breastbone or frontal bone should be no different because the bone is a unit and must vibrate as a unit.
However, in the study previously mentioned by Gould, 21 of the 30 patients with quality disease developed this symptom.
Similarly, Rolak found that 69 of the 80 patients with quality disease had this symptom, while 19 of the 20 patients had functional sensory loss.
Again, maybe our sensory system model and its thalamo-
The cortex is too simple to perform when designing these tests.
Tests involving the doctor\'s tricky include, \"when you feel like I touch you, say \'yes\', and say \'no when you don\'t touch you \'\", sensory examination with the hand at the back or at the time of chest cross and rotation.
Mandatory selection programs are also described where testing becomes complex enough to achieve worse performance than opportunities, 25, 26 indicating poor system performance.
However, this finding does not distinguish between conscious and unconscious intentions and is unlikely to increase diagnosis or treatment.
We rarely need to use these tests, although they may play a role in forensic identification.
Although it is often claimed that symptoms on the left side are more common, a systematic review of the evidence suggests that while symptoms on the left side may be slightly more dominant than on the right side, a form of published bias may account for most perceived asymmetry.
The diagnosis of functional weakness, of course, should not be based on the side of the symptoms.
La belle indifferenceLa belle indifference, or indifference to a symptom smile, poor performance as a discriminating person against organic diseases.
28, 29 this also gives the wrong impression that most patients with functional symptoms are not troubled by symptoms, while in fact the vast majority of patients are troubled and confused by problems.
As originally described, the concept of la belle indifference also applies to patients who do not know the loss of feeling found by the doctor during the examination, which is a common problem, but it is very different from indifference to physical weakness.
If the patient is suffering from a quality disease, neurologists often explain the significant abnormalities examined or investigated, and how these abnormalities support their diagnosis.
Most of us, however, may not consider doing so for functional patients.
We found that explaining how the diagnosis of dysfunction is supported by examinations, enhances trust between doctors and patients in a way that is often difficult to achieve in other ways.
For example, Hoover\'s logo can be used to show how the nervous system works properly in some cases, but otherwise.
This is one of the reasons why we found that testing that doctors are not very useful in hospital practice involves a high degree of deception.
It must be noted that your interpretation of the signs does not mean that you have \"caught them out\" or that you think they are \"showing\" symptoms.
Cosmetic and artificial diseases neurologists are usually good at judging whether the disease is organic or not.
Diagnosis usually remains stable over time.
However, it is much more difficult to distinguish between conscious and unconscious functional symptoms.
The awareness of control over symptoms is continuous.
Also, it will vary over time so that the patient may start to get sick and know little about what is going on, but gain a certain level of conscious control over time (or vice versa).
It is almost certain that doctors are worse than we thought in discovering patient deception and may be over-diagnosed, thereby harming other patients.
Secret surveillance showing significant differences in functionality or direct confession may be the only reliable method, but rarely obtained.
32 among those who consciously produce symptoms and signs, it is important to distinguish between those who aim to obtain \"medical care\" and those who pursue material benefits.
The first kind of behavior belongs to the diagnosis of human disorder, is a medical diagnosis similar to intentional self-injury, and is another kind of \"conscious\" behavior.
Those who simulate for economic or other material benefit are malingerers with no medical conditions.
Conclusion diagnosis of functional weakness and sensory impairment is not easy.
The \"positive signs\" we mentioned are as important as just looking for signs of no disease.
Car signs, especially those of Hoover, are more reliable than sensory signs, but should not be used alone, and they must be explained in the overall context of the display.
Keep in mind that your patient may have both functional and instrumental diseases at the same time.
It is hoped that the recent increase in neurological interest in this area will lead to further diagnostic improvements in the future.
Daniel Stone provides illustrations of the Hoover logo.
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