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Positive signs in functional movement disorders

Positive signs in functional movement disorders
Functional movement symptom Positive sign Description
Can be present in all functional movement symptoms Variability Generally refers to changing patterns over time, including susceptibility to distraction and enhancement with attention
Distractibility Movement normalizes during a cognitive or motor task
Enhancement with attention Movement worsens/emerges when attention is drawn to it
Motor inconsistency Movements are preserved in some circumstances and impaired in others (eg, dorsiflexion weakness during power testing, and able to stand or put on shoes when not examined)
Incongruency A clinical picture incompatible with known organically determined patterns
Suggestibility Movement is elicited with verbal instruction or by a maneuver from the examiner (eg, tuning fork test)
Weakness Hoover sign Weakness of hip extension in a paretic leg that resolves with contralateral hip flexion against resistance in the normal leg
Hip abductor sign Weakness of hip abduction in a paretic leg that resolves with contralateral hip abduction against resistance in the normal leg
Finger abduction sign Weakness of finger abduction that resolves with contralateral finger abduction against resistance
Give-way/collapsing weakness Limb collapses from a normal position with a light touch, or normal strength is developed and then suddenly collapses
Absent pronator drift Extended supinated arm drifts down without pronation
Co-contraction Simultaneous contraction of agonist and antagonist resulting in no/little movement
Tremor Variability Changes in tremor characteristics (usually frequency and/or direction) over time and with position
Entrainment Tremor takes up the same frequency of an externally cued rhythmic movement (either patient or examiner)
Co-contraction Simultaneous contraction of agonist and antagonist resulting in tremor
Whack-a-mole sign Emergence or worsening of an involuntary movement in a separate body part when the initially affected body part is suppressed by examiner restraint
Myoclonus/jerks Variability Duration, distribution, and/or latency (if stimulus sensitive) of jerks variable
Entrainment Jerks take up the same frequency of an externally cued rhythmic movement (either patient or examiner)
Axial/facial jerks Axial or facial jerks predominate
Gait/balance disorder Gait variability Inconsistent deficits in gait and stance with normal periods of walking observed
Monoplegic leg-dragging gait The leg is dragged at the hip behind the body instead of performing a circumduction
Excessive slowness Excessive slowness or hesitation incompatible with a neurologic disease
"Walking on ice" gait A walking pattern mimicking ice skating or as if on slippery ground
Functional Romberg Constant falls towards or away from the observer, large-amplitude body sway building up after a latency of a few seconds, and improvement of balance with distraction
Uneconomical postures A walking pattern that requires considerable effort as well as balance to maintain the posture (eg, crouching, dragging)
Knee-buckling The knees give way but without full collapse
Swivel chair sign Preserved ability to propel a swivel chair while seated
Facial symptoms Functional facial spasms Tonic pulling of the lips (or jaw) to one side with or without contralateral frontalis activation; usually ipsilateral platysma overactivation
Functional blepharospasm Closed eyelids resist retraction
Fixed dystonia Hand posture Flexed digits 3 to 5 with preserved pincer function
Foot posture Inversion and plantar flexion in the foot and ankle
Cervical posture Laterocollis, ipsilateral shoulder elevation, and contralateral shoulder depression
Slowness/parkinsonism Excessive slowness Excessive slowness or hesitation incompatible with a neurologic disease
Hypokinesia without decrement Continuously slow movements on repetitive testing without true decrement of speed or amplitude seen in bradykinesia
Paratonia/Gegenhalten Variable resistance during passive manipulation of a joint
"Huffing and puffing" sign Simple movements appear effortful
Tics Functional tics Not fully stereotyped, interfere with speech or voluntary actions, lack of clear premonitory urge, and inability to voluntarily suppress
Adapted from: Lidstone SC, Nassif W, Juncos J, et al. Diagnosing functional neurological disorder: Seeing the whole picture. CNS Spectr 2021; 26:593.
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