Conventional Neurological Examination Research Articles

Assessment and Rating of Motor Cerebellar Ataxias With the Kinect v2 Depth Sensor: Extending Our Appraisal.

Current assessment of patients with cerebellar disorders is based on conventional neurological examination that is dependent on subjective judgements. Quantitative measurement of cerebellar ataxias (CAs) is essential for assessment of evidence-based treatments and the monitoring of the progress or recovery of diseases. It may provide us a useful tool to navigate future treatments for ataxia. We developed a Kinect v2. sensor system with a novel algorithm to measure and evaluate movements for two tests of Scale for the Assessment and Rating of Ataxia (SARA): the nose-finger test and gait. For the nose-finger test, we evaluated and compared accuracy, regularities and smoothness in the movements of the index finger and the proximal limbs between cerebellar patients and control subjects. For the task of walking, we evaluated and compared stability between the two groups. The precision of the system for evaluation of movements was smaller than 2 mm. For the nose-finger test, the mildly affected patients tended to show more instability than the control subjects. For a severely affected patient, our system quantified the instability of movements of the index finger using kinematic parameters, such as fluctuations and average speed. The average speed appears to be the most sensitive parameter that contrasts between patients with CAs and control subjects. Furthermore, our system also detected the adventitious movements of more proximal body parts, such as the elbow, shoulder and head. Assessment of walking was possible only in patients with mild CAs. They demonstrated large sways and compensatory wide stances. These parameters appeared to show higher accuracy than SARA. This examiner-independent device measures movements of the points of interest of SARA more accurately than eye and further provides additional information about the ataxic movements (e.g., the adventitious movements of the elbow, shoulder and head in the nose-finger test and the wide-based walking with large oscillation in the gait task), which is out of the scope of SARA. Our new system enables more accurate scoring of SARA and further provides additional information that is not currently evaluated with SARA. Therefore, it provides an easier, more accurate and more systematic description of CAs.

Сlinical and physiological characteristics and therapy asthenic disorders in adolescents girls

To study clinical and psychophysiological characteristics of asthenic disorders in adolescent girls in the aspect of treatment efficacy of cortexin. Seventy-five women, aged 14-17 years, who were diagnosed with neurasthenia (ICD-10 F.48.0), were examined. Conventional neurological examination, a 10-point Visual Analogue Scale, the Multidimensional Fatigue Inventory (MFI-20), the A.M. Vein questionnaire, the Spielberger-Khanin questionnaire and EEG were used. The high level of anxiety resulted in the development of autonomic symptoms and cephalgia. The EEG study showed that women with neurasthenia were characterized by lower alpha-rhythm power in the occipital sites compared with healthy peers. Treatment with cortexin improved patient's condition in 80% of cases that was supported by the positive EG dynamics.

Quantitative Measurement of Akinesia in Parkinson's Disease.

There is great interest in developing simple, user-friendly, and inexpensive tools for the quantification and elucidation of motor deficits in patients with Parkinson's disease (PD). These systems could help to monitor the clinical status of patients with PD, to develop better treatments, and to identify individuals who have subtle motor signs that might pass unnoticed in the conventional neurological examination. Mememtum, a smartphone application that allows for the quantification of several parameters of movement, such as regularity, rhythm, and changes in the number of taps while taping with a single finger and with alternating fingers, was developed and then tested in a pilot study in Madrid and in an extensive study in Quito, Ecuador. Almost all patients could successfully perform single-finger tapping, but approximately 10% of patients with severe parkinsonism had problems taping with alternating fingers. The results revealed changes in the regularity of the pressure applied while tapping and a reduction in the number of taps on the device screen when alternating tapping among patients who had idiopathic PD and vascular parkinsonism compared with controls and individuals who had prediagnostic motor abnormalities of PD. Applications available in smartphones could be used for investigation and treatment of patients with PD, but much research is needed to optimize the ideal parameters to be investigated and the potential usefulness of this technique for patients with PD in different stages of the disease.

Psychoautonomic disorders in girls with impaired development of menstrual cycle

To study clinical and psychological features of autonomic dysfunction in girls with impaired development of menstrual functions (algodismenorrhea type) and to assess the efficacy of noofen in the treatment of these disorders. Seventy-five women, aged 14-17 years, with algomenorrhea and manifestations of autonomic dysfunction were examined. Conventional neurological and psychological examinations, a 10-cm Visual Analogue Scale (VAS), the Multidimensional Fatigue Inventory (MFI-20), A.M. Vein questionnaire, Kerdo index, Spielberger-Khanin questionnaire were used. Patients were divided into two groups. Patients of the first group (n=45) received noofen in dosage 500 mg daily. Patients of the second group (n=30) received cyclic vitamin therapy (1 tablet from the 1st to the 14th day of the menstrual cycle and 2 tablets from the 14th to the 28th day). The duration of the study was 30 days. Girls with algodismenorrhea had various neurological complaints and autonomic disorders. They were characterized by higher anxiety and asthenia as well. The efficacy of noofen in treatment of this disease was shown.

Quantifying progression of multiple sclerosis via classification of depth videos.

This paper presents new learning-based techniques for measuring disease progression in Multiple Sclerosis (MS) patients. Our system aims to augment conventional neurological examinations by adding quantitative evidence of disease progression. An off-the-shelf depth camera is used to image the patient at the examination, during which he/she is asked to perform carefully selected movements. Our algorithms then automatically analyze the videos, assessing the quality of each movement and classifying them as healthy or non-healthy. Our contribution is three-fold: We i) introduce ensembles of randomized SVM classifiers and compare them with decision forests on the task of depth video classification; ii) demonstrate automatic selection of discriminative landmarks in the depth videos, showing their clinical relevance; iii) validate our classification algorithms quantitatively on a new dataset of 1041 videos of both MS patients and healthy volunteers. We achieve average Dice scores well in excess of the 80% mark, confirming the validity of our approach in practical applications. Our results suggest that this technique could be fruitful for depth-camera supported clinical assessments for a range of conditions.

An Objective Pronator Drift Test Application (iPronator) Using Handheld Device

BackgroundThe pronator drift test is widely used to detect mild arm weakness. We developed an application that runs on a handheld device to objectify the pronator drift test and investigated its feasibility in stroke patients.MethodsThe iPronator application, which uses the built-in accelerometer in handheld devices, was developed. We enrolled acute ischemic stroke patients (n = 10) with mild arm weakness and healthy controls (n = 10) to validate the iPronator. In addition to conventional neurological examinations, the degree of average, maximum, and oscillation in drift and pronation were measured and compared using the iPronator. Follow-up tests using the iPronator were also conducted in the patient group one week later.ResultsThere was a strong correlation between the average degree of pronation and drift measured by the iPronator (r = 0.741, p<0.001). The degrees of average and maximum in pronation were greater in the patient group than in the control group [in average, 28.9°, interquartile range (IQR) 18.7–40.3 vs. 3.8° (IQR 0.3–7.5), p<0.001], in maximum, 33.0° (IQR 24.0–52.1) vs. 6.2° (IQR 1.4–9.4), p<0.001]. The degree of oscillation in pronation was not different between the groups (p = 0.166). In drift, the degrees of average, maximum, and oscillation were greater in the patient group. In stroke patients, a follow-up study at one week revealed improvements in the degrees of pronation and drift compared with baseline parameters.ConclusionsThe iPronator can reliably detect mild arm weakness of stroke patients and was also useful in detecting functional recovery for one week in patients with acute stroke.

Abnormal multifocal cerebral blood flow on Tc-99m HMPAO SPECT in a patient with anti-NMDA-receptor encephalitis

-aspartate receptor (NMDA-R) encephali-tis has been related with teratomas of the ovary in youngwomen. However, this syndrome is non-paraneoplastic inabout 40% of patients, particularly in the youngest patients[1, 3]. This encephalitis is associated with antibodies againstthe NMDA-R NR1 and NR2 subunits. The clinical pictureincludes movement disorders (dystonia, orolingual dyski-nesias, chewing movements, myoclonias,…), decreasedlevel of consciousness, seizures, central hypoventilation andautonomic disturbances. Frequently it is preceded by psy-chiatric symptoms such as changes of mood, behavior andpersonality, or acute psychosis.Brain MRI is normal or with mild changes in mostpatients. To date, scarce data from functional neuroimagingstudies [4] or MR spectroscopy are available. Few neuro-pathological cases have been described [2, 6, 7].We present a patient with anti-NMDA-R encephalitiswith a previously unreported abnormal multifocal cerebralblood flow on Tc-99m HMPAO SPECT.A 14-year-old girl was admitted to the ICU for an acutepsychiatric episode that developed 48 h after an upperrespiratory tract infection. She showed agitation, auditoryand visual hallucinations and aberrant behaviour. A con-ventional neurological examination, CT of the brain andfunduscopy were normal. A lumbar tap yield a colourlessCSF with 140 lymphocytes/ml and a normal glucose andprotein level. PCR for HSV DNA and cytology were nor-mal or negative.In the following days she worsened, developing a gen-eralized dystonia, severe facial grimacing and oculogyriccrisis with a decreased level of consciousness. Autonomicsymptoms were present with hypertensive crisis, tachy-cardia and hypersalivation. The patient did not developcentral hypoventilation. She showed generalized seizuresand was treated with phenytoin.Two gadolinium-enhanced brain MRI were normal(Fig. 1). Several EEGs showed continuous 2.5–3.5 Hz slowwaves without spikes. Brain Tc-99m HMPAO SPECTimages showed multiple focal areas of increased radiotraceruptake in both striatum and cerebral cortex more intense inthe frontal lobes (Fig. 1). Antibodies to NR1/NR2 hetero-mers of the NMDA receptor were found in CSF (immuno-logical studies performed by Drs F. Graus and A. SaizNeurology Service, Hospital Clinic, Universitat de Barce-lona). Ovarian teratoma or other tumors were not identifiedwith repeated specifically oriented CT, MRI, or ultrasound.The patient did not improve after one high dose steroidcourse. A dramatic recovery was observed with the admin-istration of IVIg at standard doses. Repeated brain-Tc-99mHMPAO-SPECT showed a near complete normalization.Brain MR Spectroscopy was performed after resolution of

Microvascular and macrovascular complications associated with diabetes in children and adolescents

Department of Pediatrics, Ulleval University˚Hospital, and Faculty of Medicine, University of Oslo, NorwayCorresponding author:Assoc. Prof. Kim DonaghueThe Children’s Hospital at Westmead, Locked Bag 4001,Westmead, NSW 2145, Australia.Tel: C61 2 9845 3172;fax: C61 2 9845 3170;e-mail: kimd@chw.edu.auAcknowledgments: Esko Wiltshire, Gisela Dahlquist, KennethLee Jones, Edna Roche, Amina Balafrej and Riccardo Bonfanti.Conflicts of interest: The authors have declared no conflictsof interest.Editors of the ISPAD Clinical Practice Consensus Guide-lines 2009 Compendium: Ragnar Hanas, Kim Donaghue,Georgeanna Klingensmith, and Peter Swift.This article is a chapter in the

Does walking change the Romberg sign?

The Romberg sign helps demonstrate loss of postural control as a result of severely compromised proprioception. There is still no standard approach to applying the Romberg test in clinical neurology and the criteria for and interpretation of an abnormal result continue to be debated. The value of this sign and its adaptation when walking was evaluated. Detailed clinical examination of 50 consecutive patients of cervical myelopathy was performed prospectively. For the walking Romberg sign, patients were asked to walk 5 m with their eyes open. This was repeated with their eyes closed. Swaying, feeling of instability or inability to complete the walk with eyes closed was interpreted as a positive walking Romberg sign. This test was compared to common clinical signs to evaluate its relevance. Whilst the Hoffman's reflex (79%) was the most prevalent sign seen, the walking Romberg sign was actually present in 74.5% of the cases. The traditional Romberg test was positive in 17 cases and 16 of these had the walking Romberg positive as well. Another 21 patients had a positive walking Romberg test. Though not statistically significant, the mean 30 m walking times were slower in patients with traditional Romberg test than in those with positive walking Romberg test and fastest in those with neither of these tests positive. The combination of either Hoffman's reflex and/or walking Romberg was positive in 96% of patients. The walking Romberg sign is more useful than the traditional Romberg test as it shows evidence of a proprioceptive gait deficit in significantly more patients with cervical myelopathy than is found on conventional neurological examination. The combination of Hoffman's reflex and walking Romberg sign has a potential as useful screening tests to detect clinically significant cervical myelopathy.

Somatosensory disturbance by methylmercury exposure

Minamata disease is methylmercury poisoning from consuming fish and shellfish contaminated by industrial waste. The polluted seafood was widely consumed in the area around Minamata, but many individuals were never examined for or classified as having Minamata disease. Following the determination of the Supreme Court of Japan in October 2004 that the Japanese Government was responsible for spreading Minamata disease, over 13,000 residents came forward to be examined for Minamata disease. We studied 197 residents from the Minamata area who had a history of fish consumption during the polluted period to determine the importance of sensory symptoms and findings in making a diagnosis of Minamata disease. We divided the exposed subjects into non-complicated (E) and complicated (E+N) groups based on the absence or presence of other neurological or neurologically related disorders and compared them to residents in control area (C) after matching for age and sex. We quantitatively measured four somatosensory modalities (minimal tactile sense by Semmes-Weinstein monofilaments, vibration sense, position sense, and two-point discrimination) and did psychophysical tests of fine-surface-texture discrimination. Subjective complaints were higher in groups E and E+N than C. Over 90% of E+N and E subjects displayed a sensory disturbance on conventional neurological examination and 28% had visual constriction. About 50% of the E and E +N groups had upper and lower extremity ataxia and about 70% had truncal ataxia. The prevalence of these neurological findings was significantly higher in exposed subjects than controls. All sensory modalities were impaired in the E and E+N groups. All four quantitatively measured sensory modalities were correlated. The prevalence of complaints, neurological findings, and sensory impairment was similar or a little worse in group E+N than in group E. We conclude that sensory symptoms and findings are important in making the diagnosis of Minamata disease and that they can be determined even in the presence of neurological or neurologically related diseases.

The test–retest reliability of motor performance measures after traumatic brain injury

Physically well recovered traumatically brain injured (TBI) patients complain of impaired motor performance, which may not be apparent in conventional neurological examination. A reliable test battery measuring mild physical impairment in TBI populations would be a welcome tool for clinical practice. The aim of this study was to evaluate the test–retest reliability of static and dynamic balance, running in a figure-of-eight (agility) and rhythm co-ordination tests. Thirty-four well-recovered TBI inpatients and 36 healthy male volunteers were tested on two occasions. The change in the mean, the typical error and the intra-class correlation coefficient (ICC) were used as statistics of reliability for continuous measurements and Cohen's kappa coefficient for categorical variables. The best result of consecutive trials within each test showed the best reliability. In the tandem walking tests and running figure-of-eight tests, the reliability was lower in the TBI group than in the controls but still good. The ...

Functional capacity after peripheral nerve lesion: significance of pain syndromes

The loss of functional capacity by peripheral nerve lesion is easy to be estimated: A certain neurologic dysfunction results in a characteristic reduction of the former individual capacity. In contrast, the effect of accompanying pain to every-day life and working ability is not known exactly. In this study, we compared the results of judgement in nerve lesions under the circumstances of additional pain syndromes. From January 1994 until December 1998 we saw 57 patients with peripheral nerve lesions, part of them with an additional pain syndrome. Beside conventional neurological examination a detailed pain analysis has been done. Lesions of the median or ulnar nerves showed regularly disturbances in neurological functions (10/14 for the median nerve, 13/16 for the ulnar nerve). Astonishing is the fact, that serious pain after nerve lesion only occurs in cases of partial nerve lesion. We saw neuralgias in 6 patients with ulnar neuropathy, in three cases of median nerve lesions we could see severe neuralgia (causalgia we found in 3 cases of ulnar neuropathy, in 6 cases after Median Nerve lesion). Patients with a lesion of the central plexus brachialis showed in 10 of 11 cases an additional pain syndrome. Other nerves have been affected more rarely. For the judgement of the loss of earning capacity we saw an additional pain related diminuition of at least 10% compared to those patients without pain problems. The common grading scales for peripheral nerve lesions are not suitable in cases accompanied by an additional pain syndrome. Beside a functional deficit the effect of severe pain in these patients has to be estimated. On an average, patients with additional pain-problems get a 10% extended loss of earning capacity, even more in particular cases.

Severity of alcohol dependence and its relationship to neurological soft signs, neuropsychological impairment and family history.

We examined the relationship between severity of alcohol dependence, subtle neurological impairment, neuropsychological deficits and genetic vulnerability among 36 day hospital attenders who satisfied the DSM-III-R criteria for alcohol dependence. Severity of alcohol dependence was unrelated to the presence of a family history, but was correlated with neurological soft signs and neuropsychological impairment. Neurological soft signs were correlated with neuropsychological impairment on both Trail A and Trail B. Patients with an affected first-degree relative exhibited more neurological soft signs. These data indicate that severity of alcohol dependence is related not only to neuropsychological impairment, but also to subtle neurological deficits which may not be apparent on conventional neurological examination. Patients with a positive family history of alcohol dependence may be particularly susceptible to the neurological sequelae of alcohol dependence, or may have neurological deficits which antedate their alcohol dependence.

Neurological ?soft' signs may identify children with sickle cell disease who are at risk for stroke

Stroke is one of the most frequent complications of sickle cell disease (HbSS), occurring in 7-17% of children. Recent studies recognized more minor lesions on MRI, not associated with clinical signs on standard neurological examination, which however have been found to be a risk factor for developing stroke later. The aim of this study was to evaluate whether minor lesions observed on imaging could be associated with 'soft' neurological signs not detectable on conventional neurological examination. Fourteen children with HbSS were assessed with MRI, standard neurological examination and evaluation of 'soft' signs (Zurich Neuromotor Test) and motor function (Movement ABC). Eight of the 14 children scanned showed lesions on MRI but only 3 of the full cohort were abnormal on standard neurological examination. However, all of the eight children with MRI lesions also showed abnormal signs on at least one of the two tests (Zurich and Movement ABC). All the children with normal MRI were normal on all the tests performed. The sensitivity of Zurich Neuromotor Test and Movement ABC in the group of children with MRI lesions is 0.88 and 0.75, respectively, and increases to 1 when the two tests are used together. The specificity of both tests is 1 even when the tests are used separately. Although the number of cases is small, 'soft' signs may reliably identify the presence of even minor MRI lesions, allow the evaluation of the global incidence of major and minor neurological signs and may also help to identify the population at risk for developing strokes. This population could then be closely monitored and benefit from early intervention.

Evaluation of the thoraco‐laryngeal reflex (‘slap test’) as an aid to the diagnosis of cervical spinal cord and brainstem disease in horses

A study was conducted over a 12 month period to assess the specificity and sensitivity of the 'slap test', using endoscopic evaluation, in the detection of cervical spinal cord and caudal brainstem lesions in horses. Fifteen ataxic horses were subjected to the 'slap test' and subsequently examined post mortem. Twelve out of the 15 had histopathological lesions consistent with their clinical signs. Thirteen horses with no history of neurological dysfunction and no histopathological evidence of cervical spinal cord or brainstem disease were used as controls. The laryngeal adductory responses exhibited by all horses were filmed and later scored independently by 3 assessors. The proportion of animals diagnosed with cervical spinal cord and/or brainstem disease, defined by histopathological criteria, was found to be statistically similar to the proportion with abnormal 'slap test' responses, using the McNemar chi-Square test. Despite statistical significance between proportions, sensitivity of the 'slap test' was low, 50% for the left side on both days and 58% for the right side. Specificity was higher, 69% (Day 1) and 75% (Day 2) for the left side and 75% (Day 1) and 69% (Day 2) for the right side. In contrast to this, conventional neurological examination was found to be 100% sensitive and 81% specific in the detection of lesions of histopathological significance in the cervical spinal cord/caudal brainstem. Agreement between scores for the 'slap test' from the same assessor on different days was good, with values for kappa of 0.59 to 0.85. In contrast, agreement between assessors on the 'slap test' score was poor, with kappa 0.35.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative measurements of vibration threshold in healthy adults and acrylamide workers

The early detection of impaired vibration sensation is necessary in order to monitor the adverse effects in workers occupationally exposed to neurotoxic chemicals such as acrylamide. The conventional neurological examination which assesses vibration sensation by utilizing a tuning fork is relatively insensitive for this purpose. In the present study, the Vibration II, a new device for the quantitative measurement of vibration thresholds, was used in 105 healthy Chinese adults. A new testing procedure combining the "two-alternative forced-choice procedure" and the "yes-or-no method-of-limits procedure" showed good reliability and was less time consuming. The results indicate that significant differences in the vibration threshold of index fingers and great toes were found neither between males and females, nor between the left and the right side. However, there was an age-dependent increase in vibration threshold in nonexposed healthy subjects. The vibration thresholds of 41 workers exposed to acrylamide detected by the Vibration II were significantly higher than those of the healthy adults in the same age group. The quantitative measurement of vibration threshold seems to be potentially useful for screening peripheral nerve dysfunction in field studies.

Interexaminer reliability of observations in physical examinations of the neck.

The purpose of this study was to collect data on interexaminer reliability of a set of tests representative of the clinical examination of a patient with neck and radicular pain. A conventional neurological examination, palpations, and tests for the provocation or relief of radicular symptoms were performed on 52 patients by two independent raters. Good reliability was obtained in the atrophy inspection of the small muscles of the hand, in the sensitivity tests for touch and pain, and in the neck compression and axial manual traction tests. Fair reliability was obtained in muscle strength testing and in the estimation of the range of motion, and poor reliability was obtained for many palpations. Poor standardization of examination procedures and changes in the patients' attention were considered the main factors affecting reliability. Better operational definitions and procedures, such as the standardization of palpation pressure and traction force, are suggested for future studies.

ASSESSMENT OF NEUROLOGICAL “SOFT SIGNS” IN ADOLESCENTS: RELIABILITY STUDIES

The validity and reliability of a scoring system for 'neurological soft signs' in teenagers was assessed. Six scales were adapted and fitted into the framework of a conventional neurological examination. The following emerged: each of the three multi-item scales had high internal consistency; inter-rater agreement on mirror movements of 'live' subjects was satisfactory; ratings of videotapes agreed among examiners for mirror movements and dysdiadochokinesis but not for choreiform movements; data-based cut-off scores defining present vs. absent were congruent with the ratings of outside neurologists; and each examiner was consistent in rating mirror movements and rapid alternating movements from videotapes over several months.

Developmental dyspraxia-dysgnosia as a cause of congenital children's clumsiness

In order to ascertain the cause of children's clumsiness in minor brain disturbances, 44 children aged 9-11 years with low birth weight and 55 children aged 7-12 years from a special class for hyperactive children were examined by especially developed tests for praxia and gnosia. Conventional neurological examination was in all of them within normal limits; some of them presented, however, soft signs in special tets for cerebellar functions, proving that there was a group of minor cerebellar disorder. But in the majority of these children special tests revealed a dyspraxia and/or dysgnosia. This was in 81.6% for hyperactive children and 71.4% for children with low birth weight. In this group was pure dyspraxia quite often present (33%). In a control group of 72 children was dyspraxia-dysgnosia only in 47.4% and had a tendency to disappear with age.

Development of flexion pyramidal signs in preterm infants.

Forty-two babies (20 boys, 22 girls) with birthweights from 800g to 2000g and gestational ages between 25 and 40 weeks were followed-up for several weeks with developmental tests and a conventional neurological examination. Here, only the flexion pyramidal signs are evaluated, i. e. downward flexion of the toes after percussion over the base of the metatarsals (Rossolimo's sign) and of the cuboid bone (Mendel-Bechterew's sign). These reflexes are signs of severe upper motor neuron lesion in children and adults, but also appear in normal newborns and disappear again until the 12th week of life. This study shows that the early response of FPS is abduction of the toes and extension of the great toe from the 25th up to the 34th to 36th gestational weeks, when it becomes the normal downward flexion of all toes. This developmental course seems to be the same in healthy preterm babies and in small-for-dates babies.