Neurological Examination For Subtle Signs Research Articles

Associations between neurological soft signs, executive functions, and brain-derived neurotrophic factor in boys with attention-deficit hyperactivity disorder.

To determine the association between neurological soft signs, executive functions, and serum brain-derived neurotrophic factor (BDNF) levels in children with attention-deficit hyperactivity disorder (ADHD). Serum BDNF levels were measured in 87 drug-naive boys with ADHD, aged 7-12 years. The Revised Physical and Neurological Examination for Subtle Signs for neurological soft signs, Stroop Color-Word Test for attention functions, and Judgment of Line Orientation Test (JLOT) for visuospatial abilities were performed. Age correlated negatively with dysrhythmia, total time, and total overflow in timed movements, Stroop Color-Word Time (SCWT), and serum BDNF levels. The JLOT significantly negatively correlated with Total Gaits and Stations (P1) and Total Time in Timed Movements (adjusted R 2 = 0.247). In addition, SCWT maintained a significant correlation with Total Overflow in Timed Movements (adjusted R 2 = 0.206). There was no correlation between serum BDNF levels and NSS. The association between NSS, visuospatial abilities, and selective attention may express a maturational delay in ADHD pathophysiology. Moreover, BDNF may play a role in this maturational delay. Future studies should investigate the contribution of BDNF to neuronal maturation in ADHD.

The impact of Toxocara-seropositivity on attention and motor skills in children with attention-deficit hyperactivity disorder

BackgroundThe study aims to compare neurological soft signs and executive functions between Toxocara-seropositive and seronegative groups in children with attention-deficit/hyperactivity disorder. MethodsThe study included 60 boys with ADHD, aged 7–12. After blood samples were taken, the Stroop Color Word Test and Judgment of Line Orientation test (JLOT) were implemented to measure executive functions. Neurological soft signs were evaluated with Physical and Neurological Examination for Subtle Signs (PANESS). ResultsSerological tests were positive for Toxocara antibodies in 20 cases. There was no significant difference between Toxocara seropositive and seronegative regarding age, socioeconomic status, developmental stages, and ADHD severity. However, Toxocara-seropositive children had higher Stroop time and Stroop interference scores and lower JLOT scores than Toxocara-seronegative children. Furthermore, Toxocara-seropositive children exhibited more neurological soft signs, such as gait and station abnormalities, dysrhythmia, and a longer total time in timed movements compared to Toxocara-seronegative children. ConclusionOur study indicates a link between Toxocara-seropositivity and impaired neurological soft signs and executive functions in ADHD. Further research is needed to understand ADHD mechanisms, develop practical treatments considering immunological factors, and thoroughly evaluate how Toxocara seropositivity affects executive functions and motor skills in children with ADHD.

74 Timed Motor Performance in Children Medically Cleared for Return to Activities Post Mild Traumatic Brain Injury

Objective:Children who sustain a mild traumatic brain injury (mTBI) are at increased odds of additive injury and continue to show altered motor performance relative to never-injured peers after being medically cleared (MC) to return to normal activities. There is a critical need to determine when children can return to activities without risk of short and long-term adverse effects, with research showing high reinjury rates for 3-12 months after RTP. The Physical and Neurological Examination for Subtle Signs (PANESS) measures subtle signs of motor impairment during gait, balance, and timed motor functions. Recent literature has demonstrated that PANESS timed motor function can distinguish between children medically cleared post-mTBI compared to never-injured controls. The present study examined performance on timed motor tasks in youth medically cleared from mTBI following medical clearance and 3-months later, compared to never-injured peers.Participants and Methods:25 children (Mage=14.16, SD=2.46; Male=68%) were enrolled within 6 weeks of medical clearance from mTBI (Mdays post MC=33, SD=13.4, Range=2-59) along with 66 typically developing, never-injured controls (Mage=13.9, SD=2.22; Male=50%). Group differences were evaluated for the Timed Motor section of the PANESS at enrollment and at a 3-month follow-up (Mdays from enrollment to follow-up=95.90, SD=12.69, Range=62-129). This 3-month follow-up occurred on average 4 months after medical clearance (Mdays from MC to follow-up=130.08, SD=17.58, Range=92 - 164). The Timed Motor section includes Repetitive (foot tapping, hand patting, and finger tapping) and Sequential (heel-toe rocking, hand pronate/supinate, finger sequencing) raw time scores, measured in seconds. The Total Timed Motor Speed score is the combination of Repetitive and Sequential Movement and the side-to-side tongue item.Results:At 3-month follow-up, mTBI participants (M=67.55, SD=8.26, Range=53.66-83.88) performed worse than controls (M=63.09, SD=10.23, Range=39.86-100.51) on Total Timed Motor Speed, t(89)= 1.95, p<0.05), including when controlling for age and sex, F(1, 87)=4.67, p<0.05. At the same time point, mTBI participants (M=36.54, SD=5.47, Range=28.74-49.17) performed worse on Sequential Speed than controls (M=32.93, SD=6.1, Range=21.49-56.76), t(89)=2.59, p<0.01, including when controlling for age and sex, F(1, 87)=7.687, p<0.01). Although groups performed similarly on Sequential Speed at the initial time point, mTBI participants exhibited a trend of less improvement from initial to follow-up (MmTBI=-1.69, Mcontrol=-3.68, t(90)=1.445, p=0.076).Conclusions:Although groups did not significantly differ on Timed Motor Speed items at the initial time point, the mTBI group showed consistently lower scores than controls at both time points and less improvement over time. Results indicate that Total Timed Motor Speed, specifically Sequential Speed, may be a sensitive marker of persisting differences in high-level motor and cognitive learning/control in children who have been medically cleared after mTBI. More data are needed to evaluate these findings over a longer time period, and future studies should examine behavioral markers concurrently with physiologic brain recovery over time.

Motor Function and Physiology in Youth With Neurofibromatosis Type 1

BackgroundNeurofibromatosis type 1 (NF1) is a genetic neurocutaneous disorder commonly associated with motor and cognitive symptoms that greatly impact quality of life. Transcranial magnetic stimulation (TMS) can quantify motor cortex physiology, reflecting the basis for impaired motor function as well as, possibly, clues for mechanisms of effective treatment. We hypothesized that children with NF1 have impaired motor function and altered motor cortex physiology compared to typically developing (TD) control children and children with attention-deficit/hyperactivity disorder (ADHD). MethodsChildren aged 8-17 years with NF1 (n = 21) were compared to children aged 8-12 years with ADHD (n = 59) and TD controls (n = 88). Motor development was assessed using the Physical and Neurological Examination for Subtle Signs (PANESS) scale. The balance of inhibition and excitation in motor cortex was assessed using the TMS measures short-interval cortical inhibition (SICI) and intracortical facilitation (ICF). Measures were compared by diagnosis and tested using bivariate correlations and regression for association with clinical characteristics. ResultsIn NF1, ADHD severity scores were intermediate between the ADHD and TD cohorts, but total PANESS scores were markedly elevated (worse) compared to both (P < 0.001). Motor cortex ICF (excitatory) was significantly lower in NF1 than in TD and ADHD (P < 0.001), but SICI (inhibitory) did not differ. However, in NF1, better PANESS scores correlated with lower SICI ratios (more inhibition; ρ = 0.62, P = 0.003) and lower ICF ratios (less excitation; ρ = 0.38, P = 0.06). ConclusionsTMS-evoked SICI and ICF may reflect processes underlying abnormal motor function in children with NF1.

Presence of neurologic signs in children with neurofibromatosis type 1

Neurofibromatosis type 1 is a common neurogenetic disorder affecting nervous system, caused by germiline mutations of the NF1 gene. Although the clinical diagnosis of NF1 is defined by presence of cafe-au-laits spots, freckling and benign tumors (neurofibromatosis), neurocognitive impairment and neuropsychiatric disorders are reported in comorbidity. Children with NF1 show higher incidence of executive deficits, such attention, response inhibition, executive planning and problem solving, working memory, and learning impairment. In this study we examine the presence of neurological soft signs and planning function in subjects with NF1. The NSS are minor motor and sensory abnormalities without focal brain damage. Eleven drug naïve children between 7-15 years with clinical and molecular diagnosis of NF are matched to 11 healthy controls to ass the presence of neurological soft signs and planning executive functions. NSS were assessed using Physical and Neurological Examination for Subtle Signs and the Tower of London task is performance test to assess the capacity of planning, organization and execution of a work. Our results revealed highest rate of NSS and planning deficit in children with NF1 compared to healthy controls. The motor abnormalities and planning deficit are possible markers to confirm that NF1 could be considering a neurodevelopmental disorder.

Thirty-Second Single-Leg Stance Identifies Impaired Postural Control in Children After Concussion: A Preliminary Report.

Objective and expedient assessments of standing postural control incorporating static and dynamic tasks are necessary for identifying subtle motor deficits and clearing children to return to high-risk activities after concussion. The Revised Physical and Neurological Examination for Subtle Signs (PANESS) gaits and stations tasks evaluate both static and dynamic aspects of postural control. While the PANESS gaits and stations subscale is sensitive to concussion in youth, the benefit of each specific task for this purpose is unknown. This study evaluated whether specific PANESS tasks identify postural impairments after youth concussion. Cross-sectional study. Academicallyaffiliated research laboratory. Sixty youth, ages 10-17years, comprised 3 groups: (1)youth symptomatic from concussion (4-14d postinjury [n = 18]), (2)clinically-recovered youth (27-122d postinjury [n = 15]), and (3)age- and gender-matched never-concussed controls (n = 27). PANESS gaits and stations tasks (6 dynamic and 3 static) at the time of the initial research visit. Kruskal-Wallis statistic identified a significant main effect of group on standing on one foot (a 30-s task). Both symptomatic and clinically-recovered youth showed deficits on standing on one foot relative to controls. Single-leg tasks of longer duration may maximize the ability to detect residual postural deficits after concussion and can be readily incorporated in targeted sport rehabilitation protocols.

A study of neurological soft signs and potential psychiatric comorbidities in children with specific learning disorders

Context: Children with specific learning disorders (SLD) are often observed with neurological soft signs (NSS) and adjunctive emotional/behavioral symptoms. Aims: This study attempts to quantify both NSS and subclinical psychiatric comorbidities in known SLD cases. Statistically relevant data, if generated, would provide clinicians with a clearer picture and further a more well-rounded treatment plan. Settings and Design: The study was observational, cross-sectional, and quantitative, conducted in learning disability clinic attached to a child psychiatry outpatient department in a public-sector tertiary-care teaching hospital in urban India. One hundred and sixty children of age 7–18 years fitting inclusion criteria were enrolled after appropriate consent/assent. Subjects and Methods: A sociodemographic data pro forma, and two scales, the child behavior checklist and Physical and Neurological Examination for Subtle Signs – Revised (PANESS-R), were used. A single-setting interview was conducted, data collected and statistically analyzed. Statistical Analysis: It was done by a qualified statistician using SPSS-16 software. Results: 36.25% had “total” psychopathology, 41.875% “internalizing problem,” and 30% “externalizing problem,” which were associated with poor interpersonal relations, more physical discipline, and “overflow” component of NSS. On PANESS-R, repetitive speed of movement was the most common. More NSS were found in younger age groups, boys and in association with perinatal maternal age of below 20 and above 30 years. Countering previous findings, right-handed children had high incidence of mixed handedness. Conclusions: We recommend routine screening for NSS and psychopathology in SLD children as these may complicate treatment outcome with secondary psychological/neurodevelopmental issues. Prompt detection and appropriate management might redress them more holistically.

Developmental Trajectory of Motor Deficits in Preschool Children with ADHD

ABSTRACTMotor deficits persisting into childhood (>7 years) are associated with increased executive and cognitive dysfunction, likely due to parallel neural circuitry. This study assessed the longitudinal trajectory of motor deficits in preschool children with ADHD, compared to typically developing (TD) children, in order to identify individuals at risk for anomalous neurological development. Participants included 47 children (21 ADHD, 26 TD) ages 4-7 years who participated in three visits (V1, V2, V3), each one year apart (V1=48-71 months, V2=60-83 months, V3=72-95 months). Motor variables assessed included speed (finger tapping and sequencing), total overflow, and axial movements from the Revised Physical and Neurological Examination for Subtle Signs (PANESS). Effects for group, visit, and group-by-visit interaction were examined. There were significant effects for group (favoring TD) for finger tapping speed and total axial movements, visit (performance improving with age for all 4 variables), and a significant group-by-visit interaction for finger tapping speed. Motor speed (repetitive finger tapping) and quality of axial movements are sensitive markers of anomalous motor development associated with ADHD in children as young as 4 years. Conversely, motor overflow and finger sequencing speed may be less sensitive in preschool, due to ongoing wide variations in attainment of these milestones.

Subtle Motor Findings During Recovery from Pediatric Traumatic Brain Injury: A Preliminary Report

ABSTRACTPediatric traumatic brain injury (TBI) is a heterogeneous condition, varying in both severity and sequelae. The long-term motor deficits following severe TBI requiring inpatient rehabilitation are better established than those following milder forms of TBI. The authors examined motor performance 2 and 12 months postinjury in children without overt motor impairment using standard measures of upper limb function and the Physical and Neurological Examination for Subtle Signs (PANESS). The PANESS was sensitive to differences between children with TBI and uninjured children as well as to changes in children with TBI over time. These data suggest that subtle motor deficits are present after milder forms of TBI and, particularly those related to balance and gait, may persist even 12 months postinjury.

Atypical lateralization of motor circuit functional connectivity in children with autism is associated with motor deficits.

BackgroundAtypical lateralization of language-related functions has been repeatedly found in individuals with autism spectrum conditions (ASC). Few studies have, however, investigated deviations from typically occurring asymmetry of other lateralized cognitive and behavioural domains. Motor deficits are among the earliest and most prominent symptoms in individuals with ASC and precede core social and communicative symptoms.MethodsHere, we investigate whether motor circuit connectivity is (1) atypically lateralized in children with ASC and (2) whether this relates to core autistic symptoms and motor performance. Participants comprised 44 right-handed high-functioning children with autism (36 males, 8 females) and 80 typically developing control children (58 males, 22 females) matched on age, sex and performance IQ. We examined lateralization of functional motor circuit connectivity based on homotopic seeds derived from peak activations during a finger tapping paradigm. Motor performance was assessed using the Physical and Neurological Examination for Subtle Signs (PANESS).ResultsChildren with ASC showed rightward lateralization in mean motor circuit connectivity compared to typically developing children, and this was associated with poorer performance on all three PANESS measures.ConclusionsOur findings reveal that atypical lateralization in ASC is not restricted to language functions but is also present in circuits subserving motor functions and may underlie motor deficits in children with ASC. Future studies should investigate whether this is an age-invariant finding extending to adolescents and adults and whether these asymmetries relate to atypical lateralization in the language domain.Electronic supplementary materialThe online version of this article (doi:10.1186/s13229-016-0096-6) contains supplementary material, which is available to authorized users.

Comparison of Neurological and Cognitive Deficits in Children With ADHD and Anxiety Disorders

Objective:To compare the neuro-cognitive profiles among initial clinic referred medication naive sample of children with anxiety disorders (ANXs) and ADHD in a youth sample. Method: Three groups of patients, ANX (n = 40), ADHD (n = 48), and ANX + ADHD (n = 33), aged 7 to 12 years, were compared with respect to their Physical and Neurological Examination for Subtle Signs (PANESS) and cognitive measures (digit span, digit symbol, Trail Making Test [TMT]-A and TMT-B, Stroop test). Results: ADHD group performed worse than the other two groups with regard to soft signs and cognitive test performance; ANX + ADHD were impaired relative to ANX but better than ADHD. Significant differences were found for gait and station problems, overflows and timed movements, TMT error points, and Stroop interference scores. ADHD patients had more difficulty in warding off irrelevant responses and lower speed of time-limited movements. Conclusion: This clinical evaluation study suggested that ANX and ADHD seem to have significantly different neuro-cognitive features: Poorest outcomes were observed among children with ADHD; rather than problems of attention, inhibitory control deficits were the most prominent differences between ANX and ADHD; and the presence of ANX appears to have mitigating effect on ADHD-related impairments.

P179 – 2255: Influence of electroencephalography neurofeedback training on motor skills of children with ADHD

Objective Neurofeedback (NFB) is a new special neurorehabilitation method that helps with specific mean in different neurological and psychological disorders. Paper analyze influence of the (NFB) on movements of children with Attention-Deficit/Hyperactivity Disorder (ADHD) and to try to document its possibilities on motor skills. Methods The study was conducted on group of 30 children (5 girls, 25 boys), mean age 8.9 years with ADHD. NFB procedure consists of 30 sessions with duration of 30–45 minutes/one session (Pendant EEG Pocket Neurobics®, Australia). EEG training was conducted with EEG Spectrum's standard (ADHD) protocols of augmentation in either the sensorimotor rhythm (SMR, 12–15 Hz) spectral band, or the low beta (15–18 Hz) spectral band, concurrently with inhibition of excessive activity in the 4–7 Hz band and the 22–30 Hz band, at sensorimotor cortex (Cz, C3 and C4). Before and after therapy there were performed Physical and Neurological Examination for Subtle Signs (PANESS test) for assessment of motor skills. We evaluated Gaits and Stations, Dysrhythmia, Repetitive and Patterns movements, Overflow. Parents completed 143 items questionnaire – TLC Subjective Assessment (motor, behavioral problems from their parents point of view). Statistical analysis: paired t-test and Wilcoxon signed-rank test, Effect size. Results Our study showed significant improvement in all followed parameters Gaits and Stations (Input M=28.9±5.89; Output M=16.17±6.46; t(29)=9.81; p Conclusion Our study has shown that NFB significantly increased control of voluntary and involuntary movements. NFB-regulation induces pronounced attention and motor-cortical activation.

The Effect of Methylphenidate on Neurological Soft Signs in ADHD.

ObjectiveNeurological soft signs are very common in children with the attention deficit hyperactivity disorder (ADHD), and the first line medication of this disorder is methylphenidate. The aim of the study was to assess the effect of methylphenidate on the neurological soft signs in children and adolescents suffering from ADHD depending on the dose of methylphenidate.MethodsThirty five patients with ADHD were investigated by the ADHD RS-IV parent version questionnaire and the Revised Neurological Examination for Subtle Signs before treatment adjustment and after four weeks of methylphenidate medication. The changes in hyperactivity symptomatology, neurological soft signs during therapy and the influence of the methylphenidate dose were statistically analyzed.ResultsA significant decrease in hyperactivity symptomatology was found after one month of methylphenidate medication (p=0.0001) and significant decrease in neurological soft signs was demonstrated in 21 from a total of 26 items (p<0.05). Correlation analysis showed no relationship between the dose of methylphenidate and the improvement of neurological soft signs. Similarly, the improvement of ADHD symptomatology had not correlation with the improvement of neurological soft signs.ConclusionThe study demonstrated the positive effect of methylphenidate on neurological soft signs in which improvement occurred independently of the dose, indicating that their progress may be due to methylphenidate treatment of any dose. The unrelated effect of methylphenidate on the attention deficit hyperactivity disorder and neurological soft signs suggest that methylphenidate might be useful in the therapy of clumsy child syndrome and in ADHD treatment of non-responders.

Relationship between reaction time variability and motor skill development in ADHD

Slower and more variable reaction times to computerized tasks have been documented in children diagnosed with attention deficit/hyperactivity disorder (ADHD). Recent research supports a role for attentional lapses in generating abnormally variable and slow responses. However, given the association between ADHD and impairments in motor control, we hypothesized that slower or more variable reaction times might also correlate with motor development. The aim of this case-control study was to explore the relationship between motor function, reaction speed and variability, and ADHD. After comprehensive educational and clinical assessments, motor skill development was evaluated in 35 children ages 9 to 14 (19 with ADHD) using the Physical and Neurological Examination for Subtle Signs (PANESS) test battery. Finger-sequencing speed and variability were quantified with goniometers. Reaction times were measured with 20 trials each of computerized simple and choice (binary) tasks. Compared to healthy controls, children with ADHD had slower and more variable reaction times, and these findings correlated with impaired motor development (PANESS) and slow and variable finger sequencing (goniometers). Further studies of motor development in ADHD may identify factors influencing speed and variability of reaction times.

Motor examination in children with Attention‐Deficit/Hyperactivity Disorder and Asperger Syndrome

Evaluating whether motor skills could differentiate drug-naive subjects with two neurodevelopmental disorders: Attention-Deficit Hyperactivity Disorder (ADHD) and Asperger Syndrome (AS). Thirty-six boys (12 with ADHD, 12 with AS and 12 with typical development) aged 8-12 were evaluated using the Physical and Neurological Examination for Subtle Signs. Three primary outcome variables were obtained as follows: (i) total speed of timed activities, (ii) total overflow and (iii) total dysrhythmia. Children with AS performed more slowly than those with ADHD and healthy children independently of age and IQ. Total dysrhythmia differentiates ADHD and AS children from controls. Dysfunction of the fronto-striatal-cerebellar networks related to motor control could be the physiopathological basis of the reported findings.

Motor cortex inhibition

Attention-deficit/hyperactivity disorder (ADHD) is a childhood-onset behavioral diagnosis in which children often fail to meet age norms in development of motor control, particularly timed repetitive and sequential movements, motor overflow, and balance. The neural substrate of this motor delay may include mechanisms of synaptic inhibition in or adjacent to the motor cortex. The primary objective of this study was to determine whether transcranial magnetic stimulation (TMS)-evoked measures, particularly short interval cortical inhibition (SICI), in motor cortex correlate with the presence and severity of ADHD in childhood as well as with commonly observed delays in motor control. In this case-control study, behavioral ratings, motor skills, and motor cortex physiology were evaluated in 49 children with ADHD (mean age 10.6 years, 30 boys) and 49 typically developing children (mean age 10.5 years, 30 boys), all right-handed, aged 8-12 years. Motor skills were evaluated with the Physical and Neurological Examination for Subtle Signs (PANESS) and the Motor Assessment Battery for Children version 2. SICI and other physiologic measures were obtained using TMS in the left motor cortex. In children with ADHD, mean SICI was reduced by 40% (p < 0.0001) and less SICI correlated with higher ADHD severity (r = -0.52; p = 0.002). Mean PANESS motor development scores were 59% worse in children with ADHD (p < 0.0001). Worse PANESS scores correlated modestly with less SICI (r = -.30; p = 0.01). Reduced TMS-evoked SICI correlates with ADHD diagnosis and symptom severity and also reflects motor skill development in children.

Effects of Gender and Age on Motor Exam in Typically Developing Children

Few studies have contrasted performance of typically developing boys and girls on standardized motor assessment. In the present study, developmental status of the motor system was assessed in 144 typically developing children (72 boys, 72 girls, ages 7–14), using the Physical and Neurological Examination for Subtle Signs (PANESS, Denckla, 1985). Four summary variables were examined: (1) Gaits and Stations, (2) Overflow, (3) Dysrythmia, and (4) Timed Movements. For most variables, gender differences were not significant; however significant gender effects were observed for some subtle signs (involuntary movements), gaits and stations, and timed patterned movements. In all instances, girls showed fewer subtle signs and were faster and more proficient than boys. Significant age-related changes were observed for some subtle signs (dysrythmia and overflow), and for timed movements. In contrast, by age 7, many of the skills assessed by the PANESS have reached “adult” level in typically developing children. Motor development appears to follow a different developmental course in girls than in boys; separate gender and age norms should be used in clinical assessment of motor function in children.

Reliability of Subtle (Soft) Neurological Signs in Children

Reliability and stability of neurological "subtle" ("soft") signs were assessed in 54 psychiatric patients and 25 normal children, aged 5-17 years, using the revised Neurological Examination for Subtle Signs (NESS). Acceptable interrater reliability (kappa greater than or equal to 0.50, or intraclass correlation coefficient greater than or equal to 0.70) was found for 40 of the 64 items tested. Test-retest reliability at 2 weeks was unsatisfactory for most of the categorically scored items, including some "classic" subtle signs such as overflows or dysrhythmias. Continuous items, such as time needed to perform 20 consecutive movements, remained mostly stable at retest. A practicing effect was evident only in the graphesthesia test. Overall internal consistency was good (Cronbach's alpha = 0.74). Given the poor stability of overflows and dysrhythmias, researchers and clinicians should rely more on subtle signs that can be assessed on continuous scales.