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Jon Stone - One of the best experts on this subject based on the ideXlab platform.
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Predisposing Risk Factors for Functional Limb Weakness: A Case-Control Study
The Journal of neuropsychiatry and clinical neurosciences, 2019Co-Authors: Jon Stone, Charles Warlow, Ian J. Deary, Michael SharpeAbstract:Objective:Functional Limb Weakness is a common symptom of functional neurological disorder. Few controlled studies have examined possible predisposing factors to determine their specificity for thi...
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The prognosis of functional Limb Weakness: a 14-year case-control study
Brain : a journal of neurology, 2019Co-Authors: Jeannette M. Gelauff, Alan Carson, Lea Ludwig, Marina A.j. Tijssen, Jon StoneAbstract:Reliable data on the prognosis of functional motor disorder are scarce, as existing studies of the prognosis of functional motor disorder are nearly all retrospective, small and uncontrolled. In this study we used a prospectively recruited, controlled cohort design to assess misdiagnosis, mortality and symptomatic and health outcome in patients with functional Limb Weakness compared to neurological disease and healthy control subjects. We also carried out an exploratory analysis for baseline factors predicting outcome. One hundred and seven patients with functional Limb Weakness, 46 neurological and 38 healthy control subjects from our previously studied prospective cohort were traced for follow-up after an average of 14 years. Misdiagnosis was determined in a consensus meeting using information from records, patients and their GPs. Numbers and causes of death were collected via death certificates. Outcome of Limb Weakness, physical and psychiatric symptoms, disability/quality of life and illness perception were recorded with self-rated questionnaires. Outcome measures were compared within and between groups. Seventy-six patients (71%) with functional Limb Weakness, 31 (67%) neurological and 23 (61%) healthy controls were included in follow-up. Misdiagnosis was found in one patient in the functional Limb Weakness group (1%) and in one neurological control (2%). Eleven patients with functional Limb Weakness, eight neurological control subjects and one healthy control subject had died. Weakness had completely remitted in 20% of patients in the functional Limb Weakness group and in 18% of the neurological controls (P = 0.785) and improved in a larger proportion of functional Limb Weakness patients (P = 0.011). Outcomes were comparable between patient groups, and worse than the healthy control group. No baseline factors were independent predictors of outcome, although somatization disorder, general health, pain and total symptoms at baseline were univariably correlated to outcome. This study is the largest and longest follow-up study of functional Limb Weakness. Misdiagnosis in functional Limb Weakness is rare after long-term follow-up. The disorder is associated with a higher mortality rate than expected, and symptoms are persistent and disabling. It appears difficult to predict outcome based on common baseline variables. These data should help inform clinicians to provide a more realistic outlook of the outcome and emphasize the importance of active and targeted therapy.
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Pyramidal versus inverse pyramidal patterns in functional Limb Weakness
Practical neurology, 2017Co-Authors: Jon StoneAbstract:Charles Mark Wiles makes some excellent points about pyramidal Weakness.1 What we observe is largely just the ‘normal’ pattern of asymmetry of strength in the upper and lower Limbs, amplified by disease and sometimes spasticity, and can often be found in lower motor neurone syndromes as well as upper. But there is one clinical scenario where I would argue it remains …
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Transcranial magnetic stimulation as a treatment for functional (psychogenic) upper Limb Weakness.
Journal of psychosomatic research, 2016Co-Authors: Laura Mcwhirter, Lea Ludwig, Alan Carson, Robert D. Mcintosh, Jon StoneAbstract:Abstract Objective There has been a recent resurgence of interest in physical treatments for functional motor disorders (FMD) including Transcranial Magnetic Stimulation (TMS). This pilot study aimed to test the effectiveness of a single session of motor cortex TMS as a treatment for functional upper Limb Weakness. Methods Ten subjects with a diagnosis of functional upper Limb Weakness were randomised to immediate ( n = 7) or delayed (3 months) ( n = 3) TMS treatment. Median age was 35 (range 23–52) and median symptom duration was 2.3 years (range 5 months – 20 years). 46–70 single pulses were applied to the motor cortex at 120–150% motor threshold. We used a verbal protocol designed to standardized the effects of suggestion. Primary outcome measures were self-reported symptom severity, grip strength and tapping frequency immediately after treatment, and symptom severity and disability (SF-12 and Modified Rankin Scale (MRS)) after 3 months. Results There was a small significant reduction in symptom severity immediately after treatment, but no improvement in grip strength or tapping frequency and no change in symptom severity, SF-12 or MRS 3 months after treatment. Small numbers precluded comparison of immediate treatment with delayed treatment. Four of eight subjects responding to three-month follow-up reported late-onset adverse effects. Conclusion This pilot study suggests limited benefits for TMS as a one-off non-neuromodulatory treatment for stable chronic outpatients. TMS may still have a role alongside more intensive multidisciplinary therapy input, or in patients with severe deficits where the possibility of normal movement can be hard to demonstrate. Trial registration NCT02102906
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Functional Limb Weakness and paralysis.
Handbook of clinical neurology, 2016Co-Authors: Jon Stone, Selma AybekAbstract:Functional (psychogenic) Limb Weakness describes genuinely experienced Limb power or paralysis in the absence of neurologic disease. The hallmark of functional Limb Weakness is the presence of internal inconsistency revealing a pattern of symptoms governed by abnormally focused attention. In this chapter we review the history and epidemiology of this clinical presentation as well as its subjective experience highlighting the detailed descriptions of authors at the end of the 19th and early 20th century. We discuss the relevance that physiological triggers such as injury and migraine and psychophysiological events such as panic and dissociation have to understanding of mechanism and treatment. We review many different positive diagnostic features, their basis in neurophysiological testing and present data on sensitivity and specificity. Diagnostic bedside tests with the most evidence are Hoover's sign, the hip abductor sign, drift without pronation, dragging gait, give way Weakness and co-contraction.
James J. Sejvar - One of the best experts on this subject based on the ideXlab platform.
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Delayed-onset and recurrent Limb Weakness associated with West Nile virus infection.
Journal of neurovirology, 2010Co-Authors: James J. Sejvar, Larry E. Davis, Erica M Szabados, Alan JacksonAbstract:Human neurologic illness following infection with West Nile virus (WNV) may include meningitis, encephalitis, and acute flaccid paralysis (AFP). Most WNV-associated AFP is due to involvement of the spinal motor neurons producing an anterior (polio)myelitis. WNV poliomyelitis is typically characterized by acute and rapidly progressing Limb Weakness occurring early in the course of illness, which is followed by death or clinical plateauing with subsequent improvement to varying degrees. We describe four cases of WNV poliomyelitis in which the Limb Weakness was characterized by an atypical temporal pattern, including one case with onset several weeks after illness onset, and three cases developing relapsing or recurrent Limb Weakness following a period of clinical plateauing or improvement. Delayed onset or recurrent features may be due to persistence of viral infection or delayed neuroinvasion with delayed injury by excitotoxic or other mechanisms, by immune-mediated mechanisms, or a combination thereof. Further clinical and pathogenesis studies are needed to better understand the mechanisms for these phenomena. Clinicians should be aware of these clinical patterns in patients with WNV poliomyelitis.
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West Nile Virus Disease: A Descriptive Study of 228 Patients Hospitalized in a 4-County Region of Colorado in 2003
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2006Co-Authors: Amy V. Bode, James J. Sejvar, W. John Pape, Grant L. Campbell, Anthony A. MarfinAbstract:Background. Risk factors for complications of West Nile virus disease and prognosis in hospitalized patients are incompletely understood. Methods. Demographic characteristics and data regarding potential risk factors, hospitalization, and dispositions were abstracted from medical records for residents of 4 Colorado counties who were hospitalized in 2003 with West Nile virus disease. Univariate and multivariate analyses were used to identify factors associated with West Nile encephalitis (WNE), Limb Weakness, or death by comparing factors among persons with the outcome of interest with factors among those without the outcome of interest. Results. Medical records of 221 patients were reviewed; 103 had West Nile meningitis, 65 had WNE, and 53 had West Nile fever. Respiratory failure, Limb Weakness, and cardiac arrhythmia occurred in all groups, with significantly more cases of each in the WNE group. Age, alcohol abuse, and diabetes were associated with WNE. Age and WNE were associated with Limb Weakness. The mortality rate in the WNE group was 18%; age, immunosuppression, requirement of mechanical ventilation, and history of stroke were associated with death. Only 21% of patients with WNE who survived returned to a prehospitalization level of function. The estimated incidence of West Nile fever cases that required hospitalization was 6.0 cases per 100,000 persons; West Nile fever was associated with arrhythmia, Limb Weakness, and respiratory failure. Conclusions. Persons with diabetes and a reported history of alcohol abuse and older persons appear to be at increased risk of developing WNE. Patients with WNE who have a history of stroke, who require mechanical ventilation, or who are immunosuppressed appear to be more likely to die. Respiratory failure, Limb Weakness, and arrhythmia occurred in all 3 categories, but there were significantly more cases of all in the WNE group.
Alan Jackson - One of the best experts on this subject based on the ideXlab platform.
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Delayed-onset and recurrent Limb Weakness associated with West Nile virus infection.
Journal of neurovirology, 2010Co-Authors: James J. Sejvar, Larry E. Davis, Erica M Szabados, Alan JacksonAbstract:Human neurologic illness following infection with West Nile virus (WNV) may include meningitis, encephalitis, and acute flaccid paralysis (AFP). Most WNV-associated AFP is due to involvement of the spinal motor neurons producing an anterior (polio)myelitis. WNV poliomyelitis is typically characterized by acute and rapidly progressing Limb Weakness occurring early in the course of illness, which is followed by death or clinical plateauing with subsequent improvement to varying degrees. We describe four cases of WNV poliomyelitis in which the Limb Weakness was characterized by an atypical temporal pattern, including one case with onset several weeks after illness onset, and three cases developing relapsing or recurrent Limb Weakness following a period of clinical plateauing or improvement. Delayed onset or recurrent features may be due to persistence of viral infection or delayed neuroinvasion with delayed injury by excitotoxic or other mechanisms, by immune-mediated mechanisms, or a combination thereof. Further clinical and pathogenesis studies are needed to better understand the mechanisms for these phenomena. Clinicians should be aware of these clinical patterns in patients with WNV poliomyelitis.
Cathy M. Stinear - One of the best experts on this subject based on the ideXlab platform.
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Transcranial magnetic stimulation in patients with functional Limb Weakness
Journal of Neurology Neurosurgery & Psychiatry, 2017Co-Authors: Benson S. Chen, P. Alan Barber, Cathy M. StinearAbstract:Objectives Functional Limb Weakness can be a protracted and debilitating condition. Most treatment approaches combine behavioural or psychiatric approaches with a motor learning programme. We aimed to determine if transcranial magnetic stimulation (TMS) could confirm the integrity of corticomotor pathways and improve outcome in patients with functional Limb Weakness. Methods Patients with functional Limb Weakness were identified. MRI of the brain and spinal cord were performed to exclude structural lesions. TMS was performed using a figure-of-eight coil connected to a MagStim 200 stimulator. Focal stimulation was delivered over the contralateral primary motor cortex to the paretic Limb. Motor evoked potentials (MEPs) were measured using surface electromyography of the first dorsal interosseous and tibialis anterior muscles. Patients were directed to attend to the presence of visible and palpable muscle twitches. A Functional Independence Measure (FIM) score was calculated pre- and post-TMS. Results Four patients (3 female; mean age (range) 33 (16-48) years) were assessed as having functional Limb Weakness after neurological and psychiatric assessment. Two patients had previous diagnoses of functional neurologic conditions. TMS was performed 15 (3-34) days after symptom onset and demonstrated the integrity of the corticomotor pathways with normal MEP latency, amplitude and morphology in all patients. There were no complications. The mean (range) FIM score improved from 69 (36-106) pre-TMS to 81 (60 to 116) post-TMS. Two patients returned to normal or near-normal at discharge and one had residual Weakness but was independent with activities of daily living (ADLs). One patient had resistant Weakness and remained dependent with ADLs. Conclusions TMS is a safe and well-tolerated tool that has both diagnostic and therapeutic applications in patients with functional Limb Weakness. It can be used alongside conventional techniques to confirm normal corticomotor physiology and, by generating muscle contractions, enable patients to recognise their own potential for recovery.
Lea Ludwig - One of the best experts on this subject based on the ideXlab platform.
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The prognosis of functional Limb Weakness: a 14-year case-control study
Brain : a journal of neurology, 2019Co-Authors: Jeannette M. Gelauff, Alan Carson, Lea Ludwig, Marina A.j. Tijssen, Jon StoneAbstract:Reliable data on the prognosis of functional motor disorder are scarce, as existing studies of the prognosis of functional motor disorder are nearly all retrospective, small and uncontrolled. In this study we used a prospectively recruited, controlled cohort design to assess misdiagnosis, mortality and symptomatic and health outcome in patients with functional Limb Weakness compared to neurological disease and healthy control subjects. We also carried out an exploratory analysis for baseline factors predicting outcome. One hundred and seven patients with functional Limb Weakness, 46 neurological and 38 healthy control subjects from our previously studied prospective cohort were traced for follow-up after an average of 14 years. Misdiagnosis was determined in a consensus meeting using information from records, patients and their GPs. Numbers and causes of death were collected via death certificates. Outcome of Limb Weakness, physical and psychiatric symptoms, disability/quality of life and illness perception were recorded with self-rated questionnaires. Outcome measures were compared within and between groups. Seventy-six patients (71%) with functional Limb Weakness, 31 (67%) neurological and 23 (61%) healthy controls were included in follow-up. Misdiagnosis was found in one patient in the functional Limb Weakness group (1%) and in one neurological control (2%). Eleven patients with functional Limb Weakness, eight neurological control subjects and one healthy control subject had died. Weakness had completely remitted in 20% of patients in the functional Limb Weakness group and in 18% of the neurological controls (P = 0.785) and improved in a larger proportion of functional Limb Weakness patients (P = 0.011). Outcomes were comparable between patient groups, and worse than the healthy control group. No baseline factors were independent predictors of outcome, although somatization disorder, general health, pain and total symptoms at baseline were univariably correlated to outcome. This study is the largest and longest follow-up study of functional Limb Weakness. Misdiagnosis in functional Limb Weakness is rare after long-term follow-up. The disorder is associated with a higher mortality rate than expected, and symptoms are persistent and disabling. It appears difficult to predict outcome based on common baseline variables. These data should help inform clinicians to provide a more realistic outlook of the outcome and emphasize the importance of active and targeted therapy.
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Transcranial magnetic stimulation as a treatment for functional (psychogenic) upper Limb Weakness.
Journal of psychosomatic research, 2016Co-Authors: Laura Mcwhirter, Lea Ludwig, Alan Carson, Robert D. Mcintosh, Jon StoneAbstract:Abstract Objective There has been a recent resurgence of interest in physical treatments for functional motor disorders (FMD) including Transcranial Magnetic Stimulation (TMS). This pilot study aimed to test the effectiveness of a single session of motor cortex TMS as a treatment for functional upper Limb Weakness. Methods Ten subjects with a diagnosis of functional upper Limb Weakness were randomised to immediate ( n = 7) or delayed (3 months) ( n = 3) TMS treatment. Median age was 35 (range 23–52) and median symptom duration was 2.3 years (range 5 months – 20 years). 46–70 single pulses were applied to the motor cortex at 120–150% motor threshold. We used a verbal protocol designed to standardized the effects of suggestion. Primary outcome measures were self-reported symptom severity, grip strength and tapping frequency immediately after treatment, and symptom severity and disability (SF-12 and Modified Rankin Scale (MRS)) after 3 months. Results There was a small significant reduction in symptom severity immediately after treatment, but no improvement in grip strength or tapping frequency and no change in symptom severity, SF-12 or MRS 3 months after treatment. Small numbers precluded comparison of immediate treatment with delayed treatment. Four of eight subjects responding to three-month follow-up reported late-onset adverse effects. Conclusion This pilot study suggests limited benefits for TMS as a one-off non-neuromodulatory treatment for stable chronic outpatients. TMS may still have a role alongside more intensive multidisciplinary therapy input, or in patients with severe deficits where the possibility of normal movement can be hard to demonstrate. Trial registration NCT02102906
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Differences in illness perceptions between patients with non-epileptic seizures and functional Limb Weakness
Journal of psychosomatic research, 2015Co-Authors: Lea Ludwig, Michael Sharpe, Kimberley Whitehead, Markus Reuber, Jon StoneAbstract:Abstract Objectives Illness perceptions play an important role in the onset and maintenance of symptoms in functional neurological symptom disorder (conversion disorder). There has, however, been little work examining differences between subtypes of this disorder. We therefore aimed to compare illness perceptions of patients with non-epileptic seizures (NES) and those with functional Weakness (FW) with matching neurological disease controls to examine their specificity. Methods The Illness Perception Questionnaire Revised (IPQ-R) was completed by patients with functional Limb Weakness, non-epileptic seizures and patients with neurological disease causing Limb Weakness and epilepsy in two separate case control studies. Results Patients with FW (n=107), NES (= 40), Epilepsy (n=34) and neurological disease causing Limb Weakness (NDLW) (n=46) were included in the analysis. Both FW and NES patients reported a low level of personal control, understanding of their symptoms and a tendency to reject a psychological causation of their symptoms. However NES patients rejected psychological causes less strongly than FW patients ( P P Conclusion Although patients with NES tended, as a group, to reject psychological factors as relevant to their symptoms, they did so less strongly than patients with functional Limb Weakness in these cohorts. This has implications for both the way in which these symptoms are grouped together but also the way in which treatment is approached.