Hoover's sign for the diagnosis of functional weakness: A prospective unblinded cohort study in patients with suspected stroke
Introduction
In 1908 Charles Hoover described a physical sign of functional (i.e. psychogenic) weakness of the lower extremities [1]. Hoover's sign is commonly used as a test for the diagnosis of functional weakness. However, no studies have tested the diagnostic performance of this sign in unselected patients with neurological symptoms.[2], [3], [4]. In the next revision of DSM, reference to positive physical signs of functional weakness may be incorporated within the criteria for conversion disorder itself [5]. Data on the specificity and sensitivity of Hoover's sign are therefore important.
In this study, we aimed to determine the sensitivity and specificity of Hoover's sign for the presence of functional weakness in patients who presented with suspected stroke and leg weakness.
Section snippets
Method
We recruited patients presenting to the emergency department of the Western General Hospital, Edinburgh, UK, in whom a nurse or doctor suspected stroke, into a study examining clinical and biochemical diagnostic methods in acute stroke [6]. The study was approved by a research ethics committee and written informed consent obtained from participants. A senior neurology trainee (WW) took a history from each patient, performed a physical examination, and recorded results using a standard research
Results
Hoover's sign was tested in 337 consecutive patients with suspected stroke between July 2007 and February 2009 of whom 124 had leg weakness (Table 1, Fig. 1). 11/337 (3%) of the patients had a diagnosis of a functional disorder and 239/337 (71%) had a diagnosis of stroke. 87/337 (26%) had other non-stroke diagnoses: migraine (14), seizure (11), sepsis (11), peripheral nerve disorder (8), syncope (7), vestibulopathy (6), metabolic disorders (5), musculoskeletal disorders (3), brain tumour (3),
Discussion
In our cohort of patients with suspected stroke, Hoover's sign was a very specific and moderately sensitive test for the diagnosis of a functional disorder in patients with unilateral leg weakness. Functional/ psychogenic weakness accounts for around 10% of 'stroke mimics' in studies of suspected stroke/transient ischaemic attack [8] and 20% among patients without ischaemic stroke who were treated with intravenous thrombolysis [9].
Our study has a number of limitations. The examining neurologist
Acknowledgments
This study was funded by the Chief Scientist's Office of the Scottish Government. Dr. Whiteley was supported the Chief Scientist's Office (CAF/06/30) and is now funded by a Clinician Scientist Fellowship from the UK Medical Research Council (G0902303).
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