Can You Identify Subtle Motor Deficits?

Can You Identify Subtle Motor Deficits?

Anyone who has gone through medical training has thought s/he has had at least one of the diseases studied. You learn the signs and symptoms and suddenly you realize you have some or all of them. In most cases, it is a “false alarm” but do you know how to identify subtle motor deficits that could be an indication of a brain tumor?

A study by Maranhao, Maranhao-Filho, Lima, and Vincent (2010) studied 13 tests for their ability to detect subtle motor deficits to identify possible unilateral/monohemispheric brain tumors. The results of this study were very interested and provide simple tests with respectable metrics for simple screening of a potentially serious concern.

The 13 tests are as follows:

The study was performed in Rio de Janeiro, Brazil. Sixty people with mono-hemispheric cerebral tumors were identified. The control group was 30 people with complaints of vertigo, migraines, or seizures but no tumors. The tests were administered by a physical therapist who was blinded to clinical and imaging data. The descriptions for the performance of the clinical tests were as follows:

Clinical Test	Description of Performance
Spasticity of Conjugate Gaze	Clinician pulls patient eyelid & patient is instructed to exert a small amount of resistance
Platysma Sign	Patient asked to retract lower jaw & stretch the neck skin
Forearm Rolling Test	Patient makes a fist with each hand, holds forearms horizontal in front of the body, & rolls the arms
Finger Rolling Test	Patient extends index fingers pointing towards each other (~1 finger length apart) & rolls fingers around each other
Digit Quinti Sign	Patient flexes shoulders to 90°, elbows extended, palms down, abduct fingers
Souques Interosseous Sign	Patient raises both arms to 180° of shoulder flexion
Pronator Drifting Test	Patient flexes shoulders to 90°, elbows & wrists extended, palms up
Mayer Sign	Clinician forcefully flexes patient’s 3^rd, 4^th, 5^th MCP joints.
Finger Tapping Sign	Patient taps index finger to distal IP of thumb quickly for 10 seconds
Digit Quinti Rolling Sign	Patient extends 5^th digits pointing towards each other while other fingers are flexed. 5^th digits roll around each other
Foot Tapping Test	Patient sits with knee & ankle flexed to 90° & heel on the floor. Patient taps the foot for 10 seconds
Babinski Sign	Clinician sweeps lateral border of plantar surface of the foot (heel to digits 4 & 5) with a blunt object
Chaddock Sign	Clinician stimulates the dorsolateral aspect of the foot (just inferior & anterior to the lateral malleolus) along the lateral edge of the foot

The chart below describes the criteria of a positive test and the associated sensitivity (screening metric), specificity (diagnostic metric), and positive/negative predictive values (PV).

Clinical Test	Criteria for a Positive Test	Sensitivity	Specificity	(+) PV	(-) PV
Spasticity of Conjugate Gaze	Eyes deviated to the opposite side of lesion	0.01	1	1	1
Platysma Sign	Platysma muscle asymmetry	0.01	1	1	1
Forearm Rolling Test	1 arm orbits around the other	0.16	1	1	0.37
Finger Rolling Test	1 finger orbits around the other	0.41	0.93	0.92	0.44
Digit Quinti Sign	5^th digit adducts on involved side	0.51	0.70	0.77	0.42
Souques Interosseous Sign	Involved fingers extend and abduct	0.23	0.80	0.70	0.34
Pronator Drifting Test	Inability to maintain position for 20-30 seconds. Pronation or downward drift of arm	0.41	0.96	0.96	0.45
Mayer Sign	Lack of thumb opposition combined with MCP flexion & IP extension	0.06	0.86	0.50	0.31
Finger Tapping Sign	.5 repetition difference between hands	0.18	0.90	0.78	0.35
Digit Quinti Rolling Sign	Involved finger orbits less around the other	0.06	0.95	0.66	0.42
Foot Tapping Test	>5 repetition difference between feet	0.23	0.93	0.87	0.37
Babinski Sign	Extension of great toe	0.08	1	1	0.35
Chaddock Sign	Extension of great toe & foot flares	0.03	1	1	0.34

Maranhao et al (2010) sought to identify the most useful tests for detection of brain tumors. Despite positive results for the Spasticity of Conjugate Gaze, Platysma Sign, Babinski Sign, Chaddock Sign, and Mayer Sign, they all are indicative of pyramidal tract dysfunction and had low indices for monohemispheric brain tumors. The Digit Quinti Sign, Pronator Drifting Test, and Finger Rolling Test was deemed the most sensitive tests. While the Digit Quinti Sign, Pronator Drifting Test, and Finger Rolling Test had the greatest specificity. These data are consistent with the research of Alter (1973), Sawyer et al (1993), Anderson et al (2005), and Yamamoto (1995). Clinicians should be aware of these tests to provide simple methods to detect subtle motor deficits that may warrant neuroimaging.

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