GLOSSARY OF MEDICAL TESTS AND SIGNS

Abdominal Reflex: The quadrants of the abdomen are stroked towards the midline above, parallel to and below the umbilicus. In corticospinal tract lesions, the reflex contraction of the abdominal muscles is lost on the side ipsilateral (same side) as the lesion.

Achilles Reflex: (SEE Ankle Jerk Reflex)

Allochiria Tests: Errors in identifying left from right assist in locating lesions near the angular gyrus.

Ankle Jerk Reflex: The Achilles tendon is struck by the examiner to test the reflex reactions related to L5-S1.

Anosognosia Tests: In cases of non-dominant side, frontal and parietal lobe lesions, the patient denies his paralysis of an affected side or limb.

Auditory Reflex: Momentary closure of both eyes upon a sudden sound.

Autopagnosia Tests: The patient is asked to hold up, point to and identify body parts such as fingers, arms, etc. Lesions of the parietal lobe causing autopagnosia, may prompt the patient to fail in the identification of his body parts or even identify the examiners hand as his own.

Babinski Toe Sign: (SEE Plantar Reflex)

Baresthesia Tests: In testing for parietal lobe lesions, the patient holds, with eyes closed, two weights that are unequal by one to two grams. Normals can generally discriminate between the weights. Sensation of weight may be lost in the contralateral limb. (SEE also Stereognosis)

Beevor's Sign: (SEE also the Hoover Test and Thigh Adduction Test). In functional paralysis, inability to inhibit the antagonist muscles.

Biceps Reflex: The tendon of the biceps is tapped. Normally there is a contraction of the bicep muscles accompanied by a jerk of the forearm. In corticospinal tract lesions, the reflex is excessive. In lesions of the peripheral reflex arc or damage to the C5-C6 segments of the cord on the side being tested, there is a depressed or absent response.

Brachioradialis Reflex: This wrist reflex test is conducted to determine lesions at C5-C6 segments of the cord on the side being tested, there is a depressed or absent response.

Brudzinski's Sign: When the neck is flexed, flexion of the knees also occurs (present in meningeal irritation). (SEE also Kernig's Sign)

Brain Mapping: (SEE EEG)

Chewing Reflex: When a tongue depressor is placed in the mouth, the patient chews or clenches his teeth on the depressor. Reflex chewing is seen in diffuse bilateral lesions of the frontotemporal cortex and is frequently seen in cases of dementia, incomplete paralysis (generalized paresis) and brain injury related to a lack of oxygen.

Coombs' Test: For the detection of red cell antibodies.

Cortical Sensation Tests: (SEE Graphism)

Cremasteric Reflex (Males): A pin is used to stroke the inside of the thighs. In normal individuals, the testis will rise on the same side. The reflex is lost with males with damage to the corticospinal tract at or above L1-L2.

Deep Reflex: A sharp tap on a tendon or muscle produces a brief stretch of the muscle.

EEG and QEEG: (Quantitative Electroencephalograph)

Electroencephalography is a method of graphically recording the electrical activity of the brain, particularly the cerebral cortex.

EEG brain mapping is a term commonly used for several quantitative (computerized) EEG techniques. These include (a) EEG frequency analysis, (b) topographic display, (c) statistical comparisons to a normative database and (d) other similar computer-based calculations based on EEG or evoked potentials. EEG brain mapping can help highlight or identify regional features of the EEG. Occasionally this will identify subtle features that escaped identification by traditional visual inspection of the polygraph EEG alone. EEG brain mapping can also help in communication of EEG features and their localization, especially for communication to persons who are not expert in EEG. Quantification of EEG features can help in the assessment of whether some features are present to an abnormal degree. Computer based EEG processing can also calculate abstract features that cannot be visualized.

However, despite these potential advantages, the clinical application of the EEG brain mapping is still very limited. Most scientific reports on these techniques have demonstrated research applications rather than clinical usefulness. Among those clinical reports, few have been prospectively verified or reproduced. Techniques used in EEG brain mapping vary substantially among laboratories, and any clinical usefulness found with one specific technique may not apply when using a different technique. A substantial number of technical and clinical problems interfere with many simple applications. These problems can easily mislead interpretation, sometimes in subtle ways. Traditional EEG artifacts can appear in unusual and surprising ways, and new artifacts can be caused by data processing and computer processing algorithms. For example, epileptic spikes are generally overlooked or considered artifactual. Also, transient slowing can be missed or washed out. The computer may consider as "abnormal" some of the unusual EEG activity known to have clinical importance such as psychomotor variant, alpha harmonics and other normal variations. Automated assessment of normality would have to take into account the subjects age, state of alertness, medication and other facts; but ways to do this are still not defined, especially when the patient is on a central nervous system active medication. Substantial unresolved statistical issues are critical in automated assessment of normality.

Little has been published on how these various tests could impact the diagnosis or treatment of individual patients. Cerebrovascular disease is one area in which these tests may fill occasional specific needs. Several quantified EEG parameters are highly correlated with regional cerebral bloodflow. Sensitivity is high for detection of ischemia-related cerebral impairment and false positive rates are low. These tests can be quite abnormal even when the CT scan is still normal, such as in the first 2-3 days after a CVA (cerebrovascular accident) or when the degree of ischemia is mild enough to cause dysfunction without infarction. However, localization ability is very inferior to that found with CT or MRI. EEG changes are unable to differentiate infarction from hemorrhage, tumor or other focal cerebral lesions.

EEG brain mapping cannot diagnose epilepsy. Some computer techniques can help to differentiate primary generalized discharges from secondary bilateral synchrony, or can help determine the location of a focus.

In dementia evaluations, the findings of an EEG abnormality can suggest an organic basis rather than depression. However, the tests cannot yet reliably distinguish between types of dementia. Most EEG changes of early dementia are seen well on routine EEG testing, and the extra yield for EEG brain mapping is small.

On the basis of the present medical literature, the sensitivity and specificity fail to completely substantiate a role for these tests in the clinical diagnostic evaluation of individual patients for possible tumors, multiple sclerosis, minor head injury, dyslexia, attention deficit disorder, schizophrenia, depression, alcoholism or drug abuse. Some research studies have shown small, reproducible differences between groups of such patients and groups of normal subjects, but the group findings are not directly relevant for diagnosis of an individual patient are situation. If EEG brain mapping is done in any of those settings and an abnormality is found, the abnormality may suggest an organic impairment but it is non-specific for the cause or type of pathology and does not necessarily correspond to any patient symptom. Careful clinical correlation is required for interpretation for any such abnormality.

Any clinical use of EEG brain mapping must be a direct extension of routine EEG testing. The actual EEG polygraph waveforms must be preserved on paper or on magnetic or optical storage medium. These EEG tracings should be interpreted thoroughly before interpretation of the computer based analysis. The technical quality of these EEG readings must be satisfactory for purposes of clinical interpretation, according to the accepted guidelines. At present, there is no clinical application for computer based clinical EEG analysis separate from analysis of the polygraph EEG. In order for these tests to be useful in clinical settings, they should be interpreted only by physicians with satisfactory skills, knowledge and abilities in routine EEG and well as additional knowledge and experience with the relevant additional technical problems, artifacts, normal variants, and statistical issues encountered in EEG brain mapping.

Fabere's Sign: (SEE Patrick's Test)Finger Jerk Reflex: The fingers are flexed and tapped in the direction of extension. In cases of corticospinal tract damage between C7-C8-T1, there may be an excessive contraction of the fingers.

Graphism Tests: As in Stereognism and Baresthesia, parietal lobe dysfunction is detected in tests of graphism. Two point discrimination and numbers written on the skin assist in the detection of parietal brain lesions.

Grasp Reflex / (Palmer Reflex): The palm is stroked. If the patient grasps the examiner's finger and frequently is unable to release the examiner's finger, the test is termed positive. This reflex disappears in the infant by the age of nine months, but is seen in the adult with frontal lobe injury, anoxic and severe toxic states.

Glabella Reflex: The forehead is tapped lightly between the eyes. If the patient responds with persistent spasm of the eye muscles and closing of the eyes, the Glabella is positive. This may indicate damage to the connections between the frontal cortex and the facial nerve complex in the pons. The reflex is seen in Parkinson's disease, frontal lobe tumors and frequently appears with dementia.

Hoover Test: Similar to the thigh adduction test, the examiner differentiates true organic paralysis from hysterical, factitious or malingered paralysis by instructing the plaintiff to move "the good leg" while monitoring the involuntary movement of the "paralyzed" leg.

Jaw Jerk Reflex: The mandible is tapped with a rubber hammer when the jaw is half open. If there is brain injury to the motor portion of the fifth cranial nerve, the jaw jerks closed. When the jaw jerk reflex is increased on the opposite side, a unilateral frontal lobe lesion may be suspected.

Kernig's Sign: In meningeal irritation, leg straightening is limited when the hips are flexed. (SEE also Brudzinski's Sign) Note: In cases of a herniated lumbosacral disk, straight leg raising with flexion of the hip may be limited on the affected side.

Knee Jerk Reflex: This test is conducted by striking the Patellar tendons of the knee for reflex indications of a lesion in the L2, L3-L4 segments.

Laseque's Sign: A limitation of straight leg raising usually associated with lumbar nerve root compression. Also, in sciatica, flexion of the hip is painful with the knee extended but painless when the knee is flexed.

MMPI: The Minnesota Multiphasic Personality Inventory, a global test of personality used by the defense to detect pre-existing personality disorders and the "fake-bad" F-K scale pattern. Also contains an addiction scale and other scales to detect the manipulation of answers. The MMPI-2 is currently being used.

Orientation in Space Tests: Holding objects in space and describing how to get from one point to another (the doctors office to home), are orientation in space tests used to locate dominant hemisphere parieto-occipital lesions.

Palmer Reflex: (SEE Grasp Reflex)

Patellar Reflex: (SEE Knee Jerk Reflex)

Patrick's Test: With the patient supine, the thigh and knee are flexed. The external malleolus rests on the patella of the opposite leg and the knee is depressed. Production of pain indicates arthritis of the hip. Also called the Fabere sign after the initial letters for Flexion, ABduction, External Rotation and Extension.

Pectoral Reflex: The anterior, (frontal) fold of the axilla, (armpit) that contains the pectoral muscle is tapped with a reflex hammer. In cortical spinal lesions above C5, there is a brisk and sometimes excessive contraction.

PET Scan: Advances in the fields of computerized tomography and in the production and detection of short lived radioactive isotopes has enabled the construction of scanners which monitor the course of radioactive labeled biological molecules. A variety of tracers can be administered which provide detailed images of cerebral functions such as metabolism, blood flow, and receptor distribution. The normal brain may be examined at rest as well as following activation can be observed. A variety of different pathological states have also been examined.

Plantar Reflex (Babinski's Toe Sign): Dorsiflexion of the big toe on stimulation of the plantar surface (sole), occurring in lesions of the pyramidal tract (nerve fibers arising in the brain and passing down through the spinal cord).

Pupillary Reflex: Contraction of the pupil after application of light, loud noise or other stimulus.

Righting Reflex: The assumption of an optimal body position after the patient has been moved from it.

Rinne Test: In a normal individual, air conduction of sound is greater than bone conduction. When there is an injury or disease that reduces the level of air conduction and bone conduction is greater than air conduction the Rinne test is said to be negative. When both air and bone conduction are diminished through disease or injury to the auditory apparatus or the auditory division of the eighth cranial nerve, or when there is no diminished hearing, the test is termed positive.

Romberg's Sign: Swaying of the body or falling when the eyes are closed with the feet placed close together.

Shilling Test: For vitamin B12 in the diagnosis of pernicious anemia. In injury cases, pernicious anemia is a variable that may be a non-proximate cause of degeneration of the brain and spinal cord.

Snout Reflex: Similar to the Glabella, the patient is tapped lightly on the nose. Excessive grimace of the face is a positive sign and may be due to a brainstem (Corticopontine), lesion.

SPECT or SPET Scan: Functional brain imaging with single photon emission tomography (SPET), also known as single photon emission computed tomography (SPECT), enables three-dimensional images of regional cerebral blood flow (rCBF) to be derived from two-dimensional data. Positron emission tomography (SEE PET) can be used to measure regional cerebral metabolism and neurotransmitter receptor characteristics in addition to rCBF. It sets the standards for spatial resolution by which SPET is judged. However, PET requires sophisticated and expensive technology, including a cyclotron on site, and has less of a prospect of general clinical application. In contrast, SPET is relatively inexpensive and is widely available for clinical use. The radiotracers used in SPET emit a single gamma ray (or photon), as opposed to dual simultaneous gamma rays of PET radiotracers, hence the term 'single photon' in SPET. There have now been a number of SPET studies investigating changes in rCBF in dementia.

The use of the SPECT scan in claims: In addition to the effects of normal aging, functional imaging studies in dementia have three further problems: (1) the normal variation in measures of cerebral blood flow or metabolism; (2) uncertainty of diagnosis of type of dementia, e.g. Alzheimer's disease (AD) or multi-infarct dementia (MID) - AD accounts for over 50% of cases, but can only be diagnosed definitively by cerebral autopsy; (3) the presence of cerebral atrophy. Brain atrophy occurs with aging in normal individuals and is greater in severity in patients with dementia than age-matched controls. However, some demented individuals have little atrophy while some normals show considerable atrophy. Consequently areas of apparently reduced rCBF in patients with dementia may be due to reduced flow to a normal volume of brain, normal flow to a reduced volume of brain, or reduced flow to a reduced volume of brain.

Stereognosis Tests: To examine for parietal lobe lesions, objects are placed in the patients hands and they are asked to identify them. Inability to identify shapes or discriminate between objects may indicate a (contralateral) parietal lobe lesion.

Suckling Reflex: The patient's lip is stroked. If this produces a pout or sucking movements, the reflex is positive and is an indication of diffuse frontal lobe injury. Although this reflex is normal in the infant until weaning, the adult should have no suckling response. A Positive Suckling Reflex frequently accompanies dementia (the loss of acquired intelligence from disease, trauma or anoxia).

Supratentorial: Literally refers to an area of the brain but is used in medical records to indicate that the plaintiff's symptoms and complaints are functional and not organic.

Tendon Reflex: Contraction of the muscle caused by percussion of its tendon.

Thigh Adduction Test (paralysis of one leg): (SEE the Hoover Test)

Tinnel's Sign: A tingling sensation in the distal end of a limb when percussion is made over the site of a divided nerve. Indicates a partial lesion.

Triceps Reflex: Testing for lesions at the C6-C7 level, the patient flexes his arms or places them on his hips. The short tendon above the elbow is tapped for a reflex response in the triceps muscle.

VDRL Test: For syphilis.

Vital Signs: Pulse, respiration and temperature.

Weber Test: A vibrating tuning fork is placed in the center of the patient's forehead. If the patient reports that the sound originates in the midline of the forehead, there is no impairment in air conduction. When the sound is referred to the involved or damaged side, the Weber test is positive. When there is disease of the cochlea or nerve deafness, the sound is lateralized to the opposite side, the test is said to be negative.