FUNCTIONAL-MD

BLEPHAROSPASM

Normal blink rate, when eyes open

Active forceful eye closure doesn't cause spasm

Tonic spasm

Resolves while speaking or moving tongue

HEMIFACIAL SPASM

Lower face at onset

Associated with pain

Lack of other Babinski sign

Forceful or longer spasms

Lower and upper face non-synchronised movements

Switching sides

Ipsilateral sensory symptoms or signs

Both sides involved

ORO-MANDIBULAR DYSTONIA

Unilateral downward or lateral jaw movement

TONGUE

Tonic tongue protrusion

Normal speech

Deep breathing normalized the movements

SPEECH

Whispering speech

Diplophonia

High pitch falsetto

Globus sensation

Speech with effortful facial or lip or neck movements

Normal phonation

Normal singing

CERVICAL

Varying semiology, may change when doing certain tasks

Fixed neck posture

Unusual, erratic and high amplitude associated tremor

Active range of movement not possible during examination but spontaneous normal head movement possible at other times

Resolution of posture while writing or performing tasks requiring concentration

Absence of typical sensory tricks

UPPER LIMB

Typical semiology of fisting posture and wrist flexion, elbow flexion or flexion of fingers at MCP or IP joints

Ring or Little fingers commonly affected. Thumb least affected

Posture resolves with contralateral Luria sequencing

Normal spontaneous movements in an affected limb (putting on glasses, swing while walking)

Pain in the affected limb

Involuntary jerks while testing range of movements

Effortful slow movement on affected side

LOWER LIMB

Typical semiology of plantar flexion and inversion with toe curling

Functional striatal toe

Persistence of abnormal posture when walking backward

Dragging leg behind and static abnormal posture throughout the gait cycle

The appearance of weakness on movement away from the dystonic direction

Paradoxical improvement with stress gait or walking in tandem

Excessive signs of effort in contrast to observed severity of gait disorder – the “huffing and puffing” sign

Sensory symptoms particularly anesthesia of the foot

Straightening out a posture or passively moving into a different posture can cause this to become a new resting fixed posture

LIMB GENERAL

Fixed dystonia early in the course (May be seen with CPRS)

Pain on attempted movement of the affected limb

Active resistance against the passive movement

Tremor or clonus-like movement when evaluating a range of motion or reflex testing of the limb.

Straightening out a posture or passively moving into a different posture can cause this to become a new resting fixed posture.

Sensory symptoms, particularly anesthesia of the affected limb

Ponderous and deliberate, slowed movements on the affected side can appear very effortful.

TRUNK/ GAIT

Inappropriate difficulties standing from sitting in comparison to gait

Fixed posturing when walking, either extension or flexion at the waist

Posture resolves when adjusting clothing or when doing a repetitive task (clicking fingers, tapping)

Associated knee bending or unusual dromedary gait in an adult patient

Posture does not improve when resting against a wall.

Episodic knee buckling

Unusual relieving maneuvers (e.g. standing on one leg)

Early use of crutches or other walking aid despite objective stability

Associated prominent back pain

Associated functional gait features (astasia abasia, unusual Romberg, unusual retropulsion pull testing), with apparently preserved balance when walking

Improves with backward walking or running

Tandem walk: excessive sway with no falls, stuck on first step

Romberg: Increased sway after few seconds with no fall

Frucht et al. Front Neurol 2020