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LETTERS: James Paul Pandarakalam Misdiagnosis of conversion symptoms: Conversion disorders still exist BMJ 2005; 331: 1145-c [Full text]

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How to look for Hoover's Sign

Elizabeth H Hare   (27 November 2005)

More on Hoover’s paresis test

Akheel A Syed   (28 November 2005)

How to look for Hoover's Sign 27 November 2005
Elizabeth H Hare, Consultant Psychiatrist Royal Edinburgh Hospital EH10 5HF Send response to journal: Re: How to look for Hoover's Sign	I agree with Dr Pandarakalam that Hoover's sign can be useful in differentiating hysterical from true hemiplegia. However, his description of how to ellicit the sign didn't sound quite correct to me. Using a Google search I find the Journal of Neurology, Neurosurgery and Psychiatry (Article here) suggests the hand is placed under the unaffected leg; in organic paresis pressure is felt. Reference: Pearce, J M S. A note on Hoover's sign. J Neurol Neurosurg Psychiatry 2003;74:432 Competing interests: None declared
More on Hoover’s paresis test 28 November 2005
Akheel A Syed, Specialist Registrar Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP Send response to journal: Re: More on Hoover’s paresis test	Although I have had the occasional opportunity to elicit Hoover’s sign in patients with suspected non-organic lower limb weakness, I had never fully understood the principle of this simple test (1). It relies on Sherrington’s crossed extensor reflex: extension of one hip causes flexion at the contralateral hip; this enables normal walking, and is retained even in decorticate animals. The test can be performed in two ways: 1. Hip extension – In the first step, the examiner places his hand under the patient’s ankle on the affected side and asks the patient to press down, to test voluntary hip extension. In the second step, the examiner asks the patient to raise the contralateral (unaffected) leg, to test involuntary extension on the affected side. In patients with non- organic weakness voluntary extension is weak but Sherrington’s reflex ensures normal involuntary extension. 2. Hip flexion – In a reversal of the extension test, the examiner places his hand under the patient’s ankle on the unaffected side and asks the patient to flex the hip on the affected side. Lack of effort in non- organic weakness results in poor downward pressure in the good leg. A variation of Hoover’s test involves testing involuntary hip flexion on the affected side wherein the patient, in the prone position, is asked to extend the hip on the unaffected side. Hoover’s test has also been described in the upper limbs: flexion against resistance of an out- stretched arm results in involuntary extension in the contralateral arm. References (1) Stone J, Zeman A, Sharpe M. Functional weakness and sensory disturbance. J Neurol Neurosurg Psychiatry 2002 73: 241-245 Competing interests: None declared