What is the term for and how to document suspected non-organic (non-neurological) weakness on a neurological exam when testing for strength?

Documenting Non-Organic Weakness in Neurological Examination

The term for suspected non-organic or non-neurological weakness on neurological examination is "give-way weakness" or "Hoover's sign" when specifically testing leg strength.

Recognizing Non-Organic Weakness

When testing for strength during a neurological examination, several specific signs can help identify non-organic weakness:

Key Physical Examination Findings

1. Give-way weakness:

   • Patient initially provides resistance but then suddenly "gives way" without a smooth gradation of weakness
   • Characterized by sudden collapse of resistance during muscle strength testing
   • Often varies with repeated testing or distraction

2. Hoover's sign (specific for lower extremity):

   • Have the patient supine
   • Place your hand under the heel of the "weak" leg
   • Ask the patient to push down with the opposite (normal) leg against resistance
   • In organic weakness: You'll feel downward pressure from the "weak" heel (involuntary contraction)
   • In non-organic weakness: No downward pressure will be felt from the "weak" heel

3. Inconsistency patterns:

   • Strength varies significantly between similar muscle groups
   • Strength improves with distraction
   • Performance on formal testing doesn't match observed functional abilities

Documentation Approach

When documenting suspected non-organic weakness, use objective language that describes the specific findings without making accusations:

Sample Documentation Template

Motor examination: Patient demonstrates inconsistent effort during strength testing with give-way weakness in [specific muscle groups]. Hoover's sign is positive on the [left/right] side. Observed functional abilities (e.g., transferring, walking, manipulating objects) are inconsistent with strength demonstrated during formal testing. No muscle atrophy, fasciculations, or other signs of lower motor neuron disease observed.

Additional Testing Considerations

1. Distraction techniques:

   • Test strength while the patient is focused on another task
   • Compare strength during formal testing versus observed functional activities

2. Complementary tests:

   • Look for other signs of non-organic neurological findings (e.g., non-anatomic sensory loss, inconsistent reflexes)
   • Document normal muscle bulk and absence of atrophy or fasciculations

3. Comprehensive assessment:

   • Document both positive findings (what you see) and negative findings (absence of expected neurological signs)
   • Compare with other elements of the neurological exam (reflexes, coordination, etc.)

Common Pitfalls to Avoid

• Avoid accusatory language in documentation (e.g., "malingering," "faking")
• Don't dismiss symptoms entirely - patients with non-organic weakness may have underlying psychological distress
• Remember that some neurological conditions can present with unusual patterns of weakness
• Be aware that patients with organic disease may also have a functional overlay

Next Steps After Identifying Non-Organic Weakness

• Consider referral to neurology for confirmation if you're not a neurologist
• Consider psychological assessment for potential underlying conditions
• Document objectively and thoroughly to support appropriate management
• Maintain therapeutic relationship by focusing on functional improvement rather than symptom validity

By using these specific examination techniques and documentation approaches, clinicians can appropriately identify and document non-organic weakness while maintaining professionalism and supporting appropriate patient care.