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Subtle Motor Signs in Children With Chronic Traumatic Brain Injury

Crasta, Jewel E. PhD; Sibel, Jamie MD; Slomine, Beth S. PhD; Mahone, E. Mark PhD; Mostofsky, Stewart H. MD; Suskauer, Stacy J. MD

American Journal of Physical Medicine & Rehabilitation: September 2019 - Volume 98 - Issue 9 - p 737–744
doi: 10.1097/PHM.0000000000001110
Original Research Articles: CME Article . 2019 Series . Number 9

Objective The aim of the study was to characterize subtle motor signs in children with moderate-severe traumatic brain injury in the chronic phase of injury.

Design Fourteen children with moderate (n = 6) or severe (n = 8) traumatic brain injury, ages 11–18 yrs, who had sustained their injury at least 1-yr before study participation (range 1–14 yrs since injury), and 14 matched typically developing controls were examined using the Physical and Neurological Examination of Subtle Signs (PANESS). To examine the neural correlates of subtle motor signs, measures of total cerebral volume and motor/premotor volume were derived from magnetic resonance imaging.

Results Children with traumatic brain injury had significantly poorer PANESS performance than controls on the total timed subscore, proximal overflow, and the PANESS total score. Participants with severe traumatic brain injury had greater proximal overflow than those with moderate injury, after controlling for age at injury. Across all participants, greater proximal overflow correlated with reduced total cerebral volume, whereas within the traumatic brain injury group, reduced motor/premotor volume correlated with lower PANESS total score.

Conclusions The study highlights the importance of examining subtle motor signs including overflow during clinical evaluation of chronic pediatric traumatic brain injury and establishes the clinical utility of the PANESS as a measure sensitive to chronic subtle motor signs in this population.

To Claim CME Credits Complete the self-assessment activity and evaluation online at

CME Objectives Upon completion of this article, the reader should be able to: (1) Define subtle motor signs including motor overflow; (2) Identify subtle motor signs such as motor overflow during clinical evaluation of children with brain injury; and (3) Explain the relevance of examining subtle motor signs in chronic pediatric brain injury during clinical evaluations.

Level Advanced.

Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

From the Kennedy Krieger Institute, Baltimore, Maryland (JEC, JS, BSS, EMM, SHM, SJS); Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland (JEC, BSS, SJS); Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland (SHM); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland (SJS); and Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland (BSS, EMM).

All correspondence should be addressed to: Stacy J. Suskauer, MD, Kennedy Krieger Institute, 716 N Broadway, Baltimore, MD 21205.

This study was supported by the National Institutes of Health (S.S.: K23HD06161, UL1TR001079-04, K12 HD001097, and R01HD090266). Rehabilitation Research Experience for Medical Students (RREMS) program and Craig H. Neilson Foundation (J.S.).

This study was completed while Dr. Sibel was at Kennedy Krieger Institute; she is currently at MedStar Baltimore Hospitals.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

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Online date: 14 12, 2018

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