Neurological examination one pdf - عملي

Neurological examination

Objectives

☤Understand neurological examination
☤Perform a neurological examination

☤Higher function
☤Cranial nerves
☤Motor system
☤Sensory system

☤Interpret neurological examination

Neuroanatomy – parts of

nervous system

Cerebrum

Cerebellum

Medulla oblongata

Pons

Midbrain

IVth Ventricle

Corpus callosum

Neuroanatomy – parts of

nervous system

Lateral ventricles

Pyramidal tract

Caudate

Putamen

Globus
pallidus

IIIrd ventricle

Thalamus

Substantia
nigra

Neuroanatomy - lobes

Neuroanatomy – blood supply

Neuroanatomy – parts of

nervous system

☤Don’t forget

☤Spinal cord
☤Peripheral nerves
☤Autonomic nerves

☤Aim of neurological examination is to locate

the lesion

☤Aim of neurological history is to determine

lesion type

☤Don’t rely on CT or MRI – you need to

know what part to scan!

General inspection

Neurological examination is part

of a full patient assessment

Things to look for

☤Observations
☤Neck stiffness, Kernig sign
☤Skin e.g. café-au-lait spots
☤Anal sensation and tone

☤With spinal problems especially e.g. cauda equina

☤General examination e.g.

☤Cyanosis (impaired consciousness)
☤Lymphadenopathy (malignancy, infection)
☤Murmurs, carotid bruit or AF (source of emboli)
☤Teeth, ears (source of infection)
☤Breasts, abdomen (malignancy)

Higher mental function -

cognition

Higher mental function -

cognition

☤Language: dysphasia,

dyslexia, dysgraphia

☤Verbal, reading and

writing

☤Gnosis “knowing

things”: agnosia

☤Geography, objects,

people

☤Praxis “doing things”:

dyspraxia

☤Dress, draw, write

☤Number skills:

dyscalculia

☤Memory: amnesia

☤Immediate, recent,

remote

☤visual, verbal
☤retrograde,

anterograde

☤Reasoning
☤Emotion
☤Personality

Testing higher mental function

☤Mini-mental state examination

(MMSE)

☤30 point score
☤Assesses multiple aspects of

cognition

☤Visit

website to see MMSE

☤Abbreviated mental test score

☤10 point easy bedside test

Abbreviated mental test score

1.  Age
2.  Time to nearest hour
3.  An address to be repeated at the end of the test
4.  Where are you now? (name of hospital etc)
5.  Year
6.  Recognition of 2 people e.g. doctor, nurse
7.  Date of birth
8.  Year second world war began
9.  Name of present monarch
10. Count backwards from 20 to 1
☤

Remember to test recall of address

Unable to

instruction

Speech

Fluent but

disorganised

Receptive

Wernicke

Unable to

repeat

Conductive

Arcuate fasciculus

Non-fluent

speech

Expressive

Broca

Unable to

name items

Nominal

Angular gyrus

Dysphasia

Slow

slurred

explosive

Cerebellar

Flaccid

Nasal

Bulbar

Spastic

"Donald Duck"

Pseudobulbar

Soft

monotone

Extrapyramidal

Articulation

Dysarthria

Hoarse voice

Bovine cough

Phonation

Dysphonia

Components

of speech disorder

Speech and

language

Test speech and language

☤ Listen to history

☤ Expression, reception and phonation

☤ Ask “take this paper with your right hand, fold in half and

place on the floor

☤ Reception

☤ Repeat “No ifs, ands or buts”

☤ Nonsense phrase to assess repetition

☤ Repeat “British constitution,” “Baby hippopotamus”

☤ Articulation

☤ Name the strap of a watch, or nib of a pen

☤ Nominal dysphasia

☤ Language disorders usually co-exist “Global”

Cognition summary

☤ 10 point MTS

☤ Age
☤ Time
☤ Address
☤ Place
☤ Year
☤ 2 people
☤ DoB
☤ WWII
☤ Monarch
☤ 20 to 1
☤ Recall

☤Speech and

language

☤Expression
☤Reception
☤Repetition
☤Articulation

Cranial nerves

Numbered for convenience…

…and named for what they do

(mostly)

(olfactory) nerve

Nuclei

None – terminates in cortex

Comes from Inferior frontal and temporal lobes

Goes
through

Cribriform plate

Supplies

Sense of smell

Tested by

Test smell in each nostril
separately e.g. coffee

(olfactory) nerve

☤Test smell in each

nostril with eyes closed.

☤Coffee
☤Vanilla
☤Perfumed soap
☤Avoid ammonia –

activates sensory nerves

Anosmia — Head injury, tumour, nasal

congestion.

Examination of Vision

☤

Optic (II) nerve – sensory

inputs from retina

☤

Oculomotor –III }

☤

Trochlear – IV } Motor

☤

Abducens – VI }

(optic) nerve

Nuclei

Lateral geniculate nucleus in
thalamus (vision), superior
colliculus (reflexes)

Comes from

Thalamus

Goes through Optic chiasm to optic foramen

Supplies

Vision from retina

Tested by

AFRO – acuity, fields, reflexes,
ophthalmoscopy

(optic) nerve

☤Visual Acuity

☤Snellen chart

Wear specs or correct with pinhole

☤Finger counting
☤Light-dark

Snellen visual acuity

Need good lighting

Patient is kept 6 metres (20ft) from the chart

Read as 6/5, 6/6, 6/10, 6/60

Test one eye at a time

☤Fields to confrontation

☤Test one eye at a time
☤Use red pin from each direction
☤Gross defect only

☤Central vision/blind spot – with red pin

faded colour with lesions with macula

Optic pathways and

defects

Optic nerve problems

Bitemporal hemianopia

Homonymous quadrantanopia

Cranial nerve nuclei

☤Different nuclei for different functions
☤One nerve can have more than one

nucleus

☤One nucleus can have more than one

nerve

☤Efferent means going out of the CNS

(like sewage effluent goes out to sea)

☤Afferent means going into the CNS

(oculomotor) nerve

Nuclei

Oculomotor nucleus (motor),
Edinger-Westphal nucleus (PS)

Comes from

Midbrain

Goes through Superior orbital fissure

Supplies

Motor to extraocular muscles
except superior oblique and
lateral rectus, levator palpebrae
superioris. PS to eye

Tested by

Extraocular movements and
pupillary reflexes (motor)

(trochlear) nerve

Nuclei

Trochlear nucleus

Comes from

Midbrain - dorsum

Goes through Superior orbital fissure

Supplies

Motor to superior oblique
muscle

Tested by

Extraocular movements

(abducens) nerve

Nuclei

Abducens nucleus

Comes from

Junction of pons and medulla

Goes through Superior orbital fissure

Supplies

Motor to lateral rectus muscle

Tested by

Extraocular movements

III (oculomotor), IV (trochlear),

VI (abducens) nerves

☤Cn III supplies

☤All extraocular muscles except lateral

rectus, superior oblique

☤Levator palpebrae superioris
☤Parasympathetic supply to eye

☤Cn IV supplies superior oblique
☤Cn VI supplies lateral rectus
☤These nerves are tested together

Extraocular muscles and actions

Lateral rectus

Medial
rectus

Superior
rectus

Inferior
rectus

Superior oblique

Inferior
oblique

Right eye

Testing extra ocular muscles

☤Look for ptosis
☤Eye movements (ask about diplopia, watch

light reflection on cornea)

☤6 directions of muscle pull
☤Watch for nystagmus

Cn III, IV, VI defects

Left abducens palsy

Cn III, IV, VI defects

Right oculomotor palsy

A painful, acute Cn III palsy is an emergency!

- could be an enlarging aneurysm

Cn III, IV, VI defects

Left trochlear palsy

Pupillary reflexes

☤Light reflex

☤Fix the eyes on a distant point
☤bring torch / light onto pupil from side
☤Look for direct light reflex and consensual light

reflex

☤Is the defect afferent or efferent

☤Accommodation reflex

Check convergence and pupillary constriction

Relative afferent pupillary

defect (RAPD)

Swinging light test – shine

light first in one eye, then

swing to the other

Relative afferent pupillary

defect (RAPD)

Left RAPD = left optic

nerve pathology

Summary of eyes

Visual equity with Snellen chart

Visual fields with confrontation

Eye movements

Pupillary reflexes

Fundoscopy

Nystagmus

Jerk

Pendular

Type

Vertical

Horizontal

Rotatory

Direction of nystagmus

1st degree

Only on looking to:

one side

2nd degree

On looking to:

one side

straight ahead

3rd degree

On looking

all directions

Degree

Direction of fast phase

Ocular

Pendular

Vestibular

Never vertical

Central

Any direction

Can be just one eye

Can change direction

Causes

Examine:

Max 30 degrees

from midline

(trigeminal) nerve

Nuclei

Trigeminal motor nucleus, trigeminal
sensory nucleus (length of brainstem into
cervical cord)

Comes from Pons

Goes
through

V1 ophthalmic: superior orbital fissure

V2 maxillary: foramen rotundum

V3 mandibular: foramen ovale

Supplies

Sensation to face, motor to muscles of
mastication

Tested by

Corneal reflex (sensory), touch, pin,
clench teeth, open mouth, jaw jerk

(trigeminal) nerve

☤Sensation to face

☤Motor to muscles of mastication

☤Corneal reflex (sensory)
☤Jaw jerk (both components)

CN V - motor

1. Inspect for wasting

2. Ask the patient to clench the teeth and

feel for the bulk

3. Ask the patient to open the mouth

against resistance

Trigeminal nerve divisions

Ophthalmic

Maxillary

Mandibular

☤Corneal reflex
Touch the cornea with a wisp of cotton
Look for direct and consensual reflexes

Touch sensation via ophthalmic branch of

Trigeminal Nerve

Then Motor nucleus of VII —Obicularis oculi

☤Jaw jerk

Loosely open the mouth
Place the fore finger above the chin
Tap with tendon hammer

(facial) nerve

Nuclei

Facial nucleus (nervus intermedius –
salivary nucleus, nucleus solitarius)

Comes from Junction of pons and medulla

Goes
through

Stylomastoid foramen, branches in
parotid (T,Z,B,M,C)

Supplies

Motor to muscles of facial expression,
taste to anterior 2/3 of tongue, sensation
to ear canal and palate, PS to salivary
and lacrimal glands (nervus intermedius)

Tested by

Corneal reflex (motor), inspect face at
rest, wrinkle forehead, close eyes, blow
out cheeks, show teeth (taste: sweet,
sour, salt, bitter)

(facial) nerve

Supplies:

☤ Motor to muscles of facial

expression

☤ Also carries:

☤ taste to anterior 2/3 of

tongue

☤ sensation to ear canal and

palate

☤ PS to salivary and lacrimal

glands (nervus intermedius)

Tested by:

☤Inspect face at rest
☤Corneal reflex (motor)
☤Wrinkle forehead
☤Close eyes
☤Blow out cheeks
☤Show teeth
☤(Taste: sweet, sour,

salt, bitter)

Upper face has bi-cortical

representation

UMN damage does not affect

upper face

Orbicularis oculi

is sometimes

represented

bilaterally, so

may be spared

or involved in

UMN lesions

LMN lesion affects whole side

of face

(facial) nerve - testing

UMN lesion

☤Spares forehead as:

☤Bilateral cortical

representation

☤LMN intact

LMN lesion

☤Can involve forehead as:

☤LMN only innervates one

side

☤Beware: can be partial

CnVII palsy!

(vestibulocochlear) nerve

Nuclei

Vestibular and cochlear nuclei
on floor of IVth ventricle

Comes from

Junction of pons and medulla

Goes through Internal acoustic meatus

Supplies

Hearing (cochlea), balance
organs

Tested by

Otoscopy, whispered speech,
Rinné, Weber (vestibular tests)

(vestibulocochlear) nerve

☤Supplies:

☤Hearing (cochlea)
☤Balance organs

☤Tested by:

☤Otoscopy
☤Whispered speech
☤Rinné, Weber tests
☤Vestibular tests e.g. Hallpike manoeuvre

Rinné test

☤Use 512Hz tuning fork
☤Place base firmly on mastoid process
☤Ask patient to tell you when sound

disappears

☤Hold fork tips 2cm from EAM

☤Can the patient hear it now?

Interpreting Rinné test

☤Tests whether bone (BC) or air

conduction (AC) is better

☤If can be heard in front of ear, AC>BC

☤Normal
☤Rinné positive

☤If cannot be heard in front of ear,

AC<BC

☤Indicates conductive deafness
☤Rinné negative

Weber test

☤Use the same tuning fork again
☤Hold somewhere on the head in the

midline

☤Usually vertex or forehead

☤Which side is louder?

Interpreting Weber test

☤Conductive deafness

☤localises to abnormal ear

☤Sensorineural deafness

☤localises to normal ear

☤Try it on yourself with a finger in an ear

☤Where does the sound localise?
☤Have you caused conductive or

sensorineural deafness?

(glossopharyngeal) nerve

Nuclei

Nucleus solitarius and nucleus
ambiguus of medulla

Comes from

Medulla

Goes through Jugular foramen

Supplies

Sensation to pharynx, middle &
inner ear, post 1/3 tongue, taste
post 1/3 tongue, PS to parotid,
visceral sense from carotid
body and sinus

Tested by

Gag reflex (sensory), (taste) –
with CnX

(vagus) nerve

Nuclei

Nucleus solitarius and nucleus
ambiguus of medulla, dorsal
vagal (motor) nucleus

Comes from

Medulla

Goes through Jugular foramen

Supplies

Sensation to pharynx and
larynx. Motor to pharynx,
larynx, palate (from CnXI). PS to
thoracic & abdominal organs

Tested by

Say “Ah” – uvula moves towards
normal side, gag reflex (motor),
phonation/cough, swallow

IX (glossopharyngeal) and X

(vagus) nerves

☤Tested together
☤Glossopharyngeal supplies:

☤Sensation to pharynx, middle & inner ear, post

1/3 tongue

☤Taste post 1/3 tongue
☤PS to parotid
☤Visceral sense from carotid body and sinus

☤Vagus supplies:

☤Sensation to pharynx and larynx
☤Motor to pharynx, larynx, palate (from Cn XI)

☤PS to thoracic & abdominal organs

IX (glossopharyngeal) and X

(vagus) nerves

☤Tested together
☤Say “Ah” – uvula moves towards

normal side

☤Phonation/cough
☤Gag reflex (IX sensory, X motor)
☤Swallow – only if rest of IX and X

normal

☤(taste – not routine)

(accessory) nerve

Nuclei

Spinal – C1-5 anterior horns

(Cranial – nucleus ambiguus, with CnX)

Comes from

Medulla

Goes through Jugular foramen

Supplies

Motor to sternocleidomastoid
and trapezius muscles (and
motor to vagus)

Tested by

Turn head against resistance,
shrug shoulders

(accessory) nerve

☤Motor to sternocleidomastoid and

trapezius muscles

☤Examine bulk of SCM and

trapezius

☤Turn head against resistance
☤Shrug shoulders

(hypoglossal) nerve

Nuclei

Hypoglossal nucleus

Comes
from

Medulla

Goes
through

Hypoglossal foramen

Supplies

Motor to muscles of tongue except
palatoglossus

Tested by Look at tongue at rest, poke out

tongue and move side-to-side

(hypoglossal) nerve

☤Motor to muscles of tongue except

palatoglossus

☤Look at tongue at rest

☤Fasciculation

☤Poke out tongue

☤Move side-to-side
☤Press into cheek against resistance

Practical – cranial nerves

☤2nd (optic) nerve

☤AFRO – acuity,

fields, reflexes,
ophthalmoscopy

☤3rd (oculomotor),

4th (trochlear), 6th
(abducens) nerve

☤Test light reflex and

extraocular muscles

☤5th (trigeminal)

nerve

☤Motor and sensory

☤7th (facial) nerve
☤8th (vestibulocochlear)

nerve

☤Rinné, Weber test

☤9th (glossopharyngeal)

nerve

☤10th (vagus) nerve
☤11th (accessory) nerve
☤12th (hypoglossal)

nerve

Trunk and limbs

Not just peripheral nervous

system

Inspection

☤ Posture – clawing hands, pes cavas
☤ Wasting/Hypertrophy – feel for muscle bulk

☤ Proximal or distal?
☤ Symmetrical?
☤ Specific muscle group?

☤ Fasciculation
☤ Abnormal movements

☤ Tremor
☤ Chorea
☤ Other uncontrolled movement

☤ Scars – tracheotomy scars,
☤ Surrounding – wheel chair, walking stick or urinary

catheter ,NG, PEG

Tone - testing

☤Patient relaxed, movements by examiner
☤Rapid alternating movements

☤Upper limb: rotate wrist, flex and extend elbow
☤Lower limb: roll leg and watch foot
☤Lift leg briskly at knee

☤Does heel lift or drag along bed?

☤Test for clonus at:

☤Ankle by rapid dorsiflexion

Tone - abnormalities

Normal

Barely perceptible
resistance to movement

Decreased Reduced resistance to

movement

LMN or
cerebellar
lesion

“Lead
pipe”

↑

Increased resistance
throughout movement

UMN lesion

“Clasp
knife”

↑

High resistance that
suddenly releases

Extrapyramidal
lesion

“Cogwheel
rigidity”

Jerky resistance

Extrapyramidal
lesion (esp. PD)

Power

☤

Arm drift

☤

↓Pyramidal lesion, ↑Parietal/ cerebellar lesion

☤

Compare with

☤

other side

☤

yourself

☤

Test each muscle group

☤

Is the deficit:

☤

Proximal or distal?

☤

Flexor or extensor?

☤

Cortical, nerve root, peripheral nerve
distribution?

MRC power rating

No movement

Flicker only

Moves with gravity eliminated (test
horizontal movement)

Moves against gravity, but not resistance

Moves against resistance (- for only just, +
for nearly normal)

Normal power

Myotomes

Shoulder abduction

Elbow flexion

Elbow extension

Finger flexion

Finger abduction

Hip flexion

Knee extension

Dorsiflexion at ankle

Extensor hallucis longus

Plantar flexion

Reflexes – what do they test?

☤Spinal arc modulated by higher centres

Biceps

C5,6

Radial (supinator, brachioradialis) C5,6

Triceps

C6,7,8

Finger jerk/ Hoffman

Abdominal (4 quadrants)

T7-12

Knee

L3,4

Ankle

S1,2

Plantar

L5,S1,2

Tendon reflexes – how do I

test them?

☤Everything needs to be floppy

☤Patient’s limb
☤Your tendon hammer wrist

☤Find tendon with finger (upper limb)
☤Hit tendon or finger on tendon
☤Try reinforcement if no response

☤Clench teeth
☤Pull hands apart

☤Abdominal –stroke each quadrant towards

umbilicus

☤Plantar – stroke outer sole and ball of foot

Interpreting reflexes

☤Reduced in

☤LMN lesion (including same level spine)
☤Muscle weakness
☤Early UMN lesion
☤Slow in hypothyroidism

☤Increased in

☤UMN lesion
☤Anxiety, thyrotoxicosis, youth

Recording reflexes

☤0 = none, even with reinforcement
☤+ = only present with reinforcement
☤++ = normal
☤+++ = hyper-reflexia
☤++++ = with clonus
☤Clonus is rhythmical beating in

response to muscle stretch

UMN lesion

¾ Normal muscle bulk
¾ Increased tone
¾ Reduced power
¾ Brisk reflexes

LMN lesion

¾ Wasting and atrophy
¾ Reduced tone
¾ Reduced power
¾ Reduced or absent

reflexes

Coordination

Upper Limb

☤Finger-nose

☤Dysmetria or past-

pointing

☤Clap with alternating

palm and dorsum

☤Dysdiadochokinesia

☤“Play piano”
☤Rebound

☤Test at same time as

drift

Lower limb

☤Heel-shin test

☤Run heel down other

shin, lift up and repeat

☤Tapping toes

Cerebellar signs

☤ D

ysdiadochokinesia

☤ A

taxia – present with eyes open/close (broad base

gait)

☤ N

ystagmus- fast component towards the lesion

☤ I

ntention tremor (=dysmetria)

☤ S

peech – slow, slurred, explosive, scanning

☤ H

ypotonia

☤ Pendular jerks-muscle contraction and relaxation is

slow

☤ Past pointing
☤ Rebound phenomenon
Ipsilateral signs. If central (vermis, alcohol) only truncal

ataxia may be present

Sensory modalities and testing

Pain

Pin (neurotip)

Spinothalamic

Cross–spinal cord

Temperature

Ice, cold tuning fork
(not routine)

Spinothalamic

Cross–spinal cord

Proprioception

Eyes closed, move
joint

Dorsal column

Cross - brainstem

Light Touch

Wisp of cotton wool

Dorsal column

Cross - brainstem

2 point
discrimination

Two-point
discriminator

Dorsal column

Cross - brainstem

Vibration

128 Hz tuning fork
on bony prominence

Dorsal column

Cross - brainstem

Dermatomes

Cape

Middle finger

Arm pit

Nipple

T10

Umbilicus

T12

Inguinal ligament

Hands in pockets

Knee

Big toe

Lateral foot

Visit

ASIA scoring sheet

Finally….

☤Romberg Test

Positive if sways when eyes closed

☤Gait

Gait assessment

☤Walk a few metres, turn and return
☤Watch width, rhythm and step length
☤If easy, try tandem walking

Tone

Strength

Visual

Vestibular

Proprioception

Balance

Sensation

Coordination

Gait depends on:

Gait

☤Hemiparetic/spastic
☤Festinant

☤PD, short shuffling steps,

leaning forward

☤Wide-based

☤Cerebellar (staggering)
☤Frontal lobe

☤Stamping

☤

↓proprioception

☤Steppage/high stepping

☤Foot drop

☤Proximal myopathy

☤waddling

Extra tests with spinal

problems

☤Straight leg raise (root entrapment, Lasegue)

☤Pain at <60º
☤Eased by bending knee
☤Can be “crossed” – pain on other side

☤Femoral stretch
☤Perianal sensation

☤Touch and pin

☤Anal tone

☤Anal “wink”

Practical - limbs

☤ Inspection
☤ Tone
☤ Power

☤ UL: Drift, SAb/Ad,EF,EE,WE,FF,FAb/Ad, opposition
☤ LL: HF, HE, KF, KE, AInv/Ev, DF, EHL, PF

☤ Sensory modalities and testing

☤ Pin, touch, proprioception, vibration

☤ Reflexes

☤ UL: Biceps, brachioradialis, triceps
☤ LL: Knee, ankle, plantar

☤ Coordination

☤ Finger-nose, heel-shin, alternating movements, Romberg

☤ Spinal tests, SLR, femoral stretch if needed

Neurological Examination of

the unconscious patient

¾ ABC, any sedative drugs, C-spine protection if

trauma

¾ Pattern of breathing –

¾ ↑RR -pontine lesions, respiratory causes, Metabolic

causes

¾ Cheyne-stokes – central medullary lesions,

Resp/CVS

¾ Irregular pattern – medullary lesions

¾ Glasgow coma scale
¾ Pulse and blood pressure ? ↑ICP
¾ Blood glucose

¾ Temperature

¾ Hypothermia
¾ Pyrexia- CNS infection, medullary lesion

¾ Neck stiffness –meningitis, SAH,↑ICP
¾ Pupils- size

¾ Small- pontine lesion, opioids
¾ Unresponsive midbrain lesions

¾ Pupils – asymmetry

¾ Large/unreactive lll nerve palsy
¾ Small slow to dilate- Horner's

¾ Light reflex
¾ Fundoscopy – papilloedema

¾ Eye movements

¾ primary position - squint
¾ Nystagmus
¾ Dolls eye movements –

horizontal –lll / Vl,pons
vertical – lll , lV, midbrain

¾ Corneal reflex- V,Vll, pontine lesion
¾ Gag reflex
¾ Posture

¾ Decorticate – pyramidal tracts from cortex to

internal capsule

¾ Decerebrate – midbrain, thalamus and

subthalamic nuclei

¾ Check the tone of the limbs

¾Limb Reflexes
¾Planters

¾Monitoring the progress at regular time

interval – improving/deteriorating

AVPU score

☤A

lert

☤Responds to

erbal stimulus

☤Responds to

ainful stimulus

☤U

nresponsive

Glasgow coma scale–eyes (4)

Open spontaneously

Open to command

Open to pain

No opening

Closed due to swelling C

☤Record best score for each section
☤Record in components, not just sum

GCS – verbal (5)

Orientated

Disorientated

Inappropriate words

Sounds

None

Intubated

GCS – motor (6)

To command

Localises pain

Withdraws from pain

Abnormal flexion to pain 3

Extension to pain

None

☤Start with command
☤If no response, squeeze side of nails
☤Sternal rub and nail bed pressure bruise

System for neurological

examination

☤General inspection
☤Glasgow coma

scale

☤Higher mental

function

☤Speech and

language

☤Cranial nerves

☤Trunk and limbs

☤Inspection
☤Tone
☤Power
☤Sensation
☤Reflexes
☤Coordination

☤Gait