 Touch and pin prick and this is my knee hammer. What does do I need? And for the time being, I'll do with this. And if I need to do it, I need to do it. You may have to remove your document. Okay. You can come even closer. Paul, can you see from there? You can't see anything. Just stand on top of the chair. No problems. Today we are very democratic. You can stand on top of the table also. Okay. So we'll start the photo system. You'll be asked to do a quick examination. So one I'll demonstrate here. Another one I'll demonstrate here. And we'll just keep switching so that all of you can see. The photo system, you have to look for just involuntary movements. Hang on. He does not. Oh, I'm sorry. We have to do the basic protocols. I'll just do it once. Hello? My name is Dr. Sanya. I'm your physician for today. You are Mr. Abbott, the Badger. So how would you like me to address you? Mr. Dabajah. And you are... How would you like me to address you? Chanel or Ms. Fernandez? Chanel's fine. Wonderful. So, okay, I did that only once. But you'll be graded for all these points, okay? So assume you have washed your hands, you have knocked on the door, and you have addressed yourself with your title and your last name. You have asked how you want the patient to be addressed and they have all confirmed. Mr. Dabajah and Chanel. Okay, then you start. Motor system. Involuntary movements. Just watch. Just watch the patient sitting quietly. No involuntary movements. Thank God. Look at the bulk of the muscle on corresponding sides. Equal. Bulk of the muscle corresponding sides. Fine. The next one is stone. Please sit down here. Stone? I definitely don't have that. Stone for the upper limb, stone for the lower limb. Can you sit down here? Oh, yeah. I don't have dads. Just keep falling there also. For the upper limb. Support the elbow. And just passively move the fingers. Passively move the wrist. Passively move the elbow. And passively move the shoulder. Remember, I'll be watching you. You should be doing both sides. You lose points because you do only one side and you forget about it. So you have to do the other side also. Support the elbow. Passively move the fingers. Passively move the wrist. Passively. Tell the patient, relax please. Passively move the wrist, the elbow, and put the shoulder through a moderate range of movement. Same thing on the leg. But I have to go through that, please. Can you go? There's a lot to do. Oh, I've not seen my laptop. Passively move the knee. It's all shown there. Just look at the pictures. And again, do the other side. Passively. You don't do anything? I just do nothing. Because there's any excess resistance or excess mobility. If there is decreased tone, it'll be like a rag doll. It'll be like a rag doll. Another way to do it is to hold both the wrists up and just let the wrists fall down. See? This is normal. If there is decreased tone, that side wrist will be lower down. And move the joints and see. It's normal. So this is tone. Examination of tone of the upper limb. Examination of tone of the lower limb. The next item. Next slide, please. Examination of muscle strength. Again, let's start with the upper leg. You have to turn the shoulder. You have to do the elbow. You have to do the wrist. And you have to do the fingers. So shoulder strength, bicep strength, tricep strength, wrist, dorsiflexion, grip strength. Then I'm going to go to the muscle in the leg. So please extend your hand against my resistance. Give resistance. This is how you test for shoulder. I'm weak, sir. Good. That's fine. That's fine. So you're tested for deltoid. Similarly, again, I'm repeating, don't forget to test the opposite side. Many of you do forget and you lose points. Next, I'll ask you to flex your elbow. And I'll give resistance. So flex it tightly. Pull off a desk. Against resistance. Now, straighten your hand. Try to straighten your hand against resistance. Keep it flexed. Keep it flexed. Flex it. Now try to straighten it. Give resistance. So biceps, triceps. Next, dorsiflexion of the wrist. Look at the picture very carefully. Next slide. Dorsiflexion should be with the hand closed. Why? Because we don't want them to use the extensor digitorum. So wrist should be in the flex position. And so please make a fist. And try to straighten the wrist against resistance. So this test for dorsiflexion of the wrist. Oh, by the way, can you just rush down and call the doctor? Call them also. He's supposed to be here. He's forgotten. So you're supposed to ask the patient to make a fist. Move it up. Move it up. And don't let me bring you down. This is dorsiflexion of the wrist. I don't want you to die. So we will watch you, whether you've asked the patient to make a fist and whether you're giving resistance. Don't keep it open because otherwise he'll use the extensor digitorum also. So here you're testing for the extensor carbaryteal as long as braves and ulnaris. Similarly on the other side, please make a fist. Yes, and you try to give resistance. Last one, grip strength. Now watch very carefully. Don't keep your fingers straight next to each other. Why? Sometimes a patient is so strong that they will crush your finger. Always keep one finger over the other finger. We will watch this. Please try to hold my fingers as tightly as you can. You can do both simultaneously. And watch for strength. With your thumb, just keep holding it. With your thumb, try to remove your finger. This is testing for grip strength. Everybody watch me. Okay, so this is for the upper limb. Now for the lower limb. Now I'm going to use you. You'll have to go a little back. What is this? I'm going to tell you the screen. First, test for adduction, abduction. It's better to do it on him. I mean, I do more. So for adduction, keep both your fists slightly separate. Try to bring my hands together. Testing for adduction. Adductors, okay? Abduction. Try to move my hands out. Abduction. Next, put your hand behind the thigh. Press down on my hand. This is extension of the hip. Gluteus medius and gluteus minimus. This is extension. Flexion. This is, no, iliosaurus. Flexion. You can do both simultaneously. There's the quickest way to do. Next, flexion of the knee. Give resistance. Yes. Patient is trying to flex. I'm trying to extend. Do the same on the opposite side. Resistance. Now try to straighten your knee. Straighten it. Try to straighten it. Straighten your knee. Yes, give resistance. Straighten. This is extension. So flexion extension. Both sides. Next, try to put your foot up. Give resistance. L5. Try to do only with a great toe. L5. Push down on my hand. S1. Just a great toe. S2. So we have tested with all the muscle strength. Grading of muscle strength. Can you go back to the slides? You have to know that they will. You'll be asked. Zero. No movement at all. One. Later. Two. Again, with gravity eliminated. It's already there in your slide. It's already eliminated means the gravity is eliminated and the pain is moving like this. Grade three against gravity. Grade four against gravity and with a little resistance provided by you and grade five normal strength. So you'll be asked the strength. Of course, the subject you'll be having will be normal. Okay. So this is about the motor system. Now next, we have tested for all. Now we come to the Cerebellar. It's all here in a simplified form. We have done the motor system. We have done the upper limb. We have done the lower limb. Upper limb. Lower limb. Now we are going to test for the cerebellum. Cerebellum basically, is he coming? Cerebellum basically tests for coordination. So we have four groups of tests. They are headed under four headings. One is called the rapid alternating movement. Ram. I'm going to show you both in the upper limb and the lower limb. Then you have the point to point test. Then you have the stance and then you have the gate. So let's start with the ramp. Rapid alternating. Can you do this on one arm? Morally fast. Maybe not. Can you do it the other way? So the absence of this is called this data book. You know that. This is an example of a ramp. Rapidly alternating movement test. There's another one for this. You can do it on this also. This is rapid alternating movement. It's shown there. There is yet one more way of doing it. There is yet one more way of doing it. Ask the patient to tap his or her thumb with the index finger. It's shown there in that picture, in the lower picture. Ask the patient to tap his or her thumb. So these are the two ramps for the upper limb. Now let's do the ramp for the lower limb. No, you can keep your leg hanging now. Ask the patient to tap your hand with his foot. You can do it simultaneously. Please, no. Tap my hand. Good job, Abit. So this is the ramp for the leg. Rapid alternating movements. Next one. Point to point. Point to point, you do basically the finger nose test. So I'll do one finger nose test with her. Both are very similar. One is to test for dysmetria, the other is to test for pass point. Dysmetria. So you have to look at me first. Extend your hand out. Your right hand out with your forefinger. You touch my forefinger and then you touch your nose. And then touch your nose. Again, touch my forefinger and bring it out. Bring it out. Do it a few times. No, no. You touch my finger. Your nose. Again, my finger back. So easy. No. Take that. Back my finger. His finger is down. Woo! What do I have to do? I'm testing for this. Build the test. This is the first one. You're moving your finger out but the patient has got his eyes open. I'm not good at coordination, sir. Doesn't matter. Okay. Josh, shut up. Touch the finger. Finger. That's my finger. Okay. So this is the finger nose test. You're testing for dysmetria. If the person is persistently overshooting, you're testing for dysmetria. That means when I'm moving, she's overshooting. She's overshooting. Now I'll do the other one which is also very similar. Keep your eyes open first. Do the same thing. Touch your nose. Again, back. My finger. Your nose. Again, my finger. Back. Again, my finger. See, he's saying it to him. Now. Close your eyes and do it. Okay. See. This is testing for the other one. Passpointing. It's so good. Dysmetria is overshooting. Passpointing is consistent deviation to one side. Suppose he had a right cerebellar lesion. He would have consistently deviated to the right. So both are very similar. In your exam, we will be testing only the passpointing. That is dysmetria. Not the passpointing. We won't ask the first subject to close his eyes. But these are the two point-to-point tests. Dysmetria and passpointing. Now for the leg. This was with a hand. With a lower limb. I'll use him. When you were college, now you weren't really charged. Yes, because this was the eye open. With eyes open. But when you're doing for the passpointing, you keep the hand in one position. Ask him to do it a few times with his eyes open. And then ask him to close his eyes and remain. Keep your hand in the same position. Because now close his eyes. Because now you're moving up. You're keeping his eyes closed. So you have to keep your hand in the same place. No, I understand that. But you still instruct him to do each step. I told him to do it a few times, right? So he got the habit. Then I asked him to close his eyes. My finger was still in the same place. In her case, since her eyes are open, I was moving my hand. So in this case, her eyes are already open. So I was moving my hand to see whether she has got that ability or not. So what's the order of that? You have to touch my finger. Your nose. Again, my finger. Your nose. And eyes open. After a few eyes open, keep it closed and keep your hand in the same place. Dismetria pass pointing. Overshooting versus tendivation to one side. It's all clearly illustrated. Now with a leg. With a leg, first you show the patient. This is the simple heel sheen test. Which all of you know. First demonstrate to the patient what I'd like you to do is with your heel, start from your knee and go all the way down to your ankle. Similarly, the other side. With your heel, go all the way. First show him. Next, ask him to close his eyes and do it. Can you close your eyes and do it please? Yes. Another headache. This is it. If the person has got a cerebellar problem, the person will do all those funny things and we try to look where he is doing all those things. So you asked him to do it once. He got the hang of it. Then he should do it. Both sides. So this is the heel sheen test. This is also a point-to-point test but with a lower leg. This was a point-to-point test with a hand. This was a point-to-point test with a lower leg. We are good. Next one, next slide please. The gate. I can use you for the gate. Would you like to walk this way or this way? Just walk normally. Go all the way up to the whiteboard and come back to me. Thank God she can do this way. This is the catwalk, isn't it? No, I can do that. I am walking normally. Just walk. Go all the way to a particular distance and then turn. So watch for the stance, the gate, the movement, the rhythm, the equilibrium, the hand motion, everything. Just a standard walking. How the person turns. Whether the person turns in one shot or whether the person turns in multiple blocks. I will be teaching all those things in Parkinson's. They will have what is called a-block turn stance and all those things. They will have magnetic gate and all those things. So her gate is fine. The next one will be tandem gate or heel to toe walking. Like you do when you are being tested for alcohol by the police, isn't it? So this is a straight line. So you have to walk in a straight line. Yes. Oh my God! She is drunk. Please turn around and come back. Wow! One smooth turn. Yes. Oh my God! So, blood alcohol is zero by zero. This is the tandem walking. Next, I can use you now. You have to walk on your heel. You can walk up and down. My socks hurt. Okay, just doesn't matter. Walk on your heel and then turn around and walk on your toes. This, walking on heel. So this is heel walk and toe walk. In corticospinal tract lesion also they allow difficulty in heel walking. It also tests for cerebral lymph. Next one, I think I'll use him. That is, you have to hop in one place first with one leg and then the other leg. Hop in one place. And down. Then with the other leg. And then with both the legs, shallow. Appreciate that. So this test for both proximal and distal muscles. Heel walking and toe walking tested only the distal musculature. The next one I'll ask you to do that. One leg, shallow knee bends. First with one leg, shallow knee bends. And then with the other leg, shallow knee bends. He's changed your tie here. And then back then both the legs. Just do it. This also test for both the legs. Thank you. So this is, this is... Abil, test the hip. Test the hip. Test the hip. You know how to do that. Okay. So this also, this also test for the proximal and distal muscles. Hop in one place. One leg at a time. Shallow knee bends. One leg at a time. Both the legs. And then finally the next one. From a sitting position. I can use you. From a sitting position, I want you to stand up. This test for the gluteus maximus muscle. The proximal muscle. Try to see whether he takes support from somewhere or not. Because again this is deficient in many conditions. So this is for the proximal muscle. So these are all the tests for gait. Next slide please. The stance. We have two tests for the stance. So I'm going to use you for one and one for the other one. So please you have to come here so that everybody can see. This is the typical long box sign which you have been taught about. We'll show you exactly how it is done. First I'll demonstrate to you. Both the legs together. Both the legs together. As a patient to stretch out both the hands. As far as possible out. Close the eyes. And remains to be for about 20 to 30 seconds. So please do that. So you'll be asking your subject to do that. So I'm letting everybody see that what you're being asked to do. 20 to 30 seconds. What do we watch? Whether the person is swaying with his eyes open. And whether the person is swaying with her. These are her eyes closed. So she's not swaying with her eyes closed. Now you can open your eyes. The person is not swaying with her eyes open either. Thank you very much. So what have we tested? We have tested. If the person sways with the eyes open. Obviously the person will sway with the eyes closed also. That indicates cerebral recognition. On the other hand, if the person does not sway with the eyes open. But starts swaying when you ask the person to close his eyes. That indicates cerebral recognition. That is wrong box sign positive. Are we clear? Because the visual cue is lost. So we have done that. Sorry. Yeah. So that is actually a combination of both. We can accept the cerebellar problem. And there is a dorsal problem problem. So you will get, actually you can't say it's dorsal. Purely dorsal problem. They have sensory. You see, a taxa can be sensory taxa. Due to dorsal condition, a taxa can be cerebellar taxa. We have learned all that. So we have tested for both actually. The next one is the pronator drip. Watch this carefully. I'll use you for this pronator drip. It's closed. I'll demonstrate to you. With the patient's eyes, legs together. Both the hands, palm up. Keep it up. And eyes closed. And watch for two things. Please do that. Palm up. Eyes closed for about 20 to 30 seconds. What do we look for? First thing. Whether the hand remains steady in its place or not. What is this pronator drip? If there is a corticospinal tract lesion on his left side, let's say. Left corticospinal tract. His right hand will do something. Or if he's got a cerebellar lesion on the right side, his right hand will do something. What will it do? I'll show you. You can open there so that you can see. Suppose I have a lesion on my corticospinal tract on the left side or my cerebellum on the left side. When I'm asked to do this, my hand will slowly pronate. And it may even flex at the wrist and at the elbow. And it will drift away. So this I'm just showing you. So when you ask the person to do this, if there's a lesion, it might go. Sometimes it may go even up. So this is called pronator drift. The second part, yes. Are they conscious of it? No, they're not aware of it. That's why there's a lesion. The hand is automatically unable to remain like that. The other component of this test is the next component, yes. We will just see how you're asking the patient to do it and what you're watching for. Okay, are you going to ask this, like, is this corticospinal tract? I usually don't, some of you. I don't like to hear your questions and practicals. I just watch for the procedures, whether you've done all the protocols, steps currently or not. That's a practical example. The next component of this test is, after you have observed this person for a few seconds to see whether the hand is deviating or not, the next component of the test continues through the same thing. You gently tap the hand down. Both the hands. You'll find that a normal person, it swings back again. Keep your hand eyes closed. If you do that, because the hand has got a certain amount of tone and it is remaining like that, it will come back to its automatic position. On the other hand, if it's a cerebellar lesion, the hand will bounce and it will do all sorts of funny things. So this is the second component of the pro-inter drift. So we have done the stance. What did we do? We did the rhombus test, rhombus sign, eyes closed, stretched out, and we watched for swing and we watched the pro-inter drift and the bouncing of the hand. So we have finished the cerebellar tests. So this stance gate and the cerebellar done. So we have finished with the motor system. We have finished with the cerebellar. Next slide, please. You will be given during the lab. The next one, sensory system. So again, we will start. This is actually the lumbar function needle which you are going to be using in our last lab. We are not going to do pain, but pain is done in the tip of safety pin. So we are not going to do the pain. Temperature, again, we won't do it. But you are supposed to do it with the test tube of hot and cold water. Which nucleus? Spinal. I'm still hopping mad. Light touch is true touch. That is done with a wisp of cotton. You will be given a cotton. You will be testing for light touch, crude touch. And fine touch is, again, with the tip of a pin. With the tip of a pin, but you don't press so hard so as to produce a pain. But we won't do that. But you will be given a light touch. You will be given a wisp of cotton. And you will do light touch. When you do the sensation, I'm just assuming that I'm holding a piece of cotton. You have to do corresponding areas. Always go from an anesthetized area to a normal area. Suppose the patient says I don't have any sensation on my wrist or wherever. So start from that area and keep going approximately till the person feels sensation. Compare with the opposite side. Again, the same area. One very important point here. You have to ask the patient to close his or her eyes. I'll be watching for these two things. Whether you are doing both the sides simultaneously or invariably you lose points on these two points. Issues. Otherwise the person sees he or she will definitely say yes, of course I'm feeling the touch. So we have to ask the patient to close their eyes. So that is how you test for. You'll be the cotton ball. Let me demonstrate the other one. The vibration and the joint position of the dorsal column sensations. This is actually 256 hertz. For vibration, you're supposed to use 120 at the low frequency one. This is used for hearing. I'm using this. How do you use the unique fork? Never touch the prongs. Always hold the step. And many of you will do all sorts of funny things to make it vibrate. Give it a sharp tap over the heel of your hand. Can you hear the whining sound? Do not hit on the table. Do not hit a hard surface. All those are wrong. Because if you hit here, see it produces two different harmonics. Did you notice? It's acceptable. We will watch this whether you're doing it the right way or not. So best is to hit the heel of your hand. If you touch here now, again, the vibrations will stop. So once you've set it in vibration, can I start by testing on the dorsum of the thumb? You can do this on the dorsum of the other digits also. This is where we start from. If this is abnormal, then you can go approximately to other bony areas. Like for example, you can do it on the Oligrenum process. You can do it on the chromium. You can simulate on the foot. I'm not asking to remove your shoes. You start on the dorsum of the great toe. If it is abnormal, then you can go to the medial valueless. Then you can go to the medial epicondyne. You can go to the iliac rest and all the rest of it. So start with the dorsum of the great toe and dorsum of the thumb. This is what we're going to be watching for. How you strike the dune fork, how you set it in motion, whether you're touching this or not, and one more point here. Many patients do not know the difference because patients are not as intellectual as you. Patients do not know the difference between pressure and vibration. Because you're holding it here, they might interpret the pressure itself as vibration. So what do we do? When you're thinking that perhaps the patient is confusing pressure with vibration, stop it. Stop the vibration with your finger, with your head. And then ask him, are you feeling the vibration or not? If he says, yes, I'm still feeling the vibration, then you know he's guessing. Because that means it is the pressure which is confusing as vibration. So these are small tricks of trade actually for doing this procedure. So that is the testing for vibration. So this is the dorsal column sensation. Now we come to the other one, the joint position. So can I use you now? For this, you'll have to remove your socks and you'll have to sit down. Where did this one come from? Okay. So here, because joint position of the great toe is a very important test. Remember in vitamin B12 deficiency this is the first sensation to be lost. In many B12 deficiency, many dorsal column lesions you have learned joint position is lost. And the best way to test for it is the great toe. First, again we will do it on both the sides. Don't forget. First you'll have to demonstrate to the patient what exactly you are doing and explain. So you want Mr. Tabajan. Yes. Mr. Tabajan, what I'm going to do is please look carefully. When you feel your great toe going up, you will say it's up. No, not now. I'm just telling you what I'm going to do. This is, when it is here, you'll say it's down. And when I do like this, you'll say it's going around. Next point. Separate the great toe away from the other toes. Why? Because he should not get the feeling from the other toes and tell you what his position is. I'll be watching this. Move the great toe away from the other toes, demonstrate to him what you are going to do and then please close your eyes Mr. Tabajan. What is the position of your great toe? Wonderful. What is the position of your great toe? What is the position now? Going around. So this is how you do. If you let it touch the other toes, I did that points. Because when you touch the other toes, he will use the sensation of the other toes to tell you his position, right? So I'll watch whether you have removed it from the other toes, whether you have clearly explained to the patient and again, patient's eyes should be closed. Don't forget, you lose points on that. You forget to tell the patient to close his or her eyes. Again, do it on the other side corresponding. You forget to do that. Again, you lose points. So please close your eyes. Which is the position of your great toe? Down. Which is the position of your great toe? What is the position now? So this is how you test for joint position sense. Both the sides, eyes closed after explaining to the patient. So this is the position sense. Next one. I can use you now. The next slide, please. All of you know stereognosis. Give a readily identifiable object to the person. Can you close your eyes? Tell me, hold this and tell me what is this? Now, what you can do is, this is one of the videos which I did last semester, give a series of very similar, a little different items. Let's give me these and one pencil. Okay. Now, with your eyes closed, I have got a few other objects here. With your other hand, pick these objects one by one and tell me which one matches the object in your right hand. I am testing the stereognosis by using the corpus callosoma. Tell us what color it is. That is synesthesia. That's a mechanical pencil. That's the one. This one. Good job. Good job. What we have done, I have gone one step beyond stereognosis. First, she identified this with her eyes closed. So that was stereognosis. And then I used her corpus callosoma to match this with that. So we extended the best of stereognosis. You have to give a familiar object. You should not give a strange object. So it's a coin or a key or a pencil or something which a person uses daily. And you should allow the person to move that object in his or her hand. They cannot just touch it. They should be allowed to move it in their hand. Because stereognosis is a complex system. It's a cortical sensation. It's a combination of touch, pressure and conscious proprioception. So all these things together will be integrated in the cortex. Remember primary sensory cortex and the superior parietal region and inferior parietal lobe. Or identification. Close your eyes please. If the person has got, let's say I'm going to do the next one again, then I'm going to do the next one. If the person has got, let's say she has got arthritis, rheumatoid arthritis, or she has got some injuries in her hand or she cannot move her fingers or something like that. Does that mean that you will not do stereognosis? We have other methods of doing it, right? What will we do? We will do the usual old-fashioned method. We will write this in the classroom. This is a familiar letter on the palm of the hand and ask the person to identify it. Again, don't forget to do it on the other side. Don't forget to tell the patient to close his eyes. I'll be watching for these things. So we did. So if you can do stereognosis you can do graphic thesis. You can write another one also. You can write something which you know the person is familiar with. So I know he's a highly educated and a highly intelligent man. He knows what is three and he does know what is eight. So he will definitely be able to identify it. So this is graphic thesis here and you know this is a cortical sensation. The next one. Two-point tactile discrimination. I don't have the object but you will be given a pin. You will be given a pin. So the two points of the pin you have to do it again with the eyes closed. You have to do it on the palm of the finger. So you can touch the two points. Do you or she can feel the two points separately or not? This is two-point tactile discrimination. Again do it on the same side opposite side corresponding areas. Normally the pulp of the finger is the most sensitive. They can identify two separate as even less than five millimeters. On the flexor aspect it becomes a little less sensitive but it is still sensitive. On the extensor aspect and on the back it is very sensitive. They cannot identify anything closer than three centimeters. Finger five millimeters. This is two-point discrimination. Next slide please. There are two related tests you will be doing them. One is called point localization and the other is called tactile extinction. We have told you all that, isn't it? What is point localization? You ask the person to close his eyes. You touch him on one particular place in the hand and ask him where did I touch you? Where did I touch you? Show me please. You can open your eyes and show me. Similarly do it on the other side. Show me where I touched you. Now you can open your eyes and show me where I touched you. So this is point localization. And an extended version of that which is used for the trunk and for the lower lips. Can you sit down please? You have to keep saying it so that he knows that you are your sort of therapy. That's how you build a rapport. What I'm going to do, I'm going to touch you in certain parts of your body. I should have done it on purpose. It would have redeemed me. And you will have to show me where I... Please tell me where I touched you. Okay. So this is tactile extinction. Bilateral simultaneous stimulation to test for tactile extinction. And you have already learned that when the person has got superior parietal cortex lesion or when a person has got corpus callosum lesion anterior cortex or the corpus callosum which by the way, again, less than 50% of the person has got contralateral tactile extinction. So these are the tests for sensations. So again, these are the sensory systems. We do it for all upper limb and lower limb. The lower limb, we do precisely the same thing. I'm not doing it again. The only difference is in lower limb, you don't do stereoscis, you don't do graphysthesia because you can't feel a coin with your foot. Can you? Neither can you feel my writing on your foot. I don't think you'll be able to do it. So we don't do stereoscis and graphysthesia for the lower limb. Otherwise, the rest of the tests, we do the same. Okay. The next one, please. So we have finished with the motor system, sensory system, cerebellar, the last one remains, and that is the deep tendon reflexes. So here, can you sit down again? I'm going to use... So, all of you know the gender six maneuver. Now, a few things I need to tell you before I start with the deep tendon reflexes. Many of you are going to use the new hammer like I'm touching it. Of course it does happen. People use their shoulder, they use their all sorts of muscles. The new hammer is supposed to be with only your finger and your wrist. Finger and your wrist, watch. Finger and your wrist. Not your elbow muscles, not your shoulder muscles. No. Yes. So that's the first point. So look at the picture down there. You see how it is moving. That's when it's been designed. That's the first point. Again, there's a grading of reflexes. Zero, no. You have to know the grading. Generally speaking, two is normal. Three is brisk. Four is very brisk. Five is clonus. I'll tell you what is clonus. Less than two is hypo, and zero is absent. You have to know the grading of reflexes. Deep tendon reflexes. So that's about the knee hammer. How to fold the knee hammer. How to do the reflexes. Next slide, please. Upper limb. The three reflexes that we will be doing. I'm going to demonstrate the upper limb. I'm going to demonstrate the lower limb. The three reflexes that we'll be doing will be the biceps, the triceps, the brachiorgiasis. So let's start with the biceps. Before that, when do we use the pointed end? When do we use the broad end? There's some simple rules of thumb. If the tendon is narrow, use the broad end. The two examples where we use the broad end is brachiorgiasis and the tendocalcaneus. Tendocalcaneus because the tendons are narrow. If you use the narrow end, you're likely to miss it. That's why you use the broad end. Biceps is also a narrow tendon, but biceps is the only exception where you don't tap on the tendon directly. You keep your thumb on it, and we'll be watching that. Biceps, there are several ways of doing it. One is in the sitting position. The patient is sitting. What I would like you to do is keep your hand very relaxed on my hand. Absolutely. Ask the person to keep the full weight of the hand absolutely relaxed on your own hand. The patient should not be stiff or tense. Relaxed. Feel for the biceps tendon, and you will be able to feel it very easily. You will be able to feel it in the cubital fossa. It's very easy. Once you feel the biceps tendon, give a gentle pressure on the biceps tendon. In fact, if you're right about it, you will feel the positions of the brachiorgiasis right in the middle to that. So the biceps tendon, I'm giving an attraction. Now what I'm going to do is because the area is very limited here, I cannot use the broad portion. I have to use the narrow portion, but I have localized it with my thumb. I'm going to tap my thumb with the pointed end of the knee hammer. Are we clear? So this is how we will do it. Keep it relaxed absolutely. Did you watch the muscle contracting? You can stand up. So, there. It did contract. I felt it. It did contract. There. It is so sensitive that I can do it with my finger. I'm tapping it with my fingers. So I prove easily that it hurts. Similarly, do it on the other side. You can do it on the other side. Keep your hand relaxed Chanel. Again, feel the biceps tendon. Feel the biceps tendon. Tap on your thumb. Here. There. And you will be able to feel the contraction of the biceps. This is the biceps replace. If the patient is lying down, you can ask the patient, you can again put your hand like this and you can tap. The patient is like, you see, it's contracting already. See? Can you see? It's contracting. Yeah, you can see that. So that is with the patient. So if the lower two pictures, the lower two pictures, patient sitting, patient lying. Next, the triceps. There are three ways of doing it. The nice method is hang the limb out to dry. This is called hanging the limb out to dry. Like you're hanging clothes, you know. So I have made her hand hang as if I'm drying it on a clothes line. So keep it relaxed. Absolutely put the full weight of your hand on my hand. Yes, that is important. And you feel it just above the Holy Cranon process. And you tap this area. There. That is the triceps reflex. Do it again. There is another one. Can you do it again? Keep it relaxed. Keep your full weight. Ask the patient to be absolutely relaxed and keep the full weight of his or her hand on your hand. Usually, patients will be stiff. You will not get the reflex. Okay. In the exams, even if you don't get the reflex, we are not judging on that. I'm going to watch your procedure, how you're doing it, whether you're doing it the right way. Keep the full weight of your hand on me. I should be able to feel the weight relaxed. That is the crisis. That is one way. The other way is if the person is lying down, you can just ask the patient to flex and you can tap. There. So, that is another way to do it. So, patient lying, patient sitting. And the third one is the brachioradialis. Remember, I said brachioradialis, the tendon is very narrow. And it is inserted on the radial styloid process. The radial styloid process, you can feel it just above the anatomical snuff box. Remember the anatomical snuff box? Remember where you take your salt before taking your shirt? Okay. Sir, I can't bruise luck. You're getting bruised? It's all right. All in the name of science. Because I'm going to use him for the lower level of using you for the upper limb. So, feel the radial styloid process first. The brachioradialis is inserted on the radial styloid process. So, you have to go approximately one inch above that. We have to use the broad end because it's a very narrow. If I try to do it with, I may miss, you see. So, I'll use the broad end. So, hold the hand in a mid-prone position because this is the position in which the brachioradialis works best. And go slightly above that and tap. You can see the contraction of the brachioradialis there. That is how you test for brachioradialis. Again, do not forget to do it on the other side. Hold its support in the mid-prone position, feel the radial styloid process, and tap. That is the brachioradialis tendon reflex. So, we have done the three reflexes. Biceps, triceps, brachioradialis. Next one, please. I'm going to do the knee, ankle, and the plantar response. And I'm going to tell you what is clonus. So, the one way to do the knee is with the patient's sitting. Give a gentle upward, keep it absolutely relaxed. Give a little stretch of the tendon. And again, this is the place where you use the broad end. Why? Because the tendo-calcaneus is pretty narrow. There. Similarly, on the other side, don't forget. So, we'll watch whether you're using the right side, right end, and whether, again, elicitation is not the important thing. I want to see whether you're doing the procedure correctly or not. Similarly, you're grinding your... Okay. Again, no, keep it relaxed, absolutely. Patients will try to tense their limbs, I'm telling you. You have to repeatedly tell them, Mr. Bajat, keep it relaxed, absolutely. You give gentle dorsiflexion to make the tendon a little taut. And there. If you do it the right way, you will get it. 100%. When people are not giving the proper instruction to the patient, that's why you're not able to elicit it. Suppose a person is lying down. There's another way to do it. Do we have a place for you to lie down? Or there's no place for you? Or you can just lie down. Oh, my God. People bring their whole house here. That's all. If the person is lying down, there's another way to do it. Watch it. Can you cross your leg for the other? Keep it relaxed, absolutely. Cross one leg over the other. Keep it relaxed. Keep it relaxed. Again, give a little dorsiflexion to tauten this tendon. And tap. Keep it relaxed, absolutely. Keep it relaxed. There. You can see it contracting. So what do you look for here? This leg. Well, you're seeing contraction of the leg. Similarly, do the other side. Can you cross over? Keep it relaxed, absolutely. Give a little gentle dorsiflexion. You don't do it. I'll do it. Keep it gentle dorsiflexion. And tap. Note, I did not use my shoulder or my wrist. I just used my wrist. It should flow freely. There. Now I'll tell you what is clonus. Clonus is great five reflexes. Nowadays they call it clonus. Can you sit down? Exaggerated reflex. Suppose a person has got a very exaggerated reflex. You can hang your leg down. If the person has got a very exaggerated reflex. So exaggerated that even by touching the tendal alginus, it moves very briskly. I can elicit something called clonus. And I'll show it to you how to do it. That happens when the person has got a corticospinal, dense corticospinal tract lesion. Very high degree of deep tendon reflex. I just rapidly dorsiflex his foot. Like this. You keep it relaxed. I just rapidly, even now I elicit a little bit. I rapidly do it and it'll start flapping a few times. That is called clonus. That is, some books call it great five. So this was the tendo. Calcaneus. Now I'm going to demonstrate. The knee jerk reflex. That's normal when it flaps. No, it should not. That's exaggerated. Average normal is two plus. Three plus is brisk. And five is clonus. Okay. Knee jerk. Again, the procedure. Watch very carefully. I think I'm going to use her for this. Because I'll show you. This is the place where you might have to do the gender six maneuver. What is the gender six maneuver? Remember? You have to ask the person to clench. You can see it in the previous slide. There. No, the ones before that. There. The top picture. Hook the fingers. Pull them apart. And ask the person to clench his teeth. That way you're increasing the gamma discharge. So we might ask you, okay. Let's say this person has got a very weak reflex. How will you exaggerate it? You will ask the person to. So we'll demonstrate both in this slide. Okay. Can you hook your fingers? Like this. Pull it apart hard. And clench your teeth. Clench your teeth and pull your fingers apart. Yes. This is the way we have increased the gender six maneuver. So, okay. I'm going to tell you when to do that. Now, can I ask you to cross your right leg over your left knee? Yes. First step. Again, tell the patient to relax. Many patients would try to keep it stiff. They are invariably stiff and the doctor is examining them. That's called the white coat syndrome. So, relax. Absolutely relax. The legs should be hanging freely. Now, you ask the person to do gender six maneuver. Let's assume that she's got a very weak reflex and I won't increase it. Can you do that, please? Feel the ligamentum patellae between these two bones. Which are the two bones? The patellae here and the tibial tuberosity here. The patellae here and the tibial tuberosity. Exactly midway between the two is the ligamentum patellae and that's exactly where we are going to hit. Keep it relaxed, absolutely. Again. Okay. Now, relax. Release this. So, now I've removed the gender six maneuver. I'm just demonstrating it to you. Relax. See the difference? It was there, but it was milder. When she did the gender six, it became exaggerated. Yes? Do the other one, please. Can you cross over the other leg, please? Keep it relaxed. You might have to spend a few seconds to tell the patient. Relax, relax. And when you tell them, invariably, they relax. I can feel her muscles relaxing. Patients always tend to tense up. Okay. Feel the ligamentum patellae between these two bony prominences. The patellae here, tibial tuberosity here. Can all of you see? Okay. You just have to do it once very gently. It will happen. Now, please do that. Gender six maneuver. Of course, patient does not know it's gender six. You'll have to explain to the patient what it is. Again, feel. Keep it relaxed. You see? Visibly how it differs. Gender six maneuver does this job. So this is the one. And now I'm going to do that. That's crazy. Later. I don't have a sharp object. So I'm going to use my key. I'm going to use my key. Stay. Can you go back? Exact procedure for doing the planter. I'm sorry. You have to start from the lateral aspect of the soul. The lateral aspect of the soul. And go from the heel. Go all the way up to the head of the meditarsals. And then turn medially. So this will be the procedure. Put a hand on the lower leg. Lateral aspect of the soul. And go deliberately. So this is the planter response. Normal. Normal planter response. All the toes with the planter flex. And the abnormal one you know. Do you see flexion is a great tool? Again, do it on the other side. Planter response. Can I do the last one on you? If you don't mind. Just lift up your... Can you lift up this? Are you feeling embarrassed? It's alright. The abdominal is shown there. Abdominal you have to open. He has a six-pack. It's alright. Anybody volunteering for the abdominal reflex? You go from the lateral to the medial. Along the rib cage. You go from lateral to medial. Search. Search. There is a six-pack. Come on. You have a six-pack. You just go from lateral to medial. Along the rib cage. Lateral to medial. Ah, there. He's the man. No, just lift it up. You have to lie down. Because the abdominal reflex is tested lying down. For obvious reasons, we are not going to do the cremastery reflex. And we are not going to do the anal to stick to the rib cage. Again, as a person to be relaxed. Keep your head down. Keep it relaxed. So this is the rib cage. This is the inguinal ligament. Go from lateral. Keep it relaxed. Absolutely relaxed. Go from the lateral. See, you saw the contraction. Again, go from lateral. There. So this is 789. This is 10. 1112. So that's the abdominal reflex. And of course other two reflexes are cremaster and anal reflexes.