1 and 2 Touch and light pressure are transmitted in the dorsal columns to the postcentral cortex. Initially they are tested by finger contact over the affected area. More detailed mapping is with a wisp of cotton wool or an artist's paint- brush. Let the patient watch while the stimulus is applied, to ensure a positive response is appreciated, and compare it with the contralateral side.3 Two blunt points are distinguished as separate contacts at varying dis- tances in different parts of the body: lips and tongue 2-3mm; fingertips 3-5mm; dorsum of fingers 4—6mm; palm 8—15mm; dorsum of hand 20-30mm; dorsum of feet 30-40mm; back 40-50mm.i 4 Pain and temperature are carried to the level of sensory awareness in the spinothalmic tracts. The former is test- ed with a sterile pin or a partially blunted 21 gauge needle, the patient being asked to respond to each con- tact, stating whether dull or sharp.5 and 6 For gross temperature differences, compare the warmth of the outer side of the little finger with the cold of the side of a tuning fork. More precise mapping is with test tubes of cold and warm water. Temperature changes may be more consistent than those of pinprick. Mapping follows the same routine to that described for touch.7 and 8 Vibration sense is assessed by applying the base of a clinical tuning fork to a bony prominence. The stimulus is generated by the examiner lightly tapping the fork on his/her hypothenar eminence. Strike the tuning fork before each application and ask the patient, with his eyes closed, whether the vibration is present and when it stops. Occasionally, deliberately stop the tuning fork to assess accuracy in response.9 The feet are particularly important to assess in the diabetic patient for dis- tal neuropathy.10 Graphasthesia is assessed by writing numbers or letters on each palm or forearm and the anterior compartment of each shin. Use a blune object, such as the blunt end of a pen or pencil. With the patient's eyes closed, give examples for otientation and then assess: the numbers 3 and 8 are useful stimuli.11 Sensory inattention, typical of pari- etal lobe lesions, is elicited by the simultaneous application of stimuli on the two halves of the body, The patient has his eyes closed and occasionally only one side is touched.14 A useful initial test of neurological function of the upper limbs, including position sense, power and coordina- tion, is to ask the subject to extend both forearms with the palms upwards and eyes closed, and observe any unconscious drift.15 Romberg’s sign is assessed by ask- ing the patient to stand upright with feet together and eyes closed, the examiner guarding against any fall. An initial gentle sway of the body is nor- mal but in abnormalities of dorsal col- umn function, the subject is unable to stand unaided.16 Antetior aspect of the body: cutan- cous dermatomes: the bold lines indi- cate axial lines.17 Posterior aspect of the body: cutaneous dermatomes: the bold lines indicate axial lines.Tone 18 Tone is assessed in the upper and lower limbs by passive movement of the major joints. With the patient in a relaxed state, there should be minimal resistance to passive movement. Minor changes may be accentuated by re- questing the subject to perform other activities simultaneously, such as mov- ing the contralateral arm or leg and clenching their teeth.19 and 20 Palpating the bulk of muscles, such as the gluteus maximus or the erector spinae group, also provides information on their tone.21 A measure of the power of spinal flexion can be obtained by asking the subject to raise his head and shoulders off the couch while supporting his thighs. Resistance can be added by pressure applied to the sternum. In resisted movements, the subject is asked to prevent the examiner from moving the part away from a fixed position.35 to 38 Resist flexion, extension and abiuction, gripping by adduction of the Fingers39 to 42 Resisted opposition, extension, abduction and adduction of the thumb.55 to 57 Resisted toc movements. Flexion, extension and abduction. The power of dorsiflexion of the great toe is 2 useful test of the LS i58 and 59 Coordination of upper limb movements is assessed by alternatively touching an examiner's finger and the subject's nose. ‘The examiner moves the finger from side to side or leaves it in position and asks the patient to repeat the movement with closed eyes. ‘The patient is also asked to describe circles and fig- ures with the outstretched arm, or screw up imaginary jam jars,60 and 61 Fine movements can be assessed by tapping the dorsum of the con- tralateral hand alternatively with the front and back of the fingers.62 to 64 In the lower limb each heel can be placed in turn on the contralat- eral shin and moved from knee to ankle and back, or from knee to ankle and on to a strategically placed finger.65 Also, describing circles with the great toe or, with closed eyes, to ‘shoot’ the passively moved foot with two fin- gers.66 Disturbances of gait can be accen- tuated by asking the subject to walk in a straight line and repeat this heel to toe fashion. Ataxia (incoordination of gait) may be due to altered state of Consciousness (e.g, excess alcohol, head injury, upper motor neurone spastici- ty), altered tone of cerebellar and basal ganglia disease and abnormalities of sensory input, where the subject is unaware of the position in space.67 and 68 Standing on toes and heels are further tests of coordination, but also depend on position sense, muscle power and normal joints. The altered coordi- nation of cerebellar disease is characteristically slow, awkward and incomplete, requiring a few tries to complete a movement and is termed dysdiadochokinesis.69 and 70 In hyper-reflexia, stimulation of one muscle may produce movements elsewhere, e.g. antagonists or more distant muscle. In marked hypet-reflexia, ten- sion on the muscle alone may produce reflex contraction, or sustained tension repeated jerking movement (clonus), as demonstrated by patellar and ankle clonus.71 Pectoralis major reflex.72 Triceps reflex.73 Biceps reflex.74 Supinator reflex.75 Finger jerk.76 Hoffman reflex.77 Knee jerk.78 and 79 Ankle jerk.82 outing refs. 84 OF che superficial rexponses, the Babinski is routinely examined. Ie is elicited by scratching the outer edge of the sole fom the heel forwards with 3 keey of other implement, a normal response being curing downwards of the toes A positive (abnormal) Bab ink’ response i extension and fanning, ofthe toes this fs present at beth but, aleer this time, is indicative of an "upper motor neurone lesion.85 Abdominal reflexes are elicited by scratching diagonally across the four quadrants, each producing contraction of the underlying abdominal muscula- ture.87 Some reflexes are most prominent at birth. These are the grasp reflex, produced by stroking the palm, and the placing reaction of the sole, pro- duced by touching the outer border of the dependent foor.88 The palmo-mental reflex is the movement of the angle of the mouth on scratching the ipsilateral hypothenar eminence.89 and 90 At the end of motor system examination check for neck rigidity (Kernig's sign) by raising the patient's head off the bed. Neck stiffness can also be elicited by simultaneous neck and straight leg raising or by bending the hip to a right angle with bent knee and then straightening the leg in this position.