DOCSLIB.ORG

Spinal Reflexes MS

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Spinal Reflexes MS Spinal reflexes MS. DOROTHY These consist of three elements: • sensory neurones • connector neurones in the spinal cord • lower motor neurones. REFLEXES A reflex action is an immediate motor response to a sensory stimulus. results from a nerve impulse passing over a reflex arc is called a reflex ; it is a predictable response to a stimulus. It may or may not be conscious. Many connector and motor neurones may be stimulated by afferent impulses from a small area of skin, e.g. the pain impulses initiated by touching a very hot surface with the finger are transmitted to the spinal cord by sensory nerves Usually the term is used to mean only involuntary responses rather than those directly willed; that is, involving cerebral cortex activity. If the centre of a reflex arc is in the brain, the response it mediates is called a cranial reflex. If the centre of a reflex arc is in the spinal cord, the response is called a spinal reflex . These stimulate many connector and lower motor neurones in the cord which results in the contraction of many skeletal muscles of the hand, arm and shoulder, and the removal of the finger. Reflex action takes place very quickly, in fact, the motor response may have occurred simultaneously with the perception of the pain in the cerebrum. Reflexes of this type are invariably protective but they can on occasion be inhibited. For example, if it is a precious plate that is very hot when lifted every effort will be made to overcome the pain to prevent dropping it! TYPES OF REFLEXES OF CLINICAL IMPORTANCE The following reflexes are frequently tested: 1. knee jerk 2. ankle jerk 3. Babinski reflex 4. corneal reflex 5. abdominal reflex KNEE JERK REFLEX It is an example of a stretch reflex ( it is also called deep tendon reflexes).It is also known as the patellar reflex It is an extension of the lower leg in response to tapping of the patellar tendon. The tap stretches the tendon and its muscles, the quadriceps femoris, and thereby stimulates muscle spindles (receptors) in the muscle and initiates conduction over the following two-neuron reflex arc: Tapping the patellar tendon elicits the knee jerk (L 2,3,4), a stretch reflex of the quadriceps femoris muscle, because the tap on the tendon stretches the muscle. A similar contraction is observed if the quadriceps is stretched manually. When a skeletal muscle with an intact nerve supply is stretched suddenly, it contracts. This response is called the stretch reflex. It is a type of monosynaptic reflex. The knee jerk reflex is an example of a deep tendon reflex (DTR) in a neurological exam and is graded on the following scale: 0 (absent), 1+ (hypoactive), 2+ (brisk, normal), 3+ (hyperactive without clonus), 4+ (hyperactive with mild clonus), and 5+ (hyperactive with sustained clonus). Absence of the knee jerk can signify an abnormality anywhere within the reflex arc, including the muscle spindle, the Ia afferent nerve fibers, or the motor neurons to the quadriceps muscle. In general the afferent loop is much more critical for reflex function than the efferent loop, so that unless the muscle is almost paralysed, loss of reflexes suggests a sensory nerve or root lesion rather than a motor nerve lesion. The most common cause is a peripheral neuropathy from such things as diabetes, alcoholism, and toxins. Increased tendon reflex activity suggests increased excitability of the anterior horn cells in the spinal segment of the stretched muscle due to loss of descending inhibition with a UMN( upper motor neurone) or corticospinal tract lesion. Brisk reflexes alone, however, are not necessarily pathological and usually result from anxiety. In hypothyroidism both the contraction and the relaxation phases of the tendon reflex may be prolonged, resulting in 'hung-up' reflexes. In cerebellar ataxia the reflexes may be 'pendular': there are oscillatory limb movements after the initial reflex associated with 'loose' tone The knee jerk can be classified in various ways as follows: • As a spinal cord reflex—because the center of the reflex arc lies in the spinal cord gray matter • As a segmental reflex—because impulses that mediate it enter and leave the same segment of the cord • As an ipsilateral reflex—because the impulses that mediate it come from and go to the same side of the body • As a stretch reflex or myotatic reflex— because of the kind of stimulation used to evoke it As an extensor reflex—because it is produced by extensors of the lower leg • As a tendon reflex—because tapping of a tendon is the stimulus that elicits it • As a deep reflex—because of the deep location of the receptors stimulated to produce this reflex ANKLE JERK REFLEX Ankle jerk reflex, or Achilles reflex, is an extension (plantar flexion) of the foot in response to tapping of the Achilles tendon. As with the knee jerk, it is a tendon reflex and a deep reflex mediated by two neuron spinal arcs. The centers for the ankle jerk lie in the first and second sacral segments of the cord. The ankle jerk reflex, also known as the Achilles Reflex, occurs when the Achilles tendon is tapped while the foot is dorsi-flexed. A positive result would be the jerking of the foot towards its plantar surface. Being a deep tendon reflex, it is monosynaptic. It is also a stretch reflex. These are monosynaptic spinal segmental reflexes. When they are intact, integrity of the following is confirmed: cutaneous innervation, motor supply, and cortical input to the corresponding spinal segment. The Achilles reflex checks if the S1 and S2[3] nerve roots are intact and could be indicative of sciatic nerve pathology. It is classically delayed in hypothyroidism. This reflex is usually absent in disk herniations at the L5—S1 level. A reduction in the ankle jerk reflex may also be indicative of peripheral neuropathy. .
Load more

Recommended publications
  • Correlation of Electrodiagnostic and Clinical Findings in Unilateral S1 Radiculopathy
    Neurol. Croat. Vol. 65, 1-4, 2016 Correlation of electrodiagnostic and clinical findings in unilateral S1 radiculopathy Seyed Mansoor Rayegani, Navid Rahimi, Elham Loni, Shahram Rahimi Dehgolan, Leyla Sedighipour ABSTRACT – Objectives: Lumbosacral radiculopathy is a challenging diagnosis and electrodiagnostic study (EDX) is a good complementary test to magnetic resonance imaging (MRI). Physical examination, MRI and electrodiagnosis have different diagnostic value in this regard. MRI can provide anatomical evidence and is 3 useful in choosing the treatment procedure, but it may also yield false-positive results. In this study, we as- 1-4, 2016 Number sessed the correlation of clinical and EDX findings in patients with L5-S1 disc herniation on MRI.Methods: EDX was performed in 87 patients referred for clinical and MRI diagnosis of S1 radiculopathy. The consist- ency of EDX results with MRI and clinical findings was evaluated by Pearson 2χ -test and odds ratio. Results: Disc protrusion was present in 58% and disc extrusion in 42% of patients. Physical examination revealed absent Achilles reflex in 83% and decreased S1 dermatome sensation in 65% of patients. In this study, EDX sensitivity was about 92%. The highest consistency between EDX parameters and physical examination find- ings was recorded between absent H-reflex and decreased Achilles reflex (OR=6.20; p=0.014), but there was no significant consistency between H-reflex and either muscular weakness or straight leg raising test result (p>0.05). There was no relationship between the type of disc herniation on MRI and H-reflex either. There was correlation between H-reflex abnormalities and absent ankle reflex in patients with unilateral L5-S1 disc herniation on MRI.
    [Show full text]
  • Theoretical Part Recruitment and Summation in Skeletal Muscle
    name number study group Theoretical part Recruitment and summation in skeletal muscle Myography and electromyography Myography is a method for recording skeletal muscle contractions. On the contrary, electromyography (EMG) is a method registering the electric activity produced by skeletal muscle. Muscle fibre Each individual skeletal muscle cell (or myocyte or fiber) contains a dense parallel array of smaller, cylindrical elements called myofibrils that have the diameter of a Z disk (Figure 1). Each of these myofibrils comprises repeating units, or sarcomeres, that consist of smaller interdigitating filaments called myofilaments. These myofilaments come in two types, thick filaments composed primarily of myosin and thin filaments composed primarily of actin. The sarcomere extends from one Z disk to another. Sarcomeres stacked end to end make up a myofibril. The repeating sarcomeres are most highly organized within skeletal and cardiac muscle and impart a striped appearance. Thin filaments are 5 to 8 nm in diameter and, in striated muscle, 1 μm in length. In striated muscle, the thin filaments are tethered together at one end, where they project from a dense disk known as the Z disk. The Z disk is oriented perpendicular to the axis of the muscle fibre; thin filaments project from both its faces. Not only do Z disks tether the thin filaments of a single myofibril together, but connections between the Z disks also tether each myofibril to its neighbours. These interconnections align the sarcomeres and give skeletal and, to a lesser extent, cardiac muscle its striated appearance. The thick filaments are 10 nm in diameter and, in striated muscle, 1.6 μm in length.
    [Show full text]
  • Cortex Brainstem Spinal Cord Thalamus Cerebellum Basal Ganglia
    Harvard-MIT Division of Health Sciences and Technology HST.131: Introduction to Neuroscience Course Director: Dr. David Corey Motor Systems I 1 Emad Eskandar, MD Motor Systems I - Muscles & Spinal Cord Introduction Normal motor function requires the coordination of multiple inter-elated areas of the CNS. Understanding the contributions of these areas to generating movements and the disturbances that arise from their pathology are important challenges for the clinician and the scientist. Despite the importance of diseases that cause disorders of movement, the precise function of many of these areas is not completely clear. The main constituents of the motor system are the cortex, basal ganglia, cerebellum, brainstem, and spinal cord. Cortex Basal Ganglia Cerebellum Thalamus Brainstem Spinal Cord In very broad terms, cortical motor areas initiate voluntary movements. The cortex projects to the spinal cord directly, through the corticospinal tract - also known as the pyramidal tract, or indirectly through relay areas in the brain stem. The cortical output is modified by two parallel but separate re­ entrant side loops. One loop involves the basal ganglia while the other loop involves the cerebellum. The final outputs for the entire system are the alpha motor neurons of the spinal cord, also called the Lower Motor Neurons. Cortex: Planning and initiation of voluntary movements and integration of inputs from other brain areas. Basal Ganglia: Enforcement of desired movements and suppression of undesired movements. Cerebellum: Timing and precision of fine movements, adjusting ongoing movements, motor learning of skilled tasks Brain Stem: Control of balance and posture, coordination of head, neck and eye movements, motor outflow of cranial nerves Spinal Cord: Spontaneous reflexes, rhythmic movements, motor outflow to body.
    [Show full text]
  • In the Name of God the Compassionate and the Merciful
    In the Name of God the Compassionate and the Merciful Cutaneomuscular Reflexes in the Lower Limbs in Man A Thesis Submitted for the Degree of Doctor of Philosophy in the Faculty of Medicine by Hossein-Bagheri BSc and MSc in Physiotherapy April 1995 Division of Neuroscience and Biomedical Systems, Institute of Biomedical Life Sciences, University of Glasgow ProQuest Number: 11007741 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a com plete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest ProQuest 11007741 Published by ProQuest LLC(2018). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States C ode Microform Edition © ProQuest LLC. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 g la s s o w r DNivEfiajr? library Dedicated to my wife and children Dedicated to my father who passed away during my Ph.D course i Contents Page List of contents i List of figures vi List of tables ix Abbreviations xi Acknowledgement xiii Declaration and list of publications xiv Summary xv 1. Introduction 1 1.1 General history 1 1.2 Techniques for identifying spinal reflexes 3 Monosynaptic testing 3 H-reflex 3 Spinal proprioceptive reflexes 4 Single motor unit EMG recording 4 Peristimulus time histogram 5 Surface
    [Show full text]
  • Development of the Flexion Withdrawal Reflex
    Spinal sensory processing in the human infant: Development of the flexion withdrawal reflex Laura Louise Cornelissen Thesis submitted for the degree of Doctor of Philosophy University College London 2011 1 Declaration The work in this thesis was conducted in the Department of Neuroscience, Physiology and Pharmacology at University College London, and in the Elizabeth Anderson and Obstetrics Wing at University College Hospital. I, Laura Louise Cornelissen, confirm that the work presented in this thesis is my own. Where other information has been derived from other sources, I confirm that this has been indicated in the thesis. Laura Louise Cornelissen March 2011 2 Abstract Immature spinal sensory reflexes have lower mechanical thresholds and are poorly coordinated and exaggerated compared to adult reflexes. However, little quantitative data is available on how these spinal sensory circuits develop in the human infant. This thesis investigates the development of cutaneous flexion withdrawal reflexes in preterm and full- term human infants following noxious and non-noxious stimulation of the heel, and tests whether flexion withdrawal reflex activity is modulated by the commonly administered analgesic, oral sucrose, in a randomised controlled trial. The studies were undertaken in infants aged 28-45 weeks gestation (GA), in-patients at University College Hospital, London. The noxious stimulus was a clinically required heel lance; non-noxious stimulation was either a light touch of the heel or application of calibrated von Frey hairs to the heel. Flexion withdrawal reflex activity was recorded with surface EMG electrodes placed over the biceps femoris muscle. Video recordings of facial expression were recorded for clinical pain assessment.
    [Show full text]
  • Caregiver-Handbook-06-Health-1
    Health Communicable Diseases What is a Communicable Disease? A communicable disease is one that is spread from one person to another through a variety of ways that include: contact with blood and bodily fluids, breathing in an airborne virus, or by having contact with a little bug called lice. For the most part, communicable diseases are spread through viruses and bacteria that live in blood and body fluids. For instance, hepatitis and human immunodeficiency virus (HIV) are examples of infections that can be carried in blood and bodily fluids. On the other hand, tuberculosis is an airborne disease. A person with tuberculosis (TB) can spread tiny germs that float in the air if they cough or sneeze without covering their nose or mouth. And, there are some communicable diseases like head lice that are caused by a live lice bug that is spread by using an infected comb or wearing a hat that is infested with lice. For more information about how to reduce potential exposure to communicable diseases, see Section 7. Let’s take a closer look at some communicable diseases. Page 6-2 - 53 - Head Lice How is Head Lice Spread? Head lice can infest people of all ages and economic standing. Head to head contact or simple exchange of hats, clothing, combs and other personal items can lead to the transmission of lice from one person to another. Head lice are contagious. If someone you know has head lice, do not panic. Caregiving Tips: 1. Inspect for Lice and Nits Using a magnifying glass and natural light, carefully examine hair, scalp, sideburns, eyebrows, beards and mustaches of all household members for lice and their eggs, called “nits.” Nits, which are yellowish-white in color and oval shaped, can be easier to locate than lice.
    [Show full text]
  • The Phenomenon of Multiple Stretch Reflexes
    Henry Ford Hospital Medical Journal Volume 34 Number 1 Article 6 3-1986 The Phenomenon of Multiple Stretch Reflexes Robert D. Teasdall Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Teasdall, Robert D. (1986) "The Phenomenon of Multiple Stretch Reflexes," Henry Ford Hospital Medical Journal : Vol. 34 : No. 1 , 31-36. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol34/iss1/6 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. The Phenomenon of Multiple Stretch Reflexes Robert D. Teasdall, MD* Multiple stretch reflexes occur in muscles adjacent to or remote from the tap. The response may be ipsilateral or bilateral. These reflexes are encountered not only in normal subjects with brisk stretch reflexes but particularly in patients with lesions of the upper motor neuron. The concussion obtained by the blow is conducted along bone to muscle. Muscle spindles are stimulated, and in this manner independent stretch reflexes are produced in these muscles. This mechanism is responsible for the phenomenon of multiple stretch reflexes. The thorax and pelvis play important roles in the contralateral responses by transmitting these mechanical events across the midline. (Henry FordHosp Med J 1986;34:31-6) ontraction of muscles remote from the site of f)ercussion is Head and neck Cencountered in patients with brisk stretch reflexes.
    [Show full text]
  • Clinical Tests and Differential Diagnosis of Cervical Spondylotic Myelopathy 39
    Clinical Tests and Differential Diagnosis of Cervical 05 Spondylotic Myelopathy Jesus Lafuente Introduction MRI, and clinical symptoms is essential for a correct diagnosis. Anterior-posterior width Cervical spondylotic myelopathy (CSM) is reduction, cross-sectional evidence of cord a disabling disease caused by a combina- compression, obliteration of the subarach- tion of mechanical compression and vascu- noid space, and signal intensity changes to lar compromise of the spinal cord. It is the the cord found on MR imaging are consid- most common cause of spinal dysfunction ered the most appropriate parameters for in older patients.1 The onset is often insidi- confirmation of a spinal cord compression ous with long periods of episodic, stepwise myelopathy.4 In some occasions when the progression and may present with different diagnosis is still not clear, the use of other symptoms from one patient to another.2 CSM studies could help, such as diagnostic elec- is a clinical diagnosis that may involve broad- trophysiology and cerebrospinal fluid (CSF) based gait disturbances first, associated with examination. weakness of the legs, and then spasticity.3 As spinal cord degeneration progresses, lower motor neuron findings in the upper extremi- Clinical Tests ties, such as loss of strength, atrophy, and CSM is the most common cause of spinal difficulty in fine finger movements, may cord dysfunction in the world. A meticu- present.3 Additional clinical findings may lous physical examination of patients with include: neck stiffness, shoulder pain, pares- cervical pathology can relatively make the thesia in one or both arms or hands, radicu- distinction between radiculopathy or mye- lopathy, a positive Hoffman and/or Babinski lopathy easy.
    [Show full text]
  • LETTERS to the EDITOR Calf Muscle Hypertrophy
    Clinical Neuropathology, Vol. 37 – No. 3/2018 – Letters to the editor 146 LETTERS TO THE EDITOR sias in the right foot and continuous calf pain. Routine blood tests, including sedimentation rate, C-reactive protein, eosinophil count, Calf muscle hypertrophy thyroid hormones, liver enzymes, and cry- following S1 radiculopathy: ocrit were within normal ranges. ANA-ENA screening and search for neurotrophic vi- Letter A stress disorder caused by ruses were negative. Serum creatine kinase ©2018 Dustri-Verlag Dr. K. Feistle hyperactivity with variable (CK) was increased (520 UI/L). ISSN 0722-5091 response to treatment Needle electromyography (EMG) showed DOI 10.5414/NP301093 e-pub: February 16, 2018 marked abnormalities consisting of continu- Nila Volpi1,2, Federica Ginanneschi1,2, ous complex repetitive discharges (CRDs), Alfonso Cerase1,3, Salvatore Francesco polyphasic motor unit potentials with reduced Carbone4, Margherita Aglianò1, voluntary recruitment in the right gastroc- Paola Lorenzoni1, Matteo Bellini3, nemius muscle. EMG recordings of right Sabina Bartalini2, Giovanni Di Pietro5, tibialis anterior, quadriceps femoris, gluteus and Alessandro Rossi1,2 maximum, and adductor magnus muscles were unremarkable. 1Department of Medical, Surgical, and Magnetic resonance imaging (MRI) (Fig- Neurological Sciences, University of ure 1) showed a volume increase of right leg Siena, 2Unit of Neurology and Clinical posterior muscles, more evident on soleus Neurophysiology, 3Unit of Neuroradiology, and medial gastrocnemius, with intrafascial 4Unit of Diagnostic Imaging, and edema and mild hypervascularization of hy- 5Unit of Neurosurgery, University pertrophic muscles. Hospital Santa Maria alle Scotte, Lumbosacral spinal MRI and computed Siena, Italy tomography (Figure 1) evidenced diffuse de- generative disease of the lumbar spine and a L5-S1 right paramedian posterior disc herni- Sir, – Neurogenic focal muscle hyper- ation compressing the ipsilateral S1 radicular trophy (NMH) is a rare event in different sheath and S1 nerve root.
    [Show full text]
  • Correlation of Electrodiagnostic and Clinical Findings
    ORIGINAL ARTICLE Correlation of Electrodiagnostic and Clinical Findings in Unilateral S1 Radiculopathy Seyed Mansoor Rayegani1,2, Seyed Ahmad Raeissadat1,3, Elham Loni4, Navid Rahimi1,2, Shahram Rahimi-Dehgolan5, Leyla Sedighipour1,2 1 Department of Physical Medicine and Rehabilitation, Physical Medicine and Rehabilitation Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2 Shohada Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3 Clinical Development Research Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 4 Department of Physical Medicine and Rehabilitation, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran 5Department of Physical Medicine and Rehabilitation, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran Received: 20 Jan. 2018; Accepted: 15 Dec. 2018 Abstract- Lumbosacral radiculopathy is a challenging diagnosis, and Electrodiagnostic study (EDX) is a good complementary test for Magnetic Resonance Imaging (MRI). Physical examination, MRI and electrodiagnosis have different diagnostic values in this regard. MRI can provide anatomical evidence and is useful in choosing a treatment process, but it could also have false positive results. In this study, we assessed the correlation of clinical and electrodiagnostic findings in patients with positive MRI findings for S1 radiculopathy. EDX was performed for 87 patients referred with clinical and MRI diagnosis of S1 radiculopathy. The consistency between EDX results, MRI, and clinical findings were evaluated by Pearson chi 2 and odds ratio. Fifty-eight percent of patients had disc protrusion, and 42% had extrusion. Physical examination revealed absent Achilles reflex in 83% and decreased S1 dermatome sensation in 65%. In this study, EDX sensitivity was about 92%.
    [Show full text]
  • Testing the Reflexes
    Page 1 of 6 ESSENTIALS Testing the reflexes 1 2 A J Lees neurologist , Brian Hurwitz former general practitioner 1The National Hospital, Queen Square, London WC1N 3BG, UK; 2King’s College London, London WC2B 6LE, UK with muscles via the nerve roots, plexuses, peripheral nerves, What you need to know and neuromuscular junction) and an upper motor neurone lesion • Tendon reflex testing allows lower and upper motor neurone lesions to (due to damage upstream from the anterior horn cell, including be distinguished reliably the corticospinal tracts, the brain stem, and motor cortex). This • Interpret reflexes alongside a clinical history and any abnormalities of distinction is the first stage in locating the site of neurological power, tone, and sensation found on examination damage. • Reflex testing is essential if you suspect spinal cord and cauda equina compression, acute cervical or lumbar disc compression, or acute There are situations where all the neurological symptoms occur inflammatory demyelinating polyradiculoneuropathy above the neck (such as bulbar symptoms due to motor neurone disease) where reflex testing is also essential. Eliciting the deep tendon reflexes is a vital component of Box 1 lists some clinical scenarios where testing the deep tendon medical assessments in general practice (where 9% of medical reflexes is discriminatory when coming to a diagnosis. problems are believed to be neurological in origin1) and in hospital (where 10-20% of admissions have a primary Box 1: Presentations in general practice where tendon reflex
    [Show full text]
  • Chiropractic Examination of an Infant. the Clinical Value of a Comprehensive Patient History and Thorough Physical Examination Must Never Be Underestimated
    The 8 Step (10 minute) Chiropractic Examination of an Infant. The clinical value of a comprehensive patient history and thorough physical examination must never be underestimated. However, an initial consultation with the child is far more than just a clinical experience and an information-gathering process. Your ability to connect with the patient and the parents plays a significant role in the outcome achieved with your paediatric patient. Your ability to examine the infant in a smooth, professional and time efficient manner is often essential to your ability to achieve the very best clinical outcome with that infant. This article details a procedure we have used with infants in our practice for many years. We hope this helps you with your assessment of children. Dr. Glenn Maginness B.App.Sc(Chiro) MCSc(Paeds) Dr. Hayley Maginness B.H.Sc.Chiropractic M.ClinChiropractic Dr. Brianna Maginness B.Health.Sc B.App.Sc(Chiro) Be Confident! The examining of any child, regardless of their age, must be a procedure that not only you feel comfortable with but also, just as importantly, you must be perceived by the parents as being comfortable with. Examining the baby is a procedure that you must perform as if you have done it 1000 times before. For this reason, prior to the examination, I would encourage you to nurse the baby for a few moments. During the history taking, the baby may be in a capsule or a pram. Once the history is completed and you are ready to conduct the examination, it can be a wonderful way to connect with the child and the parents, to physically get the baby out of the capsule or pram and spend a few moments holding the child.
    [Show full text]