Teaching the Neurological Examination in a Rapidly Evolving Clinical Climate

James M. Hillis; Tracey A. Milligan

doi:10.1055/s-0038-1667135

Seminars in Neurology, Table of Contents

Semin Neurol 2018; 38(04): 428-440
DOI: 10.1055/s-0038-1667135

Review Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Teaching the Neurological Examination in a Rapidly Evolving Clinical Climate

James M. Hillis

¹Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts

,

Tracey A. Milligan

¹Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts

› Author Affiliations

Abstract

The neurological examination remains the essence of neurology. It allows symptoms to be assessed, diagnoses to be made, and dynamic functions to be followed. Skill in the neurological examination has faced increasing challenges from the encroachment of diagnostic imaging, but has maintained its clinical utility. It has also encountered the battle for the precious time within a medical curriculum. This review considers how the neurological examination can best be taught into the future. It does so by considering factors related to the examination, the learner, the teacher, and the modern clinical environment.

Keywords

clinical examination - neurology service - feedback - technology

Full Text

References

References
1 Boes CJ. History of neurologic examination books. Proc Bayl Univ Med Cent 2015; 28 (02) 172-179
2 Sackett DL, Rennie D. The science of the art of the clinical examination. JAMA 1992; 267 (19) 2650-2652
3 Wiles CM. Introducing neurological examination for medical undergraduates--how I do it. Pract Neurol 2013; 13 (01) 49-50
4 Campbell WW, DeJong RN. DeJong's the Neurologic Examination. In: Campbell WW. , ed. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013
5 American Academy of Neurology, Association of University Professors of Neurology, American Neurological Association. Neurology Clerkship Core Curriculum Guidelines. 2000. Available at: https://www.aan.com/siteassets/home-page/tools-and-resources/academic-neurologist–researchers/clerkship-and-course-director-resources/neurology-clerkship-core-curriculum-guidelines.new.pdf . Accessed February 18, 2018
6 Association of American Medical Colleges. Recommendations for Preclerkship Clinical Skills Education for Undergraduate Medical Education. 2008. Available at: https://www.aamc.org/download/130608/data/clinicalskills_oct09.qxd.pdf.pdf . Accessed December 5, 2017
7 Association of American Medical Colleges. Recommendations for Clinical Skills Curricula for Undergraduate Medical Education. 2005. Available at: https://members.aamc.org/eweb/upload/Recommendations%20for%20Clinical%20Skills%20Curricula%202005.pdf . Accessed December 5, 2017
8 Craige E. Should auscultation be rehabilitated?. N Engl J Med 1988; 318 (24) 1611-1613
9 Ende J, Fosnocht KM. Clinical examination: still a tool for our times?. Trans Am Clin Climatol Assoc 2002; 113: 137-150
10 Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA 1997; 278 (09) 717-722
11 Ziegler DK. Is the neurologic examination becoming obsolete?. Neurology 1985; 35 (04) 559
12 Ramani S, Ring BN, Lowe R, Hunter D. A pilot study assessing knowledge of clinical signs and physical examination skills in incoming medicine residents. J Grad Med Educ 2010; 2 (02) 232-235
13 Nicholl DJ, Appleton JP. Clinical neurology: why this still matters in the 21st century. J Neurol Neurosurg Psychiatry 2015; 86 (02) 229-233
14 Peitzman SJ, Cuddy MM. Performance in physical examination on the USMLE Step 2 Clinical Skills examination. Acad Med 2015; 90 (02) 209-213
15 Lee JD, Erickson JC, Short MW, Roth BJ. Education research: evaluating acute altered mental status: are incoming interns prepared?. Neurology 2008; 71 (18) e50-e53
16 Nicholl DJ, Yap CP, Cahill V, Appleton J, Willetts E, Sturman S. The TOS study: can we use our patients to help improve clinical assessment?. J R Coll Physicians Edinb 2012; 42 (04) 306-310
17 Roshan M, Rao AP. A study on relative contributions of the history, physical examination and investigations in making medical diagnosis. J Assoc Physicians India 2000; 48 (08) 771-775
18 Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med 1992; 156 (02) 163-165
19 Sandler G. Costs of unnecessary tests. BMJ 1979; 2 (6181): 21-24
20 Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. BMJ 1975; 2 (5969): 486-489
21 Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362 (9390): 1100-1105
22 Rich EC, Crowson TW, Harris IB. The diagnostic value of the medical history. Perceptions of internal medicine physicians. Arch Intern Med 1987; 147 (11) 1957-1960
23 Young MJ, Poses RM. Medical student perceptions of the value of the history and physical examination. J Med Educ 1983; 58 (09) 738-739
24 Chimowitz MI, Logigian EL, Caplan LR. The accuracy of bedside neurological diagnoses. Ann Neurol 1990; 28 (01) 78-85
25 Paley L, Zornitzki T, Cohen J, Friedman J, Kozak N, Schattner A. Utility of clinical examination in the diagnosis of emergency department patients admitted to the department of medicine of an academic hospital. Arch Intern Med 2011; 171 (15) 1394-1396
26 Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med 1999; 341 (21) 1590-1596
27 Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009; 40 (11) 3504-3510
28 Ahsan SF, Syamal MN, Yaremchuk K, Peterson E, Seidman M. The costs and utility of imaging in evaluating dizzy patients in the emergency room. Laryngoscope 2013; 123 (09) 2250-2253
29 Becker WJ, Findlay T, Moga C, Scott NA, Harstall C, Taenzer P. Guideline for primary care management of headache in adults. Can Fam Physician 2015; 61 (08) 670-679
30 Callaghan BC, De Lott LB, Kerber KA, Burke JF, Skolarus LE. Neurology Choosing Wisely recommendations: 74 and growing. Neurol Clin Pract 2015; 5 (05) 439-447
31 Callaghan BC, Kerber KA, Pace RJ, Skolarus LE, Burke JF. Headaches and neuroimaging: high utilization and costs despite guidelines. JAMA Intern Med 2014; 174 (05) 819-821
32 Morris Z, Whiteley WN, Longstreth Jr WT. , et al. Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ 2009; 339: b3016
33 Verghese A. Beyond measure: teaching clinical skills. J Grad Med Educ 2010; 2 (01) 1-3
34 Kravitz RL, Callahan EJ. Patients' perceptions of omitted examinations and tests: a qualitative analysis. J Gen Intern Med 2000; 15 (01) 38-45
35 Little P, Everitt H, Williamson I. , et al. Preferences of patients for patient centred approach to consultation in primary care: observational study. BMJ 2001; 322 (7284): 468-472
36 Benbassat J, Baumal R, Heyman SN, Brezis M. Viewpoint: suggestions for a shift in teaching clinical skills to medical students: the reflective clinical examination. Acad Med 2005; 80 (12) 1121-1126
37 Alexander EK. Perspective: moving students beyond an organ-based approach when teaching medical interviewing and physical examination skills. Acad Med 2008; 83 (10) 906-909
38 Ramani S. Applying the Holmes method to physical examination: the reflective exam. Med Teach 2015; 37: 787-788
39 Moore FG, Chalk C. The essential neurologic examination: what should medical students be taught?. Neurology 2009; 72 (23) 2020-2023
40 Lima MA, Maranhão-Filho P. What is the essential neurological examination?. Arq Neuropsiquiatr 2012; 70 (12) 939-941
41 Glick TH. Toward a more efficient and effective neurologic examination for the 21st century. Eur J Neurol 2005; 12 (12) 994-997
42 D'Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome?. JAMA 2000; 283 (23) 3110-3117
43 Kamel H, Dhaliwal G, Navi BB. , et al. A randomized trial of hypothesis-driven vs screening neurologic examination. Neurology 2011; 77 (14) 1395-1400
44 Bagai A, Thavendiranathan P, Detsky AS. Does this patient have hearing impairment?. JAMA 2006; 295 (04) 416-428
45 Goldstein LB, Simel DL. Is this patient having a stroke?. JAMA 2005; 293 (19) 2391-2402
46 Goldstein LB, Bertels C, Davis JN. Interrater reliability of the NIH stroke scale. Arch Neurol 1989; 46 (06) 660-662
47 Issenberg SB, McGaghie WC. Clinical skills training--practice makes perfect. Med Educ 2002; 36 (03) 210-211
48 Harden RM. What is a spiral curriculum?. Med Teach 1999; 21 (02) 141-143
49 Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 1993; 100 (03) 363-406
50 Whipple ME, Barlow CB, Smith S, Goldstein EA. Early introduction of clinical skills improves medical student comfort at the start of third-year clerkships. Acad Med 2006; 81 (10, Suppl): S40-S43
51 Moore FG, Chalk C. Improving the neurological exam skills of medical students. Can J Neurol Sci 2012; 39 (01) 83-86
52 Martens MJ, Duvivier RJ, van Dalen J, Verwijnen GM, Scherpbier AJ, van der Vleuten CP. Student views on the effective teaching of physical examination skills: a qualitative study. Med Educ 2009; 43 (02) 184-191
53 Lewis SL, Józefowicz RF, Kilgore S, Dhand A, Edgar L. Introducing the neurology milestones. J Grad Med Educ 2014; 6 (01) (Suppl. 01) 102-104
54 Accreditation Council for Graduate Medical Education, American Board of Psychiatry and Neurology. The Neurology Milestone Project. 2015. Available at: http://www.acgme.org/portals/0/pdfs/milestones/neurologymilestones.pdf . Accessed March 12, 2018
55 Long DM. Competency-based residency training: the next advance in graduate medical education. Acad Med 2000; 75 (12) 1178-1183
56 Frank JR, Danoff D. The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Med Teach 2007; 29 (07) 642-647
57 Schwartzstein RM, Roberts DH. Saying goodbye to lectures in medical school - paradigm shift or passing fad?. N Engl J Med 2017; 377 (07) 605-607
58 Prober CG, Khan S. Medical education reimagined: a call to action. Acad Med 2013; 88 (10) 1407-1410
59 Mangione S, Burdick WP, Peitzman SJ. Physical diagnosis skills of physicians in training: a focused assessment. Acad Emerg Med 1995; 2 (07) 622-629
60 McClelland DC. Human Motivation. Glenview, IL: Scott, Foresman; 1985
61 Atkinson JW, Heyns RW, Veroff J. The effect of experimental arousal of the affiliation motive on thematic apperception. J Abnorm Psychol 1954; 49 (03) 405-410
62 Winter DG. Power motivation revisited. In: Smith CP. , ed. Motivation and Personality: Handbook of Thematic Content Analysis. New York, NY: Cambridge University Press; 1992: 301-310
63 Borges NJ, Manuel RS, Elam CL, Jones BJ. Differences in motives between Millennial and Generation X medical students. Med Educ 2010; 44 (06) 570-576
64 Twenge JM. Generational changes and their impact in the classroom: teaching Generation Me. Med Educ 2009; 43 (05) 398-405
65 Roberts DH, Newman LR, Schwartzstein RM. Twelve tips for facilitating Millennials' learning. Med Teach 2012; 34 (04) 274-278
66 Berk RA. Teaching strategies for the next generation. Transformative dialogues: Teach Learn J 2009; 3 (02) 1-24
67 Evans SJ. Effective direct student observation strategies in neurology. Med Educ 2010; 44 (05) 500-501
68 Barry MJ, Edgman-Levitan S. Shared decision making--pinnacle of patient-centered care. N Engl J Med 2012; 366 (09) 780-781
69 LaCombe MA. On bedside teaching. Ann Intern Med 1997; 126 (03) 217-220
70 Muijtjens AM, Hoogenboom RJ, Verwijnen GM, Van Der Vleuten CP. Relative or absolute standards in assessing medical knowledge using progress tests. Adv Health Sci Educ Theory Pract 1998; 3 (02) 81-87
71 Wormald BW, Schoeman S, Somasunderam A, Penn M. Assessment drives learning: an unavoidable truth?. Anat Sci Educ 2009; 2 (05) 199-204
72 Kromann CB, Jensen ML, Ringsted C. The effect of testing on skills learning. Med Educ 2009; 43 (01) 21-27
73 McLachlan JC. The relationship between assessment and learning. Med Educ 2006; 40 (08) 716-717
74 Larsen DP, Butler AC, Roediger III HL. Test-enhanced learning in medical education. Med Educ 2008; 42 (10) 959-966
75 Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990; 65 (9, Suppl): S63-S67
76 Dreyfus SED, Dreyfus HL. A five-stage model of the mental activities involved in directed skill acquisition. University of California Berkeley; 1980. Available at: http://www.dtic.mil/dtic/tr/fulltext/u2/a084551.pdf . Accessed December 25, 2017
77 Wilkerson L, Lee M. Assessing physical examination skills of senior medical students: knowing how versus knowing when. Acad Med 2003; 78 (10, Suppl): S30-S32
78 Williams RG, Klamen DL, Mayer D, Valaski M, Roberts NK. A sampling strategy for promoting and assessing medical student retention of physical examination skills. Acad Med 2007; 82 (10, Suppl): S22-S25
79 Srinivasan M, Li ST, Meyers FJ. , et al. “Teaching as a Competency”: competencies for medical educators. Acad Med 2011; 86 (10) 1211-1220
80 McLean M, Cilliers F, Van Wyk JM. Faculty development: yesterday, today and tomorrow. Med Teach 2008; 30 (06) 555-584
81 General Medical Council. Good medical practice. Manchester: General Medical Council; 2013. Available at: https://www.gmc-uk.org/static/documents/content/Good_medical_practice_-_English_1215.pdf . Accessed January 13, 2018
82 Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med 1998; 73 (04) 387-396
83 Steinert Y, Mann K, Centeno A. , et al. A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: BEME Guide No. 8. Med Teach 2006; 28 (06) 497-526
84 Harden RM, Crosby J. AMEE Guide No 20: the good teacher is more than a lecturer-the twelve roles of the teacher. Med Teach 2000; 22 (04) 334-347
85 Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med 2008; 83 (05) 452-466
86 Hill AG, Yu TC, Barrow M, Hattie J. A systematic review of resident-as-teacher programmes. Med Educ 2009; 43 (12) 1129-1140
87 Bernson-Leung ME, Urion DK. The child neurology trainee-as-teacher: a clinical teaching curriculum tailored to learners' needs and developmental roles. Pediatr Neurol 2018; 78: 41-45
88 Lake FR, Hamdorf JM. Teaching on the run tips 5: teaching a skill. Med J Aust 2004; 181 (06) 327-328
89 Ramani S. Twelve tips to improve bedside teaching. Med Teach 2003; 25 (02) 112-115
90 Ramani S. Twelve tips for excellent physical examination teaching. Med Teach 2008; 30 (9-10): 851-856
91 Faarvang KL, Ringsted C. A six-step approach to teaching physical examination. Med Educ 2006; 40 (05) 475
92 Peyton JWR. The learning cycle. In: Peyton JWR. , ed. Teaching and Learning in Medical Practice. Rickmansworth, England: Manticore Publishers Europe Ltd; 1998: 13-19
93 Ende J. Feedback in clinical medical education. JAMA 1983; 250 (06) 777-781
94 Veloski J, Boex JR, Grasberger MJ, Evans A, Wolfson DB. Systematic review of the literature on assessment, feedback and physicians' clinical performance: BEME Guide No. 7. Med Teach 2006; 28 (02) 117-128
95 Wall D, McAleer S. Teaching the consultant teachers: identifying the core content. Med Educ 2000; 34 (02) 131-138
96 Holmboe ES. Faculty and the observation of trainees' clinical skills: problems and opportunities. Acad Med 2004; 79 (01) 16-22
97 Hendry RG, Kawai GK, Moody WE. , et al. Consultant attitudes to undertaking undergraduate teaching duties: perspectives from hospitals serving a large medical school. Med Educ 2005; 39 (11) 1129-1139
98 Bokken L, Linssen T, Scherpbier A, van der Vleuten C, Rethans JJ. Feedback by simulated patients in undergraduate medical education: a systematic review of the literature. Med Educ 2009; 43 (03) 202-210
99 Krautter M, Diefenbacher K, Schultz JH. , et al. Physical examination skills training: faculty staff vs. patient instructor feedback—a controlled trial. PLoS One 2017; 12 (07) e0180308
100 Stark P. Teaching and learning in the clinical setting: a qualitative study of the perceptions of students and teachers. Med Educ 2003; 37 (11) 975-982
101 Seabrook MA. Medical teachers' concerns about the clinical teaching context. Med Educ 2003; 37 (03) 213-222
102 Anderson RC, Fagan MJ, Sebastian J. Teaching students the art and science of physical diagnosis. Am J Med 2001; 110 (05) 419-423
103 Busis NA, Shanafelt TD, Keran CM. , et al. Burnout, career satisfaction, and well-being among US neurologists in 2016. Neurology 2017; 88 (08) 797-808
104 Levin KH, Shanafelt TD, Keran CM. , et al. Burnout, career satisfaction, and well-being among US neurology residents and fellows in 2016. Neurology 2017; 89 (05) 492-501
105 ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002; 136 (03) 243-246
106 Dornan T. Osler, Flexner, apprenticeship and ‘the new medical education’. J R Soc Med 2005; 98 (03) 91-95
107 Chodorow S. Educators must take the electronic revolution seriously. Acad Med 1996; 71 (03) 221-226
108 Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical education. Acad Med 2006; 81 (03) 207-212
109 Luther R, Richardson L. A web-based peer feedback tool for physical examination. Clin Teach 2018; 15 (02) 132-135
110 Lim EC, Ong BK, Seet RC. Using videotaped vignettes to teach medical students to perform the neurologic examination. J Gen Intern Med 2006; 21 (01) 101
111 Chumley-Jones HS, Dobbie A, Alford CL. Web-based learning: sound educational method or hype? A review of the evaluation literature. Acad Med 2002; 77 (10, Suppl): S86-S93
112 Maloney S, Nicklen P, Rivers G. , et al. A cost-effectiveness analysis of blended versus face-to-face delivery of evidence-based medicine to medical students. J Med Internet Res 2015; 17 (07) e182
113 Bandla H, Franco RA, Simpson D, Brennan K, McKanry J, Bragg D. Assessing learning outcomes and cost effectiveness of an online sleep curriculum for medical students. J Clin Sleep Med 2012; 8 (04) 439-443
114 Micieli G, Cavallini A, Santalucia P, Gensini G. Simulation in neurology. Neurol Sci 2015; 36 (10) 1967-1971
115 Barsuk JH, Cohen ER, Caprio T, McGaghie WC, Simuni T, Wayne DB. Simulation-based education with mastery learning improves residents' lumbar puncture skills. Neurology 2012; 79 (02) 132-137
116 Malakooti MR, McBride ME, Mobley B, Goldstein JL, Adler MD, McGaghie WC. Mastery of status epilepticus management via simulation-based learning for pediatrics residents. J Grad Med Educ 2015; 7 (02) 181-186
117 Wong SH. . Walton Neuro Team. Solving the chronic lack of neurological examination equipment on the wards with the Walton Neurostand. Pract Neurol 2008; 8 (05) 318-321
118 Wechsler LR, Tsao JW, Levine SR. , et al; American Academy of Neurology Telemedicine Work Group. Teleneurology applications: report of the telemedicine work group of the American Academy of Neurology. Neurology 2013; 80 (07) 670-676
119 Shafqat S, Kvedar JC, Guanci MM, Chang Y, Schwamm LH. Role for telemedicine in acute stroke. Feasibility and reliability of remote administration of the NIH stroke scale. Stroke 1999; 30 (10) 2141-2145
120 Craig JJ, McConville JP, Patterson VH, Wootton R. Neurological examination is possible using telemedicine. J Telemed Telecare 1999; 5 (03) 177-181
121 George BP, Scoglio NJ, Reminick JI. , et al. Telemedicine in leading US neurology departments. Neurohospitalist 2012; 2 (04) 123-128
122 Govindarajan R, Anderson ER, Hesselbrock RR. , et al. Developing an outline for teleneurology curriculum: AAN Telemedicine Work Group recommendations. Neurology 2017; 89 (09) 951-959
123 Block L, Habicht R, Wu AW. , et al. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?. J Gen Intern Med 2013; 28 (08) 1042-1047
124 Smith MA, Gertler T, Freeman K. Medical students' perceptions of their housestaffs' ability to teach physical examination skills. Acad Med 2003; 78 (01) 80-83
125 Agency for Healthcare Research and Quality. HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2009. Rockville, MD: Agency for Healthcare Research and Quality (US); 2011. Available at: https://www.ncbi.nlm.nih.gov/books/NBK91984/ . Accessed February 17, 2018
126 Thompson Stone R, Tollefson T, Epstein R, Jozefowicz RF, Mink JW. Education research: positive effect of scheduled faculty modeling on clerkship student bedside skills exposure and learning. Neurology 2017; 88 (24) e236-e239
127 Josephson SA, Gillum LA. An intervention to teach medical students ankle reflex examination skills. Neurologist 2010; 16 (03) 196-198
128 Dickson JM, Harrington R, Carter MJ. Teaching clinical examination using peer-assisted learning amongst graduate-entry students. Clin Teach 2011; 8 (01) 8-12
129 Silbert BI, Lake FR. Peer-assisted learning in teaching clinical examination to junior medical students. Med Teach 2012; 34 (05) 392-397
130 Perry ME, Burke JM, Friel L, Field M. Can training in musculoskeletal examination skills be effectively delivered by undergraduate students as part of the standard curriculum?. Rheumatology (Oxford) 2010; 49 (09) 1756-1761
131 Field M, Burke JM, McAllister D, Lloyd DM. Peer-assisted learning: a novel approach to clinical skills learning for medical students. Med Educ 2007; 41 (04) 411-418
132 Tolsgaard MG, Gustafsson A, Rasmussen MB, Høiby P, Müller CG, Ringsted C. Student teachers can be as good as associate professors in teaching clinical skills. Med Teach 2007; 29 (06) 553-557
133 Haist SA, Wilson JF, Fosson SE, Brigham NL. Are fourth-year medical students effective teachers of the physical examination to first-year medical students?. J Gen Intern Med 1997; 12 (03) 177-181
134 Kerr NM, Chew SS, Eady EK, Gamble GD, Danesh-Meyer HV. Diagnostic accuracy of confrontation visual field tests. Neurology 2010; 74 (15) 1184-1190
135 Yusuf IH, Salmon JF, Patel CK. Direct ophthalmoscopy should be taught to undergraduate medical students-yes. Eye (Lond) 2015; 29 (08) 987-989
136 Purbrick RM, Chong NV. Direct ophthalmoscopy should be taught to undergraduate medical students---no. Eye (Lond) 2015; 29 (08) 990-991
137 Shuttleworth GN, Marsh GW. How effective is undergraduate and postgraduate teaching in ophthalmology?. Eye (Lond) 1997; 11 (Pt 5): 744-750
138 Bruce BB, Lamirel C, Wright DW. , et al. Nonmydriatic ocular fundus photography in the emergency department. N Engl J Med 2011; 364 (04) 387-389
139 Hoonpongsimanont W, Nguyen K, Deng W, Nasir D, Chakravarthy B, Lotfipour S. Effectiveness of a 40-minute ophthalmologic examination teaching session on medical student learning. West J Emerg Med 2015; 16 (05) 721-726
140 Couret D, Boumaza D, Grisotto C. , et al. Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study. Crit Care 2016; 20: 99
141 Hansen M, Sindrup SH, Christensen PB, Olsen NK, Kristensen O, Friis ML. Interobserver variation in the evaluation of neurological signs: observer dependent factors. Acta Neurol Scand 1994; 90 (03) 145-149
142 Teerijoki-Oksa T, Jääskeläinen S, Forssell K, Virtanen A, Forssell H. An evaluation of clinical and electrophysiologic tests in nerve injury diagnosis after mandibular sagittal split osteotomy. Int J Oral Maxillofac Surg 2003; 32 (01) 15-23
143 Kothari R, Hall K, Brott T, Broderick J. Early stroke recognition: developing an out-of-hospital NIH Stroke Scale. Acad Emerg Med 1997; 4 (10) 986-990
144 Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying stroke in the field. Prospective validation of the Los Angeles prehospital stroke screen (LAPSS). Stroke 2000; 31 (01) 71-76
145 Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med 1999; 33 (04) 373-378
146 Balagura S, Katz RG. Undecussated innervation to the sternocleidomastoid muscle: a reinstatement. Ann Neurol 1980; 7 (01) 84-85
147 Lim KS, Hew YC, Lau HK, Lim TS, Tan CT. Bulbar signs in normal population. Can J Neurol Sci 2009; 36 (01) 60-64
148 Stino AM, Smith BE, Temkit M, Reddy SN. Hypoglossal nerve palsy: 245 cases. Muscle Nerve 2016; 54 (06) 1050-1054
149 Husaini H, Krisciunas GP, Langmore S. , et al. A survey of variables used by speech-language pathologists to assess function and predict functional recovery in oral cancer patients. Dysphagia 2014; 29 (03) 376-386
150 Pérennou D, Thomas EN, Blain H. Do French medical schools provide appropriate training on gait and gait disorders?. Ann Phys Rehabil Med 2011; 54 (01) 36-47
151 Gor-García-Fogeda MD, Cano de la Cuerda R, Carratalá Tejada M, Alguacil-Diego IM, Molina-Rueda F. Observational gait assessments in people with neurological disorders: a systematic review. Arch Phys Med Rehabil 2016; 97 (01) 131-140
152 Lindholm B, Nilsson MH, Hansson O, Hagell P. External validation of a 3-step falls prediction model in mild Parkinson's disease. J Neurol 2016; 263 (12) 2462-2469
153 Sullivan SJ, Hammond-Tooke GD, Schneiders AG, Gray AR, McCrory P. The diagnostic accuracy of selected neurological tests. J Clin Neurosci 2012; 19 (03) 423-427
154 Louis ED, King D, Sacco R, Mohr JP. Upper motor neuron signs in acute stroke: prevalence, interobserver reliability, and timing of initial examination. J Stroke Cerebrovasc Dis 1995; 5 (01) 49-55
155 Teitelbaum JS, Eliasziw M, Garner M. Tests of motor function in patients suspected of having mild unilateral cerebral lesions. Can J Neurol Sci 2002; 29 (04) 337-344
156 Daum C, Aybek S. Validity of the “Drift without pronation” sign in conversion disorder. BMC Neurol 2013; 13: 31
157 Amer M, Hubert G, Sullivan SJ, Herbison P, Franz EA, Hammond-Tooke GD. Reliability and diagnostic characteristics of clinical tests of upper limb motor function. J Clin Neurosci 2012; 19 (09) 1246-1251
158 Anderson NE, Mason DF, Fink JN, Bergin PS, Charleston AJ, Gamble GD. Detection of focal cerebral hemisphere lesions using the neurological examination. J Neurol Neurosurg Psychiatry 2005; 76 (04) 545-549
159 Clopton N, Dutton J, Featherston T, Grigsby A, Mobley J, Melvin J. Interrater and intrarater reliability of the Modified Ashworth Scale in children with hypertonia. Pediatr Phys Ther 2005; 17 (04) 268-274
160 Medical Research Council: Nerve Injuries Committee. Aids to the Investigation of Peripheral Nerve Injuries. London: His Majesty's Stationery Office; 1942
161 Paternostro-Sluga T, Grim-Stieger M, Posch M. , et al. Reliability and validity of the Medical Research Council (MRC) scale and a modified scale for testing muscle strength in patients with radial palsy. J Rehabil Med 2008; 40 (08) 665-671
162 Hough CL, Lieu BK, Caldwell ES. Manual muscle strength testing of critically ill patients: feasibility and interobserver agreement. Crit Care 2011; 15 (01) R43
163 Florence JM, Pandya S, King WM. , et al. Intrarater reliability of manual muscle test (Medical Research Council scale) grades in Duchenne's muscular dystrophy. Phys Ther 1992; 72 (02) 115-122 , discussion 122–126
164 Hallett M. NINDS myotatic reflex scale. Neurology 1993; 43 (12) 2723
165 Litvan I, Mangone CA, Werden W. , et al. Reliability of the NINDS Myotatic Reflex Scale. Neurology 1996; 47 (04) 969-972
166 Manschot S, van Passel L, Buskens E, Algra A, van Gijn J. Mayo and NINDS scales for assessment of tendon reflexes: between observer agreement and implications for communication. J Neurol Neurosurg Psychiatry 1998; 64 (02) 253-255
167 Miller TM, Johnston SC. Should the Babinski sign be part of the routine neurologic examination?. Neurology 2005; 65 (08) 1165-1168
168 Isaza Jaramillo SP, Uribe Uribe CS, García Jimenez FA, Cornejo-Ochoa W, Alvarez Restrepo JF, Román GC. Accuracy of the Babinski sign in the identification of pyramidal tract dysfunction. J Neurol Sci 2014; 343 (1-2): 66-68
169 Singerman J, Lee L. Consistency of the Babinski reflex and its variants. Eur J Neurol 2008; 15 (09) 960-964
170 Jonsson M, Tollbäck A, Gonzales H, Borg J. Inter-rater reliability of the 1992 international standards for neurological and functional classification of incomplete spinal cord injury. Spinal Cord 2000; 38 (11) 675-679
171 Pestronk A, Florence J, Levine T. , et al. Sensory exam with a quantitative tuning fork: rapid, sensitive and predictive of SNAP amplitude. Neurology 2004; 62 (03) 461-464
172 Notermans NC, van Dijk GW, van der Graaf Y, van Gijn J, Wokke JH. Measuring ataxia: quantification based on the standard neurological examination. J Neurol Neurosurg Psychiatry 1994; 57 (01) 22-26
173 Agrawal Y, Carey JP, Hoffman HJ, Sklare DA, Schubert MC. The modified Romberg Balance Test: normative data in U.S. adults. Otol Neurotol 2011; 32 (08) 1309-1311