NEC manual version 4 [draft]



NEUROLOGICAL EXAMINATION FOR CHILDREN (NEC) MANUAL Version 5

INTRODUCTION

The Neurological Examination for Children (NEC) is a structured examination that was initially developed to assess neurologic abnormalities associated with HIV infection; it is also appropriate for other conditions, particularly those associated with pyramidal tract dysfunction.

The items comprising the NEC tap several domains, including head size, tone, power, reflexes, symmetry, movement disorders, vision and ocular movements. The majority of items (e.g., reflex and tone assessments, angle measures) in the NEC are applicable to children of all ages.

Earlier versions of the NEC have been studied for test-retest reliability in two samples: one comprised 31 children under age 4 years and another 35 children under age 3 years. Version 5 of the NEC includes revisions that followed on these reliability studies. These studies indicate that training in examination administration procedures and coding is necessary to produce consistent measures on items.

The NEC includes items from the Physical and Neurological Examination for Subtle Signs (PANESS, Denckla, M.B., Revised Neurological Examination for Subtle Signs (1985), Psychopharmacology Bulletin, 21(4), 773-800) to assess motor speed and coordination in children 36 months of age or older. We did not test these items in our reliability studies.

We recommend that all NEC users be trained by us in its administration and coding. We request that trained users forward computerized copies of their NEC data to us. These data will be used with our own to study redundancy and internal consistency between items and to develop composite scores for the domains measured by the NEC.

Inquiries regarding training or use of the NEC can be forwarded to Drs. Kairam, Chiriboga and Kline, Psychiatric Institute, Unit 53, 722 West 168th Street, New York, N.Y. 10032 (telephone: 212-960-5820).

GENERAL INSTRUCTIONS

The Neurological Examination for Children (NEC) should be performed with the child fully awake since other states may affect responses. Sleepiness is associated with diminished muscle tone and sluggish or absent reactions. Irritability and crying may increase resting tone. A few items (e.g., head circumference measures) can be administered to sleeping or unresponsive children.

APPROPRIATE STATE: To increase the validity and reliability of the examination, items should be administered only when the child is in the APPROPRIATE STATE for the item. Both the manual and examination form indicate the appropriate state. If the child does not attain this state during the examination, the item should be coded "9" (not in appropriate state). If necessary, items may be administered out of order. For example, if the appropriate state for an item is reached later in the examination, the examiner may administer it then. We stress that it is essential that no item be administered when the child is not in the appropriate state for that item.

Every effort should be made to relax the child prior to and during the examination to ensure that all items can be administered. If the appropriate state cannot be attained for most items because the child is crying or uncooperative, the examination should be rescheduled.

Code "8" (not assessed) for all items which the examiner does not attempt to administer. This code also applies to items not administered because the examination is not completed.

Code "9" (not in appropriate state) for children who do not attain the appropriate state or who refuse to cooperate on a particular item.

CLOTHING: The child should wear only underclothes or a tight top and shorts.

ASSISTANT: You will need an assistant during measurement of the angles, and for young children to assess items which require that the child be in a sitting position. This assistant may be the parent, caretaker or other helper.

Instructions for administration of items in the NEC Version 5 follow.

( ID NUMBER.

( CHILD'S INITIALS: First, middle and last initials.

(( DATE OF EXAMINATION: Code the month, the day and the year of the examination.

( EXAMINER'S INITIALS: First, middle and last initials.

( DATE OF BIRTH: Code the month, the day and the year of the child's date of birth.

( SEX.

( HEAD CIRCUMFERENCE:

Position: Sitting or supine

Equipment: Inser-tape (millimeter)

State: Any

Insert the distal tip of the measuring tape through the first slot of the tape.

Locate the tape firmly above the supraorbital ridges covering the most prominent part of the frontal bulge and over the most prominent occipital region to yield maximum head circumference.

Measure twice, removing and relocating the tape for the second measurement.

Record both measurements on the examination form.

CRANIAL NERVES

( VISUAL ACUITY (ROSENBAUM CHART)

( FOLLOWS FACE/OBJECT ACROSS MIDLINE:

Position: Facing the examiner, sitting or supine

Equipment: Interesting object (e.g., ring, puppet)

State: Awake, no crying

Secure the child's gaze on your face or an object.

Slowly move your face or the object from right to left to right up to three times.

Credit if the child's eyes follow your face or the object from right to left and back past the midline.

( EYE MOVEMENTS ON FOLLOWING FACE/OBJECT:

Position: Facing the examiner, sitting or supine

Equipment: Interesting object (e.g., ring, puppet)

State: Awake, no crying

Secure the child's gaze on your face or an object.

With your free hand, gently restrain the child's forehead.

Move your face or the object from right to left to right at least three times at a steady rate.

Eye movements are full (1) when, in the direction followed, the iris of the eye touches the canthus with no sclera visible in between. If eye movements are not full, code whether eye fails to adduct only (2), fails to abduct only (3), or both (4).

( FACIAL SYMMETRY ON GRIMACING OR SMILING

REFLEXES

Tap each reflex firmly three times and record the maximal response. If there is no response in three taps, tap five more times and record the maximal response.

Regardless of the reflex being elicited, the goal is to stretch the child's limb just until a little bit of resistance is felt in the relaxed position.

( BICEPS REFLEX:

Position: Child seated or supine with head midline, arms semiflexed

Equipment: Tomahawk reflex hammer

State: Awake, no crying

Hold the child's arm at the elbow with the forearm semiflexed.

Place the finger of one hand on the biceps tendon in the antecubital fossa.

With the other hand, tap your finger with the reflex hammer.

Note whether or not the child's biceps muscle contracts and the presence or absence of clonus.

( KNEE JERK:

Position: Child seated or supine with head midline, legs semiflexed

Equipment: Tomahawk reflex hammer

State: Awake, no crying

When the child is seated, optimal stretch may be obtained when the child's knees are draped over the edge of the seat or the side of the assistant's thigh (that is, the child should be seated sideways on the assistant's lap).

When the child is supine with head midline, optimal stretch may be obtained when the child's knees are supported on your forearm in a semiflexed position.

Tap the middle of the quadriceps tendon just below the patella with the reflex hammer.

Note whether or not the quadriceps muscle contracts and the presence or absence of clonus.

( ANKLE JERK:

Position: Child seated or supine with head midline

Equipment: Tomahawk reflex hammer

State: Awake, no crying

When the child is seated, optimal stretch may be obtained when the child's knees are draped over the edge of the seat or the side of the assistant's thigh.

When the child is supine with head midline, rotate one thigh outward and flex the knee.

Hold the child's foot by placing your thumb on the dorsum and your fingers on the sole of the foot (or vice versa, i.e., fingers on dorsum, thumb on sole). Dorsiflex the foot slightly.

With your other hand, tap the back of the Achilles tendon with the hammer. If there is no response, tap the part of your hand that is on the sole of the foot.

Note whether or not the gastrocnemius contracts and the presence or absence of clonus.

( ANKLE CLONUS:

Position: Child seated or supine with head midline

State: Awake, no crying

When the child is seated, optimal stretch may be obtained when the child's knees are draped over the edge of the seat or the side of the assistant's thigh.

When the child is supine with head midline, rotate one thigh outward and flex the knee.

With one hand, hold the child's foot just above the ankle to secure it in place. With your other hand, grasp the foot at the root of the toes. Dorsiflex the foot abruptly.

Observe for clonus─a rhythmic jerking of the foot of low amplitude and high frequency. If clonus occurs, estimate the number of beats.

Repeat this procedure on the same side.

If one to four beats are elicited on both trials, code "2." If five or more beats are elicited on either trial, code "3." If clonus occurs without stimulation, code "spontaneous clonus" (4).

( CROSSED ADDUCTOR RESPONSE:

Position: Child supine with head midline and legs straight or seated with legs semiflexed

Equipment: Tomahawk reflex hammer

State: Awake, no crying

When the child is seated, the knees should be draped over the edge of the seat or assistant's thigh and the legs should be separated slightly.

When the child is supine with head midline, the child's legs should be separated slightly, externally rotated at the hips and semiflexed at the knees.

Place one finger over the distal tendon of the adductor muscle just above the knee.

Tap your finger with the reflex hammer.

The crossed adductor reflex is present (2) when the tapping elicits a contraction of the contralateral adductor muscle.

Code the response by the site of tapping (not the site of contraction). For example, right crossed adductor reflex is defined as response in the left adductor when you tap the right adductor.

( UPGOING TOE:

Position: Child seated or supine with head midline

Equipment: Tomahawk reflex hammer

State: Awake, no crying

Scratch the plantar surface of the foot with your thumbnail or the metal end of the reflex hammer. The scratch should begin at the heel and move forward along the lateral border of the sole, crossing over the metatarsals to the base of the big toe.

Repeat this procedure.

Note whether, on either procedure, the big toe does not go up (1) or goes up (2).

An upgoing toe can also be a withdrawal response with concomitant dorsiflexion of the foot and leg withdrawal. If withdrawal is elicited, repeat the maneuver up to five times. If two informative trials are not obtained in five tries, code "two informative trials not obtained" (8).

( RIGIDITY ON EXTENSION:

Position: Supine or sitting

State: Awake, no crying

Elbow extension:

The child should be relaxed.

Hold the child's upper arm firmly in place.

Flex and slowly extend the child's forearm as far as possible at the elbow three times.

Code rigidity as present (2) if constant or intermittent resistance to passive extension occurs on any of the three maneuvers.

Note: if the limb is spastic, code "could not be assessed" (8).

Knee extension:

The child should be relaxed.

When the child is seated, the knees should be draped over the edge of the seat or assistant's thigh.

When the child is supine, rotate the thigh of one leg outward.

Hold the thigh firmly in place.

Flex and slowly extend the leg three times.

Code rigidity as present (2) if constant or intermittent resistance to passive extension occurs on any of the three maneuvers.

ANGLES

( POPLITEAL:

Position: Supine with head midline, legs extended

Equipment: Goniometer

State: Awake, no crying

Have the assistant hold the contralateral leg straight.

Flex the thigh of one leg towards the abdomen as far as possible without causing distress to the child.

Place the goniometer fulcrum on the lateral epicondyle of the femur of the flexed thigh. Align the end of the fixed arm with the greater trochanter.

Hold the goniometer in place with one hand. With your other hand, hold the free arm of the goniometer against the lower leg, aligned with the external malleolus.

Extend the child's lower leg at the knee at a steady pace until the first resistance is met.

Record the angle indicated by the marking line on the moving arm.

Repeat this procedure.

Code the average of the two angle measures.

( ANKLE:

Position: Supine with head midline, legs extended

Equipment: Goniometer

State: Awake, no crying

Have the assistant hold the child's contralateral leg straight.

Place the goniometer fulcrum on the external malleolus. Align the other end of the fixed arm with the head of the fibula.

Hold the goniometer in place with one hand. With your other hand, place the moving arm of the goniometer parallel to the outer border of the foot. Hold the goniometer in place by inserting your finger(s) between the dorsum of the foot and goniometer arm and your thumb on top of the goniometer arm.

Dorsiflex the foot slowly and as far as possible until the first resistance is met.

Record the angle indicated by the marking line on the moving arm.

Repeat this procedure.

Code the average of the two angle measures.

GAIT

Position: Walking

State: Awake

To encourage walking, have the caretaker stand on one side of the room and place the child on the other side of the room.

Ask the child to walk away from you for a distance of at least six feet, turn around, and walk back. Ask the child to walk back and forth again; this time observe the child from the side.

Code whether the sign is absent (1) or present (2).

( KNEE FLEXION:

Knee flexion is present (2) if the child walks with the knees bent forward.

( KNEE HYPEREXTENSION:

Knee hyperextension is present (2) if the child walks with the knees bent backwards.

( TOE WALKING:

Toe walking is present (2) if the child walks on his/her toes.

( CIRCUMDUCTING GAIT:

Circumducting gait is present (2) when the leg on one side drags stiffly and swings outward while the child is walking.

( DECREASED ARM SWING:

Arm swing during walking should be symmetric with both arms traversing the same distance. Code whether either arm has decreased range of swing compared with the other. If both arms traverse the same distance, code decreased arm swing as absent (1) for both.

( CORTICAL ARM POSTURE:

Cortical arm posture is defined as persistent adduction at the shoulder with flexion at the elbow, with or without forearm pronation.

( DYSTONIC ARM POSTURE:

Dystonic arm posture is defined as a non-purposeful intermittent posturing of the limb, usually with extension at the elbow, with or without pronation of the arm.

( SCISSORING:

Scissoring is defined as walking with the knees crossed in front of each other without circumduction.

( BROAD-BASED GAIT:

Gait is defined as broad based when the distance between the outer edges of the feet is greater than the distance between the hips.

( STUMBLES WHILE WALKING:

Stumbling occurs if the child walks unsteadily or trips.

( FALLS WHILE WALKING:

Falling occurs if any part of the child other than his/her feet touches the floor.

( STUMBLES WHILE TURNING AROUND:

Stumbling occurs if the child walks unsteadily or trips while turning around.

( FALLS WHILE TURNING AROUND:

Falling occurs if any part of the child other than his/her feet touches the floor while turning around.

( STANDS ON ONE FOOT FOR AT LEAST 5 SECONDS:

Ask the child to raise one foot and stand on the other until you have counted to five. The child is permitted to place the raised foot in any position (e.g., behind the knee). The child should receive support.

( HOPS ON ONE FOOT AT LEAST 6 TIMES:

Ask the child to raise one foot and hop on the other at least six times. The child should not receive support.

( WALKS ON TOES ON COMMAND:

Ask the child to walk away from you on his/her toes, with heels raised as high as possible off the floor, for a distance of at least six feet. Credit may only be given if the child walks on his/her toes for at least six feet. Permit two tries before coding "did not walk on toes for six feet" (2).

( WALKS ON HEELS ON COMMAND:

Ask the child to walk toward you on his/her heels, with toes raised as high as possible off the floor, for a distance of at least six feet. Credit may only be given if the child walks on his/her heels for at least six feet. Permit two tries before coding "did not walk on heels for six feet" (2).

( TANDEM WALKS ON COMMAND:

Ask the child to walk on the straight line, touching the heel of one foot to the two of the other. Demonstrate the tandem walk. Credit may only be given if the child tandem walks for at least six feet. Permit two tries before coding "did not tandem walk" (2).

( FINGER-TO-NOSE-TO-FINGER TESTING─6 TARGETS:

Position: Sitting

Equipment: Finger puppet

State: Cooperative, 36 months or older

Sit opposite the child at eye level.

Hold your index finger or finger puppet in front of the child at the child's arm length.

Give the child two practice trials. Say to the child, "Can you touch the tip of my finger with your pointer (index) finger?" (Child responds.) "Now touch the tip of your nose." (Child responds.) "Now my finger again." (Child responds.) (Practice 1.)

If the child does not initiate the movement, hold the child's hand in yours and demonstrate the task.

"Now try it again." (Practice 2.)

"Okay, now do it until I say to stop." Have the child repeat the movement for six excursions (i.e., child should repeat for six targets in total).

Count and code the number of excursions of the child's finger that are off target (i.e., the finger misses the nose or your finger or it touches the side of the nose or your finger), and the number of excursions with ataxia. Ataxia is present if the child's arm or hand movements are uncoordinated, with or without tremor of the outstretched limb. Even if the child reaches the target correctly, the movement is considered ataxic if the arm movements are not smooth. Code "0" for no excursions off target and no excursions with ataxia. Code "7" if the child cannot perform the task.

Repeat on the other side. Be sure to allow two practice tries.

( GRIP STRENGTH:

Position: Standing with legs apart laterally

State: Cooperative, 60 months or older

Equipment: Takei & Co. grip dynamometer

The child should hold the dynamometer with one hand with the meter board facing outward.

Adjust the grip distance (with the grip distance adjustment screw) so that the second joint of the child's middle finger can be bent at an angle of 90(.

Set the pointer of the meter board to 0.

Have the child stand erect with legs apart (laterally) and arms extended downward and at ease. Make sure the dynamometer does not touch the child's clothes or body.

Allow one practice and two test trials. Do not give any encouragement during the task.

Ask the child to squeeze the dynamometer as hard as he/she can without swinging it. Say to the child "Now I would like to see how strong you are. When I tell you to squeeze, I want you to squeeze this as hard as you can. Ready? Squeeze." Reset meter. (Practice trial.) "Now let's do it again. Squeeze." Record the value indicated on the board and reset the meter. (First test.) "Now let's do it one more time. Squeeze." Record the value indicated on the board and reset meter. (Second test.)

Repeat the above procedure for the contralateral hand.

TIMED COORDINATION ITEMS FROM THE PANESS [Denckla, 1985]

Position: Sitting, facing the examiner

State: Cooperative, 36 months or older

Equipment: Stopwatch

General procedures

It is necessary that the child know exactly when to begin and that he/she must continue doing each task until instructed to stop. Tell the child, "Be sure that you do not start until I say 'begin.' Do you understand? Also, be sure you continue until I tell you to stop."

The principle for all tasks is that of counting twenty movements. "Time to do twenty" is derived by the examiner by starting the stopwatch after the child has begun the required movement. The examiner may count (silently) "One, two, . . ." and turn on the stopwatch simultaneously with thinking "two," then count on silently to "twenty-one," simultaneously stopping the watch. For toe-heel tapping, it is convenient to count ten pairs of movements, allowing one pair (heel-toe) to go by before starting the stopwatch, then stopping the watch at the count of "eleven." For four-finger opposition, let one set of four oppositions (index, middle, ring, little) elapse and then time sets "two" through "six" to derive "time to do twenty."

The quality of movement may be so poor or erratic that meaningful timing becomes impossible. If the child cannot perform the task at all, code "7" under side used first. If the child cannot perform twenty trials, code "77" for time (seconds).

Procedure for counting overflow

While counting "time-to-do-twenty" for each movement, note all movements of other body parts.  If necessary, have the child continue beyond the timed 20 repetitions in order to observe mirror movements (movements on the contralateral side) or orofacial movements.

( TOE TAPPING:

Have the child practice five toe taps before beginning the timed trial. Say to the child, "Choose one foot and tap it. Keep the heel of your foot on the floor and tap your toes, like this." (Demonstrate in flat shoes or without shoes.) "Now you try it."

Foot 1: Begin the first timed trial of the foot selected above. Say, "Now tap this foot as fast as you can. Ready? Begin."

Foot 2: Repeat the practice trial and a first timed trial for the contralateral foot.

Foot 1: Have the child perform a second timed trial with foot 1.

Foot 2: Have the child perform a second timed trial with foot 2.

Record whether the child elected to perform the test with the right foot first (1), the left foot first (2), or could not perform the task at all (7). If the child performed the task, record the time in seconds.

( TOE-HEEL TAPPING:

Have the child practice five pairs of toe-heel taps before beginning the timed trial. Say to the child, "Choose one foot and rock it back and forth, heel-toe, heel-toe, like this." (Demonstrate in flat shoes or without shoes.) "Now you try it."

Foot 1: Begin the first timed trial of the foot selected above. Say, "Now rock your foot back and forth as fast as you can. Ready? Begin."

Foot 2: Repeat the practice trial and a first timed trial for the contralateral foot.

Foot 1: Have the child perform a second timed trial with foot 1.

Foot 2: Have the child perform a second timed trial with foot 2.

Record whether the child elected to perform the test with the right foot first (1), the left foot first (2), or could not perform the task at all (7). If the child performed the task, record the time in seconds.

( FINGER TAPPING:

Have the child practice five finger taps before beginning the timed trial. Say to the child, "Choose one hand and tap the thumb and index finger together, like this." (Demonstrate.) "Now you try it."

Hand 1: Begin the first timed trial of the hand selected above. Say, "Now tap your finger as fast as you can. Ready? Begin."

Hand 2: Repeat the practice trial and a first timed trial for the contralateral hand.

Hand 1: Have the child perform a second timed trial with hand 1.

Hand 2: Have the child perform a second timed trial with hand 2.

Record whether the child elected to perform the test with the right hand first (1), the left hand first (2), or could not perform the task at all (7). If the child performed the task, record the time in seconds.

( OPPOSES FOUR FINGERS SEQUENTIALLY:

Have the child practice two sets of finger opposition before beginning the timed trial. Say to the child, "Choose one hand and tap each finger against the thumb in order, then do it again, like this." (Demonstrate.) "Do not go backwards, always this way--pointer finger, middle finger, ring finger, little finger, 1, 2, 3, 4. Now you try it." Be sure the child holds his or her wrist steady (no pronation/supination).

Hand 1: Begin the first timed trial of the hand selected above. Say, "Now do these taps as fast as you can. Ready? Begin."

Hand 2: Repeat the practice trial and a first timed trial for the contralateral hand.

Hand 1: Have the child perform a second timed trial with hand 1.

Hand 2: Have the child perform a second timed trial with hand 2.

Record whether the child elected to perform the test with the right hand first (1), the left hand first (2), or could not perform the task at all (7). If the child performed the task, record the time in seconds.

MOVEMENTS DURING ENTIRE EXAM

( SYMMETRY OF VOLUNTARY LIMB MOVEMENTS:

Position: Supine

State: Awake

Upper limbs:

Observe the speed, intensity, and amount of voluntary movement of the child's upper limbs throughout the examination.

Code "1" if activity is symmetric; if activity is asymmetric, code whether there is less activity of the upper limbs on the right (2) or left (3). Code "4" indicates no spontaneous movement despite encouragement.

Lower limbs:

Observe the speed, intensity, and amount of voluntary movement of the child's lower limbs throughout the examination.

Code "1" if activity is symmetric; if activity is asymmetric, code whether there is less activity of the lower limbs on the right (2) or left (3). Code "4" indicates no spontaneous movement despite encouragement.

ABNORMAL MOVEMENTS

Position: Any

State: Awake

The assessment of movement disorders should be based on observations throughout the examination. Code "1" if the child exhibits no abnormal movements. If abnormal movements are present, indicate which side is affected: right only (2), left only (3), or both sides (4). Code movements of arms and legs separately.

( LIMB DYSTONIA:

Limb dystonia is defined as a slow and sustained movement produced by alternating contractions of agonist and antagonist muscle groups. The affected limb may assume an abnormal posture, e.g., extension and pronation of an arm, extension of a leg, or inversion of a foot.

( LIMB TREMORS:

Limb tremors are defined as small amplitude, rhythmic oscillations of the extremities that produce little displacement. Tremor may occur spontaneously, be induced by stimuli, or both.

( CHOREA:

Chorea is defined as brief, irregular, rapid and jerky movements involving more than one muscle group (e.g., extremities, face and trunk). These movements seem to flow from one muscle group to another.

( ATHETOSIS OF EXTREMITIES:

Athetosis is defined as slow and sinuous movements chiefly affecting the fingers and toes. The posture typically alternates from flexion-supination to hyperextension-pronation of the extremities and fanning of fingers and toes.

(

HISTORY FROM CARETAKER

( Ask: Which hand does your child prefer to use?

Probe, if necessary, as to which hand the child uses while eating, reaching for objects, etc.

Ask: Has your child ever had a seizure or convulsion?

Probe as to whether the seizure or convulsion was febrile and/or afebrile, the total numbers of febrile and afebrile seizures, the date and the circumstances of onset, seizure type, medication and history.

( Ask: Does your child have tingling, numbness, pins and needles or a burning sensation in his or her hands or feet?

Code paraesthesia as present (2) if the symptoms lasted several hours or longer. If symptoms are present, inquire about the date and circumstances of onset.

( Ask: Has your child ever sustained a head injury?

CLINICAL NEUROLOGICAL DIAGNOSIS

This page allows you to assess the overall tone of the child and summarize your clinical impression. If the examiner has not been trained to make these assessments, code "8" (not assessed).

TONE

Abnormalities of tone need not be associated with an underlying neurological disease to be coded here.

( Hypotonia: Hypotonia refers to decreased tone evidenced axially by head lag or an inverted U during ventral suspension, or in the limbs as lax joints or excessive range of motion.

Distribution: If it is your impression that the child's tone is decreased, record the distribution (general, axial or limb). Code "1" if there is no hypotonia.

Severity: Grade the severity of the decreased tone (mild, moderate, severe). Code "1" if there is no hypotonia.

( Hypertonia: Hypertonia refers to increased tone as evidenced axially by back arching or retrocollis, or in the limbs by resistance to passive movements and persistent fisting.

Distribution: If it is your impression that the child's tone is increased, record the distribution (general, axial, limb). Code "1" if there is no hypertonia.

Severity: Grade the severity of the increased tone (mild, moderate, severe). Code "1" if there is no hypertonia.

DIAGNOSIS BY STUDY EXAMINER

( DIAGNOSIS CODES:

If the neurological examination is normal, code "1" to indicate no diagnoses are present and leave the diagnostic codes blank.

If the neurological examination is not normal, indicate the appropriate diagnostic code(s). Up to four neurologic diagnoses can be coded.

( RIGHT/LEFT/BILATERAL/NOT APPLICABLE:

For each diagnosis, enter which side is involved. Code "7" if the condition is unilateral.

INSTRUMENTS

The instruments required to administer the NEC are:

Inser-tape or other non-cloth measuring tape with millimeter markings

Goniometer: stainless steel with individual degree scale ranging from 0( to 180(, with a tightening mechanism

Goniograph

Tomahawk reflex hammer

Takei & Co. grip dynamometer

Watch with second hand

The Goniograph is available from Ram Kairam, St. Luke's\Roosevelt Hospital Center, 114th Street and Amsterdam, New York, N.Y. 10025 (212-960-5820).

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