RU2687173C1 - Diagnostic technique of spatial functions in children and adults taking into account features of ontogenesis by investigating optomotor reactions - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to neurology, psychiatry, paediatrics, correctional pedagogics, and can be used in studying spatial functions in children and adults taking into account ontogenesis and multilevel stage space. That is ensured by aligning the levels in a sequence according to stages of development of the nervous system from 0 - vegetative, to 1 - reflex, 2 - sensorimotor, 3 - emotionally volitional, 4 - psychopathic or communicative, 5 - social. Total - 6 levels of space, which are directly related to somatic and vegetative nervous system. Sequence leveling is carried out by analyzing optomotor reactions involving simultaneous assessment of vegetative, reflex, sensorimotor, motor, emotional, speech and behavioural responses, including reflexes, in consensually conducted sensibilized samples, with the help of oculomotor and visual-manual tests, which are conducted during rest and various postural tests.EFFECT: method provides a simplified diagnosis of spatial functions in children and adults by limiting a set of necessary and sufficient for diagnosing the given pathology of symptoms while maintaining accuracy of diagnosis, which enables to determine functional insufficiency or immaturity of various structures of the nervous system, including those areas and zones of the sympathetic and parasympathetic nervous system, which make a significant contribution to the development of higher mental functions.1 cl, 3 applications

Description

The invention relates to medicine, namely to neurology, psychiatry, pediatrics, and the field of correctional pedagogy. In this method, it is proposed to correlate the known age standards of the psychomotor and speech development indicators of the first 6-7 years of life and compare it with the spatial organization of functional skills in later life. Different specialists determine the main age periods of a person in different ways. Usually they are divided into several stages, levels, development zones:

- System genesis - functional genesis (Anokhin PK, Biology and neurophysiology of the conditioned reflex. - M .: Medicine, 1968. 547 p.);

- Sensomotor intelligence by stages: J. Piaget (stages) from 0 to 18 months (Piaget J. Psychology of intelligence. / / Favor. Psychological works. / [Translated from French.]. - Moscow: Enlightenment, 1969. - 659 s.);

- Neuromotor development by organization levels: N.A. Bernstein (levels) from i / y to 12 months. (Bernstein N.A. Biomechanics and Physiology of Movements: Election Psychology, Tr. / Ed. By VP Zinchenko; comp. AI Nazarov; Academician of Pedagogy and Social Sciences, Moscow. Psychology and Soc. In-t. - M .: Publishing house "In-t practical. Psychology"; Voronezh: NPO "MODEK", 1997. - 608 p.).

In this method, the synthesis of these theories is used, and the levels of space line up in their sequence from 0-vegetative to 5-social. Total - 6 levels of space. The latter characterizes the socialization of the subject, the ability to interact with other people. The first 5 levels are directly related to the bodily functions that ensure the connection of GNI and VPF. All of them correspond to the complexity of the organization of higher mental functions and the complexity of the organization of higher nervous activity, which allow to correlate them with a certain age group. Each of the levels has a morphological basis, which corresponds to the functional organization of the central nervous system, and a functional basis, which corresponds to the development of new neuro-motor and sensory connections of the central nervous system. The construction of spaces is associated with individual experience, mastered in the process of development and ideas about this experience and about your own body, and must also correspond to an individual body pattern.

0 level - vegetative. Vegetative symptoms manifest themselves in adaptive reactions between external and internal processes. From birth, these reactions are counted as heart rhythm reactions (heart rate changes with age and is a characteristic of the formality of the body’s internal systems) and respiratory rate.

The formation of stable emotional reactions and volitional qualities is also largely due to the autonomic nervous system. (see Appendix 1)

Level 1 - reflex. It begins to manifest itself in utero, which provides the reaction of movement of the fetus. From the moment of birth, its main function is life-support on the basis of reactions: defensive, exploratory, approximate, vital, excretory. They all accompany a person throughout life and are consistent with autonomic responses. Immediate reflexes of the skin, muscles, tendons, nerves are an individual characteristic of the central nervous system. On the map-scheme of the spatial organization of the reflex level corresponds to the shoulder joints. (see Appendix 1)

Level 2 - sensorimotor. It begins to function as a motor and sensory from the intrauterine period. From the moment of birth, the child’s motor activity prevails with minimal sensory processes. As the growth and development of reflex reactions are ordered in time and space. Feelings of one's own position and movement appear, which are subsequently formalized into purposeful actions - arbitrary acts. In the first year of a child’s life, the movements are stereotypical in order to create a sense of position and a sense of movement associated with the area being mastered. On the scheme map of spatial organization, the sensorimotor level corresponds to the elbow joints. (see Appendix 1)

Level 3 - emotional and volitional. It begins to form from the neonatal period and is subject to the reflex, vegetative, sensorimotor and emotional influences that come from the mother. Therefore, from an early age, its manifestations look like a “reactivation reaction”. Subsequently, on the basis of the sensorimotor level, those motor reactions are distinguished, which in a steady state are designated and maintained by adults as mimic, gestures and postures. The time of their retention increases with the development of the child and becomes a part of the mental sphere. On the map-scheme of the spatial organization, the emotional-volitional level corresponds to the wrist joints. (see Appendix 1)

Level 4 - mental (communicative). It develops from the neonatal period, and is associated with all the levels listed above. Everything that is acquired in the process of development, both biological individual (internal) and personal (external), includes bodily, emotional, cognitive functions. The main emphasis of the mental level is associated with speech function, which is a means of transmitting information to society. On the scheme map of the spatial organization, the mental (communicative) level corresponds to the fingers. (see Appendix 1)

Level 5 - social. It develops from the neonatal period, and is associated with all the levels listed above. Everything that is acquired in the process of development as a biological individual (internal) and personal (external) includes bodily, emotional, cognitive, social and spiritual functions. On the scheme map of spatial organization, the social level begins beyond the boundaries of the bodily levels. (see Appendix 1)

The construction of levels is a natural process, due to the maturation of the nervous system and characterized by continuity and consistency in the space-time organization. The space is built tripletly and only in it it is possible to trace the heterochrony, the meaning of which is connected with the advancement (development) through the returnable function displayed in itself and previously mastered, but not yet assigned. Each level of development consists sequentially of: need (the level at which a person directs his activity into his environment), actual (occupies the level at which the child shares his interactions with the environment; at this level a transition from generalized and chaotic reactions takes place to localized and specialized actions) and support-compensatory (the level by which the child reimburses the costs of activity directed to the external space) levels of development. When the old forms are incorporated into the new scheme of action, the randomness of the reactions becomes purposeful and streamlined, while retaining all the diversity of the original connections.

The study of spatial functions can be carried out at any age. To determine the integrity of the psychophysiological state of the functions of the body, a series of sensitized samples are carried out successively, which, through specified conditions and coordination of tonic and kinetic postures, allow us to estimate their maturity and spatial organization. At the same time, the following is checked: developed space, retention of the body axis, body contact and speech coordination of actions, the ratio of the passive motor act to the active one, the time of posture retention. In contrast to the classical neurological examination aimed at finding and detecting symptoms indicating that they belong to a pathology or organic origin, this method allows you to isolate from a variety and variety of symptoms those that may indicate (or those that can be interpreted) as positive for development. Accounting for quantitative and qualitative interaction of symptoms in the process of examination provides important information about the attitude of the central nervous system to external influences and can be the basis for forming an impression of the development forecast and possible positive prognostic techniques used in various developmental techniques.

A standard neurological examination, as a rule, is performed on an outpatient basis while sitting on a chair, lying on a couch, standing and, in some cases, walking. Such a study fixes the initial status of the central nervous system and allows only tentatively assess the emotional background and mental sphere of the child.

To determine the integrity of the psychophysiological state of functions, it is necessary to consistently conduct a series of sensitized samples, which, through specified conditions and coordination of tonic and kinetic postures, allow us to estimate their maturity and spatial organization.

In a given pose, a specialist evaluates:

- The ratio of voluntary and involuntary reactions

- Postural reactions - the time and space in which poses are held

- Oculomotor reactions (eye excursion volume, tracking, presence of saccades, nystagmus)

- Vegetative reactions (redness-blanching of the skin, sweating, pupil reactions, changes in respiratory rhythm and heart rate)

- The presence of synkinesis and synesthesia

Methods of sensitization used during the study:

- Language as much as possible stick out

- Use of resistance - pressure on various parts of the extremities (the subject resists the effects):

сопротивление сведению коленей - специалист коленями сжимает колени исследуемого, пытаясь их соединить.

resistance to kneeling - a specialist knees compresses the knees of the subject, trying to connect them.

сопротивление разведению коленей - специалист коленями расжимает колени исследуемого, пытаясь их развести.

resistance to dilution of the knees - the specialist extends his knees with the knees of the subject, trying to dissolve them.

сопротивление опусканию рук - специалист нажимает сверху на кисти, предплечья, плечи исследуемого, пытаясь их опустить.

resistance to lowering the arms - the specialist presses down on the hands, forearms, shoulders of the subject, trying to lower them.

сопротивление подниманию рук - специалист нажимает снизу на кисти, предплечья, плечи исследуемого, пытаясь их поднять.

resistance to raising hands - a specialist presses from below on the hands, forearms, shoulders of the subject, trying to lift them.

It is important in the process of research after each posture to check the state of the reflex sphere, which varies depending on the given conditions and the involved mental sphere. It is necessary to constantly examine the state of muscle tone in the axial sphere, in the distal, proximal and middle parts of the limbs and the state of the sensitive sphere in its reflex (involuntary motor) response, or latent motor and arbitrary relevant place and strength of external influence.

It is equally important to note the phenomena of fatigue of a general and partial nature and in these cases give the child a rest (waiting pause) and identify this “feeling”, and the more bright and local it becomes, the more controlled and randomly held in subsequent tasks.

It is also important to observe in the process of research the saturation or manifestations of vegetative (sympathetic and parasympathetic) phenomena both in involuntary reactions and in voluntary actions that require a certain amount of personal effort from the researched.

Features examination of children.

1. Accounting for the developed space.

Inspection of children of different ages, in contrast to the standard conducted with adult patients, is always individually and variable, taking into account the developed space in which postural tonic and kinetic reactions and locomotor functions have their own characteristics in three spatial coordinates: right-left, upper lower and anteroposterior with respect to a given axial function of body retention (posture). It is important to consider the examination space in which the functional features of the child can manifest with the greatest opportunity for him to identify (feel) for both negative and positive symptoms. The severity or ease of symptoms diagnosed in these cases is quite relative, because the first place in their assessment is given to the form and space of their connectedness, interrelation with external factors requiring adaptive reactions.

2. Hold the axis of the body.

What you should pay attention to is holding the axis of the body. In infancy, these are all postures associated with a sequence in acquiring skills for vertical or horizontal and frontal position and movement. This applies to the position and retention of the head, shoulder and pelvic girdle, upper and lower extremities, facial muscles, tongue, fingers.

3. Body contact and speech coordination of actions.

Important elements to be included in the survey should be speech coordination and explanation of the actions of the investigator and constant bodily contact with the child. Pauses in the inspection process, and even more so when sensitized samples are presented, are obligatory not only to give the child a break, but also to estimate the time for his recovery to continue the study. Observing the forms of fatigue, the ways of switching for recovery and, at the same time commenting on these processes, it is necessary to remember that the most important thing is how the child adapts to these “imposed” from the outside conditions; how his nervous system responds with vegetative and reflex responses.

4. The ratio of passive motor act to active.

The ratio of the passive motor act to the active one is most noticeable in the spatial coordinates of the body alignment of the specified zones of attention. For example, eye movements while holding the head, arms or legs, but at the same time, the trajectory of eye movements behind the observed object is constantly changing, and the postures of the arms or legs in the space of the body and its axis must be stable. You can also observe the changing trajectory of the fingers in manual coordinating samples, but with the retention of the specified postures of retention of the axis of the body, head and feet.

5. Pose holding time.

The retention time of the tonic, kinetic and tonic-kinetic praxis in their agreement on the pre-defined and unpredictable for the child form of movement and space is the most diagnostic for each age range, since it may indicate fatigue, unformed or immature individual functions, and a different form of the pathological process, and on the progression of non-interconnected functional relationships in the formation of higher mental functions.

Description of the advantages of the utility model over analogues with examples.

1. The multi-level spatial organization.

It should be noted that the human space is multi-level and its development takes more than a dozen years. In this method, it is proposed to correlate the known age standards of the indicators of the psychomotor and speech development of children of the first 6-7 years of life and compare them with the spatial organization of their functional psychomotor, sensory, emotional, speech and other communication and social skills. Thus, the levels of space are lined up in their sequence from O-vegetative, to 1-reflex, 2-sensorimotor, 3-emotional-volitional, 4- / mental / or / speech / or communicative, 5-social. Total - 6 levels of space, the first 5 of which are directly related to the bodily functions of GNI and VPF. To assess the level of development and level of development using the oculomotor reaction, the visual space scheme is used (see Appendix 2).

The undeveloped and unformed visual space can give a picture of various neurological syndromes. (see Appendix 3)

2. Three-axial organization and method of space exploration.

The space is built in three directions, and only in it is it possible to trace heterochrony, the meaning of which is connected with the advancement (development) through the returnable and self-assimilated, but not yet assigned, function. The volume of perception also sets a certain rhythm of development, where the phase values of progress are consistent in the relationship T (tonic) and K (kinetic) method of mastering the space or space of its own activity, which becomes its own, mastered and TC (tonic-kinetic). The space of the first level corresponds to the time of mastering the bodily relations of axial and distal. Their natural basic ontogenetic attitude is expressed by the reflex activity of oral reflexes (search, approximate, prehensile, sucking) and distal, extremity (clingy, prehensile), maintained during stimulation by joint flexion tone. (The external T-phase prevails over the K - internal phase, associated with the act of digestion). Protective (TC) reflexes predominate, incl. reaction of liveliness and smile.

At the time when the internal act becomes the TC (the first 2 weeks - the emancipation of the internal vegetative), the possibility of freedom of the external space (activity of the freedom reflex for the rest of life / cm Sechenov /) to establish visual contact expressed by short fixation of the eye (T) and eye tracking (K) within 15 gr. in each direction with subsequent connectedness with chain lateral symmetric reflexes by movements of the head, and then the body around its axis. Such symptoms are observed during the first 3 months up to the full retention (T) of the head, incl. in position on the abdomen to 45 gr. and freedom of tracking (TC) eyes also in the range of 45-60 g. The retention time varies from 7 to 20 seconds or more, depending on the external (parental) support. At the same time, revolutions are carried out around its axis with its complete completion, but the initial anchor point is axial fixation (T) and consistent (K) sweep of coordinated chains either from the head (that is, the eye or the mouth) or from the legs (t e. coccygeal zone or perineum).

Example 1. Child M.N. 6 years 2 months examined for the first time after visiting a pediatrician before entering school. The focus was on restlessness, hyper mobility, the child did not hold attention on objects, taking them from the table, immediately threw and took another. With difficulty I came into contact not only with the doctor, but also with the parents, who explained this behavior only in a new situation for the child. He also reacted to a loud sound and a strong stimulus, but remained in a mobile state. According to parents, he knows letters, numbers, but cannot read and operate on numbers, and it is also difficult to concentrate on reading books, drawing, designing. Sleep is restless, intermittent. The child’s speech is articulating, but the request is either not responding, or the answer is delayed and does not match the request. I did not attend kindergarten due to difficulties in communication and poor learning. Suspected diagnosis of ADHD.

History: the child from the third pregnancy proceeding with toxicosis in the 1st and 2nd half was born at 37 - 38 weeks after the early discharge of water and weakness of the causarean section of labor activity. Weight 2780 grams l– 49cm, assessment on Angar 7/8. There were signs of morphofunctional over-maturity, and on day 2 they were transferred to the intensive care unit with signs of hypoxic-ischemic brain damage. Discharged on the tenth day in a satisfactory condition under the supervision of the district pediatrician. Artificial feeding. Early motor development began to roll over early, sat down and got up at the same time by 6 months, jumped, did not crawl, went (ran) to 8.5 months, the first words by 2 years. The child often suffers from acute respiratory viral infections, 2 times for 1 year he had bronchopneumonia, repeated hospitalizations with false croup, and in the gastroenterological department with symptoms of fecal blockage.

During the examination: the child of the correct physique, comes into contact for a short time, holding poses is weak, muscular dystonia is revealed in neurological status, reflex dystonia - D≠S reflexes, hypo- or hyperreflexia depending on the position of the head and body. In the study of sensitivity, a distinct sensory (skin) latency for all types of tests proposed, with motor or speech response. From 10 to 15 seconds in the distal and paroxysmal parts of the upper and lower extremities, and faster on the back (up to 6 seconds), on the face and the tips of the toes of the feet and hands within 2 seconds. The skin reaction (dermographism) was absent at rest, and in movement it manifested itself in fragments (patchwork) and quickly disappeared both on the body and on the extremities. On the face of the zones of the ternary nerve there was a high lability due to pallor turning into a persistent hyperergy. In the state of movement of the child, the latency and attention to the place of skin irritation was almost halved. Cranial nerves: vision and hearing, swallowing, phonation (not broken). Visual fixation is only at arm's length, there is no tracking of the object, however, if the object is in hand, then tracking horizontally and downwards does not exceed 30 degrees. In the position of the child on the back, visual tracking increases to 45 degrees in the S side and above the head to 15 degrees. Convergence in all samples was absent, pupillary reflexes - direct and friendly reaction to the light - sluggish, with a latency of 5 seconds. Additional examinations: EEG, MRI, echo-EG, USDG of brain vessels - pathology was not revealed. Consulted by a psychiatrist - data for autism, mental retardation has not been identified, the clinical picture corresponds to attention deficit disorder with autistic behavioral traits, learning difficulties. Consultation of a neuropsychologist: lack of formation of neurodynamic processes, praxis, visual-spatial gnosis leading to social disadaptation.

On the basis of the results obtained, a developmental atypia was found in the patient, which is based on motor-sensory disintegration, manifested by the lack of formation of t-connections in the structures of the extrapyramidal system.

Taking into account the disagreement of vegetative, reflex and skin systems (superficial and deep gravitational) sensitivity, kinesthetic, visual-motor and vestibular-motor parents were asked to independently use the holding technique in simultaneous sensory saturation of the skin in the lying position, in motion, sitting and playing form Resistance to any act of movement until the appearance of vegetative skin reactions.

After 1 week of daily activities, the child became available for a more detailed examination, as he could hold the poses assigned to him and perform coordination tests in a given space. At the same time, parents reported that during this period, the child became interested in and diving into Lego, drawing, responding to requests and responding faster, probing their body parts sometimes “freezing” in movements. Normalized sleep.

The second survey (sitting on a chair) hands apart, fingers spread, legs resting on the floor with light pressure (reinforcement) on the parietal region of the head from the distance of the outstretched hands of the hand managed to fix the eyes of the OD and OS on the object and at a slow pace track its movement in the horizontal and vertical direction to 45-60 degrees in each direction. Through pauses and repetitions, it is possible to hold the fixation and eye tracking at the level of the elbow joints, and then in the shoulder area, tracking pupillary reactions as the effect of accommodating accommodation on convergence, which led to bright conjunctival hyperemia, tearing, yawning and, most importantly, fatigue hands.

Example 2. Child Maria Ya., Born October 12, 2010.

Parents, at the age of a girl of 5 years and 2 months, complained about her lack of speech, lack of speech and emotional appeal, poor understanding of the addressed speech, poor and long sleep, during which she spins and talks to herself.

Family history is not burdened, the first child of 8 years is healthy, studying in the second grade of secondary school. Both parents have a university degree. Living conditions are good.

Anamnesis vitae:

A child from the second pregnancy, proceeding against the background of smog in the city of Moscow in the absence of complaints from the mother. Childbirth urgent on the 40th week independent. Birth weight 3960 g, length 52 cm, Apgar score of 8/9 points, applied to the chest on the first day, sucked actively, was breastfed for up to 8 months. The early development of the child according to the mother corresponded to the age indicators. However, the girl did not crawl, got up and went at the same time at 10 months. Guile, babble, words and short phrases - in accordance with age. In the outpatient card, the conclusions of the pediatrician, ENT, ophthalmologist, orthopedist, and neurologist did not indicate deviations in physical and mental development.

According to the parents, a girl who was 1.5 years old refused to have a daytime sleep, which did not bother them because of the child’s excessive activity.

Anamnesis morbi:

The beginning of the regression of parents is associated with the coincidence of DTP vaccination and kindergarten attendance at the age of two. With appearances of tycoid hyperkinesis and increasing neurotic reactions, parents turned to a neuropathologist and psychiatrist when the diagnosis was first made: an autism spectrum disorder. The clinical picture at that time was characterized by a gradual loss or slowdown of previously acquired skills with a characteristic decline in communication and behavioral functions. Excessive activity was accompanied by anxiety, anxiety, irritability, a decrease in the need for verbal communication and play, the appearance of stereotyped repetitive movements in the hands and facial muscles with a decrease in overall muscle tone and moderate trunk discoordination.

For 1.5 years, the child received the prescribed therapy: respolept, teraligene, phenibut, multivitamin complex. However, the parents did not notice any positive symptoms from the treatment, as the uncontrollability and hypermobility increased, “fears” appeared in the form of an abrupt awakening at night with shrill screams, the girl stopped talking and control urination and defecation.

The parents independently took the child from kindergarten, but at the same time they began to attend children's development centers and classes with a speech therapist, which led to a decrease in hyper mobility, but there were no obvious improvements in development.

At the age of 4 years 9 months. parents independently canceled all medications, after which over a period of 1-2 weeks, night sleep returned to normal. The developmental classes and correctional work of the speech therapist continued, but with little success.

Inspection data: Neurological status at the time of treatment was phenotypically marked by the presence of small developmental anomalies with distinct autonomic, reflex and muscular dystonia, unstable reflex symptoms in the study of tendon and periosteal reflexes varied from hypo- to hyperreflexia without reviving pathological hand and foot reflexes, but with episodes of life. distant oral and carpal grasping reflexes. The response to sensory skin, including pain irritations, revealed a delay of 6 to 20 seconds with a distinctly high latent fragmentation (like a leopard skin) of red dermographism. The child comes in contact only at a close distance from him - no more than 20 cm - while keeping his eyes monocular. Spatial functions are performed only at a slow pace and with speech reinforcement, as well as with external physical sensory-motor control. Time for a child to understand a speech with a latency of 20-30 seconds addressed to him and with phenomena of sensorimotor kinesthetic self-stimulation in the form of rotation by the head, hands and feet. There were distinct synkinesias of the axial-head, facies, mandibular, lingual with a tendency to generalization. Tempo tasks were not performed, as the girl was set up for slow, due to functional latency, mirroring and imitation.

The above symptoms can not be fully assessed as a syndrome of ASD and to a greater extent meet the diagnostic criteria of visual-motor, aural-speech, skin-kinesthetic unformedness in the VPF system. In this case, aggravation of the vegetative and reflex in the GNI system is aggravating circumstances.

Taking into account the complicated history (antenatal, postnatal, as well as family, medical and social), a program was prepared to accompany the child in the family and attend correctional and developmental activities aimed at stimulating vestibulo-motor, visual-motor, skin-kinesthetic and communicative functions in the sensory integration system. Simultaneously, massage, exercise therapy, osteopathic effect. The program consisted of two stages with a gap in between.

The first stage of training for 3 months. Characterized by:

1. changes in neurological status: the absence of thikoid manifestations, reduction of sensory skin and kinesthetic latency to 0.5–2 s, the girl performed spatial opto-motor and vestibule-motor functions in full;

2. expansion and diversity in conceptual, emotional and speech (verbal-phrase) inclusion in various forms of communicative activity.

At the end of the second stage of training for 1.5 months. the girl has become:

1. actively use drawing, counting,

2. interact in games with peers through speech enrichment, improved communication,

3. Spatial functions began to perform in full and on average, and at a fast pace.

Changes observed at the end of the 2nd year of classes were achieved in the absence of drug therapy through correctional and developmental classes aimed not at treating the syndrome of ASD, but at forming coordinated sociocultural, psychomotor, emotional and speech functions, the insufficient development of which was determined using the “Method diagnostics of spatial functions in children and adults, taking into account the characteristics of ontogenesis using the method of studying opto-motor reactions.

Claims (1)

The method of studying spatial functions in children and adults, taking into account the characteristics of ontogenesis and multilevel staged space, characterized in that the levels are arranged in their sequence according to the stages of development of the nervous system from 0 - vegetative, to 1 - reflex, 2 - sensorimotor, 3 - emotional-volitional , 4 - psycho-theoretical or communicative, 5 - social, total - 6 levels of space, which are directly connected with the somatic and autonomic nervous system, by the method of research of opto-motor re Ktsiy, consisting in the simultaneous assessment of vegetative, reflex, sensorimotor, motor, emotional, speech and behavioral reactions, including reflexes, in successive sensitized tests, using oculomotor and visual-manual samples, which are conducted during the examination at rest and at various postures.

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