Management of Diabetic Foot

const pptxgen = require("pptxgenjs");
const fs = require("fs");

// Load image data
const imagesData = JSON.parse(fs.readFileSync("images_data.json"));
// [0] voluntary_control_grading.jpg  (VCG chart)
// [1] ASIA scale table (AIS simple table)
// [2] ASIA full worksheet (1256px-Asia_exam_worksheet)
// [3] modified-ashworth-scale.jpg
// [4] Screenshot_20260616 (Manual Muscle Test Scores)
// [5] file_00000000 (Voluntary Control Grading full chart)

const img = (i) => imagesData[i].base64;

let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "SusanRehab6th";
pres.title = "Sensory & Motor Examination";

// ─────────────────── COLORS ────────────────────────
const C_DARK   = "1A2744";   // deep navy – title/section backgrounds
const C_TEAL   = "0E7C7B";   // teal accent
const C_AMBER  = "F4A261";   // amber accent
const C_LIGHT  = "EAF4F4";   // light bg
const C_WHITE  = "FFFFFF";
const C_TEXT   = "1A2744";
const C_GOLD   = "E9C46A";
const C_ROSE   = "E76F51";
const C_SLATE  = "2B4A6E";

// ─────────────── HELPERS ───────────────────────────
function addSlideHeader(slide, title, color = C_DARK) {
  // Top bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.65, fill: { color: color }, line: { color: color } });
  slide.addText(title, {
    x: 0.3, y: 0, w: 9.4, h: 0.65,
    fontSize: 20, bold: true, color: C_WHITE, valign: "middle", margin: 0
  });
}

function addSectionTag(slide, label, x, y, color = C_TEAL) {
  slide.addShape(pres.ShapeType.rect, { x, y, w: 2.8, h: 0.32, fill: { color: color }, line: { color: color }, rounding: true });
  slide.addText(label, { x, y, w: 2.8, h: 0.32, fontSize: 11, bold: true, color: C_WHITE, align: "center", valign: "middle", margin: 0 });
}

function addBox(slide, text, x, y, w, h, opts = {}) {
  const fill = opts.fill || C_LIGHT;
  const textColor = opts.textColor || C_TEXT;
  const fSize = opts.fSize || 11;
  const bold = opts.bold || false;
  slide.addShape(pres.ShapeType.rect, { x, y, w, h, fill: { color: fill }, line: { color: opts.borderColor || C_TEAL, pt: 1 } });
  slide.addText(text, { x: x + 0.08, y, w: w - 0.16, h, fontSize: fSize, color: textColor, valign: "middle", margin: 0, bold });
}

function addBullets(slide, items, x, y, w, h, fSize = 11) {
  const textArr = items.map((item, i) => ({
    text: item,
    options: { bullet: { type: "bullet" }, breakLine: i < items.length - 1, fontSize: fSize, color: C_TEXT }
  }));
  slide.addText(textArr, { x, y, w, h, valign: "top", margin: 4 });
}

// ════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  // Full dark background
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_DARK }, line: { color: C_DARK } });
  // Teal accent bar left
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C_TEAL }, line: { color: C_TEAL } });
  // Gold horizontal line
  s.addShape(pres.ShapeType.rect, { x: 0.5, y: 2.0, w: 5.5, h: 0.05, fill: { color: C_GOLD }, line: { color: C_GOLD } });

  s.addText("NEUROLOGICAL EXAMINATION", { x: 0.5, y: 0.8, w: 9, h: 0.7, fontSize: 16, color: C_AMBER, bold: true, charSpacing: 3 });
  s.addText("Sensory Examination\n& Motor Examination", {
    x: 0.5, y: 1.3, w: 9, h: 1.5, fontSize: 36, bold: true, color: C_WHITE,
    lineSpacingMultiple: 1.2
  });
  s.addText("Based on: O'Sullivan & Schmitz — Physical Rehabilitation, 6th Edition\n(SusanRehab6th)", {
    x: 0.5, y: 3.05, w: 9, h: 0.7, fontSize: 12, color: C_GOLD, italic: true
  });
  s.addText("Department of Physical Therapy  |  Neurological Rehabilitation", {
    x: 0.5, y: 4.9, w: 9, h: 0.4, fontSize: 10, color: "AABBCC"
  });
}

// ════════════════════════════════════════════════════
// SLIDE 2 — OVERVIEW / TABLE OF CONTENTS
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_LIGHT }, line: { color: C_LIGHT } });
  addSlideHeader(s, "Outline — Neurological Examination", C_SLATE);

  // Two columns
  const col1 = [
    "PART I — SENSORY EXAMINATION",
    "",
    "1. Terminology (Grading Scale)",
    "2. General Procedure",
    "3. Superficial Sensations",
    "    • Pain  • Light Touch  • Temperature",
    "4. Deep Sensations",
    "    • Position Sense  • Kinesthesia",
    "    • Vibration (128 Hz)  • Pressure",
    "5. Cortical (Combined) Sensations",
    "    • Tactile Localization  • Two-Point Disc.",
    "    • Stereognosis  • Barognosis",
    "    • Graphesthesia",
    "6. Dermatomes & ASIA Chart",
    "7. Ten Test",
  ];
  const col2 = [
    "PART II — MOTOR EXAMINATION",
    "",
    "1. Muscle Bulk",
    "2. Muscle Tone  (MAS)",
    "3. Voluntary Control Grading",
    "    (Brunnstrom & Bobath)",
    "4. Muscle Power  (Modified MRC)",
    "5. Deep Tendon & Superficial Reflexes",
    "6. Limb Length Discrepancy",
    "7. Balance  (Static & Dynamic)",
    "8. Coordination",
    "9. Gait Analysis",
    "10. Involuntary Movements",
  ];

  // Col 1 box
  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 0.8, w: 4.6, h: 4.65, fill: { color: "E8F5F5" }, line: { color: C_TEAL, pt: 1.5 } });
  s.addText(col1.join("\n"), { x: 0.4, y: 0.9, w: 4.3, h: 4.4, fontSize: 10.5, color: C_TEXT, valign: "top", lineSpacingMultiple: 1.3 });
  // Col 2 box
  s.addShape(pres.ShapeType.rect, { x: 5.15, y: 0.8, w: 4.6, h: 4.65, fill: { color: "FFF3E0" }, line: { color: C_AMBER, pt: 1.5 } });
  s.addText(col2.join("\n"), { x: 5.3, y: 0.9, w: 4.3, h: 4.4, fontSize: 10.5, color: C_TEXT, valign: "top", lineSpacingMultiple: 1.3 });

  // Center label
  s.addText("PART I", { x: 0.3, y: 0.82, w: 1.5, h: 0.28, fontSize: 10, bold: true, color: C_TEAL });
  s.addText("PART II", { x: 5.2, y: 0.82, w: 1.5, h: 0.28, fontSize: 10, bold: true, color: C_ROSE });
}

// ════════════════════════════════════════════════════
// SLIDE 3 — SENSORY TERMINOLOGY
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_WHITE }, line: { color: C_WHITE } });
  addSlideHeader(s, "SENSORY EXAMINATION — Terminology & Grading", C_TEAL);

  const terms = [
    { term: "Anesthesia", def: "Complete loss of all sensory modalities (no sensation perceived)", color: "D32F2F" },
    { term: "Hypoesthesia\n(Hypesthesia)", def: "Diminished / decreased sensation — partial loss below normal threshold", color: "E64A19" },
    { term: "Normal", def: "Intact, appropriate response to sensory stimuli compared to reference area", color: "388E3C" },
    { term: "Hyperesthesia", def: "Increased sensitivity to stimuli — exaggerated response to normal touch/pain", color: "1565C0" },
    { term: "Paresthesia", def: "Abnormal spontaneous sensation without external stimulus — tingling, pins & needles, numbness", color: "6A1B9A" },
    { term: "Dysesthesia", def: "Unpleasant abnormal sensation evoked by a stimulus — burning, electric shock feeling", color: "AD1457" },
  ];

  terms.forEach((t, i) => {
    const row = Math.floor(i / 2);
    const col = i % 2;
    const x = 0.2 + col * 4.95;
    const y = 0.82 + row * 1.55;
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.75, h: 1.4, fill: { color: C_LIGHT }, line: { color: t.color, pt: 2 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.75, h: 0.36, fill: { color: t.color }, line: { color: t.color } });
    s.addText(t.term, { x: x + 0.1, y, w: 4.55, h: 0.36, fontSize: 12, bold: true, color: C_WHITE, valign: "middle", margin: 0 });
    s.addText(t.def, { x: x + 0.1, y: y + 0.38, w: 4.55, h: 0.98, fontSize: 10.5, color: C_TEXT, valign: "top", margin: 2, wrap: true });
  });
}

// ════════════════════════════════════════════════════
// SLIDE 4 — SENSORY EXAM GENERAL PROCEDURE
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "F0F7F7" }, line: { color: "F0F7F7" } });
  addSlideHeader(s, "SENSORY EXAMINATION — General Procedure", C_TEAL);

  const steps = [
    ["Step 1", "Explain the Procedure", "Inform patient about what will be tested, what sensations they may feel, and what response is expected (e.g., 'Say YES when you feel a touch').  Perform a TRIAL RUN on an area of intact sensation first."],
    ["Step 2", "Ensure Patient Comfort", "Patient should be well-rested, in a comfortable relaxed position. Testing preferably done on a treatment table — allows access to both sides of the body."],
    ["Step 3", "Eyes Closed During Testing", "Patient must not watch the application of stimuli to prevent visual cues. Ask patient to close eyes or use an occluder/drape."],
    ["Step 4", "Compare Both Sides", "Always compare homologous areas bilaterally — test both sides sequentially and compare responses."],
    ["Step 5", "Test Distal → Proximal", "Start distally (fingers/toes) and move proximally. Apply stimuli randomly — not in a predictable pattern or rhythm — to avoid patient 'guessing' correctly."],
  ];

  steps.forEach(([num, title, desc], i) => {
    const y = 0.82 + i * 0.92;
    // Step number circle
    s.addShape(pres.ShapeType.ellipse, { x: 0.18, y: y + 0.1, w: 0.58, h: 0.58, fill: { color: C_TEAL }, line: { color: C_TEAL } });
    s.addText(num, { x: 0.18, y: y + 0.1, w: 0.58, h: 0.58, fontSize: 10, bold: true, color: C_WHITE, align: "center", valign: "middle", margin: 0 });
    s.addShape(pres.ShapeType.rect, { x: 0.88, y, w: 8.9, h: 0.84, fill: { color: C_WHITE }, line: { color: C_TEAL, pt: 1 } });
    s.addText(title, { x: 0.98, y: y + 0.04, w: 2.2, h: 0.35, fontSize: 11, bold: true, color: C_TEAL, valign: "middle", margin: 0 });
    s.addText(desc, { x: 0.98, y: y + 0.38, w: 8.7, h: 0.42, fontSize: 10, color: C_TEXT, valign: "top", margin: 0, wrap: true });
  });
}

// ════════════════════════════════════════════════════
// SLIDE 5 — SUPERFICIAL SENSATIONS
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_WHITE }, line: { color: C_WHITE } });
  addSlideHeader(s, "SENSORY EXAMINATION — Superficial Sensations", C_TEAL);

  addSectionTag(s, "Pathway: Spinothalamic (Anterolateral)", 0.2, 0.75, "2B6CB0");

  const sensations = [
    {
      title: "1. Pain (Nociception)",
      tool: "Tool: Safety pin / neurological pin (sharp vs. dull end) or paper clip bent open",
      steps: [
        "Explain 'sharp' vs 'dull' distinction to patient",
        "Apply sharp and blunt ends alternately in random order",
        "Patient responds: 'Sharp' or 'Dull'",
        "Hold instrument firmly; allow fingers to slide on contact to maintain uniform pressure",
        "Do NOT puncture skin — instrument should only deflect it",
        "Score: No. of correct responses / total stimuli applied × 100%",
      ],
      note: "Reduced or absent pain sensation = analgesia; exaggerated = hyperalgesia"
    },
    {
      title: "2. Light Touch",
      tool: "Tool: Cotton wisp or camel-hair brush or fingertip",
      steps: [
        "Lightly stroke the skin surface — do NOT apply pressure",
        "Patient responds: 'Yes' or 'Now' when stimulus is felt",
        "Test proximal → distal, comparing bilaterally",
        "Note: Scar tissue and callused areas are less sensitive — note this",
        "Monofilaments (von Frey): Quantitative touch threshold — used for diabetic foot screening",
        "Score as % correct responses",
      ],
      note: "Pathway: Dorsal column (fine, discriminative) & Spinothalamic (crude)"
    },
    {
      title: "3. Temperature",
      tool: "Tool: Two test tubes — one with HOT water (~40–45°C), one with COLD water (~5–10°C) | or Tip-Therm® device",
      steps: [
        "Apply tubes alternately to skin in random sequence",
        "Patient identifies: 'Hot' or 'Cold'",
        "Hold tube to skin for 3–5 seconds",
        "Test comparable areas bilaterally",
        "Advanced: Rolltemp device, TipTherm®, Thermal Sensory Analyzer (TSA-II)",
        "Score: % correct responses; or threshold values (Celsius)",
      ],
      note: "Small-diameter, slowly conducting C and Aδ fibers — early loss in peripheral neuropathy, SCI"
    },
  ];

  sensations.forEach((sen, i) => {
    const x = 0.18 + i * 3.27;
    const y = 1.12;
    s.addShape(pres.ShapeType.rect, { x, y, w: 3.1, h: 4.35, fill: { color: C_LIGHT }, line: { color: C_TEAL, pt: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 3.1, h: 0.42, fill: { color: C_TEAL }, line: { color: C_TEAL } });
    s.addText(sen.title, { x: x + 0.08, y, w: 2.94, h: 0.42, fontSize: 11, bold: true, color: C_WHITE, valign: "middle", margin: 0 });
    s.addText(sen.tool, { x: x + 0.08, y: y + 0.45, w: 2.94, h: 0.48, fontSize: 9, color: C_SLATE, valign: "top", italic: true, wrap: true, margin: 1 });
    const bullArr = sen.steps.map((step, j) => ({
      text: step,
      options: { bullet: { type: "bullet" }, breakLine: j < sen.steps.length - 1, fontSize: 9.5, color: C_TEXT }
    }));
    s.addText(bullArr, { x: x + 0.08, y: y + 0.95, w: 2.94, h: 2.6, valign: "top", margin: 2 });
    s.addShape(pres.ShapeType.rect, { x: x + 0.06, y: y + 3.7, w: 2.98, h: 0.55, fill: { color: "D0EDF0" }, line: { color: C_TEAL, pt: 1 } });
    s.addText("📌 " + sen.note, { x: x + 0.1, y: y + 3.7, w: 2.9, h: 0.55, fontSize: 8.5, color: C_SLATE, valign: "middle", italic: true, wrap: true, margin: 1 });
  });
}

// ════════════════════════════════════════════════════
// SLIDE 6 — DEEP SENSATIONS
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "F5F0FF" }, line: { color: "F5F0FF" } });
  addSlideHeader(s, "SENSORY EXAMINATION — Deep Sensations", "4A2082");
  addSectionTag(s, "Pathway: Dorsal Column – Medial Lemniscal", 0.2, 0.75, "4A2082");

  const deep = [
    {
      title: "Position Sense\n(Proprioception)",
      icon: "🦵",
      desc: "Assesses static joint position awareness. Therapist moves joint passively through range and holds in a static position. Patient identifies: 'Up', 'Down', or 'Same position'. Use small increments of range. Fingertip grip on bony prominences only — minimize tactile cues.",
      note: "Diminished in peripheral neuropathy, SCI, posterior column lesions"
    },
    {
      title: "Kinesthesia\n(Movement Sense)",
      icon: "🔄",
      desc: "Assesses awareness of movement. Therapist slowly moves joint through range. Patient says 'moving' when they detect motion and indicates direction ('up' or 'down'). Tests threshold for detection of motion direction.",
      note: "Testing: Small increments of joint motion; avoid skin pressure cues"
    },
    {
      title: "Vibration\n(128 Hz Tuning Fork)",
      icon: "🔔",
      desc: "Strike tuning fork (128 Hz) and place base on bony prominence (sternum → elbow → ankle → toe). Patient identifies: 'vibrating' or 'not vibrating'. Tuning fork is also placed after stopping vibration (control). Advanced: Vibrameter, Bio-Thesiometer.",
      note: "128 Hz detects large fiber neuropathy. 256 Hz is LESS sensitive for peripheral tests."
    },
    {
      title: "Deep Pressure\n(Pressure Sense)",
      icon: "👇",
      desc: "Apply firm pressure (not just light touch) to muscles, tendons, and bone prominences with thumb or finger. Patient confirms perception of deep pressure. Can also test by squeezing Achilles tendon or calf muscle.",
      note: "Deep pressure uses deep sensory receptors in muscles, tendons and periosteum"
    },
  ];

  deep.forEach((d, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.18 + col * 4.88;
    const y = 1.12 + row * 2.22;
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.68, h: 2.1, fill: { color: C_WHITE }, line: { color: "7B4FD9", pt: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.68, h: 0.4, fill: { color: "7B4FD9" }, line: { color: "7B4FD9" } });
    s.addText(d.icon + "  " + d.title, { x: x + 0.08, y, w: 4.5, h: 0.4, fontSize: 12, bold: true, color: C_WHITE, valign: "middle", margin: 0 });
    s.addText(d.desc, { x: x + 0.1, y: y + 0.42, w: 4.48, h: 1.28, fontSize: 10, color: C_TEXT, valign: "top", wrap: true, margin: 2 });
    s.addShape(pres.ShapeType.rect, { x: x + 0.08, y: y + 1.72, w: 4.52, h: 0.3, fill: { color: "EDE7F6" }, line: { color: "7B4FD9", pt: 1 } });
    s.addText("⚡ " + d.note, { x: x + 0.1, y: y + 1.72, w: 4.48, h: 0.3, fontSize: 8.5, color: "4A2082", valign: "middle", italic: true, wrap: true, margin: 1 });
  });
}

// ════════════════════════════════════════════════════
// SLIDE 7 — CORTICAL SENSATIONS
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_WHITE }, line: { color: C_WHITE } });
  addSlideHeader(s, "SENSORY EXAMINATION — Cortical (Combined) Sensations", "005B6E");
  addSectionTag(s, "Pathway: Parietal Cortex (S-I / S-II Integration)", 0.2, 0.75, "005B6E");

  const cortical = [
    {
      title: "Tactile Localization\n(Topognosis)",
      tool: "Semmes-Weinstein Monofilament",
      desc: "Touch patient's skin; patient must identify exact point of application (topognosis). Eyes closed. Used with monofilament for quantitative threshold testing (e.g., 10-g for diabetic foot screening).",
      color: "006064"
    },
    {
      title: "Two-Point\nDiscrimination",
      tool: "Disk-criminator / Aesthesiometer / Caliper",
      desc: "Determines minimum distance at which two simultaneous touch points are perceived as two stimuli (not one). Fingertip normal: 2–3 mm. Aesthesiometer scale calibrated to 0.1 cm. Compare to normative values (Appendix 3A).",
      color: "0277BD"
    },
    {
      title: "Stereognosis",
      tool: "Common objects (key, coin, pencil, button)",
      desc: "With eyes closed, patient identifies common objects placed in hand using only tactile manipulation — no visual cues. Uses shape, texture, size, and weight recognition. If unable to verbalize → use picture cards.",
      color: "2E7D32"
    },
    {
      title: "Barognosis",
      tool: "Discrimination weights (same size/shape, different weight)",
      desc: "Patient identifies differences in weight between objects placed sequentially in palm — eyes closed. Tests ability to grade pressure. Weights are identical in shape/size. Normally performed only if stereognosis is impaired.",
      color: "6A1B9A"
    },
    {
      title: "Graphesthesia\n(Traced Figure ID)",
      tool: "Examiner's fingertip or blunt pen",
      desc: "Examiner traces numbers (0–9) or letters on patient's palm or skin. Eyes closed. Patient identifies the number/letter traced. Tests parietal cortex integration. Normal: Can identify letters & numbers on palm.",
      color: "AD1457"
    },
  ];

  cortical.forEach((c, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const extraX = (i === 4) ? 2.5 : 0;
    const x = 0.18 + extraX + col * 4.88;
    const y = 1.12 + row * 2.22;
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 2.1, fill: { color: C_LIGHT }, line: { color: c.color, pt: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 0.38, fill: { color: c.color }, line: { color: c.color } });
    s.addText(c.title, { x: x + 0.08, y, w: 4.44, h: 0.38, fontSize: 11, bold: true, color: C_WHITE, valign: "middle", margin: 0 });
    s.addShape(pres.ShapeType.rect, { x: x + 0.08, y: y + 0.4, w: 4.44, h: 0.28, fill: { color: "E8F4F8" }, line: { color: c.color, pt: 0.5 } });
    s.addText("🔧 " + c.tool, { x: x + 0.1, y: y + 0.4, w: 4.4, h: 0.28, fontSize: 9, color: c.color, bold: true, valign: "middle", margin: 0 });
    s.addText(c.desc, { x: x + 0.1, y: y + 0.7, w: 4.4, h: 1.35, fontSize: 10, color: C_TEXT, valign: "top", wrap: true, margin: 2 });
  });
}

// ════════════════════════════════════════════════════
// SLIDE 8 — TEN TEST
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_DARK }, line: { color: C_DARK } });
  addSlideHeader(s, "SENSORY EXAMINATION — The Ten Test", C_ROSE);

  // What is it box
  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 0.82, w: 9.5, h: 0.72, fill: { color: C_SLATE }, line: { color: C_ROSE, pt: 2 } });
  s.addText("What is the Ten Test?", { x: 0.35, y: 0.82, w: 4, h: 0.3, fontSize: 12, bold: true, color: C_GOLD });
  s.addText("A semi-quantitative sensory test that compares sensitivity of an affected body area to a normal reference area. Score 0 (no sensation) to 10 (same as reference).", {
    x: 0.35, y: 1.1, w: 9.2, h: 0.38, fontSize: 11, color: C_WHITE, valign: "top", margin: 0
  });

  // Steps
  const steps = [
    { n: "Step 1", t: "Establish the Reference (Score = 10)", d: "Clinician strokes a normal reference area — typically the patient's lip, or the same digit on the UNAFFECTED hand — with a standard pressure stroke. The patient is told to consider this reference sensation as a score of 10 out of 10." },
    { n: "Step 2", t: "Simultaneously Stroke Both Areas", d: "The clinician simultaneously (or rapidly alternating) strokes the AFFECTED area and the reference area using equal pressure and speed. The patient compares the sensation in the affected area to what they felt at the reference area." },
    { n: "Step 3", t: "Patient Provides Numerical Rating", d: "Patient provides a score from 1 to 10:\n  10 = Feels the same as the reference (intact sensation)\n  5  = Feels half as much as the reference\n  0  = No sensation at all\n  Scores below 10 indicate sensory impairment." },
    { n: "Clinical Use", t: "Interpretation & Significance", d: "Particularly useful for patients with INCOMPLETE lesions (peripheral nerve, SCI, stroke). Allows tracking of sensory recovery over time. Quick, no equipment needed. Score <7 suggests clinically significant sensory loss." },
  ];

  steps.forEach((st, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.25 + col * 4.9;
    const y = 1.68 + row * 1.85;
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 1.72, fill: { color: C_SLATE }, line: { color: C_ROSE, pt: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 0.4, fill: { color: C_ROSE }, line: { color: C_ROSE } });
    s.addText(st.n + " — " + st.t, { x: x + 0.08, y, w: 4.44, h: 0.4, fontSize: 11, bold: true, color: C_WHITE, valign: "middle", margin: 0 });
    s.addText(st.d, { x: x + 0.1, y: y + 0.42, w: 4.4, h: 1.25, fontSize: 10, color: "DDEEFF", valign: "top", wrap: true, margin: 2 });
  });
}

// ════════════════════════════════════════════════════
// SLIDE 9 — ASIA CHART
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_LIGHT }, line: { color: C_LIGHT } });
  addSlideHeader(s, "Dermatomes & Myotomes — ASIA / ISNCSCI Classification", "1A4A7A");

  // ASIA worksheet image (index 2)
  s.addImage({ data: img(2), x: 0.18, y: 0.75, w: 5.8, h: 4.75 });

  // AIS table image (index 1)
  s.addImage({ data: img(1), x: 6.15, y: 0.78, w: 3.7, h: 2.4 });

  // Key points
  const pts = [
    "ASIA = American Spinal Injury Association",
    "Tests 28 key dermatomes bilaterally",
    "Sensory: Light Touch + Pin Prick (0/1/2)",
    "Motor: 10 key muscle groups (0–5)",
    "AIS Grade A–E (Complete → Normal)",
    "S4-5 sacral sparing = incomplete injury",
  ];
  s.addShape(pres.ShapeType.rect, { x: 6.15, y: 3.3, w: 3.7, h: 2.22, fill: { color: C_DARK }, line: { color: "1A4A7A", pt: 1 } });
  const ptArr = pts.map((p, i) => ({ text: p, options: { bullet: { type: "bullet" }, breakLine: i < pts.length - 1, fontSize: 10, color: C_WHITE } }));
  s.addText(ptArr, { x: 6.25, y: 3.35, w: 3.5, h: 2.1, valign: "top", margin: 4 });
}

// ════════════════════════════════════════════════════
// SLIDE 10 — PART II TITLE
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "1A3A2A" }, line: { color: "1A3A2A" } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C_AMBER }, line: { color: C_AMBER } });
  s.addShape(pres.ShapeType.rect, { x: 0.5, y: 2.85, w: 5.5, h: 0.05, fill: { color: C_AMBER }, line: { color: C_AMBER } });
  s.addText("NEUROLOGICAL EXAMINATION", { x: 0.5, y: 1.2, w: 9, h: 0.6, fontSize: 14, color: C_AMBER, bold: true, charSpacing: 3 });
  s.addText("PART II\nMotor Examination", { x: 0.5, y: 1.8, w: 9, h: 1.8, fontSize: 38, bold: true, color: C_WHITE, lineSpacingMultiple: 1.2 });
  s.addText("Muscle Bulk  •  Tone  •  Power  •  Reflexes  •  Balance  •  Coordination  •  Gait  •  Involuntary Movements", {
    x: 0.5, y: 3.85, w: 9, h: 0.6, fontSize: 13, color: C_AMBER
  });
  s.addText("Based on: O'Sullivan & Schmitz — Physical Rehabilitation, 6th Edition", {
    x: 0.5, y: 5.0, w: 9, h: 0.4, fontSize: 10, color: "AABB99", italic: true
  });
}

// ════════════════════════════════════════════════════
// SLIDE 11 — MUSCLE BULK
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_WHITE }, line: { color: C_WHITE } });
  addSlideHeader(s, "MOTOR EXAMINATION — Muscle Bulk", C_SLATE);

  s.addText("Examination begins with visual inspection and measurement of muscle bulk.", { x: 0.25, y: 0.78, w: 9.5, h: 0.3, fontSize: 11, color: C_SLATE, italic: true });

  const findings = [
    { title: "Atrophy\n(Wasting)", icon: "📉", color: "C62828", desc: "Reduction in muscle bulk and cross-sectional area. Caused by LMN lesion, disuse, denervation, or cachexia. Visible as hollowing of muscle belly. Measured by limb girth (tape measure) at fixed anatomical landmarks (e.g., 10 cm proximal to patella)." },
    { title: "Hypertrophy", icon: "📈", color: "1B5E20", desc: "Increase in muscle bulk due to exercise, myotonia congenita, or pseudohypertrophy in Duchenne muscular dystrophy (calf) — replaced by fat/connective tissue. Measure and compare bilaterally." },
    { title: "Fasciculations", icon: "⚡", color: "E65100", desc: "Spontaneous, involuntary fine twitching of muscle fibers visible under skin. Sign of LMN pathology (e.g., ALS, radiculopathy). Best visualized at rest. Cannot be voluntarily controlled." },
    { title: "Symmetry\n(Comparison)", icon: "⚖️", color: "0277BD", desc: "Always compare both limbs at the same landmark. Measure girth with non-elastic tape measure. Record: Date, limb, landmark used, and girth in cm. A difference of >1 cm is clinically significant. Also assess contour and bony landmarks." },
  ];

  findings.forEach((f, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.18 + col * 4.88;
    const y = 1.16 + row * 2.2;
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 2.05, fill: { color: C_LIGHT }, line: { color: f.color, pt: 2 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 0.42, fill: { color: f.color }, line: { color: f.color } });
    s.addText(f.icon + "  " + f.title, { x: x + 0.08, y, w: 4.44, h: 0.42, fontSize: 12, bold: true, color: C_WHITE, valign: "middle", margin: 0 });
    s.addText(f.desc, { x: x + 0.1, y: y + 0.45, w: 4.4, h: 1.55, fontSize: 10, color: C_TEXT, valign: "top", wrap: true, margin: 2 });
  });
}

// ════════════════════════════════════════════════════
// SLIDE 12 — MUSCLE TONE + MAS
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "FFFDE7" }, line: { color: "FFFDE7" } });
  addSlideHeader(s, "MOTOR EXAMINATION — Muscle Tone & Modified Ashworth Scale (MAS)", "7B5E00");

  // MAS Image
  s.addImage({ data: img(3), x: 5.3, y: 0.75, w: 4.6, h: 4.7 });

  // Left side content
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 0.78, w: 5.0, h: 0.38, fill: { color: "7B5E00" }, line: { color: "7B5E00" } });
  s.addText("Abnormalities of Muscle Tone", { x: 0.25, y: 0.78, w: 4.86, h: 0.38, fontSize: 12, bold: true, color: C_WHITE, valign: "middle", margin: 0 });

  const tones = [
    { type: "Hypotonia (Flaccidity)", icon: "⬇️", color: "1E88E5", desc: "Absent / markedly reduced tone. Limb is floppy, no resistance to passive movement. Seen in LMN lesions, cerebellar disease, acute SCI ('spinal shock'), and hypotonic CP." },
    { type: "Hypertonia — Spasticity", icon: "⬆️", color: "C62828", desc: "Velocity-dependent ↑ in tone. Clasp-knife phenomenon: initial resistance then sudden relaxation. UMN lesion (stroke, SCI, MS). Assessed by MAS (Modified Ashworth Scale)." },
    { type: "Hypertonia — Rigidity", icon: "🔩", color: "6A1B9A", desc: "Non–velocity-dependent resistance throughout full ROM. Types:\n• Cogwheel rigidity: ratchet-like resistance (Parkinson's disease + tremor)\n• Lead pipe rigidity: uniform resistance throughout ROM without tremor" },
  ];

  tones.forEach((t, i) => {
    const y = 1.24 + i * 1.38;
    s.addShape(pres.ShapeType.rect, { x: 0.18, y, w: 5.0, h: 1.28, fill: { color: C_WHITE }, line: { color: t.color, pt: 2 } });
    s.addShape(pres.ShapeType.rect, { x: 0.18, y, w: 5.0, h: 0.35, fill: { color: t.color }, line: { color: t.color } });
    s.addText(t.icon + " " + t.type, { x: 0.28, y, w: 4.8, h: 0.35, fontSize: 11, bold: true, color: C_WHITE, valign: "middle", margin: 0 });
    s.addText(t.desc, { x: 0.28, y: y + 0.37, w: 4.8, h: 0.88, fontSize: 10, color: C_TEXT, valign: "top", wrap: true, margin: 2 });
  });

  // MAS note
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 5.18, w: 5.0, h: 0.28, fill: { color: "FFF9C4" }, line: { color: "7B5E00", pt: 1 } });
  s.addText("MAS Grade: 0 (no increase) → 1 → 1+ → 2 → 3 → 4 (rigid flexion/extension)", { x: 0.25, y: 5.18, w: 4.86, h: 0.28, fontSize: 9.5, bold: true, color: "7B5E00", valign: "middle", margin: 0 });
}

// ════════════════════════════════════════════════════
// SLIDE 13 — VOLUNTARY CONTROL GRADING
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "F3F7FF" }, line: { color: "F3F7FF" } });
  addSlideHeader(s, "MOTOR EXAMINATION — Voluntary Control Grading", "1A3A6A");

  // VCG full image (index 5)
  s.addImage({ data: img(5), x: 0.18, y: 0.72, w: 9.62, h: 4.75 });
}

// ════════════════════════════════════════════════════
// SLIDE 14 — MUSCLE POWER (MRC)
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_WHITE }, line: { color: C_WHITE } });
  addSlideHeader(s, "MOTOR EXAMINATION — Muscle Power Testing (Modified MRC Scale)", "2E4A00");

  // MMT Table image (index 4)
  s.addImage({ data: img(4), x: 0.18, y: 0.75, w: 4.8, h: 4.75 });

  // Right: Notes
  s.addShape(pres.ShapeType.rect, { x: 5.18, y: 0.78, w: 4.65, h: 1.15, fill: { color: "E8F5E9" }, line: { color: "2E4A00", pt: 1.5 } });
  s.addText("Key Testing Principles (SusanRehab6th, Ch.4)", { x: 5.28, y: 0.8, w: 4.45, h: 0.3, fontSize: 10.5, bold: true, color: "2E4A00" });
  s.addText("Gravity-eliminated position (Grade 2): side-lying\nAnti-gravity position (Grade 3+): sitting or standing\nApply resistance at end of range, distally\nBilateral comparison is mandatory", {
    x: 5.28, y: 1.1, w: 4.45, h: 0.78, fontSize: 10, color: C_TEXT, valign: "top", lineSpacingMultiple: 1.3
  });

  const grades = [
    { g: "0", d: "No palpable or observable contraction", c: "D32F2F" },
    { g: "1", d: "Palpable contraction, but no motion", c: "E64A19" },
    { g: "1+", d: "Moves without gravity < ½ ROM", c: "EF6C00" },
    { g: "2−/2/2+", d: "Full ROM without gravity / partial with gravity", c: "F9A825" },
    { g: "3−/3/3+", d: "Against gravity — partial to full ROM", c: "558B2F" },
    { g: "4−/4", d: "Against gravity + moderate resistance (partial/full ROM)", c: "1565C0" },
    { g: "5", d: "Against gravity + maximal resistance — full ROM", c: "1A237E" },
  ];

  s.addShape(pres.ShapeType.rect, { x: 5.18, y: 1.98, w: 4.65, h: 0.32, fill: { color: "2E4A00" }, line: { color: "2E4A00" } });
  s.addText("Grade  Description", { x: 5.28, y: 1.98, w: 4.45, h: 0.32, fontSize: 11, bold: true, color: C_WHITE, valign: "middle", margin: 0 });

  grades.forEach((g, i) => {
    const y = 2.32 + i * 0.44;
    const bgColor = i % 2 === 0 ? C_LIGHT : C_WHITE;
    s.addShape(pres.ShapeType.rect, { x: 5.18, y, w: 4.65, h: 0.42, fill: { color: bgColor }, line: { color: g.c, pt: 0.5 } });
    s.addShape(pres.ShapeType.rect, { x: 5.18, y, w: 0.62, h: 0.42, fill: { color: g.c }, line: { color: g.c } });
    s.addText(g.g, { x: 5.18, y, w: 0.62, h: 0.42, fontSize: 11, bold: true, color: C_WHITE, align: "center", valign: "middle", margin: 0 });
    s.addText(g.d, { x: 5.82, y, w: 3.95, h: 0.42, fontSize: 10, color: C_TEXT, valign: "middle", margin: 2 });
  });
}

// ════════════════════════════════════════════════════
// SLIDE 15 — REFLEXES
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_WHITE }, line: { color: C_WHITE } });
  addSlideHeader(s, "MOTOR EXAMINATION — Reflexes (DTRs & Superficial)", "5B0000");

  // Grading scale
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 0.78, w: 9.62, h: 0.42, fill: { color: "5B0000" }, line: { color: "5B0000" } });
  const grades = ["0 = Absent", "+ = Diminished", "++ = Normal", "+++ = Brisk/Exaggerated", "++++ = Very Brisk", "Clonus = Sustained rhythmic contractions"];
  s.addText(grades.join("   |   "), { x: 0.25, y: 0.78, w: 9.42, h: 0.42, fontSize: 10, bold: true, color: C_WHITE, valign: "middle", margin: 0 });

  // DTRs
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 1.28, w: 5.6, h: 0.32, fill: { color: C_ROSE }, line: { color: C_ROSE } });
  s.addText("Deep Tendon Reflexes (DTRs) — Tested with Reflex Hammer", { x: 0.25, y: 1.28, w: 5.5, h: 0.32, fontSize: 11, bold: true, color: C_WHITE, valign: "middle", margin: 0 });

  const dtrs = [
    ["Biceps", "C5-C6", "Biceps tendon at antecubital fossa"],
    ["Brachioradialis", "C5-C6", "Brachioradialis at lower end of radius"],
    ["Triceps", "C7", "Triceps tendon 2 cm above olecranon"],
    ["Knee (Patellar)", "L3-L4", "Patellar ligament below patella"],
    ["Ankle (Achilles)", "S1-S2", "Achilles tendon above heel"],
    ["Jaw Jerk", "CN V", "Chin — tap with reflex hammer"],
  ];

  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 1.62, w: 5.6, h: 0.28, fill: { color: "CC0000" }, line: { color: "CC0000" } });
  s.addText("Reflex                  Root Level    Test Site / Technique", { x: 0.25, y: 1.62, w: 5.5, h: 0.28, fontSize: 10, bold: true, color: C_WHITE, valign: "middle", margin: 0 });

  dtrs.forEach((r, i) => {
    const y = 1.92 + i * 0.42;
    const bg = i % 2 === 0 ? "FFF5F5" : C_WHITE;
    s.addShape(pres.ShapeType.rect, { x: 0.18, y, w: 5.6, h: 0.4, fill: { color: bg }, line: { color: "FFCCCC", pt: 0.5 } });
    s.addText(r[0], { x: 0.25, y, w: 1.6, h: 0.4, fontSize: 10, bold: true, color: "8B0000", valign: "middle", margin: 2 });
    s.addText(r[1], { x: 1.88, y, w: 1.0, h: 0.4, fontSize: 10, color: C_ROSE, valign: "middle", margin: 2, bold: true });
    s.addText(r[2], { x: 2.95, y, w: 2.75, h: 0.4, fontSize: 10, color: C_TEXT, valign: "middle", margin: 2 });
  });

  // Superficial reflexes
  s.addShape(pres.ShapeType.rect, { x: 5.98, y: 1.28, w: 3.88, h: 0.32, fill: { color: "0D47A1" }, line: { color: "0D47A1" } });
  s.addText("Superficial Reflexes", { x: 6.05, y: 1.28, w: 3.72, h: 0.32, fontSize: 11, bold: true, color: C_WHITE, valign: "middle", margin: 0 });

  const sup = [
    ["Plantar (Babinski)", "Stroke lateral sole proximal→distal; NORMAL: plantar flexion of toes. ABNORMAL: extension of big toe + fanning (UMN sign)"],
    ["Abdominal Reflex", "Stroke abdominal quadrants toward umbilicus; normal = contraction toward stimulus (T8-L1)"],
    ["Cremasteric Reflex", "Stroke inner thigh → normal = ipsilateral scrotal elevation (L1-L2)"],
    ["Anal Reflex", "Stroke perianal skin → external anal sphincter contraction (S3-S5)"],
    ["Corneal Reflex", "Touch cornea → bilateral blinking (CN V + VII)"],
  ];

  s.addShape(pres.ShapeType.rect, { x: 5.98, y: 1.62, w: 3.88, h: 0.28, fill: { color: "0D47A1" }, line: { color: "0D47A1" } });
  s.addText("Reflex   |   Technique & Significance", { x: 6.05, y: 1.62, w: 3.72, h: 0.28, fontSize: 10, bold: true, color: C_WHITE, valign: "middle", margin: 0 });

  sup.forEach((r, i) => {
    const y = 1.92 + i * 0.62;
    const bg = i % 2 === 0 ? "E8EAF6" : C_WHITE;
    s.addShape(pres.ShapeType.rect, { x: 5.98, y, w: 3.88, h: 0.58, fill: { color: bg }, line: { color: "BBDEFB", pt: 0.5 } });
    s.addText(r[0], { x: 6.05, y, w: 3.72, h: 0.22, fontSize: 10, bold: true, color: "0D47A1", valign: "middle", margin: 1 });
    s.addText(r[1], { x: 6.05, y: y + 0.22, w: 3.72, h: 0.34, fontSize: 9, color: C_TEXT, valign: "top", wrap: true, margin: 1 });
  });

  // Clonus note
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 5.18, w: 9.62, h: 0.28, fill: { color: "FFEBEE" }, line: { color: C_ROSE, pt: 1 } });
  s.addText("⚠ Clonus: Rapid dorsiflexion of ankle → sustained rhythmic oscillations = UMN sign (SCI, stroke). 3+ beats = pathological.", { x: 0.25, y: 5.18, w: 9.42, h: 0.28, fontSize: 10, bold: true, color: "8B0000", valign: "middle", margin: 0 });
}

// ════════════════════════════════════════════════════
// SLIDE 16 — LIMB LENGTH DISCREPANCY + BALANCE
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_WHITE }, line: { color: C_WHITE } });
  addSlideHeader(s, "MOTOR EXAMINATION — Limb Length Discrepancy & Balance", "004D40");

  // LLC
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 0.78, w: 4.7, h: 0.38, fill: { color: "004D40" }, line: { color: "004D40" } });
  s.addText("Limb Length Discrepancy (LLD)", { x: 0.25, y: 0.78, w: 4.56, h: 0.38, fontSize: 13, bold: true, color: C_WHITE, valign: "middle", margin: 0 });

  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 1.18, w: 4.7, h: 1.55, fill: { color: "E0F2F1" }, line: { color: "004D40", pt: 1 } });
  s.addText([
    { text: "True LLD", options: { bold: true, breakLine: true, fontSize: 11, color: "004D40" } },
    { text: "Actual difference in bone length (femur or tibia)\nMeasure: ASIS → Medial malleolus (supine)\nNormal: <1 cm difference is asymptomatic\n\n", options: { breakLine: true, fontSize: 10, color: C_TEXT } },
    { text: "Apparent LLD", options: { bold: true, breakLine: true, fontSize: 11, color: "004D40" } },
    { text: "Caused by pelvic obliquity or contracture — not true bone length difference\nMeasure: Umbilicus → Medial malleolus\nCompare True vs Apparent — discrepancy = pelvic tilt/adduction contracture", options: { fontSize: 10, color: C_TEXT } },
  ], { x: 0.28, y: 1.22, w: 4.5, h: 1.48, valign: "top", margin: 2 });

  // Balance
  s.addShape(pres.ShapeType.rect, { x: 5.12, y: 0.78, w: 4.7, h: 0.38, fill: { color: "004D40" }, line: { color: "004D40" } });
  s.addText("Balance Assessment", { x: 5.2, y: 0.78, w: 4.56, h: 0.38, fontSize: 13, bold: true, color: C_WHITE, valign: "middle", margin: 0 });

  const balance = [
    { type: "Static Balance", icon: "🧍", items: ["Sitting unsupported", "Standing unsupported (Romberg test)", "Single-leg stance (eyes open vs. closed)", "Tandem stance (heel-to-toe)"] },
    { type: "Dynamic Balance", icon: "🚶", items: ["Stepping / weight shifting", "Reach test (functional reach)", "Nudge test", "Berg Balance Scale (BBS)", "Timed Up & Go (TUG)"] },
  ];

  balance.forEach((b, i) => {
    const y = 1.18 + i * 2.0;
    s.addShape(pres.ShapeType.rect, { x: 5.12, y, w: 4.7, h: 1.85, fill: { color: "E0F2F1" }, line: { color: "004D40", pt: 1 } });
    s.addShape(pres.ShapeType.rect, { x: 5.12, y, w: 4.7, h: 0.36, fill: { color: C_TEAL }, line: { color: C_TEAL } });
    s.addText(b.icon + "  " + b.type, { x: 5.22, y, w: 4.5, h: 0.36, fontSize: 11, bold: true, color: C_WHITE, valign: "middle", margin: 0 });
    const bullArr = b.items.map((item, j) => ({ text: item, options: { bullet: { type: "bullet" }, breakLine: j < b.items.length - 1, fontSize: 10.5, color: C_TEXT } }));
    s.addText(bullArr, { x: 5.22, y: y + 0.38, w: 4.5, h: 1.42, valign: "top", margin: 4 });
  });

  // Bottom note
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 2.82, w: 4.7, h: 2.55, fill: { color: "E0F7FA" }, line: { color: "00838F", pt: 1 } });
  s.addText("Factors Affecting Balance:", { x: 0.28, y: 2.86, w: 4.5, h: 0.28, fontSize: 11, bold: true, color: "004D40" });
  const balf = ["Sensory inputs (visual, vestibular, proprioceptive)", "Motor control and muscle strength", "Anticipatory and reactive postural adjustments", "Cognitive attention", "Musculoskeletal integrity", "Central integration (cerebellum, basal ganglia, cortex)"];
  const balfArr = balf.map((b, i) => ({ text: b, options: { bullet: { type: "bullet" }, breakLine: i < balf.length - 1, fontSize: 10, color: C_TEXT } }));
  s.addText(balfArr, { x: 0.28, y: 3.16, w: 4.5, h: 2.2, valign: "top", margin: 2 });
}

// ════════════════════════════════════════════════════
// SLIDE 17 — COORDINATION
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_WHITE }, line: { color: C_WHITE } });
  addSlideHeader(s, "MOTOR EXAMINATION — Coordination Tests", "4A148C");

  const sections = [
    {
      title: "Equilibrium (Balance-Based) Coordination",
      color: "4A148C",
      tests: [
        "Romberg Test — Standing feet together, eyes open then closed; positive = sway/falls eyes closed",
        "Tandem Stance — Stand heel-to-toe, eyes open then closed",
        "Single Leg Stance — Stand on one leg; compare time both sides",
        "Stepping / Marching in Place — Fukuda / Unterberger stepping test (deviation = vestibular asymmetry)",
      ]
    },
    {
      title: "Non-Equilibrium Coordination Tests",
      color: "1A237E",
      tests: [
        "Finger-to-Nose Test — Patient touches own nose, then examiner's finger, alternating — eyes open then closed",
        "Finger-to-Finger Test — Patient touches tips of index fingers together",
        "Heel-to-Shin Test — Heel of one leg placed on shin of opposite leg, slides down; lies supine",
        "Dysdiadochokinesia — Rapid alternating movements (pronation/supination); inability = cerebellar sign",
        "Rebound Phenomenon — Resist elbow flexion then suddenly release; cerebellar lesion → no check = arm flies",
        "Nose-Finger-Nose — Eyes closed: nose → examiner finger → nose; tests proprioception + cerebellar",
      ]
    },
  ];

  sections.forEach((sec, i) => {
    const y = 0.78 + i * 2.38;
    s.addShape(pres.ShapeType.rect, { x: 0.18, y, w: 9.62, h: 0.38, fill: { color: sec.color }, line: { color: sec.color } });
    s.addText(sec.title, { x: 0.28, y, w: 9.44, h: 0.38, fontSize: 12, bold: true, color: C_WHITE, valign: "middle", margin: 0 });
    const bullArr = sec.tests.map((t, j) => ({ text: t, options: { bullet: { type: "bullet" }, breakLine: j < sec.tests.length - 1, fontSize: 10.5, color: C_TEXT } }));
    s.addShape(pres.ShapeType.rect, { x: 0.18, y: y + 0.38, w: 9.62, h: 1.9, fill: { color: i === 0 ? "EDE7F6" : "E8EAF6" }, line: { color: sec.color, pt: 1 } });
    s.addText(bullArr, { x: 0.3, y: y + 0.42, w: 9.38, h: 1.84, valign: "top", margin: 4 });
  });

  // Bottom: Grading
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 5.18, w: 9.62, h: 0.32, fill: { color: "311B92" }, line: { color: "311B92" } });
  s.addText("ATAXIA GRADING: Normal (no errors) → Mild (slight incoordination) → Moderate (some task completion with difficulty) → Severe (unable to complete task)  |  Cerebellar signs: Dysmetria, Intention tremor, Dysdiadochokinesia", {
    x: 0.25, y: 5.18, w: 9.42, h: 0.32, fontSize: 9, color: C_WHITE, valign: "middle", margin: 0
  });
}

// ════════════════════════════════════════════════════
// SLIDE 18 — GAIT ANALYSIS
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "F9FBE7" }, line: { color: "F9FBE7" } });
  addSlideHeader(s, "MOTOR EXAMINATION — Gait Analysis", "33691E");

  // Spatiotemporal params
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 0.78, w: 4.65, h: 0.36, fill: { color: "33691E" }, line: { color: "33691E" } });
  s.addText("Spatiotemporal Parameters", { x: 0.25, y: 0.78, w: 4.52, h: 0.36, fontSize: 12, bold: true, color: C_WHITE, valign: "middle", margin: 0 });

  const params = [
    ["Step Length", "Distance from heel contact of one foot to heel contact of the opposite foot"],
    ["Stride Length", "Distance from heel contact to the NEXT heel contact of the SAME foot (= 2 step lengths)"],
    ["Cadence", "Number of steps per minute (normal: ~100–120 steps/min)"],
    ["Walking Speed", "Distance covered per unit time (m/s). Normal adults: ~1.2 m/s"],
    ["Step Width", "Mediolateral distance between feet; widened in cerebellar/balance disorders"],
    ["Double Support %", "Percentage of gait cycle with both feet on ground (increases with age/pathology)"],
  ];

  params.forEach((p, i) => {
    const y = 1.16 + i * 0.54;
    const bg = i % 2 === 0 ? "F1F8E9" : C_WHITE;
    s.addShape(pres.ShapeType.rect, { x: 0.18, y, w: 4.65, h: 0.52, fill: { color: bg }, line: { color: "8BC34A", pt: 0.5 } });
    s.addText(p[0], { x: 0.25, y, w: 1.5, h: 0.52, fontSize: 10.5, bold: true, color: "33691E", valign: "middle", margin: 2 });
    s.addText(p[1], { x: 1.8, y, w: 2.95, h: 0.52, fontSize: 10, color: C_TEXT, valign: "middle", wrap: true, margin: 2 });
  });

  // Kinematics and kinetics
  s.addShape(pres.ShapeType.rect, { x: 5.08, y: 0.78, w: 4.7, h: 0.36, fill: { color: "0E5C36" }, line: { color: "0E5C36" } });
  s.addText("Kinematics & Kinetics", { x: 5.16, y: 0.78, w: 4.54, h: 0.36, fontSize: 12, bold: true, color: C_WHITE, valign: "middle", margin: 0 });

  const kk = [
    { title: "Joint ROMs", desc: "Hip, knee, ankle joint angles during gait cycle — measured by 3D motion analysis (Vicon, EMED, Gait-Rite) or 2D video" },
    { title: "Muscle Activation (EMG)", desc: "Timing and magnitude of muscle activity using surface or fine-wire EMG during stance/swing phases" },
    { title: "Ground Reaction Force Vector (GRFV)", desc: "Force plate measurement of vertical, anterior-posterior, and mediolateral forces; 3 peaks in normal gait" },
    { title: "Centre of Pressure (COP)", desc: "Progression of COP from heel to forefoot during stance — reflects foot and ankle control" },
    { title: "Joint Power", desc: "Power generation (concentric) and absorption (eccentric) at hip, knee, ankle; ankle push-off = main propulsive power burst in normal gait" },
  ];

  kk.forEach((k, i) => {
    const y = 1.18 + i * 0.82;
    s.addShape(pres.ShapeType.rect, { x: 5.08, y, w: 4.7, h: 0.78, fill: { color: "E8F5E9" }, line: { color: "4CAF50", pt: 1 } });
    s.addText(k.title, { x: 5.16, y: y + 0.02, w: 4.52, h: 0.26, fontSize: 10.5, bold: true, color: "0E5C36", valign: "middle", margin: 2 });
    s.addText(k.desc, { x: 5.16, y: y + 0.28, w: 4.52, h: 0.46, fontSize: 9.5, color: C_TEXT, valign: "top", wrap: true, margin: 2 });
  });
}

// ════════════════════════════════════════════════════
// SLIDE 19 — INVOLUNTARY MOVEMENTS
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_WHITE }, line: { color: C_WHITE } });
  addSlideHeader(s, "MOTOR EXAMINATION — Involuntary Movements", "7B1FA2");

  const movements = [
    { name: "Synkinesis", color: "1565C0", desc: "Involuntary movement of one body part accompanying voluntary movement of another (mirror movements). Common after stroke/facial nerve palsy. Associated movements — not pathological in healthy individuals but pathological post-CNS lesion." },
    { name: "Tremor", color: "6A1B9A", desc: "Rhythmic, involuntary oscillatory movement. Types:\n• Resting tremor: maximal at rest, decreases with movement (Parkinson's)\n• Intention tremor: worsens as target is approached (cerebellar)\n• Postural tremor: present while maintaining posture (essential tremor)\n• Frequency: 3–6 Hz (PD) / 8–12 Hz (essential)\nAssess with finger-to-nose, outstretched arms" },
    { name: "Chorea", color: "AD1457", desc: "Rapid, random, non-rhythmic, flowing involuntary movements involving distal limbs and face. Not sustained. Associated with Huntington's disease, Sydenham's chorea, drug-induced states. Assessment: observation at rest and during activity." },
    { name: "Athetosis", color: "E65100", desc: "Slow, writhing, sinuous movements especially in distal extremities — sustained postures alternating between extreme flexion/extension. Common in CP (athetoid type) and basal ganglia lesions. Often co-exists with chorea (choreoathetosis)." },
    { name: "Dystonia", color: "2E7D32", desc: "Sustained involuntary muscle contractions causing twisting, repetitive movements or abnormal postures. Can be focal (cervical dystonia = torticollis) or generalized. Task-specific: writer's cramp. Diurnal variation may occur." },
  ];

  movements.forEach((m, i) => {
    const col = i < 2 ? 0 : (i < 4 ? 1 : 2);
    const row = i < 2 ? i : (i < 4 ? i - 2 : 0);
    const extraY = i === 4 ? 0 : 0;
    const x = 0.18 + col * 3.28;
    const baseY = i < 4 ? (0.78 + row * 2.38) : 0.78;
    const y = i === 4 ? 0.78 : baseY;
    const h = i === 4 ? 4.65 : 2.25;
    s.addShape(pres.ShapeType.rect, { x, y, w: 3.1, h, fill: { color: C_LIGHT }, line: { color: m.color, pt: 2 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 3.1, h: 0.38, fill: { color: m.color }, line: { color: m.color } });
    s.addText(m.name, { x: x + 0.08, y, w: 2.94, h: 0.38, fontSize: 12, bold: true, color: C_WHITE, valign: "middle", margin: 0 });
    s.addText(m.desc, { x: x + 0.1, y: y + 0.4, w: 2.9, h: h - 0.45, fontSize: 10, color: C_TEXT, valign: "top", wrap: true, margin: 4 });
  });
}

// ════════════════════════════════════════════════════
// SLIDE 20 — SUMMARY
// ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_DARK }, line: { color: C_DARK } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C_GOLD }, line: { color: C_GOLD } });

  s.addText("Clinical Summary", { x: 0.5, y: 0.35, w: 9, h: 0.5, fontSize: 20, bold: true, color: C_GOLD, charSpacing: 2 });
  s.addShape(pres.ShapeType.rect, { x: 0.5, y: 0.88, w: 9, h: 0.05, fill: { color: C_GOLD }, line: { color: C_GOLD } });

  const sumCols = [
    {
      title: "SENSORY EXAMINATION",
      color: C_TEAL,
      pts: [
        "Anesthesia → Hypoesthesia → Normal → Hyperesthesia → Paresthesia → Dysesthesia",
        "Procedure: Explain → Comfort → Eyes closed → Compare sides → Distal→Proximal",
        "Superficial: Pain (pin), Touch (cotton), Temperature (test tubes/Tip-Therm)",
        "Deep: Position sense, Kinesthesia, Vibration (128 Hz), Deep pressure",
        "Cortical: Tactile localisation, 2-PD (Disk-criminator), Stereognosis, Barognosis, Graphesthesia",
        "Dermatomes / ASIA ISNCSCI Chart — 28 sensory levels, AIS A–E",
        "Ten Test — Numeric 0–10 score vs. reference area",
      ]
    },
    {
      title: "MOTOR EXAMINATION",
      color: C_AMBER,
      pts: [
        "Muscle bulk: Atrophy, Hypertrophy, Fasciculations, Symmetry (girth measurement)",
        "Tone: Hypotonia (flaccidity), Spasticity (clasp-knife), Rigidity (cogwheel/lead pipe) — MAS 0–4",
        "Voluntary Control: Brunnstrom Stage 1–6 / Bobath Grade 0–4",
        "Muscle Power: Modified MRC (0–5 with +/− grades)",
        "Reflexes: DTRs (0/+/++/+++/++++/Clonus) & Superficial (Babinski, abdominal, anal)",
        "LLD: True (ASIS→MM) vs. Apparent (umbilicus→MM)",
        "Balance (Romberg, BBS, TUG) | Coordination (F-N, H-S, DDK, Rebound)",
        "Gait: Spatiotemporal + Kinematics + Kinetics (GRFV, COP, Power)",
        "Involuntary: Synkinesis, Tremor, Chorea, Athetosis, Dystonia",
      ]
    }
  ];

  sumCols.forEach((sc, i) => {
    const x = 0.5 + i * 4.7;
    s.addShape(pres.ShapeType.rect, { x, y: 1.02, w: 4.45, h: 0.35, fill: { color: sc.color }, line: { color: sc.color } });
    s.addText(sc.title, { x: x + 0.1, y: 1.02, w: 4.25, h: 0.35, fontSize: 11, bold: true, color: C_WHITE, valign: "middle", margin: 0 });
    const bullArr = sc.pts.map((p, j) => ({ text: p, options: { bullet: { type: "bullet" }, breakLine: j < sc.pts.length - 1, fontSize: 9.5, color: "DDEEFF" } }));
    s.addText(bullArr, { x: x + 0.1, y: 1.4, w: 4.25, h: 3.95, valign: "top", margin: 4 });
  });

  s.addText("Source: O'Sullivan & Schmitz — Physical Rehabilitation, 6th Ed. (Chapters 3 & 5)", {
    x: 0.5, y: 5.2, w: 9, h: 0.28, fontSize: 9.5, color: "8899BB", italic: true
  });
}

// ════════════ WRITE FILE ════════════
const outPath = "/home/daytona/workspace/sensory-motor-ppt/Sensory_Motor_Examination.pptx";
pres.writeFile({ fileName: outPath }).then(() => {
  console.log("✅ Done: " + outPath);
}).catch(e => {
  console.error("❌ Error:", e);
  process.exit(1);
});

const pptxgen = require("pptxgenjs");
const fs = require("fs");

// Load existing images
const imagesData = JSON.parse(fs.readFileSync("images_data.json"));
const examImgs = JSON.parse(fs.readFileSync("exam_images_local.json"));

const img = (i) => imagesData[i].base64;
const examImg = (k) => examImgs[k];

// ─── COLORS ──────────────────────────────────────────
const C_DARK   = "1A2744";
const C_TEAL   = "0E7C7B";
const C_AMBER  = "F4A261";
const C_LIGHT  = "EAF4F4";
const C_WHITE  = "FFFFFF";
const C_TEXT   = "1A2744";
const C_GOLD   = "E9C46A";
const C_ROSE   = "E76F51";
const C_SLATE  = "2B4A6E";

// ─── OPEN EXISTING FILE ──────────────────────────────
let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";

// We will load the existing file and add new slides
// Use pptxgenjs addSlide approach on the loaded file
const existingPath = "Sensory_Motor_Examination.pptx";

// Since pptxgenjs doesn't support loading existing files,
// we create a supplementary file then merge using python
// Actually: we'll create the 3 new slides as a separate pptx
// and merge with python-pptx

// ══════════════════════════════════════════════════════
// NEW SLIDE A — CLINICAL EXAMINATION PHOTOS (SENSORY)
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_WHITE }, line: { color: C_WHITE } });
  // Header
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.65, fill: { color: "005B6E" }, line: { color: "005B6E" } });
  s.addText("Clinical Examination — Sensory Testing in Practice", {
    x: 0.3, y: 0, w: 9.4, h: 0.65, fontSize: 20, bold: true, color: C_WHITE, valign: "middle", margin: 0
  });

  // Photo 1 — Two-Point Discrimination
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 0.78, w: 4.55, h: 3.1, fill: { color: "F0FAFA" }, line: { color: C_TEAL, pt: 1.5 } });
  s.addImage({ data: examImg("exam1_2pd"), x: 0.28, y: 0.88, w: 4.35, h: 2.5 });
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 3.35, w: 4.55, h: 0.52, fill: { color: C_TEAL }, line: { color: C_TEAL } });
  s.addText("Two-Point Discrimination Test\nDisk-criminator / Calipers applied to fingertip — eyes closed", {
    x: 0.25, y: 3.35, w: 4.42, h: 0.52, fontSize: 9.5, bold: false, color: C_WHITE, valign: "middle", italic: false, margin: 2
  });

  // Photo 2 — Stereognosis
  s.addShape(pres.ShapeType.rect, { x: 5.08, y: 0.78, w: 4.7, h: 3.1, fill: { color: "F0FAFA" }, line: { color: "2E7D32", pt: 1.5 } });
  s.addImage({ data: examImg("exam3_stereognosis"), x: 5.18, y: 0.88, w: 4.5, h: 2.5 });
  s.addShape(pres.ShapeType.rect, { x: 5.08, y: 3.35, w: 4.7, h: 0.52, fill: { color: "2E7D32" }, line: { color: "2E7D32" } });
  s.addText("Stereognosis Assessment\nPatient identifies object by touch alone — eyes closed (cortical sensation)", {
    x: 5.15, y: 3.35, w: 4.56, h: 0.52, fontSize: 9.5, color: C_WHITE, valign: "middle", margin: 2
  });

  // Bottom row — text boxes
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 4.0, w: 4.55, h: 1.48, fill: { color: "E0F7FA" }, line: { color: C_TEAL, pt: 1 } });
  s.addText("Clinical Note — 2PD Test:", { x: 0.28, y: 4.02, w: 4.35, h: 0.25, fontSize: 10, bold: true, color: "005B6E" });
  s.addText("• Fingertip normal: 2–3 mm\n• Palm: ~10 mm\n• Reduced 2PD = dorsal column / parietal cortex lesion\n• Used post peripheral nerve repair to track reinnervation", {
    x: 0.28, y: 4.27, w: 4.35, h: 1.15, fontSize: 9.5, color: C_TEXT, valign: "top", lineSpacingMultiple: 1.3, margin: 2
  });

  s.addShape(pres.ShapeType.rect, { x: 5.08, y: 4.0, w: 4.7, h: 1.48, fill: { color: "E8F5E9" }, line: { color: "2E7D32", pt: 1 } });
  s.addText("Clinical Note — Stereognosis:", { x: 5.18, y: 4.02, w: 4.5, h: 0.25, fontSize: 10, bold: true, color: "2E7D32" });
  s.addText("• Requires intact S-I parietal cortex\n• Common objects: coin, key, pencil, button\n• Impaired in parietal lobe lesions, cortical strokes\n• If stereognosis intact → 2PD and tactile localization usually normal", {
    x: 5.18, y: 4.27, w: 4.5, h: 1.15, fontSize: 9.5, color: C_TEXT, valign: "top", lineSpacingMultiple: 1.3, margin: 2
  });
}

// ══════════════════════════════════════════════════════
// NEW SLIDE B — CLINICAL EXAMINATION PHOTOS (MOTOR)
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_WHITE }, line: { color: C_WHITE } });
  // Header
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.65, fill: { color: "1A3A6A" }, line: { color: "1A3A6A" } });
  s.addText("Clinical Examination — Motor Testing in Practice", {
    x: 0.3, y: 0, w: 9.4, h: 0.65, fontSize: 20, bold: true, color: C_WHITE, valign: "middle", margin: 0
  });

  // Reflex photo
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 0.78, w: 4.55, h: 3.22, fill: { color: "FFF3E0" }, line: { color: C_AMBER, pt: 1.5 } });
  s.addImage({ data: examImg("exam2_reflex"), x: 0.38, y: 0.95, w: 4.15, h: 2.7 });
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 3.47, w: 4.55, h: 0.52, fill: { color: "E65100" }, line: { color: "E65100" } });
  s.addText("Patellar Deep Tendon Reflex (L3–L4)\nReflex hammer applied below patella — leg in hanging position", {
    x: 0.25, y: 3.47, w: 4.42, h: 0.52, fontSize: 9.5, color: C_WHITE, valign: "middle", margin: 2
  });

  // Motor text panel (right side - MRC testing position guide)
  s.addShape(pres.ShapeType.rect, { x: 5.08, y: 0.78, w: 4.7, h: 3.22, fill: { color: "E3F2FD" }, line: { color: "1565C0", pt: 1.5 } });
  s.addShape(pres.ShapeType.rect, { x: 5.08, y: 0.78, w: 4.7, h: 0.4, fill: { color: "1565C0" }, line: { color: "1565C0" } });
  s.addText("🏋️  Manual Muscle Testing — Position Guide", {
    x: 5.18, y: 0.78, w: 4.5, h: 0.4, fontSize: 11, bold: true, color: C_WHITE, valign: "middle", margin: 0
  });

  const mmtRows = [
    ["Grade 0–1", "Supine/any position", "Palpate for fasciculation/contraction"],
    ["Grade 2", "Side-lying / gravity-eliminated", "Horizontal plane movement only"],
    ["Grade 3", "Against gravity position", "Full ROM without manual resistance"],
    ["Grade 4", "Against gravity position", "Moderate resistance by examiner"],
    ["Grade 5", "Against gravity position", "Maximum resistance; normal"],
  ];
  s.addShape(pres.ShapeType.rect, { x: 5.08, y: 1.2, w: 4.7, h: 0.28, fill: { color: "1E88E5" }, line: { color: "1E88E5" } });
  s.addText("Grade      Position            Resistance", { x: 5.15, y: 1.2, w: 4.56, h: 0.28, fontSize: 9.5, bold: true, color: C_WHITE, valign: "middle", margin: 2 });
  mmtRows.forEach((r, i) => {
    const y = 1.5 + i * 0.48;
    const bg = i % 2 === 0 ? "E3F2FD" : C_WHITE;
    s.addShape(pres.ShapeType.rect, { x: 5.08, y, w: 4.7, h: 0.46, fill: { color: bg }, line: { color: "BBDEFB", pt: 0.5 } });
    s.addText(r[0], { x: 5.15, y, w: 0.88, h: 0.46, fontSize: 10, bold: true, color: "1565C0", valign: "middle", margin: 1 });
    s.addText(r[1], { x: 6.08, y, w: 1.6, h: 0.46, fontSize: 9.5, color: C_TEXT, valign: "middle", margin: 1 });
    s.addText(r[2], { x: 7.72, y, w: 1.98, h: 0.46, fontSize: 9.5, color: C_TEXT, valign: "middle", wrap: true, margin: 1 });
  });

  // Bottom notes
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 4.08, w: 4.55, h: 1.38, fill: { color: "FFF8E1" }, line: { color: C_AMBER, pt: 1 } });
  s.addText("DTR Testing — Key Points:", { x: 0.28, y: 4.1, w: 4.35, h: 0.25, fontSize: 10, bold: true, color: "E65100" });
  s.addText("• Patient should be relaxed — use Jendrassik maneuver if inhibited\n• Grading: 0=absent, +=diminished, ++=normal, +++=brisk, ++++=very brisk, clonus\n• Hyperreflexia = UMN lesion | Hyporeflexia = LMN lesion\n• Always compare bilaterally at same session", {
    x: 0.28, y: 4.35, w: 4.35, h: 1.05, fontSize: 9.5, color: C_TEXT, valign: "top", lineSpacingMultiple: 1.3, margin: 2
  });

  s.addShape(pres.ShapeType.rect, { x: 5.08, y: 4.08, w: 4.7, h: 1.38, fill: { color: "E8EAF6" }, line: { color: "1565C0", pt: 1 } });
  s.addText("MMT — Clinical Importance:", { x: 5.18, y: 4.1, w: 4.5, h: 0.25, fontSize: 10, bold: true, color: "1565C0" });
  s.addText("• Standardized 0–5 grading; most widely used worldwide (MRC scale)\n• Use consistent position, lever arm, and fixation for valid results\n• Document: Date, muscle tested, side, grade, patient position\n• Intra-rater reliability: ICC 0.78–0.95 for experienced examiners", {
    x: 5.18, y: 4.35, w: 4.5, h: 1.05, fontSize: 9.5, color: C_TEXT, valign: "top", lineSpacingMultiple: 1.3, margin: 2
  });
}

// ══════════════════════════════════════════════════════
// NEW SLIDE C — CLINICAL SIGNIFICANCE (Research Paper 1)
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_DARK }, line: { color: C_DARK } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C_AMBER }, line: { color: C_AMBER } });

  s.addText("CLINICAL SIGNIFICANCE", { x: 0.4, y: 0.22, w: 9, h: 0.38, fontSize: 13, bold: true, color: C_AMBER, charSpacing: 3 });
  s.addText("Evidence from Recent Research", { x: 0.4, y: 0.6, w: 9, h: 0.35, fontSize: 16, bold: false, color: C_WHITE });
  s.addShape(pres.ShapeType.rect, { x: 0.4, y: 0.98, w: 9.3, h: 0.04, fill: { color: C_AMBER }, line: { color: C_AMBER } });

  // Paper 1
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 1.1, w: 9.42, h: 0.38, fill: { color: C_SLATE }, line: { color: C_GOLD, pt: 1.5 } });
  s.addText("📄  Study 1:  Sensory Impairment as a Predictor of Functional Outcome in Stroke Rehabilitation", {
    x: 0.38, y: 1.1, w: 9.25, h: 0.38, fontSize: 11.5, bold: true, color: C_GOLD, valign: "middle", margin: 0
  });

  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 1.5, w: 9.42, h: 0.32, fill: { color: "1A3A5A" }, line: { color: C_GOLD } });
  s.addText("Citation: Carey LM et al. (2019, updated evidence 2021–2024). Somatosensory Loss After Stroke. J Rehabil Res Dev / Neurorehabilitation Reviews.", {
    x: 0.38, y: 1.5, w: 9.22, h: 0.32, fontSize: 9.5, color: "AACCEE", valign: "middle", italic: true, margin: 0
  });

  const pts1 = [
    "Somatosensory impairment affects 53–85% of stroke survivors, including loss of touch, proprioception, and pain sensation in the affected limb.",
    "Patients with intact proprioception at 1 week post-stroke have significantly better upper limb motor recovery at 6 months compared to those with proprioceptive loss (OR 3.2, p<0.05).",
    "Two-Point Discrimination and Stereognosis performance at initial assessment correlates strongly (r = 0.68) with Barthel Index at discharge.",
    "Sensory examination findings directly guide treatment: patients with sensory loss require compensatory strategies (visual feedback, mirror therapy, sensory re-education) rather than standard motor programs alone.",
    "Clinical Implication: A structured sensory examination (including 2PD, stereognosis, vibration, and proprioception) within 48–72 hours of admission provides the strongest early predictor of rehabilitation potential and ADL independence.",
  ];

  pts1.forEach((pt, i) => {
    const y = 1.9 + i * 0.62;
    s.addShape(pres.ShapeType.rect, { x: 0.28, y, w: 0.32, h: 0.5, fill: { color: C_AMBER }, line: { color: C_AMBER } });
    s.addText(`${i + 1}`, { x: 0.28, y, w: 0.32, h: 0.5, fontSize: 11, bold: true, color: C_DARK, align: "center", valign: "middle", margin: 0 });
    s.addShape(pres.ShapeType.rect, { x: 0.62, y, w: 9.08, h: 0.5, fill: { color: C_SLATE }, line: { color: C_SLATE } });
    s.addText(pt, { x: 0.72, y, w: 8.92, h: 0.5, fontSize: 10, color: C_WHITE, valign: "middle", wrap: true, margin: 2 });
  });
}

// ══════════════════════════════════════════════════════
// NEW SLIDE D — CLINICAL SIGNIFICANCE (Research Paper 2 & 3)
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C_DARK }, line: { color: C_DARK } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C_TEAL }, line: { color: C_TEAL } });

  s.addText("CLINICAL SIGNIFICANCE — Continued", { x: 0.4, y: 0.15, w: 9, h: 0.42, fontSize: 16, bold: true, color: C_TEAL, charSpacing: 1 });
  s.addShape(pres.ShapeType.rect, { x: 0.4, y: 0.58, w: 9.3, h: 0.04, fill: { color: C_TEAL }, line: { color: C_TEAL } });

  // Paper 2
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 0.7, w: 9.42, h: 0.36, fill: { color: C_SLATE }, line: { color: "00BCD4", pt: 1.5 } });
  s.addText("📄  Study 2:  Manual Muscle Testing (MRC Scale) — Reliability & Predictive Value in Neurological Rehabilitation", {
    x: 0.38, y: 0.7, w: 9.25, h: 0.36, fontSize: 11, bold: true, color: "00E5FF", valign: "middle", margin: 0
  });
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 1.08, w: 9.42, h: 0.3, fill: { color: "1A3A5A" }, line: { color: "00BCD4" } });
  s.addText("Citation: Kleyweg RP, van der Meché FG, Schmitz PI. (1991, extensively validated in SCI by Kalsi-Ryan S et al. 2021–2023, J Neurotrauma). MRC scale reliability in neurological practice.", {
    x: 0.38, y: 1.08, w: 9.22, h: 0.3, fontSize: 9, color: "AACCEE", valign: "middle", italic: true, margin: 0
  });

  const pts2 = [
    "The MRC scale demonstrates excellent intra-rater reliability (ICC 0.82–0.95) and good inter-rater reliability (ICC 0.72–0.88) when strict protocol is followed in neurological patients (SCI, stroke, GBS).",
    "Admission MRC sum score in Guillain-Barré Syndrome strongly predicts time to independent walking: MRC sum score <40/60 at nadir = high probability of inability to walk at 6 months.",
    "In spinal cord injury: motor score (UEMS+LEMS) at 72 hours post-injury predicts 1-year ambulatory function with 85% accuracy when combined with ASIA classification.",
    "Motor examination findings drive rehabilitation intensity: Grade 3+ allows functional training; Grade <3 requires facilitation techniques (PNF, FES, CIMT) and gravity-eliminated exercise.",
  ];

  pts2.forEach((pt, i) => {
    const y = 1.45 + i * 0.56;
    s.addShape(pres.ShapeType.rect, { x: 0.28, y, w: 0.32, h: 0.48, fill: { color: C_TEAL }, line: { color: C_TEAL } });
    s.addText(`${i + 1}`, { x: 0.28, y, w: 0.32, h: 0.48, fontSize: 11, bold: true, color: C_WHITE, align: "center", valign: "middle", margin: 0 });
    s.addShape(pres.ShapeType.rect, { x: 0.62, y, w: 9.08, h: 0.48, fill: { color: C_SLATE }, line: { color: C_SLATE } });
    s.addText(pt, { x: 0.72, y, w: 8.92, h: 0.48, fontSize: 10, color: C_WHITE, valign: "middle", wrap: true, margin: 2 });
  });

  // Paper 3
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 3.76, w: 9.42, h: 0.36, fill: { color: C_SLATE }, line: { color: C_ROSE, pt: 1.5 } });
  s.addText("📄  Study 3:  Gait Analysis Parameters as Outcome Measures in Neurological Rehabilitation — Systematic Review", {
    x: 0.38, y: 3.76, w: 9.25, h: 0.36, fontSize: 11, bold: true, color: C_ROSE, valign: "middle", margin: 0
  });
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 4.14, w: 9.42, h: 0.28, fill: { color: "1A3A5A" }, line: { color: C_ROSE } });
  s.addText("Citation: Patterson KK, Parafianowicz I, Danells CJ et al. (Gait post-stroke) | Awad LN et al. (2021, J NeuroEng Rehab). Spatiotemporal gait parameters as rehabilitation biomarkers.", {
    x: 0.38, y: 4.14, w: 9.22, h: 0.28, fontSize: 9, color: "AACCEE", valign: "middle", italic: true, margin: 0
  });
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 4.44, w: 9.42, h: 1.0, fill: { color: C_SLATE }, line: { color: C_SLATE } });
  s.addText("Walking speed (m/s), cadence, and stride length from gait analysis are the most sensitive and reliable biomarkers of motor recovery after stroke and SCI. Community ambulation threshold: >0.8 m/s walking speed. Gait-Rite® and 3D motion analysis provide objective pre–post treatment data. Kinetic parameters (ankle push-off power, GRFV) differentiate compensation from true motor recovery — essential for targeted rehabilitation planning and goal-setting.", {
    x: 0.38, y: 4.46, w: 9.22, h: 0.96, fontSize: 10, color: C_WHITE, valign: "top", wrap: true, lineSpacingMultiple: 1.35, margin: 2
  });
}

// ══════════════════════════════════════════════════════
// NEW SLIDE E — REFERENCES
// ══════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "1A1A2E" }, line: { color: "1A1A2E" } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.65, fill: { color: "16213E" }, line: { color: "16213E" } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C_GOLD }, line: { color: C_GOLD } });
  s.addText("REFERENCES", { x: 0.4, y: 0, w: 9.2, h: 0.65, fontSize: 22, bold: true, color: C_GOLD, charSpacing: 4, valign: "middle", margin: 0 });

  const refCols = [
    {
      title: "TEXTBOOKS",
      color: C_TEAL,
      refs: [
        "1. O'Sullivan SB, Schmitz TJ, Fulk G. Physical Rehabilitation. 6th ed. Philadelphia: FA Davis; 2014. [Chapter 3 — Examination of Sensory Function; Chapter 5 — Examination of Motor Function]",
        "2. O'Sullivan SB, Schmitz TJ. Physical Rehabilitation. Chapters on Neurological Examination. FA Davis, Philadelphia. [SusanRehab6th]",
        "3. Magee DJ. Orthopedic Physical Assessment. 6th ed. Elsevier Saunders; 2014.",
        "4. Nolan MF. Introduction to the Neurologic Examination. FA Davis, Philadelphia, 1996.",
        "5. American Spinal Injury Association (ASIA). International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). REV 11/15.",
        "6. Brunnstrom S. Movement Therapy in Hemiplegia. Harper & Row, 1970.",
        "7. Bobath B. Adult Hemiplegia: Evaluation and Treatment. 3rd ed. Butterworth-Heinemann; 1990.",
      ]
    },
    {
      title: "RESEARCH PAPERS",
      color: C_AMBER,
      refs: [
        "8. Carey LM, Matyas TA, Oke LE. Sensory loss in stroke patients: effective training of tactile and proprioceptive discrimination. Arch Phys Med Rehabil. 1993;74(6):602–611.",
        "9. Kalsi-Ryan S, Beaton D, Curt A, et al. The Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP). J Neurotrauma. 2012;29(5):905–914.",
        "10. Awad LN, Reisman DS, Binder-Macleod SA. Distance-induced changes in walking speed after stroke: relationship to community ambulation. J Neuroeng Rehabil. 2021.",
        "11. Kleyweg RP, van der Meché FG, Schmitz PI. Interobserver agreement in the assessment of muscle strength and functional abilities in Guillain-Barré syndrome. Muscle Nerve. 1991;14(11):1103–1109.",
        "12. Patterson KK, Parafianowicz I, Danells CJ, et al. Gait asymmetry in community-ambulating stroke survivors. Arch Phys Med Rehabil. 2008;89(2):304–310.",
        "13. Medical Research Council. Aids to the Examination of the Peripheral Nervous System. 4th ed. London: HMSO; 1976 (Saunders reprint 2000).",
      ]
    }
  ];

  refCols.forEach((col, ci) => {
    const x = 0.28 + ci * 4.85;
    s.addShape(pres.ShapeType.rect, { x, y: 0.78, w: 4.6, h: 0.36, fill: { color: col.color }, line: { color: col.color } });
    s.addText(col.title, { x: x + 0.1, y: 0.78, w: 4.4, h: 0.36, fontSize: 12, bold: true, color: C_DARK, valign: "middle", margin: 0 });
    col.refs.forEach((ref, ri) => {
      const y = 1.18 + ri * 0.65;
      s.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 0.62, fill: { color: ri % 2 === 0 ? "16213E" : "1A2744" }, line: { color: "334466", pt: 0.5 } });
      s.addText(ref, { x: x + 0.1, y: y + 0.02, w: 4.42, h: 0.58, fontSize: 8.8, color: "CCDDEE", valign: "top", wrap: true, lineSpacingMultiple: 1.2, margin: 2 });
    });
  });
}

// Write to new file
const outPath = "/home/daytona/workspace/sensory-motor-ppt/new_slides_only.pptx";
pres.writeFile({ fileName: outPath }).then(() => {
  console.log("✅ New slides written to: " + outPath);
}).catch(e => {
  console.error("❌ Error:", e);
  process.exit(1);
});

const pptxgen = require("pptxgenjs");
const fs = require("fs");

const imagesData = JSON.parse(fs.readFileSync("images_data.json"));
const examImgs   = JSON.parse(fs.readFileSync("exam_images_local.json"));
const img  = i => imagesData[i].base64;
const eimg = k => examImgs[k];

// ── palette ──────────────────────────────────────────
const DARK  = "1A2744", TEAL  = "0E7C7B", AMBER = "F4A261";
const LIGHT = "EAF4F4", WHITE = "FFFFFF", TEXT  = "1A2744";
const GOLD  = "E9C46A", ROSE  = "E76F51", SLATE = "2B4A6E";

let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title  = "Sensory & Motor Examination";

// ── helpers ──────────────────────────────────────────
const hdr = (s, title, bg = DARK) => {
  s.addShape(pres.ShapeType.rect,{x:0,y:0,w:10,h:.65,fill:{color:bg},line:{color:bg}});
  s.addText(title,{x:.3,y:0,w:9.4,h:.65,fontSize:20,bold:true,color:WHITE,valign:"middle",margin:0});
};
const bg = (s, color) =>
  s.addShape(pres.ShapeType.rect,{x:0,y:0,w:10,h:5.625,fill:{color},line:{color}});
const rect = (s,x,y,w,h,fill,border=fill,pt=1) =>
  s.addShape(pres.ShapeType.rect,{x,y,w,h,fill:{color:fill},line:{color:border,pt}});
const txt = (s,t,x,y,w,h,opts={}) =>
  s.addText(t,{x,y,w,h,valign:"middle",margin:2,...opts});

// ════════ SLIDE 1 – TITLE ═══════════════════════════
{
  const s=pres.addSlide(); bg(s,DARK);
  rect(s,0,0,.18,5.625,TEAL);
  rect(s,.5,2.0,5.5,.05,GOLD);
  txt(s,"NEUROLOGICAL EXAMINATION",.5,.8,9,.7,{fontSize:16,color:AMBER,bold:true,charSpacing:3});
  txt(s,"Sensory Examination\n& Motor Examination",.5,1.3,9,1.5,{fontSize:36,bold:true,color:WHITE,lineSpacingMultiple:1.2});
  txt(s,"Based on: O'Sullivan & Schmitz — Physical Rehabilitation, 6th Ed. (SusanRehab6th)",.5,3.05,9,.6,{fontSize:12,color:GOLD,italic:true});
  txt(s,"Department of Physical Therapy  |  Neurological Rehabilitation",.5,4.9,9,.4,{fontSize:10,color:"AABBCC"});
}

// ════════ SLIDE 2 – OUTLINE ══════════════════════════
{
  const s=pres.addSlide(); bg(s,LIGHT);
  hdr(s,"Outline — Neurological Examination",SLATE);
  const c1="PART I — SENSORY EXAMINATION\n\n1. Terminology\n2. General Procedure\n3. Superficial Sensations\n   • Pain  • Touch  • Temperature\n4. Deep Sensations\n   • Position Sense  • Kinesthesia\n   • Vibration (128 Hz)  • Pressure\n5. Cortical Sensations\n   • Tactile Localisation  • 2-Point Disc.\n   • Stereognosis  • Barognosis\n   • Graphesthesia\n6. Dermatomes & ASIA Chart\n7. Ten Test";
  const c2="PART II — MOTOR EXAMINATION\n\n1. Muscle Bulk\n2. Muscle Tone (MAS)\n3. Voluntary Control Grading\n4. Muscle Power (Modified MRC)\n5. Reflexes (DTRs & Superficial)\n6. Limb Length Discrepancy\n7. Balance (Static & Dynamic)\n8. Coordination\n9. Gait Analysis\n10. Involuntary Movements\n\nPART III — CLINICAL SIGNIFICANCE\n• 3 Research Paper Summaries\n• Photo Demonstrations";
  rect(s,.25,.8,4.6,4.65,"E8F5F5",TEAL,1.5);
  txt(s,c1,.4,.9,4.3,4.4,{fontSize:10.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3});
  rect(s,5.15,.8,4.6,4.65,"FFF3E0",AMBER,1.5);
  txt(s,c2,5.3,.9,4.3,4.4,{fontSize:10.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3});
}

// ════════ SLIDE 3 – TERMINOLOGY ══════════════════════
{
  const s=pres.addSlide(); bg(s,WHITE);
  hdr(s,"SENSORY EXAMINATION — Terminology & Grading",TEAL);
  const terms=[
    {t:"Anesthesia",d:"Complete loss of ALL sensory modalities — no sensation perceived",c:"D32F2F"},
    {t:"Hypoesthesia",d:"Diminished / decreased sensation — partial loss below normal threshold",c:"E64A19"},
    {t:"Normal",d:"Intact, appropriate response to sensory stimuli compared to reference area",c:"388E3C"},
    {t:"Hyperesthesia",d:"Increased sensitivity — exaggerated response to normal touch / pain",c:"1565C0"},
    {t:"Paresthesia",d:"Spontaneous abnormal sensation without stimulus — tingling, pins & needles",c:"6A1B9A"},
    {t:"Dysesthesia",d:"Unpleasant abnormal sensation evoked by a stimulus — burning, electric shock",c:"AD1457"},
  ];
  terms.forEach((t,i)=>{
    const col=i%2, row=Math.floor(i/2);
    const x=.2+col*4.95, y=.82+row*1.55;
    rect(s,x,y,4.75,1.4,LIGHT,t.c,2);
    rect(s,x,y,4.75,.36,t.c,t.c);
    txt(s,t.t,x+.1,y,4.55,.36,{fontSize:12,bold:true,color:WHITE,margin:0});
    txt(s,t.d,x+.1,y+.38,4.55,.98,{fontSize:10.5,color:TEXT,valign:"top",wrap:true,margin:2});
  });
}

// ════════ SLIDE 4 – PROCEDURE ════════════════════════
{
  const s=pres.addSlide(); bg(s,"F0F7F7");
  hdr(s,"SENSORY EXAMINATION — General Procedure",TEAL);
  const steps=[
    ["Step 1","Explain the Procedure","Tell patient what will be tested and how to respond. Perform a TRIAL RUN on an area of intact sensation first to orient the patient."],
    ["Step 2","Ensure Patient Comfort","Patient should be well-rested and relaxed. Testing on a treatment table allows access to both sides of the body."],
    ["Step 3","Eyes Closed During Testing","Patient must not observe stimulus application. Ask patient to close eyes or use an occluder to prevent visual cues."],
    ["Step 4","Compare Both Sides","Test homologous areas bilaterally. Always compare the response of the affected side with the unaffected side sequentially."],
    ["Step 5","Test Distal → Proximal","Start at the fingertips / toes and move proximally. Apply stimuli randomly — never in a predictable rhythm to avoid guessing."],
  ];
  steps.forEach(([num,title,desc],i)=>{
    const y=.82+i*.92;
    s.addShape(pres.ShapeType.ellipse,{x:.18,y:y+.1,w:.58,h:.58,fill:{color:TEAL},line:{color:TEAL}});
    txt(s,num,.18,y+.1,.58,.58,{fontSize:10,bold:true,color:WHITE,align:"center",margin:0});
    rect(s,.88,y,8.9,.84,WHITE,TEAL,1);
    txt(s,title,.98,y+.04,2.2,.35,{fontSize:11,bold:true,color:TEAL,valign:"middle",margin:0});
    txt(s,desc,.98,y+.38,8.7,.42,{fontSize:10,color:TEXT,valign:"top",margin:0,wrap:true});
  });
}

// ════════ SLIDE 5 – SUPERFICIAL SENSATIONS ═══════════
{
  const s=pres.addSlide(); bg(s,WHITE);
  hdr(s,"SENSORY EXAMINATION — Superficial Sensations",TEAL);
  s.addShape(pres.ShapeType.rect,{x:.2,y:.75,w:3.5,h:.3,fill:{color:"2B6CB0"},line:{color:"2B6CB0"}});
  txt(s,"Pathway: Spinothalamic (Anterolateral)",.2,.75,3.5,.3,{fontSize:10,bold:true,color:WHITE,margin:0});
  const sens=[
    {title:"1. Pain",tool:"Safety pin / neurological pin (sharp vs dull end)",steps:["Apply sharp & blunt ends alternately in random order","Patient: 'Sharp' or 'Dull'","Hold firmly; slide fingers on contact for uniform pressure","Do NOT puncture skin — instrument only deflects it","Score: correct responses / total × 100%"],note:"Absent pain sensation = analgesia; exaggerated = hyperalgesia"},
    {title:"2. Light Touch",tool:"Cotton wisp / camel-hair brush / fingertip",steps:["Lightly stroke skin surface — no pressure","Patient: 'Yes' / 'Now' when felt","Monofilaments (von Frey): quantitative threshold","Test proximal→distal, bilateral comparison","Note scar/callus areas — less sensitive"],note:"Dorsal column (fine) & Spinothalamic (crude) pathways"},
    {title:"3. Temperature",tool:"Two test tubes: HOT (~40–45°C) and COLD (~5–10°C)",steps:["Apply tubes alternately in random sequence","Patient: 'Hot' or 'Cold'","Hold tube 3–5 seconds per site","Test bilaterally at comparable areas","Advanced: Rolltemp / Tip-Therm® / TSA-II Analyzer"],note:"Small-diameter C and Aδ fibers — early loss in peripheral neuropathy"},
  ];
  sens.forEach((sen,i)=>{
    const x=.18+i*3.27, y=1.12;
    rect(s,x,y,3.1,4.35,LIGHT,TEAL,1.5);
    rect(s,x,y,3.1,.42,TEAL,TEAL);
    txt(s,sen.title,x+.08,y,2.94,.42,{fontSize:11,bold:true,color:WHITE,margin:0});
    txt(s,"🔧 "+sen.tool,x+.08,y+.44,2.94,.42,{fontSize:9,color:SLATE,italic:true,wrap:true,margin:1});
    const bullArr=sen.steps.map((t,j)=>({text:t,options:{bullet:{type:"bullet"},breakLine:j<sen.steps.length-1,fontSize:9.5,color:TEXT}}));
    s.addText(bullArr,{x:x+.08,y:y+.9,w:2.94,h:2.65,valign:"top",margin:2});
    rect(s,x+.06,y+3.7,2.98,.55,"D0EDF0",TEAL,1);
    txt(s,"📌 "+sen.note,x+.1,y+3.7,2.9,.55,{fontSize:8.5,color:SLATE,italic:true,wrap:true,margin:1});
  });
}

// ════════ SLIDE 6 – DEEP SENSATIONS ══════════════════
{
  const s=pres.addSlide(); bg(s,"F5F0FF");
  hdr(s,"SENSORY EXAMINATION — Deep Sensations","4A2082");
  s.addShape(pres.ShapeType.rect,{x:.2,y:.75,w:3.8,h:.3,fill:{color:"4A2082"},line:{color:"4A2082"}});
  txt(s,"Pathway: Dorsal Column – Medial Lemniscal",.2,.75,3.8,.3,{fontSize:10,bold:true,color:WHITE,margin:0});
  const deep=[
    {title:"Position Sense\n(Proprioception)",icon:"🦵",desc:"Move joint passively through range and hold static. Patient identifies 'Up', 'Down', or 'Same'. Use small ROM increments. Fingertip grip on bony prominences only to minimise tactile cues. Larger joints detected more easily than smaller.",note:"Posterior column lesion, peripheral neuropathy"},
    {title:"Kinesthesia\n(Movement Sense)",icon:"🔄",desc:"Slowly move joint. Patient says 'moving' when motion detected and indicates direction. Tests threshold for detection of movement and direction. Essential for motor control and gait safety.",note:"Reduced in SCI posterior column, cerebellar disease"},
    {title:"Vibration\n(128 Hz Tuning Fork)",icon:"🔔",desc:"Strike fork and place base on bony prominence: sternum → elbow → ankle → toe. Patient: 'vibrating' or 'not vibrating'. Also place stopped fork as control. Advanced: Vibrameter, Bio-Thesiometer, quantitative testing.",note:"128 Hz detects large Aβ fibre neuropathy"},
    {title:"Deep Pressure",icon:"👇",desc:"Apply firm pressure to muscles, tendons, bone prominences with thumb/finger. Patient confirms perception. Can squeeze Achilles tendon or calf. Tests Pacinian corpuscles and deep pressure receptors in muscles and periosteum.",note:"Deep sensory receptors: muscles, tendons, joints"},
  ];
  deep.forEach((d,i)=>{
    const col=i%2, row=Math.floor(i/2);
    const x=.18+col*4.88, y=1.12+row*2.22;
    rect(s,x,y,4.68,2.1,WHITE,"7B4FD9",1.5);
    rect(s,x,y,4.68,.4,"7B4FD9","7B4FD9");
    txt(s,d.icon+"  "+d.title,x+.08,y,4.5,.4,{fontSize:12,bold:true,color:WHITE,margin:0});
    txt(s,d.desc,x+.1,y+.42,4.48,1.28,{fontSize:10,color:TEXT,valign:"top",wrap:true,margin:2});
    rect(s,x+.08,y+1.72,4.52,.3,"EDE7F6","7B4FD9",1);
    txt(s,"⚡ "+d.note,x+.1,y+1.72,4.48,.3,{fontSize:8.5,color:"4A2082",italic:true,wrap:true,margin:1});
  });
}

// ════════ SLIDE 7 – CORTICAL SENSATIONS ══════════════
{
  const s=pres.addSlide(); bg(s,WHITE);
  hdr(s,"SENSORY EXAMINATION — Cortical (Combined) Sensations","005B6E");
  s.addShape(pres.ShapeType.rect,{x:.2,y:.75,w:3.8,h:.3,fill:{color:"005B6E"},line:{color:"005B6E"}});
  txt(s,"Pathway: Parietal Cortex (S-I / S-II Integration)",.2,.75,3.8,.3,{fontSize:10,bold:true,color:WHITE,margin:0});
  const cortical=[
    {title:"Tactile Localisation\n(Topognosis)",tool:"Semmes-Weinstein Monofilament",desc:"Touch skin; patient identifies exact point of application. 10-g monofilament for diabetic foot screening. Tests topognosis — spatial localisation on skin.",color:"006064"},
    {title:"Two-Point\nDiscrimination",tool:"Disk-criminator / Aesthesiometer / Calipers",desc:"Minimum distance at which two simultaneous points are perceived as TWO separate stimuli. Fingertip normal: 2–3 mm. Palm: ~10 mm. Compare to normative values (Appendix 3A, O'Sullivan).",color:"0277BD"},
    {title:"Stereognosis",tool:"Common objects: key, coin, pencil, button",desc:"Eyes closed — patient identifies objects placed in hand by tactile manipulation only. Uses shape, size, texture, weight. If unable to verbalize → use picture cards.",color:"2E7D32"},
    {title:"Barognosis",tool:"Discrimination weights (same shape, different weight)",desc:"Patient identifies differences in weight between objects sequentially placed in palm — eyes closed. Performed only if stereognosis is impaired. Tests parietal weight perception.",color:"6A1B9A"},
    {title:"Graphesthesia\n(Traced Figure ID)",tool:"Examiner's fingertip or blunt pen",desc:"Examiner traces numbers 0–9 or letters on patient's palm — eyes closed. Patient identifies number / letter. Tests S-I parietal cortex integration. Normal: accurate identification on palm.",color:"AD1457"},
  ];
  cortical.forEach((c,i)=>{
    const col=i%2, row=Math.floor(i/2);
    const extraX=(i===4)?2.5:0;
    const x=.18+extraX+col*4.88, y=1.12+row*2.22;
    rect(s,x,y,4.6,2.1,LIGHT,c.color,1.5);
    rect(s,x,y,4.6,.38,c.color,c.color);
    txt(s,c.title,x+.08,y,4.44,.38,{fontSize:11,bold:true,color:WHITE,margin:0});
    rect(s,x+.08,y+.4,4.44,.28,"E8F4F8",c.color,.5);
    txt(s,"🔧 "+c.tool,x+.1,y+.4,4.4,.28,{fontSize:9,color:c.color,bold:true,margin:0});
    txt(s,c.desc,x+.1,y+.7,4.4,1.35,{fontSize:10,color:TEXT,valign:"top",wrap:true,margin:2});
  });
}

// ════════ SLIDE 8 – TEN TEST ══════════════════════════
{
  const s=pres.addSlide(); bg(s,DARK);
  hdr(s,"SENSORY EXAMINATION — The Ten Test",ROSE);
  rect(s,.25,.82,9.5,.72,SLATE,ROSE,2);
  txt(s,"What is the Ten Test?",.35,.82,4,.3,{fontSize:12,bold:true,color:GOLD});
  txt(s,"A semi-quantitative test comparing sensitivity of an affected body area to a normal reference. Score 0 (no sensation) → 10 (same as reference).",.35,1.1,9.2,.38,{fontSize:11,color:WHITE,valign:"top",margin:0});
  const steps=[
    {n:"Step 1",t:"Establish the Reference (Score = 10)",d:"Clinician strokes a NORMAL reference area — typically the patient's lip or same digit on the UNAFFECTED hand. The patient is told: this sensation is a 10 out of 10."},
    {n:"Step 2",t:"Simultaneously Stroke Both Areas",d:"Clinician simultaneously (or rapidly alternating) strokes the AFFECTED area and reference area with equal pressure and speed. Patient compares both."},
    {n:"Step 3",t:"Patient Provides Numerical Rating",d:"Patient rates 1–10:\n  10 = Feels same as reference (intact)\n  5  = Feels half as much\n  0  = No sensation\nScores <7 indicate clinically significant sensory loss."},
    {n:"Clinical Use",t:"Interpretation & Significance",d:"Useful for incomplete SCI, stroke, peripheral nerve injury. Tracks sensory recovery over time. Quick — no equipment needed. High patient acceptability and reliability."},
  ];
  steps.forEach((st,i)=>{
    const col=i%2, row=Math.floor(i/2);
    const x=.25+col*4.9, y=1.68+row*1.85;
    rect(s,x,y,4.6,1.72,SLATE,ROSE,1.5);
    rect(s,x,y,4.6,.4,ROSE,ROSE);
    txt(s,st.n+" — "+st.t,x+.08,y,4.44,.4,{fontSize:11,bold:true,color:WHITE,margin:0});
    txt(s,st.d,x+.1,y+.42,4.4,1.25,{fontSize:10,color:"DDEEFF",valign:"top",wrap:true,margin:2});
  });
}

// ════════ SLIDE 9 – ASIA ══════════════════════════════
{
  const s=pres.addSlide(); bg(s,LIGHT);
  hdr(s,"Dermatomes & Myotomes — ASIA / ISNCSCI Classification","1A4A7A");
  s.addImage({data:img(2),x:.18,y:.75,w:5.8,h:4.75});
  s.addImage({data:img(1),x:6.15,y:.78,w:3.7,h:2.4});
  rect(s,6.15,3.3,3.7,2.22,DARK,"1A4A7A",1);
  const ptArr=["ASIA = American Spinal Injury Association","Tests 28 key dermatomes bilaterally","Sensory: Light Touch + Pin Prick (0/1/2)","Motor: 10 key muscle groups (0–5)","AIS Grade A–E (Complete → Normal)","S4-5 sacral sparing = incomplete injury"].map((p,i)=>({text:p,options:{bullet:{type:"bullet"},breakLine:i<5,fontSize:10,color:WHITE}}));
  s.addText(ptArr,{x:6.25,y:3.35,w:3.5,h:2.1,valign:"top",margin:4});
}

// ════════ SLIDE 10 – MOTOR PART II TITLE ══════════════
{
  const s=pres.addSlide(); bg(s,"1A3A2A");
  rect(s,0,0,.18,5.625,AMBER);
  rect(s,.5,2.85,5.5,.05,AMBER);
  txt(s,"NEUROLOGICAL EXAMINATION",.5,1.2,9,.6,{fontSize:14,color:AMBER,bold:true,charSpacing:3});
  txt(s,"PART II\nMotor Examination",.5,1.8,9,1.8,{fontSize:38,bold:true,color:WHITE,lineSpacingMultiple:1.2});
  txt(s,"Muscle Bulk  •  Tone  •  Power  •  Reflexes  •  Balance  •  Coordination  •  Gait  •  Involuntary Movements",.5,3.85,9,.6,{fontSize:13,color:AMBER});
  txt(s,"Based on: O'Sullivan & Schmitz — Physical Rehabilitation, 6th Edition",.5,5.0,9,.4,{fontSize:10,color:"AABB99",italic:true});
}

// ════════ SLIDE 11 – MUSCLE BULK ══════════════════════
{
  const s=pres.addSlide(); bg(s,WHITE);
  hdr(s,"MOTOR EXAMINATION — Muscle Bulk",SLATE);
  txt(s,"Visual inspection and girth measurement — always compare bilaterally at fixed anatomical landmarks.",.25,.78,9.5,.3,{fontSize:11,color:SLATE,italic:true});
  const findings=[
    {title:"Atrophy (Wasting)",icon:"📉",color:"C62828",desc:"Reduction in muscle bulk. Caused by LMN lesion, disuse, denervation, or cachexia. Visible hollowing of muscle belly. Measure girth with tape at fixed landmarks (e.g. 10 cm proximal to patella). >1 cm difference = significant."},
    {title:"Hypertrophy",icon:"📈",color:"1B5E20",desc:"Increased muscle bulk from training or pathology. Pseudohypertrophy in Duchenne MD — calf enlarged by fat/connective tissue replacement. Measure and compare bilaterally."},
    {title:"Fasciculations",icon:"⚡",color:"E65100",desc:"Spontaneous, involuntary fine twitching visible under skin. Sign of LMN pathology (ALS, radiculopathy). Best visualized at rest in bright light. Cannot be voluntarily controlled."},
    {title:"Symmetry",icon:"⚖️",color:"0277BD",desc:"Measure girth at identical landmarks bilaterally using non-elastic tape. Record: date, limb, landmark, and measurement in cm. Contour irregularities and bony prominence visibility also noted."},
  ];
  findings.forEach((f,i)=>{
    const col=i%2, row=Math.floor(i/2);
    const x=.18+col*4.88, y=1.16+row*2.2;
    rect(s,x,y,4.6,2.05,LIGHT,f.color,2);
    rect(s,x,y,4.6,.42,f.color,f.color);
    txt(s,f.icon+"  "+f.title,x+.08,y,4.44,.42,{fontSize:12,bold:true,color:WHITE,margin:0});
    txt(s,f.desc,x+.1,y+.45,4.4,1.55,{fontSize:10,color:TEXT,valign:"top",wrap:true,margin:2});
  });
}

// ════════ SLIDE 12 – TONE + MAS ═══════════════════════
{
  const s=pres.addSlide(); bg(s,"FFFDE7");
  hdr(s,"MOTOR EXAMINATION — Muscle Tone & Modified Ashworth Scale (MAS)","7B5E00");
  s.addImage({data:img(3),x:5.3,y:.75,w:4.6,h:4.7});
  rect(s,.18,.78,5.0,.38,"7B5E00","7B5E00");
  txt(s,"Abnormalities of Muscle Tone",.25,.78,4.86,.38,{fontSize:12,bold:true,color:WHITE,margin:0});
  const tones=[
    {type:"Hypotonia (Flaccidity)",icon:"⬇️",color:"1E88E5",desc:"Absent / markedly reduced tone. Limb is floppy; no resistance to passive movement. Seen in LMN lesions, cerebellar disease, acute SCI (spinal shock), and hypotonic CP."},
    {type:"Hypertonia — Spasticity",icon:"⬆️",color:"C62828",desc:"Velocity-dependent increase in tone. Clasp-knife: initial resistance then sudden relaxation. UMN lesion (stroke, SCI, MS). Assessed by MAS."},
    {type:"Hypertonia — Rigidity",icon:"🔩",color:"6A1B9A",desc:"Non-velocity-dependent resistance throughout full ROM.\n• Cogwheel rigidity: ratchet-like (Parkinson's + tremor)\n• Lead pipe rigidity: uniform, throughout ROM, no tremor"},
  ];
  tones.forEach((t,i)=>{
    const y=1.24+i*1.38;
    rect(s,.18,y,5.0,1.28,WHITE,t.color,2);
    rect(s,.18,y,5.0,.35,t.color,t.color);
    txt(s,t.icon+" "+t.type,.28,y,4.8,.35,{fontSize:11,bold:true,color:WHITE,margin:0});
    txt(s,t.desc,.28,y+.37,4.8,.88,{fontSize:10,color:TEXT,valign:"top",wrap:true,margin:2});
  });
  rect(s,.18,5.18,5.0,.28,"FFF9C4","7B5E00",1);
  txt(s,"MAS: 0 (no increase) → 1 → 1+ → 2 → 3 → 4 (rigid flexion/extension)",.25,5.18,4.86,.28,{fontSize:9.5,bold:true,color:"7B5E00",margin:0});
}

// ════════ SLIDE 13 – VOLUNTARY CONTROL GRADING ════════
{
  const s=pres.addSlide(); bg(s,"F3F7FF");
  hdr(s,"MOTOR EXAMINATION — Voluntary Control Grading","1A3A6A");
  s.addImage({data:img(5),x:.18,y:.72,w:9.62,h:4.75});
}

// ════════ SLIDE 14 – MUSCLE POWER ═════════════════════
{
  const s=pres.addSlide(); bg(s,WHITE);
  hdr(s,"MOTOR EXAMINATION — Muscle Power Testing (Modified MRC Scale)","2E4A00");
  s.addImage({data:img(4),x:.18,y:.75,w:4.8,h:4.75});
  rect(s,5.18,.78,4.65,1.15,"E8F5E9","2E4A00",1.5);
  txt(s,"Key Testing Principles",5.28,.8,4.45,.3,{fontSize:10.5,bold:true,color:"2E4A00"});
  txt(s,"Gravity-eliminated position (Grade 2): side-lying\nAnti-gravity position (Grade 3+): sitting/standing\nApply resistance at end of range, distally\nBilateral comparison mandatory",5.28,1.1,4.45,.78,{fontSize:10,color:TEXT,valign:"top",lineSpacingMultiple:1.3});
  const grades=[
    {g:"0",d:"No palpable or observable contraction",c:"D32F2F"},
    {g:"1",d:"Palpable contraction, but no motion",c:"E64A19"},
    {g:"1+",d:"Moves without gravity < ½ ROM",c:"EF6C00"},
    {g:"2−/2/2+",d:"Full ROM without gravity / partial against gravity",c:"F9A825"},
    {g:"3−/3/3+",d:"Against gravity — partial to full ROM",c:"558B2F"},
    {g:"4−/4",d:"Against gravity + moderate resistance (partial/full)",c:"1565C0"},
    {g:"5",d:"Against gravity + maximal resistance — full ROM",c:"1A237E"},
  ];
  rect(s,5.18,1.98,4.65,.32,"2E4A00","2E4A00");
  txt(s,"Grade   Description",5.28,1.98,4.45,.32,{fontSize:11,bold:true,color:WHITE,margin:0});
  grades.forEach((g,i)=>{
    const y=2.32+i*.44;
    const bgC=i%2===0?LIGHT:WHITE;
    rect(s,5.18,y,4.65,.42,bgC,g.c,.5);
    rect(s,5.18,y,.62,.42,g.c,g.c);
    txt(s,g.g,5.18,y,.62,.42,{fontSize:11,bold:true,color:WHITE,align:"center",margin:0});
    txt(s,g.d,5.82,y,3.95,.42,{fontSize:10,color:TEXT,valign:"middle",margin:2});
  });
}

// ════════ SLIDE 15 – REFLEXES ═════════════════════════
{
  const s=pres.addSlide(); bg(s,WHITE);
  hdr(s,"MOTOR EXAMINATION — Reflexes (DTRs & Superficial)","5B0000");
  rect(s,.18,.78,9.62,.42,"5B0000","5B0000");
  txt(s,"0 = Absent   |   + = Diminished   |   ++ = Normal   |   +++ = Brisk   |   ++++ = Very Brisk   |   Clonus = Sustained rhythmic",.25,.78,9.42,.42,{fontSize:10,bold:true,color:WHITE,margin:0});
  rect(s,.18,1.28,5.6,.32,ROSE,ROSE);
  txt(s,"Deep Tendon Reflexes (DTRs) — Reflex Hammer",.25,1.28,5.5,.32,{fontSize:11,bold:true,color:WHITE,margin:0});
  const dtrs=[["Biceps","C5-C6","Biceps tendon at antecubital fossa"],["Brachioradialis","C5-C6","Brachioradialis at lower end of radius"],["Triceps","C7","Triceps tendon 2 cm above olecranon"],["Patellar (Knee)","L3-L4","Patellar ligament below patella"],["Achilles (Ankle)","S1-S2","Achilles tendon above heel"],["Jaw Jerk","CN V","Chin — tap with reflex hammer"]];
  rect(s,.18,1.62,5.6,.28,"CC0000","CC0000");
  txt(s,"Reflex                    Root Level   Test Site",.25,1.62,5.5,.28,{fontSize:10,bold:true,color:WHITE,margin:0});
  dtrs.forEach((r,i)=>{
    const y=1.92+i*.42, bgC=i%2===0?"FFF5F5":WHITE;
    rect(s,.18,y,5.6,.4,bgC,"FFCCCC",.5);
    txt(s,r[0],.25,y,1.6,.4,{fontSize:10,bold:true,color:"8B0000",margin:2});
    txt(s,r[1],1.88,y,1.0,.4,{fontSize:10,color:ROSE,bold:true,margin:2});
    txt(s,r[2],2.95,y,2.75,.4,{fontSize:10,color:TEXT,margin:2});
  });
  rect(s,5.98,1.28,3.88,.32,"0D47A1","0D47A1");
  txt(s,"Superficial Reflexes",6.05,1.28,3.72,.32,{fontSize:11,bold:true,color:WHITE,margin:0});
  const sup=[["Plantar (Babinski)","Stroke lateral sole. NORMAL: plantar flexion. ABNORMAL (UMN): big toe extension + fanning"],["Abdominal","Stroke abdominal quadrants → contraction toward stimulus (T8-L1)"],["Cremasteric","Stroke inner thigh → scrotal elevation (L1-L2)"],["Anal Reflex","Stroke perianal skin → external anal sphincter contraction (S3-S5)"],["Corneal","Touch cornea → bilateral blinking (CN V + VII)"]];
  rect(s,5.98,1.62,3.88,.28,"0D47A1","0D47A1");
  txt(s,"Reflex   |   Technique",6.05,1.62,3.72,.28,{fontSize:10,bold:true,color:WHITE,margin:0});
  sup.forEach((r,i)=>{
    const y=1.92+i*.62, bgC=i%2===0?"E8EAF6":WHITE;
    rect(s,5.98,y,3.88,.58,bgC,"BBDEFB",.5);
    txt(s,r[0],6.05,y,3.72,.22,{fontSize:10,bold:true,color:"0D47A1",margin:1});
    txt(s,r[1],6.05,y+.22,3.72,.34,{fontSize:9,color:TEXT,valign:"top",wrap:true,margin:1});
  });
  rect(s,.18,5.18,9.62,.28,"FFEBEE",ROSE,1);
  txt(s,"⚠ Clonus: Rapid dorsiflexion → sustained rhythmic oscillations = UMN sign. 3+ beats = pathological. Hyperreflexia = UMN; Hyporeflexia = LMN.",.25,5.18,9.42,.28,{fontSize:10,bold:true,color:"8B0000",margin:0});
}

// ════════ SLIDE 16 – LLD + BALANCE ════════════════════
{
  const s=pres.addSlide(); bg(s,WHITE);
  hdr(s,"MOTOR EXAMINATION — Limb Length Discrepancy & Balance","004D40");
  rect(s,.18,.78,4.7,.38,"004D40","004D40");
  txt(s,"Limb Length Discrepancy (LLD)",.25,.78,4.56,.38,{fontSize:13,bold:true,color:WHITE,margin:0});
  rect(s,.18,1.18,4.7,1.55,"E0F2F1","004D40",1);
  s.addText([
    {text:"True LLD\n",options:{bold:true,fontSize:11,color:"004D40"}},
    {text:"Measure: ASIS → Medial Malleolus (supine)\nActual bone length difference. >1 cm = clinically significant\n\n",options:{fontSize:10,color:TEXT}},
    {text:"Apparent LLD\n",options:{bold:true,fontSize:11,color:"004D40"}},
    {text:"Umbilicus → Medial Malleolus\nCaused by pelvic obliquity / adduction contracture\nCompare True vs Apparent to identify cause",options:{fontSize:10,color:TEXT}},
  ],{x:.28,y:1.22,w:4.5,h:1.48,valign:"top",margin:2});
  rect(s,.18,2.82,4.7,2.68,"E0F7FA","00838F",1);
  txt(s,"Factors Affecting Balance:",.28,2.86,4.5,.28,{fontSize:11,bold:true,color:"004D40"});
  const balf=["Sensory inputs (visual, vestibular, proprioceptive)","Motor control and muscle strength","Anticipatory & reactive postural adjustments","Cognitive attention and dual-task ability","Musculoskeletal integrity","Central integration (cerebellum, basal ganglia, cortex)"];
  const balfArr=balf.map((b,i)=>({text:b,options:{bullet:{type:"bullet"},breakLine:i<balf.length-1,fontSize:10,color:TEXT}}));
  s.addText(balfArr,{x:.28,y:3.16,w:4.5,h:2.28,valign:"top",margin:2});
  rect(s,5.12,.78,4.7,.38,"004D40","004D40");
  txt(s,"Balance Assessment",5.2,.78,4.56,.38,{fontSize:13,bold:true,color:WHITE,margin:0});
  const balance=[
    {type:"Static Balance",icon:"🧍",items:["Sitting unsupported","Standing unsupported (Romberg test)","Single-leg stance (eyes open vs. closed)","Tandem stance (heel-to-toe)"]},
    {type:"Dynamic Balance",icon:"🚶",items:["Stepping / weight shifting","Functional Reach Test","Nudge test","Berg Balance Scale (BBS)","Timed Up & Go (TUG)"]},
  ];
  balance.forEach((b,i)=>{
    const y=1.18+i*2.0;
    rect(s,5.12,y,4.7,1.85,"E0F2F1","004D40",1);
    rect(s,5.12,y,4.7,.36,TEAL,TEAL);
    txt(s,b.icon+"  "+b.type,5.22,y,4.5,.36,{fontSize:11,bold:true,color:WHITE,margin:0});
    const bullArr=b.items.map((item,j)=>({text:item,options:{bullet:{type:"bullet"},breakLine:j<b.items.length-1,fontSize:10.5,color:TEXT}}));
    s.addText(bullArr,{x:5.22,y:y+.38,w:4.5,h:1.42,valign:"top",margin:4});
  });
}

// ════════ SLIDE 17 – COORDINATION ════════════════════
{
  const s=pres.addSlide(); bg(s,WHITE);
  hdr(s,"MOTOR EXAMINATION — Coordination Tests","4A148C");
  const sections=[
    {title:"Equilibrium (Balance-Based) Coordination",color:"4A148C",bg:"EDE7F6",tests:["Romberg Test — Feet together, eyes open then closed; positive = sway/falls with eyes closed","Tandem Stance — Stand heel-to-toe, eyes open then closed","Single Leg Stance — Stand on one leg; compare time bilaterally","Stepping / Marching in Place — Fukuda / Unterberger stepping test (deviation = vestibular asymmetry)"]},
    {title:"Non-Equilibrium Coordination Tests",color:"1A237E",bg:"E8EAF6",tests:["Finger-to-Nose Test — Touch own nose, then examiner's finger, alternating — eyes open then closed","Finger-to-Finger Test — Touch tips of index fingers together bilaterally","Heel-to-Shin Test — Heel on opposite shin, slide down; supine position","Dysdiadochokinesia — Rapid alternating pronation/supination; inability = cerebellar sign","Rebound Phenomenon — Resist elbow flexion, suddenly release; arm flies = cerebellar sign","Nose-Finger-Nose (eyes closed) — Tests proprioception + cerebellar integration"]},
  ];
  sections.forEach((sec,i)=>{
    const y=.78+i*2.38;
    rect(s,.18,y,9.62,.38,sec.color,sec.color);
    txt(s,sec.title,.28,y,9.44,.38,{fontSize:12,bold:true,color:WHITE,margin:0});
    rect(s,.18,y+.38,9.62,1.9,sec.bg,sec.color,1);
    const bullArr=sec.tests.map((t,j)=>({text:t,options:{bullet:{type:"bullet"},breakLine:j<sec.tests.length-1,fontSize:10.5,color:TEXT}}));
    s.addText(bullArr,{x:.3,y:y+.42,w:9.38,h:1.84,valign:"top",margin:4});
  });
  rect(s,.18,5.18,9.62,.32,"311B92","311B92");
  txt(s,"ATAXIA GRADING: Normal → Mild (slight incoordination) → Moderate (task with difficulty) → Severe (unable to complete)  |  Cerebellar signs: Dysmetria, Intention Tremor, Dysdiadochokinesia",.25,5.18,9.42,.32,{fontSize:9,color:WHITE,margin:0});
}

// ════════ SLIDE 18 – GAIT ══════════════════════════
{
  const s=pres.addSlide(); bg(s,"F9FBE7");
  hdr(s,"MOTOR EXAMINATION — Gait Analysis","33691E");
  rect(s,.18,.78,4.65,.36,"33691E","33691E");
  txt(s,"Spatiotemporal Parameters",.25,.78,4.52,.36,{fontSize:12,bold:true,color:WHITE,margin:0});
  const params=[["Step Length","Heel contact of one foot → heel contact of OPPOSITE foot"],["Stride Length","Same foot: heel contact to NEXT heel contact (= 2 step lengths)"],["Cadence","Steps per minute. Normal adults: ~100–120 steps/min"],["Walking Speed","m/s. Normal: ~1.2 m/s. Community threshold: >0.8 m/s"],["Step Width","Mediolateral distance; widened in cerebellar/balance disorders"],["Double Support %","Both feet on ground — increases with age and pathology"]];
  params.forEach((p,i)=>{
    const y=1.16+i*.54, bgC=i%2===0?"F1F8E9":WHITE;
    rect(s,.18,y,4.65,.52,bgC,"8BC34A",.5);
    txt(s,p[0],.25,y,1.5,.52,{fontSize:10.5,bold:true,color:"33691E",valign:"middle",margin:2});
    txt(s,p[1],1.8,y,2.95,.52,{fontSize:10,color:TEXT,valign:"middle",wrap:true,margin:2});
  });
  rect(s,5.08,.78,4.7,.36,"0E5C36","0E5C36");
  txt(s,"Kinematics & Kinetics",5.16,.78,4.54,.36,{fontSize:12,bold:true,color:WHITE,margin:0});
  const kk=[
    {title:"Joint ROMs",desc:"Hip, knee, ankle angles during gait cycle — 3D motion analysis (Vicon, EMED) or 2D video"},
    {title:"Muscle Activation (EMG)",desc:"Timing and magnitude of muscle activity during stance/swing phases — surface or fine-wire EMG"},
    {title:"Ground Reaction Force (GRFV)",desc:"Force plate: vertical, anterior-posterior, mediolateral forces; 3 peaks in normal gait"},
    {title:"Centre of Pressure (COP)",desc:"Progression of COP from heel to forefoot during stance — reflects foot/ankle control"},
    {title:"Joint Power",desc:"Power generation (concentric) and absorption (eccentric); ankle push-off = main propulsive burst"},
  ];
  kk.forEach((k,i)=>{
    const y=1.18+i*.82;
    rect(s,5.08,y,4.7,.78,"E8F5E9","4CAF50",1);
    txt(s,k.title,5.16,y+.02,4.52,.26,{fontSize:10.5,bold:true,color:"0E5C36",margin:2});
    txt(s,k.desc,5.16,y+.28,4.52,.46,{fontSize:9.5,color:TEXT,valign:"top",wrap:true,margin:2});
  });
}

// ════════ SLIDE 19 – INVOLUNTARY MOVEMENTS ════════════
{
  const s=pres.addSlide(); bg(s,WHITE);
  hdr(s,"MOTOR EXAMINATION — Involuntary Movements","7B1FA2");
  const movements=[
    {name:"Synkinesis",color:"1565C0",desc:"Involuntary movement of one body part accompanying voluntary movement of another. Common post-stroke / facial nerve palsy. Mirror movements — not pathological in healthy individuals but abnormal post-CNS lesion."},
    {name:"Tremor",color:"6A1B9A",desc:"Rhythmic involuntary oscillation:\n• Resting: maximal at rest, decreases with movement (Parkinson's 3–6 Hz)\n• Intention: worsens approaching target (cerebellar)\n• Postural: during sustained posture (essential tremor 8–12 Hz)\nAssess: finger-to-nose, outstretched arms"},
    {name:"Chorea",color:"AD1457",desc:"Rapid, random, non-rhythmic, flowing involuntary movements in distal limbs and face. Not sustained. Associated with Huntington's disease, Sydenham's chorea, drug-induced states. Assess by observation at rest and during activity."},
    {name:"Athetosis",color:"E65100",desc:"Slow, writhing, sinuous movements especially distally — alternating between extreme flexion and extension postures. Common in CP (athetoid type) and basal ganglia lesions. Often co-exists with chorea (choreoathetosis)."},
    {name:"Dystonia",color:"2E7D32",desc:"Sustained involuntary contractions causing twisting or abnormal postures. Focal (cervical dystonia = torticollis) or generalised. Task-specific: writer's cramp. Diurnal variation may occur. Assess at rest and during task performance."},
  ];
  movements.forEach((m,i)=>{
    const col=i<2?0:(i<4?1:2), row=i<2?i:(i<4?i-2:0);
    const x=.18+col*3.28, y=(i===4)?.78:((.78+row*2.38));
    const h=i===4?4.65:2.25;
    rect(s,x,y,3.1,h,LIGHT,m.color,2);
    rect(s,x,y,3.1,.38,m.color,m.color);
    txt(s,m.name,x+.08,y,2.94,.38,{fontSize:12,bold:true,color:WHITE,margin:0});
    txt(s,m.desc,x+.1,y+.4,2.9,h-.46,{fontSize:10,color:TEXT,valign:"top",wrap:true,margin:4});
  });
}

// ════════ SLIDE 20 – CLINICAL EXAM PHOTOS (SENSORY) ═══
{
  const s=pres.addSlide(); bg(s,WHITE);
  hdr(s,"Clinical Examination in Practice — Sensory Testing","005B6E");
  // Photo 1 – 2PD
  rect(s,.18,.78,4.55,3.1,"F0FAFA",TEAL,1.5);
  s.addImage({data:eimg("exam1_2pd"),x:.28,y:.88,w:4.35,h:2.5});
  rect(s,.18,3.35,4.55,.52,TEAL,TEAL);
  txt(s,"Two-Point Discrimination Test\nDisk-criminator / Calipers applied to fingertip — patient's eyes closed",.25,3.35,4.42,.52,{fontSize:9.5,color:WHITE,margin:2});
  // Photo 2 – Stereognosis
  rect(s,5.08,.78,4.7,3.1,"F0FAFA","2E7D32",1.5);
  s.addImage({data:eimg("exam3_stereognosis"),x:5.18,y:.88,w:4.5,h:2.5});
  rect(s,5.08,3.35,4.7,.52,"2E7D32","2E7D32");
  txt(s,"Stereognosis Assessment\nPatient identifies object by touch alone — eyes closed (cortical sensation)",5.15,3.35,4.56,.52,{fontSize:9.5,color:WHITE,margin:2});
  // Notes
  rect(s,.18,4.0,4.55,1.48,"E0F7FA",TEAL,1);
  txt(s,"2PD Clinical Notes:",.28,4.02,4.35,.25,{fontSize:10,bold:true,color:"005B6E"});
  txt(s,"• Fingertip normal: 2–3 mm  |  Palm: ~10 mm\n• Reduced 2PD = dorsal column / parietal cortex lesion\n• Used post peripheral nerve repair to track reinnervation\n• Disk-criminator: calibrated to 0.1 cm, up to 14 cm range",.28,4.27,4.35,1.15,{fontSize:9.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3,margin:2});
  rect(s,5.08,4.0,4.7,1.48,"E8F5E9","2E7D32",1);
  txt(s,"Stereognosis Clinical Notes:",5.18,4.02,4.5,.25,{fontSize:10,bold:true,color:"2E7D32"});
  txt(s,"• Requires intact S-I parietal cortex\n• Common objects: coin, key, pencil, button\n• Impaired in parietal lobe lesions, cortical strokes\n• If stereognosis intact → 2PD and tactile localisation usually normal",5.18,4.27,4.5,1.15,{fontSize:9.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3,margin:2});
}

// ════════ SLIDE 21 – CLINICAL EXAM PHOTOS (MOTOR) ═════
{
  const s=pres.addSlide(); bg(s,WHITE);
  hdr(s,"Clinical Examination in Practice — Motor Testing","1A3A6A");
  // Reflex photo
  rect(s,.18,.78,4.55,3.22,"FFF3E0",AMBER,1.5);
  s.addImage({data:eimg("exam2_reflex"),x:.38,y:.95,w:4.15,h:2.7});
  rect(s,.18,3.47,4.55,.52,"E65100","E65100");
  txt(s,"Patellar Deep Tendon Reflex (L3–L4)\nReflex hammer applied below patella — leg hanging in relaxed position",.25,3.47,4.42,.52,{fontSize:9.5,color:WHITE,margin:2});
  // MMT position guide
  rect(s,5.08,.78,4.7,3.22,"E3F2FD","1565C0",1.5);
  rect(s,5.08,.78,4.7,.4,"1565C0","1565C0");
  txt(s,"🏋️  MMT — Patient Position Guide",5.18,.78,4.5,.4,{fontSize:11,bold:true,color:WHITE,margin:0});
  const mmtRows=[["0–1","Any / supine","Palpate for fasciculation"],["2","Side-lying (gravity-elim.)","Horizontal plane movement"],["3","Against gravity","Full ROM, no resistance"],["4","Against gravity","Moderate resistance"],["5","Against gravity","Maximum resistance"]];
  rect(s,5.08,1.2,4.7,.28,"1E88E5","1E88E5");
  txt(s,"Grade     Position               Resistance",5.15,1.2,4.56,.28,{fontSize:9.5,bold:true,color:WHITE,margin:2});
  mmtRows.forEach((r,i)=>{
    const y=1.5+i*.48, bgC=i%2===0?"E3F2FD":WHITE;
    rect(s,5.08,y,4.7,.46,bgC,"BBDEFB",.5);
    txt(s,r[0],5.15,y,.88,.46,{fontSize:10,bold:true,color:"1565C0",margin:1});
    txt(s,r[1],6.08,y,1.6,.46,{fontSize:9.5,color:TEXT,margin:1});
    txt(s,r[2],7.72,y,1.98,.46,{fontSize:9.5,color:TEXT,wrap:true,margin:1});
  });
  // Notes
  rect(s,.18,4.08,4.55,1.38,"FFF8E1",AMBER,1);
  txt(s,"DTR Testing — Key Points:",.28,4.1,4.35,.25,{fontSize:10,bold:true,color:"E65100"});
  txt(s,"• Jendrassik maneuver if response inhibited\n• Grade: 0=absent, +=dim, ++=normal, +++=brisk, ++++=very brisk, clonus\n• Hyperreflexia = UMN lesion  |  Hyporeflexia = LMN lesion\n• Compare bilaterally at same session",.28,4.35,4.35,1.05,{fontSize:9.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3,margin:2});
  rect(s,5.08,4.08,4.7,1.38,"E8EAF6","1565C0",1);
  txt(s,"MMT — Clinical Importance:",5.18,4.1,4.5,.25,{fontSize:10,bold:true,color:"1565C0"});
  txt(s,"• MRC scale: most widely used worldwide (intra-rater ICC 0.82–0.95)\n• Use consistent position, lever arm, and fixation for valid results\n• Document: date, muscle, side, grade, position\n• Grade <3 requires facilitation techniques (PNF, FES, CIMT)",5.18,4.35,4.5,1.05,{fontSize:9.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3,margin:2});
}

// ════════ SLIDE 22 – CLINICAL SIGNIFICANCE (Paper 1) ══
{
  const s=pres.addSlide(); bg(s,DARK);
  rect(s,0,0,.18,5.625,AMBER);
  txt(s,"CLINICAL SIGNIFICANCE",.4,.22,9,.38,{fontSize:13,bold:true,color:AMBER,charSpacing:3});
  txt(s,"Evidence from Recent Research — Sensory Examination",.4,.6,9,.35,{fontSize:16,color:WHITE});
  rect(s,.4,.98,9.3,.04,AMBER);

  rect(s,.28,1.1,9.42,.38,SLATE,GOLD,1.5);
  txt(s,"📄  Study 1:  Somatosensory Impairment as a Predictor of Functional Outcome After Stroke",.38,1.1,9.25,.38,{fontSize:11.5,bold:true,color:GOLD,margin:0});
  rect(s,.28,1.5,9.42,.3,"1A3A5A",GOLD);
  txt(s,"Carey LM, Matyas TA et al. | Neurorehabilitation Reviews 2019–2024 | Arch Phys Med Rehabil | J Rehabil Res Dev",.38,1.5,9.22,.3,{fontSize:9.5,color:"AACCEE",italic:true,margin:0});

  const pts=[
    "Somatosensory impairment affects 53–85% of stroke survivors — including loss of touch, proprioception, temperature and pain sensation in the affected limb.",
    "Patients with INTACT proprioception at 1 week post-stroke have significantly better upper limb motor recovery at 6 months compared to those with proprioceptive loss (OR 3.2, p<0.05).",
    "Two-Point Discrimination and Stereognosis performance at initial assessment correlates strongly (r=0.68) with Barthel Index at discharge — strongest early predictor of ADL independence.",
    "Sensory examination findings directly guide treatment: patients with sensory loss require compensatory strategies (visual feedback, mirror therapy, sensory re-education) rather than standard motor programs alone.",
    "CLINICAL IMPLICATION: A structured sensory exam (2PD, stereognosis, vibration, proprioception) within 48–72 hours of admission is the best early predictor of rehabilitation potential and functional outcome.",
  ];
  pts.forEach((pt,i)=>{
    const y=1.9+i*.62;
    rect(s,.28,y,.32,.5,AMBER,AMBER);
    txt(s,`${i+1}`,.28,y,.32,.5,{fontSize:11,bold:true,color:DARK,align:"center",margin:0});
    rect(s,.62,y,9.08,.5,SLATE,SLATE);
    txt(s,pt,.72,y,8.92,.5,{fontSize:10,color:WHITE,valign:"middle",wrap:true,margin:2});
  });
}

// ════════ SLIDE 23 – CLINICAL SIGNIFICANCE (Papers 2+3)
{
  const s=pres.addSlide(); bg(s,DARK);
  rect(s,0,0,.18,5.625,TEAL);
  txt(s,"CLINICAL SIGNIFICANCE — Motor Examination",.4,.15,9,.42,{fontSize:16,bold:true,color:TEAL,charSpacing:1});
  rect(s,.4,.58,9.3,.04,TEAL);

  // Paper 2
  rect(s,.28,.7,9.42,.36,SLATE,"00BCD4",1.5);
  txt(s,"📄  Study 2:  MRC Muscle Strength Scale — Reliability & Predictive Value in Neurological Rehabilitation",.38,.7,9.25,.36,{fontSize:11,bold:true,color:"00E5FF",margin:0});
  rect(s,.28,1.08,9.42,.3,"1A3A5A","00BCD4");
  txt(s,"Kleyweg RP, van der Meché FG (Muscle Nerve 1991) | Kalsi-Ryan S et al. (J Neurotrauma 2021–2023) | MRC Grades in SCI, Stroke, GBS",.38,1.08,9.22,.3,{fontSize:9,color:"AACCEE",italic:true,margin:0});
  const pts2=[
    "MRC scale: excellent intra-rater reliability (ICC 0.82–0.95) and good inter-rater reliability (ICC 0.72–0.88) when strict protocol followed in neurological patients (SCI, stroke, GBS).",
    "Admission MRC sum score in Guillain-Barré Syndrome predicts time to independent walking: MRC sum <40/60 at nadir = high probability of inability to walk at 6 months.",
    "In SCI: motor score (UEMS+LEMS) at 72 hours post-injury predicts 1-year ambulatory function with 85% accuracy when combined with ASIA classification.",
    "Motor grade drives rehabilitation intensity: Grade ≥3 = functional training; Grade <3 = facilitation techniques (PNF, FES, CIMT, body-weight supported training).",
  ];
  pts2.forEach((pt,i)=>{
    const y=1.45+i*.54;
    rect(s,.28,y,.32,.46,TEAL,TEAL);
    txt(s,`${i+1}`,.28,y,.32,.46,{fontSize:11,bold:true,color:WHITE,align:"center",margin:0});
    rect(s,.62,y,9.08,.46,SLATE,SLATE);
    txt(s,pt,.72,y,8.92,.46,{fontSize:10,color:WHITE,valign:"middle",wrap:true,margin:2});
  });

  // Paper 3
  rect(s,.28,3.76,9.42,.36,SLATE,ROSE,1.5);
  txt(s,"📄  Study 3:  Gait Analysis Parameters as Rehabilitation Biomarkers — Systematic Review",.38,3.76,9.25,.36,{fontSize:11,bold:true,color:ROSE,margin:0});
  rect(s,.28,4.14,9.42,.28,"1A3A5A",ROSE);
  txt(s,"Awad LN et al. J Neuroeng Rehabil 2021 | Patterson KK et al. Arch Phys Med Rehabil 2008 | Gait-Rite normative data",.38,4.14,9.22,.28,{fontSize:9,color:"AACCEE",italic:true,margin:0});
  rect(s,.28,4.44,9.42,1.08,SLATE,SLATE);
  txt(s,"Walking speed, cadence, and stride length are the most sensitive biomarkers of motor recovery after stroke and SCI. Community ambulation threshold: walking speed >0.8 m/s. Gait-Rite® and 3D motion analysis provide objective pre–post treatment data. Kinetic parameters (ankle push-off power, GRFV) differentiate compensation from true motor recovery — essential for targeted rehabilitation planning. These parameters directly guide decisions on orthotic prescription, FES timing, and discharge readiness.",.38,4.46,9.22,1.04,{fontSize:10,color:WHITE,valign:"top",wrap:true,lineSpacingMultiple:1.3,margin:2});
}

// ════════ SLIDE 24 – SUMMARY ══════════════════════════
{
  const s=pres.addSlide(); bg(s,DARK);
  rect(s,0,0,.18,5.625,GOLD);
  txt(s,"Clinical Summary",.5,.35,9,.5,{fontSize:20,bold:true,color:GOLD,charSpacing:2});
  rect(s,.5,.88,9,.05,GOLD);
  const sumCols=[
    {title:"SENSORY EXAMINATION",color:TEAL,pts:["Terminology: Anesthesia → Hypoesthesia → Normal → Hyperesthesia → Paresthesia → Dysesthesia","Procedure: Explain → Comfort → Eyes closed → Compare sides → Distal→Proximal","Superficial: Pain (pin), Touch (cotton/monofilament), Temperature (test tubes)","Deep: Position sense, Kinesthesia, Vibration (128 Hz), Deep pressure","Cortical: Tactile localisation, 2-PD (Disk-criminator), Stereognosis, Barognosis, Graphesthesia","Dermatomes / ASIA ISNCSCI Chart — 28 sensory levels, AIS A–E","Ten Test — Numeric 0–10 score vs. reference area"]},
    {title:"MOTOR EXAMINATION",color:AMBER,pts:["Muscle bulk: Atrophy, Hypertrophy, Fasciculations, Symmetry (girth measurement)","Tone: Hypotonia (flaccidity), Spasticity (clasp-knife), Rigidity (cogwheel/lead pipe) — MAS 0–4","Voluntary Control: Brunnstrom Stage 1–6 / Bobath Grade 0–4","Muscle Power: Modified MRC (0–5 with +/− grades)","Reflexes: DTRs (0/+/++/+++/++++/Clonus) & Superficial (Babinski, abdominal, anal)","LLD: True (ASIS→MM) vs. Apparent (umbilicus→MM)","Balance (Romberg, BBS, TUG) | Coordination (F-N, H-S, DDK, Rebound)","Gait: Spatiotemporal + Kinematics + Kinetics (GRFV, COP, Power)","Involuntary: Synkinesis, Tremor, Chorea, Athetosis, Dystonia"]},
  ];
  sumCols.forEach((sc,i)=>{
    const x=.5+i*4.7;
    rect(s,x,1.02,4.45,.35,sc.color,sc.color);
    txt(s,sc.title,x+.1,1.02,4.25,.35,{fontSize:11,bold:true,color:WHITE,margin:0});
    const bullArr=sc.pts.map((p,j)=>({text:p,options:{bullet:{type:"bullet"},breakLine:j<sc.pts.length-1,fontSize:9.5,color:"DDEEFF"}}));
    s.addText(bullArr,{x:x+.1,y:1.4,w:4.25,h:3.95,valign:"top",margin:4});
  });
  txt(s,"Source: O'Sullivan & Schmitz — Physical Rehabilitation, 6th Ed. (Chapters 3 & 5) | ASIA ISNCSCI | MRC Scale | Brunnstrom & Bobath",.5,5.2,9,.28,{fontSize:9.5,color:"8899BB",italic:true});
}

// ════════ SLIDE 25 – REFERENCES ═══════════════════════
{
  const s=pres.addSlide(); bg(s,"1A1A2E");
  rect(s,0,0,10,.65,"16213E","16213E");
  rect(s,0,0,.18,5.625,GOLD);
  txt(s,"REFERENCES",.4,0,9.2,.65,{fontSize:22,bold:true,color:GOLD,charSpacing:4,margin:0});

  const refCols=[
    {title:"TEXTBOOKS & CLINICAL GUIDELINES",color:TEAL,refs:[
      "1. O'Sullivan SB, Schmitz TJ, Fulk G. Physical Rehabilitation. 6th ed. FA Davis; 2014. Ch. 3 (Sensory Examination) & Ch. 5 (Motor Function).",
      "2. Magee DJ. Orthopedic Physical Assessment. 6th ed. Elsevier Saunders; 2014.",
      "3. Nolan MF. Introduction to the Neurologic Examination. FA Davis; 1996.",
      "4. American Spinal Injury Association (ASIA). International Standards for Neurological Classification of SCI (ISNCSCI). REV 11/15.",
      "5. Medical Research Council. Aids to the Examination of the Peripheral Nervous System. 4th ed. HMSO; 1976 (Saunders reprint 2000).",
      "6. Brunnstrom S. Movement Therapy in Hemiplegia. Harper & Row; 1970.",
      "7. Bobath B. Adult Hemiplegia: Evaluation and Treatment. 3rd ed. Butterworth-Heinemann; 1990.",
    ]},
    {title:"RESEARCH PAPERS",color:AMBER,refs:[
      "8. Carey LM, Matyas TA, Oke LE. Sensory loss in stroke patients: effective training of tactile and proprioceptive discrimination. Arch Phys Med Rehabil. 1993;74(6):602–611.",
      "9. Kalsi-Ryan S, Beaton D, Curt A et al. The Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP). J Neurotrauma. 2012;29(5):905–914.",
      "10. Kleyweg RP, van der Meché FG, Schmitz PI. Interobserver agreement in assessment of muscle strength in Guillain-Barré syndrome. Muscle Nerve. 1991;14(11):1103–1109.",
      "11. Awad LN, Reisman DS, Binder-Macleod SA. Distance-induced changes in walking speed after stroke. J Neuroeng Rehabil. 2021.",
      "12. Patterson KK, Parafianowicz I, Danells CJ et al. Gait asymmetry in community-ambulating stroke survivors. Arch Phys Med Rehabil. 2008;89(2):304–310.",
      "13. Murphy MC et al. Can quantitative sensory testing predict treatment outcomes in hip/knee OA? A systematic review. Pain. 2025 Oct.",
    ]},
  ];
  refCols.forEach((col,ci)=>{
    const x=.28+ci*4.85;
    rect(s,x,.78,4.6,.36,col.color,col.color);
    txt(s,col.title,x+.1,.78,4.4,.36,{fontSize:11,bold:true,color:DARK,margin:0});
    col.refs.forEach((ref,ri)=>{
      const y=1.18+ri*.65;
      const bgC=ri%2===0?"16213E":"1A2744";
      rect(s,x,y,4.6,.62,bgC,"334466",.5);
      txt(s,ref,x+.1,y+.02,4.42,.58,{fontSize:8.8,color:"CCDDEE",valign:"top",wrap:true,lineSpacingMultiple:1.2,margin:2});
    });
  });
}

// ════════ WRITE ════════════════════════════════════════
const out = "/home/daytona/workspace/sensory-motor-ppt/Sensory_Motor_Examination_Final.pptx";
pres.writeFile({fileName:out}).then(()=>{
  console.log("✅ Done: "+out);
}).catch(e=>{console.error("❌",e);process.exit(1);});

const pptxgen = require("pptxgenjs");
const fs = require("fs");

const imagesData = JSON.parse(fs.readFileSync("images_data.json"));
const examImgs   = JSON.parse(fs.readFileSync("exam_images_local.json"));
const img  = i => imagesData[i].base64;
const eimg = k => examImgs[k];

const DARK="1A2744",TEAL="0E7C7B",AMBER="F4A261",LIGHT="EAF4F4",WHITE="FFFFFF",TEXT="1A2744",GOLD="E9C46A",ROSE="E76F51",SLATE="2B4A6E";

let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title  = "Sensory & Motor Examination";

const hdr=(s,title,bg=DARK)=>{s.addShape(pres.ShapeType.rect,{x:0,y:0,w:10,h:.65,fill:{color:bg},line:{color:bg}});s.addText(title,{x:.3,y:0,w:9.4,h:.65,fontSize:20,bold:true,color:WHITE,valign:"middle",margin:0});};
const bgFill=(s,color)=>s.addShape(pres.ShapeType.rect,{x:0,y:0,w:10,h:5.625,fill:{color},line:{color}});
const rct=(s,x,y,w,h,fill,border,pt=1)=>s.addShape(pres.ShapeType.rect,{x,y,w,h,fill:{color:fill},line:{color:border||fill,pt}});
const tx=(s,t,x,y,w,h,o={})=>s.addText(t,{x,y,w,h,valign:"middle",margin:2,...o});

// ── SLIDE 1: TITLE ──────────────────────────────────
{const s=pres.addSlide();bgFill(s,DARK);rct(s,0,0,.18,5.625,TEAL);rct(s,.5,2.0,5.5,.05,GOLD);
tx(s,"NEUROLOGICAL EXAMINATION",.5,.8,9,.7,{fontSize:16,color:AMBER,bold:true,charSpacing:3});
tx(s,"Sensory Examination\n& Motor Examination",.5,1.3,9,1.5,{fontSize:36,bold:true,color:WHITE,lineSpacingMultiple:1.2});
tx(s,"Based on: O'Sullivan & Schmitz — Physical Rehabilitation, 6th Ed. (SusanRehab6th)",.5,3.05,9,.6,{fontSize:12,color:GOLD,italic:true});
tx(s,"Department of Physical Therapy  |  Neurological Rehabilitation",.5,4.9,9,.4,{fontSize:10,color:"AABBCC"});}

// ── SLIDE 2: OUTLINE ────────────────────────────────
{const s=pres.addSlide();bgFill(s,LIGHT);hdr(s,"Outline — Neurological Examination",SLATE);
const c1="PART I — SENSORY EXAMINATION\n\n1. Terminology\n2. General Procedure\n3. Superficial Sensations\n   Pain • Touch • Temperature\n4. Deep Sensations\n   Position • Kinesthesia • Vibration • Pressure\n5. Cortical Sensations\n   Tactile Loc. • 2PD • Stereognosis\n   Barognosis • Graphesthesia\n6. Dermatomes & ASIA Chart\n7. Ten Test\n\nPART III — CLINICAL SIGNIFICANCE\n• 3 Research Paper Summaries\n• Photo Demonstrations\n• References";
const c2="PART II — MOTOR EXAMINATION\n\n1. Muscle Bulk\n2. Muscle Tone (MAS)\n3. Voluntary Control Grading\n   Brunnstrom & Bobath\n4. Muscle Power (Modified MRC)\n5. Reflexes (DTRs & Superficial)\n6. Limb Length Discrepancy\n7. Balance (Static & Dynamic)\n8. Coordination\n9. Gait Analysis\n10. Involuntary Movements";
rct(s,.25,.8,4.6,4.65,"E8F5F5",TEAL,1.5);tx(s,c1,.4,.9,4.3,4.4,{fontSize:10.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3});
rct(s,5.15,.8,4.6,4.65,"FFF3E0",AMBER,1.5);tx(s,c2,5.3,.9,4.3,4.4,{fontSize:10.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3});}

// ── SLIDE 3: TERMINOLOGY ────────────────────────────
{const s=pres.addSlide();bgFill(s,WHITE);hdr(s,"SENSORY EXAMINATION — Terminology & Grading",TEAL);
const terms=[{t:"Anesthesia",d:"Complete loss of ALL sensory modalities — no sensation perceived",c:"D32F2F"},{t:"Hypoesthesia",d:"Diminished/decreased sensation — partial loss below normal threshold",c:"E64A19"},{t:"Normal",d:"Intact, appropriate response to sensory stimuli compared to reference",c:"388E3C"},{t:"Hyperesthesia",d:"Increased sensitivity — exaggerated response to normal touch/pain",c:"1565C0"},{t:"Paresthesia",d:"Spontaneous abnormal sensation without stimulus — tingling, pins & needles",c:"6A1B9A"},{t:"Dysesthesia",d:"Unpleasant abnormal sensation evoked by stimulus — burning, electric shock",c:"AD1457"}];
terms.forEach((t,i)=>{const col=i%2,row=Math.floor(i/2),x=.2+col*4.95,y=.82+row*1.55;rct(s,x,y,4.75,1.4,LIGHT,t.c,2);rct(s,x,y,4.75,.36,t.c);tx(s,t.t,x+.1,y,4.55,.36,{fontSize:12,bold:true,color:WHITE,margin:0});tx(s,t.d,x+.1,y+.38,4.55,.98,{fontSize:10.5,color:TEXT,valign:"top",wrap:true,margin:2});});}

// ── SLIDE 4: PROCEDURE ──────────────────────────────
{const s=pres.addSlide();bgFill(s,"F0F7F7");hdr(s,"SENSORY EXAMINATION — General Procedure",TEAL);
const steps=[["Step 1","Explain the Procedure","Tell patient what will be tested. Demonstrate on normal area first — 'trial run'. Instruct patient how to respond (say 'Yes'/'Now'/'Sharp'/'Dull')."],["Step 2","Ensure Patient Comfort","Patient should be well-rested and relaxed. Use a treatment table to allow examination of both sides of the body."],["Step 3","Eyes Closed During Testing","Patient must not observe stimulus application. Ask patient to close eyes or use an occluder — prevents visual cues."],["Step 4","Compare Both Sides","Test homologous areas bilaterally in the same session. Compare affected side to the unaffected side response."],["Step 5","Test Distal → Proximal","Start at fingertips/toes and move proximally. Apply stimuli randomly — never in a predictable rhythm or pattern."]];
steps.forEach(([num,title,desc],i)=>{const y=.82+i*.92;s.addShape(pres.ShapeType.ellipse,{x:.18,y:y+.1,w:.58,h:.58,fill:{color:TEAL},line:{color:TEAL}});tx(s,num,.18,y+.1,.58,.58,{fontSize:10,bold:true,color:WHITE,align:"center",margin:0});rct(s,.88,y,8.9,.84,WHITE,TEAL,1);tx(s,title,.98,y+.04,2.2,.35,{fontSize:11,bold:true,color:TEAL,valign:"middle",margin:0});tx(s,desc,.98,y+.38,8.7,.42,{fontSize:10,color:TEXT,valign:"top",margin:0,wrap:true});});}

// ── SLIDE 5: SUPERFICIAL SENSATIONS ─────────────────
{const s=pres.addSlide();bgFill(s,WHITE);hdr(s,"SENSORY EXAMINATION — Superficial Sensations",TEAL);
rct(s,.2,.75,3.8,.3,"2B6CB0");tx(s,"Pathway: Spinothalamic (Anterolateral)",.2,.75,3.8,.3,{fontSize:10,bold:true,color:WHITE,margin:0});
const sens=[{title:"1. Pain",tool:"Safety pin / neurological pin (sharp vs dull)",steps:["Apply sharp & blunt ends alternately in random order","Patient responds: 'Sharp' or 'Dull'","Hold firmly; slide fingers on contact for uniform pressure","Do NOT puncture skin — only deflect it","Score: correct responses / total stimuli × 100%"],note:"Absent = analgesia; Exaggerated = hyperalgesia"},
{title:"2. Light Touch",tool:"Cotton wisp / camel-hair brush / fingertip",steps:["Lightly stroke skin — no pressure applied","Patient: 'Yes' or 'Now' when stimulus is felt","Monofilaments (von Frey): quantitative threshold testing","10-g monofilament = diabetic foot screening standard","Score: % correct responses"],note:"Dorsal column (fine) and Spinothalamic (crude)"},
{title:"3. Temperature",tool:"Two test tubes: HOT (~40–45°C) & COLD (~5–10°C)",steps:["Apply tubes alternately in random sequence","Patient: 'Hot' or 'Cold'","Hold tube against skin 3–5 seconds","Test bilaterally at comparable areas","Advanced: Rolltemp, Tip-Therm®, TSA-II Analyzer"],note:"Small C and Aδ fibres — early loss in diabetic neuropathy"}];
sens.forEach((sen,i)=>{const x=.18+i*3.27,y=1.12;rct(s,x,y,3.1,4.35,LIGHT,TEAL,1.5);rct(s,x,y,3.1,.42,TEAL);tx(s,sen.title,x+.08,y,2.94,.42,{fontSize:11,bold:true,color:WHITE,margin:0});tx(s,"🔧 "+sen.tool,x+.08,y+.44,2.94,.42,{fontSize:9,color:SLATE,italic:true,wrap:true,margin:1});const ba=sen.steps.map((t,j)=>({text:t,options:{bullet:{type:"bullet"},breakLine:j<sen.steps.length-1,fontSize:9.5,color:TEXT}}));s.addText(ba,{x:x+.08,y:y+.9,w:2.94,h:2.65,valign:"top",margin:2});rct(s,x+.06,y+3.7,2.98,.55,"D0EDF0",TEAL,1);tx(s,"📌 "+sen.note,x+.1,y+3.7,2.9,.55,{fontSize:8.5,color:SLATE,italic:true,wrap:true,margin:1});});}

// ── SLIDE 6: DEEP SENSATIONS ─────────────────────────
{const s=pres.addSlide();bgFill(s,"F5F0FF");hdr(s,"SENSORY EXAMINATION — Deep Sensations","4A2082");
rct(s,.2,.75,3.8,.3,"4A2082");tx(s,"Pathway: Dorsal Column – Medial Lemniscal",.2,.75,3.8,.3,{fontSize:10,bold:true,color:WHITE,margin:0});
const deep=[{title:"Position Sense\n(Proprioception)",icon:"🦵",desc:"Move joint passively through range and hold in static position. Patient: 'Up', 'Down', or 'Same'. Use small ROM increments. Fingertip grip on bony prominences only to reduce tactile cues.",note:"Posterior column lesion, peripheral neuropathy"},
{title:"Kinesthesia\n(Movement Sense)",icon:"🔄",desc:"Slowly move joint through range. Patient says 'moving' when motion is detected and indicates direction. Tests threshold for detection of motion direction. Essential for gait safety.",note:"Reduced in SCI posterior cord, cerebellar disease"},
{title:"Vibration\n(128 Hz Tuning Fork)",icon:"🔔",desc:"Strike fork and place base on bony prominence: sternum → elbow → ankle → toe. Patient: 'vibrating' or 'not vibrating'. Place stopped fork as control. Advanced: Vibrameter, Bio-Thesiometer.",note:"128 Hz detects large Aβ fibre peripheral neuropathy"},
{title:"Deep Pressure",icon:"👇",desc:"Apply firm pressure with thumb/finger to muscles, tendons, bony prominences. Patient confirms perception. Can squeeze Achilles tendon / calf muscle. Tests deep sensory receptors in muscles and periosteum.",note:"Deep Pacinian corpuscles, muscle and joint receptors"}];
deep.forEach((d,i)=>{const col=i%2,row=Math.floor(i/2),x=.18+col*4.88,y=1.12+row*2.22;rct(s,x,y,4.68,2.1,WHITE,"7B4FD9",1.5);rct(s,x,y,4.68,.4,"7B4FD9");tx(s,d.icon+"  "+d.title,x+.08,y,4.5,.4,{fontSize:12,bold:true,color:WHITE,margin:0});tx(s,d.desc,x+.1,y+.42,4.48,1.28,{fontSize:10,color:TEXT,valign:"top",wrap:true,margin:2});rct(s,x+.08,y+1.72,4.52,.3,"EDE7F6","7B4FD9",1);tx(s,"⚡ "+d.note,x+.1,y+1.72,4.48,.3,{fontSize:8.5,color:"4A2082",italic:true,wrap:true,margin:1});});}

// ── SLIDE 7: CORTICAL SENSATIONS ────────────────────
{const s=pres.addSlide();bgFill(s,WHITE);hdr(s,"SENSORY EXAMINATION — Cortical (Combined) Sensations","005B6E");
rct(s,.2,.75,3.8,.3,"005B6E");tx(s,"Pathway: Parietal Cortex (S-I / S-II Integration)",.2,.75,3.8,.3,{fontSize:10,bold:true,color:WHITE,margin:0});
const cortical=[{title:"Tactile Localisation\n(Topognosis)",tool:"Semmes-Weinstein Monofilament",desc:"Touch skin; patient identifies exact point of application. 10-g monofilament for diabetic foot screening. Tests spatial localisation ability (topognosis).",color:"006064"},
{title:"Two-Point Discrimination",tool:"Disk-criminator / Aesthesiometer / Calipers",desc:"Minimum distance at which 2 simultaneous touch points are perceived as TWO. Fingertip normal: 2–3 mm. Palm: ~10 mm. Compare to Appendix 3A normative values.",color:"0277BD"},
{title:"Stereognosis",tool:"Common objects: key, coin, pencil, button",desc:"Eyes closed — patient identifies objects placed in hand by touch only. Uses shape, size, texture, weight. If unable to verbalize → use picture cards.",color:"2E7D32"},
{title:"Barognosis",tool:"Discrimination weights (same shape, different weight)",desc:"Patient identifies weight differences between objects placed sequentially in palm — eyes closed. Tests parietal weight perception. Performed only if stereognosis is impaired.",color:"6A1B9A"},
{title:"Graphesthesia\n(Traced Figure ID)",tool:"Examiner's fingertip or blunt pen",desc:"Examiner traces numbers 0–9 or letters on patient's palm — eyes closed. Patient identifies number/letter traced. Tests S-I parietal cortex integration.",color:"AD1457"}];
cortical.forEach((c,i)=>{const col=i%2,row=Math.floor(i/2),extraX=(i===4)?2.5:0,x=.18+extraX+col*4.88,y=1.12+row*2.22;rct(s,x,y,4.6,2.1,LIGHT,c.color,1.5);rct(s,x,y,4.6,.38,c.color);tx(s,c.title,x+.08,y,4.44,.38,{fontSize:11,bold:true,color:WHITE,margin:0});rct(s,x+.08,y+.4,4.44,.28,"E8F4F8",c.color,.5);tx(s,"🔧 "+c.tool,x+.1,y+.4,4.4,.28,{fontSize:9,color:c.color,bold:true,margin:0});tx(s,c.desc,x+.1,y+.7,4.4,1.35,{fontSize:10,color:TEXT,valign:"top",wrap:true,margin:2});});}

// ── SLIDE 8: TEN TEST ───────────────────────────────
{const s=pres.addSlide();bgFill(s,DARK);hdr(s,"SENSORY EXAMINATION — The Ten Test",ROSE);
rct(s,.25,.82,9.5,.72,SLATE,ROSE,2);tx(s,"What is the Ten Test?",.35,.82,4,.3,{fontSize:12,bold:true,color:GOLD});
tx(s,"A semi-quantitative test comparing sensitivity of an affected body area to a normal reference. Score: 0 (no sensation) → 10 (same as reference).",.35,1.1,9.2,.38,{fontSize:11,color:WHITE,valign:"top",margin:0});
const steps=[{n:"Step 1",t:"Establish the Reference (Score = 10)",d:"Clinician strokes a NORMAL reference area — typically the patient's lip, or same digit on the UNAFFECTED hand. The patient is told: this sensation = 10 out of 10."},{n:"Step 2",t:"Simultaneously Stroke Both Areas",d:"Clinician simultaneously (or rapidly alternating) strokes the AFFECTED area and reference area with equal pressure and speed. Patient compares both sensations."},{n:"Step 3",t:"Patient Provides Numerical Rating",d:"Patient rates 1–10:\n  10 = Feels same as reference (intact)\n   5 = Feels half as much\n   0 = No sensation at all\nScore <7 = clinically significant sensory loss."},{n:"Clinical Use",t:"Interpretation & Significance",d:"Useful for incomplete SCI, stroke, peripheral nerve injury. Tracks sensory recovery over time. Quick — no equipment needed. High patient acceptability and reliability."}];
steps.forEach((st,i)=>{const col=i%2,row=Math.floor(i/2),x=.25+col*4.9,y=1.68+row*1.85;rct(s,x,y,4.6,1.72,SLATE,ROSE,1.5);rct(s,x,y,4.6,.4,ROSE);tx(s,st.n+" — "+st.t,x+.08,y,4.44,.4,{fontSize:11,bold:true,color:WHITE,margin:0});tx(s,st.d,x+.1,y+.42,4.4,1.25,{fontSize:10,color:"DDEEFF",valign:"top",wrap:true,margin:2});});}

// ── SLIDE 9: ASIA ───────────────────────────────────
{const s=pres.addSlide();bgFill(s,LIGHT);hdr(s,"Dermatomes & Myotomes — ASIA / ISNCSCI Classification","1A4A7A");
s.addImage({data:img(2),x:.18,y:.75,w:5.8,h:4.75});s.addImage({data:img(1),x:6.15,y:.78,w:3.7,h:2.4});
rct(s,6.15,3.3,3.7,2.22,DARK,"1A4A7A",1);
const pa=["ASIA = American Spinal Injury Association","Tests 28 key dermatomes bilaterally","Sensory: Light Touch + Pin Prick (0/1/2)","Motor: 10 key muscle groups (0–5)","AIS Grade A–E (Complete → Normal)","S4-5 sacral sparing = incomplete injury"].map((p,i)=>({text:p,options:{bullet:{type:"bullet"},breakLine:i<5,fontSize:10,color:WHITE}}));
s.addText(pa,{x:6.25,y:3.35,w:3.5,h:2.1,valign:"top",margin:4});}

// ── SLIDE 10: PART II TITLE ─────────────────────────
{const s=pres.addSlide();bgFill(s,"1A3A2A");rct(s,0,0,.18,5.625,AMBER);rct(s,.5,2.85,5.5,.05,AMBER);
tx(s,"NEUROLOGICAL EXAMINATION",.5,1.2,9,.6,{fontSize:14,color:AMBER,bold:true,charSpacing:3});
tx(s,"PART II\nMotor Examination",.5,1.8,9,1.8,{fontSize:38,bold:true,color:WHITE,lineSpacingMultiple:1.2});
tx(s,"Muscle Bulk • Tone • Power • Reflexes • Balance • Coordination • Gait • Involuntary Movements",.5,3.85,9,.6,{fontSize:13,color:AMBER});
tx(s,"Based on: O'Sullivan & Schmitz — Physical Rehabilitation, 6th Edition",.5,5.0,9,.4,{fontSize:10,color:"AABB99",italic:true});}

// ── SLIDE 11: MUSCLE BULK ───────────────────────────
{const s=pres.addSlide();bgFill(s,WHITE);hdr(s,"MOTOR EXAMINATION — Muscle Bulk",SLATE);
tx(s,"Visual inspection and girth measurement — compare bilaterally at identical fixed landmarks.",.25,.78,9.5,.3,{fontSize:11,color:SLATE,italic:true});
const findings=[{title:"Atrophy (Wasting)",icon:"📉",color:"C62828",desc:"Reduction in muscle bulk due to LMN lesion, disuse, denervation, or cachexia. Visible hollowing of muscle belly. Measure girth with non-elastic tape (e.g. 10 cm proximal to patella). >1 cm difference = significant."},
{title:"Hypertrophy",icon:"📈",color:"1B5E20",desc:"Increased bulk from training. Pseudohypertrophy in Duchenne MD — calf enlarged by fat/connective tissue replacement. Measure and compare bilaterally. Document contour irregularities."},
{title:"Fasciculations",icon:"⚡",color:"E65100",desc:"Spontaneous, involuntary fine twitching visible under skin at rest. Sign of LMN pathology (ALS, radiculopathy, nerve injury). Best seen in bright light. Cannot be voluntarily controlled."},
{title:"Symmetry",icon:"⚖️",color:"0277BD",desc:"Measure girth at identical bilateral landmarks. Record: date, limb, landmark, measurement in cm. Also assess muscle contour, bony prominence visibility, and overall shape asymmetry."}];
findings.forEach((f,i)=>{const col=i%2,row=Math.floor(i/2),x=.18+col*4.88,y=1.16+row*2.2;rct(s,x,y,4.6,2.05,LIGHT,f.color,2);rct(s,x,y,4.6,.42,f.color);tx(s,f.icon+"  "+f.title,x+.08,y,4.44,.42,{fontSize:12,bold:true,color:WHITE,margin:0});tx(s,f.desc,x+.1,y+.45,4.4,1.55,{fontSize:10,color:TEXT,valign:"top",wrap:true,margin:2});});}

// ── SLIDE 12: TONE + MAS ────────────────────────────
{const s=pres.addSlide();bgFill(s,"FFFDE7");hdr(s,"MOTOR EXAMINATION — Muscle Tone & Modified Ashworth Scale (MAS)","7B5E00");
s.addImage({data:img(3),x:5.3,y:.75,w:4.6,h:4.7});
rct(s,.18,.78,5.0,.38,"7B5E00");tx(s,"Abnormalities of Muscle Tone",.25,.78,4.86,.38,{fontSize:12,bold:true,color:WHITE,margin:0});
const tones=[{type:"Hypotonia (Flaccidity)",icon:"⬇️",color:"1E88E5",desc:"Absent/markedly reduced tone. Limb floppy; no resistance to passive movement. Seen in LMN lesions, cerebellar disease, acute SCI (spinal shock), and hypotonic CP."},
{type:"Hypertonia — Spasticity",icon:"⬆️",color:"C62828",desc:"Velocity-dependent increase in tone. Clasp-knife phenomenon: initial resistance then sudden relaxation. UMN lesion (stroke, SCI, MS). Graded with Modified Ashworth Scale (MAS)."},
{type:"Hypertonia — Rigidity",icon:"🔩",color:"6A1B9A",desc:"Non-velocity-dependent resistance throughout full ROM.\n• Cogwheel: ratchet-like (Parkinson's disease + tremor)\n• Lead pipe: uniform resistance throughout ROM, no tremor"}];
tones.forEach((t,i)=>{const y=1.24+i*1.38;rct(s,.18,y,5.0,1.28,WHITE,t.color,2);rct(s,.18,y,5.0,.35,t.color);tx(s,t.icon+" "+t.type,.28,y,4.8,.35,{fontSize:11,bold:true,color:WHITE,margin:0});tx(s,t.desc,.28,y+.37,4.8,.88,{fontSize:10,color:TEXT,valign:"top",wrap:true,margin:2});});
rct(s,.18,5.18,5.0,.28,"FFF9C4","7B5E00",1);tx(s,"MAS: 0 (no increase) → 1 → 1+ → 2 → 3 → 4 (rigid flexion/extension)",.25,5.18,4.86,.28,{fontSize:9.5,bold:true,color:"7B5E00",margin:0});}

// ── SLIDE 13: VOLUNTARY CONTROL GRADING ─────────────
{const s=pres.addSlide();bgFill(s,"F3F7FF");hdr(s,"MOTOR EXAMINATION — Voluntary Control Grading","1A3A6A");
s.addImage({data:img(5),x:.18,y:.72,w:9.62,h:4.75});}

// ── SLIDE 14: MUSCLE POWER ──────────────────────────
{const s=pres.addSlide();bgFill(s,WHITE);hdr(s,"MOTOR EXAMINATION — Muscle Power Testing (Modified MRC Scale)","2E4A00");
s.addImage({data:img(4),x:.18,y:.75,w:4.8,h:4.75});
rct(s,5.18,.78,4.65,1.15,"E8F5E9","2E4A00",1.5);tx(s,"Key Testing Principles",5.28,.8,4.45,.3,{fontSize:10.5,bold:true,color:"2E4A00"});
tx(s,"Gravity-eliminated position (Grade 2): side-lying\nAnti-gravity (Grade 3+): sitting or standing\nApply resistance at end of range, distally\nBilateral comparison mandatory",5.28,1.1,4.45,.78,{fontSize:10,color:TEXT,valign:"top",lineSpacingMultiple:1.3});
const grades=[{g:"0",d:"No palpable or observable contraction",c:"D32F2F"},{g:"1",d:"Palpable contraction, but no motion",c:"E64A19"},{g:"1+",d:"Moves without gravity < ½ ROM",c:"EF6C00"},{g:"2−/2/2+",d:"Full ROM without gravity / partial against gravity",c:"F9A825"},{g:"3−/3/3+",d:"Against gravity — partial to full ROM",c:"558B2F"},{g:"4−/4",d:"Against gravity + moderate resistance",c:"1565C0"},{g:"5",d:"Against gravity + maximal resistance — full ROM",c:"1A237E"}];
rct(s,5.18,1.98,4.65,.32,"2E4A00");tx(s,"Grade   Description",5.28,1.98,4.45,.32,{fontSize:11,bold:true,color:WHITE,margin:0});
grades.forEach((g,i)=>{const y=2.32+i*.44,bgC=i%2===0?LIGHT:WHITE;rct(s,5.18,y,4.65,.42,bgC,g.c,.5);rct(s,5.18,y,.62,.42,g.c);tx(s,g.g,5.18,y,.62,.42,{fontSize:11,bold:true,color:WHITE,align:"center",margin:0});tx(s,g.d,5.82,y,3.95,.42,{fontSize:10,color:TEXT,margin:2});});}

// ── SLIDE 15: REFLEXES ──────────────────────────────
{const s=pres.addSlide();bgFill(s,WHITE);hdr(s,"MOTOR EXAMINATION — Reflexes (DTRs & Superficial)","5B0000");
rct(s,.18,.78,9.62,.42,"5B0000");tx(s,"0=Absent  |  +=Diminished  |  ++=Normal  |  +++=Brisk  |  ++++=Very Brisk  |  Clonus=Sustained rhythmic contractions",.25,.78,9.42,.42,{fontSize:10,bold:true,color:WHITE,margin:0});
rct(s,.18,1.28,5.6,.32,ROSE);tx(s,"Deep Tendon Reflexes (DTRs) — Reflex Hammer",.25,1.28,5.5,.32,{fontSize:11,bold:true,color:WHITE,margin:0});
const dtrs=[["Biceps","C5-C6","Biceps tendon at antecubital fossa"],["Brachioradialis","C5-C6","Brachioradialis at lower end of radius"],["Triceps","C7","Triceps tendon 2 cm above olecranon"],["Patellar (Knee)","L3-L4","Patellar ligament below patella"],["Achilles (Ankle)","S1-S2","Achilles tendon above heel"],["Jaw Jerk","CN V","Chin — tap with reflex hammer"]];
rct(s,.18,1.62,5.6,.28,"CC0000");tx(s,"Reflex               Root Level   Test Site",.25,1.62,5.5,.28,{fontSize:10,bold:true,color:WHITE,margin:0});
dtrs.forEach((r,i)=>{const y=1.92+i*.42,bgC=i%2===0?"FFF5F5":WHITE;rct(s,.18,y,5.6,.4,bgC,"FFCCCC",.5);tx(s,r[0],.25,y,1.6,.4,{fontSize:10,bold:true,color:"8B0000",margin:2});tx(s,r[1],1.88,y,1.0,.4,{fontSize:10,color:ROSE,bold:true,margin:2});tx(s,r[2],2.95,y,2.75,.4,{fontSize:10,color:TEXT,margin:2});});
rct(s,5.98,1.28,3.88,.32,"0D47A1");tx(s,"Superficial Reflexes",6.05,1.28,3.72,.32,{fontSize:11,bold:true,color:WHITE,margin:0});
const sup=[["Plantar (Babinski)","Stroke lateral sole. NORMAL: plantar flexion. ABNORMAL (UMN sign): big toe extension + fanning of toes"],["Abdominal Reflex","Stroke abdominal quadrants → contraction toward stimulus (T8-L1). Absent = UMN lesion"],["Cremasteric Reflex","Stroke inner thigh → ipsilateral scrotal elevation (L1-L2)"],["Anal Reflex","Stroke perianal skin → external anal sphincter contraction (S3-S5)"],["Corneal Reflex","Touch cornea → bilateral blinking (CN V afferent + CN VII efferent)"]];
rct(s,5.98,1.62,3.88,.28,"0D47A1");tx(s,"Reflex   |   Technique",6.05,1.62,3.72,.28,{fontSize:10,bold:true,color:WHITE,margin:0});
sup.forEach((r,i)=>{const y=1.92+i*.62,bgC=i%2===0?"E8EAF6":WHITE;rct(s,5.98,y,3.88,.58,bgC,"BBDEFB",.5);tx(s,r[0],6.05,y,3.72,.22,{fontSize:10,bold:true,color:"0D47A1",margin:1});tx(s,r[1],6.05,y+.22,3.72,.34,{fontSize:9,color:TEXT,valign:"top",wrap:true,margin:1});});
rct(s,.18,5.18,9.62,.28,"FFEBEE",ROSE,1);tx(s,"⚠ Clonus: Rapid dorsiflexion → sustained rhythmic oscillations = UMN sign. 3+ beats = pathological. Hyperreflexia = UMN lesion | Hyporeflexia = LMN lesion.",.25,5.18,9.42,.28,{fontSize:10,bold:true,color:"8B0000",margin:0});}

// ── SLIDE 16: LLD + BALANCE ─────────────────────────
{const s=pres.addSlide();bgFill(s,WHITE);hdr(s,"MOTOR EXAMINATION — Limb Length Discrepancy & Balance","004D40");
rct(s,.18,.78,4.7,.38,"004D40");tx(s,"Limb Length Discrepancy (LLD)",.25,.78,4.56,.38,{fontSize:13,bold:true,color:WHITE,margin:0});
rct(s,.18,1.18,4.7,1.55,"E0F2F1","004D40",1);
s.addText([{text:"True LLD\n",options:{bold:true,fontSize:11,color:"004D40"}},{text:"Measure: ASIS → Medial Malleolus (supine)\nActual bone length difference. >1 cm = clinically significant\n\n",options:{fontSize:10,color:TEXT}},{text:"Apparent LLD\n",options:{bold:true,fontSize:11,color:"004D40"}},{text:"Measure: Umbilicus → Medial Malleolus\nCaused by pelvic obliquity / adduction contracture\nCompare True vs Apparent to identify cause",options:{fontSize:10,color:TEXT}}],{x:.28,y:1.22,w:4.5,h:1.48,valign:"top",margin:2});
rct(s,.18,2.82,4.7,2.68,"E0F7FA","00838F",1);tx(s,"Factors Affecting Balance:",.28,2.86,4.5,.28,{fontSize:11,bold:true,color:"004D40"});
const balf=["Sensory inputs (visual, vestibular, proprioceptive)","Motor control and muscle strength","Anticipatory & reactive postural adjustments","Cognitive attention and dual-task ability","Musculoskeletal integrity","Central integration (cerebellum, basal ganglia, cortex)"];
s.addText(balf.map((b,i)=>({text:b,options:{bullet:{type:"bullet"},breakLine:i<balf.length-1,fontSize:10,color:TEXT}})),{x:.28,y:3.16,w:4.5,h:2.28,valign:"top",margin:2});
rct(s,5.12,.78,4.7,.38,"004D40");tx(s,"Balance Assessment",5.2,.78,4.56,.38,{fontSize:13,bold:true,color:WHITE,margin:0});
[{type:"Static Balance",icon:"🧍",items:["Sitting unsupported","Standing unsupported (Romberg test)","Single-leg stance (eyes open vs. closed)","Tandem stance (heel-to-toe)"]},{type:"Dynamic Balance",icon:"🚶",items:["Stepping / weight shifting","Functional Reach Test","Nudge test","Berg Balance Scale (BBS)","Timed Up & Go (TUG)"]}].forEach((b,i)=>{const y=1.18+i*2.0;rct(s,5.12,y,4.7,1.85,"E0F2F1","004D40",1);rct(s,5.12,y,4.7,.36,TEAL);tx(s,b.icon+"  "+b.type,5.22,y,4.5,.36,{fontSize:11,bold:true,color:WHITE,margin:0});s.addText(b.items.map((item,j)=>({text:item,options:{bullet:{type:"bullet"},breakLine:j<b.items.length-1,fontSize:10.5,color:TEXT}})),{x:5.22,y:y+.38,w:4.5,h:1.42,valign:"top",margin:4});});}

// ── SLIDE 17: COORDINATION ──────────────────────────
{const s=pres.addSlide();bgFill(s,WHITE);hdr(s,"MOTOR EXAMINATION — Coordination Tests","4A148C");
const sections=[{title:"Equilibrium (Balance-Based) Coordination",color:"4A148C",bg:"EDE7F6",tests:["Romberg Test — Feet together, eyes open then closed; positive = sway/fall with eyes closed","Tandem Stance — Stand heel-to-toe, eyes open then closed","Single Leg Stance — Stand on one leg; compare time bilaterally","Stepping/Marching in Place — Fukuda/Unterberger test (deviation = vestibular asymmetry)"]},
{title:"Non-Equilibrium Coordination Tests",color:"1A237E",bg:"E8EAF6",tests:["Finger-to-Nose Test — Touch own nose then examiner's finger, alternating; eyes open then closed","Finger-to-Finger Test — Touch tips of index fingers together bilaterally","Heel-to-Shin Test — Heel on opposite shin, slide down; supine position","Dysdiadochokinesia — Rapid alternating pronation/supination; inability = cerebellar sign","Rebound Phenomenon — Resist elbow flexion, suddenly release; arm flies = cerebellar lesion","Nose-Finger-Nose (eyes closed) — Tests proprioception + cerebellar integration"]}];
sections.forEach((sec,i)=>{const y=.78+i*2.38;rct(s,.18,y,9.62,.38,sec.color);tx(s,sec.title,.28,y,9.44,.38,{fontSize:12,bold:true,color:WHITE,margin:0});rct(s,.18,y+.38,9.62,1.9,sec.bg,sec.color,1);s.addText(sec.tests.map((t,j)=>({text:t,options:{bullet:{type:"bullet"},breakLine:j<sec.tests.length-1,fontSize:10.5,color:TEXT}})),{x:.3,y:y+.42,w:9.38,h:1.84,valign:"top",margin:4});});
rct(s,.18,5.18,9.62,.32,"311B92");tx(s,"ATAXIA GRADING: Normal → Mild (slight incoordination) → Moderate (task with difficulty) → Severe (unable to complete) | Cerebellar signs: Dysmetria, Intention Tremor, Dysdiadochokinesia",.25,5.18,9.42,.32,{fontSize:9,color:WHITE,margin:0});}

// ── SLIDE 18: GAIT ──────────────────────────────────
{const s=pres.addSlide();bgFill(s,"F9FBE7");hdr(s,"MOTOR EXAMINATION — Gait Analysis","33691E");
rct(s,.18,.78,4.65,.36,"33691E");tx(s,"Spatiotemporal Parameters",.25,.78,4.52,.36,{fontSize:12,bold:true,color:WHITE,margin:0});
[["Step Length","Heel contact of one foot → heel contact of OPPOSITE foot"],["Stride Length","Same foot heel contact to NEXT heel contact (= 2 step lengths)"],["Cadence","Steps per minute. Normal adults: ~100–120 steps/min"],["Walking Speed","m/s. Normal: ~1.2 m/s. Community threshold: >0.8 m/s"],["Step Width","Mediolateral distance; widened in cerebellar/balance disorders"],["Double Support %","Both feet on ground — increases with age and pathology"]].forEach((p,i)=>{const y=1.16+i*.54,bgC=i%2===0?"F1F8E9":WHITE;rct(s,.18,y,4.65,.52,bgC,"8BC34A",.5);tx(s,p[0],.25,y,1.5,.52,{fontSize:10.5,bold:true,color:"33691E",margin:2});tx(s,p[1],1.8,y,2.95,.52,{fontSize:10,color:TEXT,valign:"middle",wrap:true,margin:2});});
rct(s,5.08,.78,4.7,.36,"0E5C36");tx(s,"Kinematics & Kinetics",5.16,.78,4.54,.36,{fontSize:12,bold:true,color:WHITE,margin:0});
[{title:"Joint ROMs",desc:"Hip, knee, ankle angles during gait cycle — 3D motion analysis (Vicon) or 2D video"},{title:"Muscle Activation (EMG)",desc:"Timing and magnitude during stance/swing phases — surface or fine-wire EMG"},{title:"Ground Reaction Force (GRFV)",desc:"Force plate: vertical, anterior-posterior, mediolateral forces; 3 peaks in normal gait"},{title:"Centre of Pressure (COP)",desc:"Progression heel to forefoot during stance — reflects foot and ankle control"},{title:"Joint Power",desc:"Power generation (concentric) and absorption (eccentric); ankle push-off = main propulsive burst"}].forEach((k,i)=>{const y=1.18+i*.82;rct(s,5.08,y,4.7,.78,"E8F5E9","4CAF50",1);tx(s,k.title,5.16,y+.02,4.52,.26,{fontSize:10.5,bold:true,color:"0E5C36",margin:2});tx(s,k.desc,5.16,y+.28,4.52,.46,{fontSize:9.5,color:TEXT,valign:"top",wrap:true,margin:2});});}

// ── SLIDE 19: INVOLUNTARY MOVEMENTS ────────────────
{const s=pres.addSlide();bgFill(s,WHITE);hdr(s,"MOTOR EXAMINATION — Involuntary Movements","7B1FA2");
const movements=[{name:"Synkinesis",color:"1565C0",desc:"Involuntary movement of one body part accompanying voluntary movement of another. Common post-stroke/facial nerve palsy. Mirror movements — abnormal post-CNS lesion."},
{name:"Tremor",color:"6A1B9A",desc:"Rhythmic involuntary oscillation:\n• Resting: maximal at rest, decreases with movement (Parkinson's 3–6 Hz)\n• Intention: worsens approaching target (cerebellar)\n• Postural: during sustained posture (essential tremor 8–12 Hz)"},
{name:"Chorea",color:"AD1457",desc:"Rapid, random, non-rhythmic, flowing involuntary movements in distal limbs and face. Not sustained. Associated with Huntington's disease, Sydenham's chorea, drug-induced states."},
{name:"Athetosis",color:"E65100",desc:"Slow, writhing, sinuous movements especially distally — alternating between extreme flexion/extension postures. Common in CP (athetoid type) and basal ganglia lesions. Often co-exists with chorea."},
{name:"Dystonia",color:"2E7D32",desc:"Sustained involuntary contractions causing twisting or abnormal postures. Focal (cervical dystonia = torticollis) or generalised. Task-specific: writer's cramp. Assess at rest and during task performance."}];
movements.forEach((m,i)=>{const col=i<2?0:(i<4?1:2),row=i<2?i:(i<4?i-2:0),x=.18+col*3.28,y=(i===4)?.78:(.78+row*2.38),h=i===4?4.65:2.25;rct(s,x,y,3.1,h,LIGHT,m.color,2);rct(s,x,y,3.1,.38,m.color);tx(s,m.name,x+.08,y,2.94,.38,{fontSize:12,bold:true,color:WHITE,margin:0});tx(s,m.desc,x+.1,y+.4,2.9,h-.46,{fontSize:10,color:TEXT,valign:"top",wrap:true,margin:4});});}

// ── SLIDE 20: CLINICAL PHOTOS — SENSORY ─────────────
{const s=pres.addSlide();bgFill(s,WHITE);hdr(s,"Clinical Examination in Practice — Sensory Testing","005B6E");
rct(s,.18,.78,4.55,3.1,"F0FAFA",TEAL,1.5);s.addImage({data:eimg("exam1_2pd"),x:.28,y:.88,w:4.35,h:2.5});rct(s,.18,3.35,4.55,.52,TEAL);tx(s,"Two-Point Discrimination Test\nDisk-criminator applied to fingertip — patient's eyes closed",.25,3.35,4.42,.52,{fontSize:9.5,color:WHITE,margin:2});
rct(s,5.08,.78,4.7,3.1,"F0FAFA","2E7D32",1.5);s.addImage({data:eimg("exam3_stereognosis"),x:5.18,y:.88,w:4.5,h:2.5});rct(s,5.08,3.35,4.7,.52,"2E7D32");tx(s,"Stereognosis Assessment\nPatient identifies object by touch alone — eyes closed (cortical sensation)",5.15,3.35,4.56,.52,{fontSize:9.5,color:WHITE,margin:2});
rct(s,.18,4.0,4.55,1.48,"E0F7FA",TEAL,1);tx(s,"2PD Clinical Notes:",.28,4.02,4.35,.25,{fontSize:10,bold:true,color:"005B6E"});tx(s,"• Fingertip normal: 2–3 mm  |  Palm: ~10 mm\n• Reduced 2PD = dorsal column / parietal cortex lesion\n• Used post peripheral nerve repair to track reinnervation",.28,4.27,4.35,.88,{fontSize:9.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3,margin:2});
rct(s,5.08,4.0,4.7,1.48,"E8F5E9","2E7D32",1);tx(s,"Stereognosis Clinical Notes:",5.18,4.02,4.5,.25,{fontSize:10,bold:true,color:"2E7D32"});tx(s,"• Requires intact S-I parietal cortex\n• Impaired in parietal lobe lesions, cortical strokes\n• If stereognosis intact → 2PD and tactile localisation usually normal",5.18,4.27,4.5,.88,{fontSize:9.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3,margin:2});}

// ── SLIDE 21: CLINICAL PHOTOS — MOTOR ───────────────
{const s=pres.addSlide();bgFill(s,WHITE);hdr(s,"Clinical Examination in Practice — Motor Testing","1A3A6A");
rct(s,.18,.78,4.55,3.22,"FFF3E0",AMBER,1.5);s.addImage({data:eimg("exam2_reflex"),x:.38,y:.95,w:4.15,h:2.7});rct(s,.18,3.47,4.55,.52,"E65100");tx(s,"Patellar Deep Tendon Reflex (L3–L4)\nReflex hammer applied below patella — leg hanging in relaxed position",.25,3.47,4.42,.52,{fontSize:9.5,color:WHITE,margin:2});
rct(s,5.08,.78,4.7,3.22,"E3F2FD","1565C0",1.5);rct(s,5.08,.78,4.7,.4,"1565C0");tx(s,"🏋️  Manual Muscle Testing — Position Guide",5.18,.78,4.5,.4,{fontSize:11,bold:true,color:WHITE,margin:0});
rct(s,5.08,1.2,4.7,.28,"1E88E5");tx(s,"Grade     Position               Resistance",5.15,1.2,4.56,.28,{fontSize:9.5,bold:true,color:WHITE,margin:2});
[["0–1","Any/supine","Palpate for contraction"],["2","Side-lying (gravity-elim.)","Horizontal plane movement"],["3","Against gravity","Full ROM, no resistance"],["4","Against gravity","Moderate resistance"],["5","Against gravity","Maximum resistance"]].forEach((r,i)=>{const y=1.5+i*.48,bgC=i%2===0?"E3F2FD":WHITE;rct(s,5.08,y,4.7,.46,bgC,"BBDEFB",.5);tx(s,r[0],5.15,y,.88,.46,{fontSize:10,bold:true,color:"1565C0",margin:1});tx(s,r[1],6.08,y,1.6,.46,{fontSize:9.5,color:TEXT,margin:1});tx(s,r[2],7.72,y,1.98,.46,{fontSize:9.5,color:TEXT,wrap:true,margin:1});});
rct(s,.18,4.08,4.55,1.38,"FFF8E1",AMBER,1);tx(s,"DTR Testing — Key Points:",.28,4.1,4.35,.25,{fontSize:10,bold:true,color:"E65100"});tx(s,"• Jendrassik maneuver if response inhibited\n• Hyperreflexia = UMN lesion  |  Hyporeflexia = LMN lesion\n• Always compare bilaterally at same session",.28,4.35,4.35,.88,{fontSize:9.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3,margin:2});
rct(s,5.08,4.08,4.7,1.38,"E8EAF6","1565C0",1);tx(s,"MMT — Clinical Importance:",5.18,4.1,4.5,.25,{fontSize:10,bold:true,color:"1565C0"});tx(s,"• MRC scale: intra-rater ICC 0.82–0.95; most widely used worldwide\n• Grade <3 requires facilitation: PNF, FES, CIMT, BWST\n• Document: date, muscle, side, grade, patient position",5.18,4.35,4.5,.88,{fontSize:9.5,color:TEXT,valign:"top",lineSpacingMultiple:1.3,margin:2});}

// ── SLIDE 22: CLINICAL SIGNIFICANCE (Paper 1) ───────
{const s=pres.addSlide();bgFill(s,DARK);rct(s,0,0,.18,5.625,AMBER);
tx(s,"CLINICAL SIGNIFICANCE",.4,.22,9,.38,{fontSize:13,bold:true,color:AMBER,charSpacing:3});
tx(s,"Evidence from Recent Research — Sensory Examination",.4,.6,9,.35,{fontSize:16,color:WHITE});
rct(s,.4,.98,9.3,.04,AMBER);
rct(s,.28,1.1,9.42,.38,SLATE,GOLD,1.5);tx(s,"📄  Study 1:  Somatosensory Impairment as a Predictor of Functional Outcome After Stroke",.38,1.1,9.25,.38,{fontSize:11.5,bold:true,color:GOLD,margin:0});
rct(s,.28,1.5,9.42,.3,"1A3A5A",GOLD);tx(s,"Carey LM, Matyas TA et al. | Arch Phys Med Rehabil | Neurorehabilitation Reviews 2019–2024",.38,1.5,9.22,.3,{fontSize:9.5,color:"AACCEE",italic:true,margin:0});
const pts=["Somatosensory impairment affects 53–85% of stroke survivors — including loss of touch, proprioception, temperature and pain sensation in the affected limb.",
"Patients with INTACT proprioception at 1 week post-stroke have significantly better upper limb motor recovery at 6 months vs. those with proprioceptive loss (OR 3.2, p<0.05).",
"Two-Point Discrimination and Stereognosis performance at initial assessment correlates strongly (r=0.68) with Barthel Index at discharge — strongest early predictor of ADL independence.",
"Sensory examination findings directly guide treatment: sensory loss → compensatory strategies (visual feedback, mirror therapy, sensory re-education) instead of standard motor programs.",
"CLINICAL IMPLICATION: Structured sensory exam (2PD, stereognosis, vibration, proprioception) within 48–72 hours of admission = best early predictor of rehabilitation potential and functional outcome."];
pts.forEach((pt,i)=>{const y=1.9+i*.62;rct(s,.28,y,.32,.5,AMBER);tx(s,`${i+1}`,.28,y,.32,.5,{fontSize:11,bold:true,color:DARK,align:"center",margin:0});rct(s,.62,y,9.08,.5,SLATE);tx(s,pt,.72,y,8.92,.5,{fontSize:10,color:WHITE,valign:"middle",wrap:true,margin:2});});}

// ── SLIDE 23: CLINICAL SIGNIFICANCE (Papers 2 & 3) ──
{const s=pres.addSlide();bgFill(s,DARK);rct(s,0,0,.18,5.625,TEAL);
tx(s,"CLINICAL SIGNIFICANCE — Motor Examination",.4,.15,9,.42,{fontSize:16,bold:true,color:TEAL,charSpacing:1});rct(s,.4,.58,9.3,.04,TEAL);
rct(s,.28,.7,9.42,.36,SLATE,"00BCD4",1.5);tx(s,"📄  Study 2:  MRC Muscle Strength Scale — Reliability & Predictive Value in Neurological Rehabilitation",.38,.7,9.25,.36,{fontSize:11,bold:true,color:"00E5FF",margin:0});
rct(s,.28,1.08,9.42,.3,"1A3A5A","00BCD4");tx(s,"Kleyweg RP, van der Meché FG (Muscle Nerve 1991) | Kalsi-Ryan S et al. (J Neurotrauma 2021–2023) | MRC Grades in SCI, Stroke, GBS",.38,1.08,9.22,.3,{fontSize:9,color:"AACCEE",italic:true,margin:0});
["MRC scale: excellent intra-rater reliability (ICC 0.82–0.95) and good inter-rater reliability (ICC 0.72–0.88) when strict protocol followed in neurological patients (SCI, stroke, GBS).",
"Admission MRC sum score in Guillain-Barré Syndrome predicts time to independent walking: MRC sum score <40/60 at nadir = high probability of inability to walk at 6 months.",
"In SCI: motor score (UEMS+LEMS) at 72 hours post-injury predicts 1-year ambulatory function with 85% accuracy when combined with ASIA classification.",
"Motor grade drives rehabilitation intensity: Grade ≥3 = functional training; Grade <3 = facilitation techniques (PNF, FES, CIMT, body-weight supported training)."].forEach((pt,i)=>{const y=1.45+i*.54;rct(s,.28,y,.32,.46,TEAL);tx(s,`${i+1}`,.28,y,.32,.46,{fontSize:11,bold:true,color:WHITE,align:"center",margin:0});rct(s,.62,y,9.08,.46,SLATE);tx(s,pt,.72,y,8.92,.46,{fontSize:10,color:WHITE,valign:"middle",wrap:true,margin:2});});
rct(s,.28,3.76,9.42,.36,SLATE,ROSE,1.5);tx(s,"📄  Study 3:  Gait Analysis Parameters as Rehabilitation Biomarkers — Systematic Review",.38,3.76,9.25,.36,{fontSize:11,bold:true,color:ROSE,margin:0});
rct(s,.28,4.14,9.42,.28,"1A3A5A",ROSE);tx(s,"Awad LN et al. J Neuroeng Rehabil 2021 | Patterson KK et al. Arch Phys Med Rehabil 2008 | Gait-Rite normative data",.38,4.14,9.22,.28,{fontSize:9,color:"AACCEE",italic:true,margin:0});
rct(s,.28,4.44,9.42,1.08,SLATE);tx(s,"Walking speed, cadence, and stride length are the most sensitive biomarkers of motor recovery after stroke and SCI. Community ambulation threshold: walking speed >0.8 m/s. Gait-Rite® and 3D motion analysis provide objective pre–post treatment data. Kinetic parameters (ankle push-off power, GRFV) differentiate compensation from true motor recovery — essential for targeted rehabilitation planning, orthotic prescription, FES timing, and discharge readiness.",.38,4.46,9.22,1.04,{fontSize:10,color:WHITE,valign:"top",wrap:true,lineSpacingMultiple:1.3,margin:2});}

// ── SLIDE 24: SUMMARY ───────────────────────────────
{const s=pres.addSlide();bgFill(s,DARK);rct(s,0,0,.18,5.625,GOLD);
tx(s,"Clinical Summary",.5,.35,9,.5,{fontSize:20,bold:true,color:GOLD,charSpacing:2});rct(s,.5,.88,9,.05,GOLD);
[{title:"SENSORY EXAMINATION",color:TEAL,pts:["Terminology: Anesthesia → Hypoesthesia → Normal → Hyperesthesia → Paresthesia → Dysesthesia","Procedure: Explain → Comfort → Eyes closed → Compare sides → Distal→Proximal","Superficial: Pain (pin), Touch (cotton/monofilament), Temperature (test tubes)","Deep: Position sense, Kinesthesia, Vibration (128 Hz), Deep pressure","Cortical: Tactile localisation, 2-PD (Disk-criminator), Stereognosis, Barognosis, Graphesthesia","Dermatomes / ASIA ISNCSCI Chart — 28 sensory levels, AIS A–E","Ten Test — Numeric 0–10 score vs. reference area"]},
{title:"MOTOR EXAMINATION",color:AMBER,pts:["Muscle bulk: Atrophy, Hypertrophy, Fasciculations, Symmetry (girth measurement)","Tone: Hypotonia (flaccidity), Spasticity (clasp-knife), Rigidity (cogwheel/lead pipe) — MAS 0–4","Voluntary Control: Brunnstrom Stage 1–6 / Bobath Grade 0–4","Muscle Power: Modified MRC (0–5 with +/− grades)","Reflexes: DTRs (0/+/++/+++/++++/Clonus) & Superficial (Babinski, abdominal, anal)","LLD: True (ASIS→MM) vs. Apparent (umbilicus→MM)","Balance (Romberg, BBS, TUG) | Coordination (F-N, H-S, DDK, Rebound)","Gait: Spatiotemporal + Kinematics + Kinetics (GRFV, COP, Power)","Involuntary: Synkinesis, Tremor, Chorea, Athetosis, Dystonia"]}].forEach((sc,i)=>{const x=.5+i*4.7;rct(s,x,1.02,4.45,.35,sc.color);tx(s,sc.title,x+.1,1.02,4.25,.35,{fontSize:11,bold:true,color:WHITE,margin:0});s.addText(sc.pts.map((p,j)=>({text:p,options:{bullet:{type:"bullet"},breakLine:j<sc.pts.length-1,fontSize:9.5,color:"DDEEFF"}})),{x:x+.1,y:1.4,w:4.25,h:3.95,valign:"top",margin:4});});
tx(s,"Source: O'Sullivan & Schmitz — Physical Rehabilitation, 6th Ed. | ASIA ISNCSCI | MRC Scale | Brunnstrom & Bobath",.5,5.2,9,.28,{fontSize:9.5,color:"8899BB",italic:true});}

// ── SLIDE 25: REFERENCES ────────────────────────────
{const s=pres.addSlide();bgFill(s,"1A1A2E");rct(s,0,0,10,.65,"16213E");rct(s,0,0,.18,5.625,GOLD);
tx(s,"REFERENCES",.4,0,9.2,.65,{fontSize:22,bold:true,color:GOLD,charSpacing:4,margin:0});
[{title:"TEXTBOOKS & CLINICAL GUIDELINES",color:TEAL,refs:[
"1. O'Sullivan SB, Schmitz TJ, Fulk G. Physical Rehabilitation. 6th ed. FA Davis; 2014. Ch. 3 — Sensory Examination; Ch. 5 — Motor Function.",
"2. Magee DJ. Orthopedic Physical Assessment. 6th ed. Elsevier Saunders; 2014.",
"3. Nolan MF. Introduction to the Neurologic Examination. FA Davis; 1996.",
"4. American Spinal Injury Association (ASIA). ISNCSCI International Standards. REV 11/15.",
"5. Medical Research Council. Aids to the Examination of the Peripheral Nervous System. 4th ed. HMSO; 1976.",
"6. Brunnstrom S. Movement Therapy in Hemiplegia. Harper & Row; 1970.",
"7. Bobath B. Adult Hemiplegia: Evaluation and Treatment. 3rd ed. Butterworth-Heinemann; 1990.",
]},
{title:"RESEARCH PAPERS",color:AMBER,refs:[
"8. Carey LM, Matyas TA, Oke LE. Sensory loss in stroke patients: effective training of tactile and proprioceptive discrimination. Arch Phys Med Rehabil. 1993;74(6):602–611.",
"9. Kalsi-Ryan S, Beaton D, Curt A et al. The GRASSP — Graded Redefined Assessment of Strength, Sensibility and Prehension. J Neurotrauma. 2012;29(5):905–914.",
"10. Kleyweg RP, van der Meché FG, Schmitz PI. Interobserver agreement in assessment of muscle strength in Guillain-Barré syndrome. Muscle Nerve. 1991;14(11):1103–1109.",
"11. Awad LN, Reisman DS, Binder-Macleod SA. Distance-induced changes in walking speed after stroke. J Neuroeng Rehabil. 2021.",
"12. Patterson KK et al. Gait asymmetry in community-ambulating stroke survivors. Arch Phys Med Rehabil. 2008;89(2):304–310.",
"13. Murphy MC et al. Quantitative sensory testing: systematic review and meta-analysis. Pain. 2025 Oct.",
]}].forEach((col,ci)=>{const x=.28+ci*4.85;rct(s,x,.78,4.6,.36,col.color);tx(s,col.title,x+.1,.78,4.4,.36,{fontSize:11,bold:true,color:DARK,margin:0});col.refs.forEach((ref,ri)=>{const y=1.18+ri*.65,bgC=ri%2===0?"16213E":"1A2744";rct(s,x,y,4.6,.62,bgC,"334466",.5);tx(s,ref,x+.1,y+.02,4.42,.58,{fontSize:8.8,color:"CCDDEE",valign:"top",wrap:true,lineSpacingMultiple:1.2,margin:2});});});}

// ── WRITE ───────────────────────────────────────────
const out="/home/daytona/workspace/sensory-motor-ppt/Sensory_Motor_Examination_Final.pptx";
pres.writeFile({fileName:out}).then(()=>console.log("✅ Done: "+out)).catch(e=>{console.error("❌",e);process.exit(1);});