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Neurologic Examination: Reflex Testing
Neurologic Examination: Reflex Testing
REFLEX TESTING
REFLEX TESTING
Reflex testing incorporates an assessment of the function and interplay
of both sensory and motor pathways. It is simple yet informative
and can give important insights into the integrity of the nervous
system at many different levels.
Assessment of reflexes is based on a clear understanding of the
following principles and relationships:
The signal then travels down the LMN to the target muscle.
REFLEX TESTING
The sensory and motor signals that comprise a reflex arc travel
over anatomically well characterized pathways. Pathologic
processes affecting discrete roots or named peripheral nerves will
cause the reflex to be diminished or absent. The Achilles Reflex
is dependent on the S1 and S2 nerve roots. Herniated disc
material can put pressure on the S1 nerve root, causing pain
along its entire distribution (i.e. the lateral aspect of the lower leg).
If enough pressure if placed on the nerve, it may no longer
function, causing a loss of the Achilles reflex.
In extreme cases, the patient may develop weakness or even
complete loss of function of the muscles innervated by the nerve
root, a medical emergency mandating surgical decompression.
A normal response generates an easily observed shortening of
the muscle. This, in turn, causes the attached structure to move.
Small Hammers
Large Hammers
REFLEX TESTING
Technique:
If you are having trouble locating the tendon, ask the patient to
contract the muscle to which it is attached. When the muscle
shortens, you should be able to both see and feel the cord like
tendon, confirming its precise location. You may, for example, have
some difficulty identifying the Biceps tendon within the Antecubital
Fossa. Ask the patient to flex their forearm (i.e. contract their
Biceps muscle) while you simultaneously palpate the fossa. The
Biceps tendon should become taut and thus readily apparent.
Strike the tendon with a single, brisk stroke. While this is done
firmly, it should not elicit pain. Occasionally, due to other medical
problems (e.g. severe arthritis), you will not be able to position the
patients arm in such a way that you are able to strike the tendon. If
this occurs, do not cause the patient discomfort. Simply move on to
another aspect of the exam.
This is most easily done with the patient seated, feet dangling
over the edge of the exam table. Other positions: supine, crossing
one leg over the other in a figure 4 or a frog-type position.
Be sure that the calf if exposed so that you can see the muscle
contract.
ACHILLES TENDON
This is most easily done with the patient seated, feet dangling
over the edge the exam table.
Strike the tendon directly with your reflex hammer. If you are
having trouble identifying the exact location of the tendon (e.g. if
there is a lot of subcutaneous fat), place your index finger firmly
on top of it. Strike your finger, which should then transmit the
impulse.
For the supine patient, support the back of their thigh with your
hands such that the knee is flexed and the quadriceps muscles
relaxed.
Patellar Tendon
BICEP TENDON
This is most easily done with the patient seated. The lower arm
should be resting loosely on the patients lap.
Strike this area with your reflex hammer. Usually, hitting anywhere
in the right vicinity will generate the reflex.
BRACHIORADIALIS REFLEX
BRACHIORADIALIS REFLEX
Pronator Reflex C6 C7
grasp pts hand and hold it vertically so the wrist is suspended
from the medial side, strike the distal end of the radius directlywith
horizontal blow
NORMAL RESPONSE: pronation of the forearm
Hamstring Reflex L4 S2
Patient supine with hips and knees flexed at 90 degrees, and thigh
rotated slightly outward.
place your left hand under the popliteal fossa to compress the medial
hamstring
NORMAL RESPONSE: flexion of the knee and contraction of the medial
mass of hamstring
Trouble Shooting
If you are unable to elicit a reflex, stop and consider the
following:
Are you striking in the correct place? Confirm the location of the
tendon by observing and palpating the appropriate region while
asking the patient to perform an activity that causes the muscle
to shorten, making the attached tendon more apparent.
Make sure that your hammer strike is falling directly on the
appropriate tendon. If there is a lot of surrounding soft tissue
that could dampen the force of the strike, place a finger firmly
on the correct tendon and use that as your target.
Make sure that the muscle is uncovered so that you can see
any contraction (occasionally the force of the reflex will not be
sufficient to cause the limb to move).
Sometimes the patient is unable to relax, which can inhibit the
reflex even when all is neurologically intact. If this occurs during
your assessment of lower extremity reflexes, ask the patient to
interlock their hands and direct them to pull, while you
simultaneously strike the tendon. This sometimes provides
enough distraction so that the reflex arc is no longer inhibited.
Trouble Shooting
Occasionally, it will not be possible to elicit reflexes, even
when no neurological disease exists. This is most
commonly due to a patient's inability to relax. In these
settings, the absence of reflexes are of no clinical
consequence. This assumes that you were otherwise
thorough in your history taking, used appropriate
examination techniques, and otherwise identified no
evidence of disease.
BRAINSTEM REFLEXES
Direct Pupillary Reaction to Light - the iris constricts when bright light
is shone upon the retina
Consensual Pupillary Reaction to Light - stimulation of one retina
causes contralateral constriction of the pupil
Ciliospinal Reflex - pinching the skin of the back of neck causes
pupillary dilatation
Corneal Reflex - touching the cornea causes blinking of the eyelids
Orbicularis Oculi Reflex - the eyelids close when the retina is
exposed to bright light
Auditocephalogyric Reflex - the head and eyes turn toward the
source of a loud sound
Jaw Reflex - when the mouth is partially opened and the muscles
relaxed, tapping the chin causes the jaw to close.
The reflex center is in the midpons
Gag Reflex - gagging occurs when the parhynx is stroked.
The reflex center is is the medulla
SUPERFICIAL REFLEXES
have reflex arcs whose receptor organs are in the skin
rather than in muscle fibers
adequate stimulus is stroking, scratching or touching
these reflexes are lost in disease of the pyramidal tract
SUPERFICIAL REFLEXES
Upper Abdominal Skin Reflex T5 T8
with patient supine, stroke the skin with blunt handle towards the midline
watch for ipsilateral contraction of muscles or umbilical deviation towards
the stimulated side
Plantar Reflex L4 S2
stroke the sole near its lateral aspect from the heel towards toes
produces plantar flexion of the toes
Start at the lateral aspect of the foot, near the heel. Apply steady
pressure with the end of the hammer as you move up towards the
ball (area of the metatarsal heads) of the foot.
When you reach the ball of the foot, move medially, stroking
across this area.
Hoffmanns Sign
Have pt present pronated hand with fingers extended and relaxed.
With your thumb, press his fingernails to flex the terminal digit and
stretch his flexor
Abnormal response: flexion and adduction of thumb
Mayers Reflex
Have pt present his supinated hand with thumb relaxed and
abducted. Grasp his ring finger and firmly flex the
metacarpophalengeal
joint
Normal response: adduction and apposition of the thumb
Spinal Rigidity
- movements of the spine are limited by spasms of the Erector spinae
Kernigs Sign
- with pt supine, passively flex the hip to 90 deg while the knee is
flexed at about 90 deg
- attempts to extend the knee produce pain iun the hamstring and
resistance
Brudzinskis Sign
- with pt supine and the limbs extended, passively flex the neck
- produces involuntary flexion of the hips
THE END