PY10.

11(
CONTD…)
TOPI
C:DEEPREFLEXES
Defi
nit
ion:Arefl
ex,
orref
lexacti
on, i
saninvol
untar
ycontract
ionofamuscl
eoragroupof
muscles(orsecr
eti
onofagland)inresponsetoaspecif
icsti
mulus,
andwhichi
nvol
ves
somepar toft
hecentr
alner
voussy stem (
brai
nandspinalcor
d).

Cl
ini
cal
lyt
est
edr
efl
exes:
Thesei
ncl
ude:

A.Super
fi
cial
ref
lex
esf
rom t
heski
nandmucousmembr
anes.

B.Deepr
efl
exesort
endonr
efl
exes–Thesear
e:

I
nheal
th,
theser
efl
exesshoul
dbepr
esentandequal
ont
het
wosi
desoft
hebody
.

DEEPREFLEXES
Thedeepr ef
lex
esar ealsocall
edt hetendonref
lexes,
ortendonjer
ksorsimply“j
erks”
becausewhent hetendonofal ightl
ystret
chedmuscleisgi
venasingl
e,sharpbl
owwi tha
rubberhammer( patel
l
arorper cussionhammer )
,themusclecontr
act
sbrief
lyandthen
rel
axes,i
.e.i
tgi
v esa“jer
ky”response.

Patell
ar(knee)Hammer-I tisasi mpledeviceempl oy edforeli
cit
ingdeeport endonr efl
exes.
Ithasalongmet all
ichandl
et hatbearsat r
iangularrubberpi ece.Ther ubberi
sempl oy edfor
deli
veri
ngashar pblowont het endonofasl ight
lystr etchedmuscl eunderstudy.The
suddenst r
etchofthemuscl ecausesar efl
excont ract ionofthemuscl e.Whenusi ngit,t
he
hammershoul dbehel dbetweent hethumbandf inger sandt heswi ngshouldbeatt hewr i
st
andnotatt heelboworshoul der.Theupperpar toft hehammerwhi chcanbeunscr ewed
hasashar ppointforel
ici
ti
ngsuper fi
cial
reflexes.
Sti
mulus-Thest i
mulusthatiniti
atesadeepr ef
lexisthesuddenst r
etchi
ngoft hemuscl
e
spi
ndles,whichsendsasy nchronousvol
leyofimpul sesfrom t
heprimarysensoryendi
ngs
i
ntothespinalcord.I
nthecor d,t
heseimpulsesdirectly(
monosy napt
icall
y)sti
mulat
ethe
ant
eri
orhor ncel
lswhichinnervatethest
retchedmuscl e.Thus,t
heser ef
lexesare
monosy napt
icstr
etchref
lexes.

I
mport
ant:I
tmaybenotedt
hatiti
sthespi
ndl
erecept
orsandnotthet
endonr
ecept
ors
whi
charesti
mul
atedt
houghthehammerisst
ruckonthetendonandnotont
hemuscl
e
bel
l
y

KNEEREFLEX
Supineposition:Thesubjectisaskedt orelaxhislegs,andi sreassuredt hatthepat el
l
ar
hammerwi l
lnotcausei nj
ury.Hislegsaresemi fl
exed,andt heobserv ersuppor t
sbot hknees
byplacingahandbehi ndt
hem.Thepat el
lartendonisthenst ruckmi dwaybet weent he
patell
aandt heinserti
onofthetendonont hetibi
altuberosity
.(Thetendoni slocatedby
palpati
onbef orestr
iki
ngit.Theresponsei sextensi
onoft hekneeduet ocontractionofthe
quadricepsfemor i
smuscle.Af f
erentandef fer
entpaths: Femor al
nerv e;Center:Lumbar3,4
segment s.

Sit
tingposi ti
on:Thesubj ecti sseat edi
nachai randisaskedt ocrossonel egov ert
heother,
andt hent herefl
exi selicited.Thel egcanbeseent okickfor
wards; themuscl ecanal sobe
fel
ttocont r
actiftheobser verplaceshishandont helowerfrontoft hethigh.Abet t
erwayt o
eli
citthisrefl
exist oaskt hesubj ecttositwithbothlegsdangli
ngl ooselyov ertheedgeof
thechai r.I
tpermitsamor er api
dcompar isonofthetwokneej erks.Thekneej erkmaybe
pendul arinacutecer ebellardiseaseandpr esentonthesideofthel esion.Itmaybe
sustainedi nchorea.Inhy pothyroidism,t
her emaybedel ayedreturnoft helegt otherest
ing
positi
on.I nhyperthyroidism, thejerksarebr i
sk.

ANKLEREFLEX
Thesubj ectliessupi ne, thekneeissemi flexed,andt hehi pexternall
yr ot
ated.Thenwi t
hone
hand, theex ami nerslightlydorsi
fl
exest hef ootsoast ostret
cht heAchi ll
estendon( t
endo-
calcaneus) ,andwi tht heot herhand,thetendoni sst r
uckoni tspost eriorsurface.The
responsei spl antarflexionoft hefootduet ocont ractionofthecal fmuscl es.Another
met hodi st oaskt hesubj ecttokneel overachai rsot hathef acest hebackoft hechai
rand
hisankl eslie,ov eritsedge.Theankl ejerksar ethent estedasdescr i
bedabov e.Af
fer
entand
efferent:Tibial nerve;Cent er:Sacral1,
2segment s.

BI
CEPSREFLEX
Thesubj
ect
’sel
bowi
sfl
exedt
oar
ightangl
eandt
hef
orear
m semi
pronat
edandsuppor
ted
ont heexaminer’
sar m.Theex aminerthenplaceshisthumbont hebicepstendonand
str
ikesitwit
ht hehammer .Ther esponseiscontract
ionofthebicepscausingfl
exionand
sl
ightpronati
onoft heforearm( Ifthepati
entisinbed,hisforear
m mayr estacr
osshis
chest).Theaff
erentandef ferentpathsaremuscul ocutaneousnerveandthecenterisi
n5th
and6t hcerv
icalsegments.

TRI
CEPSREFLEX
Thear misflexedtoar i
ghtangleandissupport
edont heexaminer’
sarm.Thetr
iceps
tendonisthenst r
uckjustproximalt
othepointoft
heel bow.Theresponsei
sext
ensionat
theelbow.Af f
erentandefferentpat
hs:Radi
alner
ve;Center:C-
6,7.

RADI
ALSUPI
NATORREFLEX
Thearmi spl
acedtoar i
ghtangl
eandthefor
earm placedmidwaybet
weenpr onati
onand
supi
nati
on.Uponstri
kingthesty
loi
dpr
ocessofther adi
us,t
herei
ssupinat
ionattheel
bow.
Aff
erentandeff
erentpaths:
Radial
ner
ve;Cent
er:C-6,7,
8.

WRI
STREFLEXES
I
nwr istrefl
exes,ther
ei sfl
exi
onorextensi
onatthewristwhent hecor
respondingt endons
arestruckwiththeper cussi
onhammer .Forfl
exi
on,t
heaf f
erentandefferentpathsare
medianner ve,andcent eri
sC-6,
7,
8.Forextensi
on,t
heaf f
erentandeff
er entpathsarealong
theradialnerve,andthecenteri
sC-7,
8.

REI
NFORCEMENTOFREFLEXES
Thebr isknessofkneej erk(andotherdeepr ef l
ex es)v ar
iesgreatl
yfrom persont operson
butitishar dlyeverabsentinheal th.Occasi onal l
y ,i
tmaybev eryweakorev enappeart obe
absent .Insuchcases, r
einf
orcement( Jendr assi kmaneuver )isempl oyed.Thisisdoneby
askingt hesubj ecttoperform somest rongmuscul areffort
,suchascl enchi
ngt heteeth,or
l
ockingt hef i
nger sofbothhandsashar daspossi bleandt hentryi
ngt opullthem apartwhil
e
theex ami nerstri
kesthepat ell
artendon.Ther eflexgener al
lybecomesev i
dent .
Reinforcementact sbyincreasingt heex cit
abilityoftheant eri
orhorncel l
sduet o“spil
li
ng”
overofi mpul sesf r
om theneur onsi nvolvedinr einforcementef f
orttothemot orneur
onsof
thereflex.Inaddi ti
on,gammamot orneur onact i
v i
tyincr
easest hesensiti
vit
yoft hespindle
receptorst ostretch.I
talso,perhaps, actsbydi stracti
ngt hesubject
’sattenti
on.

Di
mini
shedorabsentdeepr
efl
exes
Thet
endonr
efl
exesar
edi
mini
shedorabsent
,ononeorbot
hsi
des,
in

i
. l
esi
onsi
nvol
vi
ngt
heaf
fer
entpat
hway
s(e.
g.t
abesdor
sal
i
s),

i
i
. t
heant
eri
orhor
ncel
l
sthemsel
ves(
e.g.pol
i
omy
eli
ti
s),
ort
heef
fer
entpat
hway
s.

i
i
i. I
nperipher
alneur
opat
hiesorper
ipher
alner
vei
njur
ies,
bot
hsensor
yandmot
or
f
iber
sar eaf
fect
ed.

Thet
endonj
erksar
eal
soabol
i
shedbyspi
nal
shock,
e.g.sev
erei
njur
ytot
hecor
d.(
Inf
act
,
all
mot orandsensor yfunct
ionsarelostbel
owt hesit
eoflesi
onfort
hedur at
ionoft he
spinal
shock) .Tendonrefl
exesarealsolostbi
l
at er
all
yincoma.Asmentionedearl
ier ,
the
deepreflexesmaybesl uggishorappeartobeabol i
shedinsomehealt
hyindivi
duals;
rei
nforcementi semployedinthesecases.

Exagger
ateddeepr
efl
exes
Thedeepr
efl
exesar
eex
agger
ated(
hyper
ref
lexi
a)i
nthef
oll
owi
ngcondi
ti
ons:

1.Uppermotorneuronlesi
onsabovetheant
eri
orhorncel
ls,
especi
all
ywhenthe
hyper
refl
exi
aisunil
ater
al,oraccompani
edbyothersi
gnsofUMNdi sease.

2.Anx
iet
yorner
vousness.

3.Hy per
excit
abi
li
tyoft henervoussystem,asinhy pert
hyroi
dism,andtetanus.Thecauseof
exaggerati
onofdeepr eflexesinl
esionsofcorticospi
nalsyst
em isthehypertonia(spasti
cit
y)
resul
tingfr
om overactivi
tyofthestr
etchref
lexes; t
hissyst
em keepsthesereflexesunder
check.Whent hi
sinhibiti
onislost
,thedeepreflexesaremor eeasil
yeli
cit
ed.Ex aggerat
ionof
refl
exesisthusa“release”phenomenon—asi st heBabinskir
esponse.

CLONUS
I
tisaser i
esofinv ol
untarycontr
act i
onsofcert
ainmusclesinresponsetostret
ch.This
phenomenoni scloselyall
iedtodeepr efl
exesandcanoftenbedemonst rat
edatt heankl
e
whent heser
eflexesareex aggerated.I
tisofgreat
erimport
ancewheni ti
sincreasedby
maintaini
ngandi ncr
easingthest r
etchont hemuscle.

Anklecl onus: Thesubject’skneeisslight

lyfl
exedandt hel
egi sheldupbysuppor tingitwi
th
ahandpl acedbehi ndtheknee.Theexami nerthensuddenlydor sif
lexesthef ootafter
graspingi t
sf orepart
.Thesuddenst r
etchofcalfmuscl esresultsintheiral
ternate
contractionandr el
axati
on.Theremaybe2or3osci ll
ations(“pseudo” ,
“spurious”,or
“exhaust i
ble”clonus)innor malpersonswhoar ev er
ytenseoranxi ous,but“true”
,
“sustained”,or“ i
nexhausti
ble”cl
onusi spresentonlyinUMNl esions(Thepl antarrefl
exes
areflexorinnor mal persons).

Patel
larcl
onus:Thesubject’
slegisplacedinextensi
on.Theexaminerhol
dsthepat
ell
a
fr
om itssi
deswi t
hhisthumbandf ingersandthenpressesi
tsharpl
yandfir
mlydownwards.
I
fclonusispresent,
thepatel
lashowsar api
dupanddownmov ement,whi
chconti
nuesas
l
ongast hestret
chismaintai
ned.

GRADI
NGOFTENDONREFLEXES
Tendonordeepr
efl
exesar
eusual
l
ygr
adedasf
oll
ows:

0.Absent

1.Pr
esent(
asanor
mal
ankl
ejer
k)

2.Br
isk(
asanor
mal
kneej
erk)

3.Ver
ybr
isk

4.Cl
onus