REFLEX

PRESENTED BY : Dr. Setia Budi Trg, Sp.S

> Reflex are subconscious stimulus-response mechanisms

> The instinctive behaviour of lower animals is govern largely by reflexes

> In humans: behaviour is more a matter of conditioning and reflexes act as

basic defense mechanisms

> The reflexes : extremely important in diagnosis and localization of neurologic

lesions

> Reflex : any action performed involuntarily as the result of an impulse or

impression that is transmitted along afferent fibers to a nerve center,
thence to efferent fibers and then calls into action certain cells,
mucles, or organs
• Simple Reflex arc

Several structures are involved in the reflex arc :

> Receptor : - a special sense organ
- cutaneous end organ
 stimulation initiates an impulse
> Afferent neuron : transmits the impulse through a peripheral nerve
to the central nervous system where the nerve
synapses with a LMN or an intercalated neuron
> Intercalated neurons (interneurons) : relay the impulse to the
efferent nerve.
> Efferent neuron : passes outward in the nerve and delivers the
impulse to an effector
> Effector : muscle or gland that produces the response

> Interruption of this simple reflex arc at any point  abolishes the reponse
• Types of reflexes

The reflexes of importace to the clinical neurologist may be devided

into four groups :
1. Superficial ( skin and mucous membrane ) reflexes
2. Deep tendon ( myotatic ) reflexes
3. Visceral ( organic ) reflexes
4. Pathologic ( abnormal ) reflexes

Reflexes can also be classofied according to the level of their central representation : -
Spinal
- Bulbar ( postural and righting reflexes )
- Midbrain
- Cerebellar reflexes
• LESIONS IN THE MOTOR PATHWAYS

Lesion in the motor pathways : - the muscle

- its myoneural junction
- peripheral nerve
 all result in disturbances of motor function

Two main types of lesion :

1. Lower-motor-neuron lesions
2. Upper-motor neuron lesions
• Lower versus upper motor neuron lesions
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LMN lesion UMN lesion
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Weakness Flaccid paralysis Spastic paralysis

Deep tendon reflexes Decreased or Increased

Absent
Babinski’s reflexes Absent Present

Atrophy May be marked Absent or due to disuse

Fasciculations and May be present Absent

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• 1. Superficial reflexes
( exteroceptive, skin, mucous reflexes )
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Superficial R Afferent Center Efferent
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1.1. Coeneal N.V Pons N.VII
1.2. Nasal sneeze N.V Brain stem & N.V, VII, IX,
Upper cord spin nerve of resp
1.3. Pharyngeal N.IX Medulla N.X
& uvular
1.4. Upper abd T7.8,9,10 T7,8,9,10 T7,8,9,10
1.5. Lower abd T10,11,12 T10,11,12 T10,11,12
1.6.Cremaster Femoral L1 Genitofemoral
1.7.Plantar Tibial S1,2 Tibial
1.8. Anal Pudendal S4,5 Pudendal
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• 3. Visceral Reflexes
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Visceral R Afferent Center Efferent
___________________________________________________
3.1. Light N.II Midbrain N.III
3.2. Accomodation N.II Occipital cortex N.III
3.3. Ciliospinal Sensory nerv T1,2 Cervi. Symp
3.4. Occulocardiac N.V Medulla N.X
3.5. Carotid sinus N.IX Medulla N.X
3.6. Bulbocavernos Pudendal S2,3,4 Pelvic autonomic
3.7. Bladder & rectal Pudendal S2,3,4 Pudendal& autono
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• 2. Deep reflexes
( proprioceptive,tendo,myotatic )
_______________________________________________________
Deep R Afferent Center Efferent
_______________________________________________________
2.1. Jaw N.V Pons N.V
2.2. Biceps Musculocutaneous C5,6 M.cutaneous
2.3. Triceps Radial C6,7 Radial
2.4. Peristeo Radial C6,7,8 Radial
radial
2.5. Wrist flex Medial C6,7,8 Medial
2.6. Wrist ext Radial C7,8 Radial
2.7. Patellar Femoral L2,3,4 Femoral
2.8. Achilles Tibial S1,2 Tibial
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• 4. Pathologic reflexes
4..1. Hoffmann’s sign : The examiner supports the patient’s hand
dorsoflexed at the wrist, so that it is comple-
tely relaxed and the fingers are partially flexed.
The middle finger is partially extended and either its middle or
distal phalanx is grasp firmly between the examiner’s index
finger and thumb.
With a sharp, forcible flick of his other thumb, the examiner
nips or snaps the nail of the patient’s middle finger, causing a
forcible increased flexion of this finger by sudden release

(+) : followed by flexion and adduction and flexion of the index finger
sometimes flexion of the other fingers as well.
• 4.2. Trommer’s sign : The examiner hold the patient’s hand in
relaxation by grasping either the proximal or middle
phalanx of the partially flexed middle finger
between his thumb and index finger.
With the middle finger of the other hand he taps the
the volar surface of the distal phalanx of the middle
finger.
( + ) : the response is same as that in the Hoffmann sign
• 4.3. Babinski Sign : The Babinski sign is elicited by stimulating the plantar
surface of the foot with a blunt point, preferaably a
match stick, a toothpick, a wooden applicator, a broken
tongue blade, or the tip of a key.
The stimulus is directed from the heel forward , usually
stopping at the metatarsophalangeal joints, and both
inner and outer aspects of the sole should be tested.

( + ) : followed by dorsoflexion of the toes, especially of the great toe,

together with a seperation or fanning of the toes.
• 4.4. Chaddock sign is elicited by stimulating the lateral aspect of the
foot with a blunt point sush as that used to elici the
Babinski sign.
The stimulus is usually applied under and around
the external malleolus in a circular direction, but
may also be applied to the lateralaspect of the foot
below the malleolus , from the heel to the small toe

4.5. Oppenheim sign is elicited by applying heavy pressure with the the
thumb and index finger to the anterior surface of
tibia, mainly on its medial aspect, and stroking down
from the infrapatellar region of the ankle.
• 4.5. Gordon sign is obtained by squeezing or applying deep pressure to
the calf muscle

4.6. Schaefer sign is produced by deep pressure on the Achilles tendon.

4.7. Gonda sign is elicited by forcefull downward stretching or snapping of the

distal phalanx of the either the second or fouth toe.

4.8. Ankle clonus consist of a series of rhythmic alternating flexion and

extensions of the foot at the ankle; it follows stretching of the
triceps surae, and is the resut of repeated contractions of this
muscle.
• 4.9. Patellar clonus consist of a series of rhythmic up-and-down
movements of the patella. It follows stretching
the quadriceps , and is the result of of this
muscle.
It can be elicited by grasping the patella between
index finger and thumb.
• Palmomental Reflex
This is manifested by contaction of the ipsilateral mentalis and
orbicularis oris muscles in response to stimulation of the thenar area of
the hand. There is a wrinkling of the skin of the chin and slight retraction
of the angle of the mouth.

The reflex may be elicited by scratching with a blunt point over

eminence from the wrist to the proximal phalanx or in the
opposite direction or by tapping this area.
• Moro reflex
Any sudden stimulus, such as a loud noise, a quick movement
directed toward the body, a blow on the bed close to the body,
a tap on the abdomen, or a bright light suddenly toward the
eyes  abduction and extension of all fout extremities and
extension of the spine, wiyh extension and fanning of
the digits except for flexion of the distal phalanges of
the index finger and thumb; this is followed in turn by
flexion and adduction of the extremities.

This reflex is present during the first 3 months of life