Part 5 examination of reflex
- 1. Reflexes Examination Of SEMINAR by : ABHILASH DASH Email ID : [email protected]
- 2. CONTENTS 1. Purpose of examination 2. Upperlimb tendon reflex 3. Lower limb tendon reflex 4. Other reflexes 5. Abnormalities of deep tendon reflex 6. Grading of reflex 7. Superficial reflexes 8. Neonatal Reflexes 9. References
- 3. Reflex arc requires a stimulus, a sensory pathway, a link with a motor unit, a motor neuron and a effector element. Reflex
- 4. PURPOSE OF EXAMINATION:- o Whether the reflex is present or absent. o If present whether its normal or showing signs that influences from higher centres are defective. o If absent, whether the arc is breached on the motor or sensory side. o Whether any abnormalities are unilateral, bilateral, affecting all reflexes or whether a definite level can be detected in the nervous system at which abnormalities first appear because reflex ‘levels’ may be helpful as sensory level.
- 5. THE TENDON REFLEXES THE UPPER LIMBS 1. The Biceps Jerk (C5):- • Relax the forearm on examiner’s hand. • Place the forefinger gently on the biceps tendon and then strikes the finger with the hammer. • Normal response -flexion of elbow and visible contraction of biceps seen.
- 6. 2. The Supinator Jerk(C5, C6):- • Relax the forearm on patient’s body at pronation state. Strike the lower end of radious about 5 cm above the wrist. • Watch the movement of forearm and finger. • Contraction of brachioradialis and flexion of elbow results. • Also slight flexion of finger may occur.
- 7. 3. The Triceps Jerk(C6, C7):- • By holding the patients hand, draw the arm across the trunk and allow it to lie loosely in the new position. • Then strike the triceps tendon 5 cm above elbow. • Extension of elbow and visible contraction of triceps seen.
- 8. THE LOWER LIMBS 1. The Knee Jerk(L3-L4):- • Patient supine, flex the knee 60ᵒ by placing the forearm under the knee to be tested. • Strike the patellar tendon midway between its origin and insertion. • Extension of knee and visible contraction of quadriceps seen. • It can also be done with patient in high sitting on bed and leg hanging at edge.
- 10. 2. The Ankle Jerk(s1):- • Patient in supine position, hip externally rotated, slightly flex the knee (medial malleolus facing upward), dorsiflex the ankle by examiner as to stretch the achillis tendon. • Strike the tendon on posterior surface. • The calf contracts and moves ankle. • The plantarflexion of foot can be felt by the hand of examiner. • Alternative method:- ask the patient to kneel on the chair so that the ankle are hanging loose over the edge. Then strikes the achillis tendon. • Normal response – plantar flexion of the foot and the contraction of gastrocnemius muscle.
- 11. ABNORMALITIES OF DEEP TENDON REFLEX Pendular movements:- • Pendular movements are the slow oscillatory movements (instead of brisk movements) that are developed while eliciting a tendon jerk. • It occur because of hypotonicity of muscles. • These are very common while eliciting the knee jerk or patellar tendon reflex in the patients affected by cerebellar lesion. • In normal conditions, after the extension, the leg returns back to resting position immediately. • In cerebellar lesion, the leg swings forwards and backwards several times before coming to rest. Normally number of oscillation is 3. Hung-up reflex- • The movement is retarded, especially during delayed relaxation, so that the impression of a slightly sloe motion film is obtained. • The reflex is appearing to “hang-up” compared with a normal jerk. • It is mainly seen in hypothyrodism.
- 12. Grade Reflexes What it means 0 Absent Lower motor neuron lesion 1+ Present but depressed Normal but may indicate neuropathy 2+ Present/ brisk Normal 3+ Very brisk or increased Maybe normal but may indicate UMN lesion 4+ Clonus UMN lesion GRADING OF REFLEXES
- 13. OTHER REFLEXES- 1. The Hoffman Reflex- • The terminal phalanx of patient middle finger flicked downward between examiner’s finger and thumb. • Instead of hyperflexia the tip of other finger flex and the thumb flex and adduct. • It is a sign of unilateral pyramidal tract disease. 2. Rossolimo’s reflex – • The patient lies supine with the leg extend and the foot partially dorsiflex. • The ball of foot is then struck with the hammer and in hypertonic state there is a brisk contraction of all toes. • Normally no response
- 14. 3. Waternberg SIGN- • The patient supinate his hand slightly flexing the fingers. • The examiner pronate his hand and links his similarly flexed finger with patient’s. • Both then flex their finger further against each others resistance. • Normally the thumb extends, though the terminal phalanx may flex slightly. • In pyramidal tract lesion, the thumb adduct and flexed strongly. Normal Pyramial tract lesion
- 15. ABNORMALITIES OF TENDON REFLEX- Exaggeration – 1 – Reflex may be excessively brisk, the movement being a sudden, short lived jerk. This type of reflex is seen of UMN lesion. Also seen in fright, anxiety, after violent exercise but then return to normal on rest. 2- The reflexogenic zone maybe increased. Example- if the biceps reflex is exaggerated, it may even be obtained by tapping over the clavicle due to increase in reflexogenic zone. 3- A reflex may be clonic :- the muscle that has been stretched goes into clonic contraction until the stretch is relieved. It is seen in pyramidal disease, and in tensed individual. Reduction or absent:- Reflex reduction 1- Defective technique application 2- When there is breach of ant part of reflex system. E.g.- sensory nerve(polyneuropathy), sensory root (tabes dorsalis), anterior horn cell(poliomyelitis), the anterior root(spinal compression), the peripheral nerve(trauma), the terminal nerve ending(polyneuropathy) or the muscle itself(myopathy) 3- During cerebral or spinal shock phase which can be of some hour to some days. 4- When great rigidity, spasticity or muscle contracture more or less splint the joint so that movement cannot occur. Advanced spastic paraplegia, and severe extrapyramidal rigidity usually occurs this situation.
- 16. SUPERFICIAL REFLEXES The Abdominal Reflexes – • The patient should first lie flat. Palpate gently to asses the degree of relaxation and the sensitivity of the skin. Explain the patient the procedure. • Lightly stroke the abdomen with a pencil, key or with the end of the hammer in all quadrants of abdomen and lower margin of the thoracic case. • Normal result the muscle contract and umbilicus moves in that direction. • Segmental innervation- Epigastric-T7-T9, Upper abdominal T9-T11, Lower abdomen T11-T12 Abnormal response- Exaggerated abdominal reflexes occur in psychoneurosis, nervousness. • Absent of reflex- UMN lesion above the level of reflex arc, LMN lesion at corresponding reflex arc, obesity, rigid abdomen.
- 17. The Cremasteric Reflex- • The patient lies supine, with the lower limbs in a slightly abducted and externally rotated position. • With the handle of the knee hammer, lightly stroke the upper and inner aspects of thigh from below upwards. • The normal response is an immediate contraction of cremaster muscle that pulls the ipsilateral testis. The Anal Reflex:- • Lightly scratch the perianal skin which contract the external sphincter muscle.
- 18. The Plantar Reflex • Position the patient so that knee is slightly flexed, and thigh externally rotated. • The foot is rest on the couch. Ask the patient to let the foot remain closed. • The outer aspect of sole is then firmly stroked with the blunt point end of knee hammer. • Then curve the stimulus towards the middle metatersophalengeal joint. • Do the stimulation slowly and allow yourself time to see what is happening. • Normally great toe flex at the metatersophalengeal joint. • At the same time other toe will flex and close together.
- 19. Babinski’s sign:- • Extension of the great toe at the interphalengeal joint, and the other toes open in a fanwise manner and are dorsiflexed. • It indicates UMN lesion above L5 segment. Babinski’s sign POSITIVEBabinski’s Sign NEGATIVE
- 20. Neonatal Reflexes:- The Grasp Reflex:- • Touch palm with the finger of examiner on the radial border between thumb and index finger. • If the grasp reflex is present, the finger will be held tightly by the hand in the first instance. • The reflex is normal in babies. • Also it present in mental deficiency, birth injury, vascular accident in premotor cortex, lesion in corpus callosum. • This can occur in normal aging.
- 21. Gabellar Tap:- • Tap the gabella (root of nose) repeatedly with one finger brought from above and behind the patient’s head. • Normally there is blinking response only to first 2-3 taps. In parkinsonism the blinking continues as long as the ta given. The Sucking Reflex:- • Touching the corner of mouth produces a sucking movement of the lips and deviation of the mouth in the direction of stimulus. • This is normally present in infants. • This is also seen in advanced and diffuse cerebral atropic lesion, traumatic lesion.
- 22. References 1. BICKERSTAFF ’s Neurological Examination by KAMESHWAR PRASAD 2. Neurological Assessment by RUBEN D. RESTREPO 3. Neurological Examination by WILLIAM HOWLETT 4. Neurological intervention for Physical Therapy by MARTIN KESSLER 5. A Concise Guide to Neurology by REMA PAI 6. Neurology Illustrated by KENNETH W LINDSAY, IAN BONE
- 23. Repetition Of The Same Thought Or Physical Action Develops Into A Habit, which Repeated Frequently enough, Becomes An Automatic Reflex.. THANK YOU !