Nina Ian John “G” Rachel Mark Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickie Ricobear

Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung

S4L5:
S4L5: Reflex Testing by Dr.Alfredo Guzman
Reflex Testing January 31, 2011

OUTLINE
REFLEX TESTING
I. Reflex Testing
A. Principles
B. Achilles Reflex Reflex testing incorporates an assessment of the function and interplay
C. Patellar Reflex of both sensory and motor pathways.
D. Biceps Reflex
E. Brachioradialis Reflex Simple yet informative and can give important insights into the integrity
F. Triceps Reflex of the nervous system at many different levels.
II. Deep Tendon Reflex
A. Pectoralis Reflex
Principles of Reflex Testing:
B. Pronator Reflex
C. Upper Abdominal Reflex
D. Mid Abdominal Reflex  Tendons connect muscles to bones, usually crossing a joint.
E. Lower Abdominal Reflex  When the muscle contracts, the tendon pulls on the bone,
F. Adductor Relfex causing the attached structure to move.
G. Hamstring Reflex
III. Interpreation  When the tendon is struck by the reflex hammer, stretch receptors
IV. Troubleshooting contained within it generate an impulse that is carried via sensory
V. Brainstem Reflex
nerves to the spinal cord.
A. Direct Pupillary Reaction to Light
 At this juncture, the message is transmitted across a
Tope Ag Bien

B. Consensual Pupillary Reaction to Light

C. Ciliospinal Reflex synapse to an appropriate LMN
D. Corneal Reflex  An UMN, whose cell body resides in the brain, also provides
E. Orbicularis Oculi Reflex input to this synapse.
F. Auditocephalogyric Reflex
G. Jaw Reflex  The signal then travels down the LMN to the target muscle.
H. Gag Reflex
VI. Superficial Reflex
The sensory and motor signals that comprise a reflex arc travel over
A. Upper Abdominal Skin Reflex
B. Mid abdominal Skin Reflex
anatomically well characterized pathways.
C. Lower Abdominal Skin Reflex
D. Cremasteric Reflex  Pathologic processes affecting discrete roots or named peripheral
E. Plantar Reflex nerves will cause the reflex to be diminished or absent.
F. Superficial Anal Reflex
G. Glabellar Reflex Example:
H. Snout Reflex  The Achilles Reflex is dependent on the S1 and S2 nerve
I. Sucking Reflex
roots. Herniated disc material can put pressure on the S1
J. Chewing Reflex
VII. Abnormal Reflexes
nerve root, causing pain along its entire distribution (i.e. the
A. Babinski Reflex lateral aspect of the lower leg). If enough pressure if placed
B. Grasp Reflex on the nerve, it may no longer function, causing a loss of the
C. Hoffman’s Sign Achilles reflex.
D. Mayer’s Reflex
E. Palm-Chin Reflex  In extreme cases, the patient may develop weakness or even
VIII. Signs of Meningeal Irritation complete loss of function of the muscles innervated by the nerve
A. Nuchal Rigidity
root, a medical emergency mandating surgical decompression.
B. Spinal Rigidity
C. Kernig’s Sign
D. Brudzinski’s Sign A normal response generates an easily observed shortening of the
IX. Summary
muscle. This, in turn, causes the attached structure to move.

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 REFLEX TESTING
Grading Scale for Vigor of Contraction:
Technique:
Grade Description
0  Absent a. The muscle group to be tested must be in a neutral position (i.e.
 Decreased but still present neither stretched nor contracted).
1+
 Hyporeflexic
 Normal b. The tendon attached to the muscle(s) which is/are to be tested
2+
 Physiologic must be clearly identified. The extremity should be positioned
 Increased such that the tendon can be easily struck with the reflex hammer.
3+
 Maybe normal or pathologic
4+  Markedly hyperactive with transient clonus
c. If you are having trouble locating the tendon, ask the patient to
 Markedly hyperactive with sustained clonus
contract the muscle to which it is attached.
5+  Repetitive shortening of the muscle after a
 When the muscle shortens, you should be able to both see
single stimulation
and feel the cord like tendon, confirming its precise location
The Reflex Hammer:
Example:
 Identifying the Biceps tendon within the Antecubital Fossa.
Technique:
Ask the patient to flex their forearm (i.e. contract their Biceps
muscle) while you simultaneously palpate the fossa. The
 Use a reflex hammer when performing this aspect of the exam.
Biceps tendon should become taut and thus readily
Regardless of the hammer type, proper technique is critical.
apparent.
 The larger hammers have weighted heads, such that if you raise
them approximately 10 cm from the target and then release, they
d. Strike the tendon with a single, brisk stroke. While this is done
will swing into the tendon with adequate force.
firmly, it should not elicit pain.
 The smaller hammers should be swung loosely between thumb
 Occasionally, due to other medical problems (e.g. severe
and forefinger.
arthritis), you will not be able to position the patient’s 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.

ACHILLES REFLEX

Innervation:

S1, S2 – Sciatic Nerve

Technique:

a. 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

b. Identify the Achilles tendon, a taut, discrete, cord-like structure

running from the heel to the muscles of the calf. If you are unsure, ask
the patient to plantar flex (i.e. “step on the gas”).
c. Strike the tendon directly with your reflex hammer.
d. Be sure that the calf if exposed so that you can see the muscle
contract.

Normal Response:
 plantar flexion (contraction of the Gastrocnemius)

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 PATELLAR REFLEX

Innervation:

L3, L4 – Femoral Nerve

Technique:

a. Most easily done with the patient seated, feet dangling over the
edge the exam table.
b. Identify the patellar tendon, a thick, broad band of tissue BICEPS REFLEX
extending down from the lower aspect of the patella (knee cap). If you
are not certain where it’s located, ask the patient to extend their knee. Innervation:
This causes the quadriceps (thigh muscles) to contract and makes the
attached tendon more apparent. C5, C6 – Musculocutaneous Nerve
c. Strike the tendon directly with your reflex hammer.
 If you are having trouble identifying the exact location of the Technique:
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 a. Identify the location of the biceps tendon in the antecubital fossa. The
transmit the impulse. tendon will look and feel like a thick cord.
d. For the supine patient, support the back of their thigh with your b. The patient’s arm can be positioned in one of two ways:
hands such that the knee is flexed and the quadriceps muscles relaxed.  Allow the arm to rest in the patient’s lap, forming an angle of
slightly more than 90 degrees at the elbow.
Normal response:  Support the arm in yours, such that your thumb is resting directly
 Lower leg will extend at the knee. (contraction of the over the biceps tendon (hold the right arm with your right)
Quadriceps) c. It may be difficult to direct your hammer strike such that the force is
transmitted directly on to the biceps tendon, and not dissipated
amongst the rest of the soft tissue in the area.

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  If you are supporting the patient’s arm, place your thumb on the
tendon and strike this digit.
 If the arm is unsupported, place your index or middle fingers firmly
against the tendon and strike them with the hammer.

Normal Response:
 Elbow flexion

TRICEPS REFLEX

Innervation:

C7, C8 – Radial Nerve

Technique:

a. Identify the triceps tendon, a discrete, broad structure that can be

palpated as it extends across the elbow to the body of the muscle,
located on the back of the upper arm. Ask the patient to extend their
lower arm at the elbow while you observe and palpate in the
appropriate region
b. The arm can be placed in either of 2 positions:
 Gently pull the arm out from the patient’s body, such that it
roughly forms a right angle at the shoulder. The lower arm should
dangle directly downward at the elbow.
 Have the patient place their hands on their hips.

Normal Response:
 Lower arm to extend at the elbow and swing away from the body.
 If the patient’s hands are on their hips, the arm will not move
BRACHIORADIALIS REFLEX but the muscle should shorten vigorously

Innervation:

C5, C6 – Radial Nerve

Technique:

a. This is most easily done with the patient seated. The lower arm
should be resting loosely on the patient’s lap.
b. The tendon of the Brachioradialis muscle cannot be seen or well
palpated, which makes this reflex a bit tricky to elicit. The tendon
crosses the radius (thumb side of the lower arm) approximately 10 cm
proximal to the wrist.
c. Strike this area with your reflex hammer. Usually, hitting
anywhere in the right vicinity will generate the reflex.

Normal Response
 elbow flexion
 supination of the forearm (turn palm upward)

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 Technique:
 tapping an overlaid finger

5. Lower Abdominal Muscle Reflex

Innervation:
T11 – T12

Technique:
 Tap the muscle insertion directly near the symphysis pubis

6. Adductor Reflex

Innervation:
L2 – L4
DEEP TENDON REFLEX
Technique:
 patient supine, arrange the lower limb in slight
1. Pectoralis Reflex abduction. Tap directly on the Adductor magnus, just
proximal to its insertion on the medial epicondyle of the
Innervation: femur
C5 – T1
Normal Response:
Technique:  thigh adducts
 Have patient elevate arm
 Place fingers of your left hand upon the pt’s shoulders 7. Hamstring Reflex
with your thumb extended downwards
 Strike your thumb directed slightly upwerd toward the Innervation:
pt’s axilla L4 – S2

Normal Response: Technique:

 muscle contraction can be seen or felt  Patient supine with hips and knees flexed at 90 degrees,
and thigh rotated slightly outward.
2. Pronator Reflex  place your left hand under the popliteal fossa to compress
the medial
Innervation:
C6 – C7 Normal Response:
 flexion of the knee and contraction of the medial mass of
Technique: hamstring
 Grasp pt’s hand and hold it vertically so the wrist is
suspended
INTERPRETATION
 From the medial side, strike the distal end of the radius

Normal Response: Normal reflexes require that every aspect of the system function
 pronation of the forearm normally.
Breakdowns cause specific patterns of dysfunction.
3. Upper Abdominal Muscle Reflex
a. Disorders in the sensory limb will prevent or delay the
Innervation: transmission of the impulse to the spinal cord.
T8 – T9  Causes the resulting reflex to be diminished or completely
absent.
Technique:
 Tap the muscles directly near their insertions on the costal Example:
margins and xiphoid process  Diabetes induced peripheral neuropathy is a relatively
common reason for loss of reflexes.
4. Mid Abdominal Muscle Reflex
b. Abnormal LMN function will result in decreased or absent
Innervation: reflexes.
T9 – T10

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  Make sure that the muscle is uncovered so that you can see any
Example: contraction (occasionally the force of the reflex will not be
 If a peripheral motor neuron is transected as a result of sufficient to cause the limb to move).
trauma, the reflex dependent on this nerve will be absent.  Sometimes the patient is unable to relax, which can inhibit the
reflex even when all is neurologically intact.
c. If the UMN is completely transected, as might occur in traumatic  If this occurs during your assessment of lower extremity
spinal cord injury, the arc receiving input from this nerve becomes reflexes, ask the patient to interlock their hands and direct
disinhibited, resulting in hyperactive reflexes. them to pull, while you simultaneously strike the tendon.
 Immediately following such an injury, the reflexes are This sometimes provides enough distraction so that the
actually diminished, with hyperreflexia developing several reflex arc is no longer inhibited.
weeks later.
 A similar pattern is seen with the death of the cell body of  Occasionally, it will not be possible to elicit reflexes, even when
the UMN (located in the brain), as occurs with a stroke no neurological disease exists. This is most commonly due to a
affecting the motor cortex of the brain patient's inability to relax. In these settings, the absence of
reflexes are of no clinical consequence. This assumes that you
d. Primary disease of the neuro-muscular junction or the muscle were otherwise thorough in your history taking, used appropriate
itself will result in a loss of reflexes, as disease at the target organ examination techniques, and otherwise identified no evidence of
(i.e. the muscle) precludes movement. disease.

e. A number of systemic disease states can affect reflexes. Some

BRAINSTEM REFLEX
have their impact through direct toxicity to a specific limb of the
system.
1. Direct Pupillary Reaction to Light
Example: Iris constricts when bright light is shone upon the retina
 Poorly controlled diabetes can result in a peripheral sensory
neuropathy 2. Consensual Pupillary Reaction to Light
 Extremes of thyroid disorder can also affect reflexes, though stimulation of one retina causes contralateral constriction of the
the precise mechanisms through which this occurs are not pupil
clear.
 Hyperthyroidisim is associated with hyperreflexia, and 3. Ciliospinal Reflex
hypothyroidism with hyporeflexia pinching the skin of the back of neck causes pupillary dilatation

f. Detection of abnormal reflexes (either increased or decreased) 4. Corneal Reflex

does not necessarily tell you which limb of the system is broken, touching the cornea causes blinking of the eyelids
nor what might be causing the dysfunction.
 Decreased reflexes could be due to impaired sensory input 5. Orbicularis Oculi Reflex
or abnormal motor nerve function. Eyelids close when the retina is exposed to bright light
 Only by considering all of the findings, together with their
rate of progression, pattern of distribution (bilateral v 6. Auditocephalogyric Reflex
unilateral, etc.) and other medical conditions can the Head and eyes turn toward the source of a loud sound
clinician make educated diagnostic inferences about the
results generated during reflex testing. 7. Jaw Reflex
When the mouth is partially opened and the muscles relaxed,
tapping the chin causes the jaw to close.
TROUBLESHOOTING
The reflex center is in the midpons

If you are unable to elicit a reflex, stop and consider the following: 8. Gag Reflex
Occurs when the parhynx is stroked.
 Are you striking in the correct place? Confirm the location of the The reflex center is in the medulla
tendon by observing and palpating the appropriate region while
asking the patient to perform an activity that causes the muscle to
SUPERFICIAL REFLEX
shorten, making the attached tendon more apparent.

 Make sure that your hammer strike is falling directly on the have reflex arcs whose receptor organs are in the skin
appropriate tendon. If there is a lot of surrounding soft tissue that rather than in muscle fibers
could dampen the force of the strike, place a finger firmly on the adequate stimulus is stroking, scratching or touching
correct tendon and use that as your target. these reflexes are lost in disease of the pyramidal tract

1. Upper Abdominal Skin Reflex T5 – T8

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 With patient supine, stroke the skin with blunt handle Procedure:
towards the midline  The patient may either sit or lie supine.
 Ipsilateral contraction of muscles or umbilical deviation  Start at the lateral aspect of the foot, near the heel. Apply steady
towards the stimulated side pressure with the end of the hammer as you move up towards the
2. Mid Abdominal Skin Reflex T9 – T11 ball (area of the metatarsal heads) of the foot.
 When you reach the ball of the foot, move medially, stroking
3. Lower Abdominal Skin Reflex T11 – T12 across this area.
 Test the other foot.
4. Cremasteric Reflex L1 – L2  Some patients find this test to be particularly noxious or
Stroke the inner aspect of the thigh from the pubis uncomfortable. Tell them what you are going to do and why. If it’s
distad unlikely to contribute important information (e.g. screening exam
 Prompt elevation of the testis on the ipsilateral side of the normal patient) and they are quite averse, simply skip it.

5. Plantar Reflex L4 – S2 Interpretation:

Stroke the sole near its lateral aspect from the heel  In the normal patient, the first movement of the great toe should
towards toes be downwards (i.e. plantar flexion).
 produces plantar flexion of the toes  If there is an upper motor neuron injury (e.g. spinal cord injury,
stroke), then the great toe will dorsiflex and the remainder of the
6. Superficial Anal Reflex L1 – L2 other toes will fan out. A few additional things to remember:
Stroke the skin of the perianal region  Newborns normally have a positive Babinksi. It usually goes away
 External and anal sphincter contracts after about 6 months.
 Sometimes you will be unable to generate any response, even in
7. Glabellar Reflex (Corticopontine) the absence of disease. Responses must therefore be interpreted
lightly tapping the forehead between the eyebrows with in the context of the rest of the exam.
the fingers  If the great toe flexes and the other toes flair, the Babinski
Response is said to be present. If not (i.e. normal), it is recorded
Abnormal response: as absent.
 persistent blepharospasm  For reasons of semantics, the Babinski is not recorded as ‘+’
 closing of the eyes or ‘-‘.
 Withdrawal of the entire foot (due to unpleasant stimulation), is
8. Snout Reflex (Corticopontine) not interpreted as a positive response
tapping the nose
Grasp Reflex
Abnormal response: Stroke the pt’s palm so he grasps your index finger.
 excessive grimace of the face  If present, he cannot release the fingers
 lesions of the premotor cortex
9. Sucking Reflex (Frontal cortex)
Stroking the lip with the finger or a tongue depressor Hoffmann’s Sign
Present in infants but disappears after weaning; reappears in Have pt present pronated hand with fingers extended and
diffuse lesions of the frontal lobe and commonly noted in relaxed. With your thumb, press his fingernails to flex the
dementias terminal digit and stretch his flexor

Abnormal response: Abnormal response:

 lips pout and make sucking movements  flexion and adduction of thumb

10. Chewing Reflex (Frontotemporal cortex) Mayer’s Reflex

placing a tongue depressor in the mouth Have pt present his supinated hand with thumb relaxed and
seen in dementia, general paresis and anoxic encepalopathy abducted. Grasp his ring finger and firmly flex the
metacarpophalengeal joint
Abnormal response:
 chewing movement of the teeth and jaw Normal response
 adduction and apposition of the thumb

ABNORMAL REFLEXES
Palm-Chin Reflex (Radovici’s sign)
Vigorous scratching or pricking of the thenar eminence causes
PYRAMIDAL TRACT DISEASE ipsilateral contraction of the muscles of the chin

Babinski Sign (Hallucal Dorsiflexion Reflex)

Test used to assess upper motor neuron dysfunction SIGNS OF MENINGEAL IRRITATION

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Nuchal Rigidity Which aspects of sensation are impaired? Are all of the
pt cannot place the chin upon the chest ascending pathways (e.g. spinothalamic and dorsal columns) affected
passive flexion of the neck is limited by involuntary muscle spasm equally, as might occur with diffuse/systemic disease?

Does the loss in sensation follow a pattern suggestive of

Spinal Rigidity dysfunction at a specific anatomic level?
movements of the spine are limited by spasms of the Erector  For example, is it at the level of a Spinal nerve root? Or more
spinae distally, as would occur with a peripheral nerve problem?
Does the distribution of the sensory deficit correlate with the
Kernig’s Sign “correct” motor deficit, assuming one is present?
with pt supine, passively flex the hip to 90 deg while the knee is  Radial nerve compression, for example, would lead to
flexed at about 90 deg characteristic motor and sensory findings.
attempts to extend the knee produce pain iun the hamstring and
resistance

Brudzinski’s Sign
with pt supine and the limbs extended, passively flex the neck
produces involuntary flexion of the hips

SUMMARY

While compiling information generated from the motor and

sensory examinations, the clinician tries to identify patterns of
dysfunction that will allow him/her to determine the location of the
lesion(s). What follows is one way of making clinical sense of
neurological findings.

Is there evidence of motor dysfunction (e.g. weakness, spasticity,

tremor)?

If so, does the pattern follow an upper motor neuron or lower

motor neuron pattern?

 If it’s consistent with a UMN process (e.g. weakness

with spasticity), does this appear to occur at the level of the spinal
cord or the brain?
 Complete cord lesions will affect both sides of the body.
Brain level problems tend to affect one side or the other. 
 It is, of course, possible for a lesion to affect only part of the
cord, leading to findings that lateralize to one side (see
below, under description of Brown Sequard lesion).

 Is it consistent with an LMN process (e.g. weakness

with flaccidity)? Does the weakness follow a specific distribution
(e.g. following a spinal nerve root or peripheral nerve
distribution)? Bilateral? Distal?

Do the findings on reflex examination support a UMN or LMN

process (e.g. hyper-reflexic in UMN disorders; hyporeflexic in LMN
disorders)?

Do the findings on Babinski testing (assuming the symptoms

involve the lower extremities) support the presence of a UMN lesion?

Is there impaired sensation? Some disorders, for example, affect

only the Upper or Lower motor pathways, sparing sensation.

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