This document provides information on how to examine and test various reflexes during a neurological examination. It defines what a reflex is, classifies different types of reflexes, and describes the maneuvers for eliciting and evaluating several important reflexes, including deep tendon reflexes in the upper and lower limbs, superficial reflexes, and eye reflexes. The goal of examining reflexes is to assess the integrity of the reflex arc and detect any abnormalities.
This document provides information on how to examine and test various reflexes during a neurological examination. It defines what a reflex is, classifies different types of reflexes, and describes the maneuvers for eliciting and evaluating several important reflexes, including deep tendon reflexes in the upper and lower limbs, superficial reflexes, and eye reflexes. The goal of examining reflexes is to assess the integrity of the reflex arc and detect any abnormalities.
This document provides information on how to examine and test various reflexes during a neurological examination. It defines what a reflex is, classifies different types of reflexes, and describes the maneuvers for eliciting and evaluating several important reflexes, including deep tendon reflexes in the upper and lower limbs, superficial reflexes, and eye reflexes. The goal of examining reflexes is to assess the integrity of the reflex arc and detect any abnormalities.
This document provides information on how to examine and test various reflexes during a neurological examination. It defines what a reflex is, classifies different types of reflexes, and describes the maneuvers for eliciting and evaluating several important reflexes, including deep tendon reflexes in the upper and lower limbs, superficial reflexes, and eye reflexes. The goal of examining reflexes is to assess the integrity of the reflex arc and detect any abnormalities.
Learning objects: Introduction Definition of reflex Purpose of reflexes Classification Manoeuvre of each reflex Introduction The reflexes described in this lecture are these usually tested in the routine neurological examination of patients. The neurological examination consists of many parts:
● Assessment of conscious level
● Meningeal irritation ● Speech ● Motor function ● Sensory function ● Cranial nerves examination ● Cerebellar examination & gait The motor function examination consists of: ● Inspection ● Tone ● Power ● Reflexes
So examination of reflexes is part of motor function examination.
What is the reflex ? Reflex is defined as involuntary response to stimulus. It depends on integrity of reflex arc which consists of receptor, afferent nerve, central connections, efferent nerve, effector (e.g. muscle)
So If a normal response is obtained it indicates that the reflex pathway-
receptor, afferent nerve, central connections, efferent nerve, effector (e.g. muscle) – is intact. What is the purpose of reflexes? ● Whether the reflex is present or absent. ● If present whether it’s normal or showing signs that influences from higher centres are defective. ● If absent whether the arc is breached on the motor or sensory side. ● Whether any abnormalities are unilateral, bilateral, affecting all reflexes or whether a definitive level can be detected in the nervous system at which abnormalities first appear because reflex”levels” may be helpful as sensory level. Classification of reflexes The reflexes that you are going to elicit can be classified in the following way:
1. Deep on (tendon) reflexes. (stretch reflexes)
2. Superficial reflex. 3. Eye reflexes. Types of deep reflexes 1. Upper limbs reflexes A. The biceps jerk B. The triceps jerk C. Supinator Jerk 2. Lower limbs reflexes
A. Knee jerk B. Ankle jerk Principal (deep tendon) reflexes ● The examiner should be on the right side of the patient. ● Ask the patient to be relaxed and comfortable as possible, as anxiety and pain can cause an increased response. ● Ensure that both limbs are positioned identically with the same amount of stretch. ● Make sure that you exposed the target muscle, and you should know the reflex roots. ● Use reinforcement whenever a reflex appears to be absent. ● Record the response as: normal(++), exaggerated(+++), diminished(+), apply reinforcement absent(0),present maneuvers: only with reinforcement(+/-),change in character or -asymmetrical. Upper limb reflex: ask patient to close his eyes firmly. - lower Limb reflex: ask patient to pull one hand against the other. Manoeuvre of deep reflexes 1. Upper limbs A. biceps jerk(C5-C6) ● Flex the elbow and support it on your left forearm. ● Place your thumb on the biceps tendon and tap your thumb with hummer.
Normally : a. Brisk contraction of the biceps. b. Flexion of the forearm at the elbow, followed by prompt relaxation. Manoeuvre of deep reflexes 1. Upper limbs
B. Triceps jerk(C6-C7-C8) ● Flex the elbow and support it on your left forearm. ● tap over the triceps tendon (do not place your finger).
Normally: there will be triceps contraction
results in forearm extension. Manoeuvre of deep reflexes 1. Upper limbs
C. Supinator jerk (C6-C7)
● Gently hold the patient’s wrist.
● The forearm should be halfway between pronation and supination. ● tap the styloid process of the radius (the tendon of brachioradialis)
Normally there will be contraction of
brachioradialis, and flexion of the elbow. Manoeuvre of deep reflexes 2. Lower limbs
A. Knee jerk(L2-L3-L4) ● Hold the knee by your forearm. ● Tap on the patellar ligament (between patella and tibial tuberosity).
Normally: the quadriceps will contract,
resulting in knee extension. Manoeuvre of deep reflexes 2. Lower limbs
B. Ankle reflex(S1-S2) ● Both the knee and ankle are flexed 90˚. ● dorsiflex the ankle by pressing on the sole of the foot. ● Tap on the Achilles tendon.
Normally: there will be contraction of
gastrocnemius muscle causing planter flexion. Types of superficial or cutaneous reflexes 1. Planter reflex 2. Abdominal reflex 3. cremasteric reflex Manoeuvre of superficial reflexes 1. Planter reflex(L5-S1-S2) ● The patient lies down with the soles of both feet exposed. ● the feet must be warmed and the muscle relaxed. ● Hold the foot firmly with one hand and with the other scratch the sole with a hard, blunt-ended object such as a key. ● Scratch firmly along the outer edge of the sole of the foot, beginning at the heel and ending near the base of the Normally there will be a planter flexion of the big toe little toe. (downwards). If there is changing in character (planter extension),this is known as babinski sign. Babinski sign And it’s normal response in children under 1 year of age. Manoeuvre of superficial reflexes 2. Abdominal reflex (T8–12) ● The patient should be supine and relaxed. ● Use an orange stick and briskly but lightly stroke the upper and lower quadrants away from the midline of the relaxed abdomen, watching for a contraction.
The normal response is contraction of the
underlying muscle. Manoeuvre of superficial reflexes 3. Cremasteric reflex(L1–2)for males only ● Explain what you are going to do and why it is necessary. ● Abduct and externally rotate the patient’s thigh. ● Use an orange stick to stroke the upper medial aspect of the thigh.
Normally the testis on the side stimulated will rise
briskly. Eye reflex or corneal reflex Routine testing of the corneal reflex is unnecessary, but may be relevant when the history suggests a lesion localising to the brainstem or cranial nerves V, VII or VIII. The afferent limb is via the trigeminal nerve, the efferent limb via the facial nerve.
● Explain to the patient what you are
going to do and ask them to remove their contact lenses, if relevant. ● Gently depress the lower eyelid while the patient looks up. ● Lightly touch the lateral edge of the cornea with a wisp of damp cotton wool. ● Look for both direct and THANK YOU
