REFLEXES

Subconscious stimulus-response mechanisms. Act as defense mechanism.

Ex. Corneal (blink), Nasal (sneeze).

Activity 3 THE REFLEXES

Important in the diagnosis and localization of neurologic lesion.

5 Components of reflex arc

Receptor Dendritic endings of a sensory neuron located within the skin, a tendon, joint, or other peripheral organ that responds to specific stimuli. Sensory neuron (afferent) extending from the receptor through the posterior root, the sensory neuron conveys the stimuli to the posterior horn of the spinal cord. Center The axon of a sensory neuron synapses with an association neuron within the H-shaped gray matter of the spinal cord.

 Motor neuron (efferent) beginning at the synapse with the association neuron, the motor neuron conveys impulses from the anterior horn of the spinal cord, through the anterior root, to the effector organ. Effector The muscle or gland that responds to the motor impulse by contracting or secreting, respectively.

Assessment Techniques
Reflexes are graded on a scale of 0 to 4. A stick figure typically appears in the chart to designate the elicited reflexes. 0 ............Not present 1+ ..........Present but diminished 2+.......... Normal 3+ ..........Hyperactive, may have clonus but not sustained 4+...........Hyperactive with sustained clonus

Pontine level (brain) Jaw jerk

Rest your thumb on the subjects middle chin with mouth slightly open in relaxed state. Tap your thumb using the reflex hammer. Grade the subjects reflex response.

Jaw jerk reflex

Trigeminal - CN 5 downward stroke on jaw

Normal Response: Mouth closes as the masseter contracts and pulls the jaw upwards. the jaw should not deviate to either side. the jaw-jerk is usually weakly present. Abnormal Response:

Masseter / Temporal M.

Pons

the masseter muscles will jerk the mandible upwards

Masseter / Temporal M.

the masseter muscles will jerk the mandible upwards If the jaw-jerk is exaggerated and brisk, it Indicates damage which occured to higher centers (upper motor neurons), the reflex arc is uninhibited and reflex is hyperactive. lesions affecting the pyramidal pathways above the 5th nerve motor nucleus, especially if the lesions are bilateral. Absence of reflex may be due to pathology along the course of CN 5.

C2-C3 Neck muscles

Ask the subject to extend his neck backward and bow his neck forward. Note for jerky movements of the head.

Neck muscles reflex

Cervical C2 C3 N Head drop forward

Sternocleidomastoid (SCM) muscle spindle

C2 C3 level

Head jerks upward (SCM and trapezius flex)

SCM and Trapezius

C4 Diaphragm percussion
Ask a male subject to lie flat on his back on table or floor. Gently expose and locate his diaphragm. Put your left forefinger and middle finger together on the diaphragm and gently tap the two fingers using your right forefinger and middle finger together. Is there any wavelike movement in the abdomen? Describe and grade the response.
Tapping diaphragm

Diaphragm percussion
Phrenic nerve (C4)

Diaphragm muscle C4 level

Wavelike movement in the abdomen

Diaphragm muscle

C5 Deltoid (pectoralis) reflex

Ask the subject to lift his arm slightly and put your thumb in anterior fold of axillary fossa. Locate the deltoid muscle and pull up slightly to stretch the pectoralis tendon (reference point: axillary region). Tap using a reflex hammer. Grade the response.

Pectoralis reflex
Pectoral Nerve Tapping axillary region

Pectoralis C5 level

Pectoral muscle contraction

Pectoralis

C6 Biceps reflex and Brachioradialis reflex

A. Biceps Reflex Ask the subject to either sit or recline. Tap your thumb over the biceps tendon (reference point: antecubital fossa, opposite to elbow joint). Grade the response

A. Biceps reflex
Musculocutaneous N. Tapping biceps tendon (antecubital fossa)

B. Brachioradialis reflex
Ask the subject to sit with arms flexed while resting on the arm rest of the chair. Hold the wrist (dorsal position) and elevate the forearm slightly and tap over the brachioradialis tendon (reference point: dorsal side of the forearm) on the medial aspect of the forearm and midway between elbow and wrist. Grade the response.

biceps tendon C6 level

Biceps Bicep muscles connected towards the elbow contract.

B. Brachioradialis reflex
Tapping Brachioradialis tendon
(dorsal side of the forearm)

Radial N.

Brachioradialis tendon C6 level

Brachioradialis muscles connected towards the elbow contract

Brachioradialis

C7-C8 Pronator (wrist) reflex

Ask the subject to sit, arm flexed and slightly pronated. Tap the radial prominence on the palmar surface while holding the subjects hand; feel and observe the pronation.

Pronator / Wrist reflex

Median N. Tapping the radial prominence

Pronator quadratus C7, C8

Forearm pronates

Pronator quadratus

C6-C8-T1 Finger-flexor reflex

Ask the subject to sit and rest his arm on supine position. Place the fingers in slightly flexed position. Place your finger across the palmar surface of the subjects finger. Tap your finger while observing the flexion response of each subjects finger.
Tapping palmar surface

Finger-flexor reflex
FDS Median N. FDP Ulnar N.

- Flexor digitorum superficialis (FDS) - Flexor digitorum profundis (FDP)

C6-C8-T1

Flexion of fingers

FDS/ FDP

T1-T8 Thoracic expansion

Ask the subject to inhale and exhale at normal breathing. Note the movement of the chest, and symmetry of chest in equal or deviated symmetry. Ask the subject to inhale deeply and exhale at his maximum. Again, note the chest observations.
Inhalation / Exhalation

Thoracic expansion
Intercostal N./ Phrenic N .C4

Thoracic M. Diaphragm M. T1-T8, C4

Contraction of thoracic M/ diaphragm Raised rib/ diaphragm lowered Relaxation of thoracic M/ diaphragm lowered rib/ diaphragm raised

Thoracic M. Diaphragm M. inhalation

exhalation

T9-T10 Upper abdominal reflex

Ask the patient to lie on supine position. Using one of your hands place on top of the subjects upper abdomen, pull down the abdomen and laterally to one side of the subjects body. Tap your fingers (percussion) over the hand and feel the contraction underneath. Is it hypoactive or hyperactive contraction?

Upper abdominal reflex

T7, 8, 9, 10 Tapping upper abdomen

Upper Abdominal Muscles

T7, 8, 9, 10

Contraction of abdominal muscles

Upper Abdominal muscles

L1-L2 Lower extremity adductor reflex

Ask the subject to recline with arms supporting in laid back position. Relax and extend his legs. Place a hand over the medial lower thigh, place your hand over the muscle and tap over your fingers. Observe for the thigh adduction.
Tapping medial lower thigh

Adductor reflex
Obturator N.

Adductor M. L1, L2

Adducts the thigh at the Hip joint

Adductor M.

L3-L4 Quadriceps or patellar reflex

Ask the subject to either sit or recline. Support your hand on the lower thigh, tap below and above the patella (suprapatellar) and observe leg extension. Grade the response.

Patellar reflex
Femoral N. Tapping patellar tendon

L5-S1 Hamstring reflexes

Ask the subject to recline with one leg hanging, slightly externally or internally rotate and flex the subjects leg, place your finger over the medial or lateral tendon (the tendons are boundaries of the popliteal fossa or alak-alakan). Tap just above the popliteal fossa. Grade the response.

Quadriceps femoris L2, L3, L4

Extension of leg

Quadriceps femoris

Hamstring reflex
.Tibial N, Tapping popliteal fossa

S1 - Achilles reflex (ankle jerk)

Ask the subject to sit or recline, partially dorsiflex the ankle with one hand, tap the Achilles tendon. Observe the reflex excursion. Grade the response.

Hamstring L5, S1

Leg flexion

Hamstring

Achilles reflex
Tibial N. Tapping Achiles tendon

Gastrocnemius -soleus S1

Plantar flexion of the foot

Gastrocnemius -soleus