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9/7/16

Applied Anatomy 1 HSc-51124-


Seminar 2.2: Deep Tendon Reflex &
Sensory Testing

Carlos Ladeira PT, MSc, EdD, FAAOMPT,


MTC, OCS
Associate Professor

Objectives

Discuss sensory testing and Deep


tendon Reflex Testing in PT Practice
l Techniques
l Indications
l Validity (sensitivity & specificity)
l Interpretation and documentation

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Sensory Testing
Motor learning and movement performance
are intrinsically related to sensation
The body uses sensory input to guide our
actions (motion, feelings, danger/safety).
Sensory input comes mainly from neuro-
receptors: mechanical (pressure, speed,
vibration), temperature, and chemical.
Today, we will be dealing mostly with
examination of mechanical receptors
located mainly on the skin.
We will discuss light touch, dull-sharp, and
vibration examination.

Indications for Sensory Exam


When to perform sensory Tests?
Light touch and vibration may be used to rule
in or rule out sensory loss:
Patients with spinal disorders or spinal pain
(observe dermatomes as indicated).
Patients with suspected nerve lesions.
Suspicion of or diagnosis/symptoms of CVA and
SCI
Patients at risk for pressure sores
Sharp & dull
Rule in or confirm risk for pressure sores and burn
(e.g.; neurological lesions or diabetic patients).

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Light touch testing

Screen skin with piece of cotton, tissue,


or paper.
Patient should have eyes closed during test
Touch is very light
Cover dermatomes and peripheral nerve areas as
appropriate
Move from distal to proximal and compare
bilaterally.
Mix stimuli for patients (touch and no-touch).

Light touch testing


Light touch with monofilaments
Monofilaments are the gold standard for light
touch assessment
Start with lightest filament and press lightly
until filament bends
If patient does not recognize touch, use next
thicker filament on scale.
Score filament number or color when
recognized. (repeat 3 times and use average
score)

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Vibration with Tuning fork


128 Hz is said to be the best frequency (256
Hz acceptable)
Have the patient close the ears to prevent
auditory clues.
Hold the stem of the tuning fork.
Hit the prongs of the fork on your thigh, hip,
opposite hand, or a hard surface.
Touch the non-vibrating tip of the fork on a
bony landmark of the extremity to be tested
Time how long it takes for person to stop
feeling the vibration
Compare to opposite side

Cettomai et al, PloS One, 2010

Sensitivity and specificity of tests to screen HIV neuropathy

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Sharp/Dull
Use appropriate tool (example: paper clip for sharp,
and rubber end of pencil for dull).
After demonstrating to patient, ask patient to keep
eyes closed during test.
Touch is very light
Test along dermatomes and peripheral nerve areas
as appropriate.
Ask patient to indicate sharp or dull to determine
response
Move from distal to proximal
Compare bilaterally.
l Sensitivity (.31) & specificity (.84) for diabetic neuropathy
(Jing et al, CNKI, 2012)

Deep Tendon Reflex Testing


Reflex Integrity
l A deep tendon reflex (DTR) is a involuntary,
predictable, and specific response to a stimulus
dependent on a reflex arc (sensory receptor,
afferent neurons, efferent neurons, and muscle).
Indications (screen motor/sensory integrity)
l Every spine patient
l Insidious symptoms of unknown etiology
l Chronic condition not making progress
l Symptoms of muscle fatigue/weakness
l Suspicion of central nervous system [CNS] or
peripheral nervous system [PNS] compromise

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Deep Tendon Reflex (DTR)


l DTRs (technique)
Use the same force for every hit. Flick the
wrist.
Avoid hitting tendon more than three
times.
Palpate & place tension on tendon before
hitting it.
When having difficulty to elicit a reflex,
have the patient look away, tighten
muscles away from tendon being tested,
and/or test patient in supine (better
relaxation).

Deep Tendon Reflex (DTR)


l DTRs Interpretation
Compare bilaterally.
When interpretation of response is
questionable, compare UE with LE.
l Documentation & Scoring
Absent or +1 may indicate nerve PNS lesion
(nerve) or recent CNS lesion (stroke, spinal
cord).
2+ is normal.

3+ may be normal or indicate CNS


dysfunction.
4+ and bizarre response = CNS culprit.

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Deep Tendon
Reflex cont.

l DTRs
Upper extremity

l Deltoid (C5)
l Biceps (C6),
l Triceps(C7),
l Brachio-radialis (C6).

Key Points to Remember


Weak DTR may indicate PNS injury (or
recent CNS lesion < 8 to 12 weeks)
Hyper DTR may indicate CNS lesion
DTRs Testing is useful to assist in diagnosis
The sensory exam described here is done to
make a diagnosis and assess risk for injury
Light touch testing with monofilament is the
best method for testing and documenting
sensory loss (compared to tuning fork and
sharp vs. dull).

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