DEMONSTRATION

REFLEXES

OBJECT –
ELICITATION OF SUPERFICIAL
REFLEXES

By- Nikita Jain

(Tutor) Physiology
Reflex –

It is an rapid, predictable, unconscious and

involuntary response (i.e. contraction of a muscle
or secretion of glands) to a specific stimulus.
 Diagram showing the pathway of reflex arc with its different components

2- sensory
neuron
Stimulus
3- integration
1-Receptor center
In skin
stimulated interneuron

4 –Motor
5–Effector
neuron
 APPARATUS –
Patellar Hammer, Examination couch, torch, cotton etc.
Parts of knee hammer
1- It consist of a long metallic handle
At one end on which a triangular shaped soft rubber piece is
attached.
This rubber piece is used to give a sharp blow to muscle tendon,
in order to get sudden stretching of its muscle.
On other end of handle is also provided with brush of nylon
hairs and a pointer for testing sensory components of neurological
examination.
2- The rubber piece has two end –
-The broader end
-Pointed or narrow end.
The broader end is used when the muscle belly is broader
and thin (like tendon of triceps muscle),
while the pointed end is used when the tendon is stout and
narrow (as of biceps muscle tendon)
  The specific nerve roots that comprise the arcs are listed for each
of the major reflexes described below.
CLINICALLY TESTED REFLEXES-
A- Superficial reflexes B- Deep reflexes

6-Jaw Jerk
1-Knee Jerk 2-Ankle Jerk 3- Triceps Jerk 4- Biceps Jerk
(Or Patellar) (Or
Or Qudericeps Gasterocnemuis 5-Brachioradialis jerk
Femoris Jerk Jerk)-
Pre- requisites-
1- make sure that the subject is warm and comfortable
2- explain the procedure to the subject before
eliciting the reflex in order to make him relax,
reassure and decrease anxiety and apprehension
associated with the test.
3- subject attention should be diverted from the test
to obtain better response to the stimulus applied.
A- Superficial reflexes-
If a stimulus is applied on superficial structures of the
body like skin or mucous membrane, it results in
contraction of underlying muscles. This group of reflexes
is polysynaptic.
Following are superficial reflexes -
Reflexes based on cranial nerves-
1-Conjunctival reflex
2-Corneal reflex
3-Ciliospinal reflex
4-Pupillary reflex
Reflexes based on spinal nerves
1-Planter reflex, 2-Abdominal reflex,
Cremestric, Bulbocavernosus, Anal, Scapular reflex
 CORNEAL REFLEX
• Take a wisp of cotton and
ask the subject to look to
one side and bring the
wisp just to touch the
cornea.
• Obsevation- Closure of
the lids.
• Afferent nerve- Vth
• Efferent nerve- VIIth
 CONJUCTIVAL REFLEX
• Touch the conjuctiva
with a cotton wool
swab.
• Observation- Closure of
the lids.
• Afferent nerve- Vth
• Efferent nerve- VIIth
 CILIOSPINAL REFLEX
• Pinch the skin of
neck.
• Observation-
Dilatation of pupil.
1- PLANTER REFLEX- to elicit it the sole should be warm and clean, with
leg completely relaxed.
Procedure –gently scratch the outer edge of the foot with a blunt object (say
key or blunt end of knee hammer handle ) from heel towards the little toe
and then medially along the base of the other toes up to 2 nd toe.

Babinski Response Present

 Interpretation:
In the normal patient, the first movement of the great toe
should be downwards (i.e. plantar flexion). 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 other toes will
fan out.

Abnormal Response:
Normal Response: Babinski sign positive-
Plantar Flexion Of The Foot And Toes. Dorsiflexion Of Great Toe and
Babinski sign negative Fanning Of Other Toes and
Dorsiflexion Of Ankle
Level of Spinal cord invovles:
L5, S1,S2 afferent and efferent nerve is tibial nerve

Importance-
The plantar reflex (the Babinski response first described by
Babinski in1896) is important in identifying a UMN lesion;

Examples –
 normally in infants below 1-2 years and deep sleep
Pathologically in Upper motor neuron lesion, spinal cord
tumour, coma due to any cause etc.
2- ABDOMINAL REFLEX-
Segmental Innervation : T7-12
PROCEDURE- To elicit the abdominal reflex, patient lies relaxed and
supine, with the abdomen uncovered. A key or the reverse end of the
tendon hammer is dragged quickly and lightly across the abdominal skin
lightly in a medial direction across the upper and lower quadrants of the
abdomen parallel to coastal margin and inguinal ligament.

Fig:- abdominal reflex

NORMAL RESPONSE - A ripple of contraction of the
underlying abdominal musculature follows the stimulus.
Abdominal reflexes are difficult to elicit in obese or multiparous
women and in anxious patients.

Abnormal Response: are absent in UMN lesions above their

spinal level, as well as in lesions of the local segmental thoracic
root or the spinal cord.
Thank you
DEEP (OR TENDON) REFLEXES-
 A tendon reflex is the involuntary contraction of a muscle in
response to stretch.
It is mediated by a reflex arc consisting of an afferent (sensory)
and an efferent (motor) neuron with one synapse between: that is,
a monosynaptic reflex.
Muscle stretch activates the muscle spindles, which send a burst
of afferent signals that in turn lead to direct efferent impulses,
causing muscle contraction.
These stretch reflex arcs are served by a particular spinal cord
segment which is modified by the influence of descending upper
motor neurons.
Following deep reflexes will be examined in the clinical lab-

1- KNEE JERK (OR PATELLAR) OR QUDERICEPS FEMORIS JERK

Procedure-
In supine position – the examiner's hand is passed under
the knee to be tested and placed on the opposite knee or
the test knee rests on the dorsum of the examiners wrist.
Strike the patellar tendon midway between its origin and
insertion.
In sitting position- Alternately, it can be also more easily
elicited with the subjects sitting up , the leg hanging freely
or crossed legs on the edge of bed.
 Response- A brief contraction
of the quadriceps femoris
muscle results in extension of
the knee.

Afferent and efferent paths are

femoral nerve, level of spinal
Fig: supine position cord involves –L 2,3,4

Clinical significance- pendullar

in acute cerebellar disease and
present on the side of lesion. In
hypothyroid they are week
while in hyper the jerks are
brisk.

Fig: sitting position

2- ANKLE JERK (or gasterocnemuis jerk)-
PROCEDURE-
In supine position- subject lies in supine, with semiflexed knee and
externally rotated hip. Then with one hand the examiner slightly dorsiflexed
the foot so as to stretch the Achilles tendon and with other hand , tendon is
struck on its posterior surface.

In sitting position- Another method is to ask the subject to kneel over chair
so that the he faces the back of the chair and his ankles lie, over its edge.

RESPONSE- planter flexion of the foot due to contraction of

the calf muscle.

Afferent and efferent nerve – tibal nerve and centre is sacral

1,2 segments.
3- TRICEPS JERK-
PROCEDURE-
In standing/sitting-the arm is flexed to right angle and is
supported on the examiner’s arm. the triceps tendon is then
struck just proximal to the point of the elbow with broader end of
patellar hammer.
In supine position-flex the elbow and allow it to rest across the
subject’ chest. Tap the tendon with hammer.
RESPONSE-
Contraction of triceps muscle with extension at elbow.
Afferent and effernt path- radial nerve; centre is C-6,7
4- BICEPS JERK –
PROCEDURE-
In standing position- The subject’s arm is flexed to a right angle and
the fore arm semipronated and supported on the examiner’s hand.
-The examiner then places hi thumb on the biceps tendon and
strikes it with the narrow end of hammer.
In supine position- The subject’s arm is flexed to a right angle and
the fore arm semipronated, rest over the chest of the subject.
-The examiner then places hi thumb on the biceps tendon and
strikes it with the narrow end of hammer.
Biceps Reflex Testing, arm supported Biceps Reflex Testing, in supine
position
RESPONSE-
Contraction of biceps muscle with flexion at elbow and slightly
pronation of the fore arm in standing position .
If the patient is in supine position then biceps muscle
contraction is observed.
Afferent and efferent path- musculocutaneous nerve; centre is
C-5,6.
5-SUPINATOR JERK OR BRANCIORADIALIS JERK
Procedure – same as the biceps procedure for supine
position.tap the brachioradialis tendon upon styloid process
of radius.
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.
Response - Contraction of brachioradialis muscle with
supination of elbow.
Afferent and efferent path- radial nerve; centre is C-5,6.
6-JAW JERK –
Procedure – Ask the subject to open mouth but not too widely.
Place one finger firmly on chin and tap suddenly with the other
hand ( like percussion).
Response-contraction of massater muscle resulting in closing of
jaw. Sometime this jerk cannot elicit in the healthy subjects.
Note-

 if unable to elicit any type of reflex

then apply reinforcement; Jenderassik’s
manoeuvre.

In this subject is asked to perform

some muscular effort, such as clenching
the teeth or locking the fingers of the
hands as hard as possible and then trying
to pull them apart while the examiner
strikes the tendon foe example patellar
tendon.

It results in increasing excitability of

the anterior horn cells for impulses and
also increases of gamma motor neuron
activity which increase the sensitivity of
the spindle cells to strech.
Clinical Sense of Reflexes:
Normal reflexes require that every aspect of the system
function normally. Breakdowns cause specific patterns of
dysfunction. These are interpreted as follows:
•Disorders in the sensory limb will prevent or delay the
transmission of the impulse to the spinal cord. This causes the
resulting reflex to be diminished or completely absent. Diabetes
induced peripheral neuropathy (the most common sensory
neuropathy seen in developed countries), for example, is a
relatively common reason for loss of reflexes.

Abnormal lower motor neuron (LMN) function will result in

decreased or absent reflexes. If, for example, a peripheral motor
neuron is transected as a result of trauma, the reflex dependent
on this nerve will be absent
If the upper motor neuron (UMN)is completely transected, as
might occur in traumatic spinal cord injury, the arc receiving
input from this nerve becomes disinhibited, resulting in
hyperactive reflexes.

Note, immediately following such an injury, the reflexes are

actually diminished, with hyper-reflexia developing several
weeks later.

A similar pattern is seen with the death of the cell body of the
UMN (located in the brain), as occurs with a stroke affecting the
motor cortex of the brain.

Primary disease of the neuro-muscular junction or the muscle

itself will result in a loss of reflexes, as disease at the target
organ (i.e. the muscle) precludes movement.
•A number of systemic disease states can affect reflexes.

•Some have their impact through direct toxicity to a specific limb of the system.

•Poorly controlled diabetes, as described above, can result in a peripheral sensory

neuropathy.

•Extremes of thyroid disorder can also affect reflexes, though the precise
mechanisms through which this occurs are not clear. Hyperthyroidisim is
associated with hyperreflexia, and hypothyroidism with hyporeflexia.

•Detection of abnormal reflexes (either increased or decreased) does not

necessarily tell you which limb of the system is broken, nor what might be causing
the dysfunction.

•Decreased reflexes could be due to impaired sensory input or abnormal motor

nerve function.

•Only by considering all of the findings, together with their rate of progression,
pattern of distribution (bilateral v unilateral, etc.) and other medical conditions can
the clinician make educated diagnostic inferences about the results generated
during reflex testing.
 Note- the tendon reflex are diminised or absent, on both or one sides, in
lesion involving the affernt pathways (e.g tabes doralis), the anterior horn
cells(poliomyelitis), or the efferent pathways , and also in spinal shock.
Tendon reflex exaggerated in following conditions-
-UML above the anterior horn cells
-Anxiety
--hyperexcitibility of nervous system, as in hyperthyroidism and tetanus

Observation and result-

Tabulated your result as under:
REFLEXES RIGHT SIDE LEFT SIDE REMARK/
GRADING