Reflex Testing

Reflex testing incorporates an assessment of the function and interplay of

both sensory and motor pathways. It is simple yet informative and can give
important insights into the integrity of the nervous system at many
different levels.

Physiology of Reflexes
Assessment of reflexes is based on a clear understanding of the following
principles and relationships:
1. Tendons connect muscles to bones, usually crossing a joint. When the
muscle contracts, the tendon pulls on the bone, causing the attached
structure to move.
2. When the tendon is struck by the reflex hammer, stretch receptors
contained within it generate an impulse that is carried via sensory
nerves to the spinal cord. At this juncture, the message is
transmitted across a synapse to an appropriate lower motor neuron. An
upper motor neuron, whose cell body resides in the brain, also
provides input to this synapse.
3. The signal then travels down the lower motor neuron to the target
muscle.
4. The sensory and motor signals that comprise a reflex arc travel over
anatomically well characterized pathways. Pathologic processes
affecting discrete roots or named peripheral nerves will cause the
reflex to be diminished or absent. This can obviously be of great
clinical significance. The Achilles Reflex (see below) is dependent on
the S1 and S2 nerve roots. Herniated disc material (a relatively
common process) can put pressure on the S1 nerve root, causing pain
along its entire distribution (i.e. the lateral aspect of the lower
leg). If enough pressure if placed on the nerve, it may no longer
function, causing a loss of the Achilles reflex. In extreme cases, the
patient may develop weakness or even complete loss of function of the
muscles innervated by the nerve root, a medical emergency mandating
surgical decompression. The specific nerve roots that comprise the
arcs are listed for each of the major reflexes described below.
5. A normal response generates an easily observed shortening of the
muscle. This, in turn, causes the attached structure to move.
6. The vigor of contraction is graded on the following scale:
0 No evidence of contraction
1+ Decreased, but still present (hypo-reflexic)
2+ Normal
3+ Super-normal (hyper-reflexic)
Clonus: Repetitive shortening of the muscle after
4+
a single stimulation

The Reflex Hammer

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You will need to use a reflex hammer when performing this aspect of the
exam. A number of the most commonly used models are pictured below.
Regardless of the hammer type, proper technique is critical. The larger
hammers have weighted heads, such that if you raise them approximately 10
cm from the target and then release, they will swing into the tendon with
adequate force. The smaller hammers should be swung loosely between thumb
and forefinger.
Technique:
1. The muscle group to be tested must be in a neutral position (i.e.
neither stretched nor contracted).
2. The tendon attached to the muscle(s) which is/are to be tested must be
clearly identified. The extremity should be positioned such that the
tendon can be easily struck with the reflex hammer.
3. If you are having trouble locating the tendon, ask the patient to
contract the muscle to which it is attached. When the muscle shortens,
you should be able to both see and feel the cord like tendon,
confirming its precise location. You may, for example, have some
difficulty identifying the Biceps tendon within the Antecubital Fossa.
Ask the patient to flex their forearm (i.e. contract their Biceps
muscle) while you simultaneously palpate the fossa. The Biceps tendon
should become taut and thus readily apparent.
4. Strike the tendon with a single, brisk, stroke. While this is done
firmly, it should not elicit pain. Occasionally, due to other medical
problems (e.g. severe 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.

This grading system is rather subjective. Additional levels of response can

be included by omitting the '+' or adding a '-' to any of the numbers. As
you gain more experience, you'll have a greater sense of how to arrange
your own scale.

Achilles (S1, S2 - Sciatic Nerve):

1. This is most easily done with the patient seated, feet dangling over
the edge of the exam table. If they cannot maintain this position,
have them lie supine, crossing one leg over the other in a figure 4.
Or, failing that, arrange the legs in a frog-type position.
2. 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"), which will
cause the calf to contract and the Achilles to become taut
3. Position the foot so that it forms a right angle with the rest of the
lower leg. You will probably need to support the bottom of the foot
with your hand.
4. Strike the tendon directly with your reflex hammer. Be sure that the
calf if exposed so that you can see the muscle contract. A normal

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 reflex will cause the foot to plantar flex (i.e. move into your
supporting hand).

Positions for Checking Achilles Reflex

Patellar (L3, L4 -Femoral Nerve):

1. This is most easily done with the patient seated, feet dangling over
the edge the exam table. If they cannot maintain this position, have
them lie supine (i.e. on their backs).
2. Identify the patellar tendon, a thick, broad band of tissue 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. This
causes the quadriceps (thigh muscles) to contract and makes the
attached tendon more apparent.
3. Strike the tendon directly with your reflex hammer. If you are having
trouble identifying the exact location of the 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 transmit the impulse.

Patellar Reflex Testing, seated patient

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 4. For the supine patient, support the back of their thigh with your
hands such that the knee is flexed and the quadriceps muscles relaxed.
Then strike the tendon as described above.

Patellar Reflex, supine patient

5. Make sure that the quadriceps are exposed so that you can see muscle
contraction. In the normal reflex, the lower leg will extend at the
knee.
Biceps (C5, C6 - Musculocutaneous Nerve):
1. This is most easily done with the patient seated.
2. Identify the location of the biceps tendon. To do this, have the
patient flex at the elbow while you observe and palpate the
antecubital fossa. The tendon will look and feel like a thick cord.
3. The patient's arm can be positioned in one of two ways:
a. Allow the arm to rest in the patient's lap, forming an angle of
slightly more then 90 degrees at the elbow.

Biceps Reflex Testing

b. Support the arm in yours, such that your thumb is resting
directly over the biceps tendon (hold their right arm with your
right; and vice versa).

Biceps Reflex Testing,arm supported

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 4. Make sure that the biceps muscle is completely relaxed.
5. 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. 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.
6. Make sure that the patient's sleeve is rolled up so that you can
directly observe the muscle as well as watch the lower arm for
movement. A normal response will cause the biceps to contract, drawing
the lower arm upwards.

Brachioradialis (C5, C6 - Radial Nerve):

1. This is most easily done with the patient seated. The lower arm should
be resting loosely on the patient's lap.
2. 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.
3. Strike this area with your reflex hammer. Usually, hitting anywhere in
the right vicinity will generate the reflex.

Brachioradialis Reflex
4. Observe the lower arm and body of the Brachioradialis for a response.
A normal reflex will cause the lower arm to flex at the elbow and the
hand to supinate (turn palm upward).
Triceps (C7, C8 - Radial Nerve):
1. This is most easily done with the patient seated.
2. Identify the triceps tendon, a discrete, broad structure that can be
palpated (and often seen) as it extends across the elbow to the body
of the muscle, located on the back of the upper arm. If you are having
trouble clearly identifying the tendon, ask the patient to extend
their lower arm at the elbow while you observe and palpate in the
appropriate region.
3. The arm can be placed in either of 2 positions:
a. 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.

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 Triceps Reflex, arm supported
b. Have the patient place their hands on their hips.

Triceps Reflex, arm unsupported

Either of these techniques will allow the triceps to completely relax.
4. If you are certain as to the precise location of the tendon, strike
this area directly with your hammer. If the target is not clearly
apparent or the tendon is surrounded by an excessive amount of
subcutaneous fat (which might dissipate the force of your strike),
place your index or middle finger firmly against the structure. Then
strike your finger.
5. Make sure that the triceps is uncovered, so that you can observe the
response. The normal reflex will cause the 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 but the muscle should shorten
vigorously .
Making 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:
1. 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.
2. 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.

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 3. 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. Of
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.
4. 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.
5. 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.
6. 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.
Trouble Shooting
1. If you are unable to elicit a reflex, stop and consider the following:
a. Are you striking in the correct place? Confirm the location of
the tendon by observing and palpating the appropriate region
while asking the patient to perform an activity that causes the
muscle to shorten, making the attached tendon more apparent.
b. Make sure that your hammer strike is falling directly on the
appropriate tendon. If there is a lot of surrounding soft tissue
that could dampen the force of the strike, place a finger firmly
on the correct tendon and use that as your target.
c. Make sure that the muscle is uncovered so that you can see any
contraction (occasionally the force of the reflex will not be
sufficient to cause the limb to move).
d. Sometimes the patient is unable to relax, which can inhibit the
reflex even when all is neurologically intact. If this occurs
during your assessment of lower extremity reflexes, ask the
patient to interlock their hands and direct them to pull, while
you simultaneously strike the tendon. This sometimes provides
enough distraction so that the reflex arc is no longer inhibited.
2. Occasionally, it will not be possible to elicit reflexes, even when no
neurological disease exists. This is most commonly due to a patient's
inability to relax. In these settings, the absence of reflexes are of
no clinical consequence. This assumes that you were otherwise thorough

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 in your history taking, used appropriate examination techniques, and
otherwise identified no evidence of disease.
Babinski Response
The Babinski response is a test used to assess upper motor neuron
dysfunction and is performed as follows:
1. Use the handle end of your reflex hammer, which is solid and comes to
a point.
2. The patient may either sit or lie supine.
3. Start at the lateral aspect of the foot, near the heel. Apply gentle,
steady pressure with the end of the hammer as you move up towards the
ball (area of the metatarsal heads) of the foot.
4. When you reach the ball of the foot, move medially, stroking across
this area.
5. Then test the other foot.
6. Some patients find this test to be particularly noxious/uncomfortable.
Tell them what you are going to do and why. If it's unlikely to
contribute important information (e.g. screening exam of the normal
patient) and they are quite averse, simply skip it.
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. A few
additional things to remember:

Babinski Response Present

1. Newborns normally have a positive Babinksi. It usually goes away after
about 6 months.
2. Sometimes you will be unable to generate any response, even in the
absence of disease. Responses must therefore be interpreted in the
context of the rest of the exam.
3. 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
as absent. For reasons of semantics, the Babinski is not recorded as
'+' or '-'.
4. Withdrawal of the entire foot (due to unpleasant stimulation), is not
interpreted as a positive response

Abdominal Reflex
• The patient should be lying down and relaxed with their arms by their
side.

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 • A blunt object such as a key or tongue blade may be used (A safety pin
may also be used as long as the stimulus is delivered lightly).
• Stroke the abdomen lightly on each side in an inward direction above
and below the umbilicus.
• Note the contraction of the abdominal muscles and deviation of the
umbilicus towards the stimulus.

Oculocephalic reflex
• The patient’s eyes are held open.
• The head is briskly turned from side to side with the head held
briefly at the end of each turn.

• A positive response occurs when the eyes rotate to the opposite side
to the direction of head rotation, thus indicating that the brainstem
(CN3,6,8) is intact.

• A similar result is seen when the head is flexed and extended — a

positive result is downward deviation of the eyes during extension,
and upward deviation during flexion (the eyelids, if closed, may also
open as part of the ‘doll’s head phenomenon’). These vertical
responses indicates that the brainstem (CN3,4,8) is intact.

The eyes should gradually return to the mid-position in a smooth, conjugate

movement if the brainstem is intact.

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Meningeal signs

Brudzinski’s Sign (Neck Sign)

• With the patient supine, place one hand behind the patient’s head and
place the other hand on the patient’s chest.
• Raise the patient’s head (with the hand behind the head) while the
hand on the chest restrains the patient and prevents the patient from
rising.
• Flexion of the patient’s lower extremities (hips and knees)
constitutes a positive sign.
Kernig’s Sign
• The patient is positioned supine with hips and knees in flexion.
• Extension of the knees is attempted: the inability to extend the
patient’s knees beyond 135 degrees without causing pain constitutes a
positive test for Kernig’s sign.

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