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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
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a single stimulation
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reflex will cause the foot to plantar flex (i.e. move into your
supporting hand).
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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.
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.
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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:
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.
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Meningeal signs
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