DEEP TENDON REFLEXES:
CERVICAL SPINE AND UPPER EXTREMITIES:
There are three basic deep tendon reflexes, which evaluate the integrity
of the C5, C6 and C7 nerve supply. These are known as the biceps reflex,
the Brachioradialis reflex, and the triceps reflex. Deep tendon reflexes
are considered a lower motor reflex. Here the signal translates to the
posterior horn of the spinal cord, thought internuncial neurons into the
anterior horn cells and returning through the peripheral nerves to the
musculature.
BICEPS REFLEX – C5
Although there are multiple innervations to the biceps via C5 and C6,
primary innervation is associated with C5.
BRACHIORADIALIS REFLEX – C6
Although there are multiple innervations to the Brachioradialis via C5
and C6, primary innervation is associated with C6.
TRICEPS REFLEX – C7
The triceps muscle is innervated by the radial nerve primarily C7.
LUMBOSACRAL SPINE AND LOWER EXTREMITIES:
PATELLAR REFLEX – L2, 3, AND 4
Although the patella reflex, or knee jerk, is a deep tendon reflex,
innervated by L2, L3 and L4, primary innervation comes from L4.
ACHILLES TENDON REFLEX – S1
The S1 nerve level innervates the Achilles tendon deep reflex.
COMPLETE LIST OF THE DEEP TENDON REFLEXES
1. Maxillary reflex aka Jaw Jerk innervation Cranial Nerve V3. When
there is a sudden closure of the jaw when you strike the middle of the
chin, as the mouth was initially open.
2. Bicep reflex C5 primarily (C6)
3. Triceps reflex C6 primarily (C7)
4. Periosteoradial C7 primarily (C6, C8)
5. Periosteo-Ulnar reflex C8, T1. There is extension and ulnar abduction
of the wrist when the styloid process of the ulna is struck.
6. Wrist Reflexes C7, C8. There is flexion or extension motion when the
corresponding tendons are struck.
7. Patellar reflex L4, (L2, L3). There is extension at the knee when the
patellar tendon is struck. Absence of the reflex is known as WESTPHAL’S
SIGN. When the reflex cannot be obtained and you have the patient clasp
their hands together, clench, and the reflex is obtained you have
utilized the JENDRASSIK method of reinforcement.
8. Achilles reflex S1, S2.
NERVE LEVEL & PERIPHERAL NERVE SENSATION
TESTING AND VERIFICATION
Sensory testing for the cervical spine is associated with the integrity
of the dermatomes. Dermatomes into the upper extremities include levels
C5 to T1. The following is an outline the brachial plexus distribution
of the upper extremities.
C5 – Lateral arm – Axillary nerve
C6 – Lateral forearm, thumb, index, and half of middle finger – sensory
Branches of the Musculo-Cutaneous nerve.
C7 – Middle finger
C8 – Ring and little fingers, medial forearm – medial
antebrachial-cutaneous nerve.
T1 – Medial arm – medial brachial cutaneous nerve.
THE SUPERFICIAL REFLEXES
The superficial reflexes (i.e. abdominal, cremasteric, and anal
reflexes) or upper motor neuron reflex testing is mandatory when we
suspect specific lesion associated with an upper motor neuron lesion.
The absence of the superficial reflex perhaps indicates an upper motor
neuron lesion. If the superficial reflex is absent and the deep tendon
reflex is increased, this will add evidence to indicate an upper motor
neuron lesion and reason for consultation for Neurodiagnostic testing.
ABDOMINAL REFLEX
The patient is asked to lie in the supine position. Place the arrow end
of the reflex hammer upon the abdomen and stroke each section of the
abdomen, noting whether the umbilicus moves toward the area being
stroked. The lack of an abdominal reflex may indicate an upper motor
neuron lesion provided you perform the test correctly. You may also
detect a lower motor neuron lesion because the upper muscles of the
abdomen are innervated form T7 through T10. The lower muscles from T10
to L1. Thus, lack of a reflex will indicate the approximate level of a
lower motor neuron lesion.
CREMASTERIC REFLEX
The patient is asked to lie in the supine position. Stroke the inner
aspect of the upper thigh with the arrow end of the reflex hammer. If
the reflex is elicited the scrotum will be pulled upward as the
cremasteric muscle contracts. This is associated with a T12 level. If
the reflex is reduced or absent bilaterally this may indicate an upper
motor neuro lesion, while a unilateral absence indicates a probable
lower motor neuro lesion between L1 and L5.
ANAL REFLEX
The patient is asked to lie in the prone position. Gently touch the
perianal SKIN
. The external and anal sphincter muscles (S2, S3, S4) would contract in
response.
ANAL WINK REFLEX
If you are unable to elicit a response, take a finger cot, place your
finger gently within the anus, and pull out. The anus should contract as
if to wink.
CLINICAL UNDERSTANDING OF UPPER AND LOWER MOTOR NEURON LESIONS
The motor innervation of the striated musculature is innervated by the
Pyramidal system. The Pyramidal pathway conducts impulses to the spinal
cord anterior horn cells associated with isolated movements of the hands
ad fingers which form the basis for the development of manual skills. In
fact, it has been estimated that 55% of all pyramidal fibers end in the
cervical cord, 20% in the thoracic and 25% in the lumbosacral segments.
Therefore, the muscles of the upper extremity are more affected than the
muscles of the lower extremity and the distal muscles (hand) are most
affected compared to the proximal because they have more motor units for
complex actions.
UPPER MOTOR NEURON LESION AKA SPASTIC PARALYSIS
AKA SUPRANUCLEAR PARALYSIS
1. Initially there is loss of tone in the affected muscles (hypertonia)
2. Soon after the muscles gradually become resistant to passive movement
and yield SPASTIC PARALYSIS.
3. The myotatic deep tendon reflexes, especially in the leg, are
increased in force and amplitude known as HYPERREFLEXIA.
4. The SUPERFICIAL REFLEXES are lost or diminished.
5. Positive Babinski’s Sign is noted.
6. If the suspected lesion is above the pyramidal decussation, the
symptoms will be found on the contralateral side.
7. If the suspected lesion is below the pyramidal decussation, the
symptoms will be found on the ipsilateral side.
With an upper motor neuron lesion the first manifestation will be a
disturbance in muscular tonus, expressed as hypotonia. However, within
2-3 weeks changes occur leading to hypertonia bringing about
hyperreflexia. Thus when hyperreflexia is noted the lesion must be
considered at least 2-3 weeks old.
The reason that UMNL’s lead to a loss of the superficial reflexes is due
to the fact that there is retrograde degeneration. This retrograde
degeneration causes degeneration of the association neuron and the
afferent sensory neuron in the reflex arc.
In the geriatric population, there is a tendency for the superficial
abdominal reflexes to be absent. Thus, this may not indicate an UMNL.
It must also be noted that absence of the superficial abdominal reflexes
is not in itself indicated of a MNL. Finally, in UMNL’s flaccidity and
atrophy will be greater in the upper extremities in the distal aspect
because there are more motor units present.
LOWER MOTOR NEURON LESION AKA FLACCID PARALYSIS
LESION
1. Muscle fibers, which have been deprived of their afferent nerve
innervation, become completely paralyzed.
2. All reflexes, deep tendon and superficial are abolished and the
musculature become flaccid.
3. The muscle fibers begin to undergo progressive atrophy.
4. There are marked fibrillary tremors and fasciculations noted in the
affected musculature within three weeks of the initial injury.
5. Lower motor neuron lesions produce ipsilateral symptoms except for
the Ivth cranial nerve because the IV crosses.
It must be noted that when the lesion is found in the anterior horn
cells, it will take two weeks or more for paralysis and flaccidity to
occur. Generally, marked fasciculations and fibulation occurs while the
LMN is degenerating then they disappear. If the fasciculations occur
months to years later, it indicates that there is some nerve
regeneration.
PATHOLOGICAL REFLEXES COMPLETE BY BODY REGION
Pathological reflexes act reciprocally to the previous. The presence of
a pathological reflex may indicate an upper motor neuron lesion and its
absence indicates the norm.
HEAD
1. BABINSKI’S PLATYSMA SIGN
If resistance to flexion of the chin against the chest is presented or
opening the mouth, the platysma on the side will contract, whereas the
affected side will not.
2. HEAD RETRACTION REFLEX
Specific downward percussion upon the upper lip with the patient’s head
slightly in forward flexion produces head and neck bending followed by
brisk head retraction.
3. Mc MCCARTHY’S SIGN AKA The Glabella Reflex
With the patient in the supine position gently percuss the Supraorbital
ridge which results in the reflex contraction of the Obicularis Oculi
muscle.
4. SNOUT REFLEX
Specific tapping of the middle of the upper lip induces an exaggerated
reflex contraction of the lips.
UPPER EXTREMITIES
1. BABINSKI’S PRONATION SIGN
The patient is in the sitting position. Ask the patient to place their
hands in approximation with the palms upward. Place your fists below the
patient hand. Bring your fists upward jarring the patient’s hands
several times. The affected hand will fall in PRONATION, and the sound
hand will remain horizontal.
2. BECTEREW’S SIGN
The patient is in the sitting position. Ask the patient to flex and
relax the forearms several times. The paralyzed forearm will fall back
slowly and in a jerky manner, even when contractures are mild.
3. CHADDOCK’S WRIST SIGN
Gently stroke the ulnar side of the forearm near the wrist. Flexion of
the wrist, and extension and fanning of the fingers will indicate the
affected hand.
4. TROMNER’S SIGNS AKA Finger Flexion Reflex
A positive sign is elicited by specifically tapping the palmar surface
or the tips of the middle three fingers produces prompt flexion of the
fingers.
5. GORDON’S FINGER SIGN
Extension of the flexed fingers or the thumb and index finger when
pressure is exerted over the Pisiform bone.
6. HOFFMAN’S SIGN
This sign is demonstrated by a clawing movement of the fingers produced
by the flicking of the distal phalanx of the index finger. The thumb is
also clawed.
7. FORCED GRASPING TEST
Specifically stroke radial ward with your fingers across the patient’s
palm causes a grasp reaction of the hand.
8. KLEIST’S HOOKING SIGN
Exert pressure with your hand against the patient’s flexor surface of
the fingertips. A sudden reactive flexion of the fingers indicates the
affected hand.
9. KLIPPEL AND WEIL THUMB SIGN
Ask the patient to flex their fingers. Quickly extend the patients
fingers with your hand. A positive test is demonstrated by flexion and
abduction of the patient’s thumb.
10. LERI’S SIGN
Absence of normal flexion of the elbow upon forceful passive flexion of
the wrist and fingers.
11. MAYER’S SIGN
Ask the patient to supinate their hand. Absence of adduction and
opposition of the thumb upon passive forceful flexion of the proximal
phalanges, especially of the third and fourth fingers, of the supinated
hand.
12. SOUQUE’S SIGN
In attempting to raise the paralyzed arm, the fingers spread out and
remain separated.
13. STRUMPELL’S PRONATION SIGN
Upon the patient flexing the forearm, the dorsum of the hand approaches
the shoulder instead of the palm.
LOWER EXTREMITIES
1. ANKLE CLONUS
The patient is seated or supine. Place your stabilizing hand upper the
patient popliteal space. Forcibly and quickly dorsiflex the patient’s
foot. A positive test demonstrates and continued rapid flexion and
extension of the foot. A rapidly exhaustible clonus may be normal.
2. BABINSKI’S SIGN
With the metal end of the reflex hammer, stimulate the plantar surface
of the foot from the Calcaneus along the lateral aspect to the forefoot.
Seeing the big toe extend while the other toes plantar flex recognizes a
positive test. This would indicate an upper motor neuron lesion
indicating
brain Pathology
or trauma. In the newborn, a positive test is normal. Shapiro advices
forcible flexing of the second to fifth toes while eliciting the
Babinski’s response in the usual manner, for a more definitive test.
3. CHADDOCK’S SIGN
Babinski response obtained by the stroking of the lateral malleolus.
4. CROSSES EXTENSION REFLEX
Ask the patient to lie supine on the examining table. Have the patient
flex both legs. Stimulate the sole of the foot, which causes extension
of the contralateral leg.
5. EXTENSOR THRUST
Extension of a flexed lowed limb when the sole of the foot is forced
upward.
6. GONDA REFLEX
Press one of the patient’s toes downward and release it with a snap. The
reflex is an upward movement of the Big Toe.
7. GORDON’S LEG SIGN
Squeezing the patient’s calf will elicit a Babinski like response.
8. GASSET AND GAUSSEL SIGN
Ask the patient to lie in the supine position. The patient will be able
to raise either leg separately but cannot raise both legs
simultaneously. If the paralyzed leg is raised, it will fall back
heavily when the examiner raises the unaffected leg.
9. HIRSCHBERG’S SIGN
Stroke the inner border of the foot. The reflex will cause adduction and
internal rotation of the foot.
10. HOOVER’S SIGN
With the alleged Hemiplegic patient in the recumbent position, place the
palms of your hands directly beneath the patient’s heels, while the
patient is asked to pres down Pressure should be felt only from the heel
of the non-paralyzed leg. Next remove our hand from beneath the
non-paralyzed heel and place it o the dorsum of their foot, and the
patient is instructed to raise the healthy leg against this resistance.
If the patient has a true organic HEMIPLEGIA, the hand remaining beneath
the heel of the paralyzed leg will feel no added pressure. However, if
the patient has a hysterical paralysis, the heel of the supposedly
paralyzed leg will press down against the examiner’s had as an attempt
is made to raise the healthy leg.
11. HUNTINGTON’S SIGN
Flexion at the hip, extension at the knee, and elevation of the affected
weak lower extremity upon coughing and straining.
12. MARIE AND FOIX RETRACTION SIGN
Upon the forcing of the patient’s toes downward, the knee and hip are
drawn into flexion (important test).
13. MANDEL-BECHTEREW SIGN
Flexor movement of the four outer toes upon striking the dorsum of the
foot over the cuboid bone.
14. NERI’S SIGN
The patient is in the recumbent position. Ask the patient to alternately
raise one leg at a time. The knee of the paralyzed side flexes, the
other remaining straight. Forward flexion of the trunk in the standing
position causes the paretic lower lib to flex while the normal one
remains straight.
15. OPPENHEIM’S SIGN
Run the metal handle end of the reflex hammer along the crest of the
tibia and the Tibialis anterior muscle. A normal test indicates no
reaction or the patient complains of pain. A positive test extends the
great toe while the other toes plantar flex.
16. PATELLAR CLONUS AKA TREPIDATION SIGN
Forcibly depress the patella with a quick movement while the leg is in
extension and relaxed. A positive reflex is a rapid up and down
movement.
KINESIOLOGY-PERIPHERAL NERVE INTEGRITY TESTING CORRELATED WITH
MUSCULAR POWER
Kinesiology is defined as that branch of biomechanics, which studies the
science of movement. In general, it is divided into two fields of study.
1. Osteokinematics, which is that branch of Kinesiology, which attempts
to focus primarily on overall movement of bones, with little reference
to their related joints.
2. Arthrokinematic, which is that branch of Kinesiology, which attempt
to focus on the intimate and delicate mechanics of joints.
MUSCLE TESTING
Muscle power 0-5 scale is as follows:
0=Non Contraction (Zero)
1=Flicker of contraction (Trace)
2=Sight power sufficient to move the joint (poor)
3=Power sufficient to move the joint against gravity (fair)
4=Power to move the joint against gravity plus added resistance (good)
5=Normal power with a full range of motion against gravity with full
resistance.
From www.rxpgonline.com
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