2.

3-C
August 11, 2014
PLM CM

REFLEX TESTING
Dr. Guzman
Legend: normal text lecture/old trans; Bates italics; transers
notes red text.

THE NEUROLOGIC EXAM

Steps in the Diagnosis of Neurologic Diseases:
1. Mental Status Exam
2. Gait and Station
3. Cranial Nerves
4. Motor System
5. Coordination
6. Reflexes
7. Sensation
8. Head and Neck
9. Spine and Skin
DEEP TENDON REFLEXES
Also muscle stretch reflex
Monosynaptic (e.g., DTR of arms and legs) involves one
afferent (sensory) and one efferent (motor) neuron across
a single synapse
Simplest unit of sensory and motor function
Relayed over structures of both central and peripheral
nervous systems
SEGMENTAL LEVELS
You can remember them easily by their numerical
sequence in ascending order from ankle to triceps: S1-L2,
L3, L4-C5, C6, C7.
Ankle reflex
Sacral 1 primarily
Knee reflex
Lumbar 2,3,4
Supinator (brachioradialis)
Cervical 5,6
reflex
Biceps reflex
Triceps reflex

Cervical 5,6
Cervical 6,7

ELICITING THE DEEP TENDON REFLEX

1. Briskly tap tendon of partially stretched muscle
2. Activation of Special Sensory Fibers
3. Sensory impulse travels to spinal cord via a peripheral
nerve
4. Stimulated sensory fiber synapses with anterior horn cell
that innervates the same muscle
5. Impulse crosses neuromuscular junction
6. Muscle contraction
For the reflex to occur, all components of reflex arc must
be intact: sensory nerve fibers, spinal cord synapse, motor
nerve fibers, neuromuscular junction, and muscle fibers.
PRINCIPLES AND RELATIONSHIPS
Tendons: connects muscles and bones, usu. crossing a
joint
Muscle contracts tendon pulls on bone attached
structure moves
Striking of tendon by reflex hammer stretch receptors
sends impulse to spinal cord via sensory nerves
impulse transmitted across a synapse to a lower motor
neuron impulse travels down from LMN to target
muscle
USING THE REFLEX HAMMER
Pointed end: for striking small areas
Flat end: for larger areas
Larger hammers have weighted heads. Raise
approximately 10cm from the target then release to hit
tendon with adequate force
Smaller hammers should be swung loosely bet. forefinger
and thumb
Striking the area should not elicit pain
REINFORCEMENT
Used if reflexes are symmetrically diminished or absent
Involves isometric contraction of other muscles for up to
10 secs
Increases reflex activity
o In testing arm reflexes: ask pt to clench teeth or
squeeze one thigh with the opposite hand.

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

o JENDRASSIK
MANEUVER: In leg
reflexes: ask to lock
fingers and pull one
hand against the other.
Tell patient to pull just
before you strike the
tendon.
1.
2.
3.
4.
5.

Have patient relax. Position limbs properly and

symmetrically (Neutral Position: not stretched or
relaxed)
Hold reflex hammer loosely bet. thumb and index
finger, so it swing freely in an arc.
Relax your wrist, strike briskly using a rapid
movement.
Note speed, force and amplitude of the reflex
response. Grade the response using the scale
below.
Always compare the response of
both
sides/extremities.

If having trouble locating tendon ask patient to

contract the muscle to which it is attached muscle
contracts look and feel for the cord-like tendon (e.g.,
In identifying the Biceps tendon: ask to flex the forearm
to contract the Biceps muscle)
GRADING THE RESPONSE
Bates:
4+
Very brisk, hyperactive, with clonus (rhythmic
oscillations between flexion and extension)
3+
Brisker than average; possibly but not necessarily
indicative of disease
2+
Average; normal
1+
Somewhat diminished; low normal
0
No response
Lecture: Sabi ni Doc di raw ito gagamitin, para lang daw
aware tayo na meron ding scale na hanggang 5+
5+
Markedly hyperactive with sustained clonus
4+
Markedly hyperactive with transient clonus
3+
Increased; maybe normal or pathologic
2+
Normal
1+
Decreased but present (hyporeflexia)
0
Absent; no evidence of contraction
Hyperactive reflex (Hyperreflexia): seen in CNS lesions
along descending corticospinal tract
o Look for associated UMN findings of weakness,
spasticity and (+) Babinski sign
Hypoactive or absent reflexes (hyporeflexia/areflexia):
diseases of spinal nerve roots, spinal nerves, plexuses, or
peripheral nerves.
o Look for associated findings of lower motor unit
disease weakness, atrophy, fasciculations
REFLEX LOCATIONS
Ankle Reflex (S1-2 Sciatic Nerve)
Also Achilles reflex
Achilles tendon: taut, discrete, cord-like structure from
heel to muscles of the calf
Primarily S1
1.
2.
3.
4.
5.

Best position: Seated, feet dangling over edge of

exam table
Other positions: Supine, Crossing one leg over
the other (figure of 4/frog-type)
If unable to locate tendon, ask patient to plantar flex
the foot
Strike.
Calf must be exposed to see muscle contraction

Normal response:
Contraction)

Plantar

Flexion

(Gastrocnemius

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PLM CM

REFLEX TESTING
Dr. Guzman

Brachioradialis Reflex (C5-6 Radial Nerve)

Supinator reflex

If pt is sitting: dorsiflex foot at the ankle

Note speed of relaxation after muscular contraction
Slowed relaxation phase of reflexes in hypothyroidism
is oftenly seen and felt in ankle reflex
CLONUS. If reflexes seem hyperactive, test for ankle
clonus
1. Support knee in partly flexed position.
2. With your other hand, dorsiflex and plantar flex
the foot a few times while encouraging the
patient to relax
3. Sharply dorsiflex the foot and maintain it in
dorsiflexion.
4. Look and feel for rhythmic oscillations between
dorsiflexion and plantar flexion.
o In most normal people, the ankle does not react to
this stimulus. A few clonic beats may be seen and felt,
especially when the patient is tense or has exercised
o Clonus may also be elicited at other joints. A sharp
downward displacement of the patella, for example,
may elicit patellar clonus in the extended knee.
o Sustained clonus indicates central nervous system
disease. The ankle plantar flexes and dorsiflexes
repetitively and rhythmically.
o When clonus is present, the reflex is graded 4+

1. Position:
Seated,
lower arm resting on
pts lap
2. Tendon cant be seen
or well palpated. It
crossed the radius
approx.
10cm
proximal to the wrist.
3. Strike.
Normal response: Elbow flexion and supination of forearm
(palm upward)
Pts hand should rest on abdomen or lap, w/ forearm partly
pronated -> strike radius with point or flat edge of reflex
hammer, about 1 to 2 inches above the wrist.

Biceps Reflex (C5-6 Musculocutaneous Nerve)

1. Two ways of positioning: pts arm in his/her lap to
form an angle slightly >90 at elbow OR support pts
arm in yours. Your thumb must be directly over the
biceps tendon.
2. If arm is supported, place thumb on the tendon and
strike it.
3. If unsupported, place index or middle finger firmly
against tendon, then strike.
Normal response: Elbow flexion

Knee/Patellar Reflex (L3-4 Femoral Nerve)

Bates: Knee reflex (L2, L3, L4)
1.
2.
3.

4.

Position: Seated feet dangling

Identify tendon: thick, broad band of tissue
extending down the knee cap
If unable to locate, ask to extend the knee to
contract quadriceps. Or place index finger on top of
the knee, then strike the finger to transmit the
impulse
If in supine, support the back of thigh with hands so
the knee is flexed and quads are relaxed

Normal response: Extension of knee (contraction of Quads)

Pts arm should be partially flexed at the elbow with palm

down
Triceps Reflex (C7-8 Radial Nerve)
Bates: triceps reflex (C6, C7)
Pt may be sitting or lying down as long as knee is flexed
Hand on pts anterior thigh lets you feel this reflex
Two methods when examing supine pt:
o Supporting both knees at once (left picture below)- to
assess small differences between knee reflexes by
repeatedly testing one reflex and then the other
o Rest supporting arm under the pts leg (Right picture
below)

1.

2.
3.

Two
possible
positions: form a
right angle at the
shoulder. Lower arm
should be dangling
directly
downward.
OR. Have pt place
hands on hips
Triceps
tendon
extends across elbow to the back of the upper arm
If arms are on hips: arm will not move, but muscle
should shorten vigorously

Normal response: lower arm to extend at elbow and swing

away from body
pt may be sitting or supine flex pts arm at elbow, w/
palm toward the body, and pull it slightly across the chest

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

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PLM CM

REFLEX TESTING
Dr. Guzman

Complete
resection of
UMN

Reflex
Pectoralis
reflex

OTHER DTRs
Segment
How to Elicit
C5-T1

Pronator
reflex

C6-C7

Upper
abdominal
muscle
reflex

T8-T9

Midabdominal
muscle
reflex
Lower
abdominal
muscle
reflex
Adductor
reflex

T9-T10

Hamstring
reflex

T11-T12

L2-L4

L4-S2

Have pt elevate
arm place
fingers of your left
hand upon pts
shoulders with
your thumb
extended
downwards
strike your thumb
directly slightly
upward toward
pts axilla
Grasp pts hand
hold it
vertically so the
wrist is
suspended from
the medial side
strike distal end of
radius directly
with horizontal
blow
Tap muscles
directly near their
insertions on the
costal margins
and xiphoid
process
Tapping an
overlaid finger

Tap muscle
insertion directly
near symphysis
pubis
Supine, lower
limbs slightly
abducted Tap
directly the
Adductor magnus
just proximal to its
insertion on the
medial epicondyle
of the femur
Supine, hips and
knees flexed at
90, thigh rotated
slightly outward
Place left hand
under popliteal
fossa to
compress medial
hamstring

Normal
Response
Muscle
contraction
seen or felt

Pronation
of forearm

Contraction

Contraction

Thigh
adduction

Knee
flexion,
contraction
of medial
mass of
hamstring

MAKING CLINICAL SENSE OF REFLEXES

Disorders of Prevent or delay transmission of
the Sensory
impulse to the spinal cord
limb
causes hyporeflexia or arreflexia
Clinical
example:
Diabetes-induced
peripheral neuropathy
Abnormal
hyporeflexia to arreflexia
LMN
example: transection of peripheral
function
motor

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

neuron 2 to trauma reflexes

dependent on this nerve will be absent
traumatic spinal cord injury
arc receiving input from this nerve
becomes disinhibited hyperreflexia
immediately after such injury
hyporeflexia, hyperreflexia develops after
several weeks
also seen in death of the cell body of the
UMN (located in the brain), as occurs with
a stroke affecting motor cortex of brain

Primary
results to loss of reflexes, disease at
disease of
target organ/muscle precludes movement
NMJ or the
muscle itself
Systemic
direct toxicity to a specific limb of the
disease
system
states
poorly controlled diabetes peripheral
sensory neuropathy
extremes of thyroid disorder also affects
reflexes (mechanism unknown)
Hyperthyroidism
hyperreflexia
Hypothyroidism hyporeflexia
Detection of an abnormal reflex (hyper/hypo/arreflexia)
does not necessarily tell which limb of the system is
broken or what might be causing the dysfunction.
Impaired sensory input or abnormal motor nerve
function decreased reflexes
Only by considering all of the findings, together with the
rate of progression, pattern of distribution (unilateral,
bilateral, etc.) and other medical conditions can the
clinician make educated diagnostic inferences about the
results generated during reflex testing
TROUBLESHOOTING
If unable to elicit reflex: consider the following:
o Are you striking the correct place? confirm by
observing and palpating the appropriate region while
asking pt to perform an activity that causes the
muscle to shorten to make the tendon more apparent
o Make sure that the hammer strike is falling
directly on the appropriate tendon if plenty of
surrounding soft tissue (dampens force of strike),
place a finger firmly on the tendon and use that as
target
o Make sure that the muscle is uncovered so that
you can see any contraction occasionally, the
force of the reflex is not sufficient to move the limb
o Sometimes, the patient is unable to relax
inhibits the reflex even if pt is neurologically intact. If
this occurs, use REINFORCEMENT.
o Occasionally, it will not be possible to elicit
reflexes, even when no neurological disease
exists most commonly due to inability to relax.
Absence of reflex is of no clinical consequence,
assuming that you were thorough in the history taking,
used appropriate examination techniques, and
identified no evidence of disease
BRAINSTEM REFLEXES
Direct Pupillary
bright light is shone upon the
Reaction to Light
retina iris constricts
Consensual Pupillary
stimulation of one retina
Reaction to Light
contralateral constriction of
the pupil
Ciliospinal Reflex
pinching the skin of the back of
neck papillary dilatation
Corneal Reflex
touching the cornea
blinking of the eyelids
Orbicularis Oculi Reflex
retina is exposed to bright light
eyelids close
Auditocephalogyric
loud sound head and eyes
Reflex
turn to source
Jaw Reflex
mouth is partially opened and
the muscles relaxed + tapping
the chin the jaw to close.

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REFLEX TESTING
Dr. Guzman

Gag Reflex

The reflex center is in the

midpons
pharynx is stroked gagging.
The reflex center is in the
medulla

SUPERFICIAL REFLEXES/ CUTANEOUS STIMULATION

REFLEXES
Have reflex arcs whose receptor organs are in the skin
rather than in the muscle fibers
Adequate stimulus is stroking, scratching, or touching
These reflexes are lost in disease of the pyramidal tract

Chewing reflex

*Seen in
dementia, general
paresis, and
anoxic
encephalopathy

Superficial Reflexes
Reflex
Upper
abdominal skin
reflex
Mid abdominal
skin reflex

Segment
T5-T8
Bates: T8-T10
T9-T11

Lower
abdominal skin
reflex

T11-T12
Bates: T10-T12

Cremasteric
reflex

L1-L2

Plantar reflex

L4-S2
Bates: L5, S1

Superficial anal
reflex

L1-L2
Bates: S2-S4

Glabellar reflex

Snout reflex

Sucking reflex

Corticopontine

Corticopontine

Frontal cortex

Procedure &
Expected
Response
With patient
supine, stroke the
skin with blunt
handle towards
the midline

Ipsilateral
contraction of
muscles or
umbilical deviation
towards the
stimulated side
Stroke the inner
aspect of the thigh
from the pubis
distad

Prompt elevation
of the testis on the
ipsilateral side
Stroke the sole
near its lateral
aspect from the
heel towards toes

Plantar flexion of
the toes
Stroke the skin of
the perianal region

External anal
sphincter
contracts
Lightly tap the
forehead between
the eyebrows with
the fingers

(ABNORMAL)
Persistent
blepharospasm
and closing of the
eyes
Tap the nose

(ABNORMAL)
Excessive
grimace of the
face
Stroke the lip with
the finger or a
tongue depressor

(ABNORMAL)
Lips pout and
make sucking
movements
*Present in infants
but disappears
after weaning;
reappears in
diffuse lesions of

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

Frontotemporal
cortex

the frontal lobe

and commonly
noted in
dementias
Place a tongue
depressor in the
mouth

(ABNORMAL)
Chewing
movement of the
teeth and jaw

ABNORMAL REFLEXES IN PYRAMIDAL TRACT

DISEASE
BABINSKI SIGN
A.k.a hallucal dorsiflexion reflex
Test used to assess upper motor neuron dysfunction
1. The patient may either sit or lie supine.
2. Start at the lateral aspect of the foot, near the heel.
Apply steady pressure with the end of the hammer as
you move up towards the ball (area of the metatarsal
heads) of the foot.
3. When you reach the ball of the foot, move medially,
stroking across this area.
4. Test the other foot.

Normal response: the first movement of the great toe

should be downwards (i.e., plantar flexion)
Upper Motor injury: (e.g., spinal cord injury or stroke):
great toe will dorsiflex and the remainder of the other
toes will fan out
Some patients find this test to be particularly
noxious/uncomfortable. Tell them what you are going to do
and why. If its unlikely to contribute important information
(e.g., screening exam of the normal patient) and they are
quite averse, simply skip it.
Newborns normally have a positive Babinski which usually
goes away after about 6 months
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.
For reasons of semantics, Babinski is not recorded as +
or -
Withdrawal of the entire foot (due to unpleasant
stimulation), is not interpreted as a positive response

GRASP REFLEX
Stroke the patients palm so he/she grasps your index
finger
If present, the patient cannot release the fingers; lesions
of the premotor cortex
HOFFMANS SIGN
Have patient present pronated hand with fingers extended
and relaxed
With your thumb, press his/her fingernails to flex the
terminal digit and stretch the flexor

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REFLEX TESTING
Dr. Guzman
Abnormal response: flexion and adduction of thumb
MAYERS REFLEX
Have patient present his/her supinated hand with thumb
relaxed and abducted
Grasp the ring finger
and firmly flex the
metacarpophalangeal joint
Normal response: adduction and apposition of the thumb
PALM-CHIN REFLEX
Aka Radovicis sign
Vigorous scratching or pricking of the thenar eminence
causes ipsilateral contraction of the muscles of the chin

SPECIAL TECHNIQUE: MENINGEAL SIGNS

Testing for these signs is important if you suspect
meningeal inflammation from meningitis or subarachnoid
hemorrhage
Patient cannot place the chin
upon the chest
Nuchal rigidity

Spinal rigidity

Kernigs sign

Passive flexion of the neck is

limited by involuntary muscle
spasm
Movements of the spine are
limited by spasms of erector
spinae
With patient supine,
passively flex the hip to 90
while the knee is flexed at
about 90
Attempts to extend the knee
produce pain in the
hamstring and resistance
Bates: pain and increased
resistance to extending the
knee are a positive Kernigs
sign
With patient supine and the
limbs extended, passively
flex the neck

Brudzinskis sign

Is it consistent with a LMN process (e.g.,

weakness with flaccidity)? Does the
weakness follow a specific distribution
(e.g., following a spinal nerve root or
peripheral nerve distribution)? Bilateral?
Distal?
Do the findings on reflex examination support a
UMN or LMN process (e.g., hyperreflexic in UMN
disorders and hyporeflexic in LMN disorders)?
Do the findings on Babinski testing (assuming the
symptoms involve the lower extremities) support
the presence of a UMN lesion?
Is there impaired sensation? Some disorders, for
example, affect only the upper or lower motor
pathways, sparing sensation.
Which aspects of sensation are impaired? Are all
of the ascending pathways (e.g., spinothalamic and
dorsal columns) affected equally, as might occur
with diffuse/systemic disease?
Does the loss in sensation follow a pattern
suggestive of dysfunction at a specific anatomic
level? For example, is it at the level of a spinal
nerve root? Or more distally, as would occur with a
peripheral nerve problem?
Does the distribution of the sensory deficit
correlate with the correct motor deficit, assuming
one is present? Radial nerve compression, for
example, would lead to characteristic motor and
sensory findings.
SUMMARY OF SPINAL LEVELS

This is just Bates based. Please refer to preceding pages for

those from the lecture/ those not found here.
Deep Tendon Reflex
Biceps reflex
Supinator/Brachioradialis
Reflex
Triceps Reflex
Knee Reflex
Ankle Reflex
Cutaneous Stimulation
Reflex
Abdomen above umbilicus
Abdomen below umbilicus
Plantar Response
Anal Reflex

Spinal Levels
C5-C6
C5-C6
C6-C7
L2-L4
Primarily S1
Spinal Levels
T8-T10
T10-T12
L5-S1
S2-S4

Produces involuntary flexion

of the hips

Bates: flexion of both the

hips and knees is a positive
Brudzinkis sign
^Parang hindi naman lahat ito Reflex? :/ Pero dito siya
included sa lecture, so
MAKING SENSE OF NEUROLOGICAL FINDINGS

While compiling information generated from the

motor and sensory examination, the clinician tries
to identify patterns of dysfunction the will allow
him/her to determine the location of the lesion(s).
What follows is one way of making clinical sense of
neurological findings.

Is there evidence of motor dysfunction (e.g.,

weakness, spasticity, tremor)?
o If so, does the pattern follow an upper
motor neuron or lower motor neuron
pattern?
o If its consistent with a UMN process (e.g.,
weakness with spasticity), does this
appear to occur at the level of the spinal
cord or the brain?
- Complete cord lesions: affect
both sides of the body
- Brain level problems: affect one
side
- It is, of course, possible for a
lesion to affect only one part of
the cord, leading to findings that
lateralize to one side.

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

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