the clinical examination of the reflex in detail

2. Definition
• Reflexs is an involuntary
(automatic ) response to a
stimulus which depends
on the integrity of a
particular nervous pathway
.i.e.reflex arc
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3. Aim
• To demonstrate reflex
• To identify whether the reflex are normal or
abnormal{increased or decreased response} (UMN,LMN
lesion).
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4. APPARATUS
• Knee Hammer,
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5. APPARATUS
• Cotton wool
• pen torch
• small cardboard
• tongue depressor
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6. Types of reflexes
A. SUPERFICIAL REFLEXES
B. DEEP TENDON REFLEXES
C. ORGANIC / SPHINCTERIC / VISCERAL REFLEXES
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7. SUPERFICIAL REFLEXES

8. SUPERFICIAL REFLEXES
• Reflexes based on spinal nerves
1. Plantar reflex
2. Abdominal reflex
3. Scapular reflex
4. Anal reflex
5. Cremastic reflex
6. Bulbocavernous reflex
• Reflexes based on cranial nerves
1. Conjuctival reflex
2. Corneal reflex
3. Visual reflexes
a) Pupillary reflex
b) Accomodation reflex
4. Palatal reflex
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9. SUPERFICIAL REFLEXES
• Stimulus is applied to superficial structure like
SKIN or MUCOUS MEMBRANE
• Results in the contraction of underlying muscle.
• Polysynaptic reflexes:pathway picture
• Main characteristic features
– excitability varies with the subject
– has significances in unilateral lesion - where you can compare the reflex
with normal side.
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11. Flexsor withdrawal reflex
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12. PLANTAR REFLEX L5S1
• POSITION : Supine position and
foot out off the couch
• Exposure: from foot to knee exposed
• INSTRUMENT: blunt end of knee
hammer or blunt key
• PROCEDURE: Gentle continous stroke
on plantar surface as shown in the figure
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13. PLANTAR REFLEX L5-S1
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14. PLANTAR REFLEX
NORMAL -FLEXSOR
RESPONSE
ABNORMAL RESPONSE-EXTENSOR
OR BABINSKI SIGN
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18. ABDOMINAL REFLEX T7-T12
• POSITION : Supine position with
knee flexed
Exposure :The abdomen exposed
from ziphi sternum to pubis symphysis
• INSTRUMENT: blunt end of knee
hammer or blunt key
• PROCEDURE: Gently stroke
towards midline from periphery in
all four quadrant.
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19. T7
T8
T9
T10
T11
T12
RESPONSESTIMULUS
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20. SCAPULAR REFLEX C5-T1
• POSITION : Siting or Standing
Back of the trunk fully exposed
• INSTRUMENT : blunt end of knee
hammer or blunt key
• PROCEDURE: Gently stroke on
inner curve of the scapula or
intrascapular space in back of the
trunk.
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21. stimulus
response
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24. CONJUNCTIVAL REFLEX
Afferent : trigeminal nerve Efferent : facial nerve
conjunctiva
Cornea30/6/2020 24Dr.Divya.A.J.

25. Afferent : trigeminal nerve Efferent : facial nerve
• response : blinking of eye
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26. CORNEAL REFLEX
Afferent : trigeminal nerve Efferent : facial nerve
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27. Afferent : trigeminal nerve Efferent : facial nerve
• response : blinking of eye
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28. DIRECT LIGHT REFLEX
Afferent : optic nerve Efferent : occulomotor nerve
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30. INDIRECT LIGHT REFLEX
Afferent : optic nerve Efferent : occulomotor nerve
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32. ACCOMDATION REFLEX
Afferent : optic nerve Efferent : occulomotor nerve
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33. ACCOMDATION REFLEX or Near reflex
1. constriction of pupil
2. convergence of eye ball,
3. increase in anterior
curvature of lens
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34. ACCOMDATION REFLEX
Afferent : optic nerve Efferent : occulomotor nerve
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35. PALATAL REFLEX
Afferent : glassopharngeal nerve
Center : pons
Efferent : vagus nerve
• Light touch to soft palate
should lead to ipslateral
deviation of uvula and
elavation of thr soft palate
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38. DEEP TENDON REFLEX

39. Strecth reflex
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40. DEEP TENDON REFLEX
1. Biceps jerk
2. Triceps jerk
3. Supinator jerk { Brachioradialis
jerk}
4. Knee jerk { Patellar jerk
/Quadriceps jerk/Femoris jerk}
5. Ankle jerk {Gastronemius and
soleus jerk}
6. Jaw jerk
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41. • Appropriate use of pointed end and
broad end of hammer at
appropriate place
• encourage patient to be relax and
body position is proper
• hold reflex hammer loosely b/w
thumb and index
• swing it freely in an arc
• rapid wrist movement -i.e. quick
,direct,not glancing
• observe the response and grade it.
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42. Grading of Reflexes
Grade Response
0 Absent
1 Present(as a normal ankle jerk)
2 Brisk(A normal knee jerk)
3 Very Brisk
4 Clonus
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43. ? REFLEX TELLS YOU
• NORMAL
• INCREASED
1. Physiological:anxiety or nervousness
2. Pathological: Upper motor neuron lesion,Thyrotoxicosis,Tetanus
• DECREASED / ABSENT
 Physiological:During sleep, if subject watches it
 Pathological: Lower motor neuron lesion(LMNL)
• PENDULLAR KNEE JERK : Cerebellar disorders.
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44. REINFORCEMENT TECHINQUE- Jendrassik
manouver
• for upper limb : clenching of teeth
• squeezing thigh
• for lower limb : locking the fingers and pulling against from
one another.
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47. BICEPS JERK C5-6 Musculocutaneous nerve
Pointed end of reflex hammer to be used
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48. • response:
• Flexsion at elbow and
contraction of biceps
muscle
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49. TRICEPS JERK C6-7, Radial nerve
Broad end of reflex hammer has to be used
sitting position: elbow in flexsion with
forearm of chest supine positon forarm resting of
chest with flexsion at elbow
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50. sitting position with forearm
hanging freely with palm down.
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52. SUPINATOR JERK C5-6 radial nerve
sitting position,forearm
resting on thigh
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53. response : contraction of brachioradials muscle,
supination at elbow
supine position sitting positon
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54. KNEE JERK L2,3,4 Femoral nerve
sitting positing : On edge of the bed
,legs freely hanging ,not touching
the floor
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55. SUPINE POSITION :USE THE BROAD END OF KNEE HAMMER
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56. • response : a brief
contraction of quadriceps
muscle
• resulting in extension of
knee
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57. ANKLE JERK S1,2 tibial nerve
dorsiflex and evert the foot
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59. Response: : A sharp contraction of calf muscles
reslting in plantar flexion
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60. JAW JERK
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61. JAW JERK cranial nerve 5
Center and spinal segment :Pons,
fifth cranial nerve
sitting or supine positon
jaw relax and slightly open
Place finger on the top of chin and
tap on the finger( pointed of knee
hammer)
Response : contraction of masster
muscle resulting in closure of mouth.
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62. Clonus
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65. ORGANIC REFLEX / Sphincteric Reflexes

66. ORGANIC REFLEX / Sphincteric Reflexes
• Concerned with respiration ,deglutition,micturition and defacation
1. Deglutition Reflex
2. Micturition Reflex and
3. Defacation Reflex
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67. DEGLUTITION REFLEX
• No history of dysphagia,
• No swallowing difficulty
for solids and liquids
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68. MICTURITION
• No history of incontinence
of urine ,
• no history of increse or
decrease of urine
frequency,
• no history of burning
micturition
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69. • Atonic bladder-destruction of sensory fibres
– traumatic spinal cord injury
– overflow incontinence
• Automatic bladder:spinal cord injury above sacral region
– here micturition reflex in intact but uncontrolled
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70. DEFAECATION REFLEX
• No history of constipation ,
• no history of incontinence of faeces
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71. Report writing
• Name :xyz
• Age: ww years
• Gender: male
• Address: Human being , x door
no,y cross, z layout, D nagar
A Supeficial reflexes
based on spinal
nerves
Right side response Left side response Remarks
√ 1. Plantar reflex plantar flexion of toes
and foot
plantar flexion of toes
and foot
L 5S1
√ 2. Abdominal reflex contraction of
abdominal muscle
contraction of abdominal
muscle
T7-T12
√ 3. Scapular refex contraction of scapular
muscle
contraction of scapular
muscle
C5-T1
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72. B Superficial RefLexs
based on cranial nerves
Right side response Left side response Afferent
nreve
Efferent
nerve
√ 1
.
Conjunctival reflex rapid closing of eyes
seen
rapid closing of eyes seen trigermin
al(cr-5)
facial (cr-
7)
√ 2
.
Corneal reflex rapid closing of eyes
seen
rapid closing of eyes seen trigermin
al(cr-5)
facial (cr-
7)
√ 3
.
Pupillary light reflex
a. Direct light reflex
constriction of pupil in
same eye seen
constriction of pupil in eye
seen
optic (cr-
2)
occulomot
ort (cr-3)
√
√ b.Indirect light reflex constriction of pupil in
opposite eye seen
constriction of pupil in
opposite eye seen
optic ( cr-
2)
occulomot
ort (cr-3)
√ 4
.
Accomdation reflex constriction of pupil
convergence of eye
ball,increase in anterior
curvature of lens
constriction of pupil
convergence of eye
ball,increase in anterior
curvature of lens
optic (cr-
2)
occulomot
ort (cr-3)
5
.
Palatal reflex elevation of palate
,contraction of palatal
muscle
elevation of palate
,contraction of palatal
muscle
trigermin
al(cr-5)
vagus (cr-
10)30/6/2020 72Dr.Divya.A.J.

73. C DEEP TENDON REFLEX RIGHT SIDE
RESPONSE
LEFT SIDE
RESPONSE
REMARK
1. Biceps jerk Grade 1 Grade 1 C5-C6
2. Triceps jerk Grade 1 Grade 1 C6-C7
3. Supinator jerk Grade 1 Grade 1 C5-C6
4. Knee jerk Grade 2 Grade 2 L2,3,4
5. Ankle jerk Grade 1 Grade 1 S1-S2
6. Jaw jerk Grade 1 Trigeminal nerve
D VISCERAL REFLEX
1. Deglutition reflex No history of dysphagia,No swallowing difficulty for solids and
liquids
2. Micturition reflex No history of incontinence of urine ,no history of increse or decrease
of urine frequency, no history of burning micturition
3. Defecaion reflex No history of constipation ,no history of incontinence of faeces
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74. TELL ME ?
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75. TELL ME ?
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76. Assignment
1. Difference between monosynaptic and polysynaptic reflex
2. Draw neat labelled diagraw of relex arc and mention its
component.
3. What is reinforcement and how does it work?
4. What happens to reflexes ( superficial and deep ) in upper motor
neuron(UMN) lesion and lower motor neuron(LMN) lesion?
5. What happens to response of knee jerk in hypothyroidism?
6. Define Clonus
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77. thank you
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