examination of superficial and deep reflex

1. METHOD OF PHYSICAL EXAMINATION OF
CENTRAL NERVOUS SYSTEM
(SUPERFICIAL AND DEEP TENDON REFLEX)
By
DR.KAUSHAL SINHA
1st year PG Scholar
Dept of Panchakarma
SDM COLLEGE OF AYURVED &HOSPITAL
HASSAN
1

2. CONTENT:-
1. Introduction
2. Definition
3. Component of reflex
4. Examination of reflex:-
(A) Superficial reflex
(B) Deep tendon reflex
2

3. AN INTRODUCTION TO REFLEX
Reflexes are automatic, subconscious response
to changes within or outside the body.
 Reflexes maintain homeostasis (autonomic
reflexes) – heart rate, breathing rate, blood
pressure, and digestion.
 Reflexes also carry out the automatic action of
swallowing, sneezing, coughing, and vomiting..
 Reflexes maintain balance & posture.
3

4. DEFINITION
 A reflex may be defined as an immediate and
involuntary response to a stimulus.
 A reflex is a fast response to a change in the
body's internal or external environment in an
attempt to restore homeostasis.
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5. COMPONENT OF REFLEX
5
5 Components of Reflex
1.Arrival of stimulus
and activation of
receptor
2.Activation of sensory
neuron
3.Information
processing
4.Activation of motor
neuron
5.Response by effector

6. EXAMINATION OF REFLEX
1.Superficial reflex
2.Deep tendon reflex
1.Superficial reflex
2.Deep tendon reflex
6

7. EXAMINATION TECHNIQUE
Introduce yourself to the patient
The patient should be relaxed.
Explain to the patient the examination technique.
After obtaining the reflex on one side, always go
immediately to the opposite side for the same reflex
so that you can compare them.
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8. Superficial reflex
1. Corneal reflex
2. Palatal reflex
3. Scapular reflex
4. Abdominal reflex
5. Cremasteric reflex
6. Plantar reflex
8

9. SUPERFICIAL REFLEX
 It is a polysynaptic reflex and elicited by cutaneous
stimulation
 Are usually involving moving away from receptor
 They do not depend on muscle stretch receptor
 The abdominal reflex and planter are particularly
important
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10. 1.CORNEAL REFLEX
Nerve segment
 Afferent(sensory) : V
(Trigeminal nerve)
 Centre : Pons
 Efferent(motor) : VII (Facial
nerve)
10

11. TECHNIQUE :-
 Take a wisp of cotton
 Ask the patient look in
opposite direction
 Gently brush the cotton
against the sclera
 This will make the
patient blink
11

12. CONT....
 Normal response:-
 Blink closure of the eye
 Blinking also need 7 CN(Facial nerve) function as it
control eyelid closure
 Absence response:-
 Bells palsy
 Trigeminal neuralgia
 Brain injury 12

13. 3.PALATAL REFLEX
Nerve segment:-
 Afferent(sensory) : V
(Trigeminal nerve)
 Centre : Medulla
 Efferent(motor) : X (Vagus
nerve)
13

14. TECHNIQUE
 Ask the patient open the
mouth
 inspect the palatal arch on
each side for asymmetry.
 Use a tongue blade to
depress the base of the
tongue gently if necessary
 Ask the patient to say
"ahhh" as long as possible
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15. CONT....
 Normal response:-
 Normal palatal arches will constrict and elevate,
and the uvula will remain in the midline as it is
elevated
 The soft palate move up
 Absence response:-
In paralysis there is no elevation or constriction of
the affected side.
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16. 4.SCAPULAR REFLEX
Nerve segment:-
 Afferent(sensory) :
C4-5 nerve
 Centre : C4-5 nerve
 Efferent(motor) :
Dorsal scapular nerve
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17. TECHNIQUE
 Ask the patient stand
with arm abducted 20
degree
 The examiner should
tap the inferior angle of
the scapula with a
reflex hammer
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18. CONT...
 Normal response:-
 contraction of scapular muscle
18

19. 5.ABDOMINAL REFLEX
Nerve segment:-
 Upper abdomen :
T7-T9
 Mid abdomen
T9-T10
 Lower abdomen :
T11-T12 19

20. TECHNIQUE:-
•The patient should be bed in the supine
position and relaxed.
•Uncover the abdomen
•See that his abdomen muscle are well relaxed
•Use a blunt (key,wooden end of a cotton-tip)
object gently stroke on the abdominal skin from
lateral to the medial aspect in four quadrant .
•
•Note the contraction of the abdominal muscles
and deviation of the umbilicus toward the area
stimulus.
20

21.  Normal response:-
 The normal responses is contraction of the
underlying muscle with the umbilicus moving
laterally and up or down depending upon the
quadrant tested.
 Absense response:-
 Abdominal reflexes may be absent in both central
and peripheral nervous system disorders
 Lost in upper motor lesion.
 Obesity
 Eldery patient
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22. 6.PLANTER REFLEX
Nerve segment:-
 Afferent(sensory) :
Tibial nerve
 Segment : L5 –S1,2
 Efferent(motor) :
Tibial nerve
22

23. TECHNIQUE:-
 Ask the patient in a
supine position and tell
him or her that you are
going to scratch the foot
 use the wooden end of
an “orange stick” (thin
stick with cotton wool on
one end) however any
instrument may equally
be used if it is not too
sharp
23

24. CONT.....
 Fixate the foot by grasping the ankle or medial
surface with the examiner's hand that will be closest
to the midline of the patient: examiner's left hand
when the patient's left foot is being tested, and vice
versa with the right foot. Begin with light stroking,
using your finger; then use a blunt object such as
the point of a key.
 The lateral side of the sole of the foot is rubbed
with a blunt instrument or device so as not to cause
pain, discomfort, or injury to the skin; the instrument
is run from the heel along a curve to
the toes (metatarsal pads) 24

25.  Normal response:-
 The normally big toe
will reflex at the
metatarsophalangeal
joint
 Absence:-
 Cold feet
 Relevent muscle paralysis
 Anesthesia of skin of foot
25

26. CREMASTRIC REFLEX
Nerve segment:-
 Afferent(sensory) :
femoral nerve
 Segment : L1,2
 Efferent(motor) :
Genitofemoral nerve
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27. TECHNEQUE
 The cremasteric reflex is a superficial (i.e., close
to the skin's surface) reflex observed in human
males.
 This reflex is elicited by lightly stroking the superior
and medial (inner) part of the thigh regardless of
the direction of stroke. The normal response is an
immediate contraction of the cremaster muscle that
pulls up the ipsilateral testis .
27

28. CONT....
 Normal response:-
 The normal responses contraction of the
cremasteric muscle pulls up the scrotum and
testicle on the side examined
 Absence response:-
 The cremasteric reflex may not be eliciated in
elderly patient
 upper and lower motor neuron disorders,
 spine injury 28

29. DEEP TENDON REFLEX
29
Tendon reflex Spinal root
1. Biceps reflex 5th & 7th cervical
2. Triceps reflex 7th cervical
3. Supinator reflex 6th cervical
4. Knee reflex 2,3,4,lumber
5. Ankle reflex 1 ,2 secral
6. Jaw reflex Tregminal

30. DEEP TENDON REFLEX
 Deep tendon reflex also usually refers to this
sense.
 It is monosynaptic reflex
 A deep tendon reflex is the involuntary contraction
of a muscle in response to stretch
 Tendon reflex tests are used to determine the
integrity of the spinal cord and peripheral nervous
system, and they can be used to detect the
presence of a neuromuscular disease.
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31. BICEPS REFLEX:-
 Spinal root :-
5th,6th cervical
 Muscle:-Biceps brachii
 Nerve:-
musculocutaneous
nerve
31

32. TECHNIQUE:-
 The forearm should be
supported, either resting
on the patient's thighs or
resting on the forearm of
the examiner.
 The arm is midway
between flexion and
extension.
 Place your thumb firmly
over the biceps tendon,
with your fingers curling
around the elbow,
 and tap briskly. The
forearm will flex at the
elbow.
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33.  Normal response:-
 flexion of the muscle
 Visible contraction of the biceps muscle
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34. TRICEPS REFLEX:-
 Spinal root:-
C6-7
 Nerve:- Radial nerve
 Muscle:-Triceps brachii
muscle
34

35. TECHNIQUE:-
 Support the patient's
forearm by cradling it with
yours or by placing it on
the thigh,
 with the arm midway
between flexion and
extension. Identify the
triceps tendon at its
insertion on the
olecranon, and tap just
above the insertion.
 There is extension of the
forearm.
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36.  Normal response:-
 Extension of elbow
 Contraction of the triceps
 Absence response:-
 spondylosis,
 poliomyelitis.
36

37. SUPINATOR REFLEX(BRACIORADIALIS):-
 Spinal root:-
5th -6th cervical
 Nerve:-radial nerve
 Muscle:-brachioradialis
37

38.  The patient's arm should be
supported.
 Identify the brachioradialis
tendon at the wrist. It inserts at
the base of the styloid process of
the radius,
 usually about 1 cm lateral to the
radial artery
 ask the patient to hold the arm
as if in a sling—flexed at the
elbow and halfway between
pronation and supination—
 and then flex Place the thumb of
the hand supporting the patient's
elbow on the biceps tendon while
tapping the brachioradialis
tendon with the other hand.
Observe three potential reflexes
as you tap the forearm at the
elbow 38

39.  Normal response
 contraction of the brachioradialis
 Flexion of the elbow and slight flexion of finger
 Absence response
 Trauma
 polymeylitis
39

40. KNEE REFLEX
40
 Spinal root:-
2nd ,3rd ,4th Lumber

Nerve:- Femoral nerve

Muscle:- Qudriceps

41. KNEE REFLEX (PATELLAR REFLEX)
41
 Ask the patient in a
supine position
 Pass your hand under
the knee to be tested
 Support the relaxed les
with knee flexed at a
little less than 900
 Strike the patellar
tendon midway b/w its
origin and its insertion
 Look for a contraction
of the quadriceps.

42.  Normal response
 Muscles contract, and the contraction tends to
straighten the leg in a kicking motion
 Absence response
 Absence of the reaction suggests that there may be
damage to the central nervous system. The knee
jerk can also be helpful in recognizing thyroid
disease.
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43. ANKLE REFLEX:-
 Spinal root:-
S1,S2
 Nerve:- Tibial nerve
 Muscle:- Achilles
43

44. TECHNIQUE:-
 Ask the patient sit
position.
 The patient leg is
externally rotated and
flexed at the knee.
 The patient forefoot is
gently dorsiflexed and
the achilles tendon
 Than struck with the
knee hammer
44

45.  Normal response:-
 brisk plantarflexion of the foot
 Absence response:-
 usually absent in disk herniations at the L5—
S1 level.
 A reduction in the ankle jerk reflex may also be
indicative of peripheral neuropathy 45

46. JAW REFLEX:-
 Nerve:- Trigeminal nerve
 Muscle:- Masseter
muscles
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47. TECHNIQUE:-
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 Ask the patient open
his mouth.
 Partly open with his
mandible hanging
loosely.
 A finger is placed over
the chin and a
downward stroke is
delivered with the knee
hammer

48.  Normal response:-
 Contraction of jaw-closer muscles; jaw closing
 Absense response:-
 Damage to the trigeminal nerve.
 Facial paralysis
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49. THANK YOU....
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