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METHOD OF PHYSICAL EXAMINATION OF CENTRAL NERVOUS SYSTEM(SUPERFICIAL AND DEEP TENDON REFLEX)

ByDR.KAUSHAL SINHA

1st year PG Scholar Dept of PanchakarmaSDM COLLEGE OF AYURVED &HOSPITALHASSAN

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CONTENT:-1. Introduction2. Definition3. Component of reflex4. Examination of reflex:-(A) Superficial reflex(B) Deep tendon reflex

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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.

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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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COMPONENT OF REFLEX 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

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EXAMINATION OF REFLEX

1.Superficial reflex 2.Deep tendon reflex

1.Superficial reflex

2.Deep tendon reflex

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EXAMINATION TECHNIQUEIntroduce 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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Superficial reflex1. Corneal reflex2. Palatal reflex3. Scapular reflex4. Abdominal reflex5. Cremasteric reflex6. Plantar reflex

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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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1.CORNEAL REFLEX Nerve segment

Afferent(sensory) : V (Trigeminal nerve)

Centre : Pons

Efferent(motor) : VII (Facial nerve)

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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

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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

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3.PALATAL REFLEX Nerve segment:-

Afferent(sensory) : V (Trigeminal nerve)

Centre : Medulla

Efferent(motor) : X (Vagus nerve)

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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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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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4.SCAPULAR REFLEX

Nerve segment:-

Afferent(sensory) : C4-5 nerve

Centre : C4-5 nerve

Efferent(motor) : Dorsal scapular nerve

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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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CONT...Normal response:- contraction of scapular muscle

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5.ABDOMINAL REFLEX

Nerve segment:-

Upper abdomen : T7-T9

Mid abdomen T9-T10

Lower abdomen : T11-T12

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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.

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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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6.PLANTER REFLEX

Nerve segment:-

Afferent(sensory) : Tibial nerve

Segment : L5 –S1,2

Efferent(motor) : Tibial nerve

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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

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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)

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Normal response:-

The normally big toe

will reflex at the metatarsophalangeal joint

Absence:- Cold feet Relevent muscle paralysis Anesthesia of skin of foot

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CREMASTRIC REFLEXNerve segment:-

Afferent(sensory) : femoral nerve

Segment : L1,2

Efferent(motor) : Genitofemoral nerve

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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 .

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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

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DEEP TENDON REFLEX

Tendon reflex Spinal root

1. Biceps reflex 5th & 7th cervical2. Triceps reflex 7th cervical

3. Supinator reflex 6th cervical4. Knee reflex 2,3,4,lumber5. Ankle reflex 1 ,2 secral6. Jaw reflex Tregminal

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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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BICEPS REFLEX:-

Spinal root :- 5th,6th cervical

Muscle:-Biceps brachii

Nerve:- musculocutaneous nerve

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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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Normal response:-

flexion of the muscle

Visible contraction of the biceps muscle

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TRICEPS REFLEX:- Spinal root:- C6-7 Nerve:- Radial

nerve Muscle:-Triceps

brachii muscle

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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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Normal response:-

Extension of elbow Contraction of the triceps

Absence response:-

spondylosis,   poliomyelitis.

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SUPINATOR REFLEX(BRACIORADIALIS):-

Spinal root:-

5th -6th cervical Nerve:-radial nerve

Muscle:-brachioradialis

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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 

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Normal response contraction of the brachioradialis Flexion of the elbow and slight flexion of

finger

Absence response

Trauma polymeylitis

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KNEE REFLEX

Spinal root:-

2nd ,3rd ,4th Lumber

Nerve:- Femoral nerve

Muscle:- Qudriceps

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KNEE REFLEX (PATELLAR REFLEX) 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.

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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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ANKLE REFLEX:-

Spinal root:- S1,S2

Nerve:- Tibial nerve

Muscle:- Achilles

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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

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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

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JAW REFLEX:-

Nerve:- Trigeminal nerve

Muscle:- Masseter muscles

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TECHNIQUE:- 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

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Normal response:-

Contraction of jaw-closer muscles; jaw closing

Absense response:-

 Damage to the trigeminal nerve. Facial paralysis

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THANK YOU....