Reflex evaluation

Reflexes are the most objective part of the neurologic examination and they are very helpful
in helping to determine the level of damage to the nervous system. We will first discuss the
various reflexes used in clinical practice and will conclude the chapter with a discussion of
the significance of the findings. In some situations, reflexes may be the major part of the
examination (e.g., the comatose patient). They have the value of requiring minimal
cooperation on the part of the patient and of producing a response that can be objectively
evaluated by the examiner. A list of all possible reflexes would be almost endless and a
tangle of eponymic jargon for those with an historical bent. It is necessary to know the most
commonly elicited reflexes and this knowledge is not terribly difficult to acquire. However,
the interpretation of the reflex response requires some discussion. Table 8-1 is a list of many
reflexes, some of them in common clinical use (and some less common). As a group, these
reflexes can aid in evaluation of most of the segmental levels of the nervous system from the
cerebral hemisphere through the spinal cord.

TABLE 8-1.- THE MOST COMMONLY TESTED REFLEXES

(*These reflexes are considered part of a routine screening examination for neurologic disease. The other
reflexes are examined when suspicion of abnormality exists on the basis of history or screening examination.)

Stretch reflexes (deep Jaw jerk V sensory (s) and

tendon reflexes) motor (m)
Biceps* C5-6 (s,m)
Triceps* C6-7 (s,m)
Brachioradialis* C6,7,8 (s,m)
Finger flexor C6,7,8 (s,m)
Knee* L2,3,4 (s,m)
Ankle* S1,2 (s,m)
Superficial reflexes Corneal * V (s) and VII (m)
Nose tickle V (s) and VII+ (m)
Gag* IX, X (s,m)
Abdominal T7-TI2 (s,m)
Cremasteric S1 (s,m)
Plantar* S1,2 (s,m)
Anal wink S4,5 (s,m)
Visceral (autonomic) Pupillary-light & II (s) and III (m)
reflexes accommodation*
Oculocardiac V (s) and X (m)
Carotid sinus IX (s) and X (m)
Bulbocavernosis S2, 3, 4 (s,m)
Rectal (internal S2, 3, 4 (s,m)
sphincter)
Orthostatic blood IX (s), X &
pressure and pulse sympathtics (m)
change
"Primitive" reflexes Glabellar Associated with
Forced grasping (feet bilateral hemispheric
 and hands) dysfunction (especially
Feeding reflexes frontal lobe; see
(sucking, biting, Chaps. 2 and 16).
rooting)
Oculocephalic and
nuchocephalic
disinhibition
Miscellaneous Vestibulo-ocular VIII (s) and
responses (see Chap. extraocular (III, IV,
3) VI) (m)
Oculocephalic reflex
Caloric irrigations

In this chapter we will discuss the evaluation of commonly tested reflexes of the spinal cord.
We have previously considered reflexes involving the cranial nerves such as the pupillary
light reflex, the jaw-jerk reflex, the baroreceptor reflex and gag. We have also discussed
reflex eye movements and many of the autonomic reflexes (such as the oculocardiac and the
pupillary light reflex). Here we will consider muscle stretch reflexes and superficial reflexes
that are used to evaluate sensorimotor function of the body.

All reflexes, when reduced to their simplest level, are sensorimotor arcs. At the minimum,
reflexes require some type of sensory (afferent) signal, and some motor response. While the
simplest of reflexes involve direct synapse between the sensory fiber and the motor neuron
(monosynaptic), many reflexes have several neurons interposed (polysynaptic reflexes).

It is important to note that, even with the simplest of reflexes, there are multiple inhibitory
and facilitatory influences that can affect the excitability of the motor neuron and thus
amplify or suppress the response. These influences can arise from various levels of the
nervous system. There are intrasegmental and intersegmental connections in the spinal cord,
as well as descending influences from the brain stem, cerebellum, basal ganglia and cerebral
cortices. All of these can influence the excitability of motor neurons, thereby altering reflex
response.

Lesions that damage the sensory or motor limb of a reflex arc will diminish that reflex. This
can occur at any level of the sensory or motor pathway (in the case of the muscle stretch
reflex, for example, this can include: the peripheral nerve and receptors; the dorsal root or
dorsal root ganglion; the spinal cord gray matter; the ventral root; the peripheral nerve; the
neuromuscular junction; or the muscle).

Most of the pathways that descend the spinal cord have a tonic inhibitory effect on spinal
reflexes. For this reason, the net result of lesions that damage the descending tracts is
facilitation of reflexes that are mediated at only the level of the spinal cord (a classic example
being the muscle stretch reflex). With few exceptions, this means that these spinally mediated
reflexes become hyperactive. After acute lesions, spinal reflexes often pass through an initial
stage of hypoactivity. This stage has been called "spinal shock" or diaschisis and is more
severe and long lasting in proportion to the degree of damage. For example, transection of the
spinal cord removes the greatest amount of higher influence and may be associated with
weeks of hypoactivity. Small lesions may have little effect on reflexes. When reflexes return
after spinal transection, they become extremely hyperactive.

Some reflexes, such as the muscle stretch reflex, are semi-quantitatively graded. This is also
true for responses such as the pupillary light reflex, where the speed of reaction may indicate
a "sluggish" response. On the other hand, many reflexes are simply noted as present or
absent. This is true of the superficial reflexes (see Table 8-1) and the "primitive reflexes" that
are associated with diffuse bilateral hemispheric dysfunction. In this latter case, the reflexes
are often designated as "dysinhibited" because these are infantile responses that are
suppressed in the normal adult nervous system.

Examination of myotatic ("deep tendon") reflexes

The muscle stretch (myotatic) reflex is a simple reflex, with the receptor neuron having direct
connections to the muscle spindle apparatus in the muscle and with the alpha motor neurons
in the central nervous system that send axons back to that muscle (Figure 8-1).

Normal muscle stretch reflexes result in contraction only of the muscle whose tendon is
stretched and the agonist muscles (i.e., muscles that have the same action). There is also
inhibition of antagonist muscles.

Reflexes are graded at the bedside in a semi-quantitative manner. The response levels of deep
tendon reflexes are grade 0-4+, with 2+ being normal. The designation "0" signifies no
response at all, even after reinforcement. Reinforcement requires a maximal isometric
contraction of muscles of a remote part of the body, such as clenching the jaw, pushing the
hands or feet together (depending on whether an upper or lower limb reflex is being tested),
or locking the fingers of the two hands and pulling (termed the Jendrassik maneuver). This
kind of maneuver probably amplifies reflexes by two mechanisms: by distracting the patient
from voluntarily suppressing the reflex and by decreasing the amount of descending
inhibition.

The designation 1+ means a sluggish, depressed or suppressed reflex, while the term trace
means that a barely detectible response is elicited. Reflexes that are noticeably more brisk
than usual are designated 3+, while 4+ means that the reflex is hyperactive and that there is
clonus present. Clonus is a repetitive, usually rhythmic, and variably sustained reflex
response elicited by manually stretching the tendon. This clonus may be sustained as long as
the tendon is manually stretched or may stop after up to a few beats despite continued stretch
of the tendon. In this case it is useful to note how many beats are present.

One sign of reflex hyperactivity is contraction of muscles that have different actions while
eliciting a muscle stretch reflex (for example, contraction of thigh adductors when testing the
patellar reflex or contraction of finger flexor muscles when testing the brachioradialis reflex).
This has been termed "pathological spread of reflexes."

Practice observing normal reflexes in patients and initially among students is an excellent
way to determine the range of normalcy. Almost any grade of reflex (outside of sustained
clonus) can be normal. Asymmetry of reflexes is a key for determining normalcy when
extremes of response do not make the designation obvious. The patient's symptoms may
facilitate the determination of which side is normal, i.e., the more active or the less active
side. If this is a problem, the remainder of the neurologic examination and findings usually
clarify the issue.

Decreased reflexes should lead to suspicion that the reflex arc has been affected. This could
be the sensory nerve fiber but may also be the spinal cord gray matter or the motor fiber. This
motor fiber (the anterior horn cell and its motor axon coursing through the ventral root and
peripheral nerve) is termed the "lower motor neuron" (LMN). LMN lesions result in
decreased reflexes. The descending motor tracts from the cerebral cortex and brain stem are
termed the "upper motor neurons" (UMN). Lesions of the UMNs result in increased reflexes
at the spinal cord by decreasing tonic inhibition of the spinal segment.

Lesions of the cerebellum and basal ganglia in humans are not associated with consistent
changes in the muscle stretch reflex. Classically, destruction of the major portion of the
cerebellar hemispheres in humans is associated with pendular deep-tendon reflexes. The
reflexes are poorly checked so that when testing the patellar reflex, for example, the leg may
swing to-and-fro (like a pendulum). In normal individuals, the antagonist muscles (in this
example, the hamstrings) would be expected to dampen the reflex response almost
immediately. However, this is not a common sign of cerebellar disease and many other signs
of cerebellar involvement are more reliable and diagnostic (see Chapter 10). Basal ganglia
disease (e.g., parkinsonism) usually is not associated with any predictable reflex change;
most often the reflexes are normal.

Superficial reflexes

Superficial reflexes are motor responses to scraping of the skin. They are graded simply as
present or absent, although markedly asymmetrical responses should be considered abnormal
as well. These reflexes are quite different from the muscle stretch reflexes in that the sensory
signal has to not only reach the spinal cord, but also must ascend the cord to reach the brain.
The motor limb then has to descend the spinal cord to reach the motor neurons. As can be
seen from the description, this is a polysynaptic reflex. This can be abolished by severe lower
motor neuron damage or destruction of the sensory pathways from the skin that is stimulated.
However, the utility of superficial reflexes is that they are decreased or abolished by
conditions that interrupt the pathways between the brain and spinal cord (such as with spinal
cord damage).

Classic examples of superficial reflexes include the abdominal reflex, the cremaster reflex
and the normal plantar response. The abdominal reflex includes contraction of abdominal
muscles in the quadrant of the abdomen that is stimulated by scraping the skin tangential to or
toward the umbilicus. This contraction can often be seen as a brisk motion of the umbilicus
toward the quadrant that is stimulated. The cremaster reflex is produced by scratching the
skin of the medial thigh, which should produce a brisk and brief elevation of the testis on that
side. Both the cremaster reflex and the abdominal reflex can be affected by surgical
procedures (in the inguinal region and the abdomen, respectively). The normal planter
response occurs when scratching the sole of the foot from the heel along the lateral aspect of
the sole and then across the ball of the foot to the base of the great toe. This normally results
in flexion of the great toe (a "down-going toe") and, indeed, all of the toes. The evaluation of
the plantar response can be complicated by voluntary withdrawal responses to plantar
stimulation.

The "anal wink" is a contraction of the external anal sphincter when the skin near the anal
opening is scratched. This is often abolished in spinal cord damage (along with other
superficial reflexes).

"Pathological reflexes"

The best known (and most important) of the so-called "pathological reflexes" is the Babinski
response (upgoing toe; extensor response). The full expression of this reflex includes
extension of the great toe and fanning of the other toes. This is actually a superficial reflex
that is elicited in the same manner as the plantar response (i.e., scratching along the lateral
aspect of the sole of the foot and then across the ball of the foot toward the great toe). This is
a primitive withdrawal type response that is normal for the first few months of life and is
suppressed by supraspinal activity sometime before 6 months of age. Damage to the
descending tracts from the brain (either above the foramen magnum or in the spinal cord)
promotes a return of this primitive protective reflex, while at the same time abolishing the
normal plantar response. The appearance of this reflex suggests the presence of an upper
motor neuron lesion.

Evaluation of reflex changes

We now list the reflex changes associated with dysfunction at various levels of the nervous
system.

1. Muscle: Stretch reflexes are depressed in parallel to loss of strength.

2. Neuromuscular junction: Stretch reflexes are depressed in parallel to loss of
strength.
3. Peripheral Nerve: Stretch reflexes are depressed, usually out of proportion to
weakness (which may be minimal). This is because the afferent arc is involved early
in neuropathy.
4. Nerve root: Stretch reflexes subserved by the root are depressed in proportion to the
contribution that root makes to the reflex. Superficial reflexes are rarely depressed
since there is extensive overlap in the distribution of individual nerve roots of the skin
and muscle tested in the superficial reflexes. However, extensive nerve root damage
can depress superficial reflexes in proportion to the amount of sensory loss in the
dermatomes tested or the motor loss in the involved muscles.
5. Spinal cord and brain stem: Stretch reflexes are hypoactive at the level of the lesion
and hyperactive below the level of the lesion. As noted, during the initial state of
 spinal shock following acute lesions, the spinal reflexes below the lesion are also
hypoactive or absent.
o Superficial reflexes are hypoactive at and below the level of the lesion and
normal above. The abdominal superficial reflexes are not reliably present in
normal individuals who are excessively obese, who have abdominal scars, or
who have had multiple pregnancies, and they are frequently poorly elicited in
otherwise normal elderly persons. Therefore, though classically depressed in
persons with corticospinal system involvement, one should not place great
emphasis on depressed abdominal reflexes if they are the only abnormality
found in the examination. The plantar response is an extremely important
superficial reflex. Not only does this normal respons disppear when upper
motor neurons are damaged, the normal response is replaced by an extensor
(Babinski) response.
6. Cerebellum: Classically the stretch reflexes are hypoactive and pendular as
mentioned above. When this is so, the test is reliable; however, more often than not,
the reflexes are not visibly abnormal.
7. Basal ganglia: There are no consistent deep-tendon or superficial reflex changes.
There may be the appearance of some of the "primitive reflexes" (e.g., the glabellar,
oculocephalic, grasp, and feeding reflexes, see Chapter 2) associated with some
diffuse cerebral dysfunction (dementia).
8. Cerebral cortex: Unilateral disease affecting the motor cortex will produce an upper
motor neuron pattern of weakness (i.e., hyperactive muscle stretch reflexes and
depressed or absent abdominal and cremasteric reflexes) on the contralateral side.
Additionally, there may be a Babinski response.
o Bilateral disease is associated with the same abnormalities bilaterally, and in
addition, there may be "primitive reflexes" due to release of these responses
from cortical inhibition (see Chapter 2).
o With bilateral damage to the motor cortex (particularly when the corticobulbar
system is heavily affected), inhibitory control of the complex emotional
expression reflexes becomes defective. These individuals cry or laugh with
minimal emotional provocation and the patient usually says that they do not
understand why they are crying or laughing. These complex emotional
reflexes are subserved by the limbic system and are normally under inhibitory
modulation by the neocortex. Bilateral damage may release these responses in
a pattern that is termed "pseudobulbar" (see Chpt. 5).

References

DeJong, R.N.: The Neurologic Examination, ed. 4. New York, Paul B. Hoeber, Inc.,
1958.
Monrad-Krohn, G.H., Refsum S.: The Clinical Examination of the Nervous System,
ed. 12, London, H.K. Lewis & Co., 1964.
Wartenberg, R.: The Examination of Reflexes: a Simplification. Chicago, Year book
Medical Publishers, 1945.