1. Reflexes: classification. The reflex arc.

Tests of normal reflex function

The term reflez represents an involuntary reaction in response to a stimulus applied to the
periphery and transmitted to the brain or spinal cord.
Reflex arc: The route followd by nervous impulses in a production of a reflex act. The reflex
arc is extremely important for the diagnosis and localization of the nerurological lesion.
The simpliest type of reflez arc consists of 5 obligaroty elements:
- Periferal receptor organ (proprioceptors, skin receptors, and interceptive receptors):
These are special sense organs, located in skin, mucous membranes, connective tissue, muscles
and internal organs. They transform the sensory stimuli into nervous impulses.
- fferent neuron (pseudounipolar cells in spinal or cranial ganglions): Their bodies lie in
the dorsal root ganglia. They have two processes:
* the peripheral one, connects with the receptor
* the central one, connects the cell to the spinal cord.
The impulses through afferent neuron are transmitted via a peripheral nerve to the spinal cord
or brain stem, then transferred to the motoneurons !lower motor neuron" directly or through
an intercalated neuron.
- !entral part (s"napse or associated neuron): #epresents a segment of the spinal cord or
brain stem. $hen the receptor is stimulated, nerve impulses travel along the afferent fibers
entering the spinal cord !or brain stem" by synapse with one or more internuncial neurons,
which act as intermediate or messenger neurons. They relay the impulse to the efferent
neuron.
- #fferent neuron: The cell bodies are located in anterior horns of the spinal cord or in brain
stem, where they represent nuclei of the cranial motor nerves. The axons pass out through
ventral root to the effector organ.
- #ffector organ (muscles or glands that produce the response): %ibers from internuncial
neurons may ascend or descend in the cord to stimulate motor neurons at different segmental
levels of the spinal cord. They may also cross to the opposite side of the spinal cord and
stimulate motor neurons.
&lthough reflex arcs are at the spianl cord level, they may be influenced by the brain via
olivospinal, rubrospinal, reticulospinal, corticospinal, tectospinal and vestibulospinal tracts. The
effect of these motor connections is to suppress the activity of many reflex arcs in the spinal
cord.
$"napse: 'epending upon the number of synapses in one reflex arc, reflex arc can be divided
into monosynaptic and polysynaptic arcs.
Reflexogenic %one: The area where receptor organs lie, and stimulation elicits specific reflex
response.
!lassification:
- ccording to receptors locali%ation:
* deep reflexes !tendon, stretch or myotactic reflexes": stimulation of stretch sensitive
neuromuscular spindle afferent neuron.
* superficial !cutaneous and mucous membrane"
- ccording to num&er of s"napses:
* monosynaptic: only the afferent and the efferent neurons.
* polysynaptic: many neurons and synapses.
- ccording to central part of reflex arc in the !'$:
* in the level of spinal cord ( spinal reflexes,
* in the level of brain stem ( bulbar, pontine, midbrain reflexes,
* in the level of telencephalon or cerebral cortex.
- ccording to efferent organ (muscles or glands):
* somatic nervous system reflexes,
* autonomoic nervous system reflexes.
- ccording to their clinical importance: The reflexes that are of importance for clinics of
neurology may be divided into ) groups:
* superficial !or skin and mucous membrane",
* deep tendon !or myotactic",
* visceral !or autonomic",
* pathological !or abnormal".
#xamination of reflexes:
*t is better when the patient is lying down relaxed with drooping limbs. The examination starts
from the head, continues to the hands and finishes with the legs, symmetrically on both sides
of the body. +everal rules for conducting of examination:
, -xamination must be performed in a .uiet room with optimal temperature.
, The whole length of the hammer/s handle should be used. The hammer/s rubber should be
soft.
, %or each reflex tested, left and right limbs should be similarly positioned and the two sides
should be tested in strict se.uence.
, -nsure that the patient is relaxed. &void telling the patient to relax as this is guaranteed to
produce tension.
, *f the patient does not relax, ask him to perform reinforcement maneuvers ( 0endrassik/s
maneuver, or by isometric contraction of another group of muscles.
, *f the patient does not relax, ask him diverting .uestions: where patient comes from, how
long he is in hospital, and so on.
#xamination of (eep Tendon Reflexes
Tendon reflexes are monosynaptic stretch reflexes at the level of spinal cord.
1esions of the reflex arc, decrease or abolish the reflex response. This is the feature of
lower motor neuron disease. *n severe disease of the muscles !myopathies" the response may
be abolished too.
'escending influences are either inhibitory ! from the corticospinal tract" or facilitory ! from
the cerebellum". 2onse.uently, upper motor neuron dysfunction results in increased reflexes,
whereas cerebellar lesions result in decreased reflexes. 3uscle hypertonia is concomitant with
increased reflexes, and muscle hypotonia with decreased ones.
The symmetry of response on both sides is an essential criterion of normality or absence of
pathology.
)andi&ular reflex: striking with a hammer on index finger !of examiner", placed on patient/s
chin while the mouth is slightly open. The tap stretches the masseter muscles and the
response is sudden closure of the 4aw.
- Reflex arc:
* afferent: mandibular branch of 5th cranial nerve,
* central: pons !nucleus of 5th nerve"
* efferent: mandibular branch of 5th cranial nerve !motor"
* effector organ: masseter muscles.
&bnormal response is prompt closure of the 4aw ! bilateral upper motor neuron damage above
the level of trigem. nuclei in the pons: typical for pseudobulbar palsy, also palmomental and
snout reflex should be checked"
*iceps reflex: striking with the hammer on index finger, which is placed on the tendon of
biceps muscle on antecubital fossa. 2ontraction induces flexion at elbow.
- Reflex arc:
* afferent: musculocutaneous nerve !sensory"
* central: cervical portion of spinal cord !25,25"
* efferent: musculocutaneous nerve !motor"
* effector organ: biceps and brachialis.
Triceps reflex: striking the hammer on short tendon of triceps muscle !6 cm above on
olecranon", when forearm placed across the abdomen and elbow is at about right angle.
2ontraction produces extension of forearm.
- Reflex arc:
* afferent: radial nerve !sensory"
* central: cervical region of spinal cord !27,28"
* efferent: radial nerve !motor"
* effector organ: triceps muscle.
*rachioradial reflex: & blow on lower end of radius. #esponse is flexion of forearm.
- Reflex arc:
* afferent: musculocutaneous nerve !sensory"
* central: cervical portion of spinal cord !25,25"
* efferent: musculocutaneous nerve !motor".
$t"loradial reflex: +triking upon the styloid process of the radius, when forearms are lightly
flexed on the lower part of the abdomen and wrists are positioned between pronation and
supination. #esponse is contraction of flexor muscles of the elbow, pronator muscles and
extensor muscles of the wrist.
- Reflex arc:
* afferent: radial nerve !sensory",
* central: 25,28
* efferent: musculocutaneous, median and radial nerves !motor".
Patellar reflex: +triking with the hammer on patellar tendon of flexed knee at about right
angle. #esponse is contraction of .uadriceps muscle, extension of the leg. &bsence of this
reflex is called $estphal sign.
- Reflex arc:
* afferent: femoral nerve !sensory"
* central: 19,1)
* efferent: femoral !motor".
chilles tendon reflex: +triking with the hammer on &chilles tendon. #esponse is plantar
flexion.
- Reflex arc:
* afferent: tibial nerve !sensory"
* central: +:,+6
* efferent: tibial nerve !motor"
* effector organ: gastrocnemius and soleus muscles.
#xamination of $uperficial Reflexes
3ostly nociceptive reflexes. They are lost in lesions of corresponding reflex arc and also early
in upper motor neuron lesion.
!orneal (con+unctival) reflex: ;atient looks straight ahead. <entle irritation of the cornea
with a small piece of cotton evokes blinking of the eyes.
- Reflex arc:
* afferent: ophthalmic branch of trigeminal nerve !5th cranial",
* central: nucleus of 5th 2= on medulla oblongata,
* efferent: pontine nucleus and axons of facial nerve,
* effector organ: orbicularis oculi muscle.
#eflex is lost in lesions of 5th 2= lesions and of 7th or their central connections in the pons.
&lso reflex is absent when contact lenses cover the cornea.
'asal (snee%e) reflex: *rritaion of nasal membrane.
- Reflex arc: +ensory and motor fibers from 5th, 7th, >th, :?th 2= and spinal nerves of
expiration.
Phar"ngeal (gag) and palatal reflexes: *n position of widely open mouth irritation of the
pharyngeal wall on both sides with a tongue depressor evokes contraction of the pharyngeal
muscles, retching or gagging.
The palatal reflex is also examined by unilateral irritation of the soft palate. #esponse is
raising of soft palate on the same side.
- Reflex arc: sensory and motor fibers of >th and :?th cranial nerves, and their nuclei on
medulla oblongata.
1ack of pharyngeal reflex unilaterally is an evidence of organic lesion.
$uperficial a&dominal reflexes: <ently scratching the abdominal skin from outer aspect
towards the midline:
* 4ust below costal margin !Th7 , Th8": upper abdominal reflex
* at navel level !Th> , Th:?": middle abdominal reflex
* in iliac fossa !Th:: ( Th:6": lower abdominal reflex.
#esponse is contraction of underlying muscles and brief movement of umbilicus toward the
stimulus.
- Reflex arcs:
* upper abdominal: 7,8th intercostal nerves !sensory,motor", 7,8th Th segments of spinal
cord.
* midle abdominal: >,:?th intercostal nerves, >,:?th Th segments of spinal cord.
* lower abdominal: ::,:6th intercostal nerves, ::,:6th Th segments of spinal cord.
@nilateral absence of abdominal reflexes is an early and sensitive sign for contralateral motor
cortex or pyramidal tract lesion. The superficial abdominal reflexes are commonly absent in
multiple sclerosis.
!remasteric reflex: +troking of the inner upper aspect of the thigh with a pin, result is
elevation of the testicle on the same side.
1esions of 1: , 16 spinal segments, roots or genitofemoral nerve will abolish the reflexes.
Plantar reflex: +troking the lateral aspect of the foot from heel to the little toe and
crossing it medially across the metatarsus with a pin, results in rapid hip and knee flexion,
dorsiflexion at ankle and plantar flexion and adduction of the toes !flexor plantar
phenomenon".
- Reflex arc: 15 ( +: ( +6 segments, roots of tibial nerve. &bsence of plantar flexion is an
early sign for pyramidal tract lesion.
nal reflex: +troking with pointed ob4ect the perianal region provokes a contraction of the
external anal sphincter.
- Reflex arc:
* afferent: pudendal nerve !sensory"
* central: +) ( +5 segments
* efferent: pudendal nerve !motor".