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To be able to perform stretch reflexes accurately, you need the following:
If there is an abnormal reflex response within the extremities, perform the Jendrassik Maneuver before actually documenting it as abnormal. The
Jendrassik Maneuver is a distracting mechanism of reinforcement. To perform the
Jendrassik Maneuver, the individual is requested to place their clasped hands in front of them, direct their gaze towards the ceiling, and await the verbal cue to pull. (Regardless of the tendon being tested, the individual should never watch the process being performed.) As the practitioner is about to percuss the tendon site, they request the individual to pull their clasped hands as hard as they can without letting go. The practitioner simultaneously strikes the tendon and observes for the stretch response. Clenching the teeth on cue also serves in the evaluation of the absent response in the upper extremities. Each reflex must be tested on each limb and the two sides compared. Bilateral response is the key to interpretation.
In concert with muscle testing, nerve supply and dysfunction may be determined by segmental level. As muscles which have myofascial trigger points typically test weak, muscle testing must be viewed as a composite picture that is only accurate when numerous muscles supplied by the same segmental level are affected. Reflex response references several segmental groups responsible for contraction within a spinal region. The values determining reflex response or grading it, is as follows:
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Tendon Reflexes
Grade
Response
0
No response exhibited with reinforcement maneuvers.
+1
Demonstrated response only with reinforced maneuvers (such as the Jendrassik Maneuver).
+2
Exhibits moderate response with no reinforcement.
+3
Exhibits brief response with temporary twitch response
of 1-3 seconds (clonus).
+4
Exhibits hyper responsiveness with sustained clonus.
UPPER LIMBS
Triceps Reflex (C6, C7, C8)
With the individual’s elbow supported in the practitioner’s hand, the triceps are sharply percussed just above the olecranon. Contraction of the triceps with extension of the forearm should result.
Biceps Reflex (C5, C6)
With the patient sitting erect and their forearm extended in a semi-flexed position in front of them. The practitioner utilizes their non-dominant hand and places their thumb on top of the biceps tendon at its distal attachment, approximately 1-2 inches from the fold in the arm, and curls the fingers of the non-dominant hand around the posterior aspect of the upper arm. With their dominant hand holding the percussion hammer, the practitioner strikes their thumb of the non-dominant hand and observes for a mild to moderate contraction flexion effort of the forearm.
Brachioradialis Reflex (C5, C6)
With the individual’s arm extended, the practitioner should palpate for the brachioradialis muscle, which can be felt on the radial surface of the mid to upper forearm. The practitioner should then repetitively strike the tendon lightly along the course of the radius until a radial deviation of the wrist and the thumb; or an extension of the wrist, index finger, or middle finger is observed.
LOWER LIMBS
Patella (Knee) Reflex (L2, L3, L4)
After locating the patella tendon by palpation, the practitioner should tap lightly with a percussion hammer, utilizing increasing force until contraction of the Quadriceps muscles can be elicited. The individual may be seated on the edge of a table or bed with their legs hanging loosely. In bedridden individuals, the knees are flexed over the supporting arm of the practitioner.
Achilles (Ankle) Reflex (S1, S2)
This is best preformed by having the individual kneel on a table or chair, with their ankles and feet projecting over the edge. By grasping either the top of the chair or side of the table, when using the four point kneeling posture, Jendrassik distraction is accomplished. Regardless whether this is performed in the less qualitative seated position or recommended kneeling position, the practitioner is monitoring plantar flexion upon percussing of the Achilles tendon. This reflex is frequently obtained in bedridden individuals with the optimum position being one in which the thigh is externally rotated and the knee flexed at approximately a 45-degree angle. While the Achilles tendon response can be difficult to obtain, it is recommended that the practitioner make contact to the plantar surface of the foot while percussing the tendon. This plantar contact aids the practitioner in determining the response.
Plantar Response (L4, L5, S1, & S2)
With the thigh in slight external rotation, the outer surface of the sole of the foot is stroked lightly with a large pin or wooden applicator from the heel toward the base of the little toe and then inward across the ball of the foot. Normal plantar response usually consists of plantar flexion of the distal portion of the foot. One abnormal response may be an extension of the great toe with fanning and flexion of the other toes (Babinski reflex). This reflex response is indicative of a neurologic lesion, especially when located in the pyramidal tract.
Muscle Stretch Reflexes or Deep Tendon Reflex Response
If reflex response is absent, either unilaterally or bilaterally, sensory motor function should also be evaluated. A +4 hyperactivity either of a unilateral or bilateral nature is indicative for further evaluation of motor function, sensory function, or clonus. An abnormal plantar response (Babinski) is considered conclusive of pyramidal tract involvement. While there are numerous other maneuvers, they are less reliable and can induce trauma if not performed properly; therefore, they are being excluded.
Superficial Reflexes
If there is a question about a lesion affecting a spinal cord level, (a subtle unilateral corticospinal lesion, or a cortical lesion) have the individual lie supine and with a feather or cotton wisp stroke the four quadrants of the abdominal skin, looking for the movement of the umbilicus in response to the stimulation. Normally the umbilicus is pulled slightly toward the quadrant being stimulated. The upper quadrants test T7-T9 and the lower quadrant test T11-L1.