DTRs Flashcards
Reflexes are an__________________ response ( predictable response is what we are looking for )
involuntary, stereotyped
Reflexes are a unit of ____________ and _____________ function.
sensory (afferent)
motor (efferent)
Reflexes depend on ?
Intact sensory nerve fibers
Functional synapses in spinal cord
Intact motor nerve fibers
Functional neuromuscular junctions
Competent muscle fibers
DTRs helpful in ?
Can help to localize a lesion
Correlate with motor and sensory findings
DTR: Ankle (Achilles) ?
S1
DTR: Knee (Patellar) ?
L 2, 3, 4
DTR: Supinator (Brachioradialis) ?
C 5, 6
DTR: Biceps ?
C 5, 6
DTR: Triceps ?
C 6, 7
Cutaneous Reflexes: Abdominal – upper ?
T 8, 9, 10
Cutaneous Reflexes: Abdominal – Lower ?
T 10, 11, 12
Cutaneous Reflexes: Plantar (Babinski) ?
L5, S1
Cutaneous Reflexes: Anal ?
S 2, 3, 4
DTR: To elicit a reflex ?
Patient must be relaxed!
Strike briskly with wrist movement
Patient can be supine or sitting for all
**the patient need to be completely relaxed
hit hard enough to get a response ( same strength on each side to elect a reflex)
pointed end for smaller areas and bigger end for bigger area **
DTR: Response is affected by your force ?
Use as little force as needed to elicit a response
Compare bilaterally
Rate DTR’s on ______ scale
0-4/4
**pulse 0-3
strength 0-5 ( 5/5 is NL)
reflex 0-4
some people just have really bad reflexes and it can be normal **
DTR: 0/4 ?
absent, areflexia
DTR: 1/4 ?
low normal, hyporeflexia
DTR: 2/4 ?
average, NORMAL
DTR: 3/4 ?
above average, +/- assoc. with disease
DTR: 4/4 ?
very brisk, hyperactive, with clonus
(rhythmic oscillations) hyperreflexia
DTR: Use _________ for barely detectable response
reinforcement
**distracted to improve results **
DTR: Isometric contraction of other muscles: UE ?
clench teeth
DTR: Isometric contraction of other muscles: LE ?
lock fingers and pull hands
DTR: Biceps and location ?
C5, C6
Partial elbow flexion, press on tendon, strike own finger, watch and feel for response
**thumb on tendon and then u hit yours thumb ( easier to find the tendon with you thumb) - looking for bicep to control = hand will move or the tendon will tighten up and it will push against your finger ( tighten is most common) **
DTR: Triceps and location ?
C6, C7
OR – arm abducted, elbow flexed
DTR: Brachioradialis and location ?
C5, C6
Use flat edge of hammer, 1-2” above wrist
Hand on lap, partially pronated – watch for forearm supination and flexion
DTR: Patellar and location ?
L2, L3, L4
Flex knee, strike below patella
DTR: Achilles and location ?
S1
Support foot in neutral position
**keep foot in little dorsiflexion
because reflex makes foot plantar flex and if it is already in flexion then it has not were to move **
DTR: Clonus ?
hythmic oscillation response
Eg: Dorisflex and plantar flex foot a few times, then sharply dorsiflex foot, hold it there and feel for “beats”
**keep beating after the reflex should be over **
Clonus NL ?
A few beats of clonus can be normal if tense or after exercise
Sustained clonus can indicate CNS disease
Cutaneous Stimulation Reflexes: Plantar (Babinski) and location ?
L5, S1
Use a key or wooden end of cotton applicator
Stroke foot, curving medially over ball of foot
Normal – plantar flexion
Abnormal - fanning of toes
Plantar (Babinski) NL ?
plantar flexion
Plantar (Babinski) abnormal ?
fanning of toes
Cutaneous Stimulation Reflexes: Abdominal Reflexes ?
4 quadrants – upper and lower
Stroke toward umbilicus
Note umbilical deviation toward stimulus
Obesity can mask
Cutaneous Stimulation Reflexes: Anal and location ?
S 2, 3, 4
Dull object (cotton swab)
Stroke outward from anus in 4 quadrants
Watch for reflex contraction of the anal musculature
Recording DTR’s NL ?
All reflexes 2+/4 throughout
Recording DTR’s abnormal ?
All reflexes 2+/4 except_______
Or diagram
Special Maneuvers: Meningeal signs ?
if meningitis is suspected. Don’t do on trauma patients!
Neck mobility (nuchal rigidity) – supple flexion
Brudzinski’s sign
Kernig’s sign
- *Inflammation in the subarachnoid space causes resistance to movement that stretches the spinal nerves (neck flexion), the femoral nerve(Brudzinski) or the sciatic nerve (Kernig).
- *
Brudzinski’s sign positive ?
Positive = flexion of hips and knees in response to neck flexion
**flexion of neck stretches femoral nerve **
Kernig’s sign
Positive?
Positive = pain b/l behind knee when flexed knee is extended
**stretch on the sciatic nerve - sign of meningitis
pain behind the knee not just discomfort **
Asterixis: Helps identify metabolic _______________ when mental functions are impaired
encephalopathy
Liver disease, uremia, hypercapnia
Asterixis procedure ?
Ask patient to “stop traffic” – both arms extended, hands cocked up and fingers spread
Watch for 1-2 minutes
Asterixis positive ?
Positive if sudden, brief nonrhythmic flexion of hands and fingers
Stuporous or Comatose Patient: facts ?
Typically evaluation sequence is H&P, Labs
These patients require a different sequence of evaluation
Stuporous or Comatose Patient sequence of evaluation ?
ABC’s - first
Level of consciousness
Neuro exam
Info from relatives, friends, witnesses
Stuporous or Comatose Patient sequence of evaluation: DO NOT DO THESE?
DO NOT
Dilate the pupils - can mask signs
Flex the neck - make C-spine trauma worse
Comatose Patient: ABC’s ?
Skin color and breathing pattern
Check posterior pharynx, listen for stridor
Consider intubation
Pulse, BP and RECTAL temp ( more reflective or core temp.)
IV access/fluids
Comatose Patient: level of consciousness ?
Alert
Lethargic – drowsy but arousable. Answers questions, then back to sleep
Obtunded – opens eyes, responds but slow and confused
Stuporous – require painful stimulus to arouse
Comatose - unarousable
Comatose Patient : Posture and Tone- In response to painful stimulus NL ?
avoidant
Comatose Patient : Posture and Tone- In response to painful stimulus - stereotypical ?
Decorticate - flexion abnormal
Decerebrate - extension abnormal
Comatose Patient : Posture and Tone- In response to painful stimulus - flaccid ?
no response, no tone
Vertical forearm, wrist at 90
Raise arm 12” off bed and drop it
Stereotypic response – painful stimulus evokes a postural response
: Decorticate rigidity ?
flexor response
Stereotypic response – painful stimulus evokes a postural response: Decerebrate rigidity ?
extensor response
Decerebrate rigidity lesion location ?
Lesion in diencephalon, midbrain or pons
Decerebrate rigidity severe what can cause this ?
Or severe metabolic disorder – hypoxia, hypoglycemia
Decorticate rigidity location of lesion ?
Lesion of corticospinal tracts in or near cerebral hemispheres
Comatose Patient: Oculocephalic Reflex (Doll’s eyes) procedure ?
Hold eyelids open
Turn head side to side
Oculocephalic Reflex (Doll’s eyes): If brainstem is intact ?
– eyes turn to keep looking at the same spot
** good - the eyes staying pointed forward **
Oculocephalic Reflex (Doll’s eyes): If brainstem lesion ?
– eyes move with head
- *if eyes go with head = bad!
- *
Oculovestibular reflex (caloric test) procedure ?
Head at 30°
Cold water into EAC
Eyes deviate toward water if brainstem is intact (initial nystagmus away)
Comatose Patient: pupils inspection ?
size, equality, response to light
Comatose Patient: pupils - structural cause of coma ?
no response
Comatose Patient: pupils - Metabolic cause of coma ?
positive response
Comatose Patient: ocular movements ?
eyes should be straight ahead at rest
Comatose Patient – Signs of Poor Outcome or Death ?
Absent corneal reflex - wisp of cotton on cornea
Absent pupillary response
Absent withdrawal response from pain
No motor response
At 72 hours, no motor response
Involuntary Movements types ?
Tremors
Orofacial dyskinesias
Tics
Chorea
Athetosis (athetoid movement)
Tremors 3 types ?
Resting (Static)
Postural
Intention
Tremor: Resting (Static) ?
↑ at rest, ↓ or gone with voluntary movement
ex: Parkinsonism
Tremor: Postural ?
↑ with maintaining a posture
ex: anxiety, fatigue, hyperthyroidism
Tremor: Intention ?
absent at rest, appears with activity, worse as closer to target
ex: MLS, cerebellar dz
Orofacial dyskinesias ?
Repetitive bizarre movements of face, mouth, jaw, tongue
Orofacial dyskinesias are seen with ?
longstanding psychoses
elderly
edentulous
long term complication of certain psychotropic drugs (tardive dyskinesia)
**sometimes it is drug induced **
Tics ?
brief, repetitive, coordinated movements at irregular intervals
Tics examples ?
Wink
Grimace
Shoulder shrug
Tics seen with ?
Seen with Tourette’s, certain meds, etc.
Chorea – (choreiform movement) description ?
Unpredictable, non-repetitive
brief, rapid, jerky, irregular
Chorea can involve what ?
can involve face, head, forearms, hands
Chorea can occur at ?
can occur at rest or interrupt activity
Chorea examples disease ?
Huntington’s disease
Athetosis (athetoid movement) description ?
Slow, twisting, writhing movement of face or distal extremity
twisting movement of hand
Athetosis associated with ?
Often associated with spasticity
Athetosis example disorder ?
cerebral palsy
Abnormalities of Gait and Posture types ?
Spastic Hemiparesis
Steppage Gait
Scissors Gait
Parkinsonian Gait
Cerebellar Ataxia
Sensory Ataxia
Spastic Hemiparesis lesion ?
Corticospinal tract lesion from stroke
Spastic Hemiparesis description ?
Poor control of flexor muscles during swing phase
Spastic Hemiparesis affected arm is ?
flexed and immobile
Spastic Hemiparesis affected ankle is ?
plantar-flexed and inverted
Toe drags, may circle leg stiffly outward or lean
leg is not bending
**“swing around cause flexors are not really good “ **
Steppage Gait seen in ?
Seen in foot drop, secondary to peripheral motor unit disease
Steppage Gait
patients either ?
Patients either drag their feet or lift them high with knees flexed and bring foot down with a slap
Unilateral or bilateral
Steppage Gait cannot ?
heel walk
**foot drop so toes dont pick up unless they pick there knee up
no heel walking and it can be B/I **
Scissors Gait seen in ?
Spinal cord disease
ex: CP
Scissors Gait description ?
Bilateral lower extremity spasticity
Legs are advanced slowly and thighs tend to cross
Scissors Gait: gait is ?
stiff
Parkinsonian Gait seen in ?
Basal ganglia defects of Parkinson’s
Parkinsonian Gait
has _________ posture ?
stooped
Parkinsonian Gait: ______ of head, arms, hips and knees
Flexion
Parkinsonian Gait
extra facts ?
Slow to start
Shuffling gait with short steps
Decreased arm swing
Patients turn slowly “all in one piece”
**once they get going they move faster but they have hard time stopping and run into stuff
difficulty initiated gait
masked facies **
Cerebellar Ataxia
disease of ?
cerebellum
Cerebellar Ataxia description ?
Staggering, wide base, unsteady
Cerebellar Ataxia have exaggerated difficulty with ?
turns
Cerebellar Ataxia: Can’t stand steadily with ?
feet together
Sensory Ataxia description ?
Loss of position sense in the legs
Wide base, unsteady
Sensory Ataxia patients throw ?
Pts throw feet forward, bring them down on heels with a double tap.
They watch the ground for guidance
Can’t stand steadily with feet together (+Romberg)
Sensory Ataxia versus Cerebellar Ataxia ?
two types of ataxia but the gait is similar
wide gait cause they dont have balance
Screening Neuro Exam -AAN: Mental status ?
Level of alertness,
appropriateness of responses,
orientation to date and place
Screening Neuro Exam -AAN: Cranial nerves ?
Visual acuity, pupillary light reflex, EOM’s
Hearing
Facial strength – smile, eye closure
Screening Neuro Exam -AAN: motor system ?
Strength – shoulder, elbow, wrist, finger, hip, knee, ankle
Gait – casual and tandem
Coordination – fine finger movements, finger-to-nose
Screening Neuro Exam -AAN: sensory system ?
One modality at toes (light touch, pain/temp or proprioception)
Screening Neuro Exam -AAN: reflexes ?
DTR’s – biceps, patellar, Achilles
Plantar response (Babinski)
If anything is suspicious, then more complete exam is required
Neurologic Exam: last slide ?
Use your equipment for visual cues
Sample write up p.739 Bates
