Girth Sensory Perception and Reflexes - The Supply Center · 2020. 10. 29. · The practitioner would use the C8 dermatome on the left comparing to the right C6 dermatome. If the

Neurological: Part 3Girth Measurements, Sensory Perception and

Reflexesby Dr. Kevin McNamee, DC, L.Ac.

The purpose of neurological tests involving a musculo-skeletal complaint is to find anynervous system lesions – an interference of any type to the normal function of thenervous system. The neurological testing to consider and/or perform includes:

1. mental status, 2. cerebellar testing for coordination, 3. deep tendon reflexes, 4. superficial reflexes, 5. pathologic reflexes, 6. cranial nerve testing, 7. measuring body parts (girth), 8. grading muscular strength and 9. gross sensory perception.

Part 3 discusses the measurement of the girth for the upper and lower extremities,sensory perception and reflexes. To conduct a neurological exam, the equipmentneeded that should also be part of the practitioners available tools, includes the follow-ing:

Equipment for a Neurological Evaluation

PenlightTongue bladeSterile needlesTuning forks, 128 Hz and 512 HzFamiliar objects – coins, keys, paper clipCotton wispReflex HammerVials of aromatic substances – coffee, orange, peppermint extract, oil of clovesVials of solutions – glucose, salt, lemon or vinegar, or quinine – with applicatorsTest tubes of hot and cold water fro temperature sensation testingTape measureJ-mar Grip Strength Hand Dynometer

Mensuration of Body Parts (Girth Measurements)

Mensuration of body parts is used to determine, atrophy, functional and/or anatomicabnormalities. All measurements of the patients extremities are to be in the non-con-

1Copyright 2009 by Dr. Kevin McNamee, DC, LAc Please do not duplicate in any manner

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tracted state. Common areas of mensuration are:

Upper Extremity Circumference of the brachium and antebrachium as measured in the non-contracted state. When recording the measurements in the notes. Indicate which side is injured and which is the major extremity.

Measuring the Arm Girth: (Brachium)With the extremity hanging relaxed at the side, place the tape around the arm at the mid-biceps just approximating the skin without tension. Measure opposite arm at same level. Report injured over uninjured side.

Measuring the Forearm Girth: (Antebrachium)With the upper extremity hanging relaxed at side, apply tape at maximumcircumference of forearm. Apply tape so that it just approximates the skin without tension and report as injured over uninjured side.


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Lower Extremity Circumferences (thigh and calf) as measured in the non-contracted state. Girth measurements of the lower extremities are to be made with the patient supine in the anatomical position.

Measuring Thigh Girth: Measure the girth of the thigh at a point one-third of the distance from the upper pole of the patella to the umbilicus. The tape should just approximate the skin without tension and with muscles relaxed.

Measuring Calf Girth: Measure the circumference of the calf at the largest diameter of calf muscles. Record the distance from the lower poleof the patella to the location of the girth measurement.


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Hold the measuring tape perpendicular to the thigh. Using light pressure, measure the girth.

Sensory Perception

The sensation portion of a nerve root is evaluated for the sensations of Sharp/Dull,Light Touch, Vibration, Temperature and Two Point Discrimination, among others. Eachnerve root corresponds to specific areas of the body. The location of the dermatomesare usually consistent from patient to patient, however, in various textbooks the nerv-ous system will have subtle variations. The descriptive terms associated with eachdermatome are as follows:

Anesthesia is Complete loss of sensationHypoesthesia is Diminished sensationHyperesthesia is Increased tactile sensibilityAnalgesia is Complete loss of pain sensationHyperalgesia is Increased sensibility to pain (tenderness)Asterogenosis is Inability to recognize familiar objects by the sense of touch

(anesthesia not being present). It usually indicates a lesion in the parietal cerebral cortex.

If loss of sensation or impairment is found, map the boundaries of the impairment bythe distribution of major peripheral nerves or dermatomes. Loss of sensation can indi-cate spinal tract, brainstem or cerebral lesions.


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During the evaluation the patient is to have eyes closed in order to focus concentrationon the area tested and avoid inaccurate responses.

If the patient has a difference in sensation at the dermatome on one side of the body,the practitioner should determine if the sensation is increased or decreased relative toa normal dermatome.

For example, if the right C6 dermatome is described for light touch, the question "Isthere a loss of sensation of the C6 dermatome on the right or an increased sensationof the C6 dermatome on the left?" Assuming the C8 dermatome was equal in sensa-


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Sacral Dermatomes

Lower Extremity DermatomesDermatomes of the Feet

Lower ExtremityDermatomes

Dermatomes of theTrunk

tion, use this as a "normal" benchmark. The practitioner would use the C8 dermatomeon the left comparing to the right C6 dermatome. If the C6 is still reduced, then thereis a hypoesthesia. If there is an equal sensation comparing the right C6 to the left C8this suggests the left C6 is hyperesthesia. To test this, the practitioner compares theright C8 to the left C6 dermatome.

Light TouchTouch the skin with a cotton wisp or with your fingertip, usinglight strokes. Do not depress the skin, and avoid strokingareas with hair. Compare one side of the body to the opposite,corresponding side. Ask the patient to indicate if there is anincrease, decrease or equal sensation comparing one side tothe other. Note any changes in sensation and map out thearea.

Sharp/Dull (Superficial Pain) Alternating the sharp and smooth edges of a broken tongueblade or the point and hub of a sterile needle, touch thepatient's skin in an unpredictable pattern. Allow two secondsbetween each stimulus to avoid a summative effect. Ask thepatient to identify each sensation as sharp or dull and where itis felt. It is possible to combine evaluation of superficial painand touch. Alternate the use of the tongue blade or sterile nee-dle with strokes of your fingertip to determine whether thepatient can identify the change in sensation.

Temperature and Deep PressureOnly when superficial pain sensation is not intact are tempera-ture and deep pressure sensation tests performed. Roll testtubes of hot and cold water alternately against the skin, againin an unpredictable pattern, to evaluate temperature sensation.Ask the patient to indicate which temperature is perceived andwhere it is felt. Deep pressure sensation is tested by squeezingthe trapezius, calf or biceps muscle. The patient should experi-ence discomfort.

VibrationPlace the stem of a vibrating tuning fork (the tuning fork withlower Hz has slower reduction of vibration) against severalbony prominence, beginning at the most distal joints. The ster-num, shoulder, elbow, wrist, finger, joints, shin, ankle, and toesmay all be tested. A buzzing or tingling sensation should befelt. Ask the patient to tell you when and where the vibration isfelt. Occasionally dampen the tines before application to see ifthe patient distinguishes a difference.


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Two-Point DiscriminationUse two sterile needles and alternate touching the patient's skin with one point or bothpoints simultaneously at various locations over the body. Find the distance at whichthe patient can no longer distinguish two points. The following is the minimal distancesat which adults can discriminate two points on various parts of the body.

Body Part Minimal Distance (mm)Tongue 1Fingertips 2-8Toes 3-8Palms of hands 8-12Chest and forearms 40Back 40 - 70Upper arms and thighs 75

ReflexesThe stretch reflex arc is composed of an organ capable of responding to stretch (mus-cle spindle), a peripheral nerve (axon), the spinal cord synapse, and muscle fibers.

Impulses descend from the brain along long (upper motor neuron) tracts (lateral andanterior corticospinal) to modulate the reflex. As a general rule, an interruption in thebasic reflex arc results in the loss of reflex, while pressures on the nerve root itself maydecrease its intensity (hyporeflexia). Interruption of the upper motor neuron's regula-tory control over the reflex will ultimately cause it to become hyperactive (hyperreflex-ia).

Reflexes are reported as absent, normal, increased, or decreased. The evaluationrequires that one side of the body be compared with the other. Bilateral comparisonprovides a direct, immediately accessible way to detect any alteration in reflexes and isessential for an accurate diagnosis of pathology since the degree of reflex activityvaries from person to person.


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The concept of determining neurologic levels applies to the evaluation of spinalinjuries, developmental abnormalities, herniated discs, osteoarthritis and pathologicprocess of the cord itself. All these pathologic processes result in specific segmentaldistribution of neurologic signs in the extremities because of their direct effect on thespinal cord and nerve roots.

Differentiation between spinal cord vs. nerve root pathology vs. peripheral nerveinjuries is reflected by differences in the distribution of the neurologic findings of motorpower, sensation, and reflex. While each dermatome and myotome is enervated at acord level and by a peripheral nerve, each has its own distinct pattern of enervation.

Deep Tendon ReflexesDeep tendon reflexes help locate the lower motor neuron lesion and differentiate itfrom an upper motor neuron lesion.

Biceps ReflexFlex the patient's arm to 45 degrees at the elbow. Palpate the biceps tendon in the anticubital fossa. Place your thumb over the tendon directly, with the reflex hammer. Contraction of the biceps muscle causes visible or palpable flexion of the elbow.

Brachioradial ReflexFlex the patient's arm to 45 degrees and rest his or her forearm on your arm with the hand slightly pronated. Strike the brachioradial tendon (about 1 to 2 inches above the wrist) directly with the reflex hammer. Pronation of the forearmand flexion of the elbow should occur.

Triceps ReflexFlex the patient's arm at the elbow up to 90 degrees and rest the patient's hand against the side of the body. Palpate the triceps tendon and strike it directly with the reflex hammer, just above the elbow. Contraction of the triceps muscle causes visible or palpable extension of the elbow.


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Patellar ReflexFlex the patient's knee to 90 degrees, allowing the lower leg to hang loosely. Support the upper leg with your hand, not allowing it to rest against the edge of the examining table. Strike the patellar tendon just below the patella. Contraction of the quadriceps muscle causes extension of the lower leg.

Achilles ReflexWith the patient sitting, flex the knee to 90 degrees and keep the ankle in neutral position, holding the heel of the foot in your hand. (Alternatively, the patient may kneel on the chair with the toes pointing toward the floor.) Strike the Achilles tendon at the level of the ankle malleoli. Contraction of the gastrocnemius muscle causes plantar flexion of the foot.


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Patellar Reflex. On right with Jendrasics Maneuver. Testing L4.

Grading of deep tendon reflexes is as follows:0 No response1+ Hyporeflexia2+ Normal3+ Hyperreflexia4+ Hyperreflexia with transient clonus5+ Hyperreflexia with intermittent or sustained clonus

ClonusTest for ankle clonus, especially if the reflexes are hyperactive. Support the patient'sknee in partially flexed position and briskly dorsiflex the foot with your other hand,maintaining the foot in flexion. No rhythmic oscillating movements between dorsiflex-ion and plantar flexion should be palpated. Sustained clonus is associated with uppermotor neuron disease.

See Appendix A: Spinal Cord Levels -- Motor, Sensory and Reflexes

Reflex Muscle Tendon Nerve Root Level Evaluated

Deep Tendon Reflexes

Scapulohumeral C5-C6Biceps C5-C6Radial C5-C6Triceps C7-C8Wrist C7-C8Ulnar C8-T1

Superficial Reflexes

Upper abdominal T7, T8, and T9Lower abdominal T10, and T11


Superficial reflexes differentiate lower motor neuron lesions from upper motor neuronlesions.


Corneal III, VUpper abdominal T7-T9Lower abdominal T10-T12


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Upper Motor Neuron Reflexes

Pathologic Reflexes

These can be elicited in the lower extremities in association with paraplegia.Babinski's sign and Oppenheim's sign are two pathologic reflexes which indicate anupper motor neuron lesion.

Babinski's Reflex

Performed by running a sharp instrument acrossthe plantar surface of the foot and along the cal-caneus and lateral border of the foot. Normally,in a negative reaction, the toes plantarflex. Apositive reaction, called Babinski's sign, is whenthe great toe extends as the other toes splay inabduction. This indicates an upper motor neu-ron lesion with corticospinal tract involvement.In young infants, the presence of Babinski's signis normal rather than pathological. By 20 to 18months of age, it should have disappeared.


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Normal responsewith plantar flexion

of the toes

Babinski’s Sign / PositiveAbnormal response withgreat toe extension and

other toes splay


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See Appendix A: Spinal Cord Levels -- Motor, Sensory and Reflexes


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Girth Sensory Perception and Reflexes - The Supply Center · 2020. 10. 29. · The practitioner would use the C8 dermatome on the left comparing to the right C6 dermatome. If the