Question about reflexes

[SOONERMOM]

When my neuro (#1) tests my reflexes, he stands/sits in front of me and stops my leg from swinging out with his hand. (When I went to see the MS specialist he let it just swing out on its own.)  Do any of you have this happen?  I was asking him if my reflexes have changed any since I have been seeing him (10/07)  His answer was that HE had brisk reflexes and anyone in MY situation would also have brisk reflexes.  I thought that reflexes were one of the OBJCECTIVE signs that a patient has no control over??  The more I think over this appointment the more irritated I get.....

Stacey

[Heather3418]

I don't quite understand why the doctor said, "He has brisk reflexes."  Does he have MS or some other Neurological disorder?

All doctor's have their own way of how they test your reflexes.  Standing in front of you, stopping the leg before it hits hi in his private area and some stand to the side.  It's just persanl preference.  If you have brisk reflexes (hyperreflexia) then you have them.  

Hyperreflexes are a sign of something neurological going on within the Central Nervous System.

Heather

[Deb61]

The first time my neuro tested my reflexes, he let the leg swing way out.  The next time, he new better and stood in front, blocking the kick.  

My guess, is that your neuro would be able to tell with or without blocking the kick.  He/she just doesn't want to get whacked by your leg or wants to go on with the next reflex testing quickly.  Normal reflexes would not get much movement.  I saw my neuro write in my chart something with the word "spasticity", even when the legs were blocked.  Somehow he could tell.

Deb

[SOONERMOM]

Thanks guys, I know the time before he made some comment about he'd better be careful (about getting kicked where it counts).  

I wish I would have asked him why his reflexes are brisk!!!...I guess I just took it to mean some people normally have brisk reflexes and some people who are anxious have it too...that is how he made me feel and so I just shut up about it.  (I can honestly say that I am not a person who has problems w/anxiety and I am a lot less worried now than I was in the beginning anyway.)  

I think these neurologists are going to drive me to have to see a psychiatrist!!!  (just kidding of course)

Stacey

[Wobbly]

when is went to my last appt.... I nearly kicked him with my left leg, so he turn sideways to do my right leg...which wasn't as brisk as my left...hehehe

take care
andie

[Quixotic1]

There are as many ways to measure reflexes as there are examiners.  Stopping the kick is legitimate, They can still feel the force and see how quickly the reflex is initiated after tapping.

MEASURING THE TENDON REFLEXES

The tendon reflexes are lower level "stimulus -> reaction" effects.   This means that the reflexes occur below the level of the brain.  Each muscle group contains stretch-receptors that, when stimulated quickly cause the muscle to contract.  The stretch signal goes up to the spinal cord and the signal to the corresponding muscle to contract proceeds right back down from the spine.  The brain does not get involved.
Large muscles come together at one end in the form of a tendon that then passes across a joint to attach the muscle to a bone. Examples that you can actually see in your body are the large patellar tendon that attaches at the thigh end to the quadriceps and passes over and around the patella (kneecap) to attach to the top of the tibia (shin bone).  The patellar tendon is the main mechanism for straightening the knee.  Another large one is the Achilles tendon which gathers the calf muscles in and then travels across the ankle to attach to the underside of the heel.  The Achilles tendon is the way you are able to point your toes downward.  Another is the biceps tendon which passes in the bend of the elbow. You can feel the biceps tendon like a hard cord in the crook of your elbow when you flex your biceps.

When the tendon is tapped briskly, it quickly pushes in on the tendon and places a tiny, but quick stretch on the muscle attatched to that tendon.  The Patellar tendon is the easiest to see and describe. You always do a tendon test when the muscle is slightly stretched, so usually this is done while sitting with knee bent at 90 degrees and the lower leg able to swing freely. When the tap is done, just below the kneecap, the normal reaction of the quadriceps is to contract. When it does it causes the knee to extend (the lower leg to swing out). The nerve loop that controls a tendon reflex is a stretch receptor that travels up to the spinal cord and immediately loops over to a motor nerve that travels down and activates the proper muscle.

The evaluation of the reflexes is done on a numercial scale, but it is subject to the interpretation of the examiner, so it is not quantified. The more experience, the more reproducible the test will be between examiners, but it is still really a subjective measurement. If it were to be quantified (measured in exact numbers) it would be by electromyography and would be a research test.

The reflexes may be dulled by depressant medications, low metabolic states like low magnesium, severe depression, or hypothyroidism.  Also in low thyroid states, the reflexes not only will be lessened, but they will be delayed.   Reflexes may be accentuated by things like stimulants, caffeine, anxiety, or hyperthyroidism.  They also may be "reinforced" by either slight, active contraction of the muscle/tendon being tested or by having the patient contract another set of muscles forcefully. The usual maneuver for reinforcement is to have the patient grasp the fingers of both hands together in front of the chest and to pull tightly. (Try doing this. First tap on the tendon without grasping the hands. Then do it with the hand-pull. You will normally see a significant increase in the force of the tendon reflex)  Reinforcement is only used when there is a problem seeing any reflex action at all.

The most common rating scale of tendon reflexes is as follows:

0 – Unable to elicit any movement or contraction of the muscle

1+ - Little movement or only seen with reinforcement - lower end of normal

2+ - Normal (what "normal" looks like is learned through doing this 100's of times with hundreds of "normal" people)

3+ - Brisk (more than is normally seen, but not causing injury to the examiner, lol) this is also considered within the normal range.

4+ - Maximum movement and associated with some limited, extra repetitive movement(s) called clonus.  This is level and above is abnormal, or hyperactive.

5+ - Major kick with sustained, repetitive movements (sustained clonus).  Also considered here and in "4+" is if other muscle groups also react with contraction, called "spreading reflex." Clonus is most often seen at the ankle. The doctor will press suddenly up on the toes, dorsiflexing the ankle.  With clonus the toes will repeatedly and rhythmically bounce downward if light pressure is kept on the toes.  

Clonus is normal in newborns who all have immature nervous systems.  You can elicit clonus in newborns by taking a finger and pushing up quickly under the ball of their foot.  This will cause the foot/toes to rhythmically move up and down. (taken from "Fun and Games to Play With Your Newborn” - Activities for Bored Parents, lol).   In babies this is normal, but disappears within a couple months as their nervous system matures.

0, 4+, and 5+ are abnormal and indicate neurological problems. Some doctors use a 0 to 4+ scale and use 4.5+ (sustained clonus) instead of 5+.

Hyperactive reflexes indicate a problem (lesion) in the spinal cord.  You may hear this being called an Upper Motor Neuron Sign. Or the doctor may find hyperactive reflexes and diagnosis Myelopathy (disease of the spinal cord). This is one of the most freqently abnormal tests on the neurological exam in a person with MS.

Lots of normal people have "brisk" reflexes.

Quix

[CtResident]

Can anybody shed a light on the following variations please?

Upper reflexes and/or lower reflexes being hyper?

Or asymmetry (left vs. right) being hyper?

When I went to the Yale MS neuro, she didn't indicate to me what was mine were. But I overheard her say to one of the med students, "Her upper and lower reflexes are hyper but I know her t-spine will come back normal." I have requested the written report, don't have it yet.

I had a t-spine this week at my local hospital, and did get that report. It said I have Schmorl's Nodes, nothing about lesions.

Suzanne

[Quixotic1]

Well, as you can see from the essay I reprinted, "hyper" may or may not mean abnormal.  In the context of the doctor speaking to med students, the doc probably meant pathologically hyper.  It is never normal for the reflexes to be assymmetrical, that is different from side to side at the same reflex. (knee, ankle, wrist, etc.)

I am cetainly not good enough to know how she was able to localize where your problems would be (not thoracic) except that thoracic lesions are the least common.

Quix