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PubMed1996

Usefulness and reliability of neurological signs for level diagnosis in cervical myelopathy caused by soft disc herniation.

We retrospectively analyzed neurological signs of 106 patients with cervical myelopathy caused by single-level soft disc herniation. Neurological signs that were intensively analyzed were deep tendon reflexes, the uppermost level of impaired pinprick sensation, the uppermost weak muscle, and region of numbness in the hands. Characteristic signs for each intervertebral level were deduced, and sensitivity, specificity, and accuracy of these signs were calculated. Deep tendon reflexes were specific signs for each intervertebral level, although not as sensitive as the neurological signs. Muscle weakness and pinprick sensation were neither sensitive nor specific. Hand numbness was moderately sensitive and specific. On the whole, there was no neurological sign that was both highly sensitive and specific for an intervertebral level, and therefore, neurological level diagnosis in cervical myelopathy should be performed comprehensively according to more specific signs, i.e., deep tendon reflexes and hand numbness.

Adult↗
PubMed2006

Neurologic level diagnosis of cervical stenotic myelopathy.

STUDY DESIGN: A cross-sectional analysis. OBJECTIVE: To elucidate the accuracy of neurologic level diagnosis of cervical stenotic myelopathy. SUMMARY OF BACKGROUND DATA: Neurologic level diagnosis in cervical myelopathy has not been well established. METHODS: A total of 106 patients with cervical stenotic myelopathy, with a single-level intramedullary high-intensity area confirmed on both preoperative and postoperative T2-weighted magnetic resonance imaging (MRI), were included in this study. We performed a level diagnosis on the basis of neurologic signs (the uppermost muscle with weakness, diminished or exaggerated deep tendon reflex, the uppermost level of sensory disturbance of the upper extremities) and compared it with a level diagnosis made by T2-weighted MRI. The sensitivity, specificity, and accuracy of neurologic signs on our index corresponding to each intervertebral level were calculated. RESULTS: The averages of sensitivity, specificity, and accuracy were 42%, 80%, and 70%, respectively, in the uppermost muscle with weakness, 66%, 89%, and 83% in deep tendon reflex, and 74%, 91%, and 87% in the sensory disturbance area. The positive and negative predictive values were 40% and 91%, respectively, in the uppermost muscle with weakness, 66% and 89% in deep tendon reflex, and 74% and 91% in the sensory disturbance area. Accuracy of a diagnosis based on muscle weakness was less high, the reason being that in many patients, the uppermost muscle with weakness was extensor digiti communis or the intrinsic muscles of the hands, and this led to a lower sensitivity. CONCLUSIONS: The average accuracy of neurologic level diagnosis based on the index we proposed was > or =70%. The level diagnosis by a sensory disturbance area showed the highest accuracy (87%).

Adult↗
PubMed1996

Critical illness polyneuropathy: clinical findings and outcomes of a frequent cause of neuromuscular weaning failure.

OBJECTIVE: To describe clinical and electrophysiologic features and outcomes of critically ill patients with neuromuscular causes of failure to wean from mechanical ventilator support. DESIGN: A prospective, consecutive, case series. SETTING: Neurological, neurosurgical, and medical intensive care units in a university hospital. PATIENTS: Seven patients during a 3-yr period with failure to wean from mechanical ventilation not explained by pulmonary complications. INTERVENTIONS: Muscle and nerve biopsy in three patients. MEASUREMENTS AND MAIN RESULTS: Detailed electrodiagnostic studies were done in all patients 3 to 6 wks (median 4.5) after the onset of the acute illness and were repeated 3 months to 3.5 yrs later in those patients who survived. Primary illnesses included various intracranial and medical conditions. All patients had moderate-to-severe limb weakness with marked muscle atrophy. Tendon reflexes were decreased in three patients, exaggerated in two patients with intracranial lesions, and absent in two patients. Electromyography demonstrated severe acute denervation, with striking involvement of proximal muscles. Muscle and nerve biopsies showed severe neurogenic atrophy and axonal degeneration without inflammation. There was no evidence of primary myopathy. Two patients died of complications of sepsis. Of the survivors, three patients had no further weakness at the time of reexamination, except for peroneal nerve palsy in one patient. Two patients, still in the recovery period, showed markedly improved conditions but still showed slight weakness of the proximal muscles. By electrophysiology, signs of chronic neurogenic damage were demonstrable in all survivors at follow-up. CONCLUSIONS: Critical illness polyneuropathy is a frequent cause of neuromuscular weaning failure in critically ill patients, regardless of the type of primary illness. Involvement of proximal (including facial and paraspinal) muscles is striking. Tendon reflexes are often preserved. Patients with central nervous system injury may likewise develop critical illness polyneuropathy. In these latter patients, tendon reflexes may even be exaggerated. Recovery from critical illness polyneuropathy is usually rapid and clinically complete, although incomplete on electrodiagnostic study. Residual peripheral nerve lesion, generally of the peroneal nerve, is the most frequent feature of incomplete recovery. The need for careful electrophysiologic testing is emphasized to clarify the nature and extent of neuromuscular disturbances in critically ill patients. Failure to recognize the development of neuropathy in these patients may lead to erroneous conclusions about the ability to wean them from the ventilator.

Adult↗
PubMed2004

Clinical evaluation and patterns of chemotherapy-induced peripheral neuropathy.

PURPOSE: To determine the pattern of change in peripheral nerve function (as measured by vision, hearing, deep tendon reflexes, vibratory sense, cutaneous sensation, gait and balance, muscle strength, and orthostatic blood pressure) occurring among individuals receiving cancer treatment with known neurotoxic agents. DATA SOURCES: A convenience sample of 16 participants with cancer who were receiving chemotherapy had their peripheral nerve function assessed at baseline and at 4 weeks and 12 weeks of treatment. Data were analyzed using plots and regression slopes to determine change over time in clinical measures of peripheral nerve function. Outcome variables were vision, hearing, deep tendon reflexes, vibratory sense, cutaneous sensation, gait and balance, muscle strength, and changes in orthostatic blood pressure. CONCLUSIONS: This is the first prospective study to use comprehensive clinical measures of peripheral nerve and muscle changes resulting from combination chemotherapy or a biotherapy regimen. Alterations in vision, hearing, deep tendon reflexes, vibratory sense, cutaneous sensation, balance, muscle strength, and orthostatic blood pressure were noted, but gait remained unchanged. IMPLICATIONS FOR PRACTICE: This study provides beginning evidence of the need for careful, ongoing assessment of treatment-induced peripheral neuropathy. Standardized clinical practice procedures that incorporate patient evaluation for peripheral neuropathy must still be developed. In addition, we must educate our patients about the functional changes they may expect, and we must develop strategies to assist them in managing limitations that they experience as a result of peripheral neuropathy.

Adult↗
PubMed1993

Neurologic history and examination results and their relationship to human immunodeficiency virus type 1 serostatus in hemophilic subjects: results from the hemophilia growth and development study.

In a prospective study of the growth and neuropsychologic function of hemophilic subjects, 333 boys, median age of 12.3 years, had baseline neurologic examinations. The study population included 207 individuals (62%) who were seropositive for human immunodeficiency virus type 1 (HIV-1). Overall results indicated that 11% had abnormalities of cranial nerve function, 17% had abnormal deep tendon reflexes, 23% had abnormal strength, 25% had abnormal coordination, and 31% had abnormal tone, bulk, or range of motion. By contrast, 2% or fewer displayed abnormal movements or had abnormal pain or vibratory sensation, or altered mental status. Abnormalities were more common in older hemophilic subjects (eg, 67 [38%] of 177 subjects > or = 12 years of age had abnormal tone, bulk, or range of motion vs 36 [23%] of 156 subjects < 12 years of age). When compared with regard to HIV-1 status, HIV-seronegative and HIV-seropositive subjects did not differ with regard to head circumference or the frequency of abnormalities of cranial nerve function, sensation, muscle strength, or coordination. However, deep tendon reflexes and tone, bulk, or range of motion were more frequently abnormal in HIV-1-seropositive individuals. More HIV-1-positive subjects had at least one increased deep tendon reflex (13/207 [6.3%] vs 1/126 [0.8%] in seronegatives) and more had non-hemophilia-related decreases in muscle bulk (7/207 [3.4%] vs 0/126 in seronegatives). These results indicate that hemophilia causes substantial neurologic dysfunction and that certain findings, such as changes in muscle-stretch reflexes or muscle bulk, may also reflect the neurologic consequences of HIV infection.

Adolescent↗
PubMed1980

Reflex facilitation by remote contraction: topographic aspects.

This study compares the facilitation of various lower limb reflex arcs brought about by a selective contraction of a well-defined upper limb muscle group in able-bodied healthy subjects. Quantitatively (results expressed as a percentage of maximal motor response), the quadriceps tendon reflex is facilitated more than the soleus and biceps femoris tendon reflexes. The time course of facilitation is similar for the 3 reflexes and exhibits 3 distinct phases. Electrically induced reflexes in the quadriceps are facilitated as much as the tendon jerk but only during the 2nd phase. Complementarily, the effects of contraction of different upper limb muscle groups on a single lower limb reflex (quadriceps tendon jerk) were also investigated. This reflex is facilitated more (especially in the 2nd phase) by contraction of thenar muscle than by that of deltoid muscles and more by wrist extensors than wrist flexors. Differences in facilitation are only apparent when the effects are quantified. They depend on the segmental level of the reflex under test (more marked proximally than distally) and on the conditioning muscle group; both facts must be taken into consideration in the interpretation of the functional role of remote contraction.

Female↗
PubMed2006

Stretch reflex and Hoffmann reflex responses to osteopathic manipulative treatment in subjects with Achilles tendinitis.

CONTEXT: Irvin M. Korr, PhD, hypothesized that sensitivity of the monosynaptic stretch reflex (ie, deep tendon reflex) plays a major role in the restriction-of-motion characteristic of somatic dysfunction, and that restoration of range of motion through osteopathic manipulative treatment (OMT) could be achieved by resetting of the stretch receptor gain. OBJECTIVE: To test Korr's hypothesis in the context of Achilles tendinitis, examining whether OMT applied to patients with Achilles tendinitis reduces the strength of the stretch reflex. METHODS: Subjects were recruited through public advertisements and referrals from healthcare professionals. There were no recruitment restrictions based on demographic factors. Amplitudes for stretch reflex and H-reflex (Hoffmann reflex) in the triceps surae muscles (the soleus together with the lateral and medial heads of the gastrocnemius) were measured in subjects with diagnosed Achilles tendonitis (n=16), both before and after OMT. These measurements were also made in asymptomatic control subjects (n=15) before and after sham manipulative treatment. RESULTS: As predicated on the concepts of the strain-counterstrain model developed by Lawrence H. Jones, DO, the use of OMT produced a 23.1% decrease in the amplitude of the stretch reflex of the soleus (P<.05) in subjects with Achilles tendinitis. Similarly significant responses were measured in the lateral and medial heads of the gastrocnemius in OMT subjects. The H-reflex was not significantly affected by OMT. In control subjects, neither reflex was significantly affected by sham manipulative treatment. By using a rating scale on questionnaires before treatment and daily for 7 days posttreatment, OMT subjects indicated significant clinical improvement in soreness, stiffness, and swelling. CONCLUSION: The reduction of stretch reflex amplitude with OMT, together with no change in H-reflex amplitude, is consistent with Korr's proprioceptive hypothesis for somatic dysfunction and patient treatment. Because subjects' soreness ratings also declined immediately after treatment, decreased nociceptor activity may play an additional role in somatic dysfunction, perhaps by altering stretch reflex amplitude.

Achilles Tendon↗
PubMed1994

The effect of topical anesthetics on skin sensation and soleus motoneuron reflex excitability.

The effect that topical anesthetics has on cutaneous sensation and on soleus motoneuron reflex excitability was studied in a healthy population. Data were obtained from 16 volunteers (7 men and 9 women) between 20 and 47 years of age. The experiment consisted or recording H-reflexes and Achilles tendon reflexes (ATR) before and after administration of a 20% benzocaine spray or a placebo to the skin of the posterior calf. In addition, a sensory evaluation was conducted to determine objectively the actual quality of anesthesia obtained. Subjects served as their own controls, randomly receiving both the active medication and a placebo. The study was conducted in a single blind fashion with only the experimenter being aware of what medication (active/placebo) was being applied during a given experiment. H-reflex amplitudes increased significantly following the application of benzocaine and the placebo spray compared to control (p < .01). This increase was similar whether the active drug or placebo was administered. No significant difference was shown between active benzocaine and the placebo application. The ATR was not significantly affected by any of the treatment techniques used in this study, although some reduction in reflex amplitude was noted. No change in skin sensibility could be attributed to the topical anesthetic in any subject in this study. It was concluded that benzocaine spray did not have an effect on skin sensation and that the increased motoneuron reflex excitability was more likely in response to a stimulatory action upon cutaneous receptors from the spray technique. It is further suggested that topical anesthetics applied to intact skin may not permeate cutaneous tissue in large enough quantities to have a desensitizing effect.

Achilles Tendon↗
PubMed2003

The deep tendon and the abdominal reflexes.

The deep tendon reflexes (and the abdominal reflexes) are important physical signs which have a special place in neurological diagnosis, particularly in early disease when they alone may be abnormal. They act as "hard" signs in situations where clinical assessment is complicated by patient anxiety, and become more useful as clinical experience develops.

Central Nervous System Diseases↗
PubMed1995

Electromechanical delay in isometric muscle contractions evoked by voluntary, reflex and electrical stimulation.

Electromechanical delay (EMD) in isometric contractions of knee extensors evoked by voluntary, tendon reflex (TR) and electrical stimulation (ES) was investigated in 21 healthy young subjects. The subject performed voluntary knee extensions with maximum effort (maximal voluntary contraction, MVC), and at 30%, 60% and 80% MVC. Patellar tendon reflexes were evoked with the reflex hammer being dropped from 60 degrees, 75 degrees and 90 degrees positions. In the percutaneous ES evoked contractions, single switches were triggered with pulses of duration 1.0 ms and of intensities 90, 120 and 150 V. Electromyograms of the vastus lateralis and rectus femoris muscles were recorded using surface electrodes. The isometric knee extension force was recorded using a load cell force transducer connected to the subject's lower leg. The major finding of this study was that EMD of the involuntary contractions [e.g. mean 22.1 (SEM 1.32) ms in TR 90 degrees; mean 17.2 (SEM 0.62) ms in ES 150 V] was significantly shorter than that of the voluntary contractions [e.g. mean 38.7 (SEM 1.18) ms in MVC, P < 0.05]. The relationships between EMD, muscle contractile properties and muscle fibre conduction velocity were also investigated. Further study is needed to explain fully the EMD differences found between the voluntary and involuntary contractions.

Adult↗
PubMed1996

Effects of transcutaneous electrical nerve stimulation on H-reflex and spinal spasticity.

The purpose of this study was to investigate the short-term effects of transcutaneous electrical nerve stimulation (TENS; 99 Hz; 250 ms pulses) on H-reflex and spinal spasticity. Considering the reflex hyperexcitability commonly displayed in spinal cord-injured subjects, it was hypothesized that repetitive low threshold afferent stimulation would have an inhibitory effect on the triceps surae H-reflexes which could also be reflected by a decrease in plantarflexor spasticity. Clonus, Achilles tendon reflex and modified Ashworth evaluations were performed on 14 spinal cord-injured subjects prior to and after 30 minutes' application of TENS. Non-parametric statistical analyses (n = 14; alpha = 0.05) failed to reveal significant effects of TENS on H-reflex amplitude. However, there was a significant decrease in scores for the Achilles tendon reflex and the modified Ashworth test. The clonus score decreased in most subjects post-TENS, although not in a statistically significant manner. The present pilot results thus suggest that TENS appears to be effective in reducing spinal spasticity, as measured clinically.

Adult↗
PubMed1976

The lack of deep reflexes in myotonic dystrophy.

Clinical and electrophysiological observations have been carried out on 12 patients with myotonic dystrophy. Neurological examination showed that the tendon reflexes were absent or weak in almost all cases, whereas the cutaneous reflexes were normal. Examination of both deep and superficial sensibility gave normal results. Electromyography confirmed widespread "myopathic" activity and myotonic discharges were recorded on insertion of the needle electrode and at rest. Motor and sensory conduction velocity in the ulnar nerve and motor conduction in the peroneal nerve proved to be normal. Repetitive supramaximal nerve stimulation showed in 10 cases a decrease in potential amplitude, more evident at higher frequencies of stimulation. In the 2 other cases, by contrast, an increase in amplitude was observed, and this was suggestive of a partial presynaptic block. The jaw reflex was absent in 5 cases and reduced in amplitude in the 7 other cases. The results of blink reflex investigations were normal, with the exception of 2 cases where no early response was elicited. Spinal monosynaptic reflexes were absent in 7 cases after both electrical (H reflex) and mechanical stimulation (T reflex), whereas the response to direct stimulation of nerve motor fibres (the M response) was always present, even though reduced in amplitude. Such data lead one to reject the hypothesis that the absence of deep reflexes is due to pathological change in the muscle spindles. It seems more likely that the selective atrophy of Type 1 muscle fibres, known to be involved in deep reflex responses, is responsible for the early disappearance of the tendon reflexes.

Action Potentials↗
PubMed1999

Clinical and molecular studies of 73 Italian families with autosomal dominant cerebellar ataxia type I: SCA1 and SCA2 are the most common genotypes.

We clinically and genetically evaluated 73 Italian families with autosomal dominant cerebellar ataxia (ADCA) type I. Spinocerebellar ataxia (SCA) type 1 was the most common genotype (SCA1), accounting for 41% of cases (30 families), SCA2 was slightly less frequent (29%, 21 families), and the remaining families were negative for the SCA1, SCA2, and SCA3 mutations. Among the positively genotyped families, SCA1 was found most frequently in families from northern Italy (50%), while SCA2 was the most common mutation in families from the southern part of the country (56%). Slow saccades and decreased deep tendon reflexes were observed significantly more frequently in SCA2 patients, while increased deep tendon reflexes and nystagmus were more common in SCA1. In SCA1 and SCA2 families there was a significant inverse correlation between expansion size and age at onset. Analysis of triplet repeat numbers in parent-offspring pairs showed greater meiotic instability, which was associated with an earlier onset of the disease in SCA2 families than in SCA1 families.

Adult↗
PubMed1982

Topical anesthesia: modulation of the monosynaptic reflexes by desensitization of the skin.

Skin desensitization by topical anesthesia was studied for its effect on the motoneuron excitability of the soleus muscle. Skin areas overlying calf, tibial, quadriceps and hamstrings muscles and skin dermatomes (L2, L3, L4, L5, S1 and S2) were studied separately. Motoneuron excitabilities were measured by the H-reflex and Achilles tendon reflex (for alpha and gamma motoneurons). It was shown that anesthesia applied to all skin areas and dermatomes, except those overlying the antagonist muscles, resulted in significant facilitation of the soleus H-reflex. In these cases, the ATR showed either slight inhibition or no significant changes. Anesthesia to the skin overlying the anterior tibial antagonistic muscle produced varied and inconsistent modifications in the amplitude of the H-reflex. In these cases the ATR was either slightly facilitated or showed no significant changes. These results appear to indicate the existence of on-going excitatory and inhibitory effects from the skin on the alpha and gamma motoneuron pool probably via segmental and suprasegmental levels. A possible clinical application of these results to modulate the motoneuron pool excitability is proposed.

Administration, Topical↗
PubMed1993

Activation of carotid baroreceptors inhibits spinal reflexes in man.

The present study was designed to investigate the effect of baroreceptors on a spinal reflex. The Achilles tendon reflex (T reflex), a monosynaptic spinal reflex, was chosen as an indicator of descending influences of central activation. The baroreceptors are stretch receptors which respond to extensions of the arterial wall. Carotid sinus baroreceptors can be manipulated non-invasively by means of a cuff around the neck. In this study, the phase-related external suction (PRES) neck cuff technique was used. PRES applies short changes in cuff pressure as a function of heart cycle phase, controlling for non-specific effects found in other baroreceptor manipulation methods. The T reflex was reduced when elicited during the highest levels of baroreceptor activation. Reflex amplitude was largest when elicited during the lowest levels of baroreceptor activation. These results are consistent with previous findings that baroreceptor activation reduces CNS excitability.

Adult↗
PubMed2003

Clinical deterioration in Bickerstaff's brainstem encephalitis caused by overlapping Guillain-Barré syndrome.

A 37-year-old man developed an acute encephalitic condition after respiratory infection. His condition rapidly deteriorated, and he experienced ophthalmoplegia, tetraplegia, loss of brainstem reflexes and deep tendon reflexes, and deep coma. Electrophysiological evaluations indicated involvement of the peripheral nerve as well as the brainstem. Follow-up studies found acute progression of peripheral nerve damage. Serum anti-GQ1b IgG antibody was present. The initial condition was diagnosed as Bickerstaff's brainstem encephalitis, and subsequent overlapping of Guillain-Barré syndrome probably was responsible for the clinical deterioration. When unusual worsening is observed in clinically suspected encephalitis, neurologists must take into account the possibility of associated Guillain-Barré syndrome and related disorders.

Adult↗