Deep tendon reflexes, hyperactive
Deep tendon reflexes, hyperactive: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
Hyperactive deep tendon reflexes (DTRs) are abnormally brisk muscle contractions that occur in response to a sudden stretch induced by sharply tapping the muscle’s tendon of insertion. This elicited sign may be graded as brisk or pathologically hyperactive. Hyperactive DTRs are commonly accompanied by clonus.
The corticospinal tract and other descending tracts govern the reflex arc — the relay cycle that produces any reflex response. A corticospinal lesion above the level of the reflex arc being tested may result in hyperactive DTRs. Abnormal neuromuscular transmission at the end of the reflex arc may also cause hyperactive DTRs. For example, a deficiency of calcium or magnesium may cause hyperactive DTRs because these electrolytes regulate neuromuscular excitability.
History
After eliciting hyperactive DTRs, take the patient’s history. Ask about spinal cord injury or other trauma and about prolonged exposure to cold, wind, or water. Also find out if the patient could be pregnant. A positive response to any of these questions requires prompt evaluation to rule out life-threatening autonomic hyperreflexia, tetanus, preeclampsia, and hypothermia. Ask about the onset and progression of associated signs and symptoms. Also ask about paresthesia, vomiting, and altered bladder habits.
Physical assessment
Perform a neurologic examination. Evaluate level of consciousness, and test motor and sensory function in the limbs. Check for ataxia or tremors and for speech and visual deficits. Test for Chvostek’s sign (an abnormal spasm of the facial muscles elicited by light taps on the facial nerve in patients who have hypocalcemia), Trousseau’s sign (a carpal spasm induced by inflating a sphygmomanometer cuff on the upper arm to a pressure exceeding systolic blood pressure for 3 minutes in patients who have hypocalcemia or hypomagnesemia), and carpopedal spasm. Be sure to record the patient’s vital signs.
Medical causes
Amyotrophic lateral sclerosis
Amyotrophic lateral sclerosis (ALS), which is also known as Lou Gehrig disease, produces generalized hyperactive DTRs accompanied by weakness of the hands and forearms and spasticity of the legs. Eventually, the patient develops atrophy of the neck and tongue muscles, fasciculations, weakness of the legs and, possibly, bulbar signs (dysphagia, dysphonia, facial weakness, and dyspnea).
Brain tumor
A cerebral brain tumor causes hyperactive DTRs on the side opposite the lesion. Associated signs and symptoms develop slowly and may include unilateral paresis or paralysis, anesthesia, visual field deficits, spasticity, and a positive Babinski’s reflex.
Hepatic encephalopathy
Generalized hyperactive DTRs occur late in the comatose stage of hepatic encephalopathy and are accompanied by a positive Babinski’s reflex, fetor hepaticus (a musty, sweet odor to the breath), and coma.
Hypocalcemia
Hypocalcemia may produce sudden or gradual onset of generalized hyperactive DTRs with paresthesia, muscle twitching and cramping, positive Chvostek’s and Trousseau’s signs, carpopedal spasm, and tetany. Other signs and symptoms include abdominal cramps, muscle cramps, arrhythmias, and diarrhea.
Hypomagnesemia
Hypomagnesemia results in gradual onset of generalized hyperactive DTRs accompanied by muscle cramps, hypotension, tachycardia, paresthesia, ataxia, tetany and, possibly, seizures. Other signs and symptoms include Chvostek’s sign, confusion, delusions, hallucinations, arrhythmias, and hypotension.
Hypothermia
Mild hypothermia (90°F to 94° F [32.2° C to 34.4° C]) produces generalized hyperactive DTRs. Other signs and symptoms include shivering, fatigue, weakness, lethargy, slurred speech, ataxia, muscle stiffness, tachycardia, diuresis, bradypnea, hypotension, and cold, pale skin.
Multiple sclerosis
Typically, hyperactive DTRs are preceded by weakness and paresthesia in one or both arms or legs in patients with multiple sclerosis. Associated signs include clonus and a positive Babinski’s reflex. Passive flexion of the patient’s neck may cause a tingling sensation down his back. Later, ataxia, diplopia, vertigo, vomiting, urine retention, or urinary incontinence may occur.
Preeclampsia
Occurring in pregnancy of at least 20 weeks’ duration, preeclampsia may cause gradual onset of generalized hyperactive DTRs. Accompanying signs and symptoms include increased blood pressure; abnormal weight gain; edema of the face, fingers, and abdomen after bed rest; albuminuria; oliguria; severe headache; blurred or double vision; epigastric pain; nausea and vomiting; irritability; cyanosis; shortness of breath; and crackles. If preeclampsia progresses to eclampsia, the patient develops seizures.
Spinal cord lesion
Incomplete spinal cord lesions cause hyperactive DTRs below the level of the lesion. In a traumatic lesion, hyperactive DTRs follow resolution of spinal shock. In a neoplastic lesion, hyperactive DTRs gradually replace normal DTRs. Other signs and symptoms of spinal cord lesion include paralysis and sensory loss below the level of the lesion, urine retention and overflow incontinence, and alternating constipation and diarrhea. A lesion above T6 may also produce autonomic hyperreflexia with diaphoresis and flushing above the level of the lesion, headache, nasal congestion, nausea, increased blood pressure, and bradycardia.
Stroke
Any stroke that affects the origin of the corticospinal tracts causes sudden onset of hyperactive DTRs on the side opposite the lesion. The patient may also have unilateral paresis or paralysis, anesthesia, visual field deficits, spasticity, and a positive Babinski’s reflex.
Tetanus
With tetanus, sudden onset of generalized hyperactive DTRs accompanies tachycardia, diaphoresis, low-grade fever, painful and involuntary muscle contractions, trismus (lockjaw), and risus sardonicus (a masklike grin).
Special considerations
Prepare the patient for diagnostic tests to evaluate hyperactive DTRs. These may include laboratory tests for serum calcium magnesium and ammonia levels, spinal X-rays, magnetic resonance imaging, computed tomography, lumbar puncture, and myelography.
If motor weakness accompanies hyperactive DTRs, perform or encourage range-of-motion exercises to preserve muscle integrity and prevent deep vein thrombosis. Also, reposition the patient frequently, provide a special mattress, and massage his back and ensure adequate nutrition to prevent skin breakdown. Administer a muscle relaxant and a sedative to relieve severe muscle contractions. Keep emergency resuscitation equipment on hand. Provide a quiet, calm atmosphere to decrease neuromuscular excitability. Assist with activities of daily living.
Pediatric pointers
Hyperreflexia may be a normal sign in neonates. After age 6, reflex responses are similar to those of adults. When testing DTRs in small children, use distraction techniques to promote reliable results.
Cerebral palsy commonly causes hyperactive DTRs in children. Reye’s syndrome causes generalized hyperactive DTRs in stage II; in stage V, DTRs are absent. Adult causes of hyperactive DTRs may also appear in children.
Patient counseling
Provide emotional support to the patient and his family. Explain all procedures and treatments. Help the patient relax and provide him with quiet activities. Explain safety measures to the patient and his family.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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