Deep Tendon Reflex Abnormalities
Deep Tendon Reflex Abnormalities: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
Hyporeflexia
❑ Nerve root compression
❑ Hypothyroidism
❑ Acute stroke
❑ Diabetes
❑ Alcoholism
❑ Vitamin B12 deficiency
❑ Uremia
❑ Myopathy
❑ Occult cancer
❑ Toxins
❑ Guillain-Barré syndrome
❑ Amyloidosis
❑ Spinal shock
❑ Adie syndrome
❑ Botulism
❑ Charcot-Marie-Tooth
Hyperreflexia
❑ Cervical spondylosis
❑ Spinal cord compression
❑ Multiple small strokes
❑ Multiple sclerosis
❑ Metabolic encephalopathy
❑ Amyotrophic lateral sclerosis
Diagnostic Approach
Symmetrically hyperactive or hypoactive reflexes in the presence of downgoing toes are usually normal. A positive Babinski sign (upgoing toe) is always abnormal, signifying an upper motor neuron lesion, and is usually associated with spastic weakness and hyperreflexia. Lower motor neuron lesions are marked by hyporeflexia, flaccid weakness, atrophy, and twitching.
Clinical Findings
Nerve root compression Common presentations include asymmetric hyporeflexia affecting the ankle jerk with S1 compression, knee jerk with L3 or L4 compression, biceps and brachioradialis with C5 or C6 compression, and triceps with C7 or C8 compression.
Hypothyroidism Generalized hyporeflexia with a delayed relaxation phase is found; it is best seen at the ankle jerk.
Acute stroke Hyporeflexia is present on the side of the hemiparesis.
Diabetes Ankle jerks are bilaterally absent, and there is decreased vibratory sense but little motor weakness.
Alcoholism Sensory neuropathy, including decreased vibratory sense and tender feet, is typical.
Vitamin B12 deficiency Findings include early stocking/glove neuropathy, hypoactive or hyperactive reflexes, ataxia, and mental status abnormalities ranging from irritability to frank dementia.
Uremia Restless legs, profound distal sensory loss, muscle atrophy with areflexia, and burning sensations occur.
Myopathy Findings include hyporeflexia (not areflexia) and weakness that is more prominent proximally than distally.
Occult cancer Lung cancer especially may present with a neuropathy.
Toxins Lead, arsenic, isoniazid, vincristine, and phenytoin produce hyporeflexia in the setting of a peripheral neuropathy.
Guillain-Barré syndrome Areflexia is prominent, with acute or subacute weakness and little sensory loss. Tingling occurs in the feet and hands, and the patient has difficulty with gait and use of the hands. The occurrence of bilateral facial weakness is an important clue. Autonomic dysfunction may also be present.
Amyloidosis Presenting with a sensory neuropathy with autonomic features, it occurs in the setting of chronic inflammatory disease, such as cancer or deep tissue infection.
Spinal shock Hyporeflexia occurs in the acute stage and is associated with a sensory level and motor weakness. It can be caused by traumatic, vascular, or neoplastic processes.
Adie syndrome There is generalized areflexia with a large pupil that dilates slowly with near-to-far fixation to accomodation but does not respond to direct light.
Botulism Reflexes may be decreased or normal. Key findings are a symmetric descending paralysis, early marked cranial nerve abnormalities with diplopia, dysarthria, dysphagia, and abnormal pupillary reflexes.
Charcot-Marie-Tooth This is a familial neuropathy characterized by sensory loss, “champagne-bottle” legs, wide-spread areflexia, and pes cavus.
Cervical spondylosis Neck pain and decreased range of motion is accompanied by muscle wasting in the hands or arms. It occurs in older patients, mostly resulting from osteoarthritis. There are often peripheral signs of osteoarthritis, such as Heberden or Bouchard nodes.
Spinal cord compression There should be a high index of suspicion in the setting of known cancer. Early symptoms include back pain, paresthesias in the legs, weakness climbing stairs, constipation, or change in urinary function. Early findings include decreased pinprick, vibration, or temperature sensation in the legs, slight hyperreflexia in the legs compared with the arms, and concussion tenderness over the spine. Later findings include upgoing toes, decreased sphincter tone, and a decreased sensation at a specific spinal cord level.
Multiple small strokes These occur in hypertensive or diabetic patients. Associated signs include emotional lability, increased jaw jerk, dementia, and ataxia.
Multiple sclerosis Suggestive symptoms include heaviness or numbness in a limb, unilateral transient visual loss, urinary incontinence, diplopia, and gait disorder. Findings include asymmetric hyperreflexia, pallor of the optic disc, internuclear ophthalmoplegia, cerebellar ataxia, dysarthria, and spasticity and weakness of the legs.
Metabolic encephalopathy This is seen in uremic and hepatic encephalopathy, and myoclonic jerks are common.
Amyotrophic lateral sclerosis A combination of upper and lower motor neuron signs in the brainstem and spinal cord without sensory loss is diagnostic. Look for increased jaw jerk, upgoing toes, and fasciculations with muscle wasting of small muscles (e.g., of the tongue).
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, 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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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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