These are the instructions for evaluating perception of vibration. Use a 128 hertz tuning fork. SOUND Hit the tuning fork hard enough so that the sides touch. And make sure that the subject knows the type of sensation. Do you feel this as a vibration or a buzzing gtgt Vibration. gtgt As a vibration, very good. Now repeat the procedure in the feet. Again, strike the tuning fork hard enough so that the sides touch and immediately put the tuning fork on the distal interphalangeal joint. Count the number of seconds.
Ask the subject to tell you when the vibration stops. gtgt Now. gtgt It stopped now Good. And repeat the procedure to the opposite side. Again, the tuning fork goes on the distal interphalangeal joint. Make sure you strike the tuning fork hard enough so that the sides touch. For evaluating deep tendon reflexes, with the subject seated, examiner should use the hand to gently dorsiflex the foot at about 90 degrees. Press upwards slightly on the sole of the foot. Use a reflex hammer, preferably a longhandled reflex hammer. A tomahawk hammer is also acceptable.
And strike the Achilles tendon just behind the heel. Contraction of the gastrocnemius muscle will be both seen and felt. Repeat the procedure with the opposite leg. Have to do now is show the discrepancy between the knee reflex and the ankle reflex. Many patients with HIV disease have both central and peripheral nervous system disease. So one may see a mix of hyperreflexia at the knee and reduced reflexes, or hyporeflexia or areflexia at the ankles. So now we’ll attempt to demonstrate this. So here first for the patella reflex, the knee reflex,.
HIV Neuropathy Screening Exam with Grading Reflexes
This would be graded as a 3 plus, there is hyperrefelxia and spread of the reflex to other muscles. In the same patient, ankle reflexes are reduced significantly out of proportion to knee reflexes. So these are the different gradings for ankle reflexes. Absent means that with a strong percussion of the Achilles tendon, there is no contraction of the gastrocnemius. Now you may see some mechanical bounce of the muscle but this is not the same as a contraction. Reduced is where there is a visible contraction of the gastrocnemius.
So here we’re seeing a visible contraction. Increased is where there’s a strong contraction of gastrocnemius with spread to other muscle reflexes. Here I’m going to attempt to demonstrate the different gradings of ankle reflex in the same individual. Obviously this is artificial, but it gives you an idea of the degree of movement of the gastrocnemius after percussion of the Achilles tendon. So first, absent ankle reflexes, percussion of the Achilles elicits no contraction of gastrocnemius. Be graded as a zero. Reduced reflexes implies that there is contraction of gastrocnemius but it’s reduced compare to normal.
This would be an example of reduced. May take several percussions to elicit a small contraction. If you ask the patient to reinforce, and if we go up to include the knee. Can we pan up to the knee I want you to bring your arms down. Bring your arms down like that. Reinforcement may be necessary to bring out a reduced reflex. Reinforcement here just by asking the subject to play tug of war with her hands. The normal reflex is a brisk contraction of gastrocnemius, it’s reproducible but doesn’t spread to other muscle groups.
And the last and final grading is hyperreflexia or increased reflexes, where there is a brisk contraction and some spread of reflexes. And finally, ankle INAUDIBLE with a brisk upward movement of the foot into dorsiflexion, with INAUDIBLE there will be a repetitive movement of the foot. So here we’re gonna demonstrate the discrepancy between knee reflexes and ankle reflexes. I’m gonna touch the patient’s foot here, the knee reflexes are very brisk and will be graded as three plus. You’ll notice that there is spread of reflex to other muscle groups other than just the quadriceps.
Again, very brisk knee reflexes. Now focusing on the ankle, there’s really no appreciable contraction of the gastrocnemius muscle. So the Achilles reflex is absent. Now to confirm that, I’ll ask the patient to reinforce. We don’t need to look at that. Could you put your hands together please, and play tug of war Like this. Excellent, and one, two, three, pull. So even with reinforcement there’s no contraction of the gastrocnemius. On close up this is the knee reflex with an excessive contraction of the quadriceps. Notice the spread of reflexes to abductor and aductor groups.