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?
>> Vibration.
>> 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.
>> Now.
>> 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 long-handled 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,
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.
I'll do it one more time, okay.
This will be graded as a three plus because there is spread of
reflexes.
Okay.
Now, a close up of the gastrocnemius with an absent
ankle reflex.
No appreciable contraction of the gastrocnemius.
Notice that there's sometimes a little bit of
bounce within the muscle but this is not true contraction.
This is just from the mechanical percussion of the reflex hammer,
again this is not a true contraction.
This would be graded as zero, no reflexes.