Demonstrate observe assist perform versus video assisted teaching in teaching deep tendon reflexes to medical students: a comparative study

Background: Clinical examination of Deep tendon reflexes is a skilled technique that should be taught in an interesting way. Newer teaching learning methods like Video assisted teaching can be utilized  to facilitate self-directed and long term learning  and to cultivate enhanced interest in the study.Method: Among 120 students are divided into 6 groups.  Each group is divided into two batches of 10 members each. 6 batches are taught deep tendon reflexes separately by DOAP.  6 batches are taught deep tendon reflexes separately by video assisted teaching. At the end of teaching and 2 weeks later, each batch is  assessed by OSCE . Objective Structured Clinical Examination checklist marks are systematically entered in an excel sheet and was analysed using unpaired t-test .The perception to each teaching learning method was assessed by feedback Questionnaire using  Likert Scale.Results: On comparing between the effectiveness of video assisted teaching and clinical demonstration of the examination of deep tendon reflexes , students taught by video assisted teaching scored higher marks in the evaluation after two weeks, which was statistically significant. Regarding perception, students favoured both teaching methods for their effectiveness. For clarifying doubts, students favoured DOAP method. For reproducibility and better retaining of memory, students favoured video assisted teaching.Conclusion: Video assisted teaching was equally effective as DOAP in teaching deep tendon reflexes to medical students. For reproducibility and better retaining of memory, Video assisted teaching was perceived better as reflected in the better mean scores two weeks after the teaching sessions.

Assessment of the function of cervical spinal upper motor neuron in patients with frail arm syndrome / 中华神经科杂志

Objective To investigate cervical spinal upper motor neuron (UMN) dysfunction in patients with frail arm syndrome (FAS) by physical examination,triple stimulation technique (TST) and pectoralis tendon reflex tests.Methods Sixty-seven FAS patients,coming from Peking University Third Hospital from June 2013 to June 2016,underwent physical examination and routine electrophysiological tests.The pyramid signs,the results of pectoralis tendon reflex and TST were collected to estimate the function of cervical spinal UMN.Results On the time of diagnosis,weakness of bilateral proximal upper limbs was found in 61 patients,while weakness of unilateral proximal upper limb was found in six patients.There were 25 patients with tendon hyperreflexia,20 patients with tendon hyporeflexia and 22 patients with tendon areflexia.All the patients were pectoral muscle tendon hyperreflexia except one.UMN score of cervical region was 2.0 ± 0.5.Lower motor neuron score of cervical region was 2.0 ± O.2.The amplitude ratio of TSTtest/TSTcontrol was 78.31％ ± 6.52％.The latency and amplitude of quantitative detection of pectoralis tendon reflex was (7.80 ± 1.22) ms and (1.23 ± 0.14) mV,respectively.In the follow-up study,the tendon reflexes and the UMN score declined,the amplitude ratio of TSTtest/TSTcontrol decreased,while the lower motor neuron score increased and the latency of quantitative detection of pectoralis tendon reflex remained almost unchanged.Conclusion The results showed that there was cervical spinal UMN dysfunction in patients with FAS,and the pyramid signs were often concealed by muscle atrophy with progression of the disease.

Clinical Features of Adie's Tonic Pupil: A Retrospective and Cross-Sectional Study

PURPOSE: To report the clinical features of Adie's tonic pupil. METHODS: The medical records of 22 patients who had been diagnosed with Adie's tonic pupil from February 1998 to February 2009, were retrospectively reviewed. On March 2010, a cross-sectional examination was performed in 16 patients (19 eyes) who underwent a follow-up of more than 1 year. Measurements included pupil size in room light, bright light and in darkness; near point of accommodation; presence of segmental iris palsy; light-near dissociation; denervation supersensitivity; corneal sensitivity; and deep tendon reflex (DTR). RESULTS: Among the patients studied, 16 were women in Adie's tonic pupils. Only 3 of patients had bilateral involvement. The mean age of onset was 38.3 years. The mean size of Adie's tonic pupils was 2.3 mm larger than the fellow eyes. Segmental iris palsy was detected in 93.8% of the patients. Denervation supersensitivity was observed in all patients. Light-near dissociation was present in 88.2% and over 90% of the patients had decreased DTR in the biceps, triceps, knee and ankle jerk. CONCLUSIONS: This cross-sectional study showed Adie's tonic pupil tended to become miotic and recover accommodation power over the years.

The Correlation between Modified Ashworth Scale and Biceps T-reflex and Inter-rater and Intra-rater Reliability of Biceps T-reflex

OBJECTIVE: To establish a correlation between the modified Ashworth scale (MAS) and amplitude and latency of T-reflex and to demonstrate inter-rater and intra-rater reliability of the T-reflex of the biceps muscle for assessing spasticity after stroke. METHOD: A total of 21 patients with hemiplegia and spasticity after ischemic stroke were enrolled for this study. The spasticity of biceps muscle was evaluated by an occupational therapist using the MAS. The mean value of manual muscle test of biceps muscles was 2.3+/-0.79. Latency and amplitude of T-reflex were recorded from biceps muscles by two physicians. The onset latency and peak to peak amplitude of the mean of 5 big T-reflex were measured. The examinations were carried out by two physicians at the same time to evaluate the inter-rater reliability. Further, one of the physicians performed the examination again after one week to evaluate the intra-rater reliability. The correlations between MAS and T-reflex, and the intra- and inter-rater reliability of biceps T-reflex were established by calculating the Spearman correlation coefficients and the intra-class correlation coefficients (ICCs). RESULTS: Amplitude of the biceps T-reflex increased with increasing level of MAS (rs=0.464 and 0.573, respectively, p<0.01). ICCs of latency and amplitude of biceps T-reflex were 0.914 and 0.822. The Spearman correlation coefficients of latency and amplitude of biceps T-reflex were 0.937 and 0.635, respectively (p<0.01). CONCLUSION: Biceps T-reflex demonstrates a good quantitative measurement and correlation tool with MAS for spasticity, and also shows acceptable inter- and intra-rater reliability, which can be used for patients with spasticity after stroke.

Activation of Human Stretch Reflex by Experimental Muscle Pain

OBJECTIVE: This study was performed to investigate the effect of experimental muscle pain on the stretch reflex through electrophysiologic measuring of H-reflex and ankle tendon reflex. METHOD: Muscle pain was produced by the continuous infusion of 5% hypertonic saline into the soleus and tibialis anterior muscles respectively in the fourteen healthy, male volunteers. Control was made with infusion of 0.9% isotonic saline. H-reflex and ankle tendon reflex were recorded at the soleus before, during and 30 minutes after infusion of saline. RESULTS: The amplitude of ankle tendon reflex increased significantly during soleus and tibialis anterior muscle pain by the infusion of hypertonic saline as compared with those of before and after injection. But the H-reflex showed no significant changes during the infusion in either muscles. CONCLUSION: These results have demonstrated a muscle pain increased the amplitude of the stretch reflex without a corresponding increase of the H-reflex amplitude. One explanation could be an increased dynamic sensitivity of the muscle spindles during muscle pain caused by an increased firing of the dynamic gamma-motor neurons.

Clinical Implication of Long-Standing Delayed Plantar Reflex after Spinal Cord Injury: Case report

When recovery of specific reflexes after acute spinal cord injury are delayed or absent, we should consider an acute local complication or other factors that influence reflex function. We observed three spinal cord injury cases with a long-standing delayed plantar reflex and no evolution of Babinski sign despite enough recovery time had passed for the flexor spasm and all deep tendon reflexes of the lower extremities. In these cases we confirmed common peroneal nerve neuropathy at the fibular head by the nerve conduction study and electromyography. Long-standing delayed plantar reflex without evolution of Babinski sign, beyond expected recovery period, would be considered as a sign of local complication such as common peroneal nerve injury.

Sternocleidomastoid Tendon Reflex in Normal Korean Adults

OBJECT: The purpose of this study was to establish the normal values of sternocleidomastoid (SCM) tendon reflex in normal Korean adults. METHOD: The study for SCM tendon reflex was performed in 41 normal adults using electric reflex hammer. The compound muscle action potentials (CMAP) of SCM muscle were obtained by SCM tendon tapping. From 5 repeated trials of each subject, the shortest latency and the largest peak-to-peak amplitude of CMAP were chosen for the representative value. RESULTS: Mean values of latency and amplitude were 2.19+/-0.27 msec and 0.70+/-0.38 mV for SCM tendon reflex. There was no significant difference in the latency and amplitude regardless of side or sex (p>0.05). The age and height showed no signifiant correlation with latency and amplitude of SCM tendon reflex (p>0.05). CONCLUSION: We believe that our results can be used as an evaluation method of upper cervical spinal cord.

Diagnostic Value of Tendon Reflex in Diabetic Peripheral Neuropathy

OBJECTIVE: To investigate the role of tendon reflex test in the diagnosis of diabetic peripheral neuropathy. METHOD: Patellar tendon reflex (PTR) and achilles tendon reflex (ATR) were recorded in forty six diabetic patients and thirty seven normal adults by delivering tendon taps with an electric reflex hammer. Forty six diabetic patients were divided into two groups based on nerve conduction study and diabetic neuropathy score: group 1 consisted of nineteen patients with peripheral neuropathy, group 2 consisted of twenty seven patients without peripheral neuropathy. Multiple regression equations using latency as a variable dependent on age and height were used and upper crossing of the 3 standard deviation level with regression on height and age was considered abnormal. RESULTS: Mean latencies of PTR and ATR were prolonged in the diabetic patients in comparison with the controls (p<0.01) and were prolonged in group 1 compared to group 2. In group 1, PTR was abnormal in 14 cases (sensitivity: 73.6%, specifity: 88%) and ATR was abnormal in 13 cases (sensitivity: 68.4%, specifity: 85.1%). In group 2, PTR was abnormal in 3 cases and ATR was abnormal in 4 cases. CONCLUSION: Tendon reflex test would be a valuable supplement to conventional nerve conduction studies for detection of diabetic peripheral neuropathy, especially in the proximal segment.

Quantitative Analysis of Patellar Tendon Reflexes with Newly Designed Percussion Instrument

OBJECTIVE: There has been some existing problems with the electrical reflex hammer. The occurrence of pressure build up with percussion and change of hammering points is one example. In order to make improvements on this device, we conducted studies with a newly designed percussion instrumental stimulator. METHOD: The data collected from the first group was based on the manual percussion of electrical reflex hammer on the patella ligament. The data collected from the second group by usage of a newly designed instrumental stimulator maintained steady pressure and time and target position on the electrical reflex hammer. Comparisons were made between the two group. RESULTS: Our single measure of latency and amplitude on the manual and instrumental percussion group resulted in the reliability of 84.67%, 91.23%, 73.63%, and 83.29%. The 10 repeated measure of latency and amplitude on the manual and instrumental percussion group resulted in the reliability of 99.95%, 99.97%, 99.90%, and 99.94%. CONCLUSION: From our experiment on the tendon reflex, we found out that it is important to have an instrumental stimulator that can maintain steady pressure while it is applying percussion to accurate data. On manual percussion, it is important to obtain data based on mean value of repeated measurements.

Comparison of Tendon Reflex Responses between Two Heads of Gastrocnemius in Spastic Hemiplegia and Healthy Subjects

OBJECTIVE: To determine the differences of the tendon reflex responses (TRR) between medial and lateral heads of gastrocnemius muscles in healthy subject and spastic patients. METHOD: The TRR of medial and lateral heads were evaluated in 20 healthy subjects and 20 spastic hemiplegic patients. From 5 repeated trials on each subject, the shortest latency and duration, and the largest peak-to-peak amplitude of TRR were chosen for the representative value. RESULTS: 1. The evoked potentials by tendon reflex in medial head of gastrocnemius demonstrated significantly higher amplitude than in the lateral head of gastrocnemius in patients (P0.05). 3. Mean duration of the evoked potentials by a tendon reflex in both heads of gastrocnemius in spastic patients and healthy subjects were not significantly different (P>0.05). CONCLUSION: These results indicate that the medial head of gastrocnemius is activated more than the lateral head of gastrocnemius by a tendon reflex in recording evoked potentials of the spastic patients.

A Case of Early Onset Cerebellar Ataxia with Retained Tendon Reflexes

Early onset cerebellar ataxia with retained tendon reflexes is clinical syndrome characterized by progressive cerebelar ataxia of unknown etiology with an onset within the first two decades. This disorder was distinguished from Friedreich's ataxia by the preservation of the tendon reflexes. We have experienced a case of early onset cerebellar ataxia with retained tendon reflexes which was diagnosed by clinical features, eletrophysiologic studies, and MRI scan. This 8 year-old male patient had suffered from gait ataxia with delayed growth and development since 3 years of age. A brief review of the related literatures was also made.

A Case of Early Onset Cerebellar Ataxia with Retained Tendon Reflexes

Early onset cerebellar ataxia with retained tendon reflexes is clinical syndrome characterized by progressive cerebelar ataxia of unknown etiology with an onset within the first two decades. This disorder was distinguished from Friedreich's ataxia by the preservation of the tendon reflexes. We have experienced a case of early onset cerebellar ataxia with retained tendon reflexes which was diagnosed by clinical features, eletrophysiologic studies, and MRI scan. This 8 year-old male patient had suffered from gait ataxia with delayed growth and development since 3 years of age. A brief review of the related literatures was also made.

Normal Values of Tendon Reflexes in Normal Korean Adults

The purpose of this study was to establish the normal values of tendon reflex in normal Korean adults. Ankle tendon reflex(ATR), patellar tendon reflex(PTR) and medial hamstring tendon reflex (MHTR) responses were recorded in 96 limbs of 48 normal Korean adults by delivering tendon taps with an electric reflex hammer. Latency to the onset of the triggered response, peak to peak amplitude and duration of the wave were measured after several repetitions. Minimum latency and duration of the elicited response were chosen to calculate normal means. Side differences were also evaluated. As amplitude showed a marked interindividual variation and side to side variation, lowest recorded value was selected to represent the lower limit of normal. Mean values of latency, duration and amplitude were 30.27?3.18 msec, 11.05?1.08 msec and 1.98?0.89 mV for ATR, 16.37?1.58 msec, 20.63?1.68 msec and 1.56?0.76 mV for PTR and 20.25?2.14 msec, 10.95?1.57 msec and 0.71?0.56 mV for MHTR. Age, height, and leg length showed significant correlation with the latency of ATR, PTR and MHTR latency(P<0.001). We believe our results can be used as guideline researches in clinical practice.

DELAY OF THE ACHILLES REFLEX TIMES(ART) IN DIABETES / 解放军医学杂志

ART was determined in 104 cases of diabetics with a computerized kinemometer. It was found that of the intervals SD, SP, and VP, a delay of one of them appeared in 41 cases, two in 8 cases and all threein 15 cases. In addition, the reflex was lost in 13 cases. The abnormality of ART was positively related to peripheral diabetic neuropathy and decrease or loss of knee reflex(both p