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NC guy

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Feb 17, 2009
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With ALS, MND or any neuromuscular disorder, can neuro office exam findings fluctuate from hyperactive to normal or vise-versa in early onset?

When my wife visited the neurologist for a December appointment with previous mentioned symptoms in another thread, he said that she was displaying hyperactive reflexes. She went back for a follow-up in January and when I asked him about the reflexes, he simply said "normal", however it was at this visit that afterwards he mentioned "neuromuscular" as a possible cause despite him stating the exam was normal. He then mentioned the possibilities of "neuromuscular" in a phone conversation three weeks after the January visit. I am perplexed by him suggesting neuromuscular after stating a normal reflex test at the January visit.

We're heading back soon for another follow-up because the med she was prescribed isn't working for the restless leg syndrome he suggested as another possible cause. I realize that at this stage, diagnosis of anything can be difficult when the obvious isn't so obvious. However, basically we both got the impression his diagnosis would likely be either a bad case of RLS or some sort of neuromuscular involvement.
I believe that reflexes run in a loop and can change, even for those with neuromuscular issue's.? anyone correct me if I am wrong.
I often wondered how reliable reflex measurements are. But then, I was/am desperate for my partner's neuro to say that his relexes were/are not brisk, leaving him with PMA as opposed to ALS.

From what I gather reflexes in motor neuron disease can change, so as the atrophy progresses (in a limb for example) what was once a brisk relfex in a wasted limb, can become a slow/hypo (as opposed to hyper) or even absent reflex.
Reflexes are also like strength measurements too. They are subjective, so unless they are really brisk or almost absent even the same doctor might have difficulty assigning a rating. Also, everyone's "normal" reflex is different.

Again, someone correct me if I'm wrong, but brisk reflexes in ALS are an UMN sign. I believe as the disease atrophies a muscle the reflex becomes absent due to the muscle not being strong enough to be able to produce a reaction.

I can't really comment on them going in cycles - don't know.
Yes, brisk reflexes are UMN sign. One of the so called 'hallmarks' of ALS is a wasted limb with a brisk reflex, in earlier stages of the disease. With increased atrophy the reflex diminishes.

Personally, I think the whole reflex associated diagnostics in neurology is a bit of a grey area. For example, Hirayama disease is suppossed to be characterised by solely LMN involvement, and yet there are recorded cases of hyper reflexes in Hirayama (pointing to UMN involvement).

I agree with ktmj that assessment may be subjective, but if seen by the same doctor over a period of time at least there is some kind of a baseline.
Yep Hyper is UMN.. And yep April they sure can loop, but never loop back to a normal state.. Always brisk or absent.. I myself can tell a brisk reflex immediately, you can feel a catch.. And I can feel Clonus.
I've had neuros tell me that they don't get too excited over brisk reflexes as some people just have them naturally brisk. I've also been told that if you are hyperreflexic, you are also most likely spastic (and I declare myself Spastic King). Then, throw in Mr. Babinksi while you're at it. Some folks present with a Babinski sign and are completely well (so I've been told). I agree with the subjectivity of it all, though. At the end of the day, it doesn't matter if your reflexes are brisk. It matters more if they are non-existant!

I think folks ought not to worry unless they start having trouble where they use to not (like trouble walking, talking, eating, lifting, etc...). I love potato chips and that has nothing to do with anything unless I can no longer ingest them through my mouth!

Well, my wife followed up with the neurologist. He still declares her reflexes as normal, so she's only had one visit (out of 3 or 4) where she was hyperactive. Her problem remains a growing weakness in her limbs, hands and feet, general fatigue, constant cramping and the twitching primarily in her feet, calf muscles and hands. The doc perceives her to have good strength although knowing her as I do, I believe that she does feel weakened and she does wear out a lot faster just in taking a simple walk.

He has ordered EMGs of right arm and leg and wants her to do yet another MRI. He also thinks her fatigue could be glandular in nature, but she just had such bloodwork in February. I guess she joins a large number of mysterious symptoms with no direct answer just yet. He did say, however, that he had pretty much ruled out MS, but indicated he hasn't fully ruled it out either. As for neuromuscular, he still kept that direction open as well. At this point, it looks like more waiting and see.

He still contributes some symptoms to restless leg, although she really isn't getting any benefit that much from the medicine after about three months.

As always, I appreciate the advise and replies.
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