Cerebrovascular accident, also known as stroke, occurs when blood flow to the brain is interrupted. The main risk factors are modifiable lifestyle factors like high blood pressure, smoking, diabetes, and obesity as well as non-modifiable factors like age, gender and family history. Deep tendon reflexes are graded on a scale from 0 to 4 based on the strength of the reflex response. Diabetic peripheral neuropathy results in numbness and pain in the feet and legs due to nerve damage. Treatment focuses on managing blood sugar levels, relieving pain, and preventing complications.

1. Cerebrovascular accident (CVA) better known as a stroke,
occurs when blood flow is interrupted to any part of the brain.
There are two main types of cerebrovascular accident: ischemic
stroke and hemorrhagic stroke. Cerebrovascular accidents are
major causes of morbidity and mortality (Vora et al., 2019).
Risk factors for CVA are divided into modifiable and non-
modifiable risk factors. Non modifiable risk factors include age,
sex, ethnicity and geography, family history of stroke.
Modifiable risk factors include smoking, alcohol consumption,
drug abuse, arterial hypertension, diabetes mellitus,
dyslipidemia, heart disease and hyperhomocysteinemia. Sudden
signs of stroke consist of FAST: face drooping, arm weakness,
slurred speech, time to call 9-1-1. . Cultures are at higher risk
for Cerebrovascular accidents are American Indian/Alaska
natives. Native Americans have 2.3 greater odds of being
diagnosed with diabetes than non-Hispanic Caucasians, a
condition that is a risk factor for heart attack and stroke (Van
Hooser et al., 2020). Native American continue to experience
healthcare disparities therefore causing lack of awareness to
heart diseases, diabetes, and stroke. Deep tendon reflex reveals
involuntary muscle contraction, the intactness of the reflex arc
at specific spinal levels, and the normal override on the reflex
of the higher cortical levels. The DTR is sometimes called
stretch reflex or myotatic reflex because of the stretch action
and the muscle response involved (Rodriguez-Beato & De Jesus,
2020). The deep tendon reflex has 5 components: an intact
sensory nerve (afferent), a functional synapse in the cord, an
intact motor nerve fiber (efferent), the neuromuscular junction,
and a competent muscle. The reflex response is graded on a 4-
point scale: 0 No response, 1+ Diminished, low normal, or
occurs only with reinforcement, 2+ Average, normal, 3+ Brisker
than average, may indicate disease, probably normal, 4+ Very
brisk, hyperactive with clonus, indicative of disease.Peripheral
neuropathy is symmetric damage to peripheral nerves (feet or
hands), resulting in pain without stimulation of the nerves.

2. Diabetic peripheral neuropathy manifests as lack of sensation in
the toes spreading to the foot, and the leg causing numbness and
pain (Tahir et al., 2020). What I would expect to find in a
person with diabetic peripheral neuropathy impaired light touch
sensation to the feet, hands or legs, vibratory perception, absent
or diminished ankle-deep tendon reflexes as well as muscle
weakness. Due to neuropathy, patients have difficulty with
mobility and daily activities. We constantly have diabetic
patients in the COVID unit. Most of my family members are
diabetic as well, my mother has daily neuropathy pain. At work
many of my diabetic patients go have dialysis. I recall a time
when I cared for a diabetic patient with bilateral lower
extremity amputation and an unstageable pressure ulcer to the
sacrum. Wound healing is difficult in diabetic patients. Wound
debridement was done. Patient was frequently repositioned,
pain medication administered, glucose levels maintained, and
wound care provided. Because of diabetic peripheral
neuropathy, skin cuts and blisters often go unnoticed and lead to
complications if not treated on time.
Reference
Vora, C., Talsaniya, K., & Prajapati, B. (2019). Clinical profile
of cerebrovascular accident patients with special reference to
serum homocysteine level. International Archives of Integrated
Medicine, 6(1), 76–82.Rodriguez-Beato, F. Y., & De Jesus, O.
(2020). Physiology, Deep Tendon Reflexes. In StatPearls.
StatPearls Publishing.Van Hooser, J. C., Rouse, K. L., Meyer,
M. L., Siegler, A. M., Fruehauf, B. M., Ballance, E. H.,
Solberg, S. M., Dibble, M. J., & Lutfiyya, M. N. (2020).
Knowledge of heart attack and stroke symptoms among US
Native American Adults: a cross-sectional population-based
study analyzing a multi-year BRFSS database. BMC Public
Health, 20(1), 40. https://doi.org/10.1186/s12889-020-8150-
xTahir, M., Adil, M., Khalid, S. R., Khan, S., & Tariq, S. B.
(2020). Prevalence and Risk Factors for Diabetic Peripheral
Neuropathy among Type 2 Diabetes Mellitus Patients.

3. Professional Medical Journal, 27(9), 1885–1890.
https://doi.org/10.29309/TPMJ/2020.27.09.4239
REPLY
Cerebrovascular accident also known as stroke affects the blood
flow to the brain. Most risk factors are lifestyle based and
others are unconditional. The first lifestyle-based risk factor is
high blood pressure which is caused by the blood exerting more
pressure than normal weakening the blood vessel walls causing
cerebrovascular accident. Cigarette smoking also causes stroke.
Smoke from cigarette constricts the arteries altering movement
of blood through the vessels causing stroke. Among diabetic
people, high blood sugar levels cause atherosclerosis hence
stroke. Another common risk factor to stroke that attributes to
hypertension and high cholesterol is obesity. Lack of regular
exercise increases the chances of cerebrovascular accident as
one is exposed to obesity and high blood pressure. There are
however uncontrolled factors such as age where the elderly is
more exposed, gender, where men are at a higher risk than
women and family history in regards to the disease.
Like most chronic illnesses, the prevalence of high
blood pressure and heart diseases vary among individuals on the
basis of ethnicity, and cultural backgrounds. Due to migration,
the average blood pressures between traditional and modernized
communities shows that the modernized community is exposed
to obesity due to the different cultural lifestyles (Kyaw et al,
2018). Cultures such as drinking, smoking and drug use involve
making decisions under uncertainties and may cause high blood
pressure.
According to Rodriguez- Beato & De Jesus (2020) the
deep tendon reflex is graded as, “0 = no response; normal, 1+=

4. a slight response which may or may not be normal depending on
the patient’s medical history, 2+ = a brisk response which is
normal, 3+ = a very brisk response which may or may not be
normal and 4+ = a tap elicits a repeating response which is
abnormal”. Analysis of findings such as evidence of disease,
muscle strength and tone determine other reflexes.
Diabetic neuropathy, also, nerve damage is a
complication among diabetic patients. A patient diabetic
peripheral neuropathy has numbness in their feet and are unable
to feel their feet while walking. Sharp pains are also evident
among them. They lose their balance as they walk and feet
begin to look deformed. With sores and blisters. The patients
have exaggerated sensations where warm feels very hot and
hurts when touched by a person with cold hands according to
Iqbal et. al (2018).
A patient with lower back pain and diabetes showed
general body weakness. Muscle strength and tone, tendon
reflexes and sensitivity to touch were examined. Nerve
conduction testing was done to measure how quickly the nerves
in the arms and feet conduct electrical signals. Since the
condition has no specific treatment the treatment conducted was
meant to relieve pain, manage complications and help the body
regain function and cause slow progression of the disease.
Maintaining the blood sugar levels within the patients was
hence essential and giving prescription medications;
antidepressants and anti-seizure dugs to relieve diabetes related
nerve pain. Urinary tract infections, digestive complications,
orthostatic hypotension were sexual dysfunction were managed
in treatment.
References
Iqbal, Z., Azmi, S., Yadav, R., Ferdousi, M., Kumar, M.,
Cuthbertson, D. J., & Alam, U. (2018). Diabetic peripheral

5. neuropathy: epidemiology, diagnosis, and pharmacotherapy.
Clinical therapeutics, 40(6), 828-849.
Kyaw, H., Raju, F., Shaikh, A. Z., Lin, A. T., Abbound, J., &
Reddy, S. (2018). Staphylococcus lugdunensis endocarditis and
cerebrovascular accident: a systematic review of risk factors
and clinical outcome.
Cureus, 10(4).
Rodriguez-Beato, F. Y., & De Jesus, O. (2020). Physiology
Deep Tendon Reflexes.
StatPearls [internet]
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