By convention the deep tendon reflexes are graded as follows:
- 0 = no response; always abnormal
- 1+ = a slight but definitely present response; may or may not be normal
- 2+ = a brisk response; normal
- 3+ = a very brisk response; may or may not be normal
- 4+ = a tap elicits a repeating reflex (clonus); always abnormal
How are reflexes graded?
The MRC clinical grading scale for reflexes is outlined below:
- - = not present
- +/- = present with reinforcement
- + = present
- ++ = obviously present
- +++ = brisk
- ++++ = pathologically brisk with clonus
What are normal reflexes?
In medicine, reflexes are often used to assess the health of the nervous system. Doctors will typically grade the activity of a reflex on a scale from 0 to 4. While 2+ is considered normal, some healthy individuals are hypo-reflexive and register all reflexes at 1+, while others are hyper-reflexive and register all reflexes at 3+.
What is a deep tendon reflex rating?
Deep tendon reflexes are normal if they are 1 +, 2 +, or 3 + unless they are asymmetric or there is a dramatic difference between the arms and the legs. There are three basic deep tendon reflexes, which evaluate the integrity of your lower neck (cervical) spinal nerve supply. These are known as the biceps reflex, the brachioradialis reflex, and ...
What do deep tendon reflexes indicate?
What do deep tendon reflexes indicate? Deep tendon reflex also usually refers to this sense. A deep tendon reflex is often associated with muscle stretching. Tendon reflex tests are used to determine the integrity of the spinal cord and peripheral nervous system, and they can be used to determine the presence of a neuromuscular disease.
How do you evaluate DTR?
Testing the DTR is quick and easy but requires a proper technique for a reliable response. The examiner taps the muscle's tendon with an examination hammer, and the response is observed and graded. For effective and reliable results, the patient should be as relaxed as possible.
How do you grade a standard deep tendon reflex such as the knee jerk?
NINDS Scale:0: Reflex absent.1: Reflex small, less than normal; includes a trace response or a response brought out only with reinforcement.2: Reflex in the lower half of the normal range.3: Reflex in the upper half of the normal range.More items...•
How are stretch reflexes graded?
The stretch reflex (myotatic reflex), or more accurately "muscle stretch reflex", is a muscle contraction in response to stretching within the muscle....Clinical significance.GradeResponseSignificance2+brisk physiologic responsenormal3+very brisk responsemay or may not be normal4+clonusalways abnormal2 more rows
How do you assess deep tendon reflexes in nursing?
To perform deep reflex tendon testing, place the patient in a seated position. Use a reflex hammer in a quick striking motion by the wrist on various tendons to produce an involuntary response.
How do you assess DTR deep tendon reflex?
5:059:04If you're beginning out what you want to do is you want to find that tendon. So to find the tendon.MoreIf you're beginning out what you want to do is you want to find that tendon. So to find the tendon. We are going to have the patient flex. The arm and flex the bicep. And you will find it right in
How do you classify reflexes?
Reflexes can be categorized as either autonomic or somatic. Autonomic reflexes are not subject to conscious control, are mediated by the autonomic division of the nervous system, and usually involve the activation of smooth muscle, cardiac muscle, and glands.
What are the 4 types of reflexes?
There are different types of reflexes, including a stretch reflex, Golgi tendon reflex, crossed extensor reflex, and a withdrawal reflex.
What does absent deep tendon reflexes mean?
Deep tendon reflexes may be absent when either the afferent volley is unable to access the spinal cord (sensory polyneuropathy, the spinocerebellar degenerations, root avulsion) or when the resulting efferent volley is unable to access the muscle (motor neuronopathy, radiculopathy, and certain neuromuscular junction ...
What is a graded response in muscle contraction?
A series of action potentials to the muscle fibers is necessary to produce a muscle contraction that can produce work. Normal muscle contraction is more sustained, and it can be modified by input from the nervous system to produce varying amounts of force; this is called a graded muscle response.
Why are deep tendon reflexes assessed?
Reflex Exam (Deep Tendon Reflexes) The reflex exam is fundamental to the neurological exam and important to locating upper versus lower motor neuron lesions.
How do you check a DTR in your leg?
Knee reflex: (L2-L4) Slightly lift up the leg under the knee, and tap the patellar tendon with a reflex hammer. There should be a reflex contraction of the quadriceps muscle (knee extension). (If performed in a sitting position, have the legs dangle over the edge of the chair or table).
What level is knee-jerk reflex?
The patellar reflex, also called the knee reflex or knee-jerk, is a stretch reflex which tests the L2, L3, and L4 segments of the spinal cord.
What is normal knee-jerk reflex?
0:091:53The knee-jerk reflex is a simple reflex arc that occurs at the level of the spinal cord. In otherMoreThe knee-jerk reflex is a simple reflex arc that occurs at the level of the spinal cord. In other words the Associated movement occurs without the involvement of the brain.
How do you measure knee-jerk?
The first device switches on the electronic stopwatch timer when the hammer strikes the tendon. The second device switches the stopwatch timer off as the leg jerks. Thus, the stopwatch timer measures the reflex time of the knee jerk. This time is used in diagnosis of the thyroid state.
What level is knee-jerk?
The knee-jerk reflex is a deep tendon reflex that is mediated by the nerves in the L2, L3, and L4 of the spinal cord3.
How do you know if a tendon is fluid filled?
Tendinitis: How do you know the tendon is "fluid filled"? A tendinitis can have some swelling around the tendon that can be seen on ultrasound or mri. If there is a tear in the tendon this can happen too. Treatment would be nsaids and physical therapy first, followed possibly by a cortisone injection. If there is a tear it may need surgical repair.
What is a 0-4 reflex?
0-4: Deep tendon reflexes, of which the knee-jerk is the best known, are spinal reflexes triggered by hitting certain tendons. Triceps, biceps, patellar (knee) and ankle are the most commonly tested and are graded 0-4 as follows: 0-absent 1-small reaction 2=normal 3=brisk 4=clonic (continuous jerking) clinical context and symmetry more important than the actual reflex grade though.
Can reflexes be down?
No: If the person under the influence his reflexes should be down from normal.
What happens when a tendon is tapped?
In a normal person, when a muscle tendon is tapped briskly, the muscle immediately contracts due to a two-neuron reflex arc involving the spinal or brainstem segment that innervates the muscle.
What neuron innervates the Golgi tendon?
In a normal person, when a muscle tendon is tapped briskly, the muscle immediately contracts due to a two-neuron reflex arc involving the spinal or brainstem segment that innervates the muscle. The afferent neuron whose cell body lies in a dorsal root ganglion innervates the muscle or Golgi tendon organ associated with the muscles; the efferent neuron is an alpha motoneuron in the anterior horn of the cord. The cerebral cortex and a number of brainstem nuclei exert influence over the sensory input of the muscle spindles by means of the gamma motoneurons that are located in the anterior horn; these neurons supply a set of muscle fibers that control the length of the muscle spindle itself.
Which neuron innervates the muscle?
In a normal person, when a muscle tendon is tapped briskly, the muscle immediately contracts due to a two-neuron reflex arc involving the spinal or brainstem segment that innervates the muscle. The afferent neuron whose cell body lies in ...
Which part of the brain controls the sensory input of the muscle spindles?
The cerebral cortex and a number of brainstem nuclei exert influence over the sensory input of the muscle spindles by means of the gamma motoneurons that are located in the anterior horn; these neurons supply a set of muscle fibers that control the length of the muscle spindle itself.
Is 1 + 3 + reflex normal?
Whether the 1 + and 3 + responses are normal depends on what they were previously, that is, the patient's reflex history; what the other reflexes are; and analysis of associated findings such as muscle tone, muscle strength, or other evidence of disease. Asymmetry of reflexes suggests abnormality.
What are the five deep tendon reflexes?
There are five primary deep tendon reflexes: bicep, brachioradialis, triceps, patellar, and ankle. Each reflex corresponds to a particular root and muscle and will evaluate the integrity of the root and associated nerve.
How to perform patellar reflex?
For the tricep reflex, the patient's arm should be held and suspended by the examiner at 90 degrees. Gravitational force is usually sufficient. The patellar reflex is performed with the patient sitting and legs hanging free over the chair's edge. If no visible response occurs, the examiner places his hand over the patient's ipsilateral quadriceps muscle and tries to feel a contraction; the Jendrassik maneuver helps elicit this reflex. The same position is used for the ankle reflex. Tapping the Achilles tendon will elicit a response.
What is a DTR test?
The deep tendon reflex (DTR) examination is part of the neurologic exam. They were first described by Wilhelm Heinrich Erb and Carl Friedrich Otto Westphal more than a century ago.[1] Their use continues to this day. The presence of hyporeflexia or hyperreflexia may indicate an underlying disease. Proper technique and interpretation of results are crucial to help in the diagnosis of many upper and lower motor neuron pathologic processes such as multiple sclerosis, amyotrophic lateral sclerosis, spinal cord injuries, spinal muscular atrophies, among others. They are sometimes referred to as muscle stretch reflexes.
What is the normal response grade for NINDs?
NINDS grading of DTR ranges from 0 to 4. A normal response is grade 2 or 3.
How to test DTR?
The examiner taps the muscle's tendon with an examination hammer, and the response is observed and graded. For effective and reliable results, the patient should be as relaxed as possible. If the patient is thinking about the test or has a rigid posture, its integrity is limited.
What is the role of stretch reflex?
[14][18] It probably plays an important role in maintaining muscle tone and upright posture. The cerebral cortex and possible brainstem nuclei produce influence in the muscle spindle through the gamma motor neurons. [13][15][17][19] Dorsal spinocerebellar tracts carry the information from the spinal cord to the cerebellum.
What muscle is inhibited during the knee jerk reflex?
During the knee jerk reflex, the hamstring muscles are inhibited and relax while the quadriceps muscles are stimulated and contract. Within the muscle spindle, the gamma motor neuron cause tightening or relaxing of intrafusal muscle fibers to regulate the sensitivity of the muscle spindle and the reflex's response. It is mediated by acetylcholine.
What is reflex exam?
Reflex Exam (Deep Tendon Reflexes) The reflex exam is fundamental to the neurological exam and important to locating upper versus lower motor neuron lesions. There are five deep tendon reflexes and a number of superficial and visceral reflexes covered here.
Can you evaluate reflexes?
Reflexes are useful for the general internist to perform, but you can’t evaluate them if …. You don’t have a hammer. You don’t use proper technique, in which case the reflex will appear to be absent when it is present. If you don’t know what abnormalities to expect and what they mean.
Is grading reflexes useful?
We are not big believers in grading reflexes ( grading muscle power is much more useful). Nevertheless, if you need something beyond “absent,” “present,” “brisk,” or “hyperactive” then use below. If you have a hyperactive reflex don’t forget to look for clonus.
How many deep tendon reflexes are there?
There are five primary deep tendon reflexes: bicep, brachioradialis, triceps, patellar, and ankle. Each reflex corresponds to a particular root and muscle and will evaluate the integrity of the root and associated nerve. To provide a standard scale for the evaluation of DTR, in 1993, the National Institute of Neurological Disorders and Stroke ...
Why is the DTR called a tendon reflex?
The DTR is sometimes called stretch reflex or myotatic reflex because of the stretch action and the muscle response involved. Some authors argue that they are not the same reflex. [13] [14] [15] [16] They think that the tendon reflex occurs after the tendon's active stretching when it is tapped with the hammer.
What is a DTR test?
The deep tendon reflex (DTR) examination is part of the neurologic exam. They were first described by Wilhelm Heinrich Erb and Carl Friedrich Otto Westphal more than a century ago. [1] Their use continues to this day. The presence of hyporeflexia or hyperreflexia may indicate an underlying disease. Proper technique and interpretation of results are crucial to help in the diagnosis of many upper and lower motor neuron pathologic processes such as multiple sclerosis, amyotrophic lateral sclerosis, spinal cord injuries, spinal muscular atrophies, among others. They are sometimes referred to as muscle stretch reflexes.
What is the NINDS grade of DTR?
NINDS grading of DTR ranges from 0 to 4. A normal response is grade 2 or 3. 0: Absent reflex, no reaction. 1: Small reflex, less than normal, or obtained with reinforcement. 2: Lower half of normal reflex. 3: Upper half of normal reflex. 4: Increased reflex. Clonus may be present, and it is always pathological.
What is the DTR scale?
To provide a standard scale for the evaluation of DTR, in 1993, the National Institute of Neurological Disorders and Stroke (NINDS) propose a grading scale from 0 to 4. [2] It has been validated and is universally accepted. [3] Sometimes, a plus sign (+) is added to distinguish it from the motor examination but does not represent a little more of the reflex elicited. Subjective clinical evaluation between different observers is more accurate in the lower extremity reflexes. [4]
Which neuron provides the afferent component of the efferent component?
It is a monosynaptic reflex where only two neurons are involved; a sensory neuron provides the afferent component, and a motor neuron at the spinal cord provides the efferent component. The pathway initiates in the muscle spindle, a proprioceptive organ.
Why is the stretch reflex important?
[14] [18] It probably plays an important role in maintaining muscle tone and upright posture. The cerebral cortex and possible brainstem nuclei produce influence in the muscle spindle through the gamma motor neurons.
