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Deep Tendon Reflexes: The What, Why, Where, and How of Tapping

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 PRINCIPLES & PRACTICE
Deep Tendon Reflexes: The What, Why,
Where, and How of Tapping
Jan M. Nick
Note: This is the corrected version of the article that had several lines of text omitted from page 300 of the
print version of the May/June 2003 issue. An erratum will appear in the print version of the July/August 2003
issue.
Deep tendon reflexes demonstrate the homeo-
stasis between the cerebral cortex and the spinal cord.
When these reflexes are disrupted, hyperreflexia (dis-
ease induced) or hyporeflexia/areflexia (drug
induced) occurs. Although nurses perform deep ten-
don reflex assessments regularly, it is difficult to incor-
porate theoretical principles in these assessments
because of scant medical literature, a lack of nursing
research, and time constraints in nursing programs.
These conditions usually result in one-on-one training,
causing reduced consistency. A comprehensive exam-
ination assists the clinician to apply theoretical princi-
ples, develop expert technique, and serve as a cata-
lyst for clinical research. JOGNN, 32, 297–306;
2003. DOI: 10.1177/0884217503253491
Keywords: Clonus—DTR—High-risk pregnancy—
Hypermagnesemia—Jendrassik’s maneuver—Magne-
sium therapy—Pregnancy-induced hypertension—
Preterm labor—Reflexes—Reinforcement
Accepted: April 2002
Assessment of deep tendon reflexes (DTRs) is a
skill we use daily in our clinical practice. Yet, the lit-
erature provides scant information on the physiolo-
gy, proper technique, and research issues associated
with deep reflexes. This deficit of information caus-
es interpretive challenges and a general lack of
understanding about how valuable reflex assessment
is to our repertoire of clinical skills. For these rea-
sons, the time is ripe to revisit DTR assessment.
The improper execution of reflex assessment
invalidates the findings and clouds the patient’s true
condition. However, by understanding the physiolo-
gy of the reflex and following basic principles when
May/June 2003
eliciting a response, the nurse can assess DTRs and
interpret the findings with confidence. Improved
interpretations offer increased validity. By verifying
true patient conditions, the nurse can determine
appropriate primary, secondary, and tertiary inter-
ventions.
This article defines DTRs, explains why the limb
moves when tapped, shows where to assess DTRs,
and demonstrates how to use the hammer correctly.
Finally, possible research suggestions are provided to
induce investigation. Lack of information in the lit-
erature, coupled with a variety of patient, practi-
tioner, and clinical factors, is the root cause of unre-
liable methods. A systematic review of the
physiology and anatomy of DTRs will improve our
theoretical concept.
What Are Deep Tendon Reflexes?
What exactly do the words deep tendon reflex
mean? Does deep refer to a particular type of tendon
or to a system of reflexes? When we perform this
assessment, do we stimulate deep reflexes or do we
stimulate deep tendons?
Flexor Versus Extensor Tendons
Composed of collagenous connective tissue, ten-
dons take the form of cords or straps; they connect
muscle to bones (Williams et al., 1995, p. 781). Ten-
dons move these structures and are identified by
their function, whether flexor or extensor. A flexor
tendon causes the limb to bend upon itself. An
extensor tendon causes the limb to extend or
straighten out. Thus, the word deep does not refer to
the type of tendon but to the type of reflex.
JOGNN 297
Deep Versus Superficial Reflexes
In the literature, one can find information on deep and
superficial reflexes. The difference between the two is not
with the reflex arc, because both deep and superficial
reflexes involve the action of the reflex arc. They differ in
where the receptor organ, which initially starts the reflex
arc, is embedded. Deep reflexes involve receptor organs
embedded in the muscle, whereas superficial reflexes have
receptor organs embedded in the skin. With deep reflex-
es, an internal structure (i.e., a tendon) stretches and stim-
ulates the receptors in the muscle group. The aroused
receptors initiate the reflex arc, causing the muscle to
move. Deep reflexes include patellar, Achilles, plantar, tri-
ceps, and biceps reflexes. With superficial reflexes, light
stroking on the skin stimulates the cutaneous tissue,
which initiates the reflex arc and causes the underlying
muscle to twitch. Examples of superficial reflexes include
the plantar (Babinski’s), cremasteric, abdominal, and anal
reflexes (Swartz, 1998, p. 532).

Alternate Names
The deep tendon reflex is also known as the myotatic
reflex or the stretch reflex (Gilman & Newman, 1996;
Hallet, 1993; Molavi, 1999; Myklebust, 1990). Myo is
derived from the Greek word mys, which means muscle.
The word tatic comes from tasis and literally means
stretching (Thomas, 1997). Hence, the myotatic (muscle-
stretching) reflex is the same as the stretch reflex, and FIGURE 1
both terms are synonymous with deep tendon reflex. It Reflex Arc. The tendon is stretched by the hammer, sending a
would be correct to say deep reflex, tendon reflex, message to the spinal cord where it is routed back to the muscle
myotatic reflex, or stretch reflex, but it is actually redun- telling it to contract. The arrow from the brain illustrates the
continuous dampening signal of the cerebral cortex on the reflex
dant to say “deep tendon reflex.”
arc.

Why Do You Tap? Normoreflexia

What does it mean when a patient has areflexia,
hyporeflexia, normoreflexia, or hyperreflexia? To answer
these questions, the nurse must have a basic understand-
ing of the reflex arc and the conditions that cause changes
in the reflex. When stimulated, the reflex arc generates a
message loop that starts from the muscle, goes up to the
spinal cord, and back down to the muscle again (see Fig-
ure 1). A tap on the tendon stretches the muscle group,
which initiates the reflex arc, sending a sensory impulse
up to the spinal cord using the sensory (afferent) nerve
pathway. At the spinal cord, the signal jumps across
(synapses) to the other neuron, which sends a message
back down via the motor (efferent) nerve pathway, telling
the muscle group to contract (Bickley & Hoekelman,
1999, p. 560). Undeniably, the reflex arc, which causes
contraction, takes place in a few milliseconds. Simply put,
one side of the reflex arc detects a stretch in the muscle,
whereas the other side of the reflex arc causes the muscle
to twitch (Molavi, 1999).
Although the reflex arc occurs almost entirely between
the spinal cord and the peripheral nervous system, the
cerebral cortex also influences limb movement. The cere-
bral cortex provides continuous signals that inhibit or
reduce limb movement, and the spinal cord provides sig-
nals that facilitate or cause limb movement. Fundamen-
tally, the tendon reflex response demonstrates a balance
of signals between the cerebral cortex and the spinal cord.
For normal limb movement, both the spinal cord and the
cerebrum must work closely together to achieve homeo-
stasis.
Hyperreflexia
Perinatal nurses commonly see hyperreflexia in
patients with preeclampsia. The disease causes changes in
the cortex, which disrupt the equilibrium of impulses
between the cerebral cortex and the spinal cord. The cor-
tex cannot send inhibitory impulses to the spinal cord.
When the spinal cord does not receive sufficient restraint

298 JOGNN Volume 32, Number 3

FIGURE 2
Biceps Reflex. Support the arm so that it is completely relaxed.
Press tendon at the base of the biceps with your thumb to stretch
the tendon. Tap thumb with pointed end of the hammer. Arm
will flex.
from the cerebral cortex, the reflex arc processes only
facilitory impulses and hyperreflexia results. Therefore,
brisk reflexes (hyperreflexia) are the result of an irritable
cortex and indicate central nervous system involvement.
Whenever there is central nervous system involvement,
the potential for seizure exists. Whenever the potential for
seizure exists, the need for magnesium therapy should be
evaluated. That is how we associate DTR assessment with
preeclampsia.
Because the reflex arc is a localized response involving
the limb-spinal cord-limb arc, clients with spinal cord
injuries still have deep reflexes. The signal generating from
the muscle spindle runs up the lower extremity, jumps
across one side of the spinal cord to the other, and races
down the leg telling the muscle to contract. Unfortunate-
ly, because the cord is severed, there is no communication
between the cerebral cortex and the spinal cord; neither
voluntary muscle movement nor inhibitory signals reach the
spinal cord. These patients typically exhibit hyperreflexia.
Hyporeflexia/Areflexia
Two conditions cause diminished or absent reflex
response in obstetric patients. These include regional block
anesthesia and magnesium administration. If physiologi-
cal alterations occur at the level of the spinal cord (i.e., as
a result of regional anesthesia), the impulse from the
stretched muscle reaches the spinal cord yet cannot jump
across to the neuron and send the “go back and move”
impulse back down to the muscle. For this reason, we see
altered reflexes after initiation of an epidural or spinal
block.
We also see diminished or absent reflexes when the
patient develops magnesium toxicity. Because magnesium
May/June 2003
FIGURE 3
Triceps Reflex. Support the arm so that it is completely relaxed.
Lightly tap the base of the triceps muscle with the broad end of
the hammer and the arm will extend.
is a potent neuromuscular blockade, which decreases the
secretion of acetylcholine, the afferent and efferent nerve
pathways do not relay the message properly. Depending
on the amount of magnesium present in the blood stream,
hyporeflexia result. Hypoactive tendon reflexes indicate
developing magnesium toxicity (Chinayon, 1998; Kokko
& Tannen, 1996; Lu & Nightingale, 2000; Raman &
Rao, 1995; Sibai, 1990). Therefore, it is extremely impor-
tant to frequently assess the reflexes of patients receiving
magnesium therapy.
Where Do You Tap?
Once you realize the simplicity of deep reflexes, know-
ing all the possible places to find them is the next chal-
lenge. Although there are many locations to elicit the
stretch reflex, this article focuses on common locations
for assessing reflexes in high-risk obstetric patients. Fig-
ures 2 through 7 show tendon locations, associated mus-
cle groups, limb positioning, and proper use of the reflex
hammer.
Upper Extremities
Three common locations comprise upper extremity
reflexes. They include the biceps reflex (innervation of
dorsal roots C5, C6), the brachioradialis (innervation of
dorsal roots C5, C6), and the triceps reflex (C7, C8) (Sei-
del, Ball, Dains, & Benedict, 1999, p. 787; Swartz, 1998,
pp. 530-531). The brachioradialis reflex is at times tricky
to elicit and will not be covered in this discussion. Of the
other two, the biceps reflex is easier to elicit than the
triceps.
To assess the biceps reflex, the patient’s arm should be
slightly bent and resting comfortably at the side of the bed
JOGNN 299
FIGURE 4
Patellar Reflex. Bend knee to stretch tendon while ensuring that
the leg is relaxed. Palpate tendon to verify location and then tap
with broad end of hammer. Leg will extend.
FIGURE 5
Achilles Reflex. Grasp foot and flex upward to stretch tendon.
Tap the tendon on the back of the leg at the height of the ankle
bone. Foot will extend. This position may be awkward for the
pregnant patient to assume.
(see Figure 2). The nurse places his or her thumb over the
antecubital fossa and stretches the tendon by depressing
it. Insufficient stretching of the tendon before tapping will
reduce the response. The thumb is then tapped with the
small end of the reflex hammer. With sufficient stimula-
tion, the biceps muscle contracts, causing the arm to flex
slightly. Use of the pointed end without the practitioner’s
thumb in place prior to striking the tendon may cause
undue pain for the patient. Additionally, the tendon may
not have actually been struck.
The triceps reflex also can be easily assessed, if the limb
is completely relaxed. Relaxation can be accomplished by
resting the arm either on the patient’s chest or supporting
300 JOGNN
FIGURE 6
Achilles Reflex–Alternate Position. Position patient on side with
leg overlapped as shown. Grasp foot and flex upward to stretch
tendon. Tap the tendon on the back of the leg at the height of
the ankle bone. Foot will extend.
FIGURE 7
Plantar Reflex. Flex foot and tap the ball of the foot between the
first two digits (at arrow) with pointed end of hammer. Foot will
flex.
the arm with the practitioner’s nondominant hand. Slight-
ly bending the patient’s arm at the elbow, the practitioner
taps the tendon about an inch above the bony projections
on the back side of the elbow with the broad end of the
hammer (see Figure 3). The triceps muscle will contract,
causing the arm to extend slightly. Because of the small
size of the triceps muscle, the reflex response is more of a
Volume 32, Number 3
twitch in the forearm rather than true extension of the
extremity.
Lower Extremities
For the lower extremities, the nurse can test the patel-
lar reflex (L3 innervation), the ankle reflex (S1 innerva-
tion), and the plantar tap (S1, S2 innervation of dorsal
roots). Nurses have experience with the first two.
Although uncommon in practice today, the plantar reflex
has the potential for being used more often. For the
recumbent population, such as often seen in obstetrics, it
would be much easier to assess than the ankle reflex.
Accessibility coupled with easy palpation makes the
patellar or knee jerk reflex the most commonly assessed
lower extremity reflex. To elicit a response with the
patient lying in bed, the nurse bends the patient’s knee
slightly using his or her nondominant hand while using
the other hand to palpate the tendon. Bending the knee
gently stretches the tendon in preparation for the tap.
Proper support of the limb will ensure good relaxation.
The practitioner lightly taps the tendon with the broad
edge of the reflex hammer (see Figure 4). Stimulation of
the muscle from the patellar tendon causes the quadriceps
muscle to contract and the leg extends. The quadriceps
muscle is by far the largest muscle group of all the deep
reflexes to be stimulated; therefore, the biggest response
comes from this muscle.
The ankle reflex can be observed either by directly tap-
ping the tendon with the broad end of the reflex hammer
or by sharp dorsiflexion of the limb (Gottleib & Agarwal,
1979). Although either method is acceptable, Myklebust
(1990) supplies two arguments for using the hammer
rather than sharp dorsiflexion on the ankle reflex. The
stronger argument of the two is that the muscle spindles
respond better to velocity of the stretch stimulus (from a
hammer) than to changes in muscle length (dorsiflexion).
Second, the dorsiflexion response is slightly slower as
compared with direct tapping (Myklebust, 1990). The
second argument is probably not clinically significant
because the delay in response time is only about 10 mil-
liseconds longer.
Because of the anatomical position of the Achilles ten-
don, the ankle reflex is at times difficult to perform cor-
rectly. With the patient lying in bed, the nurse should posi-
tion her limb in either of two positions. In the first,
instruct the patient to bend the leg and cross it over the
shin of the other leg to expose the back of the ankle (see
Figure 5). Stretch the tendon slightly by flexing the foot
and tap the Achilles tendon with the broad end of the
hammer. Unfortunately, this position is difficult for many
pregnant patients to assume. A variation of this position
is to slightly bend the knee and pronate the interior
aspect of the ankle on the bed so that the Achilles tendon
is exposed to the outside (see Figure 6). Again, flex the
ankle slightly to stretch the tendon before giving a tap.
May/June 2003
Since correct positioning for the ankle reflex is labori-
ous, the plantar reflex may be a viable alternative (see Fig-
ure 7). Gently rock the foot to relax the limb, then stretch
the calf muscles by dorsiflexing the foot. Tap the ball of
the foot, and plantar flexion will occur.
W
hen the cortex is irritable, the central
nervous system produces fewer inhibitory
signals and hyperreflexia or brisk reflexes result.
Reliability of the Plantar Reflex
Schwartz et al. (1990) compared responses of the
Achilles tendon tap with the plantar tap on the ball of the
foot. Four examiners tested ankle and plantar reflexes on
each of 110 participants. They found 89% agreement
between the plantar and ankle tap methods. Participants
also preferred the plantar tap (43.3%) over the ankle tap
(14.1%). The researchers concluded that the plantar
reflex is an acceptable alternative to the ankle reflex
because of the high agreement between the two. The plan-
tar tap may also be more feasible in obstetrics because the
plantar surface of the foot is so accessible. This would be
a fertile area for additional research.
How Do You Tap?
Once the tendon is located, six basic principles must be
followed to correctly elicit a deep reflex response. Under-
standing these principles will help the nurse achieve accu-
racy and expertise.
1. Ensure complete relaxation of the limb prior to tap-
ping it (Bickley & Hoekelman, 1999, p. 590;
Swartz, 1998, p. 529). The easiest method to
achieve muscle relaxation is to instruct the patient
to relax, then support the limb and wiggle it gently
back and forth until you achieve the desired level of
relaxation. Otherwise, a dampened response to tap-
ping occurs, and either an inaccurately low reflex
reading or an asymmetric response results.
Asymmetric responses may be attributable to pro-
gression of a disease process, muscle tone, or differ-
ences in posture or mental activity (Manschot, van
Passel, Buskens, Algra, & van Gijn, 1998). In
obstetrics, practitioner error or tense muscle tone
generally contribute to asymmetrical responses.
Thus, if it’s not relaxed, don’t tap it.
2. Feel the tendon prior to tapping it. Upper and lower
tendons should be easily palpable if you are in the
correct location. Repositioning and relaxation of the
JOGNN 301
 muscle group helps isolate the tendon. If you still
have difficulty feeling the tendon, place your finger
on the area where the tendon should be and have
the patient flex and extend the extremity. You will
feel the tendon move. You can practice this on your-
self first. This second principle is important for sev-
eral reasons. Attempting to tap the tendon when in
close proximity is poor technique. The nurse wastes
time with repeated blows on or near the site before
the hammer actually touches the tendon. Additionally,
poorly stimulated tendons respond differently than
properly stimulated tendons. Dampened responses
equal useless information. When tapped properly,
the nurse will not question whether the slight
response was due to developing magnesium toxicity
or to poor technique. If you can’t feel it, don’t tap it.
3. Tap lightly. Although the reflex response is propor-
tional to the amplitude of the stimulus (Myklebust,
1990), proper technique does not require force to
assess reflexes. Bickley and Hoekelman (1999, p. 590)
and Swartz (1998, p. 529) both recommended using
wrist action to strike rather than moving at the
Insufficient stretching of the tendon before
tapping reduces the response.
elbow, so that the stimulus will be as light as possi-
ble to achieve the desired effect. Heaviness of hand
does not give a truer response.
4. Reinforce the reflex rather than tapping harder. If
the practitioner has palpated the tendon, used the
correct end of the hammer, and delivered a light tap,
yet still does not receive an adequate response, rein-
forcement of the reflex arc may be needed rather
than tapping harder. Often, the patient cannot
attain sufficient muscle relaxation and the reflex
needs to be reinforced. You can do this by having
the patient perform isometric contraction of other
muscle groups. The isometric contraction makes
muscle spindles more sensitive to the stretch stimu-
lus and facilitates or enhances the response (Stretch
Reflexes, 1999; Swartz, 1998, p. 529). When testing
the upper extremities, instruct the patient to clench
her teeth before you tap on the biceps or triceps ten-
don. To reinforce lower extremity reflexes, have the
patient perform the Jendrassik’s maneuver (see
Figure 8). The patient locks the fingers and attempts
to pull apart the hands forcefully (Burke, Schutten,
Koceja, & Kamen, 1996; Swartz, 1998, p. 530). A
variation of Jendrassik’s maneuver is the fireman’s
grip—the patient grasps his or her forearms with the
302 JOGNN
hands and then pulls in opposite directions (see
Figure 9). Either reinforcement technique is accept-
able; client preference or ability may dictate which
maneuver is performed. How long should a patient
perform isometric contraction before the tapping of
the tendon? Unfortunately, there is little documenta-
tion in the literature regarding this issue. One study
reported that having the patient perform 2 seconds
of isometric contraction before the tapping of the
tendon was sufficient for complete facilitation to
occur (Burke et al., 1996). If gentle tapping does not
elicit a response, try reinforcing the reflex.
5. Assess upper and lower extremities in the same ses-
sion. A normal finding in the upper extremity does
not have the same amplitude of response as a nor-
mal finding in the lower extremity because of differ-
ences in muscle mass. Larger muscle groups jerk
more forcefully than smaller muscle groups. Thus,
the practitioner must become proficient in eliciting
and interpreting upper extremity reflexes. After
placement of regional anesthesia, upper extremity
reflexes will be the sole indicators for magnesium
need, efficacy, or toxicity. Good practice includes
assessing both upper and lower extremities during
the same session.
6. Use the reflex hammer correctly. There are at least six
different styles of reflex hammers used today (Med-
works Instruments, 2002). Some are completely cir-
cular, whereas other designs include hammers with
two ends (a broad end and a small end). When is it
appropriate to use the larger end and when should
the smaller, pointed end be used? Nurses are often
unsure. Because hammers with two ends are more
common in the perinatal area, this discussion focus-
es on correct technique using double-ended hammers.
The triangular Taylor hammer has a broad end and
a pointed end. The heavier Troemner hammer has
two rounded ends, one larger than the other. The prin-
ciple presented here will apply to both hammers.
There is not much guidance in the literature regarding
correct technique. In a review article on the history of the
reflex hammer, Lanska (1989) reported that both Taylor
and Troemner designed the larger broad head of the ham-
mer for striking the large extensor tendons such as patel-
lar, Achilles, and triceps. The smaller head of the reflex
hammer was designed to tap flexor tendons that bend
limbs toward the body, as does the biceps reflex. The text-
book entitled Bates’ Guide to Physical Examination and
History Taking (Bickley & Hoekelman, 1999) also stated
that the pointed end is useful in striking small areas and
recommended using it on the biceps reflex (a flexor
action). However, the textbook’s photographs show the
pointed end used on the extensor tendons (p. 591).
Despite the intended design of the hammers, does it mat-
Volume 32, Number 3

FIGURE 8
Jendrassik’s Maneuver. Have patient grasp fingers and pull at
least 2 seconds before lower body reflexes are assessed. This will
enhance lower body reflex responses. Patient may be lying down
or seated.
FIGURE 9
Variation of Jendrassik’s Maneuver or Fireman’s Grip. Have
patient grasp forearms and pull while lower body reflexes are
assessed. The fireman’s grip is useful when fine motor control is
affected or when joint pain is present. Patient may be lying
down or seated.
ter which end of the hammer to use on extensor tendons?
We know that historically, clinical methods were often
based on logic rather than research. Until studies are done
comparing results with either end of a hammer, using the
larger end for patellar, Achilles, and triceps muscles and
the pointed end for biceps is appropriate.
By incorporating these principles, nurses can become
proficient and efficient in conducting an accurate reflex
assessment. Understanding the basic principles and devel-
oping confidence in the assessment phase will support the
nursing process as we assess, intervene, and evaluate our
patient’s condition.
May/June 2003
TABLE 1
Mayo Clinic Scale for Tendon Reflex Assessment
Description Score
Absent –4
Just elicitable –3
Low response –2
Moderately low –1
Normal 0
Brisk +1
Very brisk +2
Exhaustible clonus +3
Continuous clonus +4
How Do You Interpret the Results?
Because of scant information, the teaching of DTRs
has generally been from a hands-on perspective. An expe-
rienced nurse, physician, or midwife generally teaches the
novice practitioner how to perform and interpret the
reflexes. Although ideal for retention of skills, this
method is not ideal for reliably and consistently relaying
information. There is not abundant written information
about DTR rating tools; few validity/reliability studies
exist. Only two classification schemes for rating tendon
reflexes were found in the literature. They include the
Mayo Clinic scale (Stam & van Crevel, 1990) and the
NINDS scale (Hallet, 1993).
Mayo Clinic Reflex Scale
First published by a group of physicians in the 1950s
for Mayo Clinic staff, this scale uses a complicated 9-
point rating scheme ranging from –4 to +4, with normal
reflexes reported as a zero (see Table 1). Facilities around
the world use this scale, although it may not be widely
used in obstetric practice.
Stam and van Crevel (1990) studied reliability issues
using the 9-point reflex grading scale. Three neurologists
performed complete upper and lower bilateral DTR
assessments on 20 patients and graded the responses. The
authors discovered significant disagreement in classifying
responses more than 28% of the time. Worse yet, when
checking for asymmetry of DTR reflexes on each patient,
the three neurologists disagreed more than 50% of the
time. Obviously, the authors concluded, in their study
conditions “examination of tendon reflexes is subject to
considerable inter-observer disagreement.”
NINDS Reflex Scale
The National Institute of Neurological Disorders and
Stroke (NINDS) division of the National Institutes of
Health published the NINDS scale in the early 1990s
(Hallet, 1993). The NINDS scale is simpler than the
JOGNN 303

TABLE 2
NINDS Scale for Tendon Reflex Assessment
Description Score
Reflex absent 0
Reflex small, less than normal; includes a trace
response, or a response brought out only by
reinforcement 1 milk, Perry, & Bobak, 2000; Olds, London, & Ladewig,
Reflex in lower half of normal range 2 2000) all have added the plus sign (+) on their scales. At
Reflex in upper half of normal range 3
Reflex enhanced, more than normal; includes clonus
if present, which optionally can be noted in an
added verbal description of the reflex 4 meaning slightly more response than described, but not
Mayo Clinic scale and has only five categories, with
scores ranging from 0 to 4 (see Table 2); it is now accept-
ed as the research standard at the National Institutes of
Health clinical center (Hallet, 1993; Litvan et al., 1996).
Litvan et al. (1996) studied reproducibility issues on
the NINDS scale. They measured the effect of a training
session on inter- and intraobserver reliability, using four
neurologists experienced in tendon reflex assessment. The
physicians evaluated 40 patients before a training session
and then 40 more patients after a training session. Results
showed that training did not improve the reliability of the
NINDS scale. However, the authors found substantial
intraobserver reliability (rk = .77 to .89) and moderate to
substantial interobserver reliability (rk = .51 to .61) even
without the training session. Reproducibility was higher
in the lower extremities than the upper extremities.
Manschot et al. (1998) performed reliability studies on
both the Mayo scale and the NINDS scale. Neurologists
and trainees (residents) judged four different reflexes,
which included the biceps, triceps, knee, and ankle. The
authors divided patients into two groups of 50 each. The
physicians then rated the results using either the Mayo or
NINDS scale. The authors assessed intra- and interob-
server reliabilities and found that neither the Mayo nor
the NINDS scales performed sufficiently well with differ-
ent observers (rk = .35). For example, what one practi-
tioner classified as normoreflexive, another classified as
hyperreflexive. The authors concluded that possibly the
lower reproducibility numbers resulted from a truer “real
world” situation, whereas the Litvan study had factored
in certain artificial elements. To improve communication
of reflex results, Manschot et al. recommended using
condensed descriptor categories such as absent, average,
brisk, few beats of clonus, and continuous clonus,
rather than numerical codes. Their recommendations
seem logical.
Differences Between the Scales
At closer inspection, there are major differences in the
two scales. One uses mathematical notations (+ or –) with
304 JOGNN
each number, whereas the other does not. Interestingly,
although the official NINDS scale does not use the nota-
tion of a plus sign (+) with each category as does the Mayo
Clinic scale, confusion in the literature exists. Journal
articles (Manschot et al., 1998), textbooks on physical
assessment (Swartz, 1998, p. 529), and nursing obstetric
textbooks (Gorrie, McKinney, & Murray, 1998; Lowder-
first glance, the meaning of 2+ compared with 2 may not
seem significant. But assigning +/– notations creates two
problems. Some practitioners interpret the plus sign as
sufficient to move up to the next higher category. The
same reasoning follows with the minus sign notation. The
response is slightly less than the value of the descriptor,
but not quite enough to use the next lower category. Sec-
ond, other clinicians think “+” means “present only with
reinforcement” (Bradley, 1994). The plus sign should not
be used, however, if it does not add information. Facilities
must decide if they want to use plus and minus signs and
determine what the signs actually mean to them.
The numerical value ascribed to normoreflexia also
differs greatly between the two scales. The Mayo clinic
scale assigns a value of 0 (see Table 1) for normoreflexia,
whereas the NINDS scale assigns a value of 2 or 3 (see
Table 2). To decrease institutional liability, unit educators
and managers should issue clear communications about
the DTR rating scale used at the health care facility. Doc-
umenting the scale in unit protocols, providing the scale
in the code section of the unit’s flowchart, and including
DTR assessment skills in the annual competency training
would strengthen the institution’s position regarding lia-
bility. If institutions chose to develop new descriptors or
to modify existing reflex scales, validity and reliability
studies should be documented before clinical use.
Recommendations for Research
Several potential study topics have emerged because of
the paucity of research dealing with tendon reflexes.
These recommended investigations would be clinically
based, inexpensive, noninvasive, and easily testable. This
combination of attributes makes research on reflexes well
suited for clinical nurse investigators.
Because regional blocks disable the reflex arc’s ability
to send a message to move the limb via the efferent path-
way, it would be useful to determine if the reappearance
of DTRs (after an epidural is discontinued) is a reliable
indicator of ability to ambulate. Research would establish
how much motor control returns when the patient still
has hyporeflexia or has normoreflexia. At what point can
the patient safely ambulate? How much motor control (as
measured by tendon reflexes) should be required before
attempting ambulation? Many times nurses have had to
Volume 32, Number 3
catch patients who fall when getting up for the first time
after giving birth. Nurses should document the return of
reflexes before discharging patients from the recovery
area or before ambulation if an association exists between
the presence of reflexes and returning motor control.
The frequency of reflex assessments is another question
that needs to be answered. No research-based guidelines
were found regarding the frequency of assessments.
Authors simply stated “frequent assessments are neces-
sary.” Because all patients receiving magnesium therapy
are at risk for developing magnesium toxicity, a study of
the risk of developing toxicity in relation to differing fre-
quencies of assessment would be helpful. Given the
nurse’s many other responsibilities, assessing too fre-
quently would not be ideal for either the nurse or the
patient. Given the current level of litigation in perinatal
services, assessing too infrequently also would be unde-
sirable. To develop evidenced-based practice, we must
have evidence. This type of project would be very helpful
to unit coordinators when developing protocols.
As mentioned previously, why were hammers designed
with a large head for extensor tendons, and a smaller
pointed end for flexor tendons? Does it really make a dif-
ference in obstetric practice? Using patients as their own
controls, this question could be easily answered.
A lthough used infrequently by obstetric
nurses, reinforcement is a simple technique
that can be used to facilitate the reflex
response when a patient cannot relax
sufficiently or when no response is seen.
Establishing reliability for reflex measurement tools
would be fruitful to nursing science. Because both reflex
measurement tools showed poor interrater reproducibili-
ty with neurology patients, nurses should study this prob-
lem, which would enhance their technical and interpretive
skills. Could changing the patient population improve the
psychometric properties? Nurses need to compare within-
and between-observer results in the obstetric population.
In this age of evidence-based practice, nurses are posi-
tioned to identify the gaps where practice is based on his-
tory rather than research. DTR assessment is such an area
that can support many nursing studies in the future.
Conclusions
DTR assessment can quickly demonstrate the balanced
communication between the spinal cord and the cerebral
May/June 2003
cortex. Results of this assessment help obstetric and
women’s health nurses to determine appropriate treatment
when either hyperreflexia, hyporeflexia, or areflexia exists.
By following suggested principles, nurses will not only
perfect their technique but also improve the validity of their
results. This skill is useful, necessary, and easily acquired
once basic concepts are learned. Although it is unfortu-
nate that minimal research has been conducted regarding
reflexes, this leaves many avenues open for nurses to fol-
low and add to the body of health care knowledge.
Acknowledgment
The author would like to gratefully thank and
acknowledge Patrick J. Simon, RN, for his creative graph-
ics and photography.
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Jan M. Nick, PhD, RNC, is an associate professor at Loma
Linda University School of Nursing in Loma Linda, CA. She is
the lead teacher for the Nursing of the Childbearing Family
course in the undergraduate nursing program.
Address for correspondence: Jan M. Nick, PhD, RNC, Loma
Linda University, School of Nursing, Loma Linda, CA 92350.
E-mail: jnick@sn.llu.edu.
Volume 32, Number 3