Documenting Normal Deep Tendon Reflexes
Normal deep tendon reflexes should be documented as present and symmetrical bilaterally, with equal amplitude responses in corresponding limbs, using standardized grading (typically 2+ on a 0-4 scale), and noting the absence of pathological features such as hyperreflexia, hyporeflexia, or asymmetry.
Key Documentation Elements
When documenting normal DTRs, you must include:
- Bilateral presence: Reflexes should be elicitable on both sides
- Symmetry: Left-right responses should be comparable in amplitude 1
- Appropriate grade: Typically 2+ (normal/average) on the standard 0-4 scale
- Absence of pathological signs: No clonus, no hyperreflexia, no absent reflexes 1
Standard Reflexes to Document
The most reliable reflexes to assess and document include 2:
- Patellar (knee jerk): Most consistently elicitable
- Achilles (ankle jerk): Highly reliable in adults
- Biceps and brachioradialis: Upper extremity assessment
- Triceps: Less frequently elicitable but important for completeness
Technical Considerations for Accurate Assessment
The quality of your DTR assessment depends on proper technique 3, 4:
- Force application: Normal reflexes typically require 21-50 Newtons of tap force 3
- Patient state: Quiet, wakeful state is optimal for elicitation 2
- Positioning: Ensure proper limb positioning and muscle relaxation
- Jendrassik maneuver: Can enhance weak reflexes by 34.3%, helping distinguish true absence from technical difficulty 5
Critical Pitfalls to Avoid
Asymmetry is a red flag - Even if reflexes are present, marked asymmetry suggests pathology and should not be documented as "normal" 1. In Guillain-Barré syndrome criteria, absent or decreased reflexes in affected limbs are diagnostic features, while hyperreflexia or clonus cast doubt on that diagnosis 1.
Context matters - Compare upper versus lower extremities and assess overall balance. A reflex that seems "normal" in isolation may be pathological when compared to other limbs 6, 4.
Timing considerations - In acute neurological conditions, reflexes may initially appear normal before becoming abnormal, so serial examinations may be necessary 1.
Documentation Format
A complete normal DTR documentation should read:
- "DTRs 2+ and symmetric bilaterally in biceps, brachioradialis, triceps, patellar, and Achilles reflexes. No clonus. No pathological reflexes."
This approach ensures objective, reproducible documentation that captures both the presence and quality of reflexes while excluding pathological features 7, 8.