Normal Reflex Grading: 2+ is Average
A reflex grade of 2+ is considered normal or average on the standard deep tendon reflex (DTR) grading scale. 1
Standard Reflex Grading Scale
The deep tendon reflex grading system uses a 0 to 4+ scale to assess the nervous system 1, 2:
- 0 = Absent reflex (no response) 1
- 1+ = Diminished/hyporeflexia (trace response, less than normal) 1
- 2+ = Normal/average reflex response 1
- 3+ = Brisker than average (may indicate hyperreflexia) 1
- 4+ = Hyperactive with clonus (indicates upper motor neuron pathology) 1
Clinical Interpretation
The 2+ grade represents the normoreflexic range, where the reflex response is appropriate and balanced 1. This corresponds to:
- Peak tendon tap forces of approximately 21-50 Newtons when eliciting the reflex 1
- A brisk but controlled response without excessive excursion 1
- Symmetric responses bilaterally (side-to-side variability should be ≤2.0-2.2 ms for H-reflex testing) 3
Distinguishing Normal from Abnormal
Hyporeflexia (0-1+) suggests peripheral nervous system compromise and requires peak tap forces >50 Newtons to elicit 1. This may indicate:
Hyperreflexia (3+-4+) suggests central nervous system pathology and can be elicited with minimal force (0-20 Newtons) 1. This may indicate:
- Upper motor neuron lesions 1
- Spinal cord compression or myelopathy 4
- Cervical stenosis (particularly grade 3 stenosis shows static hyperreflexia in 64% of cases) 4
Common Assessment Pitfalls
- Inconsistent tap force: Clinicians should use standardized force ranges to ensure reproducibility 1
- Improper hammer selection: The Taylor hammer has a ceiling effect in the hyporeflexic range due to its small mass and short handle 1
- Failure to perform dynamic testing: In cervical spine pathology, 41% of patients show dynamic reflex changes with neck positioning that may be missed on static examination 4
- Ignoring asymmetry: Side-to-side differences exceeding 2.0 ms warrant further investigation 3