Grading reflexes

[TheRealBatmanMD]

In a nutshell, I'm a medical student and I still don't understand how to grade reflexes. Is there a more objective system that you neurologists have in grading reflexes? I can't tell the difference between a 1+ and 2+, for instance. Could really use some help.

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[Telamir]

0 --> Absent
+1 --> Diminished
+2 --> Normal
+3 --> Brisk/high
+4 --> Clonus

0 and +4 are easy. The rest is repetition. See a ton and when someone says reflexes are brisk pay attention. It's not criteria based and it's not 100% objective. You just have to do a ton of them.

 

[Lots of Snow]

I was taught that

0 --> Absent
+1 --> Present only with a maneuver (Jendrassik, other forms of patient distraction)
+2 --> Normal
+3 --> Spread to another muscle group (such as observation of hip adduction in addition to expected knee extension upon elicitation of the patellar tendon response)
+4 --> Clonus


I like this paradigm because concepts like "spread" or the requirement to use a maneuver are more concrete than trying to assess amplitude. However, I've noticed this scale is applied inconsistently by neurologists and seldom by non-neurologists, so confusion about what reflex grades mean outside the extreme values persists. Also, I haven't done much reading on how the 0+ through 4+ scale came into widespread use and I'm not sure if there was some authoritative originator of the scale, which is in contrast to the "MRC" (Medical Research Counsel) grading scale for strength which IIRC was developed for neurotrauma all the way back during World War II and which later percolated into the rest of neurology.

 

[Freeinfinity]

I was taught that

0 --> Absent
+1 --> Present only with a maneuver (Jendrassik, other forms of patient distraction)
+2 --> Normal
+3 --> Spread to another muscle group (such as observation of hip adduction in addition to expected knee extension upon elicitation of the patellar tendon response)
+4 --> Clonus


I like this paradigm because concepts like "spread" or the requirement to use a maneuver are more concrete than trying to assess amplitude. However, I've noticed this scale is applied inconsistently by neurologists and seldom by non-neurologists, so confusion about what reflex grades mean outside the extreme values persists. Also, I haven't done much reading on how the 0+ through 4+ scale came into widespread use and I'm not sure if there was some authoritative originator of the scale, which is in contrast to the "MRC" (Medical Research Counsel) grading scale for strength which IIRC was developed for neurotrauma all the way back during World War II and which later percolated into the rest of neurology.

Yes, I was taught this for residency.

But in actual practice, I think a lot of ppl go by Telamir's breakdown, which can be somewhat subjective.

At the end of the day I always "trust but verify" myself what another physician tells me.

 

[DrSatan]

0 --> Absent, though I've seen many attendings simply put trace (which drives me bonkers)
1 --> Subtle or requiring distraction maneuver
2 --> Normal
3 --> Exaggerated or spread
4 --> Clonus

I'll also use + to indicate slight asymmetry between the contralateral reflex or if it's a brisk normal.

IMO, reflexes are subjective. It's not uncommon to see attendings simply put 2+ if present at all. I've been told that slight cross-adduction is normal, so although you may rate is as 3, it could technically be normal. Brachioradialis is the hardest reflex to get sufficient at, and frequently the one I see the most disparity between different raters. Most people do not check the triceps reflexes. Achilles is absent in older folks and can be a challenge to obtain in a hospital bed.

The real utility of reflexes is to know whether there are any asymmetries between sides (left vs right) or upper vs lower limbs to help with localization. That is why it's important to compare the same reflexes back-to-back (ie, left then right or vice-versa) to get a sense of any asymmetry. It's obviously a little more complicated than that. Just know that I've never seen a medical student get a brachioradialis reflex in someone without a spinal cord lesion. And do not forget to actually use your hammer -- every medical student is so hesitant to put some oomph in the hit, but you have to elicit the reflex.

 

[TheRealBatmanMD]

I was taught that

0 --> Absent
+1 --> Present only with a maneuver (Jendrassik, other forms of patient distraction)
+2 --> Normal
+3 --> Spread to another muscle group (such as observation of hip adduction in addition to expected knee extension upon elicitation of the patellar tendon response)
+4 --> Clonus


I like this paradigm because concepts like "spread" or the requirement to use a maneuver are more concrete than trying to assess amplitude. However, I've noticed this scale is applied inconsistently by neurologists and seldom by non-neurologists, so confusion about what reflex grades mean outside the extreme values persists. Also, I haven't done much reading on how the 0+ through 4+ scale came into widespread use and I'm not sure if there was some authoritative originator of the scale, which is in contrast to the "MRC" (Medical Research Counsel) grading scale for strength which IIRC was developed for neurotrauma all the way back during World War II and which later percolated into the rest of neurology.

Thanks, this was super helpful. Also:

Question about the +1. Does the Jendrassik only apply to the patellar reflex or would it just be considered a distracting maneuver, if for instance someone asked a patient to do the Jendrassik while attempting to elicit the biceps reflex?
Question about +3: Any examples of spreading for other reflexes? I've seen cross adduction on the wards but not sure if I've seen spreading for the biceps reflex, for instance? What would that look like in a patient?

0 --> Absent, though I've seen many attendings simply put trace (which drives me bonkers)
1 --> Subtle or requiring distraction maneuver
2 --> Normal
3 --> Exaggerated or spread
4 --> Clonus

I'll also use + to indicate slight asymmetry between the contralateral reflex or if it's a brisk normal.

IMO, reflexes are subjective. It's not uncommon to see attendings simply put 2+ if present at all. I've been told that slight cross-adduction is normal, so although you may rate is as 3, it could technically be normal. Brachioradialis is the hardest reflex to get sufficient at, and frequently the one I see the most disparity between different raters. Most people do not check the triceps reflexes. Achilles is absent in older folks and can be a challenge to obtain in a hospital bed.

The real utility of reflexes is to know whether there are any asymmetries between sides (left vs right) or upper vs lower limbs to help with localization. That is why it's important to compare the same reflexes back-to-back (ie, left then right or vice-versa) to get a sense of any asymmetry. It's obviously a little more complicated than that. Just know that I've never seen a medical student get a brachioradialis reflex in someone without a spinal cord lesion. And do not forget to actually use your hammer -- every medical student is so hesitant to put some oomph in the hit, but you have to elicit the reflex.

Really helpful. Thank you!

 

[DrSatan]

Question about the +1. Does the Jendrassik only apply to the patellar reflex or would it just be considered a distracting maneuver, if for instance someone asked a patient to do the Jendrassik while attempting to elicit the biceps reflex?

If they require distracting maneuvers (eg, biting down) but the reflex can be elicited then it is a 1. This applies to all reflexes.

Question about +3: Any examples of spreading for other reflexes? I've seen cross adduction on the wards but not sure if I've seen spreading for the biceps reflex, for instance? What would that look like in a patient?

Spread from biceps or brachioradialis would involve finger flexion. Spread from achilles would involve knee extension. Those are the ones I've only really noticed. Not sure about triceps.