Reflexes are charted during a neurological assessment using a standardized numerical grading scale, typically ranging from 0 (absent) to 4+ (clonus), recorded either on a stick-figure diagram or in a structured table that maps each reflex to its spinal cord level. The system is straightforward once you know the conventions, but the quality of the chart depends heavily on how well the reflexes were elicited in the first place. Getting an accurate read involves proper patient positioning, the right hammer technique, and knowing when to use reinforcement maneuvers or test for pathological signs.
The Standard Deep Tendon Reflex Grading Scale
The most widely used system in clinical practice grades deep tendon reflexes on a scale from 0 to 4+. Each number corresponds to a specific quality of response:
- 0: No response at all, even with reinforcement techniques.
- 1+: A diminished or sluggish response. The muscle contracts, but weakly.
- 2+: A normal, expected response. This is the baseline you compare everything else against.
- 3+: A brisker-than-normal response, but not necessarily abnormal on its own. Some healthy people are naturally brisk.
- 4+: A hyperactive response that includes clonus, which is a rhythmic, involuntary oscillation of the joint after the tendon is tapped. This is almost always abnormal.
The key clinical judgment is not whether a single reflex falls at a particular number but whether reflexes are symmetric side to side and whether the overall pattern makes neurological sense. A person who is 3+ everywhere and symmetric might just be an anxious patient. A person who is 3+ on the right side and 1+ on the left side has a lateralized finding that demands further investigation. Charting should capture these asymmetries clearly.
Using the Stick Figure Diagram
The traditional way to chart reflexes is a simple stick figure drawn to represent the patient’s body, with the reflex grade written next to the corresponding limb or location. The figure faces you as if you were looking at the patient, so the patient’s right side appears on your left. Each commonly tested reflex has a fixed position on the diagram:
- Biceps (C5-C6): Marked at the inner elbow area of each arm.
- Brachioradialis (C5-C6): Marked at the outer forearm, just above the wrist.
- Triceps (C6-C7): Marked at the posterior upper arm or elbow.
- Patellar/Knee (L3-L4): Marked at the knee of each leg.
- Achilles/Ankle (S1-S2): Marked at the ankle of each leg.
You write the numerical grade (0 through 4+) next to each location. Some clinicians also use plus and minus signs within grades for finer distinctions, though this introduces subjectivity. A notation like “2+ with reinforcement” or “JM” next to the grade tells anyone reading the chart that a Jendrassik maneuver was needed to bring out the response, which changes the clinical interpretation. If you are working in an electronic health record, the same information often goes into a structured table rather than a drawing, but the logic is identical: reflex name, side, grade, and any special notes about technique.
Technique That Affects What You Chart
A reflex grade is only as good as the elicitation technique behind it. If you chart a reflex as absent, but you used poor technique, you have documented a technical failure, not a neurological finding. The tools matter: a proper reflex hammer with adequate weight produces a more consistent tendon strike than improvised instruments like the handle of a stethoscope.
Patient positioning is equally important. Muscles should be relaxed but not flaccid. For the patellar reflex, having the patient sit on the edge of the exam table with legs hanging freely works well. For the Achilles reflex, dorsiflexing the foot slightly while the patient is seated puts appropriate tension on the tendon. Striking technique matters too: aim for the tendon itself rather than the muscle belly, and use a quick, swinging motion from the wrist rather than a rigid, forceful blow. The goal is a brisk stretch of the tendon, not a painful impact.
Anxiety and voluntary guarding frequently suppress reflexes, which is why clinicians often distract patients with conversation during the exam. If reflexes seem diminished, it is standard practice to attempt a reinforcement technique before recording a low grade.
The Jendrassik Maneuver and Reinforcement
When you tap a tendon and get a weak or absent response, the next step before charting it as truly diminished is to try the Jendrassik maneuver. The patient hooks their fingers together and pulls apart forcefully while you retap the tendon. For upper extremity reflexes, you can have the patient clench their teeth or press their knees together. The idea is that a voluntary muscle contraction somewhere else in the body temporarily amplifies the reflex arc you are testing.
Research confirms this works through a physical mechanism rather than a psychological one. A study on the patellar tendon reflex found that the Jendrassik maneuver increased reflex amplitude and decreased total reflex time, while purely mental tasks like counting backward had no effect on reflex parameters.1PubMed Central. Anatomically remote muscle contraction facilitates patellar tendon reflex reinforcement while mental activity does not: a within-participants experimental trial Work on the Achilles tendon reflex similarly showed that reflex amplitudes increased significantly during the Jendrassik maneuver, with the effect likely operating through a reduction in the nervous system’s normal braking signals on the spinal cord circuit.2PubMed Central. Standardization of the Jendrassik maneuver in Achilles tendon tap reflex
When you chart a reflex that was only present with reinforcement, always note that. A “1+ with JM” tells a very different story than a plain “1+.” A reflex that is absent even with reinforcement (true 0) is a stronger finding and more likely to represent genuine nerve or spinal cord pathology.
Charting Pathological Reflexes
Beyond the standard deep tendon reflexes, neurological assessments often include pathological reflexes that are not graded on the 0-to-4+ scale. These are recorded as present or absent, sometimes with qualitative notes.
The Babinski sign is the most well-known. You stroke the lateral sole of the foot from heel to toes, and a positive response is extension of the great toe with fanning of the other toes. This indicates upper motor neuron dysfunction in adults. Proper technique matters: the patient’s leg needs to be relaxed with slight knee flexion and the thigh externally rotated, and the intensity and location of the stimulation are considered the most important factors in getting an accurate result.3Journal of the Neurological Sciences. The Babinski Sign: A comprehensive review Chart it as “Babinski positive” or “upgoing plantar” on the affected side, or “Babinski negative” or “downgoing plantar” when the normal flexion response occurs.
The Hoffmann sign tests for upper motor neuron lesions in the upper extremities: you flick the nail of the patient’s middle finger, and a positive response is involuntary flexion of the thumb and index finger. A systematic review found that the Hoffmann sign has only a modest ability to rule in or rule out cervical myelopathy on its own.4PubMed. A Systematic Review of the Utility of the Hoffmann Sign for the Diagnosis of Degenerative Cervical Myelopathy Its close relative, the Trömner sign, involves flicking the palmar surface of the fingertip instead. Research suggests the Trömner sign may actually be more sensitive than the Hoffmann sign for detecting cervical myelopathy, particularly in mild cases, with one study reporting sensitivity around 94% for the Trömner compared with 76% for the Hoffmann.5PubMed. The Significance of the Trömner Sign in Cervical Spondylotic Myelopathy Patient Despite this, the Hoffmann gets far more attention in most training programs. Chart both when you test them, noting “positive” or “negative” for each side.
Clonus, while it appears in the 4+ grading, is also often charted separately. Sustained clonus (more than three to four beats) at the ankle is clinically significant. Document the number of beats and whether it was sustained or unsustained.
When Acute Findings Do Not Match the Textbook Pattern
One charting trap for less experienced examiners is expecting reflexes to match a simple rule: upper motor neuron injury equals hyperreflexia, lower motor neuron injury equals hyporeflexia. In reality, acute upper motor neuron injuries like fresh strokes or acute spinal cord trauma often produce the opposite of what the textbook predicts. In the acute phase, these injuries frequently cause hypotonia and areflexia rather than the expected briskness.6PubMed Central. Lower motor neuron findings after upper motor neuron injury: insights from postoperative supplementary motor area syndrome The classic hyperreflexia and spasticity pattern develops later, sometimes days to weeks after the insult. If you are charting reflexes in an acute setting, document exactly what you find without trying to force it into a diagnostic pattern. Serial exams over time will reveal the evolving picture.
How Age Changes Reflexes
Age is one of the most important contextual factors when interpreting a reflex chart. A reflex grade of 1+ in a 25-year-old tells a different story than the same grade in an 80-year-old. Research consistently shows that patellar reflex responses decline with age in neurologically healthy people, and this decline does not differ between men and women.7PubMed Central. Influence of age on patellar tendon reflex response
The Achilles reflex is particularly susceptible. Many healthy older adults have absent ankle jerks, which can be a normal age-related finding rather than evidence of neuropathy. Studies have documented measurable changes in the reflex arc itself, including slower contraction rates and longer delays between the tap and the muscle response.8PubMed. Aging-related neuromuscular changes characterized by tendon reflex system properties At the cellular level, there appears to be a decline in key proteins in the sensory neurons that carry stretch signals from the muscle to the spinal cord, starting around the fifth decade of life and approaching roughly half the levels seen in young adults by age 65.9PubMed Central. Age-dependent decline in density of human nerve and spinal ganglia neurons expressing the α3 isoform of Na/K-ATPase
When charting reflexes in older adults, note the patient’s age in the assessment and keep the age-related baseline in mind. Absent ankle jerks in a 78-year-old with no other neurological symptoms may not warrant an urgent workup. Absent ankle jerks in a 35-year-old warrant a closer look.
Medications and Conditions That Alter Your Findings
Certain medications and medical conditions change reflexes in predictable ways, and your chart should note these when relevant. Magnesium sulfate, widely used to prevent seizures in preeclampsia, is one of the most clinically important examples. Magnesium acts as a neuromuscular blocker by reducing chemical signaling at the nerve-muscle junction, and as blood levels rise, reflexes diminish progressively. Loss of deep tendon reflexes is a recognized early sign of magnesium toxicity, which is why frequent reflex checks are standard practice in patients on magnesium infusions.10Journal of Obstetric Gynecologic & Neonatal Nursing. Deep Tendon Reflexes: The What, Why, Where, and How of Tapping Regional anesthesia like epidurals and spinal blocks also predictably alter lower extremity reflexes by interrupting the reflex arc at the spinal cord level.
Diabetic peripheral neuropathy is another common condition that directly affects reflex charting. The ankle reflex is often the first to go in diabetic neuropathy because the longest nerve fibers are damaged first. Research has shown that people with diabetes who have abnormal lower extremity reflexes also have significantly worse nerve conduction study results compared to those with normal reflexes.11Archives of Medical Science. Diagnostic value of clinical deep tendon reflexes in diabetic peripheral neuropathy Earlier research confirmed that absent Achilles reflexes are significantly more common in the diabetic population.12PubMed. Diabetic polyneuropathy. Corneal sensitivity, vibratory perception and Achilles tendon reflex in diabetics Charting the Achilles reflex carefully and serially in patients with diabetes serves as a low-tech screening tool for progressing neuropathy.
Thyroid disorders also shift reflexes in characteristic directions. Hypothyroidism classically produces sluggish reflexes with a notably slow relaxation phase, sometimes called a “hung-up” reflex. Hyperthyroidism can produce the opposite, with unusually brisk responses. If you notice an oddly delayed relaxation in an otherwise normal-appearing reflex, it is worth noting that quality in your chart, not just the grade.
Primitive Reflexes and Frontal Release Signs
In adults, the re-emergence of reflexes that are normal in infants can signal frontal lobe or diffuse brain disease. These primitive or “frontal release” signs include the grasp reflex, palmomental reflex, snout reflex, glabellar tap, and suck reflex. They are charted as present or absent, and because any single primitive reflex can occasionally be found in healthy people, clinicians often look for clusters rather than isolated findings.
In healthy aging, the prevalence of primitive reflexes increases: research found that roughly half of men aged 25 to 45 had at least one detectable primitive reflex, and that proportion climbed to about three-quarters of men aged 65 to 85. The pattern was similar in women.13PubMed. Prevalence of primitive reflexes and the relationship with cognitive change in healthy adults: a report from the Maastricht Aging Study This means a single positive primitive reflex in an older adult is not alarming on its own.
A recent large study took a different approach, defining participants as “positive” for frontal release signs only when two or more signs were present simultaneously. The researchers examined participants annually for a battery that included the grasp, palmomental, snout, glabellar, suck, and jaw jerk reflexes, among others.14JAMA Network Open. Frontal Release Signs and Future Decline in Research Participants With Intact Cognition Using that threshold makes the finding more specific to actual neurological disease rather than just normal aging. When charting primitive reflexes, it helps to record each one tested and its result, so that the pattern is visible to anyone reviewing the assessment later.
Reliability and Its Limits
Reflex grading is inherently subjective: one examiner’s 2+ might be another examiner’s 3+. This is one of the main criticisms of reflex charting as a clinical tool. When researchers have used instrumented hammers that measure the actual force and the resulting muscle response, inter-rater reliability has been strong, with correlation values above 0.9.15PubMed Central. Clinical availability of the deep tendon reflex test using a novel apparatus in healthy subjects Separately, measurements of the biceps tendon reflex using electromyography showed similar consistency.16PubMed Central. The Correlation between Modified Ashworth Scale and Biceps T-reflex and Inter-rater and Intra-rater Reliability of Biceps T-reflex But those are instrumented, objective measurements. In standard clinical practice with manual grading, agreement tends to be lower and experience level matters considerably.
Research in veterinary neurology (where the same basic reflex grading principles apply) found that the higher the examiner’s expertise, the higher their agreement with other experts, and that students had roughly seven times the odds of disagreeing compared to neurologists when grading the biceps tendon reflex.17PLOS ONE. Comparison of interobserver agreement between the evaluation of bicipital and the patellar tendon reflex in healthy dogs The takeaway for human clinical practice is the same: reflex grading improves with experience, and the most useful charted information is often the pattern across reflexes rather than any single grade in isolation.
Superficial Reflexes and the Abdominal Exam
Not all reflexes in a neurological assessment involve hitting tendons with a hammer. Superficial reflexes, also called cutaneous reflexes, are elicited by stroking the skin and are charted separately. The superficial abdominal reflex is one of the most commonly tested: you lightly stroke each quadrant of the abdomen, and the normal response is contraction of the underlying muscles with the belly button deviating toward the stimulus.18New England Journal of Medicine. Superficial abdominal reflex Absence of this reflex on one side or in specific quadrants can point to an upper motor neuron lesion and helps localize the spinal level of the problem. Chart these as “present” or “absent” in each of the four abdominal quadrants.
The cremasteric reflex in males (stroking the inner thigh causes elevation of the ipsilateral testicle) is another superficial reflex that can help localize spinal cord lesions, specifically at the L1-L2 level. Like the abdominal reflexes, it is charted as present or absent on each side.
Practical Tips for Cleaner Documentation
A few habits make reflex charts more useful for whoever reads them next. First, always document the setting and context: patient position, whether reinforcement was used, and any medications or conditions that could affect the findings. A chart that just says “2+ bilaterally” with no context is less helpful than one that specifies “2+ bilaterally, patient seated, legs hanging free, no reinforcement needed.”
Second, test side to side for each reflex rather than testing all reflexes on one side and then switching. Comparing the left biceps to the right biceps immediately after is more reliable for detecting asymmetry than comparing reflexes tested minutes apart. Asymmetry is often the most clinically important finding, more so than the absolute grade.
Third, when using electronic records, avoid defaulting to “2+ and symmetric” out of convenience. Reflexes should be tested and documented at every relevant assessment, and a reflexive (no pun intended) copy-paste of normal findings from a previous visit defeats the purpose. In settings like magnesium therapy, serial reflex checks need to be documented individually with timestamps so that changes over time are visible.
Finally, consider documenting reflexes you did not elicit and why. If a patient has a below-knee amputation, obviously you cannot test the ankle jerk. If an obese patient’s patellar tendon is difficult to locate, note that rather than guessing at the grade. Honest documentation of technical limitations is far more useful than a falsely clean chart.