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Deep Tendon Reflexes: The What, Why, Where, and How of Tapping
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Jan M Nick
Loma Linda University and Saniku Gakuin College, Japan
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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- eliciting a response, the nurse can assess DTRs and
stasis between the cerebral cortex and the spinal cord. interpret the findings with confidence. Improved
When these reflexes are disrupted, hyperreflexia (dis- interpretations offer increased validity. By verifying
ease induced) or hyporeflexia/areflexia (drug true patient conditions, the nurse can determine
induced) occurs. Although nurses perform deep ten- appropriate primary, secondary, and tertiary inter-
don reflex assessments regularly, it is difficult to incor- ventions.
porate theoretical principles in these assessments This article defines DTRs, explains why the limb
because of scant medical literature, a lack of nursing moves when tapped, shows where to assess DTRs,
research, and time constraints in nursing programs. and demonstrates how to use the hammer correctly.
These conditions usually result in one-on-one training, Finally, possible research suggestions are provided to
causing reduced consistency. A comprehensive exam- induce investigation. Lack of information in the lit-
ination assists the clinician to apply theoretical princi- erature, coupled with a variety of patient, practi-
ples, develop expert technique, and serve as a cata- tioner, and clinical factors, is the root cause of unre-
lyst for clinical research. JOGNN, 32, 297–306; liable methods. A systematic review of the
2003. DOI: 10.1177/0884217503253491 physiology and anatomy of DTRs will improve our
Keywords: Clonus—DTR—High-risk pregnancy— theoretical concept.
Hypermagnesemia—Jendrassik’s maneuver—Magne-
sium therapy—Pregnancy-induced hypertension— What Are Deep Tendon Reflexes?
Preterm labor—Reflexes—Reinforcement
What exactly do the words deep tendon reflex
Accepted: April 2002
mean? Does deep refer to a particular type of tendon
or to a system of reflexes? When we perform this
Assessment of deep tendon reflexes (DTRs) is a assessment, do we stimulate deep reflexes or do we
skill we use daily in our clinical practice. Yet, the lit- stimulate deep tendons?
erature provides scant information on the physiolo-
gy, proper technique, and research issues associated Flexor Versus Extensor Tendons
with deep reflexes. This deficit of information caus- Composed of collagenous connective tissue, ten-
es interpretive challenges and a general lack of dons take the form of cords or straps; they connect
understanding about how valuable reflex assessment muscle to bones (Williams et al., 1995, p. 781). Ten-
is to our repertoire of clinical skills. For these rea- dons move these structures and are identified by
sons, the time is ripe to revisit DTR assessment. their function, whether flexor or extensor. A flexor
The improper execution of reflex assessment tendon causes the limb to bend upon itself. An
invalidates the findings and clouds the patient’s true extensor tendon causes the limb to extend or
condition. However, by understanding the physiolo- straighten out. Thus, the word deep does not refer to
gy of the reflex and following basic principles when the type of tendon but to the type of reflex.
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.
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 FIGURE 7
it. Insufficient stretching of the tendon before tapping will 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
reduce the response. The thumb is then tapped with the
flex.
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 the arm with the practitioner’s nondominant hand. Slight-
thumb in place prior to striking the tendon may cause ly bending the patient’s arm at the elbow, the practitioner
undue pain for the patient. Additionally, the tendon may taps the tendon about an inch above the bony projections
not have actually been struck. on the back side of the elbow with the broad end of the
The triceps reflex also can be easily assessed, if the limb hammer (see Figure 3). The triceps muscle will contract,
is completely relaxed. Relaxation can be accomplished by causing the arm to extend slightly. Because of the small
resting the arm either on the patient’s chest or supporting size of the triceps muscle, the reflex response is more of a
W
roots). Nurses have experience with the first two.
Although uncommon in practice today, the plantar reflex hen the cortex is irritable, the central
has the potential for being used more often. For the
recumbent population, such as often seen in obstetrics, it nervous system produces fewer inhibitory
would be much easier to assess than the ankle reflex. signals and hyperreflexia or brisk reflexes result.
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 Reliability of the Plantar Reflex
slightly using his or her nondominant hand while using Schwartz et al. (1990) compared responses of the
the other hand to palpate the tendon. Bending the knee Achilles tendon tap with the plantar tap on the ball of the
gently stretches the tendon in preparation for the tap. foot. Four examiners tested ankle and plantar reflexes on
Proper support of the limb will ensure good relaxation. each of 110 participants. They found 89% agreement
The practitioner lightly taps the tendon with the broad between the plantar and ankle tap methods. Participants
edge of the reflex hammer (see Figure 4). Stimulation of also preferred the plantar tap (43.3%) over the ankle tap
the muscle from the patellar tendon causes the quadriceps (14.1%). The researchers concluded that the plantar
muscle to contract and the leg extends. The quadriceps reflex is an acceptable alternative to the ankle reflex
muscle is by far the largest muscle group of all the deep because of the high agreement between the two. The plan-
reflexes to be stimulated; therefore, the biggest response tar tap may also be more feasible in obstetrics because the
comes from this muscle. plantar surface of the foot is so accessible. This would be
The ankle reflex can be observed either by directly tap- a fertile area for additional research.
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 How Do You Tap?
(1990) supplies two arguments for using the hammer Once the tendon is located, six basic principles must be
rather than sharp dorsiflexion on the ankle reflex. The followed to correctly elicit a deep reflex response. Under-
stronger argument of the two is that the muscle spindles standing these principles will help the nurse achieve accu-
respond better to velocity of the stretch stimulus (from a racy and expertise.
hammer) than to changes in muscle length (dorsiflexion).
Second, the dorsiflexion response is slightly slower as 1. Ensure complete relaxation of the limb prior to tap-
compared with direct tapping (Myklebust, 1990). The ping it (Bickley & Hoekelman, 1999, p. 590;
second argument is probably not clinically significant Swartz, 1998, p. 529). The easiest method to
because the delay in response time is only about 10 mil- achieve muscle relaxation is to instruct the patient
liseconds longer. to relax, then support the limb and wiggle it gently
Because of the anatomical position of the Achilles ten- back and forth until you achieve the desired level of
don, the ankle reflex is at times difficult to perform cor- relaxation. Otherwise, a dampened response to tap-
rectly. With the patient lying in bed, the nurse should posi- ping occurs, and either an inaccurately low reflex
tion her limb in either of two positions. In the first, reading or an asymmetric response results.
instruct the patient to bend the leg and cross it over the Asymmetric responses may be attributable to pro-
shin of the other leg to expose the back of the ankle (see gression of a disease process, muscle tone, or differ-
Figure 5). Stretch the tendon slightly by flexing the foot ences in posture or mental activity (Manschot, van
and tap the Achilles tendon with the broad end of the Passel, Buskens, Algra, & van Gijn, 1998). In
hammer. Unfortunately, this position is difficult for many obstetrics, practitioner error or tense muscle tone
pregnant patients to assume. A variation of this position generally contribute to asymmetrical responses.
is to slightly bend the knee and pronate the interior Thus, if it’s not relaxed, don’t tap it.
aspect of the ankle on the bed so that the Achilles tendon 2. Feel the tendon prior to tapping it. Upper and lower
is exposed to the outside (see Figure 6). Again, flex the tendons should be easily palpable if you are in the
ankle slightly to stretch the tendon before giving a tap. correct location. Repositioning and relaxation of the