Understanding Reflex Assessment for Student Nurses
Learn what neurological reflexes are, why reflex findings are compared between sides and how they contribute to a wider neurological assessment.
What is a neurological reflex?
A reflex is an automatic response to a stimulus. During neurological examination, certain reflexes can provide information about the pathways connecting peripheral nerves, the spinal cord and the central nervous system.
The response is involuntary
The patient does not consciously produce the normal reflex response.
Both sides matter
Comparing corresponding reflexes can help identify important asymmetry.
Never interpret alone
Reflex findings become meaningful when connected with the rest of the neurological examination.
Which reflexes might you hear discussed?
The exact neurological examination performed will depend on the clinical setting and the competence of the practitioner. Student nurses may see several reflexes assessed during placement.
Arm reflexes
Reflexes involving the upper limb may be assessed during a more detailed neurological examination.
Knee and ankle reflexes
Lower-limb reflexes may provide information about neurological pathways affecting the legs.
A different type of response
The plantar response may also form part of a neurological examination and should be interpreted by a suitably trained clinician.
What matters when reflexes are assessed?
Position the patient safely
The relevant limb needs to be appropriately supported and as relaxed as possible.
Use correct technique
Reflex testing requires the correct anatomical position and technique taught within clinical education.
Compare corresponding sides
A difference between the right and left can be more informative than a single isolated response.
Connect the result
Consider reflexes alongside strength, tone, sensation, coordination and other neurological findings.
Reflex responses can vary
Reflexes are not simply βpresentβ or βabsentβ. Their strength and symmetry can vary between patients, and clinical interpretation requires training and context.
A response may be diminished
A reflex may appear weaker than expected or weaker than the corresponding reflex on the opposite side.
A response may be brisk
Some neurological conditions may be associated with increased reflex responses.
The two sides may differ
New asymmetry can be important when it fits with other neurological abnormalities.
Build the neurological picture
Is there weakness?
Compare active limb movement and identify new side-to-side differences.
Has resistance changed?
Reflex and tone abnormalities may be considered together during a detailed neurological examination.
Any numbness or altered feeling?
Sensory findings help build a more complete picture of neurological function.
Is movement accurate?
Poor coordination may provide additional information about the neurological problem.
Any focal neurological change?
New facial weakness or communication difficulty can significantly increase concern.
Is the patient deteriorating?
Altered consciousness alongside new neurological signs requires urgent assessment.
The clinical picture becomes much more useful when reflex findings are interpreted together with strength, tone, sensation, coordination and functional change.
When neurological findings require urgent escalation
- Sudden new unilateral limb weakness.
- New weakness combined with facial asymmetry.
- New weakness with dysarthria or aphasia.
- Rapidly worsening neurological function.
- New sensory loss associated with weakness or other focal signs.
- Neurological deterioration after a head injury.
- New neurological abnormalities associated with seizure activity.
- Any focal neurological change associated with reduced consciousness.
Why might reflex assessment be difficult?
The patient may not be relaxed
Voluntary muscle contraction can make reflex assessment more difficult to interpret.
Technique affects the result
Incorrect positioning or poor support can make a reflex harder to elicit reliably.
People are not identical
Reflex strength naturally varies, which is another reason that symmetry and the wider neurological assessment matter.
Neurological assessment still sits within ABCDE
Airway
Confirm airway patency and respond immediately to any compromise.
Breathing
Assess respiratory rate, oxygen saturation, respiratory pattern and work of breathing.
Circulation
Assess pulse, blood pressure and perfusion in the context of the wider clinical picture.
Disability
Assess consciousness, pupils, speech, facial movement, strength, sensation, coordination and other neurological findings according to local practice.
Exposure
Look for injury, illness and other relevant findings while protecting dignity.
Escalate
Significant new neurological abnormalities should be communicated promptly using the relevant local escalation pathway.
Connecting reflexes with other findings
Example
A patient is being reviewed because they have developed new difficulty using their right leg.
During neurological examination by an appropriately trained clinician, a difference in reflexes is identified between the two legs.
You have also noticed that the patient's right leg is weaker and their walking has changed significantly since earlier in the shift.
The important pattern is: new functional change + unilateral weakness + asymmetric neurological findings.
The patient requires prompt assessment and escalation according to the clinical situation and local procedures.
Communicate the whole neurological picture
Example
βI'm concerned because Mrs Khan has developed new weakness in her right leg and is no longer walking as she was earlier. During the neurological review there was also a difference between the reflex responses in her legs.β
This communicates the change from baseline, functional deterioration, side affected and associated neurological finding.
Reflex assessment errors to avoid
- Trying to interpret reflexes without appropriate training.
- Assessing reflexes without relaxing and positioning the limb appropriately.
- Ignoring side-to-side differences.
- Using one reflex result to diagnose a neurological condition.
- Failing to connect reflexes with strength, tone and sensation.
- Ignoring functional deterioration because the reflex finding seems subtle.
- Attempting lengthy specialist testing while an acutely unwell patient needs escalation.
- Failing to ask for senior assessment when a finding is uncertain.
Observe β compare β connect β escalate
Start with the patient
Notice weakness, altered mobility, asymmetry and other changes from normal function.
Use the complete assessment
Connect reflex findings with strength, tone, sensation, coordination and the patient's baseline.
Act on significant change
Describe the observed changes and escalate significant new neurological abnormalities promptly.
Connect reflexes with the complete neurological picture
Reflex findings are most useful when interpreted alongside strength, tone, sensation, coordination, function and the patient's normal neurological baseline.
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