Pathologic Reflexes, Monofilament Tests & Meningeal Signs.pptx

PPT

1. Pathologic Reflexes, Meningeal Signs & Monofilament Tests Presenter: Dr. Zeleke W/Y (NR2) Moderator: Dr. Nebiyu B (Consultant Neurologist) April 26,2022 GC.

2. Outline Objective Pathologic Reflexes Meningeal signs Monofilament

3. Objective To gain knowledge and skill on neurologic examination of Pathologic reflexes Meningial signs Monofilament

4. PATHOLOGIC REFLEXES Responses not generally found in the normal individual. Some are responses that are minimally present and elicited with difficulty in normals. others are not seen in normals at all. Many are exaggerations and perversions of normal muscle stretch and superficial reflexes.

5. Cont…. The responses normally seen in the immature nervous system of infancy. It disappears only to reemerge later in the presence of disease. A decrease in threshold or an extension of the reflexogenic zone plays a role in many pathologic reflexes.

6. Cont…. Descending motor influences normally control and modulate the activity at the local, segmental spinal cord level. It ensure efficient muscle contraction and proper coordination of agonists, antagonists, and synergists.

7. Cont…. Some pathologic reflexes may also be classified as “ associated movements ,” related to such spread of motor activity. Whether a certain abnormal response would be best classified as a reflex or an associated movement is not always clear.

8. Cont…. Responses that are more in the realm of an associated movement are sometimes referred to clinically as reflexes e.g ., the Wartenberg thumb adduction sign, an associated movement, is sometimes called a Wartenberg reflex,

9. Cont…. Pathologic reflexes are reversions to primitive responses and indicate loss of cortical inhibition. e.g., Babinski, Chaddock, Oppenheim, snout, rooting, grasp They typically present early in development of the neurotypical infant and then disappear with maturation.

10. Cont…. Most pathologic reflexes are related to disease involving the corticospinal tract and associated pathways. They also occur with frontal lobe disease Sometimes with disorders of the extrapyramidal system.

11. Cont…. The typical reflex pattern with lesions involving the upper motor neuron syndrome: exaggeration of deep tendon reflexes disappearance of superficial reflexes, and emergence of pathologic reflexes

12. PATHOLOGIC REFLEXES IN THE LOWER EXTREMITIES Characteristics more constant, easily elicited ,reliable, and clinically relevant. The most important responses dorsiflexion of the toes and plantar flexion of the toes

13. The Babinski Sign N ormal plantar reflex response: usually fairly rapid the small toes flex more than the great toe, and more marked when the stimulus is along the medial plantar surface. In disease of the corticospinal system the Babinski sign or extensor plantar response

14. The Babinski sign…. the most important sign in clinical neurology. It is one of the most significant indicator of disease of the corticospinal system at any level from the motor cortex through the descending pathways.

15. Cont…. S timulating the plantar surface of the foot with a blunt point applicator stick, handle of a reflex hammer, a broken tongue blade, the thumbnail, or the tip of a key

16. Cont…. The most common mistakes: insufficiently firm stimulation placement of the stimulus too medially, and moving the stimulus too quickly The only movements of significance are those of the great toe.

17. Cont…. The best position is supine, with hips and knees in extension and heels resting on the bed. The patient should be relaxed and forewarned of the potential discomfort. The Babinski sign is a part of the primitive flexion reflex.

18. Cont…. the primitive flexion response may reappear in disease involving the corticospinal tract. With more severe and extensive disease, the entire flexion response emerges called “triple flexion” response.

19. Cont…. The Babinski is a valuable clinical sign, but it is not perfect. The most common problem is distinguishing an upgoing toe from voluntary withdrawal. As t he Babinski sign is part of a withdrawal reflex.

20. Cont…. An extensor plantar response does not always signify structural disease. It may occur as a transient manifestation of physiologic dysfunction of the corticospinal pathways. deep anesthesia and narcosis in drug and alcohol intoxication in metabolic coma such as hypoglycemia, in deep sleep, postictally

21. Fallacies in the interpretation of plantar response Patients with callosities of feet Sensory loss in the S1 dermatome in peripheral neuropathy or tibial nerve injury Bony deformities like hallus valgus Patients with pes cavus

22. Corticospinal Tract Responses Characterized by Plantar Flexion of the Toes The maneuvers for plantar flexion of the toes G rasp reflex In the newborn infant, there is a grasp reflex in the foot as well as the hand. Elicited by light pressure on the plantar surface of the foot. The response is flexion and adduction of the toes.

23. Cont…. The plantar grasp elicited by drawing the handle of a reflex hammer from the midsole toward the toes . causes the toes to flex and grip the hammer

24. Cont…. Rossolimo sign Tapping ball of foot, or plantar surfaces of toes; giving a quick, lifting snap to tips of toes Response quick plantar flexion of toes, especially smaller ones

25. Other Lower-Extremity Pathologic Reflexes C rossed extensor reflex (Phillipson’s reflex) S evere spinal cord lesions Severe myelopathy

26. PATHOLOGIC REFLEXES IN THE UPPER EXTREMITIES They are less constant, more difficult to elicit, and usually less significant diagnostically. P rimarily fall into two categories: FRS and exaggerations of or variations on the finger flexor reflex.

27. Frontal release signs/reflexes Are responses that are normally present in the developing nervous system. Re-emergence of primitive reflex following frontal damage. They are normal in infants and children T hey may be evidence of neurologic disease when present in an older individual Many of these are exaggerations of normal reflex responses.

28. Cont…. Common frontal reflexes include: Palmomental reflex Grasp reflex (palmar vs. plantar) Glabellar Snout Routing reflex Corneomandibular Etc…..

29. Cont…. Mostly FRS occur in the patients with: severe dementias diffuse encephalopathy (metabolic, toxic, postanoxic) t raumatic head injury In general with diffuse pathologic processes is particularly involving the frontal lobes or the frontal association areas.

30. Cont…. The Palmomental Reflex=palm-chin reflex Elicited by scratching or stroking the palm of the ipsilateral hand. wrinkling of the skin of the chin with slight retraction and sometimes elevation of the angle of the mouth. Caused by contraction of the mentalis and orbicularis oris muscles.

31. Cont…. In neurologic patients, trigger zone could be forearm, chest, abdomen, or even the sole. Spread of the reflex response beyond the chin region may also occur; E.g. involvement of the platysma has been termed the palmocervical reflex.

32. Cont…. The PMR is weak and fatigable in normals and stronger and more persistent in disease. The PMR can help in the differential diagnosis of facial palsy it is absent in peripheral facial palsy and may be exaggerated in central facial paresis. Note that a unilateral PMR does not have localizing value.

33. Cont…. The Palmomental response appeared earliest and was the most frequent reflex at all ages.

34. Cont…. The Grasp (Forced grasping) Reflex Elicited by stimulation of the skin of the palmar surface of the fingers or hand. involuntary flexor response of the fingers and hand. The patient is instructed not to hold on to the examiner’s hand.

35. Cont…. The palmar grasp is normally present at birth. The response begins to diminish at the age of 2 to 4 months. It reappears primarily in a condition such as: extensive neoplastic or vascular lesions of the frontal lobes or cerebral degenerative processes it may also occur as evidence of corticospinal tract dysfunction in spastic hemiplegia.

36. Cont…. There are grasping and groping responses. When this sign is present unilaterally, it suggests a contralateral frontal or parietal lobe lesion. When it occurs bilaterally, there is no localizing value.

37. Cont…. Glabellar reflex induced by gently tapping (hammer or finger) the glabellar nerve. The reflex is positive when the patient continues to blink each time you tap. A positive glabellar (Meyerson’s) reflex is commonly seen in Parkinson’s disease & early dementias.

38. Cont…. The orbicularis oris (snout) reflex pressing firmly backward on the philtrum of the upper lip, Response is puckering and protrusion of the lips Exaggerated responses are sucking and even tasting, chewing, and swallowing movements.

39. Cont…. The sucking reflex is normal in infants. stimulation of the perioral region is followed by sucking movements of the lips, tongue, and jaw. The response may be elicited by lightly touching, striking, or tapping the lips. A rooting (searching) reflex is when the lips, mouth, and even head deviate toward a tactile stimulus delivered beside the mouth or on the cheek.

40. Cont…. A grossly exaggerated response may include: automatic opening of the mouth smacking chewing, and swallowing movements it may reappear in some patients with diffuse cerebral disease.

41. Cont…. C orneomandibular reflex stimulation of cornea causes contralateral movement of the mandible. It indicates supranuclear interruption of the ipsilateral corticotrigeminal tract. It is said to be the only eye sign in ALS.

42. The finger flexor–related responses usually a manifestation of the spasticity and hyperreflexia. And in the lesions involving the corticospinal tract. Hoffman and Trömner signs are usually classified as corticospinal tract signs. These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord.

43. Cont…. The Hoffmann and Trömner Signs and the Flexor Reflexes of the Fingers and Hand They are methods that used for delivering stretch stimulus.

44. The finger flexor reflex Elicited by a stretch stimulus delivered with a reflex hammer flexion of the patient’s fingers and distal phalanx of the thumb.

45. Hoffmann sign the patient’s relaxed hand is held with the wrist dorsiflexed and fingers partially flexed With one hand, the examiner holds the partially extended middle finger between her index finger and thumb or between her index and middle fingers. The response is flexion and adduction of the thumb and flexion of the index finger.

46. Trömner sign the examiner holds the patient’s partially extended middle finger, letting the hand dangle, then, with the other hand, thumps or flicks the finger pad The response is the same as that in the Hoffmann test.

47. Jaw reflex the examiner places an index finger or thumb over the middle of the patient’s chin Patient hold the mouth open about midway with the jaw relaxed Tapping the finger with the reflex hammer Response: an upward jerk of the mandible.

48. Cont…. The afferent impulses are carried through the sensory portion of the trigeminal nerve to the mesencephalic nucleus, The efferent one through its motor portion.

49. Cont…. Increased, or “brisk,” jaw jerk is seen in an upper motor neuron lesion, with localization of the lesion above the foramen magnum. Diminished or absent jaw jerk as in bulbar palsy. Bilateral supranuclear lesions cause a brisk jaw jerk, as in pseudobulbar palsy.

50. Other Upper-Extremity Pathologic Reflexes Reflex Stimulus Response Rossolimo’s of the hand Percussion of palmar aspect of MCP joints or tapping volar surface of fingertips Flexion of the fingers and supination of the forearm Mendel Bechterew Percussion of dorsal aspect of carpal and metacarpal areas, or tapping dorsum of either hand or fingers Flexion of the fingers and hand Flexion reflex (Dejerine hand phenomenon) Percussion of flexor tendons on volar surface of forearm Flexion of fingers and hand Thumb-adductor reflex of Marie- Foix Superficial stroking of palm of hand in hypothenar region, or scratching ulnar side of palm Adduction and flexion of thumb, Foxe reflex Pinching hypothenar region Same as Marie- Foix Oppenheim’s sign Rubbing external surface of forearm Same as Marie- Foix Schaefer sign Pinching flexor tendons at wrist Same as Marie- Foix

51. Cont…. Reflex Stimulus Response Ulnar adduction reflex of Pool Stimulation of any portion of palm innervated by ulnar nerve Adduction of the thumb Chaddock’s wrist sign Pressure or scratching in depression at ulnar side of FCR and PL tendons at wrist, Flexion of wrist and simultaneous extension and separation of digits Gordon’s extension sign Pressure on radial side of pisiform bone Extension and occasionally fanning of the flexed fingers Bachtiarow sign Stroking downward along radius with thumb and index finger Extension and slight adduction of thumb

52. CLONUS It is a series of rhythmic involuntary muscular contractions induced by the sudden passive stretching of a muscle or tendon. It often accompanies the spasticity and hyperactive DTRs seen in corticospinal tract disease.

53. Cont…. M ost frequently at the ankle, knee, and wrist. Method of eliciting ankle clonus

54. Cont…. Unsustained clonus fades away after a few beats S ustained clonus persists. Sustained clonus is never normal. In severe spasticity, clonus may occur spontaneously or with the slightest stimulus.

55. Cont…. False clonus (pseudoclonus) in psychogenic disorders It is poorly sustained and irregular in rate, rhythm, and excursion.

56. Meningeal signs Most frequently elicited when the meninges are inflamed. Meningismus is a term that refers to the presence of nuchal rigidity and other clinical signs of meningeal inflammation.

57. Cont…. Meningism is sometimes used synonymously with meningismus, but it is also used to refer to a syndrome characterized by neck stiffness without meningeal inflammation.

58. Cont…. The various maneuvers used to elicit meningeal signs produce tension on inflamed and hypersensitive spinal nerve roots , and the resulting signs are postures, protective muscle contractions, or other movements that minimize the stretch and distortion of the meninges and roots.

59. Nuchal (Cervical) Rigidity It is the most widely recognized and frequently encountered test. And on its absence the diagnosis of meningitis is rarely made. It is characterized by stiffness and spasm of the neck muscles, with pain on attempted voluntary movement as well as resistance to passive movement.

60. Cont…. Nuchal rigidity primarily affects the extensor muscles. the most prominent early finding is resistance to passive neck flexion. Difficulty of placing chin on the chest where as rotatory and lateral movement preserved. If more severe nucha , there may be resistance to extension and rotatory movements as well.

61. Cont…. Extreme rigidity causes retraction of the neck into a position of opisthotonos. Rigidity may be absent in meningitis when the disease is fulminating or terminal, when the patient is in coma, or in infants.

62. Cont…. Stiffness and rigidity of the neck may occur in other conditions. Such as cervical spondylosis and osteoarthritis How to distinguish restricted neck motion due to cervical spondylosis or osteoarthritis from nuchal rigidity???

63. Cont…. Other causes of restricted neck motion may also occur with: retropharyngeal abscess cervical lymphadenopathy neck trauma Extrapyramidal disorders, particularly progressive supranuclear palsy

64. Kernig’s Sign Flex the hip and knee to right angles and then attempt to passively extend the knee; this movement produces pain, resistance, and inability to fully extend the knee.

65. Cont…. There is some overlap between Kernig’s sign and straight leg raising sign. The technique is similar, but straight leg raising sign is used to check for root irritation in lumbosacral radiculopathy. Both Kernig’s sign and straight leg raising are positive in meningitis. In radiculopathy, the signs are usually unilateral, but in meningitis they are bilateral.

66. Brudzinski’s Neck Sign Placing one hand under the patient’s head and flexing the neck while holding down the chest with the other hand Look for flexion of the hips and knees bilaterally. Flexing the neck causes the knees to flex

67. Cont…. Jolt accentuation is an exacerbation of headache induced by quick, horizontal head rotations at two or three times per second. Amoss’s, Hoyne’s or tripod sign Patient sit in bed with the hands placed far behind, the head thrown back, the hips and knees flexed, and the back arched.

68. Other Meningeal Signs

69. Cont….

70. Screening for risk of foot ulceration  All patients with diabetes be screened annually to identify those at risk for foot ulceration. We perform a history, physical examination of the foot, and use a 10g monofilament for screening purposes. An alternative tests includes: vibration testing (128 Hz tuning fork) ankle reflex assessment, or tests of pinprick sensation

71. Monofilament Quantitative testing of touch and pressure can be done with graded monofilaments of different strengths. ADA recommends using single-use disposable monofilaments or those clearly proven to be accurate.

72. Cont…. Most commonly evaluated sites for pressure sensation include: the plantar hallux and the first, third, and fifth metatarsal heads the presence of one insensate site strongly suggest as evidence of high risk.

73. Cont…. Screening tests for neuropathy in the clinic include use of a 10 g monofilament and of a 128 Hz tuning fork. Both tests reflect the function of large myelinated sensory nerve fibers. The monofilament test has been widely adopted and is easy to use in clinical practice, its sensitivity to detect early impairment in nerve function is limited.

74. Cont…. The 10gm monofilament is the most useful test to diagnosis LOPS. In diabetic foot screening, this test is used to identify those who lost sensation. Not used to diagnose peripheral neuropathy. The foot examination uses a 5.07 monofilament, which delivers 10 g.

75. How to apply??? Sensory information should be carried out in a quiet and relaxed setting. First apply monofilament on the patient sensitive areas of skin so that he/she knows what is to expect. Patient must not be able to see whether or where the examiner apply the filament Apply monofilament perpendicular to the skin surface

76. Cont…. Apply sufficient force to cause the filament to bend or buckle The total duration of approach should be approximately 2 seconds. Don’t allow filament to slide across the skin or make repetitive contact at the test site.

77. Cont…. Ask the patient whether they feel pressure applied(yes/no) and next where they feel pressure Repeat this application two times at the same site Protective sensation is present at each site if the patient correctly answers two out of three application Absent with two out of three incorrect answer: the patient is the considered to be at risk of ulceration.

78. Reference

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