Plantar, babinski

Plantar reflex, Pathological babinski sign, Anatomy, Physiology, Types, Eliciting babinski, Variants, Mimickers, Forme-fruste, Puusepp's sign, Chaddock, Oppenheims, Gordon, Stansky, SchaeffersBrissauds,

1. PLANTAR REFLEX and Babinski sign Dhananjay gupta Dept. of neurology Ms Ramaiah medical college

2. Superficial/ cutaneous reflexes: Response to stimulation of skin/ mucous membrane d/b DTR : these are polysynaptic : slower response to stimulus : longer latency : fatigue easily : usually abolished in pyramidal lesions : U/L absence may be a sensitive indicator of CST lesion

3. Superficial/ cutaneous reflexes: Upper limbs Grasp reflex (C6-T1) Scapular Interscapular reflex Lower limbs Cremastric Scrotal/ dartos reflex Gluteal reflex (L4-S2) Plantar reflex Supf anal reflex Bulbocavernous reflex

4. Pathological ll reflexes: Dorsiflexion of toes Babinski group of signs Chaddock / oppenheims Plantar flexion of toes Plantar grasp Plantar muscle reflex Rossolimo sign

5. Pathological ll reflexes: Dorsiflexion of toes Babinski group of signs Chaddock / oppenheims Plantar flexion of toes Plantar grasp Plantar muscle reflex Rossolimo sign Miscellaneous Synkinetic movements – Strumpell’s sign Puusepps’s sign

6. PLANTAR REFLEX

7. The Virgin and Child with Two Angels, Andrea del Verrocchio : 1476-78

8. Joseph FranCois FElix Babinski:1896 Brief paper of 28 lines (his longest paper!!) ' reflexe cutane plantaire ' (cutaneous plantar reflex) in February 1896 Described the sign for the first time Remarkable observations about this reflex Absence in certain states, hemiplegia/ paraplegia

9. I have observed that in some patients.. Stimulation of the sole on the healthy side of a patient with hemiplegia or lower limb monoplegia caused withdrawal of the lower limb with flexion of the toes on the metatarsal bones. In contrast, the same stimulus applied to the sole on the affected side caused extension of the toes at the metatarso -phalangeal joints, even in patients who were unable to move their toes voluntarily. while flexion predominates in the last two or three toes, it is in the first one or two toes that extension is usually the most pronounced

10. Essentially two components Phenomene des arteils : dorsiflexion of the toes (1898) Signe de l’eventail : fanning response – abduction of toes (1903)

11. I had the opportunity to observe such a brief alteration in a child of mine subject to night terrors. As I was attempting to comfort her I ran my thumb lightly against the lateral aspect of her sole as one does and observed a definite Extensor response . As soon as the paroxysm was over the response reverted to flexor Similar responses were described in patient with Jaksonian fit and strychnine posioning

12. PHYSIOLOGY

13. Physiology: Polysynaptic reflex Normal defensive response to any painful stimulus UL are more under control of the brain LL show more of a reflex response Essentially a triple flexion response : Flexion of thigh on pelvis Of leg on the thigh Of the foot on the leg

14. 1. Pre-requisites: Entire leg exposed (not only socks!) Patient should be supine, knee extended Explain the patient Stroking of sole should not generate anxiety/ fear/ tickling Limb should remain floppy

15. 2. Stimulation: Stimulate the plantar surface of foot, on the lateral aspect Far lateral side In the distribution of the S1/ sural nerve Begin near the heel and Go upwards at a deliberate pace, not very briskly Stop short of MTP joint to turn medially But stop short of base of the great toe

16. 3. Object for Stimulation: Applicator stick Reflex Hammer Thumb nail

17. 3. Object for Stimulation: Babinski – Goose quill Henry Miller – Bentley key

18. 4. Strength of Stimulation: Firm enough to cause a consistent response Light enough not to cause undue discomfort/ pain Strong enough so as not to cause a grasp reflex Gentle enough so as not to cause withdrawal *Eliciting a plantar reflex brings out the masochistic tendencies of the examining doctors **Every physician should undergo plantar stimulation in order to appreciate the discomfort

19. 4. Strength of Stimulation: Strength of stimulus also depends upon the degree of response In patients with no response – progressively firmer stimulus may be requires In patients with strongly extensor response, only a touch of fingers may be enough Babinski : observed extensor response when the wind blew curtains across the feet of a spinal cord injury patient!

20. 5. Normal response: Plantar flexion of the toes Inward curling of toes Plantar flexion of foot Triple flexion response Flexion of the TFL

21. 6. BABINSKI response: Extension of great toe - MTP Fanning/ abduction of toes Dorsiflexion of ankle Flexion of knee/ hip Slight abduction of thigh Leading to withdrawal of leg

22. 3 rules governing BABINSKI response: Upward movement of great toe is pathological only if a.w . contraction of EHL *The contraction of EHL can be seen/ felt on dorsum of foot **Great toe may move up without contraction of the EHL as a component of flexion reflex in general

23. 3 rules governing BABINSKI response: Contraction of EHL is pathological only if it occurs in synchronously with reflex activity in other flexor muscles *The contraction of tensor fascia lata and the hamstrings **Can be seen/ felt at the lateral thigh

24. 3 rules governing BABINSKI response: A true upgoing plantar response is reproducible, unlike the voluntary withdrawal of the toes *Ideally adapt the strength of stimulus to the patient **helpful to stroke the lateral aspect of foot than the plantar aspect ***stimulate the sole only partially rather than stroke fully till the ball of toe Volunatry withdrawal does not involve TFL FATIGUE of EXTENSOR plantar is extremely rare

25. Myths regarding BABINSKI response: Site of stimulus *A true Babinski can be elicited by stimulation anywhere on the leg **Though bet response is from the lateral aspect of foot ***Any stimulus is legitimate unless not applied distal to the ball of toe

26. Myths regarding BABINSKI response: The movement should be the ‘first’ *Not necessarily Sometimes a small voluntary action may precede the reflex Sometimes a small downward movement may precede the recruitment of great toe in the flexion synergy

27. Myths regarding BABINSKI response: In doubtful cases, fanning of toes is a useful measure *Fanning of toes is only for historical interest May also occur in normal individuals Undue attention should not be paid to this

28. Myths regarding BABINSKI response: 4. The movement of toe is quick *usually it is quick, flicking motion Though what is the definition of quick/ slow ?? Sometimes the upward movement may be slow, tonic – “THE MAJESTIC RISE OF THE GREAT TOE”

29. Neonate v/s adults: Entire reflex synergy is much more brisk, as a part of withdrawal to pain Toes are a part of this synergy Toes go up at the same time as the leg flexes As the child assumes upright posture, plantar becomes a postural reflex Anatomist : upgoing toe is extensor movement Physiologist : flexor movement

30. adults: As the pyramidal system matures, exerts more dominance over spinal neurons Toes are no longer a part of flexion reflex synergy Becomes a purely local cutaneous/ segmental response Mediated by short toe flexors Flexion may predominate in great or little toe depending on side stimulated Absence of flexion is not pathological, unless Marked difference between two sides

31. Why maximum movement at great toe: Anatomical structure of MT-P joints Little toes cannot just move up enough

32. Role of pyramidal tract/ supraspinal : Inhibit entire flexion synergy Inhibit participation of toe extensors Essential for normal ambulation Otherwise our legs and feet will have unnecessary flexion response just from stumbling over a pebble Pyramidal dysfunction – restores neonatal response First to emerge is Babinski, others may re-emerge depending on extensive disease

33. Pyrimidal dysfunction: ANATOMICAL Stroke Spinal cord lesions Myelitis Demyelinating disorders PHYSIOLOGICAL Metabolic Hypoglycemia Epiletic seizures

34. Pyrimidal dysfunction leading to bs : Loss of disinhibition Flexion synergy becomes brisker Great toe is recruited in this response Is almost always a.w . some degree of weakness of toe May only be in form of difficulty in performing rapid foot movements

35. Advantages of Babinski sign: Most reliable Dependable Consistent signs Good inter-observer variability Indicates presence of organic neurological disease

36. limitations of Babinski sign: 1. d/b VOLUNTARY WITHDRAWAL Voluntary withdrawal usually a.w plantar flexion And not ankle dorsiflexion How to reduce withdrawal ? Helps to explain and fore-warn the patient Internal rotation of leg during toe extension indicates recruitment of TFL Pressure over the base of great toe inhibits withdrawal Can use variations or the AUTO/SELF-BABINSKI

37. video

38. Edouard Brissauds : Charcot’s pupil (1896) Described few days after Babinski’s famous lecture Stimulation of lateral thigh Causes contraction of TFL Brissaud’s reflex

39. Brissaud’s reflex (video)

40. limitations of Babinski sign: 2. Lack of BS in pyrimidal dysfunction Spinal shock – temporary inexcitability of spinal inter-neurons Cerebral shock LMN lesions in pathway to EHL Radiculopathy Peroneal nerve palsy ALS, peripheral neuropathy

41. Estonian neurologist Ludvig Puusepp May be present when Babinski is not elicitable Sensitive pyramidal sign Puusepp’s sign:

42. Slow, tonic abduction of the little toe On Plantar stimulation Great toe extension may be absent Puusepp’s sign:

43. limitations of Babinski sign: 3. Flexor response in spite of CST lesion Frontal lobe lesions – hyperactive plantar grasp ALS/ MND – LMN involvement of toe extensors

44. limitations of Babinski sign: 4. Basal ganglia lesions Intact extrapyramidal pathway necessary for extensor response Thus in EPS – there is no extensor response If extensor response in EPS/ Parkinson's – s/o involvement of CST

45. limitations of Babinski sign: 5. Technical limitations Missing great toe Foot amputations Bony deformities – hallux valgus Thick sole, foot callosities Peripheral neuropathy - sural Paralysis of toe flexors Pes cavus and high arched foot – fixed dorsiflexion

46. Remember Babinski is not merely a reflex of toe movement A number of other movements are associated Here comes the role of observing thigh and leg flexion Brissauds reflex is an example What if a patient has missing toe?

47. NOT ALWAYS! Hypoglycemia , metabolic coma Alcohol intoxication Post-ictal states Deep sleep, deep anesthesia Cheyne stoke – during apnea phase Is positive Babinski always pathological?

48. True Babinski Minimal Plantar : contraction of TFL Spontaneous Babinski : passive flexion of hip and knee or passive extension of knee may produce Babinski in extensive CST lesions Bilateral Babinski : crossed extensor response : B/L cerebral or SC lesion Tonic Babinski : slow, prolonged extension – in combined Frontal and EPS Exaggerated Babinski : flexor or extensor spasm Flexor spasm – B/L CST or SC lesion Extensor spasm : B/L lesion but preserved posterior column Types of babinski

49. Pseudo-Babinski : choreo-athetosis , hyperkinesia of toe Inversion of plantar : short toe flexors paralysed/ flexor tendons severed Withdrawal response : voluntary Babinski mimickers

50. Other methods for eliciting Babinski reflex

51. “Open season for the hunting of reflex by different physicians” R. Foster Kennedy (1884-1952)

52. Stimulate lateral aspect of foot Bring under lateral malleolus Bring the stimulus forward towards little toe Less specific but more sensitive Both are complementary Causes less withdrawal Reverse choddock ? Stimulus opposite! A. Choddock sign

53. Choddock sign (video)

54. Dragging the knuckles heavily Down the anteromedial shin From infrapatellar region to ankle Response is usually slow Occurs towards end of stimulation more sensitive when combined with babinski B. oppenheim sign

55. oppenheim sign (video)

56. German : Max Schaeffer Deep pressure on achillis tendon Causes upgoing plantar c. Schaeffer’s sign

57. Pricking the dorsum of the foot Elicits a plantar response d. bing’s sign

58. Forceful downward stretching/ snapping of the 2 nd / 3 rd / 4 th toe Difficult to obtain Slowly flex the toe, press on the nail Twist the toe, hold for few seconds e. Gonda sign

59. Upper limb equivalents

60. Less consistent More difficult to elicit Less significant diagnostically Confusion regarding nomenclature Upper limb pathological reflexes

61. Stimulus – reflex hammer Response – flexion of fingers And distal phalynx of thumb 1. Wartenberg’s sign

62. Hand is relaxed Wrist dorsiflexed and fingers partially flexed Middle finger partially extended Examiner holds the middle finger Stimulus – nips/ snaps the finger nail with a quick sharp stimulus f/b sudden release Rebound of distal phalynx stretches the finger flexors Response – flexion of index finger, flexion and adduction of thumb 2. Hoffman’s sign

63. Hoffman video

64. Let the wrist hang Same – fingers flexed, except middle finger partially extended Stimus – thump/ flick the finger pad Response – same as Hoffman’s 3. tromner’s sign HOFFMANS SIGN + TROMNERS SIGN = HOFFMANS TEST

65. tromner’s sign (video)

66. THANKYOU!!!