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Plantar, babinski

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

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Plantar, babinski

  2. 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. 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. 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. 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
  7. 7. The Virgin and Child with Two Angels, Andrea del Verrocchio :
  8. 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. 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
  10. 10. Essentially two components 1. Phenomene des arteils : dorsiflexion of the toes (1898) 2. Signe de l’eventail : fanning response – abduction of toes (1903)
  11. 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. 12. PHYSIOLOGY
  13. 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. 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. 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. 16. 3. OBJECT FOR STIMULATION: Applicator stick Reflex Hammer Thumb nail
  17. 17. 3. OBJECT FOR STIMULATION: Babinski – Goose quill Henry Miller – Bentley key
  18. 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. 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. 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. 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. 22. 3 RULES GOVERNING BABINSKI RESPONSE: 1. 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. 23. 3 RULES GOVERNING BABINSKI RESPONSE: 2. 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. 24. 3 RULES GOVERNING BABINSKI RESPONSE: 3. 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. 25. MYTHS REGARDING BABINSKI RESPONSE: 1. 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. 26. MYTHS REGARDING BABINSKI RESPONSE: 2. 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. 27. MYTHS REGARDING BABINSKI RESPONSE: 3. 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. 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. 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. 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. 31. WHY MAXIMUM MOVEMENT AT GREAT TOE: • Anatomical structure of MT-P joints • Little toes cannot just move up enough
  32. 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. 33. PYRIMIDAL DYSFUNCTION: ANATOMICAL • Stroke • Spinal cord lesions • Myelitis • Demyelinating disorders PHYSIOLOGICAL • Metabolic • Hypoglycemia • Epiletic seizures
  34. 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. 35. ADVANTAGES OF BABINSKI SIGN: • Most reliable • Dependable • Consistent signs • Good inter-observer variability • Indicates presence of organic neurological disease
  36. 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. 37. VIDEO
  38. 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
  40. 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. 41. • Estonian neurologist • Ludvig Puusepp • May be present when Babinski is not elicitable • Sensitive pyramidal sign PUUSEPP’S SIGN:
  42. 42. • Slow, tonic abduction of the little toe • On Plantar stimulation • Great toe extension may be absent PUUSEPP’S SIGN:
  43. 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. 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. 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. 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. 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. 48. 1. True Babinski 2. Minimal Plantar : contraction of TFL 3. Spontaneous Babinski : passive flexion of hip and knee or passive extension of knee may produce Babinski in extensive CST lesions 4. Bilateral Babinski : crossed extensor response : B/L cerebral or SC lesion 5. Tonic Babinski : slow, prolonged extension – in combined Frontal and EPS 6. Exaggerated Babinski : flexor or extensor spasm Flexor spasm – B/L CST or SC lesion TYPES OF BABINSKI
  49. 49. 1. Pseudo-Babinski : choreo-athetosis, hyperkinesia of toe 2. Inversion of plantar : short toe flexors paralysed/ flexor tendons severed 3. Withdrawal response : voluntary BABINSKI MIMICKERS
  51. 51. “Open season for the hunting of reflex by different physicians” R. FOSTER KENNEDY (1884-1952)
  52. 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
  54. 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
  56. 56. • German : Max Schaeffer • Deep pressure on achillis tendon • Causes upgoing plantar C. SCHAEFFER’S SIGN
  57. 57. • Pricking the dorsum of the foot • Elicits a plantar response D. BING’S SIGN
  58. 58. • Forceful downward stretching/ snapping of the 2nd/ 3rd/ 4th toe • Difficult to obtain • Slowly flex the toe, press on the nail • Twist the toe, hold for few seconds E. GONDA SIGN
  60. 60. • Less consistent • More difficult to elicit • Less significant diagnostically • Confusion regarding nomenclature UPPER LIMB PATHOLOGICAL REFLEXES
  61. 61. • Stimulus – reflex hammer • Response – flexion of fingers • And distal phalynx of thumb 1. WARTENBERG’S SIGN
  62. 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
  64. 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
  66. 66. THANKYOU!!!