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disease (Hamburger, 1901). Testing the peripheral apparatus by voluntary<br />
movements is usually not possible because of the primary supranuclear<br />
weakness. If there is no atrophy, only electromyography and conduction<br />
studies can reveal the secondary lesion.<br />
3. The pyramidal syndrome is really incomplete. This was the case in five<br />
of the ten patients in whom an expected Babinski sign was equivocal. The<br />
next chapter will deal with this problem.<br />
Clinical criteria<br />
Apart from specific errors enumerated above, the following general<br />
rules for interpreting equivocal plantar responses emerged from the<br />
comparison of clinical data with electromyographic results:<br />
1. Upward movement of the great toe can be pathological only when caused by<br />
contraction of the extensor hallucis longus muscle<br />
- in most patients this can be reliably checked by inspectton or at least<br />
palpation of the tendon on the dorsum of hallux and foot<br />
2. Contraction of the extensor hallucis longus muscle is pathological only if it<br />
occurs synchronously with activity in other flexor muscles<br />
- in some subjects the flexion reflex is weak, but almost always tightening<br />
of the tensor fasciae latae or hamstring muscles can be seen and<br />
used as a reference<br />
- activity of the flexion reflex as a whole can also be felt, with the hand<br />
that supports the patient's foot<br />
- it should be kept in mind that the hallux is lighter than foot, leg, or thigh<br />
- activity in physiological flexor muscles other than the extensor hallucis<br />
longus is not pathological on its own, unless asymmetrical or spasmodic.<br />
3. Voluntary withdrawal may be confused with the flexion reflex, but can be<br />
prevented and recognized<br />
- tell the patient what is going to happen; blindfolding (Crocq, 1901) is not<br />
helpful<br />
- adapt the stimulus - it is useless to complete faithfully a textbook<br />
manoeuvre while the patient is writhing on the couch; a change to the<br />
lateral dorsum of the foot may help; otherwise repeated stroking of only<br />
a few centimetres of skin will, in the case of a flexion reflex, produce<br />
each time an approximately similar reduction in the extent of the toe<br />
and leg movements, whereas voluntary retraction will then be abolished<br />
or inconstant<br />
- voluntary withdrawal does not involve the tensor fasciae latae, and may<br />
precede or outlast the stimulus (Babinski, 1906 a, 1915 b).<br />
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