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Finally the method of stimulation. In principle, any stimulus is legitimate<br />
when it produces an upgoing toe response which fulfils the above<br />
criteria, as long as it is moving (Chapter III), and as long as it is not applied<br />
more distally than the ball of the foot, as this may give false-positive<br />
results (Verger and Abadie, 1900; Dosuzkov, 1932). As to effectiveness, it<br />
is generally accepted that the lateral plantar border is preferable to the<br />
medial side, which overlies the flexor hallucis brevis. We also saw (Chapter<br />
III) that temporal and spatial summation are important. This means that<br />
the ideal stimulus should be rather slow and should extend to the plantar<br />
arch. On the other hand, repeated interference of voluntary movements<br />
makes a shorter or di"fferent stimulus desirable. Stroking the lateral<br />
dorsum of the foot often helps in these cases, and is sometimes even more<br />
effective (Bing, 1915; Landau and Clare, 1966; Dohrmann and Nowack,<br />
1973 ). This is also because irritation of the sole can give rise to voluntary<br />
clawing of the toes.<br />
In short, the Babinski sign is a reflex, not a ritual. And how to scratch is<br />
less essential than how to watch.<br />
CONCLUSIONS<br />
1. Current rules for the interpretation of equivocal plantar reflexes are<br />
scarce and arbitrary, while relatively too much attention is paid to<br />
methods of stimulation.<br />
2. Electromyographic investigation of equivocal plantar reflexes, based on<br />
findings in reference groups, can give a reproducible outcome in a large<br />
majority of cases.<br />
3. In this study, the electromyogram confirmed a pathological reflex in<br />
only one third of the patients in whom this was suspected by the<br />
clinicians. Checked with the eventual diagnosis, false pathological results<br />
did not occur; conversely, the electromyographic criteria were wide<br />
enough to demonstrate expected, but clinically. unconvincing, Babinski<br />
stgns.<br />
4. The main advantage of the electromyographic study of plantar reflexes<br />
is that it helps to delineate clinical criteria, but it may be the only feasible<br />
method in cases where skeletal or tendinous abnormalities restrain or<br />
distort hallux movements.<br />
(cont. next Paf!.e)<br />
105
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