THE PLANTAR REFLEX - RePub

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'D 00 TABLE Xlll PATIENTS WITH SOME EVIDENCE OF CENTRAL NERVOUS SYSTEM DISEASE, IN WHOM EQUIVOCAL <strong>PLANTAR</strong> <strong>REFLEX</strong> MIGHT SUGGEST AN UNEXPECTED LESION patient .rex at;e (p~ Jide clinician'.r op_inion EMG reflex final clinical diagnosis cOJnnzents 9 M 10 F 18 29 R R upward? upward? 1. none 2.EHL epileptic seizure two years before L EHL? vertigo and paraes- 2. none thesiae of L arm (cause unknown); CSF protein raised flexion reflex +++ bilaterally, including great toe flexion reflex ++ bilaterally, including great toe; bilateral pes cavus II I 2 F F 58 60 R R upward? absent? I. EHL? 2. EHL I. EHL? 2. EHL parkinsonism, dementia, depression episodic vertigo (brain stem?); genclialized arterial disease upgoing toe synchrooous with flexion reflex upgoing toe synchronous with flexion reflex ll M 62 R absent? I. EHL? 2. FHB' pyramidal weakness L leg (unknown cause) extensive voluntary movements 14 M 40 R upward? l.FHB 2. FHB? hemi-parkinsonism R hallux immobile, also on electrical stimulation of FHB; voluntary flexion possible (long flexor?); initiai!y diagnosed as R (pyramidal) hemiparesis 15 M 56 L upwatd? l. FHB' 2. FHB? cerebral concussion isolated fanning of toes \6 M 57 L upward? I.FHH 2. FHB presenile dementia jerky toe movements, out of phase with (weak) flexion reflex; originally suspected of cerehral tumour 17 M 53 R upward? L none 2. none pinealoma and hydrocephalus flexion reflex prominent in TA 18 F 39 R downward? l. none 2.none transient dysfunction 6th and 7th nerve R - multiple sclerosis? wriggles toes sometimes
Practical use of the flexion reflex Having accepted the EMG results (inconsistencies excluded), we can now compare them with the notes of the two clinical examinations which were performed in each patient. On these occasions special attention was paid to the flexion reflex as a whole, and to the time relations of this synergy to any toe movements which occurred. The action of proximal flexor muscles was particularly noted, i.e. of tensor fasciae latae, hamstring muscles, and hip flexors. This stands in some contrast to the emphasis on the tibiali' anterior as a reference muscle in the EMG procedure. The reason for the shift of attention is the supporting hand on the foot during plantar stimulation. This position sometimes makes it difficult to see dorsiflexion of the foot, and the 'tug' felt by this hand is the compound action of all flexor muscles - which is very useful information as such! In view of all previous work on the relationship between the Babinski sign and the flexion reflex, it is perhaps not surprising that in all six patients with electromyographically pathological plantar reflexes the upgoing toes were clinically found to be synchronous with activity in proximal flexors. This number is small, but I can add some results from the next chapter: of 50 patients with a unilateral Babinski sign, 48 showed activity in other (more proximal) flexor muscles. In two cases (patients 9 and 10, table XIII), there was, on clinical examination, simultaneous activity of the extensor hallucis longus and flexors of knee and hip, but electromyography showed a pathological reflex on only one occasion in each (they account for half of the four EMG inconsistencies in the study). The referring clinicians doubted if the Babinski signs were 'real', because they did not fit easily into the clinical picture, and also because they were unusually fast - but so was the flexion reflex as a whole in these two patients. Failure of the EMG technique to confirm the Babinski signs on one occasion in these two patients must also be attributed to the high speed of movement, which did not always correspond with the chosen criteria. The reproducibility of the clinical phenomena was decisive in establishing the pathological nature of the upgoing toe movements. The clinical features were even more vital in explaining why the referring physicians had had their doubts about plantar reflexes which proved to be normal electromyographically: often there were in fact upward movements of the great toe, but out of phase with the flexion reflex and in some cases not even caused by action of the extensor hallucis longus. Sometimes the confusing movements coincided accidentally with the flexion reflex and were not reproducible; fatigue of the Babinski sign (Bauer and Biach, 1910) is a negligible factor. Almost all these observations bear on patients in the first two diagnostic categories, in whom the 99
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THE PLANTAR REFLEX a historical, cl
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THE PLANTAR REFLEX A HISTORICAL, CL
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Aan mijn ouders Aan Carien, Maarten
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TELEOLOGICAL SPECULATIONS - science
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- EMG result and 'final' neurologic
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LIST OF ILLUSTRATIONS figure page 1
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Electromyographic recording from mu
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The plantar reflex before Babinski
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viz. those of Striimpell (1899), Op
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These early reports did not reach m
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Charcot's concepts about hysteria w
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TABLE I STUDIES CONFIRMING BABINSKI
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False positive findings? Babinski's
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FLEXION AND EXTENSION SYNERGIES The
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confirmed by Walshe (1914). His is
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esult in disappearance of the Babin
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without an ipsilateral upgoing toe
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RIVAL SIGNS Confusion When Babinski
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8. Stroking the anterior surface of
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Contradictory findings THE PLANTAR
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Bersot 1920,'2! ? X ]l 2 Burr 1921
Page 47: curious case of one healthy infant
Page 50 and 51: 9. Infants under one year of age ge
Page 53 and 54: INTRODUCTION Observer error: examin
Page 55 and 56: following a suggestion that most re
Page 57 and 58: TABLE IV INFORMATION PRECEDING THE
Page 59 and 60: TABLE VI RATINGS OF 'INFORMATION' G
Page 61 and 62: unm i stakab I y upward possibly up
Page 63 and 64: Clinical experience appeared to be
Page 65: CHAPTER III BABINSKI SIGN: STIMULUS
Page 68 and 69: TABLE VII CLINICAL COMMENTS ON THE
Page 70 and 71: Normal plantar response: flexor hal
Page 72 and 73: I. rn. extensor hallucis longus 2.
Page 74 and 75: TABLE VIII OCCURRENCE OF REFLEX ACT
Page 76 and 77: ecruited and even interrupted by EH
Page 78 and 79: value (the minimal stimulus intensi
Page 80 and 81: FIGURE 8 Relative dimen.riom and we
Page 82 and 83: the two separate bursts of electrom
Page 84 and 85: 5. In general, reflex effects produ
Page 87 and 88: INTRODUCTION When is an upgoing toe
Page 89 and 90: stimulated side diminishes extensor
Page 91 and 92: 30 patients with equivocal plantar
Page 93 and 94: A FHB EHL E TA EHL c FHB TA _j1mV 5
Page 95 and 96: Inexperienced observer An additiona
Page 97: patient 2 3 4 5 6 7 8 sex F M M F F
Page 101 and 102: 1. Contraction of the tibialis ante
Page 103 and 104: FHB I ! ¥ _j 02 FHB ...,. r~~a..,.
Page 105 and 106: Finally the method of stimulation.
Page 107: CHAPTER V THE BABINSKI SIGN AND THE
Page 110 and 111: TABLE XIV THEORIES INVOKING A SUPRA
Page 112 and 113: change of the plantar reflex was of
Page 114 and 115: An upgoing toe response in lower pr
Page 116 and 117: noticed no special features, and of
Page 118 and 119: 'pyramidal syndrome' were not. Thei
Page 120 and 121: movements, but also the capacity to
Page 122 and 123: - rapid foot tapping on the couch,
Page 124 and 125: TABLE XVI FREQUENCY OF V ARlO US SI
Page 126 and 127: ~ N 0\ TABLE XVIII PATIENTS WITH A
Page 128 and 129: ~ N 00 TABLE XIX LACK OF CORRELATIO
Page 130 and 131: ~ '->' 0 TABLE XX PATIENTS SHOWING
Page 132 and 133: 3. BABINSKI SIGNS APPEARING IN OR D
Page 134 and 135: --------------~~- ~ '-" TARLE XXI "
Page 136 and 137: DISCUSSION Two principal features e
Page 138 and 139: patients in the first group in whom
Page 140 and 141: The most striking examples of Babin
Page 142 and 143: eflex arc must have its impact at o
Page 144 and 145: hallucis longus motoneurones to seg
Page 146 and 147: 9. The paradoxical downward toe res
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showed very little agreement with t
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A second condition to be fulfilled
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eide met dubieuze voetzoolreflexen,
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waarin de Babinski-reflex verdween,
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BABINSKI,]. (1885). Recherches sur
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approche d'une interpretation du si
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BUCK, D. de, and MOOR, L. de (1900)
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DEJERINE, ]., and LEVY V j\LENSI, J
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FRIEDMAN, E. D. (1920). On a possib
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GROSS, F. (1971). The Emperor"s clo
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IIDA, M., and BASMAJIAN,]. V. (1974
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LANDAU, W. M., and CLARE, M. H. (19
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MANFREDI, M., SACCO, G., and SIDER!
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NYBERG-HANSEN, R., and RINVIK, E. (
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lombo-sacrCe avec amyotrophie globa
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STRDMPELL, A. VON (1887). Ueber ein
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WALSHE, F. M. R. (1956). The Babins
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ACKNOWLEDGEMENTS I am grateful for
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CURRICULUM VITAE De schrijver van d
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