Plantar, babinski
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This document discusses the Babinski sign and plantar reflex. It begins by defining the plantar reflex as the response to stimulation of the sole of the foot. It then describes Babinski's original 1896 observation of the pathological plantar reflex known as the Babinski sign, in which dorsiflexion of the toes occurs. The rest of the document covers the physiology and assessment of the plantar reflex and Babinski sign, variations, mimickers, and upper limb equivalents. It emphasizes that a positive Babinski sign indicates pyramidal tract dysfunction and underlying neurological disease.
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Plantar, babinski
- 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
- 5. PATHOLOGICAL LL REFLEXES: Dorsiflexion of toes • Babinski group of signs • Chaddock/ oppenheims Plantar flexion of toes • Plantar grasp • Plantar muscle reflex • Rossolimo sign
- 6. 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
- 10. The Virgin and Child with Two Angels, Andrea del Verrocchio :
- 14. 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
- 15. 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
- 16. Essentially two components 1. Phenomene des arteils : dorsiflexion of the toes (1898) 2. Signe de l’eventail : fanning response – abduction of toes (1903)
- 17. 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
- 19. PHYSIOLOGY
- 20. 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
- 21. 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
- 22. 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
- 24. 3. OBJECT FOR STIMULATION: Applicator stick Reflex Hammer Thumb nail
- 25. 3. OBJECT FOR STIMULATION: Babinski – Goose quill Henry Miller – Bentley key
- 26. 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
- 27. 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!
- 28. 5. NORMAL RESPONSE: • Plantar flexion of the toes • Inward curling of toes • Plantar flexion of foot • Triple flexion response • Flexion of the TFL
- 30. 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
- 32. 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
- 34. 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
- 37. 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
- 38. 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
- 39. 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
- 40. 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
- 41. 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”
- 42. 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
- 43. 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
- 44. WHY MAXIMUM MOVEMENT AT GREAT TOE: • Anatomical structure of MT-P joints • Little toes cannot just move up enough
- 45. 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
- 46. PYRIMIDAL DYSFUNCTION: ANATOMICAL • Stroke • Spinal cord lesions • Myelitis • Demyelinating disorders PHYSIOLOGICAL • Metabolic • Hypoglycemia • Epiletic seizures
- 47. 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
- 48. ADVANTAGES OF BABINSKI SIGN: • Most reliable • Dependable • Consistent signs • Good inter-observer variability • Indicates presence of organic neurological disease
- 49. 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
- 51. VIDEO
- 52. • 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
- 54. 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
- 55. • Estonian neurologist • Ludvig Puusepp • May be present when Babinski is not elicitable • Sensitive pyramidal sign PUUSEPP’S SIGN:
- 56. • Slow, tonic abduction of the little toe • On Plantar stimulation • Great toe extension may be absent PUUSEPP’S SIGN:
- 57. 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
- 58. 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
- 59. 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
- 60. • 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?
- 61. • NOT ALWAYS! • Hypoglycemia, metabolic coma • Alcohol intoxication • Post-ictal states • Deep sleep, deep anesthesia • Cheyne stoke – during apnea phase IS POSITIVE BABINSKI ALWAYS PATHOLOGICAL?
- 62. 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
- 63. 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
- 65. OTHER METHODS FOR ELICITING BABINSKI REFLEX
- 66. “Open season for the hunting of reflex by different physicians” R. FOSTER KENNEDY (1884-1952)
- 72. • 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
- 74. • 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
- 76. • German : Max Schaeffer • Deep pressure on achillis tendon • Causes upgoing plantar C. SCHAEFFER’S SIGN
- 79. • Pricking the dorsum of the foot • Elicits a plantar response D. BING’S SIGN
- 81. • 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
- 85. • Less consistent • More difficult to elicit • Less significant diagnostically • Confusion regarding nomenclature UPPER LIMB PATHOLOGICAL REFLEXES
- 86. • Stimulus – reflex hammer • Response – flexion of fingers • And distal phalynx of thumb 1. WARTENBERG’S SIGN
- 88. • 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
- 89. HOFFMAN VIDEO
- 90. • 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
- 94. THANKYOU!!!
Notes de l'éditeur
- Now we all know there are 2 types of reflexes – DTR and SCR
- Corneal reflex, palatal reflex, abdominal refle
- Pathological rlfx in LL are more easily elicitable, more reliable and clinically relevant than UL. Can be divided into 2 groups according to the toe movements. Those characterized by extension/ DF of toes
- Pathological rlfx in LL are more easily elicitable, more reliable and clinically relevant than UL. Can be divided into 2 groups according to the toe movements. Those characterized by extension/ DF of toes
- Basically a polysynaptic reflex which withdraws the toes from pain.
- A no of artists of the renaissance era including borteiceilli and da vinci painted these mary and jesus paintings. They were excellent observers of the human behaviour and phenomenon, however did not possess the required medical knowledge to explain them
- This is a 15th century painting.. On the first look.. Looks pretty usual stuff.. Just a painting of Mother Mary holding baby jesus with the help of 2 angels. However, as neurologists, we need a keen eye to see finer details.. So lets enlarge and see
- Do we see something now. Well how amazing it is that painters of that renaissance time had such keen observation powers, they painted the presence of this reflex in newborns.. Too bad no one knew the significance of this phenomenon.
- group tableau portrait painted by the genre artistPierre Aristide André Brouillet (1857-1914). imaginary scene of a contemporary scientific demonstration, based on real life, and depicts the eminent French neurologist Jean-Martin Charcot (1825-1893) delivering a clinical lecture and demonstration at the Pitié-Salpêtrière Hospital in Paris. it depicts "a woman convulsing and assuming the arc-in-circle" posture:[6] the arc en circle, or Opisthotonus, "the hysteric's classic posture
- French neurologist who was the fav pupil of jean marie charcot
- Babinski wanted a sign that clearly differentiated malingeres from organic weakness and he remarked that such a response is almost never a.w. hysterical patients
- Babinski wanted a sign that clearly differentiated malingeres from organic weakness and he remarked that such a response is almost never a.w. hysterical patients
- an van Gijn - pioneering spirit and lead of our “Pioneers of Neurology” section, a role he took on after his time as Joint Chief Editor came to an end in 2000
- Basically a polysynaptic reflex which withdraws the toes from pain.
- Demonstrating plantar response is one the most skilful practices for a neurologist.
- It helps that the leg is slightly externally rotated with knee flexed and one hand of the physician stabilizing the ankle
- Strokes are given in successive lines, each line around one cm medial to the preceding stroke. This is done until the midline of the foot is reached. This technique is essential because in few cases the response is abnormal laterally but becomes normal towards the midline. Any extensor response on any of these lines is considered abnormal, irrespective of whether a flexor response is seen on another line of stroking. An explanation for this observance is that the receptive field of the reflex in different patients is variable, depending upon individual differences and extent of pathology
- Any blunt object like the applicator stick, handle of a hammer, broken end of a tongue blade or simple the thumb nail of examiner can be used for eliciting a response. Or even a car key
- Awhile babonski favoured a goose quill, the legendary English neurologist henry miller, said that the best object is a bentlry car key.
- Buh-binski
- The pathogenesis is the recruitment of EHL with subsequent overpowering of the flexors
- Stimulation of ball of great toe – causes another reflex involving the dorsiflexion of te and withdrawal of leg from noxious stimulus – again is normal. So avaid stimulation there
- EHL contraction is a.w. with contraction of hamstrings at the back of thigh, tensor fascia lata, flexion of the leg – TA. Muscles taking part – EHL, ED,L, TA, hamstrings and TFL
- plantar becomes a postural reflex maintaining tone of the foot and leg
- It is noteworthy that
- Some authors content that pressure over the base of toe doesnot eliminate Babinski but inhibits withdrwal
- The second differentiating factor is what is known as the brissauds reflex
- In LMN lesions, toe will be paralysed for voluntary contraction as well
- In LMN lesions, toe will be paralysed for voluntary contraction as well
- EPS is necessary for upgoing plantar – thus lesions with EPS will not cause a positive Babinski unless there is associated extensive CST involvement. Now this again depends on relative involvement of EPS and PS, extensive involvement of EPS may inhibit a toe from going up inspite of CST lesion
- Always is always wrong in medicine. As we discussed transient physiological disturbances can cause a toe to go up
- Always is always wrong in medicine. As we discussed transient physiological disturbances can cause a toe to go up
- Always is always wrong in medicine. As we discussed transient physiological disturbances can cause a toe to go up
- Basically a polysynaptic reflex which withdraws the toes from pain.
- 30 years around the turn of century, there was a sudden interest in the Babinski reflex as an indication of pyramidal dysfunction. This is when foster kennedy described this era as the
- Around the same time grant came out with his article. Many physician=s of that era sought eponymous immortality by describing their own variations of the majestic rise of the great toe.
- The most useful of these are the chaddock and the oppenheims
- Oppenheims allegedly did this by raking the handle of his reflex hammer down the shin
- Oppenheims allegedly did this by raking the handle of his reflex hammer down the shin
- Now if this same is done on the great toe– elicits a rossolimo sign (but it’s a plantar flexion reflex), 5th toe – stransky sign
- When the reflexogenic area is very wide – toe may go up following minimal stimulation like removal of or pulling back bedsheets, removing socks or shoes – causing a spontaneous Babinski. Reflex may also occur with passive extension of knee of flexion of hip or knee. Then toes are held in tonic posture in extension and toes fanned out. In some extremely severe cases, toe may be held in tonic extension – botulinium toxin may be needed --- d/b striatal toe
- Basically a polysynaptic reflex which withdraws the toes from pain.
- Ul reflexes are mainly exaggerations or vafriations of finger flexor response. Wartenburg sign in itself has 2 variations – the wartenburg finger flexion reflex and the wartenburg thumb adduction test
- Normally on asking the patient to do active flexion of the terminal phalanges of the four fingers, usually done by the examiner and the patient hooking fingertips and pulling with both hands. the thumb remains in abduction and extension. quivalent of Babinski’s plantar sign. The movement consists of adduction, flexion, and opposition of the thumb f
- If only index finger responds – partial Hoffman, both index and thumb – complete hoffman
- Wrist is dangling/ hanging by the side of the table
- Wrist is dangling/ hanging by the side of the table
- An extensive list of various eponymous upper limb pathological reflexes is shown.
- Which brings us to the end. Despite having its detractors, plantar reflex and the Babinski sign is still one of the most fascinating phenomenon in neurology. If done in proper setting, it can be one of the most useful clinical tools.
- Front cover of the popular tabloid Chanteclair (1911), showing Babinski, the extensor toe sign, a fan to emphasize the toe fanning of the reflex, and the reflex hammer Babinski used in practice