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The Plantar Reflex

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The Plantar Reflex THE PLANTAR REFLEX a historical, clinical and electromyographic study From the Department of Neurology, Academic Hospital 'Dijkzigt', Rotterdam, The Netherlands THE PLANTAR REFLEX A HISTORICAL, CLINICAL AND ELECTROMYOGRAPHIC STUDY PROEFSCHRIFT TER VERKRIJGING VAN DE GRAAD VAN DOCTOR IN DE GENEESKUNDE AAN DE ERASMUS UNIVERSITEIT TE ROTTERDAM OP GEZAG VAN DE RECTOR MAGNIFICUS PROF. DR. B. LEIJNSE EN VOLGENS BESLU!T VAN HET COLLEGE VAN DEKANEN. DE OPENBARE VERDED!GING ZAL PLAATS VINDEN OP WOENSDAG 16 NOVEMBER 1977 DES NAMIDDAGS TE 4.15 UUR PREC!ES DOOR JAN VAN GIJN GEBOREN TE GELDERMALSEN 1977 KRIPS REPRO - MEPPEL PROMOTOR: DR. H. VAN CREVEL CO-PROMOTOR: PROF. DR. A. STAAL CO-REFERENTEN: PROF. DR. H. G. ]. M. KUYPERS PROF. DR. P. E. VOORHOEVE Aan mijn ouders Aan Carien, Maarten en Willem CONTENTS page GENERAL INTRODUCTION 15 CHAPTER I HISTORY OF THE PLANTAR REFLEX AS A CLINICAL SIGN DISCOVERY - the plantar reflex before Babinski 19 - the toe phenomenon . 21 - Joseph Babinski and his work 24 ACCEPTANCE - the pyramidal syndrome before the toe reflex 26 - confirmation . 26 - a curious eponym in Holland 28 - false positive findings? 29 - false negative findings 29 FLEXION AND EXTENSION SYNERGIES - the Babinski sign as part of a flexion synergy . 31 - opposition from Babinski and others . 33 - ipsilateral limb extension with downgoing toes versus the normal plantar response . 36 - crossed toe responses . 36 - tonic plantar flexion of the toes in hemiplegia 37 RIVAL SIGNS - confusion . 39 - different sites of excitation 39 - stretch reflexes of the toe muscles 41 - spontaneous or associated dorsiflexion of the great toe 42 - effects other than in the toes after plantar stimulation 42 THE PLANTAR RESPONSE IN INFANTS - contradictory findings 43 - the grasp reflex of the foot . 43 - the flexion reflex . 43 - the normal plantar response and walking 46 TELEOLOGICAL SPECULATIONS - science or fiction? . 47 - the Babinski sign . 48 - the normal plantar response 48 CONCLUSIONS . 49 CHAPTER II INTERPRETATION OF PLANTAR REFLEXES: VARIATION AND BIAS INTRODUCTION - observer error: examination or interpretation? 53 - bias . , . 53 METHODS - subjects 55 - films 55 - accompanying information 56 - recording of interpretations 56 RESULTS - cover films 56 - variation within and between observers 56 - effects of preceding information . 60 DISCUSSION - disagreement within and between observers 62 - bias . 62 - need for objective criteria 63 CONCLUSIONS . 64 CHAPTER III BABINSKI SIGN: STIMULUS AND EFFECTOR INTRODUCTION - recording the plantar reflex . 67 - electromyography and the Babinski sign: the extensor hallucis longus .............. 67 . or the extensor hallucis brevis? . 69 - normal plantar response: flexor hallucis brevis 70 - equivalence of electrical and mechanical stimuli? 70 METHODS - patients 71 - stimulation 71 - recording 71 RESULTS - effector of Babinski sign . 73 - mechanical stimulation: effects in EHL and FHB 74 - electrical stimulation: effects in EHL and FHB . 76 DISCUSSION - effector of Babinski sign 79 - mechanical and electrical stimuli 80 - punctate and moving stimuli 82 CONCLUSIONS . 83 CHAPTER IV EQUIVOCAL PLANTAR RESPONSES INTRODUCTION - when is an upgoing toe a Babinski sign? 87 - the flexion reflex . 87 - procedures to "enhance' the Babinski sign 88 - electromyography . 89 METHODS - patients . 90 - stimulation and recording . 90 - clinical examination and exclusion of bias 90 - electromyographic criteria . 92 RESULTS - observer consistency 94 - EMG consistency 94 - inexperienced observer 95 - EMG result and initial rating of referring physicians 95 - EMG result and 'final' neurological diagnosis 95 - practical use of the flexion reflex . , . 99 DISCUSSION - use of electromyography for plantar reflexes 100 - false suspicions . 100 - lacking Babinski response 102 - clinical criteria 104 CONCLUSIONS . 105 CHAPTER V THE BABINSKI SIGN AND THE PYRAMIDAL SYNDROME INTRODUCTION - early theories: supraspinal reflex pathways? 109 - Babinski signs without pyramidal lesion 111 - Babinski signs without pyramidal lesion? 112 - 'pure' pyramidal lesions . 113 - a paradoxical downward toe response in spinal shock 115 - pyramidal syndrome without Babinski sign 117 - heterogeneity of the pyramidal syndrome? 118 METHODS - patients 120 - examination 121 RESULTS Unilateral Babimki sigm - homogeneity of the group . 123 - weakness and loss of skill in the foot 123 - increased tendon reflexes . 127 - exaggerated flexion reflex in proximal muscles 127 - other signs . , . 131 Pyramidal sigm without Babinski response 131 Babinski signs appearing in or disappearing from the pyramidal syndrome - vanishing Babinski signs 132 - late Babinski signs . 133 Paradoxical downward response of the great toe after spinal tran- section . 133 DISCUSSION Impaired pyramidal control of the foot - linkage between Babinski sign and loss of skilled foot move- ments .............. 136 - proximal versus distal motor deficit 137 - involuntary dorsiflexion of the great toe 138 Activity of the flexion reflex - a prerequisite for the Babinski sign 139 - supraspinal control . 140 Babinski sign: interaction between flexion reflex and distal pyra­ midal control - release at or near the motoneurone . 141 - bilateral Babinski signs without other pyramidal features 142 The 'upper motor neurone' 144 CONCLUSIONS . 145 SUMMARY 147 SAMENVATTING 151 REFERENCES AND AUTHOR INDEX 155 ACKNOWLEDGEMENTS 183 CURRICULUM VITAE 185 LIST OF ILLUSTRATIONS figure page 1. BABINSKI, photographed in 1904...................... 20 2. The 'duck - rabbit' . 54 3. Mean ratings for test films of plantar reflexes . 61 4. The musculus extensor hallucis longus and its anatomical relationship to neighbouring muscles . 72 5. Reflex activity in flexor hallucis brevis, extensor hallucis brevis and extensor hallucis longus after mechanical stimula­ tion of the plantar surface in a normal subject and in a patient with a Babinski sign . 74 6. Reflex activity in flexor hallucis brevis and extensor hallucis longus after electrical and mechanical stimulation of the plantar surface in a normal subject and in a patient with a Babinski sign . 77 7. The Babinski sign and the tendon of the extensor hallucis longus . 79 8. Relative dimensions and weights of extensor hallucis longus and extensor hallucis brevis . 80 9. Design of study of equivocal plantar reflexes . 91 10. Patterns of activity in the extensor hallucis longus . 93 11. Occult Babinski signs in a patient with hallux valgus . 103 12. Lack of correlation between "absolute' values of flexion reflex and tendon reflexes in 50 patients with a unilateral Babinski szgn . 129 13. Electromyogram from the flexor hallucis brevis in a patient with a paradoxical downward response of the great toe after spinal transection . 13 5 14. Proposed interaction of pyramidal tract and flexion reflex pathways in the spinal cord. 143 GENERAL INTRODUCTION The plantar reflex is one of the most important physical signs in medicine. Few patients undergoing a full medical examination can avoid having their soles stroked, because an upgoing great toe is regarded as a reliable sign of dysfunction of corticospinal nerve fibres. So far, there is little to justify a new study. One problem is, however, that it can be difficult to determine the direction of the reflex response: the movements of the great toe may be slight, wavering, inconstant, or masked by voluntary activity. Soon after the introduction of the reflex the comment had already been made that ' the average ward clerk's notes are quite worthless on the subject of the plantar reflex, though he may make fair notes on the knee jerk and the pupil reflex to light' (Harris, 1903 ). Anyone who is a regular participant in medical ward rounds knows that controversies about plantar reflexes still abound today. Decisions in such cases are ususally guided by a mixture of seniority and ill-defined intuition. This is because the toe response is widely regarded as an oracle which often speaks in riddles, rather than as a definite reflex phenomenon, subject to the rules of physiology. But to give the plantar reflex its proper value, the neurologist must be aware of what is happening in the spinal cord. Therefore the first leading theme of this study was to ascertain the connections between the roe responses and other spinal reflexes, and to apply these physiological relationships to the interpretation of equivocal plantar responses. A review of previous clinical studies about the plantar reflex precedes the actual experiments. Since Babinski discovered the toe response in 1896, he has been awarded a prominent place on the neurological Olympus, and his papers on the subject have been canonized (Wilkins and Brody, 1967). However, to get full insight into the meaning of Babinski's words, we must connect these with pre-existing concepts, with the subsequent development of Babinski's own ideas, and with additional clinical and physiological observations of others (Chapter 1). A preliminary question is the extent of the problem of equivocal plantar responses. How far can the clinician differ with his colleagues, or even with himself? And does he always acknowledge that a given plantar response is ambiguous, or may doubts be discarded because 'we shut our eyes to observations which do not agree with the conclusions we wish to reach' (Asher, 1972)? If so, there would be even more reason to look for rigid clinical criteria. The variation between and within observers, as well as the bias effect of previous clinical information has been studied by means of filmed
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