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Normal Plantar Response: Integration of Flexor and Extensor Reflex Components

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Normal Plantar Response: Integration of Flexor and Extensor Reflex Components J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.26.1.39 on 1 February 1963. Downloaded from J. Neurol. Neurosurg. Psychiat., 1963, 26, 39 Normal plantar response: integration of flexor and extensor reflex components LENNART GRIMBY From the Department of Neurology, Karolinska Institute, Serafimerlasarettet, Stockholm, Sweden The reflexes elicited by painful stimulation of the the suprasegmental control of the reflex centres, the plantar surface of the foot have been studied receptive field of the reflex is limited to the skin area extensively for a long time and the relation between where it is adequate for protective purposes, viz., the reflexes obtained in normal and in pathological the ball of the great toe. cases has been the subject of considerable debate. An Previous investigations (Eklund et al., 1959; excellent survey of previous investigations is to be Kugelberg et al., 1960) have shown that the main found in the review by Walshe (1956). As in most difference between the electromyographic pattern of studies of human reflexes, the technique commonly a flexor plantar response and that of an extensor used has, however, not permitted an exact deter- plantar response is that the reflex plantar flexion of mination of the latency values of the reflexes, and the great toe is associated with activity in the short it has thus not been possible to judge with certainty hallux flexor and reciprocal inhibition of the guest. Protected by copyright. to what extent the movements studied have been voluntary activity in the short hallux extensor, purely spinal and to what extent of cerebral origin. whereas, conversely, reflex dorsiflexion of the great By means of brief electric stimuli and an electro- toe is accompanied by activity in the short hallux myographic recording technique these latency values extensor and reciprocal inhibition of the voluntary can, however, be exactly determined, and in this way activity in the short hallux flexor. Landau and Clare a clear distinction can be made between purely spinal (1959) have, however, put forward the view that the reflexes and movements of a more uncertain origin. flexor plantar response differs from the extensor Using this technique, the spinal skin reflexes of the plantar response in that the long hallux extensor is trunk (Kugelberg and Hagbarth, 1958; Hagbarth engaged in th- latter but not in the former reflex type. and Kugelberg, 1958), the leg (Hagbarth, 1960; The controversial results thus obtained in the two Kugelberg, Eklund, and Grimby, 1960), and the investigations will be discussed below. foot (Eklund, Grimby, and Kugelberg, 1959; On the basis of the results reached by Kugelberg Kugelberg et al., 1960) have previously been et al. (1960), on painful stimulation of the plantar investigated, and these studies have established the surface of the foot, investigations were started on existence of an extensive system of spinal skin pathological cases showing few pronounced or reflexes representing a highly purposeful defence uncertain Babinski signs. In the course of the experi- mechanism for appropriate withdrawal reactions. ments it was, however, soon apparent that before In investigations of the spinal pain reflexes nor- being able to judge of the results obtained in http://jnnp.bmj.com/ mally elicited from the plantar surface of the foot abnormal cases a closer study had to be undertaken Kugelberg et al. (1960) found that stimulation of the of the receptive fields and the variability normally ball and hollow of the foot evokes plantar flexion existing; the present work gives an account of the of the toe, whereas, conversely, stimulation of the results obtained in this investigation of normal cases. ball of the great toe produces dorsiflexion of the In the present study, the latency values of the toe. It was further established that in extreme patho- recorded bursts of activity have been determined logical cases (with pronounced Babinski signs) (sect. 1). Only reflexes of shorter latencies than painful stimulation of the plantar surface of the foot 200 msec. have been included. The interest has been on September 26, 2021 by elicits a stereotyped flexor reflex with dorsiflexion of focused on, and all conclusions drawn from, the great toe, independently of the stimulus site, and responses recordable within 100 msec. The receptive that the main difference between this pathological fields of the various foot and toe reflexes which could reflex and that normally evoked by hallux stimu- be elicited by stimulation of the plantar surface of lation lies in the extent of the receptive field. The the foot have been examined in detail under varying conclusion was drawn that the two reflexes -are experimental conditions (sect. 2). Special attention essentially identical but that in normal cases, due to has been given to the hallux movements evoked, as 39 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.26.1.39 on 1 February 1963. Downloaded from 40 Lennart Grimby well as to the border areas between the skin regions as the short hallux extensor and flexor are concerned, it where stimulation produces hallux dorsiflexion, viz., has become possible to record contractions that are too the ball of the toes, and the regions where plantar weak to result in discernible movements and to keep the flexion of the hallux results, viz., the hollow of the stimulus strength low enough not to make the subject foot (sect. 3). The investigations have been limited exposed to the procedure averse to further cooperation. to a In the following, when referring to the strength of the selected material of 25 subjects who were electromyographic reflex, this expression is used to denote neurologically healthy, to judge from their medical the amount of activity evoked. history and physical examination, and who proved In addition to the electromyographic recording of the to have typical and brisk flexor plantar responses. reflexes, the movements evoked have also been observed The primary aim of the work has been to establish by ocular inspection. In one series of experiments they the reflex variants that can be observed in a typical were also recorded photographically by means of a normal material under varying experimental con- stroboscope giving a series of pictures at intervals of ditions, and only secondarily to get an idea of the 50 msec. This recording was, however, abandoned as it frequency of the different reflex variants in general had no advantage over the electromyographic recording in healthy humans. plus inspection beyond giving a picture of the movements. METHODS RESULTS The technique employed in the experiments to be des- 1 LATENCY VALUES OF REFLEXES STUDIED A strong cribed below is essentially the same as that used by painful stimulation of the plantar surface of the foot Kugelberg et al. (1960), and as a detailed description may give rise to a series of discharges in the muscle has been given in their work only the salient data will involved, of latencies varying between 50 and 500 be given here. msec. Responses of short latencies were guest. Protected by copyright. Electric stimuli were applied to the skin on the plantar found to be surface of the foot by means of a pair of needle electrodes comparatively stable, whereas the later responses are insulated except for the tip and inserted a few millimetres varying and very susceptible to habituation. If, in a apart into the horny layer of the skin. In most experiments subject with brisk reflexes, a strong stimulus is applied the stimulus consisted of a series of shocks delivered over to a skin area from which no reflex activity can be a period of 20 msec. and of a single duration of 1 msec. evoked in the short hallux flexor, and if the subject and a frequency of 500/sec. The maximum strength of the is instructed to bend his toes as soon as he experiences current was approximately 25 mA. The stimuli were the stimulus, the latencies of the voluntary flexor experienced as a pinprick and, when they produced a activity thus obtained have been found to be highly reflex response, were as a rule slightly painful. Most of variable from one stimulation to the other, the sub- the experiments could, however, be carried out with stimulus strengths causing only slight discomfort. ject being never capable of reacting within 150 msec. The reflex responses obtained were recorded electro- and only exceptionally within 200 msec. The present myographically. A pair of needle electrodes insulated work is mainly concerned with reflex responses except for the tip were inserted 1 or 2 cm. apart into each obtained within 100 msec. and of constant latency muscle. Most of the muscles studied were easily accessible from one stimulation to another. There is thus a to examination, but for some of them that were not so broad margin between the latencies of the reflex easily found the following procedure had to be adopted. responses studied here and the purely voluntary In the short hallux flexor the electrodes were placed responses. immediately medial to the tendon of the long hallux A threshold stimulus often results in reflex re- http://jnnp.bmj.com/ flexor, a few centimetres behind the ball, at a depth of sponses of about 1 cm. In the long hallux flexor the electrodes were comparatively long latency, and when inserted from the lateral side of the leg, about 5 cm. using weak stimuli it is difficult to judge whether proximal to the malleoli; the muscle could then be found the recorded activity is to be considered as a reflex. at a depth of about 2 cm. In the long hallux extensor and A progressive increase of the stimulus strength the extensor digitorum longus the electrodes were placed gradually shortens the latency of the reflex up to a immediately below the respective tendons, a few centi- certain limit which differs somewhat in different metres proximal to the malleoli.
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