PPT

1. Pathologic Reflexes, Meningeal Signs & Monofilament Tests
Presenter: Dr. Zeleke W/Y (NR2)
Moderator: Dr. Nebiyu B (Consultant Neurologist)
April 26,2022 GC.

2. Outline
• Objective
• Pathologic Reflexes
• Meningeal signs
• Monofilament

3. Objective
• To gain knowledge and skill on neurologic examination of
Pathologic reflexes
Meningial signs
Monofilament

4. PATHOLOGIC REFLEXES
• Responses not generally found in the normal individual.
• Some are responses that are minimally present and elicited
with difficulty in normals.
• others are not seen in normals at all.
• Many are exaggerations and perversions of normal muscle
stretch and superficial reflexes.

5. Cont….
• The responses normally seen in the immature nervous system
of infancy.
• It disappears only to reemerge later in the presence of disease.
• A decrease in threshold or an extension of the reflexogenic
zone plays a role in many pathologic reflexes.

6. Cont….
• Descending motor influences normally control and modulate
the activity at the local, segmental spinal cord level.
• It ensure efficient muscle contraction and proper coordination
of agonists, antagonists, and synergists.

7. Cont….
• Some pathologic reflexes may also be classified as “associated
movements,” related to such spread of motor activity.
• Whether a certain abnormal response would be best classified
as a reflex or an associated movement is not always clear.

8. Cont….
• Responses that are more in the
realm of an associated
movement are sometimes
referred to clinically as reflexes
• e.g., the Wartenberg thumb
adduction sign, an associated
movement, is sometimes called a
Wartenberg reflex,

9. Cont….
• Pathologic reflexes are reversions to primitive responses and
indicate loss of cortical inhibition.
• e.g., Babinski, Chaddock, Oppenheim, snout, rooting, grasp
• They typically present early in development of the
neurotypical infant and then disappear with maturation.

10. Cont….
• Most pathologic reflexes are related to disease involving the
corticospinal tract and associated pathways.
• They also occur with frontal lobe disease
• Sometimes with disorders of the extrapyramidal system.

11. Cont….
• The typical reflex pattern with lesions involving the upper
motor neuron syndrome:
exaggeration of deep tendon reflexes
disappearance of superficial reflexes, and
emergence of pathologic reflexes

12. PATHOLOGIC REFLEXES IN THE LOWER EXTREMITIES
• Characteristics
more constant, easily elicited ,reliable, and clinically relevant.
• The most important responses
dorsiflexion of the toes and plantar flexion of the toes

13. The Babinski Sign
• Normal plantar reflex response:
 usually fairly rapid
the small toes flex more than the great toe, and
more marked when the stimulus is along the medial plantar
surface.
• In disease of the corticospinal system
the Babinski sign or extensor plantar response

14. The Babinski sign….
• the most important sign in clinical neurology.
• It is one of the most significant indicator of disease of the
corticospinal system
at any level from the motor cortex through the descending
pathways.

15. Cont….
• Stimulating the plantar surface of
the foot with a blunt point
 applicator stick,
 handle of a reflex hammer, a
 broken tongue blade, the
 thumbnail, or
 the tip of a key

16. Cont….
• The most common mistakes:
insufficiently firm stimulation
placement of the stimulus too medially, and
moving the stimulus too quickly
• The only movements of significance are those of the great toe.

17. Cont….
• The best position is supine, with hips and knees in extension
and heels resting on the bed.
• The patient should be relaxed and forewarned of the potential
discomfort.
• The Babinski sign is a part of the primitive flexion reflex.

18. Cont….
• the primitive flexion response may reappear in disease
involving the corticospinal tract.
• With more severe and extensive disease, the entire flexion
response emerges called “triple flexion” response.

19. Cont….
• The Babinski is a valuable clinical sign, but it is not perfect.
• The most common problem is distinguishing an upgoing toe from
voluntary withdrawal.
As the Babinski sign is part of a withdrawal reflex.

20. Cont….
• An extensor plantar response does not always signify structural disease.
• It may occur as a transient manifestation of physiologic dysfunction of
the corticospinal pathways.
deep anesthesia and narcosis
in drug and alcohol intoxication
in metabolic coma such as hypoglycemia,
in deep sleep, postictally

21. Fallacies in the interpretation of plantar response
Patients with callosities of feet
Sensory loss in the S1 dermatome in peripheral neuropathy or
tibial nerve injury
Bony deformities like hallus valgus
Patients with pes cavus

23. Corticospinal Tract Responses Characterized by Plantar Flexion of the Toes
• The maneuvers for plantar flexion of the toes
Grasp reflex
• In the newborn infant, there is a grasp reflex in the foot as well
as the hand.
• Elicited by light pressure on the plantar surface of the foot.
• The response is flexion and adduction of the toes.

24. Cont….
The plantar grasp
• elicited by drawing the handle of
a reflex hammer from the
midsole toward the toes.
• causes the toes to flex and grip
the hammer

25. Cont….
Rossolimo sign
• Tapping ball of foot, or plantar
surfaces of toes; giving a quick,
lifting snap to tips of toes
• Response quick plantar flexion of
toes, especially smaller ones

26. Other Lower-Extremity Pathologic Reflexes
• Crossed extensor reflex (Phillipson’s reflex)
Severe spinal cord lesions
Severe myelopathy

27. PATHOLOGIC REFLEXES IN THE UPPER EXTREMITIES
They are less constant, more difficult to elicit, and usually less
significant diagnostically.
• Primarily fall into two categories:
FRS and exaggerations of or variations on the finger flexor
reflex.

28. Frontal release signs/reflexes
• Are responses that are normally present in the developing nervous
system.
• Re-emergence of primitive reflex following frontal damage.
• They are normal in infants and children
• They may be evidence of neurologic disease when present in an
older individual
• Many of these are exaggerations of normal reflex responses.

29. Cont….
• Common frontal reflexes include:
Palmomental reflex
Grasp reflex (palmar vs. plantar)
Glabellar
Snout
Routing reflex
Corneomandibular
Etc…..

30. Cont….
• Mostly FRS occur in the patients with:
severe dementias
diffuse encephalopathy (metabolic, toxic, postanoxic)
traumatic head injury
In general with diffuse pathologic processes is particularly
involving the frontal lobes or the frontal association areas.

31. Cont….
• The Palmomental Reflex=palm-chin
reflex
 Elicited by scratching or stroking the
palm of the ipsilateral hand.
 wrinkling of the skin of the chin
with slight retraction and
sometimes elevation of the angle of
the mouth.
• Caused by contraction of the
mentalis and orbicularis oris
muscles.

32. Cont….
• In neurologic patients, trigger zone could be forearm, chest,
abdomen, or even the sole.
• Spread of the reflex response beyond the chin region may also
occur;
E.g. involvement of the platysma has been termed the
palmocervical reflex.

33. Cont….
• The PMR is weak and fatigable in normals and stronger and more
persistent in disease.
• The PMR can help in the differential diagnosis of facial palsy
it is absent in peripheral facial palsy and may be exaggerated in
central facial paresis.
• Note that a unilateral PMR does not have localizing value.

34. Cont….
• The Palmomental response appeared earliest and was the
most frequent reflex at all ages.

35. Cont….
• The Grasp (Forced grasping)
Reflex
 Elicited by stimulation of the skin
of the palmar surface of the
fingers or hand.
 involuntary flexor response of
the fingers and hand.
• The patient is instructed not to
hold on to the examiner’s hand.

36. Cont….
• The palmar grasp is normally present at birth.
• The response begins to diminish at the age of 2 to 4 months.
• It reappears primarily in a condition such as:
extensive neoplastic or vascular lesions of the frontal lobes or
cerebral degenerative processes
• it may also occur as evidence of corticospinal tract dysfunction in
spastic hemiplegia.

37. Cont….
• There are grasping and groping responses.
• When this sign is present unilaterally, it suggests a
contralateral frontal or parietal lobe lesion.
• When it occurs bilaterally, there is no localizing value.

38. Cont….
Glabellar reflex
• induced by gently tapping (hammer
or finger) the glabellar nerve.
• The reflex is positive when the
patient continues to blink each time
you tap.
• A positive glabellar (Meyerson’s)
reflex is commonly seen in
Parkinson’s disease & early
dementias.

39. Cont….
The orbicularis oris (snout) reflex
• pressing firmly backward on the
philtrum of the upper lip,
• Response is puckering and
protrusion of the lips
• Exaggerated responses are
sucking and even tasting,
chewing, and swallowing
movements.

40. Cont….
• The sucking reflex is normal in infants.
• stimulation of the perioral region is followed by sucking
movements of the lips, tongue, and jaw.
• The response may be elicited by lightly touching, striking, or
tapping the lips.
• A rooting (searching) reflex is when the lips, mouth, and even
head deviate toward a tactile stimulus delivered beside the
mouth or on the cheek.

41. Cont….
• A grossly exaggerated response may include:
automatic opening of the mouth
smacking
chewing, and
swallowing movements
• it may reappear in some patients with diffuse cerebral disease.

42. Cont….
Corneomandibular reflex
• stimulation of cornea causes contralateral movement of the
mandible.
• It indicates supranuclear interruption of the ipsilateral
corticotrigeminal tract.
• It is said to be the only eye sign in ALS.

43. The finger flexor–related responses
• usually a manifestation of the spasticity and hyperreflexia.
• And in the lesions involving the corticospinal tract.
• Hoffman and Trömner signs are usually classified as
corticospinal tract signs.
• These responses occur only with lesions above the C5 or C6
segment of the cervical spinal cord.

44. Cont….
• The Hoffmann and Trömner Signs and the Flexor Reflexes of
the Fingers and Hand
• They are methods that used for delivering stretch stimulus.

45. The finger flexor reflex
• Elicited by a stretch stimulus
delivered with a reflex hammer
flexion of the patient’s fingers
and distal phalanx of the
thumb.

46. Hoffmann sign
• the patient’s relaxed hand is held
with the wrist dorsiflexed and
fingers partially flexed
• With one hand, the examiner holds
the partially extended middle finger
between her index finger and
thumb or between her index and
middle fingers.
• The response is flexion and
adduction of the thumb and flexion
of the index finger.

47. Trömner sign
• the examiner holds the patient’s
partially extended middle finger,
• letting the hand dangle, then,
with the other hand, thumps or
flicks the finger pad
• The response is the same as that
in the Hoffmann test.

48. Jaw reflex
• the examiner places an index finger or thumb over the middle
of the patient’s chin
• Patient hold the mouth open about midway with the jaw
relaxed
• Tapping the finger with the reflex hammer
• Response: an upward jerk of the mandible.

49. Cont….
• The afferent impulses are carried through the sensory portion
of the trigeminal nerve to the mesencephalic nucleus,
• The efferent one through its motor portion.

50. Cont….
• Increased, or “brisk,” jaw jerk is seen in an upper motor
neuron lesion, with localization of the lesion above the
foramen magnum.
• Diminished or absent jaw jerk as in bulbar palsy.
• Bilateral supranuclear lesions cause a brisk jaw jerk, as in
pseudobulbar palsy.

51. Other Upper-Extremity Pathologic Reflexes
Reflex Stimulus Response
Rossolimo’s of the hand Percussion of palmar aspect of
MCP joints or tapping volar
surface of fingertips
Flexion of the fingers and
supination of the forearm
Mendel Bechterew Percussion of dorsal aspect of carpal and metacarpal
areas, or tapping dorsum of either hand or
fingers
Flexion of the fingers and
hand
Flexion reflex (Dejerine hand
phenomenon)
Percussion of flexor tendons on volar surface of
forearm
Flexion of fingers and
hand
Thumb-adductor reflex of Marie-
Foix
Superficial stroking of palm of hand in hypothenar
region, or scratching ulnar side of palm
Adduction and flexion of
thumb,
Foxe reflex Pinching hypothenar region Same as Marie-Foix
Oppenheim’s sign Rubbing external surface of forearm Same as Marie-Foix
Schaefer sign Pinching flexor tendons at wrist Same as Marie-Foix

52. Cont….
Reflex Stimulus Response
Ulnar adduction reflex of Pool Stimulation of any portion of palm
innervated by ulnar nerve
Adduction of the thumb
Chaddock’s wrist sign Pressure or scratching in depression at
ulnar side of FCR and PL tendons at wrist,
Flexion of wrist and
simultaneous extension
and separation of digits
Gordon’s extension
sign
Pressure on radial side of pisiform bone Extension and occasionally
fanning of the flexed fingers
Bachtiarow sign Stroking downward along radius with
thumb and index finger
Extension and slight
adduction of thumb

53. CLONUS
• It is a series of rhythmic involuntary muscular contractions
induced by the sudden passive stretching of a muscle or
tendon.
• It often accompanies the spasticity and hyperactive DTRs seen
in corticospinal tract disease.

54. Cont….
• Most frequently at the ankle,
knee, and wrist.
Method of eliciting ankle clonus

55. Cont….
• Unsustained clonus fades away after a few beats
• Sustained clonus persists.
• Sustained clonus is never normal.
• In severe spasticity, clonus may occur spontaneously or with
the slightest stimulus.

56. Cont….
• False clonus (pseudoclonus) in psychogenic disorders
• It is poorly sustained and irregular in rate, rhythm, and
excursion.

57. Meningeal signs
• Most frequently elicited when the meninges are inflamed.
• Meningismus is a term that refers to the presence of nuchal
rigidity and other clinical signs of meningeal inflammation.

58. Cont….
• Meningism is sometimes used synonymously with
meningismus,
• but it is also used to refer to a syndrome characterized by neck
stiffness without meningeal inflammation.

59. Cont….
• The various maneuvers used to elicit meningeal signs produce
tension on inflamed and hypersensitive spinal nerve roots, and
• the resulting signs are
postures, protective muscle contractions, or other movements that
minimize the stretch and distortion of the meninges and roots.

60. Nuchal (Cervical) Rigidity
• It is the most widely recognized and frequently encountered test.
• And on its absence the diagnosis of meningitis is rarely made.
• It is characterized by stiffness and spasm of the neck muscles,
with pain on attempted voluntary movement as well as resistance to
passive movement.

61. Cont….
• Nuchal rigidity primarily affects the extensor muscles.
• the most prominent early finding is resistance to passive neck
flexion.
• Difficulty of placing chin on the chest where as rotatory and
lateral movement preserved.
• If more severe nucha, there may be resistance to extension
and rotatory movements as well.

62. Cont….
• Extreme rigidity causes retraction of the neck into a position of
opisthotonos.
• Rigidity may be absent in meningitis when the disease is
fulminating or terminal, when the patient is in coma, or in
infants.

63. Cont….
• Stiffness and rigidity of the neck may occur in other conditions.
• Such as cervical spondylosis and osteoarthritis
• How to distinguish restricted neck motion due to cervical
spondylosis or osteoarthritis from nuchal rigidity???

64. Cont….
• Other causes of restricted neck motion may also occur with:
retropharyngeal abscess
cervical lymphadenopathy
neck trauma
Extrapyramidal disorders, particularly progressive supranuclear
palsy

65. Kernig’s Sign
• Flex the hip and knee to right
angles and then attempt to
passively extend the knee;
• this movement produces pain,
resistance, and inability to fully
extend the knee.

66. Cont….
• There is some overlap between Kernig’s sign and straight leg
raising sign.
• The technique is similar, but straight leg raising sign is used to
check for root irritation in lumbosacral radiculopathy.
• Both Kernig’s sign and straight leg raising are positive in
meningitis.
• In radiculopathy, the signs are usually unilateral, but in
meningitis they are bilateral.

67. Brudzinski’s Neck Sign
• Placing one hand under the
patient’s head and flexing the
neck while holding down the
chest with the other hand
• Look for flexion of the hips and
knees bilaterally.
Flexing the neck causes the knees
to flex

68. Cont….
• Jolt accentuation is an exacerbation of headache induced by
quick, horizontal head rotations at two or three times per
second.
• Amoss’s, Hoyne’s or tripod sign
• Patient sit in bed with the hands placed far behind, the head
thrown back, the hips and knees flexed, and the back arched.

69. Other Meningeal Signs

70. Cont….

71. Screening for risk of foot ulceration
• All patients with diabetes be screened annually to identify those at
risk for foot ulceration.
• We perform a history, physical examination of the foot, and use a
10g monofilament for screening purposes.
• An alternative tests includes:
vibration testing (128 Hz tuning fork)
ankle reflex assessment, or tests of pinprick sensation

72. Monofilament
• Quantitative testing of touch and
pressure can be done with
graded monofilaments of
different strengths.
• ADA recommends using single-
use disposable monofilaments or
those clearly proven to be
accurate.

73. Cont….
• Most commonly evaluated sites
for pressure sensation include:
 the plantar hallux and
 the first, third, and fifth
metatarsal heads
the presence of one insensate
site strongly suggest as
evidence of high risk.

74. Cont….
• Screening tests for neuropathy in the clinic include use of a 10 g
monofilament and of a 128 Hz tuning fork.
• Both tests reflect the function of large myelinated sensory nerve fibers.
• The monofilament test has been widely adopted and is easy to use in
clinical practice,
its sensitivity to detect early impairment in nerve function is limited.

75. Cont….
• The 10gm monofilament is the most useful test to diagnosis
LOPS.
• In diabetic foot screening, this test is used to identify those who lost
sensation.
Not used to diagnose peripheral neuropathy.
• The foot examination uses a 5.07 monofilament, which delivers 10 g.

76. How to apply???
• Sensory information should be carried out in a quiet and
relaxed setting.
• First apply monofilament on the patient sensitive areas of skin
so that he/she knows what is to expect.
• Patient must not be able to see whether or where the
examiner apply the filament
• Apply monofilament perpendicular to the skin surface

77. Cont….
• Apply sufficient force to cause the filament to bend or buckle
• The total duration of approach should be approximately 2
seconds.
• Don’t allow filament to slide across the skin or make repetitive
contact at the test site.

78. Cont….
• Ask the patient whether they feel pressure applied(yes/no) and next
where they feel pressure
• Repeat this application two times at the same site
• Protective sensation is present at each site if the patient correctly
answers two out of three application
• Absent with two out of three incorrect answer:
the patient is the considered to be at risk of ulceration.

80. Reference

81. THANK YOU!!!