The document discusses the plantar reflex, which is a polysynaptic reflex elicited by stimulating the plantar surface of the foot. It describes Babinski's discovery and definition of the pathological plantar reflex response, which involves dorsiflexion of the toes. The normal plantar reflex involves plantar flexion of the toes. The document outlines the physiology and maturation of the plantar reflex from infancy to adulthood. It also discusses causes, types, advantages, and limitations of the Babinski sign.

1. PLANTAR REFLEX :
A POLYSYNAPTIC REFLEX
GUIDED BY: DR PROF P.K.BAGHEL(MD)
RMO: DR.HIMANSHU

2. DEFINITION OF REFLEX
• A reflex is an involuntary response to a sensory stimulus.
• Afferent impulses arising in a sensory organ produce a response in an effector organ.
• There are segmental and suprasegmental components.
• The segmental component is a local reflex center in the spinal cord or brainstem and its
afferent and efferent connections.
• The suprasegmental component is made up of the descending central pathways that control,
modulate, and regulate the segmental activity

3. SUPERFICIAL/ CUTANEOUS REFLEXES
• Response to stimulation of skin/ mucous membrane
• : 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

4. SUPERFICIAL/ CUTANEOUS REFLEXES:
Upper limbs
• Grasp reflex (C6-T1)
• Scapular
• Interscapular reflex
Lower limbs
• Cremastric
• Scrotal/ dartos reflex
• Gluteal reflex (L4-S2)
• Plantar reflex
• Bulbocavernous reflex

5. PATHOLOGICAL REFLEXES:LOWERLIMB
Dorsiflexion of toes
• Babinski group of signs
• Chaddock/ oppenheims
Plantar flexion of toes
• Plantar grasp
• Plantar muscle reflex
• Rossolimo sign-----

6. PLANTAR REFLEX

7. NORMAL PLANTAR REFLEX
• In the normal individual, stimulation of the skin of the
plantar surface of the foot is followed by plantar
flexion of the toes.
• In the normal plantar reflex, the response is usually
fairly rapid, the small toes flex more than the great
toe, and the reaction is more marked when the
stimulus is along the medial plantar surface.
• This reflex is innervated by the tibial nerve (L4–S2).

8. 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

11. JOSEPHFRANCOISBABINSKI:1896
• A French neurologist
• His primary aim was in trying to find reliable clinical signs to distinguish organic from
nonorganic disease of the nervous system.
• 'reflexe cutane plantaire' (cutaneous plantar reflex) in February 1896
• Described the sign for the first time
• Remarkable observations about this reflex

12. ESSENTIALLY TWO COMPONENTS
1. Phenomene des arteils : dorsiflexion of the toes (1898)
2. Signe de l’eventail : fanning response
• –abduction of toes (1903)

13. 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
2. STIMULATION:
• Stimulate the plantar surface of foot, on
the lateral aspect
• 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

14. 3. 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
• In patients with no response –progressively firmer stimulus may be requires

16. BABINSKIRESPONSE:
• Extension of great toe -
• Fanning/ abduction of toes
• Dorsiflexion of ankle
• Flexion of knee/ hip
• Slight abduction of thigh
•leading to a withdrawal of the
leg on plantar stimulation

18. WHY BABINSKI SIGN PRESENT IN INFANTS…???
In the infant, before myelination of the nervous system is complete and
an upright stance has been achieved,
the normal plantar response is extensor,
due to a brisker ‘flexion synergy’ as part of the withdrawal response to
pain.

19. As the nervous system matures and the pyramidal tracts gain more control over spinal
motor neurons, the ‘ flexion synergy’ becomes less brisk and the toe ‘extensors’
are no longer a part of it.
When the child assumes an upright posture, the plantar response becomes part of the
postural reflex maintaining the tones of the foot and leg.
At this time, the normal response to stimulation becomes a flexor movement of the toes
and the ‘withdrawal extensor’ movement is suppressed by the influence of the pyramidal
tract over the spinal reflex arc.
The toe then goes down instead of up, as a result of a segmental reflex involving small
foot muscles and the overlying skin.

20. IN A NUTSHELL:
• 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

21. ROLEOF 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

22. CAUSES OF BABINSKI SIGN:
ANATOMICAL
• Stroke
• Spinal cord lesions
• Myelitis
• Demyelinating disorders
PHYSIOLOGICAL
• Normal children up to 1 year of age
• Deep sleep
• Coma
• Following severe physical exhaustion
• General Anesthesia
• Metabolic
• Hypoglycemia
• Epileptic seizures
• Alcohol intoxication
• Narcosis
• Head trauma with concussion.

23. PYRIMIDAL DYSFUNCTION LEADINGTO BABINSKISIGN:
• Loss of inhibition
• Flexion synergy becomes brisker
• Great toe is recruited in this response
• Is almost always asso.with some degree of weakness of
toe.

24. ADVANTAGES OFBABINSKISIGN:
• Most reliable
• Dependable
• Consistent signs
• Good inter-observer variability
• Indicates presence of organic neurological disease

25. LIMITATIONS OFBABINSKI SIGN:
1. 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 Tensor fascia lata
Pressure over the base of great toe inhibits withdrawal
Can use variations of reflexs.

26. LIMITATIONS OFBABINSKI SIGN:
2. Lack of BSin pyrimidal dysfunction
• Spinal shock – temporary inexcitability of spinal inter-neurons
• Cerebral shock
• LMN lesions in pathway to Extensor hallusis longus
Radiculopathy
Peroneal nerve palsy
ALS, peripheral neuropathy

27. LIMITATIONS OFBABINSKI SIGN:
3. Flexor response in spite of CST lesion
• Frontal lobe lesions – hyperactive plantar grasp
• ALS/ MND – LMN involvement of toe extensors
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 CorticoSpinalTract

28. 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

29. BRISSAUD’S REFLEX
• Described few days
after Babinski’s
famous lecture
• Stimulation of lateral thigh
• Causes contraction of TFL
• Helpful in apatient with missing toe
PUUSEPP’SSIGN:
• May be present when Babinski is not
elicitable
• Sensitive pyramidal sign
• Slow, tonic abduction of the little finger on
Plantar stimulation
• Great toe extension may be absent

30. BRISSAUD’S REFLEX

31. • True Babinski: includes all 5 component
• Minimal Plantar : contraction of TFL and the Hamstring muscles.
• Spontaneous Babinski : passive flexion of hip and knee or passive
extension of knee may produce Babinski in extensive CST lesions
• Bilateral Babinski : crossed extensor response : B/L cerebral or spinalcord
lesion: u/l foot stimulation elicit b/l response.
• Tonic Babinski : slow, prolonged extension –in combined Frontal
and EPS
TYPESOFBABINSKI

32. TYPESOFBABINSKI…
• Exaggerated Babinski : flexor or extensor spasm
• Flexor spasm –B/L CSTor spinalcordlesion
• Extensor spasm- –B/L CST with preservedpost.columnfunction.
Equivocal Babinski sign:
• Rapid but brief extension of toes at first then f/by flexion then again f/by extension
• There is only extension of great toe or extension of great toe with flexion of small toe.
• No response to planter stimulation
• May be flexion of knee and hip with no movement of toes.

33. 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

34. OTHERMETHODS FOR
ELICITING BABINSKI
REFLEX

39. UPPERLIMB
EQUIVALENTS

40. • Stimulus – reflex hammer
• Response – flexion of fingers
• And distal phalynx of thumb
1. WARTENBERG’S SIGN

41. • 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 andadduction
of thumb
2. HOFFMAN’S SIGN

43. TAKE HOME MESSAGE….
• The extensor plantar response is one of the most reliable, dependable, and
consistent signs in clinical neurology
• It gives credible evidence of organic neurologic disease
• Even though its elicitation is an art and observer bias may occur with regards
to its interpretation, its clinical utility remains unchallenged.