This document provides an overview of techniques for examining pathologic reflexes, meningeal signs, and monofilament tests in neurologic examinations. It discusses the objective of gaining knowledge and skills in these areas. For pathologic reflexes, it describes what they are, examples like Babinski's reflex, and their significance. It covers various reflexes tested in the lower and upper extremities. For meningeal signs, it explains that signs are elicited when meninges are inflamed, defines meningismus, and describes techniques like assessing nuchal rigidity.

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….
• 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.

8. 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.

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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.

15. 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.

16. 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.

17. 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.

18. 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

19. 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

21. 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.

22. 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

23. 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

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

25. 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.

26. 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.

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

28. 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.

29. 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.

30. 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.

31. 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.

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

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.

38. 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.

39. 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.

40. 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.

41. 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.

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

43. 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.

44. 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.

45. 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.

46. 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.

47. 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.

48. 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.

49. 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

50. 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

51. 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.

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

53. 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.

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

55. 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.

56. 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.

57. 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.

58. 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.

59. 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.

60. 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.

61. 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???

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

63. 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.

64. 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.

65. 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

66. 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.

67. Other Meningeal Signs

68. Cont….

69. 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

70. 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.

71. 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.

72. 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.

73. 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.

74. 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

75. 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.

76. 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.

78. Reference

79. THANK YOU!!!