Babinski's reflex
Babinski's reflex: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
Babinski’s reflex — dorsiflexion of the great toe with extension and fanning of the other toes — is an abnormal reflex elicited by firmly stroking the lateral aspect of the sole of the foot with a blunt object. (See How to elicit Babinski’s reflex, page 72.) In some patients, this reflex can be triggered by noxious stimuli, such as pain, noise, or even bumping of the bed. An indicator of corticospinal damage, Babinski’s reflex may occur unilaterally or bilaterally. It may also be temporary or permanent. A temporary Babinski’s reflex commonly occurs during the postictal phase of a seizure, whereas a permanent Babinski’s reflex occurs with corticospinal damage. A positive Babinski’s reflex is normal in neonates and in infants up to 24 months old.
History
Ask the patient about his recent medical history. Has the patient experienced a recent head trauma, spinal cord injury, or an animal bite? Then ask whether he has a personal or family history of neurologic disorders.
Physical assessment
After eliciting a positive Babinski’s reflex, evaluate the patient for other neurologic signs. Evaluate muscle strength in each extremity by having the patient push or pull against your resistance. Passively flex and extend the extremity to assess muscle tone. Intermittent resistance to flexion and extension indicates spasticity, and a lack of resistance indicates flaccidity.
Next, check for evidence of incoordination by asking the patient to perform a repetitive activity. Test deep tendon reflexes (DTRs) in the patient’s elbow, antecubital area, wrist, knee, and ankle by striking the tendon with a reflex hammer. An exaggerated muscle response indicates hyperactive DTRs; little or no muscle response indicates hypoactivity.
Then evaluate pain sensation and proprioception in the feet. As you move the patient’s toes up and down, ask him to identify the direction in which the toes have been moved without looking at his feet.
Medical causes
Amyotrophic lateral sclerosis
With amyotrophic lateral sclerosis (ALS), a progressive motor neuron disorder, bilateral Babinski’s reflex may occur with hyperactive DTRs and spasticity. Typically, ALS produces fasciculations accompanied by muscle atrophy and weakness. Incoordination makes carrying out activities of daily living difficult for the patient. Associated signs and symptoms include impaired speech; difficulty chewing, swallowing, and breathing; urinary frequency and urgency; and, occasionally, choking and excessive drooling. Although his mental status remains intact, the patient’s poor prognosis may cause periodic depression.
Brain tumor
A brain tumor that involves the corticospinal tract may produce Babinski’s reflex. The reflex may be accompanied by hyperactive DTRs (unilateral or bilateral), spasticity, seizures, cranial nerve dysfunction, hemiparesis or hemiplegia, decreased pain sensation, unsteady gait, incoordination, headache, emotional lability, and decreased level of consciousness (LOC).
Head trauma
In a patient with head trauma, unilateral or bilateral Babinski’s reflex may occur as the result of primary corticospinal damage or secondary injury associated with increased intracranial pressure. Hyperactive DTRs and spasticity commonly occur with Babinski’s reflex. The patient may also have weakness and incoordination. Other signs and symptoms vary with the type of head trauma and include headache, vomiting, behavior changes, altered vital signs, and decreased LOC with abnormal pupillary size and response to light.
Meningitis
With meningitis, bilateral Babinski’s reflex commonly follows fever, chills, and malaise and is accompanied by nausea and vomiting. As meningitis progresses, it also causes decreased LOC, nuchal rigidity, positive Brudzinski’s and Kernig’s signs, hyperactive DTRs, and opisthotonos. Associated signs and symptoms include irritability, photophobia, diplopia, delirium, and deep stupor that may progress to coma.
Multiple sclerosis
In most patients with multiple sclerosis, a demyelinating disorder, Babinski’s reflex eventually occurs bilaterally. It follows initial signs and symptoms of multiple sclerosis — usually, paresthesia, nystagmus, and blurred or double vision. Associated signs and symptoms include scanning speech (clipped speech with some pauses between syllables), dysphagia, intention tremor, weakness, incoordination, spasticity, gait ataxia, seizures, paraparesis or paraplegia, bladder incontinence and, occasionally, loss of pain and temperature sensation and proprioception. Emotional lability is also characteristic.
Pernicious anemia
Bilateral Babinski’s reflex occurs late in pernicious anemia when vitamin B12 deficiency affects the central nervous system. Anemia may eventually cause widespread GI, neurologic, and cardiovascular effects. Characteristic GI signs and symptoms include nausea, vomiting, anorexia, weight loss, flatulence, diarrhea, and constipation. Gingival bleeding and a sore, inflamed tongue may make eating painful and intensify anorexia. The lips, gums, and tongue also appear markedly pale. Jaundice may cause pale to bright yellow skin.
Characteristic neurologic signs and symptoms include neuritis, weakness, peripheral paresthesia, disturbed position sense, incoordination, ataxia, positive Romberg’s sign, light-headedness, bowel and bladder incontinence, and altered vision (diplopia, blurred vision), taste, and hearing (tinnitus). The disorder may also produce irritability, poor memory, headache, depression, impotence, and delirium. Characteristic cardiovascular signs and symptoms include palpitations, wide pulse pressure, dyspnea, orthopnea, and tachycardia.
Rabies
Bilateral Babinski’s reflex — possibly elicited by nonspecific noxious stimuli alone — appears in the excitation phase of rabies. This phase occurs 2 to 10 days after the onset of prodromal signs and symptoms, such as fever, malaise, and irritability (which occur 30 to 40 days after a bite from an infected animal). Rabies is characterized by marked restlessness and extremely painful pharyngeal muscle spasms. Difficulty swallowing causes excessive drooling and hydrophobia in about 50% of affected patients. Seizures and hyperactive DTRs may also occur.
Spinal cord injury
With acute injury, spinal shock temporarily erases all reflexes. As shock resolves, Babinski’s reflex occurs — unilaterally when injury affects only one side of the spinal cord (Brown-Séquard’s syndrome), bilaterally when injury affects both sides. Rather than signaling the return of neurologic function, this reflex confirms corticospinal damage. It’s accompanied by hyperactive DTRs, spasticity, and variable or total loss of pain and temperature sensation, proprioception, and motor function. Horner’s syndrome, marked by unilateral ptosis, pupillary constriction, and facial anhidrosis, may occur with lower cervical cord injury.
Spinal cord tumor
With spinal cord tumor, bilateral Babinski’s reflex occurs with variable loss of pain and temperature sensation, proprioception, and motor function. Spasticity, hyperactive DTRs, absent abdominal reflexes, and incontinence are also characteristic. Diffuse pain may occur at the level of the tumor.
Stroke
Babinski’s reflex varies with the site of a stroke. If it involves the cerebrum, it produces unilateral Babinski’s reflex accompanied by hemiplegia or hemiparesis, unilateral hyperactive DTRs, hemianopsia, and aphasia. If it involves the brain stem, it produces bilateral Babinski’s reflex accompanied by bilateral weakness or paralysis, bilateral hyperactive DTRs, cranial nerve dysfunction, incoordination, and unsteady gait. Generalized signs and symptoms of stroke include headache, vomiting, fever, disorientation, nuchal rigidity, seizures, and coma.
Special considerations
Babinski’s reflex usually occurs with incoordination, weakness, and spasticity, all of which increase the patient’s risk of injury. To prevent injury, assist the patient with activity and keep his environment free from obstructions.
Diagnostic tests may include a computed tomography scan or magnetic resonance imaging of the brain or spine, angiography or myelography and, possibly, a lumbar puncture to clarify or confirm the cause of Babinski’s reflex.
Pediatric pointers
Babinski’s reflex occurs normally in infants up to 24 months old, reflecting immaturity of the corticospinal tract. After age 2, Babinski’s reflex is pathologic and may result from hydrocephalus or any of the causes more commonly seen in adults.
Patient counseling
Prepare the patient for diagnostic tests by telling him what to expect before, during, and after the procedure. Reinforce the need for the patient to call for help before getting out of bed. Discuss ways to maintain a safe environment at home with the patient, his family, and caregivers. Teach the patient to use adaptive devices, such as braces or crutches, to maintain independence with activities of daily living.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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