Babinski's hand sign: many have tried…

O sinal de Babinski na mão: muitos têm tentado…

Péricles Maranhão-Filho Rosalie Branco Correa About the authors

ABSTRACT

Recognizing the semiologic importance of the second, and most famous, sign described by Joseph Babinski – the extension of the hallux after stimulation of the plantar region in order to differentiate organic from pithiatic paralysis– several authors have tried to find a comparable signal in the hand. After 122 years, no one has succeeded.

Keywords:
Reflex; Babinski sign; motor disorders

RESUMO

Reconhecida a importância semiológica do segundo e mais famoso sinal descrito por Joseph Babinski - a extensão do hálux após estimulo plantar visando diferenciar a paralisia orgânica da pitiática - diversos autores vêm tentando encontrar um sinal equiparável na mão. Após 122 anos ninguém conseguiu obter sucesso.

Palavras-chave:
Reflexo; sinal de Babinski; transtornos motores

On February 22nd, 1896, it was a cold Parisian Saturday. The temperature ranged from −0.3°C to 7.6°C but it was not raining11. Previsions Meteo-Histoclimat MCS, Milliards de Données -Evénements climatologiques em France depuis 1675: Available from: http://meteo-climat-bzh.dyndns.org/tempsjour-22-2-1896.php [Acces Oct 10, 2017].
http://meteo-climat-bzh.dyndns.org/temps...
. In a lively meeting at the Société de Biologie, the 38-year-old French-naturalized Polish neurologist, Joseph Jules François Felix Babinski, read a 28-line text named “Le réflexe cutané plantaire dans certaines affections du système nerveux central”22. Babinski J. Sur le reflexe cutane plantaire dans certaines affections du systeme nerveux central. C R Seances Soc Biol. 1896.207-208.. In this lecture, Babinski presented, for the first time, an objective sign “that allows the distinction between organic neurologic disorders and those of functional or hysteric origin”33. Philiippon J, Poirier J. Joseph Babinski: a biography. New York: Oxford University Press; 2009.. In the more than 120 years that followed this day, several neurologists have attempted to find an equivalent sign in the fingers44. Purdy RA. The most important neurologic reflex! Am J Med. 2010 Sep;123(9):793-5. https://doi.org/10.1016/j.amjmed.2010.03.023
https://doi.org/10.1016/j.amjmed.2010.03...
. The purpose of this manuscript is to highlight some of these attempts.

Carpometacarpal reflex – von Bekhterev

In 1903, the Russian, Vladimir Mikhailovich von Bekhterev (1857-1927), emphasized that his upper limb test, a stimulus made to the tendons covering the back of the hand in the carpus and the beginning of the metacarpal area, promoting a flexor response of the fingers55. Bekhterev VM. Über den Carpometacarpalreflex. Neurologisches Zentralblatt. 1903;22:195-6., also indicated – as Babinski had done in relation to the hallux – the differentiation between an organic versus functional paralysis66. Bekhterev VM. Über Reflexe distaler Abschnitte der oberen Extremitäten und über ihre diagnostische. Neurologisches Zentralblatt. 1905;24:392-5. (Figure 1).

Figure 1
VM Bekhterev and his carpometacarpal reflex article55. Bekhterev VM. Über den Carpometacarpalreflex. Neurologisches Zentralblatt. 1903;22:195-6..

In 1908, Louis Jacobsohn-Lask (1863-1941), a German neurologist (Figure 2), described a similar reflex to von Bekhterev, and considered:

“…similar to Babinski's… the finger flexion reflex appears rather constantly in cases of spastic paralysis of the upper limb of a cerebral character…” 7 7. Jacobsohn L. Über den Fingerbeugereflex. Dtsch Med Wochenschr. 1908;34(46):1971-3. https://doi.org/10.1055/s-0028-1135838
https://doi.org/10.1055/s-0028-1135838...

Figure 2
Louis Jacobsohn-Lask and the Fingerbeuge reflex artice77. Jacobsohn L. Über den Fingerbeugereflex. Dtsch Med Wochenschr. 1908;34(46):1971-3. https://doi.org/10.1055/s-0028-1135838
https://doi.org/10.1055/s-0028-1135838...
.

Due the great similarity with the von Bekhterev method, the two-finger flexion reflex began to be called the Bekhterev-Jacobsohn reflex.

Hoffmann's reflex phenomenon – the Hoffmann sign

Around 1910, Johann Hoffmann (1857-1919) was honored by his pupil, Hans Curschmann (1875-1942), when he quoted Hoffmann's name in a method of investigating the fingers flexor reflex – “ Hoffmann's Sign” or “Hoffmann's Reflex”. In the technique to elicit this, the examiner holds the median phalanx of the examined middle finger between his own second and third fingers and promotes a rapid and forced stimulation – flicking and sudden release – of the flexed terminal phalanx of the retained finger (Figure 3)88. DeJong RN. The neurologic examination. New York: Harper & Brothers; 1950. This reflex is present when the patient's other fingers – including the thumb – flex.

Figure 3
Johann Hoffmann (left), Hans Curschmann, and the method of examination.

The Hoffmann reflex acquired enormous popularity among American neurologists. For the sake of truth, Curschmann did not think it had significance as the “Babinski's upper extremity” sign99. Krouwer HG, Barkhaus PE, Antuono PG. The reflexes of Hoffmann, Trömner, and Mayer In: Koehler PJ., Bruyn GW. Neurological eponims. New York: Oxford University Press; 2000: 127-135.. However, many textbooks and articles have come to consider it as a clear sign of injury to the pyramidal path, “with the same significance as Babinski's sign”88. DeJong RN. The neurologic examination. New York: Harper & Brothers; 1950.

The fingers phenomenon – Gordon's sign

In 1911, Alfred Gordon described “Le phénomène des doigts” (the fingers phenomenon), republished in French the following year1010. Gordon A. Le phénomène des doigts. Rev Neurol (Paris). 1912;20:421-4.. In hemiplegia and monoplegia of cerebral origin, the compression of the radial face of the pisiform bone of the paralyzed segment promoted the extension of the fingers, sometimes in a fan (Figure 4).

Figure 4
Sign of the fingers in patients with pyramidal pathway impairment. Compression of the projection of the radial side of the pisiform bone, avoiding compression of the dorsal side of the hand (A). The fingers extend, sometimes in a fan (B). The sensitivity of the signal increases when the test is repeated several times1010. Gordon A. Le phénomène des doigts. Rev Neurol (Paris). 1912;20:421-4..

According to Gordon, when there is impairment of the pyramidal pathway, this signal has the same connotation as the Babinski sign1010. Gordon A. Le phénomène des doigts. Rev Neurol (Paris). 1912;20:421-4..

Finger flexor phenomenon – the Trömner Sign

In 1912, Ernest Trömner (1868-1930), from Saxony, described a finger reflex which was named the “fingerbeugephänomen” (finger flexor phenomenon) (Figure 5). The patient keeps his fingers semi-flexed, and the examiner “taps” with his own fingers on the volar surface of the patient's middle or index finger. The abnormal reflex is present when all fingers flex, including the thumb. Trömner himself stated that he only elicited this reflex in cases of spastic paralysis of the arm:

“… a pathognomonic finger reflex… a reflex of the arm, analogous to the Babinski, which is as pathognomonic for motor conduction abnormalities above the spinal centers innervating the arm, as the Babinski phenomenon is for the leg…” 11 11. Trömner E. Fingerbeugephänomen. Neurol Centralbl. 1912;31:603.

Figure 5
Ernest Trömner (left), “Fingerbeugephänomen” description, and the method of examination99. Krouwer HG, Barkhaus PE, Antuono PG. The reflexes of Hoffmann, Trömner, and Mayer In: Koehler PJ., Bruyn GW. Neurological eponims. New York: Oxford University Press; 2000: 127-135..

In 1926, Sterling1212. Sterling W. Les phénomènes des doigts analogues aux signes de Babinski et de Rossolimo. Rev Neurol (Paris). 1926;2:82., described a maneuver very similar to that of Trömner in pyramidal lesions, aiming at the same goal.

The upgoing thumb sign – Hachinski sign

In 1992, in a letter addressed to the Editor, Vladimir Hachinski, a neurologist of Ukraine origin, described “the upgoing thumb sign”1414. Hachinski V. The upgoing thumb sign. Arch Neurol. 1992 Apr;49(4):346. https://doi.org/10.1001/archneur.1992.00530280026009
https://doi.org/10.1001/archneur.1992.00...
, considering it to be “Babinski's equivalent of the hand”. In 2017, Hachinski et al. stated:

“… In a considerable proportion of patients with neurologic diseases, the thumb contralateral to the hemisphere or brainstem side involved, showed an upgoing thumb while keeping the palm facing at the level of the shoulder, corresponding to an upgoing toe sign (Babinski sign)1515. Abootalebi S, Azarpazhooh MR, Sposato L, Hachinski V. The upgoing thumb sign: an interobserver/intraobserver reliability study. Neurol Clin Pract. 2017 Dec;7(6):483-7. https://doi.org/10.1212/CPJ.0000000000000398
https://doi.org/10.1212/CPJ.000000000000...
.

Several authors have expressed ambiguity in this respect. Tamm1616. Tamm HS. The upgoing thumb: a sign in search of a name [Letter]. Arch Neurol. 1993;50(3):239. https://doi.org/10.1001/archneur.1993.00540030007004
https://doi.org/10.1001/archneur.1993.00...
, for example, suggested the name: Babinski-Hachinski sign, while Fuller et al.1717. Fuller GN, Blunt SB, Silva MT. Babinski yes, Hachinski no [Letter]. Arch Neurol. 1993 Mar;50(3):239. https://doi.org/10.1001/archneur.1993.00540030007002
https://doi.org/10.1001/archneur.1993.00...
, after evaluating 60 hands of normal individuals (hospital staff), found a positive upgoing thumb in 62% to 88% of the cases. This also generated a letter to the Editor entitled: Babinski Yes, Hachinski No!

DISCUSSION

Since Babinski, the lower extremity has been the most exploited anatomic region for the majority of reflex hunters. Until recently, some predictably directed their efforts toward the upper extremity in search of a reflex analogous to the hallux extension1515. Abootalebi S, Azarpazhooh MR, Sposato L, Hachinski V. The upgoing thumb sign: an interobserver/intraobserver reliability study. Neurol Clin Pract. 2017 Dec;7(6):483-7. https://doi.org/10.1212/CPJ.0000000000000398
https://doi.org/10.1212/CPJ.000000000000...
,1818. Hachinski V, Alsubaie R, Azarpazhooh MR. Upgoing thumb sign: a sensitive indicator of brain involvement? Neurology. 2017 Jul;89(4):370-5. https://doi.org/10.1212/WNL.0000000000004157
https://doi.org/10.1212/WNL.000000000000...
.

The plantar response to plantar stimuli is considered a superficial reflex, like the cremasteric reflex (described by M. Jastrowitz in 1875), and the abdominal reflex (described by Ottomar Rosenbach in 1876), all being affected by an upper motor neuron disorder (not necessarily a lesion). The Babinski sign is only a small fragment of the mass reflex (withdrawal reflex) of the leg, with which the animal reacts to stimuli of many kinds, when the pyramidal tract is impaired. The upgoing toe reflex is regarded anatomically as an extension of the big toe but physiologically it is part of a flexor reflex, apparently disinhibited by loss of upper motor neuron control, and its receptive field may extend, in some instances, to the leg or thigh1919. Lance JW. The Babinski sign. J Neurol Neurosurg Psychiatry. 2002 Oct;73(4):360-2. https://doi.org/10.1136/jnnp.73.4.360
https://doi.org/10.1136/jnnp.73.4.360...
. The abnormal pyramidal tract reflexes in the upper extremities are less constant, more difficult to elicit, and less definitively diagnosed than those found in the lower extremities88. DeJong RN. The neurologic examination. New York: Harper & Brothers; 1950. According to van Gijn2020. Van Gijn J. The Babinski sign: a centenary. Netherlands: Universiteit Utrecht; 1996., two aspects justify the impossibility of obtaining a finger sign like that found in the feet, with respect to impairment of the pyramidal pathway. There is no involuntary action in spinal flexion synergy comparable to the lower limbs, and besides, the thumb is far from being analogous to the big toe!

Acknowledgment:

The authors thank Miss Maria Luísa Corrêa for translating the original German texts.

References

  • 1
    Previsions Meteo-Histoclimat MCS, Milliards de Données -Evénements climatologiques em France depuis 1675: Available from: http://meteo-climat-bzh.dyndns.org/tempsjour-22-2-1896.php [Acces Oct 10, 2017].
    » http://meteo-climat-bzh.dyndns.org/tempsjour-22-2-1896.php
  • 2
    Babinski J. Sur le reflexe cutane plantaire dans certaines affections du systeme nerveux central. C R Seances Soc Biol. 1896.207-208.
  • 3
    Philiippon J, Poirier J. Joseph Babinski: a biography. New York: Oxford University Press; 2009.
  • 4
    Purdy RA. The most important neurologic reflex! Am J Med. 2010 Sep;123(9):793-5. https://doi.org/10.1016/j.amjmed.2010.03.023
    » https://doi.org/10.1016/j.amjmed.2010.03.023
  • 5
    Bekhterev VM. Über den Carpometacarpalreflex. Neurologisches Zentralblatt. 1903;22:195-6.
  • 6
    Bekhterev VM. Über Reflexe distaler Abschnitte der oberen Extremitäten und über ihre diagnostische. Neurologisches Zentralblatt. 1905;24:392-5.
  • 7
    Jacobsohn L. Über den Fingerbeugereflex. Dtsch Med Wochenschr. 1908;34(46):1971-3. https://doi.org/10.1055/s-0028-1135838
    » https://doi.org/10.1055/s-0028-1135838
  • 8
    DeJong RN. The neurologic examination. New York: Harper & Brothers; 1950
  • 9
    Krouwer HG, Barkhaus PE, Antuono PG. The reflexes of Hoffmann, Trömner, and Mayer In: Koehler PJ., Bruyn GW. Neurological eponims. New York: Oxford University Press; 2000: 127-135.
  • 10
    Gordon A. Le phénomène des doigts. Rev Neurol (Paris). 1912;20:421-4.
  • 11
    Trömner E. Fingerbeugephänomen. Neurol Centralbl. 1912;31:603.
  • 12
    Sterling W. Les phénomènes des doigts analogues aux signes de Babinski et de Rossolimo. Rev Neurol (Paris). 1926;2:82.
  • 13
    Wartenberg R. The examination of the reflex: a simplification. Chicago, U.S.A. Year Book; 1945.
  • 14
    Hachinski V. The upgoing thumb sign. Arch Neurol. 1992 Apr;49(4):346. https://doi.org/10.1001/archneur.1992.00530280026009
    » https://doi.org/10.1001/archneur.1992.00530280026009
  • 15
    Abootalebi S, Azarpazhooh MR, Sposato L, Hachinski V. The upgoing thumb sign: an interobserver/intraobserver reliability study. Neurol Clin Pract. 2017 Dec;7(6):483-7. https://doi.org/10.1212/CPJ.0000000000000398
    » https://doi.org/10.1212/CPJ.0000000000000398
  • 16
    Tamm HS. The upgoing thumb: a sign in search of a name [Letter]. Arch Neurol. 1993;50(3):239. https://doi.org/10.1001/archneur.1993.00540030007004
    » https://doi.org/10.1001/archneur.1993.00540030007004
  • 17
    Fuller GN, Blunt SB, Silva MT. Babinski yes, Hachinski no [Letter]. Arch Neurol. 1993 Mar;50(3):239. https://doi.org/10.1001/archneur.1993.00540030007002
    » https://doi.org/10.1001/archneur.1993.00540030007002
  • 18
    Hachinski V, Alsubaie R, Azarpazhooh MR. Upgoing thumb sign: a sensitive indicator of brain involvement? Neurology. 2017 Jul;89(4):370-5. https://doi.org/10.1212/WNL.0000000000004157
    » https://doi.org/10.1212/WNL.0000000000004157
  • 19
    Lance JW. The Babinski sign. J Neurol Neurosurg Psychiatry. 2002 Oct;73(4):360-2. https://doi.org/10.1136/jnnp.73.4.360
    » https://doi.org/10.1136/jnnp.73.4.360
  • 20
    Van Gijn J. The Babinski sign: a centenary. Netherlands: Universiteit Utrecht; 1996.

Publication Dates

  • Publication in this collection
    Oct 2018

History

  • Received
    10 Jan 2018
  • Reviewed
    15 May 2018
  • Accepted
    11 July 2018
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