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Should the Babinski sign be part of the routine neurologic examination?
From latest Neurology:
Quote:
Background: The Babinski sign is a well-known sign of upper motor neuron dysfunction that is widely considered an essential element of a complete neurologic examination. Little is known about reliability and validity of this sign. A less well-known sign of upper motor neuron dysfunction, decreased speed of foot tapping, also has not been carefully evaluated. Scientific evaluation of findings of the physical examination is crucial in directing busy clinicians.
Methods: Ten physicians (five neurologists and five non-specialists) examined each foot of 10 subjects, 8 of whom had known unilateral upper motor neuron weakness, 1 had bilateral leg weakness secondary to ALS, and 1 had no known neurologic deficits. Our main outcome measures were inter-rater reliability (kappa values) and accuracy (agreement with known upper motor neuron weakness).
Results: The reliability of the Babinski sign was fair (kappa 0.30) and was substantial for foot tapping (kappa 0.73). Agreement with known weakness was 56% for Babinski sign and 85% for foot tapping. Reliability and accuracy for both tests were similar for neurologists and non-specialists.
Conclusions: The interobserver reliability and validity of the Babinski sign for identifying upper motor neuron weakness are limited. Slowness of foot tapping may be a more useful sign.
seems to a relative ability between limbs (eg. between able limb and paretic limb) in unilateral UMND (CVA) or generalised inability/slowness in bilateral UMND's (spinal lesion)...............see video (need RealPlayer) of foot tapping test http://www.neuroexam.com/content.php?p=28.........
in the Neurology article quoted, the authors report, "We found the Babinski sign was unreliable and a poor predictor of the presence of upper motor neuron weakness. Physicians often found it in unaffected limbs and failed to find it in affected limbs, and their confidence in the assessment did not predict accuracy." The Babinski sign correlated with known weakness in 56% of evaluations, with a sensitivity of 35% and specificity of 77%. Physician-rated level of confidence in the results of Babinski testing was not associated with whether results agreed with presence of upper motor neurone weakness.
In contrast to the findings with the Babinski sign, slowness of foot tapping correctly predicted upper motor neuron weakness in 85% of evaluations; the test's sensitivity was found to be 86% and specificity was 84%.
There were no significant differences in the sensitivity and specificity of testing between neurologists and non-neurologists for either test. The authors note, "The fact that these two groups performed nearly identically suggests that the poor performance of the Babinski sign is not related to physician skill or training, but rather to the sign itself." They add that the level of inaccuracy was similar for all physicians, so none used a specific technique that worked well.
The authors say that, although the Babinski sign is likely to continue to be useful in some cases, such as in uncooperative or comatose patients, physicians and neurologists should focus on other tests, including speed of foot tapping, for routine neurologic."
paul, had trouble finding that reference (in relevant article) myself, so googled it (if i had more time i'd database search it, but the union is about to start!)...found a few sites .................................................. .........if that surname of yours bothers you mate, drop a few of those n's and e's...............c-o-n-l-e-y.........much simpler.......................(note admin 965..........getting worried?)
Babinski sign is only present when there is a cerebral lack of supression to the spinal reflex.
When born the toes go up due to the lack of an appropriate supression signal from the brain.
About 1 years of age the appropriate signal is issued and this lasts for life except when it is lost classically in a stroke.
The point is that it is always there.
On the other hand foot tapping is not.
One thing that worries me is how can the null hypothesis be true if the Null- hypothesis-examiners set the question (hypothesis) when most likely they have the same training and thus ability to set the hypothesis in the first place.
10 examiners is a very small group and I doubt that you can do a valid Kappa score. A kappa of less than .6 is regarded as lousy in some books while others take 0.4 or better as good.
I would like to see how they derived these figures in such a small sample. Methinks they needed Fishers test along with a 2level T test.
The dodgy brothers are at it again
As the chant goes, '' give us 2n's, give us 2e's ..... what have we got...
Re: Should the Babinski sign be part of the routine neurologic examination?
Dear Members,
Please find below a recently published article on the Babinski reflex I stumbled across this morning while wading through Medline on an un-related task. I have also attached a copy in PDF.
The study below compared the great toe reflex as elicited by the Babinski technique, in comparison to the same reflex as elicited by 3 alternative techniques: the Gordon, Chaddock and Oppenheim techniques. I have included below an excerpt from the full-text that describes these techniques, for those such as myself that may not be familiar with them.
Interestingly, the article posted at the top of this thread found a kappa coefficient value of 0.30 for the babinski reflex, indicating fair agreement between 5 neurologists and 5 non-specialist physicians (GP’s ?). The raters for the study below were all neurologists, and perhaps not surprisingly, they found a slightly higher kappa value of 0.54, indicating moderate inter-rater agreement. Of all 4 techniques, the Babinski was found to have the greatest inter-observer consistency:
Quote:
Babinski noted that this sign was best elicited with a firm stroke on the lateral sole [2], and more refined descriptions of the response included the fanning of the toes as an adjunct to the extension of the great toe [3].
In 1904, Alfred Gordon, an American neurologist, described a similar response by firmly pressing the middle or lower portion of the calf muscles in patients with known pyramidal tract lesions, producing an extensor response even in situations when the Babinski reflex was absent [5].
Chaddock, who had worked under Babinski in France from 1897–1899, published his own version of the famous sign in 1911, in which the external inframalleolar skin, rather than the sole of the foot, was stroked [6–8].
Just as Babinski was the neurological prodigy of France, so was Hermann Oppenheim in Germany. Oppenheim had described a version of the great toe reflex himself, in which the extension of the great toe could be elicited by firmly stroking the medial tibia [9].
Quote:
Consistency of the Babinski reflex and its variants
J. Singerman and L. Lee
Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
European Journal of Neurology 2008, 15: 960–964
Background and purpose: The Babinski Reflex, first described in 1896, is still an integral part of the neurological examination. Many have studied the consistency of this reflex, but none have compared the inter- and intra-observer consistency of the Babinski reflex and its variants.
Methods: Thirty-four subjects were examined by six neurologists. The Babinski, Gordon, Chaddock, and Oppenheim reflexes were tested, and each neurologist concluded if the plantar response was flexor or extensor. Six subjects were re-tested 1 week later to determine intra-observer consistency.
Results: The Babinski reflex had the highest interobserver consistency with a kappa value of 0.5491. The Chaddock, Oppenheim, and Gordon reflexes had kappa values of 0.4065, 0.3739, and 0.3515, respectively. For intra-observer consistency, Gordon was the most consistent with a kappa value of 0.6731. When reflexes were combined in pairs, the Babinski and Chaddock reflexes together were the most reliable.
Conclusions: The Babinski reflex was shown to be the most consistent between examiners. The Gordon reflex had the highest intra-observer consistency; however, the small sample size should limit conclusions drawn from this calculation. Clinicians often utilize more than one reflex to examine the plantar response; the combination of the Babinski and Chaddock reflexes was the most reliable.
Re: Should the Babinski sign be part of the routine neurologic examination?
Babinski reflex is only one of the tests and gives the professional an indication of how the secondary responses over ride the primary responses, those that we are born with. It can diferentiate between upper and lower motor neuron issues and I have used this to identify underlying CP issues that may have slipped through the Pediatric hospital system.
Alex Adam
Should the Babinski sign be part of the routine neurologic examination?
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