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Table of Contents    
ORIGINAL ARTICLE
Year : 2022  |  Volume : 70  |  Issue : 8  |  Page : 259-262

Quantifying Neurological Examination in 21st Century: Yilmaz- Ilbay Plantar Flexion Test, A Novel and Reliable Test for Evaluation of Plantar Flexion in L5-S1 Disc Herniation


1 Department of Neurosurgery, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
2 Department of Physiology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
3 Department of Biochemistry, Faculty of Medicine, Katip Celebi University, Izmir, Turkey, Turke
4 Department of Neurosurgery, Faculty of Medicine, Bahcesehir University, Istanbul, Turkey
5 Department of Neurosurgery, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey

Date of Submission25-Feb-2022
Date of Decision03-Aug-2022
Date of Acceptance08-Aug-2022
Date of Web Publication11-Nov-2022

Correspondence Address:
Murat Yilmaz
Department of Neurosurgery, Faculty of Medicine, Dokuz Eylul University, 15 Temmuz Saglik Ve Sanat Yerleskesi, Inciraltı, 35340 Izmir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.360913

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 » Abstract 


Background: Current methods used to measure the muscle strength required to achieve plantar flexion may yield highly variable results depending on the perception of the physician conducting the examination because these tests involve subjective and qualitative evaluation.
Objective: To describe and evaluate the efficacy of a novel examination technique that can quantitatively measure plantar flexion in L5–S1 disc herniation.
Materials and Methods: A total of 32 patients (average age: 49.4 years, range: 23–78) with L5–S1 disc herniations were included. The patient to be tested stood next to a table on which they could lean with their hands. The leg closer to the table was fully flexed at the knee, and the other foot was brought to maximum plantar flexion on the toes. At this point, a stopwatch was started to measure the time that passed until the muscles fatigued and the heel fell. The differences between the right and left plantar flexion times were noted. In addition, three different physicians graded muscle strength by using the classical “The Medical Research Council of the United Kingdom” method.
Results: The time until fatigue in right and left plantar flexion was measured using the proposed method, and each test underwent a video recording. The Yilmaz–Ilbay plantar flexion test yielded the correct classification for all cases.
Conclusion: We suggest that the proposed method “Yilmaz–Ilbay plantar flexion test” can serve as a useful, practical, and effective test to detect quantitative evaluation of plantar flexion in L5–S1 herniation.


Keywords: Grading, muscle strength, neurologic examination, plantar flexion, quantitative
Key Message: Grading of plantar flexion, an important parameter in clinical practice, may vary widely per the examiner. Herein, we describe a novel method for quantitative evaluation of plantar flexion in L5–S1 disc herniation.


How to cite this article:
Yilmaz M, Ilbay G, Yilmaz HE, Ertem O, Erbayraktar S, Ilbay KM. Quantifying Neurological Examination in 21st Century: Yilmaz- Ilbay Plantar Flexion Test, A Novel and Reliable Test for Evaluation of Plantar Flexion in L5-S1 Disc Herniation. Neurol India 2022;70, Suppl S2:259-62

How to cite this URL:
Yilmaz M, Ilbay G, Yilmaz HE, Ertem O, Erbayraktar S, Ilbay KM. Quantifying Neurological Examination in 21st Century: Yilmaz- Ilbay Plantar Flexion Test, A Novel and Reliable Test for Evaluation of Plantar Flexion in L5-S1 Disc Herniation. Neurol India [serial online] 2022 [cited 2022 Dec 3];70, Suppl S2:259-62. Available from: https://www.neurologyindia.com/text.asp?2022/70/8/259/360913




From comparing patients' preoperative to postoperative changes to quantifying the amount of disability of a person, measuring the muscle strength in a neurologic examination is required for a variety of reasons. To this end, distal strength can be measured semiquantitatively by using a handheld ergometer or using an inflated blood pressure cuff gripped by the patient. Furthermore, muscle strength and disability can be assessed using different moves and the number of moves a patient can perform (e.g., number of squats done or steps climbed); for example, getting up from a squatting position or stepping on chair tests proximal leg strength; walking on heels and toes tests distal strength. However, a more impartial method is required for both clinical excellence and medicolegal reasons.

The muscle strength scale, originally developed by The Medical Research Council of the United Kingdom, is now used universally [Table 1].[1] It is used for evaluating the strength of the muscles performing plantar flexion as a standard. However, because this examination technique is a subjective and qualitative evaluation, the results may vary according to the perception of the clinician performing the examination.[10] Measuring plantar flexion by using the proposed method provides quantitative results.
Table 1: Grading muscle tone and strength (The Medical Research Council of the United Kingdom strength examination scale)

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Muscles involved in plantar flexion are Musculus (M) gastrocnemius and M. soleus. Some anatomists consider both to be a single muscle: the triceps surae. M. triceps surae is innervated from the Nervus tibialis. In L5–S1 disc hernias, there may be varying degrees of strength loss in the M. triceps surae. In addition, there are auxiliary muscles such as M. tibialis posterior, M. peroneus longus and brevis, M. flexor hallucis longus, M. flexor digitorum longus, and M. plantaris that support plantar flexion. While performing this test, it should be kept in mind that when the patient's knee is in full extension, the M. gastrocnemius muscle participates in the movement dominantly, and when the knee is in slight flexion, the M. soleus muscle participates in the movement dominantly.

In the current study, we aimed to evaluate a new examination technique that can quantitatively measure plantar flexion in L5–S1 disc herniation by using a novel procedure and to share our experience of using this method with a brief review of the literature.


 » Materials and Methods Top


This prospective study has been performed per the principles of the Helsinki Declaration after approval from the local institutional review board (2021/19-44) and informed consent from all patients or relevant persons for publication were obtained. Subjects were 32 patients presenting with L5–S1 disk herniation during 2020–2021. Eighteen had left-sided herniations, whereas 14 had right-sided herniations. Twenty patients were male, and 12 were female. The patient to be tested stood next to a table on which they could support themselves using their hands. The leg closer to the table was fully flexed at the knee, and the other foot was brought to maximum plantar flexion or colloquially. The patient was instructed to stand on one leg and raise to tip-toes. Starting from this moment, the time was measured using a stopwatch [Figures [Videos 1 and 2] until the heel yielded to gravity and was level with the toes. During the application of the test, the differences between the right and left plantar flexion times were noted. Three different physicians graded muscle strength by using the classical “The Medical Research Council of the United Kingdom” method. All findings were recorded.

The examination results of three different physicians varied in many patients. Patients without deficits in classical examination and quantitative measurement were not included in the study.

Statistical analysis

SPSS 19.0 was used for all statistical analyses. Descriptive statistics of continuous variables are given with mean, standard deviation, median, and minimum and maximum values and as frequency and percent for categorical variables. The Shapiro–Wilk test was used as a test of normality. The independent sample t test was used for two independent group comparisons of normal distributed variables, and the Mann–Whitney U test was used for non-normal distributed variables. Similarly, paired sample t test was used for two dependent group comparisons of normal distributed variables, and the Wilcoxon test was used for non-normal distributed variables. For all statistical comparisons, P < 0.05 was assumed to indicate statistical significance.


 » Results Top


Yilmaz–Ilbay plantar flexion test yielded the correct classification for all 32 cases. The baseline descriptives and clinical data in our series are displayed in [Table 2]. Our population consisted of 20 men and 12 women with a mean age of 49.4 years (range: 23–78). All patients presented with L5–S1 disk herniation.
Table 2: Comparative overview of the evaluation of patients in whom plantar flexion was tested quantitatively

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In all patients, the time of standing in right and left plantar flexion was measured using the method we have described, and camera images were taken after obtaining permission from the patients. Data gathered from a total of 32 patients were analyzed.

In 27 cases (84.37%), there was a difference of more than 25 s between the right and left plantar flexion tests. The average duration of differences between right and left plantar flexion was statistically significant (20–102, P < 0.001).


 » Discussion Top


The purpose of this test was to quantitatively evaluate the loss of strength in L5–S1 unilateral discal hernias. In L5–S1 disc hernias, plantar flexion examination should be done in detail.[11],[12] Examination results obtained using the existing technique are highly subjective and qualitative. With the novel examination method we have developed (Yilmaz–Ilbay plantar flexion test), the strength loss in plantar flexion can be measured exactly and quantitatively in patients with L5–S1 discal hernia.

Is neurological examination important?

No matter how technology advances, it is essential to take a proper history and perform a detailed examination in diagnosing a patient.[13] A neurologic examination (NE) consists of identified steps including inspections, history, and maneuvers. The stages of the NE test the circuits that mediate the patient's mental, motor, and sensory functions and detect changes in the patient's body configuration and measurements. Considering the circuitry of the central nervous system provides an important feature to neuroscientists.[14],[15]

Babinski sign was described in 1899 by neurologist Joseph Babinski. Since then, it has been a sine qua non of the standard neurological examination and is easy to implement without complicated equipment.[4]

Today, it is a proven fact that the Babinski sign is an indicator of dysfunction of the fibers in the pyramidal system. It is surprising even today that the Babinski sign, which is an objective clinical sign that cannot be mimicked by the patient consciously or unconsciously, is a reliable finding for such precise localization of central nervous system dysfunction.[5],[6]

The abductor sign is a perfect test to detect non-organic paresis because it is impossible for a hysterical patient to deceive the examiner.[7]

A test called the “Barré test” is routinely used in clinical practice to find subtle hemiparesis in the arms and legs.[8]

Similarly, Mingazzini's arm and leg tests were described by Giovanni Mingazzini in 1937 and are still used as an invaluable method in neurological examination.[8]

Although examination styles vary over time all over the world, specific examinations for the patient's symptoms and signs are important.[9]

As the examination methods developed a hundred years ago are still used today and provide benefits in the diagnosis and treatment of patients, the quantitative measurement of plantar flexion will make an important contribution to the diagnostic methods.

The most important limitation of the test is that it is not possible to quantitatively evaluate patients with a strength loss of more than 3/5 on one side, that is, those who cannot overcome gravity. Small sample size, single-center design, the presence of radiculopathy that may interfere with quantification of power in the affected limb, and subjectivity of the pain threshold constitute the other restrictions.


 » Conclusion Top


We suggest our novel method “Yilmaz–Ilbay plantar flexion test” is a useful, practical, and effective test for detecting quantitative and exact evaluation of strength loss in plantar flexion in patients with L5–S1 discal herniation. Further trials are warranted to evaluate the efficacy of this method to overcome the test problems associated with the measurement of loss of strength in plantar flexion.

Statement of ethics

This study has been performed in accordance with the guidelines declared by the World Medical Association Declaration of Helsinki. The approval of the local institutional review board had been obtained before the study (2021/19-44).

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Naqvi U, Sherman Al. Muscle strength grading. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436008/. [Last accessed on 2021 Sep 02].  Back to cited text no. 1
    
2.
Bindoff L. Future of neurologic examination in clinical practice. JAMA Neurol 2018;75:382.  Back to cited text no. 2
    
3.
DeMyer W. Pointers and pitfalls in the neurologic examination. Semin Neurol 1998;18:161-8.  Back to cited text no. 3
    
4.
Acharya AB, Jamil RT, Dewey JJ. Babinski reflex. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519009/. [Last accessed on 2022 May 04].  Back to cited text no. 4
    
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Rehman HU. Babinski sign. Neurologist 2002;8:316-8.  Back to cited text no. 5
    
6.
Drouin E, Drouin G, Péréon Y. The Babinski sign. Lancet Neurol 2017;16:180.  Back to cited text no. 6
    
7.
Sonoo M. Abductor sign: A reliable new sign to detect unilateral non-organic paresis of the lower limb. J Neurol Neurosurg Psychiatry 2004;75:121-5.  Back to cited text no. 7
    
8.
Hirose G. [The Barrés test and Mingazzini test -Importance of the original paper by Giovanni Mingazzini]. Rinsho Shinkeigaku 2015;55:455-8. Japanese.  Back to cited text no. 8
    
9.
Saper CB. Is it time to reconsider the classic neurological examination? Ann Neurol 2018;84:483-4.  Back to cited text no. 9
    
10.
Ravikanth R. Magnetic Resonance Evaluation of Lumbar Disc Degenerative Disease as an Implication of Low Back Pain: A Prospective Analysis. Neurol India 2020;68:1378-84.  Back to cited text no. 10
    
11.
Sencan S, Celenlioglu AE, Yazici G, Gunduz OH. Transforaminal Epidural Steroid Injection Improves Neuropathic Pain in Lumbar Radiculopathy: A Prospective, Clinical Study. Neurol India 2021;69:910-5.  Back to cited text no. 11
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Kandregula S, Guthikonda B. Minimally Invasive TLIF. Neurol India 2021;69:1141.  Back to cited text no. 12
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Kim HS, Wu PH, Raorane HD, Jang IT. Generation Change of Practice in Spinal Surgery: Can Endoscopic Spine Surgery Expand its Indications to Fill in the Role of Conventional Open Spine Surgery in Most of Degenerative Spinal Diseases and Disc Herniations: A Study of 616 Spinal Cases 3 Years. Neurol India 2020;68:1157-65.  Back to cited text no. 13
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Grasso G, Paolini S, Sallì M, Torregrossa F. Lumbar Spinal Fixation Removal by a Minimal Invasive Microscope-Assisted Technique. Case Report with Technical Description. Neurol India 2020;68:1211-3.  Back to cited text no. 14
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Yerramneni VK, Kanala RR, Kolpakawar S, Yerragunta T. MITLIF Operative Nuances- Step by Step. Neurol India 2021;69:1196-9.  Back to cited text no. 15
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