Continuing Education Activity

Gordon reflex, also called the paradoxical flexor reflex, is a clinical sign to detect upper motor neuron lesions. Evaluation of this reflex is simple and rapid and requires no equipment. A positive Gordon reflex suggests an upper motor neuron lesion, denoted by an extensor plantar response that occurs when the calf is squeezed. A positive Gordon test can appear similar to a Babinski sign in an adult, and both procedures evaluate for upper motor neuron lesions. This activity describes the technique involved in evaluating the Gordon reflex and highlights the interprofessional team's role in diagnosing and caring for patients with upper motor neuron lesions.

Objectives:

• Identify the technique involved in evaluating the Gordon reflex.

• Assess the indications for evaluating the Gordon reflex.

• Evaluate a positive Gordon reflex and its clinical significance.

• Communicate interprofessional team strategies for enhancing care coordination to advance the evaluation of upper motor neuron lesions by using the Gordon reflex.

Introduction

The Gordon reflex was also called the “paradoxical flexor reflex” when Dr. Alfred Gordon first demonstrated the reflex in 1904 at the Philadelphia Neurological Society. The reflex is a clinical sign that can be easily elicited without equipment. The Gordon reflex describes an extensor plantar response when the calf muscle is squeezed. The Gordon reflex is very simple to complete and can be useful in determining lesion localization. The clinical sign is used to determine whether a pyramidal tract lesion exists. The Gordon reflex is closely associated with the Babinski, Chaddock, and Oppenheim reflexes.[1][2] The Gordon reflex can be used when a patient is uncooperative when eliciting the Babinski reflex or when patients have sensitive soles.

Anatomy and Physiology

The Gordon reflex is elicited by squeezing the calf muscle. The calf comprises the gastrocnemius and soleus muscles, which come together to form the Achilles tendon. Both muscles aid in the plantarflexing of the foot at the ankle. The typical plantar response reflex involves all muscles that shorten the leg, including the gastrocnemius and soleus.[3] A segmental reflex that involves all the leg and foot flexor muscles results in the toes going down during the plantar reflex.[3] When there is a lesion in the pyramidal system, the segmental downward response disappears, and the flexion synergy can become disinhibited to where the extensor hallucis longus muscle is recruited into the flexion response of the leg.[3] This leads to an upgoing toe with the Gordon, Babinski, Chaddock, and Oppenheim reflexes.[1]

Indications

The Gordon reflex can be used as an adjunct to the complete neurologic exam. It is particularly beneficial in the diagnosis of pyramidal tract lesions.[2] The test can be done along with the Babinski reflex but is extremely useful in cases where the Babinski reflex cannot be completed due to the poor cooperation of the patient or in an equivocal response.[1] The Babinski reflex is uncomfortable and somewhat painful to patients with sensitive soles or feet, and often, these patients withdraw to the stimulation of the Babinski. The Gordon reflex is an alternative because patients are typically less sensitive to calf manipulation or pain.

Contraindications

Some contraindications for performing the Gordon reflex include the presence of an open wound on the calf or in the area, a recent deep vein thrombosis, or very swollen and painful calves, which can be seen with a variety of different conditions, including congestive heart failure exacerbation. Caution should also be taken if patients have a very low platelet count, as the reflex test involves the tight squeezing of the calf muscles, potentially leading to injury and bleeding in the muscle.

Equipment

No equipment is needed to perform the Gordon reflex test. However, an area should be provided where the patient can comfortably lie supine with both legs extended while the test is performed.

Personnel

Anyone properly trained to complete the Gordon reflex can perform the test. Physicians, medical students, physician assistants, medical assistants, and nurses are a few medical staff capable of performing the test. An inexperienced medical staff member should first observe an experienced practitioner complete the reflex or view an online video of the proper technique of the Gordon reflex before attempting to perform it solo. Practice and experience increase the likelihood of accurately eliciting and recognizing the response.

Preparation

Minimal preparation is needed to complete the Gordon reflex. The patient should be relaxed and supine with both legs extended on an examination table.[3] The patient should be in a hospital gown without other clothing or shoes, as the legs must be visible and exposed from the knee down through the foot. The practitioner should wash or sanitize his or her hands before performing the test. The examiner can sit or stand next to the patient in a comfortable position with the ability to reach the calf while observing the response in the toes.

Technique or Treatment

The Gordon reflex is best completed when the patient is lying supine with legs extended, as noted above. The patient needs to be relaxed without the contraction of the leg muscles.[3] The practitioner places his or her hand on the calf muscle underneath the patient’s leg, then lifts and supports the leg with the other hand at the ankle area. The practitioner then tightly squeezes the calf muscle while monitoring the ipsilateral toes. The Gordon reflex is positive (or abnormal) if there is an extensor plantar reflex or extension of the big toe with fanning of the other toes.[3] A negative (or normal) Gordon reflex is no response in the toes with squeezing of the ipsilateral calf muscle. The reflex can be completed as often as needed to evaluate the toe response. As noted above, the Babinski, Chaddock, and Oppenheim reflex can also be completed as an adjunct to confirm the extensor plantar response.[2]

Complications

Although complications from performing the Gordon reflex test are rare, the squeezing of the calf muscle may cause bruising, pain, or soreness after the test.

Clinical Significance

The Gordon reflex can be clinically significant when assessing various diseases and neurological deficits. A positive or abnormal response correlates with a lesion in the pyramidal tract, an upper motor neuron sign that can help shape a differential diagnosis.[1] Diseases that can cause pyramidal tract lesions or damage to the corticospinal tract include strokes, multiple sclerosis, amyotrophic lateral sclerosis, encephalitis, and brain or spinal cord tumors, to name a few. A broad differential comes along with upper motor neuron lesions. Gordon first demonstrated the reflex in a patient with hemorrhagic pachymeningitis and later in a patient with epilepsy shortly after generalized convulsions. Gordon believed that the reflex was a sign of cerebral irritation or a beginning lesion of the motor pathway. At the same time, he thought that the Babinski reflex was a sign of a well-established lesion of the motor pathway. One double-blind study examining the consistency of the Babinski reflex and its variants, including the Gordon reflex, examined both inter-observer consistency and intra-observer consistency of the reflex variants.[1] The Gordon reflex was given a fair rating for inter-observer consistency with a kappa of 0.3515 (95% CI = 0.255-0.448) and the highest intra-observer consistency with a kappa of 0.6731.[1] Therefore, the Gordon reflex is a good adjunct to the Babinski reflex and should be used, especially when a practitioner cannot elicit a Babinski reflex or gets an equivocal result.

Enhancing Healthcare Team Outcomes

Anyone properly trained to complete the Gordon reflex can perform the test. Clinicians, medical students, physician assistants, medical assistants, and nurses are a few medical staff capable of performing the test. An inexperienced medical staff member should first observe an experienced practitioner complete the reflex or view an online video of the proper technique of the Gordon reflex before attempting to perform it solo. Practice and experience increase the likelihood of accurately eliciting and recognizing the response. However, relying on the Gordon reflex is not recommended when one suspects an upper motor neuron lesion. No randomized studies have determined its clinical validity. Like most other reflexes, the Gordon reflex has appeared in textbooks, but its true value in neurology remains debatable.[4][1][5]