Continuing Education Activity

Gordon reflex, also called the paradoxical flexor reflex, is a clinical sign utilized to detect upper motor neuron lesions. Evaluation of this reflex is simple and rapid and does not require the use of any 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 the diagnosis and care of patients with upper motor neuron lesions.

Objectives:

• Describe the technique involved in evaluating the Gordon reflex.
• Outline the indications for evaluating for the Gordon reflex.
• Summarize a positive Gordon reflex and its clinical significance.
• Explain interprofessional team strategies for enhancing care coordination and communication to advance the evaluation for 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 the use of any 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 of use in determining lesion localization. The clinical sign is used to determine whether a lesion of the pyramidal tract 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 patients with very sensitive soles.

Anatomy and Physiology

The Gordon reflex is elicited by squeezing the calf muscle. The calf is mainly made up of 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 who have sensitive soles or feet, and many times these patients will withdraw to the stimulation of the Babinski. The Gordon reflex is an alternative in these cases because patients are typically not as 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, there should be an area where the patient can comfortably lay back in a supine position with both legs extended while the test is performed.

Personnel

Anyone who has been 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, lying in the supine position with both legs extended on an examination table.[3] The patient should be in a hospital gown without other articles of clothing or shoes as the legs need to 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 be sitting or standing 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 with the patient lying in the supine position 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 many times as needed to evaluate the toe response. As noted above, the Babinski reflex, Chaddock reflex, and Oppenheim reflex also can be completed as an adjunct to confirm the extensor plantar response.[2]

Complications

Complications from performing the Gordon reflex test are rare. There may be bruising, pain, or soreness after the test due to the squeezing of the calf muscle.

Clinical Significance

The Gordon reflex can be of clinical significance when assessing for various diseases and neurological deficits. A positive or abnormal response correlates with a lesion in the pyramidal tract, which is 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, while he thought that the Babinski reflex was a sign of a well-established lesion of the motor pathway. One double-blind study that looked at 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 is unable to elicit a Babinski reflex or gets an equivocal result.

Enhancing Healthcare Team Outcomes

Anyone who has been properly trained to complete the Gordon reflex can perform the test. Clinicians (including PA and NPs), 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,  when one suspects an upper motor neuron lesion, reliance on just the Gordon reflex is not recommended. There are no randomized studies that 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]