What are Primitive Reflexes? Correlations to Theories ... · reflexes – Moro, Landau, STNR EFFECTS OF NON-INTEGRATION Poor posture Low muscle tone Poor ocular motor control Poor

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Session 305: Primitive Reflex Integration: Disassociating the Head from the BodyJanine Wiskind, MS, OTR/L

Leading the Way in Continuing Education and Professional Development. www.Vyne.com

What are Primitive Reflexes? Correlations to Theories?

Research?

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NEUROPLASTICITY

■ Neural connections are either made or dissolved depending on the stimulation received

■ Hebb’s Axiom – what wires together fires together

■ Dr. Norman Doidge

■ Dr. Michael Merzenich

■ Dr. Paul Bach y Rita – activity dependent neuroplasticity

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ACTIVITY-DEPENDENT PLASTICITY

■ During engagement in activity,

■ signaling molecules (ex: dopamine, glutamate)

■ facilitate synapsing (excitatory or inhibitory)

■ which alters gene expression and allows the brain to rewire itself.

NEURO - PLASTICITY AND THERAPY

■ Analyze movement to determine foundational skill levels

■ Engage in movement to achieve activity dependent plasticity

■ Activity dependent plasticity maximizes a child’s potential in function and activities of daily living

THEORETICAL FRAMEWORKS SUPPORTING PRIMITIVE REFLEX

INTEGRATION THEORY

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THEORIES

■ Rood Approach

■ NDT/Bobath: Neuro-Developmental Treatment/Bobath

■ PNF: Proprioceptive Neuromuscular Facilitation

■ Brunnstrom Approach

ROOD APPROACH

■ Theoretically based on the Reflex and Hierarchical Model of Motor Control and provides the origins for many of the facilitation techniques used today

■ Focuses on sensory stimulation and ontogenetic motor development (normal progression of motor skills along the developmental continuum)

■ Cutaneous stimulation – light touch, brushing

■ Proprioceptive stimulation – heavy joint compression, quick stretch, tapping, vestibular stimulation, vibration, neutral warmth, light joint compression

■ Reflexes are used to influence muscle tone and facilitate typical movement patterns

NDT/BOBATH■ “NDT is a holistic and interdisciplinary clinical practice

model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. An in-depth knowledge of the human movement system, including the understanding of typical and atypical development, and expertise in analyzing postural control, movement, activity, and participation throughout the lifespan, form the basis for examination, evaluation, and intervention. Therapeutic handling, used during evaluation and intervention, consists of a dynamic reciprocal interaction between the client and therapist for activating optimal sensorimotor processing, task performance, and skill acquisition to enable participation in meaningful activities.”

Instructors Group of NDTA. (2016, May 27). The NDT/Bobath (Neuro-Developmental Treatment/Bobath) Definition. Retrieved from http://www.ndta.org/whatisndt.php

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NDT/BOBATH

■ Re-learning normal movement patterns with a focus on the quality of movement

■ Focuses on alignment and symmetry

■ Focuses on mastering forward flexion with rotation in order to break up extensor tonal patterns

■ Focuses on weight shift using our own natural body forces

■ Every point of mobility has a point of stability

PNF

■ Focuses on movement patterns that are diagonal and resemble typical movement

■ Focuses on the developing sequence of movement and how the agonist and antagonist muscles work together to produce volitional movement

■ Uses reflexive movement as a basis for learning more volitional movement following the theory that a child must be able to roll before he can crawl and crawl before he walks

■ Uses a multi-sensory approach incorporating tactile, auditory, and visual systems.

BRUNNSTROM APPROACH■ The basic premise is that in typical development,

spinal cord and brain stem reflexes become modified during development, and their components are rearranged into purposeful movement by the influence of higher centers. Since reflexes represent normal stages of development, they can be used when the central nervous system has reverted to an earlier developmental stage

■ Reflexes should be used to elicit movement when none exists (normal developmental sequence)

■ Proprioceptive and exteroceptive stimuli can be used therapeutically to evoke desire motion or tonal change.

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EVIDENCE-BASED RESEARCHDo we have it?

■ A.N. Bhat, J.C. Galloway, R. Landa. Relation between early motor delay and later communication delay in infants at risk for autism. Infant Behavior and Development, 35 (2012), pp. 838-846

■ S.S. Fong, W.W. Tsang, G.Y. Ng. Altered postural control strategies and sensory organization in children with developmental coordination disorder. Human Movement Science, 31 (5) (2012), pp. 1317-1327

■ G. Esposito, S.P. Pasca. Motor abnormalities as a putative endophenotype for autism spectrum disorders Frontiers in Integrative Neuroscience, 7 (43) (2013), pp. 1-5

■ S. Goddard Blythe. Neuro-motor maturity as an indicator of developmental readiness for education TAC Journal, 4 (2011), p. 12

■ L.R. Nickel, A.R. Thatcher, F. Keller, R.H. Wozniak, J.M. Iverson. Posture development in infants at heightened versus low risk for

autism spectrum disorders Infancy, 18 (5) (2013), pp. 639-661

■ Gordon MB. The Moro embrace reflex in infancy; its incidence and significance. AMA J Dis Child 1929; 38: 26–34.

■ Harmon H, Taylor HG, Minich N, Wilson-Costello D, Hack M. Early school outcomes for extremely preterm infants with transient neurological abnormalities. Dev Med Child Neurology 2015; doi: 10.1111/dmcn.12811.

■ Bracewell M, Marlow N. Patterns of motor disability in very preterm children. MentRetard Dev Disabil Res Rev 2002; 8: 241–8

■ Chinello, A., Di Gangi, V., & Valenza, E. (2016). Persistent primary reflexes affect motor acts. Potential implications for autism spectrum disorder. Research in Developmental Disabilities, doi: 10.1016/j.ridd. 2016.07.010

■ M. McPhillips, N. Sheehy. Prevalence of persistent primary reflexes and motor problems in children with reading difficulties.

Dyslexia, 10 (4) (2004), pp. 316-338

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■ Flanagan JE, Landa R, Bhat A, Bauman M. Head lag in infants at risk for autism: a preliminary study. Am J Occup Ther 2012; 66: 577–85.

■ Romeo DM, Ricci D, Baranello G, et al. The forward parachute reaction and independent walking in infants with brain lesions. Dev Med Child Neurol 2011; 53: 636–40

■ Leroux BG, N'guyen The Tich S, Branger B, et al. Neurological assessment of preterm infants for predicting neuromotor status at 2 years: results from the LIFT cohort. BMJ Open 2013; 3: e002431.

■ Hielkema T, Hamer EG, Reinders-Messelink HA, et al. LEARN 2 MOVE 0–2 years: effects of a new intervention program in infants at very high risk for cerebral palsy; a randomized controlled trial. BMC Pediatr 2010; 10: 76.

■ COPCA and TIP family training program focusing on NDT principles

Sulltante, B., Gjipali, A., & Shkurti, F. (2017). Measuring Primitive Reflexes in Children with Learning Disorders . European Journal of Multidisciplinary Studies,5(1), 285-298. Retrieved September 1, 2017, from http://journals.euser.org/files/articles/ejms_may_aug_17/Sulltane.pdf

■ Provides history of research on primitive reflexes

■ “In 64% of cases it is noticed that children overwhelm to unexpected noises, this opens up the opportunity for the primitive retained reflex, Moro.”

■ “In 64% of cases, mothers noted that the child holds a pencil in a strange manner -this indicates the presence of the primitive Palmar and Suckling reflex”

■ “In 36% of cases, the child makes multiple mistakes when copying from the board. This is indicative of the presence of unbridled primitive reflexes, STNR and ATNR.”

■ “In 79% of cases children have had problems with reading and writing.”

■ “86% have had difficulty tying shoelaces or dressing themselves; showing the presence of the Palmar and suckling reflexes”

“ A. J. Ayres, in her theory of sensory integration, paid attention as well to the selected primitive reflexes, which, in accordance with her opinion, may disturb development, but do not produce symptoms as strong as in spastic diplegia. For that very reason, they may be less intensified.”

“…primary reflexes and postural reflexes develop also such mental functions as: lateralization, visual perception, aural perception and the coordination of them, exerting influence upon emotional development.”

“In school-age children with learning difficulties, primitive reflexes occur in their vestigial form. Those reflexes do not decrease simultaneously with the passage of time, and it rather seems that they have become more intensified”

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Hamer, E.G, & Hadders-Algra, M.(2016). Prognostic significance of neurological signs in high-risk infants – A systematic review. Developmental Medicine & Child Neurology, 58(Suppl 4), 53-60. Doi. 10.1111/dmcn. 13051

“The data indicated that, in early infancy, an absent Moro or plantar grasp response may be predictive for adverse developmental outcome. After early infancy, persistence of the Moro response and asymmetric tonic neck reflex was clinically significant. Prediction of a delayed emergence of the parachute reaction increases with age. Abnormal performances on the pull-to-sit maneuver and vertical suspension test have predictive significance throughout infancy. ”

PROGRAMS AND RESEARCH

■ Sally Goddard Blythe – Institute for Neuro-Physiological Psychology

■ Svetlana Masgutova – MNRI

■ Rhythmic Movement Training – iRMT and Blomberg RMT

■ Parkinson’s, Dementia, Stroke

■ Refer to Reference List

WHAT ARE PRIMITIVE REFLEXES?

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Innate, typical, and involuntary movement

patterns

Teach developmental sequence of movement

The body learns through the

experience the movement provides

The child acquires higher level motor skills, which, in turn, support higher level

executive functioning skills

A given reflex opens and activates the neural

pathways, conducting the impulse to the different

structures in the brain – in other words, it facilitates

activity dependent plasticity

WE KNOW THAT THEY EXIST

WHERE DO THEY GO?

MEDICAL PROFESSIONALS EVALUATE….

CHECK THEM OFF….…..and then?

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TYPICAL DEVELOPMENT

Primitive reflexes facilitate movement and engagement in the environment

Activity dependent plasticity (primitive reflex movement patterns) establishes mature neural connections

Promotes integration of primitive reflexes at the appropriate ages -rewires/fine tunes neural pathways and movement patterns

When that does not

happen….

REFLEXES ASSOCIATED WITH

HEAD CONTROL AND DISASSOCIATION OF HEAD FROM BODY

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Hands Pulling Reflex

Tonic Labrynthine Reflex

Symmetric Tonic Neck Reflex

Assymetric Tonic Neck Reflex

HANDS PULLING REFLEX


• Symmetrical Firing• Elbow flexors• Shoulder flexors• Scapula Protraction• Neck Flexors• Abdominal Flexors• Knee Flexion

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• Poor co-contraction – unstable shoulder girdle and extended arms

• No neck flexion/head lag• Chin Retraction• Extension T4-T8• Pelvic extension• Hip/knee extension

EFFECTS OF NON-INTEGRATION

■ Poor muscle tone

■ Poor hand-mouth and hand-eye coordination

■ Delayed manual skills – tool use

■ Poor head righting and ocular motor skills

■ Impact on integration of Moro, TLR, STNR, ATNR

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TONIC LABRYNTHINE REFLEX

TONIC LABYRINTHINE REFLEXES

Labyrinth of inner ear responds to movement

Head extension brings about extension of the back, arms and legs

Head flexion brings about flexion of the back, arms and legs

Balances the relationship between agonist and protagonist muscle groups

TONIC LABYRINTHINE REFLEX

TLR forward: Develops at 12

weeks in utero Integrates

around four months

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TONIC LABYRINTHINE REFLEX

TLR backward: Develops at the

time of delivery Integrates

gradually within 7 weeks through 3.5 years old

DEVELOPMENTAL IMPLICATIONS

Muscle tone

Formation of antigravity and stability mechanisms

Integration of vestibular and visual systems: stable head position – strong neck musculature – stable ocular motor mechanisms

Delays progress of integration of additional reflexes – Moro, Landau, STNR


Poor posture Low muscle tone Poor ocular motor control Poor body awareness and

perception: difficulty judging space, distance, depth, and velocity

Difficulty with head and leg coordination

Walk, run, or jump with jerky or stiff movements – if extensors dominate

Possible challenges with stairs/escalators

Motion sickness Poor sense of time,

sequencing, and organizational skills

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TLR: ERECT TEST

Stand with feet together Arms down at sides Ask child to look forward,

hold; then tilt head back into extension; hold.

Repeat at comfortable rate 3-4 times

Repeat with eyes closed

TLR: ERECT TEST

Observe posture Amount of neck

extension Increased lordosis Shoulders forward Loss of balance Change in muscle tone

at back of the knees Gripping with the toes Dizziness or nausea

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SYMMETRICAL TONIC NECK REFLEX (STNR)

SYMMETRICAL TONIC NECK REFLEX

■ Emerges 5-8 months

■ Inhibited 9-11 months

■ While on all fours:■ Neck extension results in UE

extension and LE flexion■ Neck flexion results in UE flexion

and LE extension


Purpose: precursor to crawling Supports integration of TLR Supports distribution of muscle tone in upper and lower

halves of the body Coordination of head with hands, arms, and upper back Disassociation of upper and lower body Allows child to sustain quadruped and rock back and forth Start of accommodative function – expands peripheral and

distance vision

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Child does not crawl, bottom shuffles, or crawls with poor quality

Poor posture Slumping in desk Clumsiness Poor visual accommodation Poor eye-hand coordination Academic issues: reading, writing, art, music


■ Difficulty with bilateral movements – if one hand works, the other helps by moving too

■ Difficulty with copying tasks■ Problems with attention and

concentration■ W-sitter■ Social issues – frustration;

avoidance

STNR - TESTING

■ Position in quadruped■ Ask child to slowly move head to

look down “between your legs”■ Hold 5 seconds■ Slowly move head upwards “as if

looking at the ceiling”■ Repeat up to 6 times

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August 2016 February 2017

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ASYMMETRIC TONIC NECK REFLEX

ASSYMETRIC TONIC NECK REFLEX

■ Stimulated by head position■ Present at birth■ Inhibited between fourth and

sixth month■ Extension of arm and leg to the

face side■ Flexion of arm and leg to the

occipital side


■ Asymmetrical cross lateral movements

■ Rotation around the sagittal axis

■ Foundation for auditory processing and language

■ Differentiation of left/right sides of the body and development of limb dominance

■ Hemispheric differentiation and specialization of executive functions

■ Hand-eye coordination – extension of visual focus

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■ Challenges in crossing midline■ Difficulty throwing/catching■ Difficulty tracking through midline■ Difficulty with attention, focus, and memory■ Auditory processing and/or auditory defensiveness ■ May have dyslexia or dyscalculia diagnosis■ Learning difficulties: language, reading, spelling, math,

handwriting

ATNR: QUADRUPED TEST

Quadruped Extended, yet relaxed,

arms Head in neutral Therapist turns head right Hold five seconds Turn head left Hold 5 seconds

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TREATMENT SUGGESTIONS

WHAT ARE YOUR GOALS?

■ Child has full head control against gravity –measured in supine

■ Child can engage in play and functional activities without associated body reactions in response to head flexion/extension or rotation – both in static and dynamic play/functional tasks

ACTIVITIES FOR INTEGRATION

■ Facilitate correct activation of all components of the reflex

■ Modifications– Head Control – add pillow under head to

bring in neck flexion – Pelvis – place pillow/your leg under pelvis

to facilitate full flexion of lower body– Work in small ranges first

HANDS PULLINGREFLEX

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TREATMENT IDEAS

■ “Tug-o-war” – supine; tall kneel■ Rope pull – supine/prone■ Pull/push games (isometric

engagement)■ Scooter board ■ Airplane■ Prone play

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THINK ABOUT THE PATTERN…

Stimulus: Head

Break up head flexion/extension from full body flexion/extension

Activities that dissociate head from body

Activities that move the body against gravity

Activities that support both flexor and extensor strengthening

Activities that promote balance

TLR


Lay supine and play games that only lift the head Toss/catch a ball Visual perceptual game on the wall

Sit on scooter, hold noodle/rope bilaterally and hold co-contraction while being pulled forward

Balance activities Alter head position

Tug of war with peanut ball or small toys – in supine flexion and sitting

Superman and Supine Flexion: Work on controlled breathing Sing/count adapting voice Grade by time Add in pulses Add visual activity: tracking chart, eye spy game


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Stimulus: head

Breaking up the body in the transverse plane Head and arms work together Legs are opposite

Reverse the pattern Head extends, make arms flex and legs

extend

STNR

STNR TREATMENT SUGGESTIONS Yoga poses Upward dog

Crawl Hands and feet soccer Push a balloon/ball with

nose Go in various directions

Accommodation activities in quadruped

STNR TREATMENT SUGGESTIONS

Dog-Chair

Cat-cow

Quadruped push-ups

Scooching on knees with strong engagement of shoulder girdle

Scooter board: Propel self on knees Incorporate

ball/beanbag/balloons Slalom between cones

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Stimulus: head rotation

Rotation results in: extension to the side of rotation flexion to the opposite side

Activities that support playing in the pattern, opposite the pattern, bilateral play at midline and crossing midline

ATNR

TREATMENT SUGGESTIONS Rocking horse (Athena Oden)

Ball pass around sagittal midline (Kawar zapping robots)

Bal-A-Vis-X

Differentiated angels in the snow

Differentiated crawling patterns and animal walks

Quadruped – grasp and place rings on feet ipsi- and contralateral.

Blowing bubbles with bubble wand

Lizard Cross Crawls

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CASE STUDY DISCUSSION

What are Primitive Reflexes? Correlations to Theories ... · reflexes – Moro, Landau, STNR EFFECTS OF NON-INTEGRATION Poor posture Low muscle tone Poor ocular motor control Poor

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