Session 401: Primitive Reflex Integration Through Neuroplasticity Treatment Techniques

Home , Palmar grasp reflex, Primitive reflexes, Reflex

Karen Pryor, PhD, PT, DPT

To comply with professional boards/associations standards: • I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. •Requirements for successful completion are attendance for the full session along with a completed session evaluation. •PESI and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.

Session 401: Primitive Reflex Integration Through Neuroplasticity Treatment Techniques

Karen Pryor, PhD, PT, DPT

Financial: Karen Pryor is owner of Health Sphere Wellness Center. She receives a speaking honorarium from PESI, Inc. Non-financial: Karen Pryor serves on the Leadership Interagency Council for Early Intervention board.

Primitive Reflex Integration Through Neuroplasticity Treatment Techniques

1 Overview

Brain development

Cranial Nerves

Possible reasons for retained reflex and re-emerging reflex

Developmental delays affecting reading, writing, math, ADHD, Autism

PRIMITIVE REFLEXES

Most appear at birth

Tested shortly after delivery

One of the primary determinants of developmental delay early on

Retained or obligatory reflexes interfere with voluntary movements and development

Primitive Reflexes

Where to find and elicit primitive reflexes

Get to the root of the problems

Methods to integrate primitive reflexes advance skills

Cranial Nerve function and intervention

Tools you can use

To reach and treat primitive reflexes - go into the brainstem - by way of cranial nerves

2 Challenges of obligatory primitive reflexes

Reduce progression of developmental motor milestone skills

Primitive reflexes do not travel alone

Interferes with reading, page turning and visual functions, learning

Persistence can cause deformities, abnormal movements

Medication “manages” abnormal patterns and tone

First things first

Cranial Nerves

Neonatal reflexes

Infant reflexes

Reactions

Primary Motor Patterns ©Mica Foster DC

Detour around damaged areas

Find out pathways that are working

Areas that are not working

That’s where we start

3 Neck

• Rotation can be restricted by primitive reflexes - higher tone in musculature

• Reflex demonstration follows where the eyes look

• May be restricted with torticollis

• cervical misalignment

• tightness in soft tissues

• primitive reflex influence

Cervical Considerations

• Increased tone on one side - restrictions for rotation and integration of primitive reflexes

• Plagiocephaly - misshapen head

• May have non-symmetrical posture in sitting, place feet under self, lay head on table

• Top down development approach

• Gentle mobilization of cranial plates

• Myofascial release of cervical and cranial musculature

Trunk Accommodations

• May throw arms and legs over for rolling

• Hold to furniture to pull to stand, cruise, balance

• Wide base of support for gait, side to side walk

• May not demonstrate heel toe gait

• Poor trunk stability and balance

• Easily fatigue in standing and sitting - lay head on table to desk to rest trunk

4 Treatments

• Visual tracking with sound- superior, inferior, medial, lateral, near and far - 1st rotation ability

• Vestibular stimulation - rock, roll and swing

• Sensory recognition of body 3-D Numb and dumb

• Myofascial release to bilateral sides

• Unwind cervical and trunk with myofascial stretching

VISION DEVELOPMENT RE-DEVELOPMENT - 80% connection

Birth – limited orientation to target stimulus

3 months – cortical / vision control eye and head movements

6 months – visual / reach and grasp / integration of near vision and manual actions

12 months – visual / gait control / near – far vision

18 months – speech / integration – vision, recognition, action, speech

24 months – integration, subconscious actions of vision, reach/grasp, gait actions. Able to perform walk and talk

VISION DEVELOPMENT WITH DIRECTION DETECTION

Orientation - crude at birth, improved temporal resolution 5-10 mo temporal and spatial response improved 6-12 mo.

Directional Motion – behavioral discrimination 7 wk initially. Velocity range expands 10-15 mo.

Binocular Correlation – behavior discriminations initially 11-13 wk, range expands 15 mo on.

5 TORTICOLLIS AFFECTS MOVEMENT AND INTEGRATION OF PRIMITIVE REFLEXES

Rotation is essential for function

Required to progress and connect pathways to higher centers

From brainstem to midbrain and cortex

PRIMITIVE REFLEXES DO NOT TRAVEL ALONE

Travel in gangs – usually not solitary

May see mixed patterns – depends on where the eyes are looking

Eyes are also affected by spastic patterns

Catch as soon as possible

CENTRAL NERVOUS SYSTEM LEVEL OF REFLEXES

Spinal reflexes

1. Flexor withdrawl

2. Extensor thrust

3. Crossed extension

4. Moro

5. Startle

©Mica Foster DC

6 BRAIN STEM LEVEL REFLEX - REPTILIAN BRAIN

1. Asymmetrical Tonic Reflex

2. Symmetrical Tonic Reflex

3. Static Labyrinthine

4. Positive Supporting

5. Negative Supporting

6. Equilibrium reflexes – “yes, no, I don’t know” movements

©Mica Foster DC

17 YEAR OLD - ANOXIC GLOBAL BRAIN DAMAGE

Began therapy in ICU with range of motion / specialty hospitals

Continued with ataxic movements – cerebellum and basal brain structures, chopped thoughts

Poor start and stop motion in eyes, neck, trunk, UE and LE’s

Tremors in bilateral hand movements – drawing - Like treats like

Plantar grasp + and extension synergies, high tone – gait

Integration, “Neutralize the Eyes” and “Numb and Dumb” = heel toe gait

MIDBRAIN REFLEXES - MAMMAL BRAIN

1. Kinetic Labyrinthine

2. Body righting acting on head

3. Body righting acting on body

4. Optical righting reflex

5. Protective extension

6. Parachute reflex

©Mica Foster DC

7 ASTNR - MAMMAL BRAIN DEMONSTRATION

Children can demonstrate Primitive reflexes under stress, when fatigued or when lifting objects

EYES AND VISION

Eyes team? Low or high tone in striated muscles of eyes

Give sense of 3 dimensional space

References to self – 3-D being

Spastic or low tone affecting eye musculature?

Striated muscles like arms and legs

Primitive reflexes are a motor response to a sensory stimulus

Change the stimulus Change the response

8 SUCK AND SWALLOW

Can affect and enhance head and neck control

Assists in linking cranial nerves and bilateral hemispheres

Exercise to multiple muscles of tongue

Eye stabilization, focus

ASYMMETRICAL TONIC NECK REFLEX

Anatomy and function - head and neck turn toward object, push away from danger, facilitates body awareness and hand-eye coordination

Window - 6-7 months

Test - stimulate vision, head and neck will turn toward toy/light

Persistence challenges – Difficulty feeding self, handwriting and reading challenges.

Resolution – Integration method – fatigue reflex with repeated stimulation right and left with gentle holding of shoulders, arms or lower extremities.

”Numb and dumb” tone in affected side/s.

9 ASYMMETRICAL TONIC NECK

May relate to torticollis – birth trauma C1,2,3 locking

If present on one side and not the other, indicates increased damage on one side of brain.

Torticollis can reduce integration of vision and asymmetrical tonic neck

Stress, running can reappear

Football player running with ball

DISARMING PRIMITIVE REFLEX POWER

The eyes control head turning

Asymmetrical Tonic Neck Reflex position – work with partner to see how the power changes with eye direction change

Change eye direction – Left to right to left

Give advanced challenges

COMPASS method

SYMMETRICAL TONIC NECK REFLEX Anatomy and function – neck and upper extremity flexion and extension in lower extremities.

Neck and upper extremity extension and flexion in lower extremities.

This is a total body pattern demonstration, move through environment to escape danger.

Window - After birth - 3 months

Test – have patient look up, down at a light or toy.

Persistence challenges – difficulty with looking at school black/white boards and transfer information to paper.

Difficulty with walking looking up and down at pathway.

Resolution – Integration method – Fatigue reflex by repeated elicitation. Isolate eyes only for stimulation while sitting supported or supine, without allowing body responses.

10 MORO REFLEX

Anatomy and function – look up, neck extension and arms throw back to escape

Window Prenatal- 4-6 months

Test –If infant is stimulated with a 30 degree change in neck extension, it may elicit the reflex. If testing an older child have them look up at a toy and watch for upper extremities coming away from midline and hands beside ears.

Persistence challenges – interferes with sitting, standing, jumping, one leg balance, difficulty with 2 handed activities, crossing midline, poor control when looking at objects on wall, blackboard, screens, then to paper on desk.

Elicit Resolution – Integration method – work on lower eye level activities in sitting or standing. There will be more cortical connections formed so lower centers are no longer needed.

STARTLE REFLEX

Anatomy and function – reaction to loud noise, throw into extension to lay low and protect head

Window - 4-6 months, may reappear with ACES, Adverse Childhood Event

Persistence challenges – Distractible, fidgety, poor concentration, poor performance in chaotic room, may stay in fight or flight

Elicit – reaction to loud noise, neck into extension, arms back toward head with hands extended

Resolution – Integration method – Have the child make their own noise or turn on lights .slowly increase tolerance to loud noises. Child beat on drum, pots, turn up music. When the child is in control, less reaction. Can you tickle yourself?

PALMAR GRASP REFLEX Anatomy and function – Hand grip and holding to Mother, with sensation in palm of hand, grip, food to mouth

Window – 5 months gestation - 4 months postpartum Test – stimulate the palm of the hand, hand will close

Persistence challenges – when the hand does not reopen, clasped hand can stimulate itself to stay closed (indwelling thumb), poor grip on pencil, gross grip rather than pinch, poor handwriting and drawing, may demonstrate flexed posture in the wrist and elbow.

Resolution – Integration method- This reflex is sensory driven – “numb and dumb” the sensors with a vibrator, inside out sock. When the hand is less sensitive, the palmar grasp will not over-ride learning.

11 PALMAR GRASP

GALANT REFLEX

Anatomy and function – Assists infant in movement, bilateral reflex supports advanced skills, creeping, crawling, rolling

Window - 0-2 months

Test – stroke the paraspinal musculature from scapula to iliac crest, paraspinals will contract on stimulated side and curve toward that side.

Persistence challenges – difficulty with bilateral use of trunk, poor sitting with back braced on chair, fidgeting, poor use of hands in fine motor.

Resolution – Integration method – desensitize with manual stimulation, sock, vibrator, whole trunk.

PLANTAR GRASP REFLEX

Anatomy and function – toe holding to Mother, flexion posture of toes and lower extremity to make self smaller

Window Birth – 12-14 months

Test – apply pressure on the plantar surface of the foot under metatarsal heads, toes will flex.

Persistence challenges – difficulty putting on child’s shoes, toe walking, poor balance, poor support of child on whole foot during weight bearing, decreased information into the proprioceptors, poor balance negotiation while walking.

Resolution – Integration method

12 PALMAR MANDIBULAR REFLEX

Anatomy and function – Also called the Babkin reflex.

Window Birth – 3 months

Test - Pressure to both palms with resultant eye closure, mouth opens and neck flexes. Persistence challenges – Mouth open during handwriting, fine motor concentration. Resolution – Integration method – Work child with eye / neck flexion and extension during fine motor tasks to break the pattern.

PALMAR MENTAL REFLEX Anatomy and function - Hand and face linking function

Window - Birth – 3 months

Test – Hold dorsum of hand, scratch palm with finger with resultant lower jaw opens and closes.

Persistence challenges – Open and close mouth with fine motor activities, clay play, paints, page turning.

Resolution – Integration method – Desensitize bilateral palms, cross midline with hands and eyes.

VOR REFLEX

Anatomy and function - stabilize images on retina, activation of the vestibular system causes eye movement.

Window

Test – turn head and see if child can maintain sustained focus on an object. Head turn to right, eyes will turn to left.

Persistence challenges – difficulty with reading, learning, unable to stabilize images for sustained focus, may demonstrate nystagmus (eye tremor), difficulty with walking and maintaining balance or gaze

Resolution – Integration method – Rock, roll, swing, visual tracking while still then moving, smell – stem cell formation

13 OPTICAL AND LABYRINTHINE RIGHTING RELFEX

Anatomy and function – orientation of self to gravity Window - 1 month throughout life

Test – body tilted

Persistence challenges – difficulty with reading, writing, drawing, orientation, dyslexia, “bdpq”

Resolution – Integration method – Stimulation to skin. The child has to recognize where they are to determine where everything else is in respect to themselves. Rock, roll, swing, vision rehabilitation and exercises in different orientation positions.

1 YEAR OLD MIDDLE CEREBRAL ARTERY INFARCT

Resistance to rotation in neck and trunk

Obligatory ASTNR

Spasticity in UE and LE

Poor visual tracking

FIGHT OR FLIGHT

Anatomy and function – Lower brain center response to threat, get away from danger

Window – Throughout life, previous trauma may have triggers

Test - Not advisable rather observable.

Persistence challenges – Difficulty with learning skills, may demonstrate repeating movements, yelling, freezing, falling, sudden onset of weakness

Resolution – Integration method – Slowly increase tolerance to lights, sounds, interaction with others. Investigate vagus nerve conduction.

14 CHILDREN WITH MULTIPLE CHALLENGES

What goes on - on the inside

Affects what you see on the outside

SENSORY PROCESSING PRINCIPLES

If neuronal information is stuck in lower brain levels they do not reach the sensory processing, interpretation and integration levels.

Will have retention of primitive reflexes which can carry over into interference in learning and attention.

Our development is not a pyramid, it is actually more like a tower

Neuroplasticity allows for higher level integration into new circuits

Sense of smell - 2014 NIH study

LEARNING CHALLENGES

Learning requires higher level pathways to form connections

If primitive reflexes are present / obligatory – those tracts are active

Neuroplasticity rewires the way nervous system connects sensory information

15 CASE STUDY Diagnosis of autism at 2 yr old Retention of primitive reflexes Temporal lobe deficits After 12 months of neuroplasticity physical therapy diagnosis removed

Before After

NEUROLOGICAL DEFICITS AND DAMAGE

Trauma, genetic abnormality or missing area of the central nervous system

The level below deficit is active - where primitive reflexes live

The brain prefers to use the cortex if possible – energy saving

Our goal is to connect to cortical layers for integrated motor function

CASE STUDY

Agenesis corpus callosum

Hemispheres do not talk to each other

Rotation is compromised

Eyes do not work together

Utilize integration of limbic system into treatments assisted hemisphere coordination, primitive reflex integration and rotation abilities

16 Middle cerebral artery

Hemiparesis and spasticity on one side of the body / neck

Cortical damage lower levels reveal primitive reflex active

Treatment: Stimulation to entire head, neck, body, UE and LE’s Proprioceptive information Vestibular 3 directions Visual tracking Numb and Dumb sensory endings

Result: Full use of body and extremity without supportive devices

CASE STUDY Chairi malformation Tethered cervical and lumbar cord Treatment Rotational restrictions Misaligned eyes Brain stem compression Poor suck and swallow - Tube fed Poor regulation - body temp and hunger Headaches Cranial nerve dysfunction

Result Attends regular classroom Able to eat by mouth Integration of primitive reflexes Able to run, play and climb

CRANIAL NERVES

• Go into the area where primitive reflexes live

• Facial sensation - rotational

• Movements reflect emotion (frontal lobe) and function (mouth closure for swallowing)

• Eye movements

• Smell

• Hearing

• Balance

17 BODY SENSORS

Skin sensation head, neck, trunk, upper and lower extremities

All are connected

Joints – proprioception, weight bearing, joint tap

Vibration - can numb sensation - become non-reactive

Temperature – puzzle, pencil

Adding sensory experiences aid in integrating primitive reflexes

THIS IS ME THIS IS NOT ME Recognize their own body in space

Cool tools

Vibration

Sensory stimulation

Balance

Vestibular

Vision

QUESTIONS???

• [email protected]

18 Continuing Education Credits

Access the Rehab Summit Evaluation on August 1 ststst :::

• An email will be sent to your registered email address • An evaluation link will also be available on RehabSummit.com

Once you have completed the evaluation, you can choose to print, download, or email the certificate for your records.

REFERENCES

Molnar, chapter 2 Growth and Development O’Sullivan and Siegelman – reflexes VOR – Crawford,J. Vilis T (03/1991). Axes of eye rotation and Listing’s law during rotations of the head. Journal of Neurophysiology . 65 (3): 407-23. Milani Comparetti A. Gidoni, E (1967) Pattern analysis of motor development and its disorders. Developmental Medicine and Child Neurolog y. 9, 625-630. Neuromotor Developmental Examination Futagi, Y Toribe Y, Suzuki,Y. The grasp reflex and moro reflex in infants: Hierachy of primitive reflex responses . International Journal of Pediatrics . Doi:10.1155/2012/191562 Konicarova, H. Petr, B Retained primitive reflexes and ADHD in children. Activitas Nedrvosa Superi or, vol. 54,no. 3-4, 2012. 135-138. doi:10.1007/bf03379591. Taylor, M. et al. Primitive reflexes and attention – deficit / hyperactivity disorder: Developmental origins of classroom dysfunctions. International Journal of Special Education . Vol 19. no 1 2004, 23-37. Warshowsky, J. How Behavioral Optometry Can Unlock Your Child’s Potential . (2012) London UK, Philadelphia,PA: Jessica Kingsley Publishers. Atkinson, J. The Developing Visual Brain. (2002) Oxford University Press.