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The Grasp and Other Primitive Reflexes J M Schott, M N Rossor

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The Grasp and Other Primitive Reflexes J M Schott, M N Rossor 558 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.74.5.558 on 1 May 2003. Downloaded from REVIEW: PHYSICAL SIGNS The grasp and other primitive reflexes J M Schott, M N Rossor ............................................................................................................................. J Neurol Neurosurg Psychiatry 2003;74:558–560 Primitive reflexes are typically present in childhood, resistance see in spasticity in that the former can suppressed during normal development, and may be induced with any length of the finger flexors and is self sustaining.4 The grasp reflex may reappear with diseases of the brain, particularly those diminish if the dorsum of the hand is stroked, and affecting the frontal lobes. In this review we discuss thus the reflex may not be present if the patient’s hand (palm uppermost) is rested in the examin- some historical aspects surrounding these reflexes, how er’s palm. Opposition of the thumb may also be they might be elicited and interpreted, and their noted, possibly dependent on the size and nature potential clinical utility in modern neurological practice. of the object that is grasped. In the instinctive grasp reaction, deliberate .......................................................................... progressive closure of the whole hand is made in a series of small movements on a stationary con- he primitive reflexes are a group of behav- tact within the palm, terminating eventually in a ioural motor responses which are found in complete grip. When well developed, this reaction Tnormal early development, are subsequently will occur in response to stationary light stimula- inhibited, but may be released from inhibition by tion in any part of the hand, and is often preceded cerebral, usually frontal, damage. They are thus by series of movements bringing the object closer part of a broader group of reflexes which reflect to the centre of the palm. When the reaction is release phenomena, such as exaggerated stretch weak, it may only be provoked by light pressure to reflexes and extensor plantars. They do however the radial part of the hollow of the hand. Removal of the object may lead to movements of pursuit or involve more complex motor responses than such grasping, and movement of the object within the simple stretch reflexes, and are often a normal palm leads to tightening of the grip. Pressure on feature in the neonate or infant. the palm rather than movement appears to be the References to primitive reflexes abound in most important feature when eliciting this textbooks of neurology, and they are often reflex.4 Many of the phenomena of this reaction features of clinical demonstrations. However, they have been classified as “forced groping” or are often misinterpreted and their utility overem- “forced grasping” by other authors,3 and there phasised in the modern era of detailed neuropsy- may be an overlap or coexistence with utilisation chology and neuroimaging. They can, however, be behaviour. a valuable diagnostic adjunct to the examination It has long been recognised that both these in certain instances. reflexes are present in newborn infants, disappear http://jnnp.bmj.com/ Many primitive reflexes are recognised. These during normal development, and may reappear in include grasping, oral, nucocephalic, corneoman- disease states, suggesting that these responses are dibular and glabella tap reflexes, and utilisation suppressed but not lost during maturation. While behaviour; these reflexes are discussed below. The bilateral grasp reflexes are often seen with degen- palmomental reflex has recently been reviewed as erative diseases or diffuse vascular disease affect- part of this series.1 ing the frontal lobes, attempts to localise the lesions responsible for these responses more on September 26, 2021 by guest. Protected copyright. GRASPING REFLEXES accurately have not been consistent. Early de- Grasping has been associated with lesions of the scriptions suggested that unilateral grasp re- sponses were due to lesions of the contralateral frontal lobes for nearly a century and referred to frontal lobe,35possibly as a result of failure of the by a number of different terms including “the frontal lobe to inhibit parietal lobe function.5 grasping reflex”,2 “forced grasping” and “forced More recently lesions in the supplementary See end of article for groping”,3 the “instinctive grasp reaction”, and motor cortex and cingulate gyrus have been authors’ affiliations “magnetic apraxia”.45 Seyffarth and Denny- ....................... 4 implicated in the aetiology of these responses, Brown reviewed these reflexes in detail, and sug- although there is no consensus as to which region Correspondence to: gested their separation into two distinct re- is responsible for which response.67 Moreover, Professor M N Rossor, sponses: the grasp reflex and instinctive grasp Dementia Research Group, lesions of the frontal lobes may abolish these reaction. 8 Box 16, National Hospital reflexes, and grasping is often bilateral, even for Neurology and Eliciting the grasp reflex requires dual stimuli. with a unilateral lesion. Practically, there may be Neurosurgery, Institute of The first is a distally moving deep pressure over a little value in differentiating the palmar grasp Neurology, Queen Square, specific area of the palmar surface of the hand, from the instinctive grasp reaction—the presence London WC1N 3BG, UK; which elicits a brief muscular contraction (the m.rossor@ of either should increase the suspicion of an dementia.ion.ucl.ac.uk “catching phase”). This then develops into a underlying organic brain disorder. In our experi- strong “holding” phase only if traction is made on ence, groping reactions are much less common, Received the tendons of the flexor or adductor muscles and are associated with more advanced disease 9 December 2002 now in contraction, the response being main- Accepted states. 13 December 2002 tained by continued traction. This “holding” A group of foot reflexes allied to the palmar ....................... phase can be distinguished from the myotactic grasp were described by a number of authors www.jnnp.com The grasp and other primitive reflexes 559 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.74.5.558 on 1 May 2003. Downloaded from from the 1930s onwards. Brain and Curran described the Sucking reflexes may be seen in response to tactile stimula- grasp reflex of the foot,9 Goldstein the tonic foot response,10 tion in the oral region, or in response to the insertion of an and Seyyfarth and Denny-Brown the grasp reflex of the toes.4 object (for example, a spatula) into the mouth. The snout Although there are subtle variations in the responses reflex is present when the lips pucker in response to gentle described, all these authors conclude that stimulating the sole pressure over the nasal philtrum. Rooting responses are seen of the foot (particularly over the metatarsophalangeal joints when the mouth turns towards an object gently stroking the using a distally moving object) leads to flexion and adduction cheek (tactile rooting), or towards an object (for example, ten- movements of the toes, and that while the reflex is distinct don hammer) brought into the patient’s field of view (visual from the Babinski response, the two reflexes may appear con- rooting). Particular care must be taken to distinguish these currently. As with the palmar grasp, this response is seen in reflexes from tardive or buccolingual dyskinaesias in patients infants, may reappear consequent to damage to the frontal who have been exposed to neuroleptics. lobe or its efferent connections, and may be particularly By contrast, closure of the mouth with pouting of the lips frequent with contralateral, medial frontal lobe damage.11 elicited by either tapping around the mouth or onto the lips However, as Seyyfarth and Denny-Brown found no patients (or tapping a spatula placed over the lips) represents an with grasp reflex of the toes in the absence of finger increased myotactic stretch reflex, and not a primitive grasping,4 it is unlikely that testing for the presence of this response. Pouting may be present (at least electromyographi- reflex will give more diagnostic information than can be cally) in normal individuals,15 although brisk responses, deduced from the presence or absence of palmar grasping. indicative of upper motor neurone lesions, may be seen in the context of amyotrophic lateral sclerosis, multiple sclerosis, or small vessel cerebrovascular disease.16 Confusingly, the terms UTILISATION BEHAVIOUR snout and pout have historically often been used Utilisation behaviour was first described in five patients with interchangeably.11 To avoid confusion, we suggest that the either unilateral or bilateral frontal lobe lesions by Lhermitte term pouting should only be used to describe the increased in 1983.12 He noted that these patients, when presented with myotactic stretch reflex. utilitarian objects, were compelled to grasp and use them. Examples of this behaviour were patients who, when GLABELLA TAP REFLEX presented with a bottle of water and a glass, but no In 1896 Overend first reported that in the normal subject, light instructions, would unquestioningly and automatically fill the tapping over the glabella produces a reflex blinking of both glass and drink from it. The same, automatic, unquestioning eyes.17 This reflex has been referred to as the glabella tap sign, behaviour could be elicited on presentation of a hammer and nasopalpebral reflex, and blinking reflex. The reflex has two nail; envelope and sheet
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