11/1/2012 1 DTI shows absence of Arcuate Fasiculus-image B vs normal A Slide 2 Primitive Reflexes In TBI Across All Ages Presented by: Tom A. Gross, BA, BS, BS, DC, DACNB, FACFN, FABCDD, CNS, BCIA-C (EEG) For the 2012 North Carolina Biofeedback Society Annual Conference TBI E&M, Standard…then what? • 5.3 Million Americans live with a long- term disability as a result of TBI. - The annual incidence of TBI is 1.7M - ABI (acquired brain injury) is 917K Standard Medicine often does an excellent job saving lives and limiting the initial injury. Then what?
Transcript
11/1/2012
1
DTI shows absence of ArcuateFasiculus-image B vs normal A
Slide 2
Primitive Reflexes
In TBI
Across All Ages
Presented by:
Tom A. Gross, BA, BS, BS, DC, DACNB, FACFN, FABCDD,CNS, BCIA-C (EEG)
For the
2012 North Carolina Biofeedback Society
Annual Conference
TBI E&M, Standard…then what?
• 5.3 Million Americans live with a long-term disability as a result of TBI.
- The annual incidence of TBI is 1.7M- ABI (acquired brain injury) is 917K
Standard Medicine often does an excellentjob saving lives and limiting the initialinjury.
Then what?
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Post-acute Assessment
• Level of consciousness &responsiveness to stimulation- Assessed depending on severity
• Alertness & attention- Responsiveness to stimulation
• Orientation- Person, place and time
• Memory- Visual memory
(complex figure copy/drawing)
- Prospective memory(memory to do things at specific times)
- Retention Span (digit span)
- Recall of new info (supraspan word lists)
- Retrieval of info from remote memory
(biographical memories)
• Language and communication- Written language/communication
– Arithmetic processes
– Reading Comprehension
• Abstract Thinking
– Proverb Interpretations
– Similarities and Differences
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• Reasoning
– Logical Thinking
a) Respond to questions – what would you do
if you found a stamped and addressed un-mailed letter?
– Appreciation of Relationships
a) Draw conclusions based upon analysisof relationships – friend or foe
• To facilitate early detection ofpotentially harmful eventsbefore they have a chance to causeirreversible damage …
…thereby reducing the chances ofsecondary injuries…
(metabolic, immunologic, neurologicaldiaschesis…NOT JUST FALLS)
…which represent both perpetuatingvariables and obstacles to the successof reasonable and importantinterventions.
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• To identify the process drivingpotentially harmful events, thusleaving time for effective intervention
• To enable and provide ongoingfeedback to assist therapy andinterventions directed at these threats
• Methods of monitoring the injuredbrain should be
– non-invasive
– relatively available
– and cheap
in order to be widely useful
• Current techniques used to monitorthe injured brain include
a) Neurological observationconsidered the most sensitive and specificindicator of brain function
b) EEG/EEG Spectral Arraysensitive in coma, seizures, even with musclerelaxers, useful in prognosis
c) Evoked Potentialsmorbid predictor, indicator for focal deficits aswell as prognosis
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What could be missing?
• The human nervous system developsalong very specific timeline.
• Currently Re-emergent primitivereflexes are rarely assessed, and thenonly during coma and semi coma
• However, it is well recognized thatprimitive reflexes often re-emerge inneurologic disease includingneurodegeneration and trauma to theCNS rostral to the spinal cord (BRAIN).
• And, it’s a cheap bedside diagnostic!!!
• Between day 19 and 20 we see theformation of the neural grove.
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• By day 22 the neural tube has formed,figuratively bringing the outside worldinto the developing CNS establishingthe foundation for the exquisite realityemulator which is the human brain.
• For this person’s entire mental life,he/she will scan reality with thesenses, analyze and evaluate, makepredictions and plans and executebehavior…then learn to do better.
The human nervous system developsalong very specific timeline.
• The areas of the CNS which regulatevital functions form first.
• Then sequentially the CNS maturesfrom the most vital for survivalleading to the most eloquent andresponsive to the unique environmentin which the person was born.
Survival versus Finesse
• The survival pathways are laid downfirst, thus they will always be found inthe midline of the CNS.
• Neuroanatomically, in addition tomidline, these pathways andstructures are also found on theventral surface of the brain
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• Having these structures located in thedeepest regions also confers ameasure of protection from externalthreats.
• These pathways are the mostgenetically determined and are lessdependent on sensory input for theirmaturity.
Finesse versus Survival
• The pathways which are mostinfluenced by sensory input for theirdevelopment are found more laterallyand dorsally in the cord and brain.
• Within this division, first to developare the primary sensory pathways,followed by association regions withthe frontal processing areas last.
Beauty and the Beast
• This allows the last CNS areas todevelop in humans to have animmense opportunity to adapt tounique territorial and socialenvironments. Hence, the Beauty.
• In contrast, areas which develop firstoccur, in part, before declarativefunction and have an implicit characterbest characterized by “ChildhoodAmnesia” and can operate in stealth……t h e B e a s t
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Primitive Reflexes in Stealth
• Primitive reflexes represent survivaloriented motor responses
• They begin to form in Utero- Palmar & plantar grasp @11 weeks in utero
- Moro @ 9-12 weeks in utero- TLR forward @ 12 wks in utero- ATNR @ 18 wks in utero- Spinal Galant and Perez @ 20 wks in utero
• These genetically hardwired reflexesplay a part in the amazing waltz ofpostures and movements between thebaby and mother during childbirth.
Yes, innate reflexes cause the baby to“wiggle it’s way out” from presentationthrough the birth canal andcompanion reflexes cause the motherto push...pause…push… (Ferguson Reflex)
• WOW
• These reflexes do far more than makethe baby squirm out.
As these reflexes fire they drivepathways that begin to develop thecerebellar and cerebral cortices.
Primitive reflexes initiate movementsthat form the building blocks forintentional movements.
• It is well accepted that trauma anddegeneration to the CNS are oftenmarked by re-emergence of primitivereflexes. In fact, this is often noted asa frank presentation in severe mentalillness.
WHY?
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• Recall that the primitive reflexes firerostrally to drive the development ofthe cortex.
As the cortex matures sufficiently, itfires back down to inhibit the primitivereflex that undergirded it’sdevelopment,
allowing more complex environmentaland cortical-cortical influences to havea shot at shaping neuroplasticity.
• As the cortex fails, it allows theprimitive reflex to “escape”.
These events are, in fact, commonlyreferred to as “release signs”
We will review the primitive reflexes in
detail shortly, but here are some fairly
common examples you have probably
seen yet didn’t recognize.
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Frontal release signs are commonly
“orofacial”, such as the re-emergence of
the sucking reflex indicated by tic like
pursing of lips and rooting reflex by
twitching of the side of the mouth.
• These signs can be much more subtle in
people who seem to be functioning fine.
The Spinal Gallant and Perez are often
seen by touching someone’s back
and observing them twitch with a slight
arched back toward the side touched
or jerk away.
Just ticklish eh?
• The Moro can often be seen in people
with incessant eye blinking when they
are nervous.
Also, in people with an exaggerated
startle response, especially if they
move their arms, even slightly, out to
their side when they react.
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• The Babinski reflex is commonly seenwith a Upper Motor Neuron Lesion(Spinal cord or above)
and is observed when the doctorscrapes the bottom of a patients footalong the lateral margin and observesthe big toe extend.
This can be seen in a cervical spineherniation, stroke, Arnold ChiariMalformation…etc.
• The last peripheral tract to myelinateis the corticospinal and the longestnerves reach the bottom of the feet.
This process should be complete byage 1.
Significance…We walk by age 1
Otherwise, someone would raise theirtoes when they step on their foot andcreate an instability which could bedisastrous…
yet many fail to inhibit this reflex andshow mild + Babinski
I commonly see mild + Babinski inchildren with Autism, Asperger's,AD/HD, Dyslexia…
sometimes unilateral
sometimes bilateral
Certainly in TBI/ABI
the Beast - Revisited
• Just like implicit learning operatesbelow cognitive manipulation yet canbe selectively inhibited,
emotional issues before declarativememory formation can hijackcognitive processes… (attachment theory,
etc…)
persistent primitive reflexes can hijack
motor influenced cognitive processes…
There is a potential to influence all
decisions and behavior associated with
approach / withdrawal strategies.
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PRIMITIVE REFLEXES AND ATTENTION DEFICIT/HYPERACTIVITYDISORDER: DEVELOPMENTAL ORIGINS OF CLASSROOM DYSFUNCTIONMyra Taylor, Stephen Houghton and Elaine Chapman International Journal of Special Education , 2004,Vol 19, No.1
• The present research studied thesymptomatologic overlap of AD/HD behaviorsand retention of four primitive reflexes (Moro,Tonic Labyrinthine Reflex [TLR], AsymmetricalTonic Neck Reflex [ATNR], Symmetrical TonicNeck Reflex [STNR])
in 109 boys aged 7-10 years. Of these, 54 were diagnosed withAD/HD, 34 manifested sub-syndromal coordination, learning,emotional and/or behavioral symptoms of AD/HD, and 21 had no(or near to no) symptoms of AD/HD. Measures of AD/HDsymptomatology and of the boys’ academic performance werealso obtained using the Conners’ rating scale and the WRAT-3,respectively.
• Results indicated that, in general, boysdiagnosed with AD/HD had significantlyhigher levels of reflex retention than non-diagnosed boys. Results also indicated bothdirect and indirect relationships betweenretention of the Moro, ATNR, STNR and TLRreflexes with AD/HD symptomatology andmathematics achievement.
• The pattern of relationships between thesevariables was also consistent with the notionof the Moro acting as a gateway for theinhibition of the other three reflexes.
INFANT REFLEXES AND ADULT DEVELOPMENT SensoryIntegration through MovementBy Eve Kodiak, M.M.,Newsletter of the Boston Institute for the Development of Infants and Parents, Fall, 2006
Various forms of trauma can inhibit thenormal integration of reflexes.
Factors that may inhibit the developmentof normal movement patterns includeinjuries at birth or after, drugs ingested inutero or through breast milk, allergies,physical and emotional overstimulation, anunsafe environment, blinking lights andmedia overload.
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• A significant inhibitor of normaldevelopment is the simple lack ofopportunity for movement.
• Babies carried around constantly inplastic car seats or other forms ofbodily restraintdo not gain the necessary practicetime to develop normal movementpatterns.
Older children may manifest unintegratedreflexes in the use of their bodies.
For example, children who flop to one side attheir desks, reading or doing their work withtheir heads resting on an arm, are manifestingan unintegrated Asymmetrical Tonic Neck Reflex.
They place themselves in this physical positionin order to concentrate.
• On occasion these children may actually fallsideways out of their chairs.
The movements are reflexive, and thus thechildren lack the choice of “sitting upstraight.”
As they attempt to process information sittingappropriately they must assume acompensatory mode that creates tensions andother difficulties.
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• When tired or anxious adults and children mayreturn to unconscious movement patterns.
An example of the Asymmetrical Tonic NeckReflex may be seen when observing a driverturning his or her head to the left and thenautomatically moving the steering wheel in thatdirection.
Please note the immense significance of movement/motoricity in brain related sensory integration
Postural Reflex Presentation
• As the primitive reflexes becomesuppressed, they usher in theemergence of the postural reflexes.
• The postural reflexes should persistthroughout life.
• Postural Reflexes enable us tomaintain an upright posture
• Catch ourselves from leaning or falling
• Keep our heads upright and level
• Move our eyes and head to differenttargets and at different rates
• Track objects and glance with our eyes
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• Balance in different postures, iesitting, standing, standing on 1 leg
• Coordinate finger and arm motionssuch as drawing circles and sequentialfinger and arm motions(Diadochokinesia)
1) Interventions should target the currentdeveloping system so long as earliersystems are mature.
2) Targeting later developing systemscannot resolve deficits based onpreceding systems immaturedevelopment.
• NO Skipping Steps
Guidelines for TherapySuggested
• Waterbeds are excellent sources of
early therapy for premature infants• Ingersoll & Thoman, 1991;Thoman & Ingersoll,1993)
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• These implicit reflexes seem to leavean a priori whisp which can soothe usor ravage us.
Why do people feel profoundlymoved holding hands?
Why do all dogs and some cats lovehaving their belly rubbed?
Why do we tend to panic with rapidacceleration down?
Overview ofKey Primitive Reflexes
The following discussion will highlight
the primitive reflexes which are
traditionally found in more severe CNS
problems and those I commonly find
persistent or re-emergent.
After reviewing the nature and
presentation of each reflex, I will
present some remediation activities
which can fire the reflex to restore the
normal suppression and free the
cortex to function, unfettered in it’s
volitional pursuits, by the reflex.
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Palmar Grasp Reflex
• The Palmar Grasp reflex emerges 11
weeks in utero.
Pic @12 weeks
Purpose: to help
baby hold on to
aid clinging and prevent drops/falls
You have probably seen pictures ofhuman babies grasping an instrumentor doctors finger or umbilical cord
pic@5 mos
• To test for the appropriate presence ofthe grasp reflex in an infant
Fingers till ~ 4 mos
Feet till ~ 6-12 mos
Touch palm or sole and observe grasp offingers or flexion of toes
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• To test for persistent or re-emergentPalmar grasp reflex > 1 year
scrape / scratch with fingernail acrossthe palm or sole and watch carefullyfor any subtle finger or toe flexion(not thumb or big toe)
• Remediation: Scrape the palm/sole toelicit the reflex frequently each dayuntil the reflex can no longer beelicited.
Elicit and Remediate PalmarGrasp Reflex
Persistence of a fisted hand is a sign of a UMN in an infant
Rooting Reflex
• Present in-utero dimnishes ~ 4 mosand gone by 7 mos
• Rooting reflex is tested by brushing orstroking the baby’s cheek.
• The Rooting reflex causes thenewborn to open it’s mouth and turnit’s head toward anything that theircheek or mouth. They move indiminishing arcs until successful.
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In utero
• Purpose: to assist successfulbreastfeeding.
Often co-elicits sucking reflex.
• To test >7mos and adults, scrape thecheek inward toward the edge of themouth in 3 directions (reverse crows foot)
Sucking Reflex
• Begins in-utero should diminish as a reflex~ 2 mos and resolve by 4 mosreplaced by volitional sucking
• Tested ≤ 4 mos by sticking finger in babysmouth (may require touching palate), baby sucks finger
• Test ≥ 4mos by gently brushing lip and observing for slightesttwitch of lips
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Moro Reflex
• The Moro (Startle ) Reflex should bepresent by 9-12 weeks in-utero andshould begin to diminish around 2months resolve within 5 months.
It occurs spontaneously with suddenmovement of the baby, suddensounds or sudden changes intemperature.
• Tested ≤ 5 mos by holding the infant on it’s back and dipping an infantbriskly head-ward.
• The legs and head extend while thearms jerk up and out with the palmsup and thumbs flexed.
Shortly afterward the arms are broughttogether and the hands clench intofists, and the infant cries loudly
Bilateral absence may indicate CNSinjury & Unilateral may be Erbs Palsy
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• In older children and adults, the Morocan be elicited more easily by:
• Supine – extend head quicklybackward and down + w/arm abduction
• Standing – Bunny Hop style, instructedto fall stiff straight back intoexaminers arms at the hearing of aloud clap (from behind)
Positive Moro is arms abduct/extend orwaist bends with arm extension/elevation
Tonic Labyrinthine Reflex
• TLR Forward emerges in-utero @12 wksand TLR forward and backward shouldbe gone by 3-4 months
• Tilting the head back w/pt supinecauses the legs tostraighten/stiffen/approximate, toesto point and arms to bend at elbowsand wrists
TLR -Abnormal Extensor Tone
TLR and Moro are much less severe yet interestingto compare to the decorticate posturing seen incoma patients with red nucleus lesions as theyalso originate in the mesencephalon.
In the quadruped position, the head/neck isextended and the back arches somewhat andthere is a tendency to retract to the haunches
When the head/neck is flexed, the tendencyis to advance slightly or crumple forward.
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Assymetric TLR - Fencer
• ATNR emerges @ 18 wks in-utero andshould resolve within 3-4 monthswith resolution of the TLR
• This reflex is called the fencing reflexbecause as the head is turned, the armand leg extend on the side facing andthey flex on the opposite side.
This reflex can also beassessed in the quadrupedposition by turning thehead and observing forthe arm or leg to bend onthe opposite side facing
The TLR and ATNR both hinder functionalactivities such as rolling, bringing the handstogether, or even bringing the hands to themouth.
Standing ATLR
• In children and adults, one can seepersistence or re-emergence of theATLR by examiner turning the patientshead while the patient is standing withboth arms outstretched straight infront of them (“Frankenstein” posture)
• The reflex is evident when the armsfollow the direction of head turn
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• Persistent TLR and/or ATLR impairpostural control during walking andrunning which leads to aberrant jointmechanics. Over time this leads toinflammation and joint damage,possibly impairing hip jointdevelopment.
Rolling may be the first indication there is a problem.If rolling @ 1-2 mos NOT GOOD, could be decerebrate.Important to roll by 3-5 months. Rolling absent by 3-4 mos√ Spinal Gallant. Absent one side √ Erbs Palsy or Vestibular
Spinal Gallant and PerezReflexes
• Spinal Gallant and Perez emerge @20wks in-utero and resolve by 3-6 mos
These are called the “truncalincurvation” reflexes because strokingup the back on one side will cause atwitch like response to the same side.(Gallant)
• Gallant is best observed babysuspended or ≥6 mos in the quadruped position
• Perez is observed when a stroke alongboth sides of the spine from neckdown causes a twitch with trivial toobvious extension of the back
These are among the reflexes testedin newborns to rule out brain damage!
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Babinski Reflex – Up toe
• The Babinski reflex is present at birthand should recede @ 10-12 months toallow walking. Extensor toe sign.
• Stroking the side of the foot with ablunt instrument of an infant shouldcause the great toe to extend andothers to fan out.
• ≥1yr toes curl in and foot everts
• There are many more reflexes you can
learn about and there are numerous
models of intervention based on
differing theoretical frameworks
regarding how to remediate the
reflexes.
• One popular opinion is that thereflexes should be present but need tobe properly integrated. There arenumerous protocols based on thisidea.
• I do NOT share this opinion!
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From a more traditional neurological
framework, the reflexes must be
triggered enough times to evoke
efferent neuroplasticity in their
respective CNS targets.
Remediation Exercises
• That said, many of the therapeuticactivities from the various frameworksappear to be useful in resolving thepersistent or re-emergent reflexes.
Oftentimes our observations are validand our explanations remiss…
Plantar Palmar Exercises
• Stroke the sole of foot and/or palm
• Rub knobby rubber ball on palm/sole
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Rooting Exercises
• Stroke/scrape towards the edge of themouth to elicit the reflex. Repeat oftenuntil the reflex can no longer beelicited.
Moro Exercises
1 2
Right arm Right Leg over
3 4
Left arm Left Leg over
Prone TLR Exercises
1. Start in prostate positionhead down between arms
2. Raise head simultaneouslyraising off haunches slowly
3. Continue raising up
4. Slowly return to startingposition and repeat
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Supine TLR Exercises
1. Start supine with pillow under head
2. Slowly bring knees up as a triangle
3. Slowly raise head/chin and armsso arms are straight along legs
4. Continue so as to ball-up witharms wrapped around knees –pause
5. Slowly release legs into pose #3
6. Slowly return to pose #1 - Repeat
Prone ATNR Exercises
1. Lay prone arms extended in front head up
2. Bring thumbs together by bending elbows
3. Raise chin and extend arms keeping thumbstogether
4. Raise chin, chest and arms keeping thumbstogether
5. Facing forward move right arm out to sideand follow with eyes – not moving head
6. Bring right thumb, arms extended backto meet up with the left thumb –still up
7. Repeat with left thumb to left side n back
8. Return to pose #3 and slowly repeat
Standing ATNR Exercises
• Standing ATNR is an easier version ofProne ATNR.It is performed the same except whilestanding up. Remember to keep yourhead straight and follow your thumbwith your eyes.
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Gallant – Perez Exercises
1. Lay supine with arms and legs at side
2. Very slowly raise arms and legs simultaneously
3. Till arms are over-head and legs are spread apart
