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Primitive Reflexes: Why Are They Important?

1 Contact Hour
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN)
This course will be updated or discontinued on or before Tuesday, February 1, 2022

AOTA Classification Code: CAT 3: Contemporary Issues & Trends.
Education Level: Intermediate
AOTA does not endorse specific course content, products, or clinical procedures. AOTA provider number 9575.

FPTA Approval: CE20-756304. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.
Outcomes

Participants will know current best practice for treatment of uninhibited primitive reflexes that may impair sensory motor function.

Objectives

After the completing this course, the participant will be able to:

  1. Explain the importance of primitive reflexes in typically developing infants.
  2. Discuss at what stage of development that primitive reflexes should be present.
  3. List 7 primitive reflexes.
  4. Describe how to test or observe to see if primitive reflexes are present or integrated.
  5. Identify specific exercises to use to integrate 5 primitive reflexes.
  6. List at least two side effects of each of the retained reflexes.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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  1. Take test and pass with a score of at least 80%
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    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Jody Harrington (OTD, OTR/L)

Introduction

Primitive reflexes prepare the neonate to move against gravity, which gradually leads to voluntary movement through integration during the first months of life. Mature responses in a child’s psychomotor progress can only occur if the central nervous system itself has reached maturity. The process consists of the transition from a brain stem reflex response to a cortically controlled response.1 If primitive reflexes are retained beyond the average developmental period, there is the potential to disrupt the maturation progression and impair the brain’s ability to process sensory information effectively. Severe persistence of primitive reflexes predominantly indicates physical problems such as cerebral palsy, milder persistence is associated with less severe disorders such as learning problems. The inhibition of primitive reflexes enables the development of motor skills allowing the infant to act on and interact with their environment in increasingly complex ways.2 The child with nonintegrated reflexes may have difficulty with motor coordination, this can manifest in difficulty with running, cycling, and balance, they may be described as clumsy. The child may have difficulty throwing and catching or they may avoid games that involve physical or movement activities.1 If retained, the asymmetrical tonic neck reflex (ATNR), symmetrical tonic neck reflex (STNR) and tonic labyrinthine reflex (TLR), along with the plantar reflex, palmar reflex, rooting reflex and spinal Galant reflex, decrease the brain’s ability to process sensory information efficiently.1

Side Effects of Retained Reflexes

The Moro reflex is also referred to as the ‘startle reflex.’ The Moro reflex is the earliest primitive reflex to emerge and forms a strong foundation for future life experiences. When you fail to support or hold your baby’s neck and head or if your baby becomes startled by a loud noise, bright light or sudden touch, the arms of your baby will thrust outward and curl in which looks like an attempt to embrace themselves. If retained, the child/adult may be hypersensitive to other sensations, may over-react to stimulation and be in a constant state of “fight or flight.” This will lead to overactivity of the sympathetic nervous system, including the adrenal glands. Due to the constant demands placed on them, they may become fatigued leading to allergies, asthma, a depressed immune system, and, ultimately, chronic illnesses. Other observable social/learning problems associated with a retained Moro reflex include an inability to focus on one thing at a time, poor impulse control, emotional immaturity, a tendency towards becoming withdrawn or timid, distractibility, difficulty playing ball games, and aggressive, anxious, and/or highly excitable behavior. Sensory systems associated with the Moro reflex include the auditory, tactile, visual, vestibular, and proprioceptive systems.

Difficulties associated with a retained rooting reflex include social/learning problems, poor articulation, tactile sensitivity around the face, messy eating, and poor manual dexterity. The tactile and proprioceptive systems are associated with the rooting reflex.

The spinal Galant like the ATNR, is important in the birthing process because it facilitates the movement of the hips as the baby descends into the birthing canal. Observable social/learning problems associated with a retained spinal Galant reflex include an inability to sit still “ants in the pants,” possible scoliosis, poor concentration, poor posture, hip rotation on one side when walking, chronic digestive issues, and bedwetting beyond the age of 5 years. The sensory systems associated with the spinal Galant reflex include auditory, vestibular, visual, and proprioceptive systems.

Signs of a retained ATNR include possible scoliosis, poor handwriting, difficulty expressing ideas in written form, difficulty with eye-tracking, difficulty with visual-motor coordination, difficulty with tasks that require crossing the bodies mid-line (reading/writing), and difficulty with bilateral coordination. Every time the head turns, an arm may follow it with fingers open. It will take the individual a lot of effort and concentration to hold the hand still while writing when the head has to move to look at another paper or the whiteboard. An older child or adult may complain of chronic or recurrent shoulder or neck injury/pain oftentimes on the same side of the body. The sensory systems associated with the ATNR include auditory, vestibular, visual, and proprioceptive.

The symmetrical tonic neck reflex has a very short life span and undergoes inhibition when the child starts to crawl, it enables the baby to get off the floor for the first time but does not allow mobility. Typical developing babies go through a period of "rocking" on hands and knees, a process that inhibits the STNR, so crawling may ensue. If the STNR remains strongly active for too long, then fluent crawling may never be achieved. Bending the legs as a result of head extension assists to inhibit the reflex and encourage the infant to fixate their eyes at a distance. Bending the arms in response to flexion of the head will automatically bring the child's vision back to near point, training the eyes to adjust from far to near point and back again. The retained STNR can also be characterized by poor posture, poor eye-hand coordination and focusing difficulties. Children with a retained STNR may have problems with sitting still at a desk or learning to swim, and usually do not feel comfortable with ball games.

The tonic labyrinth reflex prepares the baby for rolling over, crawling on all fours, standing and walking. Problems associated with a retained reflex include difficulty keeping the head in a flexed position, trouble paying attention when sitting at a desk and/or reading, poor posture, poor balance, motion sickness, dyspraxia, toe walking, hypo or hyper-tonus (muscle tone), a dislike for physical education class, poor sense of rhythm/timing, oculomotor difficulties (reading/writing), orientation and spatial difficulties. The sensory systems associated with this reflex include the vestibular, proprioceptive, auditory, and visual.

The disappearance of the palmar grasp reflex is significantly related to the commencement of the voluntary use of the hands. The absence of this reflex usually reflects peripheral (i.e., root, plexus, or nerve) or spinal cord involvement, especially if asymmetrical responses are noted. Lesions of the upper brain structures can affect the response. The response may be increased and retained longer compared to typical infants, on the affected side(s) of the upper limb(s) in infants with spastic hemiplegia or quadriplegia, whereas it is very weak in infants with cerebral palsy (CP) of the athetoid type.3

Testing

A primitive reflex is regarded as abnormal when it is absent or diminished during the period it should be actively elicitable or is present beyond the age limit for its disappearance/inhibition. An exaggerated reflex can also be abnormal.3 In addition to the testing descriptions listed below, many therapists have adopted their own way of testing the reflexes during their work with children. The suggestions below have been prevalent in the literature for many years and will, at the very least, give the new examiner a starting point to reflex testing.

Moro Reflex: The subject is supported in a semi-reclined position; the examiner drops the head backward and observes for a startle response. If no startle is noted, the test is negative. If there is noted abduction, extension or flexion or external rotation of arms with extension and abduction of the fingers, the test is considered positive. Positive reactions after 4 months may be an indication of delayed reflex integration. This reflex should disappear between 2-4 months of age.

Rooting Reflex: The reflex is elicited when you stroke the subject’s cheek, they will turn towards you, usually looking for food, this is very useful for breastfeeding. The reflex should be inhibited by 3-4 months of age.

Spinal Galant Reflex: the reflex is elicited by holding or laying the subject on their stomach and firmly stroking along one side of their spine, a positive reaction is for the subject to flex sideways toward the stimulated side. This is one of the reflexes tested in newborns to help rule out brain damage at birth. Stimulation down both sides of the spine at the same time simultaneously activates a related reflex that will reduce urination. This reflex should be inhibited by 3-9 months of age.

ATNR: The subject being tested is positioned in supine with the head positioned in midline and arms and legs in extension. The examiner turns the head to one side; if there is no reaction, the test is negative. If the examiner notes an increase in extensor tone or extension of the arm and leg on the face side and an increase in flexor tone or flexion of the arm and leg on the skull side, the test is considered positive. This reflex should be inhibited by 6 months of age. Ayres suggested testing of the ATNR could be done in a quadruped position, beginning with the child’s head in midline and rotating to either side looking for increased muscle tone in the arm toward which the child is facing for example if the head is turned to the right, increased tone would be noted in the right arm and decreased tone in the left arm. She reports that the child’s head can be moved passively, the child’s eyes should be closed, and elbows slightly flexed before the head is turned.4

STNR: The subject being tested is in a quadruped position or over the examiner’s knees. The examiner raises the subject’s head into extension. If there is no change noted in the subject’s muscle tone in the arms or legs, the test is considered negative. If the subject’s arms flex or legs extend or tone dominates, it would be considered a positive reaction. This reflex should be inhibited by 6 months of age. Ayres suggested that the STNR can be assessed in the quadruped position or during a clinical situation. In quadruped, the head is held in midline at 0 degrees of flexion/extension; the head is flexed, increased flexor tone in the arms is noted with a positive response. When the head is extended, a positive response would be increased extensor tone in the arms.

TLR: The reflex may be tested in supine or prone. In supine, the subject being tested is positioned with the head at midline and arms and legs in extension. The examiner passively flexes the arms and legs; if there is an increase in extensor tone, the test is considered positive. In prone, the head is actively extended in midline by the subject being tested; if there is no noted increase in the flexor tone of the head, trunk, arms, or legs, the test is negative. If the subject is unable to extend the head, retract the shoulders, extend the trunk, arms, or legs the test is considered positive. The reflex should be inhibited by 2-4 months of age.1 Ayres suggested that the reflex may be assessed using the prone extension and supine flexion positions.4

Palmar Reflex: the reflex is elicited by the examiner inserting their index finger into the palm of the infant from the ulnar side, applying light pressure into the palm. The subject is awake and lying on a flat surface in a symmetrical supine position. A positive response is noted if there is flexion of all the fingers around the examiner’s finger and is seen in two phases: finger closure and clinging. The latter occurs as a reaction to the proprioceptive stimulation of the tendons of the finger muscles due to slight traction subsequent to the application of pressure to the palm. The palmar grasp reflex can be elicited in infants during the first 3 and 6 months of age, before decreasing in intensity and disappearing by 6 -12 months of age.3

Integrating Reflexes

According to Bell, without reflex integration, it may be impossible to correct motor function and help clumsy children reach the same psychomotor level as typical peers. In order to prevent psychomotor delays of older children, the degree of reflex integration in preschoolers should be assessed and reflex therapy initiated. Treatment should be focused on the root of the problem, not just the symptoms; training should commence with focusing on inhibiting the reflexes then proceed to focusing on the child’s abilities.5

Blythe reports that neuro-developmental delay (NDD) is defined as the continued presence of a cluster of primitive reflexes above the age of one year, and the absence or underdevelopment of postural reflexes above the age of three and a half years. Primitive reflexes that persist in this way and underdeveloped postural reflexes are said to be aberrant and represent a structural weakness in the central nervous system, which will affect the development of later complex skills such as balance, motor control, oculomotor functioning and perception.

If the infant shows evidence of delayed integration of reflexes, they may participate in an Infant Motor Guidance Program. In this program, the infant’s caregiver will make the movements for them versus an older child or adult completing the integrating movement patterns independently. The program is designed to assist the infant to continue the normal sequence of development and reduce developmental motor delays in children later diagnosed with ADHD or autism spectrum disorder.

It is recommended that The Motor Guidance program is performed five minutes twice a day for one month on each reflex. After a month, move on to the next reflex movement pattern until all five reflex patterns have been integrated. The best times to apply the movement patterns were reported to be upon waking and before sleep.

The Starfish is an exercise suggested to integrate the Moro reflex; there are YouTube videos that demonstrate many of these exercises if the reader would like a visual demonstration. For the Starfish, the individual should have the arms and legs spread out in a loose, relaxed position with the head slightly extended. The arms and legs move or should be moved all together towards each other into a fetal position with arms and legs drawn into the chest. Move the head so the chin touches the chest. Hold the position for two seconds then slowly move the arms and legs back to the Starfish position. Remain in the Starfish for two seconds. The movement should be safe and relaxed. In the fetal position the left leg and left arm cross over the right leg and right arm, when the movement is repeated, cross the right leg and arm over the left leg and arm. This completes one repetition. It is very important to move the head and neck all at the same time. The exercise should be repeated a total of 5 times.

For the tonic labyrinth reflex exercise, the individual is lying in the prone position with arms and legs relaxed. The therapist lifts the right arm up, (may want a bright object such as a rattle in hand) while the individual is looking, move the right hand to the right and see if they can follow the hand until the arm is straight out to the side about 90 degrees from the starting point. You can prompt the individual to look using verbal cues. After you have moved 90 degrees from the starting point, then move the arm back until it is straight in front of the individual again. Repeat with the left arm lifting and moving it in the same way. When the left arm is back in front of the individual, let the arms and hands rest on the floor with the head down. This completes one cycle. Repeat for three cycles. The key is to relax the legs and move the arms as slowly as possible.

The spinal Galant exercise is similar to making angels in the snow. Lying in a supine position with both feet together, legs straight, and arms down to the sides of the body. Very slowly move the arms and legs out like a jumping jack. The hands should touch as the legs reach their widest point then slowly return to the starting position. Each angel in the snow should last at least 20 seconds. Do three angels to complete the exercise.

The ATNR exercise begins with the individual lying in prone with arms and legs straight and the head to one side. Bend the arms and legs on the same side the face is turned (like creeping but flat on stomach). Turn the head to the other side, then move the arm, then the leg back to the starting position and wait 5 seconds before repeating the arm and leg flexion and abduction on the other side of the body. This is considered one cycle. The author suggests 3 full cycles with the goal to relax the body as much as possible. For pictures of this exercise, see the references page to find the article written by Dr. Berne.

The STNR exercise begins with the individual sitting on their feet and calves, lower the head until the forehead is touching the surface in front of the knees, straighten the arms out above the head. Move the head and body together into a crawling position then move the infant backward down into the starting position. Continue the back and forth movement for three minutes or approximately 18-25 cycles.

There is limited research that provides specific intervention activities to integrate primitive reflexes. These activity suggestions were suggested at a conference sponsored by Summit Professional Education in Schaumberg, Illinois on 12-5-2019 presented by Tina Pipher, MA, OTR/L. Pipher suggests choosing activities that move the individual in the opposite direction of the reflex, for example, working in flexion if the individual has a positive Moro reflex. She also suggests considering the sensory input that triggers the reflex response, such as movement, sound, or vision — using activities that stimulate the vestibular system in order to inhibit the TLR and STNR, and starting with slow homolateral movements when remediating the ATNR.

Ayres provides exercises to inhibit the STNR and ATNR using a bean bag and specific body movements on page 106 of her book “Sensory Integration and Learning Disorders.” She makes it clear that these reflexes are always present in all people but states that it is the degree to which these reflexes have been integrated into the nervous system that needs to be evaluated.4

Case Example

A 6-year-old male with a medical diagnosis of auditory processing disorder was described as shy with low self-confidence due to a lack of coordination, auditory, and speech issues. His parents reported their son often felt different than other children his age and did not enjoy playgroups or social interactions. During the assessment, multiple retained primitive reflexes were noted, including ATNR, Palmar, Galant, Rooting, and Babinski. In addition to chiropractic adjustments, the child was given cross crawl integration exercises to improve left/right brain communication and primitive reflex remediation exercises to inhibit the ATNR. Brushing techniques were used to inhibit the other retained primitive reflexes (Rooting, Palmar, Gallant, and Babinski). By the 14th visit in 3 months, the child was reported to have improved independence, increased self-confidence, and significant improvements in coordination.6

Summary

There is good evidence to suggest that primitive reflexes retained beyond one year of age may adversely impact an individual’s sensory-motor performance. When an individual is referred for an occupational therapy evaluation, testing or observing for the presence of retained reflexes would be beneficial to rule out their presence and possible influence on higher-level skill development. The examiner can use this information to inform the plan of care.

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References

  1. Gieysztor EZ, Choinska AM, Paprocka-Borowicz M. Persistence of primitive reflexes and associated motor problems in healthy preschool children. Arch Med Sci. 2018; 14(1): 167-173.
  2. Chinello A, Di Gangi V, Valenza E. Persistent primary reflexes affect motor acts: Potential implications for autism spectrum disorder. Res Dev Disabil. 2018;83:287-295.
  3. Futagi Y, Toribe Y, Suzuki Y. The grasp reflex and moro reflex in infants: Hierarchy of primitive reflex responses. International journal of pediatrics. 2012; 2012:191562. Visit Source.
  4. Ayres A. Sensory Integration and Learning Disorders 9th printing. Los Angeles, CA: WPS; 1989.
  5. Bell C, Whitney, J, Deiss T, et al. The effect of the MNRI method on neurotransmitter biomarkers of Individuals with neurodevelopmental disorders. Neuroscience & Medicine. 2019; 10: 292-321. 10.4236/nm.2019.103022.
  6. Rubin D. Reflexes. tcl online today. 2015. Accessed 12-01-2019. Visit Source.