integration through neuroplasticity treatment techniques · 2020. 7. 16. · karen pryor, phd, pt,...
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Session 401: Primitive Reflex Integration Through Neuroplasticity
Treatment Techniques
Karen Pryor, PhD, PT, DPTKaren Pryor, PhD, PT, DPTKaren Pryor, PhD, PT, DPTKaren Pryor, PhD, PT, DPT
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• I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12
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all planners involved do not have any financial relationship.
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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
Karen Pryor PhD, PT, DPTCopyright 2019
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Overview
Brain development
Cranial Nerves
Possible reasons for retained reflex and
re-emerging reflex
Developmental delays affecting
reading, writing, math, ADHD, Autism
© Mica Foster D.C.
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
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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
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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
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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 DEVELOPMENTRE-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.
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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
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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
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ASTNR - MAMMAL BRAIN DEMONSTRATION
Children can demonstratePrimitive 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 stimulusChange the response
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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.
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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.
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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 REFLEXAnatomy 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.
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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
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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 REFLEXAnatomy 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
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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.
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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
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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 STUDYAgenesis 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
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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
cordTreatment
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
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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 METHIS IS NOT ME
Recognize their own body in space
Cool tools
Vibration
Sensory stimulation
Balance
Vestibular
Vision
QUESTIONS???
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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 Neurology. 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 Superior, 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.