W1 PPT- PEDS- Prenatal Development and Primitive Reflexes PDF

2/29/2024 PT Through the Lifecycle (PTA 1011) Image by clipart Power Point #1 Development- Martin/Kessler 2016 Martin/Kessler 2016 1 ...

2/29/2024 PT Through the Lifecycle (PTA 1011) Image by clipart Power Point #1 Development- Martin/Kessler 2016 Martin/Kessler 2016 1  2/29/2024 2 PT Through the Lifecycle Development- Chapter 1 Image from vitlsourceonline 2  2/29/2024 After reading and studying these chapters and the materials presented, the student will be able to: Trace the development of the neurologic system Learning Identify the levels of the central nervous system (CNS) and peripheral Objectives nervous system (PNS) Identify stages of development (pre- and postnatal) and motor milestones up through adolescence Recognize primitive reflexes and their impact on development 3  2/29/2024 Blastocyte Central Nervous System Embryonic stage Key Germinal stage Peripheral nervous system Terms Primitive reflexes Rigidity Tone zygote 4  2/29/2024 Nervous System Development It is important to review and have a general understanding of how the nervous system develops Disease or injury to the developing central nervous system or peripheral nervous system can affect how a child Figure 1-1 The central nervous system. Details of both the develops brain and the spinal cord are easily seen in this figure. (From Thibodeau GA, Patton KT: Anatomy & physiology, ed 6, St Louis, 2007, Mosby.) ©Stanbridge University 2024 5 5  2/29/2024 Nervous System Development The brain develops from a few cells of the primitive ectoderm called the “neural tube” The neural tube in the fetus develops into the central nervous system (CNS)- brain and spinal cord By the 6th week of gestation, the basic form of the CNS is completed ©Stanbridge University 2024 6 6  2/29/2024 Nervous System Development Image from slideplayer.com 7 ©Stanbridge University 2024 7  2/29/2024 Figure 12.1 Embryonic development of the human brain. (a) Formed by week 4, the neural tube quickly subdivides into (b) the primary brain vesicles, which subsequently form (c) the secondary brain vesicles by week 5. These five vesicles differentiate into (d) the adult brain structures. (e) The adult structures derived from the neural canal. Marieb 2019 ©Stanbridge University 2024 8 8  2/29/2024 Neural Tube Defects Folic acid and Vitamin B-12 important during first trimester- deficiencies may cause defects When posterior tube does not close properly to become the spinal cord, a condition called spina bifida results ©Stanbridge University 2024 9 9  2/29/2024 Embryonic Brain Development Figure 12.2 Brain development. Initially, the cerebral surface is smooth. Folding begins in month 6, and convolutions become more obvious as development continues. See- through view in (b) and (c). Marieb 2019 10 ©Stanbridge University 2024 10  2/29/2024 Brain Development If cells continue to multiply and compress the still- forming cerebral aqueduct, it can lead to obstruction and cause congenital hydrocephalus (cerebral spinal fluid increases, “water on the Signs of hydrocephalus- enlarged head, brain”) bulging fontanelles, headaches, vision changes, large veins on scalp, seizures, behavioral changes, changes in appetite, 11 ©Stanbridge University 2024 vomiting, and downward deviation of eyes 11  2/29/2024 Nervous System Development http://www.youtube.com/watch?v=86NDMfxU4ZU& feature=related movie time! The brain is the only organ not fully developed at birth By birth the brain will be ¼ the size of the adult brain Average weight of the human brain: Birth 6 Years Adult 800 g 1200 g 1400 g 1.764 lbs. 2.645lbs. 3.11 lbs. 12 ©Stanbridge University 2024 12  2/29/2024 Nervous System Development and Function (Review on your own) Central Nervous System (CNS) – Consists of brain, brainstem and spinal cord Made up of: – Gray matter » Unmyelinated – White matter » Myelinated - Myelin is an electrically Insulating material that Forms a layer, the Myelin sheath ©Stanbridge University 2024 13 13  2/29/2024 Nervous System Development and Function Peak Infants are myelination of born with little the nerves myelin in their occurs during brain the third trimester During infancy Myelination myelination begins in the occurs rapidly 14th week of and continues fetal through development adolescence ©Stanbridge University 2024 14 14  2/29/2024 The lobes of the cerebral hemispheres: – Frontal lobe controls cognition (judgment, awareness, abstract thinking, mood) and impulse control Motor cortex Expressive language – Occipital lobe controls visual stimuli Visual cortex – Temporal lobe controls language centers Receptive language Auditory cortex Musical discrimination – Parietal lobe receives messages from all sensory neurons except vision and hearing Primary sensory cortex Nervous System Development and Function 15  2/29/2024 FIGURE 2-8 Schematic midsagittal view of the brain shows the relationship between the cerebral cortex, cerebellum, spinal cord, and brain stem, and the subcortical structures important to functional movement. (From Cech D, Martin S: Functional movement development across the life span, ed 3, St Louis, 2012, Elsevier.) Martin/Kessler Cerebral Functions ©Stanbridge University 2024 16 16  2/29/2024 Cerebral Hemispheres Two hemispheres, each has three subdivisions: Cortex- outermost sheet of neural tissue covers entire surface of each hemisphere Subcortical white matter- high concentration of myelinated nerve fibers carrying information to and from the cortex Basal ganglia- a group of nuclei acting as cohesive unit involved with motor function ©Stanbridge University 2024 17 17  2/29/2024 Plays key role in memory, attention, perceptual awareness, language, thinking, and consciousness Divided into raised surface folds called gyri and grooves called Cerebral sulci (indentations in the brain surface) Cortex – Allow information to be stored Develops from the most anterior part of the neural plate that folds and closes to form the neural tube 18  2/29/2024 Acts in transmission of electrical impulses Many involuntary functions are regulated here including reflexes and balance Subcortical Controls most functions that White unconsciously keep the body running Matter Most injuries appear as lesions; in children white matter can sometimes repair itself- not so in adults Diseases- MS, encephalitis 19  2/29/2024 Refers to a group of several structures in the brain (deep in the cerebrum) Located in forebrain Variety of functions- – procedural learning related to “habits” or routine behaviors Basal – voluntary motor control – eye movements Ganglia – cognitive emotional functions – muscle tone and posture Plays a role in neurological conditions and movement disorders (i.e., Parkinson’s disease, Huntington’s disease, OCD) 20  2/29/2024 Brainstem Midbrain (midbrain, pons, – Functions: Houses the efferent & medulla oblongata) pathways and nuclei for several CNs Concerned with: – Vision and auditory pathways – Pain transmission – Motor function Pons (Latin- “bridge”) – Functions: Contains nuclei of several Marieb 2019 CNs Acts as relay station between cortex, cerebellum, and efferent ©Stanbridge University 2024 pathways 21 21  2/29/2024 Brainstem Continued Medulla Oblongata – Functions: Regulates a number of autonomic functions- breathing, HR and BP Helps transfer messages to spinal cord and thalamus Reflex center for coughing, sneezing and swallowing Contains afferent and efferent pathways and cranial nerve nuclei Part of the hindbrain (medulla, pons and cerebellum) ©Stanbridge University 2024 22 22  2/29/2024 Cerebellum In Latin means “little brain” Made up of very tightly folded gray matter Important role in motor control Some role in cognitive functions, such as, attention and language Coordination, precision and accuracy (hand-eye coordination and fine motor) Responsible for motor planning and balance/equilibrium ©Stanbridge University 2024 23 23  2/29/2024 Thalamus- Review on your own Marieb 2019 Surrounded almost completely by the cerebral hemispheres All sensory information except for smell, reaching the cortex passes through the thalamus Conveys information regarding muscle tension and limb position sense to the cortex ©Stanbridge University 2024 24 24  2/29/2024 Nervous System Development Peripheral Nervous System (PNS)- consists of nerves and ganglia outside of the brain and spinal cord It allows signals to travel between the cortex, the spinal cord and the peripheral muscles of the body. separates into somatic and autonomic Somatic- cranial nerves and spinal nerves Autonomic- sympathetic and Figure 1-3 The peripheral nervous system parasympathetic divisions is attached to the central nervous system, but its nerve fibers are distributed include regulation of circulation, throughout the body. (From Nolte J: The human brain: an introduction to its respiration, digestion, functional anatomy, ed 5, St Louis, 2002, metabolism, secretions, body Mosby. Redrawn from Krstić RV: General histology of the mammal, Berlin, 1985, temp. and reproduction Springer-Verlag.) ©Stanbridge University 2024 25 25  2/29/2024 Nervous System Development Peripheral Nervous System (PNS) cont. Afferent: (ascending tracts) Carry sensory messages, i.e., position sense, vibration, touch, etc…begin in the dorsal root ganglia and exit the spinal cord Efferent: (descending tracts) Carry motor messages, controls skilled movements; Begin in the ventral horn of the spinal cord and carry motor messages General Innervate skin, muscles, bone, B, Cross-section of the spinal cord. The and viscera central gray matter is divided into horns Special and a commissure. The white matter is divided into columns. C, Afferent and Innervate sensory organs in the efferent axons in the upper limb. A single segment is illustrated. The arrows head, e.g. taste buds, olfactory illustrate the direction of information in epithelium, retina, and cochlear relation to the central nervous system. (From Lundy-Ekman L: Neuroscience: and vestibular apparatus fundamentals for rehabilitation, ed 4, St Louis, 2013, Elsevier.) Martin/Kessler ©Stanbridge University 2024 26 26  2/29/2024 1. What is the cerebellum responsible for? a) Body temperature Learning b) Memory Assessment c) Balance and coordination d) Regulation of heart rate 27  2/29/2024 2. The afferent tracts carry what type of message? a) Innervation to skin and muscles Learning b) Innervation to vestibular Assessment apparatus c) Motor d) Sensory 28  2/29/2024 3. The brainstem consists of what three sections? a) Spinal cord, pons and cerebral cortex Learning b) Medulla oblongata, midbrain, and cerebellum Assessment c) Pons, thalamus, and midbrain d) Midbrain, medulla oblongata and pons 29  2/29/2024 Image from kissclipart Typical Physical Development Prenatal & Postnatal Clipartlibrary.com 30  2/29/2024 Typical development is based on an uncomplicated pregnancy lasting for a gestational period of 40 weeks Slideshare.net ©Stanbridge University 2024 31 31  2/29/2024 Prenatal Development Three stages: 1. Germinal stage (fertilization to roughly 2 weeks) 2. Embryonic stage (weeks 3-8) Verywellmind.com 3. Fetal stage (period between 9 weeks and birth) ©Stanbridge University 2024 32 32  2/29/2024 Prenatal Development- Germinal Stage 1. Germinal Stage- fertilization to roughly 2 weeks gestational age Sperm and ovum combine at conception, then fertilization occurs, forming a new cell called a zygote Cell division/mitosis occurs- genes and chromosomes must also duplicate for normal development Zygote implants on uterine wall ©Stanbridge University 2024 33 33  2/29/2024 Slideshare.net ©Stanbridge University 2024 34 34  2/29/2024 Prenatal Development- Germinal Stage Changes from zygote to blastocyte as it continues to divide on the uterine wall Blastocyte cells will continue to differentiate into several areas: – Thickened area evolves into ectoderm and endoderm – Later mesoderm (middle layer) – Other areas- umbilicus, amniotic sac and placenta develop ©Stanbridge University 2024 35 35  2/29/2024 Bcopentextbc.ca ©Stanbridge University 2024 36 36  2/29/2024 Nutrient uptake Placenta: an organ that connects the developing Waste elimination fetus to the uterine wall and allows for: Prenatal Development Comes from the Latin Gas exchange through the mother’s blood word for cake supply Develops upon implantation of the blastocyte ©Stanbridge University 2024 37 37  2/29/2024 Purpose- Provides cushion Amniotic Sac and Prenatal Fluid: made up of 2 membranes filled Development with clear, pale fluid Provides fluids in which the baby for baby to breathe and floats and moves in swallow Maintains a constant temperature ©Stanbridge University 2024 38 38  2/29/2024 Prenatal Development- Embryonic Stage 2. Embryonic Stage- occurs during weeks 3 thru 8 weeks of gestation Continued rapid growth and development of major body systems (respiratory, digestive and nervous systems) Considered high-risk time because embryo can sustain significant damage from a host of factors ©Stanbridge University 2024 39 39  2/29/2024 Slideplayer.com ©Stanbridge University 2024 40 40  2/29/2024 Medicinenet.com Fetal Development at 8 weeks ©Stanbridge University 2024 41 41  2/29/2024 3. Fetal Stage- 9 weeks postconception to birth; longest stage (embryo becomes fetus) Organs and body systems become more refined Prenatal Development- Fetal Stage Table 1-1 Motor Development of the Fetus 10-15 weeks 17-18 weeks 20 weeks UE Isolated extremity movements; Wide arcs of arm hands to face; thumb sucking movement Locomotion Full body rotation around the Vigorous extensor thrusts against Period of greatest umbilicus; climbing on the uterine wall repositions fetus mobility; uterine wall creeping/crawling movement Atypical Fetal akinesia Symmetric, stereotypic movements Behaviors lacking dissociation ©Stanbridge University 2024 42 42  2/29/2024 Prenatal Development- Fetal Development 10 weeks Fetal Stage Fetal Stage- 9 weeks post-conception to birth, cont. Fingernails/toenails and eyelashes develop Fetus actively moves in uterus (can be tracked by ultrasound sonography) Male fetuses tend to be more active than females HR activity and sleep/wake Slideshare.net cycles can be monitored Motor patterns arise spontaneously and are not reflexive ©Stanbridge University 2024 43 43  2/29/2024 Fetal Stage- 9 weeks postconception to birth, cont. Prenatal At around 26 weeks fetus able to respond to familiar Development- voices/sounds, mom’s heartbeat, and external Fetal Stage stimuli, (i.e., Vibration) At 28-32 weeks, fetus’s brain highly vascularized- if experience aggressive movement, great potential for injury to motor cortex ©Stanbridge University 2024 44 44  2/29/2024 Development- Learning Assessment 1. For prenatal development, the embryonic stage occurs during what weeks? a) 0-2 weeks b) 3-8 weeks c) 9-15 weeks d) 9 weeks to birth ©Stanbridge University 2024 45 45  2/29/2024 Development- Learning Assessment 2. In what prenatal stage does refining of organs occur and increased activity and movement such as climbing on the uterine wall? a) Embryonic b) Fetal c) Germinal d) Zygote ©Stanbridge University 2024 46 46  2/29/2024 Chapter 4 Motor Development ©Stanbridge University 2024 47 47  2/29/2024 48 istockphoto POSTNATAL Stages of Human Development Infant/toddler (0 to 3 years) Early Childhood (3 to 6 years) Middle Childhood (6 to 12 years) Adolescence (12 to 20 years) Young Adulthood (20 to 40 years) Middle Adulthood (40 to 65 years) Late Adulthood (older than 65 years) Clipartlook.com 48  2/29/2024 Normal Postnatal Development Is variable and there is a constant drive to progress Inherent desire to move and explore; motivation to move comes from intellectual curiosity Motor development is affected by several factors: – Social-emotional Stocksy United development – Cognitive development – Environmental and cultural Is a process of elongation 49 49  2/29/2024 Motor development occurs in an orderly sequence, based on what has come before Not like a tower of blocks, Postnatal more like a pyramid with a Development- foundation on which the next Developmental layer overlaps the preceding Concepts one Allows for growth and change to occur in more than one direction at the same time 50  2/29/2024 The developmental sequence is generally recognized to consist of the orderly development of head control, rolling, sitting, creeping and walking Postnatal This sequence is known as gross- Development- motor milestones Developmental Sequences may overlap as the Concepts child works on several skills at the same time Example: a child can be perfecting rolling while learning to balance in sitting 51  2/29/2024 Characteristics of Normal Motor Development Directional Concepts Motor development typically occurs in three directions- 1. Cephalocaudal- (head to toe)- head control is developed before the trunk 2. Proximal to distal- the axis or midline of the body must provide a stable base for head, eye, and extremity movements to occur; midline head control, then midline trunk control, followed by proximal shoulder and pelvic girdle stability through weight bearing 3. Flexion into extension- dominated by physiological flexion and move out of it into extension ©Stanbridge University 2024 52 52  2/29/2024 Gross to fine- large muscle movement to Other Develop concentric fine more discrete Characteristics- before eccentric and specific movements Random movements Mass to specific- to volitional, more from simple to more Upper body control controlled and complex before lower purposeful movements- movements dissociation Dominated by primitive reflexes to integrated reflexes Characteristics of Normal Motor Development Directional Concepts 53  2/29/2024 Primitive (Neonatal) Reflexes- What are They? What is their purpose? Reflex actions originating in the CNS, exhibited in normal infants Usually develop in utero, at birth or shortly after birth Initially dominate infant’s movements Stimulus followed by a motor response Helps with infant development and motor control against gravity They disappear or are inhibited by the frontal lobe as the child moves through normal development (get integrated) ©Stanbridge University 2024 54 54  2/29/2024 If they do not disappear or integrate properly, it can cause problems with normal development Can be assessed to determine if infant/child is developing normally Primitive Research Article: Persistence of primitive reflexes and associated Reflexes motor problems in healthy preschool children, Gieysztor, E.Z. Et al. https://www.ncbi.nlm.nih.gov/pmc/a rticles/PMC5778413/ 55  2/29/2024 Assessing Primitive Reflexes Symptoms list Physical test (different on older children and adults) Strength or Grade of reflex 0= integrated (no longer present or absent) 1= moderately present or retained 2= strongly retained (dominating child’s movement) ©Stanbridge University 2024 56 56  2/29/2024 57 Primitive Reflexes Rooting Visiontherapy.com Sucking/swallow Galant (spinal Galant) Moro/ Startle Flexor withdrawal Traction response Grasp (plantar & palmar) Babinski Crossed extension Positive Support Walking/Stepping Reflex ATNR (asymmetrical tonic neck reflex) STNR (symmetrical tonic neck reflex) TLR (tonic labyrinthine reflex) Flickr.com 57  2/29/2024 Primitive Reflexes Rooting Reflex Stimulus: stroke from corner of mouth to cheek, either side Response: Open mouth and turn head to same side (ipsilateral) as stimulus Significance: locate food source Onset: 28 weeks gestation Integration: 3 months Slideshare.net Without integration: difficulty feeding; turns head whenever cheek area stimulated ©Stanbridge University 2024 58 58  2/29/2024 Primitive Reflexes Suck-Swallow Reflex Stimulus: tactile stimulus to lips Response: infant latches on and creates a vacuum with lips, cheeks and tongue; typically, 4 sucks to 1 swallow Significance: obtain and maintain oral nutrition; learns how to nurse Onset: 28 weeks gestation Integration: 2-5 months Flickr.com Without integration: difficulty feeding; latching on to bottle or nipple; weak suck ©Stanbridge University 2024 59 59  2/29/2024 Primitive Reflexes Flexor withdrawal reflex Stimulus: noxious stimulus to plantar surface of foot Response: flexion & withdrawal of stimulated LE Significance: A protective response; A milder response persists through life- safety Interactive-biology.com when step on something sharp Onset: 28 weeks gestation Integration: 1-2 months Without Integration: difficulty walking and putting on shoes/socks; oversensitive on bottom of feet; may indicate sensorimotor delay or CNS depression -Absence of reflex could Quizlet indicate neurological impairment ©Stanbridge University 2024 60 60  2/29/2024 Primitive Reflexes Crossed Extension reflex Stimulus: hold one LE in place while stimulating plantar surface of foot Response: flexion, adduction, and then extension of contralateral LE Onset: 28 weeks gestation Integration: 1-2 months Without integration: difficulty walking and putting on shoes/socks; can interfere w/reciprocal kicking Youtube.com ©Stanbridge University 2024 61 61  2/29/2024 Primitive Reflexes Traction Response Stimulus: have child supine on table/mat then hold hands and slowly pull child to sitting Significance: if no traction response, child may have hypotonia Response: child should assist with shoulder girdle and UE’s and have some active head control after initial head lag; Easynotecards.com should feel the child reciprocating Onset: 8 weeks gestation Integration: 2-5 months 62 62  2/29/2024 Primitive Reflexes Galant Reflex Stimulus: hold child prone in horizontal suspension and stroke child along paravertebral area from C7 to buttocks Response: hip hike or rotation and spinal curvature to side of stimuli Youtube.com Significance: tested in newborns to help rule out brain damage or spinal cord lesion; helps infant get through birth canal; helps with development of rolling and controlled trunk movements Onset: 30 weeks gestation Integration: 2 months Without integration: asymmetrical sitting posture, and can interfere with sitting balance; can cause scoliosis, bladder issues or bedwetting, tag/waistband sensitivity, decreased attention and concentration, and unable to sit still; hip dislocation on side of flexion; often seen in children w/ athetoid CP Note: could be an indication of possible brain damage or spinal cord lesion. Slideserve.com 63 63  2/29/2024 Primitive Reflexes Plantar Grasp Reflex Stimulus: press on the metatarsal heads or place thumb on ball of foot Response: toes curl / toe flexion Significance: “readiness” indicator for indep. gait Onset: 28 weeks of gestation Integration: 9 months Without integration: difficulty walking or abnormal gait pattern; difficulty with wearing shoes; balance reactions and weight Flickr.com shifting in standing can be interfered with; difficulty standing with feet flat on surface 64 64  2/29/2024 Primitive Reflexes Palmar Grasp Reflex Stimulus: press on metacarpal heads or place pressure through palm starting from ulnar side Response: fingers will curl and grasp Significance: bonding w/caregiver and development of grasp Onset: 28 weeks gestation Integration: 4-9 months Without integration: inability to Flickr.com grasp and/or let go volitionally; will have difficulty feeding self and with ADLs; difficulty weight bearing on an open hand (e.g., as in reciprocal creeping, protective extension reactions) 65 65  2/29/2024 Palmar Grasp Reflex Without integration cont.. As child gets older Lack of pincer grip Poor manual dexterity Poor handwriting Unable to perform tripod grasp to hold pencil Too tight of grip on pencil (hand cramping) Speech and articulation issues Makes mouth movements when writing or drawing ©Stanbridge University 2024 66 66  2/29/2024 Primitive Reflexes Moro Reflex Stimulus: child in supine, take arms up to 90° and release them suddenly OR Stimulus: have child in partial supported sitting, release child to fall backwards and guard from Youtube.com behind, allowing head to drop a few inches Response: Shoulders will abduct, elbows, wrists and fingers extend then shoulders will adduct with elbow, wrist and finger flexion (will look startled-moving arms and may cry Significance: Fight or flight response; Look for asymmetry, can indicate brain lesion or peripheral nerve injury; later replaced by adult startle; (Giles has Startle reflex as a separate one) Onset: 28 weeks gestation Integration: 5 months (4-6 months) Medicineplus.gov 67 67  2/29/2024 Primitive Reflexes Moro Reflex Continued… Without Integration: (2 different presentations seen) Child may live in a constant state of inner Loma Linda Univ. Health News stress, oversensitive to external sensory stimuli (i.e., sound, touch, light, visual, and vestibular); anxious - With Vestibular- results in motion sickness, poor balance and coordination Child can withdraw and shut off external stimuli they cannot handle; overly shy OR Child can be over-reactive with poor impulse control Either child lacks inner security needed to be spontaneous or flexible and often react with anxiety and outbursts when their routine is changed Sensoryflow.com ©Stanbridge University 2024 68 68  2/29/2024 Moro Reflex Without Integration: Child copes one of two ways A fearful child Withdrawing from situations Difficulty socializing Does not accept or demonstrate affection easily Appears shy OR Child becomes overactive Aggressive behavior Highly excitable Cannot read body language Feels the need to dominate situations (be in control) ©Stanbridge University 2024 69 69  2/29/2024 Primitive Reflexes Walking/ Stepping Reflex Stimulus: infant held in upright, vertical position with either feet planted on surface or stroking dorsum of feet on edge of surface then planting them on it. Lean or incline the infant forward a little Response: reciprocal flexion and extension of legs; the appearance that the infant is taking steps Significance: walking Onset: 38 weeks gestation Integration: 2 months Slideshare.net Without Integration: difficulty with standing and walking; interferes with balance reactions and weight shifting in standing; affects development of smooth, coordinated movements of the LEs 70 ©Stanbridge University 2024 70  2/29/2024 Primitive Reflexes Positive Support (neonatal) Stimulus: Infant held in vertical, upright position with weight placed on the balls of the feet; bounce infant up/down Response: stiffening of legs and trunk into extension and ankles into plantar flexion, while bearing weight on LEs Significance: bearing weight on LEs and walking Onset: 38 weeks Integration: 2 months Without Integration interferes with standing upright and walking; interferes with balance reactions and weight shifting Researchgate.net in standing; can lead to contractures of ankles into plantar flexion- possibly toe- walking ©Stanbridge University 2024 71 71  2/29/2024 Primitive Reflexes Asymmetrical Tonic Neck Reflex (ATNR) Stimulus: supine on mat, rotate the child’s head to the Left side- for infant; can test in quadruped for older children Response: Left LE & UE should extend, Right LE & UE should flex; Toolstogrowot.com fencing position (when rotating child’s head to right, the opposite response is seen) Significance: helps get through the birth canal; hand regard, eye hand coordination and vision development; cause and effect knowledge development; midline use of hands; bilateral hand use; crossing midline; rolling. Retainedneonatalreflexes.com.au Onset: Birth Integration: 4-6 months Red flag if infant still has strong ATNR after 6 months 72 ©Stanbridge University 2019 72  2/29/2024 Primitive Reflexes ATNR Without integration: Difficulties with crossing midline and making cross movements Difficulty with rolling and 4-point creeping Balance affected when walking and turns head to one side Studyblue.com Difficulties riding a bike/ tricycle Dropping things when head turns to side of hand holding something Writing difficulty- immature pencil grip or excessive pressing down of writing utensil; quality of writing less; turn paper 90 degrees to avoid crossing midline and write vertically Challenges with writing the number 8 Challenges with feeding self The retention of the ATNR is the single most Pbs.org important reflex to cause reading challenges – i.e., dyslexia ©Stanbridge University 2024 73 73  2/29/2024 Primitive Reflexes Symmetrical Tonic Neck Reflex (STNR) Stimulus: hold infant in prone horizontal suspension position then flex Toolstogrowot.com the head and extend the head (or older child in tested in quadruped) Response: when the head flexes, the arms flex and the legs extend. Conversely, when the head extends, the arms extend and the legs flex Significance: necessary to achieve quadruped position and reciprocal crawling on all fours Onset: 6 months Retainedneonatalreflexes.com.au Integration: 9-11 months 74 74  2/29/2024 STNR – Symmetric Tonic Neck Reflex Facilitates static quadruped position Neck extension Allows infants Straight arms to start crawling Breaks up total extensor tone Flexed legs All-free-download.com Allows reaching and weight shifts to facilitate balance and trunk stability ©Stanbridge University 2024 75 75  2/29/2024 STNR Without Integration: When not sufficiently integrated baby cannot crawl, instead they scoot or slide on their bottom or “bear walk” on hands and feet Children who never crawl on all fours usually Cdchk.org have an active STNR Can interfere with propping on forearms when lying in prone Causes poor posture, tendency to slump when sitting at a table Difficulty using hands in sitting position and looking at object Messy eating Clumsiness Attention difficulties; difficulty staying on task “W” sitting Challenges w/swimming, doing somersaults and ball games Slideplayer.com Poor eye-hand coordination ©Stanbridge University 2024 76 76  2/29/2024 STNR cont… Without Integration: This reflex develops near-distance and binocular vision, when retained, it is linked to difficulties in vertical tracking of the eyes Immature STNR hampers production of rhythmic coordination and postures required for reading and writing while seated at a desk – Child may get up and down to relieve tension Neck and elbows tend to bend together in opposition to straightening of legs and visa versa 75% of kids classified with a learning disability are estimated to have an immature STNR Wholebrainliving.com 77 ©Stanbridge University 2024 77  2/29/2024 Primitive Reflexes Babinski Reflex Stimulus: A. hold child supine or sitting and stroke child’s foot laterally to medially towards big toe with pressure Response: B. and C. big toe should extend, and other toes should fan away from each other (this is a positive response) Onset: Birth Integration: 9-10 months (latest 2 years old) Without integration: difficulty putting on shoes and walking; may indicate neurological disease- possible corticospinal tract damage if positive after age of 2. if absent in infant- is a red flag could indicate upper motor neuron lesion FIGURE 2-12 Babinski sign. A, Normal. Stroking from the heel to the ball of the foot along the lateral sole, then across the ball of the foot, normally causes the toes to flex. B, Developmental or pathologic. Babinski sign in response to the same stimulus. In people with corticospinal tract lesions, or in infants younger than 7 months old, the great toe extends. Although Fig. 2-12 Image from Martin/Kessler the other toes may fan out, as shown, movement of the toes other than the great toe is not required for the Babinski sign. (From Lundy-Ekman L: Neuroscience: fundamentals for rehabilitation, ed 4, St Louis, 2013, Elsevier, 2013.) 78 78  2/29/2024 Primitive Reflexes Tonic Labyrinthine Reflex (TLR)- Forward and Backward Stimulus for Flexion (forward): hold child supine or prone in horizontal suspension and place head into flexion Response: flexion of UEs and LEs Stimulus for Extension (backward): hold child supine or prone in horizontal suspension and move head into extension passively Response: extension of UEs and LEs Significance: labyrinths are important organs for the development of ant-gravity postures and balance; there is increased extensor tone in supine and increased flexor tone in prone. Onset: Birth Integration: 6 months Researchgate.net 79 ©Stanbridge University 2024 79  2/29/2024 TLR – Tonic Labyrinthine Reflex TLR flexion Toolstogrowot.com Testing for TLR Memorangapp.com (NPTE) Infant Reflexes Facilitates flexor and extensor tone development ©Stanbridge University 2024 80 80  2/29/2024 Without integration: TLR: if not fully integrated by the time child learns to walk, can affect muscle tone every time head moves forward and backwards and confuses the balance center; child may skip 4-point recip. crawling Primitive Forward TLR: children with active TLR may- tire easily when standing for any Reflexes length of time; have difficulties holding head up; weak neck muscles; shrunken up posture – Weak muscle tone and over flexible joints; problems lifting arms or climbing; problems with working eye muscles and convergence – Poor balance; tendency for motion sickness; stooping posture; fear of heights 81  2/29/2024 TLR cont… Backward TLR: – Infants tend to have extensor dominance- thrust backwards, arch trunk excessively; affects their siting balance – Child may have- tense muscles; tendency to toe walk; balance and coordination problems; stiff/jerky movements – Poor sense of time – Tendency for motion sickness – Poor sequencing and organizational skills – Difficulties with conflicting visual / perceptual information (e.g., crossing a slatted bridge) ©Stanbridge University 2024 82 82  2/29/2024 VIDEO TIME Infant reflexes http://www.youtube.com/watch?v=0V4x0iQODTk 83 83  2/29/2024 Causes of Retained or Non- Integrated Primitive Reflexes C-section and/or Falls (mother during Trauma/ head trauma Birth trauma of infant or mom premature birth pregnancy) Delayed or skipped Chronic ear infections Vertebral Lack of tummy time creeping or crawling of child subluxations of child Disease or Toxicity exposure to neurological disorder Abnormal muscle mother during Anesthetics (e.g., Cerebral Palsy, tone pregnancy Autism, genetic disorders) 84  2/29/2024 Some primitive reflexes may return in an adult due to a CNS insult or upper motor neuron lesion Examples: Stroke (CVA) Traumatic brain injury (TBI) Multiple sclerosis (MS) Primitive Reflexes 85  2/29/2024 Techniques to Help Break up Primitive Reflexes There are exercises and positions that may assist the retained primitive reflex to integrate, re-integrate, or decrease the influence of it – Example: the robot or lizard exercise for ATNR 86 ©Stanbridge University 2024 86  2/29/2024 Techniques to Help Break up Primitive Reflexes Example: Slow Angels (snow angels) to break up the Galant 87 ©Stanbridge University 2024 87  2/29/2024 Techniques to Help Break up Primitive Reflexes Cat/Cow or Horsey to help break up STNR ©Stanbridge University 2024 88 88  2/29/2024 Techniques to Help Break up Primitive Reflexes Prone extension exercises when patient has dominant TLR forward and/or absent TLR backward Note: Supine flexion when TLR Sidelying backward is dominant position best and/or TLR forward is when patient absent has both directions present ©Stanbridge University 2024 89 89  2/29/2024 Development- Learning Assessment 1. The STNR helps facilitate what position? a) Quadruped b) Sitting c) Side lying d) Standing ©Stanbridge University 2024 90 90  2/29/2024 Development- Learning Assessment 2. The Galant reflex helps the infant move through the birth canal during delivery. What position should the infant be in to assess this reflex? a) Held upright in vertical b) Prone or suspended prone c) Sitting d) Supine ©Stanbridge University 2024 91 91