What are Primitive Reflexes? Correlation to Theories ...The NDT/Bobath(Neuro‐Developmental...
Transcript of What are Primitive Reflexes? Correlation to Theories ...The NDT/Bobath(Neuro‐Developmental...
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Session 306: Integrating Primitive Reflexes to Improve Emotional Regulation & Coping Skills
Janine Wiskind, MS, OTR/L
Leading the Way in Continuing Education and Professional Development. www.Vyne.com
• What are Primitive Reflexes? Correlation to Theories?Research?
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NEUROPLASTICITY
• Neural connections are either made or dissolved depending on the stimulation received
• Hebb’s Axiom – what wires together fires together
• Dr. Norman Doidge
• Dr. Michael Merzenich
• Dr. Paul Bach y Rita – activity dependent neuroplasticity
ACTIVITY-DEPENDENT PLASTICITY
• During engagement in activity,
• signaling molecules (ex: dopamine, glutamate)
• facilitate synapsing (excitatory or inhibitory)
• which alters gene expression and allows the brain to rewire itself.
NEURO - PLASTICITY AND THERAPY
• Analyze movement to determine foundational skill levels
• Engage in movement to achieve activity dependent plasticity
• Activity dependent plasticity maximizes a child’s potential in function and activities of daily living
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Theoretical Frameworks Supporting Primitive Reflex Integration Theory
THEORIES
• Rood Approach• NDT/Bobath: Neuro‐Developmental Treatment/Bobath
• PNF: Proprioceptive Neuromuscular Facilitation
• Brunnstrom Approach
ROOD APPROACH• Theoretically based on the Reflex and Hierarchical Model of Motor Control and provides the origins for many of the facilitation techniques used today
• Focuses on sensory stimulation and ontogenetic motor development (normal progression of motor skills along the developmental continuum)
• Cutaneous stimulation – light touch, brushing
• Proprioceptive stimulation – heavy joint compression, quick stretch, tapping, vestibular stimulation, vibration, neutral warmth, light joint compression
• Reflexes are used to influence muscle tone and facilitate typical movement patterns
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NDT/BOBATH• “NDT is a holistic and interdisciplinary clinical practice model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. An in‐depth knowledge of the human movement system, including the understanding of typical and atypical development, and expertise in analyzing postural control, movement, activity, and participation throughout the lifespan, form the basis for examination, evaluation, and intervention. Therapeutic handling, used during evaluation and intervention, consists of a dynamic reciprocal interaction between the client and therapist for activating optimal sensorimotor processing, task performance, and skill acquisition to enable participation in meaningful activities.”
Instructors Group of NDTA. (2016, May 27). The NDT/Bobath (Neuro‐Developmental Treatment/Bobath) Definition. Retrieved from http://www.ndta.org/whatisndt.php
NDT/BOBATH
• Re‐learning normal movement patterns with a focus on the quality of movement
• Focuses on alignment and symmetry
• Focuses on mastering forward flexion with rotation in order to break up extensor tonal patterns
• Focuses on weight shift using our own natural body forces• Every point of mobility has a point of stability
PNF
• Focuses on movement patterns that are diagonal and resemble typical movement
• Focuses on the developing sequence of movement and how the agonist and antagonist muscles work together to produce volitional movement
• Uses reflexive movement as a basis for learning more volitional movement following the theory that a child must be able to roll before he can crawl and crawl before he walks
• Uses a multi‐sensory approach incorporating tactile, auditory, and visual systems.
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BRUNNSTROM APPROACH
• The basic premise is that in typical development, spinal cord and brain stem reflexes become modified during development, and their components are rearranged into purposeful movement by the influence of higher centers. Since reflexes represent normal stages of development, they can be used when the central nervous system has reverted to an earlier developmental stage
• Reflexes should be used to elicit movement when none exists (normal developmental sequence)
• Proprioceptive and exteroceptive stimuli can be used therapeutically to evoke desire motion or tonal change.
WHAT ARE PRIMITIVE REFLEXES
Innate, typical, and involuntary movement
patterns
Teach developmental sequence of movement
The body learns through the experience
the movement provides
The child acquires higher level motor skills, which, in turn,
support higher level executive functioning skills
A given reflex opens and activates the neural pathways, conducting
the impulse to the different structures in the brain – in other words, it facilitates activity
dependent plasticity
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TYPICAL DEVELOPMENT
Promotes the appropriate use of primitive reflexes
Activity dependent plasticity (primitive reflex movement patterns) establishes mature neural connections
Promotes integration of primitive reflexes at the appropriate ages ‐rewires/fine tunes neural pathways and movement patterns
When that does not happen….
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PRIMITIVE REFLEXES AND ANXIETY
RATES OF ANXIETY
• 31.3% and 41.96% co‐morbidity with ADHD in two recent studies
• 40%‐70% within Autism
• Students with newly diagnosed learning difficulties have greater odds of being “clinically anxious” relative to their regular peers
• 1 in 4 children (did not specify typical or atypical) have anxiety
POPULAR APPROACHES TO ADDRESS STRESS/ANXIETY• Top Down vs Bottom Up
• Cognitive Behavioral Therapy
• Exposure Therapy
• Relaxation Techniques
• Biofeedback
• Hypnosis
• Exercise
• Mindfulness
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upfrom the bottomstress/anxietyAddressing
WHY ASSESS POSTURE?
• “Posture means unconscious, inattentive, anti‐gravitational adaptation to the environment. When reflex actions are functioning efficiently and at a developmentally appropriate level, they free higher cognitive systems in the brain from conscious involvement in the maintenance of postural control. Conversely, if reflexes are not functioning in an age‐appropriate fashion, then conscious attention must be diverted to the adaptation and maintenance of postural control at the expense of attention to other cognitive tasks.”
Sally Goddard Blythe, 2014 p. 7‐8.
POSTURE
Analysis of posture and movement patterns identifies dysfunction
Addressing posture and movement patterns rewires the brain – it supports integration of visual, proprioceptive, and vestibular systems, and, in turn, enhances cognitive processes….
….and ultimately supports better coping skills and reduction of stress
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PRIMITIVE REFLEXES INVOLVED IN STRESS/ANXIETY
• Tendon Guard Reflex
• Moro Reflex• Fear Paralysis Reflex
LIMBIC SYSTEM• Activates the flight/fright system
• Constantly assesses the external world for perceived threats
• Regulates emotions, play, social behaviors, and curiosity
• Proper function depends on stimulation from the tactile, proprioceptive, and vestibular systems.
• “The main emotional problem of children today is that they haven’t moved enough. Many doctors don’t make the link between inactivity and behavior problems.” –Harold Blomberg, MD.
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TENDON GUARD REFLEX
TENDON GUARD REFLEX• The tendon guard is an automatic, whole body response to messages from the brain stem
• It has important ramifications for survival, protection and development
• There are times in which high levels of stress call forth the TGR – it supports activation of the freeze, flight, fright response
• The body and brain support each other in regulating so that the stress is alleviated through various cognitive, physical, and chemical mechanisms.
• Chronic stress (anxiety) can cause the reflex to remain active without conscious awareness, causing an individual to be “primed” for a lower stress threshold.
TENDON GUARD REFLEX
• Consider being alone at home and hearing an unexpected noise….
• What is your posture? • Abdominal, shoulder, and neck muscles contract (freeze response)
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• Spinal muscle contraction, lifting and extending of the spine, shortening of Achilles getting us ready to run (flight response)
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IMPLICATIONS OF POOR INTEGRATION• Red Light reflex: (freeze)
• an excessively narrow attention field and limited ability to act
• Behavior becomes compulsive, over‐focused on unimportant details
• Perseverative or shut down responses
• excessive withdrawal and self‐protection
• Green Light Reflex (flight)• excessive widening of the attention span
• chaotic, uncontrolled, impulsive movement
• Over‐reactive/flight responses to stress
• excessive engagement and inappropriate risk taking
ASSESSING TGR
• Structurally, the TGR activates a tendon/muscle/joint system comprised of the big toe, the foot tendon, the Achilles tendon, the hamstrings, the sacrum, the spine, various back and neck muscles, and the occiput.
• Assess tension held in legs, sacral, thoracic, and cervical areas in standing or supine
ASSESSMENT IN SUPINE
• Notice the position of the head – chin extended?
• Measure the distance of the shoulders from the floor
• Measure the hip flexors:
• Bring one knee toward the chest and observe the other leg
• Assess tension in the Achilles and big toe
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RELEASING TENDON GUARD• Use your knowledge of stretching protocols, myofascial, tension release programs
FEAR PARALYSIS
REFLEX
FEAR PARALYIS REFLEX• One of the first reflexes to emerge in utero at 5‐7 weeks
• Supports a protective role – reduces the demand on the fetus by activating the parasympathetic nervous system and initiating the freeze response:
• Motor paralysis
• Restricted peripheral blood flow• Lowered heart rate• Protects the fetus from stress hormones released by the mother when she is placed into a flight/fright response
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POOR INTEGRATION OF THE FEAR PARALYSIS REFLEX• Low tolerance to stress• Constant state of anxiety• Tends to “freeze” when there is a threat, instead of fight or flee
• Sensory processing issues• Hypersensitivity to light and sound• Does not adapt to change well• Overly clingy
POOR INTEGRATION OF THE FEAR PARALYSIS REFLEX• Extreme fatigue
• Deer in the headlights response
• Selective mutism (not speaking in situations where talking is expected, especially if speaking is already an established ability)
• Holding breath when upset or angry
• Obsessive‐Compulsive Disorder (OCD) traits
• Defiant or controlling behavior
TESTING
• Qualitative observations• Eye Contact• Aversive to touch• Removes self from close proximity to therapist/peers when stimulation increases
• Walking Test with eye contact
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TREATMENT IDEAS
MORO REFLEX
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MORO REFLEX
MORO REFLEX
Protective role for the developing infant – produces automatic response to sudden stimuli
Appears in utero 9‐12 weeks
Initiate the first breathe
Triggers extension after 9 months of flexion
Whole body response diminishes 4‐6 months and replaced by Strauss Reflex
MORO PHASES
• Phase 1: • Avoidant response to possible danger
• Head extension, arms into high guard with extended fingers, gasp of air and hold
• Phase 2• Protective response (grasping)
• Head into flexion, hips flex, arms fold across chest, fists clench, breathe out, cry for help
• Protects the more vulnerable parts of the body
• Allows child to hold and cling to caregiver
Phase 3: Recovery
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MORO TRANSITION TO STRAUSS REFLEX• Adult startle takes over around 4‐6 months
• An individual may raise shoulders, blink, relax, locate source of stimuli, and then resume activities
• It teaches an individual to habituate to irrelevant sensory stimuli and filter out relevant stimuli from background stimuli.
POOR INTEGRATION OF MORO
• Overactive as an Infant: • “walking on eggshells” as an infant• Fussy• Clingy• Difficulty staying asleep• Difficult to comfort
• Dislike affection• Insecure
POOR INTEGRATION OF MORO REFLEX
• Visual problems: distractible and inattentive interfering with focus on detail
• Vestibular challenges: poor balance and coordination; motion sickness
• Behavior: higher stress• Excess secretion of cortisol and adrenaline with frequent activation of flight/fright system which then fatigues adrenal glands
• This, in turn, can weaken immune system
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POOR INTEGRATION OF MORO REFLEX
• Social: dislike change, poor adaptability• Withdrawn
• Overbearing and controlling
• Generalized insecurity and/or anxiety• Aggressive outbursts
MORO REFLEX: TESTINGChild lies supine with knees up and feet flat
Instruct, “I am going to sweep your feet straight. Tell me when you are ready”Observe: tension or a “bounce” in the hips Legs retract back up into starting position Startle or reactive response Giggle
MORO REFLEX: TESTING
Instruct, “I am going to make a loud noise by your ear. Tell me when you are ready”
Instruct, “I am going to wave my hand in front of your eyes. Tell me when you are ready” Intake of breath Reddening of skin or pallorWithdrawal after testing Giggling
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MORO REFLEX: TREATMENT SUGGESTIONS
THINK ABOUT THE PATTERN….
Activation of the flexor pattern in Moro Phase 2 supports integration of Moro
ACTIVITY SUGGESTIONS
Rocking HorsePiggy Back“Baby Monkey”
Koala bearHugging adult legSupine flexionPull to sitBolster swing
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CASE STUDY DISCUSSION
CHRIS
• 15 years old• Stroke at 2 days old – hemiparesis
• Long history of therapies ‐ $400,000• Functional Concern: severe startle resulting in left‐sided spasm with strong head turn to left and extension through arm and leg or head turn with flexor synergy pattern
EVALUATION
Posture in supine
Reaching for toes
Sitting on haunches
Primitive Reflex Assessment
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TREATMENT
Decrease tendon guard
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Bring in and integrate ATNR
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Integrate MORO
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