1
Q
What is the purpose of reflex testing?
A
Diagnostically, reflex testing is used to:
* 1. Determine the gestational age of an infant
* 2. Determine the developmental “age” of a subject
* 3. Assess the development and integrity of the CNS
* 4. Determine the integrity of peripheral nerves
* 5. Plan and implement short and long-range treatment based on the inter-relationships between motor development and reflex development
2
Q
Describe the relationship between gestational and developmental age
A
- Some reflexes emerge prior to 40 weeks gestational age. If a baby is born prematurely, they should have some of those reflexes, and that will help the neonatologist to know the infant’s approximate age
- That, combined with other reflexes and motor assessment findings, can help them to pinpoint the premature infant’s gestational age.
- Knowing when the reflexes are present or are integrated, when reactions become present, as well as other motor skills attained, will help us to determine the developmental age or “age equivalent” of an infant or young child.
3
Q
How do you assess the integrity of CNS?
A
Reflex testing
- Weak/absent or exaggerated
- Asymmetrical (Never want automatic movements to be asymmetrical-Red Flag)
- Persists past the expected time of integration
- Obligatory (movement is dominated by the reflex) vs Habituation
4
Q
What are the types of reflexes?
A
1) Primitive reflexes/automatic movement patterns
2) righting reflexes
3) equilibrium reactions
5
Q
Describe Primitive reflexes/automatic movement patterns
A
- Infants are born with some stereotypical movements referred to as primitive or neonatal reflexes/movements that appear during gestation or at birth and are integrated by 6 months.
- Their function is primarily protective or to initiate some immature movements.
- The receptors are primarily tactile.
- For example, think of the rooting reflex. The rooting reflex is elicited when we stroke the baby’s face, and the response is that the baby turns their head /face toward the stimulus, in search of a food source. The stroking of the face is the tactile input/stimulus.
6
Q
What are some considerations for reflex testing?
A
- There must be a specific, accurate stimulus given.
- Adequate time must be allowed for a response to occur due to polysynaptic and segmental involvement.
- Responses may not always be full-blown or readily visible. Palpation may be needed to detect an emerging or minimal response.
*When a child is ‘outgrowing’ the age range when reflexes might be present, we need to allow enough time to view the response, and/or passively move an extremity to see if we can feel the impact of flexion, extension, etc. on the limb. It is not always that reactions are observed, but sometimes must be felt.
7
Q
What are some considerations for reflex testing? (Pt 2)
A
- Reflexes provide the foundation and prefabricated blocks upon which
volitional movement is built; however, individual responses must always
be correlated with each other and the assessment to determine their
significance. - Age ranges are only guidelines as normal development varies greatly (we
will talk about this more in other modules). The reflex performance of a
client is also dependent on internal factors such as their arousal state
(happy? crying? sleepy?), hunger, thirst, and body temperature. - External factors such as variations in head/limb position, environmental
temperature and clothing may also affect the response. - Finally, the role of the various portions of the brain in modifying reflexes and coordinating their integration is still under investigation
8
Q
What are the components of postural reflex/reactions?
A
- Postural Tone
- Righting Reactions
- Protective Extension Reactions
- Equilibrium Reactions
- Tilting Reactions
- Postural Fixation Reactions
9
Q
Describe postural tone
A
- When the weight of the body is put on a limb, the muscles automatically
contract; contraction/tone must be high enough to resist gravity, but low
enough to permit the intended movement in a controlled manner. - Tone changes during course of development. It develops gestationally (prior to birth) beginning with higher tone distally.
- At term birth, tone is initially lower proximally relative to distal body parts (i.e. hand grasp is seen in newborns, indicating higher baseline tone); it is also higher in UE’s relative to lower extremities.
- In mature distribution (adults), tone is higher proximally relative to distal tone; this provides proximal stability while allowing free movements distally (hands, feet). Additionally, mature tone is higher in LE’s relative to UE’s (perhaps due to more weight bearing requirements).
10
Q
What are the types of righting reactions?
A
1) Neck righting–if the head is turned, the body will re-align with the
head. This changes with age: in neonates, it involves rotation at
neck, but after 4 mos. of age, we see the rotation between the
pelvis and shoulders as well.
2) Head righting–head assumes normal position in space with the
mouth horizontal and face vertical.
3) Body righting–rotational movements which realign the body part if it is displaced in relation to the other body parts. This can be body on
head righting (if the body is rotated, the head tends to follow the body), or body on body righting (if the pelvis is rotated, the shoulders will tend to follow the pelvis, though it is also
demonstrated when the pelvis follows the shoulders).
11
Q
Describe righting reactions
A
- These are automatic reactions which bring the head and trunk into
normal alignment to each other and enable man to get into the upright
posture. - These reactions appear in infancy or childhood and persist throughout life.
- The receptors are primarily vestibular and proprioceptive. You use these to
help you get out of bed each morning; most of us will roll to our side, push
up with our hands to get into a sitting position, then rise to stand from
there. - There is a lot of rotation needed to get us into the upright position. When
you think of righting reactions, think of rotation.
12
Q
Describe equilibrium reactions
A
- Automatic responses to changes in posture and movement aimed
to preserve or restore balance. - These reactions are seen in the trunk, head, and extremities as the
center of gravity (COG) is displaced over the base of support (i.e. a
far reach). - Reaction depends on the speed and direction of the displacement;
generally, the head and trunk curve against gravity and the arms
and legs attempt to equalize the body over the base of support through abduction, flexion or extension, and finally, if the COG is displaced to the point of fall, the trunk will rotate. - These reactions occur in a sequence as the child develops and can
be elicited by displacement of the body while in prone, supine, sitting, all 4’s, kneeling, or standing. - In equilibrium reactions, maturation of one reaction is only completed after the child has moved on to next milestone–i.e. a child does not have complete balance or righting in sitting until after they have begun standing
13
Q
What are the types of equilibrium reactions?
A
1) protective reactions
2) tilting reactions
3) postural fixation reactions
These are automatic reactions which the body uses to maintain its center of gravity over its base of support, whether balance is displaced by volitional movement or an external force.
14
Q
Describe protective extension reactions (UE)
A
- Forward–When the body is displaced forward, the shoulders flex, the arms extend and abduct, the hands open; arms support on hands with contact on floor or object; seen beginning at 6-7 mos. of age.
- Sideways–When the body is displaced sideways, the arm in the direction of force abducts and extends at elbow and hand, support on hand with contact with floor or object; emerge at 7 mos. of age.
- Backward–When the body is displaced backward, the shoulders and arms extend, the hands open, and there is support on hands with contact on floor or object ; emerge at 9-10 mos. of age.
- Downward–(also called UE parachute reaction); When, from a vertical suspended position, the body is displaced down toward the supporting surface, the arms extend and abduct and the hands open. These are seen at the same age as the ‘forward’ ones.
15
Q
Describe protective extension reactions (LE)
A
- Staggering reactions–When the body is displaced forward, sideways and backward, the legs and feet will flex, extend, abduct and adduct to maintain the base of support under the center of gravity; seen beginning at 15-18 mos. of age (after ~3 months of walking experience.)
- Downward–(also called LE parachute reaction); When, from a vertical suspended position, the body is displaced downward vertically, the legs extend, abduct and externally rotate, the feet dorsiflex, and support is taken on legs with contact; emerge at 4 mos. of age.
*Remember, these are reactions, so they are seen as the child matures and remain present. We will be able to elicit these in each other in lab.
16
Q
Describe tilting reactions
A
- These are like equilibrium reactions, except that the base of support is displaced under the center of gravity (i.e. on a moveable surface).
- Like equilibrium reactions, the type and extent of tilting reactions depends on the speed and direction of displacement.
- These reactions look similar to the equilibrium reactions, and also occur in developmental sequence.
- In response to a mild perturbation, we will see a concave curve of the spine to upper side. With more rapid or pronounced tilting, will also see extension of extremities on upper side.
- Finally with very rapid or pronounced tilt, we will see extension
of extremities on both sides with rotation toward the tilt. - These emerge in prone (5 mos.), supine (7-8 mos.), sitting (7-8 mos.), all 4’s (9-12 mos.), then standing (12-21 mos.).
17
Q
Describe postural fixation (postural adjustments)
A
- The purpose of these is to brace and contract appropriate groups of
muscles to provide support and react against rotational or horizontal
forces (i.e. how you prepare when walking in mall and see a kid about
to run into you, or how you react after being bumped by said kid). - These reactions occur in developmental sequence as the child
develops against gravity and develop in a cephalocaudal direction within each developmental position. - Reactions first develop in an anterior-posterior direction (Sagittal plane), then laterally, and finally in a diagonal pattern.
- When seen prior to the disturbance, they are referred to as anticipatory, following the disturbance they are referred to as reactive.
18
Q
What do these reflexes/reactions provide?
A
- normal postural tone of moderate intensity, high enough to resist gravity, but low enough to permit movement
- normal reciprocal interaction of muscles for
* a. synergic fixation proximally to allow for selective mobility of distal segments (“skill”)
* b. automatic adaptation of muscles to changes of posture during movement
* c. graded control of agonists and antagonists integrated with that of synergists for timing and direction of movement (i.e. in protective extension of UE’s) - automatic posture and movement which is the background for voluntary,
functional activities
19
Q
Can reflexes/ reactions facilitate a large variety of active movement patterns and increase the client’s normal movement pattern?
A
Yes, normal postural reactions can be facilitated by carefully using appropriate exteroceptive or proprioceptive stimuli.
They may also provide a way to control the abnormal tone and patterns of movement seen in clients with CNS dysfunction (i.e. cerebral palsy).
20
Q
What is the purpose and origin/integration of Labyrinthine Head Righting?
A
Purpose: corrects orientation of the body when it is taken out of its normal upright position
Origin: 0-2 mo
Integration: persists throughout life
21
Q
What is the stimulus and response of Labyrinthine Head Righting?
A
Stimulus: (vestibular-otolith, proprioceptors-neck) subject blindfolded and held in vertical suspension or sitting. Tilt anteriorly, posteriorly, and to each side
Response: head orients to vertical position (face vertical, mouth horizontal). If tilted too far, will align with trunk
22
Q
What is the purpose and origin/integration of Optical Righting?
A
Purpose: helps the head orient itself using visual inputs
Origin: 0-2 mo
Integration: persists throughout life
23
Q
What is the stimulus and response of Optical Righting?
A
Stimulus: (vision) like “optical righting” but subject is not blind. Observation of movement
Response: rights head and body in relationship to environment
24
Q
What is the purpose and origin/integration of Landau?
A
Purpose: Helps develop the motor control of the back (posterior) body and relationship of horizontal and vertical perspectives of the body
Origin: 3-4 mo
Integration: 12-24 mo
25
What is the stimulus and response of Landau?
Stimulus: (Labyrinths, proprioceptors of neck and trunk) Horizontal suspension, supported only at abdomen or over lap
Response: Head raises, evoking a chain extension response to include shoulders, back hips, knees
26
What is the purpose and origin/integration of Neonatal Neck on Body Righting?
Purpose: to keep head in normal upright position or to support the head to come in an upright position
Origin: 34 weeks GA
Integration: 4-5 mo
27
What is the stimulus and response of Neonatal Neck on Body Righting?
Stimulus: (Propriocepive cervical spine) Turn subject’s head to one side
Response: body will follow in log-roll fashion
28
What is the purpose and origin/integration of Neonatal Body on Body Righting?
Purpose: to keep head in normal upright position or to support the head to come in an upright position
Origin: 34 weeks GA
Integration: 4-5 mo
29
What is the stimulus and response of Neonatal Body on Body Righting?
Stimulus: flex knee and rotate pelvis to one side
Response: head and upper trunk will follow in log-roll fashion
30
What is the purpose and origin/integration of Body Righting Acting on the Head?
Purpose: helps keep the body oriented with respect to the ground or surface regardless of the position of the head
Origin: 0-2 mo
Integration: 5 years
31
What is the stimulus and response of Body Righting Acting on the Head?
Stimulus: (Otoliths, tacile, proprio) (1) blindfolded in prone or (2) side lying, rotate hip across body
Response: (1) lits head or (2) trunk, then head will align with body
32
What is the purpose and origin/integration of Neck Righting Acting on the Body?
Purpose: Helps the body maintain its orientation in space and in relation to gravity
Origin: 4-6 mo
Integration: 5 years
33
What is the stimulus and response of Neck Righting Acting on the Body?
Stimulus: (proprioceptors of neck) rotate head to one side
Response: Trunk and LEs follow segmentally
34
What is the purpose and origin/integration of Body Righting Acting on the Body?
Purpose: helps keep the body oriented with respect to the ground or surface regardless of the position of the head
Origin: 4-6 mo
Integration: 5 years
35
What is the stimulus and response of Body Righting Acting on the Body?
Stimulus: (labyrinths proprioceptors lumbar area) flex hip, rotate across body (asymmetrical contact of body on support surface)
Response: upper trunk and head follow segmentally
36
List the equilibrium reactions
(ALL PERSIST THROUGHOUT LIFE)
1) visual placing
2) protective extension (UE)
3) protective extension (LE)
4) protective staggering (LE)
5) tilting
6) postural fixation
37
What is the origin and receptor of visual placing?
Origin: (UE 3-4 mo) (LE 3-5 mo)
Receptor: vision
38
What is the stimulus and response of visual placing?
Stimulus: Lower child towards support surface, as in propriocepive placing, but do not supply tacile input
Response: Same as in proprioceptive placing
39
What is the protective extension (UE) origin and receptor?
Origin: (UE forward or inverted 6-7 mo) (UE sideward 7-8 mo) (UE backward 9-10 mo)
Receptor: vestibular
40
What is the stimulus and response of protective extension (UE)?
Stimulus: UE Forward – hold in prone and plunge head towards support surface, or place in sit and displace balance forward. UE side/back- in sing, quickly displace balance sideward, backward
Response: Extension of appropriate extremity to catch self from falling
41
What is the origin and receptor of protective extension (LE)?
Origin: 4 mo
Receptor: vestibular
42
What is the stimulus and response of protective extension (LE)?
Stimulus: hold subject vertically and plunge feet towards support surface
Response: knee extension, with hip abduction and external rotation and dorsiflexion
43
What is the origin and receptor or protective staggering (LE)?
Origin: 15-18 mo
Receptor: vestibular (proprioceptive, visual)
44
What is the stimulus and response for protective staggering (LE)?
Stimulus: in standing, push subject quickly in all directions
Response: steps to catch self in appropriate direction
45
What is the origin and receptor of tilting?
Origin: (prone 6 mo) (suppine 7-8 mo) (sit 7-8 mo) (all 4’s 9-12 mo) (stand 12-21 mo)
Receptor:
1) vestibular
2) proprioceptive, vestibular
46
What is the stimulus and response of tilting?
Stimulus: place subject in selected position on a moveable base of support (ball, tilt board). Tilt equipment slowly in all directions. If tilt too far or too fast, may observe less advanced protective reactions
Response: trunk will laterally flex towards the “up” side. The head will then turn toward the up side as well as extension and abduction of the extremities on that side
47
What is the origin and receptor of postural fixation?
Origin: (prone 6 mo) (suppine 7-8 mo) (sit 7-8 mo) (all 4’s 9-12 mo) (stand 12-21 mo)
Receptor:
1) Vestibular
2) Proprioceptive, vision
48
What is the stimulus and response of postural fixation?
Stimulus: apply external force to the subject
Response: similar to tilting, but occur as a response to counterbalance an external force applied to the body. Also see Nile dorsiflexion, plantarflexion, inversion, eversion, in standing
49
List myostatic reflexes
1) Jaw
2) biceps
3) brachioradialis
4) triceps
5) finger flexors
6) hamstrings
7) quadriceps
8) Achilles
50
What is the stimulus and response of jaw reflex?
Stimulus: Patient is sitting, with jaw relaxed and slightly open. Place finger on top of chin; tap downward on top of finger in a direction that causes the jaw to open.
Response: jaw rebounds and closes
51
What is the stimulus and response of biceps?
Stimulus: Patient is sitting with arm flexed and supported. Place thumb over the biceps tendon in the cubital fossa, stretching it slightly. Tap thumb or directly on tendon.
Response: slight contraction of elbow flexors
52
What is the stimulus and response of brachioradialis?
Stimulus: Patient is sitting with arm flexed onto the abdomen. Place finger on the radial tuberosity and tap finger with hammer.
Response: Slight contraction of elbow flexors, slight wrist extension or radial deviation
53
What is the stimulus and response of triceps?
Stimulus: Patient is sitting with arm supported in abduction, elbow flexed. Palpate triceps tendon just above olecranon. Tap directly on tendon.
Response: Slight contraction of elbow extensors
54
What is the stimulus and response of finger flexors?
Stimulus: Hold hand in neutral position. Place finger across palmar surface of distal phalanges of four fingers and tap.
Response: slight contraction of finger flexors
55
What is the stimulus and response of hamstrings?
Stimulus: Patient is prone with knee semiflexed and supported. Palpate tendon at the knee. Tap on finger or directly on tendon.
Response: slight contraction of knee flexors
56
What is the stimulus and response of quadriceps?
Stimulus: Patient is sitting with knee flexed, foot unsupported. Tap tendon of quadriceps muscle between the patella and tibial tuberosity.
Response: slight contraction of knee extensors
57
What is the stimulus and response of Achilles?
Stimulus: Patient is prone with foot over the end of the plinth or sitting with knee flexed and foot held in slight dorsiflexion. Tap tendon just above its insertion on the calcaneus. Maintaining slight tension on the gastrocnemius-soleus group improves the response.
Response: slight contraction of plantarflexors
58
List superficial reflexes (cutaneous)
1) plantar
2) abdominal reflexes
59
What is the stimulus and response of plantar?
Stimulus: With blunt object (key or wooden end of applicator stick), stroke the lateral aspect of the sole, moving from the heel to the ball of the foot, curving medially across the ball of the foot.
Or
Alternate stimuli for plantar (for sensitive feet):
* Chaddock: stroke lateral ankle and lateral aspect of foot.
* Oppenheim: stroke down tibial crest
Response: Normal response is flexion (plan-tarflexion) of the great toe, and sometimes the other toes (nega-tive Babinski sign). Abnormal response, termed a positive Babinski sign, is extension (dorsiflexion) of the great toe with fanning of the four other toes (indicates UMN lesions). Same as for plantar.
60
What is the stimulus and response of abdominal reflexes?
Stimulus: Position patient in supine, relaxed. Make brisk, light stroke over each quadrant of the abdominals from the periphery to the umbilicus.
Response: Localized contraction under the stimulus, causing the umbilicus to move toward the stimulus.
(Above umbilicas = masked by obesity) (below umbilicas = Can be absent in both UMN and
LMN disorders)
61
List the primitive/spinal reflexes
1) flexor withdrawal
2) crossed extension
3) traction
4) Moro
5) startle
6) grasp
62
What is the o/i, stimulus and response of flexor withdrawal?
Stimulus: Noxious stimulus (pinprick) to sole of foot. Tested in supine or sitting position.
Response: Toes extend, foot dorsiflexes, entire LE flexes uncontrollably.
Onset: 28 weeks of gestation.
Integrated: 1-2 months.
63
What is the o/i, stimulus and response crossed extension?
Stimulus: Noxious stimulus to ball of foot of
LE fixed in extension; tested in supine position.
Response: Opposite LE flexes, then adducts and extends.
Onset: 28 weeks of gestation.
Integrated: 1-2 months.
64
What is the o/i, stimulus and response of traction?
Stimulus: Grasp forearm and pull up from supine into sitting position.
Response: Grasp and total flexion of the UE.
Onset: 28 weeks of gestation.
Integrated: 2-5 months.
65
What is the o/i, stimulus and response of Moro?
Stimulus: Sudden change in position of head in relation to trunk; drop patient backward from sitting position.
Response: Extension, abduction of UEs, hand opening, and crying followed by flexion, adduction of arms across chest.
Onset: 28 weeks of gestation.
Integrated: 5-6 months.
66
What is the o/i, stimulus and response of startle?
Stimulus: Sudden loud or harsh noise.
Response: Sudden extension or abduction of UEs, crying.
Onset: birth.
Integrated: persists.
67
What is the o/i, stimulus and response of grasp?
Stimulus: Maintained pressure to palm of hand (palmar grasp) or to ball of foot under toes (plantar grasp).
Response: Maintained flexion of fingers or toes.
Onset: palmar, birth; plantar, 28 weeks of gestation.
Integrated: palmer, 4-6 months; plantar, 9 months.
68
List the tonic/brainstem reflexes
1) asymmetrical tonic neck
2) symmetrical tonic neck
3) symmetrical tonic labyrinthine
4) positive supporting
5) associated reactions
69
What is the o/i, stimulus and response of assymetrical tonic neck?
Stimulus: Rotation of the head to one side.
Response: Flexion of skull limbs, extension of the jaw limbs,
"bow and arrow" or "fencing" posture.
Onset: birth.
Integrated: 4-6 months.
70
What is the o/i, stimulus and response of symmetrical tonic neck?
Stimulus: Flexion or extension of the head.
Response: With head flexion: flexion of UEs, extension of LEs; with head extension: extension of UEs, flexion of LES.
Onset: 4-6 months.
Integrated: 8-12 months.
71
What is the o/i, stimulus and response of symmetrical tonic labyrinthine?
Stimulus: Prone or supine position.
Response: With prone position: increased flexor tone/flexion of all limbs; with supine: increased extensor tone/ extension of all limbs.
Onset: birth.
Integrated: 6 months.
72
What is the o/i, stimulus and response of positive supporting?
Stimulus: Contact to the ball of the foot in upright standing position.
Response: Rigid extension (co-contraction) of the LEs.
Onset: birth.
Integrated: 6 months.
73
What is the o/i, stimulus and response of associated reactions?
Stimulus: Resisted voluntary movement in any part of the body.
Response: Involuntary movement in a resting extremity.
Onset: birth-3 months.
Integrated: 8-9 years.
74
What is the o/i, stimulus, origin, and response of spinal galant reflex?
(Tactile, proprio)
Stimulus: prone lying, stroke 1” lateral from spine from scap level to butt
Response: lateral flexion or skin wrinkling towards stimulated side
Origin: 28 weeks GA
Integration: 3 mo inconsistent, up to 9 mo to integrate
75
Explain absent, present, and fading when it comes to reflexes
absent: before origin or after integration
present: during origin and early integration
fading: mid and late integration
76
What is the o/i, stimulus, origin, and response of stepping reflex?
(Tactile, proprio)
Stimulus: support subject in vertical position under arms, incline trunk forward with feet on support surface
Response: several reciprocal steps will be taken
Origin: 37 weeks GA
Integration: 2 mo
77
What is the o/i, stimulus, origin, and response of tonic labyrinthine reflex?
Stimulus: position of head determines limb posture
Response: against gravity, head falls forward in flexion (UE/LE flex)
Head falls into extension (UE/LW ext)
Origin: birth
Integration: 4-6 mo
Lifespan
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