Week 3:Postural Control & Primitive Reflexes

Integration

•Typically integrate in 1^st year of life

•When a reflex is “integrated” it has developed into a more mature movement pattern.

•The reflex is no longer present

Persistence

RETAINED

May indicate atypical development

The reflex is still present

The more mature movement pattern has not developed

Child did not experience enough movement related to that reflex and the response.

Palmar Grasp Reflex

Onset: Birth

Integration: 5-6 Months

Voluntary Grasp replaces it

Automatic flexing fingers to grab objects

Retained Reflex:

Poor manual dexterity

Poor pencil grip

Messy handwriting,

Increased Oral Overflow

Palmar Grasp: Strategies to Integrate

Promote proximal stability & strength: activities that encourage stability of joints and strengthening of muscles

Provide proprioceptive input to promote weight bearing to the palm.

Activities to help promote gross grasp, strength and release

In Hand manipulation activities

Promote integration of Extension of Index finger in (grasp)

Pincer grasp

Open Web Space

Radial Digital Grasp

Case Example of palmar grasp reflex

10m old female baby with PMH of torticollis and low tone.

OT referral: Increased flexion of digits when crawling

Standardized Assessment: PDMS-2

Grasping Standard score 6; VMI standard score 7 (Below average)

Grasp

Immature grasp with ulnar side of hand; gross raking without thumb, no clear open web space

Index finger not integrated with grasp; pincer grasp not observed

VM:

Poor precision with Put in tasks (removing pegs) Poor graded control (placing cubes in cup)

Intervention: WB with full wrist and digit extension; Promote radial digital grasp, Graded control with grasp and release (put in tasks), Pincer grasp,

Primitive Reflexes : MORO Reflex

Onset: 28 Weeks Gestation

Integration: 4-6 Months

Occurs in response to unexpected changes

Function: Flight or Fight Response

Test: Rapidly Drop Head Backwards

Response

Phase 1: Arm Extension & Abduction

Phase 2: Arm Flexion & Adduction

Strategies to Integrate Moro Reflex

Target Vestibular System

Rocking, rhythmic activities

Element of surprise

Sudden shifts in proprioceptive input (on standing surface)

Adapt Environment

Tummy Time

Swaddling Transition

Moro Reflex: Additional Interventions

Vestibular Input via Climbing Courses

Consider Change in

Direction

Speed

Angle

Orientation

Primitive Reflexes: Asymmetrical Tonic Neck Reflex (ATNR)

Onset: 37 Weeks Gestation

Integration: 4-6 Months

Function: Precursor to Hand Eye Coordination

Rolling over stomach

Crawling

Reading/writing

Test: Position Baby in Supine & Rotate Head to 90 Degrees.

Response

Face Side: Arm Extension

Skull Side: Arm Flexion

Persistence Effects of ATNR

Unable to Cross Midline (eyes/hands)

impacts creeping and crawling

Poor Reading Comprehension

Poor Visual Tracking & Eye Pursuits

Poor Handwriting

Poor Hand Eye Coordination

Poor bilateral coordination

Writing compensations: tight pencil grasp, turning paper, decreased fluency, extended arm, writing w/ slant, letter reversals

ATNR Strategies

Crawling in tunnel

Tummy time

Crossing Midline activities

Passing ball to each other and child watches as it swings side to side

ATNR Goal

Promote Head and UB dissociation

Consider variability in practice

Supine

Prone

Tall kneel

Four point

Primitive Reflexes: Tonic Labyrinthine Reflex (TLR)

Onset: 37 Weeks Gestation

Integration: 6 Months

Function:

Development of Balance, Body Position & Stability

Balances Flexion and Extension Tone

Head Neck Alignment and control

Body/Head Trunk Dissociation

there are 2 aspects of TLR: TLR PRONE and TLR Supine.

Retained: TLR: prone flexion and supine extension

persistence effects of TLR

Difficulty with Prone Extension (Increased Flexor Tone)

Difficulty with supine to sit (Increased Extensor Tone)

Poor Posture (W sit)

Poor Coordination

Impacts Auditory Processing

Impacts Visual Perception

Low muscle tone

Decreased chin tuck (impacts feeding)

strategies of TLR

Anti-gravity Movement Exercises

Prone Extension

Supine Flexion

Landau reflex

Symmetrical Tonic Neck Reflex (STNR)

Onset: 4-6 months

Integration: 8-12 Months

Function: Precursor to Crawling – (Static Quadruped Position)

disassociation of the upper and lower body

Persistence Effects of STNR

Difficulty sitting up from supine

Poor muscle tone and posture (W-sit)

Impacts Focus

Postural Control

Foundation for movement

Postural stability allows for distal mobility

Ability to control center of mass in relation to base of support

Postural Reflexes

Supine Flexion

Prone Extension

Postural Control and Function

Developmental positions

Functional mobility

Transitions

Seated Posture

Impacts reach and FM milestones

Driven by Occupation

Facilitating Functional Movement

Observe what child can do in each functional position

Stationary and Dynamic

Start by Promoting Alignment

Example

Goal: Pt will demonstrate improved postural control by sitting upright in chair without compensations (trunk lean, UE support) during 5 minute activity with minimal cueing in 4/5 trials.

Facilitation of Reach

Facilitate weight bearing on forearms or hands

Facilitate efficient weight shift and equilibrium responses

Improve control of isolated & dissociated extremity movements

transitional (dynamic) movement

Prone to Sit

Sit to 4 point

4 point to Tall Kneel

Tall kneel to stand

Neurodevelopmental Therapy (NDT)

Can help children adapt movement when they lack variety in movement or show compensatory patterns

Primarily designed for children with CP; Utilizes concepts from MC/ML

Lack of adaptability in movt. patterns to accommodate task demands & environmental constraints leads to motor dysfunction

Meaningful engagement in wide variety of activities can help develop posture and core muscle control for coordinated movement

Engaging children in Typical Movement with Therapeutic Handling Techniques

Primary focus- inhibit spasticity & primitive reflexes and facilitate normal movement patterns

Ex. Increased Internal rotation at shoulder, pronation, wrist flexion adduction versus External rotation, supination, horizontal abduction, & wrist extension.

Examples of intervention techniques typically used using this model-

Facilitate weight bearing on forearms or hands

Facilitate efficient weight shift and equilibrium responses

Improve control of isolated & dissociated extremity movements

No evidence demonstrating use of NDT techniques to improve hand function of children with CP

Studies have shown that specific handling techniques used in NDT does not improve function in children with CP

Motor Learning is more effective than NDT for retention of motor function (Khanna et al. 2023)

Ideas & concepts from NDT have “deepened therapists’ understanding of CP and other muscle tone impairments” (Case-Smith & Exner, 2015, p. 239)

proximal points of control

Downward Pressure at Pelvis to guide Transition

from side sit to short sit'

Stabilizing Trunk to Promote Selective

UE reach

Distal Points of Control

Facilitating Alignment FOR Function

Stationary tasks

Consider use of equipment

Points of Control