|ORIGINAL RESEARCH REPORT
|Year : 2016 | Volume
| Issue : 1 | Page : 12-16
Association of selected primitive reflex patterns with motor development among Nigerian children with cerebral palsy (a hospital-based study)
Cozens Bankole Aiyejusunle, Olajide Ayinla Olawale, Ngozi Florence Onuegbu
Department of Physiotherapy, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
|Date of Web Publication||2-Feb-2016|
Cozens Bankole Aiyejusunle
Department of Physiotherapy, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos
Source of Support: None, Conflict of Interest: None
Background: The retention of primitive reflexes (PRs) is considered to be one of the primary impairments associated with cerebral palsy (CP). However, little is known about the pattern of retention of PRs across the different classes of CP. Objectives: This study was undertaken to evaluate, identify, and describe selected PRs in children diagnosed with CP and to determine their association with motor development. Materials and Methods: This study was a cross-sectional analytical survey conducted in the physiotherapy departments of four conveniently selected public hospitals in Lagos metropolis. Thirty-one children diagnosed with CP aged between 18-84 months were recruited. A PR profile consisting of 15 PRs were evaluated. The World Health Organization (WHO) windows of achievement for six key motor milestones were employed to explore their motor development. Results: The placing reflex presented the highest pattern of persistence (12.96%) across all the classes of CP. Children with spastic CP had the highest mean sum of retained PRs (6.24 ± 2.36). There was no significant association between the sum of retained PRs and motor development (P > 0.05). In addition, there were characteristic patterns of responses for specific PRs. Conclusion: The pattern of retained PRs varies for the different classes of CP. There is no significant association between the retention of PRs and motor development for children with CP. There is a need for further, in-depth study of these reflexes, individually, to better understand how they influence the motor development of children with CP.
Keywords: Cerebral palsy, motor development, primitive reflexes
|How to cite this article:|
Aiyejusunle CB, Olawale OA, Onuegbu NF. Association of selected primitive reflex patterns with motor development among Nigerian children with cerebral palsy (a hospital-based study). J Clin Sci 2016;13:12-6
|How to cite this URL:|
Aiyejusunle CB, Olawale OA, Onuegbu NF. Association of selected primitive reflex patterns with motor development among Nigerian children with cerebral palsy (a hospital-based study). J Clin Sci [serial online] 2016 [cited 2019 Jul 18];13:12-6. Available from: http://www.jcsjournal.org/text.asp?2016/13/1/12/175481
| Introduction|| |
Primitive reflexes (PRs) may be retained in children with neurological disorders, and their retention is considered to be one of the primary impairments of children with cerebral palsy (CP)., PRs are brainstem-mediated automatic, stereotypic movement patterns in response to sensory stimuli that commence as early as the 12th week of gestation.
An individual with CP but with well-developed intelligence can learn to suppress these reflexes, but the reflex might resurface under certain conditions, e.g., during an extreme startle reaction. Reflexes may also be limited to those areas affected by atypical neurology, e.g., individuals with diplegia retaining the Babinski reflex in the lower limbs, while for those individuals with hemiplegia, the reflex may be seen in the foot of the affected side only.
Motor development refers to children's ability to control their body movement  and is usually assessed in terms of the age of achievement of motor milestones including sitting, hands-and-knees crawling, standing, and walking. The assumption that persistent PRs cause delayed motor development has been an integral part of physiotherapy interventions.,, For physiotherapists involved in the management of children with CP, PRs are one of the predictors of the attainment of motor abilities, especially ambulatory skills.,, These reflexes can contribute to the overall disabilities of children with CP and can result in psychological stress for the affected children as well as their families. However, there is little information about the association of PRs with the development of motor skills such as sitting, crawling, standing, or walking.
There exist contrasting views about the role of PRs in determining the outcome of motor function in children with CP.,,, While some researchers, like Fetters, are of the assumption that PRs may be adapted to accomplish functional movements, others have speculated that they may be markers indicating the severity of involvement rather than the cause of limitations in motor function., There is, therefore, a lack of consensus among researchers on the role of PRs, as far as physiotherapy interventions are concerned, in determining the outcome of motor function. Furthermore, little is known about the influence of PRs on the various types of CP and how evaluation of PR can contribute to clinical decision-making for physiotherapists.
Certain PRs [asymmetric tonic neck reflex (ATNR), crossed extensor reflex, sucking reflex] have been implicated in the delay in achievement of specific motor and functional skills;,, while others are considered to represent the basis for formulating motor prognosis or development in individual patients with CP.,, However, little is known about the pattern of persistence of the different PRs based on the types of CP and their association with motor development.
To the best of our knowledge, this is the first study conducted to evaluate PR patterns in children with CP in Nigeria. In addition, the diversity and pattern of responses of reflexes related to clinical manifestations and classification of CP and how clinicians can interpret them in a neurological context are unclear. This study is, therefore, aimed at evaluating the PRs expressed in children with CP and their influence on their motor development.
| Materials and Methods|| |
The participants in this study were recruited through convenience sampling technique, from the physiotherapy departments of four public hospitals in Lagos metropolis: Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos; Lagos State University Teaching Hospital (LASUTH), Ikeja, Lagos; General Hospital, Lagos Island; and the Child and Adolescent Unit of the Federal Neuropsychiatric Hospital, Yaba (FNHY), Lagos. Prior to the commencement of this study, ethical approval was obtained from each of these hospitals with the reference numbers ADM/DCST/HREC/936 (LUTH); LREC/10/06/316 (LASUTH); and FNPHY/ERC/13/068 (FNHY). Informed consent forms were given to the parents/caregivers to fill, and the details of the study were explained to them before their children were recruited. The study population comprised 31 children diagnosed with CP (19 males, 12 females). A PR profile of 15 PRs was evaluated including: Rooting reflex, sucking reflex, palmar grasp, plantar grasp, galant reflex, placing reflex, Babinski reflex, ATNR, symmetric tonic neck reflex (STNR), crossed extensor reflex, suprapubic extensor reflex, Rossolimo's reflex, heel reflex, tonic labyrinthine reflex (TLR), and Moro reflex. To explore their motor development, the World Health Organization (WHO) windows of achievement was employed for six key motor milestones for sitting, hands-and-knees crawling, standing with support, walking with support, independent standing, and independent walking., Descriptive statistics of mean, frequency, and percentage was employed to summarize data, while the Chi-square test was utilized to determine associations between variables. The individual PRs were summed up and utilized in data analysis.
| Results|| |
A total of 31 children diagnosed with CP participated in the study. Of them, 19 (61.29%) were males and 12 (38.71%) were females. Their ages ranged from 18 to 84 months. The mean age was 31.29 ± 15.47 months. The distribution of movement disorders included 17 (54.84%) spastic, 3 (9.68%) dyskinetic, 2 (6.45%) ataxic, 6 (14.35%) floppy, and 3 (9.68%) mixed type of CP [Figure 1]. All the children with mixed CP had a combination of spastic and dyskinetic CP. Based on the topographical distribution of impairment of the participants with spastic CP, 1 child had monoplegia, 4 were diplegic, 2 were hemiplegic, and 10 presented with quadriplegia. Based on the case note reports, in the majority (64.52%) of the cases, the etiology of the CP was unknown; otherwise, in 12.90%, the CP was secondary to bilirubin encephalopathy and in 16.13%, CP was secondary to birth asphyxia [Table 1].
|Table 1: Etiologic profile of the participants based on prenatal, perinatal, and postnatal events|
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Using the WHO scale for windows of achievement of six key motor milestones, the children were assessed for their level of motor development in sitting, crawling, standing, and walking [Figure 2].
The placing reflex showed the pattern of highest persistence among the participants as well as across all the classes of CP, with 21 (12.96%) of the participants retaining this reflex; the rooting reflex showed the pattern of lowest persistence (1.23%) [Table 2]. Based on the type of movement disorder, the participants with spastic CP showed the highest values for mean number of summed persistent reflexes (6.24 ± 2.26), while the participants with flaccid CP showed the lowest mean value of summed reflexes. Based on the topographical distribution of impairment, the participants with spastic quadriplegia had the highest mean number (6.20 ± 2.44) of sum of PRs [Table 3].
|Table 3: Distribution of PRs* based on movement disorder and topographical distribution of impairment (N=56)|
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The placing reflex showed a pattern of high persistence across all the classes of CP. For the children with flaccid CP, 11 reflexes, including the grasp and tonic neck reflexes recorded a frequency ≤25% among the participants, while for the children with ataxic CP, six reflexes had a frequency ≤25% including the ATNR, STNR, and TLR. All the reflexes of the children with mixed CP showed frequencies above 25% [Table 4].
There was no significant association between summed PRs and the achievement of motor milestones including sitting, standing with support, hands-and-knees crawling, walking with support, standing alone, and walking alone [Table 5].
| Discussion|| |
This study was conducted to describe PRs assessed in 31 Nigerian children diagnosed with CP. After reviewing the details of the classes of CP as well as the sum of PRs retained by each participant, the following noteworthy findings were made, which warrant further comment.
The study showed a pattern of high retention of the placing reflex across all the classes of CP. The placing reflex is a proprioceptive reflex, which is integrated at 6 weeks of postnatal life. The retention of this reflex implies damage to the brain centers that integrate the reflex, especially the cerebellum. It is, however, unclear what contribution a normal response makes to normal motor development, and it is therefore difficult to explain the implications of this reflex being retained in children with CP.
The children with spastic diplegia and hemiplegia manifested an asymmetrical pattern of persistence of reflexes, especially for the ATNR, palmar grasp, plantar grasp, Babinski, galant as well as STNR. Children with spastic hemiplegia tended to manifest responses on one side of the body (usually the affected side), while those with diplegia manifested responses for reflexes like the ATNR mostly in the upper limbs. The implication for this is that clinicians evaluating reflexes only on one side of the body may miss out on reflexes that manifest unilaterally. Also, these responses could be factored in to assist the clinician in predicting the topographical distribution of impairment for children with spastic CP.
The participants with ataxic CP all had absent ATNR, STNR, and TLR. The ATNR and STNR are reflexes that are mediated by the muscle proprioceptors of the neck , while the TLR is mediated by the otolith organ of the inner ear. Ataxic CP is caused by damage to the immature cerebellum. The cerebellum is involved in the development of balance and coordination, which in turn involves vestibular and proprioceptive feedback. Ataxic CP is characterized by unsteadiness, uncoordinated movements, and wide-based gait, and is often associated with nystagmus and tremors. However, since these children have all passed the age for integration of these reflexes, it is difficult to tell if these reflexes were integrated as a result of normal brain maturation, physiotherapy intervention, or if they have been absent since birth (i.e., abnormal response). The participants with ataxic CP also presented with a high persistence of the Moro reflex. Persistence of this reflex results in a constant state of fight or flight, high level of arousal, overreactions to stimulation, anxiety, and easy distractibility by unimportant stimuli., It is also noteworthy that none of these children had developed sitting, standing, or walking skills.
None of the participants in this study had achieved independent standing or walking skills, and as a result, these variables were computed as constants during the analysis. There was, therefore, no computed P value to assess the association between sum of PRs and achievement of independent standing or walking. It is important to note that the participants were all recruited from physiotherapy units where, for the children with CP who have reached the age of ambulation, the predominant presenting complaint in the case notes was “inability to walk.”
The findings of this study showed no significant association between the sum of retained PRs and the achievement of sitting, crawling, standing as well as walking skills. This refutes the assumption that the persistence of PRs can be considered as a marker indicating the severity of CP.,,,, The effect of biological maturation, as CP is a nonprogressive neurological disorder, may have accounted for the finding that there is no association of PRs with motor development. Nevertheless, the small sample size used in this study must be taken into consideration when comparing this study with that of other researchers.,,.
| Conclusion|| |
Most of the children diagnosed with CP have CP of unknown etiology. Children with spastic quadriplegia manifest a pattern of higher persistence of PRs, while children with flaccid CP retain the least number of PRs. There is no significant association between the sum of persistent PRs and motor development.
| References|| |
Schott JM, Rossor MN. The grasp and other primitive reflexes. J Neurol Neurosurg Psychiatry 2003;74:558-60.
Bartlett DJ, Palisano RJ. A multivariate model of determinants of motor change for children with cerebral palsy. Phys Ther 2000;80:598-614.
Bartlett DJ, Palisano RJ. Physical therapists' perceptions of factors influencing the acquisition of motor abilities of children with cerebral palsy: Implications for clinical reasoning. Phys Ther 2002;82:237-48.
Gardner SL, Carter BS, Enzman-Hines MI, Hernandez JA. Merenstein and Gardener's Handbook of Neonatal Intensive Care. New York: Mosby; 2011. p. 1-1040.
Berk LE. Child Development. 8th
ed. Illinois: Pearson; 2006. p. 126-8.
Adolph KE, Weise I, Marin L. Motor development. In: Lynn Nadel, editor. Encyclopaedia of Cognitive Science. London: Macmillan; 2003. p. 134-7.
Wijnhoven TM, de Onis M, Onyango AW, Wang T, Bjoerneboe GE, Bhandari N, et al
. Assessment of gross motor development for WHO multicentre growth reference study. Food Nutr Bull 2004;25:S37-45.
Bobath B, Bobath K. Motor Development in the Different Types of Cerebral Palsy. London, England: William Heinemann Medical Books Ltd.; 1975.
Campbell SK. Efficacy of physical therapy in improving postural control in cerebral palsy. Pediatr Phys Ther 1990;2:135-40.
Sugden D, Dunford C. Intervention and the role of theory, empiricism and experience in children with motor impairment. Disabil Rehabil 2007;29:3-11.
Montgomery PC. Predicting potential for ambulation in children with cerebral palsy. Pediatr Phys Ther 1998;10:148-55.
Olawale OA, Deih AN, Yaadar RK. Psychological impact of cerebral palsy on families: The African perspective. J Neurosci Rural Pract 2013;4:159-63.
Fetters L. Cerebral palsy: Contemporary treatment concepts. In: Lister M, editor. Contemporary Management of Motor Control Problems: Proceedings of the II STEP Conference. Alexandria, Virginia: Foundation for Physical Therapy; 1991. p. 219-24.
Scrutton D, Rosenbaum P. Locomotor development in children with cerebral palsy. In: Connolly KJ, Forssberg H, editors. Neurophysiology and Neuropsychology of Motor Development. London, England: MacKeith Press; 1997. p. 101-23.
Scherzer AL. Diagnostic approach to the infant. In: Scherzer AL, editor. Early Diagnosis and Interventional Therapy in Cerebral Palsy. 3rd
ed. New York: Marcel Dekker; 2000. p. 49-94.
Zafeiriou DI. Plantar grasp reflex in high-risk infants during the first year of life. Pediatr Neurol 2000;22:75-6.
Zafeiriou DI. Primitive reflexes and postural reactions in the neurodevelopmental examination. Pediatr Neurol 2004;31:1-8.
Blasco PA. Primitive reflexes. Their contribution to the early detection of cerebral palsy. Clin Pediatr (Phila) 1994;33:388-97.
Futagi Y, Toribe Y, Suzuki Y. The grasp reflex and moro reflex in infants: Hierarchy of primitive reflex responses. Int J Pediatr 2012;2012:191562.
World Health Organization. Windows of Achievement for Six Key Developmental Milestones. Available from: http://www.who.int
. [Last accessed on 2013 May 29].
WHO Multicentre Growth Reference Study Group. Relationship between physical growth and motor development in the WHO Child Growth Standards. Acta Paediatr Suppl 2006;450:96-101.
Palmer AC. Introduction to Animal Neurology. 2nd
ed. Oxford: Blackwell Scientific Publications; 1976.
Rathinam C, Bridges S, Spokes G, Green D. Effects of lycra body suit orthosis on a child with developmental coordination disorder: A case study. J Prosthet Orthot 2013;25:58-61.
Palmer M, Wyness MA. Positioning and handling: Important considerations in the care of the severely head-injured patient. J Neurosci Nurs 1988;20:42-9.
Straub K, Obrzut JE. Effects of cerebral palsy on neurophysiological function. J Dev Phys Disabil 2009;21:153-67.
Behrman RE, Kliegman R, Jenso HB. Newborn Reflexes. Nelson Textbook of Pediatrics. 16th
ed. Philadelphia: W.B. Saunders; 2000. p. 1125-6.
Lehman RK, Schor NF. Neurologic evaluation. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, editors. Nelson Textbook of Pediatrics. chap. 584 19th
ed. Philadelphia: Saunders Elsevier; 2011.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]