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256 Relationship between Primitive Reflexes in

Stroke Patients and Rehabilitation Outcome


JULIE G. BOTVIN, M.D., ROBERT ALLEN KEITH, PH.D., AND MARK V. JOHNSTON, M.A.

SUMMARY The reappearance of developmental reflexes in the usual medical admission examination. Functional status ratings for
aged has been found to be associated with severe, diffuse cerebral self-care and mobility at discharge, and the setting to which the
damage. This study examined the relationship between the presence patient was discharged, were used as outcome criteria. All of the
of such reflexes in stroke patients and the outcome of rehabilitation. reflex signs were negatively related to a favorable outcome, but the
Tests for the presence of snout, suck, jaw-jerk and palmomental correlations were not high enough for predictive value. The mental
reflexes were tested in 106 consecutive stroke patients admitted for status measures were more highly related to rehabilitation outcome
rehabilitation treatment. A mental status test was also included in the than were the presence of developmental reflexes.

PAULSON AND GOTTLIEB1 have observed that that the same reflex was very common in organic cerebral
demented senile patients may exhibit a number of primitive disorders and concluded that it was a reasonably reliable in-
neurological reflexes which are also present in the earliest dicator of encephalopathy. While Blake and Kunkle8 felt
stages of ontogenetic development. In this group of related that the inconsistency of the palmomental reflex restricted
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responses they examined 7 reflexes seen in aged populations its usefulness, they did find the accentuated response was
which also occur during normal fetal development. It was frequently seen in patients with diverse forms of cortico-
their opinion that the reappearance of such reflexes in the bulbospinal tract disease, especially when bilateral.
aged is almost always attributable to diffuse, bilateral and Hildenhagen and Schiffter8 examined 86 residents from
irreversible CNS disease. several homes for the aged and found a number of aberrant
The glabellar tap reflex has been considered a sign of neurological signs. This population was quite old, with an
Parkinsonism, but Pearce, Aziz and Gallagher2 dem- average age over 86 years. The most frequent developmental
onstrated the existence of an exaggerated response not only reflex was an oral motor response from tactile stimulation,
in Parkinsonism but also in a group of patients with other found in 40.7%. The palmomental pattern was seen in
cerebral pathology. They concluded that the reflex was a 29.1%. These authors conclude from their results that the
nonspecific sign of extensive cerebral destruction. Klawans presence of primitive reflexes is related to age-dependent
and Goodwinc found that a positive glabellar response was changes of the CNS.
reversible with L-dopa therapy in a group of patients with The appearance of primitive reflexes in the aged seems to
Parkinsonism. The failure of an L-dopa regimen to reverse be associated with the lack of inhibitory mechanisms in
the reflex in patients with clinical evidence of organic higher centers. They have been seen frequently in patients
dementia led these authors to conclude also that the ex- with severe, diffuse, cerebral damage. The fact that some
aggerated glabellar response might result from diffuse cor- responses have also been observed in populations without
tical disease. any other manifestation of neurological abnormality in-
While there is some agreement that the presence of troduces a note of caution about whether all such reflexes
developmental reflexes in older adults may be indicative of should be viewed as a sign of serious CNS pathology. The
widespread cortical damage, the utility of such signs for possibility exists, however, that individuals exhibiting these
diagnosis is far from settled. One problem in the examina- reflexes may have a diminished capacity for learning. If such
tion of the aged is whether abnormal neurological signs are were the case, it might be possible to predict a patient's
the result of pathology or are the consequences of normal response to rehabilitation treatment. The purpose of this
aging. Critchley4 has looked at both sides of the controversy. study was to examine the relationship between the presence
He cautions that standards of normality are different in the of developmental reflexes in a group of stroke patients and
aged from those in adulthood; certain neurological changes their progress in rehabilitation.
are seen so frequently that they must be discounted as
evidence of disease. After finding aberrant neurological Method
signs to be common in a group of 200 supposedly healthy
male pensioners, Howell5 also warned against making mis- Four developmental reflexes frequently seen in aged pop-
diagnoses in the elderly. ulations were selected for study: snout, suck, jaw-jerk and
palmomental. Tests for the presence of these responses,
In an investigation of 800 Japanese individuals, Otomo6
along with those routinely performed for left and right
found the palmomental reflex to be present in 53% of a
extensor-plantar reflexes, were included in the usual medical
group over age 60 with no other neurological manifesta-
admission examination for 106 consecutive stroke patients.
tions. In those with hemiplegia or hemiparesis, the oc-
The reflex response was graded as absent, present or
currence of the reflex was 70%. August and Miller7 observed
strongly present. The palmomental response was regarded
as positive whether it was seen on one side or bilaterally.
From Casa Colina Hospital for Rehabilitative Medicine, 255 East Bonita A simple mental status examination was also ad-
Ave., Pomona, CA 91767. ministered to all patients without aphasia. Of the 106
Presented at the 53rd Annual Meeting, American Congress of Rehabilita- patients, there were 29 who were aphasic and 77 who were
tion Medicine, San Diego, CA, November 12, 1976.
Reprint requests to Dr. Botvin, Casa Colina Hospital for Rehabilitative able to communicate verbally. The mental status test con-
Medicine, 255 East Bonita Ave., Pomona, CA 91767. sisted of 2 parts. In the orientation section there was 1 ques-
PRIMITIVE REFLEXES IN STROKE/florv/n et al. 257

TABLE 1 Distribution of Reflexes in 106 Stroke Patients


Level
Reflex Absent Present Strongly present Not graded
Suck 83 80.6 16 15.5 4 3.9 3
Snout 50 48.5 42 40.8 11 10.7 3
Jaw-jerk 69 69.0 25 25.0 6 6.0 6
Palmomental 78 74.3 16 15.2 11 10.5 1
Extensor-plantar, left 69 65.7 27 25.7 9 8.6 1
Extensor-plantar, right 69 65.0 26 25.2 10 9.7 3
Total mean 69.7 67.2 25.3 24.6 8.5 8.2

tion each regarding time, place and person (3 points). In Gottlieb,1 although their sample was comprised of patients
other cognitive tests, there were 2 subtractions of 7's from with senile dementia. The suck reflex, observed by these in-
100 (3 points), naming the last 4 presidents (4 points), and vestigators in 53% of their patients, was present in only
interpretation of 2 proverbs (2 points). 19.4% of stroke patients. The jaw-jerk response was seen
Two kinds of data were used as measures of rehabilita- somewhat more frequently in the present study 31.0% to
tion outcome: functional status ratings at discharge and dis- 18% in the Paulson and Gottlieb population. The presence of
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charge destination. Ratings at admission and discharge for the palmomental reflex was fairly similar in the 2 studies,
11 tasks of self-care and mobility were given by physical and 25.7% to 21%. Otomo 6 reported a much higher incidence of
occupational therapists working with the patient. The tasks this response (70%) in a group of hemiplegic and
were: eating, personal hygiene, grooming, bowel function- hemiparetic patients. In the present study, an extensor plan-
ing, bladder functioning, bed activities, dressing, transfers, tar response (Babinski) was present on either side in about a
wheelchair activities, ambulation on level surfaces, and the third of the cases.
use of stairs. A rating scale with values from 1 to 4 was used: The relationship between the presence of reflexes and out-
1 — completely dependent, 2 — requires physical assistance, come criteria was analyzed by means of Kendall's tau, a
3 — requires supervision only, and 4 — completely indepen- rank order correlation appropriate for ordinal data. 11 Table
dent. The functional status score was the sum of the 11 2 is a summary of that analysis. It is apparent, first of all,
ratings with a possible maximum of 44. that all of the reflex signs are negatively related to a
Discharge destination was ranked according to a favorable outcome on either functional status or discharge
hierarchy of independence: 1 — alone in a private residence, destination. On the other hand, the sizes of the correlations
2 — with someone else in a private residence, 3 — in a for any of the reflexes or their total are low. The snout and
custodial care facility or boarding home, 4 — in a skilled palmomental reflexes are most strongly related to both
nursing facility, or 5 — in a hospital. criteria, but the magnitude of the relationship is not high
The sample of 106 patients ranged in age from 30 to 88 enough to be of much predictive value.
years with a mean of 68.7 years. There were 48 males and 58 Table 3 shows the association between reflexes and the
females. The average length of stay for their rehabilitation two sets of mental status measures: orientation and other
program was 35 days, very close to that in a sample of 1,443 cognitive tests (serial 7s, names of presidents and proverb in-
stroke patients in 20 rehabilitation hospitals reported by terpretation). Although the various reflexes are all
Keith, Breckenridge and O'Neil.10 negatively related to mental status measures, only 2 of the
correlations are even weakly significant. In this study there
is virtually no relationship between reflex signs and perfor-
Results mance on mental status examinations.
In the distribution of reflexes (table 1) there was an In Table 4 the fairly strong correlations between the 2
average of 32.8% graded as present or strongly present. The mental status measures and functional status at discharge
snout reflex was most common, in 51.5% of the patients. The are the highest associations of the study. The mental tests
incidence is very close to that found by Paulson and are also related to discharge destination but not as well. The

TABLE 2 Relationship between Reflexes and Outcome Criteria TABLE 3 Relationship between Reflexes and Mental Status
Outcome Measures
Average functional Discharge
status at discharge destination Otheir
Reflex Tau p Tau p Orientation cognitive measures
Reflex Tau p Tau P
Suck -.10 .150 -.09 .060
Snout -.27** .003 -.21** .003 Suck -.13* .030 -.07 .180
Jaw-jerk -.09 .180 .07 .170 Snout -.06 .230 -.11 .140
Palmomental -.21* .013 -.17** .003 Jaw-jerk -.03 .370 -.01 .440
Extensor-plantar, left -.07 .220 -.001 .490 Palmomental -.11 .070 -.19* .020
Extensor-plantar, right -.17* .040 -.005 .470 Extensor-plantar, left -.09 .130 -.04 .350
Extensor-plantar, right -.06 .160 .00 .500
Total reflexes -.27** .003 -.15* .016
Total reflexes -.16* .030 -.09 .170
•Significant at the .05 level.
••Significant at the .01 level. •Significant at the .05 level.
258 STROKE VOL 9, No 3, MAY-JUNE 1978

TABLE 4 Relationship between Mental Status Measures and care and mobility tasks after a course of rehabilitation
Outcome Criteria therapy.
Outcome Several studies have found developmental reflexes in older
Average functional Discharge populations. While some of these groups exhibited severe
Mental status status at discharge destination
measures Tau p Tau p cerebral pathology, others were composed of individuals
Orientation .23** .001
without other evidence of neurological abnormality. The
.35** .001
present investigation demonstrates that such reflexes are
Other cognitive common in those stroke patients who are selected for in-
measures .48** .001 .26** .001
patient rehabilitation. The presence of developmental reflex-
Aphasia -.25** .006 .03 .360 es was found to be negatively related to favorable treatment
**Significant at the .01 level. outcome. The strength of the relationship was too small to
be useful in the selection of patients or the prediction of out-
presence of aphasia is negatively correlated to functional come. A research design which does more than examine the
ability but bears no relation to discharge destination. From presence of reflexes at one time might better establish their
these data it is apparent that a series of simple mental status predictive nature in relation to directed motor activity.
tests are better predictors of functional status at discharge than
are reflexes. While the setting to which a patient is dis- References
charged is probably roughly associated with his or her
1. Paulson G, Gottlieb G: Development reflexes: the reappearance of fetal
physical and mental condition, other factors such as family
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and neonatal reflexes in aged patients. Brain 91: 37-52, 1968


support also influence placement. 2. Pearce J, Aziz H, Gallagher JC: Primitive reflex activity in primary and
symptomatic Parkinsonism. J Neurol Neurosurg Psychiatry 31:501-508,
1968
Discussion 3. Klawans HL Jr, Goodwin JA: Reversal of the glabellar reflex in Parkin-
sonism by L-dopa. J Neurol Neurosurg Psychiatry 32: 423-427, 1969
Stroke patients make up the largest category of patients 4. Critchley M: Neurologic changes in the aged. J Chron Dis 3: 459-477,
seen in rehabilitation hospitals, comprising 31% of all dis- 1956
charges in a recent study involving 20 hospitals.10 A major 5. Howell TH: Senile deterioration of the central nervous system: a clinical
study. Br Med J 1: 56-58, 1949
consideration in the selection of such patients for treatment 6. Otomo E: The palmomental reflex in the aged. Geriatrics 20: 901-905,
directed at regaining lost functions or learning new activities 1965
is the extent to which these individuals are able to profit 7. August B, Miller RB: Clinical value of the palmomental reflex. JAMA
148: 120-121, 1952
from treatment. Traditionally, the neurological examina- 8. Blake JR Jr, Kunkle EC: The palmomental reflex. A physiological and
tion has been used to establish lesion site and diagnosis, and clinical analysis. Arch Neurol 65: 337-345, 1951
9. Hildenhagen O, Schiffter R: Neurologische befunde (insbesondere
to associate examination findings with function. In the pres- "entwicklungsreflexe") bei uber 75 jahrigen altenheimbewohnern. J
ent study the attempt was made to relate neurological ab- Neurol (Berlin) 213: 133-142, 1976
normality to future functional expectations. More 10. Keith RA, Breckenridge K, O'Neil WA: Rehabilitation hospital patient
characteristics from the Hospital Utilization Project (HUP) system.
specifically, an inquiry was directed at the relationship of Arch Phys Med Rehabil 58: 260-263, 1977
developmental reflexes at admission to performance of self- 11. Siegel S: Nonparametric Statistics. New York, McGraw-Hill, 1956

Disappearing Carotid Defects


PHILIP YARNELL, M.D., MICHAEL EARNEST, M.D., GLENN KELLY, M.D., AND BOB SANDERS, M.D.

S U M M A R Y Large intraluminal cervical carotid artery filling treated surgically. Thus, partially obstructing cervical carotid artery
defects consistent with mural thrombi were angiographically demon- thrombi may lyse either with the use of anticoagulant therapy or else
strated during acute hemispheric neurologic episodes. These thrombi spontaneously.
disappeared benignly as shown by serial angiography in 2 patients The etiology of the thrombi may partly be related to underlying
treated with intravenous heparin and spontaneously in 1 patient atheromatous disease.

CAROTID ARTERY DISEASE is a common cause of arteriography suggests a thrombus.5 The imminent danger
cerebral dysfunction. Pathophysiologically, carotid stenosis, of such a clot is either distal embolization or progression to
occlusion, ulceration, dissection, inflammation, mural occlusion. The neurologic symptoms and signs may be
thrombus and trauma have all been implicated.1"4 related to either regional flow insufficiency or embolization
A large intraluminal carotid arteryfillingdefect shown by or both. Discovery of an intraluminal lesion requires im-
mediate decisions about treatment.
From Denver General Hospital, University of Colorado Medical School, We have recently treated 3 patients with large intra-
Denver, CO 80204. luminal carotid defects and probable distal embolization.
Drs. Yarnell and Earnest are from the Department of Neurology; Dr. Kelly
is from the Department of Surgery and Dr. Sanders from the Department of Two were treated with anticoagulation and the third had
Radiology. surgical exploration. In all 3 cases the presumed carotid clot
Relationship between primitive reflexes in stroke patients and rehabilitation outcome.
J G Botvin, R A Keith and M V Johnston

Stroke. 1978;9:256-258
doi: 10.1161/01.STR.9.3.256
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
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Copyright © 1978 American Heart Association, Inc. All rights reserved.


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