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,
SUMMARY The reappearance of developmental reflexes in the
aged has been found to be associated with severe, diffuse cerebral
damage. This study examined the relationship between the presence
of such reflexes in stroke patients and the outcome of rehabilitation.
Tests for the presence of snout, suck, jaw-jerk and palmomental
reflexes were tested in 106 consecutive stroke patients admitted for
rehabilitation treatment. A mental status test was also included in the
PAULSON AND GOTTLIEB1 have observed that
demented senile patients may exhibit a number of primitive
neurological reflexes which are also present in the earliest
stages of ontogenetic development. In this group of related
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responses they examined 7 reflexes seen in aged populations
which also occur during normal fetal development. It was
their opinion that the reappearance of such reflexes in the
aged is almost always attributable to diffuse, bilateral and
irreversible CNS disease.
The glabellar tap reflex has been considered a sign of
Parkinsonism, but Pearce, Aziz and Gallagher2 dem-
onstrated the existence of an exaggerated response not only
in Parkinsonism but also in a group of patients with other
cerebral pathology. They concluded that the reflex was a
nonspecific sign of extensive cerebral destruction. Klawans
and Goodwinc found that a positive glabellar response was
reversible with L-dopa therapy in a group of patients with
Parkinsonism. The failure of an L-dopa regimen to reverse
the reflex in patients with clinical evidence of organic
dementia led these authors to conclude also that the ex-
aggerated glabellar response might result from diffuse cor-
tical disease.
While there is some agreement that the presence of
developmental reflexes in older adults may be indicative of
widespread cortical damage, the utility of such signs for
diagnosis is far from settled. One problem in the examina-
tion of the aged is whether abnormal neurological signs are
the result of pathology or are the consequences of normal
aging. Critchley4 has looked at both sides of the controversy.
He cautions that standards of normality are different in the
aged from those in adulthood; certain neurological changes
are seen so frequently that they must be discounted as
evidence of disease. After finding aberrant neurological
signs to be common in a group of 200 supposedly healthy
male pensioners, Howell5 also warned against making mis-
diagnoses in the elderly.
In an investigation of 800 Japanese individuals, Otomo6
found the palmomental reflex to be present in 53% of a
group over age 60 with no other neurological manifesta-
tions. In those with hemiplegia or hemiparesis, the oc-
currence of the reflex was 70%. August and Miller7 observed
From Casa Colina Hospital for Rehabilitative Medicine, 255 East Bonita
Ave., Pomona, CA 91767.
Presented at the 53rd Annual Meeting, American Congress of Rehabilita-
tion Medicine, San Diego, CA, November 12, 1976.
Reprint requests to Dr. Botvin, Casa Colina Hospital for Rehabilitative
Medicine, 255 East Bonita Ave., Pomona, CA 91767.
M.A.
usual medical admission examination. Functional status ratings for
self-care and mobility at discharge, and the setting to which the
patient was discharged, were used as outcome criteria. All of the
reflex signs were negatively related to a favorable outcome, but the
correlations were not high enough for predictive value. The mental
status measures were more highly related to rehabilitation outcome
than were the presence of developmental reflexes.
that the same reflex was very common in organic cerebral
disorders and concluded that it was a reasonably reliable in-
dicator of encephalopathy. While Blake and Kunkle8 felt
that the inconsistency of the palmomental reflex restricted
its usefulness, they did find the accentuated response was
frequently seen in patients with diverse forms of cortico-
bulbospinal tract disease, especially when bilateral.
Hildenhagen and Schiffter8 examined 86 residents from
several homes for the aged and found a number of aberrant
neurological signs. This population was quite old, with an
average age over 86 years. The most frequent developmental
reflex was an oral motor response from tactile stimulation,
found in 40.7%. The palmomental pattern was seen in
29.1%. These authors conclude from their results that the
presence of primitive reflexes is related to age-dependent
changes of the CNS.
The appearance of primitive reflexes in the aged seems to
be associated with the lack of inhibitory mechanisms in
higher centers. They have been seen frequently in patients
with severe, diffuse, cerebral damage. The fact that some
responses have also been observed in populations without
any other manifestation of neurological abnormality in-
troduces a note of caution about whether all such reflexes
should be viewed as a sign of serious CNS pathology. The
possibility exists, however, that individuals exhibiting these
reflexes may have a diminished capacity for learning. If such
were the case, it might be possible to predict a patient's
response to rehabilitation treatment. The purpose of this
study was to examine the relationship between the presence
of developmental reflexes in a group of stroke patients and
their progress in rehabilitation.
Method
Four developmental reflexes frequently seen in aged pop-
ulations were selected for study: snout, suck, jaw-jerk and
palmomental. Tests for the presence of these responses,
along with those routinely performed for left and right
extensor-plantar reflexes, were included in the usual medical
admission examination for 106 consecutive stroke patients.
The reflex response was graded as absent, present or
strongly present. The palmomental response was regarded
as positive whether it was seen on one side or bilaterally.
A simple mental status examination was also ad-
ministered to all patients without aphasia. Of the 106
patients, there were 29 who were aphasic and 77 who were
able to communicate verbally. The mental status test con-
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
other cognitive tests, there were 2 subtractions of 7's from
100 (3 points), naming the last 4 presidents (4 points), and
interpretation of 2 proverbs (2 points).
Two kinds of data were used as measures of rehabilita-
tion outcome: functional status ratings at discharge and dis-
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Gottlieb,1 although their sample was comprised of patients
with senile dementia. The suck reflex, observed by these in-
vestigators in 53% of their patients, was present in only
19.4% of stroke patients. The jaw-jerk response was seen
somewhat more frequently in the present study 31.0% to
18% in the Paulson and Gottlieb population. The presence of

charge destination. Ratings at admission and discharge for
11 tasks of self-care and mobility were given by physical and
occupational therapists working with the patient. The tasks
were: eating, personal hygiene, grooming, bowel function-
ing, bladder functioning, bed activities, dressing, transfers,
wheelchair activities, ambulation on level surfaces, and the
use of stairs. A rating scale with values from 1 to 4 was used:
1 — completely dependent, 2 — requires physical assistance,
3 — requires supervision only, and 4 — completely indepen-
dent. The functional status score was the sum of the 11
ratings with a possible maximum of 44.
Discharge destination was ranked according to a
hierarchy of independence: 1 — alone in a private residence,
2 — with someone else in a private residence, 3 — in a
custodial care facility or boarding home, 4 — in a skilled
nursing facility, or 5 — in a hospital.
The sample of 106 patients ranged in age from 30 to 88
years with a mean of 68.7 years. There were 48 males and 58
females. The average length of stay for their rehabilitation
program was 35 days, very close to that in a sample of 1,443
stroke patients in 20 rehabilitation hospitals reported by
Keith, Breckenridge and O'Neil.10
Results
In the distribution of reflexes (table 1) there was an
average of 32.8% graded as present or strongly present. The
snout reflex was most common, in 51.5% of the patients. The
incidence is very close to that found by Paulson and
the palmomental reflex was fairly similar in the 2 studies,
25.7% to 21%. Otomo 6 reported a much higher incidence of
this response (70%) in a group of hemiplegic and
hemiparetic patients. In the present study, an extensor plan-
tar response (Babinski) was present on either side in about a
third of the cases.
The relationship between the presence of reflexes and out-
come criteria was analyzed by means of Kendall's tau, a
rank order correlation appropriate for ordinal data. 11 Table
2 is a summary of that analysis. It is apparent, first of all,
that all of the reflex signs are negatively related to a
favorable outcome on either functional status or discharge
destination. On the other hand, the sizes of the correlations
for any of the reflexes or their total are low. The snout and
palmomental reflexes are most strongly related to both
criteria, but the magnitude of the relationship is not high
enough to be of much predictive value.
Table 3 shows the association between reflexes and the
two sets of mental status measures: orientation and other
cognitive tests (serial 7s, names of presidents and proverb in-
terpretation). Although the various reflexes are all
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-
mance on mental status examinations.
In Table 4 the fairly strong correlations between the 2
mental status measures and functional status at discharge
are the highest associations of the study. The mental tests
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
TABLE 4 Relationship between Mental Status Measures and
Outcome Criteria
Outcome
Average functional Discharge
Mental status status at discharge destination
measures Tau p Tau
Orientation .23**
.35** .001
Other cognitive
measures .48** .001 .26**
Aphasia -.25** .006 .03
**Significant at the .01 level.
presence of aphasia is negatively correlated to functional
ability but bears no relation to discharge destination. From
these data it is apparent that a series of simple mental status
tests are better predictors of functional status at discharge than
are reflexes. While the setting to which a patient is dis-
charged is probably roughly associated with his or her
physical and mental condition, other factors such as family
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support also influence placement.
Discussion
Stroke patients make up the largest category of patients
seen in rehabilitation hospitals, comprising 31% of all dis-
charges in a recent study involving 20 hospitals.10 A major
consideration in the selection of such patients for treatment
directed at regaining lost functions or learning new activities
is the extent to which these individuals are able to profit
from treatment. Traditionally, the neurological examina-
tion has been used to establish lesion site and diagnosis, and
to associate examination findings with function. In the pres-
ent study the attempt was made to relate neurological ab-
normality to future functional expectations. More
specifically, an inquiry was directed at the relationship of
developmental reflexes at admission to performance of self-
Disappearing Carotid Defects
PHILIP YARNELL, M.D., MICHAEL EARNEST, M.D.,
S U M M A R Y Large intraluminal cervical carotid artery filling
defects consistent with mural thrombi were angiographically demon-
strated during acute hemispheric neurologic episodes. These thrombi
disappeared benignly as shown by serial angiography in 2 patients
treated with intravenous heparin and spontaneously in 1 patient
CAROTID ARTERY DISEASE is a common cause of
cerebral dysfunction. Pathophysiologically, carotid stenosis,
occlusion, ulceration, dissection, inflammation, mural
thrombus and trauma have all been implicated.1"4
A large intraluminal carotid arteryfillingdefect shown by
From Denver General Hospital, University of Colorado Medical School,
Denver, CO 80204.
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
Radiology.
STROKE VOL 9, No 3, MAY-JUNE 1978
care and mobility tasks after a course of rehabilitation
therapy.
Several studies have found developmental reflexes in older
populations. While some of these groups exhibited severe
p cerebral pathology, others were composed of individuals
.001
without other evidence of neurological abnormality. The
present investigation demonstrates that such reflexes are
common in those stroke patients who are selected for in-
.001
patient rehabilitation. The presence of developmental reflex-
.360 es was found to be negatively related to favorable treatment
outcome. The strength of the relationship was too small to
be useful in the selection of patients or the prediction of out-
come. A research design which does more than examine the
presence of reflexes at one time might better establish their
predictive nature in relation to directed motor activity.
References
1. Paulson G, Gottlieb G: Development reflexes: the reappearance of fetal
and neonatal reflexes in aged patients. Brain 91: 37-52, 1968
2. Pearce J, Aziz H, Gallagher JC: Primitive reflex activity in primary and
symptomatic Parkinsonism. J Neurol Neurosurg Psychiatry 31:501-508,
1968
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
4. Critchley M: Neurologic changes in the aged. J Chron Dis 3: 459-477,
1956
5. Howell TH: Senile deterioration of the central nervous system: a clinical
study. Br Med J 1: 56-58, 1949
6. Otomo E: The palmomental reflex in the aged. Geriatrics 20: 901-905,
1965
7. August B, Miller RB: Clinical value of the palmomental reflex. JAMA
148: 120-121, 1952
8. Blake JR Jr, Kunkle EC: The palmomental reflex. A physiological and
clinical analysis. Arch Neurol 65: 337-345, 1951
9. Hildenhagen O, Schiffter R: Neurologische befunde (insbesondere
"entwicklungsreflexe") bei uber 75 jahrigen altenheimbewohnern. J
Neurol (Berlin) 213: 133-142, 1976
10. Keith RA, Breckenridge K, O'Neil WA: Rehabilitation hospital patient
characteristics from the Hospital Utilization Project (HUP) system.
Arch Phys Med Rehabil 58: 260-263, 1977
11. Siegel S: Nonparametric Statistics. New York, McGraw-Hill, 1956
GLENN KELLY, M.D., AND BOB SANDERS, M.D.
treated surgically. Thus, partially obstructing cervical carotid artery
thrombi may lyse either with the use of anticoagulant therapy or else
spontaneously.
The etiology of the thrombi may partly be related to underlying
atheromatous disease.
arteriography suggests a thrombus.5 The imminent danger
of such a clot is either distal embolization or progression to
occlusion. The neurologic symptoms and signs may be
related to either regional flow insufficiency or embolization
or both. Discovery of an intraluminal lesion requires im-
mediate decisions about treatment.
We have recently treated 3 patients with large intra-
luminal carotid defects and probable distal embolization.
Two were treated with anticoagulation and the third had
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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