TIS                         

This chapter is devoted to the reflexes observed in infants and children that therapy interventions may be directed toward integration of at the appropriate stages. Reflexes may be one factor that is investigated by therapists in infants and children referred for treatment interventions.

THE ROOTING REACTION

• Onset - 28 weeks gestation
• Integration - 3 months
• Testing position - with the infant supine, the head in midline and hands on chest
• Procedure - gently stroke the infant from the lips to the cheek
• Normal response - the infant should turn his head toward the stimulated side with the mouth opening and a trial of sucking the finger. May not be present if the infant is not hungry.
• Functional significance - persistence can interfere with sucking. Absence of this is seen in neurologically impaired infants.

THE SUCK SWALLOW REFLEX

• Onset - begins at 28 weeks gestation
• Integration - 2-5 months
• Testing position - infant supine with the head in midline
• Procedure - place a finger of nipple into the infant’s mouth
• Response observed - rhythmical sucking
• Functional significance - persistence of this reflex may inhibit voluntary sucking

MORO

• Onset - begins at 28 weeks gestation
• Integration - 5-6 months
• Testing position - child in supine with head in midline, support the child's head while pulling the child to a position halfway between supine and upright sitting
• Procedure - support the infant’s head and shoulders with one hand. Allow the neck to drop back to allow the anterior neck muscles to stretch
• Response observed - the shoulders abduct, the elbows, wrists and fingers extend. Subsequently, the shoulders adduct, and the elbows and fingers flex
• Functional significance - asymmetry during this reaction may indicate a brain lesion or injury or peripheral nerve problems to the upper extremity

THE TRACTION RESPONSE

• Onset - begins at 28 weeks gestation
• Integration - 2-5 months
• Testing position - child in supine with the arms and head in midline
• Procedure - grasp the child’s wrists and pull up to sitting placing a stretch on the shoulder adductors and arm flexors
• Response observed - the child will flex and elevate shoulders, arms and wrists
• Functional significance- traction is a primitive reflex which enables the child to hold onto the mother when being pulled. Traction helps stabilize the head before the child has voluntary head control

CROSSED EXTENTION

• Onset - begins at 28 weeks gestation
• Integration - 1-2 month
• Testing position - child in supine, head in midline, lower extremities extended
• Procedure - Holding one leg in extension at the knee, apply firm pressure to the sole of this leg
• Response observed - child’s opposite leg will flex, adduct, and then extend
• Functional significance - this reflex can interfere with reciprocal kicking and later functional activities

FLEXOR WITHDRAWAL

• Onset - begins at 28 weeks gestation
• Integration - 2 months for normal child; may persist in developmentally delayed and/or CP child
• Testing position - child supine, head midline, lower extremities extended
• Procedure - apply a noxious stimulus to the sole of the foot
• Response observed - withdrawal of the foot from the stimulus employing hip and knee flexion
• Developmental significance - failure to attain and integrate this reflex may indicate sensorimotor delay and/or CNS depression

PLANTAR GRASP

• Onset - begins at 28 weeks gestation
• Integration - 9 months
• Testing position - child supine, head midline, legs relaxed
• Procedure - apply firm pressure to the plantar surface of the child’s foot
• Response observed - plantar flexion of all of the toes
• Functional significance - this reflex is referred to as the "readiness tester". Integrates at the same time that independent gait first becomes possible.

GALANT’S RESPONSE

• Onset - begins at 32 weeks gestation
• Integration - 2 months, though may persist in atypical children
• Testing position - infant placed prone in alignment
• Procedure - gently stimulate along the paravertebral area from the C7 area to the buttocks
• Response observed - infant will laterally flex toward the stimulated side
• Functional significance - often seen with children with athetoid CP

NECK RIGHTING ON THE BODY (NOB)

• Onset - begins at 34 weeks gestation
• Integration - 4-6 months
• Testing position - infant in supine, head midline
• Procedure - turn the infant’s head to one side
• Response observed - infant’s entire body will turn in the direction of the head
• Functional significance - early in development the infant uses NOB in order to transition between supine, sidelying, and eventually prone

BODY RIGHTING REACTION (BOB)

• Onset - begins at 34 weeks gestation
• Integration - 4-5 months
• Testing position - infant supine, head midline
• Procedure - flex one limb over the chest and rotate the limb across the body
• Response observed - infant’s upper body will follow the pelvis in a log roll
• Functional significance - this reflex assists the child in rolling between supine and prone

NEONATAL POSITIVE SUPPORTING IN THE LOWER EXTREMITIES

• Onset - begins at 35 weeks gestation
• Integration - 1-2 months
• Testing position - support the infant in a vertical position
• Procedure - allow the feet to make firm contact with the floor or table
• Response observed - simultaneous contraction of the baby’s flexor and extensor muscles of the lower extremities supporting only minimal weight with the hips and knees remaining in partial flexion
• Functional significance - prerequisite for the spontaneous stepping reflex

PROPIOCEPTIVE PLACE OF LOWER EXTREMITY

• Onset - begins at 35 weeks gestation
• Integration - 2 months
• Testing position - supported in a vertical position
• Procedure - lift the infant so that the dorsum of the foot presses against the edge of the table
• Response observed - the infant flexes his knee and hip, thereby lifting the foot above the table
• Functional significance - asymmetry may indicate a CNS injury, muscles weakness, or peripheral nerve damage

SPONTANEOUS STEPPING

• Onset - begins at 37 weeks gestation
• Integration - 2 months
• Testing position supported in the vertical position
• Procedure - support the infant upright with the feet touching a hard surface. Incline the infant forward and gently move the infant forward to accompany any stepping
• Response observed - alternating, rhythmical, and coordinated steps
• Functional significance - premature infants will tend to walk in a roe-heel fashion while more mature infants will walk in a heel-toe pattern.

PALMAR GRASP

• Onset - 10 weeks gestation
• Integration - 4-6 months
• Testing position - supine, head midline, arms and hands free
• Procedure - place a finger in infant’s hand from the ulnar to the palmar surface
• Response observed - infant’s fingers will flex around the finger
• Functional significance -following the development of grasp, the infant begins to reach for objects and utilizes a crude palmer grasp to hold them

UPPER EXTREMITY PROPRIOCEPTIVE PLACING

• Onset - birth
• Integration - 2 months
• Testing position - support the infant in a vertical position
• Procedure - move the infant so that the dorsum of one hand rubs against a hard surface
• Response observed - the upper extremity flexes and the hand is brought above the surface of the surface
• Functional significance - this reflex may be obtained at any age as a withdrawal response if excessive pressure is applied to the hand

ASSYMETRICAL TONIC NECK REFLEX (ATNR)

• Onset - 0-2 months
• Integration - 4-6 months
• Testing position - supine
• Procedure - gently turn the infant’s head to one side
• Response observed - a UE flexion tone on the side opposite to the head turn with an increase in UE extensor tone in the side to which the head is turned
• Functional significance - persistence of this reflex may indicate CNS damage

TONIC LABYRINTHINE REFLEX (TLR)

• Onset - birth
• Integration - 6 months
• Testing position - prone or supine
• Procedure - prone - lift the infant up to evaluate for the presence of flexor tone; supine, lift the child to sitting to observe for extensor tone
• Response observed - prone - flexor tone will dominate; supine - extensor tone
• Functional significance - persistence of TLR will impede activities which require graded coactivation of flexor and extensor muscles

ASSOCIATED REACTIONS

• Onset - birth to 3 months
• Integration - never, less common after 8-9 years
• Testing position - sitting
• Procedure - hand grasp in younger children, rapid arm movements in older children
• Response observed - overflow of movement to the contralateral side should decrease with age
• Functional significance - excessive build-up of movement, or tonal increases in the opposite extremity indicate brain damage

LABYRINTHINE HEAD RIGHTING

• Onset - birth to 2 months
• Integration - persists throughout life
• Testing position - vertical position
• Procedure - tilt the child anterior, posterior, and lateral from the vertical
• Response observed - the head orients to the vertical position and is maintained steady
• Functional significance - in order to move around in space, this reflex is necessary to allow the body to turn freely around the head

OPTICAL RIGHTING

• Onset - birth to 2 months
• Integration - persists through life
• Testing position - vertical position
• Procedure - tile the child anterior, posterior, and lateral from the vertical
• Response observed - the head orients to the vertical position and is maintained vertically oriented in the environment
• Functional significance - allows the head and body to be upright to the horizon

BODY RIGHTING REACTION ON THE HEAD (BOH)

• Onset - birth to 2 months
• Integration - persists through life
• Testing position - upright
• Procedure - observe during play
• Response observed - righting of the head in relation to the body
• Functional significance - important in controlling the head in relation to the body in all positions

LANDAU

• Onset - 3 -4 months
• Integration - 12 - 24 months
• Testing position - prone, supported in air
• Procedure - wait for a reaction after placement
• Response observed - the head will extend and the back and hips will extend in sequence ("superman" appearance)
• Functional significance - breaks up the total flexion pattern seen at birth

UPPER EXTREMITY POSITIVE SUPPORT

• Onset - on elbows at 3 months
• Integration - persists through life
• Testing position - prone
• Procedure - keep infant horizontal and rise slowly up so that the upper extremities contact the floor
• Response observed - simultaneous contraction of the UE flexors and extensors leading to full weight bearing on hands
• Functional significance -allows for sitting and standing positions to be attained

UPPER EXTREMITY VISUAL PLACING

• Onset - 3 - 4 months
• Integration - persists through life
• Testing position - vertically held under the arms
• Procedure - advance the infant toward a supporting surface
• Response observed - the infant will lift both UE, extend and then place them on the supporting surface with fingers abducted and extended
• Functional significance - asymmetry may indicate hemispheric insult, peripheral nerve damage, or muscle weakness

LOWER EXTEMITY VISUAL PLACING

• Onset - 3 - 5 months
• Integration - persists through life
• Testing position - infant held vertically in space
• Procedure - advance the infant slowly toward a supporting surface feet first
• Response observed - the infant will orient to the surface and place both feet on top of the supporting surface
• Functional significance - needed for independent ambulation

PROTECTIVE EXTENSION DOWNWARD

• Onset - 4 months
• Integration - persists through life
• Testing position - vertically suspended in air
• Procedure - plunge the infant downward
• Response observed - the legs externally rotate and abduct with the feet dorsiflexing in preparation for weight-bearing
• Functional significance - preparation for standing and breaks a fall

POSTURAL FIXATION IN PRONE

• Onset - 6 months
• Integration - persists through life
• Testing position - prone
• Procedure - encourage the child to support on one extremity while reaching for an object
• Response observed - the child will not loose balance when reaching
• Functional significance - postural fixation is necessary for the preservation of the center of gravity in prone

TILTING REACTION IN PRONE

• Onset - 6 months
• Integration - persists through life
• Testing position - prone on a tilt board
• Procedure - slowly tile the board and wait for a response
• Response observed - the child will curve his trunk against the displacement the center of gravity. The upper arm and leg may abduct
• Functional significance - part of the balance mechanism to tolerate perturbations

PROTECTIVE EXTENSION FORWAD

• Onset - 6-7 months
• Integration - persists through life
• Testing position - vertically supported
• Procedure - plunge the child downward head first
• Response observed - the child should extend and abduct the arms with the fingers extended and spread as if to break a fall
• Functional significance - necessary for prop sitting

SYMMETRICAL TONIC NECK REFLEX (STNR)

• Onset - 4-6 months
• Integration - 8 - 12 months
• Testing position - child in quadruped position on the floor
• Procedure - passively flex the head forward and then extend it backwards
• Response observed - forward head flexion will produce flexion of the upper extremities and extension of the lower extremities; extension of the head will produce extension of the upper extremities and flexion of the lower extremities
• Functional significance - necessary to achieve quadruped crawling

POSITIVE SUPPORT WEIGHT BEARING ON LOWER EXTREMITIES

• Onset - 6-9 months
• Integration - persists through life
• Testing position - vertically positioned
• Procedure - allow the infant’s feet to make firm contact with a flat surface
• Response observed - simultaneous contraction of the lower extremity flexors and extensors bilaterally
• Functional significance -needed for upright standing and walking

MATURE NECK RIGHTING ACTING ON THE BODY (NOB)

• Onset - 4-6 months
• Integration - 5 years
• Testing position - supine
• Procedure - flex the child’s head and slowly turn to one side; hold this position and observe, repeat on the opposite side
• Response observed - child will segmentally roll in the direction of the head rotation
• Functional significance - allows for mature rolling and gait rotation

MATURE BODY RIGHTING REACTION ACTING ON THE BODY (BOB)

• Onset - 4-6 months
• Integration - 5 years
• Testing position - supine with head in midline
• Procedure - flex one leg and rotate it across the pelvis to the opposite side
• Response observed - child will roll sideways segmentally
• Functional significance - working with NOB, promotes segmental rolling and is important for sitting, quadruped and standing positions

PROTECTIVE EXTENSION SIDEWARD OF THE UPPER EXTREMITY

• Onset - 7 months
• Integration - persists through life
• Testing position - long sitting position
• Procedure - apply a force to the shoulder to displace the center of gravity
• Response observed - the arms should abduct and extend of the side toward the fall with weight borne on the open palm and fingers
• Functional significance -needed for independent sitting

POSTURAL FIXATION IN SUPINE

• Onset - 7 - 8 months
• Integration - persists through life
• Testing position - supine
• Procedure - encourage the child to reach, exert a minimal force on the shoulder of the reaching arm
• Response observed - the child will loose his balance in response to the push and demonstrate a slight curving of the spine
• Functional significance - necessary for the preservation of the center of gravity in supine

POSTURAL FIXATION IN SITTING

• Onset - 7 - 8 months
• Integration - persists through life
• Testing position - sitting on a stool
• Procedure - encourage the child to reach while exerting a minimal force to the opposite shoulder or trunk
• Response observed - will not lose balance
• Functional significance -necessary for preservation of sitting balance

TILTING REACTION IN SUPINE

• Onset - 7 - 8 months
• Integration - persists through life
• Testing position - supine on a tilt board
• Procedure - slowly tile the board laterally, wait for a response, and tilt to the opposite side
• Response observed - child’s trunk will curve against the tile with the concavity of the spine upward; the head will rotate for the face to look toward the upper side of the board
• Functional significance -allows for maintenance of the body while fine motor tasks are being undertaken; indicates the presence of previous righting reactions

POSTURAL FIXATION IN QUADRAPED

• Onset - 9 - 12 months
• Integration - persists through life
• Testing position - place the child in a quadruped on the floor
• Procedure - apply force to the shoulder and observe; to the extremity and observe; contralateral leg and observe; and ipsilateral leg and arm and observe
• Response observed - observe rotation of the body in the plane of the applied force
• Functional significance - necessary for the preservation of the quadruped position

PROTECTIVE EXTENSION BACKWARD

• Onset - 9 - 10 months
• Integration - persists through life
• Testing position - symmetrical sitting posture with legs extended
• Procedure - push the child backward with enough force to displace the center of gravity
• Response observed - the child will extend the arms backward
• Functional significance - necessary for independent sitting

PROTECTIVE STAGGERING OF LOWER EXTREMITIES

• Onset - 15 - 18 months
• Integration - persists through life
• Testing position - standing
• Procedure - push the child in all directions
• Response observed - the child will make corrective movements in order to restore center of gravity
• Functional significance - protects the upright posture

POSTURAL FIXATION IN STANDING

• Onset - 12 - 21 months
• Integration - persists through life
• Testing position - standing and one-legged standing
• Procedure - exert minimal force to the pelvis in all four directions
• Response observed - observe for force fields of the lower extremities to prevent falling or tipping
• Functional significance - allows for the preservation of the center of gravity and balance in standing and walking

TILTING REACTION IN STANDING

• Onset - 12 - 21 months
• Integration - persists through life
• Testing position - standing on a tilt board
• Procedure - tilt and wait for response, repeat the opposite direction
• Response observed - the body should flex against the tilt with the upper leg flexed and arm abducted while the lower leg is extended and braced
• Functional significance - the inner ear labyrinths need to be intact in order for the reaction to occur

This chapter presented many of the reflexes seen at birth through life. It is meant as a highlight of the most common types the therapist should be aware of and test for when presented with an infant or child with possible developmental delay or tonal problems. Reflex testing can assist the therapist in determining the cause of the delay such as CNS impairment, peripheral nerve injury, and muscle weakness. Reflex review will also assist in developing an individual treatment intervention designed to help the child integrate reflexes that appear to be delayed or missing.





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