Assessment of the Infant: Reflexes

- Brief stimuli

- Quick response

- Short duration of muscle activity

- All produce movement

- Flexion or extension of the limb

What are the characteristics of Spinal/Phasic Reflexes

- Maintained stimuli

- Slow developing response

- Prolonged muscle activity

- Contribute to posture (anti-gravity function)

What are the characteristics of Brainstem/Tonic Reflexes

- Movements that bring the body and its parts into normal alignment

- Allow individual to move from one body posture to another (supine to prone, prone to sitting, sitting to standing, etc)

- Transitional movements

What are the characteristics of Midbrain Righting Reactions

reflexes

stereotypic responses to specific stimuli

reactions

responses that vary in form and can be evoked by a variety of stimuli

noxious stimuli

Reflex Testing key points/considerations

• Always perform _______ at the end of the testing session, as needed

28-30 weeks' gestation

Rooting Reflex onset

By 3-6 months

Rooting Reflex integration

Perioral stroking

Rooting Reflex Stimulus

Turns head and lips towards stimulus with mouth open

Rooting Reflex Response

Survival (feeding)

Rooting Reflex Significance

• oral motor

• midline head

Rooting Reflex

• May interfere with ______ development, ______ control, and visual tracking

28-34 weeks gestation

Sucking-Swallowing Reflex Onset

By 4-6 months

Sucking-Swallowing Reflex Integration

Touch to lips and inside mouth for suck and liquid for swallowing

Sucking-Swallowing Reflex Stimulus

Strong sucking followed by swallow

Sucking-Swallowing Reflex Response

Survival (feeding)

Sucking-Swallowing Reflex Significance

May inhibit voluntary sucking and oral sensory stimulation

Sucking-Swallowing Reflex Persistence

28 weeks gestation

Moro Reflex Onset

3-5 months

Moro Reflex Integration

Sudden neck extension

Moro Reflex Stimulus

Extension

ABD of UE's

Hand opening and crying followed by flexion

ADD of arms across chest

Moro Reflex Response

• balance reactions

• eye-hand

Moro Reflex Persistence

• may interfere with ______ in sitting, protective responses, _______ coordination, and visual tracking

one side of the brain

peripheral nerve

If the Moro Reflex presents with an asymmetry, it may indicate injury to _______ or ______ injury.

28 weeks gestation

Startle Reflex onset

persists throughout life with response varying by age

Startle Reflex Integration

Sudden loud or harsh noise

Startle Reflex Stimulus

Similar to Moro but hands may be closed and elbows flexed, gasp

Startle Reflex Response

sitting

social interaction

Startle Reflex Persistence

• interferes with ______ balance, protective responses in sitting, eye-hand coordination, visual tracking, _______

23-24 weeks gestation

Spinal Galant Reflex Onset

It is considered pathological (“obligatory” persistence after maturity is abnormal)

What does it mean if a developmental reflex is present beyond its typical integration age?

Onset: 23–24 weeks gestation

Integration: 3–9 months

What are the onset and integration ages for the Spinal Galant reflex?

In prone, stroke the paravertebral line from shoulder to hip

What stimulus elicits the Spinal Galant reflex?

Lateral flexion of the trunk toward the stimulated side

What is the response of the Spinal Galant reflex?

It may contribute to scoliosis or delays in symmetrical trunk stabilization

What may happen if the Spinal Galant reflex persists?

An absent response below the level of a transverse spinal cord injury

What neurological finding is associated with an absent Spinal Galant response?

Onset: 28 weeks gestation

Integration: 4–6 months

What are the onset and integration ages for the Palmar Grasp reflex?

Maintained pressure on palm of hand (ulnar side)

What stimulus elicits the Palmar Grasp reflex?

Palmar Grasp Reflex

- Persistence: may interfere with grasp and release of objects, weightbearing through open hand for crawling/reflexive responses

Plantar Grasp Reflex

- Onset: 28 weeks gestation

- Integration: 9 months

- Stimulus: Supported standing on feet or maintained pressure on sole of foot

- Response: Flexion of toes

- Significance: grasp (safety)

- Persistence: may interfere with ability to stand with feet flat on ground, balance reactions and weight shifting in standing

Plantar Reflex/Babinski

- Stimulus: Stroke the lateral aspect of the plantar surface of the foot

- Response: Extension and fanning of the toes

- Age: Positive is typical up to 12 months, some resources say up to 2 years

- Positive in CP (TBI) and SCI

Flexor Withdrawal Reflex

- Onset: 28 weeks gestation

- Integration: 1-2 months (possibly persists)

- Stimulus: Noxious stimulus on sole of foot (not too noxious)

- Response: Toes extend, foot and leg flexes as withdrawal to stimulus

- Persistence: May interfere with balance and standing

- Significance: Persistence may interfere with balance and standing. Asymmetry may indicate peripheral nerve injury

- Asymmetry may indicate Peripheral Nere injury

Reappears in SCI

Crossed Extension Reflex

- Onset: 28 weeks gestation

- Integration: 1-2 mo, inconsistent

- Stimulus: Noxious stimulus to ball of fixed foot while maintaining LE extended

- Response: Contralateral leg flexes, then extends and may adduct

- Persistence: may prevent normal reciprocal kicking and subsequent walking

- Asymmetry may indicate Peripheral Nere injury (Reappears in SCI)

Automatic Walking/Stepping Reflex

- Onset: 37 weeks gestation

- Integration: By 2-4 months

- Stimulus: Support the infant vertically around the child's chest with feet touching the table surface. Incline the child forward and gently move the child forward to accompany any stepping.

- Response: Child will make alternating, rhythmical and coordinated stepping movements.

- Persistence: may interfere with standing and walking, balance reactions and weight shifting in standing, development of smooth and coordinated reciprocal movement of the LEs At end of 1st year becomes the learned behavior of walking

Brainstem/Tonic Reflexes

- Asymmetrical Tonic Neck Reflex (ATNR)

- Symmetrical Tonic Neck Reflex (STNR)

- Tonic Labyrinthine Reflex (TLR)

Asymmetrical Tonic Neck Reflex (ATNR)

- Onset: 20 weeks gestation

- Integration: By 4-5 months

- Stimulus: Turning the child’s head to activate cervical   proprioceptors, actively or passively

- Response: Fencing Position or Bow and Arrow Position UE and LE of facial side extends, UE and LE on skull/occipital side flexes and abducts. UE response stronger than LE. Spine with convexity towards face side.

- Seen in CP (TBI)

What is the importance of the ATNR

ATNR assists with early eye-hand regard, trains muscle tone, provides vestibular stimulation and balance

If ATNR persists, what are the problems a child would encounter in his/her gross and fine motor development

- Balance and trunk control

- Rolling/rotation

- Tummy time

- Moving from prone to supine

- Quadruped

- Crawling

- Hand-eye coordination

- Protective reactions against falling

- Missing visual cues

Secondary impairments if ATNR persists:

- difficulty going into and out of midline

- difficulty with feeding

- may result in scoliosis or hip dislocation

- poor isolation of movements

- poor sitting posture

Symmetrical Tonic Neck Reflex (STNR)

- Onset: 4-6 months

- Integrated: 8-12 months (when baby learns to crawl)

- Stimulus: Flexion or extension of the neck, either actively or passively.

Response: Change in postural tone; symmetrical response of extremities

- Cervical flexion: Flexion of arms, extension of legs

- Cervical extension: Extension of arms, flexion of legs

- Seen in CP (TBI)

Benefits of STNR:

- helps with Bilateral Movement getting into quadruped position for crawling

- extending head to interact with environment

- visual tracking

Problems If STNR Persists:

- Flexion of neck will cause baby to collapse → difficulty with crawling

- Poor posture/postural development

- Extension of neck can lead to W-sitting later on

- Poor hand-eye coordination → difficulty with feeding + reaching

- Difficulty with ambulation

- Difficulty with stair negotiation

- Difficulty with reactive strategies (reaching for toys)

- Challenges with swimming

- Visual tracking issues → can lead to difficulty with close focusing

Secondary impairments if STNR persists:

- generally impairs dissociation between LEs

- propping on arms in prone

- affects transitions sitting <-> quadruped

- kneel <-> stand

- difficulty sitting in a chair

Tonic Labyrinthine Reflex (TLR)

- Onset: 38 weeks gestation

- Integration: 6 months

- Stimulus: Position of labyrinth in inner ear, reflective of head position (Neck flexion vs. neck extension.)

- Response: Change in postural tone

- Prone: Flexor tone predominates

- Supine: Extensor tone predominates  

- TLR seen in CP and TBI

Motor development benefits of TLR

- Preparation of falling and rolling

- Development of head control and postural control

- Strengthen antigravity muscle & muscle tone

- Vestibular and proprioceptive information

- Training visual tracking system

- Postural integration

Problems if the TLR persists

- Decreased volitional muscle tone

- Decreased motor control, development toward crawling and rolling.

- Poor vestibular and sensory information

- Poor postural control and balance

- Poor visual tracking

Secondary Specific Problems if TLR persists:

- May inhibit development of rolling, ability to prop on elbows with extended hips, ability to flex trunk and hips to come to sitting from supine position.

- Can cause full body extension, which interferes with sitting and balance

types of righting reactions

- Neonatal Positive Supporting Reaction

- Neonatal Neck Righting Acting on Body (NOB)

- Neonatal Body Righting Acting on Body (BOB)

- Optical Righting Reflex (ORR)

- Labyrinthine Righting Reflex (LRR)

- Landau Reflex

Neonatal Positive Supporting Reaction

- Onset: 35 weeks gestation

- Duration: 2-6 months (replaced by volitional weightbearing)

- Stimulus: Support baby until contact is made to the ball of the foot in upright standing position. (stretch to PFs)

- Response: Rigid extension of the LE's and trunk (stands up) and then sags

- Persistence: interferes with walking, balance reactions, can lead to PF contractures

Continuum of Balance Responses

- Slight Perturbation Well Within Base of Support > Righting Reactions

- Moderate Perturbation Close to Edge of Base of Support > Equilibrium/Tilting Reactions

- Extreme Perturbation Beyond Base of Support > Protective Reactions

What are Righting Reactions responsible for

Responsible for securing the head in space and must develop in all planes

What are Equilibrium/Tilting Reactions responsible for

Responsible for securing the position of the body in space when the balance in challenged

What are Protective Reactions responsible for

Responsible for regaining balance when the center of mass has been pushed beyond the borders of the base of support

Key points about Righting Reactions

- "Alignment" Reactions

- An automatic reaction following a perturbation to bring the head and trunk into a normal position in space in relation to the ground

- Develop by 6 months

- Require antigravity muscle control

Neonatal Neck Righting Acting on Body (NOB)

- Onset: Begins at 34 weeks of gestation

- Integration: 4 months (inhibited by mature rolling)

- Stimulus: In supine with head in midline, rotate head to one side

- Response: The child will follow the direction of the head turn and roll toward that side without segmental rotation (this is a “log-roll”).

- Significance: Allows child to roll supine to side and side to supine

- Persistence: may interfere with the development of segmental rolling, difficulties with rotational components or may fail to develop a variety of movement patterns

- Evolves into Neck Righting Acting on Body (NOB) = a segmental rolling pattern after rotating the head

Neonatal Body Righting Acting on Body (BOB)

- Onset: Begins at 34 weeks of gestation

- Integration: 4-5 months

- Stimulus: Place child supine with head in midline and extremities extended. Flex one leg up towards chest and rotate the child’s leg across the body, rolling baby over.

- Response: The child’s thorax, chest and head will follow the direction of the pelvis turn and roll and roll without segmental rotation.

- Significance: allow child to roll supine to side

- Persistence: interferes with development of segmental rolling and acquisition of other milestones that require trunk rotation

- Evolves into the Body Righting Acting on Body Reflex (BOB) segmental rolling

Optical Righting Reflex (ORR)

- Onset: Birth

- Integration: Persists

- Stimulus: Lean infant's body out of alignment (holding child on lap or a ball)

- Response: Head with align into upright position in all directions.

- Significance: allows righting of head against gravity, use of vision for balance

Labyrinthine Righting Reflex (LRR)

- Onset: 2 months

- Integration: Persists

- Stimulus: Lean infants body out of alignment (holding child on lap or on a ball) with vision obscured.

- Response: Head with align into upright position in all directions.

- Significance: Allow child to right head against gravity and maintain that alignment even without vision.

Landau Reflex

- Onset: 3-4 months

- Integration: 12-24 months

- Stimulus: Suspend in prone with 1 hand, gravitational

- Response: head will lift up and spine will straighten

- Significance: contributes to loss of physiologic flexion and promotes extension

How does the Landau reflex give information about development of extension:

- poor antigravity response suggests hypotonia

- exaggerated response suggests hypertonia

Equilibrium Reactions

Safety Reactions to protect the body under conditions of instability

Types of Equilibrium Reactions

- Tilting/Equilibrium Reactions

- Protective Reactions

Tilting/Equilibrium Reactions

- Onset: Varies with position tested

- Duration: Persists across the lifespan

- Stimulus: Slowly displace the center of gravity by tilting or   moving the support surface

- Response: Lateral flexion of the spine toward the elevated side of support, abduction of the extremities on the elevated side and sometimes trunk rotation toward the elevated side

Tilting/Equilibrium Reactions Onset by Position:

- prone 5-6 months

- supine 7-8 months 

- sitting 8 months

- quadruped 9-12 months

- standing 12-21 month 

Protective Reactions

- Onset: Varies with position tested

- Stimulus: Position the infant with trunk support followed by quick displacement of the infant’s center of gravity outside the base of support.

- Integration: These reactions persist through life

- Response: Arms or legs extend and abduct to support and to protect the body from falling.

Protective Reactions Onset by action/position

- Downward 4 months (this is a vertical dropping motion)

- Forward/parachute (UE) 7-8 months 

- Lateral/sideways (UE) 7-8 months

- Posteriorly (UE) 9-10 months

- Protective Stagger (LE) 15-18 months

- Dorsiflexion Reaction (LE) 15-18 months

What is the purpose of protective extension

to catch the body when they are falling

Protective Extension Reactions

- Sitting-sideward PE: when the COG falls outside of the BOS laterally, the baby extends the UE of the side they are falling toward to catch themselves to prevent injury

- Backward-PE: when the COG falls outside of the BOS posteriorly, the baby extends their UE backwards to catch themselves

What is the purpose of Equilibrium reactions

readjust position of body to return COM over BOS to prevent fall

equilibrium reactions in sitting:

when COG falls outside of the BOS, lateral flexion of the spine with abduction of the UE occurs on the opposite side to prevent falling

equilibrium reactions in quadruped:

when COG falls outside the BOS, lateral flexion of the spine occurs on the opposite side to prevent falling

equilibrium reactions in standing:

when the COM falls beyond the BOS, lateral flexion of the spine with abduction of the UE occurs on the opposite side to prevent falling

Presence of Reflexes in CP

- Babinski

- ATNR-difficulty crawling, eating, sitting

- TLR - exaggerated stiffening of body/limbs

- Palmar and Plantar Grasp - stuck in grasping, flexed toes in standing &walking

- Spinal Galant Reflex

Presence of Reflexes in SCI

- Babinski

- UMN

- Flexor Withdrawal-possibility of danger and not being able to move

- Crossed Extension Reflex- abnormal gait, lack or coordination and poor balance

- Positive Hoffman's reflex

Cerebral Palsy (CP) and the development of abnormal reflexes:

Results from damage to the developing brain. It typically causes an abnormal persistence, re-emergence, or over-exaggeration of a wide variety of brainstem and spinal reflexes.

Spinal Cord Injury (SCI) and the development of abnormal reflexes:

Damage to the spinal cord pathways. It typically results in the absence or weakness of reflexes below the level of the injury ***though specific "spinal reflexes" (like flexor withdrawal) may become exaggerated

positive or exaggerated reflex in Child (>2 years) with Cerebral Palsy (TBI)

- Moro + increased

- Galant +

- Babinski +

- ATNR +

- STNR +

- TLR +

- Neonatal Positive Support Reaction + (exaggerated)

absent or decreased reflexes in Child (>2 years) with Cerebral Palsy (TBI)

- Rooting & Sucking-Swallowing Reflexes Ø or decreased

- Righting, Equilibrium and Protective Extension Reactions Ø or decreased

- Babinski +

- Flexor Withdrawal + increased

- Crossed Extension Reflex + increased

Positive or exaggerated reflex in Child with Spinal Cord Injury (3 types)

absent or decreased reflexes in Child with Spinal Cord Injury

- Galant Ø below complete lesion

- May lack righting, equilibrium and protecting reactions below the lesion but not due to brain insult or an absent reflex