OTR 704 1.3 Motor Milestones & Reflexes

What sequential order would you expect reach milestones to emerge?

• Controlled voluntary release

• Basic fine motor skills should be achieved

• Hands to midline and held together

• Begins using second hand as stabilizer when manipulating

• Arms move asymmetrically (involuntarily)

• Differentiated asymmetrical reach (voluntarily)

• Arms move asymmetrically (involuntarily) – 0:0 to 0:3

• Hands to midline and held together – 0:1 to 0:3

• Controlled voluntary release – 0:9 to 0:10

• Differentiated asymmetrical reach (voluntarily) – 0:10

• Begins using second hand as stabilizer when manipulating – 1:4 to 1:7

• Basic fine motor skills should be achieved – 6:0+

What sequential order would you expect grasp milestones to emerge?

• Digital pronated grasp of writing instrument

• Superior pincer grasp (thumb to index finger pad tip)

• Static tripod grasp of writing instrument

• Hands predominately closed

• Cylindrical grasp (i.e., picking up a glass)

• Poke with index finger

• Dynamic tripod grasp of writing instrument

• Palmar grasp

• Radial palmar grasp

1. Hands predominately closed – 0:0 to 0:3

2. Palmar grasp – 0:4 to 0:5

3. Radial palmar grasp – 0:6 to 0:7

4. Poke with index finger – 0:9 to 1:0

5. Superior pincer grasp (thumb to index finger pad tip) – 0:9 to 1:0

6. Cylindrical grasp (i.e., picking up a glass) – 1:6 to 3:0

7. Digital pronated grasp of writing instrument – 2:0 to 3:0

8. Static tripod grasp of writing instrument – 3:6 to 4:0

9. Dynamic tripod grasp of writing instrument – 4:6 to 6:0

What sequential order would you expect voluntary release milestones to emerge?

• Shoulder, elbow, wrist stable; release into containers

• Unable to voluntarily release

• Release voluntary with one hand (e.g., drops objects off tray)

1. Unable to voluntarily release – 0:0 to 0:1

2. Release voluntary with one hand (e.g., drops objects off tray) – 0:9

3. Shoulder, elbow, wrist stable; release into containers – 1:0

What sequential order would you expect hand dominance milestones to emerge?

• Hand preference established

• Uses either hand for approach and grasp

• Dominant hand leads, non-dominant not in use

• Both hands equally skilled

1. Uses either hand for approach and grasp – 0:5

2. Both hands equally skilled – 0:7

3. Dominant hand leads, non-dominant not in use – 1:0 to 1:1

4. Hand preference established – 2:0

What sequential order would you expect head control milestones to emerge?

• Holds head in line with body when pulled to sit

• Lifts head from caregiver’s shoulder

• Raises head to 90-degrees in prone

• Maintains head control while sitting with support

1. Lifts head from caregiver’s shoulder – 0:1 to 0:2

2. Raises head to 90-degrees in prone – 0:4

3. Maintains head control while sitting with support – 0:3 to 0:5

4. Holds head in line with body when pulled to sit – 0:4 to 0:6.5

What sequential order would you expect rolling milestones to emerge?

• Rolls prone to supine and supine to prone with (segmental) rotation

• Rolls prone to supine without rotation

1. Rolls prone to supine without rotation – 0:4 to 0:6

2. Rolls prone to supine and supine to prone with (segmental) rotation – 0:9

What sequential order would you expect sitting milestones to emerge?

• Sits sustained leaning on hands

• Sits sustained without arm support for 10 minutes

1. Sits sustained leaning on hands – 0:6

2. Sits sustained without arm support for 10 minutes – 0:9 to 0:10

What sequential order would you expect mobility milestones to emerge?

• Walks independently

• Weight bears on both hands while in prone

• Pulls to stand and lowers at furniture

• Bounces on legs with trunk support

• Walks with hands held

• Creeping with weight on hands and knees including trunk rotation

• Crawls with belly on ground

1. Bounces on legs with trunk support – 0:5 to 0:7

2. Weight bears on both hands while in prone – 0:6 to 0:7.5

3. Crawls with belly on ground – 0:9

4. Pulls to stand and lowers at furniture – 0:9 to 0:10

5. Creeping with weight on hands and knees including trunk rotation – 0:9 to 0:11

6. Walks with hands held – 0:10 to 1:0

7. Walks independently – 1:0 to 1:3

What is the sequential order in which all relevant FINE motor milestones emerge?

• Hands predominantly closed – 0:0–0:3

• Unable to voluntarily release – 0:0–0:1

• Arms move asymmetrically (involuntarily) – 0:0–0:3

• Hands to midline and held together – 0:1–0:3

• Symmetrical movement patterns; reaches with both hands and brings to midline – 0:3–0:10

• Palmar grasp – 0:4–0:5

• Uses either hand for approach and grasp – 0:5

• Radial palmar grasp – 0:6–0:7

• Both hands equally skilled – 0:7

• Pokes with index finger – 0:9–1:0

• Superior pincer grasp (thumb to index finger pad/tip) – 0:9–1:0

• Differentiated asymmetrical reach (voluntarily) – 0:10

• Voluntary release with one hand – 0:9

• Shoulder, elbow, and wrist stable; releases into containers – 1:0

• Dominant hand leads; non-dominant hand not in use – 1:0–1:1

• Uses second hand as stabilizer during manipulation – 1:4–1:7

• Cylindrical grasp (e.g., picking up a glass) – 1:6–3:0

• Hand preference established – 2:0

• Digital pronated grasp of writing instrument – 2:0–3:0

• Static tripod grasp of writing instrument – 3:6–4:0

• Dynamic tripod grasp of writing instrument – 4:6–6:0

• Basic fine motor skills should be achieved – 6:0+

What is the sequential order in which all relevant GROSS motor milestones emerge?

• Lifts head from caregiver’s shoulder – 0:1–0:2

• Maintains head control while sitting with support – 0:3–0:5

• Raises head to 90° in prone – 0:4

• Holds head in line with body when pulled to sit – 0:4–0:6.5

• Rolls prone to supine without rotation – 0:4–0:6

• Bounces on legs with trunk support – 0:5–0:7

• Weight bears on both hands while in prone – 0:6–0:7.5

• Sits sustained while leaning on hands – 0:6

• Rolls prone to supine and supine to prone with segmental rotation – 0:9

• Sits sustained without arm support for 10 minutes – 0:9–0:10

• Crawls with belly on ground – 0:9

• Pulls to stand and lowers at furniture – 0:9–0:10

• Creeps on hands and knees with trunk rotation – 0:9–0:11

• Walks with hands held – 0:10–1:0

• Walks independently – 1:0–1:3

Galant reflex

Primitive reflex

• Typical age of integration: 2 months

• Stimulus: Infant suspended in prone and tapped/stroked alongside of spine

• Response: Lateral flexion and skin wrinkles toward stimulus side

Suck-swallow reflex

Primitive reflex

• Typical age of integration: 2-5 months

• Stimulus: Finger is placed in infant’s mouth

• Response: Strong and rhythmical sucking elicited

Rooting reflex

Primitive reflex

• Typical age of integration: 3 months

• Stimulus: Stroke corner of infant’s mouth/lips

• Response: Head/mouth or tongue move toward the stimulus

ATNR

Primitive reflex

• Typical age of integration: 4-6 months

• Stimulus: Infant’s head is fully rotated and held

• Response: Extremities on the face side extend and extremities on the skull side flex

Moro Reflex

Primitive reflex

• Typical age of integration: 4-6 months

• Stimulus: Infant’s head is dropped backwards

• Response: Arms extend and hands open

Palmar Grasp

Primitive reflex

• Typical age of integration: 4-6 months

• Stimulus: A finger is placed in infant’s palm

• Response: Fingers flex reflexively

TLR Prone

Primitive reflex

• Typical age of integration: 6 months

• Stimulus: Infant is prone

• Response: Demonstrates increased flexor tone

TLR Supine

Primitive reflex

• Typical age of integration: 6 months

• Stimulus: Infant is supine

• Response: Demonstrates increased extensor tone

STNR

Primitive reflex

• Typical age of integration: 8-10 months

• Stimulus: a) Infant is supported quadruped and the neck is placed in flexion, OR b) Infant is supported in quadruped and the neck is placed in extension

• Response: a) The upper extremities flex and the lower extremities extend, OR b) The upper extremities extend and the lower extremities flex

***UE action mirrors action of the neck & LE action is opposite

Babinski

Primitive reflex

• Typical age of integration: 8 months to 1 year

• Stimulus: Infant stroked along the lateral aspect of the foot

• Response: Toes flare

Plantar Grasp

Primitive reflex

• Typical age of integration: 9 months

• Stimulus: Pressure is placed on infant’s ball of foot

• Response: Toes flex

Landau

Primitive reflex

• Age of onset: 3-4 months

• Typical age of integration: 1-2 years

• Stimulus: Infant is held in prone suspension (horizontal)

• Response: Extends head, trunk, and extremities

Flexor Withdrawal Reflex

Primitive reflex

• Typical age of integration: 1-2 months

• Stimulus: Noxious stimulation (tested in supine position)

• Response: Involuntary withdrawal of body

Cross Extension Reflex

Primitive reflex

• Typical age of integration: 1-2 months

• Stimulus: Extend one leg & hold (prevents flexor withdrawal); noxious stimulation to extended leg (bottom of foot)

• Response: Extension, adduction, and internal rotation of opposite leg toward noxious stimulus (tries to “kick away” noxious stimulus)

Stepping Reflex (Automatic Walking)

Primitive reflex

• Typical age of integration: ~2 months

• Stimulus: Support infant upright over surface with light-moderate pressure on soles of feet; slightly tilt infant forward

• Response: Reciprocal flexion/extension of legs

Neck Righting (Neck on Body Reaction)

Postural Balance (Righting) Reaction

• Age of onset: 4-6 months

• Typical age of acquisition: 5 years

• Stimulus: Turn head to one side

• Response: Segmented body roll to the same side as head

Body Righting (Body on Body Reaction)

Postural Balance (Righting) Reaction

• Age of onset: 4-6 months

• Typical age of acquisition: 5 years

• Stimulus: Rotate hips to one side

• Response: Segmented roll of the upper body to the same side as the head

Body on Head (prone)

Postural Balance (Righting) Reaction

• Typical age of acquisition: 4-5 months

• Stimulus: Stomach touches support surface (lying on stomach)

• Response: Head lifts (neck extension)

Body on Head (supine)

Postural Balance (Righting) Reaction

• Typical age of acquisition: 5-6 months

• Stimulus: Back touches support surface (lying on back)

• Response: Head lifts (neck flexion)

Pull to Sit/Flexion Reaction (Traction)

Postural Balance (Righting) Reaction

• Typical age of acquisition: 6.5 months

• Stimulus: Pull to sitting

• Response: Maintains head aligned with body

Head Righting (Labyrinthine/optical righting)

Postural Balance (Righting) Reaction

• Age of onset: birth to 2 months

• Typical age of acquisition: 5 years or persists

• Stimulus: Rotate/move the body and observe the head’s movement

• Response: Maintains normal head/body relationships to each other and in space

Forward Protective Reaction (parachute protective extension forward)

Protective Reaction

• Age of onset: 6-7 months

• Typical age of acquisition: on-going

• Stimulus: Acting to prevent a fall (suddenly tip/lower toward support surface)

• Response: Arms extend forward

Lateral Protective Reaction (parachute protective extension sideward)

Protective Reaction

• Age of onset: Arms extend forward 6-11 months

• Typical age of acquisition: on-going

• Stimulus: Acting to prevent a fall (suddenly tip/lower toward support surface)

• Response: Arms extend to the side

Backward Protective Reaction (parachute protective extension backward)

Protective Reaction

• Age of onset: 9 months to 1 year

• Typical age of acquisition: on-going

• Stimulus: Acting to prevent a fall (suddenly tip/lower toward support surface)

• Response: Arms extend back

Downward Protective Reaction (parachute protective reaction downward)

Protective Reaction

• Age of onset: ~4-7 months

• Typical age of acquisition: on-going

• Stimulus: Acting to prevent a fall (suddenly lowered toward surface)

• Response: Arms extend downward and legs extend and abduct

What is an equilibrium reaction?

Equilibrium reactions provide information needed to re-align the body around the center of gravity when the head is tilted.

What stimulus enacts an equliibrium reaction?

The general testing procedures involve slowly raising one side of the supporting surface once positioned.

What response is observed in an equilibrium reaction?

A neurotypical presentation includes movement of the head, trunk, and/or limb(s) toward the raised surface to compensate for changes in center of gravity. The head should be realigned over the center of gravity.

What is the age of onset of the prone equilibrium reaction?

5-6 months

What is the age of onset of the supine equilibrium reaction?

7-8 months

What is the age of onset of the sitting equilibrium reaction?

7-10 months

What is the age of onset of the quadruped equilibrium reaction?

9 months to 1 year

What is the age of onset of the standing equilibrium reaction?

1-2 years