This document discusses several primitive and tonic reflexes seen in infants, including their typical onset, integration period, grading scales, and clinical descriptions. The reflexes discussed include the asymmetric and symmetric tonic neck reflexes, positive support reflex, tonic labyrinthine reflex, and others. The document provides details on techniques for eliciting each reflex and what physical findings correspond to different grades of response.

1. PRIMITIVE AND TONIC
REFLEXES

2.  Normal infants are born with numerous primitive reflexes
because of the unrestrained influence of the “old brain”
(deep gray matter), which contains the centers for such
reflexes. These centers include the brainstem,
cerebellum, mid brain and basal ganglia.
 The “new brain” (cerebral cortical mantle) can be
viewed as an inhibitory organ: during development,
primitive reflexes are inhibited and integrated into more
functional, postural and voluntary motor responses.
 With cerebral insults, this cortical suppression
/integration is released, and various deep gray matter
responses (primitive reflexes) reappear.

3. Reflexes important to examine in the patient
suspected of abnormal reflex activity include:
 Flexor withdrawal
 Traction
 Grasp
 Tonic neck
 Tonic labyrinthine
 Positive support and
 Associated reactions.

4.  Flexor withdrawal reaction is generally the
simplest to observe and is judged by an overt
movement response.
 Tonic neck reflexes, on the other hand, bias
the musculature and may not be visible
through overt movement responses.
 In these reflexes movement is rarely produced
but rather posture is typically influenced
through tonal adjustments.

5.  Capute et al in 1976 described a quantitative reflex
scale for the grading reflexes:
0 : absent
1+ : transient; elicited involuntarily by passive action of
the infant, or noted only by change in tone.
2+ : visible movement of extremities.
3+ : pronounced or sustained; more exaggerated than
normally seen at chronological age; not readily
habituated.
4+ : obligatory; infant unable to break out of reflex for a
minimum of 60 sec (pathologic).

6. ASYMMETRICAL TONIC NECK
REFLEX
 The asymmetric tonic neck reflex is mediated
ipsilaterally through the first three cervical nerve roots.
 Mc Couch et al. (1951) localised the receptive field for
the tonic neck reflexes to the upper neck joints,
especially to the atlantoaxial and atlanto- occipital
joints.
 Pacella and Barera (1940) documented an influence
of the ATNR on the grasp reflex with a reinforcement
of the grasp reflex on the occiput side and the
weakening of the grasp reflex on the face side of an
ATNR.
 This interaction between the two reflexes explains the
occasional inclusion of finger extension/flexion in the
ATNR pattern.

7. ASYMMETRICAL TONIC NECK REFLEX
Onset: birth Integration: 4-6
months
DESCRIPTION : When the child is
supine he may be seen to lie with
head turned to one side with
extension of extremities on that
side, and contralateral flexion of
extremities. This may also be
noted in sitting position. It is often
described as “fencer” position.
TECHNIQUE: The child is placed
in supine. He is first observed for
active head turning and
subsequent extremity movement. If
the reflex is not noted, the head is
turned for 5 sec. This is repeated
for five times to each side. If no
movement is noted, the head
turning is repeated and changes in
tone are observed. This is then
repeated with the child in a seated
position.
GRADING:
 0 : Absent
 1+: tone changes in extremities with head rotation. On
the chin side there is increased tone on flexion. On the
occiput side there is increased tone on extension. Active
head rotation on the child’s part may yield slight
movement of the extremities Passive movement of the
head does not yield movement of the extremities.
 2+: Visible extension of the extremities on the chin side
and the flexion of the extremities on the occiput side.
Movement is noted on both passive and active rotation
of the head. (this is seen in normal development of reflex
between 1 and 3 months of age.)
 3+: Exaggerated quality with full extension of extremities
on the chin side (180 degrees) or full flexion of
extremities on occiput side (greater than or equal to 90
degrees at the elbow)
 4+: Pathologic. Obligatory extension/flexion for more
than 60 sec.

8. ASYMMETRICAL TONIC NECK
REFLEX

9. SYMMETRICAL TONIC NECK REFLEX
Onset: 4-6 months Integration: 8-12
months
 The symmetrical tonic reflex is analogous to
the asymmetrical tonic neck reflex, but the
head-on- body manipulation of the flexion
extension in the midline changes the axis of
differentiation from sagittal to horizontal ( i.e.,
there is an upper- lower rather than a right left
extremity difference).

10. SYMMETRICAL TONIC NECK REFLEX
DESCRIPTION : On raising the
head of a prone child, extensor tone
increases in the arms and flexor tone
increases in the legs; flexing the neck
has the opposite effect with
increased flexor tone in the arms and
increased extensor tone in the legs.
TECHNIQUE: The child is prone ,
suspended, sitting or kneeling. Active
neck extension/flexion is sought
through visual stimulus or command.
Movement or tone changes in
extremities is assessed. If there is no
active movement, the neck is
passively extended/flexed five times
and tone/movement is assessed.
GRADING:
 0 : Absent
 1+: Mild, intermittent arm extension and
leg flexion with neck extension; the
reverse with neck flexion. Frequently only
tone changes in the extremities with neck
flexion/extension.
 2+: Visible and consistent arm extension,
or leg flexion with neck extension; the
reverse is noted with flexion.
 3+: Marked arm extension or leg flexion
with neck extension, reverse with flexion.
Not easily overcome by the child. Not
readily habituated and present after five
trials.
 4+: Pathologic. Obligatory. Position
remains after 60 sec.

11. SYMMETRICAL TONIC NECK
REFLEX

12. TONIC LABYRINTHINE REFLEX
 Magnus (1926) described the essential
components of the tonic labyrinthine reflex:
 There is only one position in which the
extension becomes maximal: the supine
position with snout about 45degrees above the
horizontal plane. The extensor tone diminishes
to a relative minimum if the baby is brought into
the prone position with snout about 45degrees
below the horizontal plane.
 These reflexes are not evoked by movement but
depend upon position.

13. TONIC LABYRINTHINE REFLEX
 Tonic labyrinthine reflex in a supine position (TLS)
demonstrates not only an increase in extensor tone, but
also shoulder adduction with retraction, thus mimicking a
“surrender” position.
 In prone , the tonic labyrinthine reflex (TLP) consists of
hip-knee flexion with shoulder protraction and further
flexion.
 A persistent non physiologic TLS will prevent an infant
from rolling over in normal fashion.; however the history
of “rolling over” before 3 months of age should make the
examiner highly suspicious of a strong TL with an
attendant high risk for significant motor impairment.
 A marked TL may inhibit the “embrace” phase of MORO
reflex.

14. TONIC LABYRINTHINE REFLEX
DESCRIPTION : The
posture of the limbs
changes with respect to
the position of head in
space (orientation of the
labyrinths). Supine the
limb extends or extensor
tone increase. Prone, the
limbs flex or the flexor
tone increases.
TECHNIQUE: The child
is observed supine.
Support is then placed
between the shoulders so
that the head is extended
to 45 degrees. The tone
is assessed. The child’s
head is then flexed to 45
degrees with the back
supported and finally he
is asked to grasp the
midline. The child is then
placed prone and tone is
GRADING:
 0 : Absent
 1+: In the supine position, the shoulders are retracted and
arms are lying in “surrender” posture. There would be
momentary shoulder retraction and leg extension when
support is placed between the shoulders and head
extended. When the child is made to flex his head,
shoulder retraction is broken and hands immediately come
to midline. In prone there may be momentary flexion noted
at the hips.
 2+: With his head in extension the child is not able to
overcome shoulder retraction. His hands do not come to
the midline when his head is flexed, but he can overcome
this on command. Prone, some degree of flexion with
increased flexor tone is noted.
 3+: When the child’s head is extended there is a significant
shoulder retraction and leg extension. He is unable to bring
his hands together fully when asked to flex his head and
his shoulders do not protract. In prone there may be
considerable flexion.

15. TONIC LABYRINTHINE
REFLEX

16. POSITIVE SUPPORT REFLEX
Onset: birth Integration: 6 months
 Magnus (1925) described positive supporting reaction
as a mechanism necessary for maintaining erect
posture.
 Rademaker’s (1924) further refined its description as a
simultaneous contraction of opposing muscles so as to
fix the joints of the lower extremities; tactile, pressure,
and proprioceptive components were used to elicit it.
 He proposed it as a preparatory position for motion.
 Paine( 1964) reported that its presence to a strong
degree from a newborn period is common in spastic
tetraparesis.
 Pressure on the soles of the feet yields an anti gravity
contraction of the extensor muscles producing an erect

17. POSITIVE SUPPORT REFLEX
DESCRIPTION : Upon
stimulation, co-
contraction of the
opposing muscle
groups occurs so as to
fix the joints of the lower
extremities in a position
capable of supporting
weight.
TECHNIQUE: The
child is suspended in a
vertical position and the
balls of the feet are
brought in contact with
the floor or a surface for
60 secs. The child is
then bounced five
times.
GRADING:
 0 : Absent. No attempt at weight bearing.
 1+: The child does not maintain his weight for 60 sec. he
may land flatfooted with no discernible movement from
heel to toe. The knees may be partially flexed without
evidence of extension.
 2+: The child is able to support his weight for greater than
60 sec. there is quick movement from plantar flexion to
dorsiflexion. There is extremity extension with body
support. Slight hip and knee flexion may be noted.
 3+: There is delayed movement from plantar flexion to
dorsiflexion. The child remains in equinus position. The
knees may be hyper extended in a genu recurvatum
position or there may be fixed and persistent knee flexion.
The child seems to be standing on his toes.
 4+: The child remains in equinus position. He is not able
to move out of position without circumducting the legs and
stays in this position for greater than 60 sec.

18. POSITIVE SUPPORT REFLEX

19. ASSOCIATED REACTIONS
Onset: birth- 3months Integration: 8-9
years
 STIMULUS: Resisted voluntary
movement on any part of the body.
 RESPONSE: Involuntary movements
in a resting extremity.

20. Apeksha Besekar
Ist yr. MPTh.
A.I.I.P.M & R.
9.05.2013