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University of Connecticut
School of Physical Therapy
Storrs, Connecticut
 Digitized by the Internet Archive
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 REFLEX TESTING METHODS
for

EVALUATING C.N.S. DEVELOPMENT

 Publication Number 543

AMERICAN LECTURE SERIES®

A Monograph in

AMERICAN LECTURES IN ORTHOPAEDIC SURGERY

Edited by

CHARLES WEER GOFF, M.D.

Associate Clinical Professor of Orthopaedics
and Lecturer in Anatomy
Tale University, School of Medicine
Hartford, Connecticut
 REFLEX TESTING METHODS
for
EVALUATING C.N.S. DEVELOPMENT

By

MARY R. FIORENTINO, O.T.R.

Director of Occupational Therapy

Newington Hospital for Crippled Children

Newington, Connecticut

With a Foreword by

BURR H. CURTIS, M.D.

Medical Director
Newington Hospital for Crippled Children
Newington, Connecticut

CHARLES C THOMAS • PUBLISHER

Springfield • Illinois • U.S.A.
 Published and Distributed Throughout the World by

CHARLES G THOMAS • PUBLISHER

Bannerstone House
301-327 East Lawrence Avenue, Springfield, Illinois, U.S.A.

This book is by copyright. No

protected
part of it may be reproduced
in any manner
without written permission from the publisher.

© 1963, by CHARLES C THOMAS • PUBLISHER

Library of Congress Catalog Card Number: 63-11521

With THOMAS BOOKS careful attention is given to all details of

manufacturing and design. It is the Publisher's desire to present books
and artistic possibilities
that are satisfactory as to their physical qualities
and appropriate for their particular use. THOMAS
BOOKS will be true
to those laws of quality that assure a good name and good will.

Printed in the United States of America

S-3
I

This manual is dedicated to the therapists

in my department for their conscientious and

diligent cooperation in the application of
a method of treatment that has been found
effective for the child with cerebral palsy.
 FOREWORD
I N THE development of the program handicapped at
for the cerebrally
Newington Hospital for Crippled Children, the necessity for an increasing
awareness of what is normal has prompted Miss Fiorentino and others to
better document the normal reflex development in children.

Miss Fiorentino has accomplished this through considerable personal

effort. She is gifted with a rare ability to impart this information to physicians,

other therapists and students. Requests for her knowledge of the subject
led her to the writing of this manual which should provide a better under-
standing of the reflex patterns of both normal children and those afflicted
with neurological disorders, and should aid medical and paramedical
persons dealing with such children in establishment of diagnosis, program-
ming and recording of progress in their habilitation.

Burr H. Curtis, M.D.

Medical Director
Newington Hospital for Crippled Children
Newington, Connecticut

vn
 PREFACE

IT IS believed that a clearer understanding of normal, neurophysiological

development and methods of testing will be helpful to physicians and para-
medical personnel working closely with handicapped children. It is hoped
that this will assist in the evaluation, diagnosis and assessment of children
through six years of age, and programming rehabilitation of neurophysio-
in
logically involved children. The testing methods will be of value to:

Pediatricians
In the initial and periodic examination of all infants and children through
six years of age.

Neurologists
In the diagnosis and evaluation of infants and children where abnormal
reflexive reactions are suspected.

Orthopaedists
For the assessment of patients who would lend themselves to a neuro-
physiologically oriented treatment.

Physiatrists

A basis for diagnosis and program-planning for rehabilitation.

Occupational, Physical and Speech Therapists

To determine the maturational level and abnormal reflexes for a treatment
program.

IX
 ACKNOWLEDGMENTS

G RATEFUL appreciation is extended to Edward D. Mysak, Ph.D., former

speech pathologist at Newington Hospital for Crippled Children, for introduc-
ing this method to the Hospital and this department, and without whose
guidance and teaching in the basic theories of the Neurophysiological Ap-
proach, this manual would not have been possible at this time.
To the following members Newington Hospital for
of the staff of the
Crippled Children for their assistance and cooperation in making this
manual possible: Burr H. Curtis, M.D., Medical Director; John C. Allen,
M.D., Visiting Physiatrist; Otto G. Goldkamp, M.D., Associate Physiatrist;
Walter F. Jennings, M.D., Myron E. Shafer, M.D., and Charles W. Goff,
M.D., members of the orthopaedic staff; Miss Carol Nathan, O.T.R.,
Assistant Director of Occupational Therapy; Miss Ann P. Grady O.T.R.,
staff therapist; Mr. William McCarthy, high school teacher; the photogra-
phy department; the children and their parents who allowed their pictures
to be used.
To
Associate Professor Frieda J. Behlen, M.A., O.T.R., Advisor, Occupa-
tional Therapy Curriculum, New York University, for her sincere efforts and
interest in this manual.
Photographs taken by Miss Carol Nathan, O.T.R.

M.R.F.

XI
 University of Connecticut
School of Physical Thera]
Storrs, Connecticut

CONTENTS
Foreword by Burr H. Curtis vii

Preface ix

Acknowledgements xi

Introduction 3

Purpose 4

Rationale : 5

Procedure 7

Spinal Level — Level I 8

Spinal Reflexes:
Flexor Withdrawal 9

Extensor Thrust 10

Crossed Extension 11

Crossed Extension 12

Brain Stem Level — Level II 13

Brain Stem Reflexes:

Asymmetrical Tonic Neck 14
Symmetrical Tonic Neck — 1 15

Symmetrical Tonic Neck— 2 16

Tonic Labyrinthine — supine 17

Tonic Labyrinthine — prone 18

Associated Reactions 19

Positive Supporting Reaction 20

Negative Supporting Reaction 21

Midbrain Level — Level III 22

Righting Reactions:
Neck Righting 23
Body Righting Acting on the Body 24
Labyrinthine Righting Acting on the Head— 1 25
Labyrinthine Righting Acting on the Head —2 26
Labyrinthine Righting Acting on the Head — -3 27
Labyrinthine Righting Acting on the Head —4 28
Optical Righting — 1 29

xiii
xiv Contents

Optical Righting —2 30

Optical Righting — 3 31

Optical Righting— 4 32

Amphibian Reaction 33

Automatic Movement Reactions 34

Moro Reflex 35

Landau Reflex 36

Protective Extensor Thrust .

• .37
Cortical Level — Level IV 38

Equilibrium Reactions:
Supine 39

Prone 40

Four-foot kneeling * . .
41

Sitting 42

Kneel-standing 43

Hopping— 1
44

Hopping — 2 45

Hopping — 3 46

Dorsiflexion 47

See-saw 48

Simian position 49

Motor Development Chart 50

Reflex Testing Chart 52

Conclusion ........ ......•• 53

Recommended Reading •
^
Films 56
b I
Index ; . . .
 REFLEX TESTING METHODS
for

EVALUATING C.N.S. DEVELOPMENT

 INTRODUCTION

EARLY diagnosis of persistent abnor- festations

Though
of neurological dysfunctions,
mal reflexes may be of great significance scientist and have con-
clinician
to a more effective functioning of the cere- tributed much to our knowledge, there
bfal palsied child. Knowledge
normal
of is need for further investigation in both

and abnormal reflex responses and their theory and therapy of C.N. S. abnormali-
effect upon motor development is needed ties.

to provide a basis for evaluation in the Some of the recent advances in this
diagnosis and treatment of the cerebral country are based upon knowledge of the
palsied child and certain other cerebral neurophysiological implication of reflex-
dysfunctions, ive maturation of the C.N.S. The ratio-
Since Little applied the term "spastic nale of treatment and therapeutic appli-
paralysis" to all cerebral palsied children cation of this approach was described by
in 1843, much research has been under- the Bobaths et al. Knowledge gained from
taken in an attempt to understand the this approach can be applied to testing
physical, mental, perceptual, visual, audi- and evaluating the normal, sequential
tory, epileptic and psycho-social mani- growth and maturation of any child.
 PURPOSE

Th
.HE purpose of this manual is to orient spinal, brain stem, mid brain and cortical
the physicians and the various para- levels.

medical disciplines to a method of

Who Should Test
evaluating C.N.S. dysfunction utilizing
Tests are designed for all those evalua-
neurophysiological principles. To ac-
ting and treating children with neuro-
complish its goal, the manual presents
physiological dysfunctions, namely, the
the following:
general practitioner, pediatrician, neur-
1 Normal sequential development of ologist, orthopaedist, physiatrist, occupa-
reflexive maturation. tional, physical and speech therapists.
2. Possible abnormal responses found
When to Test
in individuals with C.N.S. disorders,
such as cerebral palsy. The initial and periodic examination
of all children from infancy through the
3. Reflex Testing and Motor Develop-
age of six years, as well as older children
ment Charts to assist in the rating of
demonstrating abnormal Ther-
reflexes.
normal and abnormal responses (see
apy should begin before children develop
pages 50 - 52).
abnormal patterns of turning, sitting,
Purpose of Testing crawling and walking. Early referral of
To determine neurophysiological re- patients for reflex therapy cannot be
flexive maturation of the C.N.S. at the over-emphasized
 University of Connecticut
School of Physical Therapy
Storrs Connecticut
,

RATIONALE

JL RIMITIVE reflexes are essential in according to sequential development of

normal development. Response to these reflex maturation and evaluated in
reflexes prepares the child for progressive terms of the status of his particular level
development, such as, rolling over, sit- of reflexology and abnormal muscle
ting, crawling, standing, etc. In normal tone. There are three levels of reflexive
development, these primitive spinal and development:
brain stem reflexes gradually diminish in
order that higher patterns of righting and Apedal —predominance of primi-
equilibrium reactions may become mani- and brain stem reflexes
tive spinal

fested. When inhibitory control of higher with motor development of a

centers is disrupted or delayed, primitive prone or supine-lying creature.
patterns dominate to the exclusion of
higher, integrated sensorimotor activi- Quadrupedal —predominance of

ties. Certain neurologic dysfunctions are midbrain development with right-

believed to result from specific G.N.S. ing reactions and motor develop-
lesions. Such lesions release primitive, ment that of a child who can
abnormal reflexes from inhibition norm- right himself, turn over, assume
ally exerted by higher centers. These crawling and sitting positions.
more primitive reflexes result in ab-
normalities manifested by phylogeneti- —
Bipedal at cortical level of de-
cally older postures and movements and velopment reveals equilibrium re-
abnormal muscle tone, as seen in cerebral actions, with motor development

palsied children. that of a child who can assume

Following above concept, the
the the standing position and ambu-
cerebral palsied child can be classified late.

Levels of C.N.S. Corresponding Levels of Resulting Levels of

Maturation Reflexive Development Motor Development

Spinal and/or Apedal Prone-lying

Brain Stem Primitive Reflexes Supine-lying

Midbrain Quadrupedal Crawling

Righting Reactions Sitting

Cortical Bipedal Standing

Equilibrium Reactions Walking

Fig. I. Normal Sequential Development.

6 Reflex Testing Methods for Evaluating C.N.S. Development

In neurologic dysfunction varying de- behavior will aid in better understanding

grees and combinations of the above the nature of the neurophysiologic dys-
levels may be seen in any one child, function, and in providing a basis for
Knowledge of normal and abnormal evaluation,
reflex responses and their effect on motor
 PROCEDURE

TtHE following pages present photo-

graphs and explanation of the four levels
of the C.N.S. in their sequence of re-
flexive maturation. Photographs and ex-
planations of reflex responses within the
four levelsand test positions with normal
and abnormal responses are illustrated.
Each reflex tested can be rated on a
Reflex Testing Chart and resulting func-
S tional responses on a Motor Develop-
ment Chart.
These reflexes are normal within
certain age limits and should be in-
terpreted as abnormal beyond those
limits. Normal growth and develop-
mental levels vary somewhat; therefore,
age levels are approximate.
 SPINAL LEVEL

OPINAL reflexes are mediated by areas of the G.N.S. up to the base of

the 4th ventricle.

Spinal reflexes are "phasic" or movement reflexes which coordinate muscles

of the extremities in patterns of either total flexion or extension. Positive or
negative reactions to spinal reflex testing may be present in the normal child
within the first two months of life. beyond two
Positive reactions persisting
months of age may be indicative of delayed maturation of the C.N.S. Nega-
tive reactions are normal. Complete domination by these primitive spinal
reflexes results in an apedal (prone, supine-lying) creature.

Flexor Withdrawal Extensor Thrust Crossed Extension

 University of Connecticut
School of Physical Therapy
Spinal Level Storrs, Connecticut 9

Flexor Withdrawal

Negative Reaction

Test Position

Patient supine.
Head in mid-position.
Legs extended.

Test Stimulus

Stimulate sole of foot. ^*

Negative Reaction

Controlled maintenance of
stimulated leg in extension or
volitional withdrawal from
irritating stimulus.

Positive Reaction

Uncontrolled flexion response of

stimulated leg. (Do not confuse
with response to tickling.)

Positive Reaction

Positive reaction is normal up to two Positive reaction after two months of

months of age. age may be one indication of delayed
reflexive maturation.
10 Reflex Testing Methods for Evaluating C.N.S. Development

Extensor Thrust

Negative Reaction

Test Position

Patient supine.
Head in mid-position.
One leg extended, opposite
leg flexed.

Test Stimulus

Stimulate sole of foot of

flexed leg.

Negative Reaction

Controlled maintenance of
leg in flexion.

Positive Reaction

Uncontrolled extension of
stimulated leg. (Do not confuse
with response to tickling.)

Positive Reaction

Positive reaction is normal up to two Positive reaction after two months of

months of age. age may be one indication of delayed
reflexive maturation.
 Spinal Level 11

Crossed Extension

Negative Reaction
Test Position

Patient supine.
Head in mid-position.
One leg flexed, opposite leg
extended.

Test Stimulus

Flex the extended leg.

Negative Reaction

On flexion of the extended leg,

the opposite leg will remain
flexed.

Positive Reaction

On flexion of the extended leg,

the opposite, or initially
flexed, leg will extend.

Positive Reaction

Positive reaction is normal up to two Positive reaction after two months of

months of age. age may be one indication of delayed
reflexive maturation.
12 Reflex Testing Methods for Evaluating C.N.S. Development

Crossed Extension

Negative Reaction

Test Position

Patient supine.
Head in mid-position.
Legs extended.

Test Stimulus

Stimulate the medial surface

of one leg by tapping.

Negative Reaction

No reaction of either leg

upon stimulation.

Positive Reaction

Opposite leg adducts, internally

rotates and foot plantar flexes.
(Typical scissor position.)

Positive Reaction

Positive reaction is normal up to two Positive reaction after two months of

months of age. age may be one indication of delayed
reflexive maturation.
 BRAIN STEM LEVEL
.DRAIN stem reflexes are mediated by areas from the 8th Nerve Nucleus
to below the Red Nucleus.

X
\
\

PRIMITIVE REFLEXES /

Brain stem reflexes are "static" postural reflexes and effect changes in
distribution of muscle tone throughout the body, either in response to a
change of the position of head and body in space (by stimulation of the
labyrinths), or in the head in relation to the body (by stimulation of pro-
prioceptors of the neck muscles). Positive or negative reactions to brain
stem reflex testing may be present in the normal child within the first four
to six months of life. Positive reactions persisting beyond six months of age
rnay be indicative of delayed maturation of the C.N.S. Negative reactions
are normal. Complete domination by these primitive brain stem reflexes
results in an apedal (prone, supine-lying) creature.

Asymmetrical Tonic Neck Symmetrical Tonic Neck

—
Tonic Labyrinthine Supine —
Tonic Labyrinthine Prone Associated Reactions
Positive Supporting Reaction Negative Supporting Reaction

13
 14 Reflex Testing Methods for Evaluating C.N.S. Development

Asymmetrical Tonic Neck

Negative Reaction

Test Position

Patient supine.
Head in mid-position.
Arms and legs extended,

Test Stimulus

Turn head to one side.

Negative Reaction

No reaction of limbs on
either side.

Positive Reaction

Extension of arm and leg on

face side, or increase in
extensor tone; flexion of
arm and leg on skull side, or
increase in flexor tone.

Positive Reaction

Positive reaction is normal up to four Positive reaction after six months of

to six months of age. age may be one indication of delayed
reflexive maturation.
 Brain Stem Level 15

Symmetrical Tonic Neck 1

Negative Reaction
Test Position

Patient in quadruped
position or over
tester's knees.

Test Stimulus

Ventroflex the head.

Negative Reaction

No change in tone of arms

or legs.

Positive Reaction

Arms flex or flexor tone

dominates; legs extend or
extensor tone dominates.

Positive Reaction

Positive reaction is normal up to four Positive reaction after six months of

to six months of age. age may be one indication of delayed
reflexive maturation.
16 Reflex Testing Methods for Evaluating C.JV.S. Development

Symmetrical Tonic Neck 2

Negative Reaction

Test Position

Patient in quadruped
position or over
tester's knees.

Test Stimulus

Dorsiflex the head.

Negative Reaction

No change in tone of arms

or legs.

Positive Reaction

Arms extend or extensor tone

dominates; legs flex or flexor

tone dominates.

Positive Reaction

Positive reaction is normal up to four Positive reaction after six months of

to six months of age. age may be one indication of delayed

reflexive maturation.
 Brain Stem Level 17

Tonic Labyrinthine Supine

Negative Reaction

Test Position

Patient supine.
Head in mid-position.
Arms and legs extended.

Test Stimulus

The supine position, per se.

Negative Reaction

No increase in extensor tone

when arms and legs are passively
flexed.

Positive Reaction

Extensor tone dominates when

arms and legs are passively flexed.

Positive Reaction

Positive reaction is normal up to four Positive reaction after four months of

months of age. age may be one indication of delayed re-
flexive maturation.
18 Reflex Testing Methods for Evaluating C.N.S. Development

Tonic Labyrinthine Prone

Negative Reaction
Test Position

Patient prone.
Head in mid-position.
Legs extended, arms
extended over head.

Test Stimulus

Prone position, per se.

Negative Reaction

No increase in flexor tone;

arms, legs or hips can
be extended.

Positive Reaction

Flexor tone dominates in arms,

legs and hips. (To test for

flexion reaction in hips,

both knees are flexed
simultaneously.)

Positive Reaction

Positive reaction is normal up to four Positive reaction after four months of

months of age. age may be one indication of delayed re-

flexive maturation.
 Brain Stem Level 19

Associated Reactions

Negative Reaction

Test Position

Patient supine.

Test Stimulus

Have patient squeeze an

object. (With a
hemiplegic, squeeze
with uninvolved hand.)

Negative Reaction

No reaction, or minimal
reaction or increase of tone
in other parts of the
body.

Positive Reaction

Mirroring of opposite limb

and /or increase of tone in
other parts of the body.

Positive Reaction

Positive reaction in patients with other abnormal reflexology may be an indica-

tion of delayed reflexive maturation
20 Reflex Testing Methods for Evaluating C.N.S. Development

Negative Reaction Positive Supporting Reaction

Test Position

Hold patient in standing

position.

Test Stimulus

Bounce several times on

soles of feet.

Negative Reaction

No increase of tone
(legs volitionally flex)

Positive Reaction

Increase of extensor tone

in legs. Plantar flexion
of feet, genu recurvatum
may occur.

Positive reaction is normal up to four

months of age.

Positive reaction after four months of

age may be one indication of delayed
reflexive maturation.

Positive Reaction
 University of Connecticut
School of Physical Therapy
Storrs Connecticut
,

Brain Stem Level 21

Negative Reaction
Negative Supporting Reaction

Test Position

Hold patient in
standing position.

Test Stimulus

Bounce several times

on soles of feet.
Hold patient in space.

Negative Reaction

No increase in flexor
tone.

Positive Reaction

Increase of flexor tone

in legs.

Positive reaction is normal up to four

months of age.

Positive reaction after four months of

age may be one indication of delayed
reflexive maturation.

Positive Reaction
 MIDBRAIN LEVEL
R IGHTING reactions are integrated at the midbrain level above the
Red Nucleus.

MIDBRAIN LEVEL

Righting reactions interact with each other and work toward establish-
ment of normal head and body relationship in space as well as in relation
to each other. These are the first such reactions to develop after birth and
reach maximal concerted effect about age ten to twelve months. As cortical
control increases, they are gradually modified and inhibited and disappear
towards the end of the fifth year. Their combined actions enable the child
to roll over, sit up, get on his hands and knees, and make him a quadrupedal
creature.
Neck Righting Body Righting Acting on the Body
Labyrinthine Righting Acting on the Head Optical Righting Acting on the Head
Amphibian

22
 Midbrain Level 23

Neck Righting Negative Reaction

Test Position

Patient supine.
Head in mid-position.
Arms and legs extended.

Test Stimulus

Rotate head to one side,

actively or passively.

Negative Reaction

Body will not rotate.

Positive Reaction

Body rotates as a whole in

the same direction as the
head.

Positive reaction is normal from birth

to six months of age.

Positive reaction beyond six months of

age may be one indication of delayed
reflexive maturation.

Negative reaction over one month of

age is one indication of delayed reflexive
maturation.

Positive Reaction
24 Reflex Testing Methods for Evaluating C.N.S. Development

Body Righting Acting on the Body

Negative Reaction

Test Position

Patient supine.
Head in mid-position.
Arms and legs extended,

Test Stimulus

Rotate head to one side,

actively or passively.

Negative Reaction

Body whole
rotates as a
(neck righting), and not
segmentally.

Positive Reaction

Segmental rotation of trunk

between shoulders and pelvis,
e.g., head turns, then

shoulders, finally the pelvis.

Positive Reaction

Positive reaction emerges about six Negative reaction over six months of
months of age. age maybe one indication of delayed re-
flexive maturation.
 Unive- of Connecticut
School of Physical
Therapy
Storrs, Connecticut
Midbrain Level
«

Labyrinthine Righting Acting on the Head 1

Negative Reaction

Test Position

Hold blindfolded patient in

space.
Prone position.

Test Stimulus

Prone position in space,

per se.

Negative Reaction

Head does not raise

automatically to the
normal position.

Positive Reaction

Head raises to normal

position, face vertical,
mouth horizontal.

Positive Reaction

normal about one

Positive reaction is Negative reaction after two months of
to two months of age and continues age may be one indication of delayed
throughout life. reflexive maturation.
26 Reflex Testing Methods for Evaluating C.N.S. Development

Labyrinthine Righting Acting on the Head 2

Negative Reaction

Test Position

Hold blindfolded patient in

space.
Supine position

Test Stimulus

Supine position in space,

per se.

Negative Reaction

Head does not raise

automatically to the
normal position.

Positive Reaction

Head raises to normal

position, face vertical,
mouth horizontal.

Positive Reaction

normal about six

Positive reaction is Negative reaction after six months of
months of age and continues throughout age may be one indication of delayed
life. reflexive maturation.
 Midbrain Level 27

Labyrinthine Righting Negative Reaction

Acting on the Head 3

Test Position

Hold blindfolded patient

in space.
Hold around pelvis.

Test Stimulus

Tilt to the right.

Negative Reaction

Head does not right itself

automatically to the normal

position.

Positive Reaction

Head rights itself to

normal position, face
vertical, mouth horizontal.

Positive reaction normal about six to

is

eight months of age and continues

throughout life.

Negative reaction after eight months of

age may be one indication of delayed
reflexive maturation.

Positive Reaction
28 Reflex Testing Methods for Evaluating C.JV.S. Development

Negative Reaction Labyrinthine Righting

Acting on the Head 4

Test Position

Hold blindfolded patient

in space.
Hold around pelvis.

Test Stimulus
V

Tilt to the left.

Negative Reaction

Head does not right

itself automatically
to the normal position.

Positive Reaction

Head rights itself to

:

? — ;,;:. normal position, face

vertical, mouth horizontal.
'f

Positive reaction isnormal about six to

eight months of age and continues
throughout life.

Negative reaction after eight months

of age may be one indication of delayed
reflexive maturation.

Positive Reaction
 Midbrain Level 29

Optical Righting 1

Negative Reaction
'.!'

Test Position *

Hold patient in space.

Prone position.

Test Stimulus

Prone position in space,

per se.

Negative Reaction

Head does not raise

automatically to the
normal position.

Positive Reaction

Head raises to normal

position, face vertical,
mouth horizontal.

Positive Reaction

Positive reactionnormally appears Negative reaction after this time may

soon after Labyrinthine Righting acting be one indication of delayed reflexive
on the head (1 -2 months) and continues maturation,
throughout life.
30 Reflex Testing Methods for Evaluating C.JV.S. Development

Optical Righting 2

Negative Reaction
m Test Position

Hold patient in space.

Supine position.

Test Stimulus

Supine position in space,

per se.

Negative Reaction

Head does not raise

automatically to the
normal position.

Positive Reaction

Head raises to normal

position, face vertical,
mouth horizontal.

Positive Reaction

Positive reaction is normal about six Negative reaction after six months of
months of age and continues throughout age may be one indication of delayed
life. reflexive maturation.
 Midbrain Level 31

Optical Righting 3 Negative Reaction

Test Position

Hold patient in space.

Hold around pelvis.

Test Stimulus

Tilt to the right.

Negative Reaction

Head does not right itself

automatically to the
normal position.

Positive Reaction

Head rights itself to

normal position, face
vertical, mouth
horizontal.

Positive reaction isnormal about six to

eight months of age and continues
throughout life.

Negative reaction after eight months

of age may be one indication of delayed
reflexive maturation.

Positive Reaction
32 Reflex Testing Methods jor Evaluating C.N.S. Development

Negative Reaction Optical Righting 4

Test Position

Hold patient in space.

Hold around pelvis.

Test Stimulus

Tilt to the left.

Negative Reaction

Head does not right

itself automatically
to the normal position.

Positive Reaction

Head rights itself to

normal position, face
vertical, mouth horizontal.

Positive reaction isnormal about six to

eight months of age and continues
throughout life.

Negative reaction after eight months

of age may be one indication of delayed
reflexive maturation.

Positive Reaction
 University oi" Connecticut
School of Physical Therapy
Storrs, Connecticut
Midbrain Level 33

Amphibian Reaction

Negative Reaction

Test Position

Patient prone.
Head in mid-position.
Legs extended, arms
extended over head.

Test Stimulus

Lift pelvis on one side.

Negative Reaction

Flexion of arm, hip and

knee cannot be elicited.

Positive Reaction

Automatic flexion of arm,

hip and knee on same side.

Positive Reaction

Positive reaction is normal at six Negative reaction after six months of

months of age and remains throughout age may be one indication of delayed re-
life, flexive maturation.
 AUTOMATIC MOVEMENT
REACTIONS

These are described as a group of

reflexes observed in infants and young
children which are not strictly righting
reflexes, but which are movements pro-
duced by stimulation of the semi-
circular canals. Like righting reflexes,
they appear at certain stages of develop-
ment and their persistence, or absence,
can be observed in patients under patho-
logical conditions.

Mow Reflex
Landau Reflex
Protective Extensor Thrust

34
 Automatic Movement Reactions 35

Moro Reflex Negative Reaction

Test Position

Patient supine.
Arms and legs extended.

Test Stimulus

Elicited by a number of
stimuli, such as, sudden
noise, movement of
supporting surface,
dropping patient backwards
while held in semi-sitting
position.

Negative Reaction

Minimal or no startle
reaction.

Positive Reaction

Abduction-extension reaction
of the arms, and /or movement
in other parts of the body.

Positive reaction is normal from birth

to four to six months of age.

Positive reaction after six months of

age may be one indication of delayed
reflexive maturation.

Negative reaction is normal after six

months of age.

Positive Reaction
36 Reflex Testing Methods for Evaluating C.N.S. Development

Landau Reflex

Negative Reaction

Test Position

Patient held in space,

supporting thorax.
Prone position.

Test Stimulus

Head raised, actively

or passively.

Negative Reaction

Spine and legs remain

in flexed position

Positive Reaction

Spine and legs extend.

(When head is

ventroflexed, spine
and legs flex.)
Positive Reaction

Positive reaction is normal from six Negative reaction is normal from birth
months to two or two and one half years to six months of age and from two and
of age. one half years throughout life.

Positive reaction after two and one half

years of age may
be one indication of
delayed reflexive maturation.
 Automatic Movement Reactions 37

Protective Extensor Thrust

Negative Reaction

Test Position

Patient prone.
Arms extended overhead.

Test Stimulus

Suspend patient in air

by ankles or pelvis and
move head suddenly towards
floor.

Negative Reaction

Arms do not protect head,

but show primitive reflex
reaction, such as,
asymmetrical or symmetrical
tonic neck reflexes.

Positive Reaction

Immediate extension of arms

with abduction and extension
of fingers to protect the
head. Positive Reaction

Positive reaction is normal about six Negative reaction after six months of
months of age and remains throughout age may be one indication of delayed
life. reflexive maturation.
 CORTICAL LEVEL

T,HESE reactions are mediated by the efficient interaction of cortex, basal

ganglia and cerebellum.

Maturation of equilibrium reactions brings the individual to the human

bipedal stage of motor development. They occur when muscle tone is nor-
malized and provide body adaptation in response to change of center of gra-
vity in the body. They emerge from six months on. Positive reaction at any
one level indicates the next higher level of motor activity is possible.
Supine Prone Four-Foot Kneeling Sitting Kneel-Standing
Standing-Hopping, Doriflexion, See-Saw Simian Position

38
 Cortical Level 39

Supine

Negative Reaction
Test Position

Patient supine on tiltboard.

Arms and legs extended.

Test Stimulus

Tilt board to one side.

Negative Reaction

Head and thorax do not right

-themselves; no equilibrium
or protective reactions.
(It is possible to have
positive reactions in some body
parts but not in others.)

Positive Reaction

Righting of head and thorax,

abduction and extension of
arm and leg on raised side
(equilibrium reaction),
protective reaction on lowered
side of board.

Positive Reaction

Positive reactionsnormal about six Negative reaction after six months of

months of age and continue throughout age may be one indication of delayed
life- reflexive maturation.
40 Reflex Testing Methods for Evaluating C.N.S. Development

Prone

Negative Reaction

Test Position

Patient prone on tiltboarcL

Arms and legs extended.

Test Stimulus

Tilt board to one side.

Negative Reaction

Head and thorax do not

right themselves; no
equilibrium or
protective reactions.
(It is possible to have
positive reactions in some
body parts but not in others.)

Positive Reaction

Righting of head and thorax,

abduction and extension of
arm and leg on raised side
(equilibrium reaction),
protective reaction on
Positive Reaction lowered side of board.

Positive reactions normal about six Negative reaction after six months of
months of age and continue throughout age may be one indication of delayed
life. reflexive maturation.
 Cortical Level 41

Four-foot Kneeling

Negative Reaction
Test Position

Patient in quadruped
position.

Test Stimulus

Tilt to one side.

Negative Reaction

Head and thorax do not

right themselves; no
equilibrium or protective
reactions.
(It is possible to

have positive reactions

in some body parts but
not in others.)

Positive Reaction

Righting of head and

thorax, abduction-extension
of arm and on raised side
leg
(equilibrium reaction), and
protective reactions on lowered
side. Positive Reaction

Positive reactions normal about eight Negative reactions after eight months
months of age and continue throughout of age may be one indication of delayed
life. reflexive maturation.
42 Reflex Testing Methods for Evaluating C.N.S. Development

Sitting

Negative Reaction
Test Position

Patient seated on chair.

Test Stimulus

Pull or tilt patient

to one side.

Negative Reaction

Head and thorax do not

right themselves; no
equilibrium or
protective reactions.
(It is have
possible to
positive reactions in some
body parts but not in
others.)

Positive Reaction

Righting of head and

thorax, abduction-extension
of arm and leg on raised
side (equilibrium
Positive Reaction reaction), and protective
reaction on lowered side.

Positive reactions normal about ten to Negative reactions after twelve months
twelve months of age and continue of age may be one indication of delayed
throughout life. reflexive maturation.
 Cortical Level 43

Kneel-standing

Negative Reaction

Test Position

Patient in kneel-standing
position.

Test Stimulus

Pull or tilt patient

to one side.

Negative Reaction

Head and thorax do not

right themselves; no
equilibrium or
protective reactions.
(It is possible to have
positive reactions in some
body parts but not in
others.)

Positive Reaction

Righting of head and

thorax, abduction-extension
of arm and leg on raised
side (equilibrium reaction),
Positive Reaction
and protective reaction on
lowered side of board.

Positive reactions normal about fifteen Negative reactions after fifteen months
months of age and continue throughout of age may be one indication of delayed
life. reflexive maturation.
44 Reflex Testing Methods for Evaluating C.N.S. Development

Negative Reaction Hopping 1

Test Position

Patient in standing
position.
Hold by upper arms.

Test Stimulus

Move to the left or

to the right sides.

Negative Reaction

Head and thorax do not

right themselves;
no hopping steps to
maintain balance.

Positive Reaction

Righting of head and

thorax, hopping steps
sideways to maintain
equilibrium.
:,m
\m

normal about fifteen

Positive reactions
to eighteen months of age and continue
throughout life.

Negative reactions after eighteen

months of age may be one indication of
delayed reflexive maturation.

Positive Reaction
 Unj c bicut
School of Physical Therapy
Storrs, Connecticut
Cortical Level 45

Hopping 2 Negative Reaction

Test Position

Patient in standing
position.
Hold by upper arms.

Test Stimulus

Move forward.

Negative Reaction

Head and thorax do not

right themselves; no
hopping steps to
maintain balance.

Positive Reaction

Righting of head and

thorax, hopping steps
forward to maintain
equilibrium.

normal about fifteen

Positive reactions
to eighteen months of age and continue
throughout life.

Negative reactions after eighteen

months of age may be one indication of
delayed reflexive maturation.

Positive Reaction
46 Reflex Testing Methods for Evaluating C.N.S. Development

Negative Reaction Hopping 3

Test Position

Patient in standing
position.
Hold by upper arms.

Test Stimulus

Move backwards.

Negative Reaction

Head and thorax do

not right themselves;
no hopping steps to
maintain balance.

Positive Reaction

Righting of head and

thorax, hopping steps
backwards to maintain
equilibrium.

normal about fifteen

Positive reactions
to eighteen months of age and continue
throughout life.

Negative reactions after eighteen

months of age may be one indication of
delayed reflexive maturation.

Positive Reaction
 y
Cortical Level 47

Dorsiflexion Negative Reaction

Test Position

Patient in standing
position.
Hold under axillae.

Test Stimulus

Tilt patient
backwards.

Negative Reaction

Head and thorax do

not right themselves;
no dorsiflexion of
feet.

Positive Reaction :
'"''
.

Righting of head and

thorax, feet dorsiflex. •
; '.

. : :

normal about fifteen

Positive reactions
to eighteen months of age and continue
throughout life.

Negative reactions after eighteen

months of age may be one indication of
delayed reflexive maturation.

Positive Reaction
48 Reflex Testing Methods for Evaluating C.N.S. Development

Negative Reaction See-Saw

Test Position

(Patient must be able

to maintain standing
balance.) Patient in
standing position.
On same side, hold by
hand and foot, flex hip
and knee.

Test Stimulus

Pull arm forward gently

and slightly to lateral
side.

Negative Reaction

Head and thorax do not

right themselves;
inability to maintain
standing balance.

Positive Reaction

Righting of head and

thorax, slight abduction
and full extension of
manually flexed knee
to maintain equilibrium.

Positive reactions normal about fifteen

months of age and continue throughout

life.

Negative reactions after fifteen months

of age may be one indication of delayed
reflexive maturation.

Positive Reaction
 Cortical Level 49

Simian Position

Negative Reaction

Test Position

Patient in squat-sitting
position.

Test Stimulus

Tilt to one side.

Negative Reaction

Head and thorax do not

right themselves;
inability toassume
or maintain position,
lack of equilibrium
or protective reactions.

Positive Reaction

Righting of head and

thorax, abduction-extension
of arm and leg on raised
side (equilibrium reaction),
and protection on the lowered
side.
Positive Reaction

normal about fifteen

Positive reactions Negative reactions after eighteen
to eighteen months of age and continue months of age may be one indication
throughout life. of delayed reflexive maturation.
 NEWINGTON HOSPITAL FOR CRIPPLED CHILDREN
Occupational Therapy Department

REFLEX TESTING CHART

Name: Reflex Level:

B.D.: Therapist:

Date:

Reflexes + Comments:

1, Level One — Spinal:

a. Flexor Withdrawal
b. Extensor Thrust
c. Crossed Extension

—
Level Two Brain Stem:
a. Asymmetrical Tonic Neck

b. Symmetrical Tonic Neck

c. —
Tonic Labyrinthine supine
prone
d. Associated Reactions
e. Positive Supporting Reaction _

f. Negative Supporting Reaction

3. Level Three — Midbrain:

Righting Reactions:
a. Neck Righting
b. Body Righting acting on the
Body !

c. Labyrinthine Righting acting

on the head
d. Optical Righting
e. Amphibian

4. Automatic Movement Reactions:

a. Moro Reflex
b. Landau Reflex
c. Protective Extensor Thrust_

Level Four-Cortical:
Equilibrium Reactions
a. Prone-lying
b. Supine-lying
c. Four-foot kneeling
d. Sitting
e. Kneel-standing
f. Standing — hopping
dorsiflexion
see-saw
g. Simian posture

50
 NEWINGTON HOSPITAL FOR CRIPPLED CHILDREN
Occupational Therapy Department

MOTOR DEVELOPMENT CHART

Name: Date:

B.D.: Dominance:

Reflex Level: Therapist:

Motor Development Comments:

I. Head^Raising:
1. Prone (1-2 mos.): .

2. Supine (4-6 mos.):.

3. Sidelying (7 mos.):

II. Turning:
1. Supine-sidelying (1-4 wks.):
2. Supine-prone (6 mos.):
3. Prone-supine (8 mos.):

III. Crawling (7-8 mos.):

1. Puppy dog:
2. Static —makes amphibian movements:
3. Creeps—makes amphibian movements;
moves body forward:
Bunny hops — assumes point crawling
3
using complete rotation:
Crawling —assumes 4 point crawling
using complete rotation:
6. Crawling — uses partial rotation up to sitting
then assumes 4-foot kneeling and crawls:

IV. Sitting:
1. Maintains (7 mos.):
2. Assumes using complete rotation (10-12 mos.)
3. Assumes using partial rotation (2-5 yrs.):
4. Assumes symmetrically (5 yrs.):
V. Standing:
1. Kneel-stands:
Kneel- walks:
Pullsup to standing (103^2 mos.):
Stands unassisted (14 mos.):
Walks (15-18 mos.):

Continued

51
52 Reflex Testing Methods for Evaluating C.N.S. Development

Arm —Hand
Development Comments:

0-4 mos. Reflexive grasp —no eye-hand coordination:

AS mos. Conscious grasp —pronation:
a. crude:
b. between palmar and fingers —ulnar:
c. thumb adducted, not utilized:

6 mos. Eye-hand coordination begins:

Arms used asymmetrically —control from
shoulder and shoulder girdle:
Corralling reach:

7 mos. Radial palmar grasp :.

8 mos. Scissor grasp:

Thumb envelopes object:
Elbow flexible:

9 mos. Crude pinch —pincer grasp:

Advertent release of grasp: _
Wrist flexibility:

Use of forearm between mid-position and

pronation : .

11 mos. Pincer release :__

Supination more frequently:

12 mos. Opposition:
Supination — cortically controlled:
 CONCLUSION

T>HE sequential development of nor-

mal and abnormal reflex maturation is

presented with illustrations and tech-

niques for testing and recording de-
scribed. Early evaluation of abnormal
reactions and the importance of early

referral for treatment are stressed. It is

hoped that this presentation will provide

a clearer understanding and stimulate the
use of a neurophysiologically-oriented
approach in the evaluation, diagnosis
and treatment of the child with cerebral
dysfunction.

53
 RECOMMENDED READING
Andre -Thomas: Integration in the infant, Cerebral Palsy Bull., 8:3, 1959

Bobath, B.: Control of postures and movements in the treatment of cerebral palsy,
Physiotherapy, 39:99, 1953.
Bobath, B.: The importance of the reduction of muscle tone and the control of mass
reflex action in the treatment of spasticity, Occup. Ther., 27:371, 1948.
Bobath, B.: A new treatment of lesions of the upper motor neurone, Brit. J. of Phys.

Med., 2:26, 1948.

Bobath, B.: A study of abnormal postural reflex activity in patients with lesions of
the central nervous system, Parts 1-4, Physiotherapy, 40:259, 295, 326, 368, 1954.
Bobath, B.: The treatment motor disorders of pyramidal and extra-pyramidal
of
origin by reflex inhibition and by facilitation of movements, Physiotherapy, 47:146,
1955.
Bobath, K. and Bobath, B.: Spastic paralysis; treatment by the use of reflex inhibi-
tion, Brit. J. Phys. Med., 13:121, 1950.
Bobath, K. and Bobath, B. Tonic reflexes and righting reflexes in the diagnosis and
:

assessment of cerebral palsy, Cerebral Palsy Rev., 16, (5):4, 1955.

Bobath K. and Bobath, B.: A treatment of cerebral palsy based on the analysis of
the patient's motor behavior, Brit. J. Phys. Med., 15:107, 1952.
Bobath, K. and Bobath, B.: Control of motor function in the treatment of cerebral
palsy, Australian J. Physiother, 2 (2):75, 1956.
Bobath, K. and Bobath, B. Treatment of cerebral palsy by the inhibition of abnormal
:

reflex action, Brit, orthop. J., 11:1, 1954.

Bobath, K.: The neuropathology of cerebral palsy and its importance in treatment
and diagnosis, Cerebral Palsy Bull., 8:13, 1959.
Bobath, K. and Bobath, B.: An assessment of the motor handicap of children with
cerebral palsy and of their response to treatment, Occ. Ther. J., 1-16, 1958.
Bobath, B. and Finnie, N. Re-education of movement patterns for everyday
: life in
the treatment of cerebral palsy, Occ. Ther. J., 1-8, 1958.
Bobath, B.: Observations on adult hemiplegia and suggestions for treatment, Physio-
therapy, 1-23, 1959-1960.

Crickmay, M.: Description and Orientation of the Bobath Method with Reference
to Speech Rehabilitation in Cerebral Palsy. Chicago, National Society of Crippled
Children and Adults, 1956.

Fay, T.: Neurophysical aspects of therapy in cerebral palsy, Arch. Phys. Med., 29:321,
1948.

Gesell, A. L., et al: The First Five Tears of Life. New York, Harper and Bros. 1940.

54
 Recommended Reading 55

Knoblock, H., and Pasamanick, B.: The developmental behavioral approach to

the neurologic examination in infancy, Child Development, 33:181, 1962.

Magnus, R.: Some results of studies in the physiology of posture, Lancet, 2:531, 1926.
Mysak, E. D.: Significance of neurophysiological orientation of cerebral palsy re-
habilitation, Jour, of Speech and Hearing Disorders, 24(3):22\, 1959.
Mysak, E. D., and Fiorentino, M. R.: Neurophysiological consideration in occupa-
tional therapy for the cerebral palsied, Amer. J. of Occ. Ther., 15 (3):113, 1961.

Rood, M.: Neurophysiological reactions as a basis for physical therapy, Phys. Ther.
Rev., 34:444, 1954.
Russell, W. R.: The physiology of memory, Proc. Roy. Soc. Med., 57:9, 1958.

Seamans, S.: A neruophysiological approach to treatment of cerebral palsy introduc-

tion to the Bobath method, The Phys. Ther. Rev., 38 (9):598.
Sherrington, C. S.: Selected Writings. (D. Denny-Brown, ed.). Hamish Hamilton
Medical Books, London, 1939.
Strauss, A., and Kephart, N. C: Psychopathology and Education of the Brain-Injured
Child, Vol. II. New York, Grune and Stratton, 1955.

Twitchell, T. E.: Sensory factors in purposive movement, J. Neurophysiol., 77:239,

1954.

Walshe, F. M.: On certain tonic or postural reflexes in hemiplegia with special

reference to the so-called associated movements, Brain, 46:\, 1923.
Weisz, S.: Studies in equilibrium reaction, J. new. ment. Dis., 88:150, 1938.
 FILMS

T,HE Bobath Approach to Cerebral

Palsy Habilitation.
Pilot Study Films of a Neurophysiological
Approach to Cerebral Palsy Habilita-
tion.
These films are available upon request
from
Newington Hospital for Crippled Child-
ren, Newington, Connecticut.

56
 INDEX
Amphibian reaction, 33 quadrupedal, 5, 22
Apedal development, 5, 8, 13 Dorsiflexion, 47
Asymmetrical tonic neck, 14
Automatic movement reactions, 34-37
Landau reflex, 36 Equilibrium, 38
Moro reflex, 35 Extensor thrust, 10
protective extensor thrust, 37 protective, 37

Bipedal development, 5, 38 Flexor withdrawal, 9

Body righting acting on body, 24
Brain stem level, 13-21
associated reactions, 19 Ganglia, basal, 38
labyrinthine, tonic Genu recurvatum, 20
prone, 18
supine, 17
neck, tonic Hemiplegia, 19
asymmetrical, 14 Hopping, 44-46
symmetrical, 15-16
postural reflexes, 13
"static" reflexes 13 Kneeling, four-foot, 41
supporting reaction Kneel-standing, 43
negative, 21
positive, 20
Labyrinthine
righting, acting on head, 25-28
Cerebellum, 38 tonic
Charts prone, 18
motor development, 51-52 supine, 17
reflex testing, 50 Labyrinths, 13
Cortical level, 38-49 Landau reflex, 36
dorsiflexion, 47
four-foot kneeling, 41
hopping, 44-46 Midbrain level, 22-33
kneel-standing, 43 amphibian reaction, 33
prone, 40 righting
see-saw, 48 body acting on body, 24
simian position, 49 labyrinthine acting on head, 25-28
sitting, 42 neck, 23
supine, 39 optical, 29-32
Crossed extension, 11-12 Moro reflex, 35
Motor development chart, 51
Movement (see Automatic movement reactions)
Development
motor, chart, 51-52
normal sequential, 5 Neck
reflexive, 5 asymmetrical tonic, 14
apedal, 5, 8 righting, 23
bipedal, 5, 38 symmetrical tonic, 15-16

57
58 Reflex Testing Methods for Evaluating C.N.S. Development

Nerves, 8th, nucleus, 13 neck

Nucleus asymmetrical tonic, 14
8th nerve, 13 righting, 23
red, 13, 22 symmetrical tonic, 15-16
primitive, 5, 8, 13
righting
Optical righting, 29-32 body acting on body, 24
labyrinthine, 25-28
neck, 23
Paralysis, "spastic," 3 optical, 29-32

Prone see-saw, 48

cortical level, 40 simian position, 49

labyrinthine tonic, 18 sitting, 42
Proprioceptors, 13 spinal, "phasic," 8

Protective extensor thrust, 37 supporting reaction

negative, 21
positive, 20
Quadrupedal development, 5, 22 testing chart, 50
therapy, early referral for, 4
Righting

Records body acting on body, 24

labyrinthine acting on head, 25-28
motor development, 51-52
neck, 23
reflex testing, 50
optical, 29-32
Red nucleus, 13, 22
Reflex (es)
amphibian reaction, 33
associated reactions, 19 Scissor position, 12
brain stem See-saw, 48
postural, 13 Simian position, 49
"static," 13 42
Sitting,
cortical level
"Spastic paralysis," 3
prone, 40 Spinal level, 8-12
supine, 39 crossed extension, 11-12
crossed extension, 11-12 extensor thrust, 10
development (see Development) flexor withdrawal, 9
dorsiflexion, 47
movement reflexes, 8
extensor thrust, 10 "phasic" reflexes, 8
protective, 37
Supine
flexor withdrawal, 9
cortical level, 39
four-foot kneeling, 41
labyrinthine tonic, 17
hopping, 44-46 Supporting reaction
kneel-standing, 43
negative, 21
labyrinthine
positive, 20
prone tonic, 18
Symmetrical tonic neck, 15-16
righting, 25-28
supine tonic, 17
Landau, 36
Moro, 35 Ventricles, 4th, 8
movement, 8 Ventroflexion, 15
University of Connecticut
School of Physical Therapy
Storrs, Connecticut
University of
Connecticut

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