Whole Movement Center

Fun Chart of ATNR, STNR, TLR

Tonic Labyrinthine-Prone & Supine (TLR): 

To Read entire very informative blog on their website 

https://www.toolstogrowot.com/blog/2016/01/11/primitive-motor-reflexes-their-impact-on-a-childs-function: To Read entire very informative blog on their website

Tonic Labyrinthine-Prone & Supine (TLR): 

Onset: Birth

Integration: 6 months

Stimulus: Change of orientation of the head in space; position of head in relation to gravity while prone (on belly) and supine (on back).

Response: In prone flexor tone will predominate with arms flexed by the child’s chest. In supine extensor tone will predominate.

Importance for Baby: Allows baby’s posture to adapt to that of the head.

Significance on Early Development if Persists: Will interfere with movement that requires smooth grading of flexor and extensor muscles. In supine child will have compromised ability to raise head up against gravity; this will affect anti-gravity control for movements such as bringing feet and hands together and rolling. In prone (on belly) child will have compromised ability to raise head, extend spine, and bear weight on elbows.  This, in turn, will limit time spent on his/her tummy for crawling and developing the movement in their pelvis and shoulders that sets the stage for moving in and out of various body positions (sitting to stand). Without such ability, the baby will be without options for exploring. This will affect social and cognitive gains.

Influence of Retained Tonic Labyrinthine Reflex (TLR):

  • Walking May present as extra cautious; the child lacks strong arms necessary to protect from trips and falls.
  • Sitting– Slouches while sitting in a chair; can sit upright for short periods.
  • Writing– Leans down over the page when writing.
  • Balance- Difficulty with stairs, curbs, bus steps and managing uneven terrain.

PERSISTENT TONIC REFLEXES:

HOW THESE MAY PRESENT IN EARLY CHILDHOOD
& SCHOOL AGE CHILDREN         

  • Walking May present as extra cautious; the child lacks strong arms necessary to protect from trips and falls.
  • Sitting– Slouches while sitting in a chair; can sit upright for short periods.
  • Writing– Leans down over the page when writing.
  • Balance- Difficulty with stairs, curbs, bus steps and managing uneven terrain.

 

COMMON FINDINGS AND TREATMENT CONSIDERATIONS

FOR

CHILDREN WITH PERSISTENT TONIC REFLEXES

Common Finding: Delayed or Incomplete Righting and Equilibrium Reactions

If primitive tonic reflexes are poorly integrated, the righting and equilibrium reactions will not optimally mature. If the tonic reflexes persist past the typical developmental age range, it is safe to assume the child’s righting and equilibrium reactions are impaired. The child will be using his/her hands to prop him/herself because of incomplete balance. This will impair bilateral hand use for function; a common concern for referral to Occupational Therapy.

Treatment Considerations: Design treatment that activates mature postural responses (righting and equilibrium reactions) and the influence of the tonic reflexes will be minimized. Increase trunk rotation; this is needed for full expression of mature equilibrium. Reach and move across midline of the body; this is also needed for full expression of mature equilibrium. Promote balance without the use of arms to support self; narrow child’s lower extremity or upper extremity base of support. For example, while child is using his/her arms while prone, skillfully minimize the amount of abduction and external rotation at one, then both hips. Also, while weight bearing on arms, facilitate prone extension with elbows positioned just below the child’s ears, rather than supporting his/her-self on forearms of widely abducted arms. When possible use movable equipment such as balls, swings, tilt boards, bolsters, or T stools.

 

Common Finding: Decreased Axial Strength & Compensatory Tightening of Certain Muscles

May see poor trunk extension with accompanying shoulder elevation to compensate for reduced strength. The rib cage may be high in the chest and flared. The child may not spontaneously rotate his/her torso while moving to perform functional tasks; instead will over rely on symmetrical flexion/extension patterns. This will compromise efficient movement for performing functional tasks and result in tightening in certain muscles such as the latissimus and pectorals.

Treatment Considerations: The procedure for inhibiting tonic reflexes requires activation of muscles antagonistic to those activated by the primitive responses. For example, to counteract the effects of the tonic labyrinthine (prone), provide intervention designed to increase strength in the posterior trunk musculature. To counteract the effects of the tonic labyrinthine (supine), provide intervention designed to increase strength by moving against gravity with rotation. Regarding flexibility, determine if stretching the muscle groups that “fix” for stability is needed. For example, to stretch the pectorals child stretches arms behind back, stretch the latissimus by externally rotating and reaching up with both arms, stretch the hamstrings by long sitting and touching toes.

Common Finding:  Joint laxity or Hypermobility  

May see pronated feet, “winging” in the scapula, hypermobile finger joints, hyper-extended knees, and/or lordosis in lumbar spine.

Treatment Considerations: The biomechanical consequence of joint laxity and hypermobility is a poor ability to generate sufficient force for movement. Just as babies develop, when treating be sure to encourage movement in small ranges to develop stability.

SAMPLE INTERVENTION ACTIVITIES

Remember to focus not only on maintaining this static position, but the transition into and out of prone. The child should remain static for brief periods; even minimal weight shifting from the child’s center of gravity may activate the muscles of the spine and shoulder girdle. Remember…upper extremity strength is important for ideal protective extension and use of the arms for transitioning between positions and minimizing the influence of primitive reflexes.

Prone for fine motor activities & games- The elbows provide a point of stability for freeing the hands for manipulating.

1. Hold a large dowel with both hands, use this to push a ball back and forth

2. Use arms to push a ball back and forth

3. Color, print, draw, read, or complete puzzles in prone

4. Use whistles or play games that require blowing through a straw

5. Pivot in both directions

6. Prone on therapy ball, platform swing, or over bolster

7. Prone on scooter board- push off with arms from wall to glide backward

8. Prone on scooter board-being pulled by a rope while grasping onto it with both hands

 

Superman/Super Woman- prone extension with arms and legs fully extended activates muscles antagonistic to the tonic labyrinthine prone reflex

 

Meatball Position- activates muscles antagonistic to the tonic labyrinthine supine reflex

  1. Child uses their own hands to place/remove stickers on knees or feet
  2. Child uses their own hands to place/remove rings from their feet

Supine

  1. Bounce ball off hands while child’s shoulders flexed to 90 degrees with elbows straight; therapist drops ball from above for child to volley back
  2. Use legs to kick suspended ball
  3. Supine on therapy ball; transition into sitting

Bridge Position

Rolling

  1. Outside-down or up hills
  2. With arms overhead or at side
  3. Be sure to encourage chin tuck

The Sidelying Position offers the opportunity to increase strength and edurance while moving in 3 planes. The child will learn to balance by keeping their head and body oriented in midline; remember to not only focus on maintaining this static position, but transition into and out of sidelying. The child should remain static for brief periods; even minimal weight shifting from the child’s center of gravity may activate head and torso righting. Be sure to encourage the use of this posiiton on their right and left sides. This will lengthen muscles needed for full rotation of the trunk. Remember…full expression of equilibrium reactions require torso rotation and freedom of movement in the upper and lower extremities.

Reach- Use free arm to encourage reaching and other movement/manipulation

  1. Play games such as Connect Four in high sidelying
  2. Swat at suspended ball with free arm while in high sidelying
  3. Work puzzles with free hand while in high sidelying

While Side Sitting strive to have child free both hands free to manipulate object at midline; this may require considerable time and practice. To work toward this encourage the child to adjust to small weight shifts away from their midline. Remember…diagonal control sets the stage for isolation of movement for each limb, important for minimizing the effects of primitive reflexes on functional movement.

  1. Side Sit
  2. String beads in side sit
  3. Lace in side sit
  4. Toss a ball while side sitting
  5. Catch a balloon while in side sitting

Long Leg Sitting offers the opportunity to stretch muscles that are often tight in children that need to “fix” due to immature balance and ongoing influence from primitive reflexes. This position can help lengthen the hamstrings; a muscle that often tightens as children over-use to stabilize. Strive to have child free both hands to manipulate an object at midline. This position also provides a chance to develop balance by narrowing the child’s base of support.