3. Motor-functional analysis of reflexes (primitive, pathological, and abnormal postural reflexes) [Table.

1] It is truly difficult to understand the motor-functional meaning of the reflexes, including postural reflexes. Fortunately, we have an opportunity to understand this through surgical correction of abnormal neck position of asymmetric tonic neck reflex (ATNR) (Fig. 18AB). Originally at the corrective surgery of hyperextended neck, we noticed an interesting fact that the hypertonic extensors such as the longissimus capitis and cervicis are more predominantly hyperactive, on the side to which the face is turned and the neck is extended (Fig. 18AB).45 It had also been observed that the neck was extended on the side to which the face was turned. We also noticed the fact that when release of these muscles was conducted, asymmetric position of the head and neck was controlled and deformity corrected (Fig. 18B).35,45,61 This meant that predominant hypertonicity of the extensors such as the longissimus capitis and cervicis was responsible for such an extended position of the neck on the side to which the face is turned. In these patients, spinal muscles such as the longissimus capitis, longissimus cervicis, longissimus thoracis and iliocostalis were also

predominantly contracted on the side to which the face is turned and on the concave side of scoliosis.46,61 Here, the multiarticular longissimus thoracis and iliocostalis were noted as hyperactive extensors. It was also interesting to note that when these multiarticular extensors of the trunk were released, scoliosis and truncal deformity in asymmetric tonic neck reflex could be corrected.44,46 It can be said that predominant contraction of these cervical and thoraco lumbar extensors causes a part of the asymmetric tonic neck reflex.45,46 It is also suggested that in patients with asymmetric tonic neck reflex, extensors in cervical, thoracic and lumbar spine are all predominantly contracted on the side to which the face is turned and where the trunk is concave. Detailed observations further disclosed that in these same patients, hypertonicity of the extensors was predominant even in the upper and lower extremities of the same side to which the face turns, and the neck and trunk extend. These facts clearly demonstrated that in patients with asymmetric tonic neck reflex, one side of the entire body was totally extended, while the opposite side was totally flexed. This analysis led us to the conclusion that asymmetric tonic neck reflex is a motor-functional entity involved in primitive

movement pattern in which one side of the entire body is totally extended and the opposite side is totally flexed (Fig. 17, 18A).46,
47,61

Fig. 17 Motor functional meaning of ATNR This observation combined with the following interpretation enabled us to arrive at a new concept that abnormal postural reflexes are a kind of totally patterned movement for propelling the body forwards in less separated and immature form. Similar analysis by Sherington was quoted by Rushmorth 1964 and by Bleck 1987. These observations provided us enormous benefits in the treatment of cervical deformity, cervical radiculomyelopathy, scoliosis and ATNR by the use of selective release surgery. Promising results

shown by selective release prove that this observation is rational and will become a clue to understanding of postural reflex involved in motor function. In order to understand the essentials of hypertonicity, analysis of the reflexes involved in motor function should be continued. Totally involved posture Totally involved extension: In the totally involved patients, totally extended posture without flexion (Fig.15, 21-A) is the most primitive posture, which is not affected by postural change. This occurs when most of the central nervous system is damaged, most of the antigravity muscles are paralyzed, and the multiarticular muscles are contracted excessively due to hyperirritability of the upper motor neurons in the brain stem and spinal cord. Since both flexors and extensors contract simultaneously, rigidity is caused in the whole body, and alternate and reciprocal movements are inhibited. The extensors are more predominant than the flexors in the totally involved extension. Hypertonicity of the extensors, such as the longissimus capitis, the longissimus thoracis and iliocostalis in the trunk, the triceps brachii

and latissimus dorsi in the shoulder and elbow, semimembranosus in the hip and rectus femoris in the knee, are more predominant, than that of the flexors. However, clinically, there seldom is a typical form of total extension posture. Posture is usually influenced with gravity and body position, and modified postures such as tonic labyrinthine reflex (Fig. 13A), asymmetric tonic neck reflex (Fig. 17, 18A) and the symmetric tonic neck reflex (Fig. 21A) are common. Thus, all abnormal postures can be mostly categorized in the following postural reflexes. Tonic labyrinthine reflex (TLR): Tonic labyrinthine reflex is a primitive and pathological reflex that is seen in totally involved patients due to abnormal simultaneous contraction of extensors and flexors in the whole body. Motor-function-wise, posture can be changed into two different phases: flexor dominant phase and extensor dominant one: Flexed posture is exaggerated in prone position, in which contraction of the flexors is predominant, whereas extended posture is exaggerated in supine posture, in which contraction of the extensors is predominant. Hypertonicity of the extensors, such as longissimus muscles, triceps

brachii and hip extensors located on the posterior side of the body is exaggerated by gravity in the supine position; therefore, extension-hypertonicity becomes predominant in supine position. On the other hand, hypertonicity of the flexors such as rectus abdominis, psoas and biceps brachii located on the anterior side of the body is exaggerated by gravity in the prone position; therefore, flexion hypertonicity become predominant in prone position. Motor-function-wise, tonic labyrinthine reflex can be defined, as a posture with extremely limited flexion-extension movements of the whole body, in which simultaneous co-contraction of the hypertonic flexors and extensors causes rigidity and, inhibits smooth reciprocal flexion-extension movements. In a normally developed human body, tonic labyrinthine reflex posture is overwhelmed by antigravity activities of well-differentiated monoarticular muscles located on the antagonist side, and it is usually difficult to find out where it exists. But, we can still see this reflex posture of different types, in various phases of activities of cerebral palsy. It is difficult to see pure form of tonic labyrinthine reflex, since most of the cerebral palsied patients

are alive with some antigravity activities. In order to control and reduce this reflex, it is necessary to understand existence of tonic labyrinthine reflex in its modified form in movements and in postures. This is a severely involved child, with a tonic labyrinthine reflex posture (Fig. 13A). In supine position, he is totally hyperextended, and hence has a totally involved extension posture. However, when he is turned into prone position, both his upper extremities show some degrees of flexion in the elbow. This change in position demonstrates that flexor activities were mildly provoked by gravity in prone position. This change in posture can be called, as a tonic labyrinthine reflex in neurology. On the contrary, this can be called as a flexion-extension movements of the whole body motor-function-wise. We can observe this reflex, in the modified form in almost all diplegic, triplegic and quadriplegic patients. This tonic labyrinthine reflex posture can be a candidate for treatment by spasticity control surgery.43,45 Here, motor functional analysis of the reflex posture should be done prior to surgery. Hypertonic muscles are selectively released at the neck, trunk, shoulders, elbows, wrists, thumb and fingers, hips and

knees, and feet and ankles appropriately, and then, this reflex posture can be controlled (Fig. 13B).

Fig. 13A. Tonic labrinthine reflex

Fig. 13B. Control of TLR After OSSCS on the neck, thunk, shoulders, elbows, hips and knees, TLR posture is controlled. This is another modified form of tonic labyrinthine reflex (Fig. 14A). He shows flexed posture mostly, in prone posture. However, he shows hyperextended posture with scissors posture, when he is in supine position. This level of tonic labyrinthine reflex posture could also be a candidate for orthopaedic selective

spasticity-control surgery. Hyperextended and hyperflexed postures can be controlled and alternate movements of the extremity can be facilitated (Fig. 14B).

Fig. 14A TLR posture.

Fig. 14B. After OSSCS on the trunk and hips, ATNR and TLR posture were blocked, and turn-over exercises were initiated. (See Clause of turn-over exercise.)
(

[Considerations] Functional entity of extension posture, in supine position: When we place a totally involved child on bed in supine position, we can see a phenomenon by which she propels herself to the cranial end of the bed by extending her whole body. She is

likely to get hurt by hitting her head against the bed-fence. This attitude of the baby in the bed can be considered to be an extension posture of the tonic labyrinthine reflex in supine position. The forward movements of this baby can be considered to be a reproduction of the most primitive level of forward-propelling locomotion. As reciprocal movements are extremely limited with co-contraction of flexors and extensors in severely paralyzed patients, this condition cannot be recognized as a movement. This condition has been recognized, as a posture. However, motor-function-wise, extended posture of the tonic labyrinthine reflex in supine position could be recognized, as an ultimate immobile form of primitive and ineffective locomotion. Thus, extension phase in tonic labyrinthine reflex in supine position is fundamentally considered to be a form of primitive locomotion. We can see this kind of primitive locomotion in nature. Fishes have developed a slight antigravity mechanism with small antigravity muscles near their fins. They can keep their bodies in prone position in water with activities of these small fins. But this mechanism acts only in water where the earth's gravity has no effect on their bodies. When a fish is taken out of water and placed on the

ground, the strong earth's gravity will act on its whole body. But antigravity mechanism of the fish is too small to counteract this gravity. So in order to escape from danger, they will jump, extending their trunk with quick contraction of the multiarticular paravertebral muscles, and will fall on the ground without body supporting movements (Fig. 15). This jumping is a kind of flexion-extension movement without antigravity activities, caused by symmetrical contractions of the paravertebral extensors and abdominal flexors. There is no such antigravity activity in the fish, as seen in amphibians, reptiles and mammals. This is the most primitive locomotion in which the head is forced to hit against the ground, without any protective movements (Fig. 15).

Fig. 17. Extesion pattern without antigravity activity These total extension and flexion movements of the entire body could be an

original form of movement pattern observed in the tonic labyrinthine reflex (Fig. 13A, 14A). We can observe similar flexion-extension locomotion style in the human baby. Babies below 3 months move themselves forward, by kicking their legs, with extension movements of the trunk and extremities in supine position. This is a primitive locomotion, using flexion-extension pattern of the tonic labyrinthine reflex. The starting jump in supine position at the backstroke in swimming is also a primitive and most propulsive locomotion, without any antigravity support. Thus, an extension pattern of the tonic labyrinthine reflex could be observed in primitive movements of human being both in children with cerebral palsy and in normal babies and adults. Flexion posture in prone position: Flexor pattern in tonic labyrinthine reflex can also be seen in various phases of human posture and in locomotion. In normal human being, when they carry out highly propulsive movements, such as running or jumping, crouched flexed posture emerges. Motor-function-wise, this can be interpreted as a sudden emergence of flexed posture of the tonic labyrinthine reflex. Flexed posture in crawling and kneeling is also similar. A newborn baby keeps the

body in a ball posture in prone position. This is a basic form of flexion pattern of tonic labyrinthine reflex. From ontogenesis point of view, motor activities in the human body have originated from totally involved flexion posture in tonic labyrinthine reflex, where flexor activity is predominant in prone position. The antigravity extensors are facilitated during growth, which overcome flexor hyperactivity in the tonic labyrinthine reflex resulting in antigravity postures such as kneeling, and standing. In cerebral palsied patients, we can see various phases of the flexion posture in the tonic labyrinthine reflex. Most of the severely involved patients show some flexion attitude in prone position and cannot maintain upright posture such as in sitting (Fig. 20A). In a child at the level of mermaid crawl, we also see a flexordominant posture. In this condition, the flexion form of the tonic labyrinthine reflex is predominant. In the prone position, hypertonicity of the flexors in the trunk and extremities are more exaggerated by gravity. This combined force induced with hypertonicity of the flexors and

gravity inhibits body-supporting activities of the antigravity extensors, such as the suboccipital and multifidus muscles (Fig. 31). In the more mature patients, you can see more mature flexor-dominant posture in symmetric on-hands and on-knees crawling (Fig. 16A). In these patients, the flexor-dominant posture of the tonic labyrinthine reflex is well controlled, and a more matured four point crawl posture is achieved (Fig. 16B).

Fig. 16A. Symmetric on-hand and -knee crawling

Fig. 16B. After OSSCS on the hips Symmetric pattern is controlled and alternate crossed pattern on crutch gait was achieved. Even in

patients who can stand, this flexor pattern such as a crouched posture can often be predominant. Crouched posture can be interpreted as a matured form of this flexion attitude of the tonic labyrinthine reflex in standing in which antigravity activities of the extensors overwhelms hypertonicity of multiarticular flexors in tonic labyrinthine reflex in prone position (Fig. 2A, 3A, 5A, 6A, 82A). Thus, we can now recognize that the tonic labyrinthine reflex can be interpreted motor-function-wise, as a form of propulsive movement and is caused by activities of hypertonic muscles in the entire body. With excessive co-contractions of the hypertonic muscles, movements are limited and the body seems to be fixed in a particular posture. Accordingly, we can control this hypertonic entity, by using orthopaedic selective spasticity-control surgery. Control of hypertonicity of the psoas in the hip joint by the use of selective release can be considered, as a form of spasticitycontrol procedure for control of the flexor pattern in tonic labyrinthine reflex. If this reflex is controlled surgically, a more matured standing posture is attained (Fig. 3B, 6B, 82B). Thus, we have to

analyze the motor function of the postural reflex in these manners, and then we will be able to use this analysis for the orthopaedic selective spasticity-control surgery in tonic labyrinthine reflex. Asymmetric tonic neck reflex (ATNR): Motor function analysis also disclosed another interesting finding. Asymmetric tonic neck reflex can be interpreted as a physical condition in which the whole body is longitudinally separated into two parts: left side and right side. This is also a condition where one side of the entire body is totally extended and the other side is totally flexed (Fig. 17, 18A Under construction). Clinical analysis of the hypertonicity of the neck and trunk has made this interesting and exciting interpretation possible. On clinical analysis of the spastic scoliosis, we noted the fact that the concave deformity is the result of hypertonic activity of the paravertebral muscles on the concave side. We could understand that concave side is the extensor-predominant side. We also noted the fact that in asymmetric tonic neck reflex posture, the face is forced to turn to the side where hypertonicity of the neck extensors such as the longissimus capitis and cervicis muscles is predominant. Here, we also noticed the fact that the side to which

the face is turned is the extensor predominant side. This fact clearly explains the question, why the extremities extend on the side to which the face turns in ATNR. In asymmetric tonic neck reflex, on the side where the face of the patients turn, hypertonicity of the extensors of the neck, trunk, upper extremity and lower extremity is concomitantly predominant. So the hypertonic extensors of the trunk, upper extremity and lower extremity in the same side act together simultaneously and cause the ATNR posture. This fact means that the head, trunk, upper extremity and lower extremity on one side cannot move separately because of their immaturity in movement. This is a situation where the neck, trunk, upper extremity and lower extremity are simultaneously extended, as an extensor block, whereas the neck, trunk, upper extremity and lower extremity on the opposite side are simultaneously flexed, as a flexor block (Fig. 17, 18A). Thus, from these clinical observations, an interesting conclusion could be deduced that the asymmetric tonic neck reflex is a manifestation of the primitive locomotion, where the body is divided into two parts, which act alternately to drive the body forwards. The treatment of the asymmetric tonic neck reflex is therefore, to bring the ineffective body movements caused by the

two blocks of the body, into an effective crossed alternate movements in the four parts of the body. The approach will be to reduce the hypertonicity of the trunk by release of the hypertonic muscles, making movement of the upper trunk free from the ones of the lower trunk on the same side, and to facilitate the independent and separate movements of each extremity (Fig. 14B, 18B). Phylogenetically, there is no vertebrate with such a primitive level of locomotion. Therefore, this asymmetric pattern cannot be considered, as a locomotion pattern of some specific animal. However, as shown in the case of tonic labyrinthine reflex, we could see a similar locomotion pattern in jumping of fish when taken out of water and placed on the ground. The fish placed on the ground often makes jumping movement in a characteristic pattern, in which one side of the body is totally extended and opposite side is totally flexed (Fig. 17). This pattern observed in fishes when taken out of water is a decisively primitive and immature locomotion pattern. Here, one side of the body is totally flexed and the other side is extended. This longitudinally separated movements are functionally almost the same as the movements of asymmetric

tonic neck reflex, observed in cerebral palsy (Fig. 14A, 17, 18A).

Fig. 17. Motor functional meaning of ATNR On the basis of these clinical, phylogenetical, and ontogenetical analysis, asymmetric tonic neck reflex can be considered, as a form of primitive propulsive movement. The original form of asymmetric tonic neck reflex can be a movement with propelling activity. However, when it is seen in severely involved cerebral palsy patients, it is usually associated with hypertonicity such as rigidity, resulting in fixed body postures with limited movements. Patients with asymmetric tonic neck reflex can be candidates for the surgical treatment. All extension hypertonicity, such as extension deformity of the neck and trunk, shoulder retraction, extension of the elbow and extension in the hip, knee and ankle which cause create

asymmetric tonic neck reflex as a whole, are relieved by release of the hypertonic extensors, whereas all flexor hypertonicity on the opposite side, such as flexion of the neck and trunk, flexion of the elbow and flexion hypertonicity in the hip, knee and ankle, are similarly relieved by selective release of the hypertonic flexors. By these releases, the asymmetric tonic neck reflex can be controlled decisively, and voluntary movements in the entire body can be facilitated (Fig. 14B, 18B).

A. ATNR before OSSCS

B. After OSSCS on the neck, trunk, shoulders,

elbows, hips and knees, ATNR posture is corrected. 18AB. Control of ATNR posture Symmetric tonic neck reflex: Symmetric tonic neck reflex is another posture in which the symmetrically positioned upper body moves separately and alternately against the symmetrically positioned lower body. This is a phenomenon where the upper extremities extend simultaneously with passive extension of the neck, but the lower extremities flex (Fig. 19A, Bottom), whereas with flexion of the neck, the upper extremities flex simultaneously but the lower extremities extend (Fig. 19A, Top).

Fig.19A. STNR pattern movements.

The head is already matured and is not influenced by STNR.

Fig.19B. After OSSCS on both the hips. Alternate crossed pattern movements are observed This is another primitive motor activity with less separated movements. In this mode of locomotion the body propels itself with symmetrical extension of the upper trunk and upper extremities, while the lower trunk and lower extremities symmetrically flex (Fig. 20A, Top). Then, the lower trunk and lower extremities symmetrically extend, while the upper trunk and upper extremities symmetrically flex, driving the body forwards (Fig. 20A Bottom). In this locomotion the driving phases in upper or lower extremities can be seen alternately in all the phases of locomotion. Phylogenetically, the original form of symmetric tonic neck reflex

is mostly seen in more propulsive movements such as swimming of the frog, leap of the frog, and symmetrical quadrupedal locomotion of the kangaroo.

A. Typical STNR before OSSCS

B. STNR is controlled after OSSCS on both the hips 20AB. Treatment of STNR with OSSCS In the human being, we can see this form in breaststroke swimming and in a vaulting horse activity. These are symmetrical

locomotion patterns in which a phase of upper body flexion and lower body extension and a phase of upper body extension and lower body flexion emerge alternately, and propel the body forwards. In the patients with cerebral palsy, we can see the symmetric tonic neck reflex pattern in various levels, such as no rolling level (Fig, 21A), mermaid crawl level (Fig. 19A), fourpoint crawl level (Fig. 16A), standing level and in the form of symmetric deformities such as spastic diplegia (Fig. 5A, 6A). STNR can be observed in the most primitive level. In this level, the elbows are symmetrically flexed, whereas the lower extremities are totally extended. Although the posture is not typical, a symmetrical pattern is observed (Fig. 21A).

21A. STNR posture (Symmetric flexion of the upper extremities and extension of the lowerextremity. You can see a STNR in a symmetric mermaid crawl on abdomen in which a pattern of upper-body-flexion and lower-bodyextension and a pattern of upper-body-extension and lower-body-flexion emerge alternately to drive the body forwards (Fig. 19A).

In another form of STNR, the upper trunk and upper extremities are extended with neck extension (Fig. 20A, Top) while the lower extremity is flexed. When neck and upper extremities are flexed, the lower extremities are extended (Fig. 20A Bottom). This movement can be called as symmetric tonic neck reflex posture. By the use of spasticity control surgery, hypertonicity is controlled and alternate-movement exercises can be given to achieve a fourpoint crawl position (Fig. 20B). You can also see STNR in a form of symmetric four-point crawl; this is a matured locomotion (Fig. 16A). Symmetrical spastic diplegia is also an expression of STNR in a more matured level (Fig. 6A). STNR in all the levels are candidates for orthopaedic selective spasticity-control surgery in order to achieve alternate crossed crawl pattern, to accomplish alternate bipedal locomotion and to gain individual movement in each extremity (Fig. 6B, 16B, 19B, 20B, 21B)).

21B. After OSSCS on both the hips

STNR (Flexion of the upperextremities and extension of the lower extremities) is corrected. Flexion on both the upper and lower extremities are achieved.

Segmental localized hypertonicity (Diplegia) When the brain is not so severely damaged, antigravity and voluntary activities of the body will be gradually activated from the cranial end of the body to the caudal end, in course of the ontogenetic development of a baby. In such a case, hypertonicity is mostly localized segmentally in lower part of the trunk while the upper part of the body has decreased hypertonicity. This localized hypertonicity is considered, as a reflex-complex, formed by a combination of many local reflexes. We can see this segmentally localized hypertonicity, in crouched posture, windswept deformity and scissors posture (Fig. 3A, 22A, 40A). Neurologically, this condition is called as segmental static reaction. Windswept deformity: This deformity is an asymmetrical posture observed in the lower extremities in diplegia, triplegia, and quadriplegia where the lower extremities are more severely involved than the upper extremities. In this deformity, flexion, abduction and external rotation of the hip is predominant on the one side, whereas extension, adduction and

internal rotation of the hip are predominant on the opposite side (Fig. 22A). Motor-function-wise, the side with the flexion, abduction and external rotation deformity is said to be in the flexion phase of the hip at locomotion, whereas the side with the extension, adduction and internal rotation deformity is in the extension phase of the hip.

22A. Crouched posture with wind-swept deformity

22B. After OSSCS on the hips, knees and rt foot. Developmentally, this deformity can be considered, as a subgroup of the asymmetric tonic neck reflex. In patients, in whom antigravity and voluntary movements of the upper extremities and

upper trunk have matured, and hypertonicity of the upper trunk and upper extremities are decreased, the typical asymmetric posture of the upper trunk and upper extremities is overwhelmed, and a fixed asymmetrical neck reflex posture such as windswept deformity remains only in the lower extremities. This is called as a windswept deformity (Fig. 22A). Thus, windswept deformity is a kind of asymmetric tonic neck reflex deformity segmentally localized in the lower trunk and lower extremities. Treatment of the windswept deformity can be carried out by correcting the asymmetric deformities of the hips, knees and feet (Fig. 22B), by using OSSCS. Scissors posture: Scissors posture is a symmetrical posture observed in the lower extremities in diplegia, triplegia, and quadriplegia. Extension and adduction attitudes of the hip are predominant in both hips (Fig. 19A, 23A). Dislocation of the hip is also a frequent accompaniment. This deformity is called, as scissors posture. Developmentally, this deformity can be considered, as a subgroup of the symmetric tonic neck reflex posture. In the patients in whom antigravity and voluntary movements of the upper trunk and upper

extremities have matured, typical symmetric posture of the upper trunk and upper extremities disappears, and fixed symmetric posture in extension remains only in the lower trunk and lower extremities, as a scissors posture. This scissors posture can be considered as remains of the primitive symmetric locomotion.

Fig.23A. Scissor posture on dipledic boy

Fig. 23B. After OSSCS on the hips, knees and feet, crutch walk was achieved. In scissors posture, bilateral dislocation of the hips can be easily caused by hypertonicity in extension and adduction of the hip, which could disturb basic motor functions such as turnover, crawling and sitting. To prevent dislocation and to facilitate reciprocal flexion and extension movements of the hips and to attain basic motor functions, control of hypertonicity of the hip is

essential (Fig. 19B, 23B). Crouched posture: Crouched posture is a flexed posture in both the lower extremities, observed in standing and walking, and is also considered as a segmental localized hypertonicity (Fig. 3A, 96A). This is also a situation, in which antigravity activity of the monoarticular extensors are not fully matured. Fundamentally, all locomotion in upright posture can be considered to start from flexor-dominant posture of the tonic labyrinthine reflex, which is an original form of locomotion. Raising of the head and neck can be possible when antigravity activities of the neck extensors have overcome the original flexor-dominant posture of the tonic labyrinthine reflex at the neck. With extension activities of the antigravity extensors, children gradually begin to raise the head and upper trunk, from flexor dominant posture of the tonic labyrinthine reflex and then begin to crawl. According to the development of antigravity extensors, children advance to quadrupedal locomotion, crouched standing and mature upright standing, overcoming flexor-dominant posture of the tonic labyrinthine reflex. In matured human body, antigravity monoarticular extensors such as the gluteus maximus, vastus medialis and lateralis and soleus have fully developed. Well-developed extension attitude in

human body is a posture in which antigravity extensors ultimately overcome the original flexor-dominant posture of the tonic labyrinthine reflex. In normal human body, flexor-dominant posture of the tonic labyrinthine reflex becomes latent in prone position, since this reflex is fully depressed with vivid activity of the antigravity extensors. Crouched posture can be understood as a condition in which development of antigravity extensors are somewhat depressed by cerebral damage, and where a flexor-dominant posture of the tonic labyrinthine reflex is revealed somewhat in prone position. So, it is concluded that crouched posture is caused by excessive hypertonicity of the multiarticular flexors as against weak antigravity extensors. Since this crouched posture is a mild form of the tonic labyrinthine reflex, extensor-dominant posture can also be easily elicited, when this patient is turned to the supine position. This extended posture can be caused by predominant hypertonicity of the multiarticular extensors as against the antigravity flexors at the hips, knees and feet in the same patient. Selective release of the both hypertonic flexors and extensors in the hips and knees and plantar flexors of the feet is essential for correction (Fig. 3B, 96B). Reflex-complex localized in a limb

(Local static reaction: Hemiplegia) This reflex-complex posture is called, as a local static reaction in neurological terms. Motor-function-wise, there are characteristic postures localized either in the entire upper limb or in the entire lower limb, such as a withdrawal posture of the upper limb, and an extended posture called a positive supporting reaction or an extensor thrust of the lower limb. The withdrawal posture of the upper extremity seen often in hemiplegic and quadriplegic patients is a combination of shoulder retraction, flexion of the elbow, pronation of the forearm, flexion of the wrist, and flexion deformities of the thumb and fingers (Fig. 71A, 73A). The extended posture of the lower extremity seen in hemiplegic and diplegic patients (Fig. 23A, 24A) is a combination of flexion of the hip, extension or flexion of the knee, and equinus deformities of the ankle and foot.

Fig. 24A. Equinus deformity

due to exxagerated Achilles tendon reflex

Fig. 24B. After OSSCS, Achilles tendon reflex was reduced, and deformity corrected. This reflex-complex posture localized in an entire limb in cerebral palsy is fundamentally a combination of exaggerated reflexes in each joint caused by hypertonicity of the multiarticular muscles. This posture can be controlled by OSSCS at all the involved joints (Fig. 23B. 24B. 71B, 73B). Local reflexes Significance of the stretch reflex in human movement Neurologically, reflex is a contraction response of muscles to prevent over-stretching of these muscles, when they are stretched too much. Stretch reflexes such as the patellar tendon reflex, the Achilles tendon reflex, the biceps reflex and the triceps brachii reflex are considered, as a quick contraction of the muscles, to prevent over-stretching of these muscle while protecting normal joint structures. Motor-function-wise, this stretch reflex can also be interpreted, as a quick movement of the joint caused by contraction

of the muscle, while preventing over-extension or overflexion of the joint. So the patellar tendon reflex can be interpreted, as a quick extension movement of the knee joint by contraction of the quadriceps muscle, while preventing over-flexion (collapse) of the knee joint. Achilles tendon reflex is also considered as a quick plantar flexion movement of the ankle, while preventing over-dorsiflexion (collapse) of the ankle. What then can be the functional meaning of a stretch reflex? Dexterity of the joint and reciprocal movement "Reciprocal innervation" is a neurological term. This is called as reciprocal movements in motor-functional term. This is a phenomenon in which the extensors relax when the flexors contract, and the flexors relax when the extensors contract. Human joints can move smoothly because of this reciprocal muscle activity. In the knee joint, when the hamstrings act as flexors and the antagonistic quadriceps responds by relaxing, then, a smooth flexion movement becomes feasible. On the other hand, when the quadriceps acts as an extensor, and the antagonistic hamstrings relax simultaneously, a smooth extension is taken place. With these reciprocal movements, a quick conversion of movements from flexion to extension, or from extension to flexion can be feasible and so an

effective locomotion is achieved. Stretch reflexes for protection of the joints from overstretching When the flexors alone act on one-side, the joint flexes beyond the normal range of motion, resulting in the capsule being stretched and torn with a possible joint dislocation. In the vertebrates in such a situation, a preventive mechanism has developed in which the extensors respond quickly by contraction to prevent overflexion of the joint. On the other hand, if the extensors alone act too much on one-side, the joint overextends beyond the normal range of motion, resulting in the capsule being stretched and torn, causing a possible dislocation. Then, similarly, a preventive mechanism has developed in which the flexors respond quickly by contracting to prevent hyperextension of the joint. This quick contraction of the antagonistic muscles which prevent hyperextension or too much flexion of the joint, are called, as a stretch reflex, in the field of neurology. Motor-function-wise, the stretch reflex is interpreted, as a protective mechanism, which prevents overactivity of the antagonistic muscles and limits hypermobility of the joint, thereby protecting the joint. Thus, the joints of the human body have

acquired smooth motion with reciprocal movements, and have also developed elaborate mechanism in which stretch reflex acts to prevent excessive flexion or extension as well. Exaggerated stretch reflex When central nervous system is damaged, the nature of the stretch reflex changes significantly. Exaggeration in the stretch reflex becomes obvious with inhibition of reciprocal movements. Our clinical observation explains that increase in patellar tendon reflex is caused by hypertonicity of the multiarticular rectus femoris (Fig. 23A, 25A). Exaggerated Achilles tendon reflex is caused by hypertonicity of the multiarticular gastrocnemius (Fig. 23A, 24A). Similarly, increase in the biceps brachii reflex and triceps brachii reflex is caused by hypertonicity of the biceps brachii and triceps brachii (Fig. 66A, 68A, 70A). Flexion deformity of the fingers and toes are other forms of the exaggerated grasp reflex. Thus, the exaggerated stretch reflexes are clinically considered to be caused mostly by hypertonicity of the multiarticular muscles of the affected limbs.

Fig. 25A. Stiff-knee gait due to exaggerated patellar tendon reflex

After OSSCS on exaggerated PTR, stiff-knee gait disappeared. On the basis of these observations, it can be concluded that deformity of each joint is caused by an exaggerated stretch reflex. Stiff-legged knee or recurvatum deformity of the knee is considered to be caused by an exaggerated patellar tendon reflex. Thus, stretch reflex is not a different entity from muscle contraction. Motor-function-wise, stretch reflexes are a quick movement of joint caused by quick contraction of the muscle.