From the Neurodevelopmental Center A Fokas, First Department of Communications should be addressed to:
Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece. Dr. Zafeiriou, Child Neurologist; Egnatia St. 106;
54622 Thessaloniki, Greece.
Received September 9, 2003; accepted January 23, 2004.
2004 by Elsevier Inc. All rights reserved. Zafeiriou: Primitive Reflexes and Postural Reactions 1
doi:10.1016/j.pediatrneurol.2004.01.012 0887-8994/04/$see front matter
Table 1. Most commonly used motor performance tools The revised Dubowitz scale [5] uses the palmar and
(References for each are given in brackets)
plantar grasp, Moro, suck, and placing reflex. Scherzer
again finds more clinically relevant the Moro, palmar and
A. Developmental Scales
Amiel-Tison [2] plantar grasp, asymmetric tonic neck reflex, rooting and
Bayley [3] sucking reflex [21]. Mandich et al. [29] compiled a
Brazelton [4] developmental test (not listed in Table 1) extrapolating
Dubowitz [5]
Haataja [6]
data from the Denver Developmental Screening Test and
Peabody [7] the Bayley scales, which mixed primitive reflexes with
Prechtl [8] postural reactions and developmental milestones and in-
cluded plantar grasp reflex, asymmetric tonic neck reflex,
B. Developmental Screening Tests
Denver Developmental Screening Test (Denver II) [9] tonic labyrinthine reflex, neck righting reflex, Landau
Battelle Screening Test [10] reaction, and parachute reaction. Futagi et al. [30] and
Clinical Adaptive Test (CAT)/Clinical Linguistic and Auditory Zafeiriou et al. [31], both drawing on the work of Vojta
Milestone Scale (CLAMS) [11] [32], place greater emphasis on the following eight re-
Knobloch Revised Screening Inventory [12]
General Movements (GMs) Assessment [13-15] flexes: palmar and plantar grasp response, crossed exten-
sor, suprapubic extensor, Galant, asymmetric tonic neck
C. Motor Assessment Instruments reflex, heel, and Rossolimo reflex. Moreover, Zafeiriou et
Alberta Infant Motor Scale (AIMS) [16]
Early Motor Pattern Profile (EMPP) [17]
al. [33] underscore the importance of eliciting a true
Gross Motor Function Measure (GMFM) [18] Babinski response by eliciting the plantar response in
Movement Assessment Inventory (MAI) [19] infancy, as well as the importance of the Moro reflex [34].
Test of Infant Motor Performance (TIMP) [20] Almost all of these investigators used the same method of
eliciting reflexes, thus indicating the validity of the
method used (Table 2). This consistency in terminology
the observation of spontaneous motility, will be briefly and concept (especially method of elicitation but also
discussed. grading) was already evident in the work of Paine [35] and
Towen [36], but was systematically advocated by Capute
Primitive Reflexes [27], thus avoiding oversimplifications or even discrepan-
cies in method of elicitation. Simultaneously with Holt
Primitive reflexes are brainstem-mediated, complex, [37] and Molnar [38], Capute introduced the concept of
automatic movement patterns that commence as early as obligatory reflexes (or 4 primitive reflex) [39]. The
the twenty-fifth week of gestation, are fully present at birth latter is defined as a fixed response or posture when the
in term infants, and with central nervous system matura- stimulus is initiated and for as long as the stimulus
tion become more and more difficult to elicit after the first persists, until it is removed.
half of the first year of life, when voluntary motor activity Special emphasis should be placed on the plantar
and thus cortical inhibition emerges and takes over response of the infant, which is a polysynaptic response
[24-26]. They are considered part of the motor repertoire elicited by stroking along the lateral aspect of the foot
of the specific age. Primitive reflexes are highly stereo- from heel to toe [40]. Different types of responses have
typical patterns and are elicited by specific sensory stim- been elicited in infants, varying from flexor to extensor
uli. according to the intensity of the stimulus used [33]. It is
The major primitive motor reflexes or patterns that have generally accepted [41,42] that extensor plantar response
been described include Moro, palmar and plantar grasp, matures to flexor by the end of the first year in most
rooting, sucking, placing, Moro, Galant (or truncal incur- normal infants. The Babinski sign refers to the extensor
vation), asymmetric tonic neck reflex, crossed extensor, toe response observed in diseases involving the cortico-
tonic labyrinthine reflex, and others [21]. Some authors spinal tract in older children and adults, and is considered
make no distinction between primitive reflexes and pos- by many authorities as the single most useful clinical
tural reactions (i.e., primitive and postural behaviors); reflex in neurology [43]. However, there is an ongoing
there is an ongoing controversy concerning the ones that, controversy whether a true Babinski sign (dorsiflexion of
alone or in combination, have the greatest predictive the great toe and fanning of the remaining toes) obtained
clinical significance. For example, Capute [27], in a by eliciting the plantar response is present in infants in the
long-term follow-up study, regards the Galant reflex context of a primitive reflex. According to some authors,
among the major predictive primitive reflexes being ex- a true Babinski response denotes dysfunction of the
tensively evaluated. Dargassies [13], on the other hand, pyramidal tract and should be clearly distinguished from
believes the crossed extensor reflex to be most critical for extensor toes that do not belong to the flexion synergy of
central nervous system maturation. Gupta [28] selects the leg [43] and constitute a primitive reflex of the infant.
plantar, palmar, rooting, Moro, crossed extensor, tonic In the same context, Fenichel [44] uses the withdrawal
labyrinthine reflex, Landau, placing, and positive support reflex, which is produced by a noxious stimulus to the sole
without a clear distinction between reflexes and reactions. of one foot and causes flexion of the stimulated limb and
Age at
Reflex Position Method Response Disappearance
Palmar grasp Supine Placing the index finger in the palm of the Flexion of fingers, fist making 6 months
infant
Plantar grasp Supine Pressing a thumb against the sole just Flexion of toes 15 months
behind the toes in the foot
Galant Prone Scratching the skin of the infants back Incurvation of the trunk, with the 4 months
from the shoulder downwards, 2-3 cm concavity on the stimulated side
lateral to the spinous processes
Asymmetric tonic neck Supine Rotation of the infants head to one side Extension of the extremities on the 3 months
reflex for 15 s chin side and flexion of those
on the occipital side
Suprapubic extensor Supine Pressing the skin over the pubic bone with Reflex extension of both lower 4 weeks
the fingers extremities, with adduction and
internal rotation into talipes
equinus
Crossed extensor Supine Passive total flexion of one lower Extension of the other lower limb 6 weeks
extremity with adduction and internal
rotation into talipes equinus
Rossolimo Supine Light tapping of the 2nd-4th toes at their Tonic flexion of the toes at the 4 weeks
plantar surface first metacarpophalangeal joint
Heel Supine Tapping on the heel with a hammer, with Rapid reflex extension of the 3 weeks
the hip and knee joint flexed, and the lower extremity in question
ankle joint in neutral position
Moro Supine Sudden head extension produced by a Abduction followed by adduction 6 months
light drop of the head and flexion of upper extremities
Babinski Supine Striking along the lateral aspect of the sole Combined extensor response: Presence always
extending from the heel to the head of simultaneous dorsiflexion of the abnormal
the fifth metatarsal great toe and fanning of the
remaining toes
extension of the contralateral limb. The flexion part of the described, used them as a set of seven items which could
withdrawal reflex can be demonstrated in a considerable serve as a motor screening test [32]. According to Vojta,
number of infants while trying to elicit the plantar re- postural responses represent complex motor responses to a
sponse. plurality of afferences such as the joints, the tendons, the
muscles, the skin, the inner organs, telereceptors (eye) and
Postural Reactions otoreceptors (ear), and of course the labyrinth. They are
characterized by a certain stereotyped posture of the trunk,
A number of postural reactions (i.e., motor patterns) head, and extremities (i.e., the entire body), when the
have been identified and repeatedly described as diagnos- examiner attempts a strictly defined sudden change of
tically relevant. Both Capute et al. [45] in the English position (Table 3, Fig 1). The response at each chronolog-
literature and Vojta [32] in the German literature empha- ical age is different and expresses the central nervous
sized the distinction between primitive reflexes and pos- system stage of maturation.
tural reactions. Blasco [26,46] and the Kennedy group Regarding postural reactions, limited data are available
(Capute et al. from the John F. Kennedy Institute in on their evolution in early infancy, and they concern
Baltimore) [45] suggested that postural mechanisms are mostly the three righting reflexes in prone position: the
not true reflexes, but rather are based on multiple input tonic labyrinthine reflex, symmetric tonic neck righting,
modalities, usually acting as a whole; they further sug- and the Landau reaction (vertical suspension) [45]. How-
gested that postural mechanisms require cortical integrity ever, from Caputes study, it was clear that there are
and thus are not present in the neonate, but instead develop differences of opinion concerning whether the postural
postnatally, being considered mature postural responses reactions are all absent in the infant period and appear
that persist as a basis for normal motor behavior. gradually later, simultaneously with the diminution of the
It was Vojta [32] who first underlined the theory that primitive reflexes. For example, the Landau reaction was
postural reactions are present at birth and follow the stages considered not present at birth, the tonic labyrinthine
of postural ontogenesis. Their mature response is elicited reflex was present in 80% of normal infants by 2 weeks of
at the age that Capute et al. [45] and other investigators age, and symmetric tonic neck righting appeared later than
[26,46] describe and is qualitatively equivalent to the the infant period and disappeared in a 3- to 6-month
latter. Vojta slightly modified six already known postural period. Again, different postural reactions are used pref-
reactions and, together with a new one that he first erentially by different investigators, either as isolated