What is the Tonic Labyrinthine Reflex (TLR)?

by Jessica Hill, COTA/L June 09, 2021 2 Comments

What is the Tonic Labyrinthine Reflex?

The Tonic Labyrinthine Reflex (TLR) is one of many infant primitive reflexes - an involuntary movement pattern that we are all born with. The TLR can be most easily seen in infants when laying on the tummy - it looks like the Superman position.

The TLR has two movement patterns - forwards and backward. This reflex is activated with neck flexion (forward) or extension (backward) - movement of the head up or down. When an infant looks down (neck flexion), this causes the arms and legs to flex or curl into the body. When an infant looks up (neck extension), this causes the arms and legs to extend (Superman!). The TLR is thought to help the infant with the newfound challenge of gravity. It also directly affects muscle tone due to the movement of the arms, legs, neck, and trunk.

Additionally, because head movements activate the TLR, this reflex is also directly related to the Moro Reflex. As the infant begins to gain head control, the TLR and Moro will begin to integrate, and the response in the arms and legs will begin to change - more control of the arms and legs will begin to develop.

The TLR forward pattern (flexion) emerges in utero, should be fully developed at birth, and should integrate - go away - at approximately four months of life. The TLR backward pattern (extension) emerges at birth and can begin integrating as early as three months and as late as three years of age.

How does the TLR integrate?

Although there is no one scientific method to ensure full primitive reflex integration, there are some things to consider when discussing the integration of the TLR.

Let’s talk about sensory integration. By providing an infant with different types of sensory stimulation, new neural pathways will be developed in the brain, thus stimulating new movement and cognitive development. An article on sensory integration discussed that the engagement in sensorimotor activities promoted adaptive behaviors via neuroplastic changes - simply put, by experiencing different types of sensory activities, our brains can change and thus promote new behaviors!

So, what types of sensory activities should you provide to your newborn infant? Keep it simple!

  • Natural movement is always a fantastic option - instead of carrying your newborn in a carrier or stroller, use a wrap to carry your newborn on your body to provide more natural movement.
  • Carry your infant in different positions - on their tummy, back, side, etc. This will provide movement in different planes and promote head movement, activating the TLR and providing natural development opportunities.
  • Tummy time. We’ve all heard it over and over again - tummy time is a must! A systematic review from 2020 identified that tummy time was positively associated with gross motor and total development. But how do you start tummy time with a newborn? Simply laying your newborn on your chest, on their tummy, is a great place to start. Then incorporating tummy time into everyday, waking play will begin to establish a routine and improve tolerance in the long run.
  • A variety of sights, sounds, smells, and tactile experiences. The more variety and the more frequent, the better!

Because every newborn is different and every experience is different, there’s no one way to guarantee that the Moro reflex will be successfully integrated by six months of age. However, you can feel more confident that your baby is getting the sensory experiences necessary for potential primitive reflex integration by using the above strategies.

What factors can contribute to an unintegrated TLR?

Potential factors for unintegrated primitive reflexes, including the TLR, are:

  • Stress during pregnancy
  • Substance abuse during pregnancy
  • Caesarean section birth
  • Brain damage during labor
  • Premature and low birth weight
  • Significant illness during the first year of life
  • Insufficient stimulation and tummy positioning
  • Lack of free movement time on the floor
  • Stressful environment
  • Not enough nourishment/insufficient weight gain

Additionally, if a child has successfully integrated their primitive reflexes, a sudden or chronic bout of trauma, stress or injury can re-activate these reflexes.

While there is no guarantee for reflex integration, there are contributing factors to consider if your child has an unintegrated TLR.

What an unintegrated TLR looks like

As previously mentioned, the TLR is linked with the Moro reflex as well as has a direct correlation to muscle tone and head movements. These connections go even further to include vision and ocular motor skills, balance, and coordination.

Symptoms related to an unintegrated TLR in older children are:

  • Challenges with creeping and crawling as an infant
  • Poor posture
  • Weak muscles / low muscle tone
  • Decreased balance
  • Poor ocular motor skills
  • Visual-perceptual challenges
  • Auditory processing difficulties
  • Decreased organization skills
  • Poor sense of space and time
  • Decreased sequencing
  • Challenges with multi-sensory processing
  • Spatial awareness difficulties
  • Dislike of sports
  • Dyslexia, Dyscalculia and/or Dysgraphia

One Way to Assess Retained TLR

What can I do if my child has an unintegrated TLR?

If your child exhibits any of the above symptoms/challenges, the first step will be to talk with your pediatrician. Discuss your concerns - if your pediatrician is familiar with primitive reflex integration, they may already have a plan of action ready. If your pediatrician is unfamiliar with primitive reflex integration, feel free to share what you've learned! If you ever feel uncomfortable or that your concerns are being pushed to the side don’t be afraid to seek out a new pediatrician.

Many Occupational Therapists (OT) are trained in primitive reflex integration techniques. Seek one out! Talk with friends and family members to see if they know anyone specific. Use Facebook groups and Instagram to find someone who has training. Physical Therapists (PT), cranio-sacral therapists, and chiropractors may also have knowledge of primitive reflex integration. It can take some time to locate the right professional, so don’t give up!

Meanwhile, there are some different exercises and play activities that you can incorporate into your child’s daily routine that can help promote the integration of the TLR.

For babies, decreasing the amount of waking time spent in containers is the best way to integrate the TLR. When baby is awake, provide natural movement activities and as much tummy time as possible. Make sure to rotate between play in supine (on the back) and side-lying on both sides as well to prepare for the next foundational milestone (rolling) to occur!

If your child is young, under 3 years old, focus on developmental movements. Try engaging them in more tummy time activities:

  • Playing in front of the mirror.
  • Looking at favorite books.
  • Laying on tummy on a therapy ball - support them at their hips/legs and roll them forward, so they land on their arms. You can place toys to grab or container toys to engage with in this position.
  • Lay on your stomach across from your child in tummy time! This promotes engagement and can be very motivating.
  • Try different animal crawls: worm crawl, snake crawl, etc. Be creative!
  • Play ball in tummy time - roll the ball back and forth.
  • Put bells or fun socks on their feet and encourage the child to kick and lift their legs up to their hands and mouth their toes, pull on the socks, etc.

If your child is older, you can still focus on the same developmental movements and incorporate tummy time into daily tasks.

  • Complete homework - handwriting, reading, etc. - laying on stomach.
  • Complete activities on a therapy ball, laying on stomach and “walking” out on hands.

If your child is struggling with some of the signs/symptoms associated with an unintegrated TLR, try some of these strategies:

  • Poor posture, low muscle tone:
    • Use different seating options such as a therapy ball or wiggle cushion.
    • Provide more rest breaks during physical activities.
    • Engage in core strengthening tasks using a therapy ball, jumping and climbing, yoga stretches, etc.
  • Decreased balance:
    • Practice! Complete activities on a balance beam or place a strip of painter’s tape on the floor and walk along like a “tight rope.”
    • Engage in core strengthening tasks using a therapy ball, jumping and climbing, and yoga stretches, etc.
  • Ocular motor challenges:
    • Play more ball games. Instead of catch and throw, try bounce and catch or even rolling back and forth.
    • Reading with a highlighter strip or a piece of paper under the line that is being read. This helps the eyes focus on the line and decreases distracting visual input.
  • Challenges with organization, sense of time, and sequencing:
    • Use more visuals. Visual schedules are great to help with sequencing and organizing tasks.
    • Use pictures of where items belong to help with organization.
    • Use visual timers to help with sense of time.
  • Auditory processing challenges:
    • Use visuals to aid with auditory processing - oftentimes, if a child struggles to process auditory information, they will be more successful with visual information.
    • Complete motor tasks to the beat of a metronome. The metronome, set at 60 beats per minute (BPM), is a great tool to improve auditory focus. Try simply clapping on each beat. Once you master that, increase the motor challenge.

One last note

As you continue on your path through primitive reflex integration, keep in mind that your child is unique and there's nothing wrong with them! Even if they have an unintegrated TLR and seem to be struggling more than other children, your job is simply to help guide them along the way and provide as much support as possible.

You and your child are doing the best you can with what you have, so keep researching and keep trying new things until you find what works. Even then, keep searching because what works now might not work forever, especially as your child grows and develops through different seasons of life!

For the ultimate education on primitive reflexes, check out our Primitive Reflex Integration Training!

Check out our video about the TLR!


Check out our podcast episode from All Things Sensory by Harkla Podcast where we discuss TLR in depth!

Jessica Hill, COTA/L
Jessica Hill, COTA/L

Jessica Hill, COTA/L, CPRCS is Harkla's in-house Certified Occupational Therapy Assistant (COTA) and Certified Primitive Reflex Clinical Specialist. She has been working with children for over 6 years in outpatient settings. Jessica specializes in creating easy-to-digest, actionable content that families can use to help their child's progress at home. Jessica is the in-house expert, content creator, and one of the podcast hosts at Harkla! To learn more about Jessica, visit the Harkla About Us Page. Make sure to listen to her weekly podcast, All Things Sensory by Harkla for actionable, fun advice on child development.

2 Responses


January 23, 2024

Thank you for this information. I found it especially interesting to see the link between retained TLR and dyslexia. Can you provide the research that supports that or an article to review? Thank you!

David Drake
David Drake

September 07, 2023

My daughter is about to turn 12. She has recently been diagnosed with orthographic dysgraphia and we have started using some suggested accommodations to even the playing field for her education. Writing is a challenge, organizing anything can be difficult.
Our OT had mentioned TLR and I am wondering if integration can be achieved at this age. If so what exercises can we use. Athletics and dance and karate, swimming , cat king rolling and throwing a ball are all pretty strong.

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