How to Test for the Retained Tonic Labyrinthine Reflex

Testing for a retained tonic labyrinthine reflex (TLR) is done through simple positional challenges, most commonly by having a person stand with eyes closed and slowly tilt the head forward or backward while an examiner watches for involuntary shifts in muscle tone, balance, and posture. The test requires no equipment and takes just a few minutes, but reading the results correctly depends on understanding what normal and abnormal responses look like and how they are scored. Because the TLR has both a forward (flexion) and backward (extension) component, a thorough assessment checks both directions.

What the TLR Does and When It Should Disappear

The tonic labyrinthine reflex is one of several primitive reflexes that emerge before or shortly after birth. Its job is to help the newborn respond to gravity: when the head tips forward, the body curls into flexion; when the head tips backward, the body stiffens into extension. In the womb and during the first months of life, these automatic responses help with positioning and early movement patterns. As the brain matures, higher motor centers gradually override these reflexes, replacing them with voluntary control of posture and balance.

Research on normal infants has shown that decreased primitive reflex activity correlates with the emergence of voluntary motor milestones like rolling, sitting, and crawling, and that reflexes work as a profile rather than in isolation.¹ Most sources place full integration of the TLR somewhere between six months and three and a half years of age, depending on the component. When the reflex persists beyond that window, it can interfere with balance, coordination, and even visual processing.

The Standard Standing Test

The most widely used clinical method for checking TLR retention is a standing balance challenge based on procedures developed at the Institute for Neuro-Physiological Psychology (INPP). Assessments of the TLR in research settings typically follow these standardized INPP procedures and use a 0-to-4 ordinal scoring scale.² The test has two parts, one for each direction.

TLR Forward (Flexion)

The person stands with feet together and arms relaxed at the sides, then closes the eyes. The examiner asks them to slowly lower the chin toward the chest. In someone whose TLR has fully integrated, this head movement produces little or no involuntary change in posture. When the reflex is retained, the forward head tilt triggers a cascade of flexion through the body: the shoulders round, the upper back curves, the knees bend, and the person may sway or step forward to catch their balance. In more pronounced cases, the whole body seems to fold in on itself as though gravity has suddenly increased.

TLR Backward (Extension)

From the same starting position with eyes closed, the person slowly tilts the head back as if looking at the ceiling. An integrated response means the person can do this with minimal postural disturbance. A retained TLR backward produces the opposite pattern from the flexion test: the shoulders pull back, the spine arches, the person may rise onto the toes, and balance is lost in a backward direction. Some individuals lock their knees and stiffen through the legs. The examiner should stand close enough to catch the person if they begin to topple.

Closing the eyes is a critical part of the setup. Vision compensates powerfully for balance problems, so testing with eyes open masks subtle reflex activity. Removing visual input forces the vestibular and proprioceptive systems to do the work alone, which is where a retained TLR shows itself most clearly.

Other Positions Used in Assessment

Some clinicians supplement the standing test with additional positions, particularly for younger children or individuals who cannot stand safely with eyes closed.

In the supine (lying on the back) version, the person lies flat and the examiner gently lifts the head to bring the chin toward the chest. A retained TLR flexion response shows up as the arms and legs pulling inward, the body curling. When the head is gently extended over the edge of the surface, extension tone increases through the limbs and trunk. One study examining children with cerebral palsy found that body positioning strategies, such as hammock positioning that promotes hip and spinal flexion, helped counteract the extensor tone driven by the TLR.³

In the quadruped (hands-and-knees) version, the child gets on all fours and is asked to look up at the ceiling, then down at the floor. A retained TLR causes the arms to collapse when the head drops and the back to sag or stiffen when the head lifts. This version is especially useful for younger children because it is less likely to result in a fall, and many occupational therapists use it as a starting screening tool before moving to the standing test.

Scoring the Response

The scoring system most commonly referenced in the research literature is a five-point ordinal scale (0 through 4) developed by Sally Goddard Blythe at the INPP. Studies evaluating reflex integration in children with autism spectrum disorder, for example, have used this validated scale to grade both TLR flexion and TLR extension separately.⁴ The general framework looks like this:

0: No observable reflex response. The person maintains balance and posture throughout the head movement. The reflex is considered fully integrated.
1: A slight, barely visible shift in tone or a small wobble. The person recovers quickly without stepping or falling.
2: A clear postural change, such as noticeable rounding of the shoulders or a definite sway, but the person remains standing without needing to step.
3: A strong response where the person has to take a step, grab for support, or shows marked changes in muscle tone through the trunk and limbs.
4: A full, uninhibited reflex pattern. The person cannot maintain standing balance and would fall without assistance. This level is most commonly seen in very young children or individuals with significant neurological conditions.

Scores of 0 are the goal. Scores of 1 are borderline and may not cause functional problems. Scores of 2 or above generally indicate that the reflex is active enough to warrant attention, especially if the person also shows related functional difficulties like poor balance, coordination problems, or reading struggles. In one study of children with autism, average pre-intervention TLR flexion scores were around 2.0 and extension scores around 2.5 on this scale.⁴

How Reliable Is the Test?

One concern with any observational test is whether two different examiners would give the same score. A standardized protocol for primitive reflex assessment tested across a large sample found weighted agreement coefficients ranging from 0.912 to 1.000 for inter-rater reliability, with even the lowest single-reflex estimate sitting well above thresholds for near-perfect agreement.⁵ A separate study of TLR assessment in youth athletes using the INPP 0-to-4 scale also examined inter-rater and intra-rater reliability specifically for the TLR among other reflexes.²

The catch is that these high reliability numbers come from examiners trained in the same standardized protocol. When untrained parents or teachers attempt to score reflex testing at home using online guides, consistency drops. If you are checking your own child, the standing test can give you a rough sense of whether something is going on, but a trained occupational therapist, developmental optometrist, or INPP-certified practitioner will produce a more accurate and useful score.

Signs That Point Toward Retained TLR

Most people do not go looking for the TLR test unprompted. They arrive at it because a child (or sometimes an adult) is struggling with something that does not quite fit the usual explanations. The functional signs of a retained TLR overlap with several other conditions, which is part of what makes the formal test useful for narrowing things down.

Common everyday signs in children include poor balance and frequent clumsiness, difficulty judging distances, motion sickness, discomfort or avoidance of activities that involve head position changes (like somersaults, swinging, or looking up at a whiteboard), slumped posture during seated work, and a tendency to either be very stiff or very floppy in their overall muscle tone. Some children have trouble with stairs or escalators because the changing head position relative to gravity disrupts their postural control.

An interesting and less obvious sign is persistent toe walking. A study of young children newly diagnosed with autism found a statistically significant association between toe walking and the presence of the tonic labyrinthine reflex pattern, while there was no such link between toe walking and sensory symptoms.⁶ Walking on the toes may be the body’s way of compensating for the extensor tone driven by a retained TLR backward, since rising onto the toes shifts the center of gravity forward and counteracts the backward pull.

Why the Vestibular System Matters to This Test

The TLR is fundamentally a vestibular reflex. It is driven by the otolith organs in the inner ear, specifically the utricle and saccule, which detect the position of the head relative to gravity. Signals from these organs travel through vestibular nuclei in the brainstem and descend via spinal pathways to influence neck muscles and postural control throughout the body.⁷ This is why the test involves tilting the head: you are changing the otolith input and watching whether the body responds with a primitive whole-body pattern or a mature, localized adjustment.

Understanding this connection explains why children with retained TLR often struggle with activities that challenge the vestibular system. It also explains why the test must be done with eyes closed: the visual system can override vestibular signals, so removing vision isolates the reflex pathway you are trying to assess.

Connections to Reading, Eye Movement, and Learning

One area that surprises many parents is the link between primitive reflex retention and academic performance. Research has found that retained primitive reflexes, including the TLR, are more common in children with learning difficulties and conditions like dyslexia.⁸ Children with dyslexia have been found to show poorer balance in challenging conditions and higher levels of retained reflexes compared to peers, pointing toward delayed neural maturation.⁹

The mechanism connecting the TLR to reading involves eye movements. A study using a device that tracks eye movements found that after therapy targeting inhibition of primitive reflexes including the TLR, children showed significant improvements in fixation stability, saccade accuracy, and overall oculomotor balance between the two eyes.¹⁰ Smooth, controlled eye movements are essential for tracking text across a page, so disruption at the reflex level can cascade into reading problems that look like attention issues or laziness. This is one reason practitioners who screen for learning difficulties are increasingly including primitive reflex checks as part of their evaluation.

The TLR Rarely Exists in Isolation

A practical point that changes how you approach testing: the TLR almost never shows up as the only retained reflex. The original research on infant motor development demonstrated that reflexes work as a profile, with several reflexes interacting simultaneously rather than acting independently.¹ Modern assessment scales reflect this. One recently developed scale for evaluating primitive reflex integration in children includes seven reflex dimensions covering the Moro, ATNR, STNR, TLR, Spinal Galant, Spinal Perez, and Landau reflexes.¹¹

If you test for the TLR and find it retained, it is worth also checking the asymmetrical tonic neck reflex (ATNR), symmetrical tonic neck reflex (STNR), and Moro reflex at minimum. These four are the reflexes most commonly assessed together in both clinical and research settings, and targeting them as a group during intervention produces better outcomes than addressing one in isolation.¹⁰ An association between persistent primitive reflexes broadly and neurodevelopmental delays including learning disabilities and processing disorders has been documented across multiple studies.¹²

What Happens After a Positive Test

Finding a retained TLR is not a diagnosis in itself. It is a piece of a larger puzzle. Most practitioners use the reflex findings alongside other developmental, sensory, and motor assessments to build a picture of what is going on and design an intervention plan. The most common intervention is a structured movement program that replicates the developmental movement patterns the child missed or did not fully complete. These programs typically run three to four months and involve daily repetitions of specific movements.

Evidence from a structured 12-week reflex integration program targeting the TLR, ATNR, and STNR in children with autism showed meaningful reductions in reflex scores. TLR flexion scores dropped from an average of about 2.0 to 0.9, and extension scores went from about 2.5 to 1.5, with large effect sizes.⁴ That study used four sessions per week across three progressive phases. While those results are encouraging, it is worth noting that extension scores were harder to bring down fully than flexion scores, which fits clinical experience suggesting TLR backward is often the more stubborn component.

The exercises themselves are not complicated. For TLR integration, a common approach involves the child lying prone (face down) and slowly lifting the head, arms, and legs into an extension pattern, holding briefly, then curling into flexion. The idea is to move through the reflex pattern under voluntary control, training higher brain centers to override the automatic response. Occupational therapists and movement-based practitioners like INPP-trained clinicians are the usual professionals who design and supervise these programs.

Testing in Adults

Primitive reflex retention is not exclusively a childhood concern. Adults can carry retained reflexes, and the standing TLR test works the same way regardless of age. Standardized reflex assessment protocols have been validated across the lifespan, not only in children.⁵ Adults with retained TLR sometimes report chronic neck tension, persistent car sickness, difficulty with spatial orientation, or a history of being “uncoordinated” that never resolved. Some describe a vague sense that their body does not respond the way they expect it to during sports, yoga, or any activity requiring precise head-position changes.

If you want to try a rough self-screen, stand in bare feet on a firm surface with your feet together, close your eyes, and slowly tilt your head back. Give yourself a few seconds. If you feel your weight shift dramatically backward, your back arch involuntarily, or you need to step to catch yourself, that is worth investigating further. Then try it with the head tilting forward. Remember, though, that adults often compensate for retained reflexes in subtle ways. Years of movement experience can mask the reflex response during a casual self-check, which is why a formal assessment by a trained practitioner gives more reliable results.

1
PubMed. Motor functions: associated primitive reflex profiles
2
PubMed Central. Intra- and Inter-Rater Reliability of Primitive Reflex Assessments in Youth Football Athletes
3
JPMA. The Journal of the Pakistan Medical Association. Effect of Positioning on Tonic Labyrinthine Reflex in Cerebral Palsy: A Single-centre Study from Lahore
4
PubMed Central. Effectiveness of Reflex Integration Exercises on Sensory-Motor Outcomes in Children With Autism Spectrum Disorder: A Quasi-experimental Study
5
Research Square. A Standardized and Validated Protocol for Primitive Reflex Assessment: Reliable Measurements Across the Lifespan for Clinical and Research Practice
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PubMed. Toe walking in autism: further observations
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PubMed. A review of otolith pathways to brainstem and cerebellum
8
The Egyptian Journal of Otolaryngology. Assessment of primitive reflexes in children with learning disability
9
Hearing Balance and Communication. Balance functions and primitive reflexes in dyslexic children
10
PubMed Central. Persistence of primitive reflexes associated with asymmetries in fixation and ocular motility values
11
PubMed Central. Development of the children’s primitive reflex integration assessment scale
12
The Journal for Nurse Practitioners. Persistent Primitive Reflex and Developmental Delay in the School-Aged Child