Tonic Labyrinthine Reflex (TLR): Signs, Effects, and Integration Exercises

Unlike some other primitive reflexes, the Tonic Labyrinthine Reflex (TLR) involves movement of both the head and the body. For this reason, it assists with maintaining head position, coordination, movement against gravity, muscle tone, and posture. The TLR (also known as the TLR reflex) also plays a role in focus and the ability to track objects with the eyes.

If a child has a retained TLR, they are likely to have difficulty focusing, reading, writing, doing basic math, playing sports, and remaining seated. Since this reflex has such a broad impact on the body, it can limit a child’s performance in school, at home, and other places, making it important to integrate the TLR for a child’s development.

In this article, I will explain in detail what the TLR is, the exact ways a child with a retained TLR may behave, and how parents can integrate this reflex at home, and how to monitor their child for progress.

What Is the Tonic Labyrinthine Reflex (TLR)?

The TLR works to support a child’s motor development by helping them hold their head (and body) in various ways against gravity. The TLR helps strengthen the neck and shoulder muscles since these play a large part in stabilizing and moving the head.

There are two main neck movements that make up the TLR: neck flexion (a forward motion/position) and neck extension (a backward motion/position). The Tonic Labyrinthine Reflex begins developing before a child is even born, but the two parts of this reflex show up at different times. The forward position develops while a child is still in utero, but a baby doesn’t carry out the backward position until they are born. The backward position may even take up to two weeks to appear after a baby is born.

The TLR is an example of a reflex that should disappear (or integrate), so it can negatively affect a child’s development if it stays. The two TLR positions disappear at different times. The forward position should disappear by the time a child is 4 months old. The backward position is not expected to go away until later. In some children, it disappears around the same time as the forward position (between 3 and 4 months of age), but other children may retain it until the age of 3.

It is important to remember that each child is different. There isn’t necessarily a cause for concern if your child keeps this reflex longer than some other children, especially if they are still within the recommended age range. However, if your child has difficulty with certain motor skills and school-related tasks as a result of keeping this reflex, then the TLR should be addressed.

While head position on its own is quite important for a child’s development, it’s also integral to the way the rest of their body moves. This means that the TLR helps a child as they learn to crawl, creep, and roll. The TLR also allows them to sit and (eventually) stand without help or support from a chair or other piece of furniture.

So a retained TLR may be impacting your child in ways you may not notice at first. The best way to learn if your child has a retained TLR is by completing a simple test. To test both positions of the TLR with your baby, follow these steps:

1. Use both hands to hold your baby in the air so they are face down. Place one hand under their chest and another under their hips.
2. Watch your baby’s head, arms, and legs. Your baby’s head should tilt down as if they are tucking their chin into their chest, while their arms and legs will bend.
3. Now, use both hands to turn your baby over so they are face up. Hold them as you were before, with one hand at their upper back and the other under their buttocks.
4. Watch your baby’s head, arms, and legs. Your baby’s head should move back while their arms and legs will straighten.

You will need to follow different directions and watch for different bodily responses when testing the TLR in an older child. To do so, you can instruct your child in the following way:

1. Ask your child to stand up tall with their feet together and both arms resting at their sides.
2. Next, ask them to move their head back as if they are about to look up at the ceiling.
3. Once they are in this position, have them close their eyes and keep this position for 10 seconds.
4. Watch your child and take note if they lose their balance, lean to one side, lean forward or backward, or become overly stiff or limp. If your child gets dizzy, confused, or says they have a stomachache, stop the test.
5. After 10 seconds have passed, ask your child to keep their eyes closed as they move their head down as if they are tucking their chin into their chest.
6. Ask them to hold this position for 10 seconds.
7. Moving the head backward and forward is considered one complete movement.
8. Ask your child to repeat these steps four more times for a total of five complete movements.

As we mentioned earlier, the results of this test are not necessarily a cause for concern on their own. It is also important to consider how a child is developing. In the next section, we will discuss the ways TLR impacts a child’s growth in the early years.

The Role of TLR in Early Development

The Tonic Labyrinthine Reflex has a big impact on a child’s ability to move within their environment. While many of us don’t think twice about moving against gravity, this isn’t something we know how to do as soon as we’re born. The TLR is one reflex that helps us learn about the weight of gravity, how it affects our bodies, and the ways we can move against it.

The TLR also helps manage our muscle tone. This refers to the brain processes that help our muscles maintain a certain position at rest, not the strength of our muscles. The TLR also helps us control our body posture throughout the day and maintain proper balance to keep us upright.

When Should the TLR Integrate?

The TLR should be fully integrated by the time a child is 3 years old, but this may take up to 3.5 years. As we mentioned earlier, every child is different, and TLR integration may take longer for some than others. You should notice a change in your child’s development when this reflex integrates. One of the most obvious signs of appropriate TLR integration is smooth and stable movements, such as crawling, walking, and jumping.

Your child should be able to move from one position to another easily, without hesitation or much difficulty. They will lose their balance, trip, bump into things, and fall less frequently. Your child may have once relied on you for reassurance as they climbed onto the couch or supervision as they walked up the stairs. But with an integrated TLR, they are likely to feel more secure and safe in their movements. This leads to greater independence and confidence in their movements and the activities they participate in.

Signs of a Retained TLR

There are several main signs that a child has a retained TLR. We have broken these into a few categories to make them easier to understand.

Posture & Muscle Tone

One of the most common signs of a retained TLR is difficulty maintaining certain postures. A retained TLR may cause a child to walk on their toes, which may be a normal behavior during the toddler stage, but less so afterwards. Children may do this due to disliking the feeling of the floor on their feet, having difficulty keeping their balance, or having tightness in the muscles of their feet. These can all stem from a retained TLR.

Children with a retained TLR may also avoid lying on their stomach to sleep, read, watch TV, or simply relax. This is often because they have difficulty moving their head along with the rest of their body, so this position makes them feel less stable. 

A retained TLR can lead children to assume other positions of comfort, such as slouching (rather than sitting upright in a chair), W-sitting (rather than squatting), and lying down (rather than sitting upright). W-sitting is when a child’s legs are splayed out to the side, and their buttocks rest on the floor between them rather than on their legs.

Lastly, weakness in the arms and legs is another concern related to a retained TLR. Children may have difficulty holding a bag and lifting or carrying objects between two places.

Balance & Movement

Balance impairments associated with a retained TLR present in several ways. Firstly, jerky, rigid, or overall stiff movements are common. Children may be described as being clumsy due to having difficulty avoiding obstacles such as furniture and toys when they walk. Since TLR also causes vision difficulties (we will discuss this more in another section), some of their falls and accidents may result from being unable to judge the depth or the space around them. 

Similarly, a retained TLR leads to difficulty judging speed and direction, meaning children who keep this reflex may struggle with sports and in recess or gym class. Balance issues may lead these children to be fearful of heights and feel uneasy any time they are off the ground, even if it’s just slightly. Motion sickness is another common concern associated with retention of this reflex.

Activities that require movement of two arms or two legs (or arms and legs at the same time) can also prove trying, meaning your child may have difficulty with biking, swimming, and walking.

Visual-Motor & Coordination

Some concerns related to visual-motor skills include poor organization of desks, rooms, and other belongings. Children with a retained TLR may have difficulty stringing various movements together, such as when doing a dance or playing a game. These struggles may lead children to avoid sports and physical activities as much as possible due to a lack of confidence or fatigue.

During school tasks, children may have difficulty telling time on a standard clock face. Handwriting, math, and reading may all be complicated to them, since they may tend to reverse letters and numbers when reading or writing.

Endurance & Regulation

Endurance is another reason why children with a retained TLR may avoid sports and similar activities. Fatigue is a common problem with these children, even when doing more sedentary tasks such as reading. As we mentioned earlier, positioning can help somewhat so their tolerance for tabletop tasks may improve if they assume an easier position.

Due to organization and sequencing problems, children may have trouble telling stories or keeping track of events in a certain order. A retained TLR can also lead to difficulties with one’s sense of time, leading kids to misuse descriptors like tomorrow, yesterday, today, now, and later.

One study found that around 65% of healthy preschool children retained some reflexes (including the TLR, ATNR, and STNR) beyond the time they were intended to disappear. Researchers found that the children who retained these reflexes had some common difficulties. These included dyspraxia (difficulty with coordination and movement), vestibular disorders (consistently poor balance), and postural concerns (trouble holding certain positions, especially for long periods of time).

How Retained TLR Affects Daily Activities

Children with a retained TLR may struggle with some of the following activities, impacting their physical fitness, academic performance, play at home, and more:

• Participating in sports or following directions for a game in gym class
• Climbing stairs
• Playing on the playground at the park or during recess
• Sitting at a desk to write or read
• Paying attention in class, especially when seated in a chair
• Throwing up or reporting feelings of an upset stomach or dizziness in response to movement, being in the car, or in similar situations
• Complaining of being tired when sitting up, standing in line, or doing other seemingly simple movements
• Getting scraped, cut, bruised, or otherwise hurt from falling, dropping items, or bumping into things as they walk
• Focusing their eyes on pictures or words when reading or watching TV

Tonic Labyrinthine Reflex Integration Exercises

If the information we’ve given you so far resonates, your child may benefit from tonic labyrinthine reflex integration exercises. Keep in mind that none of these exercises is designed to cure or treat your child. These exercises are also not considered a replacement for medical diagnosis and treatment. Instead, you can view TLR integration exercises as supportive movement strategies that can help further develop your child’s skills.

Just as we grouped the signs of a retained TLR together, we have grouped similar exercises together based on what skills they target. We suggest going through each category separately and recording your child’s responses as well as any areas they have difficulty with as you go along.

Extension-based movements

These exercises are intended to improve your child’s ability to move their head backwards while properly supporting the rest of their body.

Sphinx pose

How it helps: This modified yoga pose involves propping the body up using only your arms as you keep a steady and straight head. This strengthens the arms and the muscles in the neck by prompting your child to keep a still and stable posture. The Sphinx pose can help with upper body coordination and strength, as well as posture.

How to do it:

1. Find a comfortable spot on the floor (on carpet, a mat, or a thick blanket) and have your child lie on their stomach.
2. Tell them to stretch their legs out straight underneath them. Their toes should be pointing directly behind them, and their hips should be straight.
3. Have your child bend their back so they can prop their upper body on bent elbows. Their elbows should be lined up just below their shoulders, and their shoulders should be relaxed and rolled back (not slouching).
4. Lastly, their head should be tilted back slightly, allowing them to look up to the ceiling.
5. Once your child has assumed this pose, have them hold it for 10 seconds. As they continue to practice, slowly add time – going from 10 to 15 seconds, 15 to 20 seconds, and so on until you reach 60 seconds.

Cow pose

How it helps: The cow pose is another yoga pose that involves head and body stability. In particular, this pose helps loosen up the spine so it can better move along with the head, which is key for many body postures.

How to do it:

1. Find a comfortable spot on the floor and have your child get down on all fours. To do this, they should have straight arms and flat palms supporting the weight of their upper body. They should have bent knees supporting the weight of their lower body. Be sure your child’s back is flat, their knees and hips are lined up, and their shoulders are even with one another.
2. Have your child take a slow, deep breath in through their nose. You can tell them to pretend like they are smelling some flowers or a tasty baked treat.
3. Have them keep their arms and legs in the same position as they push their stomach toward the floor and lift their head up, looking toward the ceiling.
4. Tell your child to hold this position for 10 seconds.
5. Once the 10 seconds have passed, have them breathe out slowly through their mouth as they return their body to the starting position: on all fours with a flat back.
6. As they continue to practice this pose, slowly add time – going from 10 to 15 seconds, 15 to 20 seconds, and so on until you reach 60 seconds.

Flexion-based movements

The opposite of extension-based movements, flexion-based exercises will help strengthen your child’s ability to move their head forward.

Cat pose

How it helps: Often done in combination with the cow pose, the cat pose loosens up the spine and allows it to move through a deep arch as the head takes on a more relaxed position. Cat pose improves posture, builds strength, and helps with more intentional body movements.

How to do it:

1. Find a comfortable spot on the floor and have your child get down on all fours. To do this, they should have their arms straight and their palms flat, supporting the weight of their upper body. They should have bent knees supporting the weight of their lower body. Be sure your child’s back is flat, their knees and hips are lined up, and their shoulders are even with one another.
2. Have your child take a slow, deep breath in through their nose. You can tell them to pretend like they are smelling some flowers or a tasty baked treat.
3. Have them keep their arms and legs in the same position as they tuck their stomach in and arch their back as if they are bringing it up to the ceiling. As they do this, they should bring their head down and try to tuck their chin into their chest.
4. Tell your child to hold this position for 10 seconds.
5. Once the 10 seconds have passed, have them breathe out slowly through their mouth as they return their body to the starting position: on all fours with a flat back.
6. As they continue to practice this pose, slowly add time – going from 10 to 15 seconds, 15 to 20 seconds, and so on until you reach 60 seconds.

Child’s pose

How it helps: Child’s pose offers a deep stretch to various parts of the body while practicing, keeping the head in a stable position. Child’s pose can increase flexibility, enhance body awareness, and relieve muscle tension. This pose also slows the body’s nervous system, which can ease anxiety, balance mood, and improve focus.

How to do it:

1. Find a comfortable spot on the floor and have your child get down on all fours. To do this, they should have straight arms and flat palms supporting the weight of their upper body. They should have bent knees supporting the weight of their lower body. Be sure your child’s back is flat, their knees and hips are lined up, and their shoulders are even with one another.
2. Have your child bend their knees even more so they are sitting on their feet with their stomach resting on their upper legs. As they do this, their arms should stretch out in front of them so the palms of their hands can remain flat on the floor.
3. Have them lower their head to the floor and gently try to tuck their chin into their chest.
4. Tell your child to take a slow breath in through their nose and out through their mouth as they count to 10.
5. As they continue to practice this pose, slowly add time – going from 10 to 15 seconds, 15 to 20 seconds, and so on until you reach 60 seconds.

Rolling and rotational activities

Activities that involve rotation and rolling of the head along with the rest of the body are another excellent way to help integrate the TLR.

Pin roll

How it helps: Rolling pins encourage the use of both hands while providing a certain amount of pressure. In order to use this utensil, children must assume a certain posture (either standing or sitting upright) to properly “get the job done.” This helps them build postural control, bilateral integration, and upper body strength at the same time.

How to do it:

1. Find a flat tabletop surface that your child can easily reach by standing up or sitting in a chair. A child’s desk, countertop, or other surface is suitable for this activity.
2. Have your child hold a rolling pin with one hand on each handle (located at the sides of the rolling pin).
3. Take a piece of paper and crumple it up into a ball.
4. Place the paper ball on the table in front of them and tell them to “push” and “pull” the rolling pin to flatten the ball as much as they can.
5. Have your child do this as you keep count for 10 seconds, then tell them to take their hands off the rolling pin and rest for 15 seconds.
6. Have your child place their hands back on the rolling pin and repeat the above steps.
7. Do this for 2 sets of 10 seconds.

Log rolling

How it helps: Log rolling involves keeping the head and body stable while remaining in motion toward a certain target. This is more difficult than most people realize! Log rolling requires you to keep your muscles tense enough to keep your position, but loose enough to allow for movement, which helps build core strength and enhances coordination.

How to do it:

1. Find a comfortable spot on the floor (on carpet, a mat, or a thick blanket) and have your child lie on their stomach.
2. Be sure their arms are straight at their sides, and their legs are straight below them.
3. While staying in the same position, have your child use their feet to push themselves over and onto their back as they roll with their arms and legs tucked in.
4. Have your child continue log rolling until they reach the end of the room. Encourage them to move at a steady pace without stopping.

Balance-challenging but controlled activities

Exercises that test your child’s balance and motor control at the same time can be helpful in integrating the TLR.

Belly swinging

How it helps: Activities done on the stomach help strengthen the core of the body as well as the back. This makes it easier for a child to assume various postures, as these muscles are essential for movement.

How to do it:

1. Have your child lie on a swing on their stomach. This can be an outdoor swing that is part of a playset or an indoor activity swing.
2. Place 3 small items on the floor within a couple of feet of the swing.
3. Have your child use their legs to push themselves in all directions and get each object (one at a time) while remaining on the swing.
4. Once they get an object, have them toss it into a nearby bucket, box, or basket.
5. Have them repeat these steps until they retrieve all of the objects.
6. As they continue to practice this activity, slowly add objects – going from 3 to 5, 5 to 7, and so on until you reach 10 objects.

Soaring through the sky

How it helps: This activity involves a child holding the poses that are part of the TLR test. By practicing this, a child can strengthen the muscles in their neck to improve their ability to hold those (and similar) positions.

How to do it:

1. Find a comfortable spot on the floor (on carpet, a mat, or a thick blanket) and have your child lie on their stomach.
2. Tell them to stretch their legs out straight underneath them. Their toes should be pointing directly behind them, and their hips should be straight.
3. Have your child bend their back slightly while lifting their arms and legs up off the floor.
4. Have them hold this position for 5 seconds.
5. As they continue to practice this pose, slowly add time – going from 5 to 10 seconds, 10 to 15 seconds, and so on until you reach 30 seconds.

How Often Should TLR Exercises Be Practiced?

For the best results, it’s recommended to practice TLR integration exercises three to five times each week. Spend the first week going through one of the above exercises each day. Based on which ones your child likes and the materials you have available to you, choose one to three exercises to practice on a regular basis. It may take several months to see results in areas like endurance and overall strength.

Remember to focus on the quality of the movements rather than the length of time your child is holding each position or the number of repetitions they are doing. Once they get better at doing certain activities and positions the right way, then you can begin slowly increasing the amount of time or repetitions (depending on what the activity calls for).

Common Mistakes When Working on TLR Integration

As a pediatric occupational therapist, I educate the families I treat about what not to do, since that is often just as important as knowing what to do. 

One of the main pieces of advice I give is regarding the pace of reflex integration exercises. Be sure to avoid completing exercises too quickly. As I mentioned earlier, the quality of the movement is more important than the quantity. Your child may have difficulty at first, leading them to want to get them done more quickly. But you can make it more fun for them to encourage slower completion – maybe playing some quiet, but soft music in the background to help improve their attention, or encouraging them throughout.

Watch out for signs that your child is getting overly tired, nauseous, or uncomfortable with the exercises. If their movements are getting sloppier or more rigid as you go along, it’s best to stop for the day. The same applies to any signs of dizziness, which may especially occur with some of the more balance-intensive exercises. If they continue to show these responses, it may be time to visit their pediatrician or an occupational therapist.

Remember that building any skill takes time, and the same goes for reflex integration. Don’t try to rush the process or place extra pressure on your child to perform in a certain way. This will only make the exercises more stressful for them, leading to poorer results.

Lastly, consistency is one of the most important factors in skill-building and reflex integration. If you need to, make a note on your calendar or a digital reminder on your phone to ensure regular practice. Take a look at your child’s schedule and try to plan the exercises at a time when your child will be home and can rest after they are done.

When to Seek Professional Support

If your child has a lot of difficulty with these TLR integration exercises or their functional concerns (at school, home, etc.) begin to worsen, it may be time to bring this up with a healthcare provider. This is especially the case if your child has severe movement difficulties or consistently injures themselves. Their pediatrician is equipped to give advice, as are occupational and physical therapists. The latter two are rehabilitation providers who help children learn and strengthen skills such as walking, running, jumping, writing, reading, and manipulating small objects needed to dress, eat, and care for themselves.

Frequently Asked Questions About TLR

What age should the TLR integrate?

The forward position of the TLR should be integrated by 4 months of age. The backward position of the TLR should be integrated between 3 months and 3.5 years of age.

What age will the TLR appear?

The forward position of the TLR first appears in utero, and the backward position shows up between the time of birth and 2 weeks of age.

Should my child still have the TLR at age 4?

The TLR should fully integrate between the ages of 3 months and 3 or 3.5 years. So a child should not still have this reflex by age 4.

Can a child have both retained TLR and STNR?

Yes, it is possible for a child to retain both the TLR and STNR.

Should STNR be addressed before TLR?

Reflexes are typically addressed in the order they develop and integrate within the body, so a child with retained STNR and TLR should integrate TLR first.

Conclusion / Key Takeaways

The TLR is a primitive reflex that helps a child develop neck extension in order to control the head along with the body. This helps a child learn various movements and postures such as crawling, sitting, and standing unsupported. The TLR also helps with whole-body coordination, focus, endurance, and upper-body strength. Both aspects of the TLR should be integrated by the time a child is 3.5 years old. If this integration does not occur, a child may struggle with academic tasks such as writing, reading, and math, as well as sports and play activities. 

Parents can practice TLR reflex integration activities with their children to help this reflex disappear and improve their motor skills. SoundSory’s program is another fun, non-invasive way to improve your child’s coordination and motor skills if they have retained this reflex. Keep in mind that consistency with all exercises and programs is key to seeing the best results. Always discuss severe movement and balance difficulties, as well as major functional concerns, with your child’s doctor. 

References:

1. Arcilla, C.K., & Vilella, R.C. Tonic Neck Reflex. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/sites/books/NBK559210/ 
2. Capute, A. J., Shapiro, B. K., Accardo, P. J., Wachtel, R. C., Ross, A., & Palmer, F. B. (1982). Motor functions: associated primitive reflex profiles. Developmental medicine and child neurology, 24(5), 662–669. https://doi.org/10.1111/j.1469-8749.1982.tb13677.x 
3. PhysioPedia. (n.d.). Tonic labyrinthine reflex. Retrieved from https://www.physio-pedia.com/Tonic_labyrinthine_reflex 
4. Johnson, K. (n.d.). Integrating Tonic Labyrinthine Reflex: An exercise for children with learning disabilities. Retrieved from https://www.pesi.com/blogs/integrating-tonic-labyrinthine-reflex-an-exercise-for-children-with-learning-disabilities 
5. OT Toolbox. (2024). Retained Primitive Reflexes & Child Development. Retrieved from https://www.theottoolbox.com/retained-primitive-reflexes-child-development/
6. Melillo, R., Leisman, G., Machado, C., Machado-Ferrer, Y., Chinchilla-Acosta, M., Kamgang, S., Melillo, T., & Carmeli, E. (2022). Retained Primitive Reflexes and Potential for Intervention in Autistic Spectrum Disorders. Frontiers in neurology, 13, 922322. https://doi.org/10.3389/fneur.2022.922322 
7. Huppert, D., Wuehr, M., & Brandt, T. (2020). Acrophobia and visual height intolerance: advances in epidemiology and mechanisms. Journal of neurology, 267(Suppl 1), 231–240. https://doi.org/10.1007/s00415-020-09805-4 
8. Domingo-Sanz V. A. (2024). Persistence of primitive reflexes associated with asymmetries in fixation and ocular motility values. Journal of eye movement research, 17(2), 10.16910/jemr.17.2.5. https://doi.org/10.16910/jemr.17.2.5
9. Bongiovanni, L. G., & Hagbarth, K. E. (1990). Tonic vibration reflexes elicited during fatigue from maximal voluntary contractions in man. The Journal of physiology, 423, 1–14. https://doi.org/10.1113/jphysiol.1990.sp018007
10. Pecuch, A., Gieysztor, E., Telenga, M., Wolańska, E., Kowal, M., & Paprocka-Borowicz, M. (2020). Primitive reflex activity in relation to the sensory profile in healthy preschool children. International Journal of Environmental Research and Public Health, 17(21), 8210. https://doi.org/10.3390/ijerph17218210