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Neonatal Nervous Systemy

Chronological development of an infant in the 1st year

(Coenen 1995)

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Bilo, Voorhoeve, Koot

Kind in ontwikkeling





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Let’s have a short “frühkindliche”practical survey!

oTractiontestoATNRoLabyrinthoRolingoOcculocervical reflex

Quality of movement!

C0‐C3‐malfunction / KISS II

C0‐C3‐malfunction / KISS I

Start of primitive, posture and movement reflexes

C0‐C3‐function

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According to Inge Flehmig:

• The body‐image (concept) is the first and most important achievement of the neuro‐motor

function development, that implicates posture reflexex and the differentiation in the sense ofreflexex and the differentiation in the sense of

balance.

“Sometimes it appears as if the head is glued to the shoulders – like a block of wood”

Function: balance and the transmission of sound (hearing)

Ncl. Deiters

Lateral vestibulo spinal tract

‘stretch reflex’“sitting straight” also

influencing the sense of space

Influencing Aα and γInfluencing Aα and γmotorneurons of the m. err. tr.

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12. ncl. n VII

13. ncl. n III

Fasc. lo. medialis

14 ncl. n. XII

15 ncl. ambiguus

DvořakProjection of the cervical afferensis (especially the joint caps.) to the homolateral

occulo‐motor and the heterolateral vestibular nuclear centers.

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All the vestibular centers are connected to the eye muscle nucl. centers via the Fasciculus Longitudinalis Medialis (FLM).

Advancing to perception of space:

= integral co‐operation between the eyes, labyrinth, higher spinal

column, SI joints and the hips.

Total propriocepsis

dasz erst imVestibularis-

kernkomplex

W.L.Neuhuber ‘98

Sensory feedback

(re‐afferensis)

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Eyes

Bodypropriocepsis

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Anatomy

n. suboccipitalisall subocc. muscles!!

n. occipitalis minor

n. occipitalis maj.

Bogduk and Bartsch, 2007thx to Thorstein Bartsch

which wire is connected?????

Meningeale Afferenzen enden im spinalen Trigeminuskern

V1

V2

V3

Trigeminalganglion

Forebrain

PonsP

Me

M

SMiddle meningeal artery

Second-order

Dorsal horn

V

Ophthalmic dermatome

C-fibreA-fibreA-fibre

Caudalis

Interpolaris

Oralis

Principalis

Motor

Supratrigeminal

Mesencephalic

Pons

Medulla

O

I

C

Second-orderascending projection

neuron

1

2

3

4

5

Medulla

Pons

4

5

1

2

3

V3V2V1

V3V2

V1

Knight et al, 2002

thx to Thorstein Bartsch

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Bartsch et al, 2003thx to Thorstein Bartsch

referred pain

which wire is connected?????

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22‐n. accessorius.

23‐art. vertebralis

27‐nerv. hypoglossus

29‐nerv. glossopharingeus

30‐nerv. vagus

31‐n. accessorius (ramus ext.)

36‐n. vestibulocochlearis

37‐n. facialis

The incisura jugularis of the occipital bone together with the incisura of the temporal bone, form the foramen jugulare. .the foramen jugulare

Foramen jugulare

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Clarijs et al.

Clarijs et al.

Thin motor nerve C1

C2 sensitive to C1‐area

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When it has exited the dura, the ramus dorsalis of C1 crosses the dorsal atlas arch between the bone and the vertebral artery.

I i fib b lIt gives fibre to sub occ. musclesoften communicating (anatomosis) with the accessory nerve.

The root of C2 runs between the atlanto‐axial joint in between the sub.occipital muscles.

Fibres from the major occ. nerve reach up to the sutura coronal, where it communicateswith the supraorbital nerve.

The major occ. nerve also innervatescapsula art. C2‐C3 jt.

(see Dvořak)

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KISS ILateral shift atlas (left)i.r.t. occipital bone:

capsular strain C0‐C1

S b l

nucl. spin. n. VThe sensory projection from sub occ musc on spinal ganglion C2 (major.occ.n)

Sub.occ. muscularstrain due to raised

nociception

Because the extreme rotation component,

continuous tension on the dura.

The major occ. n. receives afference from joints C1‐C2, C0‐C1 and C2‐C3.

Nucl. n. trig. runs up to C5!

Spinal function medulla oblongata = spinal levels

Topography differs

•The spinal root of C2 has many pain‐sensors esp. from the cervical dura, they transmit to the brain‐stem causing vagus reactions – bradycardia and blood pressure fall.

•With KISS babies long‐term torsion of the high cervical and muscular structures.

•This relieves the pain sensors and causes long term existence of all vegetative reactions.

•The major occipital nerve transmits to almost all nucl. centers of nn. craniales in the brain‐stem.

QUOTES

Thoden 1975:

Observed / registered impulses from the center of the brain‐stem and vestibule.

50% of the detectable impulses were stimulated by electrical stimulation of the spinal nerves of C1 – C4

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stimulant impulses ofC0-C1C1-C2C2-C3are projected at nuclei nn. craniales

Relation of the dura withthe occiput‐atlas axis

Map of collagen fibers in the dura

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cerebral lesion

birth:spinal trauma

incorrect input

derogatoryreflex activity

disturbed (space) perception

disturbed movement

orthopedic consequences later

suffering because of disturbed function

Dynamics of neuro‐motordevelopment

According to:Heiner Biedermann

VEGETATIVE REACTIONS

Dr. Udo Mohr 1977:

Das kind hat einen neuen Gang bekommen, im Schulsport tut sie nicht mehr schwer, Gliederschmerzen sind seit der Behandlung nicht mehr aufgetreten und nachts kann das Kind jetzt durchschlafen.

So behandelte ich zwölf Kindern

mit ähnlich eindrucksvollem Erfolgmit ähnlich eindrucksvollem Erfolg.

Medikamentös waren diesen Kindern natürlich überhaupt nicht zu helfen.

BRAINSTEM REACTIONS

Gutmann:

• Talks about secondary reflex disturbances of the brain‐stem

• Disturbed sensory signal from cerv. spine combined with an immature nervous system, causes massive non systematic vegitative reactions from the brainstem.

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The heighted muscular and vegitative strain arerelated to each other and also cause other symptoms

such as cold hands and feet.

BRAIN STEM REACTIONS

• Bad motor function of mouth

sucking reflex

swallowing (hypoglossus nerve)

• Bad appetite, problems with drinking

• Tendency to vomit

• Bad digestion• Bad digestion

• Stomach colic (symptoms in the 1st – 4th week)


• Cerebral disorder (restless)

• Tires quickly

• Bad balance

• Ear infections

• Cavity infections

• Cold hands and feet

• Excessive perspiration

(Lewit: because inflammatory activity evokes C0–C1 blockage)

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BRAINSTEM REACTIONS

• Tense and not easy to handle ??

• Sudden fever (for no reason)

• Impairment of blood circulation

• Colds with lots of sneezingg


• Bad appetite

• Bad growth

Suck‐swallow‐vomit

Sucking: triggered by stimulation of the lips and mucus membrane inthe mouth that causes the sucking reflex.

The reflector contractions of the tongue throat and jaw causes oral vacuum.

All functions of the trigeminal, facial and the vagus nerve.

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Swallowing:

A complex process, demanding communication and co‐ordination with specific (step by step) muscular functions,

Gentle stimulation of the walls of the throat is necessarry.

Rough stimulation causes a ‘pushing‐back’ of food, gagging and a t l ti flstrangulation reflex.

The swallowing center is located in the medulla oblongata close to strangulation reflex center.

A weak sucking reflex causes a weak swallowing reflex.

ISBN 3 13 702403 X

THERAPY

Research into vegitative reactions of 199 KISS‐babies

By: Heiner Biedermann en Lutz Koch

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199 KISS‐BABIESin order of age

15

20

25

f ch

ildr

en

0

5

10

1 2 3 4 5 6 7 8 9 10 11 12

Months

num

ber

of

122 boys 77 girls

105 of the 199 infants (52.8%) had vegetative reactionsto high cervical manipulation.

59 boys ‐ 46 girls

8

10

12

14

f C

hild

ren

0

2

4

6

1 2 3 4 5 6 7 8 9 10 11 12

Months

Num

ber

of

59 boys 46 girls

199 KISS‐BABIESreactions to manipulation treatment

• 52,8% reacted with a vegetative reaction

• 48,7% had one registered vegetative reaction

• 10% showed 2 vegetative reactions

• 4,5% showed 3 vegetative reactions

See graph of combinations of veg. reactions

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VEGETATIVE REACTIONS

80

100

120

hild

ren Total

Flush

0

20

40

60

Num

ber

of C

h ApnoeaStar gazingTranspirationHypotoniaVomiting

st

COMBINATIONS OF VEGETATIVE REACTIONS

12

14

16

18

20

fch

ildr

en

A FA F OF OA F S O

0

2

4

6

8

10

Num

ber

of A F S O

F S A F S A OA S O

A = APNOEA F = FLUSH, RED HEADO = OPISTHOTONE POSITION S = TRANSPIRATION

105 KISS‐BABIESkind of vegetative reaction

• Redness of the face is a common reaction

• After which short‐term apnoea of less than 10 sec

• Loss of tonus and vomiting are not frequent and pass quickly

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1: Forensic Sci Int. 1998 Oct 12;97(1):1‐9. Related articles ‐ links

High cervical stress and apnoea.

Koch LE, Biedermann H, Saternus KS.

Institute of Forensic Medicine, University of Gottingen, Germany.

The aim of this study was to investigate vegetative reactions in infants after mechanical irritation of the b i it l i Th i ti ti i b d 199 i f t h b d hil b i t t dsuboccipital region. The investigation is based on 199 infants who were observed while being treated

with a suboccipital impulse (manual therapy). The results revealed vegetative reactions in more than half of all cases (52.8%, n = 105). The frequency of such vegetative reactions observed was at follows: flush48.7% (n = 97), apnoea 22.1% (n = 44), hyperextension 13% (n = 26), and sweating 7.5% (n = 15). It is

pointed out that approximately 25% of all the infants examined reacted by apnoea due to a mechanicalirritation of the suboccipital region. This symptom was part of an extensive vegetative reaction. Thismethod of inducing an apnoea has not yet been described; from this it follows that there are close

relations to sudden infant death.

PMID: 9854836 [PubMed ‐ indexed for MEDLINE]

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At birth, 1/5 of brain growth is completed!

Myelination of peripheral nervous system still incomplete at birth

First movements of foetus in uterolateral movements

pelvis head

As from the 7th week pm

•Startles

•General movements

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Startles

Short

Very frequent

Sudden (seems to startle)

Flexion and extension patterns

General movements

Last seconds to minutesVery frequentVariation!

General movements & Startles

Are made without completion of the spinal reflex‐arc……..and therefore without afference!

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Without intrauterine movement, the following may occur:

Contractures

Pulmonary hypoplasia

Joint deformations

In other words, intrauterine movement stimulates ontogenetic adaptation

→ pre‐programmed motor activitiy

Before birth:

Complete flexion and extension chains

After birth, the ability to lift the head forward immediately disappears!

As a result of the absence of the cushioning effect of the amniotic fluid, the baby’s relation with gravity changes.

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Motor response to the nociceptive system or disturbed posture in relation to gravity

→ Moro reflex (postural reflex)

→After birth, the Moro reflex has free rein for a few weeks!,

Moro → mul ‐sensory input

Sense of proximity: vital, gnostic, vestibular, taste

Sense of space: visual, acoustic, smell

Vegetative: e.g. nociception through n. phrenicus, n vagus proj. op ncl. spin. n. V

Phylogenetic development

Archi: motor reflexWhere? Spinal cord and brainstem

Paleo: automatic (lifting response) and automated locomotionWhere? BK and cerebellum

Neo: conscious motor skillsWhere? Cerebrum and cerebellum

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Imagine, in these modern times!

Does anybody have an alternative?

Another classification:

Reflexes and lifting response

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Reflex

Not learned → based on neurological circuits present at birth

A stereotypical response to a stimulus

Uniform pattern

Reflexes

Proprioceptive reflexes

Exteroceptive reflexes

Postural reflexes

Vegetative reflexesVegetative reflexes

Lifting response

• Proprioceptive reflexes

• Exteroceptive reflexes

• Postural reflexes

• Vegetative reflexes

Proprioceptive or muscle stretch reflex:

Eigenreflex → s mulus and effector organ are the same

Short arc: archi level (susceptible to cerebral influence)

one s mulus → one contrac onmonosynapticnot fatiguingincreased with central lesion. (CMN)decreased with peripheral loss (of function)

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Monosynaptic reflex arc:

HyporeflexiaHyperreflexiaClonic reflex





what is a clonic reflex????

when is a clonic reflex normal?

Tendon reflex

mono or multisegmentalstill monosynaptic





y p

Only a few muscles are monosegmentally innervated, the reflex stays in multisegmental activation, however still monosynaptic!

Clonic reflex = pyramidal tract dysfunction = disinhibition of the mvh.





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Myelination of pyramid tract system continues till the end of the first year of life

→ a few repea ng taps is therefore normal ll ± 3 months!!





Achilles tendon reflex KPRAdductor lo. ReflexBiceps

hi di li





BrachioradialisTriceps

Masseter reflex





Exteroceptive reflex = (usually) skin reflex

Fremdreflex: stimulus and effector organ are not the same

Archi + Paleo→ long arc

duration of stimulation – depends on intensityduration of stimulation – depends on intensity

polysynap c → longer reflex me

fatiguing

supraspinal control

hyperreflexia or changed reflex with central lesion

hyporeflexia with peripheral lesion

somatovisceral and somatic immunological link

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Exteroceptive reflex





Skin reflexes Disappeared

plantar reflex according to Babinsky

ends of 1e year of life

abdominal skin reflex lifelong

Galant 3 to 4 months

grasp reflex hands / feet 4 to 6 months





g p /

step reflex (positive support reflex)

after 6 months start of active support

cornea reflex lifelong

Babinski

Execution: A pointed object is used to stroke the lateral aspect of the sole of the

foot from the heel towards the little toe.

Physiological: Response navel by reflex tightening of abdominal mm.

Pathological: adults: slow tonic extension of the large toe, with often fanning of the

other four toesneonates: dorsiflexion large toe, spreading of toes

Indicative for: adults: if present positivepyramidal tract neonates: if absent / asymm. Positivelesion

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Abdominal skin

Execution: With back of reflex hammer so ly stroke lat. → med. at epi‐meso‐ and hypogastric level.

Physiological: Response navel by reflex tightening of abdominal mm.

Pathological: asymmetry

Abdominal skin reflex

Adults Neonates

Physiological symmetrically present(incid. symm. absent)

symmetrically present?

Pathological asymmetrically present, actively present

asymmetrically presentactively present present

Indicative of: pyramidal tract lesion

Galant reflex

Back skin reflex (relation with passage through birth canal?)

Appearance: around 18 weeks in utero, inhibition ± 9 months?

Execution: baby is in a face‐down position, stoke baby’s back with finger

tip ± 1 cm paraspinal from cranial → caudal. Tes ng of bdzs.

max. 3 times

Physiological: homolat. tightening of spinal muscles as a result of which homolat. incurvation of the spine / pelvis

Pathological: when absent (sensibility)

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Grasp reflex hands/feet

Appearance: as from the 10th week pm, inhibition 5months.

Execution: stroking the palm of the hand with a finger va. Ulnair

Physiological: Fingerflexion as long as palm of hand is beiing stimulated

Pathological: not present

Step reflex

Appearance from birth, inhibition 5 months

Execution Stimulating football or placing the feet on a flat surface (the feet only have to lightly touch the surface)

Physiological Extension of entire leg

Pathological not present / asymmetrical

Cornea reflex

Appearance: immediately pp., persists

Execution: light stimulation of eye lashes, snapping your fingers before the eyes

Physiological: simple closing of eye lids

Pathological: not present asymmetrical

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Postural reflexes → postural responses

fremdreflex (as from 7th week in utero)

archi & paleo level

polysynap c → mul ‐segmentalp y y p → g

inducible from several receptor organs!

mesencephalic area always involved

not rapidly fatiguing

susceptible to supraspinal influence

disinhibition by CMN (functio) lesion

(partially) absent with peripheral lesion





Postural reflexes → postural responses

fremdreflex (as from 7th week in utero)

archi & paleo level

large variability in execution = not stereotype = no reflex

cannot not always be triggered; with arousal, however, always present!

Postural responses

Postural responses continue to be active and necessary throughout a person’s life

They form part of the support motor system and are strongly influenced by



• Postural responses


They form part of the support motor system and are strongly influenced by the vestibular nuclear complex and proprioceptive information from the neck!

Postural reactions are still very active at infant age because of low supraspinal inhibition compared to adult age.

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Postural response





Postural response





postural response

tectospinalextrapyramidal vestibulospinal




• Vegetative reflexesPostural responses

ATNRSTNR = securing fundamental postureMoroMoro

congenitally acquired fremdreflexes?who constructed these??

primarily when lying down, sitting or standing

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ATNRSTNR = securing posture → balancing responseMoro





Moro

After the first year of life, these responses can no longer be triggered ar ficially, although they remain ac ve in the background → support / catch / balance.

ATNRAppearance as of 18 weeks pm.

Execution passive head rotation to one side

Physiological extension(tonus) homolateral arm / leg

suspect ‐cannot be triggered / not perceptible‐consequently asymmetrical

‐easy to induce after 1st year of life

ATNR

Film + demo in adult

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ATNR

Testing at adult age

why?

to demonstrate hyperresponse

neurological disorder?

orthopaedic disorder

ATNR


why?

to demonstrate hyporesponse


orthopeadic disorder

ATNR test structure

sensitizing; eyes closed

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STNR

Appearance from 4th – 6th month

Execution flexing head in dorsal position

Physiologial flexion pattern arms – extension patternlegs

Suspect ‐cannot be triggered / not perceptible‐easy to induce when child already starts to crawl.

STNR

film + demo in adult

STNR


why?




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STNR


why?




STNR test structure

sensitizing: eyes closed

Moro

Appearance as of 18 weeks pm.

Execution several facilitations possibleusually lowering the head backwards in relation to trunk

Physiologial extension pattern! (sec. embracing?)

Suspect ‐cannot be triggered / not perceptible‐inducible however child will‐easily inducible when child is already starting to crawl.

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MoroAlready present in utero

Resulting from the startles (flexion – extension patterns

Does not work in face‐down positionDoes not work in face‐down position

How does Moro relate to swaddling?

Moro

film + demo in adult

MORO


why?




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MORO


why?



orthopaedic response

Moro test structure

sensitizing: eyes closed

Vegetative reflexes:

Suck reflex: as of 10th to 12th week pmSwallowing reflex: as of 14th week pm





somatovisceralviscerosomaticviscerosympatheticviscerosensory→ visceromotor

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Maintain (restore) posture of head in space

Relation posture trunk and head

Relation position extremities with respect to trunk

Righting reflex

Relation position extremities with respect to trunk

Righting with respect to gravity

Righting reflexes

Provide the individual with the possibility of righting himself (again) with respect to gravity

polysynap c → multisegmentalvestibulum is central facilitator!mesencephalic area always involvedhardly fatiguing at allsusceptible to supraspinal influencedisinhibition by CMN (functio) lesion(deels) afwezig bij perifere laesie

input righting reflex

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Principal output righting reflex

Lateral response when toppling over → lateral righ ng reflexVentral righting reflex (optical / labyrinthal)Dorsal righting reflex (optical / labyrinthal)

righting reflexes:

Dorsal righting reflex (optical / labyrinthal)Cervix righting reflex (head on trunk when rolling over – neck sensors)Trunk on trunk (shoulders in relation to pelvis – neck sensors, vertebral joints)

Righting reflexes are of vital importance in the development of a normal motor system!

Untreated cervical function disorder=not able to roll over /crawl / etc. normally

In this respect, the responses and reflexes b i iare subservient in nature.

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Lateral righting reflex

As of 2 – 3 months pp.

Optical and vestibular controlled response


filmp + demo in adult



why?

to demonstrate hyperreaction



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why?

to demonstrate hypyresponse



Ventral labyrinth responsebetter;

ventral righting reflex

As of 2 – 3 months pp.

Optical and vestibular controlled response

Ventral righting reflex

demo in adult

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why?






why?

to demonstrate hypyresponse



Righting reflexes

Reflexes & postural response

Startles &GM

Post menstrual Neonate Juvenielum Adolescence

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Why does KISS become visible only after ± 4 – 6 weeks?

In utero: flexor tonus dominant, anteflexion head actively possibleNeonate: first weeks no active anteflexion head possible

extensor tonus has free rein (Moro)

A i → f llAsymmetry requires extensor tonus → for atnr as well→Only will KISS I or KISS II become visible

Even in utero there are periods of variation in flexion and extension preference patterns

Literature

Njiokiktjien C. Gedragsneurologie van het kind 2004Zonneveld B. Het neurologisch onderzoek 2008Oosterhuis H. Klinische neurologie 1985Goddart S. Reflexen, leren en gedrag 2005Goddart S. Reflexen, leren en gedrag 2005Empelen R. van KinderfysiotherapieBilo R. e.a. Kind in ontwikkeling

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