3.

Motor-functional analysis of reflexes (primitive, pathological, and abnormal postural reflexes) It is truly difficult to understand the motor-functional meaning of the reflexes, including postural reflexes. Fortunately, we have an opportunity to understand this through surgical correction of abnormal neck position of ATNR (Fig. 19AB). Originally at the corrective surgery of hyperextend neck, we noticed an interesting fact that the hypertonic extensors such as the longissimus capitis and cervicis are more predominantly hyperactive, on the side to which the face is turned and the neck is extended.43 It was also been observed that the neck was extended that on the side to which the face was turned. We also noticed the fact that when release of these muscles was conducted, asymmetric position of the head and neck was controlled and deformity is lessened.43 This meant that predominant hypertonicity of the extensors such as the longissimus capitis and cervicis was responsible for such an extended position of the neck on the side to which the face is turned. In these patients, spinal muscles such as the longissimus capitis, longissimus cervicis, longissimus thoracis and iliocostalis were also predominantly

contracted on the side to which the face is turned and on the concave side of scoliosis.33 Here, the multiarticular longissimus thoracis and iliocostalis were noted as hyperactive extensors. It was also interesting to note that when these multiarticular extensors of the trunk were released, concave scoliosis deformity and truncal deformity in ATNR could be corrected.41 It can be said that predominant contraction of these cervical and thoraco lumbar extensors causes a part of the asymmetric tonic neck reflex.44 It is also suggested that in patients with ATNR, extensors in cervical, thoracic and lumbar spine are all predominantly contracted on the side to which the face is turned and the trunk is in concave. Detailed observations further disclosed that in these same patients, hypertonicity of the extensors was predominant even in the upper and lower extremities of the same side to which the face turns, and the neck and trunk extend. These facts clearly demonstrated that in patients with ATNR, one side of the entire body was totally extended, while the opposite side was totally flexed. This analysis led us to the conclusion that ATNR is a motor-functional entity involved in primitive movement pattern in which one side of the entire body is totally extended and the opposite side is totally flexed

(Fig. 17, 19A).33,43,44 This observation combined with the following interpretation enabled us to reach to new concept that abnormal postural reflexes are a kind of totally patterned movement for propelling the body to the forward in less separated and immature form. Similar analysis by Sherington was quoted by Rushmorth 1964 and by Bleck 1987. These observations provided us enormous benefits in the treatment of cervical deformity, cervical radiculomyelopathy, scoliosis and ATNR with use of selective release surgery. Promising results shown by selective release prove that this observation is rational and will become a clue to understanding of postural reflex involved in motor function. In order to understand the essentials of hypertonicity, analysis of the reflexes involved in motor function should be continued. Totally involved posture Totally involved extension: In the totally involved patients, totally extended posture without flexion (Fig.16-A, 18-A) is the most primitive position, which is not affected by postural change. This occurs when most of the central nervous systems are damaged, most of the antigravity muscles are paralyzed, and the multiarticular

muscles are contracted excessively due to hyperirritability of the upper motor neurons in the brain stem and spinal cord. Since both flexors and extensors contract simultaneously, rigidity is caused in the whole body, and alternate and reciprocal movements are inhibited. The extensors are more predominant in the totally involved extension, than the flexors are. Hypertonicity of the extensors, such as the longissimus capitis, the longissimus thoracis and iliocostalis in the trunk, the triceps brachii and lattismus dorsi in the shoulder and elbow, semimembranosus in the hip and rectus femoris in the knee, are more predominant, than that of the flexors. However, clinically, there seldom is a typical form of total extension posture. Posture is usually influenced with gravity and body position, and modified postures such as tonic labyrinthine reflex (Fig. 13A), asymmetric tonic neck reflex (Fig. 17, 19A) and the symmetric tonic neck reflex (Fig. 18A) are common. Thus, all abnormal postures can be mostly categorized in the following postural reflexes. Tonic labyrinthine reflex (TLR):44 Tonic labyrinthine reflex is a primitive and pathological reflex that is seen in totally-involved patients due to abnormal simultaneous contraction of extensors

and flexors in the whole body. Motor-functional wise, posture can be changed into two different phases: flexor dominant phase and extensor dominant one: Flexed posture is exaggerated in prone position, in which contraction of the flexors is predominant, whereas extended posture is exaggerated in supine posture, in which contraction of the extensors is predominant. Hypertonicity of the extensors, such as longissimus muscles, triceps brachii and hip extensors located in the back side of the body is exaggerated by gravity, in the supine position, therefore, extension-hypertonicity become predominant in supine position. On the other hand, hypertonicity of the flexors such as rectus abdominalis, psoas and biceps brachii located in the abdominal side of the body is exaggerated by gravity, in the prone position; therefore, flexion hypertonicity become predominant in prone posture. Motorfunctionalal-wise, tonic labyrinthine reflex can be defined, as a posture with extremely limited flexion-extension movement of the whole body, in which simultaneous cocontraction of the hypertonic flexors and extensors cause rigidity and, inhibits smooth reciprocal flexion-extension movement. In a normally developed human body, tonic labyrinthine reflex posture is

overwhelmed by antigravity activity of well-differentiated monoarticular muscle, and it is usually difficult to find out where it exists. But, we can still see this reflex posture of different types, in various phases of activities of cerebral palsy. It is difficult to see pure form of tonic labyrinthine reflex, since most of the cerebral palsied patients are alive with some antigravity activities. In order to control and reduce this reflex, it is necessary to understand existence of tonic labyrinthine reflex in its modified form in movements and in postures. This is a severely involved child, with a tonic labyrinthine reflex posture (Fig. 13A). In supine position, he is totally hyperextended, and hence has a totally involved extension posture. However, when he is turned into prone position, his bilateral upper extremities show some degrees of flexion in the elbow. This change in position demonstrates that flexor activities were mildly provoked by gravity in prone position. This change in posture can be called, as a tonic labyrinthine reflex in neurology. On the contrary, this can be called as a flexion-extension movement of the whole body motorfunctional-wise. We can observe this reflex, in the modified form in almost all diplegic, triplegic and quadriplegic patients.

This tonic labyrinthine reflex posture can be a candidate for treatment by spasticity control surgery (Fig. 13B).43 Here, motor functional analysis of the reflex posture should be done prior to surgery. Hypertonic muscles are selectively released at the neck, trunk, shoulders, elbows, wrist, thumb and fingers, hips and knees, and foot and ankle appropriately, and then, this reflex posture can be controlled (Fig. 13AB, 18AB, 19AB). This is another modified form of tonic labyrinthine reflex (Fig. 20A). He shows flexed position mostly, in prone posture. However, he shows hyperextended position with scissors posture, when he is in supine posture. This level of tonic labyrinthine reflex posture could also be a candidate for spasticity-control surgery. Hyperextended and hyperflexed posture can be controlled and alternate movement of the extremities can be facilitated (Fig. 20B). [Memo] Functional entity of extension posture, in supine position: When we place a totally involved child on bed in supine position, we can see a phenomenon by which she propels herself to the cranial end of the bed by extending her body and extremities. She is likely to get hurt by hitting her

head against the bed-fence. This attitude of the baby in the bed can be considered to be an extension posture of the tonic labyrinthine reflex in supine position. The forward movement of this baby can be considered to be a reproduction of the most primitive level of forward-propelling locomotion. As reciprocal movement is limited in severely paralyzed patients with cocontraction of flexors and extensors, this condition can not be recognized as a movement. This condition has been recognized, as a posture. However, motorfunctional-wise, extended posture of the tonic labyrinthine reflex in spine could be recognized, as an ultimate immobile form of primitive and ineffective locomotion. Thus, extension phase in tonic labyrinthine reflex in supine position is fundamentally considered to be a form of primitive locomotion. We can see this kind of primitive locomotion in nature. Fishes have developed a slight antigravity mechanism with small antigravity muscles near their fins. They can keep their bodies in prone position in water with activity of these small fins. But this mechanism works only in water where the earth's gravity has no effect on their bodies. When a fish is put on the ground, the strong earth's gravity works, but the formers antigravity

mechanism is too small to counteract the latter. So in order to escape from danger, they jump, extending their trunk with quick contraction of the multiarticular paravertebral muscles, and falls to a supine position (Fig. 16). This jumping is a kind of flexion-extension movement without antigravity activity, caused by symmetrical contractions of the paravertebral extensors and abdominal flexors. There is no such antigravity activity in the fish, as seen in amphibians, reptiles and mammals in the fish. This is the most primitive locomotion in which head is forced to hit against the ground, without any protective movement (Fig. 16). This total extension and flexion movement of the entire body could be an original form of movement pattern with primitive total extension-flexion in the tonic labyrinthine reflex (Fig. 18A, 20A). We can observe similar flexion-extension locomotion style in the human baby. Babies below 3 months move themselves forward, by kicking their legs, with extension movement of the trunk and extremities in supine position. This is a primitive locomotion, using flexion-extension pattern of the tonic labyrinthine reflex. The starting jump in supine position at the backstroke in swimming is

also a primitive and most propulsive locomotion, without any antigravity support. Thus, a extension pattern of the tonic labyrinthine reflex could be observed in primitive movement in cerebral palsied patient, human baby, and even in normal human being, and therefore can be designated as a movement. Flexion posture in prone position: Flexor pattern in tonic labyrinthine reflex can also be seen in various phases of human posture and in locomotion. In normal human body, when they need highly propulsive movement, such as running or jumping, crouched flexed posture emerges. Motor-functional-wise, this can be interpreted as a sudden emerge of flexed position of the tonic labyrinthine reflex. Flexed position in crawl and kneel is also similar. Newborn baby keeps the body in ball posture in a prone position. This is a basic form of tonic labyrinthine reflex. From ontogenesis point of view, motor activities in the human body have originated from totally involved flexion posture in tonic labyrinthine reflex, where flexor activity is predominant in prone posture. The antigravity extensors are facilitated during growth, which overcome flexor hyperactivity in the tonic labyrinthine reflex resulting in antigravity postures such as kneeling, and

standing. In cerebral palsied patients, we can see various phases of the flexion posture in the tonic labyrinthine reflex. Most of the severely involved patients show some flexion attitude in prone position and cannot maintain upright posture such as sitting (Fig. 21A). In a child at the level of mermaid crawl, we also see a flexor-dominant posture. In this condition the flexion form of the tonic labyrinthine reflex is predominant. In the prone, flexors in the trunk and extremities are much exaggerated by gravity that inhibits extending activity of the antigravity extensors, such as the suboccipital muscles and the multifidus muscles (Fig. 41A). In the more mature patients, you can see more mature flexordominant posture in symmetric on-hands and on-knees crawl (Fig. 15A). In these patients, the flexor-dominant posture of the tonic labyrinthine reflex is well controlled, and a more matured four point crawl position is achieved (Fig. 15A). Even in patients who stand, this flexor pattern such as crouched posture can often be predominant. Crouched posture can be interpreted as a matured form of this flexion attitude of the tonic labyrinthine reflex in standing in which antigravity

activity of the extensors overwhelms hypertonicity of multiarticular flexors in tonic labyrinthine reflex in prone position (Fig. 2A, 3A, 4A, 5A).Thus, we can now recognize that the tonic labyrinthine reflex can be interpreted motorfunctional-wise, as a form of propulsive movement and is caused by activities of hypertonic muscles in the entire body. With excessive cocontraction of the hypertonic muscles, movements are limited and the body seems to be fixed in a particular posture. Accordingly, we can control this hypertonic entity, by using spasticity-control surgery. Control of hypertonicity of the psoas in the hip-joint by the use of selective release can be considered, as a form of spasticity-control procedure for control of the flexor pattern in tonic labyrinthine reflex. If the tonic neck reflex is controlled surgically, more matured standing posture is attained (Fig. 15B). Thus, we have to analyze the motor function of the postural reflex, and then we will be able to use these analyses for the spasticity-control surgery to tonic labyrinthe reflex. Asymmetric tonic neck reflex (ATNR): Motor function analysis also disclosed another interesting finding that asymmetric tonic neck reflex can be interpreted as a physical condition in

which the whole body is longitudinally separated into two parts: left side and right side. This is also a condition where one side of the entire body is totally extended and the other side is totally flexed (Fig. 17, 19A). Clinical analyses of the hypertonicity of the neck and trunk have enabled this interesting and exciting interpretation possible. At clinical analysis of the spastic scoliosis, we noted the fact that the concave deformity is the result of hypertonic activity of the paravertebral muscles on the concave side. We could understand that concave side is the extensorpredominant side. We also noted the fact that in asymmetric tonic neck reflex posture, the face is forced to turn to the side where hypertonicity of the neck extensors such as the longissimus capitis and cervicis muscles is predominant. Here, we also noticed the fact that the side to which the face is turned is the extensor predominant side. This fact clearly explains the question, why the extremities extend on the side to which the face turns in ATNR. In asymmetric tonic neck reflex, at the side where the face of the patients turn, hypertonicity of the extensors of the neck, trunk, upper extremity and lower extremity is concomitantly predominant. So the hypertonic extensors of the trunk, upper

extremity and lower extremity in the same side work together simultaneously and cause the ATNR posture. This fact means that the head, trunk, upper extremity and lower extremity on one side cannot move separately because of their immaturity in movement. This is a situation where the neck, trunk, upper extremity and lower extremity are simultaneously extended, as an extensor block, whereas the neck, trunk, upper extremity and lower extremity on the opposite side are simultaneously flexed, as a flexor block (Fig. 17, 19A). Thus, from clinical observations, interesting conclusion could be deduced that the asymmetric tonic neck reflex is a manifestation of the primitive locomotion, where the body is divided into two parts, which work alternatively to drive the body forwards. The treatment of the asymmetric tonic neck reflex is therefore, to bring the ineffective body movement caused by the two blocks of the body, into an effective crossed alternate movement in the four parts of the body. The approach will be to reduce the hypertonicity of the trunk by release of the hypertonic muscle, making movement of the upper trunk free from the ones of the lower trunk on the same side, and to facilitate the independent and separate

movement of each extremity (Fig.19B, 20B). Phylogenetically, there is no vertebrate with such a primitive level of locomotion. Therefore, this asymmetric pattern can not be considered, as a locomotion pattern of some specific animal. However, as shown in the case of tonic labyrinthine reflex, we could see a similar locomotion pattern in jumping of fish on the ground. The fish once on the ground often makes jumping movement with a characteristic pattern, in which one side of the body is totally extended and opposite side is totally flexed (Fig. 17). This pattern observed in fishes on the ground is a decisively primitive and immature locomotion pattern. Here, the one side of the body is totally flexed and the other side is extended. This longitudinally separated movement is functionally almost the same as movement of asymmetric tonic neck reflex, observed in cerebral palsy (Fig. 17, 19A). On the basis of these clinical, phylogenetical, and ontogenetical analysis, asymmetric tonic neck reflex can be designated, as a form of primitive propulsive movement. The original form of asymmetric tonic neck reflex can be a movement with propelling activity. However, when it is seen in severely

involved cerebral palsy patients, it is usually associated with hypertonicity such as rigidity, resulting in fixed body positions with limited movements. Patients with asymmetric tonic neck reflex can be candidates for the surgical treatment. All extension hypertonicity, such as extension deformity of the neck and trunk, shoulder retraction, extension of the elbow and extension in the hip, knee and ankle which cause create asymmetric tonic neck reflex as a whole, are relieved by release of the hypertonic extensors, whereas all flexor hypertonicity on the opposite side, such as flexion of the neck and trunk flexion of the elbow and flexion hypertonicity in the hip, knee and ankle, are similarly relieved by selective release of the hypertonic flexors. By these releases, the asymmetric tonic neck reflex can be controlled decisively, and voluntary movements in the entire body can be facilitated (Fig. 19B, 20B). Symmetric tonic neck reflex: Symmetric tonic neck reflex is another posture in which the symmetrically positioned upper body moves separately and alternately against the symmetrically positioned lower body. This is a phenomenon where the upper extremities extend simultaneously with passive extension of the neck, but the

lower extremities flex (Fig. 14A, Bottom), whereas with flexion of the neck, the upper extremities flex simultaneously but the lower extremities extend (Fig. 14B, Top). This is another primitive motor activity with less separated movement. In this mode of locomotion the body propels itself with symmetrical extension of the upper trunk and upper extremities, while the lower trunk and extremities symmetrically flex (Fig. 21A, Top). Then, the lower trunk and extremities symmetrically extend, while the upper extremities symmetrically flex, driving the body forwards (Fig. 21A Bottom). In this locomotion the driving phases in upper or lower extremities can be seen alternately in all the phases of locomotion. Phylogenetically, the original form of symmetric tonic neck reflex is mostly seen in more propulsive movements such as swimming of the frog, leap of the frog, and symmetrical quadripedal locomotion of the Kangaroo. In humans' body, we can see this form in breaststroke swimming and a vaulting horse activity. These are symmetrical locomotion patterns in which a phase of upper body flexion and lower body extension and a phase of upper body extension and lower body extension emerge alternatively, and propel the body

forwards. In cerebral palsied patients, we can see the symmetric tonic neck reflex pattern in various levels, such as no rolling level (Fig, 18A), mermaid crawl level (Fig. 14A), four-point crawl level (Fig. 15A), standing level and in the form of symmetric deformities such as symmetric diplegia (Fig. 5A). STNR can be observed in the most primitive level. In that level, the elbows are symmetrically flexed, whereas the lower extremities are totally extended. Although the posture is not typical, a symmetrical pattern is somewhat predominant (Fig. 18A). You can see a STNR in a symmetric mermaid crawl on abdomen in which a pattern of upper-body-flexion and lower-body-extension and a pattern of upperbody-extension and lower-body-flexion emerge alternatively to drive the body forwards (Fig. 14A). In another form of STNR, the upper trunk and upper extremities are extended with neck extension (Fig. 21A, Top) while the lower extremity is flexed. When neck and upper extremities are flexed, the lower extremities are extended (Fig. 21A Bottom). This movement can be named as symmetric tonic neck reflex posture. With spasticity control surgery, hypertonicity is controlled and

mid position exercises can be given to achieve a four-point crawl position (Fig. 21B). You can also see STNR in a form of symmetric four-point crawl; this is a matured locomotion (Fig. 15A). Symmetrical spastic diplegia is also an expression of STNR in a more matured level (Fig. 5A). STNR in all the levels are candidates for spasticity-control surgery in order to achieve alternate crossed crawl pattern, to accomplish alternate bipedal locomotion and to gain individual movement in each extremity (Fig. 5B, 14B, 15B). Segmental localized hypertonicity (Diplegia) When the brain is not so severely damaged, antigravity and voluntary activities of the body will be gradually activated from the cranial end of the body to the caudal end, in course of the ontogenetic development of a baby. In such a case, hypertonicity is mostly localized segmentally in lower part of the trunk while the upper part of the body has decreased hypertonicity. This localized hypertonicity is considered, as a reflex-complex, formed by a combination of many local reflexes. We can see this segmentally localized hypertonicity, in windswept deformity, scissors posture, and crouched posture (Fig. 5A, 22A,

83A). Neurologically, this condition is called as segmental static reaction. Windswept deformity: This deformity is an asymmetrical posture observed in lower extremity in diplegia, triplegia, and quadriplegia in which the lower extremities are more severely involved. In this deformity, flexion, abduction and external rotation of the hip is predominant on the one side, whereas extension, adduction and internal rotation of the hip are predominant on the opposite side (Fig. 22A, 22B). Motor-functional-wise, the side of the flexion, abduction and external rotation deformity means the flexion phase of the hip at locomotion, whereas the side of the extension, adduction and internal rotation deformity means the extension phase of the hip. Developmentally, this deformity can be considered, as a subgroup of the asymmetric tonic neck reflex. In patients in whom antigravity and voluntary movement of the upper extremities and upper trunk have matured, and hypertonicity of the upper trunk and upper extremities are decreased, typical asymmetric posture of the upper trunk and upper extremities is overwhelmed, and fixed asymmetrical neck reflex posture such as windswept deformity

remains only in the lower extremities. This is called as a windswept deformity (Fig. 22A). Thus, windswept deformity is a kind of asymmetric tonic neck reflex deformity segmentally localized in the lower trunk and lower extremities. Treatment of the windswept deformity can be carried out by correcting the asymmetric deformities of the hips, knees and feet, (Fig. 22B) using spasticitycontrol surgery. Scissors posture Scissors posture is a symmetrical posture observed in the lower extremities in diplegia, triplegia, and quadriplegia. Extension and adduction attitudes of the hip are predominant in both hips (Fig.13A, 14A, 23A). Dislocation of the hip is also a frequent accompaniment. This deformity is called, as scissors posture. Developmentally, this deformity can be considered, as a subgroup of the symmetric tonic neck reflex posture. In the patients in whom antigravity and voluntary movement of the upper trunk and upper extremities have matured, typical symmetric posture of the upper trunk and upper extremities disappears, and fixed symmetric posture in extension remains only in the lower trunk and lower extremities, as a scissors posture. This scissors posture can be considered

as remains of the primitive symmetric locomotion. In scissors posture, bilateral dislocation of the hips can be easily caused by hypertonicity in extension and adduction of the hip, which could disturb basic motor functions such as turnover, crawl and sit. To prevent dislocation and to facilitate reciprocal flexion and extension movement of the hips and to attain basic motor function, control of hypertonicity of the hip is essential (Fig. 14B, 23B). Crouched posture: Crouched posture is a flexed posture in both the lower extremities, observed in standing and walking, and is also considered as a segmental localized hypertonicity (Fig. 3A, 97A). This is also a situation, in which antigravity activity of the monoarticular extensors are not fully matured. Fundamentally, all locomotions in upright posture can be considered to start from flexordominant posture of the tonic labyrinthine reflex, which is an original form of locomotion. Righting of the neck can be possible when antigravity activity of the neck extensors have overcome the original flexordominant posture of the tonic labyrinth reflex at the neck. With extension activity of the antigravity extensors, children gradually begin to raise the head and upper trunk, from

flexor dominant position of the tonic labyrinthine reflex and then begin to crawl. According to the development of antigravity extensors, children advance to quadrupedal movement, crouched standing and mature upright standing, overcoming flexor-dominant posture of the tonic labyrinthine reflex. In matured human body, antigravity monoarticular extensors such as the gluteus maximus, vastus medialis and lateralis and soleus have fully developed. Well-developed extension position in human body is a posture in which antigravity extensors ultimately overcome the original flexordominant posture of the tonic labyrinthine reflex. In normal human body, flexor-dominant posture of the tonic labyrinthine reflex becomes latent in prone posture, since this reflex is fully depressed with vivid activity of the antigravity extensors. Crouched posture can be understood as a condition in which well developed antigravity extensors are somewhat damaged by cerebral damage, and where a flexor-dominant posture of the tonic labyrinthine reflex is revealed somewhat in prone position. So, it is concluded that crouched posture is caused by excessive hypertonicity of the multiarticular flexors as against weak antigravity extensors.

Since this crouched posture is a mild form of the tonic labyrinthine reflex, extensor-dominant posture can also be easily elicited, when this patients is turned to the supine position. This extended position can be caused by predominant hypertonicity of the multiarticular extensors as against the flexors at the hips, knees and feet in the same patient. Selective release of the both hypertonic flexors and extensor in the hips and knees and plantar flexors of the feet is essential for correction (Fig. 3B, 97B). Reflex-complex localized in a limb (Local static reaction) This reflex-complex posture is called, as a local static reaction in neurological terms. Motor-functional-wise, there are characteristic postures localized either in the entire upper limb or in the entire lower limb, such as a withdrawal posture of the upper limb, and an extended posture called a positive supporting reaction or an extensor thrust in the lower limb. The withdrawal posture of the upper extremity seen often in hemiplegic and quadriplegic patients is a combination of shoulder retraction, flexion of the elbow, pronation of the forearm, flexion of the wrist, and flexion deformities of the thumb and fingers (Fig. 72A, 81A). The extended posture of the lower extremity seen in hemiplegic and diplegic

patients (Fig. 23A, 24A) is a combination of flexion of the hip, extension or flexion of the knee, and equinus deformities of the ankle and foot. This reflex-complex posture localized in an entire limb in cerebral palsy is fundamentally a combination of exaggerated reflexes in each joint caused by hypertonicity of the multiarticular muscles. This posture can be controlled by spasticity-control surgery at all the involved joints (Fig. 23B. 72A, 81A). Local reflexes Significance of the stretch reflex in human movement Neurologically, reflex is a contraction response of muscles to prevent overstretching. Stretch reflexes such as the patellar tendon reflex, the Achilles tendon reflex, the biceps reflex and the triceps brachii reflex are considered, as a quick contraction of the muscles, to prevent overstretching of the muscles. Motor functional-wise, this stretch reflex can also be interpreted, as a quick movement of the joint caused by contraction of the muscle, while preventing overextension or overflexion of the joint. So the patellar tendon reflex can be interpreted, as a quick extension movement of the knee joint by contraction of the quadriceps muscle, while preventing overflexion (collapse)

of the knee joint. Achilles tendon reflex is also considered as a quick plantar flexion movement of the ankle, while preventing overdorsiflexion (collapse) of the ankle. What then can be the functional meaning of a stretch reflex? Dexterity of the joint and reciprocal movement "Reciprocal innervation" is a neurological term. This is called as reciprocal movements in motor-functional term. This is a phenomenon in which the extensors relax when the flexors contract, and the flexors relax when the extensors contact. Human joints can move smoothly because of this reciprocal muscle activity. In the knee joint, when both the hamstrings work as flexors and the antagonistic quadriceps respond by relaxing, a smooth flexion movement becomes feasible. On the other hand, when the quadriceps work as an extensor, and the antagonistic hamstrings relax simultaneously, a smooth extension takes place. With these reciprocal movements, a quick conversion of movement from flexion to extension, or from extension to flexion can be feasible and an effective locomotion is achieved. Stretch reflexes for protection of the joints from overstretching When the flexors alone work on one-side, the joint overflexes beyond the

normal range of motion, resulting in the capsule being overstretched and torn with a possible joint dislocation. In the vertebrates, a preventive mechanism has developed in which the extensors quickly respond by contracting and prevent overflexion of the joint when the flexors flex the joint and the extensors are stretched too much. On the other hand, if the extensors alone work too much on one-side, the joint overextends beyond the normal range of motion, resulting in the capsule being overstretched and torn, causing a possible dislocation. Then, similarly, a preventive mechanism has developed in which the flexors respond quickly by contracting to prevent hyperextension of the joint. This quick contraction of the antagonistic muscles which prevent hyperextension, or hyperflexion of the joint, are called, as a stretch reflex, in the field of neurology. Motor-functional-wise, the stretch reflex is interpreted, as a protective mechanism, which prevent overactivity of the antagonistic muscles and limit hypermobility of the joint, thereby protecting the joint. Thus, the joints of human body have acquired smooth motion with reciprocal movement, and have also developed elaborate mechanism in which stretch reflex works to prevent excessive flexion or extension as well.

Exaggerated stretch reflex When central nervous system is damaged, the nature of the stretch reflex changes significantly. Exaggeration in the stretch reflex becomes obvious with inhibition of reciprocal movement. Our clinical observation explains that increase in patellar tendon reflex is caused by hypertonicity of the multiarticular rectus femoris (Fig. 23A, 25A). Exaggerated Achilles tendon reflex is caused with hypertonicity of the multiarticular gastrocnemius (Fig. 23A, 24A). Similarly, increase in the biceps brachii reflex and triceps brachii reflex is caused by hypertonicity of the biceps brachii and triceps brachii (Fig. 67A, 71A). Flexion deformity of the fingers and toes are other forms of the exaggerated grasp reflex. Thus, the exaggerated stretch reflexes are clinically considered to be caused mostly by hypertonicity of the multiarticular muscles of the affected limbs. On the basis of these observations, it can be concluded that deformity of the each joint is caused by an exaggerated stretch reflex. Stifflegged knee or recurvatum deformity of the knee is considered to be caused by an exaggerated patellar tendon reflex.

Thus, stretch reflex is not a different entity from muscle contraction. Motor function-wise, stretch reflexes are a quick movement of joint caused by quick contraction of the muscle