TOOLS TO INFORM

Rhythmic Movement Training

International (RMTi) Curriculum
Evidence-Based Rationale and
Relevance to Occupational Therapy Practice
by Sonia Story

Occupational therapists (OTs and OTAs) help individuals particpate in activities, or

occupations, that are important to the specific individual’s daily life, goals and interests.
Using a holistic approach and a variety of therapeutic tools, occupational therapists help
individuals develop skills for success in meaningful activities (AOTA, 2017).

In the Rhythmic Movement Training (RMTi) courses, we teach neurodevelopmental

movements. Neurodevelopmental movements are the innate developmental, rhythmic,
primitive reflex, and postural reflex movements of early infancy and childhood.
Occupational therapists utilize these neurodevelopmental movements to improve
balance, posture, motor skills, muscle strength, stamina, coordination, sensory processing
skills and overall functioning for individuals of all ages.

Primitive and and fine motor skills, social-emotional skills,

and future learning. Because of their importance
Postural Reflexes to development, assessing the primitive infant
reflexes is part of newborn neurological exams
The Rhythmic Movement Training courses give (Fletcher, M. A., 1998).
theoretical and experiential learning of primi-
tive and postural reflex patterns useful to oc- Though primitive reflex movement patterns are
cupational therapists for both assessment and present in normally developing infants, ideally
intervention. most are integrated (i.e., no longer active, inhib-
ited) by the end of the first year. As the brain
Innate infant reflexes have long been used as and body mature, volitional movements and
signs for determining the health or dysfunction
of the central nervous system (CNS) (Fioren-
SONIA STORY developed
tino, M., 1973). The infant reflex movements are the Rhythmic Movement
crucial for development; they fuel brain growth Training curricula and
and build the neuro-sensory-motor skills needed is a certified instructor
to progress to an upright, walking toddler. These of Rhythmic Movement
Training™ (RMTi).
same neuro-sensory-motor skills are the founda-
tion for balance, posture, strength, speech, gross

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postural reflexes replace primitive reflexive move- Additionally, retained primitive reflexes are com-
ments. Children and adults with unintegrated, monly found in frontal lobe disease, Parkinson’s
retained primitive reflexes and underdeveloped disease, dementias, and advanced HIV infection
postural reflexes often experience mild to severe (McGee, S. R., 2001).
obstacles in functioning and learning. Observa-
tion of sensory and motor reflex patterns beyond Recent research shows that the reappearance of
infancy informs assessment of how the CNS is primitive oral-facial reflexes in nursing home
functioning. Use of innate reflex patterns also patients was associated with challenges in eating
serves as part of an overall plan for intervention. function, risk of malnutrition, and risk of develop-
ing aspiration pneumonia (Hobo, K., Kawase J.,
Tamura, F., Groher, M., Kikutani, T., Sunakawa,
Consequences of Retained
H., 2014).
Primitive Reflexes
Retained primitive reflexes and underdeveloped
Primitive reflexes are stereotypical movement pat-
postural reflexes correlate with abnormal muscle
terns that should be integrated in infancy as the
tone, poor postural control, and poor coordination
cortex develops and overrides reflex expression at
(Fiorentino, M., 1972; Goddard, S., 2005). Exten-
the brainstem level. However, for many children
sive studies explore this relationship in individuals
these reflex patterns are not fully integrated or
with cerebral palsy and with other known neuro-
inhibited. Even if an individual does attain fully
logical conditions such as stroke. Retained reflexes
integrated primitive reflexes, the movement pat-
that are less severe than those occurring in cases of
terns are still underlying at the brainstem level
brain injury can still drive changes in muscle tone
and may reemerge in cases such as brain injury,
and postural control. These reflex-driven tonal
stroke, dementia or trauma. The persistence of
and postural changes, though less severe, may still
primitive reflexes beyond infancy is associated
significantly affect function (Kohen-Raz, R., 1986;
with developmental delay as well as neurological
Goddard, S., 2005).
and physical challenges. Retained reflexes also are
a reliable predictor of emotional, functional and
cognitive challenges across the age span.
Specific Reflexes and
For example, retained primitive reflexes are com- Supporting Research
mon in children with challenges such as Develop-
mental Coordination Disorder (DCD) (Goddard
for Reflex Integration
Blythe, S., 2009), Attention-Deficit Hyperactivity Looking at specific retained reflex patterns and
Disorder (ADHD) (Konicarova, J., Bob, P., Rab- their impact on functional tasks helps us under-
och, J., 2013), and dyslexia (McPhillips, M., Jor- stand why it is important to address retained reflex
dan-Black, J. A., 2007), and in adults with schizo- patterns.
phrenia (Hyde, T. M., Goldberg, T. E., Egan, M.
F., Lener, M. C., Weinberger, D. R., 2007).

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Tonic Labyrinthine Reflex (TLR) rotation elicited ATNR, the authors concluded
that ATNR expression likely utilizes “a common
When retained, TLR can cause weak muscle tone, neuroanatomical link” with “flexion synergy—the
exaggerated muscle tone, tone that fluctuates with abnormal torque coupling of elbow flexion with
head movement, center of balance that changes shoulder abduction—resulting in loss of independ-
with head position, visual dysfunction, impaired ent joint control in stroke patients” (Ellis, M. D.,
balance, and poor posture (Blomberg, H., Demp- Drogos, J., Carmona, C., Keller, T., Dewald, J. P.
sey, M., 2011). A., 2012, emphasis added).

Asymmetrical Tonic Neck Reflex (ATNR) Symmetrical Tonic Neck Reflex (STNR)
A retained ATNR may cause various difficulties STNR, when retained, may cause impairment of
for the growing infant and child: lack of normal visual skills and learning challenges (Goddard, S.,
hand-to-mouth and hand-to-hand play, which 2005). Utilizing movements to integrate STNR
can result in imbalances in oral sensitivity and is highly useful in overcoming the symptoms of
poor bilateral, symmetrical upper extremity use; ADHD (O’Dell, N., Cook, P. A., 2004). In her
poor control of eye muscles resulting in poor visual book Reflexes, Learning and Behavior, Sally God-
perception (Bly, L., 1983); and poor ability to cross dard highlights studies focusing on STNR inte-
midline and poor laterality (Goddard, S., 2005). gration that show improvement in learning as well
as reduction of hyperactivity (Goddard, S., 2005).
In addition, a retained ATNR can set the stage
for scoliosis (Bly, L., 1983) and may cause further It is worthwhile to note that ADHD symptoms—
difficulty with specialized movement tasks such as linked to both a retained ATNR and a retained
handwriting and use of tools (Goddard, S., 2005). STNR—also are significantly associated with bal-
A retained ATNR is also associated with ADHD ance deficits. Balance deficits were measured even
symptoms (Taylor. M., Houghton, S., Chapman, in individuals with ADHD who have no history
E., 2004; Konicarova, J; Bob, P., 2013), and read- of medication and no neurological disease present
ing challenges (McPhillips, M., Hepper, P. G., (Konicarova, J., Bob, P., Raboch, J., 2014). In clini-
Mulhern, G., 2000; Jordan-Black, J. A., 2005). cal situations, we see that when we mature infant
Intervention programs based on replicating innate reflexes, balance skills improve measurably. Recent
infant movements, including ATNR reflex pat- research also shows that improving balance amel-
terns, showed significantly greater improvement iorates anxiety and increases self-esteem (Bart, O.,
in reading and writing speed for the experimental Bar-Haim, Y., Weizman, E., Levin. M., Sadeh, A.,
group (McPhillips, M., Hepper, P. G., Mulhern, Mintz, M., 2009).
G., 2000), and in a related study, correlated with
higher reading and mathematics scores ( Jordan- Moro Reflex
Black, J. A., 2005).
When the Moro Reflex fails to mature, we ob-
A 2012 study found evidence of ATNR reemer- serve numerous sensory processing challenges and
gence following stroke. When voluntary neck underlying stress, as the nervous system remains

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in a state of fight-or-flight (Goddard, S., 2005). In The action of integrating primitive reflexes de-
addition, a retained Moro Reflex is associated with velops the foundation for function. The basic
ADHD symptoms and learning challenges (Tay- premise supporting the use of neurodevelopmen-
lor. M., Houghton, S., Chapman, E., 2004). tal movements for occupational therapists is that
the brain recognizes and responds to these innate
Combined Reflexes movements whose original function is to support
brain, body and sensory development. These innate
In a study implementing movement corrections for neurodevelopmental movements stimulate and
several retained infant reflexes, children showed develop important neuro-sensory-motor and brain
significant improvement in reading fluency and pathways as a regular course of human develop-
reduction of headaches (Wahlberg, T., Ireland, D., ment, and we can use these movements at any age
2005). to create effects similar to those we see in infancy
(Blomberg, H., Dempsey, M., 2011).
In another study, oculo-motor functioning and
reading skills improved as retained reflexes were Svetlana Masgutova, developer of the Masgutova
corrected (Bein-Wierzbinski, W., 2001, as quoted Neuro-Sensory-Motor Reflex Integration program
in Goddard, S., 2005). (MNRI), also has experienced beneficial outcomes
for children with challenges by using the innate
primitive and postural reflex movement patterns
Rationale for Addressing Retained (Masgutova, S., Akhmatova, N., Sadowska, L.,
Reflexes and the Problems that Arise Shackleford, P., Akhmatov, E., 2016).
Subsequent to the Retained Reflexes Using a combination of techniques including
innate rhythmic movements and primitive and
According to Shereen D. Farber, MS, OTR,
postural reflex integration, Melody Edwards, a
FAOTA, author of Neurorehabilitation: A Multisen-
pediatric physical therapist, developed a successful
sory Approach, a delay in primitive integration may
treatment protocol for resolving infant torticollis
result in:
(Edwards, M., 2017).
decreased segmentation of the trunk, de-
It is reasonable that these innate neurodevelop-
creased isolation of movement, decreased
mental movements can help mature the brain and
rotation component in any action, postural
sensory systems beyond infancy. Increased brain
insecurity, decreased ability to develop anti-
maturity via neurodevelopmental movements is
gravity muscles, increased synergy patterns
the explanation given for the successes of Harald
(mass movement patterns) and increased
Blomberg, MD, psychiatrist, and one of the devel-
dependence on environmental stimulation
opers of the Rhythmic Movement Training pro-
for changes in posture. One of the main goals
gram from RMTi.
of multisensory theory of neurorehabilita-
tion is to integrate primitive reflexes while
facilitating higher-level responses. (Farber, S.,
1982; emphasis added)

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Use of Innate Rhythmic and There is promising preliminary evidence showing

that rhythmic and primitive reflex motor interven-
Developmental Movements to tion can reduce muscle tension, diminish sensory
Support Reflex Integration and Function processing challenges, and improve balance, co-
Blomberg was a student of Kerstin Linde, who ordination, and physical function (Blomberg, H.,
pioneered the use of the innate rhythmic move- Dempsey, M., 2011; Gazca, M., 2012).
ments to help individuals with developmental and
Rhythmic sensory input has been beneficial for
functional challenges. Blomberg found the rhyth-
helping with gait in patients with Parkinson’s dis-
mic movements especially helpful for adult psychi-
ease (Kadivar, Z., Corcos, D., Foto, J., Hondzinski,
atric patients with severe mental illness. Psychiatric
J., 2011) and following stroke (Hayden, R., Clair,
patients using the rhythmic movements showed
A., Johnson, G., Otto, D., 2009). Rhythmic sen-
more interest in social activities, were less irritable,
sory input has been effective for helping children
and had a greater sense of well-being (Blomberg,
exposed to trauma, most likely by means of regula-
H., 2007).
tion of the brainstem (Perry, B., 2006). Neurode-
Blomberg’s results with these adult patients are velopmental rhythmic movements such as crawling
consistent with findings that show childhood have played a part in successful rehabilitation after
neuromotor dysfunction is a risk factor for adult stroke (Doidge, N., 2007).
schizophrenia (Murray, G. K., Jones, P. B., Moil-
anen, K., Veijola, J. Miettunen, J., Cannon, T.D.,
Isohanni, M., 2006). Blomberg later used a combi-
Common Disorders Linked to
nation of rhythmic movements and reflex integra- Sensory-Motor Abnormalities
tion to help children (Blomberg, H., Dempsey, M.,
2011). Understanding that the innate neurodevelopmen-
tal movements of infancy are fueling brain growth
In his work applying innate rhythmic movements and connectivity helps us grasp why they may be
and reflex integration with children with ADHD, highly beneficial for a wide variety of conditions
developmental delay, and learning challenges, involving sensory-motor challenges, including
Blomberg witnessed immense improvements in Developmental Coordination Disorder (DCD),
function and often a reversal of ADHD symptoms ADHD, sensory processing deficits, stroke, autism
and learning challenges (Blomberg, H., Dempsey, spectrum disorder (ASD), anxiety, traumatic brain
M., 2011). injury, Parkinson’s disease, Down syndrome, and
more.
The fact that research studies conclude that symp-
toms of ADHD arise from a delay of normal brain We often see retained primitive reflexes and bal-
maturation (Sripada, C.S., Kessler, D., Angstadt, ance issues in individuals with DCD, ADHD,
M., 2014; Rubia, K., 2007) gives further support to stroke, anxiety, ASD and many other conditions.
the use of innate neurodevelopmental movements Therefore, therapists using neurodevelopmental
as a key factor in promoting brain maturation and movement tools may contribute greatly to help-
creating successful outcomes for this condition. ing individuals with these and similar disorders.

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Recent studies show that motor coordination interaction, stress resilience, physical health and
challenges are present in a high majority of indi- speech (Masgutova, S., Akhmatova, N., Sadowska,
viduals with ASD and “findings indicate that motor L., Shackleford, P., Akhmatov, E., 2016).
impairment constitutes a core characteristic of ASD”
(Hilton, C. L., Zhang, Y., Whilte, M. R., Klohr, C.
L., Constantino, J., 2012, emphasis added). Using Plausible Mechanisms for Brain
innate neurodevelopmental movements may be Maturation and Connectivity
of huge significance to individuals suffering from
ASD, especially considering that autism spectrum It is helpful to understand plausible mechanisms
disorder is highly associated with mild to severe underlying the increased brain and neuro-sensory-
movement abnormalities. motor maturity fueled by neurodevelopmental
movements. In his book Spark, John Ratey, MD,
Using a computerized posturographic procedure, cites several studies showing that movement
children with autism were found to have postural activity stimulates BDNF—Brain Derived Neu-
control patterns that differed from normal chil- rotrophic Factor (Ratey, J. J., 2008). BDNF also
dren (Kohen-Raz, R., Volkmar, F. R., Cohen, D. stimulates myelin formation repair after stroke
J., 1992). Delays in motor functioning related to (Ramos-Cejudo, J., Gutiérrez-Fernández, M.,
reflexes and development also are seen as reliable Otero-Ortega, L., Rodríguez-Frutos, B., Fuentes,
early indicators for risk of autism (Flanagan, J. E., B., Vallejo-Cremades, M. T., Navarro Hernanz, T.,
Landa, R., Bhat, A., Bauman, M., 2012; Teitel- Cerdán, S., Díez-Tejedor, E., 2014).
baum, P., Teitelbaum, O. B., Fryman, J., Maurer,
R., 2002). In a recent Physical Therapy journal, sub- Myelin, the fatty sheath surrounding neuronal
titled “Current Perspectives on Motor Function- axons, is essential for normal brain function. The
ing in Infants, Children and Adults with Autism development of the myelin sheath enables rapid,
Spectrum Disorders,” the authors state: “This effective communication across the brain and is
article aims to highlight and support our perspec- thought to be involved in higher order cognitive
tive that motor abnormalities seen in individuals functioning. We now know, through quantitative
with ASDs, if more widely recognized, may affect measures, that myelination increases greatly in the
ASD interventions and eventual outcomes.” (Bhat, first three years of life during normal development
A., Landa, R., Galloway, J. C., 2011) (Carmody, D. P., Dunn, S. M., Boddie-Willis, A.
S., DeMarco, J. K., Lewis, M., 2004).
Consistent with previous studies, we see that
application of primitive reflex patterns for Learning a new motor skill also increases myelin.
individuals with ASD results in building a Furthermore, the rate of learning correlates sig-
foundation that leads to better function. For nificantly with increased myelin density (Sam-
example, application of the Masgutova Neuro- paio-Baptista, C., Khrapitchev, A.A., Foxley, S.,
Sensory-Motor Reflex Integration method (MNRI) Schlagheck, T., Scholz, J., Jbabdi, S., DeLuca,
for individuals with ASD resulted in significant G.C., Miller, K.L., Taylor, A., Thomas, N., Kleim,
improvement in the children’s cognitive abilities, as J., Sibson, N.R., Bannerman, D., Johansen-Berg,
well as in emotional regulation, self-awareness, social H., 2013). We can reason that the enormous

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changes in myelination during infancy are stimu-

lated at least in part by the innate movements con-
Visual Processing Example
current in normal development as an infant learns Shows the Importance of
to be more skillful with motor tasks. Neurodevelopmental Movements
The simple reason that innate neurodevelopmental When we examine the development of human
movements are effective is because human de- visual skills, it helps us see the importance of
velopment itself is effective. It seems the brain is neurodevelopmental movement as a foundation
inherently wired to recognize and respond to the for function. For most human beings, daily occu-
innate movements of infancy. pations require extensive visual processing. While
all of our sensory systems are highly complex,
What is most significant is that the principles
according to Gesell, “Human vision outranks all
seen in infancy—whereby reflex patterns
other senses in the abundance of its sensory, mo-
stimulate the development of increasingly
tor, autonomic and higher cortical ramifications”
complex sensory-motor skills—can be utilized
(Gesell, 1952). The relatively large amount of
beyond infancy to promote the foundations of
“cortical ramifications”—or brain-body connec-
function at any age.
tions—required for visual processing is indicative
Another possible mechanism explaining the brain of the large degree to which we rely on our vision
maturation and beneficial effects of neurodevel- for successful growth, learning and performance of
opmental movements is their tendency to pro- daily activities. Many functional tasks with which
mote relaxation and calm. From a basis of calm, occupational therapists aim to help their clients
our brain and body systems are better able to rest, rely in part on visual skills.
digest, grow and learn. The innate rhythmic move-
Like nearly all of our sensory systems, develop-
ments especially have been observed for millennia
ment of vision is contingent on a variety of sen-
to promote calm in infants. Sucking is one of the
sory-motor inputs over time. For example, as
first calming rhythmic movements and human be-
Gesell describes, the important [asymmetrical]
ings instinctively rock their infants rhythmically to
tonic-neck-reflex pattern [ATNR] develops in the
soothe them. In the multisensory approach to neu-
womb and then “undergoes further developments
rorehabilitation, rhythmic movement is suggested
in the elaboration of the eye-hand-brain complex
to help a client relax and as an appropriate sensory
for months and even years to come” (Gesell, 1952).
input in cases of hypertonicity (Farber, S., 1982).
Along with ATNR, many primitive reflexes de-
velop and support visual skills throughout infancy
and early childhood. Carol E. Marusich, a devel-
opmental optometrist, explains that poor integra-
tion of early infant reflex movements can be the
basis of problems such as “poor ocular movement,
binocularity, accommodation, and visual perform-
ance” (Marusich, C.E., 2002).

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The neurodevelopmental movements are also im- Part One: Innate

portant for remediation of visual skills. School-age
children with visual challenges show significant
Sensory-Motor Reflex Patterns
improvements in visual activities, such as reading, For each reflex listed, we teach:
when they are given specific sensory-motor activi-
ties based on the ATNR pattern and other early » Original stimulus for the reflex pattern
infant movements (McPhillips, M., Mulhern, G., » Original motor pattern of the reflex
and Hepper, P. G., 2000; Jordan-Black, J. A. 2005;
Wahlberg, T., Ireland, D., 2005).
» Original functions of the reflex in infancy
» How to assess for retained or abnormal reflex
Since most individuals rely greatly on the visual activity
system to be successful in functional tasks, it makes
» How to recognize various compensatory
sense to utilize evidence-based sensory-motor behaviors and consequences that may relate to
tools, such as the ATNR and other reflex patterns a specific retained reflex pattern
that support the foundation for optimal function-
ing of the visual system. The same premise—using » Various motor and tactile interventions to
mature and integrate the reflex pattern
innate sensory-motor tools to support the develop-
mental foundation for function—applies to tactile, Rhythmic Movement Training, Level 1
vestibular, proprioceptive and auditory sensory
systems. Tonic Labyrinthine Reflex
Landau Reflex
Amphibian Reflex
The Rhythmic Movement Training Symmetrical Tonic Neck Reflex
Spinal Galant Reflex
(RMTi) Curriculum Overview Babinski Reflex
In the Rhythmic Movement Training curriculum Rhythmic Movement Training, Level 2
we combine an in-depth set of neurodevelop-
Fear Paralysis Reflex
mental movement tools to integrate primitive and
Moro Reflex
postural reflexes.
Tendon Guard Response
The curriculum is organized into two main parts— Rhythmic Movement Training, Level 3
primitive and postural reflexes, and rhythmic and
Moro Reflex
developmental movements.
Asymmetrical Tonic Neck Reflex
Headrighting Reflexes
Hand-Mouth Babkin Reflex
Palmar Grasp Reflex
Hands Pulling (Pull-to-Sit) Reflex

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Part Two: Innate Rhythmic and Conclusion

Developmental Movement Patterns
The evidence suggests that through the use of in-
In the Rhythmic Movement Training curricu- nate neurodevelopmental movements—the primi-
lum, along with reflex assessment and integration tive and postural reflexes plus the developmental
protocols, we teach specific developmental and and rhythmic movements of infancy—occupa-
rhythmic movements—the innate, self-initiated tional therapists can create measurable, functional
rhythmic movements of infancy—that provide and beneficial outcomes for individuals in their
tactile, vestibular, proprioceptive, rhythmic-mo- care. Utilizing this inborn sensory-motor tem-
tor, and rhythmic-auditory input. In addition to plate of movements appears to fuel brain growth,
their calming, maturing and organizing effects in connectivity, and sensory maturity. It also seems
development, many of these rhythmic movements to provide calming and increased receptivity to
involve weight shifts that are important in devel- learning new skills. These special, innate move-
oping proper upright posture, balance and gait. ments repeatedly show effectiveness in clinical and
research settings. And because of their fundamen-
The RMTi curriculum offers the therapist a variety tal importance in human life, the neurodevelop-
of intervention strategies and integrative move- mental movements show great promise for helping
ment tools for all ages. individuals of all ages overcome a large variety of
challenges in order to enhance meaningful partici-
pation in work, play, leisure, education and social
activities.

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