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IMH 201 History of Motor and Sensory Development

Rosemary White OTR/L
September - December 2008

WEEK VIII Development of Postural Control C t l

References for this Lecture

Lectures on Neurodevelopmantal Therapy and Sensory Integration presented by Rosemary White, 1980 to present. Motor Control Translating Research into Clinical Practice p p p.187 - 209 Chapter 8; Development of Postural Control; p The Components of Normal Movement During the First Year of Life and Abnormal Movement, Lois Bly 1983 Monograph, Neuro-Developmental Treatment Association; p. 1 - 40

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Postural Control & Development

Research on early development has shown that simultaneous development of the postural, locomotor, and manipulative system is essential to the emergence and refinement of skills in all areas. Amiel Tison and Grenier, 1980 note that when an infant is provided with stability in the head and neck movements seen in more mature infants emerge. Gesell, 1946 described movement development over the first few years
Proximal to distal control Spiraling Hierachy Characterized by alternating advancement and regression in the ability to perform skills

Magnus - Reflexes & Righting

Static Reactions Stiffen limbs for support of body weight against gravity Segmental Static Reactions g Involve more than one body segment (flexor withdrawl and crossed extension.) General Static Reactions (Attitudinal reflexes) Involve change in position of body in response to changes in head position. Righting Reactions Allow animal to assume or resume orientation of body with respect to environment.

Attitudinal Reflexes/Reactions (Static)

Assymetrical Tonic Neck Reflex - ATNR
Rotation of the head -> Extension on the facial side, flexion on the occipital side.

Symmetrical Tonic Neck Reflex - STNR

Extension of the neck -> extension in the UE, and flexion in the LE; Flexion of the neck -> flexion in the UE and extension in the LE

Tonic Labyrinthine Reflex (in a prone position) - TLR

Flexion of the neck -> flexion throughout the extremities; Extension of the neck -> extension throughout the body.

Elicited by stimulation to
Proprioceptors in the neck, vestibular To a lesser degree visual and auditory

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Phasic Reflexes/Reactions
Moro Reflex When the child is displaced backwards in space there is an increase in extensor tone in the extremities followed by a return to flexions (vestibular.)

Startle Reflex When there is a sudden sound the infant will have an increase in extensor tone in the extremities and then a return to flexion (auditory.)

Galant Reflex When there is tactile stimulation down the side of the spinal cord the infant will have contractions of the muscles on that side of the trunk leading to lateral flexion and then return to neutral (tactile.)

Stepping Reflex When an infant is held upright with his or her feet placed on a surface, he or she will lift their legs as if they are marching or stepping (touch pressure to the foot).

Righting Reactions
Orientation of head within space, and orientation of the head to the body and ground.
Neck Righting - Rotation of the head and neck and the body follows with no segmentation. Labyrinthine - Orientation of the head within space to bring the nose o e ca positon, ou o o a e a e o gravity. Sensory into a vertical pos o , mouth horizontal relative to g a y Se so y system that influences this is the vestibular. Body on Head - Body responds and re-aligns to movement of the head. Sensory system that influence this are somatosensory in neck, but also visual and auditory can influence. Head on Body - Head and neck respond and re-align to movement initiated by the body. Sensory system that influences this is primarily the somatosensory (proprioception and tactile.) Body on Body - Body parts respond to one another and with regard to orientation to the ground. Sensory system that influences this is the primarily the somatosensory. Optical Righting - Orientation of the neck and body within space using visual input.

Automatic Postural Mechanisms

Righting Reactions - http://www.therapyedu.com/pedi/chapter9.htm
RIGHTING REACTIONS
NECK RIGHTING Rotate head body moves in total piece Newborn in prone LABYRINTHINE Adjust to right head in space (nose vertical/mouth horizontal) 0-4 months in prone BODY ON HEAD Body adjusts on head movement (Lift head i prone b d adapts) h d in body d t ) HEAD ON BODY Head adjusts on body movement (Lift bottom to change diaper head adjusts flexing) 3 months in prone BODY ON BODY One part of body moves and rest of body adjusts to that initiating movement 4-5 months prone OPTICAL Using visual cues to influence postural responses in body Newborn Neck

SEGMENTATIONSENSORY STIMULUS
None Proprioceptive Tactile Vestibular Vestibular Utricle Saccule Proprioceptive Tactile Vestibular S.C.C Utricle and Saccule. Cerebellum

- Vertical - Lateral - Rotational - Vertical - Lateral - Rotational

Neck

Trunk

- Vertical - Lateral - Rotational

Proprioceptive and Tactile Vestibular S.C.C. Utricle and Saccule Cerebellum Visual Optical System ? Vestibular

All the above are foundations for Optical Righting

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EQUILIBRIUM REACTIONS
Reactions that serve to maintain or regain balance once the center of gravity has been displaced. Develop in a plane, or during a movement pattern, after all the righting reactions have developed as an equilibrium reaction developed, is made up of all of the righting reactions working together in the presence of normal muscle tone. There are two types of equilibrium reactions:
i. ii. When you move on a stable surface- walking, climbing stairs or really any movement pattern in which you maintain control. When you are stable, but the surface upon which you are supported moves- in a bus, or car, or boat.

Balance and Protective Reactions

Reflex-hierarchical theory - Balance emerges in association with a sequentially organized series of equilibrium reactions, of which there are three types Tilting Reactions
Control the center of gravity when tilted (emerge in prone, then sitting, then in stance.)

Parachute or Protective Reactions

Protect body from injury during a fall (emerges forward, then sideways, then backwards.)

Staggering Reactions (sideways stepping)

Occur in response to instability in a lateral direction. (Wollacott & Shumway Cook, 2007)

EQUILIBRIUM REACTIONS
Equilibrium Reaction
STATIC Support Surface moves (carry, car, Rx Ball) Align center gravity over base of support Proximal/Distal kinesiological aspect of control Begin 6 months prone continues to develop in all positions to 6-7 years DYNAMIC Support surface stable but body moves (roll, crawl, walk, climb, in Rx facilitate thru transitions)
Bring base of support under center of gravity Distal/proximal kinesiological aspects of control

Segmentation
All levels as all righting reactions working together

Sensory System
Proprioceptive Tactile Vestibular Visual Initiating sensory stimulus is from external source

All levels as all righting reactions working together

Proprioceptive Tactile Vestibular Visual Initiating sensory stimulus is from internal source

Begin 6 mths prone continues to develop in all positions to 6-7 years

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Adequate Sensory Integration

Postural Adaptation

Midline Stability (Static Balance)

Equilibrium (Dynamic Balance)

Vertical Righting Labyrinthine Head on Body Body on Head

Rotational Righting Body on Body Optical

Phasic Reactions (Movement Reactions) Moro Rooting

Tonic Reactions (Holding Reactions) ATNR TLR

Muscle Development
Visual Tactile Proprioceptive Vestibular

IMH 201 Week VIII Part 2

Development of Postural Control

* On pages in the Lecture for Week VII Video Full Section is for your readings and for reference for Full Video with Slides.

*Theories of Developing Postural Control

Classic Theories (reflex hierarchy substrate)
Posture and movement control is dependent on appearance and subsequent integration of reflexes.

More recent theories (systems, ecological, & dynamic actions theories)

Postural control emerges from a complex interaction of musculoskeletal and neural systems postural control system with organization of elements determined by task and environment with reflexes being only one of the many influences on posture and movement.

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*Role of Reflexes

Controversial Some researchers believe that reflexes are the substrates for motor control.
Th ATNR i th b i f eye h d co-ordination The is the basis for hand di ti while others disagree. Righting reactions are the basis for rolling in infants. Are these postural patterns a reflection of neurological maturation - hence as movement emerges they reflect the integration of sensory, affective, emotion maturation?

*Systems Theory
Interaction of the child with the environment
Changes in the musculoskeletal system. Balance of neuromuscular structures. Development of sensory systems. Integration of sensory systems. Internal representations -> mapping of perceptions to action. Considered essential for comparisons, interpret self motion and calibrate motor actions. Adaptive and anticipatory mechanisms -> child modifies the way they sense and move.

Thus the path from sensation to motor actions proceeds via an internal representation structure or body schema (Gurfinkel & Levik, 1978, Hirschfield, 1992)

*Emerging Head Control Motor Co-ordination

Prechtl, Harborne, Hedberg, Hirschfield & Frossberg, Woolocott and others have designed research paradigms to understand motor development Lack of head control in infants was the result of lack of strength as well as lack of organized muscle activity. Muscle contractions in the neck and trunk were assessed in response to postural displacement in infants as young as 1 month through 10 months. Results indicated the emergence of directions specific postural responses in the neck flexors begins as young as one month but responses occur only a third of the time, and by 5 months half to time. In contrast neck extension was more consistent at one month occurring 70% of the time and remaining that way through five months It was pure science.

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*Emerging Head Control

Sensory Contributions
Research to assess capacities based on response to sensory input.
Infants as young as 3 days old responded posturally to isolated visual -motor action (back and forth of a moving dot - even without affect!) This indicates that the subneural networks that contribute to visual proprioceptive control of posture is present at birth. Learning is not required for the emergence of optic flow sensitivity, although experience and self-produced movement may be important for visual/postural coupling. (Jouen et al 2000)

*Emerging Head Control Relating Reflex to Systems Theory

Reflex/hierachical theory suggest that visual co-ordination appears at approximately 2 months as optical righting matures. Body righting and labyrinthine emerge between birth and 2 months. Landau emerges between 4 and 6 months when all righting reactions have emerged Systems theory suggests that certain basic visual/postural mapping is present at birth and with movement the infant develops refined rules for mapping visual information for action. Sensory motor mapping occurring in first 2 months. Mapping between visual and vestibular system for postural action present between 2.5 and 5 months. Both theories are consistent suggesting that mapping of individual senses to action may precede the mapping of multiple senses of action reflecting the internal neural representation necessary for co-ordination.

Emergence of Independent Sitting (6 to 8 months of age)

To sit independently the infant must learn to master control of both spontaneous background sway of the head and trunk and to respond when balance is challenged challenged.
This requires co-ordination of sensory/motor information relating two body segments (head and trunk) together for postural control. Research indicates that there may be both innate components of control in the newborn as well as emergent aspects of control resulting from the infant interacting dynamically with the environment.

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Emergence of Independent Sitting Motor Co-ordination & Balance

Three Stages reflect the dynamic process in which the infant gradually learns to control the degrees of freedom involved in head/trunk control. Infant able to hold up head and trunk when positioned in sitting but not independently. I f t sits momentarily (10-30 seconds) or props with arms Infant it t il (10 30 d ) ith (a time if decreased freedom.) Sits independently but not yet crawl . Infants exhibit the precursors for balance in sitting prior to independent sitting. Reactions are stronger in response to backward movements than forwards. Reactions are present in the first month, less frequent between 3 and 4 months, then reappear with greater frequency and refinement at 5 months and as the child learns to sit independently.

Emergence of Independent Sitting Sensory Contributions

Studies have looked at the role of the visual sense in emergence of sitting.
Infants who had little experience sitting independently had complete loss of balance in response to visual stimulation of movement but with increased experience in sitting they were less influenced and their response declined. This suggests that early sitters use vision to provide stability but with experience they rely more on somatosensory input. (Butterworth et al, 1977 & 1983) Studies with continuous oscillation of visual cues led to continuous postural adaptation in the pelvis. This suggests that in the process of developing independent sitting infants learn to scale or map visual sensory information to their postural activity. (Bertenthal et al, 1997)

Emergence of Independent Sitting Sensory Considerations

Studies have looked at the role of the other senses in emergence of sitting. Balance was challenged in sitting, with and without vision, indicating that there was no difference in muscle activation patterns. This indicates that somatosensory and vestibular systems are capable of eliciting postural actions in isolation of vision in infants learning to sit (Woolacott 1987) sit. (Woolacott, Head orientation was systematically varied while seated infants balance was disturbed -> Finding that coordinated muscle activity in the trunk did not change regardless of head position. This indicates that in sitting motor responses are largely controlled by somatosensory input at the hips, not vestibular or visual. (Hirschfeld and Forssberg, 1994) Infants who were not yet sitting independently were trained over a three month period with toy presentation to the side or semibackwards to the limit of their stability. Trained infants balance responses were more efficient when compared to non trained infants. (Hadders-Algra, 1996)

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Emergence of Independent Sitting Relating Reflex to Systems Theory

Reflex-hierachical theory highlights orientation of the body emerging at around 6 months with maturation of neck-on-body and body-on-body righting and relates it to the dynamic emergence of rolling. Magnus described their actions to affect body orientation of the head and neck (neck-on-body) and supporting surface (body-on-body) Systems theory research indicates the childs ability to orient the head and trunk with respect to the support surface is present in a crude form shortly after birth, it then goes through further maturation from 4 through 9 or 10 months which coincides with emergence and maturation of independent sitting. Both theories have agreement concerning emergence of trunk control but different underlying explanations

Transition to Stance Motor Co-ordination

Requires maintenance of balance on a smaller base of support and co-ordination of leg and thigh segments with those of the trunk and head.
Strength - Infants have strength in LE to produce force greater than their body weight at 6 months. This suggests that the infant has the y pp g g gravity well before independently y p y ability to support weight against g standing, hence strength is not a major factor. Development of Muscle Synergies - Studies infants 2 months to 18 months revealed postural response synergies in response to threats to balance in fall backwards disturbance. 2-6 months infants (no pull to stand behavior) no co-ordinated muscle response organization. 7-9 months infants (emerging pull to stand behavior) had directionally appropriate response in ankles. As pull to stand increased thigh segment emerged (distal to proximal sequence) 9-11 months trunk muscles were activated - a complete synergy with gradual addition of muscles to synergy with experience and development.

Transition to Independent Stance Sensory Contributions

Vision maps to muscles controlling stance posture appear to be present by 5-6 months of age, before somatosensory mapping, and long before the infant is standing, suggesting that the infant has to reassemble the th synergies when somatosensory i i h t inputs are t mapped for stance postural control. 5 month olds swayed in response to room movement, this increased during the pull to stand phase and peaked with independent walkers, then dropped with experiences walkers. This suggests that somatosensory system develops synergies separately in association with somatosensory input.

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Transition to Independent Stance Adaptive Capability

Postural adaptation to changing support surface was assessed in infants 13 - 14 months. They were assessed on varying surfaces that had elements of instability (resistive, slick and narrow surfaces). They had better balance on the resistive and no ability on the narrow surface which requires hip adaptation. This suggests that adaptation in the hips is not mastered in the first year of walking. (Stoffregen, 1997) When the size of the balance threat was increased passively new walkers with 3-6 months of walking had hip determined responses (Wollacott, 1998; Roncesvalles, 2003) When adaptation was actively assessed in new walkers (1017mths); hopper (2-3yrs); gallopers (4-6yrs); skippers (7-10yrs) it was not until 7-10yrs that children began to show consistent active control of strategy with high levels of abdominal muscle activity.

Transition to Independent Stance Relating Reflex to Systems Theory

The divergence of focus of the theories make comparison difficult. Reflex/hierachical theory distinguishes the righting reactions underlying orientation from the tilting and p postural fixation reactions essential to the emergence g of balance.
Thus suggesting different neural mechanisms are involved.

Systems theory suggests that the time course for emerging stability is different in each of the sensory systems.
Visual inputs relating the bodys position in space map to muscular action controlling the bodys position during stance emerges earlier than the somatosensory, and the vestibular is not yet known.

Refinement of Stance Musculoskeletal System

The center of gravity in a child is higher than that of an adult due to the fact that the head is heavier. This fact and the fact th t f t that a child i shorter -> children hild is h t hild sway at a faster rate that adults making static balance more difficult.
This persists until 7 years of age (Lebiedowsha & Syczewska, 2000; Zeller, 1964)

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Refinement of Stance Motor Coordination

Younger children make large fast correction as they adapt over their base of support. By 8-9 years they show shorter excursions and more accurate control .(Riach & Starkes, 1994) Variance in sway amplitude becomes systematically lower with g p age and improved balance. Contribution of vision to balance during stance. Children of 4 years swayed more with eyes open; 9-12 year olds reach adult levels with eyes open, and 12-15 year olds reach adult levels with eyes closed. Sway velocity also decreases with age. (Taguchi & Tada, 1988) 3 year olds have restricted degrees of freedom over base of support in quiet stance balance; 5 year olds have more control over and adaptability over their base of support (center of pressure.) (Newell, 1997)

Refinement of Stance Compensatory Posture

Compensatory postural responses in 15 month olds are more variable and slower than adults, with bigger sway amplitudes and more oscillations. (Fossberg and Nashner, 1982) Children 18 months to 3 years produce well organized muscle p y g response when balance is threatened , but they are larger and delay of response and duration are longer.(Shumway Cook and Wollacott, 1985) Children 4 to 6 year olds have a regression of postural response organization.
The body is growing and previous motor programs are no longer highly effective -> period of transition with marked instability and variability and then a new plateau of stability. Kugler et al, 1982) Developmental changes in the nervous system.

Children 7 to 10 years old have responses similar to adults.

Refinement of Stance Sensory Adaptation

Postural control is characterized by the ability to adapt how we use sensory information about the position and movement of the body in space to changing task and environmental conditions. Visual inputs reporting the bodys position in space appear to be mapped to muscular actions earlier than inputs from other sensory systems. The invariant use of visual inputs from postural control can sometimes mask the capability of other senses to activate postural reactions. At times when vision is occluded postural actions activated by other sensory inputs can be better organized.

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Refinement of Stance Sensory Adaptation

Predominance of visual control of balance gives way to somatosensory control of balance by age 3 but is not adult like until after 7. 4-6 year olds had more sway than older children when balance was challenged even when they all sensory input available. When vision was occluded they had greater sway but did not fall. When somatosensory was reduced they had reduced stability and half the group lost balance. When the children had to maintain balance using primarily vestibular input all but one lost their balance.
Thus, children under 7 are unable to maintain efficient balance when both somatosensory and visual cues are removed. In addition when one or more sensory cue is inaccurately reported (hence there is conflict) children under the age of 7 have reduces ability to posturally adapt.

Refinement of Stance Anticipatory Control

Skilled movement has both postural (stabilizing framework) and voluntary components (primary movement.) Studies show that prior to an action there is an anticipatory preparation in muscles. When reaching in sitting (3-6 months) it was found that as age increased and successful reaching increased the increased, amount of postural activity decreased due to postural stablity. When 10 to 17 month olds opened a cabinet draw in standing it was found that anticipatory muscle activity occurred in the leg prior to action in the arm.
10 to 11 month anticipatory activity was present but not consistent. 13 months had consistent anticipatory posture. Experienced walkers showed more rapid anticipatory posture in half the children but if there was resistance they did not have adaptational abilities until 15 months. (Witherington, 2002)

*Cognitive Systems in Development

Postural control requires attentional resources with additional resources required with increasing postural task complexity. While performing a postural or a cognitive task or both a childs performance will deteriorate if attentional capacities are exceeded. Studies show that postural demands of younger children tax their attentional resources more than older children during dual tasking (maintaining balance while doing a visual memory task. (Reilly, unpublished)

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*Development of Postural Control

Changes in motor components of postural control involve Body morphology - body is shorter and head is heavier and influences balance up until 6 years. After 6 body balance is more that of an adult. Refinement of muscular response synergies when balance is threatened Decrease in onset latency, Improvement in timing and amplitude of muscle response, Decrease in variability of muscle response -> Decrease in sway velocity and reduction of oscillatory sway.

*Development of Postural Control

Refinement in the sensory aspects of postural control include A shift from predominance of visual control of balance to a somatosensory control of balance by age 3. The ability to adapt senses for postural control appropriately is reduced, in children under 7, when one or more of these senses (visual, somatosensory, vestibular) is inaccurately reporting body orientation information. The ability to perform both postural and cognitive tasks in dual task situation is reduced in children under 7.

*Sensory, Affective, Emotional Contribution

Was there something missing in this research when we compare the results of the research to babies responses in the natural environment ? What are the contributors to infants amazing capacities?

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Reflection for the Week

Review Video of movement. Consider postural control and the integration of movement relating to the body - reflex to systems theories theories. Do you see one theory or the other influencing your observations. What are the the major influencing your observations. Remember function, neurobiology, integration and emotion as you consider this reflection.

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