Changes in Posture Control Across the Life Span-

A Systems Approach

m this article, a systems approach to the development of posture control across the Marjorie Hines Woollacott
life span and its integration with voluntary tasks such as walking is described. Anne ShumwapCook
Research shows a clear cephalocaudal gradient in the development of postural
responses. Postural muscle synergies develop appropriate temporal olganization
through e.xperience in each new level of postural skill development. Sensoy inputs
contributing to posture control influence postural responses very early in develop-
ment, with responses being elicited by vision alone, or by somatosensoy and vesti-
bular cues in isolation. Studies of older adults indicate small, but signz3cant, in-
creases in onset latencies and disruptions in the temporal olganization of
postural muscle responses when subjects are given external threats to balance. In
addition, older adults, like young children, use antagonist muscles more open in
coactivation with agonist muscles. Older adults also have more dzficulty balanc-
ing when sensory inputs are reduced experimentally or pathologically. Ankle dor-
szj7exor muscle weakness is also a factor zn balance dysfunction in the older
adult. [W(~ollacott MH, Shumwajl-Cook A. Changes in posture control across the
life span--a gstems approach. Phjls Ther. 1990;70:799407.1

Key Words: Child development; Equilibrium; Pediatrics, development; Posture,

general; Systems theory.

An analysis of the behavioral changes
occurring during the acquisition of
independent stance shows that infants
begin to stand with help at about 8 to
9 months of age, begin to walk with
help at 11 months, pull themselves to
a standing position at about 12
months, stand alone at 14 months,
and walk alone at about 15 months of
age.l.2 It is widely noted that in the
first few months of walking, the infant
steps with a wide base and the arms
raised. Walking characteristics gradu-
ally change over the next few years,
becoming adultlike by about 5 to 7
years of age.
M Woollacr)tt, PhD, is Professor, Institute of Neuroscience and the Department of Physical
Education and Human Movement Studies, Gerlinger Hall, University of Oregon, Eugene, OR 97403
(USA). Address correspondence to Dr Woollacott.
What neural mechanisms underlie the
predictably changing patterns of be-
havior seen in infants learning to
stand and walk independently? Two
models of central nervous system
(CNS) control-the reflex-hierarchical
model and the systems model-have
been used to describe the neural ba-
sis for developing posture and move-
ment control in children. In the
reflex-hierarchical model, the CNS is
hypothesized to be organized as a
strict vertical hierarchy. In this ascend-
ing hierarchy, primitive reflexes such
as stretch reflexes are controlled at
the spinal cord level, with the asym-
metric tonic neck, symmetric tonic
neck, and tonic labyrinthine reflexes
being controlled by the next higher
level, the brain stem. The righting
reactions, a group of reactions re-
sponsible for maintaining alignment
to gravity and keeping body parts in
alignment after rotation, are con-
trolled at a slightly higher CNS level,
the midbrain.314
Equilibrium reactions, described as
the body's response to tilting of the
support surface, are hypothesized to
be controlled by the highest level of
the CNS, the cortex.5j6Higher-level
equilibrium reactions, as described by
Weiss,5 are purported to be elicited
by stimulation of the labyrinth; how-
ever, this explanation ignores the con-
tribution of visual and somatosensory
components to equilibrium control.

A Shumway-Cook, PhD, PT, is Director, Balance Disorders Program, Emanuel Rehabilitation Center,
3001 N Gantenbein, Ponland, OR 97227.

Physical 'Therapy /Volume 70, Number 12 /December 1990

Researchers who have taken a reflex-
hierarchical approach have hypothe-
sized that voluntary movement con-
trol is achieved either through the
inhibition of the more primitive re-
flexes by cerebral cortical pathways7
or through reflexes that become the
substrata for voluntary actions.8 The
model predicts that prior to attaining
the next developmental milestone,
equilibrium reactions must mature in
the previous milestone. Thus, before
children can sit, they must first have
developed mature equilibrium reac-
tions in the prone position; prior to
standing, equilibrium reactions must
be present in the sitting and quadru-
ped positions.4.6,'
In summary, in the reflex-hierarchical
model, motor development is viewed
as movingfrom reflexive to voluntary
control as the child matures. In addi-
tion, the emergence of independent
balance and locomotion is seen as
dependent on the maturation of se-
quentially higher levels of the CNS
hierarchy, with higher levels of behav-
ior, such as the equilibrium reactions,
modifying immature behaviors such
as tonic reflexes, controlled by lower
levels within the CNS.10
Many therapeutic techniques used in
rehabilitation of balance disorders are
based on assumptions regarding the
importance of normal reflex matura-
tion to development. For example,
neurodevelopmental treatment sug-
gests positions and movements de-
signed to inhibit primitive reflexes,
such as bilateral midline activities de-
signed to inhibit the asymmetric tonic
neck reflex.I1l2 Pediatric assessment
techniques relying on a reflex-
hierarchical model atrempt to deter-
mine a developmental level using
both reflex tests (spinal reflexes,
brain-stem reflexes, midbrain re-
flexes) and tests of voluntary control.
For example, developmental proto-
cols such as those of Chandler et al?
Milani-Comparetti and Gidoni,'
Fiorentino,'3 and Brazeltonl+were
created to provide a systematic ap-
proach to evaluating essential parame-
ters of function in children, including
muscle tone, primitive reflexes, auto-
matic reactions, and voluntary move-
ments. A potential explanation for
lack of balance control would be the
presence of primitive reflexes that
constrain the emergence of more ma-
ture higher-level righting and equilib-
rium reactions. Treatment of a child
with developmental delays would fo-
cus on sensorimotor techniques that
progress the child through succes-
sively higher levels of reflexes and
reactions.
A more recent model of motor con-
trol is the "systems," o r "distributed
control," model that evolved from the
work of Bernstein.l5 In systems the-
ory, the body is modeled as a me-
chanical system with mass that is sub-
ject to gravity and inertial forces.
Because these factors change as we
move, the same motor program gives
different movements depending on
the position we are in. Bernstein's
model asks questions about the orga-
nism as an active agent in a continu-
ously changing environment. He thus
explored the physiology of activity,
not reactions.
It was also Bernstein15who first
brought forth the idea of synergies as
muscles that are constrained to act as
a unit. He viewed the synergy as a
way for the nervous system to solve
the control problem of coordinating
many joints as part of a single move-
ment, and he gave examples of possi-
ble synergies such as those found in
locomotion, postural control, and
breathing.
According to the systems model, the
nervous system is seen as part of a
flexible complex of systems and sub-
systems sharing in the control pro-
cess. Thus, movement is always an
emergent property that comes from
the complex interactions of these
systems.
Development of
Posture Control-
A Systems Perspective
Our experimental approach to study-
ing the development of balance con-
trol in children relies on the systems
model. In the following sections, we
will introduce some of our basic con-
Physical Therapy /Volume 70, Number 12 /December 1990
cepts related to the study of balance
development from a systems perspec-
tive and present results from research
on developmental changes in compo-
nents of postural control underlying
the emergence of independent ma-
ture balance control.
A fundamental hypothesis in our work
is that the development of indepen-
dent stance and locomotion emerges
from an interaction among multiple
neural and mechanical components
contributing to balance control. We
hypothesize that certain critical com-
ponents are rate-limiting in the devel-
opment of balance and gait. Rate-
limiting components are those aspects
of the system that limit the rate at
which the independent behavior
emerges. Thus, the emergence of in-
dependent stance must await the mat-
uration of the slowest critical compo-
nent. Experimental studies examining
the development of balance control in
healthy children suggest the following
nervous system and musculoskeletal
components may contribute to the
emergence of independent stance and
locomotion: postural muscle response
synergies for controlling balance; vi-
sual, vestibular, and somatosensory
systems for detecting loss of balance;
adaptive systems for modifying sen-
sory and motor systems to changes in
task or environment; muscle strength;
joint range of motion; and body mor-
ph0logy.7.l~~' Current studies are ex-
amining the relative influence of each
of these components on the emer-
gence of independent stance and
lo~ornotion.~~
The systems model suggests that mul-
tiple neural and biomechanical factors
interact to achieve the goal of balance.
The task of balance requires that the
center of body mass be maintained
over the base of support. A cone has
been used to represent the task of
upright balance because, for a subject
standing with feet together on a nor-
mal flat surface, the area of stability
resembles that of a cone-shaped struc-
ture, with its base originating at the
base of support.l"he cone repre-
sents a set of equivalent positions, that
is, all the points from which you can
return to a point of origin without
taking a step o r otherwise moving
your base of s ~ p p o r t . l ~The
, ~ l"stabili-
ty cone" is the domain of stable
movement for a particular postural
task, the edges of which are the outer
bounds of equilibrium for the task.16
The following sections present results
from research exploring developmen-
tal changes in components of postural
control.
Musculoskeletal and Body
Morphology Changes
In healthy adults, limits of stability are
determined by mechanical constraints
that include those from both the indi-
vidual (eg, height and foot length,
strength, and ROM) and the environ-
ment (eg, type and consistency of the
support surface).Zl How do rapidly
changing musculoskeletal and body
morphology characteristics affect the
development of stability in children?
We hypothesize that, because of dif-
ferences in body morphology (eg,
height, center of mass, foot length),
the boundaries of individual stability
cones will vary and that this variability
will affect the selection of motor strat-
egies appropriate to maintaining the
body within the boundaries of the
cone.16 For example, previous re-
search"-2" has identified three pos-
tural movement strategies that are
typically used by healthy adults for
controlling balance: (1) the ankle
strategy, in which balance adjustments
are made at the ankle joint and the
individual sways as an inverted pen-
dulum; (2) the hip strategy, in which
adjustments are made predominantly
at the hip; and (3) the suspensory
strategy, in which the subject flexes at
the ankle, knee, and hip to lower the
center of gravity toward the base of
support.
The efficic:ncy of a particular strategy,
however, depends on a number of
characteristics. For example, McCol-
lum and ken16 have indicated that
the movement of an inverted pendu-
lum is characterized by a time con-
stant that indicates the rate of fall
from an upright position. The time
constant is the inverse of the natural
frequency of a pendulum, and the
shorter the pendulum, the faster its
Physical Therapy /Volume 70, Number
natural frequency. A typical adult has
a time constant for a single oscillation
of 1.92 seconds, with a quarter cycle
(the time to go from upright to the
limits of stability) of 480 milliseconds.
Because an adult's muscle response
times for the ankle strategy are in the
order of 100 milliseconds, he or she
can easily respond to external threats
to balance. According to McCollum
and Leen,16 the time constant for bal-
ance involving movement at the hip is
shorter than that for the ankle, be-
cause a two-link pendulum is being
modeled. In this case, a quarter cycle
is 173 milliseconds. However, the on-
set of muscle responses for a hip
strategy is between 73 and 110 milli-
sec0nds.~3Thus, the adult can still use
this strategy with a reasonable safety
margin.
However, because of infants' shorter
height, McCollum and Leen16 predict
that I-year-old infants will have a
quarter-cycle time of 333 millisec-
onds. Their ankle muscle responses
are typically activated at 100 to 125
milliseconds, which is still within an
effective range for regaining balance,
if it is perturbed. An infant's hip
movement, however, would have a
quarter-cycle time of 114 milliseconds
and thus would complete a quarter
cycle too quickly to be corrected. As a
result, they predict that a hip strategy
would not be seen in young children.
Thus, the changes in height that occur
during an infant's or a toddler's devel-
opment are examples of musculoskel-
etal changes that may contribute to
the emergence of stability.
Changes in Muscle
Response Synergies
Hartbourne et all7 performed a longi-
tudinal study on the development of
muscle activation sequences associ-
ated with independent sitting in chil-
dren aged 2 to 5 months. Children
were first supported around the trunk
by the experimenter, then released to
sit on their own, during which time
they slumped forward. Electromyo-
graphic (EMG) data were collected
from muscles of the back and hip.
The authors noted that trunk displace-
ment significantly decreased between
2 to 3 and 4 to 5 months of age.
Hartbourne et all7 also noted that
children in stage 1 (age 2-3 months),
who were unable to sit indepen-
dently, showed great variability in the
order of muscle activation, both
within and across subjects. Children
in stage 2 (age 4-5 months) showed
an emergence of a distinctive order of
muscle response organization, with
each child showing a preferred pat-
tern o r synergy. The most frequent
patterns seen were: lumbar
paraspinal-hamstring muscles, lumbar
paraspinal-quadriceps femoris mus-
cles, and hamstring-quadriceps femo-
ris muscles, with the lumbar
paraspinal-hamstring and hamstring-
quadriceps femoris muscle synergies
associated with the least trunk dis-
placement. Hartbourne et all7 con-
cluded that the postural synergies that
aid in postural control while sitting
develop over time (with each child
developing a preferred synergy). Be-
cause the study was longitudinal in
nature, it also gives a window for ob-
serving the gradual emergence in
each child of a preferred muscle re-
sponse synergy.
Recent studies in our own laboratory
on the development of neuromuscu-
lar response organization underlying
postural control in seated infants 4 to
14 months of age have attempted to
determine the time course of the de-
velopment of postural muscle re-
sponse synergies used in response to
external threats to balance.18In these
experiments, the infant was placed in
an infant seat o r seated independently
on a support surface (a hydraulically
activated platform) that could be
moved forward o r backward. Surface
EMGs were used to monitor the re-
sponses of the neck extensors and
flexors, the trunk extensors, and the
abdominal muscles.
We found that infants aged 5 to 6
months, who could not yet sit inde-
pendently, showed responses only in
the muscles of the neck. When the
platform was moved backward and
the child swayed forward, the neck
extensor muscles were activated to

Figure 1. Drawing of a child stand-
ing on the platform The platform could
be moved in an anterior or posterior di-
rection or rotated upward or downward
about the axis of the ankle joints. Electro-
myographic profiles were recorded from
the gastrocnemius, tibialis anterior, ham-
string, and quadricepsfemoris muscles.
(Reprinted with permission fiom Woolla-
cott MH, Sbumway-Cook A, eds. Detlelop-
ment of Posture and Gait Across the
Lifepan. Columbia, SC: IJniuersity of
South Carolina Press; 19133:8.?.)
compensate for the sway. Postural
response synergies of independently
seated 8- to 14-month-old children
included muscles of both the neck
and trunk and were directionally spe-
cific to compensate for the platform-
induced sway. Thus, when the plat-
form moved backward, causing
forward sway, the trunk extensor and
neck extensor muscles were activated,
and, when the platform moved for-
ward, causing backward sway, the
trunk flexor and neck flexor muscles
were activated.
A cross-sectional study18 using the
same platform system to study pos-
ture control in the developmental
transition period leading to indepen-
dent stance (Fig. 1) has examined
infants in a range of stages in learning
to stand, from no experience in inde-
pendent stance at 8 months, through
minimal experience at 10 months, to
6 weeks' experience in stance and
walking at 14 months. The 8-month-
old infant (lightly supported at the
waist, to maintain stability) showed no
muscle responses to platform move-
ments. These results could lead to the
assumption that lack of nervous sys-
tem maturity or experience caused
this lack of response; however, it is
also possible that the support given
by the mother reduced the effect of
the platform movement or the need
for a postural response.
For the 10-month-old infant, who was
standing but not walking indepen-
dently, directionally specific responses
were observed in the distal muscle of
the leg (gastrocnemius) during 40%
of the platform movements causing
anterior sway. Hamstring muscle re-
sponses were observed in only one
trial.
For the 14-month-old infant, who was
walking independently, directionally
appropriate leg muscle responses
with adultlike response organization
were observed consistently. When the
platform was moved backward, the
infant showed forward sway, and the
gastrocnemius (distal) and hamstring
(proximal) muscles responded in an
ascending sequence in which the ten-
ter of mass returned to its normal
range. Gastrocnemius muscle re-
sponses in the 14-month-old infant
were at latencies close to those seen
in adults (109+24 milliseconds).
Thus, this gradual emergence of pos-
tural response organization in chil-
dren learning to stand is similar to
that seen by Hartbourne et all7 and
Woollacott et allHin children learning
to sit. In each study, an increase in
neuromuscular response organization
was observed with age and experi-
ence with the new skill.
Although adultlike response organiza-
tion in the infant has been observed
within 6 weeks of experience walking,
there are still many response charac-
teristics that are immature. For exam-
ple, Forssberg and Nashner24 ob-
served that responses of children
Physical Therapy /Volume 70, Number 12 /December 1990
aged 1 to 3 years were slower and
more variable than those of adults
and showed more antagonist muscle
coactivation. As in the model of
McCollum and Leen,l6 slower EMG
responses and faster rates of sway
acceleration were seen in young chil-
dren as a result of their shorter stat-
ure. These outcomes caused larger
and more oscillatory sway amplitudes
than Forssberg and Nashnerz4 ob-
served in older children and adults.
Shumway-Cook and Woollacott25
showed that responses of 15- to 31-
month-old children were consistently
large in amplitude and longer in du-
ration when compared with older
children and adults (Fig. 2). An un-
predicted change in response charac-
teristics in the 4- to 6-year-old age
group was also noted. A regression
was apparent in the postural response
organization in the 4- to 6-year-old
children in that their synergies were
more variable and longer in latency
than in the 15-month- to 3-year-old
children, the 7- to 10-year-oldchil-
dren, or the adults (Fig. 2). The 4- to
6-year-old group was more variable in
muscle response characteristics than
the 15-month- to 3-year-old children;
however, behavioral data indicated
that they swayed less in response to
platform movements.25 By the age of
7 to 10 years, this variability was
greatly reduced, and this age group
exhibited postural responses that
were essentially like those seen in the
adult synergy (Figs. 2C, 2D). Thus,
children go through a transition pe-
riod at 4 to 6 years of age in which
their responses become slower and
more variable, followed by maturation
of the responses at about 7 to 10
years of age.
Developmental Changes
in Sensory Inputs for
Posture Control
In addition to these motor strategies
for posture control, a number of sen-
sory strategies are available to aid in
balancing. Thus, a child or adult may
create different rules for combining
the use of the available sensory inputs
depending on the environmental cir-
cumstances. Normally, three classes of
 sensory inputs are available for bal-
ance control: (1) somatosensory in-

:&
puts, (2) visual inputs, and (3) vestibu-
B lar inputs. It has previously been

~QF& \H
shown that healthy adults rely primar-
ily on somatosensory inputs under
normal sensory conditions in which
all sensory inputs are available.26
However, they can be made to rely
on visual inputs by giving them a
novel stance condition o r by making
T
h\&
Q
support-surface inputs unreliable (eg,
by standing on a narrow beam).27

2~@ ' -1 Lee and Aronsonl9 have shown that

children learning to stand initially are
more influenced by visual cues than

QB
are adults. Owen and Lee28 hypothe-
size that this initial high susceptibility
T'
to incongruent visual information is
due to the infant having poorer infor-
mation from the ankles and feet than
27 months the adult, because the infant has not
yet had the opportunity to calibrate o r
5 years fine-tune this information for use in
balance control. With practice in inde-
D pendent stance and walking, this cali-

1
Q
T\ L
% bration takes place and the infant re-
lies less on visual cues.

Another experimental paradigm29 that

has been used to test the ability of
children to use different sensory in-
puts and to adapt to altered sensory
conditions requires the child to stand

:Qlzzzzzl
fx- & T

24\r*--_J
H
quietly for 5 seconds under condi-
tions in which the redundancy of sen-
sory inputs relevant for balance con-
trol is gradually reduced until only
vestibular inputs remain. The condi-
tions include (1) somatosensory ankle
joint, visual, and vestibular inputs nor-

L
Tk
mal; (2) somatosensory ankle joint
and vestibular inputs normal, eyes
Q
\ closed; (3) ankle joint inputs mini-
Q mized by rotating the platform in di-
3
rect relationship to body sway, but
7 years \ ADULT i visual and vestibular inputs normal;
and (4) ankle joint inputs minimized
(as above), eyes closed, vestibular
system normal.
Figure 2. Electromyographic activation pattemsfrom three successizle trials of
platform translations causing posterior sway. The adult (D) and the 7-year-old child (C)
showed directionally specijc, short-duration responses, with the stretched tibialis anterior In studies by Forssburg and Nashner25
(7J and qtradricepsfemons (Q) muscles being activated The 27-month-old child (A) and Shumway-Cook and Woollacott,25
showed longer-duration responses, with additional activation of the antagonist gastroc- the performance of children under
nemius (G) and hamstring (H) muscles. The 5-year-old child (B) showedgreat trial-to- these conditions was measured by
trial z~artability.(Reprinted with permission from the Helen Dwight Reid Educational determining body sway as a percent-
Foundation.-?5Published 611 Heldref Publications. 4000 Albemarle St h W )Washington,
DC 20016 CopyrightQ1985,) age of theoretical maximum sway,
with 100% indicating loss of balance.

Physical 'Therapy /Volume 70, Number 12 /December 1990


Figure 3. Histograms shouling stabili~index Gercentage of theoretical maximum
swaJ')for 4- to 6year-olds, 7- to 10-uvear-olds,and adults under four dgerent sensoly
conditions: (from left to right) eyes open, normal support sulface; eyes closed, normal
support surface; eyes open, support surface rotating to eliminate sway-related ankle
joint inputs; eyes closed, support surface rotating.
This procedure allows the compari-
son of balance abilities in children of
d ~ e r e n heights.
t Shumway-Cook and
W o ~ l l a c o t indicated
t~~ that even under
normal stance conditions, 4- to 6-year-
old children swayed significantly
more (Fig. 3, far left) than older chil-
dren o r adults (the youngest children
could not tolerate the altered condi-
tions without crying). With eyes
closed, the stability of the 4- to 6-year-
old children decreased further, yet all
of them were able to remain within
their limits of stability (Fig. 3). How-
ever, in the condition in which the
support surface was rotated with body
sway, thus keeping thc ankle joint at
90 degrees and eliminating sway-
related ankle joint inputs, the 4- to
58 / 804
6-year-old children were greatly desta-
bilized and one lost balance (Fig. 3).
The last sensory condition, with ankle
joint inputs unrelated to sway and
with eyes closed, leaving primarily
vestibular cues to aid in balance, was
the most difficult. Four of the five
children in this age group needed
assistance to maintain stability,
whereas none of the older children
o r adults lost balance (Fig. 3, far
right).
An interesting observation by Forss-
bcrg and Nashnerzqs that when the
youngest children balanced under
conditions in which the support sur-
face and the visual environment were
rotated with body sway to remove
Physical Therapy / Volume 70, Number 12 / December 1990
sway-related inputs, the youngest age
group showed long delays between
the beginning of forward sway and
the activation of the appropriate gas-
trocnemius muscle. They noted that
the children then began to sway back-
ward, but this time activated the ap-
propriate tibialis anterior muscle re-
sponse only when beyond the limits
of stability. They noted that postural
responses were activated much more L.
quickly in 7- to 10-year-old children
and that oscillations remained within
normal limits.
These studies suggest that children
under 7 years of age are unable to
balance efficiently when both soma-
tosensory and visual cues are re-
moved, leaving only vestibular cues to
control stability. Shumway-Cook and
Wo~llacott*~ found that 4- to 6-year-
old children showed progressively
decreasing stability as they lost redun-
dant sensory inputs for postural con-
trol. This age group also was less effi-
cient than older children at shifting
from the use of ankle joint soma-
tosensory cues to visual cues when
ankle joint inputs were made incon-
gruent with body sway. This finding
may indicate the inability of 4- to
6-year-old children to resolve in-
tersensory conflict dunng postural
control.
Integration of Posture Control
Into the Gait Cycle
Berger et aBOstudied children who
walked on a treadmill and examined
their ability to integrate postural re-
sponses into the step cycle. Responses
were evoked by momentarily acceler-
ating or decelerating the treadmill
speed during the step cycle.
Results indicated that monosynaptic
reflexes were present in the youngest
children (1 year old), diminished in
amplitude in 2.5-year-old children,
and absent in 4-year-old children and
adults. Postural responses also be-
came shorter in duration and showed
less antagonist muscle coactivation as
the children developed. The results of
this study were similar to those re-
ported previously (ie, both a shorten-
ing in the duration of postural re-
 A C
L TIB-
L QUAD -
L TORQUE
SWAY
YOUNG ADULT 200 ms
NORMAL TIMING
Figure 4. Comparison of electromyographic activation pattern of young and older adults from single trials of platform pertur-
bations cawing posterior sumy: (AJ response of a young adult; (B) delayed onset response of an older adulr; (C) reversal in the re-
sponse pattern for a second older adult. (L TIB = left tibialis anterior mwcle; L Q U L = left quadriceps femoris muscle.) (Reprinted
with permission..^*)
sponses during development and a
reduction in the coactivation of antag-
onist muscles along with the agonist
muscles). The monosynaptic reflexes
were observed in addition to the
longer-latency automatic postural re-
sponses. I t is of interest that the chil-
dren showed a gradual reduction in
amplitude and disappearance between
the ages of 1 and 4 years, as the pos-
tural responses began to show more
mature characteristics.
Aging and Balance Control
Studies in our own laboratory have
used the systems approach to expand
the study of balance control to the
entire life span in order to determine
the specific changes in the different
nervous system and musculoskeletal
components contributing to balance
control. The following sections will
summarize changes in the different
subsystems in the elderly.
Muscle Response Synergies
Woollacott et a13l and Manchester et
a132 have investigated whether there
are age-related changes in the ability
to appropriately activate and organize
postural ~nusclesynergies when ex-
posed to threats to balance. Woolla-
cott et a121 compared the muscle re-
sponse cl~aracteristicsof 12 older
adults (6:l-78 years of age) with those
of 14 younger adults (19-38 years of
age), using the platform translations
described previously. They noted that
Physical 'Therapy /Volume 70, Number 12 /December 1990
L QUAD
AGING 1 200 ms
TEMPORAL DELAYS
the automatic postural responses of
the older adult group showed the
following changes in both timing and
amplitude characteristics when com-
pared with the young adults:
1. Significant increases in the abso-
lute latency of distal (ie, tibialis
anterior) muscle responses in re-
sponse to platform translations
causing posterior sway (onset la-
tencies: young adults, 102+6 milli-
seconds; older adults, 109+9 milli-
seconds). Figure 4 shows the EMG
responses of young and older
adults to a platform perturbation,
giving examples of the response
delays seen in the older adults.
2. Intermittent reversals in the nor-
mal distal-to-proximal sequence of
leg muscle contractions so that the
proximal quadriceps femoris m u s
cle was activated before the distal
tibialis anterior muscle. Five of the
12 older subjects showed these
intermittent reversals (Fig. 4C).
3. A larger incidence of short-latency
spinal monosynaptic reflexes, when
subjected to platform rotations.
Seven of the 12 older adults
showed an activation of monosyn-
aptic reflexes, whereas none of the
younger subjects showed this acti-
vation. However, the incidence of
these reflexes was small (18% of
the trials), even in those subjects in
which they were elicited. Manches-
ter et als2 also found that older
LQUAD
SWAY
AGING 2 200 ms
TEMPORAL REVERSAL
adults coactivated antagonist mus-
cles with the agonist muscle signifi-
cantly more than did young adults
when responding to platform
translations.
Sensory Inputs Contributing to
Posture Control
Woollacott et al3l also tested the abil-
ity of older adults to retain stability
under conditions of reduced o r con-
flicting infonnation from the visual,
vestibular, and somatosensory sys-
tems. The protocol required that the
older and younger adult groups bal-
ance for a 10-second period under six
different sensory conditions: (1) nor-
mal vision, normal base of support;
(2) eyes closed, normal base of sup-
port; (3) visual environment rotated to
follow body sway, normal base of
support; (4) normal vision, base of
support rotated to follow body sway;
(5) eyes closed, base of support ro-
tated to follow body sway; and (6) vi-
sion and base of support rotated to
follow body sway. The last two condi-
tions reduced both relevant visual and
somatosensory cues for posture con-
trol, so that primarily vestibular cues
remained. They found that the sway
measurements of the older adults
were not significantly greater than
those of the young adults for the first
four sensory conditions. However, for
the last two conditions, the older
adults had significantly more sway
than the young adults, and many of
the older adults lost stability, requir-
805 / 59
ing assistance to regain their balance.
Two of the older adults lost balance
under condition 5, and 6 of the 12
older adults lost balance under condi-
tion 6.
According to the systems model, these
results indicate that postural control is
an emergent property that involves
the interactions of a number of sen-
sory systems. The results show that as
long as two sensory inputs are avail-
able, both young and older adults can
easily shift from the use of one sen-
sory input to another. However, when
only one sensory input-the vestibu-
lar system-remains, the sway of the
older adult is sufficiently impaired to
cause loss of balance in many in-
stances.
Musculoskeletal Changes
An additional body system that con-
tributes to balance control is the mus-
culoskeletal system, and one charac-
teristic of the musculoskeletal
system-muscle strengthaecreases
significantly with age.33-" Whipple et
a135 found that elderly nursing home
residents with a history of falls had
severe impairments in overall ankle
muscle strength when compared with
age-marched controls. They noted that
ankle dorsiflexion strength was most
severely impaired in these nursing
home residents with a history of falls.
These data are similar to those re-
ported by Woollacott et al,." which
showed a significant slowing in onset
latency for the tibialis anterior mus-
cles in response to external threats to
balance.
Summary and Conclusions
These studies on the development of
posture control across the life span
and its integration with voluntary tasks
such as walking show a number of
interesting principles of developmen-
tal progression. First, infants show a
clear cephalocaudal gradient in the
development of postural responses,
with control first appearing in the
muscles of the neck, then the trunk,
and finally the legs. Data show that
postural muscle synergies develop
appropriate temporal organization
through experience in each new level
of postural skill development. Muscle
strength changes may also contribute
to the development of postural con-
trol, but few data are available on this
aspect of postural development. We
believe sensory inputs contributing to
posture control may be able to influ-
ence postural responses very early in
development, with postural responses
being evident if influenced by vision
alone, o r by somatosensory and vesti-
bular cues in isolation.
Studies on the older adult indicate
small, but significant, increases in the
onset latencies and disruptions in the
temporal organization of postural
muscle responses when subjects are
given external threats to balance. In
addition, older adults, like young chil-
dren, use antagonist muscles more
often in coactivation with agonist
muscles when balan~ing.3~
Older adults also have more difficulty
balancing when sensory inputs con-
tributing to balance control are re-
duced, so that they have less redun-
dancy of sensory information. Thus,
when both somatosensory and visual
inputs are made incongruent with
postural sway, the older adult shows
significantly increased sway compared
with the young adult, and many older
adults lose balance completely. This
characteristic is also similar to that
seen in young children. Muscle (ie,
ankle dorsiflexor) weakness may also
be a factor in balance dysfunction in
the older adult.
Given the many similarities in func-
tional capabilities of the different sys-
tems contributing to balance control
in the child and the older adult when
compared with the young adult, d o
these results support the strict vertical
hierarchy hypothesis [hat as children
mature, higher nervous system ten-
ters take over function from more
primitive reflex systems, and that as
adults age and higher centers deterio-
rate, lower-level systems begin to
show functions that reemerge? A-
though there are limited data to show
that there is some reemergence of
spinal reflexes in the older adult,36 all
other similarities in function between
Physical Therapy / Volume 70, Number 12 /December 1990
the different musculoskeletal and ner-
vous subsystems can be explained by
developmental changes in functional
status of each system independently.
There is no need to invoke the exis-
tence of a strict vertical hierarchy. For
example, the similarities in use of
antagonist muscles along with ago-
nists in posture control in the two age
groups (children versus older adults)
simply imply that each may use the
agonist-antagonist coactivation to
stiffen the ankle joint and thus limit
the degrees of freedom needed for
postural control. This is a typical strat-
egy found in any motor skill when
function is not optimal; it is not an
indication of a "lower level" of the
vertical hierarchy reemerging in
dominance.
The systems model can be used to
evaluate changes in the different sys-
tems contributing to balance control
across the life span by asking ques-
tions such as: When the function of
one system contributing to balance
control is unavailable, what other sys-
tems can compensate? Are there spe-
cific environmental conditions that
threaten balance control when spe-
cific systems are impaired, and can
these conditions be avoided? and Can
balance strategies be modified to im-
prove balance function when a spe-
cific system is no longer functioning
at optimal levels? Thus, this model
has great flexibility and great potential
in contributing not only to our under-
standing of balance changes across
the life span, but to therapeutic inter-
ventions in the child or the older
adult with balance dysfunction. How-
ever, our understanding of the clinical
implications of many of the experi-
mental findings has only recently
been e x p l ~ r e d . j ~As
. ' ~a result, effec-
tive approaches to assessment and
treatment of some types of postural
problems identified through systems
research are still limited.
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