Development of Postural Control

Presenter: Laxmi Bhattarai

MPT II
Neurological sciences
CONTENT
 Background

 Theories of development of postural control

 Reflex Hierarchical theory
 The system perspective theory
 Refinement of postural control
 Role of cognitive system in postural control
Objectives
 To know the key developmental milestones.

 To know factors influencing the development of postural control in infants and

children.

 To understand the basis for the development of postural control under sequence of
motor behaviour.

 To understand how musculoskeletal and nervous system plays role in development of

postural control in infant.
Background
 During the early years of life, children develop an incredible repertoire of skills,
including crawling, independent walking and running, climbing, eye- hand
coordination, and the manipulation of objects in variety of ways. The emergence of all
these skills requires the development of postural activity to support the primary
movements.
 Postural control is the critical part of motor development. The development of postural
control predictable sequence of motor behaviours, referred to as “motor milestones.”

Shumway-Cook A, Woollacott MH. Motor control: translating research into clinical practice. Lippincott Williams &
Wilkins; 2007.
Background
 Gesell et.al state that the development of skilled behaviour does not follow a strict
linear sequence, always advancing, constantly improving with time and maturity.
 For example, of the children learning to crawl and then creep. Initially, in learning to
crawl, the child uses a primarily symmetrical arm pattern, eventually switching to a
more complex alternating arm pattern as the skill of crawling is perfected. When the
child first begins to creep, there is a return to the symmetrical arm pattern. Eventually,
as creeping becomes perfected, the emergence of an alternating arm pattern occurs.
Thus, as children progress to each new stage in the development of a skill, they may
appear to regress to an earlier form of the behaviour as new, more mature and adaptive,
versions of these skills emerge.
Background
 There is various scale to evaluate the emergence of motor behaviours use
developmental norms.
 Using these scales, the therapist evaluates the performance of the infant or child on
functional skills that require postural control.
 The Gross Motor Function Measure (GMFM) (Russell et al., 1993), the Peabody
Developmental Motor Scales (Folio & Fewell, 1983), the Bayley Scales of Infant
Development (Bayley, 1969), and the Movement Assessment of Infants (Chandler et
al., 1980).
 These and other tests follow normal development and are used to identify children at
risk for developmental problems.
Theories of developing postural control
 In the normal child the emergence of posture and movement control is dependent on
the appearance and subsequent integration of reflexes According to these theories, the
appearance and disappearance of these reflexes reflect the increasing maturity of
cortical structures that inhibit and integrate reflexes controlled at lower levels within
the central nervous system (CNS) into more functional postural and voluntary motor
responses.
 There 2 main theories they are
1. Reflex-Hierarchical Theory of Postural Control

2.System Theory
Reflex-Hierarchical Theory of Postural Control
Reflex-Hierarchical Theory of Postural Control
 Attitudinal reflexes: Change in Head position → Change in Body posture

 Righting reflexes: According to a reflex/hierarchical model, the interaction of five

righting reactions produces orientation of the head in space and orientation of the body in
relationship to the head and ground. They are considered as the automatic reactions that
enable a person to assume the normal standing position and maintain stability when
changing positions.

 Balance &protective reactions: According to reflex/hierarchical theory, balance emerges

in association with a sequentially organized series of equilibrium reactions, including the
tilting reactions, used for controlling the centre of gravity in response to a tilting surface;
the parachute, or protective, responses which protect the body from injury during a fall;
and the staggering reactions (sideways stepping), a response to instability in the lateral
direction.
New Models of Development
Development is a complex process, with new behaviours and skills emerging from an
interaction of the child (and the maturing nervous and musculoskeletal system) with the
environment.

1.Changes in the musculoskeletal system, including development of muscle strength and

changes in relative mass of the different body segments.

2. Development or construction of the coordinative structures or neuromuscular response

synergies used in maintaining balance.

3. Development of individual sensory systems, including somatosensory, visual, or

vestibular systems.

4. Development of sensory strategies for organizing these multiple inputs.

5. Development of internal representations important in the mapping of perception to

action.
Development of postural control: A system perspective

a) General movements in infants

I. Spontaneous movements in infants occur, are complex and involve the whole body (arm, leg, neck
and trunk movements)

1. Have gradual beginning and ending; vary in intensity and velocity (shows coordination and fluidity

I. Fidgety movements: small movements of the neck, trunk, and limbs performed at medium speed

II. When nervous system is impaired, movements become monotonous and poorly differentiated.

III. Two changes in movements patterns that predict a later diagnosis of cerebral palsy

1. Cramped-synchronized general movements (lacking a normal fluid character)

2. Absence of general movements of fidgety character

Development of postural control: A system perspective

Emerging Head control

I. Motor Coordination

1. Steady – state postural control isn’t present at birth: due to lack of muscle strength
(musculoskeletal constraint) or lack of coordinated muscle activity for controlling the
head relative to gravity.

2. Reactive balance control: can develop as early as 1 month old.

ii. Sensory contributions

Development of postural control: A system perspective

1. Visual

a. Important in calibration of both the vestibular and proprioceptive system – contributes

to development of internal models of posture.

b. Blinds infants are unable to use their normal vestibular inputs to orient the head in
space

c. Blind infants demonstrate impairments in fine manipulation of object – suggests

importance of visual inputs in calibrating proprioceptive function
a. Neural programs underlying visual orientation are present at birth: required
experience and learning in order to be maintained / refined

b. Early optic flow in infants: Subcortical neural networks that contribute to visual
proprioceptive control.

 Learning isn’t required for initial emergence of optic flow sensitivity ,but
experience and visual feedback are important for the maintenance and
refinement of visual/postural coupling
Development of postural control: A system perspective

2.Vestibular

a. Important in the emergence of gross motor skills like head control

b. Deaf children who have abnormal vestibular function show significantly delayed
acquisition of head control

c. Visual info appears to be critical in calibrating vestibular info for postural control

3.Somatosensory

Visual info appears to be critical in calibrating somatosensory inputs for control of head
posture
Development of postural control: A system perspective

b.Emerence of independent sitting

a. Infants need to master the control of background sway of head/trunk as they begin to
sit independently: requires coordination of sensory /motor info relating 2 body
segments (the head and trunk) together in the control of posture

b. Motor coordination: emergence of independent sitting requires the coordination of

multiple muscles to control the position of the head and trunk during steady-state,
reactive, and anticipatory balance control.

c. Stage 3: independent sitting, but not yet crawling (6-8months)

Development of postural control: A system perspective

a. Steady-state Balance

i. Independent sitting is characterised by infants’ ability to control spontaneous sway

sufficiently to remain upright (mainly occurs around 6-8months)

ii. Emergence of static balance supports the hypothesis that postural development of the
head and trunk is an emergent dynamic skill

iii. Methods from nonlinear dynamics to analyse the complexity (level of predictability)
and dimensionality (degree of freedom) of centre of pressure across 3 stages of sitting
development:
a. Stage 1: defined as the time when infants were able to hold up the head and upper
trunk but not sit independently. (4-4.5 months)

b. Stage 2: infants able to sit independently briefly (10-30 sec) or prop themselves on
their arms (5-6.5months)
 Development of postural control: A system perspective
 Research suggests that development of sitting postural control is dynamic process where
infants gradually learn to control the degree of freedom involved in head/trunk control
through 3 stages of development of sitting balance. Trunk is not just a single segment; it is
made up of multiple spinal subunits controlled by a combination of muscles. Trunk control
develops gradually through 4 stages

 No control

 Attempts to initiate upright sitting

 Partial control with large range of body sway

 Functional control with minimal sway

 Hence, stability and control of the head in sitting improved with the development of control
over sequential trunk segments.
 Development of postural control: A system perspective
d. Reactive Balance Control

 Harbourne et al 1993; Hedberg et al., 2005; Hirschfeld and Forssberg, 1994; Woollacott et
al., 1987 suggest that reactive balance control in the trunk appears to be available to a
limited extent in infants well before sitting develops (as early as 1 month of age) and
continues to develop through the onset of independent sitting.

 Responses synergies are being shaped during the months prior to the emergence of
independent sitting and are organized appropriately by the time the infants are able to sit
independently.

 By 1 months, postural response synergies are present which are highly variable and present
in only a small percentage of trials. Postural responses appear less frequently in infants 3-4
months old and then reappear with greater frequency/refinement as the child learns to sit
independently.
Development of postural control: A system perspective
e. Anticipatory Balance Control
Postural control is the rate-limiting factors in reaching in young infants. As infants develop,
trunk control improves, which is associated with improved reach trajectories

f.Sensory Contributions

i. Infants with relatively little experience in sitting independently showed a complete loss of
balance in response to visual stimuli: with increasing experience in sitting, response amplitude
declined, which implies that sitting infants rely heavily on visual inputs when controlling
sway; this dependence decreases with increasing experience in independent sitting (as infants
rely more on somatosensory inputs)

ii. During the process of learning to sit independently, infants are learning to scale /Map visual
sensory info to their postural control
Development of postural control: A system perspective

f.Sensory Contributions

iii. Taking away visual stimuli doesn’t change the muscle activation patterns in response
to a moving platform: somatosensory and vestibular systems are capable of eliciting
postural actions in isolation from vision in infants first learning to sit

iv. In the seated position, postural responses to perturbations are largely controlled by
somatosensory inputs at the hip joints (not by vestibular or visual stimulation)

v. In infants learning to sit, visual inputs alone can activate postural responses: when
surface perturbations are used, somatosensory inputs are the primary inputs used to
activate postural responses
Development of postural control: A system perspective

g. Modifiability of Postural Responses

i. When comparing EMG responses to platform perturbations (pre-training vs post-

training), they found that trained infants showed a higher probability of complete
responses to perturbations and increased response modulation at higher perturbation
velocities, along with decreased pelvic displacement
Development of postural control: A system perspective
Transition to independent stance

I.Motor Coordination

1.Development of steady-State Balance: During the process of learning to stand

independently, infants must learn to:

(a) balance within significantly reduced stability limits compared to those used
during sitting,

(b) control many additional degrees of freedom, as they add the coordination of the
leg and thigh segments to those of the trunk and head, and recalibrate sensorimotor
representations for postural control to include the thigh, shank, and foot for
balance to create an improved internal model for postural control of independent
stance.
 Transient disruption in sitting posture results from a processing involving recalibration
of the infant’s internal model for the sensorimotor control of posture as they practice
the newly emerging bipedal behaviour of independent walking.
Development of postural control: A system perspective

2.Role of strength

 Research suggests that muscle strength to support the body during standing and
walking is a primary rate-limiting factor for the emergence of independent
stance and gait.

 By 6months of age, infants are capable of producing forces beyond their own
body weight. Ability to support weight against the force of gravity in the
standing position occurs before the emergence of independent stance. So, it
probably isn’t the major constraint to emerging stance postural control.
Development of postural control: A system perspective

3.Reactive Balance: Development of muscle Synergies

 As pull-to-stand behaviour progressed, infants began to show directionally appropriate

responses in their ankle muscles as the behaviour improved, muscles in the thigh
segments were added, and a consistent distal -to-proximal sequence began to emerge
during late pull-to -stand, independent stance, and walking

 Trunk muscles became consistently activated: resulted in complete synergy

 There is a gradual reduction in one-muscles responses

 There is a gradual increase in the 2-to -3 muscle response patterns

Development of postural control: A system perspective

II. Sensory Contributions

 It appears that vision maps to muscles controlling stance posture by at least 5-6
months, prior to somatosensory system mapping and long before the infant has much
experience in standing position.

 The visual system elicits organized postural responses in standing infants at an earlier
age than the somatosensory system does.
Development of postural control: A system perspective

III. Modifiability of postural activity

1.Development of adaptation

 Higher -level adaptive processes related to postural control have not yet matured by
the time of emergence of independent walking

 Infants couldn’t stand crosswise on a beam (because it requires active control of the
hips rather than just control of ankle movements): suggests that this adaptive ability to
use hips in balance isn’t mastered in infants during their first year of walking.
Development of postural control: A system perspective

2.Effect of practice

 Experience may influence the strength of the connections between the sensory and
motor pathways controlling balance: increases the probability of producing postural
responses

 Lack of training effect on muscle response onset suggests that neural maturation may
be rate -limiting factor in reducing muscle onsets with development: Myelination of
nervous system pathways responsible for reducing onset of postural responses during
development isn’t affected by training
REFINEMENT OF POSTURAL CONTROL
1. Musculoskeletal System: Changes in Body Morphology
Children are top heavy. The relative size of the head, in comparison to the lower
extremities, places the center of mass at about T12 in the child, as compared with L5–S1
in the adult. Because of their shorter height, and the difference in the location of their
center of mass, children sway at a faster rate than adults. Thus, the task of static balance
is slightly more diffi cult, since the body is moving at a faster rate during imbalance.
However, after 7 years of age, there is no correlation between structural growth of the
human body (body height, body mass, and age) and sway during normal quiet stance
(Lebiedowska & Syczewska, 2000; Zeller, 1964).
2. Motor Coordination : Refinement of steady -state stance
A number of studies have examined t in spontaneous sway with development (e.g., from
2 to 14 years of age) and have shown that both the amplitude and the frequency of
postural sway decreased during this period (Hayes & Riach, 1989; Kirshenbaum et al.,
2001; Taguchi & Tada, 1988).
Young children used a high-velocity balance strategy, making large, fast corrections of
the COP as they attempted to maintain their COM within their base of support, while at
around 8 to 9 years of age, they show shorter excursions and more accurate control
(Riach & Starkes, 1994).
 Research also shows considerable variability in sway amplitude in the young children.
This variance became systematically lower with age and with the children’s improved
balance. Effects of eye closure were represented by the Romberg quotient (eyesclosed
sway expressed as a percentage of eyes-open sway), giving an indication of the
contributions of vision to balance during quiet stance. Very low Romberg quotients
were recorded for the youngest children who completed the task (4-year-olds), with
values of less than 100%. This indicates that these children were swaying more with
eyes open than with eyes closed (Hayes & Riach, 1989).
3. Refinement of Reactive Postural Control : Refinement of compensatory balance
adjustments in children 15 months to 10 years of age has been studied by several
researchers using a movable platform to examine changes in postural control.
Research has shown that compensatory postural responses of young children (15 months
of age) are more variable and slower than those of adults (Forssberg & Nashner, 1982).
These slower muscle responses and the more rapid rates of sway acceleration observed in
young children cause sway amplitudes (in response to balance threats) that are bigger and
often more oscillatory than those of older children and adults.
 Postural responses in children 4 to 6 years of age are, in general, slower and more
variable than those found in children 15 months to 3 years old, those 7 to 10 years old,
or adults, suggesting an apparent regression in the postural response organization.
 By 7 to 10 years of age, postural responses were basically like those in adults. There
were no significant differences in onset latency, variability, or temporal coordination
between muscles within the leg synergy between this age group and adults (Shumway-
Cook & Woollacott, 1985).
 4. Development of Sensory Adaptation: Postural control is characterised by the
ability to adapt how we use sensory information about the position and movement of
the body in space to changing tasks and environmental conditions.
 The development of sensory adaptation in children ages 2 to 14 years of age has been
studied by a number of investigators using this protocol (FerberViart et al., 2007;
Forssberg & Nashner, 1982; Foudriat et al., 1993; Shumway-Cook & Woollacott,
1985). The results of the combined studies suggest that 1.5-to3-year-olds sway more
than older children and adults, even when all three sensory inputs are present
(condition 1). Performance continues to improve slightly across all age groups through
14 years of age. With eyes closed (condition 2), children’s stability did not
significantly decrease further in the youngest age groups (Forssberg & Nashner, 1982);
however, other studies using children four and older have shown slight decreases in
stability in most age groups either with eyes closed or the visual surround stabilised
(conditions 2 and 3).
5. Refinement of Anticipatory Postural Control : Skilled movement has both postural
and voluntary components; the postural component establishes a stabilizing framework
that supports the second component, that of the primary movement.
Infants as young as 9 months of age show activation of the postural muscles of the trunk
in advance of most, but not all, reaching movements
 Van der Fits et al. (1999) examined the longitudinal development of anticipatory
postural control while seated infants from 3 to 6 months of age reached for a toy. They
found that postural muscle activation accompanied spontaneous and goal-directed arm
movements before the onset of successful reaching at 4 to 5 months of age.
 During goal-directed arm movements, postural responses were direction-specific and
were predominantly in the neck extensor muscles. As age increased and successful
reaching increased, the amount of postural activity decreased (possibly because of
increased postural stability in sitting), although it continued to improve in organization.
 The development of preparatory postural control during standing in infants from 10 to
17 months of age, standing infants were asked to open a cabinet drawer to retrieve a
toy while a force resisting the pull was applied to the drawer. Results showed that both
timing and the proportion of trials involving anticipatory postural activity in the
gastrocnemius before the biceps was activated (to pull the drawer open) progressively
improved from 10 to 17 months. At 10 to 11 months (infants were just beginning to
stand independently), anticipatory activity was present, but highly inconsistent. By 13
months, as they gained experience walking, infants began to show consistent
anticipatory postural activity. After the onset of independent walking, over half of the
infants’ pulls involved anticipatory adjustment in the gastrocnemius muscle within 240
msec of pull onset. However, the ability of the infants to deal with different external
resistances during the drawer pull (adaptational abilities) did not occur until about 15
months of age (Witherington et al., 2002)
 Cognitive Systems in Postural Development
 Studies have shown that children's postural sway increases when they perform a
concurrent cognitive task, indicating that cognitive demands can interfere with postural
control. This dual-task interference is particularly evident in younger children, who
may struggle to maintain stable posture while performing tasks that require attention
and concentration.
 Additionally, the attentional demands of cognitive tasks can also impact postural
control, with children exhibiting less stable postural control when they are focused on
motor tasks that consciously control posture. Furthermore, the development of postural
control strategies in children is influenced by their age, with younger children
exhibiting less stable postural control than older children.

Stephan DN, Hensen S, Fintor E, Krampe R, Koch I. Influences of postural control on cogniti
 Sensory integration also plays a crucial role in postural control, and any sensory
mismatches can lead to poor postural control and balance issues in children. Finally,
the difficulty of cognitive tasks can also impact postural control in children, with more
challenging tasks increasing postural sway and indicating that cognitive demands can
interfere with postural control.
 References
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 Shumway-Cook A, Woollacott MH. Motor control: translating research into clinical practice.
Lippincott Williams & Wilkins; 2007.
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 Ivanenko Y, Gurfinkel VS. Human postural control. Frontiers in neuroscience. 2018 Mar
20;12:301583.
 Alcock L, O’Brien TD, Vanicek N. Association between somatosensory, visual and vestibular
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