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34 BALANCE FUNCTION ASSESSMENT AND MANAGEMENT
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that chicks are able to walk and run within hours of
hatching, show that in the chick the vestibular periphery matures early and is functional even before hatch.
DEVELOPMENTAL MILESTONES OF
VESTIBULAR
FUNCTION AND BALANCE
BEHAVIORS IN THE HUMAN
By the twelfth to fourteenth weeks of gestation, the
human vestibular epithelium appears almost mature
and contains types I and II hair cells, myelinated calyxbearing and bouton-terminated afferent neurons, as
well as efferent axon terminals (Dechesne, 1992). Ten
weeks later (week 24) they are considered adult-like,
and at birth, some 10 to 16 weeks later (weeks 36 to
40), the periphery is considered mature. Although
the vestibular periphery may be mature at birth in
the human, this is not readily apparent from human
behavior (unlike the case in the chick above). The
human neonate requires years (see below) to acquire
a mature vestibular-linked behavioral repertoire. It is
clear that central myelination and circuit refinements
must take place in order to fully equip the otherwise
largely immature cortical, cerebellar, extrapyramidal,
and brainstem descending motor control systems for
the support of mature behavioral motor programs and
postures. Behaviors such as walking and running as
well as mature posturing must develop after birth in
the human (e.g., sitting up, rolling over, even holding
one’s head up; see Table 2–2; Eviatar & Eviatar, 1978;
Frankenburg & Dodds, 1967). Table 2–2 summarizes
well-known developmental milestones for motor skills
in the human infant. Central immaturities therefore can
obscure or mask true vestibular functional capability as
well as deficits in neonates and children. Moreover, failure to recognize vestibular deficits may, in the absence
of intervention, put individuals at risk for developing
abnormal postural, dynamic motor control and/or
motor effector systems (e.g., De Kegel et al., 2012; Fife
et al., 2000; Shall, 2009; Van Cleave & Shall, 2006)
A functional vestibular periphery is evident in
the human neonate. Full-term normal infants typically
demonstrate vestibular mediated ocular compensation
induced by head rotation (Cyr et al., 1985; Donat et al.,
1980; Eviatar & Eviatar, 1978; Eviatar et al., 1974, 1979;
Ornitz et al., 1979; Staller, 1986; Tibbling, 1969; WienerVacher et al., 1996). Head rotation elicits a bilateral
response from the vestibular periphery. VOR measurements at the youngest ages generally show tonic conjugate deviation of the eyes in a direction opposite that
of rotation, and may include occasional rapid saccades.
The slow compensatory movement is dependent on
the vestibular periphery, whereas saccades depend on
brainstem circuitry (see Chapters 3 and 4). A reduced
number or frequency of saccades reflects the immature
state of brainstem neural circuits. The presence of saccades in the neonate is in part dependent on frequency
of rotation. Saccades may be absent in very young or
premature infants but are found consistently in normal
1- to 3-month-old babies.
Caloric testing in the neonate evaluates each ear
separately and has often provided evidence of central
immaturity, especially in premature infants (Eviatar
et al., 1974, 1979; Donat et al., 1980). VOR responses
to calorics are variable and may be absent in infants
less than 6 months. By 3 to 6 months a consistent VOR
is generally present (Cyr et al., 1985, Eviatar et al.,
1974, 1979; Donat et al., 1980). The absence of a VOR at
Table 2–2. Familiar Developmental Milestones for Motor Skills in the Human Infant*
Motor Skill 25% (mo) 50% (mo) 75% (mo) 90% (mo)
Lifts head (prone) 0.7
Lifts head 90 degrees (prone) 1.3 2.2 2.6 3.2
Chest up, arm support (prone) 2.0 3.0 3.5 4.3
Sits (head steady) 4.8 5.5 6.5 7.8
Rolls over 2.3 2.8 3.8 4.7
Stands holding on 5.0 5.8 8.5 10.0
Walks well 11.3 12.1 13.5 14.3
*Selected data from Frankenberg and Dodds (1967). Age (months) at which the respective fraction
(25%, 50%, 75%, and 90%) of infants successfully completed motor tasks listed.

2. ontogEny oF tHE vEstiBulAr systEm And BAlAnCE 35
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10 months or older is considered abnormal (Fife et al.,
2000). Most abnormal responses (e.g., disconjugate eye
movements, tonic ocular deviation, absent saccades)
were found in premature or very young normal term
babies (Donat et al., 1980; Tibbling, 1969), but such
abnormalities generally reflected central immaturities
which disappeared with maturation. Thus, improvements in vestibular responses largely represent central
maturational processes which occur over several years.
Vestibular reflex testing and posturography also
have been used to assess the time course of maturation
in children and demonstrate that the process begins
very early in the neonate and continues into adolescence. There is considerable variation in the VOR findings for some parameters in growing children. Results
depend on the particular metric used to characterize
eye movements and the range of subject ages represented. Measurements can also be affected by the
subjects’ state of alertness. The ability to arouse and
maintain alertness throughout testing is itself a function of age and this can influence results.
Using Barany rotary chair testing, a number of
investigators have reported a decrease in velocity of the
VOR slow component with maturation (Ornitz et al.,
1979; Tibbling, 1969; Wiener-Vacher et al., 1996). Maturational changes appeared to be larger during the first
year after birth and change more slowly thereafter into
adolescence. Although these results outline a temporal
profile, it is difficult to relate the findings to specific
components of the vestibular ocular reflex.
VOR gain provides better insight regarding the
effectiveness of vestibular reflex compensation for
head motion. VOR gain reportedly increased linearly
in a group of 120 children studied longitudinally over
the period from 3 to 9 years of age (e.g., mean gains,
3 years: 0.58 to 9 years: 0.82, for 0.5 Hz rotations; Casselbrant et al., 2010), whereas thereafter from young
adolescence to the adult, gain reportedly may decrease
slightly at some frequencies (Herman et al., 1982;
Valente, 2007). The findings of Charpiot et al. (2010)
also indicated a decreasing gain for a slightly older
group of children (6 to 12 years old). Others found
little difference in VOR gain over ages studied (7 to
12 years old; Horak et al., 1988; 3 months to 6 years:
Cyr et al., 1985). However, the range of ages and frequencies studied were somewhat different and sample
sizes were smaller in the latter cases, which may in part
account for differences in findings. At any given age the
variance for VOR gain in humans is quite large (e.g.,
Peterka et al., 1990a, 1990b). Nonetheless, there is support for the hypothesis that a slow systematic maturation of VOR gain (increasing mean) occurs in the young
child through preadolescence and small reductions in
mean gain from the second to third decade of life. In
addition to that cited above, evidence for this comes
from a large cross-sectional study of 261 individuals,
ages 7 to 81 years, which indicates a similar temporal
profile where VOR gains appear highest for ages 7 to
20 years and then decrease somewhat and remain relatively stable over the ages from 30 to 81 years (Peterka
et al., 1990a, 1990b). Changes in VOR gain are small
relative to the variance in any case. Controversy persists in the literature regarding maturation over ages
from approximately 10 to 30 years. In the future, it will
be important to use standardized methods and metrics
including standard frequencies and rotational velocities to minimize variability across studies. It would be
helpful to see large longitudinal studies providing normative data for VOR in children and adults through the
third decade of life. Such studies, although difficult to
achieve, would serve to clarify the profile of change in
the VOR over the human lifetime.
Computerized dynamic posturography (CDP)
includes a sensory organization test (SOT), which provides a measure of how effectively sensory information is used by an individual to maintain balance and
stability under dynamic postural challenge (see Chapter 15). SOT examines how one uses visual, somatosensory, and vestibular information to maintain balance
and quantifies, among other things, the amount of
sway exhibited. Several investigators have used the
SOT in children between the ages of 3 and 15 years to
characterize changes in balance skills with maturation
and to develop normative data on sensory weighting strategies (e.g., Casselbrant et al., 2010; Charpiot,
Tringali, Ionescu, Vital-Durand, & Ferber-Viart, 2010;
Hirabayashi & Iwasaki, 1995; Peterka & Black, 1990;
Peterson et al., 2006; Valente, 2007). The evidence suggests a steady improvement on vestibular tasks that
continues into late childhood and by some reports
into adolescent years when scores approached those of
adults. In general, skills in the use of vestibular sensory
input were the last to mature relative to use of somatosensory and visual cues for maintaining balance.
In summary, whereas the peripheral vestibular
apparatus is essentially mature at birth, central maturation continues into adolescence. The VOR can be
elicited in the neonate and it matures substantially
over the first three years. Improvement generally continues into adolescence when adult balance skills are
achieved. Although progress in our understanding has
been made, it should be clear that we are only meagerly
informed about the complex multisensory process of
maturation in human postural balance and vestibular reflex systems. Our understanding of human vestibular development would benefit substantially from

36 BAlAnCE FunCtion AssEssmEnt And mAnAgEmEnt
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additional research aimed at establishing normative
data over wider age ranges and improving our ability
to make functional assessments at all ages.
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3
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Practical Anatomy and Physiology
of the Ocular Motor System
Scott D. Z. Eggers
FUNCTIONAL CLASSES OF EYE MOVEMENTS
The common goal of all eye movements is to facilitate
a clear and stable view of the environment (Leigh &
Zee, 2006). Lateral-eyed animals like rabbits have
a large field of view to survey the environment and
avoid predators. But the brain cannot manage the data
processing requirements of a visual system with high
resolution across the entire visual field. Thus, lateraleyed animals generally have the tradeoff of poor visual
acuity. Birds of prey have evolved a visual compromise
by restricting their visual field in return for superior
visual acuity within that narrow field. Other frontaleyed animals like humans have developed a small area
of very high spatial resolution at the center of the retina
(the fovea) while maintaining lower resolution in the
periphery. This “foveal compromise” (Wong, 2008)
solves the problem of information overload but also
requires that the image of an object of interest fall on
the fovea for maximal visual acuity.
Mechanisms have evolved to complement this
foveal compromise strategy by ensuring that images of
interest are brought to and maintained on the foveae of
both eyes. Image stability on the retina must be maintained despite object or head motion, because image
“slip” across the retina or movement away from the
fovea leads to blur or degrades visual acuity. Thus, one
category of eye movements helps hold target images
steady on the retina. These include (1) active processes
of the visual fixation system to hold the image of sta-
tionary objects on the fovea when the head is still;
(2)
the vestibular system to hold target images steady
on the retina during brief head movements; and (3) the
optokinetic system to hold target images steady on the
retina during sustained head rotation. A second category of eye movements has evolved to direct the highresolution fovea to objects of interest. These include
(1) the saccadic system to bring a target image rapidly
onto the fovea; (2) the smooth pursuit system to hold
the image of a small moving target on the fovea; and
(3) the vergence system to move both eyes in opposite
directions (i.e., convergence or divergence) in order to
simultaneously place the target image onto both foveae
regardless of target distance or eccentricity (Table 3–1).
To fulfill these visual requirements, the ocular motor
system requires complex anatomy and physiology at
every level, from the extraocular muscles to cortical
ocular motor regions.
Visual Fixation
The fixation system holds the image of a stationary
target on the fovea while the head is still. Fixation
may be a special type of smooth pursuit (suppressing
unwanted drift of the eyes) or an independent fixation
system. Rather than simply the absence of visible eye
movements, visual fixation actually consists of constant
miniature movements not detectable to the naked eye,
with the illusion of steady fixation. Normal fixation
includes (1) microtremor (<0.01 degree, up to 150 Hz);
43
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