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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
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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