DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY REVIEW

Typical and atypical development of reaching and postural

control in infancy
MIJNA HADDERS-ALGRA

University of Groningen, University Medical Center Groningen, Department of Paediatrics – Developmental Neurology, Groningen, the Netherlands.
Correspondence to Dr Mijna Hadders-Algra, Department of Pediatrics – Developmental Neurology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands.
E-mail: [email protected]

Successful reaching requires postural control, either by active regulation or by postural

PUBLICATION DATA support. The present paper reviews literature on typical and atypical development of reaching
Accepted for publication 4th April 2013. and postural control during infancy. Typically, reaching movements end in grasping around
4 months of age. Initially, reaches are characterized by large variation, including many trajec-
ABBREVIATION tory corrections. During the first year, the movements get increasingly straight and smooth.
COP Centre of pressure Reaching in low-risk preterm infants is initially characterized by advanced development, but
minor impairments may emerge in the second half of infancy. In high-risk preterm infants,
development of reaching is characterized by delay and non-optimal reaching performance.
Typical development of postural adjustments is characterized by variation and an increasing
ability to adapt the variable repertoire to the specifics of the situation. The latter is facilitated
by an increasing role of anticipatory mechanisms in the second half of infancy. Atypically
developing infants may have a reduced repertoire and usually have difficulties in adapting
postural adjustments. In infancy, most reaching movements are performed during sitting.
The postural challenge of sitting may interfere in particular with the development of reaching
in atypically developing infants. The practical implications of this suggestion are discussed.

Many times a day we reach towards an object. Reaching is a task correlates of the improvement in reaching initially consist of an
involving extensive neural circuitries, in which primary motor and increase in movement velocity and a decrease in the number of
somatosensory cortices and frontal and parietal areas play promi- trajectory corrections.4,5 These corrections are termed movement
nent roles.1 Successful reaching requires postural control, either units and are sub-movements of reaching, which are determined
in the form of an active regulation of posture or in the form of with the help of peaks in the velocity profile of the hand.4 The
postural support. presence of multiple movement units emphasizes the probing
The aim of the present paper is to discuss the development of nature of early reaches and the heavy reliance of the first reach-
reaching and its associated postural control during infancy, in par- ing movements on feedback control mechanisms, in which vision
ticular in supine and sitting positions during the first postnatal only plays a limited role.6 From about 6 months onwards, devel-
year. The paper starts with a concise review of typical and atypi- opment of reaching continues at a slower pace, with a gradual
cal development of reaching. Next, it addresses typical and atypi- reduction of the number of movement units and a gradual
cal development of postural control and the relation between increase of the straightness of the reaching path. During this
reaching performance and infant position. It concludes with sug- period the role of vision in reaching performance increases.7 In
gestions for the promotion of reaching in atypically developing addition, the orientation of the hand during reaching gets
infants. increasingly adapted to the orientation and size of the object.7,8
This suggests an increasing role of anticipatory control, a sug-
DEVELOPMENT OF REACHING gestion that is corroborated by the study of Southgate et al.9
Typical development of reaching This study recorded electroencephalography activity in 9-month-
Successful reaching is preceded by various forms of pre-reaching old infants while they reached towards a toy and while they
activity. For instance, Von Hofsten2 demonstrated that newborn observed other persons reaching for a toy. Nine-month-old
infants move their hands closer to a nearby object when they infants, in contrast to 6-month-old infants,10 not only showed
visually fixate it than when they do not pay visual attention to attenuation of sensorimotor alpha-band activity during reaching
the object. Before the age of about 4 months, i.e. the age at but also during the observation of reaching. This suggests that –
which reaching usually results in grasping of the object, object- in 9-month-olds – neural activity during execution and observa-
oriented arm movements become increasingly smooth.3 At tion of actions overlaps (‘mirror neuron system’ activity). Inter-
4 months, reaching movements that result in grasping (‘success- estingly, when the infants had observed the reaching action a
ful’ reaches) are characterized by variation: variation in trajec- few times and could predict the event, the motor activation of
tory, in movement velocity, movement amplitude, and movement the infant’s brain during observation of reaching began before
duration.4,5 During the following months, reaching trajectories the observation of the action. The latter suggests the emergence
rapidly become more smooth and fluent. The kinematic of anticipatory motor control.

© The Author. Developmental Medicine & Child Neurology © 2013 Mac Keith Press, 55 (Suppl. 4): 5–8 DOI: 10.1111/dmcn.12298 5
Atypical development of reaching What this paper adds
Studies on atypical development of reaching are restricted to • Low risk preterm infants and high risk preterm infants show an atypical
high- and low-risk preterm infants. The development of reaching development of reaching, the latter group more pronounced than the former.
in low-risk preterm infants is initially characterized by perfor- • At risk infants have limited abilities to learn to adapt postural control to the
mance that is advanced compared with that of term peers (in specifics of the situation during reaching.
supine at 4mo* 11; in semi-reclined position at 6–7mo).12 Recently
it was shown that 20 minutes of daily movement training between still. Postural sway is often assessed by means of the behaviour of
2 and 4 months facilitates reaching behaviour and object manipu- the centre of pressure (COP) at the base of support. Formerly, it
lation in preterm infants.13 Despite the favourable findings in was thought that postural sway was an expression of ‘neuromechan-
early infancy, low-risk preterm infants have less efficient reaching ical noise’, but current evidence suggests that postural sway may be
movements in the second half of the first year when they try to considered as an active process of the nervous system, reflecting its
catch a moving object.14 search of the limits of stability.16 This searching behaviour is also
High-risk preterm infants often show some delay in the devel- expressed by the variable behaviour of the COP of young infants
opment of the clinically observable characteristics of reaching and lying supine.20 The main findings of the studies on development of
grasping.15 They also more frequently show reaches with non- postural sway in sitting infants are intra-individual and inter-indi-
optimal kinematic characteristics at 6 months.11 The latter turned vidual variation and the presence of phases of transition.21,22 For
out to be associated with the presence of the complex form of instance, the study by Harbourne and Stergiou21 indicated that the
minor neurological dysfunction and fine manipulative disability at emergence of the ability to sit independently was accompanied by
the age of 6 years.16 selection of a specific set of postural behaviours, which temporarily
was accompanied by a freezing of degrees of freedom.
DEVELOPMENT OF POSTURAL CONTROL The perturbation studies showed that already at 1 month of
Postural organization age direction-specific postural adjustments are present in 70 to
Postural control involves the regulation of the relative position of 85% of perturbations.23 This suggests that direction-specificity
parts of the body and that of the whole body with respect to a has an innate origin. At 6 months of age, the rate of direction-
reference frame. A major goal of the latter aspect of postural con- specific adjustments has increased to over 90% and from 7 to
trol is to keep the projection of the centre of mass within the 8 months onwards infants respond virtually always with direction-
margins of the support surface, i.e. to keep balance. The complex- specific adjustments.24 The adjustments are characterized by vari-
ity of postural control is illustrated by the fact that almost all ation: variation in which muscles are recruited and when and how
parts of the brain are engaged in the control of posture.17 much they are recruited. Within the variation, a gradual selection
In the control of posture two functional levels can be distin- process emerges from 3 months onwards. The infant increasingly
guished.18 The basic level deals with the generation of direction- often selects the adjustment in which all direction-specific muscles
specific adjustments. This means that dorsal muscles are primarily are recruited.24 This so-called ‘complete’ pattern is associated
activated when the body sways forwards, whereas ventral muscles with a better stability of the head in space.25 At 9 to 10 months
are primarily activated when the body sways backwards. The sec- the ‘complete’ pattern is selected in 70 to 100% of the perturba-
ond level is involved in adaptation of the direction-specific adjust- tions. At this age also, a more subtle form of adaptation of the
ments on the basis of multisensorial afferent input from postural adjustments develops, namely the ability to adapt EMG
somatosensory, visual, and vestibular systems. This adaptation can amplitude to the degree of perturbation and to initial sitting posi-
be achieved in various ways, for instance by changing the recruit- tion.25 Both the selection of the ‘complete’ pattern and the ability
ment order of the direction-specific muscles or by modifying the to modulate EMG amplitude are significantly promoted by daily
size of the muscle contraction (electromyogram [EMG] practice.26 The recruitment order of the direction-specific muscles
amplitude).19 remains highly variable during the first year.24,25
Postural control during external perturbations mainly involves
reactive control, whereas postural control during reaching more
Typical development of postural control
heavily relies on anticipatory postural mechanisms. Both situations
Postural control does not develop as a solitary entity; the develop-
also differ in the size of the postural perturbation: it is rather gross
ment of posture and motility is closely intertwined. The intimate
during the perturbation experiments and relatively subtle during
relationship of the development of the two aspects of motor behav-
reaching. The latter is presumably the reason why only 40 to 50%
iour is not only due to the fact that goal directed motility practically
of postural adjustments accompanying reaching movements during
always requires postural adjustments, but also to the fact that the
early infancy are direction-specific.27,28 The rate of direction-spe-
development of both posture and motility are the result of long last-
cific adjustments rises slowly during the first year of life, to reach
ing developmental processes in the nervous system.19
60% and about 100% at 1½ and 2 years respectively.28,29 During
A few studies addressed typical development of postural control
reaching the ‘complete’ pattern is the dominant pattern from early
in infancy. The studies mainly used three types of design: (1) eval-
age onwards.28 The recruitment order of the direction-specific
uation of postural sway; (2) application of external perturbation,
muscles during reaching is highly variable. However, within the
meaning that the infant sits on a support surface that makes an
variation the infant’s preference gradually changes during the first
abrupt movement; and (3) assessment of postural control during
year from top-down to bottom-up recruitment.28 Throughout
reaching. The last two approaches usually include the recording
infancy approximately one-third of reaches is accompanied by
of surface EMGs with or without kinematics.
anticipatory postural muscle activity.28
Postural sway is the phenomenon that occurs when a person tries
to sit or stand still. It is almost impossible to keep the body entirely
Atypical development of postural control
It is well known that infants at high risk for developmental disor-
*
Note that age is consistently reported in terms of corrected age. ders, such as preterm infants, frequently exhibit deviancies in

6 Developmental Medicine & Child Neurology 2013, 55 (Suppl. 4): 5–8

postural development. Examples are a delayed development of performed in semi-reclined sitting end more often in successful
postural milestones (e.g. sitting independently),30 and hyperexten- grasping and consist of fewer movement units than those per-
sion of neck and trunk or transient dystonia.31 But relatively little formed supine.37,38 Presumably, the worse performance in supine
is known about the neural organization of postural control of may be attributed to the larger challenge of the reaching arm by
high-risk infants. the forces of gravity in supine compared with the sitting situation.
Kyvelidou et al.32 studied postural sway by means of COP Anyway, the difference cannot be explained by a difference in pos-
behaviour in infants with typical development, developmental tural challenge, as this challenge is larger in sitting than in supine.
delay, and cerebral palsy (CP) when they were just able to sit The latter is illustrated by the finding that in supine the success of
independently (at the ages of 5, 12, and 16mo respectively). Total reaching of young infants does not depend on the presence of
sway path and range of mediolateral sway of infants who devel- direction-specific postural adjustments. However, in the sitting
oped CP was smaller than that of typically developing infants, position the presence of direction specificity is associated with
suggesting a rather rigid posture with limited variation in the more success of reaching.27
frontal plane in infants with CP. Additional nonlinear data on the
temporal organization of postural sway indicated that the infants CONCLUSION
with CP had a severely limited repertoire of adjustments, those During the first year of life, typical development of reaching and
with developmental delay a moderately reduced repertoire, postural control is characterized by variation and an increasing
whereas typically developing infants had a large and flexible reper- ability to adapt the variable repertoire to the specifics of the situa-
toire in which fast control mechanisms seemed to play a role.33 tion. The latter is facilitated by an increasing role of anticipatory
Postural behaviour during reaching has been studied in low- mechanisms and vision beyond the age of 6 months. Atypically
and high-risk preterm infants and in infants developing CP. The developing infants may have a reduced repertoire and usually have
study of Fallang et al.34 on COP behaviour during reaching in difficulties in adapting motor behaviour.
supine at 4 and 6 months indicated that both low- and high-risk In infancy, reaching movements are performed in supine and
preterm infants showed a remarkable still COP behaviour. This sitting positions. However, the sitting position challenges pos-
still behaviour was associated with better reaching at 6 months, tural control more than the supine position. This may imply
but with a less optimal neurological condition and worse motor that in atypically developing infants, whose postural control is
abilities at 6 years.16,34 The still COP behaviour may correspond impaired, reaching is particularly difficult in sitting. Future stud-
to the finding of Van der Fits et al.35 that, throughout infancy, ies need to address this issue, as it has practical implications. If
preterm infants exhibit excessive postural muscle activity during the development of reaching is hampered, especially in the sit-
reaching. This excessive postural activity is also temporally disor- ting position, guidance preferably should include three compo-
ganized and – in older infants – cannot be modulated appropri- nents:39 (1) practice of balance control during daily activities,
ately with respect to the velocity of the arm movement and the such as bathing, dressing, and playing; (2) provision of situations
initial sitting position. It is conceivable that this disability to mod- in which the infant may easily experience the joy of reaching
ulate postural adjustments is due to a reduced capacity to learn and grasping a toy, i.e. in supine position or in sitting situations
from previous experience.35 with substantial postural support, for instance on the parent’s
The study that evaluated the development of postural adjust- lap or in an infant chair with additional cushions supporting the
ments in seven infants developing CP showed that six had direc- infant’s trunk; and (3) challenge of infant reaching in sitting sit-
tion-specific adjustments.36 By the end of the first year, the uations that require substantial active postural control. In other
infants’ most prominent problem was a limited capacity to modu- words, families of atypically developing infants need to be
late EMG amplitude to the specifics of the situation, comparable informed about the many different ways in which infant develop-
to the impairment of the preterm infants. The seventh infant, ment may be promoted.39
who had the most severe form of CP (Gross Motor Function
Classification System level V), did not show direction-specific
adjustments throughout infancy.36 A CK N O W L E D G E M E N T S
I gratefully acknowledge Lieke van Balen, Tineke Dirks, and Elisa
Hamer for comments on a previous draft of the manuscript.
Position, posture, and reaching in infancy
Only a few studies in typically developing infants addressed the
relations between position, posture, and reaching. The available CONFLICTS OF INTEREST
data suggest that, until the age of 6 months, reaching movements The author reports no conflicts of interest.

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