**3. Background**

#### **3.1 Developmental coordination disorder. Old problems but a new label**

The vignettes, above, from Binet and Simon (Strauss & Lehtinen, 1947), Orton (1937) and Annell (1949) show that the sensorimotor and concentration problems we face today among children and adolescents are far from new. It is obvious that sensorimotor difficulties have been a documented companion to mental retardation as well as to learning disorders throughout the last century. What is now labeled DCD (Pennington, 2000) has previously been recognized under different names such as 'motor deficiency', 'congenital maladroitness', and 'minimal brain dysfunction'. As a motor skills disorder, DCD is described as follows in DSM-IV (American Psychiatric Association, 1994);

"The essential feature of Developmental Coordination Disorder is a marked impairment in the development of motor coordination (Criterion A). The diagnosis is made only if this impairment significantly interferes with academic achievement or activities of daily living (Criterion B). The diagnosis is made if the coordination difficulties are not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy) and the criteria are not met for Pervasive Developmental Disorder (Criterion C). If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it (Criterion D). The manifestations of this disorder vary with age and development. For example, younger children may display clumsiness and delays in achieving developmental motor milestones (e.g., walking, crawling, sitting, tying shoelaces, buttoning shirts, zipping pants). Older children may display difficulties with the motor aspects of assembling puzzles, building models, playing ball, and printing or handwriting" (pp.53-54).

It is a pity that still, after at least 100 years, we lack sufficient methods to help those affected.

One reason might be that for a long time the child was supposed to 'out-grow' his problems.

Another reason might be a lack of consensus. As mentioned above, because of the difficulty of measuring the appropriate index, problems organic in nature might be diagnosed as functional, and vice versa. Gillberg and Kadesjö (2009) give the example of Attention Deficit Disorders (ADDs) and DCD. DCD and motor clumsiness are traditionally considered to be within the territory of a child neurologist or a developmental pediatrician while ADDs, including ADHD, typically fall within the domain of child psychiatry and psychology. "This 'split' may explain the fact that few psychiatrists are aware of the implications of the motor and perceptual problems that are so often comorbid with childhood ADHD. Conversely, child neurologists often fail to appreciate the effect of attention deficits on the lives of the clumsy children whom they see for diagnosis and workup" (p.305).

My second assumption, which is connected to education, is that change is possible from

My third assumption is that information and education are complementary and that a pedagogical challenge will be to evaluate how they can counterbalance each other according

My fourth assumption is that it might be possible that learning disabilities to a higher

The vignettes, above, from Binet and Simon (Strauss & Lehtinen, 1947), Orton (1937) and Annell (1949) show that the sensorimotor and concentration problems we face today among children and adolescents are far from new. It is obvious that sensorimotor difficulties have been a documented companion to mental retardation as well as to learning disorders throughout the last century. What is now labeled DCD (Pennington, 2000) has previously been recognized under different names such as 'motor deficiency', 'congenital maladroitness', and 'minimal brain dysfunction'. As a motor skills disorder, DCD is

"The essential feature of Developmental Coordination Disorder is a marked impairment in the development of motor coordination (Criterion A). The diagnosis is made only if this impairment significantly interferes with academic achievement or activities of daily living (Criterion B). The diagnosis is made if the coordination difficulties are not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy) and the criteria are not met for Pervasive Developmental Disorder (Criterion C). If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it (Criterion D). The manifestations of this disorder vary with age and development. For example, younger children may display clumsiness and delays in achieving developmental motor milestones (e.g., walking, crawling, sitting, tying shoelaces, buttoning shirts, zipping pants). Older children may display difficulties with the motor aspects of assembling puzzles, building

It is a pity that still, after at least 100 years, we lack sufficient methods to help those affected. One reason might be that for a long time the child was supposed to 'out-grow' his problems. Another reason might be a lack of consensus. As mentioned above, because of the difficulty of measuring the appropriate index, problems organic in nature might be diagnosed as functional, and vice versa. Gillberg and Kadesjö (2009) give the example of Attention Deficit Disorders (ADDs) and DCD. DCD and motor clumsiness are traditionally considered to be within the territory of a child neurologist or a developmental pediatrician while ADDs, including ADHD, typically fall within the domain of child psychiatry and psychology. "This 'split' may explain the fact that few psychiatrists are aware of the implications of the motor and perceptual problems that are so often comorbid with childhood ADHD. Conversely, child neurologists often fail to appreciate the effect of attention deficits on the lives of the

degree than previously realized are due to sensorimotor immaturity.

**3.1 Developmental coordination disorder. Old problems but a new label** 

described as follows in DSM-IV (American Psychiatric Association, 1994);

models, playing ball, and printing or handwriting" (pp.53-54).

clumsy children whom they see for diagnosis and workup" (p.305).

within and that such change is of a second-order.

to the special needs of the child.

**3. Background** 

A third reason might be the fact that no method, so far, has proved to be effective enough. Several longitudinal studies of DCD (Polatajko, 1999) show that motor problems persist and that other parts of the child's development are affected. Meanwhile a lot of research concerning diagnoses and conceptual issues has been published while few, if any, (Polatajko, Rodger, Dhillon, & Hirji, 2004) cohesive training methods have been developed, evaluated and used. Polatjko *et al.* (2004) end their review by stressing the importance and need for rigorous research to explore methods of treatment suitable for DCD. The method Retraining for Balance, to be presented below, is a new strong candidate which in initial studies (Niklasson, Niklasson, & Norlander, 2009; 2010) has shown not only promising results but also has opened up a novel perspective on sensorimotor training. This novel perspective might give us a hint as to why previous methods have failed to break through. I will tentatively discuss this below.

To conclude; for progress to be possible, there has to be, not only an extended co-operation between different faculties but also a recognition from the scientific community of the need for the development and evaluation of therapy methods.

Coming from the field of education, I have written this chapter in dialogue with representatives from two other fields of science, child neurology and psychology, each with its special interest in the wellbeing of the child. One has argued elsewhere for an early screening and detection of ADHD and DCD (Rasmussen & Gillberg, 2000) not least since coexistence (comorbidity) means that poor psychosocial functioning is very likely. Two of us have previously (Niklasson, *et al.,* 2009; 2010) evaluated a method for sensorimotor therapy, Retraining for Balance. Together we have published (Niklasson, Rasmussen, & Norlander, 2010) a call for the importance of further studies. At this time there exists no standardized manual for the testing of primitive/primary reflexes in older children and adolescents. Therefore, we have recently started such a study.

#### **3.2 Different approaches to sensorimotor training**

Techniques used in formalized sensorimotor training differ both from a theoretical and a methodological perspective. Pless (2001) makes a distinction between General Abilities Approach (GAA), Sensory Integration Approach (SIA) and Special Skills Approach (SSA). The GAA proposes that age-appropriate reflexes, postural reactions, and perceptuomotor proficiency form the basis of functional motor ability and the development of thought processes. The SIA stresses vestibular stimulation and suggests that sensory integration might be the basis for language, motor and intellectual development. According to the SSA, finally, more sophisticated motor skills are formed by specific motor learning.

### **3.3 Retraining for balance - An introduction**

The method Retraining for Balance (RB) can be considered as a mixture between the approaches of GAA and SIA. The concepts of primary reflexes and postural reactions are borrowed from GAA while the theoretical foundation of vestibular stimulation is borrowed from SIA. The basic GAA perspective, theoretically and practically used in RB was developed by Peter Blythe (Goddard Blythe, 2009) at the Institute for Neuro-Physiological Psychology (INPP) in Chester, Great Britain. Peter Blythe and Sally Goddard Blythe have over the last 20 years very successfully spread their work globally and a lot of practitioners

Could Motor Development Be an Emergent Property of Vestibular Stimulation

**3.5 Semantics and concepts** 

explanation of how the brain works" (pp. 122-123).

mentioning.

appropriate;

(1994) use 'archaic'.

and Primary Reflex Inhibition? A Tentative Approach to Sensorimotor Therapy 251

retained primitive reflexes (grasp, snout and sucking), a deficit in sensory integration and subtle deficits in sequencing of complex motor functions and in motor coordination. Children diagnosed with DCD (Polatajko, 1999) don't show any clear-cut evidence of neuropathology or neurological 'hard' signs but they might show 'soft' neurological signs.

As neonates (Illingworth, 1987) we were all equipped with about 70 brainstem mediated primitive (primary) reflexes, some of which were closely connected to the vestibular system. To begin with these reflexes were like a 'survival kit' and easy to elicit. During the first year of life (Capute, & Accardo, 1991) as the nervous system matured and voluntary motor activity emerged they became more difficult to elicit. These early reflexes (Chrutchfield, & Barnes, 1993) are traditionally called 'primitive' either because they are thought not to persist throughout life or "because the infant's brain is considered to be a primitiveunderdeveloped, incompetent, deficient- edition of the adult brain" (Touwen, 1984 p.115). There are, however, some controversies surrounding the concept which are worth

First, Touwen (1984) argues that neither the concept 'primitive' nor the concept 'reflex' are

"In a conception of the developing brain which emphasizes the involvement of the whole system in all changes during development, and that considers the healthy infant's brain as an age-specific and age-adequate organ system, it is no longer valid to use the term 'primitive reflexes'. The word 'primitive' is simply inadequate. Purely stereotyped reflexes do not occur, although reflex mechanisms may be hidden by the variable display of the infant's complex brain. Reflexes and reactions, and their developmental course, are useful in the neurological examination of infants but their existence in itself is not an adequate

I agree with Touwen when he writes (p.120) that the concept used mirrors ones view of the developing brain. In line with his discussion, with Bergström (1972, 1989) and also with Gesell (1988) we have used the concept 'behavioral movement patterns' as a complementary term (Niklasson, *et al.*, 2009). Other authors, for example McPhillips, Hepper, and Mulhem (2000), use the term 'primary reflexes' while French authors such as Mehler and Dupoux

Second, there is a controversy as to whether,' the reflexes' persist throughout life or not. Paulsen and Gottlieb (1968) state "Senile and presenile patients who are demented may show several responses which can be called developmental, foetal or primitive reflexes. These responses are normally present during the early maturation of the central nervous system and they may reappear when the central nervous system has been altered by age and disease" (p.37). "The initial background from which the primitive reflex arose apparently still remains, and any foetal reflex responses may reappear whenever higher controls are weakened" (p.50). This view is shared by Teitelbaum (1967) who finds it obvious that the reflexes remain within the nervous system but as Jean Ayres (1973) concludes "the degree to which a person suppresses or attains mastery over them usually reflects the degree of maturation and integration of postural mechanisms" (p.80). A possible

are using their method. Although Blythe stresses the importance of vestibular stimulation (Vose, 1986), it is the ground breaking work of Jean Ayres (1973) which is to be regarded as foremost in the SIA approach.

In the early 1990s, the INPP- guidelines for how to carry out assessments (Goddard, 1990) and use exercises were strictly mechanical and linear. The meaning being, that when through assessment you identified certain immaturities (to be explained below) you were supposed to use certain exercises in a 'goal directed' way. This meant that some children went through training using just a few exercises while others had to use more exercises and the duration and content became rather different from child to child. Vestibularis, a private practice in Sweden, was not satisfied with the results achieved whilst working in this way. It had noticed that some exercises seemed more powerful than others and this inspired the attempt to create a harmonious totality of the different movements (Niklasson, Niklasson, & Bergström, 1999, 2007). To put it 'poetically', something more like soft and round rather than sharp and strait. Vestibularis' modification or rather re-construction was named 'Retraining for Balance' and aimed at forming a method with a common start and end and with a sense of cohesion between exercises. The re-construction and further development was influenced by theories from research carried out by the Finish brain neurophysiologist and physicist Matti Bergström, who also took an active part as an advisor. Bergström had previously suggested (1967, 1972, 1989) that, "The psychological state is a macrostate of the same system of which the physical state is a microstate" (1989, p. 130). Coming from another angle, Paul Schilder (1886-1940) much earlier appears to be "the first psychiatrist to view the human psyche as a physical phenomenon" (Hubbard, & Wright, 1984). This was also what empirically became obvious during training when different movement patterns seemed to affect behavior in different ways. I will return to this below.

#### **3.4 Primitive reflexes and neurological soft signs**

Among psychologists, the 'reflex' is recognized as a basic aspect of physiological psychology (Clarke, & Jacyna, 1987) and given a certain status. Although the papillary reflex (Flugel, 1933) was observed by Galen (A.D 129-199) and the word 'reflex' was used by Jean Astruc (1684-1766) the concept did not reach widespread recognition until the substantive 'the reflex' (Clarke, & Jacyna, 1987) was coined by Marshall Hall in 1833 and used in a biological and purely mechanical sense. Through his research on decapitated animals (Flugel, 1933) he had observed that by proper stimulation certain kinds of bodily movements were elicited with the help of the spinal cord and the peripheral nerves. These movements were independent of the brain and therefore had another character compared to voluntary and conscious movements. One of the first to document the development of infant reflexes from birth and beyond, through experience and learning, was W. Preyer (1841-1897) a pioneer in the science of child psychology. Preyer who was a physiologist born in England and working in Germany published 'Die Seele des Kindes' (On the Soul of the Child) in 1882.

The concept 'neurological soft signs' (NSS) (Ayd jr, 2000) is used to describe neurological aberrations not believed to constitute well-defined neurological disturbances. Because they are difficult to localize, NSS might sometimes be considered as reflecting a diffuse brain dysfunction, but they nonetheless are frequent among youths with hyperactivity and emotional disorders. According to Mitchell (2003), NSS are of importance because they are rarely present in healthy controls. There is no standard list of NSS but the concept includes retained primitive reflexes (grasp, snout and sucking), a deficit in sensory integration and subtle deficits in sequencing of complex motor functions and in motor coordination. Children diagnosed with DCD (Polatajko, 1999) don't show any clear-cut evidence of neuropathology or neurological 'hard' signs but they might show 'soft' neurological signs.

#### **3.5 Semantics and concepts**

250 Learning Disabilities

are using their method. Although Blythe stresses the importance of vestibular stimulation (Vose, 1986), it is the ground breaking work of Jean Ayres (1973) which is to be regarded as

In the early 1990s, the INPP- guidelines for how to carry out assessments (Goddard, 1990) and use exercises were strictly mechanical and linear. The meaning being, that when through assessment you identified certain immaturities (to be explained below) you were supposed to use certain exercises in a 'goal directed' way. This meant that some children went through training using just a few exercises while others had to use more exercises and the duration and content became rather different from child to child. Vestibularis, a private practice in Sweden, was not satisfied with the results achieved whilst working in this way. It had noticed that some exercises seemed more powerful than others and this inspired the attempt to create a harmonious totality of the different movements (Niklasson, Niklasson, & Bergström, 1999, 2007). To put it 'poetically', something more like soft and round rather than sharp and strait. Vestibularis' modification or rather re-construction was named 'Retraining for Balance' and aimed at forming a method with a common start and end and with a sense of cohesion between exercises. The re-construction and further development was influenced by theories from research carried out by the Finish brain neurophysiologist and physicist Matti Bergström, who also took an active part as an advisor. Bergström had previously suggested (1967, 1972, 1989) that, "The psychological state is a macrostate of the same system of which the physical state is a microstate" (1989, p. 130). Coming from another angle, Paul Schilder (1886-1940) much earlier appears to be "the first psychiatrist to view the human psyche as a physical phenomenon" (Hubbard, & Wright, 1984). This was also what empirically became obvious during training when different movement patterns seemed to

Among psychologists, the 'reflex' is recognized as a basic aspect of physiological psychology (Clarke, & Jacyna, 1987) and given a certain status. Although the papillary reflex (Flugel, 1933) was observed by Galen (A.D 129-199) and the word 'reflex' was used by Jean Astruc (1684-1766) the concept did not reach widespread recognition until the substantive 'the reflex' (Clarke, & Jacyna, 1987) was coined by Marshall Hall in 1833 and used in a biological and purely mechanical sense. Through his research on decapitated animals (Flugel, 1933) he had observed that by proper stimulation certain kinds of bodily movements were elicited with the help of the spinal cord and the peripheral nerves. These movements were independent of the brain and therefore had another character compared to voluntary and conscious movements. One of the first to document the development of infant reflexes from birth and beyond, through experience and learning, was W. Preyer (1841-1897) a pioneer in the science of child psychology. Preyer who was a physiologist born in England and working in Germany published 'Die Seele des Kindes' (On the Soul of the Child) in 1882.

The concept 'neurological soft signs' (NSS) (Ayd jr, 2000) is used to describe neurological aberrations not believed to constitute well-defined neurological disturbances. Because they are difficult to localize, NSS might sometimes be considered as reflecting a diffuse brain dysfunction, but they nonetheless are frequent among youths with hyperactivity and emotional disorders. According to Mitchell (2003), NSS are of importance because they are rarely present in healthy controls. There is no standard list of NSS but the concept includes

foremost in the SIA approach.

affect behavior in different ways. I will return to this below.

**3.4 Primitive reflexes and neurological soft signs** 

As neonates (Illingworth, 1987) we were all equipped with about 70 brainstem mediated primitive (primary) reflexes, some of which were closely connected to the vestibular system. To begin with these reflexes were like a 'survival kit' and easy to elicit. During the first year of life (Capute, & Accardo, 1991) as the nervous system matured and voluntary motor activity emerged they became more difficult to elicit. These early reflexes (Chrutchfield, & Barnes, 1993) are traditionally called 'primitive' either because they are thought not to persist throughout life or "because the infant's brain is considered to be a primitiveunderdeveloped, incompetent, deficient- edition of the adult brain" (Touwen, 1984 p.115). There are, however, some controversies surrounding the concept which are worth mentioning.

First, Touwen (1984) argues that neither the concept 'primitive' nor the concept 'reflex' are appropriate;

"In a conception of the developing brain which emphasizes the involvement of the whole system in all changes during development, and that considers the healthy infant's brain as an age-specific and age-adequate organ system, it is no longer valid to use the term 'primitive reflexes'. The word 'primitive' is simply inadequate. Purely stereotyped reflexes do not occur, although reflex mechanisms may be hidden by the variable display of the infant's complex brain. Reflexes and reactions, and their developmental course, are useful in the neurological examination of infants but their existence in itself is not an adequate explanation of how the brain works" (pp. 122-123).

I agree with Touwen when he writes (p.120) that the concept used mirrors ones view of the developing brain. In line with his discussion, with Bergström (1972, 1989) and also with Gesell (1988) we have used the concept 'behavioral movement patterns' as a complementary term (Niklasson, *et al.*, 2009). Other authors, for example McPhillips, Hepper, and Mulhem (2000), use the term 'primary reflexes' while French authors such as Mehler and Dupoux (1994) use 'archaic'.

Second, there is a controversy as to whether,' the reflexes' persist throughout life or not. Paulsen and Gottlieb (1968) state "Senile and presenile patients who are demented may show several responses which can be called developmental, foetal or primitive reflexes. These responses are normally present during the early maturation of the central nervous system and they may reappear when the central nervous system has been altered by age and disease" (p.37). "The initial background from which the primitive reflex arose apparently still remains, and any foetal reflex responses may reappear whenever higher controls are weakened" (p.50). This view is shared by Teitelbaum (1967) who finds it obvious that the reflexes remain within the nervous system but as Jean Ayres (1973) concludes "the degree to which a person suppresses or attains mastery over them usually reflects the degree of maturation and integration of postural mechanisms" (p.80). A possible

Could Motor Development Be an Emergent Property of Vestibular Stimulation

especially as Aristotle once wrote (Berthoz, 2000),

'proprioceptive'.

(pp 57-58).

and by sight" (book II, ch.6).

and Primary Reflex Inhibition? A Tentative Approach to Sensorimotor Therapy 253

medium and particular organ. Among the senses he considered touch to be primary. I will return to Aristotle and the senses below but first let me take a leap forward in history.

In the late 18th century (Finger, 1994, Wade, 2009), observations gave empirical support for a separation of a muscle sense from touch. The British neurologist Henry Charlton Bastian (1837-1915) who was a devoted researcher on this muscle sense believed that information, necessary for the brain's coordination of motor acts, was provided by the muscles. In 1880 he coined the term 'kinaesthetic' a concept replaced in 1906 by Sherrington's term

The late 18th and early 19th centuries were very active and fruitful years for physiological research. Although giddiness and vertigo (Wade, 2009) had been well known phenomena described mostly in medical terms since ancient times it took a long time for science to connect the feelings to the vestibular system. By 1765, Robert Whytt included vertigo among the symptoms caused by nervous diseases. In 1803, Bell discussed diseases of the inner ear documenting that an inflammation around the auditory nerve also gave an increased sensitivity for vertigo but concluded "Of the diseases of the labyrinth, there is little on the record" (p.71). The gross anatomy of the labyrinth was known but its function was not understood. Through the interest in vertigo, the vestibular system was obviously investigated indirectly. William Charles Wells (1757-1817) who carried out research on postrotational vertigo and nystagmus was later to be recognized as the first to give "…the first clear behavioral evidence for the vestibular sense" (p.75). Theoretically, he also understood that some neurological system must register the body's position in relation to gravity but he never came up with an answer. The answer was provided in the 20th century when the electron microscope was invented and scientists were able to identify hair cells in the cochlea and later in the vestibular system. By habit or tradition the senses had been studied separately and it was not until the 1960s (Berthoz, 2000) that physiologists realized the importance of studying the combining of sensations. In the light of history this is strange

"We perceive things as a whole, rather than what some may refer to as a continuity of their parts. Yet we can say that things do not always appear to us as they are; and that is why the size of the sun as we see it is not its true size. But let us return to our earlier question, whether we can perceive several things simultaneously, that is, in a single part of the soul, in an indivisible moment. It has been proved that the soul perceives all sensations with one and the same faculty, which collects the information from all the senses. Yet this faculty, though numerically one, differs in its accounts: it is the same soul, but differently disposed"

In 'De Anima', 'On the soul', (Aristotle, 1992) book II and III, Aristotle discusses the senses and concludes that there could not be more than five. Yet, he argues, each sense is not enough to explain the totality of sensory experience and proposes the perceptual phenomena 'common sensibles'. "'Common sensibles' are movement, rest, number, figure, magnitude; these are at any rate certain kinds of movement which are perceptible by touch

In book III, chapter 1 he advises, as interpreted by Alexander of Aphrodisias, (Heller-Roazen, 2007) that "There Is Something with which We Sense Everything Simultaneously" (p.48). Throughout history the term has been used and discussed within Greek, Arabic and

regression to lower level brain activity when higher levels are impaired, resulting in primitive motor behavior is suggested by Bergström (1963). Jacobs and Gossman (1980) investigated certain primitive reflexes and found them active in healthy adults. So did van Boxtel, Bosma, Jolles, and Vreeling (2006) who found their increased prevalence with age but that their presence could not be a marker of cognitive decline. Touwen (1984) on the other hand, considered the morphological difference between the adult's brain and the infant's brain. Emphasizing their different functions, he argued that the adult's ageing brain and the infant's healthy brain cannot possibly display identical mechanisms. Although I agree with Touwen's semantic objections, sensorimotor training according to RB is based upon the concept of the possible life long persistence of 'behavioral movement patterns'. However, in order for me to be consistent with most literature I will use the concepts primitive/primary reflexes until my conclusion.

#### **3.6 Primitive reflex inhibition and the emergence of postural reactions and gross motor milestones**

As primitive/primary reflexes are inhibited during the first year of life postural (bodyrighting) reactions (Morrison, 1985; Capute, & Accardo, 1991) as well as gross motor milestones such as rolling, creeping (locomotion in prone), and crawling (quadrupedal locomotion) appear. Gross motor milestones generally emerge during the 6th to 12th month. This is also one of the intervals when the vestibular system is most sensitive and receptive to stimulation (Ornitz, 1983). During the period when the child is creeping and crawling (Maurer & Maurer, 1989) it is also very likely that a more mature sense of balance develops.

#### **3.7 The common sense and the vestibular system**

The vestibular system can easily be seen purely anatomically, as just what it is, a part of the inner ear, physiologically responsible for balance, the detection of movement and closely connected to hearing but not recognized as one of our basic senses. As the main purpose of this chapter is an attempt to connect its physiological function with psychology and behavior, I shall leave it to the reader to consult any book in basic neuroscience in order to learn more about the structure and mechanics of the vestibular system, e.g. Guyton (1991).

The vestibular system is different from other senses not least because experiences after stimulation are not specifically located as they are with other senses. Wade (2009) explains, "we feel giddy or see the world spin rather than have a single sensation like sight or hearing" (p.79). One of the first to study its psychological implications was Paul Schilder who wrote (1942), "Organic changes in the vestibular apparatus will be reflected in the psychic structures. They will not only influence the tone, the vegetative system, and the attitudes of the body, but they must also change our whole perceptive apparatus and even our consciousness. These general considerations make it possible that the study of the vestibular apparatus may have great importance for the understanding of psychotic and neurotic states"(p.85).

Even before Aristotle (ca. 384-322 B.C), Greek philosophers discussed and described perception, much of which was collected by Theophrastus (ca. 370-286 B.C.) (Stratton, 1917). The senses, as analyzed by Aristotle himself (Heller-Roazen, 2007), were sight, hearing, smell, taste and touch and to each he added a corresponding proper object, characteristic

regression to lower level brain activity when higher levels are impaired, resulting in primitive motor behavior is suggested by Bergström (1963). Jacobs and Gossman (1980) investigated certain primitive reflexes and found them active in healthy adults. So did van Boxtel, Bosma, Jolles, and Vreeling (2006) who found their increased prevalence with age but that their presence could not be a marker of cognitive decline. Touwen (1984) on the other hand, considered the morphological difference between the adult's brain and the infant's brain. Emphasizing their different functions, he argued that the adult's ageing brain and the infant's healthy brain cannot possibly display identical mechanisms. Although I agree with Touwen's semantic objections, sensorimotor training according to RB is based upon the concept of the possible life long persistence of 'behavioral movement patterns'. However, in order for me to be consistent with most literature I will use the concepts

**3.6 Primitive reflex inhibition and the emergence of postural reactions and gross** 

As primitive/primary reflexes are inhibited during the first year of life postural (bodyrighting) reactions (Morrison, 1985; Capute, & Accardo, 1991) as well as gross motor milestones such as rolling, creeping (locomotion in prone), and crawling (quadrupedal locomotion) appear. Gross motor milestones generally emerge during the 6th to 12th month. This is also one of the intervals when the vestibular system is most sensitive and receptive to stimulation (Ornitz, 1983). During the period when the child is creeping and crawling (Maurer & Maurer, 1989) it is also very likely that a more mature sense of balance develops.

The vestibular system can easily be seen purely anatomically, as just what it is, a part of the inner ear, physiologically responsible for balance, the detection of movement and closely connected to hearing but not recognized as one of our basic senses. As the main purpose of this chapter is an attempt to connect its physiological function with psychology and behavior, I shall leave it to the reader to consult any book in basic neuroscience in order to learn more about the structure and mechanics of the vestibular system, e.g. Guyton (1991). The vestibular system is different from other senses not least because experiences after stimulation are not specifically located as they are with other senses. Wade (2009) explains, "we feel giddy or see the world spin rather than have a single sensation like sight or hearing" (p.79). One of the first to study its psychological implications was Paul Schilder who wrote (1942), "Organic changes in the vestibular apparatus will be reflected in the psychic structures. They will not only influence the tone, the vegetative system, and the attitudes of the body, but they must also change our whole perceptive apparatus and even our consciousness. These general considerations make it possible that the study of the vestibular apparatus may have great importance for the understanding of psychotic and

Even before Aristotle (ca. 384-322 B.C), Greek philosophers discussed and described perception, much of which was collected by Theophrastus (ca. 370-286 B.C.) (Stratton, 1917). The senses, as analyzed by Aristotle himself (Heller-Roazen, 2007), were sight, hearing, smell, taste and touch and to each he added a corresponding proper object, characteristic

primitive/primary reflexes until my conclusion.

**3.7 The common sense and the vestibular system** 

**motor milestones** 

neurotic states"(p.85).

medium and particular organ. Among the senses he considered touch to be primary. I will return to Aristotle and the senses below but first let me take a leap forward in history.

In the late 18th century (Finger, 1994, Wade, 2009), observations gave empirical support for a separation of a muscle sense from touch. The British neurologist Henry Charlton Bastian (1837-1915) who was a devoted researcher on this muscle sense believed that information, necessary for the brain's coordination of motor acts, was provided by the muscles. In 1880 he coined the term 'kinaesthetic' a concept replaced in 1906 by Sherrington's term 'proprioceptive'.

The late 18th and early 19th centuries were very active and fruitful years for physiological research. Although giddiness and vertigo (Wade, 2009) had been well known phenomena described mostly in medical terms since ancient times it took a long time for science to connect the feelings to the vestibular system. By 1765, Robert Whytt included vertigo among the symptoms caused by nervous diseases. In 1803, Bell discussed diseases of the inner ear documenting that an inflammation around the auditory nerve also gave an increased sensitivity for vertigo but concluded "Of the diseases of the labyrinth, there is little on the record" (p.71). The gross anatomy of the labyrinth was known but its function was not understood. Through the interest in vertigo, the vestibular system was obviously investigated indirectly. William Charles Wells (1757-1817) who carried out research on postrotational vertigo and nystagmus was later to be recognized as the first to give "…the first clear behavioral evidence for the vestibular sense" (p.75). Theoretically, he also understood that some neurological system must register the body's position in relation to gravity but he never came up with an answer. The answer was provided in the 20th century when the electron microscope was invented and scientists were able to identify hair cells in the cochlea and later in the vestibular system. By habit or tradition the senses had been studied separately and it was not until the 1960s (Berthoz, 2000) that physiologists realized the importance of studying the combining of sensations. In the light of history this is strange especially as Aristotle once wrote (Berthoz, 2000),

"We perceive things as a whole, rather than what some may refer to as a continuity of their parts. Yet we can say that things do not always appear to us as they are; and that is why the size of the sun as we see it is not its true size. But let us return to our earlier question, whether we can perceive several things simultaneously, that is, in a single part of the soul, in an indivisible moment. It has been proved that the soul perceives all sensations with one and the same faculty, which collects the information from all the senses. Yet this faculty, though numerically one, differs in its accounts: it is the same soul, but differently disposed" (pp 57-58).

In 'De Anima', 'On the soul', (Aristotle, 1992) book II and III, Aristotle discusses the senses and concludes that there could not be more than five. Yet, he argues, each sense is not enough to explain the totality of sensory experience and proposes the perceptual phenomena 'common sensibles'. "'Common sensibles' are movement, rest, number, figure, magnitude; these are at any rate certain kinds of movement which are perceptible by touch and by sight" (book II, ch.6).

In book III, chapter 1 he advises, as interpreted by Alexander of Aphrodisias, (Heller-Roazen, 2007) that "There Is Something with which We Sense Everything Simultaneously" (p.48). Throughout history the term has been used and discussed within Greek, Arabic and

Could Motor Development Be an Emergent Property of Vestibular Stimulation

and by Alan Turing in the 1950s. I will return to Prigogine's research below.

Gravitation (Rees, 2000) is the most perplexing of the basic forces of nature and still today is a mystery. The force is so fundamental that if we should start anew with intelligent life on another planet we would have to start with gravitation. As gravitation is always an attraction it is the organizing force for the cosmos. Even Isaac Newton (1642-1727) had difficulties understanding what gravitation really is. Just the scientific, mechanical explanation did not seem to satisfy him. It is said that he regarded Pythagoras´ (569-475 BC) concept 'music of the spheres' as a metaphor for the law of gravitation. Although (Torretti, 1999) Newton's most celebrated scientific achievement is the discovery of universal

**3.9 Music of the spheres** 

and Primary Reflex Inhibition? A Tentative Approach to Sensorimotor Therapy 255

In a scientific context it might seem a bit odd to write about us humans in a universal perspective but it is not only Bergström who holds this view. Further east, V.I Hasnulin, member of the Russian Academy of Medical Sciences Siberian Branch, wrote in a monograph (2004), "Every particle of a human body, as of any other material object is connected simultaneously by means of gravity with all the bodies in the Universe" (p.33). Appearing nine weeks after conception, the vestibular nuclei are functional by the eleventh week (Humphrey, 1965). At about the 21st week (Robbins, 1977; Larsen, 1993), aside from the interoceptive sensory receptors (sensory receptors in the walls of the thoracic, abdominal, and pelvic viscera), the vestibular system is the only sensory system which is mature. Although developed this early, some authors (Windle, 1971; Prechtl, 1984) believe that the system is inhibited during prenatal life. Others like Odent (1986) and Restak (1979) claim that the floating fetus is constantly stimulated by the mother's movements and registers its first perceptions through the vestibular system. It is because of this early maturation that the vestibular system is so important for brain development and "a disturbance of its function by any factor will be reflected in the formation of the whole nervous system" (Klosovskii, 1963, p. 116)). In favour of the proposition that the fetus reacts to the gravitational force (Hubbard, & Wright, 1984, Eliot, 2000) is the turning of its head into the head-down position weeks or days before birth. The first scientific evidence that the early development of the vestibular system is dependant upon gravitational stimulus was provided by a study (Ronca, & Alberts, 2000) on pregnant rats flown on the Space Shuttle. The rats, developed in space, had a limited sense of balance after delivery on earth. The study showed that the vestibular system needs the gravitational force to mature correctly. Meanwhile the British journal 'New Scientist' (MacKenzie, 2000) reported on a study involving a chemical reaction and the gravitational force. Initially, physicists insisted that the research was not worth doing because the force of gravitation on molecules was presumed to be too weak to affect chemical reactions, compared to other forces. However, the study (Papaseit, Pochon, & Tabony, 2000) was completed and results showed how gravitation had indeed influenced chemical reactions on the cellular level. The scientists studied microtubules, fibers made of a protein called tubulin. When cold solutions of mammalian tubulin mixed with GTP (an energy releasing compound) were adjusted to body temperature for a certain time, distinct bands of microtubules were formed at right angles to gravity. When the procedure was repeated in microgravity the bands pointed in all directions. This spontaneous generation of patterns in a chemical reaction, due to tiny environmental asymmetries, was the first experimental model of biological selforganization. The result had previously been predicted by the biophysicist Ilya Prigogine

Latin scholastic traditions. Thomas Aquinas wrote in 'Commentaria in Aristotelem' "it is by the common sense that we perceive that we are living" (p.162). Another man of the church, Jean d'Arckel (1314-1378) is ascribed with saying "The common sense is a power that embraces all proper things that affect the proper senses…We thus say that the common sense is the fountain and the source of all the individual senses, to which all sensible movement is brought back, as to its ultimate end…Some locate this capacity in the back of the brain, where the nerves of the five senses meet; others place it in the heart, since it is the fountain and the source of life" (pp.160-161). Returning to the 18th century (Clarke & Jacyna, 1987) and to Jiri Procháska (1749-1820), most famous for his publications about the reflex but also interested in 'sensorium commune', which for him was the place where the sensory impression turned into a motor message which activated the muscle. He proposed 'sensorium commune' to be located in the brain stem, spinal cord, cerebellum and thalamus. Consulting 'The Oxford Companion to the Mind' (2004) for an up to date definition of 'common sense' it says, "The original meaning is a 'common centre' or neural pool, into which all the five senses were supposed to contribute to give coherent perceptions, though the various senses are so very different" (p.193). From my point of view it is very tempting to think in terms of the vestibular system, knowing also that Schilder (1933) described the vestibular apparatus as a coordinating system for sensory functions, "The vestibular apparatus is an organ the function of which is directed against the isolation of the diverse functions of the body"(p.161). This is an opinion also held by Ayres (1973) who emphasized the importance of the functional integration of the senses. Could it be that Aristotle, the scholars and even the physiologists of the 18th century were intuitive forerunners to the discovery of the function of the vestibular system? Although Aristotle declares firmly that there is no sixth sense, he states that all form a unity through incidental perception (book III, ch.1). Over the centuries we have seen a slight movement from his original writing towards the essence of the vestibular system as it is understood today, especially with its closeness to proprioception and to the reticular formation. It is not unlikely that they, in their time, were closer to nature than we are today. However, none seems to have come up with a suggestion as to what makes the 'common sense' able to combine different perceptions in to a coherent one. The vestibular system together with the reticular formation (Guyton, 1991) and the proprioceptive system (Brodal, 1960, 2004; Robbins, 1977) appear to be good candidates for an integrating system as impulses from the five senses and from muscle joints are directly and indirectly received by vestibular nuclei. But which factor might be the integrating factor?

#### **3.8 The gravitational force**

Turning to Bergström (1997) the answer is the gravitational force;

 "We have to proceed from the premise that the human brain belongs to nature instead of being separated from it. This means, for us to understand child development and play, we must presume nature to be a larger system containing the brain as a smaller system which is influenced by incoming and outgoing information" (p.22).

He continues with a description of how the proprioceptors are driven by the gravitational force and how this force is a precondition for a proper brain stem function and for consciousness. "We can now understand that consciousness is basically transformed gravitation, thus being a 'planetary' quality bound to matter"(p.25). (These citations are translated from Swedish. For another summary in English, see Bergström, 1989).

Latin scholastic traditions. Thomas Aquinas wrote in 'Commentaria in Aristotelem' "it is by the common sense that we perceive that we are living" (p.162). Another man of the church, Jean d'Arckel (1314-1378) is ascribed with saying "The common sense is a power that embraces all proper things that affect the proper senses…We thus say that the common sense is the fountain and the source of all the individual senses, to which all sensible movement is brought back, as to its ultimate end…Some locate this capacity in the back of the brain, where the nerves of the five senses meet; others place it in the heart, since it is the fountain and the source of life" (pp.160-161). Returning to the 18th century (Clarke & Jacyna, 1987) and to Jiri Procháska (1749-1820), most famous for his publications about the reflex but also interested in 'sensorium commune', which for him was the place where the sensory impression turned into a motor message which activated the muscle. He proposed 'sensorium commune' to be located in the brain stem, spinal cord, cerebellum and thalamus. Consulting 'The Oxford Companion to the Mind' (2004) for an up to date definition of 'common sense' it says, "The original meaning is a 'common centre' or neural pool, into which all the five senses were supposed to contribute to give coherent perceptions, though the various senses are so very different" (p.193). From my point of view it is very tempting to think in terms of the vestibular system, knowing also that Schilder (1933) described the vestibular apparatus as a coordinating system for sensory functions, "The vestibular apparatus is an organ the function of which is directed against the isolation of the diverse functions of the body"(p.161). This is an opinion also held by Ayres (1973) who emphasized the importance of the functional integration of the senses. Could it be that Aristotle, the scholars and even the physiologists of the 18th century were intuitive forerunners to the discovery of the function of the vestibular system? Although Aristotle declares firmly that there is no sixth sense, he states that all form a unity through incidental perception (book III, ch.1). Over the centuries we have seen a slight movement from his original writing towards the essence of the vestibular system as it is understood today, especially with its closeness to proprioception and to the reticular formation. It is not unlikely that they, in their time, were closer to nature than we are today. However, none seems to have come up with a suggestion as to what makes the 'common sense' able to combine different perceptions in to a coherent one. The vestibular system together with the reticular formation (Guyton, 1991) and the proprioceptive system (Brodal, 1960, 2004; Robbins, 1977) appear to be good candidates for an integrating system as impulses from the five senses and from muscle joints are directly and indirectly received by vestibular nuclei. But which factor might be the integrating factor?

**3.8 The gravitational force** 

Turning to Bergström (1997) the answer is the gravitational force;

influenced by incoming and outgoing information" (p.22).

 "We have to proceed from the premise that the human brain belongs to nature instead of being separated from it. This means, for us to understand child development and play, we must presume nature to be a larger system containing the brain as a smaller system which is

He continues with a description of how the proprioceptors are driven by the gravitational force and how this force is a precondition for a proper brain stem function and for consciousness. "We can now understand that consciousness is basically transformed gravitation, thus being a 'planetary' quality bound to matter"(p.25). (These citations are

translated from Swedish. For another summary in English, see Bergström, 1989).

In a scientific context it might seem a bit odd to write about us humans in a universal perspective but it is not only Bergström who holds this view. Further east, V.I Hasnulin, member of the Russian Academy of Medical Sciences Siberian Branch, wrote in a monograph (2004), "Every particle of a human body, as of any other material object is connected simultaneously by means of gravity with all the bodies in the Universe" (p.33).

Appearing nine weeks after conception, the vestibular nuclei are functional by the eleventh week (Humphrey, 1965). At about the 21st week (Robbins, 1977; Larsen, 1993), aside from the interoceptive sensory receptors (sensory receptors in the walls of the thoracic, abdominal, and pelvic viscera), the vestibular system is the only sensory system which is mature. Although developed this early, some authors (Windle, 1971; Prechtl, 1984) believe that the system is inhibited during prenatal life. Others like Odent (1986) and Restak (1979) claim that the floating fetus is constantly stimulated by the mother's movements and registers its first perceptions through the vestibular system. It is because of this early maturation that the vestibular system is so important for brain development and "a disturbance of its function by any factor will be reflected in the formation of the whole nervous system" (Klosovskii, 1963, p. 116)). In favour of the proposition that the fetus reacts to the gravitational force (Hubbard, & Wright, 1984, Eliot, 2000) is the turning of its head into the head-down position weeks or days before birth. The first scientific evidence that the early development of the vestibular system is dependant upon gravitational stimulus was provided by a study (Ronca, & Alberts, 2000) on pregnant rats flown on the Space Shuttle. The rats, developed in space, had a limited sense of balance after delivery on earth. The study showed that the vestibular system needs the gravitational force to mature correctly. Meanwhile the British journal 'New Scientist' (MacKenzie, 2000) reported on a study involving a chemical reaction and the gravitational force. Initially, physicists insisted that the research was not worth doing because the force of gravitation on molecules was presumed to be too weak to affect chemical reactions, compared to other forces. However, the study (Papaseit, Pochon, & Tabony, 2000) was completed and results showed how gravitation had indeed influenced chemical reactions on the cellular level. The scientists studied microtubules, fibers made of a protein called tubulin. When cold solutions of mammalian tubulin mixed with GTP (an energy releasing compound) were adjusted to body temperature for a certain time, distinct bands of microtubules were formed at right angles to gravity. When the procedure was repeated in microgravity the bands pointed in all directions. This spontaneous generation of patterns in a chemical reaction, due to tiny environmental asymmetries, was the first experimental model of biological selforganization. The result had previously been predicted by the biophysicist Ilya Prigogine and by Alan Turing in the 1950s. I will return to Prigogine's research below.

#### **3.9 Music of the spheres**

Gravitation (Rees, 2000) is the most perplexing of the basic forces of nature and still today is a mystery. The force is so fundamental that if we should start anew with intelligent life on another planet we would have to start with gravitation. As gravitation is always an attraction it is the organizing force for the cosmos. Even Isaac Newton (1642-1727) had difficulties understanding what gravitation really is. Just the scientific, mechanical explanation did not seem to satisfy him. It is said that he regarded Pythagoras´ (569-475 BC) concept 'music of the spheres' as a metaphor for the law of gravitation. Although (Torretti, 1999) Newton's most celebrated scientific achievement is the discovery of universal

Could Motor Development Be an Emergent Property of Vestibular Stimulation

**4. Retraining for balance** 

**4.2 Instruments of assessment** 

Moro reflex.

knees, and skipping.

& Niklasson, 1999a, 2007a).

technique developed by Johansen (1993).

rooting reflex, and the suck reflex.

catching a tennis ball, and tandem walk.

**4.1 Clients** 

method RB. For a more thorough description see Niklasson, *et al.*(2009, 2010).

from such diffuse pain and fatigue that it was making them unable to work.

and Primary Reflex Inhibition? A Tentative Approach to Sensorimotor Therapy 257

sensorimotor problems which made it suitable to discuss some essential features concerning primitive/primary reflexes, the vestibular system and the gravitational force. I will now reconnect to **3.3** and give a brief presentation of assessment and training according to the

Vestibularis is a private practice using the method Retraining for Balance. Clients are mostly children and youngsters with concentration problems and / or learning disorders. Not all of them are considered clumsy by their parents but notwithstanding this, they will display sensorimotor immaturities on our tests. Adults can also benefit from the training and have completed it with very good results – this has included people who were initially suffering

The initial assessment uses the instruments (Niklasson, *et al.*, 2009) *RB–Physiological Test* (Niklasson & Niklasson, 1999a, 2007a), *Retraining for Balance-Orientation and Balance Test* (Niklasson & Niklasson, 1999b, 2007b) and *Retraining for Balance-Audiometric test*, based on a

*RB–Physiological Test* consists of 41 different tests which assess sensorimotor (physiological) proficiency (maturity) of clients in terms of primitive/primary reflexes, postural responses,

1. Primitive/primary reflexes-vestibular stimulation; tonic labyrinthine reflex prone and supine, symmetric tonic neck reflex, tonic labyrinthine reflex in upright position, Schilder's test (asymmetric tonic neck reflex and tonic labyrinthine reflex), asymmetric tonic neck reflex supine, asymmetric tonic neck reflex on all fours (Ayres' test), and the

2. Primitive/primary reflexes- tactile stimulation; spinal Galant, palmar grasp reflex,

3. Postural reactions; Landau reaction, amphibian reaction prone, segmental rolling reaction, the oculoheadrighting reaction, and the labyrinthine headrighting reaction. 4. Gross motor milestones; rolling, crawling on the stomach, creeping on hands and

5. Eye movements; passive horizontal-tracking and active horizontal tracking in three positions (sitting on the floor with legs crossed, sitting on a stool, and in erect position). 6. Sports related gross motor skills; spring jumping, skipping with a rope, bouncing and

Each test is scored on a quantitative 5-point scale from 0 – 4 (Field & Blythe, 1989; Niklasson

0: No deviation, 1: Small remainder of a primitive/primary reflex or minor difficulty completing a specific feature, 2: Remainder of a primary reflex or partial absence of a postural response or difficulty completing an item, 3: Almost intact primary reflex or almost

gross motor milestones, and vestibular ability. The tests are divided into six groups;

gravitation he also communicated a spiritual side. In General Scholium, an appendix to the second edition of 'Principia' (1726, p.528), he writes that God "endures forever, and is everywhere present; and, by existing always and everywhere, he constitutes time and space".

As healthy humans we take an upright position for granted although defying the gravitational force is a life long struggle. Very soon after birth the infant starts to lift his head up against gravitation. According to Paul Schilder (Hubbard & Wright, 1984) it will take the growing child about 15 years to master the force. However, this struggle might have its rewards as Lin, Woolacott and Jensen (2004) showed that postural control among elderly people was not only linked to age but correlated with functional balance as well. In another study (Carpenter, Adkin, Brawley, & Frank, 2006) it was examined how young adults and older adults with balance problems reacted when balance demands increased. In both groups, increased demands affected both blood pressure, anxiety, and the capacity to handle the body. At the beginning of the 20th century, Joel E. Goldthwait (Goldthwait, Brown, Swaim, & Kuhns, 1937; Oschman, 2000) and his colleagues at Harvard Medical School were trying to attract scientific attention with their research on patients with various chronic disorders all of which were due to faulty 'Body Mechanics'. Goldthwaith stressed the importance of people paying attention to how they moved and held their bodies in relation to gravitation. If posture was correct more energy would be left for use in daily activities and less strain would be put on different body parts and joints. An incorrect posture would be likely to also have unhealthy effects on the viscera of both the thorax and the abdomen. Once again we can hear history speaking to us but unfortunately the trace left from Goldthwait is not to be found within traditional science but has been picked up by movement therapies and modern body work.

In his sequel to 'Zen and the art of motor cycle maintenance', 'Lila-an inquiry into morals', Robert M. Pirsig (1991) wrote:

 "The law of gravity, for example, is perhaps the most ruthlessly static pattern of order in the universe. So, correspondingly, there is no single living thing that does not thumb its nose at that law day in and day out. One could show that the degree to which an organism disobeys this law is a measure of its degree of evolution. Thus, while the simple protozoa just barely get around their cilia, earthworms manage to control their distance and direction, birds fly in the sky, and man goes all the way to the moon"(p. 147).

Pirsig suggests that man's bodily struggle against the gravitational force has over time contributed to an intelligence good enough to conquer space and by doing so even gravitation itself. Much focus is presently placed on cognition and cognitive development while our neurological heritage seems to have been neglected or even forgotten when it comes to education. So how do we connect the gravitational force to learning disabilities?

I propose that an important connection between the gravitational force and learning disabilities is the maturation of the vestibular system and the integration of primitive/primary reflexes.

#### **3.10 Summary**

So far, you have been provided with an historical background as to how learning disorders in general have been viewed over the centuries. From there, I moved towards DCD and sensorimotor problems which made it suitable to discuss some essential features concerning primitive/primary reflexes, the vestibular system and the gravitational force. I will now reconnect to **3.3** and give a brief presentation of assessment and training according to the method RB. For a more thorough description see Niklasson, *et al.*(2009, 2010).
