need a broad platform to discuss studies on typically developing children and gain a better understanding of physiological

processes. To identify developmental trends and health deter-

minants, and to define and validate risk factors for disease

and disability, we need a stronger commitment to the study
of normal development. After all, physiology still matters.

REFERENCES
1. Touwen BCL. How normal is variable, or how variable
is normal? Early Hum Dev 1993; 34: 112.
2. Piaget J. La psychologie de lintelligence. Paris: A.
Colin, 1947.
3. Miller GA, Galanter E, Pribram KH. Plans and the
Structure of Behavior. New York: Holt, Rinehart &
4. Connolly KJ. Skill development: problems and plans. In:
KJ,

editor.

7. Hitzert MM, Roze E, van Braeckel KNJA, Bos AF.

Motor development in 3-month-old healthy term-born

5. Edelman GM. Neural Darwinism. The Theory of Neuro-

infants is associated with cognitive and behavioural

nal Group Selection. Oxford: Oxford University Press,

outcomes at early school age. Dev Med Child Neurol

1987.

2014; 56: 86976.

6. Hadders-Algra M. The neuronal group selection theory:

a framework to explain variation in normal motor

Winston, 1960: 2139.

Connolly

Skill Development. London: Academic Press, 1971: 3

17.

Mechanisms

of

Motor

development.

Dev

Med

Child

Neurol

2000;

42:

56672.

Support for the stability of the Alberta Infant Motor Scale after
back-to-sleep
JILDA VARGUS-ADAMS
Division of Pediatric Rehabilitation, Departments of Pediatrics and Neurology &
Rehabilitation Medicine, Cincinnati Childrens Hospital Medical Center, University
of Cincinnati College of Medicine, Cincinnati, OH, USA.
doi: 10.1111/dmcn.12479
This commentary is on the original article by Darrah et al. on pages
877881 of this issue.

The Alberta Infant Motor Scale (AIMS)1 has been a preferred measure of infant motor ability for two decades.
Nonetheless, questions have surfaced as to whether it
remains a valid and accurate assessment tool. Concerns
arose about the generalizability of the measure because of
the homogeneous initial validation sample. Further doubt
was cast on the AIMS normative values as the effects of
public health back-to-sleep initiatives have been purported to alter infant development since the AIMS was
developed.2 The paper by Darrah et al.3 provides robust
answers to those concerns by establishing the ongoing performance of the AIMS in a new sample of infants. With an
efficient design to leverage a relatively limited sample size,
while still ensuring greater diversity of the sample, the
continuing fidelity of the AIMS normative values are
reported. The findings should be of great interest to current users of the AIMS, as well as to clinicians and
researchers who have doubted either the validity of the
AIMS outside Alberta, Canada or the conservation of
motor development timelines since the implementation of
sleep positioning campaigns.
The AIMS was originally developed with a predominantly Caucasian sample of infants in Alberta, Canada to
establish normative developmental trajectories. In the ensu804 Developmental Medicine & Child Neurology 2014, 56: 801807

ing 20 years, Canada has become increasingly racially

diverse. At the same time, more opportunities to use the
AIMS developed around the world. Darrah et al. demonstrate that the AIMS continues to perform remarkably similarly to historic reports. The findings help support use of
the AIMS in contemporary Canada as well as suggest that
the AIMS may be appropriate for much more diverse or
divergent populations as well.
Has motor development remained stable despite changes
in infant positioning? This is a controversial question. Darrah et al. report that for this sample of infants, all of whom
were born after back-to-sleep had been initiated, the normative AIMS data have not changed. The age of attainment of specific skills differed by less than 1 week from
the initial sample. Some authors have speculated that
development, especially rolling and other skills that require
time in prone to master, would slow with increased supine
positioning and some studies support this claim. Perhaps
the amount of tummy time versus seated postures for play
may contribute to relative delays in skill acquisition.
Regardless, this work with the AIMS reveals that the order
and age of skill development was unchanged for the contemporary study sample.
The AIMS is still valid and valuable. The authors rightly
state that the AIMS should be used broadly. However, this
paper cannot single-handedly establish that motor development has remained the same since the early 1990s. Practice
and error and variation are key contributors to motor skill.
What does it mean if major changes in infant position for
sleep and for play are altered dramatically and nothing
about development changes? Darrah et al. cannot tell us if
their study sample was truly back-to-sleep or if the infants
achieved frequent playtime in a prone position; they cannot

tell us how the sample directly compares to international

populations. They can, however, reassure us that the AIMS
hasnt changed and results from the AIMS should be utilized as they have been in the past. The authors stress
appropriate caution in interpreting the AIMS related to

developmental windows, cut-off points, and other history.

Serendipitously, their methodology is well described and
could be readily replicated with alternate populations, work
that might contribute additional information on the big
questions of motor development.

REFERENCES
1. Piper M, Darrah J. Motor Assessment of the Developing
Infant. Philadelphia, PA: Saunders, 1994.

motor development in infants. Dev Med Child Neurol

ged in 20 years? A re-evaluation of the Alberta Infant

2007; 49: 85867.

Motor Scale normative values Dev Med Child Neurol

2. Pin T, Eldridge B, Galea MP. A review of the effects of

3. Darrah J, Bartlett D, Maguire TO, Avison WR, Lacaze-

sleep position, play position, and equipment use on

Masmonteil T. Have infant gross motor abilities chan-

2014; 56: 87781.

Are proprioceptive functions affected in Duchenne muscular

dystrophy?
DIDO GREEN
Centre for Rehabilitation, Oxford Brookes University, Oxford, UK.
doi: 10.1111/dmcn.12476
This commentary is on the original article by Troise et al. on pages
882887 of this issue.

The processing of sensory and perceptual information

has long been a focus of interest for researchers and clinicians in attempting to understand the motor coordination difficulties of children with developmental disorders1
and those with cerebral palsy (CP).2,3 Until recently the
assessment of tactile, proprioceptive, and visual functions
has formed an important component in the diagnostic
formulation of developmental coordination disorder
(DCD). This included the assumption that impaired sensorimotor integration underpinned the perceptual-motor
problems of these children and thus should be the focus
of treatment (European Academy for Childhood Disability recommendations). The evidence for the benefits of
sensory motor treatments for children with DCD however, is marginal.4 The sensory deficits of children with
CP have been shown to affect movement production,
particularly upper limb performance.3 Furthermore, children with CP with better sensory status have shown prolonged retention of motor skill progress following
practice.5
In both DCD and CP, the predominant disturbance to
function is linked to atypical structural or functional connectivity within the central nervous system (CNS) affecting
both sensory and motor systems, although the neural basis
of DCD has yet to be defined. Less well known though is
how the sensory system is affected in children with muscle
weakness that is not due to atypical brain function or

development, such as in Duchenne muscular dystrophy

(DMD), and what impact this may have on functional
motor skills.
The study by Troise et al.6 draws attention to potential
sensory impairments associated with DMD. Their findings
highlight a dependence on visual feedback for manual dexterity in the absence of impairments in either two-point
tactile discrimination or stereognosis. Their results, reflecting a greater discrepancy in the manual skills of young
males with DMD than control children only when performing the manual task with the eyes closed, lead to a
number of hypotheses. While muscle weakness may have
played a role in the slower speeds for identifying objects,
this does not provide an explanation for equivalent speeds
in the manual dexterity task when the eyes were open. The
authors have therefore conjectured that this may be due to
reduced glucose metabolism although it is not particularly
evident that this may be due to lateralisation of hypometabolism to the right hemisphere.
Alternatively, Troise et al. also postulate that the dependence on visual feedback is similar to that in younger
children and therefore may reflect more generalized delays
in motor development in children with DMD. They did
not however explore proprioception directly.
It has been shown from both human and animal studies
that the discharge from muscle spindles, which provide
the main source of proprioceptive feedback to the CNS,
is modulated by the contractile state of the skeletal muscles in which they are embedded.7 While Ribot-Ciscar
et al.8 suggest that muscle spindle proprioceptive functions may in fact be spared in muscular dystrophy, their
sample only included four participants with DMD or
Becker muscular dystrophy, the remaining with myotonic,
fascioscapulohumeral, or limb-girdle dystrophies. The
Commentaries

805

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