A Systematic Review and Meta-analysis of the Effect of Active Video Games on Postural Balance

OBJECTIVE

To conduct a comprehensive systematic review and meta-analysis of the effects of active video game (AVG) interventions on postural balance across all ages in populations with and without neurologic impairments, using all types of platforms.

DATA SOURCE

Six databases (PubMed, PsycINFO, Sport Discus, MEDLINE, Web of Science, and Google Scholar) were reviewed by December 31, 2020.

STUDY SELECTION

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42020204191). For inclusion, a study must be original, published in English peer-reviewed venues and employed AVGs as the sole or primary intervention to enhance, maintain, or regain postural balance. At least 2 within- or between-subjects conditions must be included with ≥10 participants per condition.

DATA EXTRACTION

Three reviewers independently performed data extraction and assessed the risk of bias.

DATA SYNTHESIS

129 studies were identified, with 102 eligible for meta-analysis. The total number of tested participants was 6407 (60.0% women, M_age=55.1 years, range=3-99 years, SD=22.6). The average intervention duration was 35.6 min/session with 3.1 sessions/week for 7.6 weeks. The overall effect favored AVG interventions (Hedges' g=0.469; 95% confidence interval [CI]=0.407-0.531). Although the overall study quality was relatively low, the analysis expectedly indicated significantly larger effects (P<.001) for AVG-interventions over passive controls (Hedges' g=0.627; 95% CI=0.466-0.788), but importantly also favored AVG-interventions over conventional treatment (Hedges' g=0.389; 95% CI=0.311-0.468). All clinical populations responded positively, although with different effect sizes (P=.023). Children experienced larger treatment effects (Hedges' g=0.550; 95% CI=0.336-0.764), closely followed by seniors (Hedges' g=0.529; 95% CI=0.402-0.656). The largest intervention effect on balance improvements was seen in healthy people without a medical condition (Hedges' g=0.609; 95% CI=0.465-0.753).

CONCLUSIONS

AVGs can produce postural balance improvements and better postural maintenance. All populations could benefit from AVG interventions.

Interrater, Test-retest Reliability of the Y Balance Test: A Reliability Study Including 51 Healthy Participants

The aim was to determine the relative and absolute interrater, test-retest reliability of the Y-Balance Test (YBT) in a sample of healthy and active adults aged 18 to 50 years. The sample consisted of 51 healthy and active participants, 30 men and 21 women with a mean age of 28 ± 7 years. The YBT was performed on the right leg in the three test directions. Test and retest of the YBT were performed with a median interval of 15 days. The method for data collection was in line with the Y Balance Test Lower Quarter Protocol (YBT-LQ). The test was conducted by raters previously inexperienced in the use of the YBT. The relative reliability was reported as Intraclass Correlation Coefficient (ICC_(2,1)). The absolute reliability was reported as Standard Error of Measurement (SEM) and Minimal Detectable Change (MDC). The ICC ranged from 0.79-0.86. SEM ranged from 2%-4%, indicating the measurement error at group level and MDC ranged from 5%-11%, indicating the measurement error at individual level. The YBT showed good relative and absolute reliability. The YBT is therefore considered suitable at both group and individual level in physically active populations.

Analysis of pain intensity and postural control for assessing the efficacy of shock wave therapy and sonotherapy in Achilles tendinopathy - A randomized controlled trial

BACKGROUND

The troublesome symptoms of Achilles tendinopathy prompt patients to seek effective forms of conservative treatment. The main aim of the study was to determine the therapeutic efficacy of shock wave and ultrasound therapies for Achilles tendinopathy in reducing pain intensity. Treatment efficacy was also assessed using objective posturographic measurements.

METHODS

Thirty-nine patients patients were randomly allocated to one of three experimental groups that received shock wave therapy (group A), ultrasound therapy (group B) and placebo ultrasound (group C). Posturographic measurements and subjective assessment of pain intensity were taken prior to therapy and at weeks 1 and 6 of therapy completion.

FINDINGS

A comparison of percentage change in activity-related pain from baseline to 6 weeks post-therapy revealed a significantly greater pain reduction in group A compared to group B. The three-way ANOVA demonstated an effect of treatment type on all posturographic variables. The Bonferroni post-hoc test showed the means of all variables were significantly smaller for group A than group B. Limb condition also had an effect on the center-of-pressure trajectories in anteroposterior plane; the post-hoc test showed the mean values of the variables were significantly greater for the non-affected compared to affected limb.

INTERPRETATION

Shock wave therapy was significantly more effective than sonotherapy for alleviation of activity-related pain of Achilles tendinopathy. An association was also shown between shock wave therapy and more efficient postural control in patients with Achilles tendinopathy. The parameters of center-of-pressure trajectories in the sagittal plane were significantly greater for the non-affected compared to affected limb. The trial was prospectively registered in the Australian and New Zealand Clinical Trials Registry (no. ACTRN12617000860369; registration date: 9.06.2017).

Effects of two different dual-task training protocols on gait, balance, and cognitive function in community-dwelling older adults: a 24-week randomized controlled trial

Background

Although alternating dual-task (ADT) training is functionally easier for older adults, a large part of the motor and cognitive tasks is simultaneously performed, especially during activities of daily living that require maintaining body balance.

Objective

To evaluate the effects of mixed dual-task training on mobility, cognitive function, and balance in community-dwelling older adults.

Methods

Sixty participants were randomly allocated at a 1:1 ratio into the experimental group-single motor task (SMT) and simultaneous dual task (SDT) interchangeably in stage 1 (for 12 weeks) and after strictly with SDT in stage 2 (the last 12 weeks)-or into the control group-only SMT and SDT interchangeably in stages 1 and 2. Gait parameters were acquired by two inertial sensors. Physical and cognitive performance were acquired by specific questionnaires. Generalized linear mixed models were used for analyzing interaction and main effects.

Results

No between-group difference was observed for gait performance. Both protocols improved mobility (mean change ((MC) = 0.74)), dual-task effect (MC = -13.50), lower limb function (MC = 4.44), static (MC = -0.61), and dynamic balance (MC = -0.23), body sway (MC = 4.80), and cognitive function (MC = 41.69).

Conclusion

Both dual-task training protocols improved these outcomes.

Determinants of age-related decline in walking speed in older women

Background

Walking speed is reduced with aging. However, it is not certain whether the reduced walking speed is associated with physical and coordination fitness. This study explores the physical and coordination determinants of the walking speed decline in older women.

Methods

One-hundred-eighty-seven active older women (72.2 ± 6.8 years) were asked to perform a 10-m walk test (self-selected and maximal walking speed) and a battery of the Senior fitness test: lower body strength, lower body flexibility, agility/dynamic balance, and aerobic endurance. Two parameters characterized the walking performance: closeness to the modeled speed minimizing the energetic cost per unit distance (locomotor rehabilitation index, LRI), and the ratio of step length to step cadence (walk ratio, WR). For dependent variables (self-selected and maximal walking speeds), a recursive partitioning algorithm (classification and regression tree) was adopted, highlighting interactions across all the independent variables.

Results

Participants were aged from 60 to 88 years, and their self-selected and maximal speeds declined by 22% and 26% (p < 0.05), respectively. Similarly, all physical fitness variables worsened with aging (muscle strength: 33%; flexibility: 0 to -8 cm; balance: 22%; aerobic endurance: 12%; all p < 0.050). The predictors of maximal walking speed were only WR and balance. No meaningful predictions could be made using LRI and WR as dependent variables.

Discussion

The results suggest that at self-selected speed, the decrease in speed itself is sufficient to compensate for the age-related decline in the motor functions tested; by contrast, lowering the WR is required at maximal speed, presumably to prevent imbalance. Therefore, any excessive lowering of LRI and WR indicates loss of homeostasis of walking mechanics and invites diagnostic investigation.

Directional virtual time-to-contact: A new measure for investigating temporal, spatial, and control aspects of postural balance control

Virtual time-to-contact (VTC) is a promising approach for investigating postural balance control. However, current VTC calculation approaches are limited as they (1) cannot be used to evaluate directional components of balance, and (2) only assess a single, temporal aspect of balance control. This study introduces a new approach for VTC calculation, namely directional VTC, expanding VTC to assess temporal, spatial, and control aspects of balance. Three case studies were conducted across varying populations and conditions as a proof-of-concept of the presented method. The first study examined quiet stance on a firm surface in people with Parkinson's disease (PD; n = 10) in comparison to their healthy peers (n = 10). The second and third studies assessed balance control of healthy individuals under challenging environments. Ten healthy individuals participated in standing tasks on compliant ground surfaces, while another ten on oscillatory ground surfaces, all simulated by a dual-axis robotic platform. Preliminary results not only provided a closer look at balance control with multiple aspects, including temporal, spatial, and control aspects, but also showed how different aspects of balance changed due to neurological diseases (Case Study I) or challenging standing grounds (Case Studies II and III). This study advances our understanding of posture biomechanics and its clinical applications.

The effects of clinical pilates training on disease-specific indices, core stability, and balance in patients with ankylosing spondylitis

OBJECTIVE

To assess the effects of clinical Pilates training on disease-specific indices, core stability, and balance in ankylosing spondylitis (AS) patients.

METHODS

AS patients were randomly assigned to either the Pilates group (PG) or control group (CG). The PG participated in Pilates training 3 times a week for 8 weeks. Patients in the CG were instructed to follow a home exercise program for 8 weeks. Assessments were performed before and after the interventions. BASDAI, BASFI, BASMI, and the AS Quality of Life (ASqOL) questionnaire were used were used to evaluate disease activity, functionality spinal mobility and quality of life respectively. Static core endurance was assessed with trunk flexor, extensor endurance, and lateral bridge tests, while dynamic core endurance was assessed using modified sit-up test. Balance was evaluated with bilateral and unilateral stance static postural stability (PS), bilateral stance dynamic PS and limits of stability (LOS) tests using the Biodex Balance System.

RESULTS

Twenty-one patients in the PG and 21 patients in the CG completed the study. PG showed statistically significant improvements in BASDAI, BASFI, BASMI, and ASQoL scores, all core endurance tests, and dynamic PS and LOS results. The CG demonstrated significant improvement only in flexor endurance and LOS results. Post-intervention BASDAI, BASMI, and all core endurance tests were significantly better in the PG than in the CG (p < 0.05).

CONCLUSION

Pilates training has positive effects on disease activity and functional capacity, spinal mobility, core endurance, balance, and quality of life in AS patients.

CLINICALTRIALS

GOV IDENTIFIER

NCT04292028.

Predictive Ability of the Three-Time Stand and Walk Test to Determine Frailty and its Associations with Fear of Falling and Cognitive Function in Community-Dwelling Older Adults

BACKGROUND

The three-time stand and walk test (TTSW) is a complex functional task used to determine muscle strength, balance, and fall risk in older individuals. This study hypothesized that TTSW is an appropriate tool for detecting frailty related to falls and the cognition of community-dwelling older adults. The study objectives were to assess the ability of the TTSW to determine frailty by exploring the optimal cut-off score, and to investigate the correlations between TTSW outcomes with falls and cognitive function in 118 community-dwelling older adults.

METHODS

The demographic data of eligible participants were assessed, and the participants were diagnosed with frailty based on the frailty phenotype. The participants then completed the Frail Non-Disabled (FiND) questionnaire, TTSW, Falls Efficacy Scale-International (FES-I), and Mini-Mental State Examination Thai version (MMSE-Thai 2002).

RESULTS

The results demonstrated that the TTSW outcomes were significantly correlated with FiND, FES-I, and MMSE-Thai 2002 (rho=0.705 and r=0.482 and =-0.510, respectively; p&lt;0.001). Moreover, a TTSW time of 18 s or longer had a good ability to indicate frailty in older individuals (sensitivity=88.41%, specificity=83.67%, area under the receiver operating characteristic curve [AUC]=0.926). Conclusions: Implementing this tool in a community setting may be useful for the initial screening, monitoring, and referral of data by healthcare professionals. A cut-off TTSW time of 18 seconds or longer was the optimal criterion to indicate frailty in community-dwelling older people.

Correlation of Femoral Muscle Volume Using Three-Dimensional Modeling and Locomotor Function After Unilateral Trans-femoral Amputation

OBJECTIVE

To evaluate the relationship between femoral muscle volume (FMV) and physiological outcomes after trans-femoral amputations (TFAs) affecting overall locomotor function in patients.

METHODS

Seven individuals who underwent TFA and had been using a prosthesis participated in this cross-sectional study. Gait and balance were assessed using clinical tests, such as 10-m walk test, 6-minute walk test, Berg Balance Scale, and automatic balance system. Respiratory gas analysis was performed to check oxygen consumption rate. Five participants were evaluated for bilateral FMV by MR imaging and FMV was reconstructed using three-dimentional remodeling.

RESULTS

In five participants, significant differences were found between the non-involved and involved sides in femur length, total FMV, and functional muscle volume (all p<0.01) in all groups except for the hip adductor volume. The %mean difference between the non-involved and involved sides was 30% for femur length, 52.55% for hip flexor volume, 26.55% for hip adductor volume, 51.86% for hip extensor volume, and 60.21% for knee extensor volume. The hip flexor volume to hip extensor volume ratio in the involved limb and oxygen consumption rate during comfortable gait were negatively correlated (r=-0.96, p=0.04).

CONCLUSION

In individuals who underwent unilateral TFA, hip girdle muscle imbalance in the involved limbs may be associated with oxygen consumption rate while using a prosthesis.

Postural balance strategies during landing at the moment of return-to-sports after anterior cruciate ligament reconstruction

Most athletes that return to sport (RTS) after Anterior Cruciate Ligament (ACL) injury undergo reconstruction (ACLR) to restore their knee stability. The major concern for RTS is for the patient to be able to perform challenging dynamic tasks whilst adequately stabilizing the knee joint and maintaining their postural balance. Nevertheless, the interaction between knee protective mechanisms (such as knee unloading and knee stabilisation) and postural balance strategies has not yet been comprehensively analyzed. Thus, the aim of this study was to investigate landing balance strategies in ACLR athletes at time of RTS. Twenty-one athletes with a unilateral ACLR were tested at the time of RTS while performing a single leg hop for distance on both limbs. Three balance mechanisms that influence the GRF during the landing phase (foot placement, center of pressure (CoP) excursion, counter-rotation of segments) were investigated and compared between the ACL injured and uninjured limb. Interactions between knee protective mechanisms and postural balance strategies were tested using a statistical parametric mapping regression analysis. Results show that CoP excursions in the injured limb increased, as well as ankle joint moment contribution to anterior-posterior (A-P) GRF. Besides, patients presenting reduced knee joint contribution to A-P GRF had to compensate with higher hip joint contribution in order to maintain postural balance. In conclusion, ACLR athletes who at RTS still protect their reconstructed knee are forced to employ compensatory postural balance strategies. Therefore, there is a persistent trade-off between knee protection and postural balance at the moment of RTS.

Core stability-based balance training and kinesio taping for balance, trunk control, fear of falling and walking capacity in patients with multiple sclerosis: A randomized single-blinded study

BACKGROUND

Trunk performance-based therapies are important in the Multiple Sclerosis (MS) rehabilitation process since they have been associated with balance, trunk performance, fall prevention, and walking capacity. Kinesio taping (KT) is a popular approach that has recently been used to treat a variety of musculoskeletal and neuromuscular impairments. Therefore, the aim of this single-blind, randomized controlled study was to investigate the effects of KT combined trunk stabilization-based balance training on balance, trunk control, walking capacity, and fear of falling in patients with MS.

MATERIAL AND METHODS

Thirty patients diagnosed with MS were randomly assigned to the KT group or the control group. The control group received core stability-based balance training and the KT group was treated with KT applied on global trunk muscles in addition to core stability-based balance training. Balance was measured with the Mini BESTest, trunk control with the Trunk Impairment Scale, fear of falling with the Falls Efficacy Scale and walking capacity with the 2-minute walk test.

RESULTS

Balance, trunk control, fear of falling, and walking capacity of all the patients improved after treatment (p < 0.05). No superiority was found between the groups in terms of treatment efficacy (p > 0.05).

CONCLUSION

In conclusion, core stability-based balance training was effective in patients with MS, and the addition of KT had no additional effect in terms of balance, trunk control, fear of falling, and walking capacity.

Effects of Conservative Interventions on Static and Dynamic Balance in Individuals With Chronic Ankle Instability: A Systematic Review and Meta-analysis

OBJECTIVE

To determine which conservative interventions are effective for static and dynamic balance in patients with chronic ankle instability (CAI).

DATA SOURCES

PubMed, Cochrane Library, Web of Sciences, and CINAHL databases were searched up to March 20, 2022.

STUDY SELECTION

Randomized controlled trials investigating the effects of conservative interventions on static and/or dynamic balance in patients with CAI compared with those of different conservative interventions or controls were included.

DATA EXTRACTION

Two independent reviewers extracted the data. Certainty of the evidence was assessed using the GRADE approach.

DATA SYNTHESIS

Forty-eight studies (1906 participants) were included. Whole-body vibration training (WBVT) was significantly more effective than controls for both static (standardized mean difference, 1.13; 95% confidence interval [CI], 0.58-1.68; moderate-certainty evidence) and dynamic balance (0.56; CI, 0.24-0.88; low-certainty evidence). Balance training (BT) and joint mobilization were significantly more effective than controls for dynamic balance (0.77; CI, 0.41-1.14; and 0.75; CI, 0.35-1.14, respectively), but not for static balance (very low to low-certainty evidence). Adding other interventions to BT had no significant effect on either type of balance compared with that of BT alone (moderate to low-certainty evidence). Strength training (ST) and taping had no significant effect on either type of balance (very low- to low-certainty evidence). Multimodal interventions were significantly effective in improving dynamic balance (0.76; CI, 0.32-1.20; low-certainty evidence). Adding transcranial direct current stimulation to ST was significantly more effective for dynamic balance than ST (0.81; CI, 0.08-1.53; moderate-certainty evidence). The effects on balance were not significantly different among BT, ST, and WBVT (very low- to low-certainty evidence).

CONCLUSIONS

The significantly effective interventions reviewed may be treatment options for balance impairments associated with CAI. However, interventions should be chosen carefully, as much of the certainty of evidence is very low to low.

Transcranial direct current stimulation for balance rehabilitation in neurological disorders: A systematic review and meta-analysis

Postural instability is common in neurological diseases. Although transcranial direct current stimulation (tDCS) seems to be a promising complementary therapy, emerging evidence indicates mixed results and protocols' characteristics. We conducted a systematic review and meta-analysis on PubMed, EMBASE, Scopus, and Web of Science to synthesize key findings of the effectiveness of single and multiple sessions of tDCS alone and combined with other interventions on balance in adults with neurological disorders. Thirty-seven studies were included in the systematic review and 33 in the meta-analysis. The reviewed studies did not personalize the stimulation protocol to individual needs/characteristics. A random-effects meta-analysis indicated that tDCS alone (SMD = -0.44; 95%CI = -0.69/-0.19; p < 0.001) and combined with another intervention (SMD = -0.31; 95%CI = -0.51/-0.11; p = 0.002) improved balance in adults with neurological disorders (small to moderate effect sizes). Balance improvements were evidenced regardless of the number of sessions and targeted area. In summary, tDCS is a promising therapy for balance rehabilitation in adults with neurological disorders. However, further clinical trials should identify factors that influence responsiveness to tDCS for a more tailored approach, which may optimize the clinical use of tDCS.

Systematic Review of the Importance of Hip Muscle Strength, Activation, and Structure in Balance and Mobility Tasks

OBJECTIVE

The aim of this systematic review was to identify the associations of the hip abductor muscle strength, structure, and neuromuscular activation on balance and mobility in younger, middle-aged, and older adults.

DATA SOURCES

We followed PRISMA guidelines and performed searches in PubMed, Embase, CINAHL, and Physiotherapy Evidence Database.

STUDY SELECTION

Study selection included: (1) studies with patients aged 18 years or older and (2) studies that measured hip abduction torque, surface electromyography, and/or muscle structure and compared these measures with balance or mobility outcomes.

DATA EXTRACTION

The extracted data included the study population, setting, sample size, sex, and measurement evaluated.

DATA SYNTHESIS

The present systematic review is composed of 59 research articles including a total of 2144 young, middle-aged, and older adults (1337 women). We found that hip abductor strength is critical for balance and mobility function, independent of age. Hip abductor neuromuscular activation is also important for balance and mobility, although it may differ across ages depending on the task. Finally, the amount of fat inside the muscle appears to be one of the important factors of muscle structure influencing balance.

CONCLUSIONS

In conclusion, a change in all investigated variables (hip abduction torque, neuromuscular activation, and intramuscular fat) appears to have an effect during balance or mobility tasks across age ranges and may elicit better performance. Future studies are necessary to confirm the effect of these variables across age ranges and the effects of interventions.

Cumulative additional information does not improve the neuromuscular control during postural responses to perturbations in postural instability/gait disorders subtype of Parkinson's disease

BACKGROUND

Postural response impairments in postural instability and gait disorders (PIGD) subtype patients may be attributed to Parkinson's disease (PD)-deterioration in central-set (programing/modulating of central outputs during motor responses). Although additional information improves some PD motor impairments, an unanswered question is whether additional information can benefit postural response in PIGD subtype.

OBJECTIVE

To analyze the effect of cumulative additional information on postural responses after perturbation in PIGD and neurologically healthy older adults (CG).

METHODS

Perturbations were applied in 16 PIGD and 19 CG by the support-base translation. Participants performed 3 blocks of 5 trials without additional information (B1-B3, Day 1) and 5 trials of each cumulative additional information (C1-C4, Day 2): information about perturbation (C1), visual (C2), verbal (C3), and somatosensory information (C4). Electromyography and center of pressure (CoP) parameters were analyzed by ANOVAs with Group (PIGD × CG) and Block (B1 × B2 × B3) and with Group (PIGD × CG) and Condition (B3 × C1 × C2 × C3 × C4).

RESULTS

PIGD decreased the range of CoP in B3 while CG decreased both range of CoP and the integral of antagonist's muscle activity (iEMG) in B2. Also, PIGD decreased the recovery time in C4 while CG increased the iEMG of agonist's muscle in C2 and antagonist's muscle in all conditions except C2.

CONCLUSION

Additional information provided before postural control assessment influences the postural response in PIGD and CG differently. PIGD demonstrated inflexibility of central-set in modulating the neuromuscular control regardless of additional information. CG presents a flexible system evidenced by the increase of agonist muscle iEMG when provided visual information.

Changes in static balance during pregnancy and postpartum: A systematic review

BACKGROUND

Because pregnant women show a high risk of falling, some researchers examined their balance during static standing. This systematic review summarized the findings from all studies evaluating static balance in women during pregnancy and postpartum.

RESEARCH QUESTION

Do pregnant and postpartum women show differences in static balance compared to non-pregnant women, and does static balance change during pregnancy and postpartum?

METHODS

Pubmed, Embase, CINAHL, and Web of Science databases were searched systematically from inception until Feb 23, 2022. Studies were eligible for inclusion if they measured COP sway with a force plate during bipedal static standing, and compared COP outcomes between healthy pregnant or postpartum women and non-pregnant women, and/or during different stages of pregnancy and the postpartum period. Methodological quality was assessed overall with a modified version of the Downs and Black checklist, and specifically related to COP measurement by using recommendations of Ruhe et al. (2010). The protocol was registered in PROSPERO (CRD42020166302).

RESULTS

Thirteen studies were included. Because methodological approaches varied greatly between studies, results were summarized descriptively. Studies reported either greater overall and anteroposterior COP sway magnitude, velocity and variability in women from the second half of pregnancy until six months postpartum compared to non-pregnant controls, or no differences in static balance. Changes in static balance throughout pregnancy were generally not found. Finally, there was no clear consensus on the influence of pregnancy on the reliance on visual inputs for balance control, and on whether differences in balance in pregnant and postpartum women reflect poorer balance or positive adaptations to the physical changes experienced during pregnancy.

SIGNIFICANCE

Methodological heterogeneity between studies prevented us from drawing strong conclusions regarding the effect of pregnancy on static balance. Assessing the methodological quality of the studies revealed weaknesses that should be taken into account in future studies.

Impact of age on the postural stability measured by a virtual reality tracker-based posturography and a pressure platform system

BACKGROUND

Center of pressure (CoP) parameters are commonly used to evaluate age-related changes in postural control during standing. However, they mainly reflect ankle strategies and provide limited information about hip strategies, which are essential for postural control among the aged population. Body displacement at the lumbar level (LD) can be used as a proxy for hip strategies.

OBJECTIVES

We set up a virtual reality tracker-based posturography to measure LD and compared the CoP and LD parameters in two age groups to explore the roles of ankle and hip strategies during bipedal stance.

METHODS

Twenty-seven older healthy participants (63.8 ± 7.1 years old) and 27 younger controls (31.7 ± 9.9 years old) performed four standing tasks with their postural steadiness measured simultaneously with both systems under four stance conditions (combination of eyes-open/eyes-closed and wide-based/narrow-based). Five parameters were calculated from the trajectories of the CoP and LD. The difference in the parameters between two groups was analyzed with the Mann-Whitney U test. The discriminative ability of the parameters from the two systems was computed by the receiver operating characteristic curve analysis and area under the curve (AUC). We also used the intraclass correlation coefficient (ICC) to assess the correlation between two measures.

RESULTS

Most of the parameters obtained from both systems were significantly different between the younger and older groups. Mean velocity in the medial-lateral and anterior-posterior directions could effectively discriminate age-related changes, especially with the LD parameters. The receiver's operation curve analysis gained the largest AUC (0.85 with both systems) with mean velocity in the medial-lateral direction during narrow-based standing with eyes closed. Meanwhile, we observed a low correlation between parameters obtained from the two methods in velocity measures, with the lowest ICC in the mean velocity in the medial-lateral direction in the older group (ICC = 0.34 ~ 0.41).

CONCLUSION

Both systems could differentiate age-related changes in postural steadiness, but with dissociated information about mean velocity, especially the mean velocity in the medial-lateral direction in the older group. The results support the complimentary role of using tracker-based posturography to understand the effect of age on the mechanisms of postural control.

Orthostatic intolerance: a handicap of aging or physical deconditioning?

Despite several studies that have been investigated physical inactivity and age-related effects on orthostatic tolerance, impaired hemodynamics and postural balance responses to orthostatic stress are incorrectly attributed to aging or sedentarism alone. The isolated effects from aging and sedentarism should be investigated through comparative studies between senior athletes and age-matched controls, and physical activity assessments on aging follow-up studies. On the other hand, bed rest and space flight studies mimic accelerated physical inactivity or disuse, which is not the same physiological decline provoked by aging alone. Thus, the elementary question is: could orthostatic intolerance be attributed to aging or physical inactivity? The main purpose of this review is to provide an overview of possible mechanisms underlying orthostatic tolerance contrasting the paradigm of aging and/or physical inactivity. The key points of this review are the following: (1) to counterpoint all relevant literature on physiological aspects of orthostatic tolerance; (2) to explore the mechanistic aspects underneath the cerebrovascular, cardiorespiratory, and postural determinants of orthostatic tolerance; and (3) examine non-pharmacological interventions with the potential to counterbalance the physical inactivity and aging effects. To date, the orthostatic intolerance cannot be attributed exclusively with aging since physical inactivity plays an important role in postural balance, neurovascular and cardiorespiratory responses to orthostatic stress. These physiological determinates should be interpreted within an integrative approach of orthostatic tolerance, that considers the interdependence between physiological systems in a closed-loop model. Based on this multisystem approach, acute and chronic countermeasures may combat aging and sedentarism effects on orthostatic tolerance.

Risk factors for falls in community-dwelling older people with mild cognitive impairment: a prospective one-year study

Objective

Mild cognitive impairment (MCI) is considered an intermediate stage between normal cognitive function and dementia. Fall risk is increased in this group, but there is limited literature exploring specific fall risk factors that may be addressed in fall prevention strategies. The aim of this study was to examine risk factors for falls in older people with MCI, focusing on cognitive, psychological and physical factors.

Methods

Participants (n = 266, 45% women) were community-dwelling older people aged 70-90 years who met the criteria for MCI. Cognitive, psychological, sensorimotor and physical assessments, physical activity levels, medication use, general health and disability were ascertained at baseline. Falls were monitored prospectively for 12 months.

Results

During follow-up, 106 (40%) participants reported one or more falls. Poorer visual contrast sensitivity, increased postural sway, lower levels of weekly walking activity, higher levels of depressive symptoms and psychotropic medication use were significantly associated with faller status (≥1 falls) in univariable analyses. Of these factors, poor visual contrast sensitivity, increased postural sway and psychotropic medication use were found to be significant independent predictors of falls in multivariable analysis while controlling for age and sex. No measures of cognitive function were associated with falls.

Conclusions

Poor visual contrast sensitivity, impaired balance and psychotropic medication use predicted falls in community-dwelling people with MCI. These risk factors may be amenable to intervention, so these factors could be carefully considered in fall prevention programs for this population.

The measurement properties of the Lean-and-Release test in people with incomplete spinal cord injury or disease

OBJECTIVE

To evaluate test-retest reliability, agreement, and convergent validity of the Lean-and-Release test for the assessment of reactive stepping among individuals with incomplete spinal cord injury or disease (iSCI/D).

DESIGN

Multi-center cross-sectional multiple test design.

SETTING

SCI/D rehabilitation hospital and biomechanics laboratory.

PARTICIPANTS

Individuals with motor incomplete SCI/D (iSCI/D).

INTERVENTIONS

None.

OUTCOME MEASURES

Twenty-six participants attended two sessions to complete the Lean-and-Release test and a battery of clinical tests. Behavioral (i.e. one-step, multi-step, loss of balance) and temporal (i.e. timing of foot off, foot contact, swing of reactive step) parameters were measured. Test-retest reliability was determined with intraclass correlation coefficients, and agreement was evaluated with Bland-Altman plots. Convergent validity was assessed through correlations with clinical tests.

RESULTS

The behavioral responses were reliable for the Lean-and-Release test (ICC = 0.76), but foot contact was the only reliable temporal parameter using data from a single site (ICC = 0.79). All variables showed agreement according to the Bland-Altman plots. The behavioral responses correlated with scores of lower extremity strength (0.54, P<0.01) and balance confidence (0.55, P < 0.01). Swing time of reactive stepping correlated with step time (0.73, P < 0.01) and cadence (-0.73 P < 0.01) of over ground walking.

CONCLUSIONS

The behavioral response of the Lean-and-Release test is a reliable and valid measure for people with iSCI/D. Our findings support the use of the behavioral responses to evaluate reactive stepping for research and clinical purposes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02960178.

Validity of balance measures in cerebellar ataxia: A prospective study with 12-month follow-up

INTRODUCTION

Balance deficits are common in cerebellar ataxia. Determining which balance outcome measures are psychometrically strong for this population remains an unmet need.

OBJECTIVE

Evaluate the validity and responsiveness of two clinic-based balance measures [Berg Balance Scale (BBS) and balance sub-component of the Scale for the Assessment and Rating of Ataxia (SARA-bal)] and two laboratory-based balance measures [Sensory Organization Test (SOT) and Limits of Stability (LOS)] in cerebellar ataxia.

DESIGN

Prospective cohort study.

SETTING

Institutional study assessing 40 participants with cerebellar ataxia at baseline, 6, and 12 months.

MAIN OUTCOME MEASURES

Balance was assessed using the BBS, SARA-bal, SOT, and LOS; disease severity was assessed using the SARA; and Patients' Global Impression of Change (PGIC) was used to estimate responsiveness to disease progress at 6 and 12 months.

RESULTS

BBS and SARA-bal (Spearman's correlation coefficient, ρS = -0.89, p < 0.01) demonstrated strong criterion validity. Convergent validity was moderate to high (ρS range:-0.75 to 0.92) and external validity was low (ρS range:-0.75 to 0.11). Composite SOT scores (SOT-COM; ρS=0.29, p<0.01) and maximal excursion (MXE-LOS) in the forward (F) and right (R) directions of the LOS (ρS = 0.18, p < 0.01) demonstrated moderate to low criterion and convergent validity. The area under the receiver operating characteristic curve (AUC_ROC ) and its effect size (standard response mean [SRM]) for categorizing 'stable' and 'worsened' patients at 6 and 12 months were satisfactory for the BBS (AUC_ROC :0.75; SRM-Stable:1.06; SRM-Worsened:1.16), SARA-bal (AUC_ROC :0.76; SRM-Stable:0.86; SRM-Worsened:0.85), and MXE-LOS(R) (AUC_ROC :0.29; SRM-Stable:0.41; SRM-Worsened:1.39).

CONCLUSION

BBS and SARA-bal have moderate to strong criterion and convergent validity and adequate responsiveness to balance changes. Both laboratory-based measures (SOT and LOS) demonstrated a high floor effect. The SOT-COM and MXE-LOS(R) demonstrated moderate to low criterion validity, with only the MXE-LOS(R) displaying adequate responsiveness to balance changes after 6 and 12 months. This article is protected by copyright. All rights reserved.

An association between excessive valgus hindfoot alignment and postural stability during single-leg standing in adolescent athletes

BACKGROUND

Diminished balance is associated with the incidence of ankle and lower extremity injuries in adolescents. Although flexible flatfoot is a common foot condition in pediatric and adolescent populations, the association between balance control and foot morphology remain unclear in adolescent athletes.

METHODS

Rearfoot angle in the double-limb standing position, body mass index (BMI), and isometric muscle strength related to the knee joint were retrospectively reviewed in 101 adolescent athletes (75 boys and 26 girls) with a mean age of 14.0 years (range 12-17). Postural stability during single-leg standing on static and dynamic platforms was investigated using Balance System SD in 119 feet without functional ankle instability. The participants were divided according to their rearfoot angle into control (less than 7°) and valgus (greater than or equal to 7°) groups. The measured parameters were compared between the control and valgus groups using Welch's t-test, and P values < 0.05 were considered statistically significant. Multiple regression analysis was conducted to identify the factors that significantly influenced postural control.

RESULTS

The average rearfoot angle was 4.6° in all participants. An excessive valgus rearfoot angle was detected in 53 feet (26.2%). No significant difference was found between the groups in terms of BMI and isometric knee muscle strength. Although no statistical differences were observed in postural stability on the static platform between the control and valgus groups, the valgus group demonstrated poorer postural stability for single-leg standing on the dynamic platform. Multiple regression analysis revealed that BMI and rearfoot angle were significantly associated with a poor postural control on the dynamic platform.

CONCLUSIONS

Our findings suggest that excessive rearfoot valgus specifically contributes to the deterioration of postural stability in adolescent athletes, and that rearfoot alignment should be evaluated for the adolescent population to prevent sports-related lower extremity injury.

Center of pressure position in the touches of the star excursion balance test in healthy individuals

BACKGROUND

The Star Excursion Balance Test (SEBT) is a clinical test that aims to assess postural control. Its interpretation is related to the understanding of the motor specificities required. Adjustments must be made to the center of pressure (COP) to maintain balance during testing movements. Comprehend the specifics of these adjustments for each direction can allow the development of more suitable exercises for balance training. The aim was to compare the positions of the COP on the different directions of the SEBT and correlate the reachs obtained in the SEBT with the distances from the COP to the borders of the base of support (BOS).

METHODS

Sixteen healthy subjects participated in the study. Measurements were made by performing the SEBT over the force platform. The Kruskal-Wallis test followed by Bonferroni's post hoc test was used to compare directions. The Pearson correlation test was used to check the correlation of parametric variables and Spearman correlation test for the nonparametric ones.

RESULTS

The position of the COP at the touch differs from the anterior direction to the other directions of the SEBT and the performance in this direction is correlated with the proximity of the COP to the anterior limit of the support base. The performances in the other directions did not correlate with the COP position.

CONCLUSION

The requirements of the compensation mechanisms for postural control are different between the directions of the SEBT.

Evaluation of peripheral neuropathy in lower limbs of patients with rheumatoid arthritis and its relation to fall risk

Background

Rheumatoid Arthritis (RA) is a chronic disabling systemic disease characterized by joint inflammation, and extra-articular manifestations, including peripheral neuropathy, a condition that can be associated with changes in muscle strength, proprioception and postural balance contributing for the risk of falls. The objective of this study is to analyze the incidence of peripheral neuropathy in patients with RA and its association with the occurrence of falls.

Methods

Patients were assessed by an electroneuromyography (ENMG) exam and by a questionnaire on accidental falls occurrence in the previous 12 months. They were also assessed on balance by the Short Physical Performance Battery (SPPB), functionality by the Health Assessment Questionnaire (HAQ), disease activity by the Disease Activity Score (DAS-28), neuropathic pain by the Questionnaire for the Diagnosis of Neuropathic Pain (DN4), and cutaneous sensitivity of the feet by the monofilament testing of Semmes–Weinstein. Monthly calls on falls were made in the subsequent six months. Data analysis was performed using the Shapiro–Wilk test for normality and Spearman, Chi-square, and T-student correlation tests, with a significant P level ≤ 0.05.

Results

A sample of 33 patients were evaluated. The incidence of peripheral neuropathy was 48.5%, of which 68.7% were axonal and 31.3% myelinic. The sensorimotor type was present in 64.7%, motor in 17.6%, and sensorial in 11.7% of the cases. Neuropathy was associated to balance (P = 0.026), neuropathic pain (P = 0.016), deep tendon reflexes absence (P = 0,049), altered skin sensitivity of the feet (P = 0.029) and fear of falling (P = 0.001). No association was found between peripheral neuropathy and age, gender, disease activity, or functionality. No significant association was found between peripheral neuropathy and occurrence of falls, in a 12-month retrospective and 6-month prospective evaluation.

Conclusion

Peripheral neuropathy has a high incidence in patients with RA, and is related to neuropathic pain, altered postural balance, but not to the occurrence of falls.

Relationship between Depressive Symptoms and Cognitive, Psychological, and Physical Performance in Community-Dwelling Older People with Cognitive Impairment

INTRODUCTION

Dementia and depression often coexist. Understanding how concomitant comorbidities affect function can improve assessment and management strategies. We examined the relationship between cognitive, psychological, and physical function and depressive symptoms in people with cognitive impairment.

METHODS

Cross-sectional study using baseline data from the iFOCIS randomized controlled trial involving 309 participants with mild-moderate cognitive impairment. The association between cognitive (Addenbrooke's Cognitive Examination-III [ACE-III], Frontal Assessment Battery), psychological (Goldberg Anxiety Scale; Iconographical Falls Efficacy Scale), and physical (Physiological Profile Assessment; Short Physical Performance Battery [SPPB]) function, and quality of life (QoL), physical activity levels and activities of daily living, and depressive symptoms (15-item Geriatric Depression Scale [GDS]) were assessed (adjusted for age, sex, education, and ACE-III as appropriate).

RESULTS

Participants with depressive symptoms (GDS ≥4) had significantly more falls in the previous year and a higher number of comorbidities than people without depressive symptoms (GDS <4). Each point increase in the GDS was associated with better memory, higher levels of anxiety and concern about falling, poorer balance, slower gait speed, and reduced QoL. The relationship between the GDS and poor balance and QoL withstood additional adjustment for comorbidity tertiles. The relationship between GDS and concern about falls withstood additional adjustment for previous falls (12 months) and SPPB scores.

CONCLUSIONS

Depressive symptomatology is associated with poorer physical and psychological function and reduced QoL in people with cognitive impairment. These factors should be considered when assessing and intervening in this group. Future research could examine these relationships longitudinally to establish causality and examine intervention efficacy in this group.