Thresholds for step initiation induced by support-surface translation: a dynamic center-of-mass model provides much better prediction than a static model

The impact of backpack load on adolescent's stair descent gait

This study investigates the impact of increasing backpack load on the gait of adolescents during stair descent. Sixteen healthy male students (age = 12.9 ± 0.6 years) were required to descend the stairs in 4 loaded conditions. The kinematic, kinetic, and EMG data were collected synchronously and gait parameters, especially indicators of balance control, were analyzed. The posterior tilt angles (COM-COP IA in the sagittal plane) (0 %-42 %, 48 %-53 %, 58 %-91 %, p < 0.01), trunk anterior tilt angles (9-33 %, 51-65 %, p < 0.01), and CV of stride length (p < 0.01) increased with the backpack load. The COM-Step edge separation decreased with the increased backload (p < 0.01). In addition, the hip flexion torque (25-40 %, 45-51 %, p < 0.01), the rectus femoris activation, and the hip stiffness increased significantly as the load up to 15 % Body Weight (BW)and 20 % BW. The increasing backpack load may affect adolescent's stair descent gait. Especially as the load was up to 15 % BW, the adolescents' bodies tended to tilt backwards relative to the support foot during the single stance phase. They may activate the hip flexors and tilt forward the trunk to recover from the balance perturbation, which was associated with increased hip flexion torques. This adjustment was more pronounced with the increasing backpack load. However, excessive forward flexion may increase the risk of forward falls. The boundaries of adjustment need further research in the future. Findings from this study provide baseline information on the intrinsic mechanisms of balance control during stair descent.

Notes on the margin of stability

The concept of the 'extrapolated center of mass (XcoM)', introduced by Hof et al., (2005, J. Biomechanics 38 (1), p. 1-8), extends the classical inverted pendulum model to dynamic situations. The vector quantity XcoM combines the center of mass position plus its velocity divided by the pendulum eigenfrequency. In this concept, the margin of stability (MoS), i.e., the minimum signed distance from the XcoM to the boundaries of the base of support was proposed as a measure of dynamic stability. Here we describe the conceptual evolution of the XcoM, discuss key considerations in the estimation of the XcoM and MoS, and provide a critical perspective on the interpretation of the MoS as a measure of instantaneous mechanical stability.

Compensatory stepping responses during real-life falls in older adults

BACKGROUND

Laboratory studies of postural responses suggest that stepping is a common strategy for balance recovery. Yet little is known about the frequency and characteristics of stepping responses during real-life falls in older adults.

RESEARCH QUESTIONS

(1) Among falls experienced by older adults in long-term care (LTC), what is the prevalence of attempts to recover balance by stepping? (2) How often are steps aligned to the direction of the fall? (3) Do the prevalence and characteristics of steps associate with intrinsic and situational factors?

METHODS

We collected and analyzed video footage of 1516 falls experienced by 515 residents of LTC (of mean age 82.7 years). Using generalized estimating equations, we tested whether the prevalence, direction and size of steps associated with sex, age, fall direction, activity at the time of falling, cause of imbalance, and holding or grasping objects.

RESULTS

Stepping after imbalance was observed in 76% of falls, and 80% of these cases involved multiple steps. The direction of steps aligned with the initial fall direction in 81% of cases. The size of the first step was less than one-half foot length in 64% of cases. Secondary steps tended to be similar in size to the first step. Steps were more common for falls during walking than standing, and for sideways falls. Steps were less common in falls involving held objects, and steps were less likely to be aligned with the fall direction when reach-to-grasp responses were observed.

SIGNIFICANCE

Older adults in LTC tended to respond to falls with multiple compensatory steps. Steps were tailored to the direction of the fall, but small in size (less than one-half foot length in size). Exercise programs for fall prevention in older adults should focus on increasing step size to enhance the effectiveness of step recovery responses.

Description, reliability and utility of a ground-reaction-force triggered protocol for precise delivery of unilateral trip-like perturbations during gait

Tripping is a common cause of falls and a focus of many biomechanical investigations. Concerns regarding the precision of delivery of simulated-fall protocols reside in the current biomechanical methodology literature. This study aimed to develop a treadmill-based protocol that generated unanticipated trip-like perturbations during walking with high timing precision. The protocol utilized a side-by-side split-belt instrumented treadmill. Programmed treadmill belt acceleration profiles (two levels of perturbation magnitude) were triggered unilaterally at the instant the tripped leg bore 20% of the body weight. Test-retest reliability of fall responses was examined in 10 participants. Utility was examined as to whether the protocol could differentiate the fall recovery responses and likelihood of falls, estimated using peak trunk flexion angle after perturbation, between young and middle-aged adults (n = 10 per group). Results showed that the perturbations could be precisely and consistently delivered during early stance phases (10-45 milliseconds after initial contact). The protocol elicited excellent reliability of responses in both perturbation magnitudes (ICC = 0.944 and 0.911). Middle-aged adults exhibited significantly greater peak trunk flexion than young adults (p = 0.035), indicating that the current protocol can be utilized in differentiating individuals with different levels of fall risks. The main limitation of the protocol is that perturbations are delivered in stance rather swing phase. This protocol addressed some issues discussed in previous "simulated fall" protocols and may be useful for future fall research and subsequent clinical interventions.

Sensory signals of unloading in insects are tuned to distinguish leg slipping from load variations in gait: experimental and modeling studies

In control of walking, sensory signals of decreasing forces are used to regulate leg lifting in initiation of swing and to detect loss of substrate grip (leg slipping). We used extracellular recordings in two insect species to characterize and model responses to force decrements of tibial campaniform sensilla, receptors that detect forces as cuticular strains. Discharges to decreasing forces did not occur upon direct stimulation of the sites of mechanotransduction (cuticular caps) but were readily elicited by bending forces applied to the leg. Responses to bending force decreases were phasic but had rate sensitivities similar to discharges elicited by force increases in the opposite direction. Application of stimuli of equivalent amplitude at different offset levels showed that discharges were strongly dependent upon the tonic level of loading: firing was maximal to complete unloading of the leg but substantially decreased or eliminated by sustained loads. The contribution of cuticle properties to sensory responses was also evaluated: discharges to force increases showed decreased adaptation when mechanical stress relaxation was minimized; firing to force decreases could be related to viscoelastic “creep” in the cuticle. Discharges to force decrements apparently occur due to cuticle viscoelasticity that generates transient strains similar to bending in the opposite direction. Tuning of sensory responses through cuticular and membrane properties effectively distinguishes loss of substrate grip/complete unloading from force variations due to gait in walking. We have successfully reproduced these properties in a mathematical model of the receptors. Sensors with similar tuning could fulfil these functions in legs of walking machines.

NEW & NOTEWORTHY Decreases in loading of legs are important in the regulation of posture and walking in both vertebrates and invertebrates. Recordings of activities of tibial campaniform sensilla, which encode forces in insects, showed that their responses are specifically tuned to detect force decreases at the end of the stance phase of walking or when a leg slips. These results have been reproduced in a mathematical model of the receptors and also have potential applications in robotics.

The effects of slow breathing on postural muscles during standing perturbations in young adults

Maintaining standing balance is vital to completing activities in daily living. Recent findings suggest an interaction between cardiovascular and postural control systems. Volitional slow breathing can modulate the cardiovascular response and affect postural control during quiet standing. However, the effects of slow breathing during threats to standing balance have not been studied. The study examined the effect of slow breathing on the latency and amplitude of postural muscle responses to perturbations of the base of support in healthy, young adults. Twenty-seven participants completed two balance perturbation tasks in standing on an instrumented split-belt treadmill while breathing spontaneously and breathing at 6 breaths per minute. Each perturbation task consisted of 25 posteriorly directed translations of the treadmill belts every 8-12 s. Muscle latency and muscle burst amplitude were measured using surface electromyography from the right limb for the quadriceps (QUADS), medial hamstring (MH), gastrocnemii (GASTROC), soleus (SOL), and tibialis anterior (TA) muscle groups, while a respiratory belt was used to record respiratory rate. Results indicated that during the slow breathing task both muscle latency (p = 0.022) and muscle burst amplitude (p = 0.011) decreased compared to spontaneous breathing. The EMG pre-perturbation activation was not significantly different in any muscle group between conditions (p > 0.167). The study found that reducing respiratory rate to approximately 6 breaths per minute affects the neuromuscular responses in the lower limb muscles to perturbations.

How Does Lower Limb Respond to Unexpected Balance Perturbations? New Insights from Synchronized Human Kinetics, Kinematics, Muscle Electromyography (EMG) and Mechanomyography (MMG) Data

Making rapid and proper compensatory postural adjustments is vital to prevent falls and fall-related injuries. This study aimed to investigate how, especially how rapidly, the multiple lower-limb muscles and joints would respond to the unexpected standing balance perturbations. Unexpected waist-pull perturbations with small, medium and large magnitudes were delivered to twelve healthy young adults from the anterior, posterior, medial and lateral directions. Electromyographical (EMG) and mechanomyographical (MMG) responses of eight dominant-leg muscles (i.e., hip abductor/adductors, hip flexor/extensor, knee flexor/extensor, and ankle dorsiflexor/plantarflexors) together with the lower-limb joint angle, moment, and power data were recorded. The onset latencies, time to peak, peak values, and/or rate of change of these signals were analyzed. Statistical analysis revealed that: (1) agonist muscles resisting the delivered perturbation had faster activation than the antagonist muscles; (2) ankle muscles showed the largest rate of activation among eight muscles following both anteroposterior and mediolateral perturbations; (3) lower-limb joint moments that complied with the perturbation had faster increase; and (4) larger perturbation magnitude tended to evoke a faster response in muscle activities, but not necessarily in joint kinetics/kinematics. These findings provided insights regarding the underlying mechanism and lower-limb muscle activities to maintain reactive standing balance in healthy young adults.

Development of an exercise programme for balance abilities in people with multiple sclerosis: a development of concept study using Rasch analysis

Background

People with multiple sclerosis (PwMS) frequently have impaired balance from an early stage of the disease. Balance difficulties can be divided into categories; although, to date, these lack scientific foundation. Impaired balance in PwMS can be addressed using specific and challenging exercises. Such exercises should provide an optimal challenge point; however, the difficulty of balance exercises is often unknown, making it difficult to target the exercises to an individual’s abilities.

The aims of this study were: to develop an exercise programme for PwMS relating the exercises to the balance problem categories; to establish the order of difficulty of exercises in each category and; to evaluate the content and structural validity of the exercise programme.

Methods

A “construct map” approach was used to design and develop an exercise programme for PwMS. Potentially relevant balance exercises were identified, then a framework was set up, comprising four dimensions (subsequently reduced to three dimensions) of balance exercises. The relevance, comprehensibility, and comprehensiveness of the exercise programme were rated by 13 physiotherapists, who also linked 19 key exercises to balance categories. A total of 65 PwMS performed the 19 balance exercises, rated their difficulty and commented on the relevance and comprehensibility of each exercise. A Rasch model was used to evaluate the relative difficulty of the exercises. To assess fit of the data to the Rasch model a rating scale model was used, which is a unidimensional latent trait model for polytomous item responses.

Results

Evaluation by the physiotherapists and PwMS indicated that the content validity of the exercise programme was adequate. Rasch analysis showed that the latent trait “balance exercises in PwMS” comprised three subdimensions (“stable BOS”, “sway” and “step and walk”). The 19 balance exercises showed adequate fit to the respective dimensions. The difficulties of the balance exercises were adequate to cover the ability spectrum of the PwMS.

Conclusion

A balance exercise programme for PwMS comprising three dimensions of balance exercises was developed. Difficulty estimates have been established for each of the exercises, which can be used for targeted balance training. Content and structural validity of the programme was adequate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-021-00120-3.

Predicted Threshold for Seated Stability: Estimation of Margin of Stability Using Wearable Inertial Sensors

Individuals with spinal cord injury suffer from seated instability due to impaired trunk neuromuscular function. Monitoring seated stability toward the development of closed-loop controlled neuroprosthetic technologies could be beneficial for restoring trunk stability during sitting in affected individuals. However, there is a lack of (1) a biomechanical characterization to quantify the relationship between the trunk kinematics and sitting balance; and (2) a validated wearable biomedical device for assessing dynamic sitting posture and fall-risk in real-time. This study aims to: (a) determine the limit of dynamic seated stability as a function of the trunk center of mass (COM) position and velocity relative to the base of support; (b) experimentally validate the predicted limit of stability using traditional motion capture; (c) compare the predicted limit of stability with that predicted in the literature for standing and walking; and (d) validate a wearable device for assessing dynamic seated stability and risk of loss of balance. First, we used a six-segment model of the seated human body for simulation. To obtain the limit of stability, we applied forward dynamics and optimization to obtain the maximum feasible initial velocities of the trunk COM that would bring the trunk COM position to the front-end of the base-of-support for a set of initial COM positions. Second, experimental data were obtained from fifteen able-bodied individuals who maintained sitting balance while base-of-support perturbations were applied with three different amplitudes. A motion capture system and four inertial measurement units (IMUs) were used to estimate the trunk COM motion states (i.e., trunk COM position and velocity). The margin of stability was calculated as the shortest distance of the instantaneous COM motion states to those obtained as the limit of stability in the state-space plane. All experimentally obtained trunk COM motion states fell within the limit of stability. A high correlation and small root-mean-square difference were observed between the estimated trunk COM states obtained by the motion capture system and IMUs. IMU-based wearable technology, along with the predicted limit of dynamic seated stability, can estimate the margin of stability during perturbed sitting. Therefore, it has the potential to monitor the seated stability of wheelchair users affected by trunk instability.

Multisensory postural control in adults: Variation in visual, haptic, and proprioceptive inputs

Maintaining balance is fundamentally a multisensory process, with visual, haptic, and proprioceptive information all playing an important role in postural control. The current project examined the interaction between such sensory inputs, manipulating visual (presence versus absence), haptic (presence versus absence of contact with a stable or unstable finger support surface), and proprioceptive (varying stance widths, including shoulder width stance, Chaplin [heels together, feet splayed at approximately 60°] stance, feet together stance, and tandem stance) information. Analyses of mean velocity of the Centre of Pressure (CoP) revealed significant interactions between these factors, with stability gains observed as a function of increasing sensory information (e.g., visual, haptic, visual + haptic), although the nature of these gains was modulated by the proprioceptive information and the reliability of the haptic support surface (i.e., unstable versus stable finger supports). Subsequent analyses on individual difference parameters (e.g., height, leg length, weight, and areas of base of support) revealed that these variables were significantly related to postural measures across experimental conditions. These findings are discussed relative to their implications for multisensory postural control, and with respect to inverted pendulum models of balance. (185 words).

Interactions between initial posture and task-level goal explain experimental variability in postural responses to perturbations of standing balance

Postural responses to similar perturbations of standing balance vary widely within and across subjects. Here, we identified two sources of variability and their interactions by combining experimental observations with computational modeling: differences in posture at perturbation onset across trials and differences in task-level goals across subjects. We first collected postural responses to unpredictable backward support-surface translations during standing in 10 young adults. We found that maximal trunk lean in postural responses to backward translations were highly variable both within subjects (mean of ranges = 28.3°) and across subjects (range of means = 39.9°). Initial center of mass (COM) position was correlated with maximal trunk lean during the response, but this relation was subject specific (R² = 0.29-0.82). We then used predictive simulations to assess causal relations and interactions with task-level goal. Our simulations showed that initial posture explains the experimentally observed intrasubject variability with a more anterior initial COM position increasing the use of the hip strategy. Differences in task-level goal explain observed intersubject variability with prioritizing effort minimization leading to ankle strategies and prioritizing stability leading to hip strategies. Interactions between initial posture and task-level goal explain observed differences in intrasubject variability across subjects. Our findings suggest that variability in initial posture due to increased sway as observed in older adults might increase the occurrence of less stable postural responses to perturbations. Insight in factors causing movement variability will advance our ability to study the origin of differences between groups and conditions.NEW & NOTEWORTHY Responses to perturbations of standing balance vary both within and between individuals. By combining experimental observations with computational modeling, we identified causes of observed kinematic variability in healthy young adults. First, we found that trial-by-trial differences in posture at perturbation onset explain most of the kinematic variability observed within subjects. Second, we found that differences in prioritizing effort versus stability explained differences in the postural response as well as differences in trial-by-trial variability across subjects.

A comparison of balance-correcting responses induced with platform-translation and shoulder-pull perturbation methods

The understanding of reactive balance control mechanisms in humans emanates from studies utilizing a variety of perturbation methods, instructions, and sensory conditions. The use of different perturbation methods may produce method-specific balance-correcting responses. This study evaluated balance-correcting responses induced with platform-translation and shoulder-pull methods with equilibrated perturbation intensities, and whether the absence of vision affects balance-correcting responses differently between perturbation methods. Fifteen healthy young males participated. Unexpected forward and backward platform-translation and shoulder-pull perturbations were induced with eyes-open and eyes-closed. Participants were asked to behave naturally. Forward stepping trials were analyzed. Margin of stability (MOS) was calculated from the position data of reflective markers placed strategically around the body. MOS was reported at step onset and at foot contact. MOS was smaller at step onset (0.01 ± 0.01 m) and at foot contact (0.09 ± 0.01 m) during platform-translation trials and at both time points during shoulder-pull trials (0.04 ± 0.01 m and 0.17 ± 0.01 m, respectively). The absence of vision did not affect MOS at step onset. At foot contact during platform-translation with eyes-closed MOS was larger (0.11 ± 0.01 m) than with eyes-open (0.08 ± 0.01 m), but not different between eyes-open (0.17 ± 0.01 m) and eyes-closed (0.18 ± 0.01 m) during shoulder-pull. Participants required a second step to recover balance in 14% of the platform-translation and 3% of the shoulder-pull trials. During platform-translation trials participants demonstrated smaller MOS which placed them in a less favorable circumstance for balance recovery. Platform-translation appears to be more challenging than shoulder-pull perturbation in terms of balance recovery. This study underscores that caution is required when interpreting results of studies utilizing different perturbation paradigms.

Perturbation in public transport as a basic concept for perturbation-based balance training for fall prevention

INTRODUCTION

The aim of the study was to collect real-world sensor data on acceleration and deceleration while riding a bus or tram. With respect to the risk of suffering fall-related injuries while using public transportation, our interest was to understand the amplitude of real-world perturbations to translate them to innovative reactive balance training programs.

METHODS

Acceleration and deceleration data were collected during 12 days in buses and trams in a German city. A sensor, which was fixed to a vertical bar in the vehicle, measured the acceleration signals. Additionally, extreme values of deceleration during full braking were collected in a driving school bus.

RESULTS

For the incident type acceleration from standing extreme values of acceleration and jerking were higher in buses compared to trams with a maximum acceleration of 3.37 m/s² and 1.80 m/s², respectively, and extreme jerking of 13.30 m/s³ and -5.56 m/s³, respectively. Similarly, for the incident type deceleration approaching a stop extreme values of deceleration and jerking were higher in buses compared to trams with maximum deceleration of -3.12 m/s² and -2.31 m/s², respectively, and extreme jerking of -19.19 m/s³ and -10.83 m/s³, respectively. Extreme values for maximum deceleration and extreme jerking as simulated at the driving school were not reached during real-world measurements. The duration of incidents in acceleration from standing and deceleration approaching a stop was shorter for buses than for trams.

CONCLUSION

Acceleration and jerking values were higher in buses compared to trams. Based on this study, laboratory simulation paradigms can be developed to study balance responses in older persons and to design fall prevention interventions which are ecologically valid.

Effects of task-specific obstacle-induced trip-perturbation training: proactive and reactive adaptation to reduce fall-risk in community-dwelling older adults

BACKGROUND

Trips account for over half of outdoor falls among community-dwelling older adults.

AIMS

To investigate to what extent obstacle-induced trip-perturbation training could reduce fall-risk among older adults and to see whether training effects could be retained short term.

METHODS

Forty community-dwelling older adults were exposed to 24 repeated trip-perturbations given in a "blocked-and-mixed" manner during over-ground gait. Another trip was given 30 min post-training. For each trip, recovery strategies and outcomes (fall versus no fall) were analyzed. Within-trial changes to proactive and reactive dynamic center of mass stability, pre-trip toe clearance and trunk angle, trunk angle at recovery completion, and recovery step length were analyzed.

RESULTS

48% of participants fell on their novel trip. The fall rate decreased significantly for subsequent trips, with no falls on the last trip. The decreased fall incidence resulted from improved feedforward and feedback adjustments for controlling center of mass stability and body kinematics. Proactive adaptations included reduced forward center of mass velocity, which lessened forward instability, and larger toe clearance, which increased the likelihood of obstacle avoidance. Reactive adjustments included reduced forward instability and improved trunk control (reduced forward rotation) at recovery step completion. Post-training, training effects were retained in terms of fall incidence, with slight decay in toe clearance and reactive stability.

CONCLUSIONS

Older adults demonstrated appropriate locomotor-based proactive and reactive adaptations to repeated obstacle-induced trips with short-term retention similar to young adults, and thus could reduce their fall-risk through such training.

Visual field motion during a body pull affects compensatory standing and stepping responses

KEY POINTS

It is unclear whether the visual input that accompanies a perturbation of a standing person can affect whether a recovery step is taken. Visual motion speeds were manipulated during unexpected forward and backward shoulder pulls. Visual motion that appeared slower than actual body motion reduced the initial in-place resistance to the perturbation. As a result of the modulation of the in-place response, less pull force was needed to trigger a step when visual velocity appeared slower than normal. The visuomotor postural response occurred earlier and was larger when the full-field visual input was paired with a mechanical perturbation.

ABSTRACT

The present study aimed to determine how visual motion evoked by an upper body perturbation during standing affects compensatory postural responses. This was investigated by rotating the visual field forwards or backwards about the ankle, time-locked to a forwards or backwards shoulder pull. Kinematic, kinetic and electromyographic responses were recorded to a range of pull forces over 160 trials in 12 healthy adults (mean ± SD = 31 ± 5.8 years). Stepping threshold forces and in-place postural responses were compared between conditions. When the visual field moved in the same direction as the pull, so that the apparent velocity of the body was reduced (SLOW condition), the pull-force required to induce a step was less than when the visual field either rotated in the opposite direction (FAST) or was unaltered (NATURAL). For in-place responses, the body was displaced further in the direction of the pull in the SLOW condition. This was the result of a reduction in the resistive force from lower leg muscles 130 ms after the visual motion onset. In trials with no pull, the visual motion induced postural responses that were later (290 ms) and had smaller amplitudes compared to when visual motion is paired with an unexpected perturbation of the body. The results suggest that the apparent speed of the visual environment during a perturbation does influence whether a compensatory step is taken, not via a direct effect on the decision to step but by modulating the initial in-place response.

Modelling the dynamic margins of stability for use in evaluations of balance following a support-surface perturbation

The dynamic margin of stability provides a method that captures the center of mass (CoM) state (position-velocity) in relation to the base of support (BoS). However, the model upon which this concept was derived does not consider how the inertial characteristics of forced support-surface perturbations would influence balance control. Within the current article, the inverted pendulum model was restructured to account for fixed, piecewise accelerations of the BoS. From this logic, two variations of the adjusted margin of stability, each maintaining a similar definition of extrapolated CoM, are proposed; one ignoring horizontal ground contact and inertial forces applied to the BoS, the other incorporating these forces. Unique within the proposed models is the time-variant BoS boundaries that depend on the perturbation applied. Verification of the solution for each model is provided, along with a comparison of obtained values to previous methods of defining CoM position-velocity stability metrics using a computational model and optimal control. For the simpler model variation (ignoring forces), we also assessed how CoM position and perturbation parameter selection over/underestimate the predicted maximal permissible velocity. The results of these analyses suggest that factors which increase the acceleration impulse decrease the difference between the two models; the opposite was observed for factors increasing displacements between the CoM and BoS boundary. Lastly, use of the proposed adjusted margin of stability within an experimental data set highlights the ability of our model to predict instability (stepping strategies; negative margin of stability) relative to the use of the extrapolated CoM alone.

Predicted threshold against forward and backward loss of balance for perturbed walking

The biomechanical mechanisms of loss of balance have been studied before for slip condition but have not been investigated for arbitrary perturbation profiles under non-slip conditions in sagittal plane. This study aimed to determine the thresholds of center of mass (COM) velocity and position relative to the base of support (BOS) that predict forward and backward loss of balance during walking with a range of BOS perturbations. Perturbations were modeled as sinusoidal BOS motions in the vertical or anterior-posterior direction or as sagittal rotation. The human body was modeled using a seven-link model. Forward dynamics alongside with dynamic optimization were used to find the thresholds of initial COM velocity for each initial COM position that would predict forward or backward loss of balance. The effects of perturbation frequency and amplitude on these thresholds were modeled based on the simulation data. Experimental data were collected from 15 able-bodied individuals and three individuals with disability during perturbed walking. The simulation results showed similarity with the stability region reported for slip and non-slip conditions. The feasible stability region shrank when the perturbation frequency and amplitude increased, especially for larger initial COM velocities. 89.5% (70.9%) and 82.4% (68.2%) of the measured COM position and velocity combinations during low (high) perturbations were located inside the simulated limits of the stability region, for able-bodied and disabled individuals, respectively. The simulation results demonstrated the effects of different perturbation levels on the stability region. The obtained stability region can be used for developing rehabilitative programs in interactive environments.

Treadmill-gait slip training in community-dwelling older adults: mechanisms of immediate adaptation for a progressive ascending-mixed-intensity protocol

The study purpose was to investigate whether older adults could improve their stability against a backward loss of balance (BLOB) after receiving repeated treadmill slips during walking and to see how such adaptive changes would be affected by practice dosage (combination of slip intensity and the number of slips at each intensity). Twenty-five healthy community-dwelling older adults received forty treadmill slips given over eleven blocks at five intensities (P1-P1-P2-P3-P4-P5-P4-P5-P5-P3-P1, larger number indicating higher intensity). Center of mass (COM) stability was calculated as the shortest distance of the instantaneous COM position and velocity relative to the base of support (BOS) from a theoretical threshold for BLOB (larger stability value indicated a better stability against BLOB). Stability, step length, and trunk angle were measured before and after slip onset to reflect proactive and reactive control, respectively. The first slips at each intensity block (i.e., P1, P3, P4, and P5) were compared with the first slips in the last blocks at those intensities to examine main effects of training dosage (intensity and repetition). Improvements in proactive and reactive stability were more pronounced for receiving more slips at larger intensities than fewer slips at smaller intensities. Older adults only demonstrated partial positive scaling effects to proactively, not reactively, establish a more stable initial COM state. The improved proactive stability was associated with an anterior shift of COM position relative to the BOS, resulting from a shorter pre-slip step length. The improved reactive stability was associated with an anterior shift of COM position, resulting from a larger compensatory step length and a faster COM velocity relative to the BOS. Our findings indicated that treadmill-gait slip perturbations elicited similar proactive and reactive control to that from over-ground slip perturbations, but greater slip intensity and repetition might yield more immediate adaptive improvements.

Does Perturbation-Based Balance Training Improve Control of Reactive Stepping in Individuals with Chronic Stroke?

BACKGROUND

Although perturbation-based balance training (PBT) may be effective in improving reactive balance control and/or reducing fall risk in individuals with stroke, the characteristics of reactive balance responses that improve following PBT have not yet been identified. This study aimed to determine if reactive stepping characteristics and timing in response to support-surface perturbations improved to a greater extent following PBT, compared to traditional balance training.

MATERIALS AND METHODS

This study represents a substudy of a multisite randomized controlled trial. Sixteen individuals with chronic stroke were randomly assigned to either perturbation-based or traditional balance training, and underwent 6-weeks of training as a part of the randomized controlled trial. Responses to support-surface perturbation were evaluated pre- and post-training, and 6-months post-training. Reactive stepping characteristics and timing were compared between sessions within each group, and between groups at post-training and 6-months post-training while controlling for each measure at the pre-training session.

RESULTS

The frequency of extra steps in response to perturbations decreased from pre-training to post-training for the PBT group, but not for the control group.

CONCLUSIONS

Improvements in reactive balance control were identified after PBT in individuals with chronic stroke. Findings provide insight into the mechanism by which PBT improves reactive balance control poststroke, and support the use of PBT in balance rehabilitation programs poststroke.

Age-Related Differences in Postural and Goal-Directed Movements During Medial-Lateral Rhythmic Stepping

Lateral stability and weight transfer are important for successful stepping and are associated with falls in older adults (OAs). This study assessed the influence of step pacing frequency during medial-lateral stepping in place on body center of mass and lower limb movement in young adults, middle-aged adults, and OAs. Medial-lateral center of mass and stepping limb motion and lower limb loading data were collected. Center of mass motion decreased with increasing pacing frequency and increased to a lesser extent with decreasing pacing frequency. Step length was relatively resistant to changes in pacing frequency. OAs exhibited reductions in whole body and stepping motion compared with younger adults. OAs exhibited greater support limb loading. OAs adapt both postural and stepping strategies to successfully step under time-critical conditions.

An Initial Passive Phase That Limits the Time to Recover and Emphasizes the Role of Proprioceptive Information

In the present experiments, multiple balance perturbations were provided by unpredictable support-surface translations in various directions and velocities. The aim of this study was to distinguish the passive and the active phases during the pre-impact period of a fall. It was hypothesized that it should be feasible if one uses a specific quantitative kinematic analysis to evaluate the dispersion of the body segments trajectories across trials. Moreover, a multi-joint kinematical model was created for each subject, based on a new 3-D minimally invasive stereoradiographic X-ray images to assess subject-specific geometry and inertial parameters. The simulations allowed discriminating between the contributions of the passive (inertia-induced properties) and the active (neuromuscular response) components during falls. Our data show that there is limited time to adjust the way one fall from a standing position. We showed that the pre-impact period is truncated of 200 ms. During the initial part of a fall, the observed trajectory results from the interaction between the destabilizing external force and the body: inertial properties intrinsic to joints, ligaments and musculotendinous system have then a major contribution, as suggested for the regulation of static upright stance. This passive phase is later followed by an active phase, which consists of a corrective response to the postural perturbation. We believe that during a fall from standing height, it takes about 300 ms for postural responses to start correcting the body trajectory, while the impact is expected to occur around 700 ms. It has been argued that this time is sufficient to change the way one falls and that this makes it possible to apply safer ways of falling, for example by using martial arts fall techniques. Also, our results imply visual and vestibular information are not congruent with the beginning of the on-going fall. This consequence is to be noted as subjects prepare to the impact on the basis of sensory information, which would be uniquely mainly of proprioceptive origin at the fall onset. One limitation of the present analysis is that no EMG was included so far but these data are the subject of a future study.

Characterization of Reactions to Laterally Directed Perturbations in People With Chronic Stroke

BACKGROUND

Reactive balance control is often impaired poststroke. Studies addressing responses to laterally directed perturbations in this population are currently lacking. Given that stroke-related motor impairments are unilateral, a better understanding of reactive balance responses to these types of perturbations is critical.

OBJECTIVE

This study aimed to quantify differences in reactive balance control in response to laterally directed perturbations in people with chronic stroke, based on perturbation direction and ability to step with either limb.

DESIGN

This study used a cross-sectional design.

METHODS

Participants with chronic stroke (N = 19) were divided into groups representing their ability to step with either limb, based on performance on a reactive balance task in a baseline assessment. The preferred stepping limb was also identified during this assessment. Each participant then underwent a series of laterally directed perturbations on a motion platform. Behavioral measures were compared between platform direction and group.

RESULTS

Trials with extra steps, step initiation with the preferred limb, and crossover steps were more common with platform motion toward the preferred limb compared to the nonpreferred limb; the latter effect was only observed for participants with an impaired ability to step with either limb. Side-step sequences were more common in those able to step with either limb when the platform moved toward the preferred limb.

LIMITATIONS

The participant sample was likely higher functioning than the general population of stroke survivors due to equipment constraints. Additionally, participants may have developed strategies to use the platform's motion characteristics to aid with balance recovery.

CONCLUSIONS

These findings provide an indication of responses to laterally directed perturbations in people with chronic stroke and may help inform strategies for improving reactive balance control during stroke rehabilitation.

Stepping boundary of external force-controlled perturbations of varying durations: Comparison of experimental data and model simulations

This study investigated the stepping boundary - the force that can be resisted without stepping - for force-controlled perturbations of different durations. Twenty-two healthy young adults (19-37 years old) were instructed to try not to step in response to 86 different force/time combinations of forward waist-pulls. The forces at which 50% of subjects stepped (F₅₀) were identified for each tested perturbation durations. Results showed that F₅₀ decreased hyperbolically when the perturbation's duration increased and converged toward a constant value (about 10%BW) for longer perturbations (over 1500 ms). The effect of perturbation duration was critical for the shortest perturbations (less than 1 s). In parallel, a simple function was proposed to estimate this stepping boundary. Considering the dynamics of a linear inverted pendulum + foot model and simple balance recovery reactions, we could express the maximum pulling force that can be withstood without stepping as a simple function of the perturbation duration. When used with values of the main model parameters determined experimentally, this function replicated adequately the experimental results. This study demonstrates for the first time that perturbation duration has a major influence on the outcomes of compliant perturbations such as force-controlled pulls. The stepping boundary corresponds to a constant perturbation force-duration product and is largely explained by only two parameters: the reaction time and the displacement of the center of pressure within the functional base of support. Future work should investigate pathological populations and additional parameters characterizing the perturbation time-profile such as the time derivative of the perturbation.

Exploring the relationship between stability and variability of the centre of mass and centre of pressure

BACKGROUND

There are competing perspectives in the literature regarding the role of movement variability in quiet standing and balance control. Some view high variability as indicative of poor balance control and a contributor to increased fall risk, whereas others view variability as beneficial in providing sensory information that aids balance control.

RESEARCH QUESTION

This study aimed to help to clarify the role of variability in balance control by testing two competing hypotheses: that increased variability would lead to instability, or that increased variability would improve stability, where stability is defined as the ability to respond to a perturbation.

METHODS

Fourteen healthy young adults (20-35 years old) were recruited. Participants experienced postural perturbations of varying magnitudes, delivered via sudden backward movement of the support surface. Magnitudes of postural perturbation were chosen such that both step and no-step responses could be observed at each magnitude. Variability in the centre of mass and centre of pressure movement was measured for 10 s prior to the postural perturbation. Multiple regression was used to determine if movement variability predicted step responses when controlling for perturbation magnitude, trial order, and margin of stability at perturbation onset.

RESULTS

Lower variability in medio-lateral centre of mass and centre of pressure position, and lower variability in medio-lateral centre of pressure velocity were related to increased odds of stepping in response to the perturbation (p-values ≤0.001).

SIGNIFICANCE

This study provides support for the hypothesis that, at least for relatively low variability values, increased centre of pressure and mass movement variability improves stability. Specifically, increasing movement of the centre of pressure and mass in the medio-lateral direction may help to preserve stability in the antero-posterior direction by providing the central nervous system with information about the antero-posterior centre of mass across a wide range of medio-lateral positions.

Balance perturbations

Impairments of balance and gait leading to loss of mobility, falls, and disability are common occurrences in many neurologic conditions and with older age. Much of our current understanding about posture and balance control and its impairments has come from investigations of how healthy individuals and those with neurologic disorders respond to situations that perturb standing balance during instructed voluntary tasks or in reaction to externally imposed challenges to stability. Knowledge obtained from these investigations has come from documenting the physical and physiologic characteristics of the perturbations together with the body's electrophysiologic, structural, kinetic, kinematic, and behavioral responses. From these findings, basic mechanisms, diagnostic and pathologic criteria, and targets for clinical care have been identified while continued gaps in understanding have been exposed. In this chapter, we synthesize and discuss current concepts and understanding concerning the sensorimotor control of posture and balance while standing. We draw insights gained from perturbation studies investigating these functions in healthy adults, and those with neurologic pathologies.

A wearable vibrotactile biofeedback system improves balance control of healthy young adults following perturbations from quiet stance

Maintaining postural equilibrium requires fast reactions and constant adjustments of the center of mass (CoM) position to prevent falls, especially when there is a sudden perturbation of the support surface. During this study, a newly developed wearable feedback system provided immediate vibrotactile clues to users based on plantar force measurement, in an attempt to reduce reaction time and CoM displacement in response to a perturbation of the floor. Ten healthy young adults participated in this study. They stood on a support surface, which suddenly moved in one of four horizontal directions (forward, backward, left and right), with the biofeedback system turned on or off. The testing sequence of the four perturbation directions and the two system conditions (turned on or off) was randomized. The resulting reaction time and CoM displacement were analysed. Results showed that the vibrotactile feedback system significantly improved balance control during translational perturbations. The positive results of this preliminary study highlight the potential of a plantar force measurement based biofeedback system in improving balance under perturbations of the support surface. Future system optimizations could facilitate its application in fall prevention in real life conditions, such as standing in buses or trains that suddenly decelerate or accelerate.

Trunk sway in idiopathic normal pressure hydrocephalus-Quantitative assessment in clinical practice

BACKGROUND

In diagnosis and treatment of patients with idiopathic normal pressure hydrocephalus (iNPH), there is need for clinically applicable, quantitative assessment of balance and gait. Using a body-worn gyroscopic system, the aim of this study was to assess postural stability of iNPH patients in standing, walking and during sensory deprivation before and after cerebrospinal fluid (CSF) drainage and surgery. A comparison was performed between healthy elderly (HE) and patients with various types of hydrocephalus (ventriculomegaly (VM)).

METHODS

Trunk sway was measured in 31 iNPH patients, 22 VM patients and 58 HE. Measurements were performed at baseline in all subjects, after CSF drainage in both patient groups and after shunt surgery in the iNPH group.

RESULTS

Preoperatively, the iNPH patients had significantly higher trunk sway compared to HE, specifically for the standing tasks (p<0.001). Compared to VM, iNPH patients had significantly lower sway velocity during gait in three of four cases on firm support (p<0.05). Sway velocity improved after CSF drainage and in forward-backward direction after surgery (p<0.01). Compared to HE both patient groups demonstrated less reliance on visual input to maintain stable posture.

CONCLUSIONS

INPH patients had reduced postural stability compared to HE, particularly during standing, and for differentiation between iNPH and VM patients sway velocity during gait is a promising parameter. A reversible reduction of visual incorporation during standing was also seen. Thus, the gyroscopic system quantitatively assessed postural deficits in iNPH, making it a potentially useful tool for aiding in future diagnoses, choices of treatment and clinical follow-up.

Reactions of Standing Bipeds on Moving Platforms to Keep Their Balance May Increase the Amplitude of Oscillations of Platforms Satisfying Hooke's Law

Consider a person standing on a platform that oscillates laterally, i.e. to the right and left of the person. Assume the platform satisfies Hooke's law. As the platform moves, the person reacts and moves its body attempting to keep its balance. We develop a simple model to study this phenomenon and show that the person, while attempting to keep its balance, may do positive work on the platform and increase the amplitude of its oscillations. The studies in this article are motivated by the oscillations in pedestrian bridges that are sometimes observed when large crowds cross them.

Timing paradox of stepping and falls in ageing: not so quick and quick(er) on the trigger

Physiological and degenerative changes affecting human standing balance are major contributors to falls with ageing. During imbalance, stepping is a powerful protective action for preserving balance that may be voluntarily initiated in recognition of a balance threat, or be induced by an externally imposed mechanical or sensory perturbation. Paradoxically, with ageing and falls, initiation slowing of voluntary stepping is observed together with perturbation-induced steps that are triggered as fast as or faster than for younger adults. While age-associated changes in sensorimotor conduction, central neuronal processing and cognitive functions are linked to delayed voluntary stepping, alterations in the coupling of posture and locomotion may also prolong step triggering. It is less clear, however, how these factors may explain the accelerated triggering of induced stepping. We present a conceptual model that addresses this issue. For voluntary stepping, a disruption in the normal coupling between posture and locomotion may underlie step-triggering delays through suppression of the locomotion network based on an estimation of the evolving mechanical state conditions for stability. During induced stepping, accelerated step initiation may represent an event-triggering process whereby stepping is released according to the occurrence of a perturbation rather than to the specific sensorimotor information reflecting the evolving instability. In this case, errors in the parametric control of induced stepping and its effectiveness in stabilizing balance would be likely to occur. We further suggest that there is a residual adaptive capacity with ageing that could be exploited to improve paradoxical triggering and other changes in protective stepping to impact fall risk.

The effect of weight-bearing asymmetry on dynamic postural stability in healthy young individuals

BACKGROUND

In people with lateralized disorders, such as stroke, Weight-Bearing Asymmetry (WBA) is common. It is associated with postural instability, however, WBA is one of several abnormalities that may affect postural stability in these disorders. Therefore, we investigated the isolated effects of WBA on dynamic postural stability in healthy individuals.

METHODS

Ten young participants were subjected to multidirectional stance perturbations by support surface translations at three levels of WBA (0, 10 and 20% of body weight unloading of one leg). The stepping threshold was determined iteratively for each condition and in four perturbation directions (forward, backward, leftward and rightward). The stepping threshold was defined as the highest perturbation intensity recovered from with a feet-in-place response. The Margin of Stability (MOS) at the stepping threshold was defined as the smallest distance between the vertical projection of the Extrapolated Center of Mass (XCOM) and the edge of the base of support.

RESULTS

WBA decreased the stepping threshold (stability decreased) for perturbations towards the loaded side (translations towards the unloaded side), whereas it increased stepping thresholds for perturbations towards the unloaded side. No significant effects of WBA were found on the MOS. WBA increased the frequency of stepping with the unloaded leg upon forward and backward perturbations.

CONCLUSION

WBA increased dynamic stability towards the unloaded leg following external balance perturbations and resulted in a greater probability of stepping with this leg. Future studies are needed to evaluate the functional significance of these WBA-related effects on postural stability in people with lateralized disorders.

Dynamic stability during running gait termination: Differences in strategies between children and adults to control forward momentum

Rapid deceleration during running is key for successful participation in most childhood activities and sports; this requires modulation of body momentum and consequent challenges to postural equilibrium. The purpose of this study was to investigate the strategies employed by adults and children to control forward momentum and terminate running gait. Sixteen young adults and 15 pre-pubertal children completed two tasks as fast as possible: an unobstructed run (RUN) and a run and stop (STOP) at a pre-determined location. For STOP, center of mass (COM) approach velocity and momentum prior to deceleration and spatiotemporal characteristics and COM position during deceleration were compared between groups. Position and velocity variables were normalized to height and maximum velocity during RUN, respectively. Children used fewer steps with relatively longer step length to decelerate over a relatively longer distance and longer time than adults. Children approached at higher relative velocity than adults, but adults approached with greater momentum. Adults positioned their COM lower and more posterior than children throughout deceleration. Our results suggest that pre-pubertal children and young adults employ different strategies to modulate body momentum, with adults exhibiting mechanics characteristic of a more stable strategy. Despite less stable mechanics, children and adults achieved similar success.

Moving beyond quiet stance: applicability of the inverted pendulum model to stooping and crouching postures

BACKGROUND

Currently, it is unknown whether the inverted pendulum model is applicable to stooping or crouching postures. Therefore, the aim of this study was to determine the degree of applicability of the inverted pendulum model to these postures, via examination of the relationship between the centre of mass (COM) acceleration and centre of pressure (COP)-COM difference.

METHODS

Ten young adults held static standing, stooping and crouching postures, each for 20s. For both the anterior-posterior (AP) and medio-lateral (ML) directions, the time-varying COM acceleration and the COP-COM were computed, and the relationship between these two variables was determined using Pearson's correlation coefficients. Additionally, in both directions, the average absolute COM acceleration, average absolute COP-COM signal, and the inertial component (i.e., -I/Wh) were compared across postures.

RESULTS

Pearson correlation coefficients revealed a significant negative relationship between the COM acceleration and COP-COM signal for all comparisons, regardless of the direction (p<0.001). While no effect of posture was observed in the AP direction (p=0.463), in the ML direction, the correlation coefficients for stooping were different (i.e., stronger) than standing (p=0.008). Regardless of direction, the average absolute COM acceleration for both the stooping and crouching postures was greater than standing (p<0.002).

CONCLUSION

The high correlations indicate that the inverted pendulum model is applicable to stooping and crouching postures. Due to their importance in completing activities of daily living, there is merit in determining what type of motor strategies are used to control such postures and whether these strategies change with age.

The effect of actual and imaginary handgrip on postural stability during different balance conditions

The stabilizing effect of holding an object on upright posture has been demonstrated in a variety of settings. The mechanism of this effect is unknown but could be attributed to either additional sensorimotor activity triggered by a hand contact or cognitive efforts related to performance of a supra-postural task. A potential mechanism was investigated by comparing postural stability in young healthy individuals while gripping a custom instrumented wooden stick with a 5N force and while imagining holding the same stick in the hand. Twenty subjects were tested during three standing balance conditions: on a stationary surface, on a freely moving rockerboard, and with an unexpected perturbation of 10° forward rockerboard tipping. Postural stability was evaluated as velocity of the center of mass (COM) and center of pressure (COP) compared across all experimental conditions. COM and COP velocities were equally reduced when subjects gripped the stick and imagined gripping while standing stationary and on the rockerboard. When perturbed, subjects failed to show any postural stability improvements regardless of handgrip task. Results indicate a stabilizing effect of focusing attention on motor task performance. This cognitive strategy does not appear to contribute any additional stabilization when subjects are perturbed. This study adds to the current understanding of postural stabilization strategies.

Effect of attentional interference on balance recovery in older adults

Since most working memory (WM) tasks used in dual-task (DT) postural paradigms include both storage and processing of information, it is difficult to determine the extent to which each of these contributes to interference with balance control. In the current study, a change-detection task (changes in colored squares between two presentation events) that estimates visual working memory capacity (VWMC) was paired with tasks of increasing postural demand (stance, perturbation) in young adults (YAs) and older adults (OAs) and performance compared between the two postural conditions and across the two populations. The change-detection task was selected as it requires storage of information without updating or manipulation; 34 YAs, 34 OAs, and five frail OAs were recruited. A significant reduction in VWMC occurred with increasing postural demand during the perturbation condition for both YAs (p < 0.01) and OAs (p < 0.001). VWMC was also significantly lower for OAs than YAs in the control condition (1.8 ± 0.7 vs. 2.8 ± 0.6) (p < 0.001). OAs showed a significant increase in the number of trials in which steps or rise to toes occurred during recovery between single-task (ST) and DT (p < 0.05; p < 0.05). OAs also showed a significant increase in normalized tibialis anterior amplitude (p < 0.001) following perturbations. YAs showed an increase in normalized area under the center of pressure trajectory and in AP forces (nAcopx1: p < 0.001; nFap1: p < 0.05) during the DT condition.

Dynamic stability and compensatory stepping responses during anterior gait-slip perturbations in people with chronic hemiparetic stroke

To examine the control of dynamic stability and characteristics of the compensatory stepping responses to an unexpected anterior gait slip induced under the non-involved limb in people with hemi-paretic stroke (PwHS) and to examine any resulting adaptive changes in these on the second slip due to experience from prior slip exposure. Ten PwHS experienced overground slip (S1) during walking on the laboratory walkway after 5-8 regular walking (RW) trials followed by a second consecutive slip trial (S2). The slip outcome (backward loss of balance, BLOB and no loss of balance, NLOB) and COM state (i.e. its COM position and velocity) stability were examined between the RW and S1 and S1 and S2 at touchdown (TD) of non-involved limb and at liftoff (LO) of the contralateral limb. At TD there was no difference in stability between RW and S1, however at LO, subjects demonstrated a lower stability on S1 than RW resulting in a 100% backward loss of balance (BLOB) with compensatory stepping response (recovery step, RS, 4/10 or aborted step, AS, 6/10). On S2, although there was no change in stability at TD, there was a significant improvement in stability at LO with a 40% decrease in BLOB. There was also a change in step strategy with a decrease in AS response (60% to 35%, p<0.05) which was replaced by an increase in the ability to step (increased compensatory step length, p<0.05) either via a recovery step or a walkover step. PwHS have the ability to reactively control COM state stability to decrease fall-risk upon a novel slip; prior exposure to a slip did not significantly alter feedforward control but improved the ability to use such feedback control for improved slip outcomes.

Motor imagery modulation of body sway is task-dependent and relies on imagery ability

In this study we investigate to what extent the effects of motor imagery on postural sway are constrained by movement features and the subject's imagery ability. Twenty-three subjects were asked to imagine three movements using the kinesthetic modality: rising on tiptoes, whole-body forward reaching, and whole-body lateral reaching. After each task, subjects reported the level of imagery vividness and were subsequently grouped into a HIGH group (scores ≥3, “moderately intense” imagery) or a LOW group (scores ≤2, “mildly intense” imagery). An eyes closed trial was used as a control task. Center of gravity (COG) coordinates were collected, along with surface EMG of the deltoid (medial and anterior portion) and lateral gastrocnemius muscles. COG variability was quantified as the amount of fluctuations in position and velocity in the forward-backward and lateral directions. Changes in COG variability during motor imagery were observed only for the HIGH group. COG variability in the forward-backward direction was increased during the rising on tiptoes imagery, compared with the control task (p = 0.01) and the lateral reaching imagery (p = 0.02). Conversely, COG variability in the lateral direction was higher in rising on tiptoes and lateral reaching imagery than during the control task (p < 0.01); in addition, COG variability was higher during the lateral reaching imagery than in the forward reaching imagery (p = 0.02). EMG analysis revealed no effects of group (p > 0.08) or task (p > 0.46) for any of the tested muscles. In summary, motor imagery influences body sway dynamics in a task-dependent manner, and relies on the subject' imagery ability.

Altered visual and feet proprioceptive feedbacks during quiet standing increase postural sway in patients with severe knee osteoarthritis

Objective

The objective was to investigate how postural control in knee osteoarthritis (KOA) patients, with different structural severities and pain levels, is reorganized under different sensory conditions.

Methods

Forty-two obese patients (BMI range from 30.1 to 48.7 kg*m⁻², age range from 50 to 74 years) with KOA were evaluated. One minute of quiet standing was assessed on a force platform during 4 different sensory conditions, applied 3 times at random: Eyes open (EO) and eyes closed (EC) standing on firm and soft (foam) surfaces (EO-soft and EC-soft). Centre of pressure (Cop) standard deviation, speed, range and Cop mean position in both directions (anterior-posterior and medial-lateral) were extracted from the force platform data. Structural disease severity was assessed from semiflexed standing radiographs and graded by the Kellgren and Lawrence (KL) score. Pain intensity immediately before the measurements was assessed by numeric rating scale (range: 0–10).

Results

The patients were divided into “less severe” (KL 1 and 2, n = 24) and “severe” (KL>2, n = 18) group. The CoP range in the medial-lateral direction was larger in the severe group when compared with the less severe group during EC-soft condition (P<0.01). Positive correlation between pain intensity and postural sway (range in medial-lateral direction) was found during EC condition, indicating that the higher the pain intensity, the less effective is the postural control applied to restore an equilibrium position while standing without visual information.

Conclusion

The results support that: (i) the postural reorganization under manipulation of the different sensory information is worse in obese KOA patients with severe degeneration and/or high pain intensity when compared with less impaired patients, and (ii) higher pain intensity is related to worse body balance in obese KOA patients.

Effect of externally cued training on dynamic stability control during the sit-to-stand task in people with Parkinson disease

BACKGROUND

Previous studies have shown that people with Parkinson disease (PD) have difficulty performing the sit-to-stand task because of mobility and stability-related impairments. Despite its importance, literature on the quantification of dynamic stability control in people with PD during this task is limited.

OBJECTIVE

The study objective was to examine differences in dynamic stability control between people with PD and people who were healthy and the extent to which externally cued training could improve such control during the sit-to-stand task in people with PD.

DESIGN

This was a quasi-experimental controlled trial.

METHODS

The performance of 21 people with PD was compared with that of 12 older adults who dwelled in the community. People with PD were randomly assigned to 2 groups: a group that did not receive training and a group that received audiovisually cued training (3 times per week for 4 weeks) for speeding up performance on the sit-to-stand task. Outcome measures recorded at baseline and after 4 weeks included center-of-mass position, center-of-mass velocity, and stability against either backward or forward balance loss (backward or forward stability) at seat-off and movement termination.

RESULTS

Compared with people who were healthy, people with PD had greater backward stability resulting from a more anterior center-of-mass position at seat-off. This feature, combined with decreased forward stability at movement termination, increased their risk of forward balance loss at movement termination. After training, people with PD achieved greater backward stability through increased forward center-of-mass velocity at seat-off and reduced the likelihood of forward balance loss at movement termination through a posterior shift in the center-of-mass position.

LIMITATIONS

The study applied stability limits derived from adults who were healthy to people with PD, and the suggested impact on the risk of balance loss and falling is based on these theoretical stability limits.

CONCLUSIONS

For people with PD, postural stability against backward balance loss at task initiation was increased at the expense of possible forward balance loss at task termination. Task-specific training with preparatory audiovisual cues resulted in improved overall dynamic stability against both forward and backward balance loss.

Postural coordination patterns as a function of rhythmical dynamics of the surface of support

This study investigated the organization of postural coordination patterns as a function of the rhythmical dynamics of the surface of support. We examined how the number and nature of the dynamical degrees of freedom in the movement coordination patterns changed as a function of the amplitude and frequency of support surface motion. Young adult subjects stood on a moving platform that was translated sinusoidally in anterior-posterior (AP) direction with the task goal to maintain upright bipedal postural balance. A force platform measured the kinetics at the surface of support and a 3D motion analysis system recorded torso and joint kinematics. Principal components analysis (PCA) identified four components overall, but increasing the average velocity of the support surface reduced the modal number of components of the postural coordination pattern from three to two. The analysis of joint motion loadings on the components revealed that organizational properties of the postural pattern also changed as a function of platform dynamics. PC1 (61.6-73.2 %) was accounted for by ankle, knee, and hip motion at the lowest velocity conditions, but as the velocity increased, ankle and hip variance dominated. In PC2 (24.2-20.2 %), the contribution of knee motion significantly increased while that of ankle motion decreased. In PC3 (9.7-5.1 %) neck motion contributed significantly at the highest velocity condition. Collectively, the findings show that the amplitude and frequency of the motion of the surface of support maps redundantly though preferentially to a small set of postural coordination patterns. The higher platform average velocities led to a reduction in the number of dynamical degrees of freedom of the coordination mode and different weightings of joint motion contributions to each component.

Validity and reliability of limits-of-stability testing: a comparison of 2 postural stability evaluation devices

CONTEXT

A lack of published comparisons between measures from commercially available computerized posturography devices and the outcome measures used to define the limits of stability (LOS) makes meaningful interpretation of dynamic postural stability measures difficult.

OBJECTIVES

To compare postural stability measures between and within devices to establish concurrent and construct validity and to determine test-retest reliability for LOS measures generated by the NeuroCom Smart Balance Master and the Biodex Balance System.

DESIGN

Cross-sectional study.

SETTING

Controlled research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 23 healthy participants with no vestibular or visual disabilities or lower limb impairments.

INTERVENTION(S)

The LOS were assessed during 2 laboratory test sessions 1 week apart.

MAIN OUTCOME MEASURE(S)

Three NeuroCom LOS variables (directional control, endpoint excursion, and movement velocity) and 2 Biodex LOS variables (directional control, test duration).

RESULTS

Test-retest reliability ranged from high to low across the 5 LOS measures (intraclass correlation coefficient [2,k] = 0.82 to 0.48). Pearson correlations revealed 4 significant relationships (P < .05) between and within the 2 computerized posturography devices (r = 0.42 to -0.65).

CONCLUSIONS

Based on the wide range of intraclass correlation values we observed for the NeuroCom measures, clinicians and researchers alike should establish the reliability of LOS testing for their own clinics and laboratories. The low to moderate reliability outcomes observed for the Biodex measures were not of sufficient magnitude for us to recommend using the LOS measures from this system as the gold standard. The moderate Pearson interclass correlations we observed suggest that the Biodex and NeuroCom postural stability systems provided unique information. In this study of healthy participants, the concurrent and construct validity of the Biodex and NeuroCom LOS tests were not definitively established. We recommend that this study be repeated with a clinical population to further explore the matter.

The influence of footwear sole hardness on slip characteristics and slip-induced falls in young adults

Theoretically, a shoe that provides less friction could result in a greater slip distance and foot slipping velocity, thereby increasing the likelihood of falling. The purpose of this study was to investigate the effects of sole hardness on the probability of slip-induced falls. Forty young adults were randomized into a hard or a soft sole shoe group, and tested under both nonslippery and slippery floor conditions using a motion analysis system. The proportions of fall events in the hard- and soft-soled shoe groups were not statistically different. No differences were observed between shoe groups for average slip distance, peak and average heel velocity, and center of mass slipping velocity. A strong association was found between slip distance and the fall probability. Our results demonstrate that the probability of a slip-induced fall was not influenced by shoe hardness. Once a slip is induced, slip distance was the primary predictor of a slip-induced fall.

A NOVEL MEASUREMENT SYSTEM FOR QUANTITATIVE ASSESSMENT OF AGE-RELATED SENSORI-MOTOR DEGRADATION

Early identification of individuals with impaired balancing ability could lead to timely interventions and reduce the hazard of age-related falls. Numerous methods for researching the prevention of falls and age-related sensori-motor degradation have been proposed and tested. Most are either too expensive for practitioners or too physically demanding to use with seniors. A simple, reliable technique is desired. The aim of this research is to develop a practical and quantitative solution for assessment of age-related degradation of human sensori-motor function, which could in turn serve as a means of fall prevention among seniors. A novel testing apparatus, the dynamic balance testing platform, was developed. The design includes artificial neural network (ANN) technology to address the nonlinearity and redundancy in the neural network that controls sensori-motor functions. A total of 62 male subjects aged from 18 to 84 years were tested using the proposed method. Results showed that (1) the new device did reflect the sensori-motor degradation related to age, (2) reliable evaluation of sensori-motor function need not be complicated, time consuming, or costly, and (3) the developed equipment powered with ANN technology holds great potentials for predicting fall possibility. Overall, this study validated a strategy of fall prevention with a potential for prevalent use in the healthcare industry.

The discriminant capabilities of stability measures, trunk kinematics, and step kinematics in classifying successful and failed compensatory stepping responses by young adults

This study evaluated the discriminant capability of stability measures, trunk kinematics, and step kinematics to classify successful and failed compensatory stepping responses. In addition, the shared variance between stability measures, step kinematics, and trunk kinematics is reported. The stability measures included the anteroposterior distance (d) between the body center of mass and the stepping limb toe, the margin of stability (MOS), as well as time-to-boundary considering velocity (TTB(v)), velocity and acceleration (TTB(a)), and MOS (TTB(MOS)). Kinematic measures included trunk flexion angle and angular velocity, step length, and the time after disturbance onset of recovery step completion. Fourteen young adults stood on a treadmill that delivered surface accelerations necessitating multiple forward compensatory steps. Thirteen subjects fell from an initial disturbance, but recovered from a second, identical disturbance. Trunk flexion velocity at completion of the first recovery step and trunk flexion angle at completion of the second step had the greatest overall classification of all measures (92.3%). TTB(v) and TTB(a) at completion of both steps had the greatest classification accuracy of all stability measures (80.8%). The length of the first recovery step (r ≤ 0.70) and trunk flexion angle at completion of the second recovery step (r ≤ -0.54) had the largest correlations with stability measures. Although TTB(v) and TTB(a) demonstrated somewhat smaller discriminant capabilities than trunk kinematics, the small correlations between these stability measures and trunk kinematics (|r| ≤ 0.52) suggest that they reflect two important, yet different, aspects of a compensatory stepping response.

Stability in a frontal plane model of balance requires coupled changes to postural configuration and neural feedback control

Postural stability depends on interactions between the musculoskeletal system and neural control mechanisms. We present a frontal plane model stabilized by delayed feedback to analyze the effects of altered stance width on postural responses to perturbations. We hypothesized that changing stance width alters the mechanical dynamics of the body and limits the range of delayed feedback gains that produce stable postural behaviors. Surprisingly, mechanical stability was found to decrease as stance width increased due to decreased effective inertia. Furthermore, due to sensorimotor delays and increased leverage of hip joint torque on center-of-mass motion, the magnitudes of the stabilizing delayed feedback gains decreased as stance width increased. Moreover, the ranges of the stable feedback gains were nonoverlapping across different stance widths such that using a single neural feedback control strategy at both narrow and wide stances could lead to instability. The set of stable feedback gains was further reduced by constraints on foot lift-off and perturbation magnitude. Simulations were fit to experimentally measured kinematics, and the identified feedback gains corroborated model predictions. In addition, analytical gain margin of the linearized system was found to predict step transitions without the need for simulation. In conclusion, this model offers a method to dissociate the complex interactions between postural configuration, delayed sensorimotor feedback, and nonlinear foot lift-off constraints. The model demonstrates that stability at wide stances can only be achieved if delayed neural feedback gains decrease. This model may be useful in explaining both expected and paradoxical changes in stance width in healthy and neurologically impaired individuals.

Limb collapse, rather than instability, causes failure in sit-to-stand performance among patients with parkinson disease

BACKGROUND

Previous studies focused on describing successful sit-to-stand (STS) performance in patients with Parkinson disease (PD). Little is known about why these patients fail to perform this transfer activity. Objective This study aimed to determine the role of dynamic stability and limb support in governing successful STS performance in patients with PD and to determine the limits of recovery for discriminating between successful and failed STS trials.

DESIGN

This was a cross-sectional study.

METHODS

Twenty-eight patients with PD were instructed to perform the STS task. Kinematic data on 18 successful trials and 14 failed trials (when the patients fell backward) were collected with a motion analysis system. Dynamic stability was determined by the anteroposterior position of the body's center of mass (COM) relative to the base of support (BOS) and by the anteroposterior velocity of the COM relative to the BOS (Velocity(COM/BOS,AP)). Limb support was characterized by the hip height (Height(hip)).

RESULTS

/b> The findings revealed no between-group ("risers" versus "fallers") differences in dynamic stability. The fallers shifted their COM in a significantly more anterior position to compensate for their lower Velocity(COM/BOS,AP) at seat-off. It was in the vertical direction that the fallers had significantly reduced peak COM velocity (Velocity(COM,vertical)) and lower corresponding Height(hip) than the risers. Results of a stepwise regression model showed that Velocity(COM/BOS,AP) and Height(hip) at the instant of peak Velocity(COM,vertical) could best predict the STS outcome (success versus failure), with an overall prediction accuracy of 87.5%. The limit differentiating successful from failed STS trials was: Height(hip)=-0.814 Velocity(COM/BOS,AP) + 0.463. Limitations All of the patients were community dwelling and had a moderate level of disease severity. The results cannot be generalized to those who are institutionalized or with advanced PD.

CONCLUSIONS

Limb support and ill-timed peak forward COM velocity, rather than dynamic stability, play the dominant roles in determining successful STS performance in patients with PD.

Control of center of mass motion state through cuing and decoupling of spontaneous gait parameters in level walking

Can the center of mass (COM) motion state, i.e., its position and velocity relative to the base of support (BOS), which dictate gait stability, be predictably controlled by the global gait parameters of step length and gait speed, or by extension, cadence? The precise relationships among step length and gait speed, and the COM motion state are unknown, partially due to the interdependence between step length and gait speed and the difficulty in independent control of both parameters during spontaneous level walking. The purposes of this study were to utilize simultaneous audio-visual cuing to independently manipulate step length and gait speed, and to determine the extent to which the COM position and velocity can be subsequently controlled. Fifty-six young adults were trained at one of the three gait patterns in which both the step length and gait speed were targeted simultaneously. The results showed that the cuing could successfully "decouple" gait speed from step length. Although this approach did yield reliable control of the COM velocity through manipulation of gait speed (R(2)=0.97), the manipulation of step length yielded less precise control of COM position (R(2)=0.60). This latter control appears to require manipulation of an additional degree-of-freedom at the local segment level, such that the inclusion of trunk inclination with step length improved the prediction of COM position (R(2)=0.80).

Role of individual lower limb joints in reactive stability control following a novel slip in gait

Instability after slip onset is a key precursor leading to subsequent falls during gait. The purpose of this study was to determine the impact of reactive muscular response from individual lower limb joints on regaining stability control and impeding a novel and unannounced slip during the ensuing single-stance phase. Ten young adults' resultant moments at three lower limb joints of both limbs, initially derived by an inverse-dynamics approach from empirical data, were optimized to accurately reproduce the original motion before being applied as input to the control variables of their individualized forward-dynamics model. Systematic alteration of the moments of each joint caused corresponding changes in the displacement and velocity of the center of mass (COM) and base of support (BOS) (i.e. their state variables, x(COM), x (COM), x(BOS), x (BOS)), and in the COM stability. The model simulation revealed that these joints had little influence on x (COM) but had substantial impact on x (BOS) reduction, leading to improve the COM stability, mostly from knee flexors, followed by hip extensors, of the slipping limb. Per unit reactive increase in normalized knee flexor or hip extensor moments and per unit reactive reduction in commonly observed plantar-flexor moments could lead to as much as 57.72+/-10.46 or 22.33+/-5.55 and 13.09+/-2.27 units of reduction in normalized x (BOS), respectively. In contrast, such influence was negligible from the swing limb during this period, irrespective of individual variability.