The dynamics of visual reweighting in healthy and fall-prone older adults

The prediction model of fall risk for the elderly based on gait analysis

INTRODUCTION

Early screening and identification are crucial for fall prevention, and developing a new method to predict fall risk in the elderly can address the current lack of objectivity in assessment tools.

METHODS

A total of 132 elderly individuals over 80 years old residing in some nursing homes in Shanghai were selected using a convenient sampling method. Fall history information was collected, and gait data during a 10-meter walk were recorded. Logistic regression was employed to establish the prediction model, and a nomogram was used to assess the importance of the indicators. The Bootstrap method was utilized for internal validation of the model, while the verification set was used for external validation. The predictive performance of the model was evaluated using the area under the ROC curve, calibration curve, and decision curve analysis (DCA) to assess clinical benefits.

RESULTS

The incidence of falls in the sample population was 36.4%. The Tinetti Gait and Balance Test (TGBT) score (OR = 0.832, 95% CI: 0.734,0.944), stride length (OR = 0.007, 95% CI: 0.000,0.104), difference in standing time (OR = 0.001, 95% CI: 0.000,0.742), and mean stride time (OR = 0.992, 95% CI:0.984,1.000) were identified as significant factors. The area under the ROC curve was 0.878 (95% CI: 0.805, 0.952), with a sensitivity of 0.935 and specificity of 0.726. The Brier score was 0.135, and the Hosmer-Lemeshow test (χ2 = 10.650, P = 0.222) indicated a good fit and calibration of the model.

CONCLUSION

The TGBT score, stride length, difference in standing time, and stride time are all protective factors associated with fall risk among the elderly. The developed risk prediction model demonstrates good discrimination and calibration, providing valuable insights for early screening and intervention in fall risk among older adults.

The effects of Tai Chi on standing balance control in older adults may be attributed to the improvement of sensory reweighting and complexity rather than reduced sway velocity or amplitude

Introduction

Tai Chi has proved to be an effective therapy for balance performance and cognition. However, non-consistency exists in the results of the effect of Tai Chi training on standing balance control in older adults. This study aimed to use traditional and non-traditional methods to investigate the effect of Tai Chi on standing balance in older adults.

Methods

Thirty-six Tai Chi practitioners (TC group) and thirty-six older adults with no Tai Chi practice (control group) were recruited in this study. A Nintendo Wii Balance Board was used to record the center of pressure (COP) during standing balance over 20 s in the condition of eyes closed with three repetitions. The wavelet analysis, multiscale entropy, recurrence quantification analysis, and traditional methods were used to evaluate the standing balance control in the anterior-posterior (AP) and mediolateral (ML) directions.

Results

(1) Greater sway mean velocity in the AP direction and sway Path length were found in the TC group compared with the control group; (2) lower Very-low frequency band (0.10-0.39 Hz) and higher Moderate frequency band (1.56-6.25 Hz) in the AP and ML directions were found in the TC group compared with the control group; (3) greater complexity index (CI) and lower determinism (DET) in the AP and ML directions were observed in the TC group compared with control group; (4) greater path length linked with smaller Very-low frequency band in the AP and ML directions and higher Moderate frequency band in the AP direction in both groups; (5) greater path length linked with lower DET and higher CI in the AP direction only in the TC group.

Conclusion

Long-term Tai Chi practice improved sensory reweighting (more reliance on the proprioception system and less reliance on the vestibular system) and complexity of standing balance control in older adults. In addition, greater sway velocity may be as an exploratory role in standing balance control of TC older adults, which correlated with greater complexity, but no such significant relationship in the control group. Therefore, the effects of Tai Chi practice on standing balance control in older adults may be attributed to the improvement of sensory reweighting and complexity rather than reduced sway velocity or amplitude.

The Effects of Optical Flow Perturbations on Standing Balance in People With Multiple Sclerosis

Multiple sclerosis is a neurodegenerative disease that causes balance deficits, even in early stages. Evidence suggests that people with multiple sclerosis (PwMS) rely more on vision to maintain balance, and challenging balance with optical flow perturbations may be a practical screening for balance deficits. Whether these perturbations affect standing balance in PwMS is unknown. Therefore, the purpose of this study was to examine how optical flow perturbations affect standing balance in PwMS. We hypothesized that perturbations would cause higher variability in PwMS compared with matched controls during standing and that standing balance would be more susceptible to anterior-posterior (A-P) perturbations than medial-lateral (M-L) perturbations. Thirteen PwMS and 13 controls stood under 3 conditions: unperturbed, M-L perturbation, and A-P perturbations. A-P perturbations caused significantly higher A-P trunk sway variability in PwMS than controls, although both groups had similar center-of-pressure variability. Both perturbations increased variability in A-P trunk sway and center of pressure. Trunk variability data supported the hypothesis that PwMS were more susceptible to optical flow perturbations than controls. However, the hypothesis that A-P perturbations would affect balance more than M-L perturbations was partially supported. These results suggest potential for optical flow perturbations to identify balance deficits in PwMS.

NSF DARE-transforming modeling in neurorehabilitation: a patient-in-the-loop framework

In 2023, the National Science Foundation (NSF) and the National Institute of Health (NIH) brought together engineers, scientists, and clinicians by sponsoring a conference on computational modelling in neurorehabiilitation. To facilitate multidisciplinary collaborations and improve patient care, in this perspective piece we identify where and how computational modelling can support neurorehabilitation. To address the where, we developed a patient-in-the-loop framework that uses multiple and/or continual measurements to update diagnostic and treatment model parameters, treatment type, and treatment prescription, with the goal of maximizing clinically-relevant functional outcomes. This patient-in-the-loop framework has several key features: (i) it includes diagnostic and treatment models, (ii) it is clinically-grounded with the International Classification of Functioning, Disability and Health (ICF) and patient involvement, (iii) it uses multiple or continual data measurements over time, and (iv) it is applicable to a range of neurological and neurodevelopmental conditions. To address the how, we identify state-of-the-art and highlight promising avenues of future research across the realms of sensorimotor adaptation, neuroplasticity, musculoskeletal, and sensory & pain computational modelling. We also discuss both the importance of and how to perform model validation, as well as challenges to overcome when implementing computational models within a clinical setting. The patient-in-the-loop approach offers a unifying framework to guide multidisciplinary collaboration between computational and clinical stakeholders in the field of neurorehabilitation.

Age-Related Changes in Temporal Binding Involving Auditory and Vestibular Inputs

Maintaining balance involves the combination of sensory signals from the visual, vestibular, proprioceptive, and auditory systems. However, physical and biological constraints ensure that these signals are perceived slightly asynchronously. The brain only recognizes them as simultaneous when they occur within a period of time called the temporal binding window (TBW). Aging can prolong the TBW, leading to temporal uncertainty during multisensory integration. This effect might contribute to imbalance in the elderly but has not been examined with respect to vestibular inputs. Here, we compared the vestibular-related TBW in 13 younger and 12 older subjects undergoing 0.5 Hz sinusoidal rotations about the earth-vertical axis. An alternating dichotic auditory stimulus was presented at the same frequency but with the phase varied to determine the temporal range over which the two stimuli were perceived as simultaneous at least 75% of the time, defined as the TBW. The mean TBW among younger subjects was 286 ms (SEM ± 56 ms) and among older subjects was 560 ms (SEM ± 52 ms). TBW was related to vestibular sensitivity among younger but not older subjects, suggesting that a prolonged TBW could be a mechanism for imbalance in the elderly person independent of changes in peripheral vestibular function.

Sensory conflicts through short, discrete visual input manipulations: Identification of balance responses to varied input characteristics

Human balance control relies on various sensory modalities, and conflict of sensory input may result in postural instability. Virtual reality (VR) technology allows to train balance under conflicting sensory information by decoupling visual from somatosensory and vestibular systems, creating additional demands on sensory reweighting for balance control. However, there is no metric for the design of visual input manipulations that can induce persistent sensory conflicts to perturb balance. This limits the possibilities to generate sustained sensory reweighting processes and design well-defined training approaches. This study aimed to investigate the effects that different onset characteristics, amplitudes and velocities of visual input manipulations may have on balance control and their ability to create persistent balance responses. Twenty-four young adults were recruited for the study. The VR was provided using a state-of-the-art head-mounted display and balance was challenged in two experiments by rotations of the visual scene in the frontal plane with scaled constellations of trajectories, amplitudes and velocities. Mean center of pressure speed was recorded and revealed to be greater when the visual input manipulation had an abrupt onset compared to a smooth onset. Furthermore, the balance response was greatest and most persistent when stimulus velocity was low and stimulus amplitude was large. These findings show clear dissociation in the state of the postural system for abrupt and smooth visual manipulation onsets with no indication of short-term adaption to abrupt manipulations with slow stimulus velocity. This augments our understanding of how conflicting visual information affect balance responses and could help to optimize the conceptualization of training and rehabilitation interventions.

Concentrating to avoid falling: interaction between peripheral sensory and central attentional demands during a postural stability limit task in sedentary seniors

Evidence suggests falls and postural instabilities among seniors are attributed to a decline in both the processing of afferent signals (e.g., proprioceptive, vestibular) and attentional resources. We investigated the interaction between the non-visual and attentional demands of postural control in sedentary seniors. Old and young adults performed a postural stability limit task involving a maximal voluntary leaning movement with and without vision as well as a cognitive-attentional subtraction task. These tasks were performed alone (single-task) or simultaneously (dual-task) to vary the sensory-attentional demands. The functional limits of stability were quantified as the maximum center of pressure excursion during voluntary leaning. Seniors showed significantly smaller limits of postural stability compared to young adults in all sensory-attentional conditions. However, surprisingly, both groups of subjects reduced their stability limits by a similar amount when vision was removed. Furthermore, they similarly decreased their anterior-posterior stability limits when concurrently performing the postural and the cognitive-attentional tasks with vision. The overall average cognitive performance of young adults was higher than seniors and was only slightly affected during dual-tasking. In contrast, older adults markedly degraded their cognitive performance from the single- to the dual-task situations, especially when vision was unavailable. Thus, their dual-task costs were higher than those of young adults and increased in the eyes-closed condition, when postural control relied more heavily on non-visual sensory signals. Our findings provide the first evidence that as posture approaches its stability limits, sedentary seniors allot increasingly large cognitive attentional resources to process critical sensory inputs.

The effects of errorless psychomotor training in the Y balance lower limb reaching task

This study investigated the training effect of errorless psychomotor training, a motor training method with perceptual, attentional, and psychological manipulation, in a balance-related, lower limb reaching task (Y balance reaching task) on dynamic balance by young adults. Thirty-nine participants (Mean age = 27.03 years, SD = 2.64 years) were trained with different psychomotor training methods in the Y balance reaching task. Results illustrate that errorless psychomotor training significantly improved the participants' dynamic balance and proprioceptive abilities. Additionally, gaze fixation duration on target during reaching decreased after errorless psychomotor training, suggesting that errorless psychomotor training could decrease visual information demand and be concurrently compensated by up-weighting on proprioception. This multisensory reweighting and cross-modal attention could contribute to the improvement of dynamic balance ability in sports.

Age-related impairments and influence of visual feedback when learning to stand with unexpected sensorimotor delays

Background

While standing upright, the brain must accurately accommodate for delays between sensory feedback and self-generated motor commands. Natural aging may limit adaptation to sensorimotor delays due to age-related decline in sensory acuity, neuromuscular capacity and cognitive function. This study examined balance learning in young and older adults as they stood with robot-induced sensorimotor delays.

Methods

A cohort of community dwelling young (mean = 23.6 years, N = 20) and older adults (mean = 70.1 years, N = 20) participated in this balance learning study. Participants stood on a robotic balance simulator which was used to artificially impose a 250 ms delay into their control of standing. Young and older adults practiced to balance with the imposed delay either with or without visual feedback (i.e., eyes open or closed), resulting in four training groups. We assessed their balance behavior and performance (i.e., variability in postural sway and ability to maintain upright posture) before, during and after training. We further evaluated whether training benefits gained in one visual condition transferred to the untrained condition.

Results

All participants, regardless of age or visual training condition, improved their balance performance through training to stand with the imposed delay. Compared to young adults, however, older adults had larger postural oscillations at all stages of the experiments, exhibited less relative learning to balance with the delay and had slower rates of balance improvement. Visual feedback was not required to learn to stand with the imposed delay, but it had a modest effect on the amount of time participants could remain upright. For all groups, balance improvements gained from training in one visual condition transferred to the untrained visual condition.

Conclusion

Our study reveals that while advanced age partially impairs balance learning, the older nervous system maintains the ability to recalibrate motor control to stand with initially destabilizing sensorimotor delays under differing visual feedback conditions.

Visual motion detection thresholds can be reliably measured during walking and standing

Introduction

In upright standing and walking, the motion of the body relative to the environment is estimated from a combination of visual, vestibular, and somatosensory cues. Associations between vestibular or somatosensory impairments and balance problems are well established, but less is known whether visual motion detection thresholds affect upright balance control. Typically, visual motion threshold values are measured while sitting, with the head fixated to eliminate self-motion. In this study we investigated whether visual motion detection thresholds: (1) can be reliably measured during standing and walking in the presence of natural self-motion; and (2) differ during standing and walking.

Methods

Twenty-nine subjects stood on and walked on a self-paced, instrumented treadmill inside a virtual visual environment projected on a large dome. Participants performed a two-alternative forced choice experiment in which they discriminated between a counterclockwise ("left") and clockwise ("right") rotation of a visual scene. A 6-down 1-up adaptive staircase algorithm was implemented to change the amplitude of the rotation. A psychometric fit to the participants' binary responses provided an estimate for the detection threshold.

Results

We found strong correlations between the repeated measurements in both the walking (R = 0.84, p < 0.001) and the standing condition (R = 0.73, p < 0.001) as well as good agreement between the repeated measures with Bland-Altman plots. Average thresholds during walking (mean = 1.04°, SD = 0.43°) were significantly higher than during standing (mean = 0.73°, SD = 0.47°).

Conclusion

Visual motion detection thresholds can be reliably measured during both walking and standing, and thresholds are higher during walking.

Effect of age on postural performance and control strategies during changes in visual input and dual-tasking stances

Background

With age, people begin to experience deterioration in standing balance, especially when sensory input is suddenly removed or added. Here, we sought to explore the effects of age on postural performance and postural control strategies.

Methods

The convenience sample consisted of 15 young, 10 middle-aged, and 14 elderly healthy adults. They were instructed to stand with their feet together in four randomly administered conditions involving visual input removal/addition and single-/dual-tasking. Dual-tasking involved continuous subtraction by 3s.

Results

Postural sway displacement in the two older groups seemed larger than that in the younger group; however, neither the main effect of group (F_{2, 36} = 1.152, p = .327) nor the group × time interaction effect (F_{4, 27} = 0.229, p = .922) was significant. Greater stiffness of the lower leg muscles was observed in the vision-addition condition than in the vision-removal condition in only the elderly group (t₁₃ = -2.755, p = .016). The dual-tasking condition resulted in smaller sway displacement (F_{1, 36} = 7.690, p = .009) and greater muscle stiffness (F_{1, 36} = 5.495, p = .025). In the vision-removal condition, the increase in muscle stiffness due to dual-tasking was significantly larger in the middle-aged (t₉ = -3.736, p = .005) and elderly groups (t₁₃ = -2.512, p = .026).

Conclusions

In healthy older individuals, age-related changes were observed in control strategies used to maintain standing balance upon changes in visual input. The dual-task paradigm induced the use of an ankle-stiffening strategy in middle-aged and elderly adults.

EMG-EMG coherence during voluntary control of human standing tasks: a systematic scoping review

Background

Intra- or inter-muscular (EMG-EMG) coherence is a simple and non-invasive method for estimating central nervous system control during human standing tasks. Although this research area has developed, no systematic literature review has been conducted.

Objectives

We aimed to map the current literature on EMG-EMG coherence during various standing tasks to identify the research gaps and summarize previous studies comparing EMG-EMG coherence between healthy young and elderly adults.

Methods

Electronic databases (PubMed, Cochrane Library, and CINAHL) were searched for articles published from inception to December 2021. We incorporated studies that analyzed EMG-EMG coherence of the postural muscles in various standing tasks.

Results

Finally, 25 articles fulfilled the inclusion criteria and involved 509 participants. Most participants were healthy young adults, while only one study included participants with medical conditions. There was some evidence that EMG-EMG coherence could identify differences in standing control between healthy young and elderly adults, although the methodology was highly heterogeneous.

Conclusion

The present review indicates that EMG-EMG coherence may help elucidate changes in standing control with age. In future studies, this method should be used in participants with central nervous system disorders to understand better the characteristics of standing balance disabilities.

Perceptual visual dependence for spatial orientation in patients with schizophrenia

BACKGROUND

Patients with schizophrenia are reported to have vestibular dysfunction and to weigh vestibular input to a lesser extent compared to healthy controls. Such deficits may increase visual dependence (VD) for spatial orientation at a perceptual level in these patients. The aim of this study is to compare VD levels between healthy control and patients with schizophrenia and to explore associations between VD and clinical measures in these patients. Relation of VD to antipsychotic drug treatment is also discussed.

METHOD

18 patients with schizophrenia and 19 healthy controls participated in this study. The Rod and Disc Test (RDT) was used to create an optokinetic surround around a centrally located rod. Participants aligned the rod to their subjective visual vertical (SVV) in both static and dynamic disc conditions. VD was calculated as the difference in SVV between these two conditions.

RESULTS

There was no group difference or gender difference in static or dynamic SVV as well as VD. There was no correlation between VD and any of the Positive and Negative Syndrome Scale (PANSS) scores, however VD was significantly correlated to illness duration in the patient group.

CONCLUSIONS

Schizophrenia is not associated with greater VD levels at a perceptual level, compared to controls, indicating adequate visuo-vestibular integration for judging line verticality in these patients. Patients with greater chronicity of the disease are more visually dependent than those less chronically ill, consistent with previous reports of possible vestibular dysfunction in patients with schizophrenia. This may affect their daily functioning in dynamic visual environments.

Impact of Sensory Afferences in Postural Control Quantified by Force Platform: A Protocol for Systematic Review

Older adults’ postural balance is a critical domain of research as balance deficit is an important risk factor for falls that can lead to severe injuries and death. Considering the effects of ageing on sensory systems, we propose that posturographic evaluation with a force platform exploring the effect of sensory deprivation or perturbation on balance could help understand postural control alterations in the elderly. The aim of the future systematic review and meta-analysis described in this protocol is to explore the capacity of older adults to maintain their balance during sensory perturbations, and compare the effect of perturbation between the sensory channels contributing to balance. Seven databases will be searched for studies evaluating older adults’ balance under various sensory conditions. After evaluating the studies’ risk of bias, results from similar studies (i.e., similar experimental conditions and posturographic markers) will be aggregated. This protocol describes a future review that is expected to provide a better understanding of changes in sensory systems of balance due to ageing, and therefore perspectives on fall assessment, prevention, and rehabilitation.

The impact of external and internal focus of attention on visual dependence and EEG alpha oscillations during postural control

Background

The ability to maintain upright posture requires successful integration of multiple sensory inputs (visual, vestibular, and somatosensory). When one or more sensory systems become unreliable, the postural control system must “down-weight” (or reduce the influence of) those senses and rely on other senses to maintain postural stability. As individuals age, their ability to successfully reweight sensory inputs diminishes, leading to increased fall risk. The present study investigates whether manipulating attentional focus can improve the ability to prioritize different sensory inputs for postural control.

Methods

Forty-two healthy adults stood on a balance board while wearing a virtual reality (VR) head-mounted display. The VR environment created a multisensory conflict amongst the different sensory signals as participants were tasked with maintaining postural stability on the balance board. Postural sway and scalp electroencephalography (EEG) were measured to assess visual weighting and cortical activity changes. Participants were randomized into groups that received different instructions on where to focus their attention during the balance task.

Results

Following the instructions to direct attention toward the movement of the board (external focus group) was associated with lower visual weighting and better balance performance than when not given any instructions on attentional focus (control group). Following the instructions to direct attention towards movement of the feet (internal focus group) did not lead to any changes in visual weighting or balance performance. Both external and internal focus groups exhibited increased EEG alpha power (8–13 Hz) activity over the occipital cortex as compared to the control group.

Conclusions

Current results suggest that directing one’s attention externally, away from one’s body, may optimize sensory integration for postural control when visual inputs are incongruent with somatosensory and vestibular inputs. Current findings may be helpful for clinicians and researchers in developing strategies to improve sensorimotor mechanisms for balance.

Novel applications of Bayesian inference clarify sensorimotor uncertainty during stepping movements

The human nervous system relies on sensory information from the feet and legs to control the way we balance and walk. However, even in healthy individuals this sensory information is inherently variable and clouded with uncertainty. Researchers have found that the central nervous system (CNS) estimates body position amid the uncertainty of sensory signals in a way consistent with Bayesian inference. Bayesian inference posits that the brain accounts for variability in sensory data by combining it with learned expectations built from previous movement attempts. While initial findings on this topic are promising, they have neglected to study full-body movements such as gait and balance. The purpose of this research was to determine if the CNS controls balance-related stepping tasks in a way that fits a Bayesian framework. To address this purpose, we created a virtual reality protocol where participants moved their center of mass (CoM) to various targets while relying on uncertain visual cues and compensating for an alternating shift to the cursor position. We showed that as incoming sensory information became less certain, participants relied more on their learned expectation of body position and demonstrated more uncertainty in their responses. Accordingly, as participants learned to control and estimate their CoM position during our mobility task, they relied both on the sensory information they were receiving as well as learned expectations for its location. These results provide further evidence that the CNS is aware of the variability in sensory information and is proficient at compensating for the resultant uncertainty. We aim to apply these findings as a method for measuring the efficacy of interventions targeting sensory function.

Increased co-contraction reaction during a surface perturbation is associated with unsuccessful postural control among older adults

Background

As a strategy to maintain postural control, the stiffening strategy (agonist-antagonist co-contractions) is often considered dysfunctional and associated with poor physical capacity. The aim was to investigate whether increased stiffening is associated with unsuccessful postural control during an unpredictable surface perturbation, and which sensory and motor variables that explain postural stiffening.

Methods

A sample of 34 older adults, 75.8 ± 3.8 years, was subjected to an unpredicted surface perturbation with the postural task to keep a feet-in-place strategy. The participants also completed a thorough sensory- and motor test protocol. During the surface perturbation, electromyography was measured from tibialis anterior and gastrocnemius to further calculate a co-contraction index during the feed-forward and feedback period. A binary logistic regression was done with the nominal variable, if the participant succeeded in the postural task or not, set as dependent variable and the co-contraction indexes set as independent variables. Further, the variables from the sensory and motor testing were set as independent variables in two separate Orthogonal Projections of Latent Structures (OPLS)-models, one with the feed-forward- and the other with the feedback co-contraction index as dependent variable.

Results

Higher levels of ankle joint stiffening during the feedback, but not the feed-forward period was associated with postural task failure. Feedback stiffening was explained by having slow non-postural reaction times, poor leg muscle strength and being female whereas feed-forward stiffening was not explained by sensory and motor variables.

Conclusions

When subjected to an unpredicted surface perturbation, individuals with higher feedback stiffening had poorer postural control outcome, which was explained by poorer physical capacity. The level of feed-forward stiffening prior the perturbation was not associated with postural control outcome nor the investigated sensory and motor variables. The intricate causal relationships between physical capacity, stiffening and postural task success remains subject for future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03123-2.

Sinusoidal Optic Flow Perturbations Reduce Transient but Not Continuous Postural Stability: A Virtual Reality-Based Study

Optic flow perturbations induced by virtual reality (VR) are increasingly used in the rehabilitation of postural control and gait. Here, VR offers the possibility to decouple the visual from the somatosensory and vestibular system. By this means, it enables training under conflicting sensorimotor stimulation that creates additional demands on sensory reweighting and balance control. Even though current VR-interventions still lack a well-defined standardized metric to generate optic flow perturbations that can challenge balance in a repeatable manner, continuous oscillations of the VR are typically used as a rehabilitation tool. We therefore investigated if continuous sensory conflicts induced by optic flow perturbations can challenge the postural system sustainably. Eighteen young adults (m = 8, f = 10, age = 24.1 ± 2.0 yrs) were recruited for the study. The VR was provided using a state-of-the-art head-mounted display including the virtual replica of the real environment. After familiarization in quiet stance without and with VR, bipedal balance was perturbed by sinusoidal rotations of the visual scenery in the sagittal plane with an amplitude of 8° and a frequency of 0.2 Hz. Postural stability was quantified by mean center of mass speed derived from 3D-kinematics. A rmANOVA found increased postural instability only during the first perturbation cycle, i.e., the first 5 s. Succeeding the first perturbation cycle, visual afferents were downregulated to reduce the destabilizing influence of the sensory conflicts. In essence, only the transient beginning of sinusoidal oscillation alters balance compared to quiet standing. Therefore, continuous sinusoidal optic flow perturbations appear to be not suitable for balance training as they cannot trigger persisting sensory conflicts and hence challenge the postural system sustainably. Our study provides rationale for using unexpected and discrete optic flow perturbation paradigms to induce sustainable sensory conflicts.

Identification of Human Balance Control Responses to Visual Inputs Using Virtual Reality

Human upright balance is maintained through feedback mechanisms that use a variety of sensory modalities. Vision senses information about the motion of the visual surround to improve balance. This study characterized the effects of visual information on human anterior-posterior body sway in upright stance by presenting perturbations through a virtual reality system. This made it possible to use a new visual stimulus, whose amplitude and velocity could be controlled separately. To date, the influences of visual field position and velocity have only been studied independently due to the experimental limitations. The hip displacement, ankle torques, shank angles, and surface EMGs of four major ankle muscles were measured bilaterally as outputs. We found that the root-mean-square (RMS) hip displacement (body angle) increased systematically with visual input amplitude. However, for each amplitude, the RMS body angle increased when input velocity was changed from 2 to 5 degree per second and then decreased from 5 to 10 dps. Spectral analysis was utilized to compute frequency response over a frequency range from 0.04-0.6 Hz. The gain of body sway relative to the perturbation increased with frequency, while the coherence declined. Moreover, as the stimulus amplitude increased, the gain generally decreased, while the mean coherence values always increased. The mean gains and mean coherence values were greatest for the velocity of 5 dps. This study presents a novel experimental approach to study human postural control and augments our knowledge on how the visual information is processed in the central nervous system to maintain balance.

Influence of vision on gait initiation and first step kinematics in young and older adults

The study investigated whether anticipatory postural adjustments (APAs) of gait initiation and kinematics of the first step are modified with absence of vision in relation to age. Twenty-two young and twenty-two older subjects initiated a self-paced gait with the vision available and deprived. APAs were measured by: (1) force platform and evaluated by maximal amplitude of the center of pressure (CoP) displacements; (2) two inertial sensors attached to the trunk and evaluated by maximal accelerations. Step kinematics was recorded using a motion capture system and evaluated by duration, length and maximal velocity of the first step. Visual deprivation led to a significant reduction of forward trunk accelerations during the anticipatory phase of stepping in older adults. Moreover, they significantly reduced first step length and maximal velocity and prolonged duration of the first step. Contrary, young adults did not respond to absence of vision by significant changes of neither APAs, nor first step kinematics. These findings suggest that gait initiation is strongly associated with increased reliance on vision in older adults. We further indicate that trunk accelerations during the anticipatory phase of stepping may be a more sensitive measure to detect age-related changes of APAs due to absent visual information compared to CoP.

What Explains Successful or Unsuccessful Postural Adaptations to Repeated Surface Perturbations among Older Adults?

As we age there are natural physiological deteriorations that decrease the accuracy and flexibility of the postural control system, which increases the risk of falling. Studies have found that there are individual differences in the ability to learn to manage repeated postural threats. The aim of this study was to investigate which factors explain why some individuals are less proficient at adapting to recurrent postural perturbations. Thirty-five community dwelling older adults performed substantial sensory and motor testing and answered surveys regarding fall-related concerns and cognitive function. They were also subjected to three identical surface perturbations where both kinematics and electromyography was captured. Those that were able to adapt to the third perturbation were assigned to the group “Non-fallers” whereas those that fell during all perturbations were assigned to the group “Fallers”. The group designation dichotomized the sample in a hierarchical orthogonal projection of latent structures— the discriminant analysis model. We found that those who fell were older, had poorer physical performance, poorer strength and longer reaction times. The Fallers’ postural control strategies were more reliant on the stiffening strategy along with a more extended posture and they were less skillful at making appropriate feedforward adaptations prior to the third perturbation.

Saccadic eye movement performance reduces visual manipulation influence and center of pressure displacements in older fallers

This study examined changes in postural control and gaze performance of faller and non-faller older adults under conditions of visual tasks and optical flow manipulations. Fifteen older non-fallers (69.8 years, ± 3.2) and fifteen older fallers (71.1 years, ± 6.4) stood on a force platform inside a moving room wearing an eye tracker. Four tasks were performed: gaze fixation; predictable saccades; unpredictable saccades; and free-viewing. The stimuli appeared at a frequency of 1.1 Hz during conditions of predictable and unpredictable saccades. Sixteen trials were divided into two blocks. In the first block, the room remained stationary. In the second block, the room oscillated, without the participant's awareness, with a 0.6 cm amplitude and 0.2 Hz frequency. Results showed postural sway attenuation in older fallers during the saccadic tasks compared to gaze fixation and free-viewing tasks, in both stationary and moving room conditions. Both groups showed increased center of pressure (CoP) magnitude during the moving room condition and CoP displacements strongly coupled to the room's movement. The influence of the moving room on the postural sway was reduced during the saccadic tasks for both older groups. Older fallers exhibited higher variability compared to older non-fallers. Gaze behavior differences between groups were dependent on the goals of the visual tasks. Therefore, CoP displacements of older adults are reduced during saccadic tasks regardless of their falling history. However, postural and gaze performance of older fallers suggests increased deterioration of postural and oculomotor control which may be used as a predictor of fall risk.

Impoverished Inhibitory Control Exacerbates Multisensory Impairments in Older Fallers

Impaired temporal perception of multisensory cues is a common phenomenon observed in older adults that can lead to unreliable percepts of the external world. For instance, the sound induced flash illusion (SIFI) can induce an illusory percept of a second flash by presenting a beep close in time to an initial flash-beep pair. Older adults that have enhanced susceptibility to a fall demonstrate significantly stronger illusion percepts during the SIFI task compared to those older adults without any history of falling. We hypothesize that a global inhibitory deficit may be driving the impairments across both postural stability and multisensory function in older adults with a fall history (FH). We investigated oscillatory activity and perceptual performance during the SIFI task, to understand how active sensory processing, measured by gamma (30–80 Hz) power, was regulated by alpha activity (8–13 Hz), oscillations that reflect inhibitory control. Compared to young adults (YA), the FH and non-faller (NF) groups demonstrated enhanced susceptibility to the SIFI. Further, the FH group had significantly greater illusion strength compared to the NF group. The FH group also showed significantly impaired performance relative to YA during congruent trials (2 flash-beep pairs resulting in veridical perception of 2 flashes). In illusion compared to non-illusion trials, the NF group demonstrated reduced alpha power (or diminished inhibitory control). Relative to YA and NF, the FH group showed reduced phase-amplitude coupling between alpha and gamma activity in non-illusion trials. This loss of inhibitory capacity over sensory processing in FH compared to NF suggests a more severe change than that consequent of natural aging.

Persistent Visual and Vestibular Impairments for Postural Control Following Concussion: A Cross-Sectional Study in University Students

OBJECTIVE

To examine how concussion may impair sensory processing for control of upright stance.

METHODS

Participants were recruited from a single university into 3 groups: 13 participants (8 women, 21 ± 3 years) between 2 weeks and 6 months post-injury who initiated a return-to-play progression (under physician management) by the time of testing (recent concussion group), 12 participants (7 women, 21 ± 1 years) with a history of concussion (concussion history group, > 1 year post-injury), and 26 participants (8 women, 22 ± 3 years) with no concussion history (control group). We assessed sensory reweighting by simultaneously perturbing participants' visual, vestibular, and proprioceptive systems and computed center of mass gain relative to each modality. The visual stimulus was a sinusoidal translation of the visual scene at 0.2 Hz, the vestibular stimulus was ± 1 mA binaural monopolar galvanic vestibular stimulation (GVS) at 0.36 Hz, the proprioceptive stimulus was Achilles' tendon vibration at 0.28 Hz.

RESULTS

The recent concussion (95% confidence interval 0.078-0.115, p = 0.001) and the concussion history (95% confidence interval 0.056-0.094, p = 0.038) groups had higher gains to the vestibular stimulus than the control group (95% confidence interval 0.040-0.066). The recent concussion (95% confidence interval 0.795-1.159, p = 0.002) and the concussion history (95% confidence interval 0.633-1.012, p = 0.018) groups had higher gains to the visual stimulus than the control group (95% confidence interval 0.494-0.752). There were no group differences in gains to the proprioceptive stimulus or in sensory reweighting.

CONCLUSION

Following concussion, participants responded more strongly to visual and vestibular stimuli during upright stance, suggesting they may have abnormal dependence on visual and vestibular feedback. These findings may indicate an area for targeted rehabilitation interventions.

Age-related changes in the neuromuscular control of forward and backward locomotion

Previous studies found significant modification in spatiotemporal parameters of backward walking in healthy older adults, but the age-related changes in the neuromuscular control have been considered to a lesser extent. The present study compared the intersegmental coordination, muscle activity and corresponding modifications of spinal montoneuronal output during both forward and backward walking in young and older adults. Ten older and ten young adults walked forward and backward on a treadmill at different speeds. Gait kinematics and EMG activity of 14 unilateral lower-limb muscles were recorded. As compared to young adults, the older ones used shorter steps, a more in-phase shank and foot motion, and the activity profiles of muscles innervated from the sacral segments were significantly wider in each walking condition. These findings highlight age-related changes in the neuromuscular control of both forward and backward walking. A striking feature of backward walking was the differential organization of the spinal output as compared to forward gait. In addition, the resulting spatiotemporal map patterns also characterized age-related changes of gait. Finally, modifications of the intersegmental coordination with aging were greater during backward walking. On the whole, the assessment of backward walk in addition to routine forward walk may help identifying or unmasking neuromuscular adjustments of gait to aging.

Reliance on Visual Input for Balance Skill Transfer in Older Adults: EEG Connectome Analysis Using Minimal Spanning Tree

Skill transfer from trained balance exercises is critical to reduce the rate of falls in older adults, who rely more on vision to control postural responses due to age-dependent sensory reweighting. With an electroencephalography (EEG) minimum spanning tree (MST) structure, the purpose of this study was to compare the organization of supraspinal neural networks of transfer effect after postural training using full and intermittent visual feedbacks for older adults. Thirty-two older adults were randomly assigned to the stroboscopic vision (SV) (n = 16; age = 64.7 ± 3.0 years) and control (16; 66.3 ± 2.7 years) groups for balance training on a stabilometer (target task) with on-line visual feedback. Center-of-pressure characteristics and an MST-based connectome of the weighted phase-lag index during the bilateral stance on a foam surface (transfer task) were compared before and after stabilometer training. The results showed that both the SV and control groups showed improvements in postural stability in the trained task (p < 0.001). However, unlike the control group (p = 0.030), the SV group who received intermittent visual feedback during the stabilometer training failed to reduce the size of postural sway in the anteroposterior direction of the postural transfer task (unstable stance on the foam surface) in the post-test (p = 0.694). In addition, network integration for the transfer task in the post-test was absent in the SV group (p > 0.05). For the control group in the post-test, it manifested with training-related increases in leaf fraction in beta band (p = 0.015) and maximum betweenness in alpha band (p = 0.018), but a smaller diameter in alpha (p = 0.006)/beta (p = 0.021) bands and average eccentricity in alpha band (p = 0.028). In conclusion, stabilometer training with stroboscopic vision impairs generalization of postural skill to unstable stance for older adults. Adequate visual information is a key mediating factor of supraspinal neural networks to carry over balance skill in older adults.

Processing moving visual scenes during upright stance in elderly patients with mild cognitive impairment

Background

The ability to maintain balance in an upright stance gradually worsens with age and is even more difficult for patients with cognitive disorders. Cognitive impairment plays a probable role in the worsening of stability. The purpose of this study was to expose subjects with mild cognitive impairment (MCI) and healthy, age-matched controls to moving visual scenes in order to examine their postural adaptation abilities.

Methods

We observed postural responses to moving visual stimulation while subjects stood on a force platform. The visual disturbance was created by interposing a moving picture in four directions (forward, backward, right, and left). The pre-stimulus (a static scene for 10 s), stimulus (a dynamic visual scene for 20 seconds) and post-stimulus (a static scene for 20 seconds) periods were evaluated. We separately analyzed the total path (TP) of the center of pressure (COP) and the root mean square (RMS) of the COP displacement in all four directions.

Results

We found differences in the TP of the COP during the post-stimulus period for all stimulus directions except in motion towards the subject (left p = 0.006, right p = 0.004, and away from the subject p = 0.009). Significant RMS differences between groups were also observed during the post-stimulus period in all directions except when directed towards the subject (left p = 0.002, right p = 0.007, and away from the subject p = 0.014).

Conclusion

Exposing subjects to a moving visual scene induced greater destabilization in MCI subjects compared to healthy elderly controls. Surprisingly, the moving visual scene also induced significant aftereffects in the MCI group. Our findings indicate that the MCI group had diminished adaptation to the dynamic visual scene and recovery. These results suggest that even mild cognitive deficits can impair sensory information integration and alter the sensory re-weighing process.

Age-related differences in gait adaptations during overground walking with and without visual perturbations using a virtual reality headset

Older adults have difficulty adapting to new visual information, posing a challenge to maintain balance during walking. Virtual reality can be used to study gait adaptability in response to discordant sensorimotor stimulations. This study aimed to investigate age-related modifications and propensity for visuomotor adaptations due to continuous visual perturbations during overground walking in a virtual reality headset. Twenty old and twelve young subjects walked on an instrumented walkway in real and virtual environments while reacting to antero-posterior and medio-lateral oscillations of the visual field. Mean and variability of spatiotemporal gait parameters were calculated during the first and fifth minutes of walking. A 3-way mixed-design ANOVA was performed to determine the main and interaction effects of group, condition and time. Both groups modified gait similarly, but older adults walked with shorter and slower strides and did not reduce stride velocity or increase stride width variability during medio-lateral perturbations. This may be related to a more conservative and anticipatory strategy as well as a reduced perception of the optic flow. Over time, participants adapted similarly to the perturbations but only younger participants reduced their stride velocity variability. Results provide novel evidence of age- and context-dependent visuomotor adaptations in response to visual perturbations during overground walking and may help to establish new methods for early identification and remediation of gait deficits.

Interactions Between Different Age-Related Factors Affecting Balance Control in Walking

Maintaining balance during walking is a continuous sensorimotor control problem. Throughout the movement, the central nervous system has to collect sensory data about the current state of the body in space, use this information to detect possible threats to balance and adapt the movement pattern to ensure stability. Failure of this sensorimotor loop can lead to dire consequences in the form of falls, injury and death. Such failures tend to become more prevalent as people get older. While research has established a number of factors associated with higher risk of falls, we know relatively little about age-related changes of the underlying sensorimotor control loop and how such changes are related to empirically established risk factors. This paper approaches the problem of age-related fall risk from a neural control perspective. We begin by summarizing recent empirical findings about the neural control laws mapping sensory input to motor output for balance control during walking. These findings were established in young, neurotypical study populations and establish a baseline of sensorimotor control of balance. We then review correlates for deteriorating balance control in older adults, of muscle weakness, slow walking, cognitive decline, and increased visual dependency. While empirical associations between these factors and fall risk have been established reasonably well, we know relatively little about the underlying causal relationships. Establishing such causal relationships is hard, because the different factors all co-vary with age and are difficult to isolate empirically. One option to analyze the role of an individual factor for balance control is to use computational models of walking comprising all levels of the sensorimotor control loop. We introduce one such model that generates walking movement patterns from a short list of spinal reflex modules with limited supraspinal modulation for balance. We show how this model can be used to simulate empirical studies, and how comparison between the model and empirical results can indicate gaps in our current understanding of balance control. We also show how different aspects of aging can be added to this model to study their effect on balance control in isolation.

Effect of stroboscopic vision on depth jump performance in female NCAA Division I volleyball athletes

Anticipation of ground reaction force (GRF) in depth jumping requires multisensory integration of exteroceptive, vestibular, and proprioceptive inputs. Vision contributes to the anticipation of GRF in drop landings and may influence depth jump performance when disrupted. The purpose of this investigation was to evaluate the effects of stroboscopic vision on depth jump performance. Thirteen female NCAA Division I volleyball athletes completed a testing protocol consisting of 0.38 m depth jumps under condition of full vision and stroboscopic vision at strobe frequencies of 4 and 1.75 Hz. Depth jump performance was assessed via the Reactive Strength Index (RSI) and time-series vertical GRF (vGRF) data. Main effects of stroboscopic vision were evaluated for statistical significance via Repeated Measures Multivariate Analysis of Variance with post hoc multiple paired t-tests (α = 0.05). RSI (p < 0.001) and rebound jump height (p = 0.006) were lower in the 1.75 Hz stroboscopic condition versus full vision, while ground contact time (p = 0.008), and rate of vertical ground reaction force development (p = 0.016) were greater in the 1.75 Hz stroboscopic condition versus full vision. Stroboscopic vision could be used to modify the intensity of depth jumping and considered for inclusion into plyometric training.

Impaired Multisensory Integration Predisposes the Elderly People to Fall: A Systematic Review

Background: This systematic review pooled all the latest data and reviewed all the relevant studies to look into the effect of multisensory integration on the balance function in the elderly.

Methods: PubMed, Web of Science and Scopus were searched to find eligible studies published prior to May 2019. The studies were limited to those published in Chinese and English language. The quality of the included studies was assessed against the Newcastle-Ottawa Scale or an 11-item checklist, as recommended by Agency for Healthcare Research and Quality (AHRQ). Any disagreement among reviewers was resolved by comparing notes and reaching a consensus.

Results: Eight hundred thirty-nine records were identified and 17 of them were included for systematic review. The result supported our assumption that multisensory integration works on balance function in the elderly. All the 17 studies were believed to be of high or moderate quality.

Conclusions: The systematic review found that the impairment of multisensory integration could predispose elderly people to fall. Accurate assessment of multisensory integration can help the elderly identify the impaired balance function and minimize the risk of fall. And our results provide a new basis for further understanding of balance maintenance mechanism. Further research is warranted to explore the change in brain areas related to multisensory integration in the elderly.

Postural Control Profiles of Typically Developing Children From 6 to 12 Years old: An Approach Using Self-Organizing Maps

The purposes of the present study were a) to establish postural control profiles for individuals 6–12 years of age, b) to analyze the participants’ characteristics (age, sex, weight, height, and physical activity) in those profiles, and c) to analyze the influence of visual information in the profiles found. Two hundred and eight typically developing children aged 6–12 years performed two trials in bipedal standing position with eyes open and closed. Feature extraction involved time, frequency, and sway-density plot variables using signals from the center of pressure. A Self-Organizing Map was used to classify and visualize the values of the participants in all the postural control variables tested. A k-means cluster analysis was applied to generate a small number of postural control profiles. The results determined six postural control profiles; three with participants denoting high stability and three considered as low stability profiles. Age, sex, and height were related to the postural control profiles. Boys were more frequently allocated in high stability clusters than girls, while the other factors yielded unclear difference between high and low stability profiles. The analysis of children’s profiles reflecting postural stability should therefore involve more than one factor including the individuals’ age, sex, and height.

Can optical flow perturbations detect walking balance impairment in people with multiple sclerosis?

People with multiple sclerosis (PwMS) who exhibit minimal to no disability are still over twice as likely to fall as the general population and many of these falls occur during walking. There is a need for more effective ways to detect preclinical walking balance deficits in PwMS. Therefore, the purpose of this study was to investigate the effects of optical flow perturbations applied using virtual reality on walking balance in PwMS compared to age-matched controls. We hypothesized that susceptibility to perturbations–especially those in the mediolateral direction–would be larger in PwMS compared to controls. Fourteen PwMS and fourteen age-matched controls walked on a treadmill while viewing a virtual hallway with and without optical flow perturbations in the mediolateral or anterior-posterior directions. We quantified foot placement kinematics, gait variability, lateral margin of stability and, in a separate session, performance on the standing sensory organization test (SOT). We found only modest differences between groups during normal, unperturbed walking. These differences were larger and more pervasive in the presence of mediolateral perturbations, evidenced by higher variability in step width, sacrum position, and margin of stability at heel-strike in PwMS than controls. PwMS also performed worse than controls on the SOT, and there was a modest correlation between step width variability during perturbed gait and SOT visual score. In conclusion, mediolateral optical flow perturbations revealed differences in walking balance in PwMS that went undetected during normal, unperturbed walking. Targeting this difference may be a promising approach to more effectively detect preclinical walking balance deficits in PwMS.

Optic flow and attention alter locomotion differently in the young and old

BACKGROUND

Optic flow is used in the control of walking speed and aids in navigation through space. However, the influence of attention on optic flow processing during locomotion is not known.

RESEARCH QUESTION

Does attentional focus influence the processing of optic flow during locomotion in young and older adults?

METHODS

Auditory and visual concurrent reaction time tasks were conducted while walking on a treadmill within an anterior-posterior modulating optic flow field in young and older adults. Optic flow was generated with full field back-projected scenes shown while walking on a treadmill under three conditions: a) optic flow consistent with the treadmill speed, b) slow sinusoidal modulation of the speed (SINE), and c) reversals of optic flow velocity from congruent with walking to the opposite direction (REV). Movement in response to the scenes along with reaction times were measured.

RESULTS

The optic flow perturbations altered movement on the treadmill. Older adults responded more than young adults during the slowly changing sinusoidal perturbations, but not to the rapid reversing scenes. Our main hypothesis that sensory modality of a concurrent cognitive task influences the processing of optic flow was confirmed for the reversing optic flow condition but not for the sinusoidal optic flow. The impact of optic flow conditions on reaction times was only found during the REV condition, with impact on visual RTs being greater than auditory RTs.

SIGNIFICANCE

Taken together, the results suggest attentional focus on sensory modality of concurrent tasks while walking can impact optic flow processing for navigation and control; however, the characteristics of the optic flow (e.g. perturbation speed) play an important role.

Aging Impairs Temporal Sensitivity, but not Perceptual Synchrony, Across Modalities

Encoding the temporal properties of external signals that comprise multimodal events is a major factor guiding everyday experience. However, during the natural aging process, impairments to sensory processing can profoundly affect multimodal temporal perception. Various mechanisms can contribute to temporal perception, and thus it is imperative to understand how each can be affected by age. In the current study, using three different temporal order judgement tasks (unisensory, multisensory, and sensorimotor), we investigated the effects of age on two separate temporal processes: synchronization and integration of multiple signals. These two processes rely on different aspects of temporal information, either the temporal alignment of processed signals or the integration/segregation of signals arising from different modalities, respectively. Results showed that the ability to integrate/segregate multiple signals decreased with age regardless of the task, and that the magnitude of such impairment correlated across tasks, suggesting a widespread mechanism affected by age. In contrast, perceptual synchrony remained stable with age, revealing a distinct intact mechanism. Overall, results from this study suggest that aging has differential effects on temporal processing, and general impairments with aging may impact global temporal sensitivity while context-dependent processes remain unaffected.

Alterations of Functional Brain Connectivity After Long-Duration Spaceflight as Revealed by fMRI

The present study reports alterations of task-based functional brain connectivity in a group of 11 cosmonauts after a long-duration spaceflight, compared to a healthy control group not involved in the space program. To elicit the postural and locomotor sensorimotor mechanisms that are usually most significantly impaired when space travelers return to Earth, a plantar stimulation paradigm was used in a block design fMRI study. The motor control system activated by the plantar stimulation involved the pre-central and post-central gyri, SMA, SII/operculum, and, to a lesser degree, the insular cortex and cerebellum. While no post-flight alterations were observed in terms of activation, the network-based statistics approach revealed task-specific functional connectivity modifications within a broader set of regions involving the activation sites along with other parts of the sensorimotor neural network and the visual, proprioceptive, and vestibular systems. The most notable findings included a post-flight increase in the stimulation-specific connectivity of the right posterior supramarginal gyrus with the rest of the brain; a strengthening of connections between the left and right insulae; decreased connectivity of the vestibular nuclei, right inferior parietal cortex (BA40) and cerebellum with areas associated with motor, visual, vestibular, and proprioception functions; and decreased coupling of the cerebellum with the visual cortex and the right inferior parietal cortex. The severity of space motion sickness symptoms was found to correlate with a post- to pre-flight difference in connectivity between the right supramarginal gyrus and the left anterior insula. Due to the complex nature and rapid dynamics of adaptation to gravity alterations, the post-flight findings might be attributed to both the long-term microgravity exposure and to the readaptation to Earth's gravity that took place between the landing and post-flight MRI session. Nevertheless, the results have implications for the multisensory reweighting and gravitational motor system theories, generating hypotheses to be tested in future research.

Time-dependent tuning of balance control and aftereffects following optical flow perturbation training in older adults

Background

Walking balance in older adults is disproportionately susceptible to lateral instability provoked by optical flow perturbations. The prolonged exposure to these perturbations could promote reactive balance control and increased balance confidence in older adults, but this scientific premise has yet to be investigated. This proof of concept study was designed to investigate the propensity for time-dependent tuning of walking balance control and the presence of aftereffects in older adults following a single session of optical flow perturbation training.

Methods

Thirteen older adults participated in a randomized, crossover design performed on different days that included 10 min of treadmill walking with (experimental session) and without (control session) optical flow perturbations. We used electromyographic recordings of leg muscle activity and 3D motion capture to quantify foot placement kinematics, lateral margin of stability, and antagonist coactivation during normal walking (baseline), early (min 1) and late (min 10) responses to perturbations, and aftereffects immediately following perturbation cessation (post).

Results

At their onset, perturbations elicited 17% wider and 7% shorter steps, higher step width and length variability (+171% and +132%, respectively), larger and more variable margins of stability (MoS), and roughly twice the antagonist leg muscle coactivation (p-values<0.05). Despite continued perturbations, most outcomes returned to values observed during normal, unperturbed walking by the end of prolonged exposure. After 10 min of perturbation training and their subsequent cessation, older adults walked with longer and more narrow steps, modest increases in foot placement variability, and roughly half the MoS variability and antagonist lower leg muscle coactivation as they did before training.

Conclusions

Findings suggest that older adults: (i) respond to the onset of perturbations using generalized anticipatory balance control, (ii) deprioritize that strategy following prolonged exposure to perturbations, and (iii) upon removal of perturbations, exhibit short-term aftereffects that indicate a lessening of anticipatory control, an increase in reactive control, and/or increased balance confidence. We consider this an early, proof-of-concept study into the clinical utility of prolonged exposure to optical flow perturbations as a training tool for corrective motor adjustments relevant to walking balance integrity toward reinforcing task-specific, reactive control and/or improving balance confidence in older adults.

Trial registration

clinicaltrials.gov (NCT03341728). Registered 14 November 2017.

Electronic supplementary material

The online version of this article (10.1186/s12984-019-0555-3) contains supplementary material, which is available to authorized users.

Age-related changes in leg proprioception: implications for postural control

In addition to being a prerequisite for many activities of daily living, the ability to maintain steady upright standing is a relevant model to study sensorimotor integrative function. Upright standing requires managing multimodal sensory inputs to produce finely tuned motor output that can be adjusted to accommodate changes in standing conditions and environment. The sensory information used for postural control mainly arises from the vestibular system of the inner ear, vision, and proprioception. Proprioception (sense of body position and movement) encompasses signals from mechanoreceptors (proprioceptors) located in muscles, tendons, and joint capsules. There is general agreement that proprioception signals from leg muscles provide the primary source of information for postural control. This is because of their exquisite sensitivity to detect body sway during unperturbed upright standing that mainly results from variations in leg muscle length induced by rotations around the ankle joint. However, aging is associated with alterations of muscle spindles and their neural pathways, which induce a decrease in the sensitivity, acuity, and integration of the proprioceptive signal. These alterations promote changes in postural control that reduce its efficiency and thereby may have deleterious consequences for the functional independence of an individual. This narrative review provides an overview of how aging alters the proprioceptive signal from the legs and presents compelling evidence that these changes modify the neural control of upright standing.

Balance and gait in the elderly: A contemporary review

Background

The prevalence of balance and gait deficits increases with age and is associated with the increased incidence of falls seen in the elderly population; these falls are associated with significant morbidity and mortality.

Objectives

To review changes in gait and balance associated with aging and the effect of visual perturbations on gait and balance in the elderly to provide a basis for future research.

Methods

PubMed and Cochrane Library were searched for articles from 1980 to present pertaining to gait and balance in older adults (>60) and younger adults (<60). Search terms included balance, posture, gait, locomotion, gait variability, gait disorders, gait disturbance, elderly, aging, falls, vision, visual, vestibular, and virtual reality. The references section of queried articles was also used to find relevant studies. Studies were excluded if subjects had a diagnosed gait or balance disorder.

Results

Elderly adults show age-related decline in sensory systems and reduced ability to adapt to changes in their environment to maintain balance. Elderly adults are particularly dependent on vision to maintain postural stability. Distinct changes in spatiotemporal gait parameters are associated with aging, such as slower gait and increased gait variability, which are amplified with exposure to visual perturbations. Increased gait variability, specifically with mediolateral perturbations, poses a particular challenge for elderly adults and is linked to increased falls risk. Virtual reality training has shown promising effects on balance and gait.

Conclusion

Elderly adults show age-related decline in balance and gait with increased gait variability and an associated increased risk of falls.

Level of Evidence

5.

Slowed sensory reweighting and postural illusions in older adults: the moving platform illusion

We investigated whether postural aftereffects witnessed during transitions from a moving to a stable support are accompanied by a delayed perception of platform stabilization in older adults, in two experiments. In experiment 1, postural sway and muscle cocontraction were assessed in 11 healthy young, 11 healthy older, and 11 fall-prone older adults during blindfolded stance on a fixed platform, followed by a sway-referenced platform and then by a fixed platform again. The sway-referenced platform was more compliant for young adults, to induce similar levels of postural sway in both age groups. Participants were asked to press a button whenever they perceived that the platform had stopped moving. Both older groups showed significantly larger and longer postural sway aftereffects during platform stabilization compared with young adults, which were pronounced in fall-prone older adults. In both older groups elevated muscle cocontraction aftereffect was also witnessed. Importantly, these aftereffects were accompanied by an illusory perception of prolonged platform movement. After this, experiment 2 examined whether this illusory perception was a robust age effect or an experimental confound due to greater surface compliance in young adults, which could create a larger perceptual discrepancy between moving and stable conditions. Despite exposure to the same surface compliance levels during sway-reference, the perceptual illusion was maintained in experiment 2 in a new group of 14 healthy older adults compared with 11 young adults. In both studies, older adults took five times longer than young adults to perceive platform stabilization. This supports that sensory reweighting is inefficient in older adults. NEW & NOTEWORTHY This is the first paper to show that postural sway aftereffects witnessed in older adults after platform stabilization may be due to a perceptual illusion of platform movement. Surprisingly, in both experiments presented it took older adults five times longer than young adults to perceive platform stabilization. This supports a hypothesis of less efficient sensory reintegration in this age group, which may delay the formation of an accurate postural percept.

Effects of Foot Placement on Postural Sway in the Anteroposterior and Mediolateral Directions

The common practice of standardizing foot placement in postural research and in clinical practice may serve to increase postural sway. The focus of this study was to investigate foot placement strategies in the tandem (anteroposterior, AP) and side-to-side (mediolateral, ML) stance in healthy adults. Foot placement was either experimenter-controlled or selected by the participant. Greater sway was observed for the AP stance than the ML stance, where sway was minimal. When foot placement was self-selected, participants recruited additional degrees of freedom by rotating both feet outward to expand the base of support; they narrowed their stance width in the AP stance only. Self-selection served to decrease AP sway for the AP stance and increase ML sway for both the AP and ML stances. A dynamical measure, the largest Lyapunov exponent, supported the finding that self-selection of foot placement serves to stabilize posture. The implication is that improvements in postural control were due primarily to self-selection of foot placement and not to adjustments in stance width. Experimental and perhaps clinical procedures should be revised to allow participants to self-select foot placement during postural tasks.

Critical Role of Somatosensation in Postural Control Following Spaceflight: Vestibularly Deficient Astronauts Are Not Able to Maintain Upright Stance During Compromised Somatosensation

The free-fall of orbital spaceflight effectively removes the gravitational vector used as a primary spatial orientation reference on Earth. Sustained absence of this reference drives adaptive changes in the internal perception-action models of the central nervous system (CNS), most notably in the processing of the vestibular otolith inputs. Upon landing, the return of the gravitational signal triggers a re-adaptation that restores terrestrial performance; however, during this period, the individual suffers from a functional vestibular deficiency. Here we provide evidence of a transient increase of the weighting of somatosensory inputs in postural control while the CNS resolves these vestibular deficiencies. Postural control performance was measured before and after spaceflight in 11 Shuttle astronauts and 11 matched controls and nine elderly who did not experience spaceflight. A quiet-stance paradigm was used that eliminated vision, modulated the lower extremity somatosensory cues by subtly modulating the orientation of the support surface beneath feet of subjects in all groups. Additionally, in astronauts and matched controls, we challenged the vestibular system with dynamic head tilts. Postural stability on the landing day (R+0) was substantially decreased for trials with absent visual and altered somatosensory cues, especially those also requiring dynamic head tilts ( ± 5° @ 0.33 Hz) during which 20/22 trials ended prematurely with a fall. In contrast, none of the astronauts fell during eyes-closed, dynamic head tilt trials with unaltered somatosensory cues, and only 3/22 trials resulted in falls with eyes-closed and altered somatosensory cues, but static upright head orientation. Furthermore, postural control performance of astronauts was either statistically not different or worse than that of healthy elderly subjects during the most challenging vestibular conditions on R+0. Overall, our results demonstrate a transient reweighting of sensory cues associated with microgravity-induced vestibular deficiencies, with a significant increase in reliance on somatosensory cues, which can provide an effective reference even without vision and with dynamic vestibular challenges. The translation of these results to aging population suggests that elderly individuals with visual and vestibular deficits may benefit from therapeutic interventions enhancing sensorimotor-integration to improve balance and reduce the risk of falling.

From One to Two: Can Visual Feedback Improve the Light Touch Effects on Postural Sway?

The postural control is improved by implicit somatosensory information from lightly touching a rigid bar or explicit visual information about the postural sway. Whether these two additional sources provided at the same time further reduce the postural sway is still unknown. Participants stood on a force plate as quiet as possible lightly touching the bar while received or not visual feedback of the center of pressure position on a monitor screen. Postural sway reduced similarly with the light touch regardless of the additional visual feedback. The findings suggested that providing explicit visual feedback of the center of pressure does not increase the light touch effects on the postural sway. The importance of the implicit somatosensory information on postural control is discussed.

Age and falls history effects on antagonist leg muscle coactivation during walking with balance perturbations

BACKGROUND

Inspired by a reliance on visual feedback for movement control in older age, optical flow perturbations provide a unique opportunity to study the neuromuscular mechanisms involved in walking balance control, including aging and falls history effects on the response to environmental balance challenges. Specifically, antagonist leg muscle coactivation, which increases with age during walking, is considered a neuromuscular defense against age-associated deficits in balance control. The purpose of this study was to investigate the effects of age and falls history on antagonist leg muscle coactivation during walking with and without optical flow perturbations of different amplitudes.

METHODS

Eleven young adults [mean (standard deviation) age: 24.8 (4.8) years], eleven older non-fallers [75.3 (5.4) years] and eleven older fallers [age: 78 (7.6) years] participated in this study. Participants completed 2-minute walking trials while watching a speed-matched virtual hallway that, in some conditions, included mediolateral optical flow perturbations designed to elicit the visual perception of imbalance.

FINDINGS

We first found that lower leg antagonist muscle coactivation during normal walking increased with age, independent of falls history. We also found that older but not young adults increased antagonist leg muscle coactivation in the presence of optical flow perturbations, with more pervasive effects in older adults with a history of falls.

INTERPRETATION

Our findings allude to a greater susceptibility to optical flow perturbations in older fallers during walking, which points to a higher potential for risk of instability in more complex and dynamic everyday environments. These findings may also have broader impacts related to the design of innovative training paradigms and neuromuscular targets for falls prevention.

The motor repertoire of older adult fallers may constrain their response to balance perturbations

Older adults are at a high risk of falls, and most falls occur during locomotor activities like walking. This study aimed to improve our understanding of changes in neuromuscular control associated with increased risk of falls in older adults in the presence of dynamic balance challenges during walking. Motor module (also known as muscle synergy) analyses identified changes in the neuromuscular recruitment of leg muscles during walking with and without perturbations designed to elicit the visual perception of lateral instability. During normal walking we found that a history of falls (but not age) was associated with reduced motor module complexity and that age (but not a history of falls) was associated with increased step-to-step variability of module recruitment timing. Furthermore, motor module complexity was unaltered in the presence of optical flow perturbations. The specific effects of a history of falls on leg muscle recruitment included an absence and/or inability to independently recruit motor modules normally recruited to perform biomechanical functions important for walking balance control. These results suggest that fallers do not recruit the appropriate motor modules necessary for well-coordinated walking balance control even in the presence of perturbations. The identified changes in the modular control of walking balance in older fallers may either represent a neural deficit that leads to poor balance control or a prior history of falls that results in a compensatory motor adaptation. In either case, our study provides initial evidence that a reduced motor repertoire in older adult fallers may be a constraint on their ability to appropriately respond to balance challenges during walking. NEW & NOTEWORTHY This is the first study to demonstrate a reduced motor repertoire during walking in older adults with a history of falls but without any overt neurological deficits. Furthermore, using virtual reality during walking to elicit the visual perception of lateral instability, we provide initial evidence that a reduced motor repertoire in older adult fallers may be a constraint on their ability to appropriately respond to balance challenges during walking.

"Walking" through the sensory, cognitive, and temporal degradations of healthy aging

As we age, there is a wide range of changes in motor, sensory, cognitive, and temporal processing due to alterations in the functioning of the central nervous and musculoskeletal systems. Specifically, aging is associated with degradations in gait; altered processing of the individual sensory systems; modifications in executive control, memory, and attention; and changes in temporal processing. These age-related alterations are often inter-related and have been suggested to result from shared neural substrates. Additionally, the overlap between these brain areas and those controlling walking raises the possibility of facilitating performance in several tasks by introducing protocols that can efficiently target all four domains. Attempts to counteract these negative effects of normal aging have been focusing on research to prevent falls and/or enhance cognitive processes, while ignoring the potential multisensory benefits accompanying old age. Research shows that the aging brain tends to increasingly rely on multisensory integration to compensate for degradations in individual sensory systems and for altered neural functioning. This review covers the age-related changes in the above-mentioned domains and the potential to exploit the benefits associated with multisensory integration in aging so as to improve one's mobility and enhance sensory, cognitive, and temporal processing.

Does local dynamic stability during unperturbed walking predict the response to balance perturbations? An examination across age and falls history

BACKGROUND

Older adults are at an exceptionally high risk of falls, and most falls occur during locomotor activities such as walking. Reduced local dynamic stability in old age is often interpreted to suggest a lessened capacity to respond to more significant balance challenges encountered during walking and future falls risk. However, it remains unclear whether local dynamic stability during normal, unperturbed walking predicts the response to larger external balance disturbances.

RESEARCH QUESTION

We tested the hypothesis that larger values of local dynamic instability during unperturbed walking would positively correlate with larger changes thereof due to optical flow balance perturbations.

METHODS

We used trunk kinematics collected in subjects across a spectrum of walking balance integrity - young adults, older non-fallers, and older fallers - during walking with and without mediolateral optical flow perturbations of four different amplitudes.

RESULTS

We first found evidence that optical flow perturbations of sufficient amplitude appear capable of revealing independent effects of aging and falls history that are not otherwise apparent during normal, unperturbed walking. We also reject our primary hypothesis; a significant negative correlation only in young adults indicated that individuals with more local dynamic instability during normal, unperturbed walking exhibited smaller responses to optical flow perturbations. In contrast, most prominently in older fallers, the response to optical flow perturbations appeared independent of their baseline level of dynamic instability.

SIGNIFICANCE

We propose that predicting the response to balance perturbations in older fallers, at least that measured using local dynamic stability, likely requires measuring that response directly.

Aging effects on leg joint variability during walking with balance perturbations

BACKGROUND

Older adults are more susceptible to balance perturbations during walking than young adults. However, we lack an individual joint-level understanding of how aging affects the neuromechanical strategies used to accommodate balance perturbations.

RESEARCH QUESTION

We investigated gait phase-dependence in and aging effects on leg joint kinematic variability during walking with balance perturbations. We hypothesized that leg joint variability would: 1) vary across the gait cycle and 2) increase with balance perturbations. We also hypothesized that perturbation effects on leg joint kinematic variability would be larger and more pervasive in older versus young adults.

METHODS

We collected leg joint kinematics in young and older adults walking with and without mediolateral optical flow perturbations of different amplitudes.

RESULTS

We first found that leg joint variability during walking is gait phase-dependent, with step-to-step adjustments occurring predominantly during push-off and early swing. Second, young adults accommodated perturbations almost exclusively by increasing coronal plane hip joint variability, likely to adjust step width. Third, perturbations elicited larger and more pervasive increases in all joint kinematic outcome measures in older adults. Finally, we also provide insight into which joints contribute more to foot placement variability in walking, adding that variability in sagittal plane knee and coronal plane hip joint angles contributed most to that in step length and step width, respectively.

SIGNIFICANCE

Taken together, our findings may be highly relevant to identifying specific joint-level therapeutic targets to mitigate balance impairment in our aging population.