Abnormal center of mass feedback responses during balance: A potential biomarker of falls in Parkinson's disease

Age- and Parkinson-related differences in trunk and lower-limb muscle activation during four balance tasks: A case-control pilot study

BACKGROUND

Poor postural control has been reported in people with Parkinson's disease, which could be explained by the changes in muscular activation patterns related to antigravitational muscles. This study aims to measure the muscle activation of antigravitational muscles during balance tasks in individuals, with and without Parkinson's.

METHODS

Sixteen (16) participants (9 with Parkinson's), aged ≥65 yrs., performed 2 × 30-s trials of 4 balance tasks (bipodal and semi-tandem opened eyes and closed eyes) on a force platform (center of pressure measurement); while surface electromyography measurements were obtained bilaterally on the multifidus at L5, biceps femoris and medialis gastrocnemius. Electromyography amplitude analysis was processed by the Root Mean Square (250 ms window epochs) and normalized by the peak of activation during the balance task, to determine each muscle's activity level.

FINDINGS

The Parkinson's group reported lower muscle activation than control across tasks (in mean for multifidus = 8%, biceps femoris = 16%, gastrocnemius = 7%), although not statistically significant. Parkinson's reported significantly poorer postural control than control, mainly for the center of pressure sway ellipse area (p = 0.016) from challenge balance tasks such as semi-tandem.

INTERPRETATION

Poor postural control was confirmed in the Parkinson's group, but not significantly associated by the changes from muscle activation of trunk and lower limbs, during balance performance.

Combined translational and rotational perturbations of standing balance reveal contributions of reduced reciprocal inhibition to balance impairments in children with cerebral palsy

Balance impairments are common in cerebral palsy. When balance is perturbed by backward support surface translations, children with cerebral palsy have increased co-activation of the plantar flexors and tibialis anterior muscle as compared to typically developing children. However, it is unclear whether increased muscle co-activation is a compensation strategy to improve balance control or is a consequence of reduced reciprocal inhibition. During translational perturbations, increased joint stiffness due to co-activation might aid balance control by resisting movement of the body with respect to the feet. In contrast, during rotational perturbations, increased joint stiffness will hinder balance control as it couples body to platform rotation. Therefore, we expect increased muscle co-activation in response to rotational perturbations if co-activation is caused by reduced reciprocal inhibition but not if it is merely a compensation strategy. We perturbed standing balance by combined backward translational and toe-up rotational perturbations in 20 children with cerebral palsy and 20 typically developing children. Perturbations induced forward followed by backward movement of the center of mass. We evaluated reactive muscle activity and the relation between center of mass movement and reactive muscle activity using a linear feedback model based on center of mass kinematics. In typically developing children, perturbations induced plantar flexor balance correcting muscle activity followed by tibialis anterior balance correcting muscle activity, which was driven by center of mass movement. In children with cerebral palsy, the switch from plantar flexor to tibialis anterior activity was less pronounced than in typically developing children due to increased muscle co-activation of the plantar flexors and tibialis anterior throughout the response. Our results thus suggest that a reduction in reciprocal inhibition causes muscle co-activation in reactive standing balance in children with cerebral palsy.

Delayed center of mass feedback in elderly humans leads to greater muscle co-contraction and altered balance strategy under perturbed balance: A predictive musculoskeletal simulation study

Falls are one of the leading causes of non-disease death and injury in the elderly, often due to delayed sensory neural feedback essential for balance. This delay, challenging to measure or manipulate in human studies, necessitates exploration through neuromusculoskeletal modeling to reveal its intricate effects on balance. In this study, we developed a novel three-way muscle feedback control approach, including muscle length feedback, muscle force feedback, and enter of mass feedback, for balancing and investigated specifically the effects of center of mass feedback delay on elderly people's balance strategies. We conducted simulations of cyclic perturbed balance at different magnitudes ranging from 0 to 80 mm and with three center of mass feedback delays (100, 150 & 200 ms). The results reveal two key points: 1) Longer center of mass feedback delays resulted in increased muscle activations and co-contraction, 2) Prolonged center of mass feedback delays led to noticeable shifts in balance strategies during perturbed standing. Under low-amplitude perturbations, the ankle strategy was predominantly used, while higher amplitude disturbances saw more frequent employment of hip and knee strategies. Additionally, prolonged center of mass delays altered balance strategies across different phases of perturbation, with a noticeable increase in overall ankle strategy usage. These findings underline the adverse effects of prolonged feedback delays on an individual's stability, necessitating greater muscle co-contraction and balance strategy adjustment to maintain balance under perturbation. Our findings advocate for the development of training programs tailored to enhance balance reactions and mitigate muscle feedback delays within clinical or rehabilitation settings for fall prevention in elderly people.

Precise cortical contributions to sensorimotor feedback control during reactive balance

The role of the cortex in shaping automatic whole-body motor behaviors such as walking and balance is poorly understood. Gait and balance are typically mediated through subcortical circuits, with the cortex becoming engaged as needed on an individual basis by task difficulty and complexity. However, we lack a mechanistic understanding of how increased cortical contribution to whole-body movements shapes motor output. Here we use reactive balance recovery as a paradigm to identify relationships between hierarchical control mechanisms and their engagement across balance tasks of increasing difficulty in young adults. We hypothesize that parallel sensorimotor feedback loops engaging subcortical and cortical circuits contribute to balance-correcting muscle activity, and that the involvement of cortical circuits increases with balance challenge. We decomposed balance-correcting muscle activity based on hypothesized subcortically- and cortically-mediated feedback components driven by similar sensory information, but with different loop delays. The initial balance-correcting muscle activity was engaged at all levels of balance difficulty. Its onset latency was consistent with subcortical sensorimotor loops observed in the lower limb. An even later, presumed, cortically-mediated burst of muscle activity became additionally engaged as balance task difficulty increased, at latencies consistent with longer transcortical sensorimotor loops. We further demonstrate that evoked cortical activity in central midline areas measured using electroencephalography (EEG) can be explained by a similar sensory transformation as muscle activity but at a delay consistent with its role in a transcortical loop driving later cortical contributions to balance-correcting muscle activity. These results demonstrate that a neuromechanical model of muscle activity can be used to infer cortical contributions to muscle activity without recording brain activity. Our model may provide a useful framework for evaluating changes in cortical contributions to balance that are associated with falls in older adults and in neurological disorders such as Parkinson's disease.

Imbalance and gait impairment in Parkinson's disease: discussing postural instability and ataxia

Gait and balance difficulties pose significant clinical challenges in Parkinson's disease (PD). The impairment of physiological mechanisms responsible for maintaining natural orthostatism plays a central role in the pathophysiology of postural instability observed in PD. In addition to the well-known rigidity and abnormalities in muscles and joints, various brain regions involved in the regulation of posture, balance, and gait, such as the basal ganglia, cerebellum, and brainstem regions like the pontine peduncle nucleus, are affected in individuals with PD. The recognition of the cerebellum's role in PD has been increasingly acknowledged. Cortical areas and their connections are associated with freezing of gait, a type of frontal lobe ataxia commonly observed in PD. Furthermore, impairments in the peripheral nervous system, including those caused by levodopatherapy, can contribute to gait impairment and imbalance in PD patients. Consequently, individuals with PD may exhibit frontal ataxia, sensory ataxia, and even cerebellar ataxia as underlying causes of gait disturbances and imbalance, starting from the early stages of the disease. The complex interplay between dysfunctional brain regions, impaired cortical connections, and peripheral nervous system abnormalities contributes to the multifaceted nature of gait and balance difficulties in PD. Understanding the intricate mechanisms is crucial for the development of effective therapeutic approaches targeting these specific deficits in PD.

Increased muscle responses to balance perturbations in children with cerebral palsy can be explained by increased sensitivity to center of mass movement

BACKGROUND

Balance impairments are common in children with cerebral palsy (CP). Muscle activity during perturbed standing is higher in children with CP than in typically developing (TD) children, but we know surprisingly little about how sensorimotor processes for balance control are altered in CP. Sensorimotor processing refers to how the nervous system translates incoming sensory information about body motion into motor commands to activate muscles. In healthy adults, muscle activity in response to backward support-surface translations during standing can be reconstructed by center of mass (CoM) feedback, i.e., by a linear combination of delayed (due to neural transmission times) CoM displacement, velocity, and acceleration. The level of muscle activity in relation to changes in CoM kinematics, i.e., the feedback gains, provides a metric of the sensitivity of the muscle response to CoM perturbations.

RESEARCH QUESTION

Can CoM feedback explain reactive muscle activity in children with CP, yet with higher feedback gains than in TD children?

METHODS

We perturbed standing balance by backward support-surface translations of different magnitudes in 20 children with CP and 20 age-matched TD children and investigated CoM feedback pathways underlying reactive muscle activity in the triceps surae and tibialis anterior.

RESULTS

Reactive muscle activity could be reconstructed by delayed feedback of CoM kinematics and hence similar sensorimotor pathways might underlie balance control in children with CP and TD children. However, sensitivities of both agonistic and antagonistic muscle activity to CoM displacement and velocity were higher in children with CP than in TD children. The increased sensitivity of balance correcting responses to CoM movement might explain the stiffer kinematic response, i.e., smaller CoM movement, observed in children with CP.

SIGNIFICANCE

The sensorimotor model used here provided unique insights into how CP affects neural processing underlying balance control. Sensorimotor sensitivities might be a useful metric to diagnose balance impairments.

Static posturography analysis for postural instability in patients with Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is initially characterized by a rigid-akinetic syndrome and later by the development of postural instability. This condition often leads to balance impairments, potentially resulting in postural deformities and foot asymmetry. This study aimed to assess balance changes in PD patients.

METHODS

We evaluated 56 PD patients and 30 controls using static posturography. The variables examined included foot type, the primary region of body weight distribution on the plantar surface, statokinesigram (center of pressure [COP]), and stabilogram (COP in the X- and Y-axes).

RESULTS

PD patients exhibited a high prevalence of pes cavus (92.8%) (p < 0.001) and greater weight distribution toward the hindfoot. In all assessments, COP sway areas were significantly larger in PD patients (p < 0.001). The total COP area increased in the non-fall group during the foot parallel assessment and in the X-axis in the fall group with eyes open (p = 0.046) and closed (p = 0.023). Significant correlations between body weight discharge on the plantar area and COP sway were observed, particularly in the non-postural instability group in the COP X-axis with feet parallel and eyes open on the more rigid limb and in the postural instability group in the Y-axis with feet parallel and eyes open on the more rigid limb and with eyes closed bilaterally.

CONCLUSION

Progressive rigidity may disrupt compensatory mechanisms, altering foot morphology, shifting body weight discharge posteriorly, and increasing COP sway. This cascade of events results in impaired balance and an elevated risk of falls.

Assisting walking balance using a bio-inspired exoskeleton controller

BACKGROUND

Balance control is important for mobility, yet exoskeleton research has mainly focused on improving metabolic energy efficiency. Here we present a biomimetic exoskeleton controller that supports walking balance and reduces muscle activity.

METHODS

Humans restore balance after a perturbation by adjusting activity of the muscles actuating the ankle in proportion to deviations from steady-state center of mass kinematics. We designed a controller that mimics the neural control of steady-state walking and the balance recovery responses to perturbations. This controller uses both feedback from ankle kinematics in accordance with an existing model and feedback from the center of mass velocity. Control parameters were estimated by fitting the experimental relation between kinematics and ankle moments observed in humans that were walking while being perturbed by push and pull perturbations. This identified model was implemented on a bilateral ankle exoskeleton.

RESULTS

Across twelve subjects, exoskeleton support reduced calf muscle activity in steady-state walking by 19% with respect to a minimal impedance controller (p < 0.001). Proportional feedback of the center of mass velocity improved balance support after perturbation. Muscle activity is reduced in response to push and pull perturbations by 10% (p = 0.006) and 16% (p < 0.001) and center of mass deviations by 9% (p = 0.026) and 18% (p = 0.002) with respect to the same controller without center of mass feedback.

CONCLUSION

Our control approach implemented on bilateral ankle exoskeletons can thus effectively support steady-state walking and balance control and therefore has the potential to improve mobility in balance-impaired individuals.

Voluntary muscle coactivation in quiet standing elicits reciprocal rather than coactive agonist-antagonist control of reactive balance

Muscle coactivation increases in challenging balance conditions as well as with advanced age and mobility impairments. Increased muscle coactivation can occur both in anticipation of (feedforward) and in reaction to (feedback) perturbations, however, the causal relationship between feedforward and feedback muscle coactivation remains elusive. Here, we hypothesized that feedforward muscle coactivation would increase both the body's initial mechanical resistance due to muscle intrinsic properties and the later feedback-mediated muscle coactivation in response to postural perturbations. Young adults voluntarily increased leg muscle coactivation using visual biofeedback before support-surface perturbations. In contrast to our hypothesis, feedforward muscle coactivation did not increase the body's initial intrinsic resistance to perturbations, nor did it increase feedback muscle coactivation. Rather, perturbations with feedforward muscle coactivation elicited a medium- to long-latency increase of feedback-mediated agonist activity but a decrease of feedback-mediated antagonist activity. This reciprocal rather than coactivation effect on ankle agonist and antagonist muscles enabled faster reactive ankle torque generation, reduced ankle dorsiflexion, and reduced center of mass (CoM) motion. We conclude that in young adults, voluntary feedforward muscle coactivation can be independently modulated with respect to feedback-mediated muscle coactivation. Furthermore, our findings suggest feedforward muscle coactivation may be useful for enabling quicker joint torque generation through reciprocal, rather than coactivated, agonist-antagonist feedback muscle activity. As such our results suggest that behavioral context is critical to whether muscle coactivation functions to increase agility versus stability.NEW & NOTEWORTHY Feedforward and feedback muscle coactivation are commonly observed in older and mobility impaired adults and are considered strategies to improve stability by increasing body stiffness prior to and in response to perturbations. In young adults, voluntary feedforward coactivation does not necessarily increase feedback coactivation in response to perturbations. Instead, feedforward coactivation enabled faster ankle torques through reciprocal agonist-antagonist muscle activity. As such, coactivation may promote either agility or stability depending on the behavioral context.

The effect of walking with reduced trunk motion on dynamic stability in healthy adults

BACKGROUND

Most people with Parkinson's disease (PD) walk with a smaller mediolateral base of support (BoS) compared to healthy people, but the underlying mechanisms remain unknown. Reduced trunk motion in people with PD might be related to this narrow-based gait. Here, we study the relationship between trunk motion and narrow-based gait in healthy adults. According to the extrapolated center of mass (XCoM) concept, a decrease in mediolateral XCoM excursion would require a smaller mediolateral BoS to maintain a constant margin of stability (MoS) and remain stable.

RESEARCH QUESTION

As proof of principle, we assessed whether walking with reduced trunk motion results in a smaller step width in healthy adults, without altering the mediolateral MoS.

METHODS

Fifteen healthy adults walked on a treadmill at preferred comfortable walking speed in two conditions. First, the 'regular walking' condition without any instructions, and second, the 'reduced trunk motion' condition with the instruction: 'Keep your trunk as still as possible'. Treadmill speed was kept the same in the two conditions. Trunk kinematics, step width, mediolateral XCoM excursion and mediolateral MoS were calculated and compared between the two conditions.

RESULTS

Walking with the instruction to keep the trunk still significantly reduced trunk kinematics. Walking with reduced trunk motion resulted in significant decreases in step width and mediolateral XCoM excursion, but not in the mediolateral MoS. Furthermore, step width and mediolateral XCoM excursion were strongly correlated during both conditions (r = 0.887 and r = 0.934).

SIGNIFICANCE

This study shows that walking with reduced trunk motion leads to a gait pattern with a smaller BoS in healthy adults, without altering the mediolateral MoS. Our findings indicate a strong coupling between CoM motion state and the mediolateral BoS. We expect that people with PD who walk narrow-based, have a similar mediolateral MoS as healthy people, which will be further investigated.

Dopamine replacement therapy normalizes reactive step length to postural perturbations in Parkinson's disease

BACKGROUND

Postural instability is one of the most disabling motor symptoms of Parkinson's disease (PD) given its association with falls and loss of independence. Previous studies have assessed biomechanical measures of reactive stepping in response to perturbations, showing that individuals with PD exhibit inadequate postural responses to regain balance.

RESEARCH QUESTION

Does dopamine replacement therapy normalize step length in response to balance perturbations?

METHODS

In this study, we estimated reactive step length, to a postural perturbation, retrospectively from a dataset of frontal plane video using 2D motion tracking and direct linear transform methods. We compared two perturbation methods: support surface translation and shoulder pull (the clinical standard) in 14 individuals with PD and 13 without PD (on and off medication), with and without partial body weight support (BWS). The primary outcome was the length of the first step taken to regain balance after the perturbation analyzed with mixed effects ANOVA, with post hoc analysis of anteroposterior (AP) and mediolateral (ML) components.

RESULTS

PD OFF medication exhibited shorter reactive step length compared to PD ON and compared to control groups for the surface translation perturbations, but no significant difference was observed for the shoulder pull perturbations.

SIGNIFICANCE

Dopamine replacement therapy affects step length in response to perturbation more robustly for surface translations than for a pull by the shoulders.

Exoskeletons need to react faster than physiological responses to improve standing balance

Maintaining balance throughout daily activities is challenging because of the unstable nature of the human body. For instance, a person's delayed reaction times limit their ability to restore balance after disturbances. Wearable exoskeletons have the potential to enhance user balance after a disturbance by reacting faster than physiologically possible. However, "artificially fast" balance-correcting exoskeleton torque may interfere with the user's ensuing physiological responses, consequently hindering the overall reactive balance response. Here, we show that exoskeletons need to react faster than physiological responses to improve standing balance after postural perturbations. Delivering ankle exoskeleton torque before the onset of physiological reactive joint moments improved standing balance by 9%, whereas delaying torque onset to coincide with that of physiological reactive ankle moments did not. In addition, artificially fast exoskeleton torque disrupted the ankle mechanics that generate initial local sensory feedback, but the initial reactive soleus muscle activity was only reduced by 18% versus baseline. More variance of the initial reactive soleus muscle activity was accounted for using delayed and scaled whole-body mechanics [specifically center of mass (CoM) velocity] versus local ankle-or soleus fascicle-mechanics, supporting the notion that reactive muscle activity is commanded to achieve task-level goals, such as maintaining balance. Together, to elicit symbiotic human-exoskeleton balance control, device torque may need to be informed by mechanical estimates of global sensory feedback, such as CoM kinematics, that precede physiological responses.

The cortical N1 response to balance perturbation is associated with balance and cognitive function in different ways between older adults with and without Parkinson's disease

Mechanisms underlying associations between balance and cognitive impairments in older adults with and without Parkinson's disease are poorly understood. Balance disturbances evoke a cortical N1 response that is associated with both balance and cognitive abilities in unimpaired populations. We hypothesized that the N1 response reflects neural mechanisms that are shared between balance and cognitive function, and would therefore be associated with both balance and cognitive impairments in Parkinson's disease. Although N1 responses did not differ at the group level, they showed different associations with balance and cognitive function in the Parkinson's disease vs. control groups. In the control group, higher N1 amplitudes were correlated with lower cognitive set shifting ability and lower balance confidence. However, in Parkinson's disease, narrower N1 widths (i.e., shorter durations) were associated with greater parkinsonian motor symptom severity, lower balance ability and confidence, lower mobility, and lower overall cognitive function. Despite different relationships across populations, the present results suggest the N1 response reflects neural processes related to both balance and cognitive function. A better understanding of neural mechanisms linking balance and cognitive function could provide insight into associations between balance and cognitive decline in aging populations.

Lower Cognitive Set Shifting Ability Is Associated With Stiffer Balance Recovery Behavior and Larger Perturbation-Evoked Cortical Responses in Older Adults

The mechanisms underlying associations between cognitive set shifting impairments and balance dysfunction are unclear. Cognitive set shifting refers to the ability to flexibly adjust behavior to changes in task rules or contexts, which could be involved in flexibly adjusting balance recovery behavior to different contexts, such as the direction the body is falling. Prior studies found associations between cognitive set shifting impairments and severe balance dysfunction in populations experiencing frequent falls. The objective of this study was to test whether cognitive set shifting ability is expressed in successful balance recovery behavior in older adults with high clinical balance ability (N = 19, 71 ± 7 years, 6 female). We measured cognitive set shifting ability using the Trail Making Test and clinical balance ability using the miniBESTest. For most participants, cognitive set shifting performance (Trail Making Test B-A = 37 ± 20 s) was faster than normative averages (46 s for comparable age and education levels), and balance ability scores (miniBESTest = 25 ± 2/28) were above the threshold for fall risk (23 for people between 70 and 80 years). Reactive balance recovery in response to support-surface translations in anterior and posterior directions was assessed in terms of body motion, muscle activity, and brain activity. Across participants, lower cognitive set shifting ability was associated with smaller peak center of mass displacement during balance recovery, lower directional specificity of late phase balance-correcting muscle activity (i.e., greater antagonist muscle activity 200-300 ms after perturbation onset), and larger cortical N1 responses (100-200 ms). None of these measures were associated with clinical balance ability. Our results suggest that cognitive set shifting ability is expressed in balance recovery behavior even in the absence of profound clinical balance disability. Specifically, our results suggest that lower flexibility in cognitive task performance is associated with lower ability to incorporate the directional context into the cortically mediated later phase of the motor response. The resulting antagonist activity and stiffer balance behavior may help explain associations between cognitive set shifting impairments and frequent falls.