Implementation of a Central Sensorimotor Integration Test for Characterization of Human Balance Control During Stance

Development and validation of a two-dimensional pseudorandom balance perturbation test

Introduction

Pseudorandom balance perturbations use unpredictable disturbances of the support surface to quantify reactive postural control. The ability to quantify postural responses to a continuous multidirectional perturbation in two orthogonal dimensions of sway (e.g., AP and ML) has yet to be investigated.

Methods

We developed a balance perturbation paradigm that used two spectrally independent sum of sinusoids signals (SoS1, SoS2), one for each orthogonal dimension of tilt (roll and pitch), to deliver a two-dimensional (2D) balance perturbation. In a group of 10 healthy adults we measured postural sway during 2D perturbations, as well as for each of the two individual 1D perturbation components.

Results

We found that during 2D perturbations, spectral peaks in the sway response were larger at the perturbed frequencies when compared to (1) the adjacent non-perturbed frequencies and (2) the frequencies contained within the orthogonal, spectrally independent perturbation signal. We also found that for each of the two spectra (SoS1, SoS2), the magnitude and timing of the sway response relative to the platform disturbance was similar when measured during 1D and 2D conditions.

Discussion

These data support that our novel 2D SoS perturbation test was able to evoke ML and AP postural responses that were (1) specific to the roll and pitch perturbations, respectively, and (2) similar to the responses provoked by individual 1D perturbations.

Effects of balance training with visual input manipulations on balance performance and sensory integration in healthy young adults: a randomized controlled trial

Although balance training can improve balance across various populations, the underlying mechanisms, such as how balance training may alter sensory integration, remain unclear. This study examined the effects of balance training with visual input manipulations provided by virtual reality versus conventional balance training on measures of postural sway and sensory integration during balance control. Twenty-two healthy young adults were randomly allocated into a balance training group (BT) or a balance training with virtual reality group (BT + VR). The BT received traditional balance training, while the BT + VR additionally received visual manipulations during the 4-week balance training to elicit sensory conflicts. Static balance was measured in the form of center of pressure (COP) sway speed in trained (eyes open) and untrained (eyes closed) balance conditions. A model-based analysis quantified the sensory integration and feedback characteristics of the balance control mechanism. Herein, the visual weight quantifies the contribution of visual orientation information to balance while the proportional and derivative feedback loop-gains correct for deviations from the desired angular position and angular velocity, respectively. Significant main time effects were observed for the visual sensory contribution to balance (p = 0.002, [Formula: see text] = 0.41) and for the derivative feedback loop-gain (p = 0.011, [Formula: see text] = 0.29). Significant group-by-time interactions were observed for COP sway speed in the untrained task (p = 0.023, [Formula: see text] = 0.23) in favor of BT + VR and in the proportional feedback loop-gain, with reductions only in the BT + VR group (p = 0.043, [Formula: see text] = 0.2). BT + VR resulted in larger performance improvements compared with traditional BT in untrained tasks, most likely due to reduced reliance on visual information. This suggests that the systematic modulation of sensory inputs leads to enhanced capacity for motor adaptation in balance training.

Agonist-antagonist myoneural interface surgery on the proprioceptive reconstruction of rat hind limb

Currently, prosthesis users rely on visual cues to control their prosthesis. One reason for this is that prostheses cannot provide users with proprioceptive functional signals. For this reason, we propose an agonist-antagonist myoneural interface (AMI) surgery. We examined how this surgery affects the restoration of motor function and proprioceptive reconstruction in the hind limb of Sprague-Dawley rats. The procedure entails grafting the soleus muscle, suturing the two tendon ends of the soleus muscle, and anastomosing the tibial and common peroneal nerves to the soleus muscle. We found that, following surgery, AMI rats exhibited improved neurological repair, shorter walking swings, braking, propulsion, and stance times, and greater compound action potentials than control rats. This means that in rats with neurological impairment of the hind limb, the proposed AMI surgical method significantly improves postoperative walking stability and muscle synergy. AMI surgery may become an option for regaining proprioception in the lost limb.

Velocity dependence of sensory reweighting in human balance control

The relative contributions of proprioceptive, vestibular, and visual sensory cues to balance control change depending on their availability and reliability. This sensory reweighting is classically supported by nonlinear sway responses to increasing visual surround and/or surface tilt amplitudes. However, recent evidence indicates that visual cues are reweighted based on visual tilt velocity rather than tilt amplitude. Therefore, we designed a study to specifically test the hypothesized velocity dependence of reweighting while expanding on earlier findings for visual reweighting by testing proprioceptive reweighting for standing balance on a tilting surface. Twenty healthy young adults stood with their eyes closed on a toes-up/-down tilting platform. We designed four pseudorandom tilt sequences with either a slow (S) or a fast (F) tilt velocity and different peak-to-peak amplitudes. We used model-based interpretations of measured sway characteristics to estimate the proprioceptive sensory weight (Wprop) within each trial. In addition, root-mean-square values of measured body center of mass sway amplitude (RMS) and velocity (RMSv) were calculated for each tilt sequence. Wprop, RMS, and RMSv values varied depending on the stimulus velocity, exhibiting large effects (all Cohen's d >1.10). In contrast, we observed no significant differences across stimulus amplitudes for Wprop (Cohen's d: 0.02-0.16) and, compared with the differences in velocity, there were much smaller changes in RMS and RMSv values (Cohen's d: 0.05-0.91). These results confirmed the hypothesized velocity, rather than amplitude, dependence of sensory reweighting.NEW & NOTEWORTHY This novel study examined the velocity dependence of sensory reweighting for human balance control using support surface tilt stimuli with independently varied amplitude and velocity. Estimates of the proprioceptive contribution to standing balance, derived from model-based interpretations of sway characteristics, showed greater sensitivity to changes in surface tilt velocity than surface tilt amplitude. These results support a velocity-based mechanism underlying sensory reweighting for human balance control.

Postural impairments in unilateral and bilateral vestibulopathy

Chronic imbalance is a major complaint of patients suffering from bilateral vestibulopathy (BV) and is often reported by patients with chronic unilateral vestibulopathy (UV), leading to increased risk of falling. We used the Central SensoriMotor Integration (CSMI) test, which evaluates sensory integration, time delay, and motor activation contributions to standing balance control, to determine whether CSMI measures could distinguish between healthy control (HC), UV, and BV subjects and to characterize vestibular, proprioceptive, and visual contributions expressed as sensory weights. We also hypothesized that sensory weight values would be associated with the results of vestibular assessments (vestibulo ocular reflex tests and Dizziness Handicap Inventory scores). Twenty HCs, 15 UVs and 17 BVs performed three CSMI conditions evoking sway in response to pseudorandom (1) surface tilts with eyes open or, (2) surface tilts with eyes closed, and (3) visual surround tilts. Proprioceptive weights were identified in surface tilt conditions and visual weights were identified in the visual tilt condition. BVs relied significantly more on proprioception. There was no overlap in proprioceptive weights between BV and HC subjects and minimal overlap between UV and BV subjects in the eyes-closed surface-tilt condition. Additionally, visual sensory weights were greater in BVs and were similarly able to distinguish BV from HC and UV subjects. We found no significant correlations between sensory weights and the results of vestibular assessments. Sensory weights from CSMI testing could provide a useful measure for diagnosing and for objectively evaluating the effectiveness of rehabilitation efforts and future treatments designed to restore vestibular function such as hair cell regeneration and vestibular implants.

Balance Impairment in the Burn Population: A Burn Model System National Database Study

Balance is an important component of daily function and impairments can lead to injury and quality-of-life limitations. Balance is not well studied in the burn population. This study examines the frequency of long-term balance impairments and associated factors after a burn injury. The Burn Model System National Database was analyzed. Trouble with balance was self-reported at discharge, 6, 12, 24, and 60 months after injury. Regression analyses examined the associations between demographic and clinical characteristics and balance impairments at 12 months. Of 572 participants, balance impairments were most reported at discharge (40.3%), continuing over 60 months (26.8-36.0%). Those reporting balance impairments (n = 153) were more likely to be older, unemployed, have Medicaid or Medicare, receive inpatient rehabilitation, receive outpatient physical or occupational therapy, have vision problems, have leg or feet burns and swelling, and have foot numbness compared to those without (p ≤ 0.001). Regression analysis demonstrated a 4% increased odds of balance impairment for every increase in year of age (p < 0.001), 71% lower odds if employed at time of injury (p < 0.001), and 140% higher odds if receiving outpatient physical or occupational therapy at 12 months (p = 0.008). Common reports of balance impairments highlight the need for routine screenings to identify burn survivors that may benefit from targeted interventions.

The role of torque feedback in standing balance

It has been proposed that sensory force/pressure cues are integrated within a positive feedback mechanism, which accounts for the slow dynamics of human standing behavior and helps align the body with gravity. However, experimental evidence of this mechanism remains scarce. This study tested predictions of a positive torque feedback mechanism for standing balance, specifically that differences between a "reference" torque and actual torque are self-amplified, causing the system to generate additional torque. Seventeen healthy young adults were positioned in an apparatus that permitted normal sway at the ankle until a brake on the apparatus was applied, discreetly "locking" body movement during stance. Once locked, a platform positioned under the apparatus remained in place (0 mm) or slowly translated backward (3 mm or 6 mm), tilting subjects forward. Postural behavior was characterized by two distinct responses: the center of pressure (COP) offset (i.e., change in COP elicited by the surface translation) and the COP drift (i.e., change in COP during the sustained tilt). Model simulations were performed using a linear balance control model containing torque feedback to provide a conceptual basis for the interpretation of experimental results. Holding the body in sustained tilt positions resulted in COP drifting behavior, reflecting attempts of the balance control system to restore an upright position through increases in plantar flexor torque. In line with predictions of positive torque feedback, larger COP offsets led to faster increases in COP over time. These findings provide experimental support for a positive torque feedback mechanism involved in the control of standing balance.NEW & NOTEWORTHY Using model simulations and a novel experimental approach, we tested behavioral predictions of a sensory torque feedback mechanism involved in the control of upright standing. Torque feedback is thought to reduce the effort required to stand and play a functional role in slowly aligning the body with gravity. Our results provide experimental evidence of a torque feedback mechanism and offer new and valuable insights into the sensorimotor control of human balance.

Balance disorders and migraine

BACKGROUND

Migraine is associated with motion sensitivity symptoms such as kinetosis, vestibular symptoms and balance alterations. While focus is given to headache management, addressing these symptoms is often neglected, although they are related to additional migraine burden and increased disability.

PURPOSE

Our aim is to disseminate the current understanding of the motion sensitivity symptoms among patients with migraine, with focus on balance impairments. We discuss the susceptibility of migraine to motion sensitivity, its suggested mechanisms, the balance alterations during quiet standing, mobility tasks and reactions to external perturbations. The role of migraine subdiagnosis, implications for clinical practice and future perspectives are also acknowledged.

IMPLICATIONS

Balance disorders are one of the signs reflecting a broader and complex spectrum of motion sensitivity, which are present even between attacks. Migraineurs are especially inherent to these symptoms probably due to brain hyperexcitability and to shared pathophysiological mechanisms. Patients, especially with aura and chronic migraine, exhibit balance instability during quiet standing under different surface and visual input conditions. Migraineurs demonstrated reduced limits of stability and lower performance on walk, transposing obstacles and sit to stand tasks. Only patients with aura present impairment of motor control reactions following external perturbations. Balance alterations are associated with falls and are influenced by aura, migraine frequency and psychosocial aspects, but not by vestibular symptoms or vestibular migraine diagnosis. There is a high demand for high quality of evidence regarding the assessment and care of motion sensitivity symptoms in migraineurs, considering approaches to manage not just the pain, but its associated symptoms.

Sport dependent effects on the sensory control of balance during upright posture: a comparison between professional horseback riders, judokas and non-athletes

Introduction

Compared to judokas (JU) and non-athletes (NA), horseback riders (HR) may develop specific changes in their sensory control of balance.

Methods

Thirty-four international-level JU, twenty-seven international-level HR and twenty-one NA participated. Participants stood upright on a plateform (static condition) or on a seesaw device with an instability along the mediolateral (ML) or the anteroposterior (AP) direction (dynamic conditions). These conditions were carried out with eyes opened (EO) or closed (EC), and with (wF) or without a foam (nF). Experimental variables included conventional (linear), non-linear center-of-pressure (COP) parameters, Romberg Quotient (RQ) and Plantar Quotient (PQ).

Results

Group effects. COP Surface (COPS) and standard deviation of COP along AP (SDY) were lower in HR than in JU in Static. SD Y was lower in HR than in JU in Dynamic AP. COP velocity (COPV) was lower in both HR and JU than in NA in Static and Dynamic. Sample entropy along AP and ML (SampEnY and SampEnX) were higher in HR than in JU in Static. SampEnY was higher in HR than in JU in Dynamic ML. Sensory effects. In EC, COPV was lower in JU than in NA in Dynamic AP, and lower in JU than in both HR and NA in Dynamic ML. In EO, COPV was lower in both JU and HR than in NA in Dynamic ML. RQ applied to COPS was lower in JU than in both HR and NA in Dynamic AP, and lower in JU than in HR in Dynamic ML. RQ applied to COPV was lower in JU than in both HR and NA in Static and Dynamic. PQ applied to COPS was higher in JU than in both HR and NA in Dynamic ML.

Conclusion

Results showed that the effects of sport expertise on postural control could only be revealed with specific COP variables and were directionally oriented and sport-dependant. HR seem to rely more on vision than JU, thus revealing that the contribution of the sensory inputs to balance control is also sport-dependent. Results open up new knowledge on the specificity of sport practice on multisensory balance information during upright posture.

Coordination tending towards an anti-phase relationship determines greater sway reduction during entrainment with a simulated partner

The increased risk of falls in the older aged population demands the development of assistive robotic devices capable of effective balance support. For the development and increased user acceptance of such devices, which provide balance support in a human-like way, it is important to understand the simultaneous occurrence of entrainment and sway reduction in human-human interaction. However, sway reduction has not been observed yet during a human touching an external, continuously moving reference, which rather increased human body sway. Therefore, we investigated in 15 healthy young adults (27.20±3.55 years, 6 females) how different simulated sway-responsive interaction partners with different coupling modes affect sway entrainment, sway reduction and relative interpersonal coordination, as well as how these human behaviours differ depending on the individual body schema accuracy. For this, participants were lightly touching a haptic device that either played back an average pre-recorded sway trajectory ("Playback") or moved based on the sway trajectory simulated by a single-inverted pendulum model with either a positive (Attractor) or negative (Repulsor) coupling to participant's body sway. We found that body sway reduced not only during the Repulsor-interaction, but also during the Playback-interaction. These interactions also showed a relative interpersonal coordination tending more towards an anti-phase relationship, especially the Repulsor. Moreover, the Repulsor led to the strongest sway entrainment. Finally, a better body schema contributed to a reduced body sway in both the "reliable" Repulsor and the "less reliable" Attractor mode. Consequently, a relative interpersonal coordination tending more towards an anti-phase relationship and an accurate body schema are important to facilitate sway reduction.

Estimation of the visual contribution to standing balance using virtual reality

Sensory perturbations are a valuable tool to assess sensory integration mechanisms underlying balance. Implemented as systems-identification approaches, they can be used to quantitatively assess balance deficits and separate underlying causes. However, the experiments require controlled perturbations and sophisticated modeling and optimization techniques. Here we propose and validate a virtual reality implementation of moving visual scene experiments together with model-based interpretations of the results. The approach simplifies the experimental implementation and offers a platform to implement standardized analysis routines. Sway of 14 healthy young subjects wearing a virtual reality head-mounted display was measured. Subjects viewed a virtual room or a screen inside the room, which were both moved during a series of sinusoidal or pseudo-random room or screen tilt sequences recorded on two days. In a between-subject comparison of 10 [Formula: see text] 6 min long pseudo-random sequences, each applied at 5 amplitudes, our results showed no difference to a real-world moving screen experiment from the literature. We used the independent-channel model to interpret our data, which provides a direct estimate of the visual contribution to balance, together with parameters characterizing the dynamics of the feedback system. Reliability estimates of single subject parameters from six repetitions of a 6 [Formula: see text] 20-s pseudo-random sequence showed poor test-retest agreement. Estimated parameters show excellent reliability when averaging across three repetitions within each day and comparing across days (Intra-class correlation; ICC 0.7-0.9 for visual weight, time delay and feedback gain). Sway responses strongly depended on the visual scene, where the high-contrast, abstract screen evoked larger sway as compared to the photo-realistic room. In conclusion, our proposed virtual reality approach allows researchers to reliably assess balance control dynamics including the visual contribution to balance with minimal implementation effort.

Asymmetry measures for quantification of mechanisms contributing to dynamic stability during stepping-in-place gait

The goal of this study is to introduce and to motivate the use of new quantitative methods to improve our understanding of mechanisms that contribute to the control of dynamic balance during gait. Dynamic balance refers to the ability to maintain a continuous, oscillating center-of-mass (CoM) motion of the body during gait even though the CoM frequently moves outside of the base of support. We focus on dynamic balance control in the frontal plane or medial-lateral (ML) direction because it is known that active, neurally-mediated control mechanisms are necessary to maintain ML stability. Mechanisms that regulate foot placement on each step and that generate corrective ankle torque during the stance phase of gait are both known to contribute to the generation of corrective actions that contribute to ML stability. Less appreciated is the potential role played by adjustments in step timing when the duration of the stance and/or swing phases of gait can be shortened or lengthened to allow torque due to gravity to act on the body CoM over a shorter or longer time to generate corrective actions. We introduce and define four asymmetry measures that provide normalized indications of the contribution of these different mechanisms to gait stability. These measures are 'step width asymmetry', 'ankle torque asymmetry', 'stance duration asymmetry', and 'swing duration asymmetry'. Asymmetry values are calculated by comparing corresponding biomechanical or temporal gait parameters from adjacent steps. A time of occurrence is assigned to each asymmetry value. An indication that a mechanism is contributing to ML control is obtained by comparing asymmetry values to the ML body motion (CoM angular position and velocity) at the time points associated with the asymmetry measures. Example results are demonstrated with measures obtained during a stepping-in-place (SiP) gait performed on a stance surface that either remained fixed and level or was pseudorandomly tilted to disturb balance in the ML direction. We also demonstrate that the variability of asymmetry measures obtained from 40 individuals during unperturbed, self-paced SiP were highly correlated with corresponding coefficient of variation measures that have previously been shown to be associated with poor balance and fall risk.

Central sensorimotor integration assessment reveals deficits in standing balance control in people with chronic mild traumatic brain injury

Imbalance is common following mild Traumatic Brain Injury (mTBI) and can persist months after the initial injury. To determine if mTBI subjects with chronic imbalance differed from healthy age- and sex-matched controls (HCs) we used both the Central SensoriMotor Integration (CSMI) test, which evaluates sensory integration, time delay, and motor activation properties and the standard Sensory Organization Test (SOT). Four CSMI conditions evoked center-of-mass sway in response to: surface tilts with eyes closed (SS/EC), surface tilts with eyes open viewing a fixed visual surround (SS/EO), visual surround tilts with eyes open standing on a fixed surface (VS/EO), and combined surface and visual tilts with eyes open (SS+VS/EO). The mTBI participants relied significantly more on visual cues during the VS/EO condition compared to HCs but had similar reliance on combinations of vestibular, visual, and proprioceptive cues for balance during SS/EC, SS/EO, and SS+VS/EO conditions. The mTBI participants had significantly longer time delays across all conditions and significantly decreased motor activation relative to HCs across conditions that included surface-tilt stimuli with a sizeable subgroup having a prominent increase in time delay coupled with reduced motor activation while demonstrating no vestibular sensory weighting deficits. Decreased motor activation compensates for increased time delay to maintain stability of the balance system but has the adverse consequence that sensitivity to both internal (e.g., sensory noise) and external disturbances is increased. Consistent with this increased sensitivity, SOT results for mTBI subjects showed increased sway across all SOT conditions relative to HCs with about 45% of mTBI subjects classified as having an “Aphysiologic” pattern based on published criteria. Thus, CSMI results provided a plausible physiological explanation for the aphysiologic SOT pattern. Overall results suggest that rehabilitation that focuses solely on sensory systems may be incomplete and may benefit from therapy aimed at enhancing rapid and vigorous responses to balance perturbations.

The effects of augmenting traditional rehabilitation with audio biofeedback in people with persistent imbalance following mild traumatic brain injury

Complaints of non-resolving imbalance are common in individuals with chronic mild traumatic brain injury (mTBI). Vestibular rehabilitation therapy may be beneficial for this population. Additionally, wearable sensors can enable biofeedback, specifically audio biofeedback (ABF), and aid in retraining balance control mechanisms in people with balance impairments. In this study, we described the effectiveness of vestibular rehabilitation therapy with and without ABF to improve balance in people with chronic mTBI. Participants (n = 31; females = 22; mean age = 40.9 ± 11 y) with chronic (>3 months) mTBI symptoms of self-reported imbalance were randomized into vestibular rehabilitation with ABF (n = 16) or without ABF (n = 15). The intervention was a standard vestibular rehabilitation, with or without ABF, for 45 min biweekly for 6 weeks. The ABF intervention involved a smartphone that provided auditory feedback when postural sway was outside of predetermined equilibrium parameters. Participant's completed the Post-Concussion Symptom Scale (PCSS). Balance was assessed with the sensory organization test (SOT) and the Central Sensorimotor Integration test which measured sensory weighting, motor activation, and time delay with sway evoked by surface and/or visual surround tilts. Effect sizes (Hedge's G) were calculated on the change between pre-and post-rehabilitation scores. Both groups demonstrated similar medium effect-sized decreases in PCSS and large increases in SOT composite scores after rehabilitation. Effect sizes were minimal for increasing sensory weighting for both groups. The with ABF group showed a trend of larger effect sizes in increasing motor activation (with ABF = 0.75, without ABF = 0.22) and in decreasing time delay (with ABF = −0.77, without ABF = −0.52) relative to the without ABF group. Current clinical practice focuses primarily on sensory weighting. However, the evaluation and utilization of motor activation factors in vestibular rehabilitation, potentially with ABF, may provide a more complete assessment of recovery and improve outcomes.

Do sensorimotor control properties mediate sway in people with chronic balance complaints following mTBI?

BACKGROUND

Up to 40% of mild traumatic brain injuries (mTBI) can result in chronic unresolved symptoms, such as balance impairment, that persist beyond three months. Sensorimotor control, the collective coordination and regulation of both sensory and motor components of the postural control system, may underlie balance deficits in chronic mTBI. The aim of this study was to determine if the relationship between severity of impairment in chronic (> 3 months) mTBI and poorer balance performance was mediated by sensorimotor integration measures.

METHODS

Data were collected from 61 healthy controls and 58 mTBI participants suffering persistent balance problems. Participants completed questionnaires (Dizziness Handicap Inventory (DHI), Neurobehavioral Symptom Inventory (NSI), and Sports Concussion Assessment Tool Symptom Questionnaire (SCAT2)) and performed instrumented postural sway assessments and a test of Central Sensory Motor Integration (CSMI). Exploratory Factor Analysis was used to reduce the variables used within the mediation models to constructs of impairment (Impairment Severity - based on questionnaires), balance (Sway Dispersion - based on instrumented postural sway measures), and sensorimotor control (Sensory Weighting, Motor Activation and Time Delay - based on parameters from CSMI tests). Mediation analyses used path analysis to estimate the direct effect (between impairment and balance) and indirect (mediating) effects (from sensorimotor control).

RESULTS

Two out of three sensorimotor integration factors (Motor Activation and Time Delay) mediated the relationship between Impairment Severity and Sway Dispersion, however, there was no mediating effect of Sensory Weighting.

SIGNIFICANCE

These findings have clinical implications since rehabilitation of balance commonly focuses on sensory cues. Our findings indicate the importance of Motor Activation and Time Delay, and thus a focus on strategies to improve factors related to these constructs throughout the rehabilitative process (i.e., level of muscular contractions to control joint torques; response time to stimuli/perturbations) may improve a patient's balance control.

Migraine With Aura Is Related to Delayed Motor Control Reaction and Imbalance Following External Perturbations

Background: It is evidenced that migraineurs present balance deficits. However, the balance recovery following unexpected ground perturbations, which reflect conditions of everyday activities, has not been investigated in this population. Aim: We aimed to assess the reactive postural responses among patients with migraine with and without aura, chronic migraine, and controls. We further aimed to assess the factors associated with greater self-report of falls. Methods: Ninety patients diagnosed by headache specialists were equally classified into three migraine subgroups according to the presence of aura and chronic migraine. Thirty controls were also recruited. All participants underwent the motor control test (MCT) and adaptation test (ADT) protocols of dynamic posturography tests (EquiTest®, NeuroCom, USA). Clinical and headache features and information on falls in the previous year, fear of falling, and vestibular symptoms were also assessed. Results: Patients with aura presented a greater sway area in most of the MCT conditions than the other three groups (p = 0.001). The aura group also presented delayed latency responses after perturbations compared with controls and patients without aura (p < 0.03). In the ADT, a greater sway area was observed in patients with aura than in groups without aura, chronic migraine, and controls (p < 0.0001). The MCT and ADT sway area, the frequency of aura, and the fear of falling explained 46% of the falls in the previous 12 months. Conclusion: Patients with aura exhibited greater delay and sway area after unexpected ground perturbations than controls and other migraine subgroups, which are related to the reported number of falls.

Exploring persistent complaints of imbalance after mTBI: Oculomotor, peripheral vestibular and central sensory integration function

BACKGROUND

Little is known on the peripheral and central sensory contributions to persistent dizziness and imbalance following mild traumatic brain injury (mTBI).

OBJECTIVE

To identify peripheral vestibular, central integrative, and oculomotor causes for chronic symptoms following mTBI.

METHODS

Individuals with chronic mTBI symptoms and healthy controls (HC) completed a battery of oculomotor, peripheral vestibular and instrumented posturography evaluations and rated subjective symptoms on validated questionnaires. We defined abnormal oculomotor, peripheral vestibular, and central sensory integration for balance measures among mTBI participants as falling outside a 10-percentile cutoff determined from HC data. A X-squared test associated the proportion of normal and abnormal responses in each group. Partial Spearman's rank correlations evaluated the relationships between chronic symptoms and measures of oculomotor, peripheral vestibular, and central function for balance control.

RESULTS

The mTBI group (n = 58) had more abnormal measures of central sensory integration for balance than the HC (n = 61) group (mTBI: 41% -61%; HC: 10%, p's <  0.001), but no differences on oculomotor and peripheral vestibular function (p >  0.113). Symptom severities were negatively correlated with central sensory integration for balance scores (p's <  0.048).

CONCLUSIONS

Ongoing balance complaints in people with chronic mTBI are explained more by central sensory integration dysfunction rather than peripheral vestibular or oculomotor dysfunction.

A preliminary cross-sectional assessment of postural control responses to continuous platform rotations following a sport-related concussion

BACKGROUND

Individuals suffering a sport-related concussion typically recover within 1 month; however, persistent post-concussive symptoms are known to occur beyond this period. Clinical guidelines may not be sufficient to determine if dynamic postural control is still impaired at the point of the return to play decision.

RESEARCH QUESTION

Do individuals with a previous sport-related concussion who have returned to play show differences in postural control compared to individuals without a previous concussion, in response to continuous platform perturbations?

METHODS

Eight previously concussed and eight age- and position-matched participants completed six one-minute trials (three with eyes open/closed) whilst stood on a moving platform that rotated about the pitch axis with a peak-to-peak amplitude of 4° at a frequency of 0.8 Hz. Six trials were also captured during static quiet stance for comparison. Reactive and anticipatory stages of postural control were analysed by determining anteroposterior margins of stability (MoS) as a measure of whole-body postural control and head-to-trunk anchoring index as an indication of the head-trunk segmental coupling strategy.

RESULTS

Posterior MoS during platform rotations reduced for both groups during eyes closed trials, but previously concussed participants exhibited a significantly greater reduction (1.97 cm) in comparison to matched-controls (0.34 cm). Participants, regardless of group, showed a preference towards a head-stabilised-to-trunk strategy during platform rotations. There were no differences during static trials.

SIGNIFICANCE

This preliminary study suggests previously concussed athletes demonstrate a greater reduction in postural control whilst undergoing continuous platform rotations with eyes closed, which could indicate possible lingering deficits to other sensory systems such as the vestibular system, though participants were not likely to lose their balance.

Evaluating Sensory Acuity as a Marker of Balance Dysfunction After a Traumatic Brain Injury: A Psychophysical Approach

There is limited research on sensory acuity i.e., ability to perceive external perturbations via body-sway during standing in individuals with a traumatic brain injury (TBI). It is unclear whether sensory acuity diminishes after a TBI and if it is a contributing factor to balance dysfunction. The objective of this investigation is to first objectively quantify the sensory acuity in terms of perturbation perception threshold (PPT) and determine if it is related to functional outcomes of static and dynamic balance. Ten individuals with chronic TBI and 11 age-matched healthy controls (HC) performed PPT assessments at 0.33, 0.5, and 1 Hz horizontal perturbations to the base of support in the anterior-posterior direction, and a battery of functional assessments of static and dynamic balance and mobility [Berg balance scale (BBS), timed-up and go (TUG) and 5-m (5MWT) and 10-m walk test (10MWT)]. A psychophysical approach based on Single Interval Adjustment Matrix Protocol (SIAM), i.e., a yes-no task, was used to quantify the multi-sensory thresholds of perceived external perturbations to calculate PPT. A mixed-design analysis of variance (ANOVA) and post-hoc analyses were performed using independent and paired t-tests to evaluate within and between-group differences. Pearson correlation was computed to determine the relationship between the PPT and functional measures. The PPT values were significantly higher for the TBI group (0.33 Hz: 2.97 ± 1.0, 0.5 Hz: 2.39 ± 0.7, 1 Hz: 1.22 ± 0.4) compared to the HC group (0.33 Hz: 1.03 ± 0.6, 0.5 Hz: 0.89 ± 0.4, 1 Hz: 0.42 ± 0.2) for all three perturbation frequencies (p < 0.006 post Bonferroni correction). For the TBI group, the PPT for 1 Hz perturbations showed significant correlation with the functional measures of balance (BBS: r = −0.66, p = 0.037; TUG: r = 0.78, p = 0.008; 5MWT: r = 0.67, p = 0.034, 10MWT: r = 0.76, p = 0.012). These findings demonstrate that individuals with TBI have diminished sensory acuity during standing which may be linked to impaired balance function after TBI.

Adaptation of balancing behaviour during continuous perturbations of stance. Supra-postural visual tasks and platform translation frequency modulate adaptation rate

When humans are administered continuous and predictable perturbations of stance, an adaptation period precedes the steady state of balancing behaviour. Little information is available on the modulation of adaptation by vision and perturbation frequency. Moreover, performance of supra-postural tasks may modulate adaptation in as yet unidentified ways. Our purpose was to identify differences in adaptation associated to distinct visual tasks and perturbation frequencies. Twenty non-disabled adult volunteers stood on a platform translating 10 cm in antero-posterior (AP) direction at low (LF, 0.18 Hz) and high frequency (HF, 0.56 Hz) with eyes open (EO) and closed (EC). Additional conditions were reading a text fixed to platform (EO-TP) and reading a text stationary on ground (EO-TG). Peak-to-peak (PP) displacement amplitude and AP position of head and pelvis markers were computed for each of 27 continuous perturbation cycles. The time constant and extent of head and pelvis adaptation and the cross-correlation coefficients between head and pelvis were compared across visual conditions and frequencies. Head and pelvis mean positions in space varied little across conditions and perturbation cycles but the mean head PP displacements changed over time. On average, at LF, the PP displacement of the head and pelvis increased progressively. Adaptation was rapid or ineffective with EO, but slower with EO-TG, EO-TP, EC. At HF, the head PP displacement amplitude decreased progressively with fast adaptation rates, while the pelvis adaptation was not apparent. The results show that visual tasks can modulate the adaptation rate, highlight the effect of the perturbation frequency on adaptation and provide evidence of priority assigned to pelvis stabilization over visual tasks at HF. The effects of perturbation frequency and optic flow and their interaction with other sensory inputs and cognitive tasks on the adaptation strategies should be investigated in impaired individuals and considered in the design of rehabilitation protocols.

The Sensor Technology and Rehabilitative Timing (START) Protocol: A Randomized Controlled Trial for the Rehabilitation of Mild Traumatic Brain Injury

BACKGROUND

Clinical practice for rehabilitation after mild traumatic brain injury (mTBI) is variable, and guidance on when to initiate physical therapy is lacking. Wearable sensor technology may aid clinical assessment, performance monitoring, and exercise adherence, potentially improving rehabilitation outcomes during unsupervised home exercise programs.

OBJECTIVE

The objectives of this study were to: (1) determine whether initiating rehabilitation earlier than typical will improve outcomes after mTBI, and (2) examine whether using wearable sensors during a home-exercise program will improve outcomes in participants with mTBI.

DESIGN

This was a randomized controlled trial.

SETTING

This study will take place within an academic hospital setting at Oregon Health & Science University and Veterans Affairs Portland Health Care System, and in the home environment.

PARTICIPANTS

This study will include 160 individuals with mTBI.

INTERVENTION

The early intervention group (n = 80) will receive one-on-one physical therapy 8 times over 6 weeks and complete daily home exercises. The standard care group (n = 80) will complete the same intervention after a 6- to 8-week wait period. One-half of each group will receive wearable sensors for therapist monitoring of patient adherence and quality of movements during their home exercise program.

MEASUREMENTS

The primary outcome measure will be the Dizziness Handicap Inventory score. Secondary outcome measures will include symptomatology, static and dynamic postural control, central sensorimotor integration posturography, and vestibular-ocular-motor function.

LIMITATIONS

Potential limitations include variable onset of care, a wide range of ages, possible low adherence and/or withdrawal from the study in the standard of care group, and low Dizziness Handicap Inventory scores effecting ceiling for change after rehabilitation.

CONCLUSIONS

If initiating rehabilitation earlier improves primary and secondary outcomes post-mTBI, this could help shape current clinical care guidelines for rehabilitation. Additionally, using wearable sensors to monitor performance and adherence may improve home exercise outcomes.

Reductions in body sway responses to a rhythmic support surface tilt perturbation can be caused by other mechanisms than prediction

Studies investigating balance control often use external perturbations to probe the system. These perturbations can be administered as randomized, pseudo-randomized, or predictable sequences. As predictability of a given perturbation can affect balance performance, the way those perturbations are constructed may affect the results of the experiments. In the present study, we hypothesized that subjects are able to adapt to short, rhythmic support surface tilt stimuli, but not to long pseudo-random stimuli. 19 subjects were standing with eyes closed on a servo-controlled platform tilting about the ankle joint axis. Pre and post to the learning intervention, pseudo-random tilt sequences were applied. For the learning phase, a rhythmic and easy-to-memorize 8-s long sequence was applied 75 times, where subjects were instructed to stand as still as possible. Body kinematics were measured and whole body center of mass sway was analyzed. Results showed reduced sway and less forward lean of the body across the learning phase. The sway reductions were similar for stimulus and non-stimulus frequencies. Surprisingly, for the pseudo-random sequences, comparable changes were found from pre- to post-tests. In summary, results confirmed that considerable adaptations exist when exposing subjects to an 8-s long rhythmic perturbation. No indications of predictions of the learning tilt sequence were found, since similar changes were also observed in response to pseudo-random sequences. We conclude that changes in body sway responses following 75 repetitions of an 8-s long rhythmic tilt sequence are due to adaptations in the dynamics of the control mechanism (presumably stiffness).

Anticipatory coadaptation of ankle stiffness and sensorimotor gain for standing balance

External perturbation forces may compromise standing balance. The nervous system can intervene only after a delay greater than 100 ms, during which the body falls freely. With ageing, sensorimotor delays are prolonged, posing a critical threat to balance. We study a generic model of stabilisation with neural delays to understand how the organism should adapt to challenging balance conditions. The model suggests that ankle stiffness should be increased in anticipation of perturbations, for example by muscle co-contraction, so as to slow down body fall during the neural response delay. Increased ankle muscle co-contraction is indeed observed in young adults when standing in challenging balance conditions, and in older relative to young adults during normal stance. In parallel, the analysis of the model shows that increases in either stiffness or neural delay must be coordinated with decreases in spinal sensorimotor gains, otherwise the feedback itself becomes destabilizing. Accordingly, a decrease in spinal feedback is observed in challenging conditions, and with age-related increases in neural delay. These observations have been previously interpreted as indicating an increased reliance on cortical rather than spinal control of balance, despite the fact that cortical responses have a longer latency. Our analysis challenges this interpretation by showing that these observations are consistent with a functional coadaptation of spinal feedback gains to functional changes in stiffness and neural delay.

Being able to stand still can be difficult when faced with an unexpected push. It takes the nervous system more than a tenth of a second to respond to such a perturbation, and during this delay the body falls under the influence of its own weight. By co-contracting their ankle muscles in anticipation of a perturbation, subjects can increase their ankle stiffness, which slows down their fall during the neural delay. Young subjects indeed adopt this strategy when they need to remain particularly still (for example when they stand in front of a cliff). Older subjects adopt this strategy even during normal standing. We present a model of standing balance that shows that this postural strategy provides partial compensation for the increase in neural delays with ageing. According to our model, increasing ankle stiffness only improves balance if it is accompanied by a decrease in sensorimotor gain. This provides a novel and functional interpretation for the decrease in spinal feedback observed during ageing, and observed in young subjects when they stand in challenging balance conditions.

Sensory Re-weighting for Postural Control in Parkinson's Disease

Postural instability in Parkinson's disease (PD) is characterized by impaired postural responses to transient perturbations, increased postural sway in stance and difficulty transitioning between tasks. In addition, some studies suggest that loss of dopamine in the basal ganglia due to PD results in difficulty in using proprioceptive information for motor control. Here, we quantify the ability of subjects with PD and age-matched control subjects to use and re-weight sensory information for postural control during steady-state conditions of continuous rotations of the stance surface or visual surround. We measure the postural sway of subjects in response to a pseudorandom, surface-tilt stimulus with eyes closed, and in response to a pseudorandom, visual-tilt stimulus. We use a feedback control model of the postural control system to interpret our results, focusing on sensory weighting as a function of stimulus amplitude. We find that subjects with PD can re-weight their dependence upon sensory information in response to changes in surface- or visual-stimulus amplitude. Specifically, subjects with PD behaved like age-matched control subjects by decreasing proprioceptive contribution to stance control with increasing surface-tilt amplitude and decreasing visual contribution with increasing visual-tilt amplitude. However, subjects with PD do not decrease their reliance on proprioception as much as age-matched controls for small increases in surface-stimulus amplitudes. Levodopa medication did not affect sensory re-weighting behaviors for postural control. The impairment in PD subject's ability to respond differently to small changes in surface rotation amplitudes is consistent with an increased threshold for perceiving proprioceptive signals, which may result from decreased signal-to-noise in the dopaminergic pathways associated with sensory processing and/or sensory integration.