Comparison of forward and backward postural perturbations in mild-to-moderate Parkinson's disease

BackgroundAssessing postural stability in Parkinson’s disease (PD) often relies on measuring the stepping response to an imposed postural perturbation. The standard clinical technique relies on a brisk backwards pull at the shoulders by the examiner and judgement by a trained rater. In research settings, various quantitative measures and perturbation directions have been tested, but it is unclear which metrics and perturbation direction differ most between people with PD and controls.Objectives(1) Use standardized forward vs. backward perturbations of a support surface to evaluate reactive stepping performance between PD and control participants. (2) Evaluate the utility of using principal components analysis to capture the dynamics of the reactive response and differences between groups.MethodsSixty-two individuals participated (40 mild-to-moderate PD, off medication). Standardized rapid translations of the support surface were applied, requiring at least one step, backward or forward, to restore balance. The number of steps taken and the projection of the first principal component (PC1) of the center of pressure (COP) time series were entered in linear repeated-measures mixed effect models.ResultsForward falls required significantly fewer steps to recover than backward falls. PC1 captured more than half of the variance in the COP trajectory. Analysis of the PC1 projection revealed a significant interaction effect of group (PD vs. controls) by direction, such that there was a group difference in forward stepping, but not backward.SignificanceForward reactive stepping in PD differed from controls more than backward-stepping. PC1 projections of the COP trajectory capture the dynamics of the postural response and differ between PD and controls.     

Advanced characterization of static postural control dysfunction in persons with multiple sclerosis and associated neural mechanisms

BackgroundMultiple sclerosis (MS) is an autoimmune-based chronic inflammatory disease characterized by the neurodegeneration of the central nervous system and produces postural dysfunction. Quiet or static standing is a complex task carried out through afferent sensory inputs and efferent postural corrective outputs. Currently the mechanisms underlying these outputs remain largely unknown.Research questionAssess the relationship between multi-dimensional measures of postural control and microstructural integrity of the cortical sensorimotor pathway (CSP) in persons with MS (PwMS) and neurotypical adults.MethodsPostural control performance was assessed by both overall and directional time-to-boundary measures across four manipulated sensory stance conditions (eyes open/closed; stance firm/foam) in twenty-nine neurotypical and twenty-seven PwMS. These postural outcomes were evaluated with mixed-model repeated measures analysis of variance across group (MS and control) and stance condition. Postural performance was also correlated with magnetic resonance imaging diffusion tensor-derived measures of microstructural integrity of the CSP.ResultsPwMS displayed significantly (p = 0.026) worse anterior-posterior postural control compared to their neurotypical counterparts across sensory testing conditions and poorer CSP microstructural integrity in comparison to neurotypical adults (p = 0.008). Additionally, PwMS displayed a significant association (2D (rho = -0.384, p = 0.048), AP (rho = -0.355, p = 0.035), and ML (rho = -0.365, p = 0.030) between integrity of the CSP and postural control performance during proprioceptive-based balance, such that those with worse cortical structure had poorer balance control.SignificanceThis is the first study to establish connections between the microstructural integrity of the CSP and multi-dimensional postural control performance. Results indicate that a reduction in the CSP microstructural integrity is associated with poorer postural control in PwMS. These outcomes identify neural underpinnings of postural control dysfunction in PwMS and provide new avenues for evaluating the efficacy of postural rehabilitation strategies in PwMS that express proprioceptive-based postural deficits.     

Characterizing inter-limb synchronization after incomplete spinal cord injury: A cross-sectional study

BackgroundIndividuals with incomplete spinal cord injury (iSCI) demonstrate greater postural sway and increased dependency on vision to maintain balance compared to able-bodied individuals. Research on standing balance after iSCI has focused on the joint contribution of the lower limbs; however, inter-limb synchrony in quiet standing is a sensitive measure of individual limb contributions to standing balance control in other neurological populations. It is unknown if and how reduced inter-limb synchrony contributes to the poor standing balance of individuals with iSCI.Research questionHow does an iSCI affect inter-limb synchrony and weight-bearing symmetry in standing?MethodsEighteen individuals with non-progressive motor iSCI and 15 age- and sex-matched able-bodied individuals (M-AB) were included in the study. Participants stood in a standardized position on two adjacent force plates in eyes open and closed conditions for 70 s per condition. Net centre-of-pressure (COP) root mean square (RMS), net COP velocity, COP inter-limb synchrony (i.e. cross-correlation between left and right COP), and weight-bearing asymmetry (i.e. vertical force from each limb over total vertical force) were calculated. Muscle strength of the lower limbs was assessed with manual muscle testing.ResultsIndividuals with iSCI demonstrated reduced inter-limb synchrony when standing with eyes open and eyes closed, but did not differ to M-AB with respect to weight-bearing asymmetry. They also produced greater net COP RMS and velocity when compared to M-AB. Muscle strength of the two lower limbs demonstrated an overall asymmetry in individuals with iSCI.SignificanceIndividuals with iSCI demonstrated impaired balance control as evidenced by reduced inter-limb synchrony and greater COP RMS and velocity compared to M-AB individuals. This increased understanding of how balance control is impaired following iSCI may inform balance assessment and intervention for this population. Future work examining the association between inter-limb synchrony and the occurrence of falls in iSCI is warranted.     

Does increased gait variability improve stability when faced with an expected balance perturbation during treadmill walking?

BackgroundCurrently, there is uncertainty as to whether movement variability is errorful or exploratory.Research questionThis study aimed to determine if gait variability represents exploration to improve stability. We hypothesized that 1) spatiotemporal gait features will be more variable prior to an expected perturbation than during unperturbed walking, and 2) increased spatiotemporal gait variability pre-perturbation will correlate with improved stability post-perturbation.MethodsSixteen healthy young adults completed 15 treadmill walking trials within a motion simulator under two conditions: unperturbed and expecting a perturbation. Participants were instructed not to expect a perturbation for unperturbed trials, and to expect a single transient medio-lateral balance perturbation for perturbed trials. Kinematic data were collected during the trials. Twenty steps were recorded post-perturbation. Unperturbed and pre-perturbation gait variabilities were defined by the short- and long-term variabilities of step length, width, and time, using 100 steps from pre-perturbation and unperturbed trials. Paired t-tests identified between-condition differences in variabilities. Stability was defined as the number of steps to centre of mass restabilization post-perturbation. Multiple regression analyses determined the effect of pre-perturbation variability on stability.ResultsLong-term step width variability was significantly higher pre-perturbation compared to unperturbed walking (mean difference = 0.28 cm, p = 0.0073), with no significant differences between conditions for step length or time variabilities. There was no significant relationship between pre-perturbation variability and post-perturbation restabilization.SignificanceIncreased pre-perturbation step width variability was neither beneficial nor detrimental to stability. However, the increased variability in medio-lateral foot placement suggests that participants adopted an exploratory strategy in anticipation of a perturbation.     

Effects of social anxiety on static and dynamic balance task assessment in older women

BackgroundSocial anxiety caused by the presence of an evaluator can impair balance performance in older women. However, it is unknown whether co-performing balance tasks with a partner mitigates this effect.Research questionDoes the presence of a partner mitigate the effect of social anxiety on static and dynamic balance assessment in older women?MethodsTwenty-one older women (mean age 66.5 (SD = 5.2) years) performed nine balance tasks under three conditions: (a) Alone (no evaluator present); (b) Evaluator (male evaluator present); (c) Partner (evaluator + performing tasks in parallel with partner). Participants were split into two groups post-hoc: Affected (n = 10) and Unaffected (n = 11), based on their emotional response to the presence of the evaluator (increased self-reported anxiety and fear).ResultsThe affected group took a longer time to complete tandem walking with eyes open in the Evaluator vs. Alone condition, but not in the Partner condition. Both groups increased anterior-posterior trunk angular velocity during tandem walking with eyes closed in the Evaluator vs. Alone condition, but not in the Partner condition.SignificanceSocial anxiety impairs the balance performance of older women, particularly in those most affected by the evaluator, and during more dynamic modified gait tasks that challenge balance while walking. However, co-performing balance tasks with a partner reduced the effects of social anxiety, suggesting that social support may help to mitigate some of the potential ‘white coat’ effects experienced during clinical balance assessments.     

Maturation of the postural control in adolescent girls: A 3-year follow-up study

BackgroundStable posture is a manifestation of the appropriate functioning of the neuromuscular system that is essential for proper motor development and control. Balance and stability of the erect posture are shaped during the entire childhood to culminate in its full efficiency in adolescent subjects.MethodsIn this 3-year follow-up study, the process of the postural control maturation has been assessed in a group of 18 girls at the transition period between childhood to adolescence. Their balance and postural stability control were assessed using standard static posturography supplemented by two postural stability tests: the rising-on-toes (ROT), and the maximum forward lean (MFL), all performed with (EO) and without vision (EC). Balance control was analyzed with the sway vector (SV) and sway directional indices, whereas the anteroposterior trajectories of the center-of- pressure (COP) during forward-leaning and the raise-on-toes tests were used to determine changes in postural stability control.ResultsThe study documented that stability control in girls aged 11–13 is shaped according to their own pace of development. Their postural sway was characterized by the lower COP velocity but very sensitive to visual input. The directional sway measures remained at the same level for the entire period of observation. MFL and ROT tests provided similar information on postural stability and its dependence on visual input. These tests allow for more thorough assessment of postural stability to compare with quiet stance testing.SignificanceSubtle changes in postural control in adolescents could be assessed based on the results of combined static and dynamic tests. In particular, the ROT test can be recommended for the assessment of postural stability.     

Investigating the validity of a single tri-axial accelerometer mounted on the head for monitoring the activities of daily living and the timed-up and go test

BackgroundQuantitative assessments of activities of daily living (ADL) play an essential role in evaluating the impact of disease and interventions on people's quality of life. Motion capture systems traditionally used for quantitative assessments of postural transitions and movement associated with ADL are limited to the laboratory setting. Wearable accelerometers can remove these limitations and enable easier-to-use, longer-term, and remote functional evaluations.ObjectiveTo investigate the validity of a single tri-axial accelerometer mounted on the head for monitoring postural transition and the timed-up-and-go test.MethodsTwo accelerometers with a sampling frequency of 100 Hz were attached to twelve able-bodied study participants' sternum and right mastoid process. We developed algorithms for the functional calibration of accelerometers and the detection of the postural transitions by measuring the head inclination angle and variations of the gravitational components of the accelerometer readout. Participants performed a battery of ADL tests involving a wide variety of postural transitions. The head-mounted accelerometers results were compared with a sternum-mounted accelerometer and validated against a video motion capture system as a gold standard reference.Results and SignificanceThe results indicate that, utilizing our proposed algorithm, a single tri-axial accelerometer mounted on the head can deliver high accuracy (>95 %), sensitivity (>90 %), and specificity (100 %) for detecting both postural transitions and walking events. Together with the small size and unobtrusive placement of the head-mounted accelerometer, these results demonstrate an attractive solution for the reliable assessment of ADLs and clinical evaluations based on functional tests such as the timed-up-and-go test.     

The feasibility and efficacy of a serial reaction time task that measures motor learning of anticipatory stepping

BackgroundMotor learning has been investigated using various paradigms, including serial reaction time tasks (SRTT) that examine upper extremity reaching and pointing while seated. Few studies have used a stepping SRTT, which could offer additional insights into motor learning involving postural demands. For a task to measure motor learning, naïve participants must demonstrate a) improved performance with task practice, and b) a dose-response relationship to learning the task.Research questionIs a stepping SRTT feasible and efficacious for measuring motor learning?MethodsIn this prospective study, 20 participants stood on an instrumented mat and were presented with stimuli on a computer screen. They stepped to the corresponding positions on the mat as quickly as possible. Presented stimuli included random sequences and a blinded imbedded repeating sequence. Three days after completing the randomly assigned practice dose [high dose group (n = 10) performed 4320 steps; low dose group (n = 10) performed 144 steps], a retention test of 72 steps was performed. Feasibility was measured as the proportion of participants who completed the assigned practice dose without adverse events. Efficacy was measured as within-group performance improvement on the random sequences and on the repeating sequence (paired t-tests), as well as a dose-response relationship to learning both types of sequences (independent t-tests).ResultsAll participants (mean age 26.8 years) completed all practice sessions without adverse events, indicating feasibility. High dose practice resulted in performance improvement while low dose did not; a dose-response relationship was found, with high dose practice resulting in greater learning of the task than low dose practice, indicating efficacy.SignificanceThis stepping SRTT is a feasible and efficacious way to measure motor learning, which could provide critical insights into anticipatory stepping, postural control, and fall risk. Future research is needed to determine feasibility, efficacy, and optimal practice dosages for older and impaired populations.     

Lower limb joint-specific contributions to standing postural sway in persons with unilateral lower limb loss

BackgroundIndividuals with lower limb loss are at an increased risk for falls, likely due to impaired balance control. Standing balance is typically explained by double- or single-inverted pendulum models of the hip and/or ankle, neglecting the knee joint. However, recent work suggests knee joint motion contributes toward stabilizing center-of-mass kinematics during standing balance.Research QuestionTo what extent do hip, knee, and ankle joint motions contribute to postural sway in standing among individuals with lower limb loss?MethodsForty-two individuals (25 m/17f) with unilateral lower limb loss (30 transtibial, 12 transfemoral) stood quietly with eyes open and eyes closed, for 30 s each, while wearing accelerometers on the pelvis, thigh, shank, and foot. Triaxial inertial measurement units were transformed to inertial anterior-posterior components and sway parameters were computed: ellipse area, root-mean-square, and jerk. A state-space model with a Kalman filter calculated hip, knee, and ankle joint flexion-extension angles and ranges of motion. Multiple linear regression predicted postural sway parameters from intact limb joint ranges of motion, with BMI as a covariate (p < 0.05).ResultsWith eyes open, intact limb hip flexion predicted larger sway ellipse area, whereas hip flexion and knee extension predicted larger sway root-mean-square, and hip flexion, knee extension, and ankle plantarflexion predicted larger sway jerk. With eyes closed, intact limb hip flexion remained the predictor of sway ellipse area; no other joint motions influenced sway parameters in this condition.SignificanceHip, knee, and ankle motions influence postural sway during standing balance among individuals with lower limb loss. Specifically, increasing intact-side hip flexion, knee extension, and ankle plantarflexion motion increased postural sway. With vision removed, a re-weighting of lower limb joint sensory mechanisms may control postural sway, such that increasing sway may be regulated by proximal coordination strategies and vestibular responses, with implications for fall risk.     

Effect of postural changes on lower limb blood volume,detected with non-invasive photoplethysmography

This paper describes the effect of passive leg raising on blood volume change in the lower limb, using a dual probe photoplethysmography (PPG) system employing a tissue optics model. The normalized AC/DC ratio and DC value are introduced from the model to evaluate the dynamic pulsation and total blood volume changes due to postural effects. The AC and DC components of PPG signals were collected from a passive leg raising protocol. With the leg raised, the normalized AC/DC ratio significantly decreased when supine, while the normalized DC value increased significantly in both supine and reclining positions. The parameters from the stationary leg showed similar but smaller responses. These results demonstrate a local and systemic physiological phenomenon in the lower limb blood volume change caused by postural changes. The normalized AC/DC ratio and DC value derived from the tissue optics model could be applied to assess the blood volume change.