The influence of knee rigidity on balance corrections: a comparison with responses of cerebellar ataxia patients.

Knee rigidity due to aging or disease is associated with falls. A causal relationship between instability and knee rigidity has not been established. Here, we examined whether insufficient knee movement due to knee rigidity could underlie poor balance control in patients. We addressed this by examining the effect of artificially "locking" the knees on balance control in 18 healthy subjects, tested with and without individually fitted knee casts on both legs. Subjects were exposed to sudden rotations of a support surface in six different directions. The primary outcome measure was body centre of mass (COM) movement, and secondary outcome measures included biomechanical responses of the legs, pelvis and trunk. Knee casts caused increased backward COM movement for backward perturbations and decreased vertical COM movement for forward perturbations, and caused little change in lateral COM movement. At the ankles, dorsiflexion was reduced for backward perturbations. With knee casts, there was less uphill hip flexion and more downhill hip flexion. A major difference with knee casts was a reversed pelvis pitch movement and an increased forward trunk motion. These alterations in pitch movement strategies and COM displacements were similar to those we have observed previously in patients with knee rigidity, specifically those with spinocerebellar ataxia (SCA). Pelvis roll and uphill arm abduction were also increased with the casts. This roll movement strategy and minor changes in lateral COM movement were not similar to observations in patients. We conclude that artificial knee rigidity increases instability, as reflected by greater posterior COM displacement following support surface tilts. Healthy controls with knee casts used a pitch movement strategy similar to that of SCA patients to offset their lack of knee movement in regaining balance following multidirectional perturbations. This similarity suggests that reduced knee movements due to knee rigidity may contribute to sagittal plane postural instability in SCA patients and possibly in other patient groups. However in the roll plane, healthy controls rapidly compensate by adjusting arm movements and hip flexion to offset the effects of knee rigidity.

Are postural responses to backward and forward perturbations processed by different neural circuits?

Startle pathways may contribute to rapid accomplishment of postural stability. Here we investigate the possible influence of a startling auditory stimulus (SAS) on postural responses. We formulated four specific questions: (1) can a concurrent SAS shorten the onset of automatic postural responses?; and if so (2) is this effect different for forward versus backward perturbations?; (3) does this effect depend on prior knowledge of the perturbation direction?; and (4) is this effect different for low- and high-magnitude perturbations? Balance was perturbed in 11 healthy participants by a movable platform that suddenly translated forward or backward. Each participant received 160 perturbations, 25% of which were combined with a SAS. We varied the direction and magnitude of the perturbations, as well as the prior knowledge of perturbation direction. Perturbation trials were interspersed with SAS-only trials. The SAS accelerated and strengthened postural responses with clear functional benefits (better balance control), but this was only true for responses that protected against falling backwards (i.e. in tibialis anterior and rectus femoris). These muscles also demonstrated the most common SAS-triggered responses without perturbation. Increasing the perturbation magnitude accelerated postural responses, but again with a larger acceleration for backward perturbations. We conclude that postural responses to backward and forward perturbations may be processed by different neural circuits, with influence of startle pathways on postural responses to backward perturbations. These findings give directions for future studies investigating whether deficits in startle pathways may explain the prominent backward instability seen in patients with Parkinson's disease and progressive supranuclear palsy.

Loading enhances the occurrence of startle responses in leg muscles.

INTRODUCTION: The startle reflex is an involuntary reaction to sudden sensory input and consists of a generalized flexion response. Startle responses in distal leg muscles occur more frequently during standing compared to sitting. We hypothesized that sensory input from load receptors modulates the occurrence of startle responses in leg muscles. METHODS: We administered sudden startling auditory stimuli (SAS) to 11 healthy subjects while (1) sitting relaxed, (2) standing relaxed, (3) standing while bearing 60% of their weight on the right leg, (4) standing while bearing 60% of their weight on the left leg, and (5) standing with 30% body weight support ('bilateral unloaded'). The requested weight distribution for each condition was verified using force plates. Electromyography data were collected from both tibialis anterior (TA) and the left sternocleidomastoid muscles. RESULTS: In the TA, startle responses occurred much more frequently during normal standing (26% of trials) compared to both sitting (6% of trials, p<0.01) and bilateral unloading (3% of trials, p<0.01). In the asymmetrical stance conditions, startle responses in the TA were more common in the loaded leg (21% of trials) compared to the unloaded leg (10% of trials, p<0.05). DISCUSSION: The occurrence of startle responses in the leg muscles was strongly influenced by load. Hence, it is likely that information from load receptors influences startle response activity. We suggest that, in a stationary position, startling stimuli result in a descending volley from brainstem circuits, which is gated at the spinal level by afferent input from load receptors.

First trial reactions and habituation rates over successive balance perturbations in Parkinson's disease.

BACKGROUND: Balance control in Parkinson's disease is often studied using dynamic posturography, typically with serial identical balance perturbations. Because subjects can learn from the first trial, the magnitude of balance reactions rapidly habituates during subsequent trials. Changes in this habituation rate might yield a clinically useful marker. We studied balance reactions in Parkinson's disease using posturography, specifically focusing on the responses to the first, fully unpractised balance disturbance, and on the subsequent habituation rates. METHODS: Eight Parkinson patients and eight age- and gender-matched controls received eight consecutive toe-up rotations of a support-surface. Balance reactions were measured with a motion analysis system and converted to centre of mass displacements (primary outcome). RESULTS: Mean centre of mass displacement during the first trial was 51% greater in patients than controls (P=0.019), due to excessive trunk flexion and greater ankle plantar-flexion. However, habituated trials were comparable in both groups. Patients also habituated slower: controls were fully habituated at trial 2, whereas habituation in patients required up to five trials (P=0.004). The number of near-falls during the first trial was significantly correlated with centre of mass displacement during the first trial and with habituation rate. CONCLUSIONS: Higher first trial reactions and a slow habituation rate discriminated Parkinson's patients from controls, but habituated trials did not. Further work should demonstrate whether this also applies to clinical balance tests, such as the pull test, and whether repeated delivery of such tests offers better diagnostic value for evaluating fall risks in parkinsonian patients.

Improving community healthcare for patients with Parkinson's disease: the dutch model.

Because of the complex nature of Parkinson's disease, a wide variety of health professionals are involved in care. Stepwise, we have addressed the challenges in the provision of multidisciplinary care for this patient group. As a starting point, we have gained detailed insight into the current delivery of allied healthcare, as well as the barriers and facilitators for optimal care. To overcome the identified barriers, a tertiary referral centre was founded; evidence-based guidelines were developed and cost-effectively implemented within regional community networks of specifically trained allied health professionals (the ParkinsonNet concept). We increasingly use ICT to bind these professional networks together and also to empower and engage patients in making decisions about their health. This comprehensive approach is likely to be feasible for other countries as well, so we currently collaborate in a European collaboration to improve community care for persons with Parkinson's disease.

Review of first trial responses in balance control: influence of vestibular loss and Parkinson's disease.

The reaction to an unexpected balance disturbance is unpracticed, often startling and frequently associated with falls. This everyday situation can be reproduced in an experimental setting by exposing standing humans to sudden, unexpected and controlled movements of a support surface. In this review, we focus on the responses to the very first balance perturbation, the so-called first trial reactions (FTRs). Detailed analysis of FTRs may have important implications, both for clinical practice (providing new insights into the pathophysiological mechanisms underlying accidental falls in real life) and for understanding human physiology (what triggers and mediates these FTRs, and what is the relation to startle responses?). Several aspects of the FTRs have become clear. FTRs are characterized by an exaggerated postural reaction, with large EMG responses and co-contracting muscles in multiple body segments. This balance reaction is associated with marked postural instability (greater body sway to the perturbation). When the same perturbation is repeated, the size of the postural response habituates and the instability disappears. Other issues about FTRs remain largely unresolved, and these are addressed here. First, the functional role of FTRs is discussed. It appears that FTRs produce primarily increased trunk flexion during the multi-segmental response to postural perturbations, thus producing instability. Second, we consider which sensory signals trigger and modulate FTRs, placing specific emphasis on the role of vestibular signals. Surprisingly, vestibular signals appear to have no triggering role, but vestibular loss leads to excessive upper body FTRs due to loss of the normal modulatory influence. Third, we address the question whether startle-like responses are contributing to FTRs triggered by proprioceptive signals. We explain why this issue is still unresolved, mainly because of methodological difficulties involved in separating FTRs from 'pure' startle responses. Fourth, we review new work about the influence of perturbation direction on FTRs. Recent work from our group shows that the largest FTRs are obtained for toe-up support surface rotations which perturb the COM in the posterior direction. This direction corresponds to the directional preponderance for falls seen both in the balance laboratory and in daily life. Finally, we briefly touch upon clinical diagnostic issues, addressing whether FTRs (as opposed to habituated responses) could provide a more ecologically valid perspective of postural instability in patients compared to healthy subjects. We conclude that FTRs are an important source of information about human balance performance, both in health and disease. Future studies should no longer discard FTRs, but routinely include these in their analyses. Particular emphasis should be placed on the link between FTRs and everyday balance performance (including falls), and on the possible role played by startle reactions in triggering or modulating FTRs.

Dynamic posturography in Parkinson's disease: diagnostic utility of the "first trial effect".

Previous dynamic posturography studies demonstrated clear abnormalities in balance responses in Parkinson's disease (PD) patients compared to controls at the group level, but its clinical value in the diagnostic process and fall risk estimation in individual patients leaves for improvement. Therefore, we investigated whether a new approach, focusing on the balance responses to the very first and fully unpractised trial rather than a pooled mean response to a series of balance perturbations, could further improve the diagnostic utility of dynamic posturography. Following the first trial, subjects were exposed to repeated balance perturbations, which also permitted us to investigate the training responses. Fourteen patients with PD and 18 age-matched controls were enrolled, who received a series of multidirectional postural perturbations, induced by support surface rotations. We measured trunk and upper arm kinematics and electromyographic responses, and evaluated group differences at three levels: the postural response to the very first backward perturbation; pooled first and habituated postural responses; and habituation rates. Analysis of the first trial responses yielded similar results as evaluation of the mean response over trials: forward flexion of the trunk induced by backward perturbations was decreased in patients, accompanied by increased muscle responses present. Moreover, trunk movement and muscle activity were equally present in both groups-suggesting a preserved training response in PD patients. Early masseter activity in both groups might be indicative of a startle-like component to the balance response. In terms of diagnostic utility, focusing on the first trial response or habituation rate is no better than analysis of pooled responses to a series of perturbations. The apparently preserved training response in PD patients suggests that balance reactions in PD can be improved by repeated exposure, and this may have implications for future exercise studies. Early masseter activity warrants further studies to evaluate a potential startle component in the pathophysiology of balance disorders.