Time to disengage: holding an object influences the execution of rapid compensatory reach-to-grasp reactions for recovery from whole-body instability.

Rapid reach-to-grasp (RTG) reactions are important for balance recovery. Despite the benefit of having hands free to regain balance, people do not always release a handheld object. We investigated whether reluctance to release is related to central nervous system (CNS) processing delays that occur when the initial reaction is to drop the object rather than RTG. Young adults sat in a custom-designed chair that tilted backwards. Participants regained balance by reaching to a handle with hands free or while holding onto (1) a chair-fixed object or (2) a SMALL or LARGE free-moving object (unbreakable plastic tubes). EMG was collected from the upper limb to determine onset of reaction. Kinematic data from a digitized wrist marker were used to determine movement time. 9 of 10 participants released the object in every trial. Extensor digitorum onset occurred significantly later than anterior deltoid onset in all conditions. LARGE object release induced further delays in extensor onset while both SMALL and LARGE object release increased response and movement time. Object disengagement led to delays in perturbation-evoked, RTG reactions, particularly in the focal muscle (extensor digitorum) and when the objects' properties posed greater risk for a failed RTG response. We propose that time required for cognitive disengagement accounts for the observed delays. This study offers a potential explanation for the tendency to avoid disengaging from a handheld object during balance recovery. Results also provide insight into the challenges imposed upon the CNS during temporally urgent movements.

Online Learning of Gait Models From Older Adult Data.

This paper proposes a novel approach for online, individualized gait analysis, based on an adaptive periodic model of any gait signal. The proposed method learns a model of the gait cycle during online measurement, using a continuous representation that can adapt to inter- and intra-personal variability by creating an individualized model. Once the algorithm has converged to the input signal, key gait events can be identified based on the estimated gait phase and amplitude. The approach is implemented and tested on retirement home resident 6 min walk (6MW) data using wearable accelerometers at the ankle. The proposed approach converges within approximately four gait cycles and achieves 3% error in detecting initial swing events.11 An early version of this work was presented in [1]. A more extensive description of related work and an extended method, including optimization of learning rates, were added to this paper. Further, this paper applies and evaluates the method to a new and much larger gait dataset taken from older adults who each have a variety of medical conditions. Therefore, the experimental protocol was also updated and the results are entirely novel.

Cortical responses associated with the preparation and reaction to full-body perturbations to upright stability.

OBJECTIVE: To examine the cortical activity associated with 'central set' preparations for induced whole-body instability. METHODS: Self-initiated and temporally unpredictable perturbations to standing balance were caused by the release of a load coupled to a cable affixed to a harness while participants stood on a force plate. Electroencephalographic and electromyographic signals were recorded. RESULTS: Peak activity was located at the Cz electrode. The predictable condition elicited a DC shift 950 ms prior to perturbation onset and was 18.0+/-10.5 micro V in magnitude. Pre-perturbation activity was not associated with the motor act of perturbation initiation and was dissociable from cortical activity related to anticipatory postural muscle activation. Following perturbation onset, N1 potentials were observed with a peak amplitude of 17.6+/-7.2 micro V and peak latency of 140.1+/-25.9 ms. In unpredictable trials, pre-perturbation activity was absent. The peak amplitude (32.0+/-14.8 micro V) and latency (156.5+/-11.8 ms) of the post-perturbation N1 potential were significantly larger (p=0.002) and later (p<0.001) than for predictable trials. CONCLUSIONS: Self-initiated postural instability evokes cortical activity prior to and following perturbation onset. Pre-perturbation cortical activity is associated with changing central set to modulate appropriate perturbation-evoked balance responses. SIGNIFICANCE: These findings establish a link between reactive balance control and cortical activity that precedes and follows perturbations to stability.

Changes in gait variability during different challenges to mobility in patients with traumatic brain injury.

Postural stability may be compromised in patients who have sustained a traumatic brain injury (TBI). The purpose of the present study was to examine dynamic stability during gait by measuring spatial and temporal variability of foot placement, and to determine the effect of increased difficulty of the walking task on gait variability in patients with TBI. It was hypothesized that patients with TBI will show increased variability in step time, step length, and step width in comparison to healthy controls and that such differences would be accentuated by increased task difficulty. Participants (patients: n=20, controls: n=20) were asked to walk across a pressure sensitive mat at their preferred pace (PW), as fast as possible (FW), and with their eyes closed (EC). In accordance with the hypotheses, patients had significantly greater variability in step time and step length in comparison to healthy controls, and when the complexity of the gait task increased (FW and EC tasks). Although step width variability showed no significant difference between the groups, both control and patient groups had increased step width variability in the EC task. It is proposed that such increases in variability reflect greater challenges to maintaining dynamic stability during gait among individuals with TBI and when performing more difficult tasks.

Sensori-sensory afferent conditioning with leg movement: gain control in spinal reflex and ascending paths.

Studies are reviewed, predominantly involving healthy humans, on gain changes in spinal reflexes and supraspinal ascending paths during passive and active leg movement. The passive movement research shows that the pathways of H reflexes of the leg and foot are down-regulated as a consequence of movement-elicited discharge from somatosensory receptors, likely muscle spindle primary endings, both ipsi- and contralaterally. Discharge from the conditioning receptors in extensor muscles of the knee and hip appears to lead to presynaptic inhibition evoked over a spinal path, and to long-lasting attenuation when movement stops. The ipsilateral modulation is similar in phase to that seen with active movement. The contralateral conditioning does not phase modulate with passive movement and modulates to the phase of active ipsilateral movement. There are also centrifugal effects onto these pathways during movement. The pathways of the cutaneous reflexes of the human leg also are gain-modulated during active movement. The review summarizes the effects across muscles, across nociceptive and non-nociceptive stimuli and over time elapsed after the stimulus. Some of the gain changes in such reflexes have been associated with central pattern generators. However, the centripetal effect of movement-induced proprioceptive drive awaits exploration in these pathways. Scalp-recorded evoked potentials from rapidly conducting pathways that ascend to the human somatosensory cortex from stimulation sites in the leg also are gain-attenuated in relation to passive movement-elicited discharge of the extensor muscle spindle primary endings. Centrifugal influences due to a requirement for accurate active movement can partially lift the attenuation on the ascending path, both during and before movement. We suggest that a significant role for muscle spindle discharge is to control the gain in Ia pathways from the legs, consequent or prior to their movement. This control can reduce the strength of synaptic input onto target neurons from these kinesthetic receptors, which are powerfully activated by the movement, perhaps to retain the opportunity for target neuron modulation from other control sources.

Cortical control of anticipatory postural adjustments prior to stepping.

Human bipedal balance control is achieved either reactively or predictively by a distributed network of neural areas within the central nervous system with a potential role for cerebral cortex. While the role of the cortex in reactive balance has been widely explored, only few studies have addressed the cortical activations related to predictive balance control. The present study investigated the cortical activations related to the preparation and execution of anticipatory postural adjustment (APA) that precede a step. This study also examined whether the preparatory cortical activations related to a specific movement is dependent on the context of control (postural component vs. focal component). Ground reaction forces and electroencephalographic (EEG) data were recorded from 14 healthy adults while they performed lateral weight shift and lateral stepping with and without initially preloading their weight to the stance leg. EEG analysis revealed that there were distinct movement-related potentials (MRPs) with concurrent event-related desynchronization (ERD) of mu and beta rhythms prior to the onset of APA and also to the onset of foot-off during lateral stepping in the fronto-central cortical areas. Also, the MRPs and ERD prior to the onset of APA and onset of lateral weight shift were not significantly different suggesting the comparable cortical activations for the generation of postural and focal movements. The present study reveals the occurrence of cortical activation prior to the execution of an APA that precedes a step. Importantly, this cortical activity appears independent of the context of the movement.

Do measures of reactive balance control predict falls in people with stroke returning to the community?

OBJECTIVE: To determine if reactive balance control measures predict falls after discharge from stroke rehabilitation. DESIGN: Prospective cohort study. SETTING: Rehabilitation hospital and community. PARTICIPANTS: Independently ambulatory individuals with stroke who were discharged home after inpatient rehabilitation (n=95). MAIN OUTCOME MEASURES: Balance and gait measures were obtained from a clinical assessment at discharge from inpatient stroke rehabilitation. Measures of reactive balance control were obtained: (1) during quiet standing; (2) when walking; and (3) in response to large postural perturbations. Participants reported falls and activity levels up to 6 months post-discharge. Logistic and Poisson regressions were used to identify measures of reactive balance control that were related to falls post-discharge. RESULTS: Decreased paretic limb contribution to standing balance control [rate ratio 0.8, 95% confidence interval (CI) 0.7 to 1.0; P=0.011], reduced between-limb synchronisation of quiet standing balance control (rate ratio 0.9, 95% CI 0.8 to 0.9; P<0.0001), increased step length variability (rate ratio 1.4, 95% CI 1.2 to 1.7; P=0.0011) and inability to step with the blocked limb (rate ratio 1.2, 95% CI 1.0 to 1.3; P=0.013) were significantly associated with increased fall rates when controlling for age, stroke severity, functional balance and daily walking activity. CONCLUSIONS: Impaired reactive balance control in standing and walking predicted increased risk of falls post-discharge from stroke rehabilitation. Specifically, measures that revealed the capacity of both limbs to respond to instability were related to increased risk of falls. These results suggest that post-stroke rehabilitation strategies for falls prevention should train responses to instability, and focus on remediating dyscontrol in the more-affected limb.

Aging of human segmental oligosynaptic reflexes for control of leg movement.

A heteronymous group I oligosynaptic reflex from the common peroneal nerve to vastus medialis muscle was compared with a group I homonymous monosynaptic reflex to soleus, using electrical stimulation of peripheral nerve trunks in two groups of healthy men, mean ages 22 and 65 years. The oligosynaptic reflex was still elicitable with age, its magnitude decreasing similarly to the monosynaptic reflex. A further group of older subjects, mean age 75 years, showed similar results. Clearly, the oligosynaptic reflex is not lost with healthy aging. The motor interneuronal pool may at least partially avoid the age-related cell loss of motoneuronal pools, with consequent maintenance of segmental participation for movements such as gait. The slowing of conduction velocities, for these proprioceptive reflex arcs, may reduce the effectiveness of autoregulation of the gait.

Bilateral movement enhances ipsilesional cortical activity in acute stroke: a pilot functional MRI study.

Functional MRI was performed in two acute stroke patients and six control subjects performing unilateral and bilateral repetitive gripping tasks. Patients were tested at three time points during recovery. Initially, bilateral movement enhanced activation in the primary motor cortex (M1) of the affected hemisphere compared with unilateral paretic hand movement. With recovery, activation of M1 in the affected hemisphere did not differ between unilateral paretic hand and bilateral movement. These preliminary data may have potential implications for acute stroke motor rehabilitation.

Adaptation in the motor cortex following cervical spinal cord injury.

BACKGROUND: The nature of the adaptive changes that occur in the cerebral cortex following injury to the cervical spinal cord are largely unknown. OBJECTIVE: To investigate these adaptive changes by examining the relationship between the motor cortical representation of the paretic right upper extremity compared with that of the tongue. The tongue was selected because the spinal cord injury (SCI) does not affect its movement and the cortical representation of the tongue is adjacent to that of the paretic upper extremity. METHODS: FMRI was used to map cortical representations associated with simple motor tasks of the right upper extremity and tongue in 14 control subjects and 9 patients with remote (>5.5 months) cervical SCI. RESULTS: The mean value for the site of maximum cortical activation during upper limb movement was identical between the two groups. The site of maximum left hemispheric cortical activation during tongue movement was 12.8 mm (p < 0.01) medial and superior to that of control subjects, indicating the presence of a shift in cortical activation. CONCLUSION: The findings indicate that the adult motor cortex does indeed adapt following cervical SCI. The nature of the adaptation and the underlying biological mechanisms responsible for this change require further investigation.

Clinical significance of primitive reflexes in Alzheimer's disease.

STUDY OBJECTIVE: To establish the relationship between cognition, behavior, function, and clinical characteristics on the one hand, and the presence of primitive reflexes (PR) (pout, snout, palmomental and grasp) in patients with Alzheimer's disease (AD). DESIGN: Cross-sectional survey. SETTING: Secondary care geriatric practice specializing in the assessment of cognitive impairment. SUBJECTS: 136 consecutive patients presenting with AD. MEASUREMENTS: PR were assessed in standardized fashion by a single clinician. Cognitive function was measured using the Standardized Mini-Mental Status Examination, activities of daily living (ADL) and instrumental activities of daily living (IADL) were measured using the Lawton scale, and behavior was measured using the Behavioural Problem Checklist. RESULTS: There was no difference in age or duration of dementia in those with and without PR, nor was there any difference in cognitive function. Despite this, patients with PR showed a greater degree of functional limitation and dysfunctional behavior. There was also a higher incidence of rigidity, gait abnormalities, and apraxia in patients with PR. CONCLUSIONS: Patients with primitive reflexes had more severe impairment in ADL function and dysfunctional behavior for an equal level of cognitive function.

Age-related changes in compensatory stepping in response to unpredictable perturbations.

BACKGROUND: Recent studies highlight the importance of compensatory stepping to preserve stability, and the spatial and temporal demands placed on the control of this reaction. Age-related changes in the control of stepping could greatly influence the risk of falling. The present study compares, in healthy elderly and young adults, the characteristics of compensatory stepping responses to unpredictable postural perturbations. METHODS: A moving platform was used to unpredictably perturb the upright stance of 14 naive, active and mobile subjects (5 aged 22 to 28 and 9 aged 65 to 81). The first 10 randomized trials (5 forward and 5 backward) were evaluated to allow a focus on reactions to relatively novel perturbations. The behavior of the subjects was not constrained. Forceplate and kinematic measures were used to evaluate the responses evoked by the brief (600 msec) platform translation. RESULTS: Subjects stepped in 98% of the trials. Although the elderly were less likely to execute a lateral anticipatory postural adjustment prior to foot-lift, the onset of swing-leg unloading tended to begin at the same time in the two age groups. There was remarkable similarity between the young and elderly in many other characteristics of the first step of the response. In spite of this similarity, the elderly subjects were twice as likely to take additional steps to regain stability (63% of trials for elderly). Moreover, in elderly subjects, the additional steps were often directed so as to preserve lateral stability, whereas the young rarely showed this tendency. CONCLUSIONS: Given the functional significance of base-of-support changes as a strategy for preserving stability and the age-related differences presently revealed, assessment of the capacity to preserve stability against unpredictable perturbation, and specific measures such as the occurrence or placement of multiple steps, may prove to be a significant predictor of falling risk and an important outcome in evaluating or developing intervention strategies to prevent falls.

Age-related differences in laterally directed compensatory stepping behavior.

BACKGROUND: Lateral falls are common in older adults and are associated with an elevated risk of hip fracture, compared with falls in other directions. Although rapid stepping movements can play an important functional role in maintaining balance, control of lateral stepping is a complex and demanding motor task. This study examined whether there are age-related differences in the stepping behavior used to recover from lateral loss of balance. METHODS: Rapid stepping reactions were evoked in healthy, active young (aged 20-30 years; N = 10) and older (aged 65-73 years; N = 10) volunteers by means of a sudden unpredictable motion of a platform on which the subject either stood quietly or walked in place. Subjects were instructed to respond naturally. Video analysis was performed to characterize the patterns of limb movement evoked by lateral platform motion. RESULTS: In responding to lateral perturbation of stance, the older adults were much more likely than the young adults to take multiple steps or use arm reactions to regain equilibrium, particularly when attempting crossover steps. During walk-in-place trials, both young and older subjects more frequently used a sequence of side steps rather than crossovers; however, older adults were still more likely to take extra steps or use arm reactions. Collisions between swing foot and stance limb occurred in 55% of walk-in-place trials in older adults versus only 8% in young adults. CONCLUSIONS: Control of lateral-stepping reactions appears to create difficulties for active and healthy older adults above and beyond previously reported problems in controlling forward and backward stepping. Impaired control of lateral-stepping reactions may be an early indicator of increased risk for lateral falls and hip fracture and should be an important consideration in the development of clinical approaches to predicting and preventing falls and related injuries.

Effect of facilitation of sensation from plantar foot-surface boundaries on postural stabilization in young and older adults.

BACKGROUND: One of the more pervasive effects of aging is loss of cutaneous sensation, which appears to correlate with impaired postural control and increased risk of falling. This study examined the potential for compensating for the destabilizing effects of reduced cutaneous sensitivity by placing a raised edge underneath the perimeter of the plantar foot surface, so as to facilitate sensation from the stability boundaries of the base of support. METHODS: The main experiment involved 14 healthy older adults (aged 65-73) selected because they were known, from a previous study, to have moderate plantar cutaneous insensitivity. We also report results of an initial experiment involving 7 healthy young adults (aged 23-31). In both experiments, we studied effects of the plantar facilitation on control of rapid stepping reactions evoked by unpredictable postural perturbation, applied via sudden platform movement in forward, backward, and lateral directions. We also studied effects on "feet-in-place" responses evoked by continuous pseudorandom platform motion in mediolateral and anteroposterior directions. Subjects were blindfolded in all tests. RESULTS: Plantar facilitation reduced the incidence of "extra" limb movements, beyond the initial step, during forward-step reactions in the older adults. There also appeared to be an improved ability to control feet-in-place reactions: young subjects were better able to recover balance without stepping when falling backward (given instructions to "try not to step"), and both young and older subjects reduced the extent to which the center of foot pressure approached the posterior foot boundary during continuous anteroposterior platform motion. CONCLUSIONS: This study provides evidence that mechanical facilitation of sensation from the boundaries of the plantar surface of the foot can improve the efficacy of certain types of stabilizing reactions evoked by unpredictable postural perturbation. The results may be directly transferable to the design of special footwear insoles to reduce instability and risk of falling in older adults.

Passive and active lower-limb movements delay upper-limb balance reactions.

This study investigated the influence of rhythmic lower-limb activity on the timing of upper-limb balance reactions. Compensatory grasping reactions were evoked in healthy subjects by rapid sagittal tilts of a chair under three conditions: (1) active leg pedaling, (2) passive (motor-driven) leg pedaling, and (3) no lower-limb movement (control task). Compared with control trials, both active and passive pedaling resulted in similar delays in the initiation (43-47 ms) and execution (12-17 ms) of grasping reactions. The similarity between effects due to active and passive movement suggests that the conditioning arose predominantly from sensory discharge associated with lower-limb movement. These results may have important implications for understanding the influence of locomotion or other ongoing movement on the control of stability.

Task-relevant selective modulation of somatosensory afferent paths from the lower limb.

Leg movement attenuates initial somatosensory evoked potentials (SEPS) from both cutaneous and muscle afferent origin. To date, as different sensory inputs become relevant for task performance, selective facilitation from such movement-related gating influences has not been shown. We hypothesized that initial SEP amplitudes from cutaneous (sural nerve, SN) and muscle afferent (tibial nerve, TN) sources are dependent on the relevance of the specific afferent information to task performance. SEPs were obtained at rest and during three movement conditions. In each movement condition, the left foot was passively moved episodically and additional cutaneous 'codes' of sensory information were applied to the dorsum of the left foot. Subjects were instructed to: simply relax (passive), or to make a response following the cessation of movement, dependent either on the cutaneous code (cutaneous task), or the passive movement trajectory of the left foot (position task). Passive movement, with no required subsequent response, attenuated initial TN and SN SEPs to approximately 40% of that at rest (p < 0.05). Versus passive movement, when cutaneous inputs provided the relevant cue for the task, mean SN SEPs significantly increased (p < 0.05), and when the proprioceptive inputs provided the relevant cue for the task, mean TN SEPs significantly increased (p < 0.05). We conclude that specific relevancy of sensory information selectively facilitates somatosensory paths from movement-related attenuation.

Cognitive demands of executing postural reactions: does aging impede attention switching?

A new dual-task paradigm was used to investigate age-related differences in attentional dynamics during rapid balancing reactions evoked by small, unpredictable antero-posterior platform movements. The perturbations were delivered while subjects performed a continuous visuo-motor pursuit-tracking task. Onset of significant deviation in tracking was inferred to indicate switching of attentional resources between tracking and balancing tasks. Although tracking deviation was equally likely to occur subsequent to postural perturbation in healthy young and older adults, deviation onset was delayed, on average, by 67% (123 ms) in the older subjects. Delay in onset of tracking deviation correlated with subsequent delay in generating the peak stabilizing postural response at the ankle. These results suggest that impaired attentional dynamics may exacerbate postural instability in older adults.

Phasic modulation of somatosensory potentials during passive movement.

Tibial nerve somatosensory evoked potential (SEP) amplitude modulates to passive stretch of leg extensors with movement, paralleling spinal reflex modulation. We therefore hypothesized that SEP amplitude is phasically attenuated during flexion in passive pedalling. SEPs and soleus H reflexes were evoked at four phase positions when the leg was static and passively moved. Initial SEPs were attenuated at full flexion compared with extension for both conditions (p < 0.05). SEPs during movement were significantly lower than those in the static condition (p < 0.05). There were no significant movement or phase effects on subsequent SEP components. H reflex modulation resembled that for initial SEPs. We conclude that movement-induced amplitude modulation of initial SEPs arises, partly, from phasic discharge of extensor muscle spindles.

Temporal properties of attention sharing consequent to disturbed balance.

The time course and extent of attentional shifts associated with compensatory balancing reactions were explored using a novel dual-task paradigm. Seated subjects performed a continuous visuomotor tracking task with the hand while the feet simultaneously balanced an inverted pendulum. The pendulum was randomly perturbed, evoking compensatory balance reactions. Changes in tracking performance were held to reflect attentional shifts. Discrete deviation in visuomotor tracking, typically a pause in tracking, began on average 235 ms after the onset of the balance reaction (TA EMG; average latency 90 ms). Such pauses lasted on average 600 ms, although additional errors in tracking lasted up to 9 s following the perturbation. The findings reveal evidence of dynamic shifts in attention associated with distinct phases of compensatory balance control. The initial phase appears to be triggered automatically, whereas later phases involve varying degrees of attentional resources.

A technique for electrically induced perturbation of rhythmic leg movement.

The paper describes electrical circuitry which replaces a mechanical brake, for perturbation of the contractile load of the legs during pedalling. The turning flywheel of an ergometer is connected to an alternator, with the electrical load provided by a power resistor connected across the output terminals. A 12-V battery provides the field current. Through variable resistors the field current is altered under microprocessor control, providing different steady-state loads when pedalling and also sudden transient changes of load. The point of change in load in the movement cycle can be accurately selected. The ergometer is instrumented for accurate measurement of pedal crank position, crank angular velocity and reaction force at the foot, to provide a physical description of the evoked steady states and transients, using microprocessor controlled sampling. The results show that the technique has application to the study of the range of reflex responses within a movement cycle and also to the more complex restoration of a movement pattern over a number of cycles. It is applicable to investigation of normal and diseased states.