Assessment of the underlying systems involved in standing balance: the additional value of electromyography in system identification and parameter estimation.

BACKGROUND: Closed loop system identification (CLSIT) is a method to disentangle the contribution of underlying systems in standing balance. We investigated whether taking into account lower leg muscle activation in CLSIT could improve the reliability and accuracy of estimated parameters identifying the underlying systems. METHODS: Standing balance behaviour of 20 healthy young participants was measured using continuous rotations of the support surface (SS). The dynamic balance behaviour obtained with CLSIT was expressed by sensitivity functions of the ankle torque, body sway and muscle activation of the lower legs to the SS rotation. Balance control models, 1) without activation dynamics, 2) with activation dynamics and 3) with activation dynamics and acceleration feedback, were fitted on the data of all possible combinations of the 3 sensitivity functions. The reliability of the estimated model parameters was represented by the mean relative standard errors of the mean (mSEM) of the estimated parameters, expressed for the basic parameters, the activation dynamics parameters and the acceleration feedback parameter. To investigate the accuracy, a model validation study was performed using simulated data obtained with a comprehensive balance control model. The accuracy of the estimated model parameters was described by the mean relative difference (mDIFF) between the estimated parameters and original parameters. RESULTS: The experimental data showed a low mSEM of the basic parameters, activation dynamics parameters and acceleration feedback parameter by adding muscle activation in combination with activation dynamics and acceleration feedback to the fitted model. From the simulated data, the mDIFF of the basic parameters varied from 22.2-22.4% when estimated using the torque and body sway sensitivity functions. Adding the activation dynamics, acceleration feedback and muscle activation improved mDIFF to 13.1-15.1%. CONCLUSIONS: Adding the muscle activation in combination with the activation dynamics and acceleration feedback to CLSIT improves the accuracy and reliability of the estimated parameters and gives the possibility to separate the neural time delay, electromechanical delay and the intrinsic and reflexive dynamics. To diagnose impaired balance more specifically, it is recommended to add electromyography (EMG) to body sway (with or without torque) measurements in the assessment of the underlying systems.

Adaptation of multijoint coordination during standing balance in healthy young and healthy old individuals.

Standing balance requires multijoint coordination between the ankles and hips. We investigated how humans adapt their multijoint coordination to adjust to various conditions and whether the adaptation differed between healthy young participants and healthy elderly. Balance was disturbed by push/pull rods, applying two continuous and independent force disturbances at the level of the hip and between the shoulder blades. In addition, external force fields were applied, represented by an external stiffness at the hip, either stabilizing or destabilizing the participants' balance. Multivariate closed-loop system-identification techniques were used to describe the neuromuscular control mechanisms by quantifying the corrective joint torques as a response to body sway, represented by frequency response functions (FRFs). Model fits on the FRFs resulted in an estimation of time delays, intrinsic stiffness, reflexive stiffness, and reflexive damping of both the ankle and hip joint. The elderly generated similar corrective joint torques but had reduced body sway compared with the young participants, corresponding to the increased FRF magnitude with age. When a stabilizing or destabilizing external force field was applied at the hip, both young and elderly participants adapted their multijoint coordination by lowering or respectively increasing their neuromuscular control actions around the ankles, expressed in a change of FRF magnitude. However, the elderly adapted less compared with the young participants. Model fits on the FRFs showed that elderly had higher intrinsic and reflexive stiffness of the ankle, together with higher time delays of the hip. Furthermore, the elderly adapted their reflexive stiffness around the ankle joint less compared with young participants. These results imply that elderly were stiffer and were less able to adapt to external force fields.

Changes in sensory reweighting of proprioceptive information during standing balance with age and disease.

With sensory reweighting, reliable sensory information is selected over unreliable information during balance by dynamically combining this information. We used system identification techniques to show the weight and the adaptive process of weight change of proprioceptive information during standing balance with age and specific diseases. Ten healthy young subjects (aged between 20 and 30 yr) and 44 elderly subjects (aged above 65 yr) encompassing 10 healthy elderly, 10 with cataract, 10 with polyneuropathy, and 14 with impaired balance, participated in the study. During stance, proprioceptive information of the ankles was disturbed by rotation of the support surface with specific frequency content where disturbance amplitude increased over trials. Body sway and reactive ankle torque were measured to determine sensitivity functions of these responses to the disturbance amplitude. Model fits resulted in a proprioceptive weight (changing over trials), time delay, force feedback, reflexive stiffness, and damping. The proprioceptive weight was higher in healthy elderly compared with young subjects and higher in elderly subjects with cataract and with impaired balance compared with healthy elderly subjects. Proprioceptive weight decreased with increasing disturbance amplitude; decrease was similar in all groups. In all groups, the time delay was higher and the reflexive stiffness was lower compared with young or healthy elderly subjects. In conclusion, proprioceptive information is weighted more with age and in patients with cataract and impaired balance. With age and specific diseases the time delay was higher and reflexive stiffness was lower. These results illustrate the opportunity to detect the underlying cause of impaired balance in the elderly with system identification.

Influence of subscapularis tendon reattachment after reverse shoulder arthroplasty: clinical findings and ultrasonographic evaluation of the subscapularis at 89 months mean follow-up.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is commonly used to treat rotator cuff arthropathy. In the deltopectoral approach for RSA, the subscapularis tendon is (partly) detached. The clinical effects of subscapularis reattachment are still under debate. An observational study was performed to evaluate the clinical effects of subscapularis tendon reattachment on the mid- to long-term following RSA. METHODS: In this study, 40 patients for a total of 46 shoulders with a reverse shoulder prosthesis participated. Constant Murley Score (CMS), Oxford Shoulder Score (OSS), Range of Motion (ROM) and abduction and internal rotation strength were measured. The integrity of the subscapularis tendon at follow-up was assessed using ultrasound. Outcomes were compared between three groups: repair and intact at follow-up, repair and not intact, and no repair. RESULTS: Mean follow-up was 89 months with a minimum of three years. CMS, OSS, ROM and strength did not differ between groups. One-third of the initially reattached subscapularis tendons were still present at follow-up. No dislocations were reported. CONCLUSION: This study showed no clinical effects of subscapularis reattachment after reverse shoulder arthroplasty on the mid- to long-term.

Sensory reweighting of proprioceptive information of the left and right leg during human balance control.

To keep balance, information from different sensory systems is integrated to generate corrective torques. Current literature suggests that this information is combined according to the sensory reweighting hypothesis, i.e., more reliable information is weighted more strongly than less reliable information. In this approach, no distinction has been made between the contributions of both legs. In this study, we investigated how proprioceptive information from both legs is combined to maintain upright stance. Healthy subjects maintained balance with eyes closed while proprioceptive information of each leg was perturbed independently by continuous rotations of the support surfaces (SS) and the human body by platform translation. Two conditions were tested: perturbation amplitude of one SS was increased over trials while the other SS 1) did not move or 2) was perturbed with constant amplitude. With the use of system identification techniques, the response of the ankle torques to the perturbation amplitudes (i.e., the torque sensitivity functions) was determined and how much each leg contributed to stabilize stance (i.e., stabilizing mechanisms) was estimated. Increased amplitude of one SS resulted in a decreased torque sensitivity. The torque sensitivity to the constant perturbed SS showed no significant differences. The properties of the stabilizing mechanisms remained constant during perturbations of each SS. This study demonstrates that proprioceptive information from each leg is weighted independently and that the weight decreases with perturbation amplitude. Weighting of proprioceptive information of one leg has no influence on the weight of the proprioceptive information of the other leg. According to the sensory reweighting hypothesis, vestibular information must be up-weighted, because closing the eyes eliminates visual information.

Estimating ankle torque and dynamics of the stabilizing mechanism: No need for horizontal ground reaction forces.

Changes in human balance control can objectively be assessed using system identification techniques in combination with support surface translations. However, large, expensive and complex motion platforms are required, which are not suitable for the clinic. A treadmill could be a simple alternative to apply support surface translations. In this paper we first validated the estimation of the joint stiffness of an inverted pendulum using system identification methods in combination with support surface translations, by comparison with the joint stiffness calculated using a linear regression method. Second, we used the system identification method to investigate the effect of horizontal ground reaction forces on the estimation of the ankle torque and the dynamics of the stabilizing mechanism of 12 healthy participants. Ankle torque and resulting frequency response functions, which describes the dynamics of the stabilizing mechanism, were calculated by both including and excluding horizontal ground reaction forces. Results showed that the joint stiffness of an inverted pendulum estimated using system identification is comparable to the joint stiffness estimated by a regression method. Secondly, within the induced body sway angles, the ankle torque and frequency response function of the joint dynamics calculated by both including and excluding horizontal ground reaction forces are similar. Therefore, the horizontal ground reaction forces play a minor role in calculating the ankle torque and frequency response function of the dynamics of the stabilizing mechanism and can thus be omitted.

Effect of Amplitude and Number of Repetitions of the Perturbation on System Identification of Human Balance Control During Stance.

To unravel the underlying mechanisms of human balance control, system identification techniques are applied in combination with dedicated perturbations, like support surface translations. However, it remains unclear what the optimal amplitude and number of repetitions of the perturbation signal are. In this study we investigated the effect of the amplitude and number of repetitions on the identification of the neuromuscular controller (NMC). Healthy participants were asked to stand on a treadmill while small continuous support surface translations were applied in the form of a periodic multisine signal. The perturbation amplitude varied over seven conditions between 0.02 and 0.20 m peak-to-peak (ptp), where 6.5 repetitions of the multisine signal were applied for each amplitude, resulting in a trial length of 130 sec. For one of the conditions, 24 repetitions were recorded. The recorded external perturbation torque, body sway and ankle torque were used to calculate both the relative variability of the frequency response function (FRF) of the NMC, i.e., a measure for precision, depending on the noise-to-signal ratio (NSR) and the nonlinear distortions. Results showed that the perturbation amplitude should be minimally 0.05 m ptp, but higher perturbation amplitudes are preferred since they resulted in a higher precision, due to a lower noise-to-signal ratio (NSR). There is, however, no need to further increase the perturbation amplitude than 0.14 m ptp. Increasing the number of repetitions improves the precision, but the number of repetitions minimally required, depends on the perturbation amplitude and the preferred precision. Nonlinear contributions are low and, for the ankle torque, constant over perturbation amplitude.

Compliant support surfaces affect sensory reweighting during balance control.

To maintain upright posture and prevent falling, balance control involves the complex interaction between nervous, muscular and sensory systems, such as sensory reweighting. When balance is impaired, compliant foam mats are used in training methods to improve balance control. However, the effect of the compliance of these foam mats on sensory reweighting remains unclear. In this study, eleven healthy subjects maintained standing balance with their eyes open while continuous support surface (SS) rotations disturbed the proprioception of the ankles. Multisine disturbance torques were applied in 9 trials; three levels of SS compliance, combined with three levels of desired SS rotation amplitude. Two trials were repeated with eyes closed. The corrective ankle torques, in response to the SS rotations, were assessed in frequency response functions (FRF). Lower frequency magnitudes (LFM) were calculated by averaging the FRF magnitudes in a lower frequency window, representative for sensory reweighting. Results showed that increasing the SS rotation amplitude leads to a decrease in LFM. In addition there was an interaction effect; the decrease in LFM by increasing the SS rotation amplitude was less when the SS was more compliant. Trials with eyes closed had a larger LFM compared to trials with eyes open. We can conclude that when balance control is trained using foam mats, two different effects should be kept in mind. An increase in SS compliance has a known effect causing larger SS rotations and therefore greater down weighting of proprioceptive information. However, SS compliance itself influences the sensitivity of sensory reweighting to changes in SS rotation amplitude with relatively less reweighting occurring on more compliant surfaces as SS amplitude changes.

Impaired standing balance: the clinical need for closing the loop.

Impaired balance may limit mobility and daily activities, and plays a key role in the elderly falling. Maintaining balance requires a concerted action of the sensory, nervous and motor systems, whereby cause and effect mutually affect each other within a closed loop. Aforementioned systems and their connecting pathways are prone to chronological age and disease-related deterioration. System redundancy allows for compensation strategies, e.g. sensory reweighting, to maintain standing balance in spite of the deterioration of underlying systems. Once those strategies fail, impaired balance and possible falls may occur. Targeted interventions to prevent falling require knowledge of the quality of the underlying systems and the compensation strategies used. As current clinical balance tests only measure the ability to maintain standing balance and cannot distinguish between cause and effect in a closed loop, there is a clear clinical need for new techniques to assess standing balance. A way to disentangle cause-and-effect relations to identify primary defects and compensation strategies is based on the application of external disturbances and system identification techniques, applicable in clinical practice. This paper outlines the multiple deteriorations of the underlying systems that may be involved in standing balance, which have to be detected early to prevent impaired standing balance. An overview of clinically used balance tests shows that early detection of impaired standing balance and identification of causal mechanisms is difficult with current tests, thereby hindering the development of well-timed and target-oriented interventions as described next. Finally, a new approach to assess standing balance and to detect the underlying deteriorations is proposed.