Long-term effects of a progressive and specific balance-training programme with multi-task exercises for older adults with osteoporosis: a randomized controlled study.

OBJECTIVE: To evaluate long-term effects of balance-training on concerns about falling, gait, balance performance, and physical function in older adults with osteoporosis and increased risk of falling. DESIGN: Randomized controlled trial, including three groups (training, training+physical activity, and control group), with follow-ups at three, nine, and 15 months. Short-term, three-month follow-up, benefits for those who fulfilled the first follow-up ( n = 69) have previously been reported. SETTING: Stockholm, Sweden. PARTICIPANTS: A total of 96 elderly, age 66-87, with verified osteoporosis. INTERVENTIONS: Balance-training programme including dual- and multitasks, with or without supplementary physical activity, three times/week over 12 weeks. MEASUREMENTS: Concerns about falling Falls Efficacy Scale -International (FES-I), walking at preferred speed with and without a cognitive dual-task and at fast speed, balance tests (one-leg stance and modified figure-of-eight), and physical function Late-Life Function and Disability Instrument (LLFDI). RESULTS: Participants in the training group maintained positive effects throughout the study period for concerns about falling (baseline vs. 15 months, median 27.5 vs. 23 points, p < 0.001) and walking performance (baseline vs. 15 months, p ⩽ 0.05 with an improvement of 0.9-1.4 m/s). The Training+physical activity group declined to baseline values at the nine-month follow-up, and were even lower at the 15-month follow-up for concerns about falling (median 26 vs. 26 points), walking performance (changes of -0.02 to 0.04 m/s), and physical function (mean 44.0 vs. 42.9 points). The control group remained unchanged throughout the study period. CONCLUSIONS: This balance-training programme reduced concerns about falling, and also improved gait in older adults with osteoporosis and increased risk of falling in a long-term perspective - important issues for fall prevention.

A Pilot Study to Evaluate the Relationships between Supine Proprioception Assessments and Upright Functional Mobility.

Long-duration bedrest impairs upright postural and locomotor control, prompting the need for assessment tools to predict the effects of deconditioning on post-bedrest outcome measures. We developed a tilt board mounted vertically with a horizontal air-bearing sled as a potential supine assessment tool for a future bedrest study. The purpose of this pilot study was to examine the association between supine proprioceptive assessments on the tilt board and upright functional mobility. Seventeen healthy participants completed variations of a supine tilt board task and an upright functional mobility task (FMT), which is an established obstacle avoidance course. During the supine tasks, participants lay on the air-bearing sled with axial loading toward the tilt board. Participants tilted the board to capture virtual targets on an overhead monitor during 30 s trials. The tasks included two dynamic tasks (i.e., double-leg stance matching mediolateral tilt targets over ±3° or ±9° ranges) and two static tasks (i.e., single-leg stance maintaining a central target position). The performances during the dynamic tasks were significantly correlated with the FMT time to completion. The dominant-leg static task performance showed a moderate trend with the FMT time to completion. The results indicate that supine proprioceptive assessments may be associated with upright ambulation performance, and thus, support the proposed application in bedrest studies.

Improving balance control and self-reported lower extremity function in community-dwelling older adults: a randomized control trial.

OBJECTIVES: To evaluate the effect of a group-based functional and specific balance training programme that included dual-task exercises on balance function in healthy older adults. DESIGN: A single-blind randomized controlled trial. SETTING: General community. PARTICIPANTS: Sixty-six community-dwelling older adults (age 77.0 ± 6.5 years), without functional balance impairment were recruited and allocated at random to an intervention group (n = 33) or a reference group (n = 33). INTERVENTION: The intervention group received 24 training sessions over three months that included perturbation as well as dual-task exercises. The reference group received no intervention. OUTCOME MEASURES: The voluntary step execution times during single- and dual-task conditions, stabilogram-diffusion analysis in upright standing, and self-reported physical function; all were measured assessed at baseline and at the end of intervention. The intervention group was retested after six months. RESULTS: Compared with the reference group, participation in group-based functional and specific balance training led to faster voluntary step execution times under single-task (P = 0.02; effect size (ES) = 0.34) and dual-task (P = 0.036; ES = 0.55) conditions; lower transition displacement and shorter transition time of the stabilogram-diffusion analysis under eyes-closed conditions (P = 0.007, ES = 0.30 and P = 0.08, ES = 0.44, respectively); and improved self-reported lower extremity function (P = 0.006, ES = 0.37). Effects were lost at six-month follow-up. CONCLUSIONS: Functional and specific balance training can improve voluntary stepping and balance control in healthy older non-fallers, parameters previously found to be related to increased risk of falls and injury in older adults.

Long-term effects of new progressive group balance training for elderly people with increased risk of falling - a randomized controlled trial.

OBJECTIVE: To evaluate the long-term effects of a progressive and specific balance group-based program in healthy elderly individuals with increased risk of falling. DESIGN: Follow-up of a randomized controlled trial at nine and 15 months on a population that has previously been described at three months. SETTING: The study was conducted in Stockholm, Sweden. SUBJECTS: 59 community-dwelling elderly (age 67-93 years), recruited by advertisement, were randomly allocated to training or to serve as controls. INTERVENTION: Group balance training three times per week during 12 weeks with a 15 month follow-up time. MAIN MEASURES: Participants were assessed at baseline, three, nine, and 15 months thereafter for gait function (preferred and fast walking), rapid step execution (single and dual task), fear of falling, and likelihood of depression. RESULTS: Fast gait speed (p = 0.004), dual task step execution (p = 0.006) and fear of falling (p = 0.001) were still improved in the training group at nine months follow-up. Only self-perceived fear of falling remained significantly improved (p = 0.012) at 15 months follow-up. Although fast gait speed had decreased to baseline level in the training group (1.49 m/s) it remained significantly higher than in the control group (1.37 m/s) at the end of the study, a difference between the groups that was not seen at baseline. CONCLUSION: This training program provided important positive short and long-term benefits to gait, balance function, and fear of falling.

The effect of vibrotactile feedback on postural sway during locomotor activities.

BACKGROUND: Although significant progress has been achieved in developing sensory augmentation methods to improve standing balance, attempts to extend this research to locomotion have been quite limited in scope. The goal of this study was to characterize the effects of two real-time feedback displays on locomotor performance during four gait-based tasks ranging in difficulty. METHODS: Seven subjects with vestibular deficits used a trunk-based vibrotactile feedback system that provided real-time feedback regarding their medial-lateral (M/L) trunk tilt when they exceeded a subject-specific predefined tilt threshold during slow and self-paced walking, walking along a narrow walkway, and walking on a foam surface. Two feedback display configurations were evaluated: the continuous display provided real-time continuous feedback of trunk tilt, and the gated display provided feedback for 200 ms during the period immediately following heel strike. The root-mean-square (RMS) trunk tilt and percentage of time below the tilt thresholds were calculated for all locomotor tasks. RESULTS: Use of continuous feedback resulted in significant decreases in M/L trunk tilt and increases in percentage times below the tilt thresholds during narrow and foam trials. The gated display produced generally smaller changes. CONCLUSIONS: This preliminary study demonstrated that use of continuous vibrotactile feedback during challenging locomotor tasks allowed subjects with vestibular deficits to significantly decrease M/L RMS trunk tilt. Analysis of the results also showed that continuous feedback was superior.

Wearable Technologies Using Peripheral Neuromodulation to Enhance Mobility and Gait Function in Older Adults-A Narrative Review.

BACKGROUND: Mounting evidence suggests that wearable technologies using peripheral neuromodulation can provide novel ways of improving mobility and gait function in various patient populations including older adults. The purpose of this narrative review is to provide an overview of wearable technologies/devices to improve mobility and gait function through noninvasive peripheral neuromodulation in older adults over the age of 65 and to indicate the suggested mechanism of action behind these technologies. METHODS: We performed searches for articles and conference abstracts written in English, using the following databases: Embase Classic+Embase from 1947 to July 15, 2021; Ovid MEDLINE; Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions from 1946 to July 15, 2021; PubMed; and Scopus. RESULTS: Forty-one technologies met the inclusion/exclusion criteria. We found that the primary implementation of the 41 technologies can be divided into 3 main categories: sensory substitution, sensory augmentation (open loop, closed loop), and motor stimulation. Using these technologies, various aspects of mobility are treated or addressed, including, gait function, fall risk, foot drop, navigating environment, and postural control. CONCLUSIONS: This narrative review summarizes wearable technologies that are currently commercially available and in stages of research and development. Overall, studies suggest that wearable peripheral neuromodulation technologies can improve aspects of mobility for older adults. Existing literature suggests that these technologies may lead to physiological changes in the brain through sensory reweighting or other neuroplastic mechanisms to enhance the performance of mobility and gait function in older adults over the age of 65.

Postural control among children with and without attention deficit hyperactivity disorder in single and dual conditions.

Given the known deficits in attention in attention deficit hyperactivity disorder (ADHD) and the evidence suggesting that postural control requires attention, this study aimed to investigate the mechanisms of postural control of children with and without ADHD in single-(ST) and dual-task (DT) conditions. Postural sway and stabilogram diffusion analysis (SDA) were performed on the Center of Pressure trajectories on 24 ADHD children and 17 age-gender-matched healthy controls. The subjects were instructed to stand as stable as possible on a force platform in two task conditions: (1) single task (ST) and (2) dual task (DT)-an auditory-memory attention-demanding cognitive task. During ST and DT conditions, the ADHD children showed significantly greater ML-sway, short- and long-term effective diffusion coefficients, and critical displacement of SDA compared with controls. The effects of DT were somewhat unexpected; the control group indicated a significant decrease in ML-sway, AP-sway, sway area, and critical displacement of SDA; the ADHD group showed a significant decrease in ML-sway range and critical displacement. It is concluded that a greater sway displacement before closed-loop mechanisms is called into play in ADHD children. The DT enhanced balance control by reinforcing balance automaticity and minimizing sway in both healthy and ADHD children.

Six month lower-leg mechanical tactile sensory stimulation alters functional network connectivity associated with improved gait in older adults with peripheral neuropathy - A pilot study.

Foot sole somatosensory impairment associated with peripheral neuropathy (PN) is prevalent and a strong independent risk factor for gait disturbance and falls in older adults. Walkasins, a lower-limb sensory prosthesis, has been shown to improve gait and mobility in people with PN by providing afferent input related to foot sole pressure distributions via lower-leg mechanical tactile stimulation. Given that gait and mobility are regulated by sensorimotor and cognitive brain networks, it is plausible improvements in gait and mobility from wearing the Walkasins may be associated with elicited neuroplastic changes in the brain. As such, this study aimed to examine changes in brain network connectivity after 26 weeks of daily use of the prosthesis among individuals with diagnosed PN and balance problems. In this exploratory investigation, assessments of participant characteristics, Functional Gait Assessment (FGA), and resting-state functional magnetic resonance imaging were completed at study baseline and 26 weeks follow-up. We found that among those who have completed the study (N = 8; mean age 73.7 years) we observed a five-point improvement in FGA performance as well as significant changes in network connectivity over the 26 weeks that were correlated with improved FGA performance. Specifically, greater improvement in FGA score over 26 weeks was associated with increased connectivity within the Default Mode Network (DMN; p < 0.01), the Somatosensory Network (SMN; p < 0.01), and the Frontoparietal Network (FPN; p < 0.01). FGA improvement was also correlated with increased connectivity between the DMN and the FPN (p < 0.01), and decreased connectivity between the SMN and both the FPN (p < 0.01) and cerebellum (p < 0.01). These findings suggest that 26 weeks of daily use of the Walkasins device may provide beneficial neural modulatory changes in brain network connectivity via the sensory replacement stimulation that are relevant to gait improvements among older adults with PN.

Extended effects of a wearable sensory prosthesis on gait, balance function and falls after 26 weeks of use in persons with peripheral neuropathy and high fall risk-The walk2Wellness trial.

Background: We recently reported that individuals with impaired plantar sensation and high fall risk due to sensory peripheral neuropathy (PN) improved gait and balance function following 10 weeks of use of Walkasins®, a wearable lower limb sensory prosthesis that provides directional specific mechanical tactile stimuli related to plantar pressure measurements during standing and walking (RxFunction Inc., Eden Prairie, MN, United States). Here, we report 26-week outcomes and compare pre- and in-study fall rates. We expected improvements in outcomes and reduced fall rates reported after 10 weeks of use to be sustained. Materials and methods: Participants had clinically diagnosed PN with impaired plantar sensation, high fall risk (Functional Gait Assessment, FGA score < 23) and ability to sense tactile stimuli above the ankle at the location of the device. Additional outcomes included 10 m Gait Speed, Timed Up and Go (TUG), Four-Stage Balance Test, and self-reported outcomes, including Activities-Specific Balance Confidence scale and Vestibular Disorders Activities of Daily Living Scale. Participants tracked falls using a calendar. Results: We assessed falls and self-reported outcomes from 44 individuals after 26 weeks of device use; 30 of them conducted in-person testing of clinical outcomes. Overall, improvements in clinical outcomes seen at 10 weeks of use remained sustained at 26 weeks with statistically significant increases compared to baseline seen in FGA scores (from 15.0 to 19.2), self-selected gait speed (from 0.89 to 0.97 m/s), and 4-Stage Balance Test (from 25.6 to 28.4 s), indicating a decrease in fall risk. Non-significant improvements were observed in TUG and fast gait speed. Overall, 39 falls were reported; 31 of them did not require medical treatment and four caused severe injury. Participants who reported falls over 6 months prior to the study had a 43% decrease in fall rate during the study as compared to self-report 6-month pre-study (11.8 vs. 6.7 falls/1000 patient days, respectively, p < 0.004), similar to the 46% decrease reported after 10 weeks of use. Conclusion: A wearable sensory prosthesis can improve outcomes of gait and balance function and substantially decreases incidence of falls during long-term use. The sustained long-term benefits in clinical outcomes reported here lessen the likelihood that improvements are placebo effects. Clinical trial registration: ClinicalTrials.gov, identifier #NCT03538756.

Effects of new, individually adjusted, progressive balance group training for elderly people with fear of falling and tend to fall: a randomized controlled trial.

OBJECTIVE: To evaluate the effects of a new, individually adjusted, progressive and specific balance group training programme on fear of falling, step execution, and gait in healthy elderly people with fear of falling and tend to fall. DESIGN: Randomized controlled trial. SETTING: The study was conducted in Stockholm County, Sweden. SUBJECTS: Fifty-nine community dwelling elderly people were recruited by advertisement, and allocated at random to an intervention group (n = 38) or a control group (n = 21). INTERVENTION: Individually adjusted, progressive and specific balance group training was given three times a week for three months. The training incorporated elements included in, and required for, independent activities of daily living, and for reactions to loss of balance during dual or multiple tasks. MAIN MEASURES: Fear of falling was assessed with Falls Efficacy Scale International (FES-I). The reaction time of step execution was measured with the step-execution test, and gait was measured with GAITRite®. RESULTS: After three months the intervention group showed significant positive changes in the FES-I (P = 0.008), in the step-execution phase of dual-task performance (P = 0.012), and in gait at preferred speed during single-task performance; in cadence (P = 0.030) and, at fast speed, in velocity (P = 0.004) and cadence (P = 0.001). Significant decreases were also found for the likelihood of depression after participating in the training programme. CONCLUSION: This new balance training programme is feasible and leads to decreased fear of falling, decreased time for step execution during dual-task performance and increased velocity during fast walking.

Long-Term Use of a Sensory Prosthesis Improves Function in a Patient With Peripheral Neuropathy: A Case Report.

Background: Peripheral neuropathy (PN) can result in either partial or complete loss of distal sensation resulting in an increased fall risk. Walkasins® uses a shoe insert to detect the magnitude and direction of sway and sends signals to a leg unit that provides sensory balance cues. The objective of this case report is to describe the long-term influence of the Walkasins® lower limb sensory neuroprosthesis on balance and gait for an individual with diabetic PN. Case Description: A 51-year-old male with a 3-year history of PN and a 10-year history of type II diabetes mellitus was fitted bilaterally with Walkasins® and utilized them 8-10 hours/day for more than 2 years. Although, vibration and tactile sensation thresholds were severely impaired at his 1st metatarsophalangeal joint and the lateral malleolus bilaterally he could perceive tactile stimuli from the Walkasins® above the ankles. Outcomes: Following Walkasins® use, his Activities-specific Balance Confidence Scale (ABC) scores improved from 33 to 80%. His mean Vestibular Activities of Daily Living (VADL) scores decreased from 3.54 to 1. His Functional Gait Assessment (FGA) scores increased from 13/30 to 28/30 and his miniBESTest scores improved from 15/28 to 26/28. Gait speed increased from 0.23 to 1.5 m/s. The patient described a decrease in pain and cramping throughout his lower extremities and an increase in function. Discussion: Gait and balance improved with the use of the Walkasins® and participation in a wellness program. This improvement suggests that the use of sensory substitution devices, such as the Walkasins®, may replace sensory deficits related to gait and balance dysfunction experienced by patients with PN. Further research is needed to determine if other patients will have a similar response and what the necessary threshold of sensory function is to benefit from use of the Walkasins®.

Developing Proprioceptive Countermeasures to Mitigate Postural and Locomotor Control Deficits After Long-Duration Spaceflight.

Astronauts experience post-flight disturbances in postural and locomotor control due to sensorimotor adaptations during spaceflight. These alterations may have adverse consequences if a rapid egress is required after landing. Although current exercise protocols can effectively mitigate cardiovascular and muscular deconditioning, the benefits to post-flight sensorimotor dysfunction are limited. Furthermore, some exercise capabilities like treadmill running are currently not feasible on exploration spaceflight vehicles. Thus, new in-flight operational countermeasures are needed to mitigate postural and locomotor control deficits after exploration missions. Data from spaceflight and from analog studies collectively suggest that body unloading decreases the utilization of proprioceptive input, and this adaptation strongly contributes to balance dysfunction after spaceflight. For example, on return to Earth, an astronaut's vestibular input may be compromised by adaptation to microgravity, but their proprioceptive input is compromised by body unloading. Since proprioceptive and tactile input are important for maintaining postural control, keeping these systems tuned to respond to upright balance challenges during flight may improve functional task performance after flight through dynamic reweighting of sensory input. Novel approaches are needed to compensate for the challenges of balance training in microgravity and must be tested in a body unloading environment such as head down bed rest. Here, we review insights from the literature and provide observations from our laboratory that could inform the development of an in-flight proprioceptive countermeasure.

The Effects of a Wearable Sensory Prosthesis on Gait and Balance Function After 10 Weeks of Use in Persons With Peripheral Neuropathy and High Fall Risk - The walk2Wellness Trial.

BACKGROUND: Sensory peripheral neuropathy (PN) is associated with gait, balance problems and high fall risk. The walk2Wellness trial investigates effects of long-term, home-based daily use of a wearable sensory prosthesis on gait function, balance, quality of life and fall rates in PN patients. The device (Walkasins®, RxFunction Inc., MN, United States) partially substitutes lost nerve function related to plantar sensation providing directional tactile cues reflecting plantar pressure measurements during standing and walking. We tested the null hypothesis that the Functional Gait Assessment (FGA) score would remain unchanged after 10 weeks of use. METHODS: Participants had PN with lost plantar sensation, gait and balance problems, an FGA score < 23 (high fall risk), and ability to sense tactile stimuli above the ankle. Clinical outcomes included FGA, Gait Speed, Timed Up&Go (TUG) and 4-Stage Balance Test. Patient-reported outcomes included Activities-Specific Balance Confidence (ABC) scale, Vestibular Disorders Activities of Daily Living Scale, PROMIS participation and satisfaction scores, pain rating, and falls. Evaluations were performed at baseline and after 2, 6, and 10 weeks. Subjects were not made aware of changes in outcomes. No additional balance interventions were allowed. RESULTS: Forty-five participants of 52 enrolled across four sites completed in-clinic assessments. FGA scores improved from 15.0 to 19.1 (p < 0.0001), normal and fast gait speed from 0.86 m/s to 0.95 m/s (p < 0.0001) and 1.24 m/s to 1.33 m/s (p = 0.002), respectively, and TUG from 13.8 s to 12.5 s (p = 0.012). Four-Stage Balance Test did not improve. Several patient-reported outcomes were normal at baseline and remained largely unchanged. Interestingly, subjects with baseline ABC scores lower than 67% (high fall risk cut-off) increased their ABC scores (49.9% to 59.3%, p = 0.01), whereas subjects with ABC scores above 67% showed a decrease (76.6% to 71.8%, p = 0.019). Subjects who reported falls in the prior 6 months (n = 25) showed a decrease in the number of fall-risk factors (5.1 to 4.3, p = 0.023) and a decrease in fall rate (13.8 to 7.4 falls/1000 days, p = 0.014). Four pre-study non-fallers (n = 20) fell during the 10 weeks. CONCLUSION: A wearable sensory prosthesis presents a new way to treat gait and balance problems and manage falls in high fall-risk patients with PN. TRIAL REGISTRATION: ClinicalTrials.gov (#NCT03538756).

Speed of voluntary stepping in chronic stroke survivors under single- and dual-task conditions: a case-control study.

OBJECTIVE: To investigate voluntary step behavior of chronic stroke survivors during single- and dual-task conditions and compare the results to healthy age- and sex-matched controls. DESIGN: Case-control. SETTING: Laboratory-based study. PARTICIPANTS: Chronic stroke survivors (n=16) and healthy controls (n=16). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Forward and backward rapid voluntary stepping were performed as a reaction time task under 2 conditions: (1) awaiting a cutaneous cue (single task), and (2) awaiting a cutaneous cue while performing an attention-demanding task. Step initiation, preparatory and swing phases, foot-off time, and foot-contact time were extracted from center of pressure and ground reaction forceplate data. RESULTS: Chronic stroke survivors were significantly slower than healthy controls in all step parameters under single- and dual-task conditions. For dual compared with single task, the foot-contact time increased from 1295 ms to 1445 ms (12%) in chronic stroke survivors and from 876 ms to 1006 ms (15%) in controls. CONCLUSIONS: The significant increase in step phase's duration during single- and dual-task conditions may be a factor contributing to the large number of falls seen in stroke patients. The interference effects of attention-demanding task were similar between groups, suggesting that both groups used similar strategies. Future research should determine whether step training can improve step decrements in chronic stroke survivors.

Neuromodulation to improve gait and balance function using a sensory neuroprosthesis in people who report insensate feet - A randomized control cross-over study.

Peripheral neuropathy may cause loss of sensory information from plantar cutaneous mechanoreceptors that is important for balance control and falls management. The current study investigated short-term effects of using Walkasins, an external lower-limb sensory neuroprosthesis, on clinical outcomes of balance and gait in persons who reported peripheral neuropathy and balance problems. The device replaces lost plantar sensation with tactile balance information that modulates cutaneous mechanoreceptors above the ankle where sensation is intact. Thirty-one male community-dwelling Veterans, 56-84 years old with insensate feet and balance problems participated. Initial Functional Gait Assessment, gait speed, and 4-Stage Balance Test outcomes were assessed. After initial assessment, subjects were randomly assigned to either wearing Walkasins turned ON, or OFF, and outcomes were re-assessed following a set of standardized balance exercises. Following a one-hour rest and washout period, treatments were crossed-over between groups and a third outcomes assessment was performed. Before cross-over, 10 of 15 subjects in the ON-then-OFF group improved their Functional Gait Assessment score by at least four points, the Minimal Clinically Important Difference, compared to 5 of 16 in the OFF-then-ON group. After cross-over, 7 of 16 subjects in the OFF-then-ON group improved by at least four points versus 2 of 15 in the ON-then-OFF group. ON treatment was associated with a Functional Gait Assessment improvement of 4.4 ± 3.7 points versus 1.5 ± 1.2 for the OFF treatment (p<0.01). Overall, Functional Gait Assessment scores changed from 15.2 ± 4.8 at initial assessment to 21.1 ± 5.2 after final assessment (p<0.001). At the end of the two treatment sessions, 16 of the 31 individuals had improved their Functional Gait Assessment score beyond 23, indicating normal fall-risk status. Future studies should investigate long-term benefits of the device to reduce fall risk and actual falls in patients with peripheral neuropathy and balance problems.

A water-based training program that include perturbation exercises to improve stepping responses in older adults: study protocol for a randomized controlled cross-over trial.

BACKGROUND: Gait and balance impairments may increase the risk of falls, the leading cause of accidental death in the elderly population. Fall-related injuries constitute a serious public health problem associated with high costs for society as well as human suffering. A rapid step is the most important protective postural strategy, acting to recover equilibrium and prevent a fall from initiating. It can arise from large perturbations, but also frequently as a consequence of volitional movements. We propose to use a novel water-based training program which includes specific perturbation exercises that will target the stepping responses that could potentially have a profound effect in reducing risk of falling. We describe the water-based balance training program and a study protocol to evaluate its efficacy (Trial registration number #NCT00708136). METHODS/DESIGN: The proposed water-based training program involves use of unpredictable, multi-directional perturbations in a group setting to evoke compensatory and volitional stepping responses. Perturbations are made by pushing slightly the subjects and by water turbulence, in 24 training sessions conducted over 12 weeks. Concurrent cognitive tasks during movement tasks are included. Principles of physical training and exercise including awareness, continuity, motivation, overload, periodicity, progression and specificity were used in the development of this novel program. Specific goals are to increase the speed of stepping responses and improve the postural control mechanism and physical functioning. A prospective, randomized, cross-over trial with concealed allocation, assessor blinding and intention-to-treat analysis will be performed to evaluate the efficacy of the water-based training program. A total of 36 community-dwelling adults (age 65-88) with no recent history of instability or falling will be assigned to either the perturbation-based training or a control group (no training). Voluntary step reaction times and postural stability using stabiliogram diffusion analysis will be tested before and after the 12 weeks of training. DISCUSSION: This study will determine whether a water-based balance training program that includes perturbation exercises, in a group setting, can improve speed of voluntary stepping responses and improve balance control. Results will help guide the development of more cost-effective interventions that can prevent the occurrence of falls in the elderly.

Reliability of voluntary step execution behavior under single and dual task conditions.

BACKGROUND: The current study investigated the repeatability (test-retest reliability) of ground reaction force parameters recorded during a voluntary step execution under single (motor task) and dual task (motor and cognitive task) conditions for healthy adults and elderly individuals as well as the number of trials required to produce repeatable results. METHODS: Twenty-four healthy adults (21-63 years old) and 16 elderly adults (66-87 years) performed a voluntary rapid step execution following a tap on their heel while standing on a force platform under single and dual task conditions on three separate occasions. The first two tests were performed 30-60 minutes apart and the third test was performed a week later. Variables analyzed from the ground reaction force data included onset latency of step initiation (initiation phase), preparation and swing phases, foot-off and foot-contact times. RESULTS: Intraclass correlation coefficients (ICC(2,1)) were good to excellent across all parameters and test conditions for the pooled population and for elderly (0.74-0.92 and 0.62-0.88, respectively) except for the swing phase duration where lower values were seen (0.54-0.60 and 0.32-0.64 respectively). Values were similar under single and dual task conditions. CONCLUSION: A voluntary step execution test, performed under single and dual task conditions especially foot-off and foot-contact times, is a reliable outcome measure that may be a useful tool to asses dynamic balance function for diagnostic purposes as well as clinical intervention trials.

A rehabilitation tool for functional balance using altered gravity and virtual reality.

BACKGROUND: There is a need for effective and early functional rehabilitation of patients with gait and balance problems including those with spinal cord injury, neurological diseases and recovering from hip fractures, a common consequence of falls especially in the elderly population. Gait training in these patients using partial body weight support (BWS) on a treadmill, a technique that involves unloading the subject through a harness, improves walking better than training with full weight bearing. One problem with this technique not commonly acknowledged is that the harness provides external support that essentially eliminates associated postural adjustments (APAs) required for independent gait. We have developed a device to address this issue and conducted a training study for proof of concept of efficacy. METHODS: We present a tool that can enhance the concept of BWS training by allowing natural APAs to occur mediolaterally. While in a supine position in a 90 deg tilted environment built around a modified hospital bed, subjects wear a backpack frame that is freely moving on air-bearings (cf. puck on an air hockey table) and attached through a cable to a pneumatic cylinder that provides a load that can be set to emulate various G-like loads. Veridical visual input is provided through two 3-D automultiscopic displays that allow glasses free 3-D vision representing a virtual surrounding environment that may be acquired from sites chosen by the patient. Two groups of 12 healthy subjects were exposed to either strength training alone or a combination of strength and balance training in such a tilted environment over a period of four weeks. RESULTS: Isokinetic strength measured during upright squat extension improved similarly in both groups. Measures of balance assessed in upright showed statistically significant improvements only when balance was part of the training in the tilted environment. Postural measures indicated less reliance on visual and/or increased use of somatosensory cues after training. CONCLUSION: Upright balance function can be improved following balance specific training performed in a supine position in an environment providing the perception of an upright position with respect to gravity. Future studies will implement this concept in patients.

Importance and Difficulties of Pursuing rTMS Research in Acute Stroke.

Although much research has been done on repetitive transcranial magnetic stimulation (rTMS) in chronic stroke, only sparse research has been done in acute stroke despite the particularly rich potential for neuroplasticity in this stage. We attempted a preliminary clinical trial in one active, high-quality inpatient rehabilitation facility (IRF) in the -United States. But after enrolling only 4 patients in the grant period, the study was stopped because of low enrollment. The purpose of this paper is to offer a perspective describing the important physiologic rationale for including rTMS in the early phase of stroke, the reasons for our poor patient enrollment in our attempted study, and recommendations to help future studies succeed. We conclude that, if scientists and clinicians hope to enhance stroke outcomes, more attention must be directed to leveraging conventional rehabilitation with neuromodulation in the acute phase of stroke when the capacity for neuroplasticity is optimal. Difficulties with patient enrollment must be addressed by reassessing traditional inclusion and exclusion criteria. Factors that shorten patients' length of stay in the IRF must also be reassessed at all policy-making levels to make ethical decisions that promote higher functional outcomes while retaining cost consciousness.

Assessing Somatosensory Utilization during Unipedal Postural Control.

Multisensory-visual, vestibular and somatosensory information is integrated for appropriate postural control. The primary goal of this study was to assess somatosensory utilization during a functional motor task of unipedal postural control, in normal healthy adults. Assessing individual bias in the utilization of individual sensory contributions during postural control may help customization of rehabilitation protocols. In this study, a test paradigm of unipedal stance control in supine orientation with and without vision was assessed. Postural control in this test paradigm was hypothesized to utilize predominantly contributions of somatosensory information from the feet and ankle joint, with minimal vestibular input. Fourteen healthy subjects "stood" supine on their dominant leg while strapped to a backpack frame that was freely moving on air-bearings, to remove available otolith tilt cues with respect to gravity that influences postural control when standing upright. The backpack was attached through a cable to a pneumatic cylinder that provided a gravity-like load. Subjects performed three trials each with Eyes-open (EO) and Eyes-closed (EC) while loaded with 60% body weight. There was no difference in unipedal stance time (UST) across the two conditions with EC condition challenging the postural control system greater than the EO condition. Stabilogram-diffusion analysis (SDA) indicated that the critical mean square displacement was significantly different between the two conditions. Vestibular cues, both in terms of magnitude and the duration for which relevant information was available for postural control in this test paradigm, were minimized. These results support our hypothesis that maintaining unipedal stance in supine orientation without vision, minimizes vestibular contribution and thus predominantly utilizes somatosensory information for postural control.