Validation of the Equidyn protocol for evaluation of dynamic balance in older adults through a smartphone application.

BACKGROUND: Different tasks and proxy measurements have been employed to evaluate dynamic balance in older individuals. However, due to inherent limitations, results from most evaluations could hardly be taken as valid measurements of dynamic balance. RESEARCH QUESTION: Is the Equidyn smartphone application-based protocol valid and sensitive for assessment of dynamic balance in older adults? METHODS: Dynamic balance was evaluated in 52 physically active individuals, age range 60-80 years (M = 69.36). The dynamic tasks were one-leg sway either in the mediolateral (ML) or anteroposterior (AP) direction while supported on the contralateral leg, and cyclic sit-to-stand with a narrow support base. These tasks were performed under standardized movement amplitude and rhythm. Outcomes were correlated with unipedal quiet standing. A smartphone was attached to the trunk backside, and a custom-made application (Equidyn) was employed to provide guidance throughout evaluation, timed beeps to pace the movements, and three-dimensional trunk acceleration measurement for balance evaluation. RESULTS: Our data showed (a) that both ML and AP leg sway tasks were sensitive to aging and to direction of leg sway movements; (b) referenced to quiet unipedal stance, moderate/strong correlations for the ML/AP leg sway tasks and moderate correlations for the sit-to-stand task; and (c) moderate/strong correlations between the ML and AP leg sway tasks, and moderate correlations between the sit-to-stand and the two unipedal dynamic tasks in the ML acceleration direction. SIGNIFICANCE: The current results support the conclusion that the Equidyn protocol is a sensitive and valid tool to evaluate dynamic balance in healthy older individuals. The protocol tasks standardized in amplitude and rhythm favor their reproducibility and trunk acceleration data interpretation. As the whole assessment is made through a smartphone application, this dynamic balance evaluation could be made in a low-cost simple way both in the laboratory and clinical settings.

Mesencephalic Locomotor Region and Presynaptic Inhibition during Anticipatory Postural Adjustments in People with Parkinson's Disease.

Individuals with Parkinson's disease (PD) and freezing of gait (FOG) have a loss of presynaptic inhibition (PSI) during anticipatory postural adjustments (APAs) for step initiation. The mesencephalic locomotor region (MLR) has connections to the reticulospinal tract that mediates inhibitory interneurons responsible for modulating PSI and APAs. Here, we hypothesized that MLR activity during step initiation would explain the loss of PSI during APAs for step initiation in FOG (freezers). Freezers (n = 34) were assessed in the ON-medication state. We assessed the beta of blood oxygenation level-dependent signal change of areas known to initiate and pace gait (e.g., MLR) during a functional magnetic resonance imaging protocol of an APA task. In addition, we assessed the PSI of the soleus muscle during APA for step initiation, and clinical (e.g., disease duration) and behavioral (e.g., FOG severity and APA amplitude for step initiation) variables. A linear multiple regression model showed that MLR activity (R2 = 0.32, p = 0.0006) and APA amplitude (R2 = 0.13, p = 0.0097) explained together 45% of the loss of PSI during step initiation in freezers. Decreased MLR activity during a simulated APA task is related to a higher loss of PSI during APA for step initiation. Deficits in central and spinal inhibitions during APA may be related to FOG pathophysiology.

Prediction of ball direction in soccer penalty through kinematic analysis of the kicker.

The penalty kick is a crucial opportunity to score and determine the outcome of a soccer match or championship. Anticipating the direction of the ball is key for goalkeepers to enhance their defensive capabilities, considering the ball's swift travel time. However, it remains unclear which kinematic cues from the kicker can predict the ball's direction. This study aimed to identify the variables that predict the ball's direction during a soccer penalty kick. Twenty U19 soccer players executed penalty kicks towards four targets positioned in the goal, while kinematic analysis was conducted using a 3D motion analysis system. Logistic regression analysis revealed that trunk rotation in the transverse plane (towards the goal - left; or slightly to the right - right) served as the primary predictor of the ball's horizontal direction at 250 and 150 ms before the kicking foot made contact. Additionally, the height of the kicking foot in the sagittal plane solely predicted the vertical direction at the moment of contact. This information, encompassing trunk rotation and kicking foot height, can be employed in perceptual training to enhance decision-making and the implementation of feints during penalty kicks.

Control of interjoint coordination in the performance of manual circular movements can explain lateral specialization.

Between-arm performance asymmetry can be seen in different arm movements requiring specific interjoint coordination to generate the desired hand trajectory. In the current investigation, we assessed between-arm asymmetry of shoulder-elbow coordination and its stability in the performance of circular movements. Participants were 16 healthy right-handed university students. The task consisted of performing cyclic circular movements with either the dominant right arm or the nondominant left arm at movement frequencies ranging from 40% of maximum to maximum frequency in steps of 15%. Kinematic analysis of shoulder and elbow motions was performed through an optoelectronic system in the three-dimensional space. Results showed that as movement frequency increased circularity of left arm movements diminished, taking an elliptical shape, becoming significantly different from the right arm at higher movement frequencies. Shoulder-elbow coordination was found to be asymmetric between the two arms across movement frequencies, with lower shoulder-elbow angle coefficients and higher relative phase for the left compared to the right arm. Results also revealed greater variability of left arm movements in all variables assessed, an outcome observed from low to high movement frequencies. From these findings, we propose that specialization of the left cerebral hemisphere for motor control resides in its higher capacity to generate appropriate and stable interjoint coordination leading to the planned hand trajectory.

Perturbation-based balance training leads to improved reactive postural responses in individuals with Parkinson's disease and freezing of gait.

Perturbation-based balance training (PBT) exposes individuals to a series of sudden upright balance perturbations to improve their reactive postural responses. In this study, we aimed to evaluate the effect of a short PBT program on body balance recovery following a perturbation in individuals with freezing of gait due to Parkinson's disease. Volunteers (mean age = 64 years, SD = 10.6) were pseudorandomly assigned either to a PBT (n = 9) or to a resistance training (RT, n = 10) group. PBT was implemented through balance perturbations varying in the kind, direction, side and magnitude of support base displacements. Both groups exercised with progressive difficulty/load activities twice a week for 4 weeks. Specific gains and generalization to dual-tasking and faster-than-trained support base displacements were evaluated 24 h after the end of the training, and retention was evaluated after 30 days of no training. Results showed that, compared with RT, PBT led to more stable postural responses in the 30-day retention evaluation, as indicated by decreased CoP displacement, velocity and time to direction reversal and reduced numbers of near-falls. We found no transfer either to a dual task or to a higher perturbation velocity. In conclusion, a training program based on diverse unpredictable balance perturbations improved the stability of reactive postural responses to those perturbations suffered during the training, without generalization to more challenging tasks.

Cognitive and emotional factors influence specific domains of postural control in individuals with moderate-to-severe Parkinson's disease.

INTRODUCTION: Cognition and emotional state are domains that highly interfere with postural control in individuals with Parkinson's disease (PD). This study aims to find associations between executive function, anxiety, depression, and reactive and anticipatory postural control domains in individuals with moderate-to-severe Parkinson's disease. METHODS: In this study, 34 individuals with PD while on medication were thoroughly assessed for postural control in perturbed, quiet standing and stepping. We performed multiple linear stepwise regressions using postural variables as dependent and cognitive/emotional as independent variables. RESULTS: The results showed that cognitive flexibility explained 23 % of anticipatory postural adjustments (APA) duration, inhibitory control explained 42 % of instability on a malleable surface, anxiety explained 21 % of APA amplitude, and 38 % of reactive postural response amplitude. CONCLUSION: Our results highlight the impact of emotional and cognitive states on particular domains of postural control in individuals with PD while on medication. These results may have significant implications for future treatments, mainly considering the predictors for postural control domains, which were consistent with the assumption that impairments in affective and executive domains underlie posture. As we have shown that cognitive and emotional states influence postural control domains in individuals with PD, this should be taken into account in rehabilitation protocols.

Freezing of gait, gait initiation, and gait automaticity share a similar neural substrate in Parkinson's disease.

Individuals with Parkinson's disease (PD) and freezing of gait (FOG) have difficulty initiating and maintaining a healthy gait pattern; however, the relationship among FOG severity, gait initiation, and gait automaticity, in addition to the neural substrate of this relationship has not been investigated. This study investigated the association among FOG severity during turning (FOG-ratio), gait initiation (anticipatory postural adjustment [APA]), and gait automaticity (dual-task cost [DTC]), and the neural substrates of these associations. Thirty-four individuals with FOG of PD were assessed in the ON-medication state. FOG-ratio during a turning test, gait automaticity using DTC on stride length and gait speed, and APA during an event-related functional magnetic resonance imaging protocol to assess brain activity from the regions of interest (e.g., dorsolateral prefrontal cortex [DLPFC] and mesencephalic locomotor region [MLR]) were assessed in separated days. Results showed that FOG-ratio, APA amplitude, and DTC on stride length are negatively associated among them (P < 0.05). APA amplitude and DTC on stride length explained 59% of the FOG-ratio variance (P < 0.05). Although the activity of the right DLPFC and right MLR explained 55% of the FOG-ratio variance (P < 0.05) and 30% of the DTC on stride length variance (P ≤ 0.05), only the activity of the right MLR explained 23% of the APA amplitude (P < 0.05). FOG severity during turning, APA amplitude, and stride length automaticity are associated among them and share a similar locomotor substrate, as the MLR activity was a common brain region in explaining the variance of these variables.

Between-leg asymmetry in automatic postural responses to stance perturbations in people with Parkinson's disease.

BACKGROUND: People with Parkinson's disease (PwPD) showed impairments of balance control which can be aggravated by the presence of higher interlateral postural asymmetry caused by a distinct dopaminergic loss in the substantia nigra between cerebral hemispheres. RESEARCH QUESTION: We evaluate asymmetries between the more and the less affected leg in PwPD in responses to unanticipated stance perturbations. METHODS: Sixteen 16 PwPD participated in the experiment that consisted of recovering a stable upright stance, keeping the feet in place, in response to a perturbation caused by a sudden release of a load equivalent to 7 % of the participant's body mass. Anterior displacement and velocity of the center of pressure (CoP), the latency of gastrocnemius medialis muscle (GM) activation onset, rate of GM activation, and normalized magnitude of muscular activation were analyzed. RESULTS: Analysis revealed significantly rate (p = 0.04) and magnitude (p = 0.02) higher activation of GM in the less affected limb. No significant effects of the leg were found for GM activation latency or CoP-related variables. SIGNIFICANCE: There is a higher contribution of the less affected leg in automatic postural responses in PwPD.

Use of accelerometry to investigate standing and dynamic body balance in people with cerebral palsy: A systematic review.

BACKGROUND: People with cerebral palsy (CP) often have difficulties related to maintaining body balance in their daily living activities. Accelerometers are low-cost wearable devices with potential use to objectively assess balance. RESEARCH QUESTION: What are the main characteristics and findings from protocols used in research aiming to investigate standing or dynamic body balance stability through trunk accelerometry in people with CP? METHOD: We searched in December 2021 seven databases, Pubmed, Embase, Cochrane, Science Direct, Scopus, PEDro, and Lilacs, with descriptors related to cerebral palsy, accelerometer, and balance. RESULTS: Ten studies were included, with a total of 197 evaluated people with CP. These studies were classified as moderate or high methodological quality. We found convergence on the use of the sensor at the lumbar region (L3), with sampling frequency at 100 Hz. For balance assessment, 60 % of the reviewed studies used the 10-m walk test, while the other studies used different walking distances, or the quiet standing test. For data processing, the low-pass filter at 20 Hz has been used predominantly, and the most commonly used variable to evaluate balance stability has been root mean square of trunk acceleration. Children and adolescents with CP had higher acceleration values and greater gait complexity than typically developing children. Individuals with bilateral impairment had greater anteroposterior and mediolateral trunk accelerations than those with unilateral impairment. Trunk acceleration was shown to be sensitive to improvement in gait stability from interventions, and acceleration-based measures have been found to correlate with qualitative balance assessment tools. SIGNIFICANCE: Trunk accelerometry in quiet posture and dynamic tasks was shown to be a valid and sensitive measurement to evaluate balance stability in children and adolescents with CP. It is a small, light, low-cost and easy-to-handle tool that is effective for measuring body balance on different tasks in this population.

Differential activation of the plantar flexor muscles in balance control across different feet orientations on the ground.

The ankle plantar flexor muscles act synergistically to control quiet and dynamic body balance. Previous research has shown that the medial (MG) and lateral (LG) gastrocnemii, and soleus (SOL) are differentially activated as a function of motor task requirements. In the present investigation, we evaluated modulation of the plantar flexors' activation from feet orientation on the ground in an upright stance and the ensuing reactive response to a perturbation. A single group of young participants (n = 24) was evaluated in a task requiring initial stabilization of body balance against a backward pulling load (5% or 10% of body weight) attached to their trunk, and then the balance was suddenly perturbed, releasing the load. Four feet orientations were compared: parallel (0°), outward orientation at 15° and 30°, and the preferred orientation (M = 10.5°). Results revealed a higher activation magnitude of SOL compared to MG-LG when sustaining quiet balance against the 10% load. In the generation of reactive responses, MG was characterized by earlier, steeper, and proportionally higher activation than LG-SOL. Feet orientation at 30° led to higher muscular activation than the other orientations, while the activation relationship across muscles was unaffected by feet orientation. Our results support the conclusion of task-specific differential modulation of the plantar flexor muscles for balance control.

Vigor of reactive postural responses is set from feedback and feedforward processes.

I explore a distinct perspective from that brought in the book by arguing that in postural control our organism selects the vigor of reactive responses guided by an optimization rule considering first the required postural response for balance recovery as indicated by afferent information from a myriad of sensory receptors, and second the history of previous responses to similar perturbations.

Preserved flexibility of dynamic postural control in individuals with Parkinson's disease.

BACKGROUND: Continuous oscillation of the support base requires anticipatory and reactive postural adjustments to maintain a stable balance. In this context, postural control flexibility or the ability to adjust balance mechanisms following the requirements of the environment is needed to counterbalance the predictable, continuous perturbation of body balance. Considering the inflexibility of postural responses in individuals with Parkinson's disease (PD), maintaining stability in the support base's continuous oscillations may be challenging. Varying the frequency of platform oscillation is an exciting approach to assess the interactions between reactive and anticipatory adjustments. RESEARCH QUESTION: This study aimed to analyze postural responses of individuals with PD on an oscillatory support base across different frequencies. METHODS: Thirty participants with moderate PD diagnosis (M = 64.47 years, SD = 8.59; Hoehn and Yahr scale 3) and fifteen healthy age-matched controls (M = 65.8 years, SD = 4.2) were tested. Subjects maintained a dynamic balance on a platform oscillating in sinusoidal translations. Four oscillation frequencies were evaluated in different trials that ranged from 0.2 to 0.8 Hz in steps of 0.2 Hz. RESULTS: Analysis showed similar performance between PD and healthy participants, with modulation of amplitudes of head displacement, center of pressure, center of mass and feet-head coordination to platform oscillation frequency. DISCUSSION: Our findings suggest a preserved ability of individuals with PD to dynamically control body balance on a support base with predictable oscillatory translations.

Age-Related Changes in Presynaptic Inhibition During Gait Initiation.

Age-related changes in presynaptic inhibition (PSI) have not been observed during gait initiation, which requires anticipatory postural adjustment (APA). As APA is centrally modulated and is impaired in older compared to young adults, here we aimed to study the presynaptic control and co-contraction levels in the ankle muscles during gait initiation in older compared to young adults. Fifteen older (age range 65-80 years) and 15 young adults (age range 19-30 years) performed a gait initiation task on a force platform under 3 conditions: (i) without electrical stimulation; (ii) test Hoffman reflex (H-reflex); and (iii) conditioned H-reflex. H-reflexes were evoked on the soleus muscle when the APA amplitude exceeded 10%-20% of the average baseline mediolateral force. Participants also performed quiet stance as a control task. Results showed that both age groups presented similar PSI levels during quiet stance (p = .941), while in the gait initiation older adults presented higher PSI levels, longer duration, and lower amplitude of APA than young adults (p < .05). Older adults presented higher co-contraction ratio in both tasks than young adults (p < .05). Correlations between the PSI levels and the APA amplitude (r = -0.61, p = .008), and between the PSI levels and the co-contraction ratio during gait initiation (r = -0.64, p = .005) were found for older adults only. APA amplitude explained 49% of the variance of the PSI levels (p = .003). Our findings suggest that older compared to young adults have increased presynaptic control to compensate for the decreased supraspinal modulation on impaired APAs during gait initiation.

Compensatory control between the legs in automatic postural responses to stance perturbations under single-leg fatigue.

In response to sudden perturbations of stance stability, muscles of both legs are activated for balance recovery. In conditions that one of the legs has a reduced capacity to respond, the opposite leg is predicted to compensate by responding more powerfully to restore stable upright stance. In this investigation, we aimed to evaluate between-leg compensatory control in automatic postural responses to sudden perturbations in a situation in which plantar flexor muscles of a single leg were fatigued. Young participants were evaluated in response to a series of perturbations inducing forward body sway, with a focus on activation of plantar flexor muscles: lateral and medial gastrocnemii and soleus. Muscular responses were analyzed through activation magnitude and latency of muscular activation onset. For evaluation of balance and postural stability, we also analyzed the center of pressure and upper trunk displacement and weight-bearing asymmetry between the legs. Responses were assessed in three conditions: pre-fatigue, under single-leg fatigue, and following the recovery of muscular function. Results showed (a) compensation of the non-fatigued leg through the increased magnitude of muscular activation in the first perturbation under fatigue; (b) adaptation in the non-fatigued leg over repetitive perturbations, with a progressive decrement of muscular activation over trials; and (c) maintenance of increased muscular activation of the non-fatigued leg following fatigue dissipation. These findings suggest that the central nervous system is able to modulate the descending motor drive individually for each leg's muscles apparently based on their potential contribution for the achievement of the behavioral aim of recovering stable body balance following stance perturbations.

Is freezing of gait correlated with postural control in patients with moderate-to-severe Parkinson's disease?

Freezing of gait (FoG) is one of the main reasons for movement initiation disorders and abnormal coupling of posture and gait in Parkinson's disease (PD). Patients with FoG have poor postural control when compared to patients without FoG. However, the nature of the interrelationship between FoG and domains of postural control remains unknown. The aim of this study was to estimate the association between different domains of postural control and severity of FoG in patients with moderate-to-severe PD. Thirty patients with idiopathic PD with FoG (age range 45-80 years, Hoehn & Yahr stages 3 and 4) participated in the study. We evaluated objective (FoG-ratio during turning task) and subjective (New Freezing of Gait Questionnaire, NFoG-Q) measures of FoG severity, reactive postural adjustments in response to an external perturbation, first step anticipatory adjustment for step initiation and quiet standing stability. In the multiple regression analysis, step initiation was the strongest significant correlation of the NFoG-Q score explaining 23% of the variance of the assessment. For the objective FoG measure, mediolateral CoP amplitude in quiet standing and mediolateral CoP amplitude in step initiation explained 39% of the variance of the FoG-ratio. As main conclusions, this study identified the association between objective and subjective measure for FoG severity and postural control domains. The results support conducting step initiation training during rehabilitation of individuals with FoG.

Associations Between Women's Obesity Status and Diminished Cutaneous Sensibility Across Foot Sole Regions.

People who are obese sustain very high foot pressures when standing, with potential consequences to their feet soles' cutaneous sensibility. In the current investigation, we performed a detailed assessment of foot sole sensibility in women with morbid obesity (n = 13; age = 38.85, SD = 8.09 years) status in comparison with leaner women (n = 13; age = 37.62, SD = 7.10 years). We estimated tactile feet sole sensibility through graduated monofilament light touch applied at several hotspots of both feet soles, covering the toes, metatarsal heads, midfoot internal and lateral arches, and heel. Intergroup comparisons per foot sole region indicated significantly lower sensibility for the group with morbid obesity under the fifth and third metatarsal heads, midfoot lateral and internal arches and heel. We found a large variation across the sole regions, with the lowest difference between the obese and lean groups observed under the hallux (18%) and the largest difference observed under the lateral arch of the midfoot (76%). Correlation analyses between body weight and sensibility scores revealed a significant positive correlation among participants who were leaner (rs = 0.56, p = 0.05) but not among participants who were obese (rs = -0.06, p = 0.83). Mainly, our results showed that morbid obesity was associated with significantly higher cutaneous sensibility thresholds, with large variability of the sensibility deficit across different regions of both feet soles. Due to its functional relevance for body balance control, reduced sensibility thresholds among women who are morbidly obese may have implications for stance stability.

Are the Predictions of the Dynamic Dominance Model of Laterality Applicable to Children?

According to the dynamic dominance model, the left cerebral hemisphere is specialized for the control of intersegmental dynamics and the right hemisphere for impedance control. Our aim was to test predictions from the dynamic dominance model in children by comparing performance between the right (preferred) and left hands in aiming. Three groups were compared: 4-7, 8-11, and 18-38 years old. Results showed higher movement linearity in the performance with the right hand in all age groups (P < .01), while initial directional error and endpoint accuracy were equivalent between hands. These results provided partial support for the dynamic dominance model.

Are the predictions of the dynamic dominance model of laterality applicable to the lower limbs?

Investigation of manual actions has supported the proposition that the right and left cerebral hemispheres have complementary specializations relevant for movement control. To test the extent to which hemisphere specialization affect lower limb control, we compared performance between the legs in two motor tasks. A pedal aiming task was employed to test the notion of left hemisphere specialization for dynamic control, and unipedal balance was employed to test the notion of right hemisphere specialization for impedance control. Evaluation was conducted on young adults, in the contexts of separate (Experiment 1) and integrated (Experiment 2) performance of the probing tasks. Results from the aiming task showed equivalent movement linearity toward the target between the right and left feet across experiments. Analysis of unipedal balance revealed that increased stance stability when supported on the left leg was observed when performing simultaneously the aiming task with the contralateral foot, but not in the context of isolated task performance. These results are inconsistent with the proposition of left hemisphere specialization for dynamic control in the lower limbs, and suggest that specialization of the right hemisphere for impedance control can be observed in balance control when stance is associated with voluntary movements of the contralateral lower limb.

A Randomized, Controlled Trial of Exercise for Parkinsonian Individuals With Freezing of Gait.

BACKGROUND: Exercises with motor complexity induce neuroplasticity in individuals with Parkinson's disease (PD), but its effects on freezing of gait are unknown. The objective of this study was to verify if adapted resistance training with instability - exercises with motor complexity will be more effective than traditional motor rehabilitation - exercises without motor complexity in improving freezing-of-gait severity, outcomes linked to freezing of gait, and brain function. METHODS: Freezers were randomized either to the adapted resistance training with instability group (n = 17) or to the active control group (traditional motor rehabilitation, n = 15). Both training groups performed exercises 3 times a week for 12 weeks. The primary outcome was the New Freezing of Gait Questionnaire. Secondary outcomes were freezing of gait ratio (turning task), cognitive inhibition (Stroop-III test), motor signs (Unified Parkinson's Disease Rating Scale part-III [UPDRS-III]), quality of life (PD Questionnaire 39), anticipatory postural adjustment (leg-lifting task) and brain activation during a functional magnetic resonance imaging protocol of simulated anticipatory postural adjustment task. Outcomes were evaluated before and after interventions. RESULTS: Only adapted resistance training with instability improved all the outcomes (P < 0.05). Adapted resistance training with instability was more effective than traditional motor rehabilitation (in improving freezing-of-gait ratio, motor signs, quality of life, anticipatory postural adjustment amplitude, and brain activation; P < 0.05). Our results are clinically relevant because improvement in the New Freezing of Gait Questionnaire (-4.4 points) and UPDRS-III (-7.4 points) scores exceeded the minimally detectable change (traditional motor rehabilitation group data) and the moderate clinically important difference suggested for PD, respectively. The changes in mesencephalic locomotor region activation and in anticipatory postural adjustment amplitude explained the changes in New Freezing of Gait Questionnaire scores and in freezing-of-gait ratio following adapted resistance training with instability, respectively. CONCLUSIONS: Adapted resistance training with instability is able to cause significant clinical improvement and brain plasticity in freezers. © 2020 International Parkinson and Movement Disorder Society.