A pelvis-oriented margin of stability is robust against deviations in walking direction.

The Margin of Stability (MOS) is often assessed relative to the intended, linear path of walking progression. When an unanticipated or irregular change in direction occurs, such as during a sudden turn or during activities of daily living, distinguishing the lateral from anteroposterior MOS can be challenging. The purpose of this study was to assess an anatomically orientated method of calculating the MOS using the pelvic orientation to define lateral and anteroposterior directions. We hypothesized that when straight walking was disrupted with a curved path, the pelvis-oriented MOS measure would be less variable compared to the global-oriented MOS measure. We recruited 16 unimpaired participants to walk at preferred and fast walking speeds along a straight walking path, as well as a path with an exaggerated, curvilinear deviation. We determined the within-subject mean and standard deviation of the anterior MOS at mid-swing and the posterior and lateral MOS at ipsilateral foot strike. For straight walking and curved walking separately, repeated measures factorial ANOVAs assessed the effects of model (global or pelvis-oriented), limb (left or right), and speed (preferred or fast) on these MOS values. Based on reduced variability during curved walking, the pelvis-oriented MOS was more robust to walking deviations than the globally defined MOS. In straight walking, the pelvis-oriented MOS was characterized by less lateral and more anterior stability with differences exacerbated by faster walking. These results suggest a pelvis-oriented MOS has utility when the path of progression is unknown or unclear.

How should the margin of stability during walking be expressed to account for body size?

When expressing the margin of stability as a distance, it does not directly estimate the perturbation magnitude needed to change stability states. Additionally, it is unknown how body size may influence this measure. Therefore, we propose other expressions of stability margins, including that of an impulse, a change in center of mass velocity, and a scaled, unitless impulse. The purpose of this study was to determine the influence of body size on these margin expressions using walking data from children and adults. We anticipated that margins expressed as an impulse would have strong correlations with body mass and height, as well as large between-group differences. We predicted that scaling this impulse value would result in small correlations and between-group effect sizes. We calculated each stability margin at minimum lateral values and in the anteroposterior directions at mid-swing and foot strike. In the lateral direction, margins expressed as an impulse had strong correlations with body size (r≥0.58, p<0.01) and large between-group differences (|d|≥1.07, p<0.01). The other expressions did not have strong positive correlations (|r|≤0.20) or large between-group effects (|d|≤0.44). In the anteroposterior directions, impulse margins had strong correlations with body size (|r|≥0.83, p<0.01) and large between-group differences (|d|≥1.74, p<0.01). The scaled, unitless impulse margin was the only variable that resulted in small, non-significant differences (|r|≤0.22, p≥0.24) as well as small between-group effect sizes (|d|≤0.46, p≥0.22). We propose expressing stability margins as an impulse. If scaling is needed, we encourage using the scaled, unitless impulse.

A novel method to quantify individual limb contributions to standing postural control.

BACKGROUND: Understanding individual limb contributions to standing postural control is valuable when evaluating populations with asymmetric function (e.g., stroke, amputations). We propose a method of quantifying three contributions to controlling the net anteroposterior center of pressure (CoP) during quiet standing: CoP moving under left and right limbs and weight shifting between the two limbs. RESEARCH QUESTION: Can these contributions to standing postural control be quantified from CoP trajectories in neurotypical adults? METHODS: Instantaneous contributions can be negative or larger than one, and integrated contributions sum to equal one. Proof-of-concept demonstrations validated these calculated contributions by restricting CoP motion under one or both feet. We evaluated these contributions in 30 neurotypical young adults who completed two (eyes opened; eyes closed) 30-s trials of bipedal standing. We evaluated the relationships between limb contributions, self-reported limb dominance, and between-limb weight distributions. RESULTS: All participants self-reported as right-limb dominant; however, a range of mean limb contributions were observed with eyes opened (Left: mean [range] = 0.52 [0.37-0.63]; Right: 0.48 [0.31-0.63]) and with eyes closed (Left: 0.51 [0.39-0.63]; Right: 0.49 [0.37-0.61]). Weight-shift contributions were small with eyes opened (0.00 [-0.01 to 0.01]) and eyes closed (0.00 [-0.01 to 0.02]). We did not identify any between-limb differences in contributions when grouped by self-reported limb dominance (p > 0.10, d < 0.31). Contributions did not significantly correlate with Waterloo Footedness scores (-0.22 < r < 0.21, p > 0.25) or between-limb weight distributions (0 < r < 0.24, p > 0.20). SIGNIFICANCE: Across neurotypical participants, we observed a notable range of limb contributions not related to self-reported limb dominance or between-limb weight distributions. With this tool, we can characterize differences in the amount of CoP motion and the underlying control strategies. Changes in limb contribution can be measured longitudinally (i.e., across rehabilitation programs, disease progression, aging) representative of limb function, which may be particularly useful in populations with asymmetric function.

The construct and concurrent validity of brief standing sway assessments in children with and without cerebral palsy.

BACKGROUND: Standing postural sway is often quantified from center of pressure trajectories. During assessments of longer durations, children may fidget, thus limiting the feasibility and validity of sway recordings. RESEARCH QUESTION: Do postural sway sample durations less than 30 s maintain construct and concurrent validity? METHODS: In this case-control, observational study, we measured postural sway in 41 children (age 5-12 years, 23 typically developing (TD); 18 with spastic cerebral palsy (CP), 13 diplegic and 5 hemiplegic, 11 GMFCS level I and 7 level II) for 30-second eyes-opened and eyes-closed conditions. From a single recording, 5-second incremental durations of 5-30 s were considered in this analysis. We quantified anteroposterior, mediolateral, and transverse-plane sway using seven time-domain variables: root-mean-square error, total excursion, mean frequency, mean distance, sway area, and 95 % confidence circle and ellipse areas. Variables were calculated in eyes-opened and eyes-closed conditions, as well as the ratio of the two. Construct validity was evaluated by the persistence of large effect sizes (Glass's Δ ≥ 0.80) between CP and TD participants at shorter durations than 30 s. Concurrent validity was evaluated by the correlations of shorter duration measures to the 30 s measure. RESULTS: Seven sway measures had large between-group effects (Glass's Δ ≥ 1.02) for the 30 s measure that persisted (Glass's Δ ≥ 0.81) at shorter durations (5-25 s) and also maintained concurrent validity (r ≥ 0.83). Six of these seven measures were taken in the eyes-closed condition, and all seven measures were in the mediolateral direction or transverse plane. SIGNIFICANCE: Our analysis suggests that sway durations less than 30 s can uphold construct and concurrent validity. These measures were primarily in the eyes-closed conditions and mediolateral direction. These results are a promising indicator that shorter-duration sway measures may be of utility when fidgeting prevents longer recordings.

Predicting vertical ground reaction force during running using novel piezoresponsive sensors and accelerometry.

Running is a common exercise with numerous health benefits. Vertical ground reaction force (vGRF) influences running injury risk and running performance. Measurement of vGRF during running is now primarily constrained to a laboratory setting. The purpose of this study was to evaluate a new approach to measuring vGRF during running. This approach can be used outside of the laboratory and involves running shoes instrumented with novel piezoresponsive sensors and a standard accelerometer. Thirty-one individuals ran at three different speeds on a force-instrumented treadmill while wearing the instrumented running shoes. vGRF was predicted using data collected from the instrumented shoes, and predicted vGRF were compared to vGRF measured via the treadmill. Per cent error of the resulting predictions varied depending upon the predicted vGRF characteristic. Per cent error was relatively low for predicted vGRF impulse (2-7%), active peak vGRF (3-7%), and ground contact time (3-6%), but relatively high for predicted vGRF load rates (22-29%). These errors should decrease with future iterations of the instrumented shoes and collection of additional data from a more diverse sample. The novel technology described herein might become a feasible way to collect large amounts of vGRF data outside of the traditional biomechanics laboratory.

Brain Stiffness Relates to Dynamic Balance Reactions in Children With Cerebral Palsy.

Cerebral palsy is a neurodevelopmental movement disorder that affects coordination and balance. Therapeutic treatments for balance deficiencies in this population primarily focus on the musculoskeletal system, whereas the neural basis of balance impairment is often overlooked. Magnetic resonance elastography (MRE) is an emerging technique that has the ability to sensitively assess microstructural brain health through in vivo measurements of neural tissue stiffness. Using magnetic resonance elastography, we have previously measured significantly softer grey matter in children with cerebral palsy as compared with typically developing children. To further allow magnetic resonance elastography to be a clinically useful tool in rehabilitation, we aim to understand how brain stiffness in children with cerebral palsy is related to dynamic balance reaction performance as measured through anterior and posterior single-stepping thresholds, defined as the standing perturbation magnitudes that elicit anterior or posterior recovery steps. We found that global brain stiffness is significantly correlated with posterior stepping thresholds (P = .024) such that higher brain stiffness was related to better balance recovery. We further identified specific regions of the brain where stiffness was correlated with stepping thresholds, including the precentral and postcentral gyri, the precuneus and cuneus, and the superior temporal gyrus. Identifying brain regions affected in cerebral palsy and related to balance impairment can help inform rehabilitation strategies targeting neuroplasticity to improve motor function.

Anteroposterior balance reactions in children with spastic cerebral palsy.

AIM: To compare anterior and posterior standing balance reactions, as measured by single-stepping thresholds, in children with and without spastic cerebral palsy (CP). METHOD: Seventeen ambulatory children with spastic CP (eight males, nine females) and 28 typically developing children (13 males, 15 females; age range 5-12y, mean [SD] 9y 2mo [2y 3mo]), were included in this cross-sectional, observational study. Balance reaction skill was quantified as anterior and posterior single-stepping thresholds, or the treadmill-induced perturbations that consistently elicited a step in that direction. In order to understand the underlying mechanisms of between-group differences in stepping thresholds, dynamic stability was quantified using the minimum margin of stability. Ankle muscle activation latency, magnitude, and co-contraction were assessed with surface electromyography. RESULTS: We observed an age and group interaction for anterior thresholds (p=0.001, partial η2 =0.24). At older (≈11y; p<0.001, partial η2 =0.48), but not younger (≈7y; p=0.33, partial η2 =0.02) ages, typically developing children had larger anterior thresholds than those with CP. In response to near-threshold anterior perturbations, older typically developing children recovered from more instability than their peers with CP (p=0.004, partial η2 =0.18). Older children had no between-group differences in ankle muscle activity. No between-group differences were observed in posterior thresholds. INTERPRETATION: The effects of CP on balance reactions are age- and direction-specific. Older typically developing children are more able or willing to withhold a step when unstable. WHAT THIS PAPER ADDS: Children with spastic cerebral palsy have age- and direction-specific balance-reaction impairments. Lower anterior stepping thresholds were observed in older, but not younger children. Older typically developing children withheld a forward step at higher levels of instability. No between-group differences were seen in posterior stepping thresholds.

The cross-sectional relationships between age, standing static balance, and standing dynamic balance reactions in typically developing children.

BACKGROUND: Static balance performance is a common metric for evaluating the development of postural control in children. Less is known about the potentially independent development of dynamic balance performance. RESEARCH QUESTION: How does age relate to static (i.e. postural sway) and dynamic (i.e. stepping thresholds) standing balance performance, and what is the relationship between postural sway and stepping thresholds? METHODS: Twenty-six typically developing children (12 males, 14 females; 5-12 years of age) were recruited for this cross-sectional study. Static balance performance was quantified as the total path length during a postural sway assessment using a force platform with conditions of eyes open and eyes closed. Dynamic balance performance was quantified using a single-stepping threshold assessment, whereby participants attempted to prevent a step in response to treadmill-induced perturbations in the anterior and posterior directions. Relationships between age and body-size scaled measures of static and dynamic balance performance were assessed using Spearman rank correlations. RESULTS: There was a weak correlation between age and postural sway (|rs| < 0.10, p >  0.68), but a moderate-to-strong correlation between age and single-stepping thresholds (rs > 0.68, p < 0.001). A weak correlation was found between postural sway and single-stepping thresholds (|rs| < 0.20, p >  0.39). SIGNIFICANCE: Dynamic, but not static standing balance performance, may improve with typical development between the ages of 5 and 12 years. Static and dynamic balance should be considered as unique constructs when assessed in children.

Dynamic stability during walking in children with and without cerebral palsy.

BACKGROUND: Cerebral palsy (CP) is associated with a high risk of falling during walking. Many gait abnormalities associated with CP likely alter foot placement and center of mass (CoM) movement in a way that affects anterior or lateral dynamic stability, in turn influencing fall risk. RESEARCH QUESTION: Do children with CP demonstrate altered anterior or lateral dynamic stability compared to typically-developing (TD) children? METHODS: In this case-control, observational study, we measured gait kinematics of two groups of children (15 CP, 11 GMFCS level I, 4 GMFCS level II; 14 TD; age 5-12) in walking conditions of a preferred speed, a fast speed, and a preferred speed while completing a cognitive task. For dominant and non-dominant limbs, the margin of stability (MoS), a spatial measure of dynamic stability, was calculated as the distance between the edge of the base of support and the CoM position after accounting for scaled velocity. Statistical comparisons of were made using mixed factorial ANOVAs. Post hoc comparisons were Sidak adjusted. RESULTS: The anterior MoS before foot strike and at mid-swing differed between each condition but not between groups. Based on the minimum lateral MoS, children with CP had more stability when bearing weight on their non-dominant limb compared to TD children. These differences were not apparent when on the dominant limb. SIGNIFICANCE: This high-functioning group of children with CP exhibited a more conservative lateral stability strategy during walking when bearing weight with the non-dominant limb. This strategy may be protective against lateral falls. We observed no between-group differences in anterior stability. Because CP has been previously associated with impaired anterior balance reactions, and there was no observed compensation in anterior gait stability, this lack of group differences could contribute to a higher risk of falling in that direction.

Estimation of 3D Ground Reaction Force Using Nanocomposite Piezo-Responsive Foam Sensors During Walking.

This paper describes a method for the estimation of the 3D ground reaction force (GRF) during human walking using novel nanocomposite piezo-responsive foam (NCPF) sensors. Nine subjects (5 male, 4 female) walked on a force-instrumented treadmill at 1.34 m/s for 120 s each while wearing a shoe that was instrumented with four NCPF sensors. GRF data, measured via the treadmill, and sensor data, measured via the NCPF inserts, were used in a tenfold cross validation process to calibrate a separate model for each individual. The calibration model estimated average anterior-posterior, mediolateral and vertical GRF with mean average errors (MAE) of 6.52 N (2.14%), 4.79 N (6.34%), and 15.4 N (2.15%), respectively. Two additional models were created using the sensor data from all subjects and subject demographics. A tenfold cross validation process for this combined data set resulted in models that estimated average anterior-posterior, mediolateral and vertical GRF with less than 8.16 N (2.41%), 6.63 N (7.37%), and 19.4 N (2.31%) errors, respectively. Intra-subject estimates based on the model had a higher accuracy than inter-subject estimates, likely due to the relatively small subject cohort used in creating the model. The novel NCPF sensors demonstrate the ability to accurately estimate 3D GRF during human movement outside of the traditional biomechanics laboratory setting.