The capacity to adapt to changing balance threats: a comparison of children with cerebral palsy and typically developing children.

OBJECTIVES: This study investigated differences in reactive balance abilities of typically developing children and those with spastic diplegia. Recovery from balance threats was compared by: (i) Platform velocity and amplitude thresholds: Speed and size of platform movement at which children required assistance to remain upright, (ii) percentage of trials with feet-in-place vs. loss of balance, and (iii) center of pressure measures. Participants included 8 children with spastic diplegic cerebral palsy, 15 developmentally matched children (similar walking stages) and 21 age-matched control children. METHODS: Backward platform movements graded as easy, moderate and difficult were unexpectedly imposed on children standing on a moveable platform. RESULTS: Children with cerebral palsy (CP) had lower platform velocity thresholds, greater percentages of loss of balance trials, increased distances and increased frequency of directional changes in center-of-pressure (COP) trajectories than control children. Older children with CP fell more often than those under 5 years. Greatest differences between children with and without CP were found in comparisons based on age rather than developmental levels. CONCLUSIONS: Using balance perturbations that challenged children with CP to the limits of their balance abilities effectively identified age performance differences and differences compared to typically developing children. Implications for rehabilitation programs are presented.

The translating platform paradigm: perturbation displacement waveform alters the postural response.

The translating platform paradigm is widely used to investigate the regulation of upright standing and locomotion. This study investigated how the displacement waveform characteristics underlying the translating platform perturbation are revealed in the resulting postural response. Eight participants experienced a series of backward-directed perturbations using a hydraulically driven forceplate. Two ranges of platform displacement (5 and 15 cm) in combination with two peak velocities (40 and 60 cm/s) were achieved using three distinct waveforms for platform displacement: (a) RAMP: ramp onset and ramp offset, (b) Ramp-to-Parabola (R-P): ramp onset with parabolic offset and (c) SINE: sine-wave onset with sine wave offset. Our findings indicated that the unique and distinctive acceleration and deceleration characteristics that result from the three different platform displacement waveforms significantly altered the postural response to the perturbation.

Compensatory stepping: the biomechanics of a preferred response among older adults.

The purpose of this study was to evaluate age-related differences in the mechanics of the compensatory stepping response to balance threats. A moving platform was used to disturb the balance of 16 younger (21 to 35 years) and 19 older (68 to 88 years) adults. Backward platform translations consisted of 15-cm displacements with peak accelerations ranging from 9.4 to 15.2 m/s2. Older adults were more likely to use a step to recover balance and stepped at lower perturbation magnitudes than younger adults. Group differences were not found in time to step initiation or segmental momentum. The lack of group differences in momentum revealed that lower perturbation accelerations created an equivalent or greater magnitude of body motion in older adults compared to higher accelerations experienced by younger adults. Older adults also showed a reduced ability to attenuate the input acceleration and experienced significantly greater linear acceleration of the head.

Development of lower extremity kinetics for balance control in infants and young children.

Developmental changes in the kinematics and kinetics underlying balance control were studied in 61 children, 9 months to 10 years of age. The children were classified according to developmental milestones as standers; new, intermediate, and advanced walkers; runners-jumpers; hoppers; gallopers; and skippers. The children experienced support-surface translations of varying size and speed. Children with greater locomotor experience withstood larger balance threats without collapsing or stepping. Analyses of scaled trials (perturbations normalized in size to foot length and center of gravity height) revealed that improvement in balance was not related to initial configuration parameters surrounding the task (degree of crouch or lean). Children with advanced locomotor skills had faster recovery times and relatively larger muscle torques than children with less experience. Relative torque-time histories of the more experienced children began to match the adult response to similar perturbations. With increased experience and changing muscle torque regulatory abilities, balance skills became more robust.

The effect of age-related declines in proprioception and total knee replacement on postural control.

BACKGROUND: An experiment was designed to examine the effects of a decrease in threshold joint position sense (TJPS) at the knee and ankle and of total knee replacement (TKR) on postural control in older adults. It was hypothesized that older adults with a decrease in TJPS and those who had undergone TKR would display increased center of pressure (COP) variance during quiet stance and late onsets for muscle responses to balance threats. METHODS: Older adult subjects (> or = 70 years) were evaluated and grouped according to the status of their ankle and knee threshold joint position sensation as well as their surgical history. COP data were collected while subjects stood on a force plate with feet together under eyes-open and -closed conditions. Threats to balance were given using a platform that moved forward and backward. RESULTS: Older subjects with poor knee extension TJPS had significantly increased COP variance, although those with very poor knee flexion and extension TJPS demonstrated even greater increases. Similarly, subjects with decreased ankle TJPS demonstrated increased COP variance. However, reduced TJPS did not affect the ability of subjects to respond to threats to balance. Post-TKR subjects showed no reductions in any aspect of postural control. CONCLUSIONS: This study showed that the task of standing quietly has a direct relationship to threshold JPS, although the task of recovering from an abrupt perturbation does not. Older adult TKR results suggest that there is no negative effect on balance from elective joint replacement.

The development of compensatory stepping skills in children.

The development of the ability to use the step for balance recovery was studied among twenty-five 9- to 19-month-old children. The children were grouped according to walking experience (4 levels) and exposed to backward support surface translations, 8 cm in amplitude, under 3 velocity conditions: 15, 20, and 25 cm/s. New walkers (up to 2 weeks' walking experience) used the step infrequently and ineffectively in response to threats to balance. Intermediate walkers (1-3 months' walking experience) showed an increasing use of the step and significant improvement in step execution compared with new walkers. Advanced walkers (>3; months' walking experience) experienced no falls throughout the protocol, capturing balance with feet-in-place or step responses under all perturbation conditions. A significant developmental transition in the emergence of the compensatory step occurred between the new walker and the intermediate walker experience levels, that is, within the first 3 months of walking experience. Three to 6 months' experience was required for the development of an effective stepping response. A concomitant change in mediolateral stability paralleled the emergence of compensatory stepping.

Cognitive influence on postural stability: a neuromuscular analysis in young and older adults.

BACKGROUND: Previous literature indicates that attentional resources are required for recovery of postural stability. Previous studies have also examined the effect of aging on the performance of a static postural task while a secondary cognitive task is being conducted. This study describes the effect of a cognitive task on the neuromuscular response characteristics underlying reactive balance control in young versus older adults. METHODS: The attentional demand on the neuromuscular system was examined in 14 young and 12 healthy older adults by analysis of the integrated electromyography activity while the adults were performing a dual-task paradigm. The primary task involved standing platform perturbations and the secondary task was a math task that involved subtraction by threes. Integrated electromyography activity was compared between the cognitive (math and balance) task versus control (balance only) task. RESULTS: For both groups of subjects, onset latency of postural muscle responses did not change under dual-task conditions. In contrast, the amplitude of postural muscle activity was significantly affected by performance of a secondary task. When electromyography data were combined for both young and older adults, there was a decrease in muscle response amplitude in both agonist (gastrocnemius) and antagonist (tibialis anterior) muscles when the cognitive math task was performed. This was apparent at 350-500 milliseconds from plate onset for the gastrocnemius and between 150 and 500 for the tibialis anterior. When young and older adults were compared, an age by task interaction effect was seen in muscle response amplitude for the agonist (gastrocnemius) muscle between 350 to 500 milliseconds, with older adults showing a significantly greater reduction than young adults. CONCLUSION: The decline of muscle activity when the secondary task was performed suggests that less attentional processing capacity was available for balance control during the dual-task paradigm. The results also indicate that the dual-task activity has a greater impact on balance control in the older adults than in the young adults.

Parkinson's disease impairs the ability to change set quickly.

We tested the hypothesis that basal ganglia dysfunction in Parkinson's disease impairs the ability to quickly change set. The ability to change set was inferred by measuring the change in the amplitude of automatic gastrocnemius or tibialis anterior muscle responses in standing subjects: (1) when the direction of a surface perturbation changed from a backward translation to a toes up rotation; and (2) when subjects were instructed to 'give' or 'resist' while responding to the translations and rotations. In experiment 1, a change in sensorimotor set was assessed by the suppression of gastrocnemius responses to toes up rotations following a series of backward translations. Unlike healthy young and older subjects, Parkinson subjects did not change sensorimotor set immediately to the first rotation, but needed several rotations to change their responses. When required to alternate their responses between backward translations and toes up rotations, Parkinson subjects showed a smaller amplitude change in gastrocnemius responses. In experiment 2, Parkinson subjects had more difficulty in using cognitive set to modify their responses, especially when instructed to 'resist' the perturbations. A small number of healthy older subjects also had difficulties changing set quickly, but to a lesser extent than the Parkinson subjects. Levodopa medication did not improve the Parkinson subjects' ability to change set quickly. These results suggest that the basal ganglia, which are affected in Parkinson's disease, are critical neural substrates in the ability to change set quickly.

Age-related changes in rate and magnitude of ankle torque development: implications for balance control.

BACKGROUND: One of the key components of postural control is the motor system's ability to produce appropriate torques to counteract perturbations that may lead to a loss of balance. Evidence exists to show that there is an age-related decline in absolute strength and in the ability to rapidly produce torque. The relationship between age-related decreases in these voluntary torque production capabilities and the ability to rapidly produce torques in a reactive balance task has not been studied. Thus, the purpose of this study was to examine the magnitude and rate of torque production in younger and older adults under reactive balance conditions. METHODS: Older (OA) and younger (YA) adults received forward and backward support surface translations of varying amplitudes and velocities. Maximum ankle muscle torque (maxMa) and rate of change of ankle muscle torque (Ma) following a perturbation were calculated. RESULTS: Two balance responses emerged: a no-step and a step response. With increasing perturbation difficulty, YA and OA used different responses. The no-step and step responses were examined for age-group differences in the force characteristics. No significant age-group differences were found for maxMa or rate of change of Ma within either no-step or step responses. CONCLUSION: The results of this study suggest that neither the magnitude nor rate of ankle muscle torque production, as produced during the initial balance response in this set of reactive balance control tasks, determines the different balance responses seen in younger versus older adults.

Stance balance control with orthoses in a group of children with spastic cerebral palsy.

Although ankle-foot orthoses (AFOs) are frequently prescribed to correct skeletal malalignment in children with spastic diplegia, their effect on standing balance abilities has not been documented. This study investigated balance differences related to the presence of pathology and orthotic conditions during conditions of unexpected stance perturbation by comparing four children aged between 3 1/2 and 15 years with spastic cerebral palsy and four control children matched for years of independent walking experience. Electromyographic and kinematic data were collected and compared between groups and in three orthotic conditions (no AFOs, solid AFOs, dynamic AFOs). Results revealed that balance responses of children with spasticity were characterized by: increased coactivation of muscles as opposed to distal to proximal recruitment, decreased presence of upright posture in stance, increased use of 'on-toes' strategies, and different sway characteristics compared with the typically developing children. In both groups of children, the use of solid AFOs during perturbed stance resulted in: decreased activation of gastrocnemius muscles, disorganized muscle-response patterns, decreased use of ankle strategies, and increased joint angular velocities at the knee compared with conditions without AFOs or with dynamic AFOs. These preliminary results support the use of dynamic AFOs to correct skeletal malalignment in children with spastic diplegia.

Attentional demands and postural recovery: the effects of aging.

BACKGROUND: Cognitive demands associated with balance and locomotion may contribute to the incidence of falling among older adults. This study addressed issues related to the effects of aging on the attentional demands of recovering from an external disturbance to balance. This research also investigated whether performing a secondary cognitive task differentially affects postural recovery in young versus older adults. METHOD: Fifteen young and 10 healthy older adults were exposed to a series of balance disturbances. Attentional demands were assessed using a dual task paradigm where postural recovery served as the primary task, and counting backwards served as a concurrent secondary cognitive task. The effect of the counting task was assessed by comparing kinematic variables related to feet-in-place and stepping recovery strategies. RESULTS: Recovering upright stance was found to be attentionally demanding in both age groups. The type of recovery strategy did not influence attentional demands in young adults; however, a hierarchy of increasing attentional demands between the ankle strategy and compensatory stepping was apparent among older adults. In addition, stepping appears to be more attentionally demanding for older adults than for younger adults. Counting backwards did not affect the type of strategy used; however, it did affect the kinematics of stepping. For both age groups, steps occurred when the center of mass was located in a more central location within the base of support when the secondary task was added. CONCLUSIONS: The ability to recover a stable posture following an external perturbation is more attentionally demanding for older adults than for younger adults. This would suggest that for some older adults, an increased risk for loss of balance and falls may result if sufficient attentional resources are not allocated to the task of postural recovery.

Phase-dependent modulation of proximal and distal postural responses to slips in young and older adults.

BACKGROUND: Phase-dependent modulation of postural responses plays an important functional role in integrating reflexes into ongoing locomotion behaviors. This study tested the hypotheses that proximal and distal postural responses are modulated differently according to the phases of the gait cycle in young adults and that there is a decline in this modulatory ability with normal aging. METHODS: Thirty-three healthy young adults (age = 25 +/- 4 years) and 32 healthy older adults (mean age 74 +/- 14 years) participated. Subjects walked across a movable force plate with its movement timed to heel strike or midstance to simulate a forward slip occurring at different times during the gait cycle. Surface electromyography was recorded from bilateral leg, thigh, hip, and trunk muscles. Kinematic data were collected from the right (perturbed) side of the body. RESULTS: Postural responses to the heel strike slips occurred more frequently, and were of shorter latency, longer burst duration, and greater burst magnitude, than those in response to the midstance slips. Whereas the early and predominant postural responses came from bilateral tibialis anterior, rectus femoris, and biceps femoris muscles in heel strike slips, early postural responses were observed in bilateral erector spinae muscles in midstance slips. The late postural responses in midstance slips (from bilateral biceps femoris muscles and medial gastrocnemius and tibialis anterior of the nonperturbed leg) assisted in foot liftoff of the perturbed leg and earlier and safe landing with the nonperturbed leg. In response to the heel strike versus midstance slips, older adults preserved the phase-dependent modulatory abilities of the occurrence, onset latency, and burst duration of their postural responses, but not the ability to modulate burst magnitude, as compared to young adults. CONCLUSION: Postural responses from the proximal and distal muscles in reaction to different temporal phasing of slips during the step cycle showed differential modulation to meet the different task requirements. Older adults preserve this modulatory ability but with limited capacity. Physiological or psychological factors may influence older adults' phase-dependent modulatory capacity.

Time-dependent influence of sensorimotor set on automatic responses in perturbed stance.

These experiments tested the hypothesis that the ability to change sensorimotor set quickly for automatic responses depends on the time interval between successive surface perturbations. Sensorimotor set refers to the influence of prior experience or context on the state of the sensorimotor system. Sensorimotor set for postural responses was influenced by first giving subjects a block of identical backward translations of the support surface, causing forward sway and automatic gastrocnemius responses. The ability to change set quickly was inferred by measuring the suppression of the stretched antagonist gastrocnemius responses to toes-up rotations causing backward sway, following the translations. Responses were examined under short (10-14 s) and long (19-24 s) inter-trial intervals in young healthy subjects. The results showed that subjects in the long-interval group changed set immediately by suppressing gastrocnemius to 51% of translation responses within the first rotation and continued to suppress them over succeeding rotations. In contrast, subjects in the short-interval group did not change set immediately, but required two or more rotations to suppress gastrocnemius responses. By the last rotation, the short-interval group suppressed gastrocnemius responses to 33%, similar to the long-interval group of 29%. Associated surface plantarflexor torque resulting from these responses showed similar results. When rotation and translation perturbations alternated, however, the short-interval group was not able to suppress gastrocnemius responses to rotations as much as the long-interval group, although they did suppress more than in the first rotation trial after a series of translations. Set for automatic responses appears to linger, from one trial to the next. Specifically, sensorimotor set is more difficult to change when surface perturbations are given in close succession, making it appear as if set has become progressively stronger. A strong set does not mean that responses become larger over consecutive trials. Rather, it is inferred by the extent of difficulty in changing a response when it is appropriate to do so. These results suggest that the ability to change sensorimotor set quickly is sensitive to whether the change is required after a long or a short series of a prior different response, which in turn depends on the time interval between successive trials. Different rate of gastrocnemius suppression to toes-up rotation of the support surface have been reported in previous studies. This may be partially explained by different inter-trial time intervals demonstrated in this study.

Inefficient postural responses to unexpected slips during walking in older adults.

BACKGROUND: Slips account for a high percentage of falls and subsequent injuries in community-dwelling older adults but not in young adults. This phenomenon suggests that although active and healthy older adults preserve a mobility level comparable to that of young adults, these older adults may have difficulty generating efficient reactive postural responses when they slip. This study tested the hypothesis that active and healthy older adults use a less effective reactive balance strategy than young adults when experiencing an unexpected forward slip occurring at heel strike during walking. This less effective balance strategy would be manifested by slower and smaller postural responses, altered temporal and spatial organization of the postural responses, and greater upper trunk instability after the slip. METHODS: Thirty-three young adults (age range=19-34 yrs, mean=25+/-4 yrs) and 32 community-dwelling older adults (age range=70-87 yrs, mean=74+/-14 yrs) participated. Subjects walked across a movable forceplate which simulated a forward slip at heel strike. Surface electromyography was recorded from bilateral leg, thigh, hip, and trunk muscles. Kinematic data were collected from the right (perturbed) side of the body. RESULTS: Although the predominant postural muscles and the activation sequence of these muscles were similar between the two age groups, the postural responses of older adults were of longer onset latencies, smaller magnitudes, and longer burst durations compared to young adults. Older adults also showed a longer coactivation duration for the ankle, knee, and trunk agonist/antagonist pairs on the perturbed side and for the knee agonist/antagonist pair on the nonperturbed side. Behaviorally, older adults became less stable after the slips. This was manifested by a higher incidence of being tripped (21 trials in older vs 5 trials in young adults) and a greater trunk hyperextension with respect to young adults. Large arm elevation was frequently used by older adults to assist in maintaining trunk stability. In an attempt to quickly reestablish the base of support after the slips, older adults had an earlier contralateral foot strike and shortened stride length. CONCLUSION: The combination of slower onset and smaller magnitude of postural responses to slips in older adults resulted in an inefficient balance strategy. Older adults needed secondary compensatory adjustments, including a lengthened response duration and the use of the arms, to fully regain balance and prevent a fall. The shorter stride length and earlier contralateral foot strike following the slip indicate use of a more conservative balance strategy in older adults.

The influence of vision on the automatic postural muscle responses of newly standing and newly walking infants.

In adults, visual inputs do not appear to contribute significantly to automatic postural muscle responses (90-100 ms latency) activated by transient support surface displacements causing threats to standing balance, but are activated through slow pathways with latencies of more than 200 ms. However, it has been shown that the postural sway behavior of early walking infants is strongly influenced by visual flow cues that falsely signal self-movement. To determine whether there also are significant contributions of vision to automatic postural muscle responses in this age group, two groups of infants were tested on a moveable platform; pre-walkers (n=6) and early walkers (n=6). Pre-walkers did not show any measurable effect of visual condition (vision vs no vision) on muscle response characteristics. However, the integrated gastrocnemius activity of early walkers increased significantly in vision versus no vision conditions (P<0.05). These results show that visual cues contribute to, or modulate, the automatic postural responses in children who are in the developmental transition to independent walking.

Development of postural responses during standing in healthy children and children with spastic diplegia.

Studies on the development of balance control show a clear developmental progression of the emergence of organized muscle response patterns, with tonic background muscle activity decreasing and phasic bursts of activity emerging in all three agonist muscles in a synergic group (gastrocnemius-hamstrings-trunk extensors or tibialis anterior-quadriceps-abdominals) just prior to the onset of independent stance. The rudimentary ability to adapt postural responses to changing task conditions is present in children as young as 1 year of age. Older children with spastic diplegia have muscle activation patterns typically seen in normal children who are at the pull-to-stand stage of development, including poorly organized (proximal activated before distal muscles) responses with a high degree of antagonist co-activation. When normal children were asked to stand in a crouched posture like the CP children, the additional constraint caused muscle response patterns to resemble those of CP children, suggesting that differences in balance control in CP children are due to both CNS deficits and biomechanical changes in postural alignment.

Correlation between two clinical balance measures in older adults: functional mobility and sensory organization test.

BACKGROUND: Functional mobility of older adults has been shown to correlate with stance stability to various extents. This variability could be due to the difference in the way sensory information is processed in these two types of balance tests. Correlations between functional mobility and stance stability under altered sensory conditions, such as those in the Sensory Organization Test (SOT), are needed to test this possibility. The present study investigated the correlation between the performance of older adults on a newly developed Sensory-Oriented Mobility Assessment Instrument (SOMAI) and on the various sensory conditions of the SOT. METHODS: Twenty-seven community-dwelling older adults (76 +/- 7 years) underwent tests of the six SOT conditions and 10 SOMAI mobility maneuvers performed under normal- and focal-vision (peripheral vision eliminated) conditions. Behavioral performance in the two SOMAI conditions and the amounts of postural sway in the six SOT conditions were ranked among the subjects. Correlations of performance rankings on these two tests were analyzed. RESULTS: Performance on the two SOMAI conditions significantly correlated with that on the SOT conditions in which accurate visual, vestibular, and somatosensory inputs were all present (p < .05). Performance on the focal-vision SOMAI condition was also significantly correlated with that on the SOT condition in which somatosensory input was unreliable for orientation while visual and vestibular inputs were reliable (p < .05). There were no correlations between the SOMAI performance and performance on the no-vision or unreliable-vision SOT conditions. CONCLUSIONS: The ability to use all visual, somatosensory, and vestibular inputs for balance was correlated with functional mobility. The moderate correlations between the performance on the normal-sensory SOT condition and the SOMAI conditions suggest that body systems other than balance senses also contribute to mobility performance.

Control of reactive balance adjustments in perturbed human walking: roles of proximal and distal postural muscle activity.

Studies on the proactive control of gait have shown that proximal (hip/trunk) muscles are the primary contributors to balance control, while studies on reactive balance control during perturbed gait, examining only activity in distal (leg/thigh) muscles, have shown that these muscles are important in compensating for a gait disturbance. This study tested the hypothesis that proximal muscles are also primary contributors to reactive balance control during perturbed gait. Thirty-three young adults participated in a study in which an anterior slip was simulated at heel strike by the forward displacement of a force plate on which they walked. Surface electromyographic data were recorded from bilateral leg, thigh, hip and trunk muscles. Kinematic data were collected on joint angle changes in response to the perturbation. The results did not support the hypothesis that the proximal muscles contribute significantly to balance control during perturbed gait. The proximal muscles did not demonstrate more consistent activation, earlier onset latency, longer burst duration or larger burst magnitude than distal muscles. Moreover, although proximal postural activity was often present in the first slip trial, it tended to adapt away in later trials. By contrast, the typical postural responses exhibited by young adults consisted of an early (90-140 ms), high-magnitude (4-9 times muscle activity during normal walking) and relatively long duration (70-200 ms) activation of bilateral anterior leg muscles as well as the anterior and posterior thigh muscles. Thus, postural activity from bilateral leg and thigh muscles and the coordination between the two lower extremities were the key to reactive balance control and were sufficient for regaining balance within one gait cycle. The adaptive attenuation of proximal postural activity over repeated trials suggests that the nervous system overcompensates for a novel balance threat in the first slip trial and fine-tunes its responses with experience.

Balance control during walking in the older adult: research and its implications.

In this article, we highlight the unique nature of balance control during walking in humans. A control framework, including proactive and reactive balance control, is introduced to lay out age-related changes in different balance control mechanisms during walking. Clinical implications that may be useful for clinicians for assessment and treatment of balance problems that occur during walking are also discussed.