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.

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.

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.

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.

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.

Loss of presynaptic inhibition for step initiation in parkinsonian individuals with freezing of gait.

KEY POINTS: Individuals with freezing of gait (FoG) due to Parkinson's disease (PD) have small and long anticipatory postural adjustments (APAs) associated with delayed step initiation. Individuals with FoG ('freezers') may require functional reorganization of spinal mechanisms to perform APAs due to supraspinal dysfunction. As presynaptic inhibition (PSI) is centrally modulated to allow execution of supraspinal motor commands, it may be deficient in freezers during APAs. We show that freezers presented PSI in quiet stance (control task), but they presented loss of PSI (i.e. higher ratio of the conditioned H-reflex relative to the test H-reflex) during APAs before step initiation (functional task), whereas non-freezers and healthy control individuals presented PSI in both the tasks. The loss of PSI in freezers was associated with both small APA amplitudes and FoG severity. We hypothesize that loss of PSI during APAs for step initiation in freezers may be due to FoG. ABSTRACT: Freezing of gait (FoG) in Parkinson's disease involves deficient anticipatory postural adjustments (APAs), resulting in a cessation of step initiation due to supraspinal dysfunction. Individuals with FoG ('freezers') may require functional reorganization of spinal mechanisms to perform APAs. As presynaptic inhibition (PSI) is centrally modulated to allow execution of supraspinal motor commands, here we hypothesized a loss of PSI in freezers during APA for step initiation, which would be associated with FoG severity. Seventy individuals [27 freezers, 22 non-freezers, and 21 age-matched healthy controls (HC)] performed a 'GO'-commanded step initiation task on a force platform under three conditions: (1) without electrical stimulation, (2) test Hoffman reflex (H-reflex) and (3) conditioned H-reflex. They also performed a control task (quiet stance). In the step initiation task, the H-reflexes were evoked on the soleus muscle when the amplitude of the APA exceeded 10-20% of the mean baseline mediolateral force. PSI was quantified by the ratio of the conditioned H-reflex relative to the test H-reflex in both the tasks. Objective assessment of FoG severity (FoG-ratio) was performed. Freezers presented lower PSI levels during quiet stance than non-freezers and HC (P < 0.05). During step initiation, freezers presented loss of PSI and lower APA amplitudes than non-freezers and HC (P < 0.05). Significant correlations were only found for freezers between loss of PSI and FoG-ratio (r = 0.59, P = 0.0005) and loss of PSI and APA amplitude (r = -0.35, P < 0.036). Our findings suggest that loss of PSI for step initiation in freezers may be due to FoG.

Instantaneous interjoint rescaling and adaptation to balance perturbation under muscular fatigue.

Adaptation of automatic postural responses (APR) to balance perturbations might be thought to be impaired by muscle fatigue, given the associated proprioceptive and effector deficits. In this investigation, we aimed to evaluate the effect of muscular fatigue on APR adaptation over repetitive balance perturbations through support base backward translations. APR adaptation was evaluated in three epochs: (a) pre-fatigue; (b) post-fatigue, immediately following fatigue of the plantiflexor muscles through isometric contractions and (c) post-recovery, 30 min after the end of fatiguing activity. Results showed the following: (a) Decreasing amplitudes of joints' maximum excursion over repetitive perturbations in the three fatigue-related epochs. (b) Modulation of joints' excursion was observed in the first trial in the post-fatigue epoch. (c) In the post-fatigue epoch, we found interjoint rescaling, with greater amplitude of hip rotation associated with reduced amplitude of ankles' rotation. (d) Amplitudes of ankles' rotation were similar between the post-fatigue and post-recovery epochs. These findings lead to the conclusions that adaptation of automatic postural responses over repetitive trials was effective under focal muscular fatigue; modulation of the postural response took place in the first perturbation under fatigue, and generalization of response characteristics from post-fatigue to post-recovery suggests that feedforward processes in APRs generation are affected by the recent history of postural responses to stance perturbations.

Automatic postural responses are scaled from the association between online feedback and feedforward control.

Generation of automatic postural responses (APRs) scaled to magnitude of unanticipated postural perturbations is required to recover upright body stability. In the current experiment, we aimed to evaluate the effect of previous postural perturbations on APR scaling under conditions in which the current perturbation is equal to or different from the previous perturbation load inducing unanticipated forward body sway. We hypothesized that the APR is scaled from the association of the current perturbation magnitude and postural responses to preceding perturbations. Evaluation was made by comparing postural responses in the contexts of progressive increasing versus decreasing magnitudes of perturbation loads. Perturbation was applied by unanticipatedly releasing a cable pulling the body backwards, with loads corresponding to 6%, 8% and 10% of body mass. We found that the increasing as compared to the decreasing load sequence led to lower values of (a) displacement and (b) velocity of center of pressure, and of activation rate of the muscle gastrocnemius medialis across loads. Muscular activation onset latency decreased as a function increasing loads, but no significant effects of load sequence were found. These results lead to the conclusion that APRs to unanticipated perturbations are scaled from the association of somatosensory feedback signaling balance instability with feedforward control from postural responses to previous perturbations.

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.

High contextual interference in perturbation-based balance training leads to persistent and generalizable stability gains of compensatory limb movements.

Reactive responses to balance perturbations have been shown to be improved by training. This investigation aimed to compare the effects of block and random training perturbation schedules on stability gains of compensatory arm and leg movements in response to unpredictable large-magnitude balance perturbations. Perturbations were produced by means of sudden displacements of the support base, associating mode (rotation, translation, combined), direction, and velocity of platform motion. Healthy young participants were assigned to one of three groups: random, block, and control. For the random group, perturbation sequence was unpredictable. For the block group, each balance perturbation was repeated over blocks of four trials. Controls were tested only, serving as reference of first trial responses in the post-test. Evaluation was made through a scale rating stability of compensatory arm and leg movements (CALM). We probed immediate and persistence gains (1-week retention), in addition to generalizability to perturbations of higher velocity and to dual-tasking (mental subtraction). In the post-test both the block and random groups achieved higher leg and global scores in comparison with controls in the most challenging perturbations. In retention and transfer tests, results for the global score indicated higher values for the random than for the block and control groups. These results support the conclusion that high but not low contextual interference in perturbation-based balance training leads to enduring and generalizable increased stability gains of compensatory limb movements in response to unpredictable balance perturbations.

Right in Comparison to Left Cerebral Hemisphere Damage by Stroke Induces Poorer Muscular Responses to Stance Perturbation Regardless of Visual Information.

OBJECTIVE: Fast and scaled muscular activation is required to recover body balance following an external perturbation. An issue open to investigation is the extent to which the cerebral hemisphere lesioned by stroke leads to asymmetric deficits in postural reactive responses. In this experiment, we aimed to compare muscular responses to unanticipated stance perturbations between individuals who suffered unilateral stroke either to the right or to the left cerebral hemisphere. METHODS: Stance perturbations were produced by releasing a load attached to the participant's trunk, inducing fast forward body oscillation. Electromyography was recorded from the gastrocnemius medialis and biceps femoris muscles. Muscular activation from age-matched healthy individuals was taken as reference. RESULTS: Analysis indicated that damage to the right hemisphere induced delayed activation onset, and lower rate and magnitude of activation of the proximal and distal muscles of the paretic leg. Those deficits were associated with stronger activation of the nonparetic leg. Comparisons between left hemisphere damage and controls showed deficits limited to activation of the biceps femoris of the paretic leg. Manipulation of visual information led to no significant effects on muscular responses. CONCLUSIONS: These results suggest that right cerebral hemisphere damage by stroke leads to more severe deficits in the generation of reactive muscular responses to stance perturbation than damage to the left cerebral hemisphere regardless of visual information.

Regulation of dynamic postural control to attend manual steadiness constraints.

In daily living activities, performance of spatially accurate manual movements in upright stance depends on postural stability. In the present investigation, we aimed to evaluate the effect of the required manual steadiness (task constraint) on the regulation of dynamic postural control. A single group of young participants ( n = 20) were evaluated in the performance of a dual posturo-manual task of balancing on a platform oscillating in sinusoidal translations at 0.4-Hz (low) or 1-Hz (high) frequencies while stabilizing a cylinder on a handheld tray. Manual task constraint was manipulated by comparing the conditions of keeping the cylinder stationary on its flat or round side, corresponding to low and high manual task constraints, respectively. Results showed that in the low oscillation frequency the high manual task constraint led to lower oscillation amplitudes of the head, center of mass, and tray, in addition to higher relative phase values between ankle/hip-shoulder oscillatory rotations and between center of mass/center of pressure-feet oscillations as compared with values observed in the low manual task constraint. Further analyses showed that the high manual task constraint also affected variables related to both postural (increased amplitudes of center of pressure oscillation) and manual (increased amplitude of shoulder rotations) task components in the high oscillation frequency. These results suggest that control of a dynamic posturo-manual task is modulated in distinct parameters to attend the required manual steadiness in a complex and flexible way. NEW & NOTEWORTHY We evaluated dynamic postural control on a platform oscillating in sinusoidal translations at different frequencies while performing a manual task with low or high steadiness constraints. Results showed that high manual task constraint led to modulation of metric and coordination variables associated with greater postural stability. Our findings suggest that motor control is regulated in an integrative mode at the posturo-manual task level, with reciprocal interplay between the postural and manual components.

Improvement of Balance Stability in Older Individuals by On-Water Training.

In the present investigation we evaluated the effect of stand-up paddle practice on upright postural control in older individuals. Participants were assigned to a group practicing stand-up paddle on seawater or to a walking control group. Balance stability was evaluated in the tandem Romberg and tiptoes postures, comparing the conditions of eyes open versus closed. Results showed that stand-up paddle practice led to reduced anteroposterior and mediolateral amplitudes of body sway in both visual conditions, while walking led to no effect on balance. These results suggest that the challenge of keeping body balance on an unstable board during on-water stand-up paddle practice is transferred to postural tasks performed on a stable support surface, with generalization to sensory and biomechanical conditions different from those experienced during the training. Our results suggest that on-water balance training could be considered as a potential procedure to improve balance control in older adults.

Cognition and balance control: does processing of explicit contextual cues of impending perturbations modulate automatic postural responses?

Processing of predictive contextual cues of an impending perturbation is thought to induce adaptive postural responses. Cueing in previous research has been provided through repeated perturbations with a constant foreperiod. This experimental strategy confounds explicit predictive cueing with adaptation and non-specific properties of temporal cueing. Two experiments were performed to assess those factors separately. To perturb upright balance, the base of support was suddenly displaced backwards in three amplitudes: 5, 10 and 15 cm. In Experiment 1, we tested the effect of cueing the amplitude of the impending postural perturbation by means of visual signals, and the effect of adaptation to repeated exposures by comparing block versus random sequences of perturbation. In Experiment 2, we evaluated separately the effects of cueing the characteristics of an impending balance perturbation and cueing the timing of perturbation onset. Results from Experiment 1 showed that the block sequence of perturbations led to increased stability of automatic postural responses, and modulation of magnitude and onset latency of muscular responses. Results from Experiment 2 showed that only the condition cueing timing of platform translation onset led to increased balance stability and modulation of onset latency of muscular responses. Conversely, cueing platform displacement amplitude failed to induce any effects on automatic postural responses in both experiments. Our findings support the interpretation of improved postural responses via optimized sensorimotor processes, at the same time that cast doubt on the notion that cognitive processing of explicit contextual cues advancing the magnitude of an impending perturbation can preset adaptive postural responses.

Improved children's motor learning of the basketball free shooting pattern by associating subjective error estimation and extrinsic feedback.

This study aimed at assessing the interaction between subjective error estimation and frequency of extrinsic feedback in the learning of the basketball free shooting pattern by children. 10- to 12-year olds were assigned to 1 of 4 groups combining subjective error estimation and relative frequency of extrinsic feedback (33% × 100%). Analysis of performance was based on quality of movement pattern. Analysis showed superior learning of the group combining error estimation and 100% feedback frequency, both groups receiving feedback on 33% of trials achieved intermediate results, and the group combining no requirement of error estimation and 100% feedback frequency had the poorest learning. Our results show the benefit of subjective error estimation in association with high frequency of extrinsic feedback in children's motor learning of a sport motor pattern.

Motor imagery training promotes motor learning in adolescents with cerebral palsy: comparison between left and right hemiparesis.

This experiment was designed to evaluate the effects of pure motor imagery training (MIT) and its combination with physical practice on learning an aiming task with the more affected arm in adolescents suffering from cerebral palsy. Effect of MIT was evaluated as a function of side of hemiparesis. The experiment was accomplished by 11- to 16-year-old participants (M = 13.58 years), who suffered left (n = 16) or right (n = 15) mild hemiparesis. They were exposed to pure MIT (day 1) followed by physical practice (day 2) on an aiming task demanding movement accuracy and speed. Posttraining movement kinematics of the group receiving MIT were compared with movement kinematics of the control group after receiving recreational activities (day 1) and physical practice (day 2). Kinematic analysis showed that MIT led to decreased movement time and straighter hand displacements to the target. Performance achievements from MIT were increased with further physical practice, leading to enhanced effects on motor learning. Retention evaluation indicated that performance improvement from pure MIT and its combination with physical practice were stable over time. Performance achievements were equivalent between adolescents with either right or left hemiparesis, suggesting similar capacity between these groups to achieve performance improvement from pure imagery training and from its association with physical practice. Our results suggest that motor imagery training is a procedure potentially useful to increase motor learning achievements in individuals suffering from cerebral palsy.

Light touch modulates balance recovery following perturbation: from fast response to stance restabilization.

Light fingertip touch of a static bar generates extra somatosensory information used by the postural control system to reduce body sway. While the effect of light touch has been studied in quiet stance, less attention has been given to its potential benefit for reactive postural responses. In the present study, we tested the effect of light fingertip touch of a stable surface on recovery of postural stability from a mechanical perturbation. Participants stood upright on a force plate touching a static rigid bar while being pulled backward by a load. Unpredictable release of the load induced fast anterior body sway, requiring a reactive response to recover balance. Effect of light touch on postural responses was assessed as a function of vision and malleability of the support surface, analyzing different epochs ranging from the pre-perturbation period to recovery of a relatively stable quiet stance. Results showed that light touch induced lower magnitude of muscular activation in all epochs. Center of pressure (CoP) displacement/sway was affected by interaction of light touch with manipulation of the other sensory information. For the periods associated with quiet stance, light touch led to decreased CoP sway in the malleable surface in the pre-perturbation epoch, and in the condition combining no vision and malleable surface in the balance restabilization and follow-up quiet stance epochs. For the fast reactive response epoch, light touch induced smaller amplitude of CoP displacement across conditions, and lower CoP maximum velocity in the condition combining no vision and rigid surface. These results showed that light touch modulates postural responses in all epochs associated with an unanticipated mechanical perturbation, with a more noticeable effect in conditions manipulating sensory information relevant for balance control.

Footedness across ages: distinction between mobilization and stabilization tasks.

Foot preference was assessed in 5- to 20-year-old participants separately for mobilization and stabilization task categories through observation of performance. Results revealed different laterality profiles of pedal preference between task categories. Interindividual consistency and strong preference for the right foot in mobilization tasks contrasted to large interindividual variability and weak pedal preference in stabilization tasks. Strength of pedal preference for each task category was stable across age groups. These findings suggest that daily living experiences over years of use do not modify the footedness profile observed in childhood.

Asymmetric balance control between legs for quiet but not for perturbed stance.

Interlateral performance asymmetry in upright balance control was evaluated in this investigation by comparing unipedal stance on the right versus the left leg. Participants were healthy young adults, hand-foot congruent preference for the right body side. Balance performance was evaluated in unperturbed quiet stance and in the recovery of balance stability following a mechanical perturbation induced by unexpected load release. Evaluation was made under availability of full sensory information, and under deprivation of vision combined with distortion of sensory inputs from the feet soles. Results from perturbed posture revealed that muscular response latency and postural sway were symmetric between the legs. Unipedal stance was more stable when the body was supported on the right as compared with the left leg. No interaction was found between leg and sensory condition. Our findings are interpreted as resulting from specialization of the sensorimotor system controlling the right leg for continuous low-magnitude postural adjustments, while corrections to large-scale stance sway are symmetrically controlled between body sides.